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March 2010 | Volume 19 | Number 1

Remembering AAST Founding President Peter A. McGregor Sr., RPSGT  San

Antonio to Host AAST 32nd Annual Meeting

 Apnea-induced  Low-Pass  BRPT

Hypoxia and Heart Failure

(High Frequency) Filters

Launches New CPSGT Exam

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march2010 | Volume19Number 1

From the editor

By Jon Atkinson, BS, RPSGT his edition of A2Zzz is dedicated to the memory of Peter McGregor, the first registered polysomnographic technologist (RPSGT) and the founding president of the American Association of Sleep Technologists (AAST) - formerly the Association of Polysomnographic Technologists (APT). I was privileged to have known Peter over the years, being present Jon Atkinson, BS, when “Number One” met “Number RPSGT 1,000” on a rooftop at the Los Angeles meeting and having adjudicated with him in the days when the RPSGT exam had a practical component. Most recently at the 30th anniversary celebration of the AAST, I had the opportunity to introduce Peter and Sharon Keenan to the group of people at the foyer reception in Baltimore. I commented that I had always marveled at his insight in spurring the development of our organization, which started with a small group of about 20 people and now has nearly 5,000 members. We are all in some fashion bonded to each other through Peter McGregor. The present is a reflection of our past, which is a window into our future. See pages 13-15 for tributes by doctors Sharon Keenan, Mark Pressman and Michael Thorpy. Another recent passing of note is Verne Hulce, who was well known in the Michigan sleep and neurodiagnostics arena. Verne was a true gentleman with a little devilish sense of humor, and he was a huge advocate for sleep medicine, neurodiagnostics and education. I had the pleasure of rooming with Verne during a board examination on a blustery Minneapolis weekend in November 1993. A tribute by Connie Kubiak is found on pages 34-35. The annual meeting in San Antonio is just around the corner. Here is an opportunity to acquire over half the continuing education credits (CECs) necessary to maintain your RPSGT credential in one meeting. It is also a great time for networking, gathering with old friends and colleagues and making new acquaintances. For more information see page 5 and browse through the preliminary program that was mailed together with this issue. Lastly, I would like to draw your attention to the Certification Update on page 37. There are numerous changes coming up from the Board of Registered Polysomnographic Technologists (BRPT) including a revised exam blueprint for the RPSGT exam, a new entry-level Certified Polysomnographic Technician (CPSGT) exam, and upcoming on-demand testing and real-time results. Wow, some exciting changes are taking place to advance our profession.


Table of Contents From the President................................................................ 8 AAST News Briefs.................................................................. 9 San Antonio to Host AAST 32nd Annual Meeting............... 10 In Memoriam: Peter A. McGregor, 1928-2010........... 13-15 Continuing Education Credit Offering................................ 16 AAST CEC Evaluation Form................................................. 17 Apnea-Induced Hypoxia and Heart Failure.................. 18-19 Sleep Disorders and Fibromyalgia............................... 20-21 Enhancing Conventional Sleep Medicine with Herbal Supplements..................................................... 22-24 AASM Scoring Manual FAQ's - Continued..........................25 Cardiac Corner: Name that Arryhythmia...................... 26-27 Technical Corner: Low-Pass (High Frequency) Filters................................................ 28-29 Legal Notes: When Should a Sleep Lab Sign a NonDisclosure Agreement?................................................ 30-31 Patient's Perspective: Humidification for CPAP.................32 Commentary: Shifting Sleep Norms..................................33 In Memoriam: Verne D. Hulce, 1942-2009................. 34-35 Education and Training Update..........................................36 Certification Update............................................................ 37 Classified Ads......................................................................38 Sleep Fragments.................................................................38

Father Jon

Submit an original article for publication in A2Zzz. The deadline for the June issue is March 21, 2010. See page 6 for details.

A2Zzz 19.1 | March 2010

This year, the AAST 32nd Annual Meeting will be held in San Antonio, Texas, from June 6-9, 2010. Register by April 21 to receive a substantial discount on registration. The 32nd Annual Meeting features four days of educational and networking opportunities, including: • Postgraduate Courses • AAST Workshops • Invited Lecturers • Symposia • Discussion Groups • Focus Groups • AAST Membership Meeting • Philips Respironics’ AAST Membership Appreciation Reception • Awards Ceremony For more information on these topics and to register, please visit the AAST Web site at The AAST 32nd Annual Meeting has been approved for up to 26.50 hours of Continuing Education Credits (CECs); an application has been submitted to the American Association for Respiratory Care (AARC) for Continuing Respiratory Care Education (CRCE) contact hours for respiratory therapists.


Official publication of the American Association of Sleep Technologists (AAST)

About A2Zzz

A2Zzz is published quarterly by the American Association of Sleep Technologists (AAST), One Westbrook Corporate Center, Suite 920, Westchester, Illinois 60154. Postage paid at Eau Claire, Wisconsin.

Advertising: Advertising is available in A2Zzz. Please contact the AAST national office for information concerning A2Zzz rates and policies, or find more details online at

Learning Objectives: Readers of A2Zzz should be able to do the following: • Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options • Interpret this information to determine how it relates to the practice of sleep technology • Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments • Apply this knowledge in the practice of sleep technology

Disclaimer: The statements and opinions contained in articles and editorials in this magazine are solely those of the authors thereof and not of the American Association of Sleep Technologists (AAST); the American Academy of Sleep Medicine (AASM), which provides management services for the AAST; or of either organization’s officers, regents, members or employees. The appearance of products and services, and statements contained in advertisements, are the sole responsibility of the advertisers, including any descriptions of effectiveness, quality or safety. The Editor; Managing Editor; AAST; AASM; and each organization’s officers, regents, members and employees disclaim all responsibility for any injury to persons or property resulting from any ideas, products or services referred to in articles or advertisements in this magazine.

Annual Subscription Rates: Subscription to A2Zzz is included as a member benefit of the AAST. Subscription rates (non-members and institutions) for 2010, Volume 19: $60, outside U.S. $140. Submissions: Original articles submitted by AAST members and by invited authors will be considered for publication. Published articles become the permanent property of the AAST. Change of Address: Changes of address should be submitted four to six weeks in advance of the change to ensure uninterrupted service. Members of the AAST can edit their address online when they log in at www. Subscribers also can send to the AAST national office their new address, the effective date of change and a copy of the current mailing label showing the old address. Postmaster: Send change of address to AAST, One Westbrook Corporate Center, Suite 920, Westchester, IL 60154. Missing Issue Claims: Claims for missing issues must be submitted within 60 days of the publication date by fax to the AAST at (708) 273-9344 or by e-mail to Permission to Use and Reproduce: A2Zzz is published quarterly by the AAST, all rights reserved. Permission to copy or republish A2Zzz material is limited by restrictions. Visit to view the full A2Zzz permissions and use policy. Reprints: Contact the AAST national office for orders of 100 reprints or more.

Mission: To promote and advance the sleep technology profession through the continued development of educational, technical and clinical excellence in sleep disorders.

Vision: To preserve the autonomy and future of the sleep technology profession by providing educational and professional pathways with innovative approaches that promote professional growth and development Purpose: To provide a voice for the professionals who ensure the safe and accurate assessment and treatment of sleep disorders One Westbrook Corporate Center, Suite 920 Westchester, IL 60154 Phone: (708) 492-0796 Fax: (708) 273-9344 E-mail: Web: © 2010 American Association of Sleep Technologists


Share your expertise with colleagues in the profession of sleep technology by submitting an original article to A2Zzz. Read the A2Zzz Writer’s Guidelines at To propose an article topic or to get more information, send an e-mail to A2Zzz@ Although articles may be submitted at any time, the deadline for the June issue is March 21, 2010.

Contributors Editor Jon Atkinson, BS, RPSGT

managing Editor Thomas M. Heffron

senior writers

Joseph Anderson, RPSGT, RPFT, CRT Edwin Cintron, RPSGT Will Eckhardt, BS, RPSGT, CRT Reg Hackshaw, EdD, RPSGT Mary Jones-Parker, RPSGT, RRT, RPFT Regina Patrick, RPSGT Theresa Shumard, BA Kimberly Trotter, MA, RPSGT

contributing writers

Kent Caylor, RPSGT, LPN Sharon Keenan, PhD, RPSGT, REEGT Mohammed Quadri, RPSGT Mary Ellen Wells, MS, RPSGT, REEGT

Special features

Jacob Borodovsky Connie Kubiak, REEG/EPT Jayme Matchinski, Esq. Tracy Nasca Mark R. Pressman, PhD Michael J. Thorpy, MD


Barbara Ludwig-Cull, RPSGT

A2Zzz 19.1 | March 2010

cec article review panel Karen Allen, RPSGT, CRT Eric Bell, PsyD Richard Bonato, PhD, RPSGT Rita Brooks, RPSGT Todd Eiken, RPSGT David Gregory, RPSGT Henry Johns, RPSGT, CRT Douglas Kirsch, MD Jennifer May, RPSGT David Wolfe, MSEd, RPSGT, RT

A2Zzz publishes articles that relate to the profession of sleep technology and informs members about recent and upcoming activities of the American Association of Sleep Technologists (AAST).


From the president

By Cindy Kistner, RPSGT, REEGT he profession of sleep technology lost one of its shining stars when Peter McGregor Sr., RPSGT, died Jan. 23, 2010, at the age of 81. I wasn’t yet involved in the profession when Peter led the initiative to establish the Association of Polysomnographic Technologists (APT) in 1978. But I did have the pleasure of meeting him on a couple of occasions, and everything I have heard about him indicates that he was a remarkable AAST PRESIDENT individual and a beloved member of the Cindy kistner, RPSGT, REEGT sleep community. In 2007 the APT became the American Association of Sleep Technologists (AAST), and in 2008 it celebrated its 30th anniversary. The small society that was organized for an emerging profession more than three decades ago has grown into a dynamic association that has more than 4,800 members. This is the legacy of Peter McGregor. Today the AAST remains the only professional society that is dedicated exclusively to advancing the profession of sleep technology. It’s hard to believe that it’s already time to register for the AAST 32nd Annual Meeting, which will be held from June 6 to 9, 2010, in San Antonio, Texas. The seventh-largest city in the U.S., San Antonio is full of culture and has a charming feel that I am sure you will enjoy. The downtown River Walk’s blend of galleries, restaurants and shops creates a European atmosphere, and the historic Alamo is a symbolic reminder of a bygone era. Much of the excitement in San Antonio will be happening inside the Henry B. Gonzalez Convention Center, where the premier educational meeting for sleep technologists will take place. Chair Stephen Tarnoczy, RPSGT, RRT, and the AAST Program Committee have put together a full day of postgraduate courses and a three-day general session that will provide exceptional learning opportunities for sleep technologists at every level of experience. You should refer to the preliminary program for complete details. Make plans to attend one of the four postgraduate courses that will be offered on Sunday, June 6: Scoring of Sleep, Pediatric Sleep, Making the Management Transition, and Topics for the Advanced Practitioner. All of the courses are ticketed events and have limited seating, so be sure to register in advance. This also will be the second year that the meeting’s program includes focus groups, which are informal, small-group, moderated discussions on hot topics in the profession. You can pre-register to attend one of these five focus groups: Legal Regulatory Issues, How Big is Accreditation?, RPSGT Certification Exam, Automated Scoring, and State Sleep Societies. The registration form for the focus groups is available on the AAST Web site at As an AAST member you receive reduced registration fees for the meeting, and you can save even more when you register prior to April 21, 2010. After you register for the meeting, you also may want to reserve your hotel room through the APSS San Antonio Housing Bureau to receive discounted room rates available


only for meeting attendees. Rooms in the hotels located closest to the convention center will fill up fast, so don’t procrastinate. Register for the meeting and make your hotel reservation today at The annual meeting also provides attendees an opportunity to earn up to 26.5 continuing education credits (CECs), which you will be able to claim online after the conclusion of the meeting. (The fee for CECs is included in the general registration fee for AAST members.) Then you can easily keep track of all your AAST CECs using the online AAST CEC transcript. Hopefully you’ve already logged in as a member on the AAST Web site to view your CEC credits. This new feature is an exclusive benefit that is available only to AAST members. You can keep track of the credits you’ve earned from educational providers that offer AAST continuing education credits, verify that recent credits you’ve earned have been recorded, and print your transcript at your own convenience. Earning CECs is just as convenient when you register for one of the AAST webinars. These 60-minute, online sessions provide a quick learning opportunity that you can enjoy from the comfort of your own home or office. The Advances in Sleep Technology Series will continue this spring with “Inter-scorer Reliability and Gold Standard Scoring” on March 10, and “Use of Pulse Transit Time during Sleep Monitoring” on May 12. In between these two sessions, a new Career Enhancement Series will begin with a “Research” webinar on April 14. Get complete details about all of these webinars on the AAST Web site. In closing, let me issue two important reminders. First, there is still time left for you to invest in your profession by making a three-year commitment to volunteer for one of the seven AAST standing committees. I encourage you to review the committee mandates to find the one that will provide the best fit for your talents and interests. All of the information you need is in the Call for Volunteers on the AAST Web site. Finally, be sure to cast your vote in the upcoming AAST online election, which will begin in mid-March and remain open for two weeks. An e-mail containing the election login will be sent to each AAST regular member, so you need to make sure that you have a valid e-mail address on file with the AAST. You can check your e-mail address and update you contact information when you log in as a member on the AAST Web site. Four positions on the AAST board of directors will be open for election this year: president-elect, secretary and two directorsat-large. Watch your e-mail inbox for the important election message, and make your vote count by participating in this year’s AAST election. I look forward to seeing you in San Antonio. Sleep Well,

A2Zzz 19.1 | March 2010



Registration is open for the American Association of Sleep Technologists (AAST) 32nd Annual Meeting, which will be held at the Henry B. Gonzalez Convention Center in San Antonio, Texas, from June 6 to 9, 2010. The meeting begins with four postgraduate courses on Sunday, June 6, and the general session from Monday to Wednesday incorporates a wide variety of educational opportunities. Receive a discount on registration fees when you register prior to April 21. The deadline for all advanced registrations is May 26. When AAST members register for the meeting, the fee for continuing education credits (CECs) is already included in the AAST member general registration fee. The meeting is held in conjunction with SLEEP 2010, the 24th Annual Meeting of the Associated Professional Sleep Societies LLC (APSS). The registration fee for the AAST Annual Meeting includes admission to AAST and SLEEP 2010 general sessions, as well as to the SLEEP 2010 exhibit hall. Blocks of rooms have been reserved at several hotels in San Antonio for meeting attendees. The discounted room rates are only available until Friday, May 7, 2010, or until the room blocks sell out. Reservations must be made directly with the APSS San Antonio Housing Bureau. For more details, to register online, or to reserve a hotel room, visit the AAST Web site at


