Techniques for measurement of thoracoabdominal asynchrony

Visual Measurements of Breathing Parameters in Children With a Particular Focus on Phase Angle: A Pilot Study

Introduction Pediatric respiratory monitoring, crucial for assessing children's health, particularly those with respiratory diseases, often relies on invasive or cumbersome methods. Here, we propose a non-invasive approach using a video depth camera to measure breathing parameters in children, offering innovation and promise. Aims We aim to introduce and validate a straightforward remote procedure for measuring crucial breathing parameters in children. These include respiratory rate (RR), volumetric changes during inhalation and exhalation, and the phase angle (PA) between chest and abdomen expansions. Methods The proposed method involves detecting three feature points - nipples and navel - using a video depth camera. A 30- to 60-second video is recorded to track chest and abdomen movements. Analysis of feature point locations, distances between them, and signal frequencies is conducted to estimate respiratory parameters. To validate the accuracy of our method, we employed mechanical lung simulators within dolls for procedure testing and measurement accuracy verification. Additionally, recordings of pediatric patients, both healthy and with respiratory diseases, were analyzed to correlate computational parameter estimations with physician assessments, ensuring the reliability and effectiveness of our approach. Results Our results show a strong correlation between simulator inputs and algorithm estimations, validating our method's accuracy. Additionally, applying the procedure to pediatric patient recordings significantly correlates with physician assessments, notably, marking the first remote measurement of the respiratory PA. Conclusions This remote procedure presents a promising alternative for pediatric respiratory monitoring, offering accurate measurements without invasive techniques or extensive equipment. The robust correlation between computational estimations and physician assessments underscores its reliability, suggesting potential for broader clinical applications and advancements in pediatric respiratory care.

SolunumWear: A smart textile system for dynamic respiration monitoring across various postures

We introduce SolunumWear, a multi-sensory e-textile system designed for respiration in daily life settings, addressing the gap in continuous, real-world respiration event monitoring. Leveraging a textile pressure sensor belt to capture chest movements and a wireless data acquisition system, SolunumWear offers a promising solution for both medical and wellness applications. The system's efficacy was evaluated through a human study involving 10 healthy adults (six female and four male) across various breathing rates and postures, demonstrating a strong correlation (R value = 0.836) with the gold-standard system. The study highlights the system's computational and communication efficiencies, with latencies of approximately 4.84 s and 2.13 ms, respectively. These findings highlight the efficacy of SolunumWear as a wireless, wearable technology for respiration monitoring in daily settings. This research contributes to the expanding body of knowledge on smart textile-based health monitoring technologies, demonstrating its potential to provide reliable respiratory data in real-world environments.

Breathing Chest Wall Kinematics Assessment through a Single Digital Camera: A Feasibility Study

The identification of respiratory patterns based on the movement of the chest wall can assist in monitoring an individual's health status, particularly those with neuromuscular disorders, such as hemiplegia and Duchenne muscular dystrophy. Thoraco-abdominal asynchrony (TAA) refers to the lack of coordination between the rib cage and abdominal movements, characterized by a time delay in their expansion. Motion capture systems, like optoelectronic plethysmography (OEP), are commonly employed to assess these asynchronous movements. However, alternative technologies able to capture chest wall movements without physical contact, such as RGB digital cameras and time-of-flight digital cameras, can also be utilized due to their accessibility, affordability, and non-invasive nature. This study explores the possibility of using a single RGB digital camera to record the kinematics of the thoracic and abdominal regions by placing four non-reflective markers on the torso. In order to choose the positions of these markers, we previously investigated the movements of 89 chest wall landmarks using OEP. Laboratory tests and volunteer experiments were conducted to assess the viability of the proposed system in capturing the kinematics of the chest wall and estimating various time-related respiratory parameters (i.e., fR, Ti, Te, and Ttot) as well as TAA indexes. The results demonstrate a high level of agreement between the detected chest wall kinematics and the reference data. Furthermore, the system shows promising potential in estimating time-related respiratory parameters and identifying phase shifts indicative of TAA, thus suggesting its feasibility in detecting abnormal chest wall movements without physical contact with a single RGB camera.

