Sleep Center Organisiation and Managment

Sleep Center Organisiation and

ManagmentDoç. Dr. Sadık Ardıç

SB Dışkapı Eğitim ve Araştırma Hastanesi Göğüs Hastalıkları ve TBC Kliniği

Uyku Hastalıkları Tanı ve Tedavi Merkezi

Türk Toraks Derneği 11.Annual Congress

FEMTOS Session23 - 27 April 2008

Maritim Pine Beach Resort - Antalya

Dr. Karacan’ın örgütlenmesi doğru, benim ki doğru değil. Sleep Disorders Centers,Baylor College of Medicine, 10.9.1992

Sleep Center Organisiation and Managment

• Sleep Disorders Center(SDC)

• In these centers, All of Sleep Disorders are been diagnosed and treated.

• SDC is managed by Medical Sleep Specialists which have studied sleep medicine

• Sleep Disorders Center is described as a unit which is an individual and a separate location..

• Personnels which work in SDC,respect the ethics of sleep disorders.

• Medical Director(MD)• Medical Director has been a Medical

Doctor.

• Medical Sleep Specialists:• The certificate intends to show that the

named person is able to carry out the diagnosis and differential diagnosis of sleep-related diseases, as listed in ICSD-2 (2), and their management.

Other Personnels• Sleep Technician (ST)• ST is able to carry out the organization,

logistics, preparation, recording, observation, analysis & evaluation and documentation of

polysomnography(PSG) and other investigations carried out in the SMC.

• ST is responsible for the correct instruction and care of the patients

Other Personnels• Sleep Technician (ST)

• ST is able to score the polysomnographic record by manually

• ST must receive a training during a full time equivalent period of the described time in an accredited Sleep Disorder Center

Rooms;• Rooms; minimum bedroom

surface of 10-12 m2 is recommended.

• SDC has two bedrooms at least.

Sleep Center Organisiation and

Managment• The following criteria must be met for

the approval of a polysomnographic bed:

• Only those beds that are located in

single bedrooms and ,• in which the polysomnograph allows

recording of all relevant biosignals will be approved as polysomnographic beds.

• The bedrooms must be equipped to allow Professional diagnosis and therapy in the field of sleep medicine to be carried out and to enable both nocturnal examinations and assessment of daytime sleepiness

• The rooms must be sound and light attenuated and equipped with temperature and ventilation controls.

• To enable daytime assessments, such

as the multiple sleep latency test (MSLT), the rooms must be adequately darkened.

• Adequate sanitary facilities must be available near the bedrooms.

• Each bedroom should be equipped with a suitable video monitoring system.

• A two-way communication system must be installed which allows the patient and night duty technician to communicate with each other, and to enable biosignal calibration.

• Disabled people should be examined in

these rooms

Control Room• It is been at the same floor which the bed rooms are.

•Its location must be The central of Sleep Lab,

•Its distance to each room must be equal

Control Room• A two-way communication system must be installed which allows the patient and night duty technician to communicate with each other, and to enable biosignal calibration.

•Control Room•A separate room, which is also sufficiently large and •Which ensures undisturbed working conditions, must be available for the monitoring equipment and the technical/nursing staff.

Laboratory Guide Manuel(LGM)

• There must be a LGM which has to be described all of procedure and application in SDC.

• This book describes all of the dailly procedure in SDC.

• This book is a reference book for sleep technician(ST) who apply for every thing and problems in SDC.

• Laboratory Guide Manuel(LGM)

• It has to show all of the details of tests which PSG,CPAP titration, MSLT,Epileptic follow up

• It has to show all procedures when the patient is accepted SDC.

• SDC must follow the national sleep society guide manuel.

Baylor Collage of Medicine,Sleep Disorders Center Houstun-Texas, USA- 1992

PSG has AC channels and DC channels. At the same time DC channels are able to record.

Equipment:

Each Room has to be connected PSG which has sixteen channels (6 EEG, EOG, 3 EMG)

Uyku Laboratuvarı Standartları

Equipment:

• PSG has Respiratory channels,oxymeter, ECG,leg EMG,body position sensor, microphone

• Polisomnographic records(all nights)has to be evaluated 30 or 60 second epochs.

