Breathing Disorders

James D. Geyer, MD

Paul R. Carney, MD

FIGURE 4-1 Strip chart: Position chart and pulse oximetry.

Clinical: 46-year-old obese man with severe obstructive sleep apnea.

Pulse oximetry: Frequent oxygen desaturations, which are most prominent during REM sleep. Apneas occurred repeatedly while the patient was supine and in the right lateral decubitus position.

FIGURE 4-2 Strip chart: Pulse oximetry and position.

Pulse oximetry: Obstructive sleep apnea with prolonged oxygen desaturations when supine. This finding can be seen with hypoventilation or with conditions associated with ventilation-perfusion mismatch.

FIGURE 4-3 Strip chart: Pulse oximetry, position, and CPAP settings.

Pulse oximetry: Severe obstructive sleep apnea. The initial half of the night (labeled CPAP setting 1.0) is the baseline portion of the recording with no CPAP. CPAP is applied at four different settings, ranging from 5 cm of water (setting 2.0) to 11 cm of water (setting 5.0). Continued moderate obstructive sleep apnea is present with CPAP at levels 2.0 and 3.0. Further improvement of the obstructive sleep apnea is evident at CPAP levels 4.0 and 5.0.

FIGURE 4-4 Strip chart: Pulse oximetry, position, and CPAP settings.

Pulse oximetry: Severe obstructive sleep apnea. The initial half of the night (labeled CPAP setting 1.0) is the baseline portion of the recording with no CPAP. CPAP is applied at three different settings, ranging from 5 cm of water (setting 2.0) to 9 cm of water (setting 4.0). Continued moderate obstructive sleep apnea is present with CPAP at levels 2.0 and 3.0. Further improvement of the obstructive sleep apnea is evident at CPAP level 4.0.

FIGURE 4-5 Polysomnogram: Standard montage; 30 second page.

Clinical: 32-year-old man with retrognathia and suspected obstructive sleep apnea.

Staging: Stage W in this epoch because of the timing of the event.

Respiratory: Obstructive apnea followed by a snort, arousal, and an oxygen desaturation. (Copyright NeuroTexion, 2017.)

FIGURE 4-6 Polysomnogram: Standard montage; 30 second page.

Clinical: 36-year-old woman with retrognathia and suspected obstructive sleep apnea.

Staging: Stage N1 with an arousal.

Respiratory: Obstructive apnea followed by a snort, arousal, and oxygen desaturation. (Copyright NeuroTexion, 2017.)

FIGURE 4-7 Polysomnogram: Standard montage; 30 second page.

Clinical: 36-year-old woman with retrognathia and suspected obstructive sleep apnea. Staging: Stage N1 with an arousal.

Respiratory: Obstructive apnea followed by a snort, arousal, and oxygen desaturation on the following page. (Copyright NeuroTexion, 2017.)

FIGURE 4-8 Polysomnogram: Standard montage; 60 second page.

Clinical: 36-year-old woman with retrognathia and suspected obstructive sleep apnea.

Staging: Stage N1 with arousals.

Respiratory: Obstructive apnea followed by snorts, arousals, and oxygen desaturations. (Copyright NeuroTexion, 2017.)

FIGURE 4-9 Polysomnogram: Standard montage; 120 second page.

Clinical: 36-year-old woman with retrognathia and suspected obstructive sleep apnea. Staging: Stage N2 with arousals.

Respiratory: Obstructive apnea followed by snorts, arousals, and oxygen desaturations. (Copyright NeuroTexion, 2017.)

FIGURE 4-10 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 29-year-old obese woman with a thick neck and suspected obstructive sleep apnea.

Staging: Stage N2 sleep with an arousal.

Respiratory: Obstructive apnea with inphase respiratory effort in the thoracic and abdominal channels followed by an arousal, a snort, and an oxygen desaturation.

FIGURE 4-11 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea.

