PSG Scoring for the Pediatric Patient
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Transcript PSG Scoring for the Pediatric Patient
PSG Scoring
for the Pediatric Patient
Jennifer Chen Hopkins, M.D.
D. ABP, ABIM & Sleep Medicine
Texas Society of Sleep Professionals
October 28, 2011
Objectives
Indications for pediatric sleep study
Normal sleep and EEG changes during childhood
development
Differences between adult and pediatric PSG scoring
and interpretation
Kids who may need
a sleep study
Suspected OSA (snoring + “ADHD”/behavior problems,
tonsillar hypertrophy, Down syndrome, craniofacial
malformation, obesity, HTN)
Suspected Narcolepsy
Suspected PLMD
Suspected seizure disorder
Congenital neuromuscular disorder
Suspected central hypoventilation
Infants: apnea of prematurity, severe GER, ALTEs/SIDS
Normal sleep in kids
Birth to 1 year:
Sleep 50-75% of day, gradually decreases
Circadian rhythm begins by 6 mo., still 2-3 naps
NREM-REM cycles shorter (50 min/50 wga), gradually
increases
More REM: 40-50% of TST
Preschool kids:
12-14 hours sleep/24h
Usually phase advanced
Take 1-2 naps
Behavioral sleep problems start
Normal sleep in kids
School-age kids:
9-11 hours sleep/24h
No nap
90 minute NREM-REM cycle
Increase in slow wave sleep
More phase-delayed, towards puberty
Normal sleep
When to use
Pedi Scoring Rules
2 months to 12 yrs – use pedi rules
13 yrs to 17 – can use either adult or pedi
rules
Better to use 3% desat if use adult rules
(C. Marcus, SLEEP v33, n10, 2010)
Normal Pediatric
Sleep EEG
Normal EEG in kids
ODR (“alpha”)
present at birth
Spindles
2 to 3 mo
Delta waves
4 to 5 mo
K-complex
4 to 6 mo
Occipital Dominant Rhythm
(ODR)
- AKA: Dominant Posterior Rhythm (DPR)
- Their “alpha” rhythm
- Occipital leads during eyes closed
Occipital Dominant Rhythm
(ODR)
Development of EEG
Characteristics
Spindles
2 to 3 mo
Delta waves
4 to 5 mo
K-complex
4 to 6 mo
Infants:
- May have to stage sleep as Quiet (N) vs.
Active (R) sleep.
- Use other parameters to help stage: eye
movements, chin tone, RR, HR, etc.
Things that look funny but really
are quite normal…
Tracé alternans
Hypnagogic
hypersynchrony
Trace Alternans
- NREM sleep
- Seen in full term newborns (until 3 mo)
Hypnagogic hypersynchrony
- Synchronous, high voltage theta
waves associated with sleep onset
- Seen in infants and children
Pediatric Scoring:
Respiratory Events
Respiratory Events
OA
90% decreased flow
At least 2 missed breaths
OH
50% decreased nasal pressure for at least
2 breaths
Associated with arousal or 3% desaturation
Respiratory events
RERA
Discernable fall or flattening of nasal pressure, but
<50%
Snoring or increase in pCO2
Increased respiratory effort
At least 2 breaths
Central Apnea
Absence of respiratory effort for 2 breaths +
arousal or 3% desaturation
20 sec or longer without arousal or desat
Pedi Diagnostic Criteria
for OSA
Mild
AHI 1 to 5
Moderate
AHI 5 to 15
Severe
AHI >15
Only need 7 events during a 7 hour PSG to earn
a diagnosis of Sleep-disordered breathing!!!
Other respiratory
considerations
Hypoventilation: >25% of TST with CO2 >50
mm Hg
Periodic breathing: >3 episodes of central
apnea lasting >3 sec, separated by no more
than 20 sec of normal breathing. (Physiologic in
infants)
Non-invasive CO2
End Tidal CO2 (more common)
Transcutaneous CO2
Periodic Limb Movements
PLMS in kids are scored the same way as in
adults.
Only need PLMAI ≥ 5 for diagnosis of PLMD.
Can support a diagnosis of RLS.
Take-Home Points
Kids need sleep studies for some of the reasons that
adults do but also for some reasons specific to
Pedatrics (hyperactivity/behavior problems, tonsillar
hypertrophy, dysmorphic features).
EEG characteristics and sleep staging vary
dramatically with age from birth to age 17. Pay
attention to ODR and be able to recognize normal EEG
patterns commonly seen in pedi patients.
Respiratory scoring in pediatrics: NOT the same as
adults. Being meticulous is paramount because every
event counts!
References
The AASM Manual for the Scoring of Sleep and
Associated Events, 2007.
Sheldon SH, Ferber R, Kryger MH. Principles and
Practice of Pediatric Sleep Medicine, 2005.
C. Marcus, “Differences in Overnight PSG Scores
using Adult and Pediatric Criteria for Respiratory
Events in Adolescents”, SLEEP v33, n10, 2010.
http://naraamt.or.jp/Academic/kensyuukai/2005
Google images
Questions?