بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. SLEEP STAGE SCORING BY Prof . Mohammad El –Desouky Abou-Shehata Prof. Of Thoracic Medicine Sleep Medicine Unite Mansoura University

3. Sleep

4. Objectives Definition and Historical pre Sleep stages Sleep architecture

5. History Of Sleep In Greek mythology,sleep was considered a state similar to death and as such, the goddess of night, Nxy was portrayed as the mother of both god of sleep, hypnos ,and the god of death,Thanatos ,Aristotle recognised sleep was characterised by relative inattention to the environment an physical immobility and suggested that sleep reflected the time needed to replinish “Power” lost from systems involved in sensory perception during wakefulness Sleep was originally considered a time of brain inactivity it is now recognised, however,that sleep is an extremely active process as evidenced by a highly predictable change in brain electrical activity.muscle,activity,and autonomic control

6. بسم الله الرحمن الرحيم اللَّهُ يَتَوَفَّى الأَنفُسَ حِينَ مَوْتِهَا وَالَّتِي لَمْ تَمُتْ فِي مَنَامِهَا فَيُمْسِكُ الَّتِي قَضَى عَلَيْهَا الْمَوْتَ وَيُرْسِلُ الأُخْرَى إِلَى أَجَلٍ مُسَمًّى إِنَّ فِي ذَلِكَ لآيَاتٍ لِّقَوْمٍ يَتَفَكَّرُونَ  سورة الزمر ايه 42

7. Definition Of Sleep Sleepis a naturally recurring state characterized by reduced or lacking consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles.It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, but it is more easily reversible than hibernation or coma

8. Historical Prespectives of Sleep Staging IN 1937 Loomis and colleaguesnoted fragmentation and fallout of alpha rhythm with sleep onset, and subsequent onset of sleep spindles, K complexes and high amplitude slow waves. Sleep was divided into 5 stages (A-E), with later stages possessing more slow-frequency and high-amplitude waves. In 1957 Kleitman and Dement :The discovery of rapid eye movement (REM) sleep led to a classification of sleep stages that included REM sleep. In 1968, Rechtschaffen and Kalesstandardized manual for the scoring of sleep stages. - Sleep stages were divided into wakefulness, stage 1-4 (non-REM), or REM . - At least 1 EEG lead was recommended (C3 or C4 referenced to the opposite ear or mastoid) - 2 electro-oculogram (EOG) leads and a submental electromyography lead. - The R and K rules recommended dividing the polysomnographic record of sleep into 30 second epochs, commencing at the start of the study In 2004,(AASM): Introduced new sleep scoring manual that would address sleep staging as well as the scoring of arousals, respiratory, cardiac, and movement events

9. Why We SLEEP ? Sleep is necessary for survival. In animal studies : The normal life span of rats is 2-3 years. However, rats deprived of sleep live for only about 3 weeks. They also develop abnormally low body temperatures and sores on their tails and paws The sores probably develop because of impairment of the rats’ immune systems.

10. Sleep Importance IN human studies SLLEEP DEPRIVATION metabolic activity of the brain decreases significantly after 24 hours of sustained wakefulness. a decrease in immune system function as measured by white blood cell count impairment of memory and physical performance and reduced ability to carry out mathematical calculations Release of growth hormone in children and young adults takes place during deep sleep Sleep deprivation can also cause increased heart rate variability Most cells of the body show increased production and reduced breakdown of proteins during deep sleep maintain optimal emotional and social functioning while we are awake.

11. Normative Sleep Stage Data Normative values have been constructed based on sleep staging results to help quantify the composition and quality of sleep. Normative data change with age and vary from center to center. In addition, most were collected using the R and K rules.

12. Sleep Stage Nomenclature R&K AASM Wake Stage W Stage W NREM Stage 1 N1 Stage 2 N2 Stage 3 N3 Stage 4 REM Stage REM Stage R AASM = American Academy of Sleep Medicine2; NREM = non–rapid eye movement; R&K = Rechtschaffen and Kales A1; REM = rapid eye movement; stages 3 and 4 are combined into stage N3.