Staging: Stage N2 sleep with transition into REM sleep. Although the epoch does not meet scoring criteria for REM sleep due to the absence of rapid eye movements, the reduction in chin EMG activity and the occurrence of sawtooth waves (*) are consistent with REM sleep.

Respiratory: Obstructive apnea with decreased but inphase respiratory effort followed by an arousal and an oxygen desaturation.

FIGURE 4-12 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea.

Staging: Stage R sleep with rapid eye movements and arousals.

Respiratory: Obstructive apnea with increasing respiratory effort followed by an arousal.

EEG: Sawtooth waves (*) in REM sleep.

FIGURE 4-13 Polysomnogram: Standard montage (prior recording/display montage); 120 second page.

Clinical: 42-year-old man with a low-lying soft palate and suspected obstructive sleep apnea.

Staging: Stage R sleep with rapid eye movements and arousals.

Respiratory: Obstructive apneas with increasing respiratory effort followed by arousals, snorts, and oxygen desaturations.

EEG: Sawtooth waves in REM sleep.

FIGURE 4-14 Polysomnogram: Standard montage (prior recording/display montage); 30 second page.

Clinical: 12-year-old with large tonsils and suspected obstructive sleep apnea.

Staging: Stage R sleep with rapid eye movements and bursts of leg EMG activity.

Respiratory: Obstructive apnea with decreased but inphase respiratory effort followed by an arousal.

FIGURE 4-15 Polysomnogram: Standard montage (prior recording/display montage); 120 second page.

Clinical: 12-year-old with large tonsils and suspected obstructive sleep apnea.

Staging: Stage R sleep with rapid eye movements.

Respiratory: Prolonged obstructive apnea with decreased but inphase respiratory effort followed by an arousal and an oxygen desaturation. There is also a brief postarousal central apnea (*). The oxygen desaturation at the beginning of this page was caused by an apnea from the preceding page of the record.

FIGURE 4-16 Polysomnogram: Standard montage; 60 second page.

Clinical: 29-year-old moderately obese woman with excessive daytime sleepiness and suspected obstructive sleep apnea.

Staging: Stage N2.

Respiratory: prolonged mixed apnea.

FIGURE 4-17 Polysomnogram: Standard montage (prior recording/display montage); 120 second page.

Clinical: 22-year-old obese man with marked retrognathia.

Staging: Stage N3 sleep with arousals.

Respiratory: Mixed apnea with inphase respiratory effort at the beginning and end of the apnea followed by an arousal and an oxygen desaturation. The oxygen desaturation at the beginning of this page is a result of an apnea from the preceding page of the record.

FIGURE 4-18 Polysomnogram: Standard montage (prior recording/display montage); 120 second page.

Clinical: 42-year-old woman with multiple sclerosis, restless legs syndrome and suspected obstructive sleep apnea.

Staging: Stage N1 sleep with arousals.

Respiratory: Repeated mixed apneas with arousals and minimal oxygen desaturations.

FIGURE 4-19 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 52-year-old man with snoring and excessive daytime sleepiness.

Staging: Stage N1 sleep with arousals.

Respiratory: Mixed apnea with increasing effort and paradoxical respirations followed by a snort, an arousal, an oxygen desaturation, and snoring. The oxygen desaturation on this page was caused by an apnea from the preceding page of the record.

FIGURE 4-20 Polysomnogram: Standard montage with intrathoracic pressure monitoring (prior recording/display montage); 30 second page.

Clinical: 44-year-old woman with snoring and excessive daytime sleepiness.

Staging: Stage N1 sleep with arousals.

Respiratory: Mixed apnea with an initial portion without respiratory effort followed by two obstructed breaths. Respiratory effort, as measured by the esophageal pressure monitor (PES), increases with the second obstructed breath and then decreases after the arousal and resumption of breathing. There is minimal oxygen desaturation from 94% to 91%.

FIGURE 4-21 Polysomnogram: Standard montage; 30 second page.

Clinical: 77-year-old thin man with severe peripheral polyneuropathy and excessive daytime sleepiness.

Staging: Stage N2 sleep with an arousal.

