AASM Scoring Manual Updates for 2017 (Version 2.4)

The Editorial Board of The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (AASM Scoring Manual) would like to notify the membership and the sleep community that an update for the AASM Scoring Manual (Version 2.4) was released April 1, 2017.¹ All AASM-accredited sleep facilities will be required to implement the new rules in the new version by October 1, 2017. The changes for Version 2.4, which were approved by the AASM Board of Directors, are briefly outlined as follows:

• A new section on performing calibrations and biocalibrations to document appropriate system response was added to chapter III. Technical and Digital Specifications (Section E).

• The recommended electrooculography (EOG) electrode positions and figure were updated in Section B in chapter IV. Sleep Staging Rules Part 1: Rules for Adults.

• A new note was added to rule D.1 in chapter IV. Sleep Staging Rules Part 1: Rules for Adults to clarify when to use the term “Stage R” versus “REM sleep.”

• The definition of “slow wave activity” in rule D.3 in chapter IV. Sleep Staging Rules Part 1: Rules for Adults, and throughout the manual, was updated for consistency to be > 75 μV.

• The definition of “atrial fibrillation” was updated in both the glossary and in rule B.6 in chapter VI. Cardiac Rules.

• Rule B.4 in chapter VII. Movement Rules was revised to remove mention of a “sleep-disordered breathing event.”

• New notes were added in chapter VIII. Respiratory Rules Part 2: Rules for Children for the scoring of apneas and the scoring of hypopneas.

Compared to previous revisions, only a modest number of changes have been made. The major revision is the addition of a standard set of calibrations and biocalibrations to document adequate function of the electroencephalography, EOG, and electromyography electrodes as well as the respiratory sensors at the start and end of a sleep study. Most sleep centers already perform similar calibrations and biocalibrations. The goal of this addition was to standardize the procedure and to improve the quality of sleep recordings in sleep centers not currently performing such procedures. High-quality biocalibrations improve the ability to accurately stage sleep and allow the sleep technologist to troubleshoot problems before the study begins. The electrode locations for the recommended EOG electrodes (E1, E2) have also been slightly modified to conform to what the Editorial Board believes is a more practical location consistent with the current practice in most sleep centers. New respiratory notes were added to the respiratory scoring rules for children to make them more consistent with those in the adult section. A note clarifying use of the term stage R versus REM sleep has been added. Additional changes were also made to improve consistency throughout the manual.

Each month the Editorial Board receives numerous inquiries about interpretation of the scoring rules and recommendations for changes in the rules or need for clarification in the wording. The Editorial Board appreciates the many thoughtful questions and suggestions. We are developing an FAQ section for the AASM website for the membership to view previous inquiries and responses. There are some recurring questions for which there are no definitive answers because of a lack of published data. The Editorial Board initiated ongoing meetings with the AASM Inter-scorer Reliability (ISR) gold standard scorers in an effort to understand the challenges involved with applying the current rules to real life tracings. Communication between the ISR gold standard scorers and the Editorial Board is ongoing. The Editorial Board is well aware that revisions may require some additional effort in changing scoring habits developed over many years. Our goal is to make changes only when the perceived benefit is worth the challenges of change.

DISCLOSURE STATEMENT

Dr. Vaughn is a paid author for UptoDate (subject nocturnal events) and Neurobase (variety of sleep and epilepsy subjects), and receives research funding as a co-investigator from Axovant for a REM sleep behavior study. Dr. Quan receives grant funding from the National Institutes of Health, and serves as a consultant to the American Board of Internal Medicine, Nightbalance and Best Doctors. Dr. Gamaldo has an agreement with UpToDate, Inc. and has been paid royalties for her contribution of medical articles for this publication. Dr. Harding receives publishing royalties from UpToDate for revising one editorial card each year. Dr. Harding also receives an honorarium from the American Board of Internal Medicine for MOC process. Drs. Berry, Troester, Lloyd and Ms. Brooks have indicated no financial conflicts of interest.

CITATION

Berry RB, Brooks R, Gamaldo C, Harding SM, Lloyd RM, Quan SF, Troester MT, Vaughn BV. AASM scoring manual updates for 2017 (Version 2.4). J Clin Sleep Med. 2017;13(5):665–666.