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The AASM Manuai

for the Scoring of Sleep


and Associated Events
Rules, Terminology and Technical Specifications
CONRAD10ER, MD, SONIAANCOLl-IsRAEL, PHD, Al DREW L. CHESSONJR. , MD AND
STUART F.Q UAN, MD fOR THEA;\IERICAN ACADEMYOf SLEEP M EDICI NE
AMERICAN A CADEMY OF S LEEI' M EDICI1', WESTCII ESTER, IL
AASM Manualfor Scoring Sleep, 2007 3
Copyright2007American Academy of Sleep Medicine,1WestbrookCorporate Center, Suite 920, Westchester,IL
60154, U.S.A
Copies ofthe manual areavailable fromtheAmerican Academy ofSleep Medicine inthe U.S.A.
Ali rights reserved. Unless authorized inwriting bytheMSM.noportion ofthis book may be reproduced or used
in a manner inconsistent with the copyright. This applies to unauthorized reproductions in any form, including
computerprograms.
Correspondenceregarding copyright permissions should bedirected totheExecutive Director,AmericanAcademy
of Sleep Medicine, 1 Westbrook Corporate Center, Suite 920, Westchester, IL 60154, U.S.A. Translations to other
languagesmust beauthorized bytheAmerican AcademyofSleep Medicine, U.S.A.
Recommended Citations
(Numerical)
Iber C. Ancoli-Israel S, Chesson A, and Quan SF for the American Academy of Sleep Medicine. TheMSM Manual for
the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, 1
s1
ed. : Westchester,
Illinois: American AcademyofSleep Medicine, 2007.
(Alphabetical)
IberC,Ancoli-IsraelS,ChessonA,andQuanSFfortheAmericanAcademy ofSleepMedicine.TheMSMManualfor
theScoring ofSleepandAssociated Events: Rules,TerminologyandTechnicalSpecifications, 1
5
\ ed.:Westchester,
Illinois: American AcademyofSleep Medicine, 2007.
Library ofCongressControl Number:0-9657220-4-X
AASM Manualfor Scoring Sleep, 2007 4
TABLE OF CONTENTS
pages
ContributorsandAcknowledgements 6
Preface 9
11 DevelopmentProcess
Scoring Manual
1. Key 15
II. Parametersto Be Reported for Polysomnography 17
III. Technical and Digital Specifications 19
IV. Visual Rules 23
Visual Rules forAdults 23
Visual Rulesfor Children 32
V. Arousal Rule 37
VI. CardiacRules 39
VII. MovementRules 41
VIII. RespiratoryRules 45
RespiratoryRules forAdults 45
RespiratoryRules for Children 48
IX. ProceduralNotes 51
X. GlossaryofTerms 59
AASMManualfor Scoring Sleep, 2007 5
Contributors
Editor ,Conrad Iber
Steering Committee: Conrad Iber, Chair
SoniaAncoli-Israel,AndrewL.Chesson Jr.,Stuart F.Quan
Task Forces:
Arousal
Ronald D.Chervin,MD,MS Rochester, MN
Mi chael H.Bonn et,PhD,Chair
University of Michigan, Ann Arbor, MI Carol L.Rosen,MD
Wright State University,Dayton,OH
Meir Kryger, MD Rainbow Babies&Children'sHospital,
Karl Doghramji, MD
Universityof Manitoba,Winnipeg,MB Cleveland, OH
ThomasJefferson University,Phiadelphia,
Canada Stephen Sheldon, DO,FAAP,
PA
Clete A.Kushida, MD,PhD, RPSGT Children'sMemorialHospital, Chicago, IL
Timothy Roehrs,PhD
Stanford University,Stanford, CA Stuart F. Ouan,MD
Wayne State University,Detroit,MI
Beth A. Malow, MD,MS University of Arizona, Tucson,Al
Stephen Sheldon, DO,FAAP
Vanderbilt University, Nashville, TN
Children'sMemorialHospital, Chicago,IL
Michael H.Silber,MBChB Respiratory
Edward J.Stepanski ,PhD
MayoClinicCollege ofMedicine, Susan Redlin e, MD, MPH , Chair
RushUniversityMedicalCenter,Chicago,IL
Rochester,MN CaseWestern Reserve University,
ArthurS. Wallers,MD
Michael V.Vitello,PhD, Cleveland, OH
NJNeuroscienceInstitute atJFK Medical
UniversityofWashingt on,Seattle, WA Rohit Budhiraja, MD
Center,Edison,NJ
AndrewL.Chesson Jr,MD,LSU SouthernArizona VAHeallhcare System,
Merrill S.Wi se, MD
Heallh Sciences Centerin Shreveport, SouthernArizona, Tucson,Al
MethodistHealthcare Sleep Disorders
Shreveport ,LA David Gozal, MD
Center,Memphis, TN
UniversityofLoui svill e,Louisvill e,KY
AndrewL. ChessonJr, MD
Geriatrie Vishesh K.Kapur,MD,MPH
LSUHeallh SciencesCenter in
Sonia Ancoli-Israel, PhD,Chair University of Washington,Seattle,WA
Shreveport ,Shreveport, LA
University ofCalifornia,San Diego, CA Carol L. Marcus, MB, BCh
DonaldL.Bliwise,PhD Children'sHospitalofPhil adelphia,
Emory UniversityMedical Scnool ,Atlanta, Philadelphia,PA
Sean M. Caples,DO,Cha ir
GA Jason H. Mateika,PhD
Mayo ClinicColl ege ofMedicine,
Susan Redlin e,MD, MPH Wayne State UniversityandJohn D.
Rocheste r, MN
Case Western Reserve University, Dingell VAMedical Center, Detroit , MI
Cardiae
Cleveland,OH Reena Mehra,MD, MS
Mayo ClinicCollegeof Medi cine,
Virend K. Somers, MD, PhD,Co-Chair
Edward Stepanski ,PhD Case Western Reserve University,
Rochester,MN
Rush University Medical Center, Chicago, IL Clevel and, OH
MichaelV.Vitiello, PhD SariamParthasarthy,MD
MichaelE.Adams, ResearchAssociate
Hol ston ValleyMedical Center,Kingsport ,
Uni versityofWashington,Seattle, WA SAVAHCSandUniversityof Arizona,
TN
Timothy 1. Morgenthaler, MD Tucson,Al
William G.Colts,MD
MayoClinic College of Medicine, Kingman Strohl, MD
Northwestern University,Chicago, IL
Rochester,MN Case Western Reserve University,
Cleveland,OH
RainbowBabies &Children'sHospital,
Movements Merrill S.Wise,MD
Clevel and,OH
ArthurS.Walters,MD, Chair MethodistHealthcare Sleep Disorders
ThomasKara,MD
Parvin Dorostkar,MD
JFK Medi calCenter,Edison,NJ Center,Memphis , TN
MayoClinicCollegeof Medicine,
Richard P.Allen,PhD StuartF. Ouan,MD
Rochester,MN
Johns Hopkins University,Baltimore,MD Universityof Arizona, Tucson,Al
Timothy 1. Morgenthaler,MD
Donald L. Bliwise, PhD
Mayo Clinic College ofMedicine,
Emory UniversityMedical Scnoot,Atlanta, Visual
Rochester, MN
GA Mi chael H.Silber,MBChB, Chair
SudhansuChokroverty, MD,FRCP Mayo ClinicCollege ofMedi cine,
RainbowBabies&Children'sHospital,
Carol L.Rosen,MD
NJNeuroscience Institute atJFK, Edi son, Rochester,MN
Cleveland,OH
NJ Sonia Ancoli-Israel, PhD
Wayne A.Hening , MD, PhD, UniversityofCalifornia,San Diego, CA
Rush University Medical Center, Chicago,
UMDNJ - RWJohnson Medical School , MichaelH.Bonnet ,PhD
NewBrunswick, NJ WrightState University,Dayton, OH
Edward J.Stepanski, PhD
IL
CleteA. Kushida,MD,PhD,RPSGT SudhansuChokroverty,MD,FRCP
Win K.Shen,MD
Stanford University,Stanford,CA NJNeuroscienceInstitute atJFK Medical
Rochester,MN
Mayo ClinicCollege of Medi cine,
GillesLavigne, DMD, PhD,FRCD Center,Edison,NJ
Kalyanam Shivkumar, MD
UniversitedeMontrealSleepDisorder MadeleineGrigg-Damberger,MD
David Geffen Schoolof Medicineat UCLA,
Laboratory,Sacre Coeur Hospital , Universityof New Mexico School of
LosAngeles, CA
Montreal , QC Canada Medicine,Albuquerque, NM
Daniel Picchielli ,MD Max Hirshkowitz,PhD
Conrad Iber,MD
University ofIllinois,Urbana, IL BaylorCollege ofMedi cine &VAMC,
Universityof MinnesotaMedi calSchool ,
Sonia Ancoli-Israel ,PhD Houston, TX
Minneapolis,MN
Hennepin County Medical Centerand
UniversityofCalifornia,San Diego, CA Sheldon Kapen, MD
WayneState Univ.Med.School and
Digital
Pediatrie VAMC,Detroit, MI
MadeleineGrigg-Damberger, MD, Chair Sharon Keenan, PhD, ABSM, RPSGT,
UniversityHospital ,Departmentof
University of New MexicoSchool of REEGT
Medi cine,Sleep Laboratory,Marburg,
ThomasPenzel ,PhD,Chair
Medicine,Albuquerque,NM TheSchoolfor Sleep Medicine,Inc.,Palo
Germany
David Gozal, MD,Co-Chair Alto,CA
Max Hirshkowitz,PhD, Co-Chair
University of Louisville,Louisville,KY Meir Kryger, MD
BaylorCollege ofMedicine &VAMC,
Carole L.Marcus, MBBCh Universityof Manitoba, Winnipeg,MB
Houston,TX
Children'sHospitalofPhiladelphia, Canada
Philadelphia,PA ThomasPenzel, PhD
Schoolof Clinical Polysomnography,
Timothy 1. Morgenthaler,MD University Hospital, Departmentof
Medford, OR
NicButkov, RPSGT
Mayo Clinic CollegeofMedicine, Medicine,Sleep Laboratory, Marburg,
AASM Manual f or Scoring Sleep, 2007 6
Germany
Mark Pressman, PhD
LankenauandPaoliHospit als,
Wynnewood,PA
Conrad [ber, MD
Hennepin County Medical Centerand
Universityof Minnesot aMedicalSchool,
MN
Consensus Process Contributors
Dig ital
John Harsh, PhD
The University ofSouthern Mississippi,
Hattiesburg,MS
Movements
Carlos H. Schenck, MD
University ofMinnesotaMedicalSchool,
Minneapolis,MN
Mark W. Mahowald, MD
Hennepin CountyMedical Centerand
University ofMinnesotaMedicalSchool,
Minneapolis,MN
Acknowledgements:
Pediatrie
Laurel Wills, MD
MinnesotaRegional Sleep Disorders
Center,Minneapolis,MN
Visual
Donald L. Bliwise, PhD
Emory UniversityMedicalSchool, Atlanta,
GA
Industry Panel
Eric Stubn a
Respironics
George Minasyan
Respironi cs
Marc Paliotta
AstroMed
Liz Kealy
Compumedics
Richard Bogan, MD
SleepMed,Incorporated
Technical Panel
Marietta Bibbs, RPSGT
Sleep Management Cent ersLLC,Cape
Coral,FL
Mark DiPhillipo, RPSGT
Centerfor SleepMedi cine,LafayetteHill,
PA
Angela Giacomini , RPSGT
Stanford UniversityCenter,Stanford, CA
Cameron Harris , RPSGT
MayoClinicColl egeofMedi cine,
Rochester,MN
Terrence Malloy, RPSGT
Atl antaSchoolofSleepMedicine&
Technology,Atlanta,GA
Rawan Nawabit, RPSGT
Case Western Reserve University,
Cleveland, OH
Andrea Patterson , RPSGT
HennepinCountyMedical Center,
Minneapolis,MN
Linda Webster
MedOneMedical
SaltLake City,UT
The Steering Committee gratefully acknowledges the scoring schemat ics provided by Richard B. Berry that provide
illustration of adult visual scoring rules.
The Steering Committee acknowledges AASM Leadership that served over the course of this project and provided
direction and support : Michael Sateia (President 2004-2005; Director 2002-2006), Lawrence Epstein (President
2005-2006; Director 2002-2007) , Michael Silber (President 2006-2007; Director 2003-2008), Alejandro Chediak
(President-elect 2006-2007; Director 2004-2009)
ln addition the Steering Committee acknowledges the following Directors : Barbara Phillips (2001-2004), W. Vaughn
McCa11 (2001-2004), J. Baldwin Smith III (2002-2004) , Donna Arand (2003-2006) , Richard Berry (2005-2008),
David Bruce (2006-2008), Lee Brown (2006-2009), Nancy Collop (2006-2009), Mary Susan Esther (2004-2007),
Clete A. Kushida (Secretary/Treasurer 2006-2009; Director 2005-2009), Stephen Sheldon (Secretary/Treasurer
2003-2006; Director 2000-2006) , John Shepard (2003-2005), Arthur Spielman (2006-2008), and Patrick Strollo, Jr.
(2005-2008).
The Steering Committee would like to acknowledge the administrat ive support of AASM staff : Jennifer Markkanen,
Richard Rosenberg, and Maria DeSena . We particularly wish to acknowledge the support and expertise of Jerome
A. Barrett, who provided continuous supervisory support of staff throughout the project.
AASMManualf or Scoring Sleep, 2007 7
AASMManual for Scoring Sleep, 2007 8
PREFACE
Sleepthat knits uptheravel!'d sleaveofcare,
ThedeathofeachdayS life,sore labours bath,
Balm ofhurt minds, greatnaturessecondcourse,
Chiefnourisherinlife 'sf east.
- Macbeth.ActII, Sc.ii.
ln its simplest and most positive terms, sleep is a desired state of unconsciousness. Each evening we
willingly and most pleasantly surrender ourselves ta a state of disconnection and vulnerability, expecting
ta be safe, restored, and comforted upon awakening many hours later. It is no small wonder that this state
and ifs unique attributes have long provoked fascination. As the inquisitive science of sleep began ta
catalog the unique and varying texture of this state over the past 75 years, standard metrics were needed ta
characterize what could be observed. After many germinal studies and an evolving consensus at the time,
standardized methods for characterizing normal sleep were published in 1968 by Allan Rechtschaffen and
Anthony Kales.
Although the utility and durabilityofthe first manual forcharacterizing normal sleep have served countless
mill ions who have had sleep studies, the advancing science of sleep and the rapidly emerging field of sleep
medicine require a more comprehensive system of standardized metrics that considers events occurring
outside of normal brain activity. Sleep disorders are now recognized as a major public health burden that
must be addressed in any standardized methodology for characterizing the events and nature of sleep.
The explosion of technology and scientltic information has provided many opportunities for evolution in this
process of revising the manner in which we measure and catalog ail the attributes of sleep.
ln 2003, the Board of Directors of the American Academy of Sleep Medicine approved the proposed
development of a new scoring manual. The vision of the development of a new manual was a very considered
process, including a blueprint for future revisions which would address the needs of the ever- changing field
of sleep. This process, which was initiated in 2004 and is described in the ensuing sections of this menuet,
has incorporated both a standardized review of evidence as weil as a standardized method of consensus
in oroer to draft rules, specifications, and terminology that may better reflect the current weight of scieniitic
evidence and expertise in the field of sleep.
Although the development of the scoring manual has been supervised by a steering committee, its
success and execution have hinged on the expertise and dedicated effort of the task force members who
have executedbath the evidence review and consensus processes as weil as the committed and outstanding
staff of the American Academy of Sleep Medicine (AASM) who provided invaluable logistical support.
AASM Scoring Manual Steering Committee :
Conrad Iber, Chair
Sonia Ancoli-Israel, Andrew L.Chesson, Jr, and Stuart F. Quan
AASMManualforScoringSleep,2007 9
AASM Manual for Scoring Sleep, 2007 10
DEVELOPMENTPROCESS
HI5TORICAL BACKGROUND
The science of sleep emerged as a discipline as a result
of the development of tools able to detect and record both
the activity of the brain and the physiologie events that oc-
cur during this unique and sometimes vulnerable state. The
germinal reports of methods that were eventually employed to
characterize electrical activity of sleep include the recording
of brain surface electrical activity in animais in 1875
3
and the
subsequent demonstration of the ability to detect and charac-
terize wakeful activity in humans with external scalp record-
ings in 1929.
4
Detection and recording of electrical activity
of the human heart had been developing at about the same
times with identification of cardiac electrical wavefonns by
Einthoven in 1895
6
occurring at nearly the same time as the
characterization of human brain activity. Although allusions
to abnormal breathing during sleep date to antiquiry? combin-
ing breathing and brain monitoring in physiologie recordings
to identify pathologie conditions during sJeep evolved in the
mid-twentieth century. " Respiratory recordings at this time
identified periodic interruptions in breathing effort that were
both obstructive and non-obstructive." Sleep recordings were
termed polysomnography to recognize the multiple physi-
ologic parameters that were being recorded during sleep. Ad-
ditional parameters were added when limb myoclonus was
described in 1953
10
and identification of its polysomnographic
correlates" were folded into the emerging image of normal
and abnormal physiologie activity during sleep.