AAST members attending the 32nd Annual Meeting in San Antonio, Texas, have an opportunity to participate in a focus group, which is an informal, small-group, moderated discussion on an important topic in the profession. Focus groups will be held on Monday, June 7, 2010, from 5:15 p.m. to 6:45 p.m. at the Henry B. Gonzalez Convention Center. There is no additional fee to attend. Seating is limited to 10 registrants per focus group, so you will need to pre-register for this educational activity. Use the registration form on the AAST Web site at to pre-register for one of these five focus groups: “Legal Regulatory Issues” Jayme Matchinski, JD “How Big is Accreditation?” Brian Foresman, DO “RPSGT Certification Exam” Becky Appenzeller, RPSGT

AAST members will fill out ballots online to elect officers and directors in the 2010 election. Watch your e-mail inbox in March for an important message with voting instructions. You can verify and update the e-mail address that you have on file with the AAST when you log in as a member at


AAST webinars are a convenient way to improve your knowledge and understanding of key issues related to the practice of sleep technology. A webinar is a real-time, online seminar that is led by an expert in the profession. The interactive Web conferencing system allows you to listen to the speaker as you view his or her presentation during these 60-minute, online sessions. Visit the AAST Web site at for detailed information and to register today for these upcoming webinars: “Inter-scorer Reliability and Gold Standard Scoring” Advances in Sleep Technology Series March 10, 2010   “Foundations of Clinical Research: Research Project Planning” Career Enhancement Series April 14, 2010 “Use of Pulse Transit Time during Sleep Monitoring” Advances in Sleep Technology Series  May 12, 2010


A Technologist’s Guide to Performing Sleep Studies is a new resource that provides step-by-step instructions for collecting sleep study data from patients. It includes suggestions for putting the patient at ease; reviewing the patient’s symptoms and medications; attaching the sensors; preparing to record; making biological calibrations; detecting and correcting artifacts; and completing documentation. A joint publication of the AAST and the American Academy of Sleep Medicine (AASM), this 92-page guide is an excellent introduction to sleep technology and can be used as a review text for those with sleep center experience. Purchase your copy in the online store on the AAST Web site at


“Automated Scoring” Richard Bogan, MD “State Sleep Societies” Timothy Ruse, MEd, RPSGT



You can now retrieve and print a transcript of your AAST continuing education credits (CECs) online. Log in as a member on the AAST Web site at and click on the “My CEC Credits” link at the top of the webpage.

The Fundamentals of Sleep Technology – Preparing for Certification is a review course designed to help sleep technicians study for the registry exam. It features real-time video alongside an electronic presentation on CD-ROM. The course has four package options to suit your needs – each with the same content and the same total AAST CEC value. AAST members can earn up to 12.00 AAST CECs by purchasing and viewing this product, which is available in the online store on the AAST website at 

A2Zzz 19.1 | March 2010


San Antonio to Host AAST 32nd Annual Meeting


an Antonio, Texas, will host the American Association of Sleep Technologists (AAST) 32nd Annual Meeting from June 6 to 9, 2010, at the Henry B. Gonzalez Convention Center. As the premier educational event for sleep technologists, the AAST 32nd Annual Meeting will provide outstanding learning opportunities, current information and a diverse program that focuses on the latest trends, practices and advances in the profession. When you walk outside the convention center, you will find yourself deep in the heart of one of the most unique and vibrant cities in the U.S. One story below the bustling street level is the River Walk, which winds along the banks of the San Antonio River. The River Walk is lined with restaurants, galleries and shops, as well as quiet pathways that surprise you with outdoor art and relaxing patios. The River Walk’s new “Museum Reach” stretches north along the river, where it connects to the San Antonio Museum of Art, which is renowned for its Latin American folk art collection. You can climb aboard a river taxi to help you explore the downtown section of the River Walk by water. Or take a river tour to learn more about San Antonio’s rich history. San Antonio’s historic sites include the Mission Trail, which links four 18th-centrury Spanish missions. The city’s fifth historic mission is the Alamo, site of the legendary 1836 battle between the Texans and the Mexican army. The Alamo sits in the heart of

the city, with a chapel façade that beckons photographers and a museum that contains relics from the Republic of Texas. The King William District is a 25-block area near downtown on the south bank of the San Antonio River. In the late 1800’s it was the most elegant residential area in the city. Today the historic district offers a stunning glimpse of early-American architecture and luxury. Market Square, also know as El Mercado, is the largest Mexican market north of the Rio Grande. Both El Mercado and the nearby Farmers Market Plaza feature family-owned shops and food courts that combine the cultural, artistic and ethnic influences of the Southwest. The 343-acre Brackenridge Park is adjacent to both the river and the San Antonio Zoo. Among its attractions is the Japanese Tea Garden, which has year-round floral displays, stone bridges, a Koi habitat and a 60-foot waterfall. Outside the city are popular attractions such as Six Flags Fiesta Texas, SeaWorld San Antonio and Natural Bridge Caverns, an incredible underground world of natural beauty. Take a 75-minute tour through a half-mile of the cavern to view the spectacular rock formations. Experience all that San Antonio has to offer when you attend the AAST 32nd Annual Meeting. Get discounted registration fees when you register prior to April 21, 2010. Go to to register today! 


AAST members attending the 32nd Annual Meeting in San Antonio, Texas have an opportunity to participate in Focus Groups, an educational activity introduced at last year’s AAST annual meeting. Members will have the opportunity to participate in one of the following Focus Groups: Legal Regulatory Issues Moderator: Jayme Matchinski, JD How Big is Accreditation? Moderator: Brian Foresman, DO RPSGT Certification Exam Moderator: Becky Appenzeller, RPSGT Automated Scoring Moderator: Richard Bogan, MD State Sleep Societies Moderator: Timothy Ruse, MEd, RPSGT Focus Groups will be held on Monday, June 7, 2010 from 5:15 pm to 6:45 pm at the Henry B. Gonzalez Convention Center. Participation in Focus Groups is limited to 10 registrants per topic. To participate in this educational activity, members will need to pre-register. There is no additional fee to attend, but seating is limited to 10 participants per group. The registration form for the Focus Groups can be found on the AAST Web site at AAST members can earn up to 1.50 AAST CECs for participating.

A2Zzz 19.1 | March 2010

American Association Sleep Technologists




American Association of Sleep Technologists tOne Westbrook Corporate Center, Suite 920, Westchester, IL 60154 P : 708-492-0796 tF : 708-273-9344 tE-mail: tWeb Site:

Educational Resources






Sleep Technology Self Assessment Exam Part I Prepare for the registry exam with this self-assessment tool, which is based on the AASM scoring manual and comprises 100 questions with a referenced answer key.






Sleep Technology Self Assessment Exam Part II Part II continues where Part I leaves off with an additional 100 questions and a referenced answer key.






Normal and Abnormal Record Flashcards, (2009) This set of 138 flashcards will help you review normal and abnormal EKG records.






Registry Exam Flashcards, 2nd Edition 2008 This comprehensive set of 168 flash cards allows you to prepare for the registry exam anytime and anywhere.






Pediatric Flashcards, 1st Edition 2008 This innovative set of 50 flash cards will help you gain a better understanding of the unique aspects of pediatric sleep studies and pediatric sleep disorders.






Technologist’s Guide to Performing Sleep Studies The Guide is an excellent introduction to sleep technology and can be used as a review text for those with sleep center experience.






1) Emergencies in the Sleep Center






2) Central and Complex Sleep Apnea






3) Parasomnias






4) Making a CPAP Clinic Work in Your Facility






5) Developing Formal Sleep Education Programs






6) Pediatric Sleep Medicine & Technology






7) Seizure Disorder






8) EKG Complex Arrhythmias






9) State Legistlation (No CEC offered)











AAST 10-20 Head Measurement Chart This reference & training tool is designed to assist sleep technologists with converting head measurements to determine electrode placement.






Manual Titration of PAP in Patients with OSA & Sleep Related Sleep Disturbances This reference & training tool is designed to provide quick access to CPAP & BiPAP protocols.






2007 Salary and Benefits Survey This 63-page survey provides compensation and benefits information received from 156 accredited sleep centers throughout the U.S.






AAST Policy and Procedure Manual This reference tool assists sleep disorders center personnel in the development of a policy and procedure manual. The manual includes sample forms and policies, job descriptions and core competencies.






Artifact & Troubleshooting Guide This unique guide is a quick-reference that will help you recognize and correct 32 different recording artifacts that can appear during polysomnography.






Advances in Sleep Technology Webinar Series This new professional educational opportunity provides individuals with 1.00 CEC for each webinar topic.

Technical References

 Continued on Page 12 Page 1 of 2


Member #

Subtotal (pg. 1):

 Continued from Page 11

Page 2 of 2

Fundamentals of Sleep Technology - Preparing for Certification - 1st Edition Promotional pricing good until April 1, 2010

The Fundamentals of Sleep Technology - Preparing for Certification is a review course designed to help sleep professionals study for the registry exam and features real-time video alongside an electonic presentation. The course has four package options - each has the same content and the same total AAST CEC value, but it’s divided to suit your needs. Item#




The Full Course includes the entire course recording session in two CD-ROMs. Also included are a course Price after April 1 book with printouts of each presentation and the Self Assessment Exam Part II. Earn up to 12.00 AAST CECs.

Full Course









Full Course - Institutional





The Institutional Version is intended for sleep center managers looking to provide credits to their technologists. It includes 5 copies of the course and 5 copies of the course book, allowing up to 5 technologists to claim 12.00 AAST CECs at a discounted price.

Price after April 1




Fundamentals of Sleep Technology Collection The Fundamentals of Sleep Technology Collection breaks up the course into three CD-ROMs, each available separately. This edition is perfect if you are only looking to study one broad area in preparation for the exam. 4.00 AAST CECs each. 1) Intro to Sleep






2) Performing and Scoring the Polysomnogram






3) Treatments and Other Topics








Fundamentals of Sleep Technology Set The Fundamentals of Sleep Technology Set breaks up the course into six CD-ROMs, each available separately. This edition is perfect if you are only looking to study a particular area in preparation for the exam. 2.00 AAST CECs each.

Price per collection after April 1

1) Introduction to Sleep Medicine






2) Physiology of Sleep






3) Performing the Polysomnogram






4) Scoring the Polysomnogram






5) Pediatrics in Sleep






6) Treatment and Other Topics








Price per set after April 1

Subtotal (pg. 2): ________

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E-mail: ___________________________________ Orders accepted online, by mail or fax. Please allow up to two weeks for delivery.

*For a Visa or MasterCard, the validation code is the last 3 numbers in the signature box. For an American Express, the validation code is the 4 numbers above the credit card number.

Prepayment only, no purchase orders accepted. The AAST does not accept returns


remembering aast founding president


to represent our Society in the best possible way.” McGregor held the office until 1983, when he was succeeded by Sharon Keenan, PhD, RPSGT, REEGT. He was a lifelong proponent of professional education, training and certification for sleep technologists. “We must keep our standards high and let’s get our examination curriculum developing at a high level, because there is no room for second best,” he wrote in a past-president’s report in 1983. “Sleep Disorders Centers are now rapidly developing and there will be a need for capable technologists at every level, including supervisors and managers. It is very important to have our members well trained and prepared.” From 1983 until his retirement in 1993, McGregor was the manager of the Montefiore Sleep-Wake Disorders Center, working alongside Dr. Michael Thorpy, who became the center’s medical director in 1982. During his career, he also worked as an educational consultant and lectured on sleep medicine, instrumentation and sleep stage scoring. He also was a technologist examiner for the Board of Registered Polysomnographic Technologists (BRPT). In 1984 McGregor was the recipient of the inaugural Elliot D. Weitzman, MD Service Award, which is presented each year to a member of the AAST in recognition of service and dedication to the advancement of the sleep technology profession. He also received the inaugural German Nino-Murcia, MD Achievement Award in 1997, earning recognition as an AAST member who best exemplifies excellence in the performance of a polysomnogram and in patient care. In 1995 the first annual Peter A. McGregor, RPSGT Service Award was presented to a member of the AAST who has exhibited outstanding service and contribution to the association and organizational development. In 2008 at the AAST 30th Anniversary Reception in Baltimore, Md., both McGregor and Keenan were recognized for the significant contributions they made to the establishment and development of the AAST. McGregor is survived by his loving wife Barbara (Yatsko) McGregor; his dear children Kenneth Dean Tucker, Barbara Tucker O’Brochta, Thirsa Ann Paray and Peter McGregor, Jr.; and beloved grandchildren Adam Paray and Kimberly Tucker.

 Continued on Page 14

eter A. McGregor Sr., RPSGT, the founding president of the American Association of Sleep Technologists (AAST), died Jan. 23, 2010, at the age of 81. McGregor, who was born in Edinburgh, Scotland, Aug. 9, 1928, played an instrumental role in the growth and development of both the AAST and the profession of sleep technology. As a colleague and friend, he was respected and loved by all who knew him. “As the founding president of the American Association of Sleep Technologists, Peter McGregor was a visionary and an outstanding leader,” said AAST President Cindy Kistner, RPSGT, REEGT. “He will be missed by everyone who had the privilege of knowing him, but his contributions to the development of both the AAST and the profession of sleep technology will continue to have a lasting impact on the sleep field.” McGregor received a Bachelor of Science degree in Edinburgh and began his career as an electronic technician before coming to the U.S. in 1960. At that time, he took a position as a research assistant at Columbia-Presbyterian Medical Center in New York. In 1964 at Albert Einstein College of Medicine, he began his work in sleep research with Dr. Elliott Weitzman. The department moved to Montefiore Medical Center in 1969, with McGregor serving as the chief polysomnographic technologist, conducting both human and animal sleep research. The Sleep-Wake Disorders Center at Montefiore Medical Center became the first sleep disorders center to earn accreditation from the American Academy of Sleep Medicine in 1977. In 1978 McGregor was the elected chairperson of the founding Steering Committee of the Association of Polysomnographic Technologists (APT), which later became the AAST. In 1979 he was one of seven sleep technologists to take the inaugural certification examination in polysomnographic technology, and he has the distinction of holding the registered polysomnographic technologist (RPSGT) credential #001. In 1981 McGregor was elected the first president of the AAST. “First of all let me say that I appreciate your vote of confidence on being elected President of APT,” he wrote in a president’s report to the members. “My first term of office was on an interim basis until this election. I can assure you all that I will do my best

peter a. McGregor Sr., RPSGT 1928 - 2010

 Continued from Page 13



By Mark R. Pressman, PhD I first met Peter in 1978 at Montefiore Hospital in the Bronx. He taught me most of my basic tech skills including scoring. At the time I was a graduate student in psychology working with Dr. Arthur Spielman. I also worked as a sleep tech on the night shift, three nights per week. Peter was chief cook and bottle washer for the Sleep-Wake Disorders Center, at the time one of only four sleep centers in the U.S. and the first accredited center anywhere. The standard equipment of the time was Grass 78D polysomnographs and paper – lots and lots of paper. Oh, and ink - if your fingers weren’t stained with black ink each morning you probably slept through your shift. These were formative years with the foundation of new professions and new societies. Peter was of the opinion that sleep techs needed to have a proper society and certification if they were to be treated by the hospital establishment

as professionals and paid accordingly. From these concerns came the APT (now AAST) and the BRPT. The first exam was held in 1979. The decision to hold the first RPSGT exam was a major one. The exam had to be designed and written literally from scratch. As opposed to the digital, computer-based exam of today, the major part of the first exam was practical: real set-ups, collodian, paper, ink, recording and scoring. Two groups of examiners were recruited: techs and docs. After much discussion, Peter decided to be in the first group of examinees, and I became an examiner. This was a major decision. Peter was one of the driving forces in the technology field and was almost always in charge. Now he was an examinee, subject to the whims of examiners and a test that had never been given before. One part of the exam proved especially tricky. It had been decided that as part of the practical examination, examinees had to demonstrate their knowledge of the recording equipment. We