Preliminary Assessment of a Flexible Multi-Sensor Wearable System Based on Fiber Bragg Gratings for Respiratory Monitoring of Hemiplegic Patients

Respiratory diseases are common in post-stroke hemiplegic patients and represent a major social problem as they worsen the quality of life and reduce the life span. As a consequence, being able to monitor respiratory parameters such as the respiratory rate (RR) and assess the presence of respiratory asynchronies could be of paramount importance to define hemiplegics' health status. Moreover, RR is a useful parameter to investigate the level of fatigue and distress that these patients undergo during rehabilitation processes. Although motion capture systems and flowmeters are the leading instruments for respiratory pattern evaluation, smart wearable systems are gaining ever more acceptance since they allow continuous monitoring by detecting chest wall breathing displacements, ensuring reduced costs and no need for dedicated spaces. Among other sensing technologies, fiber Bragg grating (FBG) sensors have emerged thanks to their high sensitivity to strain, lightness, and multiplexing capability. In this work, a wearable system composed of four flexible dumbbell-shaped sensing modules is proposed for respiratory monitoring in hemiplegic patients. The system is light and easy to wear and can be adapted to any anthropometry thanks to the modular anchoring system. Its feasibility assessment in RR evaluation was performed on seven hemiplegic volunteers in eupnea and tachypnea breathing conditions. In addition, an explorative investigation was conducted to assess the system's ability to detect asynchronies between torso compartments. The good results suggest that this device could be a useful instrument to support clinicians and operators in hemiplegic patients' management.

Physiological changes and compensatory mechanisms by the action of respiratory muscles in a porcine model of phrenic nerve injury

Phrenic nerve damage may occur as a complication of specific surgical procedures, prolonged mechanical ventilation, or physical trauma. The consequent diaphragmatic paralysis or dysfunction can lead to major complications. The purpose of this study was to elucidate the role of the nondiaphragmatic respiratory muscles during partial or complete diaphragm paralysis induced by unilateral and bilateral phrenic nerve damage at different levels of ventilatory pressure support in an animal model. Ten pigs were instrumented, the phrenic nerve was exposed from the neck, and spontaneous respiration was preserved at three levels of pressure support, namely, high, low, and null, at baseline condition, after left phrenic nerve damage, and after bilateral phrenic nerve damage. Breathing pattern, thoracoabdominal volumes and asynchrony, and pressures were measured at each condition. Physiological breathing was predominantly diaphragmatic and homogeneously distributed between right and left sides. After unilateral damage, the paralyzed hemidiaphragm was passively dragged by the ipsilateral rib cage muscles and the contralateral hemidiaphragm. After bilateral damage, the drive to and the work of breathing of rib cage and abdominal muscles increased, to compensate for diaphragmatic paralysis, ensuing paradoxical thoracoabdominal breathing. Increasing level of pressure support ventilation replaces this muscle group compensation. When the diaphragm is paralyzed (unilaterally and/or bilaterally), there is a coordinated reorganization of nondiaphragmatic respiratory muscles as compensation that might be obscured by high level of pressure support ventilation. Noninvasive thoracoabdominal volume and asynchrony assessment could be useful in phrenic nerve-injured patients to estimate the extent and type of inspiratory muscle dysfunction.NEW & NOTEWORTHY This was the first (to our knowledge) implanted porcine model of phrenic nerve injury with a detailed multidimensional analysis of different degrees of diaphragmatic paralysis (unilateral and bilateral). Noninvasive thoracoabdominal volume and asynchrony assessment was shown to be useful in estimating the extent of diaphragmatic dysfunction and the consequent coordinated reorganization of nondiaphragmatic respiratory muscles. High level of pressure support ventilation was proved to obscure the interaction and compensation of respiratory muscles to deal with phrenic nerve injury.

Advancements in Methods and Camera-Based Sensors for the Quantification of Respiration

Assessment of respiratory function allows early detection of potential disorders in the respiratory system and provides useful information for medical management. There is a wide range of applications for breathing assessment, from measurement systems in a clinical environment to applications involving athletes. Many studies on pulmonary function testing systems and breath monitoring have been conducted over the past few decades, and their results have the potential to broadly impact clinical practice. However, most of these works require physical contact with the patient to produce accurate and reliable measures of the respiratory function. There is still a significant shortcoming of non-contact measuring systems in their ability to fit into the clinical environment. The purpose of this paper is to provide a review of the current advances and systems in respiratory function assessment, particularly camera-based systems. A classification of the applicable research works is presented according to their techniques and recorded/quantified respiration parameters. In addition, the current solutions are discussed with regards to their direct applicability in different settings, such as clinical or home settings, highlighting their specific strengths and limitations in the different environments.

