Respiration Signals from Photoplethysmography

A Brief Review of Non-invasive Monitoring of Respiratory Condition for Extubated Patients with or at Risk for Obstructive Sleep Apnea after Surgery

Obstructive sleep apnea (OSA) is one of the important risk factors contributing to postoperative airway complications. OSA alters the respiratory physiology and increases the sensitivity of muscle tone of the upper airway after surgery to residual anesthetic medication. In addition, the prevalence of OSA was reported to be much higher among surgical patients than the general population. Therefore, appropriate monitoring to detect early respiratory impairment in postoperative extubated patients with possible OSA is challenging. Based on the comprehensive clinical observation, several equipment have been used for monitoring the respiratory conditions of OSA patients after surgery, including the continuous pulse oximetry, capnography, photoplethysmography (PPG), and respiratory volume monitor (RVM). To date, there has been no consensus on the most suitable device as a recommended standard of care. In this review, we describe the advantages and disadvantages of some possible monitoring strategies under certain clinical conditions. According to the literature, the continuous pulse oximetry, with its high sensitivity, is still the most widely used device. It is also cost-effective and convenient to use but has low specificity and does not reflect ventilation. Capnography is the most widely used device for detection of hypoventilation, but it may not provide reliable data for extubated patients. Even normal capnography cannot exclude the existence of hypoxia. PPG shows the state of both ventilation and oxygenation, but its sensitivity needs further improvement. RVM provides real-time detection of hypoventilation, quantitative precise demonstration of respiratory rate, tidal volume, and MV for extubated patients, but no reflection of oxygenation. Altogether, the sole use of any of these devices is not ideal for monitoring of extubated patients with or at risk for OSA after surgery. However, we expect that the combined use of continuous pulse oximetry and RVM may be promising for these patients due to their complementary function, which need further study.

Robust respiration detection from remote photoplethysmography

Continuous monitoring of respiration is essential for early detection of critical illness. Current methods require sensors attached to the body and/or are not robust to subject motion. Alternative camera-based solutions have been presented using motion vectors and remote photoplethysmography. In this work, we present a non-contact camera-based method to detect respiration, which can operate in both visible and dark lighting conditions by detecting the respiratory-induced colour differences of the skin. We make use of the close similarity between skin colour variations caused by the beating of the heart and those caused by respiration, leading to a much improved signal quality compared to single-channel approaches. Essentially, we propose to find the linear combination of colour channels which suppresses the distortions best in a frequency band including pulse rate, and subsequently we use this same linear combination to extract the respiratory signal in a lower frequency band. Evaluation results obtained from recordings on healthy subjects which perform challenging scenarios, including motion, show that respiration can be accurately detected over the entire range of respiratory frequencies, with a correlation coefficient of 0.96 in visible light and 0.98 in infrared, compared to 0.86 with the best-performing non-contact benchmark algorithm. Furthermore, evaluation on a set of videos recorded in a Neonatal Intensive Care Unit (NICU) shows that this technique looks promising as a future alternative to current contact-sensors showing a correlation coefficient of 0.87.

Fast and Robust Real-Time Estimation of Respiratory Rate from Photoplethysmography

Respiratory rate (RR) is a useful vital sign that can not only provide auxiliary information on physiological changes within the human body, but also indicate early symptoms of various diseases. Recently, methods for the estimation of RR from photoplethysmography (PPG) have attracted increased interest, because PPG can be readily recorded using wearable sensors such as smart watches and smart bands. In the present study, we propose a new method for the fast and robust real-time estimation of RR using an adaptive infinite impulse response (IIR) notch filter, which has not yet been applied to the PPG-based estimation of RR. In our offline simulation study, the performance of the proposed method was compared to that of recently developed RR estimation methods called an adaptive lattice-type RR estimator and a Smart Fusion. The results of the simulation study show that the proposed method could not only estimate RR more quickly and more accurately than the conventional methods, but also is most suitable for online RR monitoring systems, as it does not use any overlapping moving windows that require increased computational costs. In order to demonstrate the practical applicability of the proposed method, an online RR estimation system was implemented.