By Sharon A. Keenan, PhD, RPSGT, REEGT My first recollection of Peter was as a voice on the phone while I was seated at a Grass Model 8. He was talking me through the interface of the PT5 volumetric pressure transducer to be used with chest bellows to monitor breathing. This was in 1977. Earlier that year Dr. Calvin Stafford of Crozer-Chester Medical Center and I attended a lecture in Baltimore given by Dr. Elliot Weitzman. Dr. Stafford and I were expanding the services of the EEG lab to include all-night sleep studies, and Peter’s assistance was invaluable in the process. I met him in June 1978 at a meeting of the Association for the Psychophysiological Study of Sleep at Rickey’s Hyatt Hotel in Palo Alto, Calif., hosted by Dr. Bill Dement’s group at Stanford. Peter was given permission to organize a gathering of individuals who were responsible for collecting data during sleep. Some of us worked in research settings, some in a clinical environment, but all of us knew what it was to watch as someone or something slept. It was wonderful. Peter had the insight to recognize that we needed an organization to give us a voice. He also encouraged us to establish an examination process to allow for the demonstration of competence in the critical set of skills and knowledge demanded to collect high-quality data. The Association of Polysomnographic Technologists was a strong organization from its inception. Peter’s combined talents in science and technology, coupled with his gregarious and winning nature, were a great force in rallying all of us who shared the burdens and the blessings of working in the sleep lab. Most of us had the experience of being the academic or clinical “stepchild” of some larger entity. Work space and lab space often were carved out of basements or stairwells, and equipment had to be moved to beds that became available to perform the sleep studies. Peter was also a great teacher. Many will recognize the name of the late Dr. German Nino-Murcia. German’s appreciation of Peter’s talents was evidenced by his weekly train trips from Jefferson Hospital in Philadelphia to Montefiore Medical Center in New York. German would carry PSGs by hand (pre-HIPPA days) to review with Peter to learn sleep stage scoring, detection of abnormal events and recognition of artifact. This led to German’s ever-present appreciation for the contribution of the technologist to the practice of sleep medicine. And it was our appreciation of this recognition that led to the establishment of the award in his name. It is fitting that Peter was the first recipient of this award. Peter’s leadership of the APT was driven by principles of dedication to the highest quality of work and recognition of the skills necessary to do good work, creating a voice and mechanism for a group of individuals who may have gone unrecognized for a long time. We remain grateful to Peter McGregor, our Number 1, our First President. His impact on polysomnography and sleep medicine has been forever woven into our history. Sharon A. Keenan, PhD, RPSGT, REEGT, is the founder and director of The School of Sleep Medicine Inc. in Palo Alto, Calif.

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15 decided to do this by literally sabotaging the 78Ds and having the examinees troubleshoot and correct the problems before proceeding with calibrations and recordings. For those of you who have never seen a Grass 78D, it is as big as a refrigerator with a bank of 12-24 separate amplifiers up the back. Each amplifier was connected by cables to a strip in the back. A large chart drive was in front. Additional cables were connected to galvanometers on which pens were mounted. Well, I guess we were caught up in the excitement of the first examination, realizing that we were actually asked to sabotage Peter McGregor’s polysomnograph – with permission! We went overboard and essentially disabled the entire machine. The lights were on, but nothing worked! Those of you who were lucky enough to know Peter knew that he was basically a gentle soul, and a little Scottish accent might be detectable from time to time. However, if he got excited or angry – a very rare occurrence in my experience – the Scottish accent appeared. I always thought his level of annoyance and anger could be measured by just how strong a Scottish accent was present. Well, the exam began and Peter began to work on his dysfunctional 78D. Ten minutes passed, and a Scottish accent was now detectable. James Bond? Twenty minutes passed, and his Scottish accent now resembled Scottie from Star Trek: “Captain, she’s not gonna’ hold together!” Thirty minutes later, and everything still was not working. The accent now had a definite resemblance to Scrooge McDuck or maybe Groundskeeper Willie from the Simpsons. What had we done? We – the tech examiners – were getting really apprehensive. What if we had messed up the equipment so badly that the founder of sleep technology actually ran out of time and failed the exam??!! Fortunately, the 78D suddenly hummed back to life just in time, all amps and pens firing. Peter passed with flying colors and a new profession was born. Peter forgave us, but when I would see him at annual meetings, he would often wag his finger at me. I always knew exactly what that meant. Mark R. Pressman, PhD, is director of sleep medicine services at Lankenau and Paoli Hospitals, professor at Lankenau Institute for Medical Research and clinical professor of medicine at Jefferson Medical College in Philadelphia, Pa.


I first met Peter in 1980 when I joined Montefiore Medical Center as a fellow. When I first arrived in New York, Peter quickly became a very good friend as well as a helpful and trusted colleague. In 1982 Dr. Elliot Weitzman, then the director of the SleepWake Disorders Center, left the institution. Peter chose to remain at Montefiore and helped me, as the newly appointed director, continue the clinical and research activities of the facility. Peter’s strengths were not just his technical ability, which was clearly superior, but his personality and willingness to help whenever and wherever there was a need. During the early stages of the transition Peter would not only perform overnight sleep studies and MSLTs, and run the sleep lab, but he also helped out with administrative and secretarial duties when the need arose. He subsequently became the administrator for the Sleep-Wake Disorders Center, a position he held until he retired in 1993. Despite his retirement Peter continued in a part-time capacity and always made himself available to help with sleep studies, teaching or administrative duties. Over the years Peter trained not only many technologists but also many physicians in how to perform and read sleep studies. I recall one situation when Peter and I were asked to set up a sleep lab on the stage of the Phil Donahue show at the CBS studios in New York City. We sought out the worst sleep apnea patient we could find, someone who was very obese and could not stay awake in any situation. Dr. Bill Dement was there with a narcoleptic poodle that ran around the stage having cataplectic episodes. Peter brought in a Grass model P78 machine and set up the lab in a side room. After connecting the patient and turning down the lights, we waited for the patient to sleep. Peter used his best abilities to get the patient to sleep, but to no avail. It was impossible. Surrounded by cameras and being on the Donahue show was too much for the patient. We ended up getting some drowsy tracings that probably meant as much to the audience as sleep stages, anyway. Over the years I knew Peter, I counted him as one of my very best friends. Although he will be recognized for his leadership in founding the APT (now AAST) and for being both its first president and the first registered polysomnographic technologist (Reg #001), it is Peter’s personality that all of those who knew him will remember most. The APT could not have had a finer first president, not just for his technical ability, but because he led the way in being a role model for how the good technologist should be professionally. Peter’s devotion to quality in technical aspects; an understanding of the history of electrophysiology and the early development of the field of polysomnography; his kind, generous and personable personality; and his willingness to teach others and pass on his knowledge without conditions made Peter stand out as the perfect role model for the future technologist. Michael J. Thorpy, MD, is the director of the Sleep-Wake Disorders Center at Montefiore Medical Center and professor of neurology at Albert Einstein College of Medicine in Bronx, N.Y. 

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continuing education credit offering Instructions for Earning Credit

A Registered Polysomnographic Technologist (RPSGT™) can read A2Zzz to earn continuing-education credits (CECs) that are required for recertification by the Board of Registered Polysomnographic Technologists (BRPT). The American Association of Sleep Technologists (AAST) offers 1.5 AAST CECs for each quarterly issue of A2Zzz. To earn credit carefully read four of the designated CEC articles from the list below and complete the AAST CEC Evaluation Form on the next page. You must fax your completed form to the AAST national office, or have it postmarked, by the deadline of May 14, 2010. A confirmation letter acknowledging that you have earned 1.5 AAST CECs will be mailed six to eight weeks after the deadline to participating technologists who successfully complete this activity. It is the responsibility of each technologist to maintain a record of his or her CEC certificates. The AAST also validates AAST CECs as a free benefit for members.


The A2Zzz continuing education credit offering is a free benefit for AAST members. An individual who is not an AAST member is required to become an A2Zzz subscriber and pay a $20 administrative fee with each AAST CEC Evaluation Form that he or she submits.

Statement of Approval

This activity has been planned and implemented by the AAST Board of Directors to meet the educational needs of sleep technologists. The BRPT has approved this activity and designates it for a maximum of 1.5 hours of continuing education. Each technologist should only claim credit for the time that he or she actually spends in the educational activity.

Statement of Educational Purpose/Overall Educational Objectives

A2Zzz provides current sleep-related information that is relevant to sleep technologists. The magazine also informs readers about recent and upcoming activities of the AAST. CEC articles should benefit readers in their practice of sleep technology or in their management and administration of either a sleep disorders center or a laboratory for sleep related breathing disorders. Readers of A2Zzz should be able to do the following: ▪ Analyze articles for information that improves their understanding of sleep, sleep disorders, sleep studies and treatment options ▪ Interpret this information to determine how it relates to the practice of sleep technology ▪ Decide how this information can improve the techniques and procedures that are used to evaluate sleep disorders patients and treatments ▪ Apply this knowledge in the practice of sleep technology

Read and evaluate four of the following articles to earn 1.5 AAST CECs: Apnea-induced Hypoxia and Heart Failure Objective: Understand how apnea-induced hypoxia may negatively impact cardiac function, especially in people with heart failure

Page # 18

Sleep Disorders and Fibromyalgia Objective: Understand that patients who have fibromyalgia may have comorbid sleep disorders and may present in the sleep laboratory with extreme fatigue


Enhancing Conventional Sleep Medicine with Herbal Supplements Objective: Understand how patients with hypertension, depression or seizures may benefit from using specific herbal supplements


AASM Scoring Manual Frequently Asked Questions – Continued Objective: Understand some of the rules in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications


Cardiac Corner: Name that Arrhythmia Objective: Use established principles to analyze and identify cardiac arrhythmias


Technical Corner: Low-Pass (High Frequency) Filters Objective: Understand the function of a low-pass filter and when it should be used


A2Zzz 19.1 | March 2010



To earn 1.5 hours of continuing-education credit (CEC), carefully read four of the designated CEC articles from the list on the previous page. Then evaluate each article using the statements on this form. When completing this form be sure to include in the appropriate blanks the page number for each article that you read. After you have completed and signed this form you must fax it to the American Association of Sleep Technologists (AAST) national office, or have it postmarked, by the deadline of May 14, 2010, in order to receive credit. This service is free to AAST members. An A2Zzz subscriber who is not an AAST member is required to include payment of a $20 administrative fee with this form. Nonmembers who do not have an A2Zzz subscription must contact the AAST national office to become a subscriber. A confirmation letter acknowledging that you have earned 1.5 AAST CECs will be mailed six to eight weeks after the deadline to participating technologists who successfully complete this activity. According to the BRPT recertification guidelines participants can accumulate no more than 15 CECs over five years for this type of activity. 5=Strongly Agree, 4=Agree, 3=Unsure, 2=Disagree, 1=Strongly Disagree 1. Educational value: I learned something new that was important. I verified some important information. I plan to discuss this information with colleagues. I plan to seek more information on this topic. My attitude about this topic changed in some way. This information is likely to impact my practice. 2. Readability feedback: I understood what the authors were trying to say. I was able to interpret the tables/figures (if applicable). Overall, the presentation of the article enhanced my ability to read and understand it.

Article 1 Page# _______

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3. Additional comments/feedback to be used by the AAST CEC Committee:

4. Commitment to change:

What change(s), if any, do you plan to make in your practice as a result of reading any of these 4 articles?

5. Statement of completion: I attest to having completed the AAST CEC activity (sign below). Signature


Phone: ________/________/________Fax: ________/________/ ________ Name (please print legibly)



Address City



Are you a member of the AAST?  Yes  No AAST Membership No: If you are not an AAST member, then are you an A2Zzz subscriber?  Yes No Non-members who do not have an A2Zzz subscription must contact the AAST national office to become a subscriber. Non-members who have a subscription must complete the following payment information:

 Check made payable to the AAST for $20 is enclosed or  Charge $20 to (circle one): VISA / MasterCard / American Express Card#:

Cardholder name (please print)

Expiration Date /



Cardholder Address

You must fax your completed form to the AAST national office, or have it postmarked, by May 14, 2010 AAST National Office, One Westbrook Corporate Center, Suite 920, Westchester, IL 60154, Fax: (708) 273-9344


Apnea-induced hypoxia and heart failure By Regina Patrick, RPSGT


eart failure is a condition in which the heart does not pump blood efficiently. Inefficient pumping can occur if the heart can not fill with enough blood or if heart contractions are not sufficiently strong enough. A person with heart failure may have either of these problems or both. An estimated 40 percent of people with heart failure have obstructive sleep apnea (OSA, the intermittent cessation of breathing during sleep).1 Heart failure patients have a worse prognosis if they also have OSA. Why OSA worsens the course of heart failure is unclear. One possibility may be that changes in intrathoracic pressures during apnea episodes alter the heart’s pumping action, further impairing an alreadyweakened heart’s ability to pump blood. Another possibility may be that repeated arousals resulting from hypoxia in OSA induce activation of the sympathetic nervous system; this increases blood pressure, the heart rhythm, and the heart’s oxygen needs, further stressing an already-weakened heart.2,3 Recent studies point to hypoxia, rather than arousals, as the factor that worsens heart failure. The right atrium of the heart collects unoxygenated blood and, on contracting, expels it into the right ventricle. Once the right ventricle is filled, it contracts, sending the unoxygenated blood to the lungs. After the blood is oxygenated in the lungs, it is transported to the left atrium. When the left atrium contracts, it expels the oxygenated blood into the left ventricle. The subsequent contraction of the left ventricle sends the oxygenated blood through the aorta. The blood then travels throughout the body, bringing oxygen to the body’s tissues. Heart failure typically involves damage to one or both ventricles, although damage to the atria can increase the risk of heart failure. Heart failure due to dysfunction of the left ventricle primarily produces pulmonary symptoms (e.g., dyspnea [difficulty breathing], wheezing, hypoxia, cyanosis), while heart failure due to dysfunction of the right ventricle produces primarily systemic symptoms (e.g., peripheral edema, jugular vein distention, ascites [fluid retention in the abdominal cavity], fainting). Heart failure symptoms may be treated by medications (e.g., diuretics, vasodilators, digoxin); lifestyle changes (e.g., bed rest, dietary changes); devices (e.g., defibrillator); or surgery (e.g., heart transplant). OSA has long been associated with an increased risk of cardiovascular problems such as cardiac arrhythmias, coronary artery disease, left ventricular dysfunction, and hypertension (i.e., high blood pressure).3 In OSA, the cessation of breathing (i.e., apnea) occurs when upper airway tissue collapses into and obstructs the upper airway during sleep, preventing air flow through the respiratory tract. During an obstructive apnea episode, a person continues Regina Patrick, RPSGT Regina Patrick, RPSGT, has been in the sleep field for more than 20 years and works as a sleep technologist at the St. Anne Mercy Sleep Disorders Center in Toledo, Ohio.