In 1937, scalp brain recordings during polysornnography
initially focused on visually identifiable patterns of brain
activity during NREM sleep. " Continuous periods of brain
wavefonn patterns such as alpha and delta activity, as weil as
isolated wavefonns including K complexes, spindles, vertex
waves, and posterior occipital sharp transients were identified
during this period. P-" Rapid eye movements (REM) associ-
ated with respiratory and cardiac effects were identified in
1953 by Aserinsky and Kleitman" and later more formally
incorporated into the stage of REM sleep."
Although there were several early efforts to characterize the
patterns ofsleep,IJ,'4,I S,1 6demonstration ofrather poor reliabil-
ity in scoring these patterns" provided the needed rationale
for a standardized scoring manual. After several exploratory
meetings in the early 1960s and Iively consensus meetings in
April 1967, an enduring standardized scoring manual for nor-
mal sleep was developed and published under the direction
of Allan Rechtschaffen and Anthony Kales.' There have been
several subsequent initiatives to develop rules for scoring
sleep since 1968 including an effort by the Sleep Disorders
Atlas Task Force of the American Sleep Disorder Association
in 1992
19
and preJiminary studies of automatic methods by
the SIESTA group." The recognition of qualitative differenc-
es in sleep in newborns resulted in publi cation of a separate
manual for this age group in 1971.
21
Since the publication of
the scoring manual by Rechtschaffen and Kales 38 years ago,
there has been a rich evolution in our understanding of sleep.
The evolving science of sJeep and the clinical field of sleep
medicine are employing novel metrics to characterize sleep.
Developmental changes are recognized that affect the charac-
terization of sleep throughout the lifespan. The nature and im-
portance of sleep-related phenomena such as arousal, cardiac
dysrhythmias, respiratory patterns, movements, and behaviors
are now areas of both clinical practice and scientific discov-
ery. A more comprehensive scoring manual has been needed
that would incorporate these evolutionary changes as weil as
newer technical methods and capabilities.
5CORING MANUAL DEVELOPMENT
The development ofthis new scoring manu al was designed
to encourage a visible and standardized decision-rnaking pro-
cess that wou Id broadly represent expertise in the field . The
goal was to create a manual that reflected current knowledge
and that would provide more comprehensive standardized
specifications and scoring rules for characterizing natural
sleep as commonly perfonned in polysomnography. Potential
rules that were drafted reflected evidence for reliability and
validity as assessed by content experts performing structured
evidence review or convening for a standardized consensus
when evidence was lacking. Visibility of the process and un-
structured feedback was encouraged by open discussions at
meetings of the Associated Professional Sleep Societies in
2004-2006. Structured feedback on drafted rules was provid-
ed by a panel of sleep technologists and a panel of industry
experts prior to finalization by content experts and approval or
adjudication by a steering committee. The key for the recom-
mendation tenninology and the tenninology that was used for
the decision-rnaking process may be found in Section I, Key.
An outline of the details of the procedural processes in deci-
sion-making may be found in the procedural notes on pages
51-57 (Section IX). For the details of the rationale and bases
of the decisions, the reader is referred to the review papers of
the respective task forces published as an issue of the Journal
ofClinical Sleep Medicine.
The principal participants in the scoring manual develop-
ment process included a) a supervising steering committee of
4 individuals appointed by the AASM Board of Directors, b) 8
task forces leaders with content expertise selected by the steer-
ing committee, c) 8-12 task force members for each task force
who were chosen by consensual agreement of the task force
leaders and steering committee and d) the extremely able ad-
ministrative staff of the AASM. Steering committee members
also attended task force activities as liaisons to help guide the
evidence review and consensus processes. Task forces used
an evidence-based process to do literature searches, grade evi-
dence and create evidence-based tables on their topics, which
summarized the accumulated evidence. Using this material,
they wrote review papers on the topies of their task force as-
signments. The evidence review papers were periodically re-
viewed by the steering committee for format and progress.
AASM Manua/ for Scoring Sleep , 2007 JJ
Review papers were sent for independent outside review, and
the reviewers' cornrnents were addressed. Upon completion,
review papers were approved by the Scoring Manual Steering
Committee and subsequently by the AASM Board of Direc-
tors.
Following construction of the review papers and based on
their literature review, task forces identified a list of poten-
tial specifications and principles for which rules might be ap-
propriate. Task force leaders, in conjunction with the steer-
ing committee, constructed ballots for potential scoring rules,
technical specifications, and reporting parameters. Utilizing
the RAND/VCLA Appropriateness Method" and the evi-
dence gathered in the review paper process, these consider-
ations were subjected to a formai series of ballots to determine
the soundness of principles upon which to develop final rules .
Using the final ballot data , preliminary scoring rules were then
drafted by the steering committee. The task force chairs, and
industry and technical panels reviewed the draft rules to pro-
vide comments regarding feasibility and appropriateness. Fi-
nal modifications were made by the steering committee. The
scoring rules were then reviewed by the AASM Board of Di-
rectors who approved the rules following final modifications
by the steering committee.
The task force meetings commenced in July 2004; the fi-
nal rules, terminology and specifications were drafted in May
2006 and approved by the Board of Directors in December
2006.
Ali scoring manual committee members completed AASM
conftict of interest statements. Steering Committee members
did not have any Level 1 conflicts of interest with any moni-
toring deviee that might be affected by the development of
any recommendation. Potential conflicts of task force mem-
bers were reviewed by the steering committee for decision
regarding inclusion or exclusion of participants in task force
activities. No approved task force members had Level l con-
flicts in the scope of their respective tasks.
TASK FORCES
Six task forces were developed to review evidence for the
scoring manual. The 6 task forces covered each of the major
areas: visual scoring, digital seoring, arousal , movement, re-
spiratory issues, and cardiac issues.
Two additional special population task forces were created
for pediatries and geriatries. In addition to task force liaisons
from each of the other areas, the geriatrie and pediatrie task
forces each included 5 sleep medicine specialists with exper-
tise in the age range under consideration.
Each of the 6 topical task forces was made up of at least 5
experts in the specifie content area of sleep medicine, along
with an advisor who represented expertise in evidence review,
and liaisons from the pediatrie and aging task forces and the
steering committee, for a total of 8-13 task force members.
Task forces spent 8-20 hours in either phone or face-to-face
conferences over the 18 months of evidence review and con-
sensus activity.
As described above, each task force was charged with the
AASM Manualfor Scoring Sleep, 2007
task of identifying papers relevant to their topics, reviewing
the papers and extracting evidence information, writing a re-
view paper and, in conjunction with the steering committee,
developing a RAND ballot and voting on it.
As evidence papers were identified within the topical task
forces, those portions of the review process that were relevant
to either pediatrie or geriatrie populations were assigned to
the appropriate liaison member for consideration and modi-
fication . RAND ballots that were constructed by the topical
task forces were reviewed by the Pediatrie and Geriatrie Task
Forces and items were identified for modification and ballot-
ing to develop separate age-appropriate scoring rules,
Within pediatries, separate scoring rules were developed in
areas of visual scoring, respiratory events, and cardiac events.
These differences are outlined within their respective sections
of the scoring manual.
Within geriatries, the only rule that needed to be voted
upon by the Geriatrie Task Force was the question ofwhether
amplitude criteria for SWS should be different in oider adults
than in younger adults The result of the final vote was the
same in both the Geriatrie Task Force and the Visual Task
Force, and therefore no adjudication was needed.
EVIDENCE REVIEW
Task forces were charged with developing review papers
that addressed evidence supporting reliability and validity of
technical specifications and the related components of scor-
ing in each of 6 content areas: visual, digital , arousaI, respira-
tory, cardiac, and movements. The specifie details of each task
force evidence review and search focus can be found in the
methods section of the individual review papers.
In ail evidence review papers, a computer-based PubMed
literature search was performed for ail human studies, in Eng-
lish, published between 1968 and September 2004 , using key
words identified by the task forces . For the assignments, the
respective task forces selected between 91 and 372 articles as
appropriate for formal evidence review. Evidence was then
extracted by task force members under the direction of a task
force liaison with previous experience in evidence grading.
The criteria for evidence levels generally folJowed Sack-
ett," although in sorne instances appropriate modifications
were made to complement the nature of the content area. ln
the case of digital signal analysis, where sampling methods
were critical to evidence review, comparison of identical ep-
ochs or events was mandated, and a minimum sample size
was required for each level of evidence.
CONSENSUS
When there was insufficient Level 1 or Level 2 evidence
for clear evidence-based rule development, terminology or
specifications, a consensus process based on considerations in
the appropriate review paper was ernployed. This consensus
process followed the standardized RANDIUCLA Appropri-
ateness Method. " RAND ballots were constructed to formalJy
/2
assess consensus opinion regarding terminology, technical
specifications, and the components of scoring rules. The bal-
lots were developed by the task forces and submitted to the
steering committee for approval. In compliance with RAND
methods, 9 to Il participants cornpleted each series of ballots.
Task force members and liaisons participated in balloting. If
less than 9 voting members were available, additional experts
were selected by the steering committee to assist with the bal-
loting process.
In order to encourage single recommendations, consensus
ballots were constructed when possible to address mutually
exclusive options. In order to encourage a progressive deci-
sion-making process, participants were directed, when felt
appropriate by the steering committee, to achieve agreement
on the validity, reliability and final preference for any of the
optional choices.
At least 2 rounds of consensus were convened for each task
force : round 1 was completed individually without discus-
sion by task force members, whereas round 2 was completed
following a face-to-face or conference cali discussion of the
RAND items and the results of the first vote. In 2 task forces,
selected items from round 1 were approved by the task force
because of agreement during round 1 voting.
For balloting, items were rated on a 9-point scale for ap-
propriateness and a 4- letter rank for specifying a judgment re-
garding whether the decision was being made on evidence vs.
opinion. The "classic" definition of agreement was assessed
using definitions from the RAND manual :
Agreement for or against: No more than 2 panelists rate
the indication outside the 3-point region (1-3; 4-6; 7-9)
containing the median.
Disagreement: At least 3 panelists rate the indication in
the 1-3 region, and at least 3 panelists rate it in the 7-9
region.
Indeterminate: Criteria are not met for agreement or dis-
agreement.
In order to ensure that consensus rested as much as possible
within the content expertise of the task force, an additional
round with discussion was employed for initially indetermi-
nate decisions within a series of mutually exclusive options.
In instances when there was indeterminate agreement from
the RAND process after the series of ballots and there was
insufficient evidence for recommendation from the task force
among 2 options used in practice, the steering committee ad-
judicated a recommended and an alternative acceptable ruIe or
specification. Any items that did not achieve consensus during
round 3 or additional rounds were adjudicated by the steering
committee. Only 9 items required adjudication by the steering
committee.
Following the decisions regarding standardized rules by the
task forces, the geriatrie and pediatrie task forces reviewed
results of balloting to determine what items required modi-
fication or revision for age and pediatrie considerations. A
separate evidence review was then conducted and a single
round of RAND balloting was completed with interaction to
conclude the pediatrie and age modifications for items with
limited evidence.
INDUSTRY AND TECHNICAL REVIEW
Technical and industry panels were constituted for the pur-
pose of obtaining structured input on preliminary rules drafted
after evidence review and consensus. These panels were asked
to evaluate the appropriateness of proposed rules and to com-
ment on any perceived impediments to implementation. Tech-
nical panels met by conference cali to allow interaction prior
to drafting their input. The structured input from the industry
and technical panels then were provided to task force leaders
who developed a rationale for either modifying the rule(s) or
for retaining the original language. The structured input from
panels and responses from task force leaders were used by the
steering committee in crafting the final rules and in the final
adjudication when there were substantial differences.
Industry input was also solicited during a face-to-face
meeting with task force chairs, members of the steering com-
mittee, and AASM staff on July 16, 2004 . Representatives
from several software and hardware companies involved in
polysomnography data acquisition or scoring were invited to
discuss and provide materials regarding potential reporting
parameters, the current state of digital acquisition of poly-
somnographic data, and automated scoring. Information ex-
changed at this meeting was used to focus the assignments of
the scoring manual task forces .
SLIMMARY AND FUTURE EDITIONS
The reader will find that this edition of the "AASM Manual
for the Scoring of Sleep and Associated Events" has a com-
prehensive scope which incorporates events, technical speci-
fications, pediatrie scoring, as well as modified staging ter-
minology and rules. Arousals, movements, respiratory events,
and cardiac events are now folded into the standardized scor-
ing system using both new and existing evidence as weIl as
consensus. The design of decision-making encouraged both
the retention of existing valid and reliable methods when ap-
propriate and the development of new terminology, specifica-
tions, and rules when supported. The rules and specifications
in the visual scoring of sleep retain much of the framework of
Rechtschaffen and Kales, based on the accumulated validity
and reliability of this scoring system, with some new defini-
tions and rule modifications as weil as with new rules for pe-
diatric visual scoring. A visible format is provided for iden-
tifying evidence and/or consensus-driven recommendations
as weIl as optional specifications or rules for scoring. While
rules and definitions are the product of evidence review and
consensus, explanatory notes have been added following each
rule to provide additional clarifications that were not derived
from consensus. Readers are referred to the review papers for
more detailed analysis of the rationale underpinning the rec-
ommendations in the manual.
The expanded choice of analytical tools used in this edition
reflects the evidence review and consensus processes. The use
of digital interfaces has required extensive specifications that
were not necessary in the previous standardized scoring man-
ual. The scope and methods characterizing respiratory events
AASMManual for Scoring Sleep, 2007 13
has been extended from earlier practices to address new evi-
dence. Basedoncurr ent evidence andconsensus,certainareas
of active invest igation have not been util ized for digit al rules
in this edition. Quantitative electr oencephalography, cyclic
altemating pattern, and methods characterizing autonomie
events have notbeen incorporatedalthoughaproc essforrevi-
sionhas been created to incorporate techn iques ifaccumulat-
ing evidencesupports their utili ty.
Though schematics are used to assi st in demonstrating vi-
suaI and respirat ory rules,readerswillnot etharreproduct ions
of sleep recordings do not accompany the rules . Thi s scor-
ingmanualdoesnot incorporatean at lasof visuallypresented
examples and emphasizes instead an articulationofrules and
specifications based on a standardized decisi on-making pro-
cess and desi gned toencourage theobj ective basi s for imple-
mentat ion ofstaging and event rul es, The rules are craft ed as
a platform tosupport theevoluti on ofboth non-vi sual and v-
suaImethods for the future.
The science ofsleep and the speci alty ofsleep med icine
have evolved rapidl y since the initial attempts in the 1930s
to develop a consistent frame work to describe the complex-
ity ofsleep. Although the first generall y accepted scoring
manual byRecht schaffenand Kales hasserved thefield weil ,
the need for modifi cati on and additions has been apparent
to sleep scientists and clinicians for a number of years. This
new scoringmanualrepresents anattempttocombine thebest
available evidence with the opinion ofexperts in sleep sci-
ence and medicine. However, ju st as the field of sleep is not
a static doctrine, this manual is not intended to remain im-
mutable. It is the intenti on of the stee ring committee that thi s
scoring manual should be reviewed on a periodic basis with
additions, modifi cations, and deletions made based on new
scientificdata accumulated over interim periods. In thisman-
ner,the scoringmanual will become a"living" documentthat
incorporatesnew information as itbecomesavailable.
REFERENCES:
1. Rechtschaffen A, Kales A. A Manual of Standardized Terminol-
ogy,TechniquesandScoringSystemforSleepStagesofHuman
Subjects. US Department of Health, Education, and Welfare
PublicHealthService- NIH/NIND; 1968.
2. lberC. Development ofanew manual forcharacterizingsleep.
Sleep2004;27: 190-2.
3. Caton R. The electric currents of the brain. Br Med J
1875;2:278.
4. Berger H. Uber das Elektroenkelphalogramm des Menshcen.
ArchPyschiatrNervenkr 1929;87:527-70.
5. WallerA.Ademonstrationonmanofelectromotivechangesac-
companying theheart'sbeat.JPhysiol 1887;8:229-34.
6. Einthoven W. Uber die form des menschlichen electrocardio-
gramms.ArchGesamtePhysiol 1895;60:101-23.
7. Ancoli-Israel S. "Sleep is not tangible" or what the Hebrew
tradition has to say about sleep. Psychosomatic Medicine
2001;63:778-87.
8. GastautH,TassinariCA,DuronB.Polygraphicstudyofdiurnal
and nocturnal (hypnic and respiratory)episodalmanifestations
14 AASM Manua/ fo r Scoring Sleep, 2007
ofPickwicksyndrome.RevueNeurologique 1965;112:568-79.
9. Bulow K. Respiration and wakefulness in man. Acta Physiol
Scand 1963;59:1-110.
10. SymondsCP.Nocturnalmyoc1onus.JNeurNeurosurgPsychia-
try 1953;16(3):166-71.
Il. ColemanRM,PollakCP, WeitzmanED.Periodic movements in
sleep(nocturnalmyoclonus):relationtosleepdisorders.AnnNeu-
roI1980;8:416-21.
12. Loomis AL, Harvey EN, Hobart GA. Cerebral states during
sleep, as studied by human brain potentials. J Exper Psychol
1937;21:127--44.
13. BlakeH,GerardR,KleitmanN.Factorsincludingbrainpoten-
tial sduringslee p.JNeurophysiol 1939;2:48-60.
14. GibbsE,LorirnerF,GibbsF. AtlasofElectroencephalography.
In: Volume 1, Methodology and Controis. 2nd ed. Reading,
MA:Addison-WesleyPublishingCompany; 1950:90-6.
15. Aserinsky E, Kleitman N. Regularly occurring periods of eye
motility and concomitant phenomena during s1eep. Science
1953; 118:273-4.