13. Electroencephalographic Electrode Nomenclature LEFT RIGHT MIDLINE • Frontopolar Fp1 Fp2 Fpz • Frontal F3 F4 Fz • Central C3 C4 Cz • Occipital O1 O2 Oz • Mastoid M1 M2

14. Sleep Cycle A complete sleep cycle, from the beginning of stage I to the end of REM sleep, usually takes about one and a half hours. REM sleep represents 20-25% of the total sleep time. REM sleep follows NREM sleep and occurs 4-5 times during a normal 8- to 9-hour sleep period. The first REM period of the night may be less than 10 minutes in duration, while the last may exceed 60 minutes. In a normal night’s sleep, bouts of REM occur every 90 minutes.

15. Sleep cycle A complete cycle lasts around 90 to 110 minutes. So eight hours of sleep will give you around five of these sleep cycles per night

16. Sleep Stage Scoring Electroencephalography EEG Electro-oculography EOG Electromyography EMG

17. Cortical Signals Electrocephalic Waves Delta is the slowest activity at <4 cycles per second (cps). Theta is 4-8 cps. Alpha is 8-13 cps. Beta is >13 cps

19. Characteristic of Alpha Rhythm and Sleep Spindles

20. Characteristic of K complex and slow wave activity

21. K complex associated with arousal

22. EOC – K complex in-phase –REM out-phase

23. Eye Movement Pattern

24. Sleep Stage Scoring SCORING BY EPOCHS The AASM scoring manual continues the convention of staging sleep in sequential 30-second epochs. Each epoch is assigned a sleep stage. If two or more stages coexist during a single epoch, the epoch is assigned the stage comprising the greatest portion of the epoch.

25. Wake Stage AASM RULE Epochs

26. Stage N1 Scoring

27. Stage N1

29. Stage N2 Scoring

30. Stage 2 scoring

31. Stage N2

32. Stage N3 Scoring Stage N3 Rules A. Score stage N3 when 20% or more of an epoch consists of SWA, irrespective of age (20% of 30-sec epoch = 6 sec). 1. EEG: SWA ≥ 20% of the epoch (≥6 sec), sleep spindles may be present in stage N3. 2. EOG: Eye movements are not typically seen during stage N3 sleep. 3. EMG: In stage N3, the chin EMG is of variable amplitude, often lower than in stage N2 sleep and sometimes as low as in stage R sleep.

33. Stage N3 sleep (30-sec epoch). The dotted lines in F4-M1 are 75 μV apart. The grid lines are 1 second apart. Slow wave activity is present in all 30 seconds of the epoch

34. Stage R Stage R A low – amplitude EEG without KCs or SSs REMS Low EMG tone - These three component of stage R may not all start or stop at the same time - Not all epochs of stage R have REMS - Therefore, special rules are needed fore the start, contnuation and end of sage R as well as transition from N2 to REM stage

35. Stage - R

36. Stage -R

37. Continuation of stage R: Continue to score stage R Sleep, even in the absence of REMs, for epochs following one or more epochs of stage R if a. EEG continues to show low-amplitude mixed-frequency activity without K complexes or sleep spindles. b. Chin EMG: Tone remains low (at REM level).

38. End of Stage R

39. End of Stage R ( transition to stage W or N3

40. End of REM sleep : increase in chin EMG activity

41. Stage R Interrupted by arousal

42. End Stage R by transition to N2

43. Transition from definite N2 to R

44. Transition from stage N2 to R

45. Interruption of Stage R by K complex

46. Stage N1 is scored after an arousal during stage N2 sleep.

47. MAJOR BODY MOVEMENTS An MBM is defined as movement and muscle artifact obscuring the EEG for more than half an epoch to the extent that sleep stage cannot be determined

49. Scoring Major Body Movement

50. Arousals Arousals are transient phenomenon that may lead to wakefulness or only briefly interrupt sleep. They are worth scoring because patients with frequent arousals may have daytime sleepiness even if the total sleep duration is normal. An arousal is scored during sleep stages N1, N2, and N3 (NREM sleep) if there is an abrupt shift of EEG frequency including alpha, theta, and/or frequencies greater than 16 Hz (but not spindles) that lasts at least 3 seconds, with at least 10 seconds of stable sleep preceding the change