to make efforts to breathe, but no air − or an insufficient amount of air − enters the lungs. The effort involved in trying to breathe, and the reduction of oxygen, impacts the heart’s function in several different ways. The inspiratory efforts during an apneic episode can significantly decrease intrathoracic pressure, which allows the right ventricle to expand and fill with an increased amount of blood.2 This distends the right ventricle, which leaves less room for the left ventricle to expand. As a result, the left ventricle is less able to fill with blood. The decreased amount of blood in the left ventricle, combined with the increased force exerted against it by the extra blood in the right ventricle, increases the left ventricle’s afterload (i.e., the pressure against which the ventricle contracts). A chronically increased left ventricular afterload can result in hypertrophy (i.e., increased muscle mass) of the left ventricle. This stiffens the ventricle and reduces its ability to contract efficiently. In a person with heart failure, left ventricular hypertrophy can decrease the pumping action of the heart, thereby worsening heart failure. Another impact of OSA on the heart is that frequent OSAinduced arousals increase sympathetic activity, which triggers vasoconstriction of the peripheral blood vessels (thereby increasing blood pressure) and the release of catecholamines such as epinephrine (thereby increasing the heart rate and the heart’s oxygen needs).2 In people with heart failure for whom the heart is already insufficiently providing oxygen to the body’s tissues, the increased oxygen demand may worsen heart failure by further depleting the heart of needed oxygen. Scientists remain unsure which aspect of OSA – arousals or hypoxia – is more responsible for worsening the course of heart failure. Researchers Joshua Gottlieb and colleagues investigated this subject in a recent study.1 They used brain (B-type) natriuretic peptide (BNP) as a marker of heart stress. This peptide is secreted by heart muscle cells in response to stretching. They hypothesized that the stress placed on the heart during an apneic episode would increase the ventricular production of BNP and, therefore, people with severe apnea would have a significantly greater amount of BNP than someone with no or mild apnea. The patients involved in the study were being treated for heart failure. All of the patients underwent a baseline sleep study. Afterward, they were divided into three groups: a no/mild OSA group (an apnea-hypopnea index [AHI] of less than 5 respiratory events per hour); an intermediate OSA group (an AHI of 6 to 39.9); and a severe OSA group (an AHI greater than 40). The intermediate OSA group was not studied after the baseline night. By comparing the no/mild OSA group with the severe OSA group, the researchers aimed to maximize the sensitivity of their results in detecting significant effects of sleep apnea on BNP levels. The no/mild OSA group and the severe OSA group underwent a second sleep study during which their blood was sampled for BNP levels every 20 minutes throughout the night. Two weeks later the severe OSA group came back for a third night, during which the patients were administered oxygen during sleep while their blood was sampled every 20 minutes for BNP levels. The researchers measured the ejection fraction of each patient’s heart to assess its pumping ability. The ejection fraction is the portion of blood that is ejected

A2Zzz 19.1 | March 2010

19 from the ventricles on contraction. About 68 percent of the blood volume is normally ejected on the contraction of the ventricles; an ejection fraction less than 68 percent can indicate ventricular dysfunction. The researchers found that patients with moderate or severe apnea had a lower ejection fraction (i.e., less efficient cardiac pumping) than the no/mild OSA group. The ejection fraction of patients in the severe OSA group was less than that of the moderate OSA group. They concluded that the heart’s ability to pump is increasingly reduced with increasing severity of OSA. They also found that, although the addition of oxygen in the severe OSA group reduced the total amount of apneic events by 27 percent, there was no significant difference between the BNP levels on night two and night three in this group. This indicated that the number of apnea episodes did not stress the heart. Then they analyzed the collective BNP level results of the no/ mild OSA group and severe OSA group to compare the impact of apnea vs. hypoxia on BNP levels. In doing this, the researchers noted that the BNP levels rose and fell in association with the rise and fall of blood oxygen saturation. By contrast, the BNP level did not rise and fall in association with the frequency of apneic events. Gottlieb and colleagues concluded that changes in the level of BNP were related to the severity of hypoxemia, but not to the frequency of the apnea episodes. A Brazilian research team, headed by Cristiana Marques de Araújo, similarly found that the frequency of apnea events may not be correlated with heart dysfunction.4 Rather than using BNP, the researchers used ischemia (i.e., low blood flow) as a marker of cardiac stress and a measure of the impact of OSA on heart function. The study involved 53 patients who had OSA and were being treated for angina or for ischemic heart disease resulting from myocardial infarction, narrowing of the coronary arteries or multivessel disease. The patients underwent simultaneous polysomnography and continuous electrocardiographic recording using a Holter monitor. From the patients’ electrocardiograms, the researchers determined the number of ischemia episodes that occurred. Based on the patients’ AHI, they were placed in either a control group (an AHI of less than 15); an apnea group (an AHI greater than 15); or a severe apnea group (an AHI greater than 30). They found that the number and duration of ischemic episodes significantly decreased during sleep in all groups. During wakefulness, patients with severe apnea had fewer and shorter ischemic episodes than the controls. From this, they concluded that there was no link between the frequency of apnea episodes (i.e., severity of OSA) and myocardial ischemia. Several studies indicate that OSA treatment – in particular, continuous positive airway pressure (CPAP) therapy – significantly improves heart function in people with heart failure. For example, Canadian researcher Yasuyuki Kaneko and colleagues treated one group of heart failure patients with the normal medical therapy alone.5 They treated a second group of heart failure patients with the normal medical therapy plus CPAP therapy, which prevents apnea by blowing pressurized air into the airway to prevent collapse of tissues into the upper airway during sleep. By preventing apnea, a person’s blood oxygen saturation remains at normal levels, and arousals are eliminated during sleep. The researchers assessed the left ventricular ejection fraction in both groups and found no improvement in the group that received medical therapy alone. By contrast, the left ventricular ejection fraction improved by 35 percent in the group that had been treated with medical therapy and

CPAP. Kaneko and colleagues concluded that CPAP treatment could improve left ventricular function in heart failure patients. Another group of Canadian researchers assessed the left ventricular ejection fraction in heart failure patients before and after CPAP therapy.6 They found that the ejection fraction increased, on average, by 32 percent after one month of treatment with CPAP. Some of the patients were then withdrawn from CPAP treatment for one week, and the ejection fraction was re-assessed. This time the researchers found that the ejection fraction decreased by 15 percent. From these results, they also concluded that CPAP can improve left ventricular function. About 5 million people (both children and adults) in the U.S. have heart failure, and about 300,000 people die from heart failure every year.7 Improving heart function can improve the course of heart failure in some people. People with both OSA and heart failure have a worse prognosis, and treating OSA in people with heart failure improves left ventricular function and other aspects of heart function. Therefore, treating OSA could improve the prognosis of some people with heart failure. However, studies have not yet proven that treating OSA reduces cardiac mortality in heart failure patients. The finding that BNP increases with hypoxia – indicating increased stress on the heart – suggests that preventing hypoxia may be especially important in heart failure patients. Therefore, patients with heart failure may need to be assessed and treated for OSA or other sleep-disordered breathing problems to reduce the impact of intermittent episodes of hypoxia on the heart.


1. Gottlieb JD, Schwartz AR, Marshall J, et al. Hypoxia, not frequency of sleep apnea, induces acute hemodynamic stress in patients with chronic heart failure. J Am Coll Cardiol. 2009 Oct 27;54(18):1706-12. 2. Dorasamy P. Obstructive sleep apnea and cardiovascular risk. Ther Clin Risk Manag. 2007 Dec;3(6):1105-11. 3. Chaicharn J, Carrington M, Trinder J, Khoo MCK. The effects on cardiovascular autonomic control of repetitive arousal from sleep. Sleep. 2008 Jan 1;31(1):93-103. 4. Marques de Araújo C, Solimene MC, Grupi CJ, et al. Evidence that the degree of obstructive sleep apnea may not increase myocardial ischemia and arrhythmias in patients with stable coronary artery disease. Clinics (Sao Paulo). 2009;64(3):223-30. 5. Kaneko Y, Floras JS, Usui K, et al. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med. 2003 Mar 27;348(13):1233-41. 6. Malone S, Liu PP, Holloway R, et al. Obstructive sleep apnea in patients with dilated cardiomyopathy: effects of continuous positive airway pressure. Lancet. 1991 Dec 14;338(8781):1480-4. 7. Department of Health and Human Services. National Institutes of Health (NIH). National Heart, Lung, and Blood Institute. Heart failure: what is heart failure? 2007 December. Available at: dci/Diseases/Hf/HF_WhatIs.html. Accessed Dec. 17, 2009. 

A2Zzz 19.1 | March 2010


sleep disorders and fibromyalgia By Mohammed Quadri, RPSGT


ibromyalgia is a connective-tissue disorder that is a fairly common syndrome. It is characterized by chronic, widespread musculoskeletal pain; multiple “tender points;� fatigue; sleep disturbance; stiffness; and other symptoms such as headache, dizziness, trouble with concentration, irritable bowel syndrome, urinary urgency and depression. Fibromyalgia may occur at any age, even in childhood, and is much more common in women than in men. The cause of fibromyalgia is unknown. It is difficult to diagnose because many of the symptoms are similar to those of other disorders. A hallmark of fibromyalgia is chronic pain. This could be due to neuroplastic changes resulting in central sensitization. Importantly, after central sensitization has been established, only minimal peripheral input is required for the maintenance of the chronic pain state. Additional factors, including pain-related negative affect and poor sleep, may contribute significantly to clinical fibromyalgia pain. Central nervous system (CNS) dysfunction is the main pathophysiological mechanism in fibromyalgia. Current hypotheses center on atypical sensory processing in the CNS, dysfunction of skeletal muscle nociception, and the hypothalamicpituitary-adrenal (HPA) axis. Sleep disturbances also involve CNS dysfunction. Many patients experience difficulty with concentration and memory and many others have mood disturbance, including depression and anxiety. Fibromyalgia is associated with substantial morbidity and disability.1 Current research shows that patients with fibromyalgia experience pain differently from the general population because of dysfunctional pain processing in the CNS. Aberrant pain processing, which can result in chronic pain and associated symptoms, may be the result of several interplaying mechanisms, including central sensitization, blunting of inhibitory pain pathways, alterations in neurotransmitters, and psychiatric comorbid conditions.2 Ghrelin levels increase before meals and decrease after meals. Ghrelin is considered to be the counterpart of the hormone leptin, which is produced by adipose tissue and induces satiation when present at higher levels.3 Patients with fibromyalgia may have mood disorders that are significant predictors of sustained pain. Therefore, it may be helpful to incorporate anxiety and depression scales as screening tools to better manage fibromyalgia patients. The experience of pain can contribute to disturbances in sleep and sleep pattern. When evaluated by overnight polysomnography, Mohammed Quadri, RPSGT Mohammed Quadri, RPSGT, is a foreign medical graduate who has been in the sleep field for three years. He is Project Coordinator Clinical Trials at Hackensack University Medical Center in Hackensack, N.J.

fibromyalgia patients usually have interrupted periods of wakingtype brain activity that result in sleep fragmentation. There is a decrease in delta and sigma waves but an increase in alpha and beta EEG frequencies during sleep. The alpha EEG patterns include phasic and tonic alpha EEG sleep as well as periodic K alpha EEG sleep or frequent periodic cyclical alternating pattern.4 Both sleep duration and quality tend to be worsened in patients with fibromyalgia. Sleep has an upstream role in daily functioning and is directly correlated to negative affect.Thus sleep problems can play a critical role in exacerbating fibromyalgia symptoms. Limited findings also suggest that sleep may predict subsequent pain in this population and may be related to depression through pain and physical functioning.5 Anxiety and depression can cause distress and decrease quality of life, especially when combined with difficulty initiating and maintaining sleep. Women with fibromyalgia and pain have fewer sleep spindles and reduced electroencephalogram power in spindle frequency activity compared with control women of similar age. During overnight polysomnography, stage 2 sleep was shorter in the fibromyalgia subjects. Researchers suggest that analysis of the lengths of individual sleep stages, in addition to the usual sleep stage amounts and percentages listed in standard polysomnogram reports, may have clinical use in the management of fibromyalgia patients.6 The cyclic alternating pattern (CAP) is a long-lasting periodic activity consisting of two alternate electroencephalogram (EEG) patterns. This variation in EEG is closely related to fluctuations in the level of arousal that characterize two different functional states in the arousal control mechanism. In these patients with fibromyalgia the quality of sleep is lessened due to an increase in CAP of sleep. Rizzi and colleagues found that fibromyalgia patients had less sleep efficiency than controls, a higher proportion of stage 1 non-rapid eye movement (NREM) sleep, and twice as many arousals per hour of sleep. The CAP rate (total CAP time divided by NREM sleep time) was significantly increased in fibromyalgia patients compared with controls. CAP rate seemed to correlate with the severity of clinical symptoms in fibromyalgia and with lower sleep efficiency.7 Fibromyalgia often is accompanied by chronic fatigue syndrome (CFS), which involves excessive daytime sleepiness. This subset of patients has significant differences from healthy controls in polysomnographic findings. Sleep disruption related to overwhelming fatigue and pain causes them to feel sleepier and more fatigued after a night of unrefreshing sleep.8 Nonrestorative sleep is a common complaint in the general population, although its prevalence largely varies. Often it is associated with mental disorders and characteristics of sleep deprivation such as extra sleep time on weekends. This sleep pattern often affects working adults and is more likely to cause daytime impairment than difficulty initiating or maintaining sleep. One study compared subjects who reported having nonrestorative sleep with people whose sleep was restorative even though they had difficulty initiating or maintaining sleep. Subjects with nonrestorative sleep reported more frequent daytime impairments (irritability, physical and mental fatigue) than the subjects with

A2Zzz 19.1 | March 2010

21 insomnia, and they consulted a physician twice as often for their sleeping difficulties.9 It is common for patients with obstructive sleep apnea (OSA) to have periodic limb movements in sleep. Risk factors for the development of PLMS include OSA, fibromyalgia, diabetes mellitus, increasing age, predisposing medications, obesity, and OSA.10 Other sleep disorders that can co-occur with fibromyalgia include restless leg syndrome (RLS), bruxism, exploding head syndrome, and sleep myoclonus (a sudden rapid contraction of a muscle or a group of muscles during sleep or as one is falling asleep).