Respiratory: Hypopnea (oval) with decreased airflow and respiratory effort followed by an arousal (arrow). (Copyright JNP Enterprises, 2017.)

FIGURE 4-22 Polysomnogram: Standard montage; 60 second page.

Clinical: 64-year-old obese woman with daytime sleepiness and loud snoring.

Staging: Stage R.

Respiratory: Recurrent hypopneas with arousals and oxygen desaturations.

EKG: Tachycardia-bradycardia with events. (Copyright JNP Enterprises, 2017.)

FIGURE 4-23 Polysomnogram: Standard montage; 60 second page.

Clinical: 41-year-old woman with excessive daytime sleepiness and intractable headaches.

Staging: Stage N2 sleep.

Respiratory: Repeated hypopneas followed by arousals and oxygen desaturations. The pressure transducer is flat during the event. (Copyright JNP Enterprises, 2017.)

FIGURE 4-24 Polysomnogram: Standard montage; 60 second page.

Clinical: 51-year-old man with excessive daytime sleepiness and hypertension.

Staging: Stage N1 sleep with arousals.

Respiratory: Repeated hypopneas followed by arousals and oxygen desaturations. The pressure transducer is flat during the first event, but there are low-amplitude deflections during the second event. (Copyright JNP Enterprises, 2017.)

FIGURE 4-25 Polysomnogram: Standard montage; 30 second page.

Clinical: 64-year-old obese woman with daytime sleepiness and loud snoring.

Staging: Stage R.

Respiratory: Recurrent hypopneas with arousals and oxygen desaturations.

EKG: Tachycardia-bradycardia with events. (Copyright JNP Enterprises, 2017.)

FIGURE 4-26 Polysomnogram: Standard montage; 60 second page.

Clinical: 37-year-old man with fatigue and loud snoring.

Staging: Stage N2 sleep.

Respiratory: Hypopnea with increasing respiratory effort followed by an oxygen desaturation. (Copyright JNP Enterprises, 2017.)

FIGURE 4-27 Polysomnogram: Standard montage; 60 second page.

Clinical: 29-year-old obese woman with excessive daytime sleepiness.

Staging: Stage R sleep.

Respiratory: Prolonged hypopnea with an associated oxygen desaturation during phasic REM sleep. There is an arousal and increased respiratory effort at the end of the page. (Copyright JNP Enterprises, 2017.)

FIGURE 4-28 Polysomnogram: Standard montage; 30 second page.

Clinical: 33-year-old woman with excessive daytime sleepiness.

Staging: Stage N2 sleep with an arousal.

Respiratory: There are paradoxical respirations with flattening of the nasal pressure transducer waveform. This suggests resistance in the upper airway. There is loud snoring. (Copyright JNP Enterprises, 2017.)

FIGURE 4-29 Polysomnogram: Standard montage; 30 second page.

Clinical: 36-year-old man with snoring and coronary artery disease.

Staging: Stage N2 sleep.

Respiratory: Snoring is present. Normal respirations. (Copyright JNP Enterprises, 2017.)

FIGURE 4-30 Polysomnogram: Standard montage; 30 second page.

Clinical: 49-year-old man with unrefreshing sleep.

Staging: Stage N2 sleep transitioning toward N3.

Respiratory: Decreased nasal pressure waveform amplitude (oval) followed by a small snort. There is no significant associated change in the airflow or effort channels. Furthermore, there is no arousal or associated oxygen desaturation. (Copyright JNP Enterprises, 2017.)

FIGURE 4-31 Polysomnogram: Standard montage; 30 second page.

Clinical: 34-year-old man with daytime sleepiness and irritability.

Staging: Stage R sleep.

Respiratory: There is some respiratory irregularity, which is a normal component of REM sleep, especially phasic REM sleep. (Copyright JNP Enterprises, 2017.)

FIGURE 4-32 Polysomnogram: Standard montage; 120 second page.

Clinical: 37-year-old woman with excessive fatigue and daily headaches.