16. Dement WC, Klei tman N. Cyclic variations in EEG during
sleep and their relation to eye movements, body motility and
dreaming. Electroencephalogr Clin Neurophysiol 1957;9:673-
90.
17. Williams RL, Karacan 1, Hursch C. Electroencephalography of
Human Sleep: ClinicalApplications. New York: John Wiley&
Sons; 1974.
18. Monroe LJ. Inter-rater reliabilityand the role ofexperience in
scoringEEGsleep.Psychophysiol 1967;5:376-84.
19. EEGarousals:scoringrulesandexamples:apreliminaryreport
from the Sleep Disorders Atlas Task Force ofthe Arnerican
SleepDisordersAssociation.Sleep 1992;15:173-84.
20. GrubeG,FlexerA,DorffnerG.Unsupervisedcontinuoussleep
analysis. Methods Find Exp Clin Pharmacol 2002;24 Suppl
D:51-6.
21. Anders T, Emde R, ParmeleeA(eds).AManual OfStandard-
ized Terminology,Techniques and Criteria For Scoring States
OfSleepandWakefulnesslnNewbornInfants.UCLABrainIn-
formationService.NINDSNeurological InformationNerwork;
/971.
22. Sackett DL. Rules of evidence and clinical recommendati ons
forthemanagementofpatients.CanJCardiol 1993;9:487-9.
23. Fitch F, Bernstein SJ, Aguilar MS, et al. The RANDIUCLA
Appropriateness Method User' s Manual. Santa Monica, CA:
RANDCorporation;2001.
1. RULES
[RECOMMENDED]
[ALTERNATIVE]
[OPTIONAL]
2. PROCEDURAL NOTES
[STANDARD]
[GUIDELINE]
[CONSENSUS]
[ADJUDICATION]
1. KEY
These rules are recommended for the routine scoring of polysomnography.
These are rules that may be used as alternatives to the recommended rules at the di scretion of the
clinician or investigator.
These are suggested rules for uncommonly encountered events, events not known to have physi-
ologie significance or events for which there was no consensus deci sion . Scoring may be performed
at the discretion of the clinician or investigator.
Recommendation based on level 1 evidence or overwhelming level 2 evidence.
Recommendation based on level 2 evidence or a consensus of level 3 evidence.
Recommendation with less evidence than guideline for which agreement was reached in a standard-
ized consensus process based on available information.
Recommendation from the steering committee based on ail available information. Adjudication was
only performed a) when there was insufficient evidence and no consensus agreement or b) in con-
junction with task force leaders on issues regarding minor clarifications and add itions to rules.
AASM Manualfor Scoring Sleep, 2007 15
AASM Manual f or Scoring Sleep, 2007 16
Il. PARAMETERS TO BE REPORTED FOR POLYSOMNOGRAPHY
1. POLYSOMNOGRAPHY
A. Parameters
1) EEG derivations
2) EOG derivations
3) Chin EMG
4) Leg EMG deri vations
5) Airftow parameters
6) Effort parameters
7) Oxygen satur ation
8) Body posi tion
B. Sleep Scoring Data
1) Light s out dock time (hr: min)
2) Lights on dock time (hr:min)
3) Total sleep time (TST; in min)
4) Total recording time (" Iights out " to " lights on" in min)
5) Sleep latency (SL; lights out to first epoch of any sleep in min)
6) Stage R latency (slee p onset to first epoc h of Stage R in min)
7) Wake after sleep onset (WASO; Stage W during B4, minus B5, in mi n).
8) Percent sleep efficiency (B31B4)x 100
9) Time in each stage (min)
10) Percent ofTST in each stage (B9 values/ 83)x 100
Nole: Wake afier sleep onset includes ail wake activity, including wake OUi ofbed.
C. Arousal Events
1) The number of arou sals
2) The arousal index (Ar! ; C Ix60/B3)
D. Respiratory Events
1) Number of obstructive apneas
2) Number of mi xed apn eas
3) Number of cen tral apneas
4) Number ofhypopneas
5) Number of apneas + hypopneas
6) Apnea ind ex (AI; (D I+ D2+D3)x60/83)
7) Hypopnea index (HI; D4x601B3)
8) Apnea + Hypopnea index (AHI; D5x60/B3)
9) Resp iratory effort related arousals, total number
10) Respi ratory effort related arousal index (D9x60/B3 )
II ) Oxygen des aturat ions 2'.3% or 2'.4%, total number
12) Oxygen desaturation index 2'.3% or 2'.4% (DI; D11x60/83)
13) Continuousoxygen saturation, mean value
14) Mi nimum oxygen saturation dur ing sleep
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMEND ED]
[RECOMM END ED]
[RE COMMENDED]
[RECOMMENDED]
[RE COMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMME NDED]
[RECOMME ND ED]
[RE COMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMEN DED]
[OPTIONAL]
[OPTIONAL]
[OPTIONAL]
[OPTIONAL]
[RECOMMENDE D]
[RECOMMEND ED]
AASM Manual fo r Scoring Sleep, 2007 17
15) Occurrence of hypoventilat ion (yes1no)
[OPTIONAL]
16) Occurrenceof Cheyne Stokes breathing(yes1no)
[RECOMMENDED]
No/es:
1. For oxygen desaturation, percent time spent below a given threshold may he reported al /he discretion of /he investigat or.
2. ln adults, the choice ofhypopnea defini /ion (recommended, Vll.4A or al/erna/ive, Vll. 4B) should he specified in D4, D5, D7, DB.
E. Cardiac Events
1) Average heart rateduringsleep
[RECOMMENDED]
2) Highestheart rateduring sleep
[RECOMMENDED]
3) Hi ghest heart rate duringrecording
[RECOMMENDED]
Occurrenceof the fo/lowingarrhythmias(yes/no). Ifpresent, listarrhythmiaandheartrate or duration of pause.
4) Bradycardia;report lowest heart rate observed
5) Asyst ole;report longest pause observed
6) Sinus tachycardi aduring sleep; repor thighest heart rate observed
7) Narro wcomplex tachycardia ;reporthighest heart rate observed
8) Widecomplex tachycardi a;report highesrheart rat eobserved
9) At rial fibrill ation
Occurrenceof theotherarrhythmias (yes/no).
10) Ifpresent ,list arrhythmia
F. Movement Events
1) Number ofperi odi climb movementsofsleep(PLMS)
2) Number of periodi c limb movements ofsleep(PLMS) with arous als
3) PLMS index (PLMSI;FIx60/B3)
4) PLMSarousal index(PLMSArl ;F2x60/B3)
G. Summary Statements
1. Findings relatedto sleepdiagnoses
2. EEO abnorrnalities
3. ECO abnormalities
4. Behavioralobservations
5. Sleep hypnogram
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[OPTlONAL]
AASM Manual for Scoring Sleep, 2007 18
III. TECHNICAL AND DIGITAL SPECIFICATIONS
1. SPECIFICATIONS
A. Digital Specificationsfor Routine PSG Recordings(Notes) [RECOMMENDED]
Maximum Electrode Impedances 5K
MinimumDigital Resolution 12bits per sample
SamplingRates Desirable Minimal
EEG 500 Hz2 200 Hz1
EOG 500 Hz
4
200 Hz
EMG 500 Hz5 200 Hz
ECG 500 Hz6 200Hz
Airflow 100Hz 25 Hz
Oximetry 25 Hz? 10Hz
Nasal Pres sur e 100Hz8 25 Hz
Esophageal Pressure 100Hz 25 Hz
Body Position 1 Hz 1 Hz
Snoring Sounds 500 Hz
9
200 Hz
Rib Cage and Abdominal Movement s 100Hz
'o 25 Hz
Routinely Recorded FilterSettings Low FrequencyFilter High FrequencyFilter
lI
EEG 0.3Hz 35 Hz
J
EOG 0.3Hz 35 Hz
EMG ID Hz
5
100Hz5
ECG 0.3Hz" 70Hz
Respiration 0.1 Hz 15Hz
Snori ng 10Hz 100Hz
Notes:
l . This applies to measured EEG and EDG electrode Impedan ce. El ectrode Impedances should be rechecked during a recording when any
p att ern that mightbe art ifactualappears .
2, For EEG, 500 Hz could improve resolution ofspikes in theEEG and beuer maintain details ofthe waveform.
3. For more detailed EEGanalys is, sampling rate and highfrequency filter settings may be increased. ln these circums tances, thesampling
rateshould beat least 3times the highfrequencyfilter settings .
4, For EDG, using the 500 HzdesirableEEG sampling rat ealsoall ows the reflection oftheEEGinthis leadas an EEG backupandmay
bellerdefinesome artifacts in theseleads.
5, This applies to submental and leg EMG. Higher sampling rates bett er defin e waveforms; white the waveform itselfis not an issue, a
better-defined waveform can help avoid amplitude attenuation as the envelope ofthe rapidly osc illating signal isread and interpreted.
6, For ECG, 500Hz can bellerdefin epacemaker spikes andECGwaveforms,howeverpacemakersp ikes can besee n al 200 Hz and the
evaluationofcardiac ischemi a by ECG waveform is nol a usual PSG issue. Higher fre quencies may be required f or complex waveform
analysisand research applications,
7. Foroximetry, 25Hz is desirable 10 assist with artifact rej eciion.
8. For nasalpressure transduc er technology (especially with settings which identify snoring occurring on top of the airflow 11'aveform),
this higherfrequency may beofbenefit for better definition of'flauening, plateauing,and/or fiuuering in the wave airflow form.
9. For snori ng sound, 500 Hz can beuerdefineamplitude variat ion by clearer waveforms with more accurateamplitudedet erminationas
the enve lopeof the rapidly osc illating signal is interpreted, (asfor EMG), Ifa preprocessingofsnoring results in a continuous sound
loudness level orinaso und intensi ty level, then a much lowersampling rat e is acceptable, That sampling rate isnot specifiedbecause
it depends on the preprocess ing ofthe so und in order to produ ce loudness.
10. For rib cage and abdominal mo vements using indu ctance plethysmography, cardioge nic oscillations can be better seen and may result
in beuer artifactassessment.
11. To accommodateol derequipment. fi ltersettings intherange of 30-35 Hz may beusedtocomply withthe aboverecommendations of 35
Hz, This applies most specifically in the context of EEG and EDG high fi lter settings.
12, For ECG, 1011' frequency settings and wide bandwidth minimizes distortion in a 12 lead ECG; however in PSG recording fo r s ingle-
channel modified lead Il usedfor identifying bas ic heart l'ales and dysrhythmias, it may not be as necessa ry.Advanced cardiac assess-
ment maybe more optimal using an LFF of 0.3 Hzforslo wer partsof the cardiac cycle . The channel is susceptible ta artifa cts at thi s
setting due tapatient movement,perspiration. muscle acti vity and electrode displacemenl with more sweat artifact, whic h isa cammon
problem inthelabo rat ory. It is less likely aproblem usingstandardECG leads with goodcontactandstabilityofapplication than using
EEGleadsforcardiac monitoring.
General not e:inthe absence ofc1earpreferences, there isconsensus10 usesimilarseuings amongleadstosimplifytechnicalimpl ementation.
AASMManual f orScoring Sleep, 2007 19
B. Digital PSG Recording Features
Digital systems must include the following features:
1) A toggle switch permitting visual (on-screen) standard negative 50 IlV DC
calibration signal for a1l channels to demonstrate polarity, amplitude and time
constantsettingsfor eachrecorded parameter
2) Aseparate50/60 Hz filter control for each channel
3) The capabilityofselectingsamplingrates foreach channel
4) Amethodofmeasuringactualindividualelectrodeimpedanceagainstareference
(the lattermay be the sum ofail otherapplied electrodes)
5) The capabilityofretainingand viewing the data inthe exactmannerinwhich it
was recorded bythe attendingtechnologist(i.e.,retain and displayailderivation
changes,sensitivityadjustments, filter settings, temporal resolution)
6) The capabilityofretainingand viewingthe data inthe exactmanneritappeared
when it was scored by the scoring technologist (i .e., retain and display ail
derivationchanges,sensitivityadjustments, filter settings, temporal resolution)
7) A filter design for data collection which functionally simulates or replicates
conventional(analog-style) frequency responsecurves ratherthan removingail
activityand harmonieswithin the specitied bandwidth
Digital systems should include the following features:
8) An electrodeselectorprocess with the flexibility for choosingand/orchanging
electrode input signal derivations without relying on a common reference
electrode
C. Rules for PSG Display and Display Manipulation
Systems must include the following PSG features:
l) Resolution ofa digital screen and videocard must be at least 1600 x 1200 for
display and scoringofraw PSG data
2) Histogram with stage, respiratory events, leg movement events, O
2
saturation,
and arousals, with cursor positioning on histogram and ability to jump to the
page
3) Abilitytoview ascreenonatime scalerangingfrom the entirenight towindows
as small as 5seconds
4) Recordedvideo data mustbesynchronizedwith PSG data and have an accuracy
ofat least one video frameper second
Systems should include the following PSG features:
5) Page automaticturningand automaticscrolling
6) Channeloffcontrol key or toggle
7) Channel invertcontrol key or toggle
8) Changeorderofchannel by clickand drag
9) Displaysetupprofiles(includingcol ors) whichmay beactivatedat any time
10) FastFourierTransformationorspectralanalysisonspecifiableinterval(omitting
segmentsmarkedas data artifact)
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[OPT/ONAL]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[RECOMMENDED]
[OPTIONAL]
[OPT/ONAL]
[OPTIONAL]
[OPTIONAL]
[OPTIONAL]
[OPTIONAL]
AASM Manual for Scoring Sleep, 2007 20
D. Digital Analysis of PSG
Digital sleep systems must include the abilityta:
1) Identi fy whether sleep stage scoring was performed visually or computed by
thesystem
Digital sleep systems shauld include the capabilitytaturn offand on, as demanded, highlighting for:
2) Patternsidentifying sleep stage decisions (for cxample sleep spindle, K complex,
alpha,delta)
3) Patterns identifying the respir atory anal ysis (for example apneas, hypopneas,
desaturations)
4) Patterns identifying the movement analysis (forexamplePLMs)
[RECOMMENDATION]
[OPTIONAL]
[OPTIONAL]
[OPTIONAL]
AASMMant/al fo r Scoring Sleep. 2007 21
AASM Manua/for Scoring S/eep, 2007 22
IV. VISUAL RULES
VlsUAL RU LES FOR ADULTs
1. TECHNICAL SPECIFICATIONS
A. Electroencephalogram (EEG)
1) The recommended derivations are: [RECOMMENDED]
a. F
4-M 1
b. C -M
4 J
c. 0 2-M)
Backup electrodes should be placed at F
3
, C ' O[ and M
2
ta allowdisplay ofF 2, C -M
2
and 0 [-M
2
ifelectrodes malfunc-
3 3-M 3
tian during the study.
2) Alternative acceptable derivations are: [ALTERNATIVE]
a. F -C
z z
b. C-O
z z
c. C
4-M[
Backup electrodes should be placed at F , C ' 0[, and M
2
ta allow substitution of F for F C for C or C for and
pz 3 pz z' 3 z 4' J z
M
2
for M[ if electrodes malfunction during the study.
AASMManual fo r Scoring Sleep, 2007 23

3) EEG electrode position is detennined by International 10-20 System [RECOMMENDED]
Note:
1. A minimum of 3 EEG derivati ons are required in order to sample activity f rom the frontal, central, and occipital regions.
2. M, and Ml refe r to the left and right mastoidprocesses.
B. Electrooculogram (EOG)
1) The recommended EOG derivations are :
[RECOMMENDED]
a. (El is placed 1 cm below the left outer canthus) E
l-M2
b. E
2
-M
2
(E
2
is placed 1 cm above the right out er canthus)

o o
Right Left

2) Alternati ve acceptable derivations are: [ALTERNATI VE]
a. E,-F (El is placed 1 cm below and 1 cm lateral to the oute r canthus of the left eye)
pz
b. E F (E is placed 1 cm below and 1 cm lateral to the out er canthus of the right eye)
2- pz 2
C) C)
Right Left
Note: The alternati ve derivati ons record the direction ofeye movements, i.e. vertical movements will show in-phase deflections and horizontal
eye movements out-of- phase defiections.
C. Electromyogram (EMG) [RECOMMENDED]
1) Three electrodes should be placed to record chin EMG:
a. One in the midline 1 cm above the inferior edge of the mandibl e
b. One 2 cm below the inferior edge of the mandible and 2 cm to the right of the midline
c. One 2 cm below the inferior edge of the mandible and 2 cm to the left of the midlin e
2) The standard chin EMG derivation consists of either of the electrodes below the mandible referred to the electrode above
the mandible. The other inferior electrode is a backup electrode to allow for continued display of EMG activity if 1 of the pri-
mary elect rodes malfunctions.
2. SCORING OF SLEEP STAGES [RECOMMENDED]
A. Stages of Sleep
1) The following tenninology is recommended for the stages of sleep:
a. Stage W (Wakefulness)
b. Stage NI (NREM 1)
c. Stage N2 (NREM 2)
d. Stage N3 (NREM 3)
e. Stage R (REM)
Note: Stage N3 represents slow wave sleep and replaces the R &K nomencl ature ofstage 3 and stage 4 sleep.
B. Scoring by Epochs [RECOMMENDED]
1) Score sleep stages in 30 second sequential epochs commencing at the start of the study.
2) Assign a stage to each epoch.
3) If 2 or more stages coexist during a single epoch , assign the stage compri sing the greatest portion of the epoch.