People with fibromyalgia experience lower quality of life due to pain, sleep disturbance, fatigue, depression, anxiety and cognitive impairment. Fibromyalgia can have a negative impact on social, mental, emotional, physical and occupational well-being. Sleep technologists should keep in mind that patients who have fibromyalgia may have comorbid PLMS, OSA, bruxism and alpha intrusions. These patients could present in the sleep laboratory with extreme anxiety, fatigue and other mental health issues.


1. Gur A, Oktayoglu P. Central nervous system abnormalities in fibromyalgia and chronic fatigue syndrome: new concepts in treatment. Curr Pharm Des. 2008;14(13):1274-94. 2. Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007 May 15;146(10):726-34.

3. Tander B, Atmaca A, Aliyazicioglu Y, Canturk F. Serum ghrelin levels but not GH, IGF-1 and IGFBP-3 levels are altered in patients with fibromyalgia syndrome. Joint Bone Spine. 2007 Oct;74(5):477-81. Epub 2007 Jun 29. 4. Moldofsky H. Sleep and pain. Sleep Med Rev. 2001 Oct;5(5):385-396. 5. Bigatti SM, Hernandez AM, Cronan TA, Rand KL. Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression. Arthritis Rheum. 2008 Jul 15;59(7):961. 6. Burns JW, Crofford LJ, Chervin RD. Sleep stage dynamics in fibromyalgia patients and controls. Sleep Med. 2008 Aug;9(6):689-96. Epub 2008 Mar 7. 7. Rizzi M, Sarzi-Puttini P, Atzeni F, et al. Cyclic alternating pattern: a new marker of sleep alteration in patients with fibromyalgia? J Rheumatol. 2004 Jun;31(6):1193-9. 8. Togo F, Natelson BH, Cherniack NS, et al. Sleep structure and sleepiness in chronic fatigue syndrome with or without coexisting fibromyalgia. Arthritis Res Ther. 2008;10(3):R56. Epub 2008 May 13. 9. Ohayon MM. Prevalence and correlates of nonrestorative sleep complaints. Arch Intern Med. 2005 Jan 10;165(1):15-6. 10. Theadom A, Cropley M. Dysfunctional beliefs, stress and sleep disturbance in fibromyalgia. Sleep Med. 2008 May;9(4):376-81. Epub 2007 Aug 2. ď ś

A2Zzz 19.1 | March 2010


enhancing conventional sleep medicine with herbal supplements By Kent Caylor, RPSGT, LPN


any patients presenting to a sleep disorders center have cardiologic, neurologic or psychiatric co-morbidities. Often these patients are prescribed medications that can alter sleep architecture and negatively affect sleep/wake states. Another option is to supplement conventional treatments with herbal supplements, a biologically based practice that is a part of complementary and alternative medicine (CAM). Herbal supplements are a type of dietary supplement that contain a single herb or a mixture of herbs. Unlike drugs, which must receive pre-marketing approval from the U.S. Food and Drug Administration, herbal supplements are subject to neither premarket approval nor a specific postmarket surveillance period. The manufacturers of herbal supplements are responsible for ensuring that their products are safe. Although there is scientific evidence to support the use of some herbal supplements, in many cases there are key questions that have yet to be answered through well-designed scientific studies. Patients who have one of the following medical conditions may benefit from using specific herbal supplements.

sion.5 However, another review published in 2009 concluded that the effect of garlic on blood pressure cannot be ascertained from current research because of inadequate study designs and methodological deficiencies.6 A double-blind, placebo-controlled trial published in 2009 found that time-released garlic powder tablets are more effective than “regular� garlic supplements for the treatment of mild and moderate arterial hypertension.7 The most common side effects of garlic are bad breath and body odor. However, garlic does stimulate liver enzymes responsible for the metabolism of certain medications such as the blood thinner warfarin. This also may have the effect of lowering the blood concentrations of these medications and will produce hypoglycemia when taken with the diabetic drug chlorpropamide (Diabinese).8 Valerian is another herb that may be useful as a complementary treatment for people who have secondary insomnia caused by hypertensive medications. Valerian has been used to treat insomnia as far back as the second century, and its therapeutic use was described by Hippocrates.9 Valerian may have an agonistic effect on GABA receptors, giving it sedative properties.10 Patients also have reported that their nightmares disappeared with valerian use.11 Side effects are generally mild and may include upset stomach, dizziness and headache. Although some research has suggested that valerian may be helpful for insomnia, there remains a lack of evidence from well-designed studies. In 2007 a systematic review of valerian as a sleep aid reported that most studies found no significant differences between valerian and placebo, and none of the most recent studies found significant effects of valerian on sleep.12 A study published in 2009 found that valerian did not improve sleep in a sample of older women with insomnia.13

The manufacturers of herbal supplements are responsible for ensuring that their products are safe.


Studies have shown a strong relationship between obstructive sleep apnea (OSA) and hypertension.1 This means that many patients who are seen at a sleep center for suspected OSA will already be managing their blood pressure with a beta-blocker such as metoprolol. Studies also have shown that positive airway pressure (PAP) therapy can measurably lower blood pressure in OSA patients who are mildly sleepy.2 In most cases, however, the need for continued management of blood pressure with a medication is likely. This creates a dilemma for the sleep medicine provider since lipophilic (i.e., lipid soluble) beta-blockers such as metoprolol tend to provoke hallucinations and nightmares. Although hydrophilic (i.e., water soluble) beta-blockers such as atenolol are less likely to cause these side effects, patients still can experience them.3 Other potential side effects of beta-blockers are fatigue and insomnia.4 An herb that may be helpful for people with OSA and comorbid hypertension is garlic, which has been used for thousands of years to treat various conditions. In 2008 a systematic review and meta-analysis concluded that garlic preparations are superior to placebo at reducing blood pressure in individuals with hypertenKent Caylor, RPSGT, LPN Kent Caylor, RPSGT, LPN, has been in the sleep field since 2006 and is an acquisition technologist for Precision Diagnostic Services in Fargo, N.D.


There is a high rate of depression among people with OSA, and a large cohort study found that OSA is a risk factor for depression.14 Although the exact cause has not been established, there is a clear connection between the two disorders. However, because sleepiness and fatigue occur in both conditions, it can be difficult to establish the existence and severity of one in the presence of the other. One study of nocturnal oxygen supplementation and continuous positive airway pressure (CPAP) therapy found that as sleep quality and oxygen saturations improved, psychological symptoms declined.15 However, oxygen supplementation appeared to have a greater influence on mood than CPAP, suggesting that hypoxemia is more a factor than sleep disturbance. Medications typically prescribed for depression include a family of drugs known as selective serotonin reuptake inhibitors, or SSRIs. Serotonin is a neurotransmitter that is thought to enhance mood as well as promote sleep. Fluoxetine (Prozac) and sertraline (Zoloft) are two examples of SSRIs, which work by inhibiting the reuptake of serotonin. This has the effect of increasing the concentration levels of serotonin, thereby enhancing mood. However, at least one

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23 study has shown that periodic limb movements (PLMs) are more prevalent with SSRI use.4 Another aspect of antidepressants, particularly of the SSRI family, is the suppression of rapid eye movement (REM) sleep. This has led some researchers to propose that REM suppression itself could improve symptoms of depression. At least one study seems to contradict this theory; however, its findings are just as intriguing.16 The German research team found that sleep phase advancement not only increased REM sleep, but enhanced mood as well. The study suggests that there may be a crucial time period in the morning during which the avoidance of sleep may have an antidepressant effect. St. John’s wort was used in ancient Greece, and today in Germany it is the most frequently prescribed antidepressant.10 Hypericin, the active ingredient in St. John’s wort, has the same action as SSRIs in that it inhibits the reuptake of serotonin. An updated review published in 2008 found St. John’s wort to be superior to placebo and similarly effective as standard antidepressants in patients with major depression.17 Another review published in 2009 concluded that current evidence supports the use of St. John’s wort in the treatment of mild to moderate depression.18 When used within its therapeutic range, St. John’s wort has essentially no toxicological effects. Also, unlike SSRIs, it appears that St. John’s wort does not increase PLMs. However, similar to garlic, St. John’s wort may lower blood concentrations of certain medications such as warfarin.



Both conventional medicine and CAM have their strengths as well as their weaknesses; but the two when knowledgeably applied can work well together. In 2007 adults in the U.S. spent $33.9 billion out of pocket on visits to CAM practitioners and purchases of CAM products, classes and materials.24 Because of CAM’s popularity, it is imperative that health professionals become well informed about CAM treatments such as the use of herbal supplements.


Goncalves SC, Martinez D, Gus M, et al. Obstructive sleep apnea and resistant hypertension: a case control study. Chest. 2007;132:1858-62.


Hui DS, To KW, Ko FW, et al. Nasal CPAP reduces systemic blood pressure in patients with obstructive sleep apnoea and mild sleepiness. Thorax. 2006 Dec;61(12):1083-90. Epub 2006 Aug 23.


Westerlund A. Central nervous system side-effects with hydrophilic and lipophilic beta-blockers. Eur J Clin Pharmacol. 1985;28 Suppl:73-6.


Ash C . Drug effects on polysomnography. Advance for Managers of Respiratory Care. 2007;June.


Ried K, Frank OR, Stocks NP, Fakler P, Sullivan T. Effect of garlic on blood pressure: a systematic review and metaanalysis. BMC Cardiovasc Disord. 2008 Jun 16;8:13.


Simons S, Wollersheim H, Thien T. A systematic review on the influence of trial quality on the effect of garlic on blood pressure. Neth J Med. 2009 Jun;67(6):212-9.


Sobenin IA, Andrianova IV, Fomchenkov IV, Gorchakova TV, Orekhov AN. Time-released garlic powder tablets lower systolic and diastolic blood pressure in men with mild and moderate arterial hypertension. Hypertens Res. 2009 Jun;32(6):433-7. Epub 2009 Apr 24.


Izzo AA, Ernst E. Interactions between herbal medicines and prescribed drugs: a systematic review. Drugs. 2001;61(15):2163-75.


National Center for Complementary and Alternative Medicine. Herbs at a glance: valerian. Created May 2006. Updated June 2008. Available at: health/valerian/.

10. Lanca JA. Herbal medications: an evidence-based review.

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 Continued on Page 24

Many patients who suffer from seizures also are treated for sleep disorders. Neurological medications, which act directly on the central nervous system, can affect cognitive abilities; fatigue and daytime drowsiness may result from the use of antiepileptics. Patients periodically complain of disturbed sleep as well. Some of these medications reduce REM sleep.4 Seizures are more apt to occur during arousals and transitions into sleep. As a result, there may be a link between seizure activity and OSA. One small study involving three adults and one child with epilepsy and coexisting OSA found that each person experienced at least a 45 percent reduction in seizure frequency during CPAP treatment.19 Yet to date, a comprehensive trial of CPAP therapy in patients with OSA and epilepsy has not been reported. Having a stroke also increases the risk of developing epilepsy due to possible stroke-induced brain damage. Strokes are responsible for as many as half of all epilepsy cases in those over the age of 65.20 Seizures affect one out of 100 people overall, and the elderly - especially males – have an even higher risk. This means that sleep centers may see a higher percentage of people who present with seizures. For some people conventional antiepileptic drugs do not control seizures very well. As a result some turn to complementary treatment options such as ginkgo. This herb has been used in traditional Chinese medicine to treat a range of disorders. A 2006 study examined the prevalence of herb prescribing in nursing homes for a sample of elderly adults diagnosed with epilepsy/seizure disorder. It found that ginkgo was prescribed more than any other herb.21 Although up to 50 percent of all seizures have no clear pathogenesis, dementia is a leading cause of epilepsy among older adults.20 Some studies have shown ginkgo to be as effective as donepezil (Aricept) in the treatment of the early stages of Alzheimer’s disease, although these findings have not been supported by additional studies.20 In 2009 a systematic review of ginkgo for cognitive im-

pairment and dementia found that the evidence to support ginkgo is inconsistent and unreliable.22 As with garlic and St. John’s wort, ginkgo acts on liver enzymes responsible for the metabolism of certain medications. In this case bleeding occurs when combined with warfarin, and increased blood pressure has been noted when taken with thiazide diuretics.8 One concern about ginkgo use is that uncooked ginkgo seeds contain a chemical known as ginkgotoxin, which can cause seizures. Although ginkgo leaf and ginkgo leaf extracts appear to contain little ginkgotoxin, seizure activity that may have been associated with ginkgo use has been reported.23

 Continued from Page 23

24 CME Resource. 2008 Oct;134(3). Available at: http://www. 11. Eckhardt WW. Herbs and sleep. A2Zzz. 2000 Spring;8(1). 12. Taibi DM, Landis CA, Petry H, Vitiello MV. A systematic review of valerian as a sleep aid: safe but not effective. Sleep Med Rev. 2007 Jun;11(3):209-30. 13. Taibi DM, Vitiello MV, Barsness S, et al. A randomized clinical trial of valerian fails to improve self-reported, polysomnographic, and actigraphic sleep in older women with insomnia. Sleep Med. 2009 Mar;10(3):319-28. Epub 2008 May 14. 14. Harris M, Glozier N, Ratnavadivel R, Grunstein RR. Obstructive sleep apnea and depression. Sleep Med Rev. 2009 Jul 9. 15. Bardwell WA, Norman D, Ancoli-Israel S, et al. Effects of 2-week nocturnal oxygen supplementation and continuous positive airway pressure treatment on psychological symptoms in patients with obstructive sleep apnea: a randomized placebo-controlled study. Behav Sleep Med. 2007;5(1):21-38. 16. Riemann D, Vollmann J, Hohagen F, et al. Treatment of depression with sleep deprivation and sleep phase advancement [article in German]. Fortschr Neurol Psychiatr. 1995 Jul;63(7):270-6. 17. Linde K, Berner MM, Kriston L. St John's wort for major depression. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD000448.