An Ethnographic Observational Study to Evaluate and Optimize the Use of Respiratory Acoustic Monitoring in Children Receiving Postoperative Opioid Infusions

BACKGROUND

Respiratory depression in children receiving postoperative opioid infusions is a significant risk because of the interindividual variability in analgesic requirement. Detection of respiratory depression (or apnea) in these children may be improved with the introduction of automated acoustic respiratory rate (RR) monitoring. However, early detection of adverse events must be balanced with the risk of alarm fatigue. Our objective was to evaluate the use of acoustic RR monitoring in children receiving opioid infusions on a postsurgical ward and identify the causes of false alarm and optimal alarm thresholds.

METHODS

A video ethnographic study was performed using an observational, mixed methods approach. After surgery, an acoustic RR sensor was placed on the participant's neck and attached to a Rad87 monitor. The monitor was networked with paging for alarms. Vital signs data and paging notification logs were obtained from the central monitoring system. Webcam videos of the participant, infusion pump, and Rad87 monitor were recorded, stored on a secure server, and subsequently analyzed by 2 research nurses to identify the cause of the alarm, response, and effectiveness. Alarms occurring within a 90-second window were grouped into a single-alarm response opportunity.

RESULTS

Data from 49 patients (30 females) with median age 14 (range, 4.4-18.8) years were analyzed. The 896 bedside vital sign threshold alarms resulted in 160 alarm response opportunities (44 low RR, 74 high RR, and 42 low SpO2). In 141 periods (88% of total), for which video was available, 65% of alarms were deemed effective (followed by an alarm-related action within 10 minutes). Nurses were the sole responders in 55% of effective alarms and the patient or parent in 20%. Episodes of desaturation (SpO2 < 90%) were observed in 9 patients: At the time of the SpO2 paging trigger, the RR was >10 bpm in 6 of 9 patients. Based on all RR samples observed, the default alarm thresholds, to serve as a starting point for each patient, would be a low RR of 6 (>10 years of age) and 10 (4-9 years of age).

CONCLUSIONS

In this study, the use of RR monitoring did not improve the detection of respiratory depression. An RR threshold, which would have been predictive of desaturations, would have resulted in an unacceptably high false alarm rate. Future research using a combination of variables (e.g., SpO2 and RR), or the measurement of tidal volumes, may be needed to improve patient safety in the postoperative ward.

Integrating Sphere Finger-Photoplethysmography: Preliminary Investigation towards Practical Non-Invasive Measurement of Blood Constituents

The aim of this study was to compare conventional photoplethysmography (PPG) in a finger with PPG using an integrating sphere (_ISPPG) to enhance scattered light collection. Two representative wavelengths were used; 1160 nm, a window through the absorption spectra of water and alcohol, and 1600 nm around where water absorption is high and there is an absorption peak of blood glucose. Simultaneous transmission-type measurements were made with conventional PPG and with _ISPPG for each wavelength in the tips of index fingers of both hands in a total of 10 healthy young male and female volunteers (21.7 ± 1.6 years old). During a 5 min period in which subjects were in a relaxed state we determined the signal-to-noise ratio, SNR, and the PPG detectability (or sensitivity) by the two techniques. SNR during the test period was significantly higher with _ISPPG as compared with conventional PPG, especially for the 1600 nm wavelength. PPG signals with 1600 nm could scarcely be detected by conventional PPG, while they could be detected with good sensitively by _ISPPG. We conclude that under controlled conditions _ISPPG has better SNR and higher sensitivity than conventional transmission PPG, especially in wavelength regions where water absorption is high but where there is potential for practical measurement of blood constituents including glucose.