AASM Manual fo r Scoring Sleep, 2007 24
3. STAGEW [RECOMMENDED]
Definitions
Alpha rhythm: Trains of sinusoidal 8- 13 Hz acti vity recorded over the occi pital region with eye clos ure, attenuat ing wi th eye opening.
Eye blinks: Conj ugate vertica l eye movements at a frequencyof 0.5-2 Hz prese nt in wakefulness with the eyes open or closed.
Reading eye movements: Trainsof conjugate eye move ments consistingof a slow phase followed by a rapid phase in the opposite direc-
tion as thesubjcctreads.
Rapid eye movements (REM): Conj ugate, irregul ar, sharply peaked eye movements with an initial deflection usually lasting <500 rnsec.
While rapideye movcmcntsarecharac teristicof stageRsleep,theymayalsobesceninwakefulnesswitheyes openwhensubjcctsscan
theenvironmenl.
Rules
A. Score epochs asstage Wwhen more than50% of theepoch hasalpha rhythm over theoccipital region.
B.Score epochs without visuallydiscernable alpha rhythm asstage Wif anyof thefollowingare present:
1) Eye blinksata frequency of 0.5-2Hz
2) Reading eye movements
3) Irregul arconjugaterapi deye movement sassociated withnor malor high chin muscletone
Notes:
1. Stage Wrepresentsthewaking state,rangingfromfullalertness throughearlystagesofdrowsiness.Electrophysiologicaland
psychophysiological markersof drowsinessmay bepresentduringstage Wand maypersist intostageNI.
2. ln stage rv, the maj orityof individuals with eyes closed will demonstrate alpha rhythm. The EEG pattern with eyes open consistsoflow
amplitude activity (chiefly betaand alphafrequencies) without the rhyt hmicityofalpha rhythm. About 10% ofsubjects do not generate
alpha rhythm on eye closure,and afu rther 10% may generate limited alpha rhythm. In these subjects, the occipital EEG activity is
similarduring eye openingandeye closure.
3. The EGG during wakefulness may demons trate rapid eye blinks at afrequency ofabout 0.5-2 Hz. As drowsiness develops, the
frequency ofblinking slows,and eye blinks may be replaced by slow eye movements, even in the presence of continued alpha rhythm. If
the eyes are open. voluntary rapid eye movements or reading eye movements may be seen.
4. The chin EMG during stage W isof variable amplitude, but is usually higher than during sleep stages.
4.STAGE N1 [RECOMMENDED]
Definitions
Slow eye movements (SEM) : Conj ugate, reasonabl y regul ar, sinusoidal eye movement s with an initial deflection usually lasting >500
msec.
Lowamplitude, mi xed frequenc yactivity: Lowamplitude,predominantl y4-7Hzactivity.
Vertexsharpwaves (V waves): Sharplycontoured waves withduration<0.5seconds maximalover thecentralregion anddistingui sh-
able from thebackgroundactivity.
Sleep onset: The startofthe firstepochscored as any stage othcr than stageW.(In mostsubjccts this willusuall y be the first epochof
stageNI.)
Rules
A.Insubjectswhogenerate alpha rhythm, scorestage N1 ifalpha rhythm isattenuated andreplaced bylowamplitude, mixed
frequency activityformorethan50% oftheepoch.
B. In subjectswho do notgenerate alpha rhythm, scorestage N1 commencing with the earliest of any of the followingphenom-
ena:
1) Activity in range of 4-7 Hz with slowingof background frequencies by2:1 Hz from those of stageW.
2) Vertexsharp waves .
3) Slow eye movement s.
Notes:
1. Vertex sharp waves may be present but are not requiredfor scoring stage NI.
2. The EGG will ojien sho wslow eye movement in stage NI, but these are not required f or scoring.
3. DuringstageNI,thechinEMG amplitude isvariable,butoflen lowerthan instage W
4. Assloweye movements ofl encommencebeforeattenuationofalpha rhythm,sleep latency may beslightlyshorterforsomeindividuals
whodo notgeneratealpha rhythm comparedtothosewhodo.
AASMManual forScoring Sleep,2007 25
5. STAGE N2
[RECOMMENDED]
Definitions
K complex: A well-delineated negative sharp wave immediatcl y followed by a positivecomponent standingout l'rom the background
EEG,with totalduration ~ O 5 seconds, usually maximal in amplitude whenrecorded usi ng fron tal de rivations. Foran amusai to be as-
sociatedwitha Kcomplex, itmustcommenceno more than 1second after termination ofthe Kcomplcx.
Sleep spindle: A train ofdistinct waves with frequency 11-16Hz(most cornmonly 12-14Hz)with a duration ~ O 5 seconds, usually
maximal in amplitudeusingcentralderivations.
Rules
A.The following ruledefinesthestart of aperiod of stageN2 sleep:
1) Begin scoring stage N2 (in absenceof criteria for N3) if 1or bothof the following occur during the first half of that epoch
orthe last halfofthe previousepoch:
a. One or more Kcomplexesunassociatedwith arousals
b. One or more trains ofsleep spindles
NOie:
1. Continue10 scorestageNI forepochs witharousal-associatedKcomplexesbutnospontaneous Kcomplexesorsleep spindles.
2. Forthe purpos esofscoringN2sleep,arousalsaredefinedaccording10 arousalmie V. I.
B.The following rule definescontinuationofaperiodofstage N2 sleep:
1) Continue to score epochswith low amp litude, mixed frequency EEG activity witho utK complexesor sleepspindlesas
stageN2 iftheyare preceded bya) Kcomplexes unassociatedwith arousalsor b)sleepspindles.
C. Thefollowing ruledefinestheend of aperiodof stageN2 sleep.
1) End stageN2 sleepwhen 1ofthe followingeventsoccurs:
a. Transition tostageW
b. An arousal (changetostageNI until aK complexunassociated with an arousal orasleepspindleoccurs)(See
Figure 1)
c. Amajorbody movementfollowed byslow eye movements and lowamplitudemixed frequency EEG withoutnon-
arousal associatedKcomplexesor sleepspindles(scorethe epoch following the majorbody movement asstage
NI;score the epochas stage N2 ifthere are no sloweye movements;theepochcontainingthe body movement is
scored using criteria inSection8)(See Figure2)
d. Transition tostageN3
e. Transitiontostage R
Epoch Epoch
50
51
52 53 50
51
52 53
1 1 1 1 1 .
1 KWlth
Kcomplex 1 1 ~ complex 1
1 arousal
~ ~ :
1 1 1 1
1 1 : 1
1
1
1
1
1
1
11 il R .. I
...1I I I
1

EMG,-EMG
z
f."',.....
*
1 1
1 1
StageN2 StageN2 StageN1 StageN2 StageN2 StageN2 StageN1 StageN2
Figure 1
AASMManualforScori ng Sleep.2007 26
Epoch Epoch
50 51 52 53 50 51 52 53
1 1 1 Body 1 Body 1
1 rnovernnt
Il
1 rnovernent
:Kcomplex :
Il 1 1 1
1 1
C4-M1 : ~ : 1 ~ I
1 1
-------'--,--'. 1
I ~ ~ 1 1
J 1
o-M alpha1 1
2 1
~ :
1 1
1 1
1 1
~ - - - ; - - - 1
1 1
: fi :
~ r
1 1
EMG,-EMG
2
1 1
1 1
1 1
1 1
StageN2 StageN2 StageN2 StageN2 StageN2 StageN1 StageN1 StageN2
Figure2
Notes:
1. The EOG usually shows no eye movement activity during stage N2 sleep. but slow eye movements may persist in some subjects.
2. ln stage N2. the chin EMG is ofvariable amplitude. bill is usually lower than in stage W. and may be as low as in slage R sleep.
6.STAGE N3 [RECOMMENDED]
Definition
Slow wa ve activity: Waves of frequency 0.5 Hz-2 Hzand peak-t o-peak amp litude >75J.IV,measured overthe frontalregions.
Rule
A. Score stage N3 when 20% or more of an epoch consists of slowwave activity, irrespective of age.
Noies:
1. Sleep spindies may persist in stage N3 sleep.
2. Eye movements are nol typically seen during stage N3 sleep.
3. ln stage N3. the chin EMG isof variable amplitude. often lower than in stage N2 sleep and sometimes as low as in stage R sleep.
7. STAGE R [RECOMMENDED]
Definitions
Rapid eye mo vements (REM): Conjugate, irregular, sha rply peaked eye movements with an initial deflection usuall y lasting <500
msec.
Low chin EMG tone :Basel ine EMGac tivity in the chi n deri vati on no higher than in any ot her sleep stage and usually at the lowest level
of the entirerecording.
Sawtooth waves: Trains of sharply contoured or triangular, oft en serrated, 2-6 Hz waves maxi mal in amp litude over the central head
regions and oftc n, but not alway s, preceding a burst of rap id eye movements.
Transient muscl eactivity: Short irregular bur stsof EMGactivity usuallywithduration <0.25seconds supe rimposed on low EMGtone.
The activity may be see n in the chi n or anterior tibial EMGderivations, as we il as inEEGor EOGdeviat ions, the latter indicati ng activity
of cranial nerve innervated muscles. The act ivity is maximal in association with rapid eyemovement s.
Rules
A. Scorestage Rsleep in epochswithail thefollowing phenomena:
a. Low ampl itude,mixed frequencyEEG
b. LawchinEMG tane
c. Rapid eye movements
AASM Manual fo r Scorlng Sleep, 2007 27
B. The following rule defines the continuation of a period of stage Rsleep:
Continue tascore stage Rsleep,even in theabsence of rapid eye movements, for epochs following 1or more epochs of stage
Ras defined in A above, if the EEG continues to show low amplitude, mixed freque ncy acti vity wi thout K complexes or sleep
spi ndles and the chi n EMG tone remai ns low. (Figure 3)
Epoch
Epoch
50 51
52 53
50
51
52 53
1
i
1 1
1 1
1Kco mplex 1
1Kcomplex 1
-----t--- ----'----- .:.......Y-: --- --t-- -----'----- .:.......Y- :
1
1
:

REM REM
1
Ez-M
z:
1
t. r I 1:1J .
1
1
EMG,-EMG
2
:1- .......- EMG,-EMG
2
.IMI 1
1
...
1 1 1
Stage R Stage R StageR Stage N2 Stage R Stage R Stage N1 Stage N2
Figure3
C. The following rule defines theend of a period of stage Rsleep:
1) Stop scori ng stage R sleep whe n 1 or moreof the followi ng occur:
a. There isatransiti on tostage W or N3
b. An increase in chin EMG tone above the levelof stageRis seen and criteria for stage N I are met (Figure 4)
c. An arousa l occurs followed by low amplitude, mixed frequ ency EEG and slow eye move ments (score as stag e NI;
if no slow eye move ments and chinEMG tone rema ins low, continue to score as stage R) (Figure 5)
d. A major body movement followed by slow eye movement s and low amplitude mixed freque ncy EEG without
non-arousal asso ciated K complexes orsleep spindles (score the epoch followi ng the maj orbody movementas
stage N I; if no slow eye move ments and the EMG tone remains low, continue to score as stage R; the epoch
contai ning thebodymovement isscoredusingcriteriainSection 8) (Figur e6)
e. One or more non-a musai associated K complexes or sleep spind les are present in the firsthalf of the epoc h in the
abse nceof rapid eye movement s, eve n if chinEMG tone remains low (score as stage N2) (Figure 7)
Epoch
Epoch
50
51 52 53 50
51
52 53
C
4
-M
1
OZ-M
1
E
1-MZ
REM
1
1
1
1 . 1
Low amPlltudj
1 mixed traqua ev
1
1
1
1
1
1
1
1
1
1
1 1
IKcomplex 1
1
!\r--:
1r-
C
4
-M
1
OZ-M
1
E
1-MZ
REM
1
1
1
1Law ampliludJ
1mixed frequerky
1
1
1
1
1
1
1
1
1
1 1
IKcompl ex 1
1
!\r--:
1r-
EZ-M
Z
1
1 Ez-M
z
1
1
EMG, -EMG
2
EMG, -EMG
2
:h1....1
1
1

Stage R Stage R StageN1 Stage N2
StageR StageR Stage R StaqeN2
Figure4
AASMManual fo r Scoring Sleep. 2007 28
Epoch Epoch
50
51 52 53 50
51 52 53
1 1 1
1 1 1 1 1
: 1Kcomplex 1 Arosal 1Kcomplex 1
C 1 1 1
1
4-M1
:
-----t---'M _ 1
-----t---;N!I.< 1 J1 _ 1
1 1 . V- 1
1 1 1
1 1 1 i l 1
O M
--------+1- 2- 1 --_-+-__IM'I.<-- 1 1
- - - --t-- - 4'---+-1r-:
1 1 1
1 1 1 1 1 1
1 1 1
1
1 1
l ' 1 1
1Sioweye 1 1 1 1 1 1
1 1movement 1 1 1 1 1 1
E -M 1 -----, r--+-----...J.. r>; 1JI 1
2 2
1
V 1 T V' '\---IV 1
' VI
1 1 1 1 1 l , 1
1 1
EMG,-EMG, 1 1 .. .11 EMG,-EMG,:- , -----.... , III
1 1 1
1 1
Stage R StageR StageN1 StageN2 StageR StageR Stage R Stage N2
Figure5
'---1----'''11I('
REM 1
Epoch
Epoch
50
51 52 53
50
51
52 53
1 1Body 1
Body ,
1
rnovernent ,
1 C-M
1
1
EMG,-EMG,,---""--
1
4
1
02-
M
1
E
1-M2
E
2-M2
EMG,-EMG, 1
StageR Stage R StageR Stage R StageR Stage N1StageN1 Stage N1
1movemenl '
1
1
1

1
1
1
1
1
1
1
1
- - - ...-
1
1
1
1 1_-----''''-''''''--
Figure6
Epoch Epoch
50 51
52 53 50
51
52 53
1 1 i
1 1 1
1 Kcomplex 1
Kc0nflex
1
1

,
1
,
1
1
-----.----------L-t--
REM 1 1
EM
,
E
1-M2
__
1
,
1 1
1 1
1
E
2-M2

1
, 1 1
,
1
IEMG,-EMG, : -+-__---L ...:.....__
EMG,-EMG, '1----+---........---....:...---
1
,
1
StageR StageR StageN2 StageN2 StageR StageR StageR StageN2
Figure7
AASM Manual for ScoringSleep,2007 29
D. Scoreepochsat thetransitionbetween stageN2 and stageRas follows:
1) In between epochs of definite stage N2 and defini te stage R, score an epoch with a distinct drop in chin EMG in the first
half of the epoch to the level seen in stage R as stage R if ailof the following criteria are met, even in the absence of rapid eye
movements(Figure8):
a. Absence ofnon-arousal associated Kcomplexes
b. Absenceofsleepspindles
2) Inbetweenepochs ofdefinitestageN2 and definitestage R,scoreanepoch withadist inctdropinchin EMG inthefirst
halfoftheepoch to the levelseen instage RasstageN2 ifailofthefollowingcriteriaare met(Figure9A):
a. Presence of non-arousal associated K complexes or sleep spindles
b. Absence of rapid eye movements
3) In betweenepochs ofdefinite stage N2 with minimalchin EMG tone and defini te stage R withoutfurth er drop in chin
EMG tone,scoreepochs as stage Rifa1l ofthefollowingare met,even intheabsenceofrapi deye movements(Fi gure98):
a. Abse nceofnon-arousal assoc iatcd K complexes
b. Absence of sleep spindles
Epoch Epoch
50
51
52 53 50
51
52 53
1 1
1 1
1
Kcompl ax
1
Kcomplax
1 1
C
4-M1

1
1 1
1
1 1
1
02-
M
l :-1-
1
1
02-
M
l
1
1 1
1
1
1
1
1
REM 1
1
REM
1 1
E
1
-M
2
1 E
1
-M
21
1 1
1 1
E
2
-M
2
1 E
2
-M
2
1
1 1
1 1
1
EMG,-EMG, li.Unb EMG,-EMG, :-i",l
1 1
1
StageN2 StageR Stage R StageR StageN2 StageN2 StageR StageR
Figure8
Epoch Epoch
50
51 52 53 50
51
52 53
1
1
1
1 1 1
1
Kcomplax Sleep 1
1
Kcomplax
1 spind le 1
1 1
. 1
C
4-M1
:----1
1
1 C
4-M1
:
1
----1
1
1
Sleep 1
1 1
1 spi ndlel
1

1
.1

1
1 1
1
1
1
1 REM 1
1
REM
1 1
1 1 1
E -M 1 E -M 1
1 2
1
1 2
1
1 1
E
2
-M
2
: E
2
-M
2
:
1 1
1
1 1
EMG,-EMG,/r1.1H.._t
EMG,-EMG'I
1
1
1
StageN2 StageN2 Stage N2
StageR
Stage N2 Stage R Stage R Stage R
A B
Figure9
AASM Manual for Scoring Sleep. 2007 30
Notes:
1. Low amplitude, mixed frequ ency activity in stage R resembles that seen in stage NI. ln some individuals, a greater amount of alpha
activity can be seen in stage R than in stage NI . The alphafre quency in stageR oflen is 1-2 Hzslowerthanduring wakefulness.
2. The fo llowing phenomena are strongly supportiveof the presenceofstage R sleep and may be helpf ul when the stage is in doubt :
a. Sawtooth waves
b. Transient muscle activity (Sawtooth wavesand transient muscle activity may bepresent but are not requiredf or scoring stage R.)
