Electroneurodiagnostic & Polysomnography

Recommendations

1. Fund the replication and development of courses in Polysomnography (PSG).

   Increased awareness of sleep disorders and an increase in the number of sleep labs and lab capacity has created an unprecedented demand for formally trained and certified polysomnographic technologists (RPSGT) in many regions of the State. Douglas Gibson, McLennan Community College (MCC), created the first PSG CERT1 in the State of Texas two years ago and has found great success in both recruitment and placement of students. 

   There is no doubt that the employers in Texas would support other college or university programs. We would be surprised if other colleges did not start looking at polysomnography awards. Curriculum development should be coordinated in the state to reduce duplication of effort.

           –Douglas Gibson, McLennan Community College

   The MCC program is an extension of MCC’s also unique Electroneurodiagnostics Associate Degree program. Alvin Community College (ACC) has a PNG ATC in connection with the college’s existing Respiratory Care Associate Degree program. Diane Flatland has found high demand for formally trained PSGTs in the Houston area and in connection with regional medical centers. 

   Scott and White and others expressed a desperate need for polysomnography technicians. 

           –Dr. Gregg Marshall, Texas State University

   The Respiratory Care Department of Temple College will be the third College in Texas to offer an ATC in PSG and will enroll its first students in the coming Fall semester. This program will be very similar to the ACC program and both will seek accreditation through The Committee on Accreditation for Respiratory Care (CoARC). 

2. Fund the replication and development of courses in Electroneurodiagnostics (END).

   There are currently 16 colleges in the United States with accredited Electroneurodiagnostic Technologist programs and of these only a handful include a PSG option. MCC will be the first program in the State of Texas to obtain accreditation from the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and will also offer a PSG option. This is a very compelling offering for students interested in entering this field as graduates will be eligible for both PSG and END board exams upon graduation. Diane Flatland, Alvin College, has found similar industry demand and the college is planning to develop a similar END offering to complement their newly created PSG ATC. 

   In researching and talking to all the department directors in the Houston Medical Center, they really wanted the Associate Degree for END but we couldn’t do this physically at this time. After the bond election we are planning to build a new building in two years and then we might create an END Associate Degree program.

           –Diane Flatland, Alvin College

   While PSG is considered to be in the family of END, stand-alone ATC programs can complement existing respiratory care programs as well as new ENG programs and PSG serves as a beneficial ATC option in either case. Insurance companies and Medicaid now require RPSGTs for reimbursements, and similar trends appear on the horizon for END techs. 

   Another reason we considered starting a program was because the American Society of Electroneurodiagnostic technologists  published a guideline in 1999 that required anyone intending to work in the field of Electroneurodiagnostics to have a minimum of an Associate degree.

           –Douglas Gibson, McLennan Community College

Employment Potential

Polysomnography Certificate Option

Observations & Findings

1. There is a growing need for formally trained and certified polysomnography technologists in the State of Texas.

   This increasing demand is being generated by a number of factors including: increasing awareness of sleeping disorders and available treatments, insurance and Medicaid requirements for RPSGTs, new studies linking cardiopulmonary disease with sleeping disorders, and a growing number of sleep diagnostic clinics. 

   "Increasing awareness within the medical community is also driving the demand. Sleep medicine is 25 years old, but it has not been on the check-list of physicians. A significant percentage of our population has sleep disorders that cause learning disorders and serious physical problems. In some cases the problems are purely psychological."

           Douglas Gibson, McLennan Community College
2. There is an expressed industry demand for more qualified electroneurodiagnostic technologists.

   In contract to the expressed industry demand for experienced and certified PSGTs, the demand for END techs appears to be driven primarily by the complete lack of any accredited programs in Texas. The MCC program is the first in the state to recognize and respond to this demand. Alvin College will be the second in the state and at least one additional Texas College has expressed an interest in developing an additional program. 

   "In the past therapists have been cross-trained to do EEG. The EEG profession has not come out and said that you need to be a registered person to do these things. Utah now requires EEG techs to have at least an AAS in Respiratory Care."