18. Sarris J, Kavanagh DJ. Kava and St. John's Wort: current evidence for use in mood and anxiety disorders. J Altern Complement Med. 2009 Aug;15(8):827-36. 19. Malow BA, Weatherwax KJ, Chervin RD, et al. Identification and treatment of obstructive sleep apnea in adults and children with epilepsy: a prospective pilot study. Sleep Med. 2003 Nov;4(6):509-15. 20. Mayo Clinic. Epilepsy. Mayo Foundation for Medical Education and Research. 2009 Apr 28. Available at: DSECTION=all&METHOD=print. 21. Harms SL, Garrard J, Schwinghammer P, et al. Ginkgo biloba use in nursing home elderly with epilepsy or seizure disorder. Epilepsia. 2006 Feb;47(2):323-9. 22. Birks J, Grimley Evans J. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD003120. 23. Granger AS. Ginkgo biloba precipitating epileptic seizures. Age Ageing. 2001 Nov;30(6):523-5. 24. Nahin RL, Barnes PM, Stussman BJ, Bloom B. Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007. National health statistics reports; no 18. Hyattsville, MD: National Center for Health Statistics. 2009. Available at: 


Make Your Vote Count - Online

This year, AAST members will fill out ballots online to elect Officers and Directors. Watch your e-mail inbox in March for an important message with voting instructions. For more information, visit the AAST website at

A2Zzz 19.1 | March 2010


aasm scoring manual frequently asked questions - continued From the American Academy of Sleep Medicine


he signals specified in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications now must be recorded and used for scoring sleep studies by American Academy of Sleep Medicine-accredited sleep disorders centers and laboratories for sleep related breathing disorders.1,2 The following answers to frequently asked questions regarding the new scoring manual have been printed with permission of the AASM. Responses to other FAQs have been published in previous issues of A2Zzz. A complete list of frequently asked questions is available and is periodically updated on the AASM Web site.3


A.2. There is a disagreement between the scoring of arousals in wake and the scoring of respiratory events in wake. The scoring of arousals allows for one arousal every 13 seconds, resulting in a possible maximum arousal index of 276.9 per hour. Use of this rule introduces the statistical possibility for reporting of an irrational index. The AASM should reconsider its position with regard to scoring arousals in wake epochs, change the guidelines for scoring wake in the concurrence with “scorable” arousals or else change the definition of C2 from the reported arousals per hour of sleep to arousals per hour in bed (Ar/hrTIB). The ability to count respiratory events if they “touch” sleep (R10) and reporting observations in the narrative (R5) help tie respiratory events to sleep fragmentation. FAQ A.1. helps count arousals related to drowsiness/wake [A2Zzz. 2008 17(4);23]. Using epoch scoring rules one could not have a theoretical average of >1 arousal/epoch in wake (for 2 arousals, 10 seconds + 10 seconds = 20 seconds and thus sleep would be the majority of the epoch and would be scored as an epoch of sleep). Excessive scoring of arousals in wake does not seem a practical problem.


P.R.2. In reviewing the respiratory rules for hypopneas in children, the only alternative sensor for detection of airflow for identification of a hypopnea is an oronasal thermal sensor. The option of using an uncalibrated or calibrated inductance plethysmography sensor when the nasal pressure device is not functioning is listed as an alternative option in the adult respiratory rules. It is NOT listed as an alternative for children. Is this an oversight? It’s important to have the option to use an inductance “sum” sensor in children. Directly measured airflow signals placed under the nose like nasal pressure (or even oronasal airflow) are frequently absent or poor quality because of mouth breathing or patient intolerance. Slippage of the inductance plethysmography belts is common in children and the sum channel is not considered to be an accurate measure of flow. Airflow should be measured at the nose in children.


R.23. My question is about respiratory sighs during sleep. Was this normal, physiological event ever addressed during the creation of the new respiratory scoring rules? I would like to know how the committee feels about scoring or not scoring, single or multiple sighs during sleep. There is no mention of sighing at all in the new handbook.

Many phenomena that occur during the recording of sleep studies were not included in the scoring manual because of their uncertain significance. Deep breaths that accompany arousals may be followed by single central apneas though the significance of this phenomenon is not defined.


T. 2. Is there a requirement for CONTINUOUS AUDIO RECORDING during polysomnography under the new guidelines? The manual does not specifically require audio recording. Most laboratories incorporate it within the required video recording process however because there are so many clinical situations in which audio is extremely useful, including but not limited to bruxism, snoring, behavioral disorders, parasomnias, seizures and catathrenia.


V.10. The rule for N3 sleep (p. 27) says that you should score N3 whenever 20% of the epoch consists of slow wave activity. This makes sense if the rest of the epoch is low amplitude mixed frequency EEG, but what if there is an awakening after 6 seconds of dense slow wave activity and alpha rhythm activity for the remainder of the epoch? Would this still be N3? No, this would be scored as W using IV.2.B.3. V.11. R ends with a transition to W (p. 28), but doesn’t end if there is an arousal that is not followed by slow eye movements. What if the arousal consists of a shift to alpha rhythm that lasts 3 seconds? Would that be a transition to W? How about 5 seconds? Or do you need an epoch of W to end R? Arousals in R do not end R. A 3 or 5 second shift to alpha in R requires a 1 second rise in EMG to constitute an arousal in R under Rule V. An epoch containing alpha for greater than 15 seconds would be scored W, ending R.


American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Westchester, Ill: American Academy of Sleep Medicine; 2007.


American Academy of Sleep Medicine. Standards for Accreditation. December 2008. Available at: http://www. Accessed Jan. 25, 2010.


American Academy of Sleep Medicine. Scoring Manual Frequently Asked Questions. Available at: http://www. Accessed Jan. 25, 2010.

Now available from the AASM is A Technologist’s Handbook, a new resource that will help sleep technologists implement The AASM Manual for the Scoring of Sleep and Associated Events in an everyday setting. The handbook includes illustrations of the waveforms and patterns used in sleep scoring, a glossary of important terms and step-by-step instructions for scoring stages and events. Learn more or order a copy by visiting the AASM online store at 

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his is the eighth in a series of recurring columns that will keep cardiac arrhythmias fresh in the minds of sleep technologists. The goal is to present arrhythmias from actual recordings and to analyze them using the principles presented in the recent articles on cardiac arrhythmias in A2Zzz1. The previous columns presented a basic overview of arrhythmia analysis and examples of the AASM scoring manual recommendations.2 The arrhythmias presented in this edition of the Cardiac Corner were recently discussed during the EKG Complex Arrhythmia webinar.3

Step 2. Look at the QRS complex. QRS complexes are present; all QRS complexes look the same in this example. Step 3. Examine the relationship between P wave and QRS complexes. There is a P wave for every QRS complex and a QRS complex for every P wave; a 1:1 P:QRS ratio exists

EXAMINE FIGURE 1. This is a five-second window. Proceed as follows:

Step 4. Examine the intervals (P-R interval and QRS interval). The P-R interval is slightly shorter than normal at 0.10 seconds. The QRS interval is narrow and within normal limits (0.04 - 0.11 seconds), but it could be wider in the presence of bundle branch block.

Step 1. Look at the P wave. A P wave is present at the beat beneath the “X,” but it has a different appearance than other P waves in the example.

Step 5. Examine the rhythm. The rhythm is irregular. There is an increased R-to-R interval between the 2nd and 3rd QRS complex.

Step 2. Look at the QRS complex. QRS complexes are present; all QRS complexes look the same in this example.

Step 6. Determine the rate. The ventricular rate is about 60 beats per minute.

Step 3. Examine the relationship between P wave and QRS complexes. There is a P wave for every QRS complex and a QRS complex for every P wave; a 1:1 P:QRS ratio exists.

EXAMINE FIGURE 3. This is a five-second window. Proceed as follows:

Step 4. Examine the intervals (P-R interval and QRS interval). The P-R interval is normal, between 0.12 and 0.20 seconds. The QRS interval is narrow and within normal limits (0.04 - 0.11 seconds), but it could be wider in the presence of bundle branch block. Step 5. Examine the rhythm. The rhythm is irregular. There is an increased R-to-R interval between the 2nd and 3rd QRS complex. Step 6. Determine the rate. The ventricular rate is about 72 beats per minute. EXAMINE FIGURE 2. This is a five-second window. Proceed as follows: Step 1. Look at the P wave. A P wave is present at the beat beneath the “X,” but it has a different appearance than other P waves in the example; it is inverted. Jon Atkinson, BS, RPSGT

Step 1. Look at the P wave. No P wave is present at the beat beneath the “X.” Step 2. Look at the QRS complex. QRS complexes are present, but the QRS complex of the 3rd beat is distinctly different. Step 3. Examine the relationship between P wave and QRS complexes. There are more QRS complexes than P wave. The P:QRS ratio is less than 1:1. Step 4. Examine the intervals (P-R interval and QRS interval). The P-R interval is normal for the normal beats and non-existent at beat # 3. The QRS interval is normal for the normal beats but is prolonged at about 0.18 seconds in beat #3. Step 5. Examine the rhythm. The rhythm is irregular. There is an increased R-to-R interval between the 2nd and 3rd QRS complex. Step 6. Determine the rate. The ventricular rate is about 48 beats per minute.


Jon Atkinson, BS, RPSGT, is the A2Zzz Editor. He has been in the sleep field for 28 years, and he currently works as a selfemployed consultant in sleep medicine technology.

The examples in this article demonstrate three different types of “escape” beats. These beats occur after the SA node, the normal pacemaker of the heart, fails to function, producing a sinus pause. This pause could be due to failure of the SA node to discharge (Sinus arrest) or failure of an SA node discharge to depolarize the atrial muscle mass (Sinus block). In either case, no P wave is seen, and the expected QRS complex is absent. If a sinus pause occurs, one of several events may ensue:

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1. The SA node restarts and fires again, resulting in a normal-appearing P wave and QRS complex. 2. An ectopic atrial focus fires, resulting in an abnormal P wave and a normal QRS complex. 3. The AV node fires, resulting in an inverted P wave where the normal P wave is upright, no P wave, or an inverted P wave occurring just after the QRS complex; and a normal QRS complex. 4. The bundle branches or Purkinje system fires, resulting in the absence of a P wave and a widened, bizarreappearing QRS complex. 5. Prolonged asystole Figure 1 demonstrates an atrial escape beat (situation 2 above). The delay from the previous normal beat is usually rather brief. In Figure 1, the interval is only about 1.2 seconds and may be barely noticeable. If the atrium fails to provide the escape mechanism, the AV nodal pacer usually will intervene, providing the recovery. This junctional escape beat is seen in Figure 2 where the delay is about 1.7 seconds. As expected, the delay from the previous normal beat is often somewhat longer (situation 3 above). If that mechanism fails, the HisPurkinje system assumes the role (situation 4 above) and provides a ventricular escape beat. The delay from the previous normal beat is usually more prolonged than either of the other situations. In Figure 3, the delay is 2.4 seconds. If three or more consecutive beats occur from the “back-up generator” focus, an escape rhythm has occurred. On occasion, a patient may present with a long-standing escape rhythm such as idiojunctional or accelerated junctional rhythm or, highly unlikely, accelerated ventricular or idioventricular rhythm.


second window. Increasing the amplitude or changing the lead combination may be beneficial.


Escape beats, if infrequent, usually do not require intervention, and even may go unrecognized on the polysomnogram. Frequent sinus pauses resulting in escape beats may indicate some underlying sinus node dysfunction and should be noted for the interpreter to consider cardiology referral. If prolonged asystole (> 3.0 seconds) occurs, it should be included in the report according to AASM standards. Multiple or very prolonged events warrant physician notification to determine disposition of the patient, e.g., discharge to emergency department or immediate follow up post-test. Similarly, if escape rhythm is noted at the start of the recording (it should be apparent during bio-cals) and no history or documentation of the problem is present on the chart, the medical director or designee should be notified to determine the proper course of action.


1. Atkinson J. Scoring center: scoring cardiac dysrhythmias part 2. A2Zzz 2008;17(1):30-32. 2. American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Westchester, Ill: American Academy of Sleep Medicine; 2007. 3. Atkinson J. EKG complex arrhythmia webinar. Advances in sleep technology series. 2009 Dec. 9. Westchester, Ill: American Association of Sleep Technologists.


The irregularity of the ventricular rhythm may be better seen at a 30-second window, but the details of the atrial waveform and the measurement of intervals are best viewed with a 5 to10-

Atkinson JW. Cardiac arrhythmias. In: Butkov N, Lee-Chiong T, editors. Fundamentals of sleep technology. Philadelphia: Lippincot Williams & Wilkins; 2007. p. 314-332. 

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TECHNICAL CORNER: low-pass (high frequency) filters By Mary Ellen Wells, MS, RPSGT, REEGT, RNCST QUESTION

What is a low-pass filter and when should it be used?


The concept of filtering data has troubled new and seasoned technologists for as long as the polysomnogram has been used in clinical practice. To understand the practical aspects of using the low-pass filter, let’s begin by briefly describing what the low-pass filter is and how it works. First, the terms “low-pass” filter and “high frequency” filter are synonymous. Second, filters (e.g., air, water, e-mail) are typically designed to block things. For polysomnography, the high frequency filter (HFF) is designed with a manually set frequency “cut-off ” to help block relatively fast or high, interfering frequencies. The HFF works by attenuating (i.e., reducing) the amplitude of frequencies close to and above a specified level, sometimes eliminating them completely. At the cut-off frequency, amplitude is reduced to 70 percent or 80 percent, depending on the equipment manufacturer. For example, using a 35Hz HFF will allow frequencies below 35Hz to pass through (hence “low-pass”) and display on the screen without being altered; frequencies of 35Hz and above will not be allowed to pass through the filter without amplitude reduction. Although there are differences between analog and digital HFF filters, the basic concepts described are the same for both. When should a low-pass (high frequency) filter be used? The sleep laboratory is full of signal interference. Examples include signal interference from cellular telephones, lamps, radios, television signal transmissions and other diagnostic equipment. Bioelectric interference also can be generated by the patient in the form of heart pulses, body movements, sweat and activity from muscles close to recording electrodes. Differential amplifiers eliminate most major forms of interference by common mode rejection. However, the recording is still susceptible to other forms of interference. Selectively using filters helps reduce or eliminate the remainder of the unwanted signals, achieving a recording most reflective of the true biologic signals of interest. The HFF should not be used to correct artifact from improper electrode application or improper polysomnographic recording techniques. These, and many other types of artifacts including 60Hz artifact, should be corrected at the source and not by use of the HFF. It is important to note that failing to filter a channel enough should have minimal effects on the recording when proper Mary Ellen Wells, MS, RPSGT, REEGT, RNCST Mary Ellen Wells, MS, RPSGT, REEGT, RNCST, has been in the sleep field since 1999 and is a clinical assistant professor in the Department of Allied Health Sciences at the University of North Carolina at Chapel Hill School of Medicine.

patient preparation and equipment setup are used. On the other hand, over filtering a channel may be detrimental to the recording and could filter out the true signals from the patient. HFFs eliminate or reduce fast activity regardless of its origin. Using an HFF in combination with a low frequency filter (LFF) creates an upper and lower limit so that only the band of frequencies you need are allowed to go through. All physiologic variables recorded during polysomnography fall within a frequency band or range, so you should set filters just outside of this range. For example, if you are only interested in frequencies less than or equal to 25Hz, then you should set the HFF to an interval above 25Hz, such as 30Hz. This will ensure that you will not lose important data close to 25Hz. Figure 1 shows the HFF settings for routine recordings that are recommended in The AASM Manual for the Scoring of Sleep Recording HFF and Associated Events.1 EEG 35 Hz EOG

35 Hz

How do you know when “low” is too low? There are instances when the ECG 70 Hz AASM’s HFF recommendaRespiration 15 Hz tions may not be appropriate. Snoring 100 Hz Setting the HFF too low will cause a loss of valuable data, FIGURE 1. High frequency filter settings recommended and too low is different per channel type. To determine by the American Academy of the appropriate HFF setting, Sleep Medicine. the most important questions to ask for each channel are: What physiologic variable am I trying to record (e.g., EEG, respiration), and within what frequency band does it usually fall? The following explanations provide additional details about variables specific to each HFF setting. EMG

100 Hz

EEG Neurophysiological activity in the brain ranges from 0.25Hz to as high as 2,000Hz. In routine polysomnography, sleep stages are usually recognizable within the range 0.5-16Hz, with 16Hz being the upper limit for sleep spindles. Decreasing the HFF to 15Hz may reduce the appearance of sleep spindles, yielding unrecognizable stage N2 epochs as seen in Figure 2. Also, when the HFF is set too low, muscle activity may be misleading, appearing as normal brain activity. A higher frequency (beta) provides useful clinical information. Beta ranges from more than 13Hz to 30Hz. Benzodiazepines, barbiturates, antidepressants and many other psychotropic agents may cause increased beta activity in ranges of 13Hz to 20Hz or more. A HFF setting of less than 25Hz to 30Hz can remove significant beta frequency patterns. A final issue for the HFF with regard to EEG is seizure activity in the form of spikes, which range from 13.3Hz to 50Hz. HFF settings less than 50Hz may attenuate seizure activity. The AASM recommends raising the HFF to 70Hz if seizure activity is suspected.