3. At times, especially in thefirst REMsleep period of the night, K complexes or sleep spindles may be interspersedamong epochsofwhat
otherwise appears 10 be stage R sleep. The above rules indicale that epochs with rapid eye movements should bescored as stage R
eveninthepresenceof Kcomplexes orspindles.However. if rapid eyemovementsareabsenl,subsequentepochswithKcomplexesor
sp indlesshouldbescoredasstage N2,evenif chinmuscletoneremainslow.
8. MAJORBODYMOVEMENTS [RECOMMEND ED]
Definition
Major body movem ent: Movernent and muscle artifact obscuring the EEG for more than half an epoc h to the ext ent that the sleep stage
cannot be deterrnined
Rules
Score an epoch with a maj or body movement as follows:
A. If alpha rhythm ispresentfor partofthe epoch (even <15 seconds duration), scoreas stage W.
B. Ifno alpha rhythm isdiscernable, but an epoch scorable as stage Weither precedes orfoliows the epoch with amajor body
movement,scoreas stageW.
C. Otherwise, scorethe epoch asthe same stage as the epochthatfoliows it.
AASMManual forScoring Sle ep,2007 31
VISUAL RULES FOR CHILDREN
1. AGES FOR WHICH PEDIATRIC SLEEPSCORINGAPPLY: [RECOMMENDED]
A. Pediatriesleepscoring rules can be usedto score sleepandwakefulness in children 2months post-term orolder.
NOIes:
1. For children less than 2months post-term, ref er la discussion in the Pediatrie Task Force revie w paper.
2. There is no precise upper age boundaryfor pediatrie visual rul es; ref er la discussion in the Pediatrie Task Force review paper.
2. TERMINOLOGY OF SLEEPSTAGES [RECOMMENDED]
A. Thefollowing terminologyshould be usedwhen scoring sleep in children 2months post-tarrn orolder:
1) StageW(Wakefulness)
2) StageNI (NREM 1)
3) StageN2 (NREM2)
4) StageN3 (NREM3)
5) Stage N (NREM)
6) StageR(REM)
3. TECHNICALCONSIDERATIONS
Seeadult sleep scoring rules and digital PSGsection fortechnical considerations other than those in the notes below.
Not es:
1. Adult electrode derivationsfor EEG. EOG and chin EMG are acceptablefor recording sleep except that the distance between the chin
EMGelect rodes oftenneedslabereduced f rom 2cm 10 1 cm and the dist ancefromthe eyes in EOG electrodes oft enneed ta bereduced
from 1cmla 0.5 cm inchildren and infants withsmallheadsize.
2. An initialEEGsensitivity of7 Il V/mm (verti cal scaling) is appropriale f or routinePSG recordings but the sens itivity oft en needs la be
adjusted in infants andyounger children typi cally la 10 or even 15 IlV/mm.If sensitivilies of 1001' 15Il V/mm are used, parlions of the
sleep recording should bereviewedusing 7 IlV/mm in arder ladisplay and recognize low voltage[as ter frequenci es (incl uding spindle
frequencies).
4. SCORING SLEEPSTAGES [RECOMMENDED]
Because of the variability of sleep in infants, 4possible scenarios are described below:
A. Ifail epochsofNREM sleepcontain norecognizablesleepspindles, Kcomplexesorhigh-amplitude0.5to2Hzslowwave activ-
ity, score ail epochs ofNREM sleep as stage N(NREM).
B. Ifsome epochs ofNREM sleep contain sleep spindles or Kcomplexes, score those as stage N2 (NREM 2).Ifin the remaining
NREM epochs, there isno slowwave activity comprising morethan 20% ofthe duration ofepochs,score as stage N(NREM).
C.lf some epochs ofNREMsleep contain greater than 20% slow wave activity, scoretheseasstageN3 (NREM3). If intheremaining
NREM epochs,thereare no Kcomplexesorspindlesthen score as stage N(NREM).
D. If NREM issufficiently developedthatsomeepochscontain sleepspindles or Kcomplexesand otherepochs contain sufficient
amountsof slowwave activity, then score NREM sleep in this infantas eitherstage N1, N2 or N3 as inan olderchiId oradult.
NOIes:
1. Sleep spindles usually arepresent in NREMsleep ofinfant s 2la3monthspost-termor aider.
2. K comp lexes are usuallypresent inNREMsleep in infants 4la 6monthspost-term or aider.
3. Slow wave acti vity r?-75 Il V; 0.5-2 Hz typ ical/y in the fro ntal regions) is usually present 4 la 5 mont hspost-term.
4. NREMsleep can be scored as stage NI . N2 or N3 in most infants S-mont hspost-term or aider, occasionally in infants asyoung as 4
la4.5 monthspost-term.
5. Non-EEGcorrelatesare veryhelpfulinrecognizingNREMandREMsleep ininfants 6months post-t erm or younger. These correlates in
REMsleep include thepresenceofirregular respiration, chin EMG atonia, transi at muscle activity,and rapid eye movement s. In NREM
sleep, correlates include regular respiration, noor rare vertical eye movements, andpreser ved chinEMG tone.
AASM ManualforScoring Sleep, 2007 32
5.STAGEW [RECOMMENDED]
Definitions
Alpha r hyt hm: Tra ins of sinusoida l 8- 13 Hz activity recorded over the occipital region present with eye closure and whieh is reacti ve
(attcnuatcs wi theyeopening).
Eycblinks: Conj ugate verticaleye movementsata frequeney 01'0.5-2 Hzpresent inwakefulness with cyes open orclosed,
Reading eye movernents : Trains ofconjugat e eye rnovement s consisting ofa slow phase followcd by a rapid phase in the opposite
di recti on as the ehild rcads or visually scans theenvironrnent.
Rapid eye movements (REM): Conjugatc, irregular,sharp lypeakcd cye movemcnts with an initial deflection usuall y lasting <500 msec.
Whil e rapid eye movernents arc characteristicof stage R sleep, they may also be seen in wakcfulness with eyes open whcn subjeets visu-
ally scan theenvironrnent.
Dominant posteriorrhythm (DPR): The dominant reactive EEG rhythm over the occipital regions in relaxed wakefulness with eyes
closed whi eh isslowerin infantsand youngchildrenand attenua teswith eycopeningorattention.Frequeneyis3.5-4.5 Hzwhenfirstseen
in infant s3-4 monthspost-term,5-6 Hz by 5-6 months,and 7.5 to9.5 Hz by 3 years ofage and amplitude isusually>50 f-ly.
Rules
A. In children thedominant posterior rhythm replaces theterm alpha rhythm for thepurposes of scoring wakefulness andNREM
stages.
B. Score epochs as stage Wwhen more than 50% of theepoch haseitherreactive alpha or age-appropriate dominant posterior
rhythmovertheoccipitalregion.
C. If there is nodiscernable reactive alpha or noage-appropriate dominant posterior rhythm, scoreepochs asstage Wif anyof the
followingarepresent:
1) Eye blinksat a frequency of 0. 5- 2 Hz
2) Readingeyemovements
3) Irregular conjugate rapid eye movements assoc iated with normal or hi gh chin mu scle tone
Not es:
1. The dominant posterior rhythm (DPR) over the occipital derivat ions in adults has amplitude of <50JIV, afrequencyof8.5 to 13Hz,
and is reactive to eye opening. The frequency and amplitudeofthe dominant posterior rhythm over the occipital derivat ions in chi ldren
changes with age.
a. Only slowirregularpotentialchangesareseen over theoccipitalscalp regions in infantsbefore3to 4monthspost -term.
b. The majori ty (75%)ofinfants by 3 to 4 months post-t erni have an irregular50-100JIV, 3.5 to 4.5 Hz acti vity over the occipi tal
regio ns which isreactive (i.e., blocks or attenuates with eye ope ning and appears with passive eye c!osure).
c. By 5-6months of age,many children have 50 to 110JIV, 5-6Hzacti vityoverthe occipitalregions, andthisrhythmispresent in 70%
ofnor malchildren byage 12months.
d. By 3y ears of age.82%ofchildren who werenormalpost-term infantsshowameanoccipital frequencyof >8Hz (range 7.5to 9.5
Hz).
e. Amean alphafrequencyof9Hz isfound in 65%of9yearolds and increases to 10Hz in 65%byage15.
1 Theaverageamplitudeofthedominantpost eri orrhythminchildrenis 50-60JIV,'9%ofchildrenhave >100JIV(especially between
6-9years); children rarely have alpha acti vity <30JIV.
2. The high est amplitudeandsharpest componentofreading eye movements in children is usually surf ace-negative in the occip ital deriva-
tions, typically last 150 to 250msec,andhaveamplitudes up to 65JIV.
3. Occipitalsharp waves with eye blinks are typi cally singlemonophasic orbiphasic <200JIVsharp waves overtheoccipitalderiv ations
which usually last 200 to400 msecand occ ur 100 to 500 msec f ollowing an eye blink oreye mo vement . In children, the ini tial compo nent
ofthe occip ital sharp wave is surface-positive; the asce ndi ng phaseofnext surface-negative component has a steep wave fro nt;and the
desce ndi ngphase ofthe second compo nent less steep.
4. The dominant posterior rhythm (DPR) in inf ants and chil dren typically contains intermixed slower EEG rhythms including:
a. Posteriorslow waves ofyouth(PSW) which are intermittentruns ofbilateralbut often asymmetric 2.5-4.5Hz slowwaves super-
imposed, riding upon, orfus edwith the dominant posterior rhythm, are usually <120% of dominant poster ior rhythm voltage,
block with eye openingand disappear with drows iness and sle ep.PSWare uncommon in children <2yearsofage,haveamaximal
incidence betweenages 8to 14years, andare uncommon afterage 21years.
b. Randomorsemi-rhythinicoccipitalslowing: <100JIV, 2.5to 4.5Hz rhythmicor arrhythmicactivity lasting <3seconds; anormal
fi nding inEEGsofchildrenages 1 to 15 years, especiallyprominentages 5to 7years; theamount ofintermixedslowing decreases
and itsfrequency increases with increasing age.
5. Spontaneous eyec!osure inan infantsignalsdrowsiness.
AASMManualforScoring Sleep, 2007 33
6. STAGE N1
[RECOMMENDED]
Definitions
Slow eye movernents (SEM): Conjugate, reasonably regul ar, sinusoida leye movement s with an initial deflection whi ch usually last
>500 msec.
Lowamplitude,mixed frequencyactivity: Low amplitude,predominantly4-7 Hzactivity.
Vertexsharpwa ves (V wa ves): Sharpl ycontoured waves with duration <0. 5seconds maximal over thecentralregionand di stingui sh-
able from the background activit y,
Sleep onset: The startof the first epoc h scored as any stage other than stage W.
Rhythmic anterior theta activity: Runs of 5-7 Hz rhythmi c theta activity maximal over the frontal or frontocentral regions.
Hypnagogic hypcrsynchrony: Paroxysmal bursts or runsof diffuse high amplitude sinusoidal 75 to 350 V,3-4.5Hz waveswhi ch begin
abruptly, are usually widely distributed butonen maximal ovcr the central, frontal , or frontocentral scalp regions.
Rules
A. In subjects whogenerate a dominant posterior rhythm, score stageN1 if theposteriorrhythm is attenuated or replaced by low
amplitudemixedfrequencyactivityformore than50% of theepoch.
B. Insubjects whodo notgenerate adominant posterior rhythm, score stageN1 commencing withtheearliest of anyof thetoilow-
ingphenomena:
1) Activity in the range of 4-7 Hz with slowing of background frequencies by 1-2Hz from those of stageW
2) Slow eye movements
3) Vertexsharp waves
4) Rhythmicanteriorthetaactivity(RAT)
5) Hypnagogichypersynchrony
6) Diffuseor occipitalpredominanthigh amplitude rhythmic3-5 Hzactivity
Notes:
1. Drowsiness in infants up 10 age6108 months is characterized by the gradua! appearance of diffuse high amplitude (oflen 75 10200JIV)
3-5Hzactivitywhichistypically ofhigher amplitude,morediffuse,and 1-2Hzslowerthanthewaking EEG backgroundactivity.
2. Drowsinessinchildren8months 103years ischaracterizedby either diffuse runs or bursts of rhythmic or semi-rhythmic bisynchronous
7510200JIV. 3-4Hzactivity oftenmaximalovertheoccipitalregionsand/or higheramplitude (>200f.lV) 4-6Hzthetaacti vityma.ximal
overthefrontocentral orcenlral regions.
3. Sleeponset from3years on is ofte n characterized by a 1-2 Hz slowingofthe dominant posterior rhythm fre quency and/or the dominanl
posterior rhythm of ien becomes diffusely distribut ed then is gradually replaced by relalively low voltage mixed frequen cy EEG activ-
ity.
4. In most subjects sleep onsel will be thefi rst epoch of stage NI but in infants younger than3monthspost-term, thisisoftenstage R.
5. Rhythmicanteriorthetaactivi ty(RAT)arel'unsofmoderate voltage5-7Hz thetaactivityoverthe frontalregions iscommonlyseen in
adolescents and young adults when drowsy, may first appear around5yearsofage.
6. Vertexsharp waves are monophasicsurface-negativesharp waves maximal over the cenlral regions which last <0.5 second (usually
<200 msec). can occur in bursts or11111S, most often seen during transition 10 stage NI sleep but can occur in either stage NI or N2 sleep.
By 6monthspost- term, a f ew broad verlex sharp waves can be seen over the central regions but vertex sharp waves which resemble
thoseseeninolderchildrenand adultstypicallyfi rstappem'16monthspost-term.
7. Hypnagogichypersynchrony(HH)isadistinctiveEEGpatternofdrowsinessandstage NIcharacterizedbyparoxysmall'unsorbursts
ofdiffusebisynchronous 7510350JIV. 3-4.5Hz waves often maximal over the central. f rontalorfrontocentral or derivations. HH often
disappears with deeper stagesofNREMsleep. HHis seen in approximat ely 30%of infants3monthspost-term, 95%ofailnormal chil-
drenages6108months, and is lessprevalenlafterage 4105years, seeninonly 10%ofhealthy childrenage 11,rarely seenafterage
12years.
7.STAGE N2
Sameas adultrules asnoted insectionIV 5.
Notes:
1. Sleepspindles(SS) are usually arefirs t seen in infant s4106weekspost-termasbrief burstsoflowamplitude lesssinusoidal 12-14Hz
activitymaximaloverthe vertex(C) region,areusually well-developedandarepresenlinailnormal infants 8109weeks.
2. Eightypercenlofchildren <13yea;'sof agehave2independent scalp locations andfrequency ranges for sleep spindles: 10.010 12.75
Hz overthe frontaland 12.51014. 75Hz maximal overthecentralorcentroparietalregion.
3. Frontal sleep spindles are moreprominentthan centroparietal spindles in young childrenbUI abruptly decrease in EEGpowerandpres-
ence beginningalage 13whereascentroparietalspindIes persistunchangedin presenceorlocalion.
4. Kcompl exesareusuallypresent5106months post-term and are maximal over the pre-front al andfrontalregions, as they are in adults.
Fordefinition,seeIV
AASMManualforScoringSleep,2007 34
8. STAGE N3
Same as adult rules in section IV. 6.
Note: Slow wave activity (SWA) in pediatrie populations oflen 100 to 400 IlV, 0.5 to 2.0 Hz activity maximal over the recommended deriva-
tions in the frontal scalp regions (F , F.) first appears as early as 2 months, more oflen about 3 to 4.5 months post-term.
4
9. STAGE R
Same as adult rules section IV. 7.
Note: The continuous low voltage, mixedfrequency EEG activity of stage R in infants and children resembles adults though the dominant
frequencies increase with age: approximately 3 Hz activity at 7 weeks post-term; 4-5 Hz activity with bursts of saw tooth waves at 5
months; 4-6 Hz at 9 months; and prolonged runs or bursts of notched 5- to 7-Hz theta activity at 1 to 5 years age. By 5 to 10 years of
age, the low voltage mixedfrequency activity in stage R resembles that ofadults
AASM Manual for Scoring Sleep, 2007 35
AASM Manual for Scoring Sleep, 2007 36
V. AROUSALRULE
1. SCORINGAROUSALS [RECOMMENDED]
A. Score arousal during sleep stages N1, N2, N3, orRifthere isan abrupt shift ofEEG frequency including alpha, theta and/or
frequencies greaterthan 16Hz (but notspindles)that lasts at least 3seconds, with at least10seconds of stable sleep preceding
the change. Scoring ofarousal during REM requires aconcurrent increase in submental EMG lasting at least1second.
Notes:
1. Arousalscoringshouldincorporateinformation from boththeoccipitalandcentralderivations.
2. Arousalscoringcanbeimprovedbytheuseofadditionalinformationintherecordingsuchasrespiratoryeventsand/oradditionalEEG
channels.Scoringofarousals,however; cannotbebased0/1thisadditionalinformationaloneandsuchinformationdoesnotmodifyany
ofthearousalscori ngru/es.
AASMManual fo rScoringSleep,2007 37
AASM Manual for Scoring Sleep, 2007 38
VI. CARDIAC RULES
1. TECHNICALSPECIFICATIONS [RECOMMENDED]
A. Asingle modified electrocardiograph Lead Il using torsoelectrode placement isrecommended.
Notes:
1. Addilionalleads may beplaced if clinically-indicated at thediscretionofthepractitioner:
2. Increas ing imagesizeondisplay may improvedetection ofarrhythmias.
3. While classically LeadIl is derivedfrom electrodes placedon the right arm andleft leg. the electrodes may beplaced on the torso
aligned inparallel to the right shoulder and lefl hip.