Excessive variations in the plethysmographic waveform during spontaneous ventilation: an important sign of upper airway obstruction

The respiratory variations in the plethysmographic (PLET) waveform of the pulse oximeter during mechanical ventilation can be automatically quantified as the PLET variation index (PVI(®)). Like other dynamic variables, the PVI may provide useful information about fluid responsiveness but only when the patient is receiving fully controlled mechanical ventilation with no spontaneous breathing activity. However, a growing number of monitors that automatically measure and display the values of the PVI and other dynamic variables are being introduced into clinical practice. Using these monitors in spontaneously breathing patients may cause inadequately trained personnel to make erroneous decisions or may eventually lead to a total disregard of dynamic parameters altogether. The aim of this study is to call attention to the fact that excessive variations in the PVI during spontaneous ventilation, termed sPVI, should not be regarded as artifactual since they may be an early important sign of upper airway obstruction (UAO). Among the monitor screen shots that were stored for educational purposes, I have identified 4 screen shots of patients who were clinically diagnosed as having significant UAO. In all instances, UAO was associated with prominent variations in the PLET waveform. These variations were calculated as the difference between the maximal and minimal amplitudes of the PLET signal divided by either the maximal amplitude (sPVI) or by the mean of the 2 values (ΔPOP). The ranges of the measured ΔPOP and sPVI values during UAO were 28% to 42% and 25% to 39%, respectively. These values are 2 to 3 times higher than the range of 9.5% to 15% that was repeatedly found as the best threshold for the identification of fluid responsiveness in mechanically ventilated patients. In 2 of these cases, simultaneously measured values of the pulse pressure variation were high as well (19% and 34%), while the calculated pulsus paradoxus was 28 and 40 mm Hg. In 2 cases, the analog signals of impedance plethysmography and capnography persisted, despite the presence of clinically significant UAO. It is, therefore, suggested that monitoring the sPVI may be of great clinical importance in spontaneously breathing patients who are susceptible to develop UAO.

Inter-device differences in monitoring for goal-directed fluid therapy

PURPOSE

Goal-directed fluid therapy is an integral component of many Enhanced Recovery After Surgery (ERAS) protocols currently in use. The perioperative clinician is faced with a myriad of devices promising to deliver relevant physiologic data to better guide fluid therapy. The goal of this review is to provide concise information to enable the clinician to make an informed decision when choosing a device to guide goal-directed fluid therapy.

PRINCIPAL FINDINGS

The focus of many devices used for advanced hemodynamic monitoring is on providing measurements of cardiac output, while other, more recent, devices include estimates of fluid responsiveness based on dynamic indices that better predict an individual's response to a fluid bolus. Currently available technologies include the pulmonary artery catheter, esophageal Doppler, arterial waveform analysis, photoplethysmography, venous oxygen saturation, as well as bioimpedance and bioreactance. The underlying mechanistic principles for each device are presented as well as their performance in clinical trials relevant for goal-directed therapy in ERAS.

CONCLUSIONS

The ERAS protocols typically involve a multipronged regimen to facilitate early recovery after surgery. Optimizing perioperative fluid therapy is a key component of these efforts. While no technology is without limitations, the majority of the currently available literature suggests esophageal Doppler and arterial waveform analysis to be the most desirable choices to guide fluid administration. Their performance is dependent, in part, on the interpretation of dynamic changes resulting from intrathoracic pressure fluctuations encountered during mechanical ventilation. Evolving practice patterns, such as low tidal volume ventilation as well as the necessity to guide fluid therapy in spontaneously breathing patients, will require further investigation.

Bedside clinical and ultrasound-based approaches to the management of hemodynamic instability--part I: focus on the clinical approach: continuing professional development

Shock is defined as a situation where oxygen transport is inadequate to meet the body's oxygen demand. An understanding of the mechanism(s) of reduced cardiac output, a determinant of oxygen transport, is crucial in order to initiate appropriate therapy to manage shock. Combining the concept of venous return with the ventricular pressure-volume relationship is a useful method to appreciate the complex circulatory physiology of shock. Clues from the patient's history, physical examination, and key laboratory tests, along with the careful inspection of hemodynamic, electrocardiographic and respiratory waveforms can help with the identification of the etiology and mechanism(s) of shock. Following verification of the arterial pressure, general resuscitation can begin, and more specific treatment can be undertaken to manage shock. If the patient is unresponsive to these measures, bedside ultrasound can then be performed to ascertain more detail regarding the mechanism(s) and etiology of shock.