CHIN-EMG

EEG: Zemin; nispeten düşük voltaj, karışık frekans, Uyku iğciği 12-14 cps (>0.5 sn) K Kompleks

EOG: Arasıra SEM, EMG: Tonik aktivite düşük düzeyde

EEG: Nispeten düşük voltaj, karışık frekans, Teta aktivitesi, yavaş Alfa, testere dişli dalga

EOG: Fazik REM, EMG: Tonik supresyon, fazik dönemler

• Minimum montage for standard sleep medicine polysomnography

• 6 EEG (e.g. F4-M1,C4-M1,O2-M1 or F3-M2, C3-M2, O2-M2)• 2 EOG• 3 mentalis/submentalis EMG• SaO2• Snoring signal• Body position sensor• Nasal pressure/flow signal (thermistors are no longer acceptable as a single recording method in adults)• Validated method of respiratory effort• 2 EMG, tibialis anterior• ECG, one channel• Video monitoring with possibility of recording

POLİSOMNOGRAPHY

•EEG, EOG, EMG EEG, EOG, EMG (Submental)(Submental)•Oro-Nasal Oro-Nasal AirflowAirflow•Respiratory Respiratory Effort Effort ChannelsChannels•OxymeterOxymeter•ECGECG•EMG (Tibial)EMG (Tibial)•Body Position Body Position SensorSensor•MicrophoneMicrophone

Recording in SMC,

• In SMC, the ongoing recording should be monitored by trained technical or nursing staff who MD is responsible from .

• SDC has to have atleast two Sleep

Technicians who has their knowledge of and experience in sleep medicine. Each ST is responsible from two patient.

Recording in SMC,• Polysomnography (PSG) technologists for

nocturnal and diurnal recordings are required to ensure the proper, artefactfree functioning of the recording devices, to detect problems and resolve them.

• This makes their presence during the entire recording process an absolute necessity.

• Between Night and Daytime technicians’s

working schedule will be planned consistenly

• Diagnostic tests• Additional diagnostic tests that are routinely

performed at the SMC should be listed here, e.g.

• Physical examination• Clinical investigations (e.g. laboratory

analyses, radiology, pulmonary function tests, etc.)

• MSLT, • MWT• Sleep diary

• Diagnostic tests• Sleep questionnaires [e.g. Pittsburg Sleep

Quality Index(PSQI), Epworth Sleepiness Scale (ESS), Stanford Sleepiness Scale (SSS), etc.]

• Psychological and personality questionnaires (e.g. MMPI, etc.)

• Neuropsychological examinations (vigilance, psychometric and cognitive tests)

• Other.

EEG 10-20 SystemJasper 1958

In polisomnography which parameters are been recorded?

Sleep Parametres

• EEG• EOG• EMG• EKG

EEG -Recommended

a. F4-M1b. C4-M1c. O2-M1

F3, C3, O1 and M2 derivations are placed backup electrods If there is necessary to use backup channels for PSG record.

a. F3-M2b. C3-M2c. O2-M2

LOCLOC

ROCROC

EOG; Recommended

E1-M2 (E1;Left outer cantus lower 1 cm)

E2-M2 (E1;Right outer cantus above1 cm)

Sleep Stages

• W: ‘’Wakefullness’’• N1: ‘’NREM 1’’• N2: ‘’NREM 2’’• N3: ‘’NREM 3’’ (NREM3 and 4

combined)• R : ‘’REM’’- 30 sn epoch- If there is multiple sleep stage in an

epoch,that the longer stage is scored .

• Respiratory parameters

• Oro-nasal airflow• Respiratory Effort(Thoracic and Abdominal effort)• Oxygen Saturation• Snoring and respiratory sounds• CO2 measurement• Intra thoracic effort

• Other Parameters

• Position

• Limbs Movements (EMG)

• Nocturnal Penile Tumescence (NPT)

• Body Temperature

• Oesophageal pH

• Scoring Evaluation of Polisomnographic Records

• Sleep related parameters• Sleep latency• Sleep Stage Time• Percentage of Sleep Stage• Total Sleep Time• Sleep Efficiency Index• Behavioral and Bioelectrical Arousal Index

• Respiratory Parameters• Apnea and/or Hypopnea Index• Effort Index• Abnormal Respiratory Event Index• Abnormal Respiratory Events Time• Minimum 02 level• ECG variations• Maximum Intrathoracic Pressure

• Correlation between sleep and respiratory Parameters

• Relationship between sleep sateges and respiratory events

• Relationship between body position and respiratory events

• Scoring Evaluation of Polisomnographic Records;

• VisualManuel

• Automatic Scorring.

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