4. StandardECG electrode applicalions aresuperior laEEGeleclrodes inminimizing artifact.
2.SCORING RULES [RECOMM ENDED]
A. Score sinustachycardiaduring sleepforasustained sinus heartrate ofgreaterthan 90 beats perminuteforadults.
B. Score bradycardiaduring sleepforasustained heart rate of less than 40/minuteforages6years through adult.
C.Score asystole for cardiac pauses greater than 3secondsfor ages 6years through adult.
D. Score wide complex tachycardia forarhythm lasting a minimum of 3consecutive beats at arate greater than 100 per minute
with QRS duration ofgreater than orequal to120 msec.
E. Score narrowcomplextachycardiafora rhythm lastinga minimum of3consecutivebeatsatarate ofgreaterthan 100permin-
utewith QRS duration of lessthan 120msec.
F. Score atrial fibrillation if there isan irregularly irregular ventricular rhythm associated with replacement of consistent Pwaves
by rapid oscillationsthatvary in size,shape,and timing.
NOIes:
1. Signifi canlarrhythmiassuchas heartblackshouldbereportedif thequalityofthesinglelead issufficientforaccuratescoring.
2. Ectopiebeats shouldbe reported iffeltto beclinically signifi canl.
3. Sinus rates vary according 10 age in children, with faster rates in young children as compared10 adults .For typical sinusrat es inchil-
dren,refer10 theCardiac TaskForcereviewpaper.
AASMManualforScoring Sleep, 2007 39
AASM Manualfor Scoring Sleep, 2007 40
VII.MOVEMENTRULES
1.SCORING PERIODIC L1MB MOVEMENTS IN SLEEP(PLMS) [RECOMMENDED]
A. The following rules define asignificantleg movement(LM) event:
1) The minimumdur ation of aLM event is0.5second s
2) The maximumdur at ion of a LM event is 10 seconds.
3) The minimum amplitude ofaLM event isan 8 uv-incre ase in EMGvoltageabove restingEMG.
4) The timin g of the onset ofa LM event is defined as the point at which there is an 8 uv-increase in EMG voltage above
resting EMG.
5) The timingofthe ending of a LM event is defined as the startofa period lastingat least 0.5 secondsduring which the
EMG does not exceed2 IlVabove resting EMG.
B. The following rules define aPLM series:
1) The minimumnumberofconsecutiveLM eventsneeded todefine a PLM series is4LMs.
2) The minimumperiod length between LMs (definedas the time between onsets of consecutiveLMs ) to include them as
partofa PLM series is5seconds .
3) The maximumperiod lengthbetweenLMs(definedas the time betweenonset sof consecuti ve LMs) to include them as
partofa PLM seriesis 90 sec.
4) Leg movements on 2 different legs separa ted by less than 5seco nds between movementonsets are counted as a single
leg movement.
Notes:
1. AnLMshould not be scoredif il occursduringa periodfr om0.5 seconds precedinganapneaorhypopneato0.5 secondsfo llowingan
apnea orhypopnea.
2. Anarousal anda PLMshould beconsideredassociated witheachother whenthere is <0.5secondsbetweentheendofoneeventand
theonsetoftheothereventregardlessofwhichisfirst.
3. Surfaceelectrodesshould beplacedlongitudinally andsymmetricallyaroundthemiddleofthemusclesothotthey are2to3cmapart
or 1/3ofthelength of/heanteriortibialismuscle,whicheverisshorter.Bothlegsshouldbemonitoredforthepresenceofthelegmove-
men/s. Separate channels f or each leg are strongly pref erred. Combining electrodes from the 2legs togi ve l recorded channel may
suffice fo rsomeclinicalsettings,though isshouldberecognizedthatthisstrategymayreducethenumber ofdetectedLMs. Movements
oftheupperlimbsmay besampledif clinicallyindicated.
4. The rules in "A " above defi ne a significant leg movement event by absolute increase inJIVaboverestingbaselinefortheanterior tibi-
alis EMG.Thisrequiresastablerest ing EMGfor therelaxedanteriortibialis whoseabsolutesignalshouldbenogreater than +la JIV
betweennegativeandpositi vedefiection( 5JIV) or+ 5JIVforrectifiedsignaIs.
5. Use of60Hz (notch)filtersshould beavoided. 1mpedancesneedtabelessthan 10,000n. Less than5,000n ispreferredbutmay be
difficulttoobtain.Sensitivitylimitsof-100and 100JIV(upper/lower)arepreferred.
2.SCORINGALTERNATING LEG MUSCLEACTIVATION (ALMA) [OPTIONAL]
A. The following rules defineALMA:
1) The minimum number ofdiscrete and alternating bursts ofleg muscle activity needed to score an ALMA series is 4
ALMAs.
2) The minimumfrequencyofthe alternatingEMG bursts inALMAis0.5 Hz.
3) Themaximumfrequency ofthe alternatingEMG bursts inALMAis3.0Hz.
Notes:
1. ALMAs alternate between legs.
2. Theusualrangeforduration ofALMA is 100-500msec.
3. ALMA may simply be a benign movementphenomenon associated with characteristic EMGpatterns as there have been no reported
clinical consequences
AASMManua/ f orScoringSleep,2007 41
3. SCORING HYPNAGOGIC FOOTTREMOR(HFT)
[OPTIONAL]
A. Thefollowing rulesdefineHFT:
1) The minimum numberofbursts neededto make atrain ofburstsinhypnagogicfoot tremoris4 bursts.
2) The minimum frequen cyof the EMG bursts in hypnagogic foot tremor is 0.3 Hz.
3) The maximum frequency oftheEMGbursts inhypnagogic foot tremoris4.0 Hz.
Noies:
1. The usual range/ or durati on0/hypnagogicfoo ttremoris 250-1000msec.
2. HFT may simply be benign movement phenomenon associated with characteristic EMGpatterns as there have been no reported clinical
consequences.
4. SCORING EXCESSIVE FRAGMENTARYMYOCLONUS (EFM)
[OPTIONAL]
A. Thefollowing rulesdefineEFM:
1) The usuaI maximum EMG burstdurat ion seen infragmenta rymyoclonus is ISO msec
2) At least 20 minutesofNREMsleep with EFM must be recorded
3) At least5EMG potentials per minute must berecorded
Noies:
1. EFMmay be a benign movementphenomenon associated witha characteristic EMGpatt ern asthere have been no reported clinical
consequences.
2. ln many cases no visible movements are presenl. Gross je rk-like movements across thejoinl spaces are nol observed. When minor move-
men!acrossajointspace ispresent, the movement resembles the small twilch-like movementsofthefi ngers, toes, and the cornerofthe
mouth intermiuentlyseen inREMsleep innormalindividuals.
3. Insomecases when visiblemovement ispresenl,theEMG burstduration may be>150msec.
5. SCORING BRUXISM [RECOMMENDED]
A. Thefollowing rulesdefinebruxism:
1) Bruxism may consist of brief (phasic) or sustained (tonie) elevations of chin EMG activity that are at least twice the
amplitudeofbackground EMG.
2) Briefelevationsofchin EMGactivityarescored asbruxism ifthey are0.25-2 seconds indur ation and ifatleast 3 such
elevationsoccurinaregul arsequence.
3) Sustained elevationsof chinEMG act ivity are scored as bruxi sm if the duration is more than 2seconds.
4) A period ofat least 3 seconds ofstable background chin EMG must occur befo re a new epi sode ofbruxism can be
scored.
5) Bruxism can be scored reliabl y by audi o in comb ination with polysomnography by a minimumof2 audible tooth grind -
ing episodes/nightof pol ysomnography in the absenceof epilepsy.
Noies:
1. ln sleep, j aw contractionfrequ ently occurs. This contraction can lakeZforms: a) sustained (tonie)jaw c1enching tonie contractions or
b) aseries0/repetitivebrie/(phasic) musclecontractionstermedrhythmicmasticatory muscleactivity(RMMA).
2. ln addition 10 the recommended placemenl0/chin EMG electrodes as noted in section I VA.I .c, additi onal masseter electrodes may be
placedat thediscretionoftheinvestigatororclinician.
6. SCORING PSG FEATURES OF REM SLEEPBEHAVIORDISORDER (RBD): [RECOMMENDED]
Definitions
Sustainedmuscleaetivity(tonieaetivity)in REMsleep:Anepoch ofREMsleep with at least 50%ofthedurationoftheepoch having
achin EMG amplitude greaterthan theminimumamplitudethan inNREM.
Excessive transient muscleactivity(phasicactivity)in REMsleep: Ina30-secondepoch ofREM sleep divided into [0 sequenti al 3
second mini-epochs, at least 5 (50%)of the mini-epochs conta in burst sof transient muscle activity. In RED, excessive transient muscle
acti vity bursts are 0. 1- 5.0seconds indurati onand at least4times as high inamplitudeasthe background EMG activity.
Rule:
1) The polysomnographiccharacteristicsofRBD arecharacterizedby eitheror both ofthe following features:
a. Sustained muscle acti vity in REM sleep in the chin EMG
b. Excessivetransientmuscle acti vityduring REM inthechinorlimb EMG
AASM Manual fo r ScoringSleep, 2007 42
Notes:
1. Time synchronized video PSG audio or a characteristic clinical hist ory are necessary to make the diagnosisofRBD in addition to po ly-
somnographic evidence ofREMwithoutatoniaorexcessivetransientmuscleactivity inREM
2. Transient muscle activityandoccasional accompanying visibl e twitchingofsmall muscle groups are a normal phenomenon seen in REM
sleep (see1V. Adul t. 7). Whenlarger musclegroups areinvolved, thisacti vityis notassociated withlarge.overtmuscularactivityacting
across largejoints. Whensmallermusclegroups areinvolved, themovement ofteninvolvesthedistal muscl es ofthehands andfaceor
thecorners ofthemouth.Transient muscl eact ivitymay beexcessi veinRBD.
3. The sustained muscle activity or the excess ive transient muscle activityobserve d in REMsleep may be interrupted by superimposed
(usuallydream- enacting) behaviors ofRBD.
4. ln normalindividualsthereis anatonia seeninREMsleep inthechinandanteriortibialisEMG. ln thisstatethebaselineamplitudeof
the EMG signal decreases markedly. This atonia of REM sleep is lost to a considerable extent in RBD, with variablefrequency, and as
aresult,theEMG baselineamplitudeisoften higher: ln thissituation,theEMGcanbesaidtobeinatonierather thanatoniestate.
7. SCORING THE PSG FEATURES OF RHYTHMIC MOVEMENTDISORDER [RECOMMENDED]
A. The following rule definesthe polysomnographic characteristicsof rhythmic movementdisorder:
1) The minimum frequency for scoring rhythmi c movements is 0.5 Hz
2) The maximum frequency for scoring rhythmi c movements is 2.0 Hz
3) Th e minimum number of indi vidual moveme nts requ ired to make a c1uster of rhythmic movements is 4 movements
4) The minimum amplitude of an individual rhythmic burst is 2 time s the background EMG activity
Notes:
1. Bipolar surface electrodes should be placed to record electrical activityofthe large muscle groups involved.
2. Timesynchronizedvideo PSG, inadditionto polysomnographiccriteria, isnecessary tomakethediagnosis ofrhythmic movementdis-
order.
AASMManualfor Scoring Sleep, 2007 43
AASM Manua/for Seoring Sleep, 2007 44
VIII. RESPIRATORYRULES
RESPIRATORYRULES FORADULTS
1.TECHNICALCONSIDERATIONS [RECOMMENDED]
A. The sensor todetect absence of airflow foridentification ofan apnea isan oronasal thermal sensor.
B. The sensor fordetection ofairflow foridentification ofahypopnea isanasal airpressure transducer with orwithout square root
transformation ofthe signal.
C. The sensorfor detection of respiratory effort iseitheresophageal manometry, orcalibrated or uncalibrated inductance pleth-
ysmography.
D. The sensor fordetection of blood oxygen ispulse oximetry with a maximum acceptable signal averagingtime of3seconds.
Notes:
l. Alternativesensors aretobeused whenthesignalfrom therecommendedsensor isnotreliable.
2. Thealternativesignaltodetect absence ofairflowfor identification ofanapnea whenthethermistor signal isunreliable isanasal air
pressure transducer.
3. An alternativesensorfordetection of effort isdiaphragmatic/intercostalEMG.
4. For scoringofhypopnea when the nasal pressure deviee is notfunctioning, alternative sensors including uncalibratedor calibrated
inductanceplethysmographyoranoronasal thermalsensor maybeused.
5. Asmallbiasi.e.,moreeventsinreportinghypopneas attheflowthresholdrecommendedforscoring hypopneas (<:50% ofbaseline), may
becorrectedbysquare roottransformation.
2. EVENTDURATION RULES [RECOMMENDED]
A. For scoring either an apnea orahypopnea, the event duration ismeasured from the nadir preceding the first breath that is
clearly reduced tothe beginning ofthe first breath that approximates the baseline breathing amplitude (see horizontal brackets,
Figures 1and 2).
B. When baselinebreathingamplitudecannotbeeasilydetermined(andwhen underlyingbreathingvariabilityislarge),eventscan
also be terminated when eitherthere isaclearand sustained increase in breathing amplitude, orin the casewhere adesaturation
hasoccurred, there isevent-associated resaturation ofatleast2%.
3. SCORING OFAPNEAS [RECOMMENDED]
A. Score an apnea when ail ofthefollowing criteria are met(Figure 1):
1) Thereisadrop inthe peakthermal sensorexcursion by2:90%ofbaseline
2) The duration ofthe eventlasts atleast 10seconds. (see Section2above)
3) At least 90% ofthe event'sduration meets the amplitudereduction criteriafor apnea
B. Classityan apnea in an adult based upon inspiratoryeffort:
1) Score arespiratoryeventasan obstructiveapnea ifitmeets apnea criteriaand isassociated with continued or increased
inspiratoryeffortthroughoutthe entire period ofabsentairflow.
2) Score a respiratory event as a central apnea if it meets apnea criteria and is associated with absent inspiratory effort
throughoutthe entireperiodofabsentairflow.
3) Score arespiratoryeventasamixed apnea ifitmeets apnea criteriaand isassociated with absentinspiratoryeffortinthe
initial portionofthe event, followed by resumptionofinspiratoryeffortin the second portionofthe event.
Notes:
l. identificationof anapnea does not requireaminimum desaturation criterion.
2. Thecriteriafordetermination of thelength ofanapneaarespecifiedinSection 2.
AASMManual forSeoringSleep, 2007 45
51
EPOCH
50
Thennal
Sensor
Induclanc
Pleth
Sum
Sp02
10sec ---
Figure2
A. Score a hypopneaif ail of thefollowing criteriaare met(See Figure2): [RECOMMENDED]
1) The nasal pressuresignal excursions(or those ofthe alternativehypopneasensor)drop by2:30%ofbaseline
2) The durationofthis drop occursfor aperiodlastingat least 10seconds
3) Thereisa2:4%desaturationfrom pre-eventbaseline
4) At least 90% ofthe event'sduration must meet the amplitude reductionofcriteriafor hypopnea
B. Score a hypopneaif ail of thefollowing criteriaare met: [ALTERNATIVE]
1) The nasal pressuresignalexcursions(or those ofthe alternativehypopneasensor)drop by2:50%ofbaseline
2) The durationofthis drop occursforaperiod lasting atleast10seconds
3) There isa2:3%desaturationfrom pre-eventbaselineorthe eventisassociatedwith arousal
4) At least 90% ofthe event'sduration must meet the amplitudereduction ofcriteriafor hypopnea
Note:
J. The definition ofhypopneaused(VJl.4.A or VJl.4.B)shouldbespecifiedinthe PSG report.
2. Classification ofa hypopnea as obstructive, central, or mixed should not be performed without a quantitative assessmentof ventilatory
effort (esophagealmanometry, calibratedrespiratoryinductanceplethysmography, ordiaphragmatic/intercostalEMG).
5. RESPIRATORYEFFORTRELATEDAROUSAL RULE
A. Score arespiratory effort-related arousal (RERA)(Figure 3): [OPTION]
1) Ifthere isasequenceofbreaths lastingat least 10secondscharacterizedbyincreasingrespiratoryeffortorf1attening of
the nasal pressurewaveforrn leadingtoan arousalfrom sleep when the sequenceofbreathsdoes notmeetcriteriafor an
apnea orhypopnea.
Notes:
J. With respect to scoring a RERA, useofesophageal pressure is the preferred methodofassessing change in respiratory effort, although
nasalpressureandinductanceplethysmographycan beused.
6. HYPOVENTILATION RULE [OPTION]
A. Scorehypoventilationduringsleepaspresentifthereisa 0mmHg increasein PaC0
2
duringsleepin comparisontoan awake
supinevalue.
Notes:
J. Persistentoxygen desaturation isnotsufficient todocumenthypoventilation.
2. An increasedPaCO! value obtainedimmediatelyupon awakeningfrom sleep issuggestiveofsleephypoventilation.
3. At this time, there is insufficient evidenceto allow specification ofsensorsfor direct or surrogate measures of PaCO . Both end-tidal
l
AASMManual forSeoring Sleep, 2007
EPOCH 50 51
Thennal
Sensor
InductanCll
Pleth
Sum
Sp02
--------......_-
10sec
Figure1
4. HYPOPNEARULES
46
EPOCH
50
51
1
1
1
'1
1
Thermalf\J\J\IVV\J:VV\f\M
Sensor
1
1
lnductan
Pleth
Sum
Sp02
10sec
Figure 3
CO and transcutaneous CO may be used as surrogate measures of PaC0 if there is demonstration ofreliability and validity within
2 2 2
laboratory practices.