Novel Flexible Wearable Sensor Materials and Signal Processing for Vital Sign and Human Activity Monitoring

Advances in flexible electronic materials and smart textile, along with broad availability of smart phones, cloud and wireless systems have empowered the wearable technologies for significant impact on future of digital and personalized healthcare as well as consumer electronics. However, challenges related to lack of accuracy, reliability, high power consumption, rigid or bulky form factor and difficulty in interpretation of data have limited their wide-scale application in these potential areas. As an important solution to these challenges, we present latest advances in novel flexible electronic materials and sensors that enable comfortable and conformable body interaction and potential for invisible integration within daily apparel. Advances in novel flexible materials and sensors are described for wearable monitoring of human vital signs including, body temperature, respiratory rate and heart rate, muscle movements and activity. We then present advances in signal processing focusing on motion and noise artifact removal, data mining and aspects of sensor fusion relevant to future clinical applications of wearable technology.

Comparison between the phase angle and phase shift parameters to assess thoracoabdominal asynchrony in COPD patients

Determining the presence of thoracoabdominal asynchrony in chronic obstructive pulmonary disease (COPD) patients is clinically relevant, but there is no consensus on the optimal parameters for performing this analysis. We assessed 22 COPD patients (FEV1 40 ± 10% predicted) and 13 healthy controls during rest and exercise with optoelectronic plethysmography (70% maximum workload) on a cycle ergometer. Thoracoabdominal asynchrony was calculated by using phase angle and phase shift parameters following a three-compartment model involving the upper and lower rib cages and abdomen. Patients were classified as having thoracoabdominal asynchrony (TAA+) or not (TAA−) based on control values (mean ± 2 SDs). The chest wall volume and compartmental contribution were also measured. Thoracoabdominal asynchrony was observed in the lower rib cage. The phase angle detected more TAA+ patients at rest (15 vs. 7 patients) and during exercise (14 vs. 8 patients) compared with the phase shift. TAA+ patients also presented a lower chest wall volume, lower rib cage contribution, and higher abdominal contribution to chest wall volume compared with the control and TAA− patients. Thoracoabdominal asynchrony was more detectable during rest and exercise using the phase angle parameter, and it was observed in the lower rib cage compartment, reducing the chest wall volume during exercise in patients with COPD.

NEW & NOTEWORTHY This study contributes to advance the knowledge over the previous lack of consensus on the assessment of thoracoabdominal asynchrony. We rigorously evaluated the related features that interfere in the measurement of the asynchrony (measurement tool, chest wall model and calculation parameter). Our results suggest that phase angle detects more suitably thoracoabdominal asynchrony that occurs on the lower ribcage and leads to a reduction in the chest wall volume during exercise in COPD patients.

Instantaneous phase difference analysis between thoracic and abdominal movement signals based on complementary ensemble empirical mode decomposition

BACKGROUND

Thoracoabdominal asynchrony is often adopted to discriminate respiratory diseases in clinics. Conventionally, Lissajous figure analysis is the most frequently used estimation of the phase difference in thoracoabdominal asynchrony. However, the temporal resolution of the produced results is low and the estimation error increases when the signals are not sinusoidal. Other previous studies have reported time-domain procedures with the use of band-pass filters for phase-angle estimation. Nevertheless, the band-pass filters need calibration for phase delay elimination.

METHODS

To improve the estimation, we propose a novel method (named as instantaneous phase difference) that is based on complementary ensemble empirical mode decomposition for estimating the instantaneous phase relation between measured thoracic wall movement and abdominal wall movement. To validate the proposed method, experiments on simulated time series and human-subject respiratory data with two breathing types (i.e., thoracic breathing and abdominal breathing) were conducted. Latest version of Lissajous figure analysis and automatic phase estimation procedure were compared.

RESULTS

The simulation results show that the standard deviations of the proposed method were lower than those of two other conventional methods. The proposed method performed more accurately than the two conventional methods. For the human-subject respiratory data, the results of the proposed method are in line with those in the literature, and the correlation analysis result reveals that they were positively correlated with the results generated by the two conventional methods. Furthermore, the standard deviation of the proposed method was also the smallest.

CONCLUSIONS

To summarize, this study proposes a novel method for estimating instantaneous phase differences. According to the findings from both the simulation and human-subject data, our approach was demonstrated to be effective. The method offers the following advantages: (1) improves the temporal resolution, (2) does not introduce a phase delay, (3) works with non-sinusoidal signals, (4) provides quantitative phase estimation without estimating the embedded frequency of breathing signals, and (5) works without calibrated measurements. The results demonstrate a higher temporal resolution of the phase difference estimation for the evaluation of thoracoabdominal asynchrony.

