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Volume 08 No. 05
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Accepted Papers


Not SAD at All: New Scoring Rules and an Online Scoring Manual

Nancy A. Collop, M.D., F.A.A.S.M.1; Michelle M. Tangredi, Ph.D.2; Richard B. Berry, M.D., F.A.A.S.M.3
1The Emory Sleep Disorders Center, Wesley Woods Health Center, Atlanta, GA; 2American Academy of Sleep Medicine, Darien, IL; 3Division of Pulmonary Medicine, University of Florida Health Science Center, Gainesville, FL

In this issue of the Journal of Clinical Sleep Medicine, the Sleep Apnea Definitions (SAD) task force of the American Academy of Sleep Medicine (AASM) redefines many of the respiratory rules found in the 2007 AASM Manual for the Scoring of Sleep and Associated Events. This task force labored over a two-year period, analyzing the recent literature pertaining to respiratory events and sensor technology, and striving to reach consensus on a new set of respiratory rules. The paper details some significant changes including a single definition of a hypopnea. In addition, there is now the option to score hypopneas as central or obstructive. There is also greater concordance between adult and pediatric scoring rules for various respiratory events. (Please refer to the forthcoming new version of the scoring manual for the final version of the rules for scoring respiratory events.) As the AASM Board of Directors worked through adopting these changes, significant consternation was raised about adopting a singular hypopnea definition using 3% oxygen desaturation with or without arousals since the Center for Medicare and Medicaid Services (CMS) still uses only a 4% desaturation definition. The AASM sent a letter to CMS in July asking them to consider changing their criteria based on this new document. As of the writing of this editorial, we have not received a response from CMS. We realize that for the time being, this will create some problems for labs that have not been using the 3% rule; however, we are hopeful that soon enough, there will be one agreed upon rule for both clinical, CMS, and research studies. Congratulations to the SAD task force for all their hard work on this project.

With the development of new respiratory rules by the SAD task force underway, the AASM Board of Directors began to grapple with how to update the scoring manual. Because of the need to be flexible for future changes, a decision was made to convert the printed scoring manual to an online product. An online version has several advantages: it can be easily updated in response to new evidence and member inquiries; it is accessible from a variety of locations using smartphones, tablets, and computers. The online version allows for more detailed and colorful graphics, and the timely inclusion of answers to frequently asked questions. The board approved a Scoring Manual Committee with members chosen for their expertise applicable to the different sections of the scoring manual. The 2012-2013 members include: Richard Berry, chair; Charlene Gamaldo (legs); Bradley Vaughn (EEG); Carole Marcus (pediatrics); Rita Brooks (AAST representative); and Susan Harding (breathing). In addition to moving the manual online, the mandate of the task force is to, on a regular basis, review and update the AASM Manual for the Scoring of Sleep and Associated Events to ensure it is current with AASM practice parameters, clinical guidelines, and policy, and addresses the evolution of clinical literature and technology.

In order to make timely and appropriate changes, the Scoring Manual Committee will, at minimum on a quarterly basis, review inquiries from Manual users including but not limited to: individuals, sleep centers, industry representatives, and government agencies. The new scoring manual e-mail ( will provide a conduit for stakeholders to submit their questions and comments. The Scoring Manual Committee will hold a face-to-face meeting at the annual meeting of the Associated Professional Sleep Societies, and when deemed appropriate by either the committee or the Board of Directors, a member forum will be held at the annual meeting. On an annual basis, the Scoring Manual Committee will be tasked with providing a critique of the rules by individual section. Such a review will include requests from users for revisions of the text. Some years, the Scoring Manual Committee may simply indicate that the rules remain valid and supported. Other years, the critique will include suggestions for clarification, minor modifications and/or major revisions of scoring rules.

In the case of major revisions, AASM staff will evaluate the proposed rules in need of change and institute a formal literature search for relevant materials. The results of the search will be analyzed by the Scoring Manual Committee and presented to the board as evidence along with a new set of rules. All additions, deletions, changes, corrections and explanations will require board approval prior to implementation. Acceptable evidence to make changes may include published research in peer-reviewed journals. Such research may have been financially supported by government, industry and/or public or private foundations. Anecdotal evidence such as testimonials from users of novel technology may be considered as well. The Scoring Manual Committee may request supportive information from users advocating major revisions. It is hoped that this process will allow flexibility in updating rules as new technologies, studies, and information become available.

The AASM Board of Directors has decided to charge an annual subscription fee of $25.00 for electronic access to the scoring manual. The easiest way to subscribe will be with the membership dues renewal and could be either an individual subscription or a center subscription, meaning all who work in a center would be permitted access. Subscriptions will run on a calendar year and will be formatted for regular monitor as well as tablet/mobile-device viewing. Each time the journal is updated, it will receive a new version number which should be used for referencing. Older versions of the manual will continue to be accessible with the annual subscription.

We hope that you will find all these changes advancements in the AASM's desire to remain relevant and on point with emerging technologies and research.


The authors have indicated no financial conflicts of interest.


Collop NA; Tangredi MM; Berry RB. Not SAD at all: new scoring rules and an online scoring manual. J Clin Sleep Med 2012;8(5):621-622.