CCSH cheat sheet

Adult sleep cycles last about 90–110 minutes; a normal night contains 4–6 cycles, with REM periods lengthening toward morning.

N1 occupies roughly 5% of total sleep time and shows theta activity, slow eye movements, and vertex sharp waves.

N2 occupies about 45–55% of total sleep time and is defined by sleep spindles and K-complexes.

N3 (slow-wave sleep) requires ≥20% of an epoch containing 0.5–2 Hz waves >75 µV and predominates in the first third of the night.

REM sleep occupies about 20–25% of total sleep time with low-voltage mixed-frequency EEG, rapid eye movements, and chin EMG atonia; first REM latency is ~90 minutes.

Two-process model: Process S is homeostatic sleep pressure (adenosine accumulation); Process C is the circadian rhythm generated by the suprachiasmatic nucleus and entrained by light.

OSA severity by AHI: mild 5–<15, moderate 15–30, severe >30 events/hour; diagnosis requires AHI ≥5 with symptoms or ≥15 regardless of symptoms.

Narcolepsy type 1 is linked to hypocretin (orexin) deficiency; MSLT shows mean sleep latency ≤8 minutes with ≥2 sleep-onset REM periods.

Insomnia disorder = difficulty initiating or maintaining sleep ≥3 nights/week for ≥3 months with daytime impairment despite adequate opportunity to sleep.

Core history elements: habitual bedtime and wake time, sleep latency, awakenings, naps, snoring, witnessed apneas or gasping, leg sensations, and daytime sleepiness.

Epworth Sleepiness Scale: 8 situations scored 0–3, total 0–24; a score >10 indicates excessive daytime sleepiness.

STOP-BANG: 8 yes/no items; ≥3 indicates intermediate and ≥5 indicates high risk for moderate-to-severe OSA.

Insomnia Severity Index totals 0–28 with ≥15 indicating clinical insomnia; a Pittsburgh Sleep Quality Index score >5 indicates poor sleep quality.

Neck circumference >17 inches in men or >16 inches in women, BMI, Mallampati grade, retrognathia, and nasal patency are key physical findings.

Review all medications and substances (benzodiazepines, opioids, stimulants, alcohol, caffeine) plus comorbidities such as hypertension, atrial fibrillation, heart failure, stroke, and hypothyroidism.

Pediatric OSA clues include snoring, tonsillar hypertrophy, enuresis, failure to thrive, and ADHD-like behavior.

Ask about drowsy driving and occupational risk (commercial driving, safety-sensitive work) at every assessment.

A standard PSG records EEG, EOG, chin and leg EMG, ECG, airflow (thermistor and pressure), respiratory effort, SpO2, body position, and snoring.

Sleep is scored in 30-second epochs; sleep onset is the first epoch of any sleep stage.

AHI = (apneas + hypopneas) ÷ total sleep time in hours; ODI = desaturations ≥3% per hour of sleep.

Apnea = ≥90% airflow reduction for ≥10 seconds; hypopnea = ≥30% reduction with ≥3% desaturation or an arousal.

Central apnea requires absent airflow with absent respiratory effort; Cheyne–Stokes respiration is crescendo–decrescendo breathing with central apneas, often in heart failure.

MSLT: 4–5 naps of 20 minutes at 2-hour intervals starting 1.5–3 hours after the PSG; mean sleep latency ≤8 minutes is abnormal and a SOREMP is REM within 15 minutes of sleep onset.

HSAT uses limited channels, tends to underestimate AHI, and is not recommended when central sleep apnea, hypoventilation, or major comorbidity is suspected.

Actigraphy (usually 7–14 days) estimates sleep–wake patterns and is useful for circadian rhythm disorders and insomnia assessment.

PAP adherence benchmark: ≥4 hours per night on ≥70% of nights; residual AHI on therapy should be <5 events/hour.

Device types: CPAP (fixed), APAP (auto-titrating), and BPAP (bilevel); humidification, ramp, and mask type (nasal, pillows, full-face) affect tolerance.

Oral appliance therapy advances the mandible and is an option for mild-to-moderate OSA or CPAP intolerance, titrated by a qualified dental provider.

Weight loss lowers AHI (~26% reduction with ~10% weight loss); positional therapy helps supine-dependent OSA; hypoglossal nerve stimulation requires CPAP intolerance, BMI ≤32, and AHI 15–65.

CBT-I is first-line for chronic insomnia and includes stimulus control, sleep restriction, cognitive restructuring, relaxation training, and sleep hygiene education.

Sleep restriction sets time in bed near the average total sleep time (floor ~5 hours), then increases 15–30 minutes weekly when sleep efficiency is ≥85–90%.

Stimulus control: use the bed only for sleep and intimacy; leave the bedroom if awake >20 minutes and return only when sleepy.

RLS: check ferritin/iron status; treat with alpha-2-delta ligands or dopamine agonists while watching for augmentation; RBD is managed with melatonin or clonazepam plus safety measures.

Narcolepsy pharmacotherapy includes modafinil/armodafinil, sodium oxybate, pitolisant, and solriamfetol; scheduled naps are adjunctive.

Teach-back: ask the patient to explain the plan in their own words; this verifies understanding better than asking whether they have questions.

Motivational interviewing uses OARS - open questions, affirmations, reflections, summaries - and matches intervention to the patient's stage of change.

Early PAP follow-up within the first week, with mask refit and data download, improves adherence more than late intervention.

Common PAP side effects to address: nasal congestion or dryness, mouth leak, aerophagia, claustrophobia, pressure intolerance, and skin irritation.

Sleep hygiene counseling: consistent schedule, caffeine avoided ~6 hours before bed, limited alcohol and nicotine, bright morning light, dark quiet cool bedroom.

Sleep efficiency = total sleep time ÷ time in bed × 100; it is used to titrate sleep restriction therapy.

Adherence is predicted by self-efficacy, social support, early experience with therapy, and perceived benefit; screen for depression and claustrophobia.

CCSH scope: screening, education, and adherence counseling; diagnosis, study interpretation, and prescribing remain with licensed clinicians.

HIPAA: safeguard protected health information, obtain authorization before disclosure, and use secure channels for sleep study data and communications.

Document objective findings, education delivered, patient response and understanding, barriers identified, and the follow-up plan.

Informed consent is required before sleep testing and treatment; document discussion of purpose, benefits, risks, and alternatives.

Common codes: 95810 (attended polysomnogram), 95806 (unattended HSAT), plus E/M codes; billing must reflect services actually rendered (no upcoding).

Maintain professional boundaries, disclose conflicts of interest, and refer outside your scope of practice.

Drowsy driving counseling and patient-reported driving risk should be documented and communicated to the treating clinician.