           Diane Flatland, Alvin College

    

3. The curriculum for END and PSG has already been developed and approved by the THECB in the State of Texas.

   MCC has fully developed the END curriculum and courses are WECM approved. Therefore, replicating this program will be much easier for interested Colleges. Two PSG ATC programs are approved and operational today and a third will accept students in the Fall. Colleges with existing Respiratory programs are well positioned to extend PSG ATC offerings.

   Colleges with existing respiratory programs are well positioned to start new PSG programs since these areas are closely related.   Faculty can cross-teach to both sides of the curriculum.  Colleges will have to seek accreditation from one of the three agencies.  I highly recommend CoARC because existing respiratory programs are likely already involved with this agency and obtaining a temporary accreditation for a new PSG program is literally a matter of filing the paperwork, if the RC Program is in good standing with CoARC.

           Dr. Gregg Marshall, Texas State University
4. Choosing an accrediting agency is very important in developing a new PSG or ENG program because some committees offer accreditation for both END and PSG.

   There are three accrediting agencies in the United States. Temple College and Texas State University are seeking this accreditation from the Committee on Accreditation for Respiratory Care (CoARC). MCC already has an accredited respiratory program but because of their new END program has chosen to pursue the Commission for Electroneurodiagnostics (CoEND) since they provide accreditation for both END and PSG. The Commission for Polysomnography (CoPSG) is the third source of accreditation. All of these accreditation pathways are options for Colleges, but each has different requirements that should be carefully considered. Texas State will have a CoARC site visit in Spring 2006 and will seek full PSG accreditation at that time (Marshall). 

Related Technologies

Electroencephalogram (EEG)

Six electrodes (labeled C3, C4, A1, A2 O1, and O2) and one ground electrode are placed around the cranium to record electrical activity across the brain. These leads are used to determine the stage of sleep the patient is in during any given period of the night.

Electroocculogram (EOG)

One electrode is placed above and to the outside of the right eye, and another electrode is placed below and to the outside of the left eye. These leads record the movements of the eyes during sleep and serve to help determine sleep stages. 

Electromyogram (EMG)

Three leads are placed on the chin (one in the front and center and the other two underneath and on the jawbone) and two are placed on the inside of each calf muscle 2-4cm apart. These leads serve to demonstrate muscle movement during sleep. This is helpful in documenting a wake period, an arousal, or just a spastic movement. 

Electrokardiogram - Electrocardiogram (EKG/ECG)

Two electrodes are placed on the upper chest near the right and left arms. These record the heart rate and rhythm and serve to alert the technician to a possible emergency situation. They also demonstrate whether apneic desaturation leads to arrhythmias or not. A device that looks similar to a nasal cannula is secured just under the patient’s nose. It senses the amount of air moving into and out of the airways and sends a signal to a physiological recorder. This tracing is used to determine the presence and extent of apneic episodes.

Respiratory Effort (piezo crystal effort sensor)

Two Velcro bands, one placed around the chest under the breasts and one around the abdomen, serve to determine chest wall and abdominal movements during breathing. Each band is joined together by a piezo crystal transducer. The force of chest/abdominal expansion on the bands stretches the transducer and alters the signal to a physiological recorder. These leads, combined with the airflow sensor, are how apnea is demonstrated and categorized during the test.

Oxygen saturation (Pulse oximeter)

The O2 saturation is measured by a pulse oximeter probe placed on the patient i.e. finger, earlobe, etc. 

If the sleep disorders center is equipped with video cameras in the patient rooms, the patient can be taped while sleeping. This allows the technician to review the tape at any time during the test and verify whether strange looking waveforms were caused by an actual arousal, a period of wake, or normal patient movement in bed.

Nerve Conduction Studies (NCS)

Several flat metal disc electrodes are attached to your skin with tape or a special paste. A shock-emitting electrode is placed directly over the nerve to be studied, and a recording electrode is placed over the muscles supplied by that nerve. Repeated, brief electrical pulses are administered to the nerve, and the time it takes for the muscle to contract in response to the electrical pulse is recorded. The speed of the response is called the conduction velocity. The corresponding nerves on the other side of the body may be studied for comparison. When the testing is completed, the electrodes are removed. Nerve conduction studies are usually done before an EMG if both tests are being done. Nerve conduction testing may take from 15 minutes to 1 hour or more, depending upon how many areas of the body are studied. 