4. At this time, there is insufficient evidence to allow specification ofa duration ofhypoventilation though the duration should be sufficient
to account for the efJects ofresponse time ofthe sensor used and to exclude brief changes that reflect sensor artifact.
7.CHEYNE STOKES BREATHING RULE [RECOMMENDED]
A.Score Cheyne Stokes breathing ifthere are atleast 3consecutive cycles ofcyclical crescendo and decrescendo change in
breathing amplitude (Figure4)and at least 1ofthefollowing:
1) Five or more centralapneas or hypopneasper hour ofsleep
2) The cyclic crescendoand decrescendochangeinbreathingamplitude hasdurationofatleast 10consecutiveminutes.
Note: Cheyne Stokes breathing has variable cycle length that is most commonly in the range of 60 seconds.
Minutes
2 3 4 5 8 7 8 9 10
Nasal
Pressure
Thermal
Sensor
Inductance
Pleth
Sum
Sp02
Figure4
AASM Manual for Scoring Sleep, 2007 47
RESPIRATORYRULES FORCHILDREN
1. TECHNICAL CONSIDERATIONS
[RECOMMENDED]
A. The sensorused todetectabsenceofairflowfor identification ofan apnea isan oronasalthermal sensor.
B. The sensorfordetection ofairflowfor identificationofahypopnea isanasal airpressuretransducerwithoutsquare roottrans-
formation of the signal.
C. Acceptable sensors for detection ofrespiratory effort are either esophageal manometry, orcalibrated oruncalibrated induc-
tance plethysmography.
D. The sensor fordetection of blood oxygen ispulse oximetry with amaximum acceptablesignal averagingtime of 3seconds.
E. Acceptablemethodsforassessing alveolarhypoventilation are eithertranscutaneous orend-tldal PC0 monitoring.
2
Note:
1. AI/erna/i vesensorsare /0 beused whenthesignal f romtherecommendedsensoris no/reliabl e.
2. The al/erna/ivesignal/a detect absence of airflowf or identificationofan apnea is anasalairpressuretransducer.
3. Alterna/ive signaIsfor identificationofapnea are end-tidal peo
2
and summed calibrated inductance plethysmography.
4. The al/erna/ive sensorfor detectionofairflowfor identificationofa hypopneais anoronasalthermalsensor.
2.AGES FORWHICH PEDIATRIC SCORING RULES SHOULD BE USED [RECOMMENDED]
A. Criteria for respiratory events during sleepfor infants and children can be used forchildren <18 years, butan individual sleep
specialist can choosetoscorechildren ~ 1 3 years using adultcriteria.
No te : Several studies have published da/a usingpediatrie criteria in children up/0 18 yearsof age. However; there have been nostudies
comparing adult and pediatrie criteria in adolescents,particularly those appraachingadulthood. Empiric observa/ions would suggest that
adultcriteriacould beusedinsomeaIderchildren.
3. APNEA RLiLES [RECOMMENDED]
A. Scorea respiratory eventas an obstructiveapnea if itmeets ail of thefollowing criteria:
1) The event lasts for at least 2 missed breaths (or the durat ion of 2 breaths as deterrnined by baseline breathing pattern)
2) The event is associated with a >90% fall in the signal amplitude for ~ 9 of the entire respiratory event compared to the
pre- event basel ine amplitude
3) The event is associated with continued or increased inspir atory effort throughout the ent ire peri od of decreased airfl ow
4) The duration of the apne a is measured from the end of the last normal breath to the beginning of the first breath that
achieves the pre-event baseline inspiratory excursion
B. Score a respiratory event as a mixed apnea if itmeets both 3.A.1 ,and 3.A.2, and itisassociated with associated with absent
inspiratoryeffortin the initial portion ofthe event, followed by resumption of inspiratoryeffortbeforethe end ofthe event.
C. Score arespiratory event as acentral apnea ifit isassociated with absent inspiratory effort throughout the entire duration ofthe
eventand 1of the following ismet:
1) The event lasts 20 seconds or longer
2) The event lasts at least 2 missed breaths (or the dur at ion of 2 breaths as determined by basel ine breathing pattern) and is
asso ciated with an arousal , an awakening or a ~ 3 desaturation
Notes:
1. An apnea during sleep in an infant or child does no/ need la cause an arousal, awakening or an arterial oxygen desaturation /0 be
scored.
2. Acentralapneawhichlasts atleast 2 missedbreaths (orthedura/ionof 2 breathsasdeterminedby baseline breathingpattern), but is
lessthan20secondsandimmediatelyfa110wsasnore,sigh,respira/oryeven/orarousalisnolscoredunless itcauseseitheranarousal,
anawakeningora~ 3 desaturation.
AASM ManualforScoring Sleep, 2007 48
4.PEDIATRIC HYPOPNEARULES [RECOMMENDED]
A. Scorea respiratoryevent asahypopnea if itmeetsail of thefollowingcriteria:
1) The eventisassociatedwith a2:50% fall inthe amplitudeofthenasal pressureoralternativesignalcomparedtothe pre-
eventbaselineexcur sion
2) The event lastsat least 2missed breaths(or the dur ation of2 breaths as determined by baseline breathingpattern)from
the end ofthe last normal breathingamplitude
3) The fall inthenasal pressure signalamplitudemust last for2:90%ofthe entirerespiratoryeventcomparedto the signal
amplitude precedingthe event
4) The eve nt isassociatedwith an arousal ,awakening,or2:3%desaturation
B. Score a respiratory effortrelated arousal (RERA) event if theconditions in either1or 2aremet:
1. Whenusing a nasal pressuresensorail ofthefollowingmust be met:
a. There isadiscerniblefall inthe amplitudeofsignal from anasal pressuresensor,but itislessthan 50%incompari-
son tothe baselinelevel
b. There isfiatteningofthe nasal pressurewaveform
c. The event is accompanied by snoring, noisy breathing, elevation in the end-tidal PC0
2
, transcutaneous PC0
2
or
visual evidenceofincreased work ofbreathing
d. Theduration oftheeventisatleast 2breath cycles (orthedurationof2breathsasdetermined bybaselinebreathing
pattern)
2) When using an esophagealpressuresensorail ofthe foll owing must be met:
a. There isaprogressive increa se ininspiratoryeffortduringtheevent
b. The event is accompanied by snoring, noisy breathing, elevation in the end-tidal PC0
2
, transcutaneous PC0
2
or
visualevidenceofincreased work ofbreathing
c. The duration of the event is at least 2 breath cycles (or the durationof2 breaths as detennined by baseline breathing
patt ern)
Notes:
1. Removal or malfun ctionofthe nasal pressure sensor occurs more commonly in infants and children than in adults.Ifthis occurs during a
recordin g, hyp opneas may be scored using a thermal sensorif the signalqualityisadequate,following the samecriteriausedf or scoring
hypopneas withanasalpressuresensor.
2. ARERA (or flow limitat ion event) cannotbescoredwithout anadeq uatenasalpressureoresophagealpressuresignal.
3. Classificati on ofa hypopnea as obstructive, central or mixed should not be pe rformed without a quantitative assess mentof ventilatory
effort(esophagealmanometry orcalibratedrespiratory inductanceplethysmography).
5.HYPOVENTILATION RULE [RECOMMENDED]
A. Score the presence of sleep-related hypoventilationwhen >25% of thetotalsleep timeasmeasured byeither thetranscutane-
ousPC0 and/orend-tldal CO sensor(s) isspentwithaCO >50 mm Hg.
2 2 2
Notes:
1. The end-tidal PCO
l
often malfunctions or pro videsfa lsely low values in patients who have markednasal obstruction, profuse nasal
secretions, areobligate mouthbreathers, or who arerecei ving supplemental oxygenor CPAPduring thePSG.It iscrucial to obtain a
plateauintheend-tidalwaveformforthesignalto beconsidered valid.
2. Transcutaneous PCO
l
monitoringprovides only a semi-quantitative index of trends in alveolar ventil ation, and varies unpredictably
fr om thePaCO
l
typically laggingaflerthe event .
6.PERIODIC BREATHING RULE [RECOMMENDED]
A. Score periodicbreathing if there are>3 episodes of centralapnea lasting >3seconds separated by nomore than20 seconds of
normalbreathing.
AASMManualforScoringSleep, 2007 49
AASM Manualfor Seoring Sleep, 2007 50
IX. PROCEDURAL NOTES
PARAMETERS TO BE REPORTED PROCEDURE NOTES
1.A.I-8. Parameters. No evidence. Adopted and modified from previous AASM practice
[CONSENSUS]
parameter. Consensus ofTask Force with approval by Steering Committee.
I.B.I-IO. Sleep scoring data . No evidence. Adopted and modified from previous AASM
practice parameter. Consensus of Task Force with approval by Steering Com- [CONSENSUS]
mittee.
1.C.1-2. Arousal events. No evidence. Adopted and modified from previous AASM prac-
tice parameter and compliant with mies of Arousal Task Force. Consensus of [CONSENSUS]
Task Force with approval by Steering Committee.
I.D.I-16. Respiratory events. No evidence. Adopted and modified from previous AASM
practice parameter and compliant with mies of Respiratory Task Force. Consen- [CONSENSUS]
sus of Respiratory Task Force with approval by Steering Committee.
1.E.I-JO. Cardiac events. No evidence. Compliant with rules ofCardiac Task Force. Con-
[CONSENSUS]
sensus ofCardiac Task Force with approval by Steering Committee.
1.F.1-4. Movement events. No evidence. Compliant with rules ofMovements Task Force.
Consensus of Movements Task Force with approval by Steering Committee.
[CONSENSUS]
l.G.1-4. Summary statements. No evidence. Adopted and modified from previous
AASM practice parameter. Consensus of Movements Task Force with approval [CONSENSUS]
by Steering Committee.
TECHNICAL AND DIGITAL SPECIFICATIONS PROCEDURE NOTES
I.A . Sampling frequency and filter specifications for routine PSG recordings. No evi-
dence. Non-systematic review on ECG sampling rates and commonly applied
princip les in practice. Consensus of Digital Task Force with approval by Steer-
[CONSENSUS]
ing Committee.
1.B.1-8. Digital PSG recording systems feature s. No evidence. Consensus of Digital Task
Force with approval by Steering Committee.
[CONSENSUS]
1.cI-lO. PSG display and display manipulation. No evidence. Consensus of Digital Task
Force with approval by Steering Committee.
[CONSENSUS]
1.0.1-4. Digital analysis ofPSG. No evidence. Consensus of Digital Task Force with ap-
proval by Steering Committee.
[CONSENSUS]
VISUAL RULES FORADULTS PROCEDURE NOTES
I .A.l. Recommended EEG derivation. Level 4 evidence. Consensus agreement by Vi-
suaI Task Force approved by Steering Committee.
[CONSENSUS]
1.A.2. Alternative EEG derivation. Level 4 evidence. Consensus agreement by Visual
Task Force approved by Steering Committee.
[CONSENSUS]
I.A.3. Ten-twenty application map. No evidence. Consensus vote was not felt neces-
sary, Steering Committee approved as a standardi zed and universally accepted [ADJUDICATION]
procedure.
1.B.1. Recommended EOG derivation. Level 4 evidence. Consensus agreement by Vi-
suaI Task Force approved by Steering Committee.
[CONSENSUS]
1.B.2. Alternative EOG derivation. Level 4 evidence. Consensus agreement by Visual
Task Force approved by Steering Committee.
[CONSENSUS]
I.e. 1-2 EMG derivation. No evidence. Consensus agreement with clarification of spe-
cifie distances and back-up electrode requested by industry and technical revicw [CONSENSUS AND
panel and provided by Visual Task Force chair with Steering Committee ap- ADJUDICATION]
proval.
AASMManual for Scoring Sleep, 2007 51
2.A. Sleep stage terminology, No evidence. Consensus agreement by Visual Task
Force approved by SteeringCommittee.
2.B.I-2 Scoring by epochs. No evidence. Consensus agreement by Visual Task Force
approvedby SteeringCommittee.
2.B.3. Assignmentofepochwith multiplestages. No evidence. Clarification was pro-
vided by agreementofVisualTask Forcechairand SteeringCommittee.
3. StageWdefinitions. Very limited level 3 and 4 evidence. Consensusagreement
by Visual Task Forceapproved by SteeringCommittee.
3.A. Presence ofalpha. Inconsistent level 1and level 2 evidence for reliability and
level 3 evidence for validity. Consensus agreement by Visual Task Force ap-
proved by SteeringCommittee.
3.B. Absence of alpha. Limited evidence. Consensus agreement by Visual Task Force
approved by SteeringCommittee.
4. Stage NI definitions. Limited evidence. Consensus agreement by Visual Task
Forceapprovedby SteeringCommittee.
4.A. StageNI basedon replacementofalpha. Inconsistentlevel 1and 2evidencefor
reliabilityand level3evidenceforvalidity. ConsensusagreementbyVisualTask
Forceapproved by SteeringCommittee.
4.B. StageNI basedon frequency slowing, vertex waves, and sloweye movements.
Limited evidence. Consensus agreement ofVisual Task Force approved by
SteeringCommittee.
5. Stage N2 definitions. Limited level 3 and 4 evidence. Consensus agreement of
Visual Task Force approved by SteeringCommittee.
S.A. Stage N2 based on K complexes and spindles. Consistent level 1and 2 evi-
dence. Decision by Steering Committee and consensus agreement ofVisual
Task Force.
5.B. Stage N2 continuation. Limitedevidence. ConsensusagreementofVisual Task
Force approved by SteeringCommittee.
5.C. StageN2 ending.Limitedevidence,inferredfrom otherrules. Consensusagree-
mentofVisualTask Forceapproved by SteeringCommittee.
6. Stage N3 definition. Consistent levels 3 and 4 evidence. Consensus agreement
ofVisualTask Forceapproved by SteeringCommittee.
6. StageN3 rule. Consistentlevel 1and 2evidence.Decisionby SteeringCommit-
tee and consensusagreementofVisual Task Force.
7. Stage R definitions. Limited evidence. Consensus agreement ofVisual Task
Forceapprovedby SteeringCommittee.
7.A. StageRbased on rapid eye movements, low EMGand EEG.Consistent level 1
and 2 evidence. Decision by Steering Committeeand consensus agreement of
Visual Task Force.
7.B. Continuation ofStage R. Limited evidence. Consensus agreement ofVisual
Task Forceapprovedby SteeringCommittee.
7.C. Stage R ending.Inferred from otherrules. Limited evidence. Consensus agree-
mentofVisualTask Forceapproved by SteeringCommittee.
7.D. ScoringStageN2 at Stage N2-R boundary. No evidence.Cons ensus agreement
ofVisualTask Forceapproved by SteeringCommittee.
7.E. ScoringStageRatStageN2-R boundary. Noevidence.Consensusagreementof
Visual Task Forceapproved by SteeringCommittee.
8. Majorbody movementdefinition.No evidence.ConsensusagreementofVisual
Task Force approvedby SteeringCommittee.
8.A-C. Majorbodymovementrules.No evidence.ConsensusagreementofVisualTask
Forceapprovedby SteeringCommittee.
[CONSENSUS]
[CONSENSUS]
[ADJUDICATION]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[STANDARD]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[STANDARD]
[CONSENSUS]
[STANDARD]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
AASMManual for Scoring Sleep, 2007 52
VISUAL RULES FOR CHILDREN PROCEDURE NOTES
I.A. Ages. Limited evidenee. Consensus agreementof Pediatrie Task Force approved
by SteeringCommittee.
2. Terminology. No evidenee. Consensus agreement ofPediatrie Task Force ap-
provedby SteeringCommittee.
3. Teehniealconsiderations.Adultmiesaeeepted by PediatrieTask Forcewith pe-
diatrieeaveatsprovided innotes.
4. Scoringsleepstages.Limitedevidence.ConsensusagreementofPediatrieTask
Forceapproved by SteeringCommittee.
5. StageW definitions . Limited evidence. Consensus agreementofPediatrieTask
Forceapprovedby SteeringCommittee.
5. StageW rules. Limitedevidence. ConsensusagreementofPediatrieTask Force
approved by SteeringCommittee.
6. Stage NI definitions. Limited evidence.Consensus agreementof Pediatrie Task
Forceapproved by SteeringCornmittee.
6. StageNI mies. Limitedevidence.Consensusagreementof PediatrieTask Force
approved by SteeringCommittee.
7. StageN2 mies.Adultmiesacceptedby PediatrieTask Force.
8. StageN3. Adultmiesaccepted by PediatrieTask Force.
9. StageR.Adultmiesaccepted by PediatrieTask Force.
AROUSALRULE PROCEDURE NOTE
1. ArousalRule.
Durationand EEGchange. Level 1and 2evidence. Decisionby SteeringCorn-
mitteeand consensusof ArousalTask Force.
Specificationfor durationofEMGincreasewas requested bytechnical/industry
and recommended by task force chair. This deeision was then adjudieated by
SteeringCornmittee.
CARDIAC RULES PROCEDURE NOTES
I.A. Single lead. No evidenee. Consensus agreement by Cardiac Task Force approved
by SteeringCommittee.
2.A. Tachycardia. Level 3 and 4 evidence. Consensus agreement by Cardiac Task
Forceapproved by SteeringCommittee.
