Box 4.

MWT general testing, data acquisition, and data reporting procedures.

General Testing Procedures

1. Relevant clinical data such as preceding sleep schedules, PAP adherence, or other therapies should be available to the interpreting clinician. The MWT should be performed after the patient’s major sleep period. Performance of a PSG before the MWT is at the discretion of the sleep clinician.

2. The patient’s clothing should be comfortable, be appropriate to the environment, and not interfere with the performance of tests. If a PSG is performed, then a change in clothing is not required between the PSG and the MWT.

3. The patient should abstain from alcohol, marijuana, and other sedating substances on the day of the test.

4. Patients on PAP/non-PAP therapies for sleep-disordered breathing should use them the night before (but not during) the MWT. If a PSG is performed, then the PAP settings and mask interface should match those used at home.

5. The recording montage for the MWT should, at a minimum, include 3 EEG recording leads with 1 each for frontal (F3-M1 or F4-M2), central (C3-M2 or C4-M1), and occipital (O1-M2 or O2-M1) derivations, left and right eye EOGs, mental/submental EMG, and EKG.

6. Audiovisual recordings must be made during the wake trials and be accessible to interpreting sleep specialists. The patient must be audiovisually monitored throughout the day, but retention of recordings made between trials is discretionary.

7. The MWT should consist of four 40-minute wake trials. The initial trial should begin 1.5–3 hours after termination of the preceding night’s sleep at home, and a subsequent trial should begin 2 hours after the start of the prior trial.

8. Before each wake trial, the patient should be offered the use of the restroom and queried regarding other requirements for comfort.

9. Sleep rooms should be dimly lit, quiet, and at a comfortable temperature during testing. The light source should deliver an illuminance of 0.1–0.13 lux at the corneal level (such as a 7.5-watt nightlight) placed 12 inches off the floor and 3 feet lateral to the patient’s head. The patient should be given sufficient time to acclimate to the recording room before the start of the first trial.

10. The patient should be seated in a bed or reclining chair with the back and head comfortably supported. This should be the same for all wake trials.

11. Patient bio-calibrations should be conducted before starting each wake trial. Standard instructions include: (1) “sit quietly with your eyes open for 30 seconds”; (2) “close both eyes for 30 seconds”; (3) “without moving your head, look to the right, then left, then right, then left, right and then left”; (4) “blink eyes slowly for 5 times”; and (5) “clench or grit your teeth tightly together.” Before the trials, patients should be instructed to refrain from activities and vocalizations that promote wakefulness such as fidgeting or singing.

12. At the start of each wake trial, the patient should be instructed as follows: “Please sit still and remain awake for as long as possible. Look directly ahead of you, and do not look directly at the light.” Testing starts immediately after instructions are given, and bedroom lights are turned off.

13. Each wake trial is ended once the patient has 3 consecutive epochs of stage N1 sleep or 1 epoch of any other sleep stage or after 40 minutes.

14. Stimulating activities such as consuming nicotine and the use of electronic devices and cell phones should end at least 30 minutes before each wake trial. Vigorous physical activity and prolonged exposures to sunlight/bright artificial light should be avoided all day.

15. Between wake trials, the patient should be out of bed and not permitted to sleep.

16. A light breakfast at least 1 hour before the first wake trial and a light lunch immediately after the termination of the second wake trial are recommended.

17. Urine drug screening should be employed when indicated to ensure that the MWT results are not confounded by inadvertent, intentional, or illicit medication or substance use.

Data Acquisition and Reporting

1. Patient demographics (name, DOB, test date, BMI, medical record number).

2. Names of referring clinician, sleep specialist, and sleep technologist.

3. Documentation of medications used within 24 hours of and during the MWT and any changes to medications within last 2 weeks. If performed, the type of drug screening should be documented.

4. Documentation of available prestudy data including sleep diary, actigraphy, and PAP download.

5. Recording parameters including start time, end time, total sleep time, and sleep latency of each wake trial. Sleep latency is defined as the time from lights out until the start of the first epoch of any stage of sleep (an epoch of N1, N2, N3, or R).

6. Mean sleep latency averaged over the 4 wake trials. If no sleep occurs on a trial, then 40 minutes is used as the sleep latency and in the calculation of the mean sleep latency.

7. Deviations from ideal testing times and conditions (eg, nicotine, caffeine, napping, cell phone, fire alarms, or other stimulating activities), should be documented by the sleep technologist.

8. Interpretation of study findings with signature of board-certified sleep medicine physician.

BMI = body mass index, DOB = date of birth, EEG = electroencephalogram, EKG = electrocardiogram, EMG = electromyogram, EOG = electro-oculogram, MWT = Maintenance of Wakefulness Test, PAP = positive airway pressure, PSG = polysomnogram.