Evoked Potentials (EPs)

Evoked potential tests measure electrical activity in certain areas of the brain in response to stimulation of certain groups of nerves. These tests are often used to assist in the diagnosis of MS because they can indicate problems along the pathways of certain nerves that are too subtle to be noticed or found on a doctor's exam. Problems along the nerve pathways are a direct result of the disease. The demyelination causes the nerve impulses to be slowed, garbled, or halted altogether. While evoked potentials are used to help diagnose MS, other conditions can also produce abnormal test results, so the tests are not specific for MS. 

Autonomic Testing

Autonomic tests measure how the systems in the body that are controlled by the autonomic nerves respond to stimulation. The data collected during testing will indicate if the autonomic nervous system is functioning as it should, or if nerve damage has occurred. The autonomic system manages all internal functions such as blood pressure, blood flow, and sweating. Autonomic tests are conducted to see if the autonomic nervous system is functioning normally. Autonomic testing can help determine if a patient is suffering from certain diseases that attack the autonomic nervous system, or as a way to diagnose an illness, or source of pain. To see if a disease is affecting the autonomic nervous system, several tests are done to monitor blood pressure, blood flow, heart rate, skin temperature, and sweating. 

Nature of PSG Work

Polysomnographic technologists are specialists who work in state-of-the-art sleep disorders centers. Technologists operate, monitor, and troubleshoot sophisticated computerized sleep equipment to collect and analyze physiologic patient data. Polysomnographic technologists also work closely with physicians and other sleep specialists participating in patient education and treatment plan coordination. Most polysomnographic technologists work 10- to 12-hour night shifts. This career choice should be made after careful consideration of the nature of the hours and the student's desire and ability to work the night shift. 

PSG Related Technology

Polysomnography is a diagnostic test during which a number of physiologic variables are measured and recorded during sleep. Physiologic sensor leads are placed on the patient in order to record: brain electrical activity; eye and jaw muscle movement; leg muscle movement; airflow; respiratory effort (chest and abdominal excursion); EKG; and oxygen saturation. Information is gathered from all leads and fed into a computer and outputted as a series of waveform tracings which enable the technician to visualize the various waveforms, assign a score for the test, and assist in the diagnostic process. 

PSG Related Job Titles

Graduates of the certificate program in polysomnography will be qualified for employment as polysomnographic technologists in hospital-based and freestanding sleep disorders centers. Typical job titles include: polysomnographic technologist, neurophysiology technologist—polysomnography, sleep technologist, neurodiagnostic technologist—polysomnography. 

PSG Employment Outlook

According to the BLS Occupational Outlook Handbook, Respiratory therapy technicians are one of the fastest growing occupations projected to have the largest numerical increases in employment between 2002 and 2012 (BLS 2005). Hospitals will continue to employ the vast majority of respiratory therapists, but a growing number of therapists will work in other settings. In a survey reported in Advance for Managers of Respiratory Care, 31 percent of respondents earned between $40,000 and $49,000 per year; 26 percent earned between $30,000 and $39,999 per year. 

PSG Certification

Accredited program graduates are eligible to take the comprehensive board for registered polysomnographic technologist examination to earn the credential Registered Polysomnographic Technologist. Certified patient care providers are eligible for exams after 6 months of work experience in polysomnography. All other applicants require 18 months of work experience. 

Interpretation of test results:

Each sleep study is scored epoch by epoch both for stage of sleep and any abnormalities that can be seen. An epoch is a convenient time interval, usually equal to one page of record. Epoch durations should be 20 - 30 sec respectively depending on whether the recommended 15 or 10 mm/sec paper speeds are used. In the tracing on the right, nasopharyngeal pressures (Pn) of zero mark an apneic event.

Obstructive sleep apnea is labeled and marked any time there is a greater than 50% decrease in airflow with continued efforts to breathe lasting over 10 seconds in duration. Cessation of airflow can be easily seen in the graphic below from medscape.com.

Central sleep apnea is marked when there is a cessation in airflow as well as respiratory effort lasting at least 10 seconds in duration.  

Mixed sleep apnea is labeled if you see at least 10 seconds of central apnea followed by an obstructive component. 

Related Texas Programs

Sample of Other Related Programs

Registered Texas Sleep Clinics