PURPOSE

To develop an approach to the management of the hemodynamically unstable patient.

PRINCIPAL FINDING

Not applicable.

CONCLUSION

Not applicable.

Non invasive monitoring in mechanically ventilated pediatric patients

Cardiopulmonary monitoring is a key component in the evaluation and management of critically ill patients. Clinicians typically rely on a combination of invasive and non-invasive monitoring to assess cardiac output and adequacy of ventilation. Recent technological advances have led to the introduction: of continuous non-invasive monitors that allow for data to be obtained at the bedside of critically ill patients. These advances help to identify hemodynamic changes and allow for interventions before complications occur. In this manuscript, we highlight several important methods of non-invasive cardiopulmonary monitoring, including capnography, transcutaneous monitoring, pulse oximetry, and near infrared spectroscopy.

Respiratory Variations in Pulse Pressure Reflect Central Hypovolemia during Noninvasive Positive Pressure Ventilation

Background. Correct volume management is essential in patients with respiratory failure. We investigated the ability of respiratory variations in noninvasive pulse pressure (ΔPP), photoplethysmographic waveform amplitude (ΔPOP), and pleth variability index (PVI) to reflect hypovolemia during noninvasive positive pressure ventilation by inducing hypovolemia with progressive lower body negative pressure (LBNP). Methods. Fourteen volunteers underwent LBNP of 0, -20, -40, -60, and -80 mmHg for 4.5 min at each level or until presyncope. The procedure was repeated with noninvasive positive pressure ventilation. We measured stroke volume (suprasternal Doppler), ΔPP (Finapres), ΔPOP, and PVI and assessed their association with LBNP-level using linear mixed model regression analyses. Results. Stroke volume decreased with each pressure level (-11.2 mL, 95% CI -11.8, -9.6, P < 0.001), with an additional effect of noninvasive positive pressure ventilation (-3.0 mL, 95% CI -8.5, -1.3, P = 0.009). ΔPP increased for each LBNP-level (1.2%, 95% CI 0.5, 1.8, P < 0.001) and almost doubled during noninvasive positive pressure ventilation (additional increase 1.0%, 95% CI 0.1, 1.9, P = 0.003). Neither ΔPOP nor PVI was significantly associated with LBNP-level. Conclusions. During noninvasive positive pressure ventilation, preload changes were reflected by ΔPP but not by ΔPOP or PVI. This implies that ΔPP may be used to assess volume status during noninvasive positive pressure ventilation.

Sternal pulse rate variability compared with heart rate variability on healthy subjects

The heart rate variability (HRV) is a commonly used method to quantify the sympathetic and the parasympathetic modulation of the heart rate. HRV is mainly conducted on electrocardiograms (ECG). However, the use of photo-plethysmography (PPG) as a marker of the autonomic tone is emerging. In this study we investigated the feasibility of deriving pulse rate variability (PRV) using PPG signals recorded by a reflectance PPG sensor attached to the chest bone (sternum) and comparing it to HRV. The recordings were conducted on 9 healthy subjects being in a relaxed supine position and under forced respiration, where the subjects were asked to breathe following a visual scale with a rate of 27 breaths/min. HRV parameters such as the mean intervals (meanNN), the standard deviation of intervals (SDNN), the root mean square of difference of successive intervals (RMSSD), and the proportion of intervals differing more than 50 ms (pNN50) were calculated from the R peak-to-R peak (R-R) and pulse-to-pulse (P-P) intervals. In the frequency domain the low and high frequency ratio of the power spectral density (LF/HF) was also computed. The Pearson correlation coefficient showed significant correlation for all the parameters (r > 0.95 with p < 0.001) and the Bland-Altmann analysis showed close agreement between the two methods for all the parameters during resting and forced respiration condition. Thus, PRV analysis using sternal PPG can be an alternative to HRV analysis on healthy subjects at.