A2Zzz 19.1 | March 2010


FIGURE 2. The top image demonstrates typical stage N2 sleep. The bottom image demonstrates how decreasing the HFF attenuates the spindles seen in the top image, making it difficult to identify the sleep stage.

EOG The fastest eye movements occur during rapid eye movement (REM) sleep and have a frequency of more than 1Hz. The sharpest REM slopes last 50 to 200 milliseconds. Muscle artifact is of concern in the EOG due to the close proximity of active muscles; therefore, a HFF setting of 30Hz to 35Hz will reduce muscle artifact while recording the fastest eye movements. EmG Muscle activity is very fast and produces high frequency waveforms, even above 1,000Hz. The HFF should be set as high as possible (usually 70Hz to 100Hz) or turned off to provide a faithful representation of EMG potentials. ECG In adults most of the diagnostic information in the ECG is below 100Hz. The fastest component of the ECG may be as fast as 0.04 seconds or about 25Hz. A HFF setting of 30 to 35Hz produces a stable, relatively artifact-free ECG. However, this setting may be too low for diagnostic purposes. A HFF setting of 70Hz is

recommended to produce a wider bandwidth for a more detailed ECG analysis. Respiration For respiratory channels, very slow frequencies are of primary interest. Therefore, the HFF can be fairly low (about 15Hz). However, if snoring is recorded within the primary respiratory channels, the HFF should be raised to allow for faster frequencies up to 100Hz. Snoring Snoring produces very fast frequencies (like EMG). Using HFF settings similar to the EMG settings (i.e., 70Hz to 100Hz, or turned off ) should adequately represent snoring.


1. American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. Westchester, Ill: American Academy of Sleep Medicine;2007. p. 19. ď ś

A2Zzz 19.1 | March 2010




s your sleep lab makes decisions about pursuing a business relationship or enters into negotiations for joint ventures, affiliations and the purchase or sale of a lab, you may be required to review and sign a non-disclosure agreement (NDA). Prior to signing an NDA, a sleep lab should consider several key issues in order to protect its confidential information and/or documents from unauthorized use or disclosure and to reduce its exposure if the lab is the recipient of such information or documents. This article will highlight some of the key issues to consider when reviewing an NDA.


NDAs or confidential disclosure agreements (CDAs) are contracts between two parties that protect confidential documents and information, including software and inventions, which the parties want to share with one another for specific purposes. Other confidential information covered by NDAs may include copyrighted materials and intellectual property. NDAs enable the parties to restrict disclosure of certain information to third parties or for general use by the recipient of such information. NDAs are used by sleep labs when the lab is considering whether it wants to work with another health care provider or entity, and the parties need to understand the technology or processes used by each party for the purpose of evaluating the potential business relationship. NDAs are intended to allow both parties to have open discussion while also providing protection against disclosure of or unauthorized use of confidential information and documents. NDAs place mutual parameters on both parties for the restrictive use of certain documents or property, or NDAs may restrict only one party. New employees also may be asked to sign an NDA or a CDA with a sleep lab at the time of hire. Sleep labs also may consider including a provision in their employment agreements that restricts the use and disclosure of the lab’s confidential information or property.

defined in the NDA. Most NDAs include an extensive laundry list of the types of items that are considered confidential, including: patient lists, copyrights, patents, financial information, referral sources, verbal representations, business strategies and vendor lists. The definition of confidential information also should include exclusions identifying the information and/or documents that are not considered to be confidential and protected by the NDA. Typically, exceptions to the use of confidential information or documents are appropriate if: The recipient had prior knowledge of the confidential information or documents; the recipient gained subsequent knowledge of the confidential information or documents from another source; the confidential information or documents were obtained illegally; the confidential information or documents are subject to a subpoena; or the confidential information or documents are generally available to the public. One potential pitfall that a sleep lab should avoid when reviewing an NDA is failing to specify a length of time for which the NDA will be in effect in relation to the protection of the information or documents. Prior to signing an NDA, sleep labs should make sure that the agreement identifies a specific length of time and describes any event(s) that would trigger the return of the confidential information or property.

Make sure that you carefully review how confidential information is defined by the NDA.


If your sleep lab is approached to sign an NDA or the lab is presenting an NDA to another individual or entity, you should consider including certain language in the contract to protect your rights and not unduly restrict your present and future activities. Make sure that you carefully review how confidential information is


In its NDA a sleep lab also should consider including a statement of purpose containing a description of how the NDA is being executed in connection with discussions and other exchanges of information that the lab has had or will have for the purpose of evaluating the possibility of entering into a business relationship. The statement of purpose provision should indicate that the purpose of the NDA is to protect and prevent unauthorized disclosure of confidential information, and it should define the term “confidential information.” Examples of confidential information include: written information or computer-generated information; data or programs that relate to the business purpose (as defined in the NDA); oral or visual information; and information in any form that has been identified by the sleep lab, as the disclosing party, at the time of disclosure as confidential or proprietary information. It is important that any NDA signed by your lab include a statement of purpose and a clear definition of which documents and information are considered to be confidential or proprietary information.


Jayme R. Matchinski, Esq. Jayme R. Matchinski, Esq., a partner with the law firm of Hinshaw & Culbertson LLP in Chicago, concentrates on health-care law and has counseled sleep disorder centers, physicians and health-care providers nationally. She can be reached at (312) 704-3574 and

If your sleep lab is disclosing confidential information to another individual, provider, or entity, then you want to ensure that the receiving party cannot claim that it relied upon your information to its detriment. The following language is a sample disclaimer, putting the receiving party on notice that there is no warranty provided with the release of confidential information: No Warranty. Disclosing Sleep Lab makes no warranty, express or implied, with respect to its confidential information. Disclos-

A2Zzz 19.1 | March 2010

31 ing Sleep Lab shall not be liable to Receiving Party hereunder for amounts representing loss of profits, loss of business or indirect, consequential, or punitive damages of Receiving Party in connection with the use of the confidential information.


What happens if the proposed joint venture, affiliation, purchase or sale of your lab, or proposed business relationship does not happen? Your sleep lab should consider how the confidential information or documents will be returned to the lab upon termination of the NDA. You may want to include the following provision in your NDA: Return of Confidential Information. Upon receipt of a written request from the Disclosing Sleep Lab or termination of this NDA, the Receiving Party will return all confidential information disclosed by the Sleep Lab (regardless of the form in which such information was disclosed), including all compilations, copies, notes, summaries or abstracts of such confidential information, and Receiving Party will erase from computer storage (including all related or peripheral storage devices) any and all images, compilations, copies, summaries or abstracts of such confidential information.


Recently a sleep lab client received a letter from an attorney representing a health care system alleging that my client violated an NDA in relation to a proposed joint venture. This NDA sought to protect the software developed by the health care system; however, the NDA did not contain a description of the actual confidential

information and proprietary property to be reviewed and protected during the negotiations for the proposed joint venture between the sleep lab and health care system. The attorney’s letter alleged that the sleep lab exploited the health care system’s data management system in violation of the signed NDA and further alleged there was an unauthorized disclosure of the system and related information to a physician practice group. While my sleep lab client did not exploit the data management system or disclose any confidential information to a third party, the NDA gave the health care system a basis for alleging an unauthorized disclosure by my client due to the vaguely worded contract provisions. The attorney’s letter also alleged infringement of proprietary rights and breach of contractual restrictions pursuant to the NDA. The letter further stated that if the health care system instituted legal proceedings to enforce the NDA, it would seek disgorgement of all profits generated from the alleged commercial exploitation of the data management system, recovery of attorneys’ fees and costs, temporary and permanent injunctive relief, and outof-pocket costs and expenses incurred in connection with enforcement of the NDA. Following several discussions and letters, I was able to convince the other attorney that the NDA was not breached and that his client did not have any viable claims against my sleep lab client. This case illustrates why your sleep lab must carefully review all NDAs prior to signing in order to ensure that there are clear parameters and safeguards for the use, disclosure and return of confidential information and documents. Consider including key provisions in your NDA that relate to statement of purpose, definition of confidential information, non-disclosure exclusions, disclaimer of liability, and return of confidential information. ď ś

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Patient’s Perspective: humidification for cpap By Tracy R. Nasca


y goal as a continuous positive airway pressure (CPAP) therapy user is to breathe well through the night so that I can wake up each morning feeling refreshed and ready to get on with living an energized life. As a sleep technologist, it’s your job to help CPAP patients become and remain compliant with treatment to achieve their health and lifestyle goals. Aside from providing them with the right mask and CPAP comfort settings, adding heated humidification is an important and often underappreciated method of improving compliance. In recent years it has been recognized as a valuable addition to CPAP therapy, but too often it is regarded as only a seasonal option. I consider humidification a necessity, as logic dictates that compliance will be reached sooner when all available tools are provided. With the Centers for Medicare & Medicaid Services (CMS) now requiring documentation of CPAP compliance within 90 days, patient education is more important than ever. The clock is ticking, and compliance is best achieved by providing the right tools in combination with instruction and close follow-up. The instruction you provide helps satisfy patient expectations and motivates them to succeed. Common complaints that can be resolved with humidification include: excessive dry mouth in the morning, discoloration or white coating of the tongue, mucous in the mouth, painful burning of the nasal lining, runny nose, sneezing and nasal congestion. Your patients will probably experience one or more of these conditions. If they know in advance that they should expect these problems, then they will be more likely to appreciate and use their humidifier. Humidification education should be more than pointing to the temperature control knob and showing them how to fill the water chamber with distilled water. Although scientific and evidencebased information is available, the following practical advice may be easier to communicate with your patients.


Patients should expect challenges as they get used to using CPAP. Dryness is going to occur to some degree. The continual flow of air delivered by CPAP creates a drying affect that that can cause discomfort to the nasal lining and even nose bleeds. Especially during winter months, the air is much drier than normal and tends to increase the thickness of secretions like saliva and post nasal drip. Surprisingly, CPAP can have the opposite effect of causing a runny nose because the body has its own natural humidification system that kicks in when dryness occurs. Sneezing also is common as secretions in the nose or the mouth are manufactured to combat Tracy R. Nasca Tracy R. Nasca is Senior Vice President of Talk About Sleep, Inc. She is a sleep educator and patient advocate.

dryness caused by CPAP use. Humidification can make the CPAP experience more pleasant whether your patient lives in a humid or dry climate. It resolves common and known comfort issues. There is no need to experience these discomforts when humidification can resolve most of these problems. But not everyone thinks they need the addition of a CPAP humidifier. Having lived in both frigid Minnesota and warm, humid Florida, I can attest to the year-round benefits of humidification. Whether the heat or air conditioner is on, CPAP delivery of forced air directly into the nostrils can be uncomfortable. Although all CPAP patients may benefit from humidification, some people may have a greater need than others. Patients who use nasal pillows or full-face masks tend to find humidification especially advantageous. Patients on high and low CPAP pressures also are likely to benefit from using humidification. Cold passover humidification may prove effective for some patients when moisture – but not heat - is needed. But the addition of heat is particularly helpful when the temperature of the bedroom sleeping environment is in the mid-60s or below, which is common in the Midwest and Northeast. Although highly effective, CPAP humidifiers do not guarantee the resolution of dryness issues. If needed, patients should discuss the use of nasal sprays with their physician. Simple saline solutions are available over the counter as well as with a prescription. An evaluation by an ear, nose and throat (ENT) specialist is recommended to address problems with chronic nasal congestion or a deviated septum.


Here are some simple tips that you can give to your patients for the effective use of CPAP humidification: ▪ Use distilled water instead of tap water to lessen themineral deposits that can collect in the water chamber. ▪ Fill the water chamber away from the CPAP unit to avoid damaging its circuits, which would void the system’s warranty. ▪ Pour water up to the “fill line” on the water chamber. Exceeding this line will cause a gurgling noise, and water may seep back into the mask. ▪ Pay attention to how much water is used each night, and fill only to that level to avoid wasting water. More water will likely be used at higher CPAP pressure and heat settings. ▪ In the morning empty any unused water and clean the chamber daily as recommended by the manufacturer. ▪ For heated humidification, start with the lowest temperature and gradually turn it up as needed to reach the desired level of comfort. ▪ Adjust the heat setting as needed when the bedroom temperature changes with the seasons. ▪ Heat can cause excess condensation, so cover the hose with insulated tubing to reduce or eliminate any “rain out” effect. ▪ Drink plenty of water during the day to boost the body’s natural humidification system. 

A2Zzz 19.1 | March 2010


COMMENTARY: shifting sleep norms By Jacob Borodovsky


leep is critical for normal daily functioning, and now proper sleep hygiene is being overlooked or disregarded more so than ever before. This recently was brought to my attention while I was involved as an intern with the Institute for SleepWake Disorders at Hackensack University Medical Center (HUMC) in Hackensack, N.J. After three months of my experience at the sleep disorders clinic, I have become aware of a large and yet seemingly unnoticed sleep problem that plagues our society: Our sleep norms have made a radical shift. Across the United States, as higher education becomes more and more competitive, students slowly but surely put proper sleep hygiene on the backburner. I am by no means free of guilt. In fact, I think it is safe to say that my own sleep habits are atrocious. I, like many of my fellow students, have stayed up much of the night while finishing a research paper, hopped up on caffeine, only to wake up a few hours later to hand in the paper and sleep for the rest of the day. Then throw in the occasional party on Friday or Saturday night, as well as waking up Sunday morning to work all day, and you have a pretty tiring week. Looking back, sometimes I wonder how I managed to survive. The problem is that we have let this lifestyle become the norm. It is OK to pull all-nighters a few times a month. It is OK to consume unnaturally large amounts of caffeine throughout the day. And it is OK to take many naps during the day.