Staging: Stage N2 sleep.

Respiratory: There is a respiratory event-related arousal. There is a decrease in the nasal pressure waveform followed by a sudden increase (oval) with an associated arousal (arrow).

Limb movements: There are periodic limb movements involving the right leg. (Copyright JNP Enterprises, 2017.)

FIGURE 4-33 Polysomnogram: Standard montage; 30 second page.

Clinical: 50-year-old man with snoring and fatigue.

Staging: Stage R sleep.

Respiratory: There is flattening of the nasal pressure transducer waveform. (Copyright JNP Enterprises, 2017.)

FIGURE 4-34 Polysomnogram: Standard montage with intrathoracic pressure (Pes) monitoring (prior recording/display montage); 120 second page.

Clinical: 49-year-old man with upper airway resistance syndrome.

Staging: Stage N2 sleep with an arousal.

Respiratory: Negative intrathoracic pressure increases gradually from -12 (*) to 19 (ˆ) cm of water. There is a subsequent arousal but no oxygen desaturation.

FIGURE 4-35 Polysomnogram: Standard montage with intrathoracic pressure monitoring (prior recording/display montage); 30 second page.

Clinical: 17-year-old woman with mild retrognathia, excessive daytime sleepiness associated with recent weight gain.

Staging: Stage N3 sleep with alpha intrusion and an arousal.

Respiratory: Negative intrathoracic pressure increases gradually over several breaths followed by an arousal but no oxygen desaturation. Snoring is minimal. The increased respiratory effort preceding the arousal would be more difficult to appreciate without the Pes monitoring.

FIGURE 4-36 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 39-year-old man with snoring, unrefreshing sleep and headaches.

Staging: Stage N2 sleep with an arousal.

Respiratory: Snoring increases in amplitude for several breaths and then is followed by an arousal (*). The increase in snoring is inferential evidence of increased respiratory effort, which is difficult to detect in the thoracic and abdominal channels.

FIGURE 4-37 Polysomnogram: Standard montage (prior recording/display montage); 30 second page.

Clinical: 24-year-old man with snoring and hypertension.

Staging: Stage N1 sleep.

Respiratory: Snoring increases in amplitude over several breaths accompanied by subtle evidence of increased respiratory effort in the thoracic and abdominal channels.

FIGURE 4-38 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 24-year-old man with snoring and hypertension.

Staging: Stage N2 sleep.

Respiratory: Snoring increases over several breaths without a subsequent arousal. Blocking of the intrathoracic pressure signal does not allow quantitation of inspiratory force.

FIGURE 4-39 Polysomnogram: Standard montage (prior recording/display montage); 30 second page.

Clinical: 39-year-old man with loud snoring and excessive daytime sleepiness.

Staging: Stage N2 sleep.

Respiratory: Snoring with otherwise normal respirations.

FIGURE 4-40 Polysomnogram: Standard montage (prior recording/display montage); 30 second page.

Clinical: 47-year-old woman with fatigue and snoring.

Staging: Stage N3 sleep.

Respiratory: Snoring with otherwise normal respirations.

FIGURE 4-41 Polysomnogram: Standard montage (prior recording/display montage); 30 second page.

Clinical: 45-year-old man with snoring and hypertension.

Staging: Stage N3 sleep.

Respiratory: Normal respirations except for pronounced snoring.

FIGURE 4-42 Polysomnogram: Standard montage (prior recording/display montage); 60 second page.

Clinical: 45-year-old man with snoring and hypertension.

Staging: Stage N3 sleep.

Respiratory: Normal respirations except for loud snoring.

FIGURE 4-43 Polysomnogram: Standard montage; 30 second page.

Clinical: 44-year-old man with excessive daytime sleepiness and witnessed apneas.

Staging: Stage N2 sleep with an electrographic seizure.

Respiratory: Central apnea. There is cardioballistic artifact in the chest effort channel. EKG: Premature atrial contractions. (Copyright JNP Enterprises, 2017.)