2.8. Bradycardia. Level 3 and 4 evidence. Consensus agreement by Cardiae Task
Forceapproved by SteeringCommittee.
2.C. Asystole. Limited evidence. Consensus agreement by Cardiac Task Force ap-
proved by SteeringCommittee.
2.D. Wide complex tachycardia. Limited evidence. ConsensusofCardiac Task Force
and approved by SteeringCommittee.
2.E. Narrow complex tachycardia. Limited evidence. Consensus ofCardiae Task
Forceand approved by SteeringCommittee.
2.F. Atrial fibrillation. Ameriean HeartAssociation consensus modified by consen-
sus ofCardiacTask Forceand approved by SteeringCommittee.
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[STANDARD]
[ADJUDICATION]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
AASM Manual for Scoring Sleep, 2007 53
MOVEMENT RULES PROCEDURE NOTES
I.A.I. Leg movements.Evidence level 5. Consensus agreement byMovements Task
Force, approved by Steering Committee.
I.A.2. Leg movements. Evidence level 5. Rule stat es 10 seconds instead of the previ-
ous 5 second rule based on con sensu s agreement by Movements Task Forc e;
approved by Steering Committee.
1.A.3-6. Leg movements . Evidence leveJ 5. Consensus agreement by Movements Task
Force,approved by Steering Committee.
1.B.I. PLM series. Evidencelevel 5. Consensusagreementby MovementsTask Force,
approved by Steering Committee.
I.B.2-S. PLM series. Evidence level 5based on ICSD Consensus.Consensusagreement
by MovementsTask For ce,approved by SteeringCommittee.
2.A. Theminimumdura tion of themuscle burstsforALMAwasremo ved due tocon-
cernsby the techni cal paneland MovementsTask Forceleaderand adjudication
bysteeringcommittee.
2.A.1-3 . Alternating Leg MuscleActivation (ALMA) . Evidence level 4 based on ICSD
Consensus. Consensus agreement by Movements Task Force; approved by
SteeringCommittee.
3.A.I-4. Hypn agogic Foot Tremor (HFT). Evidence level 2 Consensus agreement by
MovementsTask Force;approved by SteeringCommittee
4.A.1-3 Excessive Fragmentary Myoclonus(EFM). Evidence level 4. Consensus agree-
mentby MovementsTask Force,approved by SteeringCommittee.
S.A. 1-2. Bru xism phasic bursts. Evidence Jevel 5.Consensus agreement by Movements
Task Force,approved by SteeringCommittee.
S.A.3. Bru xism tonie bursts. Evidence Jevel 5. Con sensus agreement by Movements
Task Force,approved by SteeringCommittee.
S.A.4. Bruxismepi sodes.Evidence level 5. Consensus agreementby MovementsTask
Force,approved by SteeringCommittee.
S.A.S. Bruxism scoring. Evidence level 2 and evidence level 5. Consensus agreement
by MovementsTask Force,approved by SteeringCommittee.
S.A.6. Bruxism number ofbursts. Evidence level 5.Consensus agreement by Move-
mentsTask Force, approved by SteeringCommittee.
S.A.7. Bruxism amplitude ofindividu al burst. No evidence.Consensus agreementby
MovementsTask Forceplus adjudicati on bySteeringCommitteebased on tech-
nical panel inputand discussionsofthe MovementsTask Force.
6.A. Definitions for REMBehaviorDisorder. Evidence level 3.
REM withoutatoni aand durationofburstsoftransientmuscleactivity.Consen-
susagreementby MovementsTask Force,approved by Steerin g Committee.
Amplitudecriterion and 3secondsequencesoftransientmuscl eactivityrecom-
mended by task forcechairand approved by Steering Committee.
6.A. Rule for REM Behavior Disorder. Evidence level 3. Consensus agreement by
MovementsTask Force,approved by Steering Committee.
7.A.1-2. Rhythmic Movement Disorder(RMD)frequency. Evidencelevel 4. Consensus
agreementby MovementsTask Force,approved by SteeringCommittee.
7.A.3-4. Rhythmic Movement Disorder (RMD) .No evidence.Consensusagreement by
MovementsTask Forceapproved by SteeringCommittee.
RESPIRATORY RULES FOR ADULTS PROCEDURE NOTES
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[GUIDELINE]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[STANDARD]
[CONSENSUS]
[ADJUDICATION]
[CONSENSUS]
[ADJUDICATION]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
l. A. Preferred primary airflow sensor for apnea detection. Limited evidence. Con sen-
[CONSENSUS]
sus agreement by RespiratoryTask Forceapproved bySteering Committee.
AASMManual fo rScoringSieep,2007 54
I.B. Preferred secondaryairfiow sensorfor apneadetection. Limitedevidence.Con-
sensusagreementby RespiratoryTaskForceapproved by SteeringCommittee.
I.e. Preferred airfiow sensor for detection ofa hypopnea. Consistent level 1-5 evi-
dence. Consensus agreement by RespiratoryTask Force approved by Steering
Committee.
I.D. Acceptablesensors for detection ofrespiratory effort. Consistent level 1-5 evi-
dence. Consensus agreement by RespiratoryTask Force approved by Steering
Committee.
I .E. Preferredsensorfor detectionofbloodoxygen.
Useofpulseoximetry. No evidence. Consensusagreementby RespiratoryTask
Force, approved by SteeringCommittee.
Pulseoximetryaveragingtimes. Level3-4 evidence. No agreementby Respira-
toryTask Force,adjudicatedby SteeringCommittee.
2. Eventduration rules.
2.A. Identificationofbreathsbeginningand endingevents. Limited level4evidence.
Consensus agreement by Respiratory Task Force, approved by Steering Com-
mittee.
2.B. Identification ofbeginning and end ofevents with large variability. Limited
level4 evidence.Consensusagreementby RespiratoryTaskForce,approved by
SteeringCommittee.
3.A. Scoringapnea.
Amplitude criterion. Level 3-5 evidence. Consensus agreement by Respiratory
TaskForce,approvedby SteeringCommittee.
Durationof eventcriterion.Level3-5 evidence.ConsensusagreementbyRespi-
ratoryTaskForce,approved by SteeringCommittee.
Minimaleventamplitudedurationcriterion. No evidence.Consensusagreement
by RespiratoryTask Force,approved by SteeringCommittee.
3.B. Scoringtypesofapneas. Level 3-5 evidence. Consensusagreementby Respira-
toryTask Force,approved by SteeringCommittee.
4.A. Scoringhypopnea.
Amplitudecriterion. Level3-5 evidence. Recommendationby AASM Board of
Directorsta meetCUITent practice.
Duration criterion. Level3-5 evidence. Consensus agreement by Respiratory
Task Force,approvedby SteeringCommittee.
Desaturation criterion . Level 2-5 evidence. Recommendation by AASM Board
ofDirectors to meetCUITent practice.
No arousal criterion. Limited level 2 and 5 evidence. Recommendation by
AASM Board ofDirectorsto meetcurrentpractice.
Minimal eventamplitudeand durationcriterion.No evidence. No agreementby
RespiratoryTask Force,adjudicated by SteeringCommittee.
4.B. Scoringhypopnea.
Amplitude criterion. Level 3-5 evidence. Consensus agreement by Respiratory
Task Force,approved by SteeringCommittee.
Duration criterion. Level 3-5 evidence. Consensus agreement by Respiratory
Task Force,approved by SteeringCommittee.
Desaturation criterion. Level 2-5 evidence. Consensus agreement by Respira-
toryTask Force,approved bySteeringCommittee.
Arousal criterion. Limited level 2 and 5evidence. Consensusagreementby Re-
spiratoryTask Force,approved by SteeringCommittee.
Minimaleventamplitudeand durationcriterion. No evi dence. No agreementby
RespiratoryTask Force,adjudicatedbySteeringCommittee.
[CONSENSUS]
[STANDARD]
[STANDARD]
[CONSENSUS]
[ADJUDICATION]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[ADJUDICATION]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[ADJUDICATION]
AASM Manual for Scoring Sleep, 2007 55
5.8.
Respiratory Effort Related Arousal (RERA. Limited level 3-5 evidenee. No
agreementamong Respiratory Task Force members and Teehnieal Committee,
adjudicatedby SteeringCommittee.
6.A.
Hypoventilation Rule. No evidenee.Consensusagreementby RespiratoryTask
Force, approved by Steering Committee. The Respiratory Task Force did not
endorsemethodology for PC0 measurement.
2
7.A.
Chey ne Stokes breathing. No evidenee. Consensus agreement by Respiratory
Task Force, approvedby SteeringCommittee.
RESPIRATORY RULES FOR CHILDREN PROCEDURE NOTES
I.A. Preferred primaryairflow sensor forapnea deteetion. Limited level 3evidenee.
Consensus agreement by PediatrieTask Force approved by Steering Commit-
tee.
I.B. Preferred airflow sensor for deteetionofa hypopnea. Limited level 3evidenee.
Consensusagreement by the PediatrieTask Force approved by Steering Com-
mittee.
I. e. Acceptablesensorsfordeteetionofrespiratoryeffort. Consistentlimited level 3
evidenee. Consensusagreementby thePediatrieTaskForce approved bySteer-
ingCommittee.
J.O. Preferredsensor fordeteetion ofbloodoxygen. Level3-4evidenee.Consensus
agreementbythe PediatrieTask Force approved by SteeringCommittee.
1.E. Acceptable methods for assessing alveolar hypoventilation. Consistent limited
level 3-5 evidenee. Consensusagreementby the PediatrieTask Force approved
by SteeringCommittee.
2.A. Age eriterion.Limited level 3evidenee. Consensusagreementby the Pediatrie
Task Force approved by SteeringCommittee.
3.A. Seoringobstructiveapnea.
Length eriterion. Level 3evidenee. Consensusagreement bythe PediatrieTask
Force approvedbySteeringCommittee.
Amplitude eriterion. No evidenee. Consensus agreement by the PediatrieTask
Force approved bySteeringCommittee.
Effort eriterion. Level 3-5evidenee.Consensusagreementby thePediatrieTask
Force approved bySteeringCommittee.
Minimal event amplitudeduration eriterion.Level3evidenee.Consensusagree-
ment bythe PediatrieTask Force approvedbySteeringCommittee.
3.B. Seoring mixed apnea. No evidenee.Consensusagreementby Respiratory Task
Forceapproved bySteeringCommittee.
3.e. Seoring central apnea. Limited level 3 evidenee. Consensus agreement by Re-
spiratoryTask Force approvedbySteeringCommittee.
4.A. Seoringhypopnea.
Amplitude eriterion: Conflieting level 2-5 evidenee. Consensus agreement by
PediatrieTaskForce approvedbySteeringCommittee,
Length eriterion. Level 3-5 evidenee. Consensus agreement by PediatrieTask
Force approvedbySteeringCommittee.
Minimaleventamplitudedurationeriterion.Noevidenee.Consensusagreement
byPediatrieTask Force approved bySteeringCommittee.
Assoeiatedevent criteria. Limited level 3-5 evidenee.Consensusagreement by
PediatrieTask Force approvedbySteeringCommittee.
4.B. RERA seoring.
Nasal pressure sensor criteria. Limited level 3-5 evidenee. Consensus agree-
ment byPediatrieTask Force approved bySteeringCommittee.
AASM Montfa!for Scoring Sleep, 2007
[ADJUDICATION]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
[CONSENSUS]
56
Esophageal catheter criteria. Limited level 2 evidenee. Consensus agreement by
Pediatrie Task Force approved by Steering Committee.
[GUIDELINE]
S.A. Sleep related hypoventilation. Leve! 3 evidenee. Consensus agreement by Pedi-
atrie Task Force approved by Steering Committee.
[CONSENSUS]
6.A. Periodie breathing definition. Leve! 3 evidenee. Consensus agreement by Pedi-
atrie Task Force approved by Steering Committee.
[CONSENSUS]
AASM Manual for Scoring Sleep, 2007 57
AASM Manual for Scoring Sleep. 2007 58
x.GLOSSARY Of TERMS
Apnea: An interruption of airflow lasting at least 10 seconds in adults or the equivalent of 2 breaths in children.
Alpha rhythm: An EEG pattern consisting of trains of sinusoidal 8- 13 Hz activity recorded over the occipital region with eye closure and
attenuating with eye opening.
Asystole: An interruption of cardiac rhythm lasting more than 3 seconds.
At r ial fibrillat ion: An irregularly irregular ventricular rhythm associated with replacement of consistent P waves by rapid electrical oscil-
lations.
Beta rhythm: An EEG rhythm consisting of 13-30 Hz activity.
Bradycardia: A sustained heart rate less than 40 beats per minute.
Bruxism: Grinding or clenching of the teeth during sleep that is often associated arousal.
Cheyne Stokes breathing: A breat hing rhythm with a specified crescendo and decrescendo change in breathing amplitude.
Co nsens us: Aspecified agreement of appropriateness amongst a minimum of 7 individuals using RAND/UCLA methods.
Delt a rhythm: An EEG rhythm consisting of 1-4 Hz activity.
Dominant post erior rhythm: An EEG pattern with frequency appropriate to age which is observed over the occipital regions during re-
laxcd wakefulness with eyes closed and attenuates with eye opening or attention.
Excessive fragment ary myoclonus: Limb EMG activit y of a specified frequency and duration often unassociated with visible moveme nt;
not a defined disorder.
Eye blinks: EOG event s consisting of conjugate vertical eye movements at a frequency of 0.5-2 Hz present in wakefulness with the eyes
open or closed.
Guideline: A recommendation based on level 2 evidence or a consensus of leve! 3 evidence .
Hypnagogic foot t remor : Trains of EMG activity of the lower limb with a specified frequency, not a defined disorder.
Hypnagogic hyper synchrony: An EEG pattern consisting of paroxysmal runs or bursts of diffuse high amplitude sinusoidal 75 to 350
!JV, 3-4.5 Hz waves which begin abruptly, are usually widely distributed but often maximal over the central, frontal, or frontocentra l scalp
regions
Hypopnea: Aspecified reduction in airflow lasting at least 10 seconds in adults or the equivalent of2 breaths in children.
Hypo ventil ation: A specified period of increased PC0
2
of >50 mm Hg in children or a rise of PaC0
2
during sleep of 2:: 10 mm Hg in
adults.
K complex: An EEG event consisting of a weil delineated negative sharp wave immediately followed by a positive component standing out
from the background EEG with total duration 2:: 0.5 seconds, usually maximal in amplitude over the frontal regions.
Low amplitude, mi xed frequency acti vity : An EEG pattern consisting of low amplitude, predominantly 4-7 Hz activity,
Low chin EMG tone: Baseline EMG activiry in the chin derivat ion no higher than in any other sleep stage and usually at the lowest level
of the entire recording.
Narrow compl ex tachycardia: A sustained cardiac rhythm lasting a minimum of3 consecutive beats with QRS duration ofless than 120
rnsec and a rate of greater than 100 per minute.
Periodic Limb Movements of Sleep: Movements of the limbs during sleep and occurring with a specified frequency, duration, and am-
plitude.
Rapid eye movements : EOG events consisting conjugate, irregular, sharply peaked eye movements with an initial deflection usually last-
ing <500 msec.
Reading eye movements : EOG events consisting of trains of conj ugate eye movements consisting of a slow phase foJlowed by a rapid
phase in the opposite direction as the subject reads.
REM Beha vior Disorder: A parasomnia characterized by relative atonia during REM and associated with potentially harmful dream-en-
acting behaviors.
Respiratory effort related arousal: A sequence of breaths lasting at least 10 seconds which does not meet criteria for an apnea or hypop-
nea and is characterized by increasing respiratory effort leading to an arousal from sleep.
Rh ythmic Movement Disorder: Repetitive, stereotyped and rhythmic motor behaviors that occur predominantly during drowsiness or
sleep and involve large muscle groups.
Rhythmic theta activity: An EEG pattern consis ting of runs of 6-7 Hz rhythmic theta activity maximal over the frontal or frontocentral
regio ns
Sawtooth waves: An EEG pattern consis ting of trains of sharply contoured or triangular, often serrated, 2-6 Hz waves maximal in ampli-
tude over the central head regions and often, but not always, preceding a burst of rapid eye movements.
Sleep spindle: An EEG event consisting of a train of distinct waves with frequency 11 - 16 Hz (most commonly 12-14 Hz) with a duration
2:: 0.5 seconds, usually maximal in amplit ude over the central regions.
Slow eye movements: EOG events cons isting of conj ugate, reasonably regular, sinusoidal eye movements with an initial deflection usually
lasting >500 msec.
Sta ndar d: A recommendation based on lcvel 1evidence or overwhel ming level 2 evidence.
Th eta rhythm: An EEG rhythm consisting of 4-8 Hz activity,
Transient muscl e act ivity: Short irregular bursts of EMG activity usually with duration <0.25 seconds superimposed on low EMG tone.
The activity may be seen in the chin or anterior tibial EMG derivat ions, as weil as in EEG or EOG deviations, the latter indicating activity
of cranial nerve innervated muscles. The activity is maximal in association with rapid eye movements.
Ver tex shar p waves (V waves): An EEG pattern consisting of sharply contoured waves with duration <0.5 seconds maximal over the
central region and distinguishable from the background activity.
Wide complex ta chycardia: A sustained cardiac rhythm lasting a minimum of 3 consecutive beats with QRS duration of greater than or
equa l ta 120 msec and a rate of greater than 100 per minute.
AASM Manualfo r Scoring Sleep, 2007 59