People are not designed to function like this, and yet we continue to do so. Now some might say that this way of living has always been around in one form or another for as long as people have been going to college. To them I say, yes, I agree. However, today the prevalence of such a lifestyle is drastically more pronounced, which is what has led me to conclude that our norm has shifted. This shift is largely a product of the increasing workload and competitiveness. We also can be fairly certain this lifestyle on college campuses will not change overnight, and in fact may never change. But it is important for us to recognize that this college system is not an isolated one. Our behavior as college students, in many ways, reflects how our society as a whole functions. Increasingly, everyone - not just students - requires naps, caffeine, amphetamines and sleep aids to keep going. The pace with which our world is moving often times demands these substitutes because sometimes there just aren’t enough hours in the day. And on top of this it is only getting worse, which leads me to believe that in the days to come, a better understanding of how and why people sleep will be more critical than ever before. Jacob Borodovsky is a sophomore at Tufts University in Massachusetts, where he is a psychology major. 


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IN MEMORIAM: VERNE D. HULCE, 1942 – 2009 By Connie Kubiak, REEG/EPT, CNIM, CLTM


he neurodiagnostics family lost one of its most beloved members when Verne D. Hulce, PhD, REPT, CNIM, RPSGT, RRT, died unexpectedly on Sept. 3, 2009. Verne was born in New York City on March 9, 1942. He always said he had a “normal” childhood. Personally I don’t think there was ever anything “normal” about Verne; he was exceptional. Verne overcame his hearing disability. He told me one time that his sister started calling him “what” because that was always his reply when someone spoke to him. He was grateful to her for recognizing his deafness at an early age. In order to converse with people, he learned to read lips. Because of how intently he concentrated on a person who was speaking, people would at times be uncomfortable around him. But Verne, once he realized their discomfort, had a way of putting them at ease. He also loved his gadgets and was always at the forefront of audio technology. Verne led an interesting life, although he didn’t really speak a lot about himself. For instance, most people never knew that he didn’t finish high school. He also was a National Science Fair winner, held a commercial pilot’s license, was a flight instructor, served as an adjunct professor at five colleges, spoke numerous languages and was an avid sailor. His wife, June, told me that he left school when he started working. He walked to the science building at Michigan State University (MSU) at the age of 15. He built research equipment for the school, whatever they needed. When MSU agreed to enroll him in college, he was required to get his GED, which he completed in 1964. The military and numerous companies approached Verne to design equipment for them. Verne earned a doctorate in pharmacology and began research work with Dow Chemical in Midland, Mich., where he was involved in animal research. During that time he began to wonder if there was more to life. After developing an allergy to lab rats, he decided he might want to get into “people stuff.” His next move was to Chicago, where Verne completed a six-month respiratory therapy program. After graduation he returned to Lansing, Mich., where he started working at Lansing General Hospital (now Ingham Regional Medical Center) as a respiratory therapist. He developed the neurodiagnostics program and was lovingly called “the Incredible Hulce.” He met June, although she told me that it took him more than a year to ask her out because he didn’t like rejection. They celebrated their 24th anniversary in March 2009. He and June shared a passion for animals, and their menagerie included cats, dogs and monkeys. Verne loved to teach, although he was unimpressed by

academic degrees and titles. The first time we met, I asked him what I thought was an important question: In which field of study did you earn your doctorate degree? He answered, eyes twinkling, “Oh, some pharmacology thing.” Then he asked me, “Do you know what PhD means?” When I stated no, he said, “PhD means Piled High and Deep.” He always had a way of deflecting attention away from himself. I pursued the matter further by asking him if he had received his PhD after he earned all of the other credentials that followed his name. He replied, “Oh no, I take these exams so I know what to teach the staff so they will pass the exams.” I took the certification examination in neurophysiologic intraoperative monitoring (CNIM) with Verne sitting behind me. The exam comprised 250 questions and was scheduled to last four hours. Verne finished the exam in 45 minutes. Talk about intimidating! I never asked his score but knew that he had passed. My children met Verne once when I brought old electroencephalography (EEG) machines to him at the Field Neurosciences Institute (FNI) at St. Mary’s of Michigan in Saginaw, where he was the executive administrator. Verne had a “cage” of rooms in the basement where he stored “other people’s junk.” He would take these items and utilize them in research labs with which he was affiliated. Both of my children thought he was “a mad scientist,” and my oldest son said, “He has Albert Einstein hair.” They both wondered why, on Saturday when he wasn’t working, he was wearing a suit and tie. That was Verne. At FNI, he was involved in many projects: patient transportation, dementia, hearing evaluation, bicycle safety, and education of the community and health care professionals. I think one of his favorite projects was his “low rider” van. He customized a minivan so that it would lower itself to the ground to provide easy boarding access for the elderly and infirm. At St. Mary’s he was involved with the sleep lab, the neurodiagnostics lab and a new-found love - the operating room. He enjoyed all those new gadgets, much to the dismay of the staff. Verne never declined an invitation to give a lecture, because he said that’s how he learned so much. He’d decide on a topic, or at times a topic would be given to him, and then he would research it thoroughly. Whether it was instrumentation, electrical concepts or prion disease, Verne would cover every aspect of the subject. He was always willing to help the Michigan Society of Electroneurodiagnostic Technologists (MSET). He served as a board member, committee member and president. I jokingly made him a “lifetime board member and chair of the By-laws Committee.” He graciously accepted and worked tirelessly.

A2Zzz 19.1 | March 2010

35 Verne had a way of making you want to be a better professional. His passion for education was contagious. Verne was a regular contributor to the activities of the MSET, the Central Society of Electroneurodiagnostic Technologists (CSET), the American Society of Electroneurodiagnostic Technologists (ASET), and the American Association of Sleep Technologists (AAST). He was an author of numerous publications and coauthor of just as many. A memorial service was held for Verne on Friday, Nov. 13, 2009, at the Old Town Christian Outreach Center in Saginaw. Terrific memories were shared with all in attendance. His family was surrounded by many who knew and loved Verne. In memory of Verne, and to honor his passion, the MSET has developed the â&#x20AC;&#x153;Verne Hulce Award of Excellence.â&#x20AC;? The award is a grant, to be presented annually to a current MSET member, for the purpose of funding their continuing education. This award may be used to purchase educational material, attend a conference/seminar, or obtain END/PSG credentials in pursuit of professional excellence. To submit a donation to the â&#x20AC;&#x153;Verne Hulce Award of Excellenceâ&#x20AC;? fund, please contact MSET President Mary Harvey at or MSET Secretary/Treasurer Greg Miller at, or find more information on the MSET Web site at Connie Kubiak, REEG/EPT, CNIM, CLTM, is the past president of the Michigan Society of Electroneurodiagnostic Technologists (MSET). ď ś

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From the American Academy of Sleep Medicine AASM LAUNCHES ONLINE INTER-SCORER RELIABILITY TESTING PROGRAM American Academy of Sleep Medicine (AASM)-accredited centers looking for a solution to meet the Standards for Accreditation regarding inter-scorer reliability can visit www. to register an account with the AASM’s new Inter-scorer Reliability Testing Program. From now until March 31, 2010, all accredited centers have the opportunity to use this program for FREE. This convenient, comprehensive program can be used both as a solution for measuring inter-scorer reliability as well as a tool for testing the scoring ability of job applicants at your facility. A new set of 200 consecutive epochs is posted online each month so that your scorers can log in to their accounts and complete the required amount of testing at their convenience. Then you can compare these results to the AASM gold standard score as well as to other users of the program from across the country. The program also gives your scorers immediate feedback. Results with correct and incorrect answers for every epoch are displayed, allowing your scorers to see which questions they got wrong. The first two records for this program are currently posted. Register an account for your facility and get your scorers started now during the free trial period. The modules run in your Internet browser, so there is no need to download special scoring software. The AASM has developed several resources to familiarize individuals with this new program. Stepby-step instructions and answers to frequently asked questions about the program have been posted online at Anyone who is interested in learning more about the AASM Inter-scorer Reliability Testing Program can contact the AASM at with your questions.


The AASM accredits providers of the Accredited Sleep Technologist Education Program (A-STEP) Introductory Course. As of January 2010, there are 88 providers of the course. University of California San Francisco Sleep Disorders Center San Francisco, Calif. Program & Technical Director: Mary Kay Hobby, RPSGT Delaware Technical and Community College – Wilminton Campus Wilmington, Del. Program & Technical Director: Steven D. Conley, RPSGT

The Sleep Medicine Center in Affiliation with Larry Head Institute LLC Kalispell, Mont. Program Director: Larry Head, RPSGT, REEG/EPT, CNIM Technical Directors: Pam Lang, RPSGT, RCP, & Carol Heater, RPSGT, RCP Firelands Regional Medical Center Sleep Disorders Center in Affiliation with Larry Head Institute LLC Sandusky, Ohio Program Director: Larry Head, RPSGT, REEG/EPT, CNIM Technical Directors: Pam Lang, RPSGT, RCP, & Mary Stacy, RPSGT, CR Lifeline Partners Youngstown, Ohio Program Director: Salim Abou Jaoude, MD Technical Director: Wendy Mooney, BS, RPSGT, CRT Dallas School of Neurodiagnostic and Sleep Medicine Irving, Texas Program Director: Tiffany Bell, RPSGT, REEGT Technical Director: John Canizares, RPSGT For a complete list of A-STEP providers go to http://www.


Currently there also are 26 training programs accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) through the Committee on Accreditation for Polysomnographic Technologists Education (CoA PSG). Johnson County Community College Overland Park, Kan. Program Director: Chad Sanner, BS, RPSGT (913) 469-7655 TSSMT/STRC Consortium for Polysomnography Education San Antonio, Texas Program Director: Martin Olivares, RPSGT (210) 614-6000 For a complete list of CAAHEP-accredited programs go to

Cleveland Clinic Florida Sleep Disorders Center Weston, Fla. Program & Technical Director: Patrick McMahon, RPSGT

A2Zzz 19.1 | March 2010


Certification Update

From the Board of Registered Polysomnographic Technologists


he Board of Registered Polysomnographic Technologists (BRPT) is launching the new CPSGT exam this month, is introducing a new exam blueprint for the RPSGT exam, and has announced plans for on-demand testing to begin this summer. “2010 is shaping up to be an important and exciting year for the BRPT,” said BRPT President Janice East, RPSGT, REEGT. “We’re very pleased with the update and revision we’ve accomplished with the RPSGT exam based on the 2009 Job Task Analysis, and with the strong interest we’ve seen in the CPSGT certification.”


In January the BRPT named Janice East, RPSGT, REEGT, president of the board of directors. East is the director of sleep disorders, neurodiagnostics and rehabilitation services for Morton Plant Mease Health Care in Clearwater, Fla. “Over the past two years, under Becky Appenzeller’s leadership, we’ve accomplished an extraordinary amount in a number of key areas including the creation of the CPSGT exam, a new RPSGT job task analysis, and the development of a new RPSGT exam blueprint," said East. "I look forward to maintaining this momentum and continuing the work we’ve begun to recertify sleep technologists beginning in 2011, to expand opportunities for international RPSGT candidates, and to move ahead with the development of an advanced credential.” Becky Appenzeller, RPSGT, REEGT, CNIM, will serve in 2010 as BRPT past president and has stepped into the role of Exam Development Committee chair. BRPT board member Susan Hanson, RPSGT, CRT, will serve as secretary. East and Hanson are joined by two new board members: Cindra Altman, RPSGT, REEG/EPT, and Edward Perez, RPSGT.


The March RPSGT exam is built against the exam blueprint developed following last year’s Job Task Analysis. According to BRPT Past President Becky Appenzeller, “Last year’s Job Task Analysis assures us that we are offering a valid exam, reflective of the knowledge, skills and abilities required of a working RPSGT. The core body of knowledge needed for the RPSGT exam has remained constant. Some areas currently tested have declined in importance while others have become more important. Those changes are reflected in the new exam blueprint.” The updated RPSGT exam candidate handbook and the new RPSGT exam blueprint are available for download at no charge at Information about purchasing a new RPSGT exam study guide and an updated practice exam is available at


Beginning in mid-June, the BRPT plans to offer both the RPSGT and CPSGT exams to candidates “on demand.” Once authorized to take the RPSGT or CPSGT exam, candidates will be able to test on a date of their choosing, anytime during the one-year period for which their authorization is valid. Candidates who are unsuccessful on one exam attempt will be able to re-test without waiting for the next fixed exam window. And, perhaps most importantly to candidates, results will be delivered in real time, as soon as an exam is completed and submitted for electronic scoring. 


The BRPT reports strong interest in the new CPSGT exam, a competency-based exam developed to test the knowledge and skills of an individual new to the sleep field. The BRPT expects this first testing pool to top 200 candidates, enabling the organization to perform validation and reliability tests on the exam essential to establishing the validity of the CPSGT certificate. “We’re excited to offer this entry-level certificate that will further enhance the level of professionalism in the field of sleep technology,” said Janice East. “In addition, we believe the CPSGT certificate program, which puts new sleep professionals solidly on the path to earning the RPSGT credential, will ensure the availability of trained sleep professionals to help treat the escalating number of people with sleep disorders.” The CPSGT exam blueprint and candidate handbook can be found at

A2Zzz 19.1 | March 2010



The AAST acknowledges and thanks the following organizations for their

Scoring Unlimited offers Outsourced Scoring Services Scoring services are provided with a scoring team of Registered Polysomnography Technologists. All scoring is performed using current guidelines and customized to follow the scoring standards by lab policies. Scoring Unlimited offers secure remote scoring with fast turna-round time and competitive pricing. For further information, please contact: Karen Phone: 765-524-1199 Email: Website:

generous support and for investing in the future of the sleep technology

profession as AAST Supporter Members:


American American Associatio Associatio nn of of Sleep Sleep TTechnologists echnologists

AAST 2009

American Associatio Associatio nn American of Sleep Sleep TT echnologists echnologists of


Philips Respironics & ResMed

Cadwell Laboratories, Inc.

MVAP Medical Supplies, Inc.


sleepfragments IN HIS OWN WORDS

AAST Founding President Peter A. McGregor Sr., RPSGT “I’ve gotten to know many of you very well at various meetings, examinations, at other gatherings and I’ve made many good friends along the way. You have been very supportive, even when things could have been better." (1983) "Looking back over the years which I have been involved with the APT as Chairperson of the Steering Committee and later as President, I can only say that it has been a great experience as well as a lot of fun. It has been great meeting and making friends from sleep labs throughout the country.” (1986)

by barbara ludwig-cull, rpsgt

A2Zzz 19.1 | March 2010


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