Monitoring of Vital Signs with Flexible and Wearable Medical Devices

Advances in wireless technologies, low-power electronics, the internet of things, and in the domain of connected health are driving innovations in wearable medical devices at a tremendous pace. Wearable sensor systems composed of flexible and stretchable materials have the potential to better interface to the human skin, whereas silicon-based electronics are extremely efficient in sensor data processing and transmission. Therefore, flexible and stretchable sensors combined with low-power silicon-based electronics are a viable and efficient approach for medical monitoring. Flexible medical devices designed for monitoring human vital signs, such as body temperature, heart rate, respiration rate, blood pressure, pulse oxygenation, and blood glucose have applications in both fitness monitoring and medical diagnostics. As a review of the latest development in flexible and wearable human vitals sensors, the essential components required for vitals sensors are outlined and discussed here, including the reported sensor systems, sensing mechanisms, sensor fabrication, power, and data processing requirements.

Breathing and Singing: Objective Characterization of Breathing Patterns in Classical Singers

Singing involves distinct respiratory kinematics (i.e. movements of rib cage and abdomen) to quiet breathing because of different demands on the respiratory system. Professional classical singers often advocate for the advantages of an active control of the abdomen on singing performance. This is presumed to prevent shortening of the diaphragm, elevate the rib cage, and thus promote efficient generation of subglottal pressure during phonation. However, few studies have investigated these patterns quantitatively and inter-subject variability has hindered the identification of stereotypical patterns of respiratory kinematics. Here, seven professional classical singers and four untrained individuals were assessed during quiet breathing, and when singing both a standard song and a piece of choice. Several parameters were extracted from respiratory kinematics and airflow, and principal component analysis was used to identify typical patterns of respiratory kinematics. No group differences were observed during quiet breathing. During singing, both groups adapted to rhythmical constraints with decreased time of inspiration and increased peak airflow. In contrast to untrained individuals, classical singers used greater percentage of abdominal contribution to lung volume during singing and greater asynchrony between movements of rib cage and abdomen. Classical singers substantially altered the coordination of rib cage and abdomen during singing from that used for quiet breathing. Despite variations between participants, principal component analysis revealed consistent pre-phonatory inward movements of the abdominal wall during singing. This contrasted with untrained individuals, who demonstrated synchronous respiratory movements during all tasks. The inward abdominal movements observed in classical singers elevates intra-abdominal pressure and may increase the length and the pressure-generating capacity of rib cage expiratory muscles for potential improvements in voice quality.

Accuracy of tumor motion compensation algorithm from a robotic respiratory tracking system: a simulation study

The Synchrony Respiratory Tracking System (RTS) is a treatment option of the CyberKnife robotic treatment device to irradiate extra-cranial tumors that move due to respiration. Advantages of RTS are that patients can breath normally and that there is no loss of linac duty cycle such as with gated therapy. Tracking is based on a measured correspondence model (linear or polynomial) between internal tumor motion and external (chest/abdominal) marker motion. The radiation beam follows the tumor movement via the continuously measured external marker motion. To establish the correspondence model at the start of treatment, the 3D internal tumor position is determined at 15 discrete time points by automatic detection of implanted gold fiducials in two orthogonal x-ray images; simultaneously, the positions of the external markers are measured. During the treatment, the relationship between internal and external marker positions is continuously accounted for and is regularly checked and updated. Here we use computer simulations based on continuously and simultaneously recorded internal and external marker positions to investigate the effectiveness of tumor tracking by the RTS. The Cyberknife does not allow continuous acquisition of x-ray images to follow the moving internal markers (typical imaging frequency is once per minute). Therefore, for the simulations, we have used data for eight lung cancer patients treated with respiratory gating. All of these patients had simultaneous and continuous recordings of both internal tumor motion and external abdominal motion. The available continuous relationship between internal and external markers for these patients allowed investigation of the consequences of the lower acquisition frequency of the RTS. With the use of the RTS, simulated treatment errors due to breathing motion were reduced largely and consistently over treatment time for all studied patients. A considerable part of the maximum reduction in treatment error could already be reached with a simple linear model. In case of hysteresis, a polynomial model added some extra reduction. More frequent updating of the correspondence model resulted in slightly smaller errors only for the few recordings with a time trend that was fast, relative to the current x-ray update frequency. In general, the simulations suggest that the applied combined use of internal and external markers allow the robot to accurately follow tumor motion even in the case of irregularities in breathing patterns.

Estimation of bilateral asynchrony between diaphragm mechanomyographic signals in patients with chronic obstructive pulmonary disease

The aim of the present study was to measure bilateral asynchrony in patients suffering from Chronic Obstructive Pulmonary Disease (COPD) performing an incremental inspiratory load protocol. Bilateral asynchrony was estimated by the comparison of respiratory movements derived from diaphragm mechanomyographic (MMGdi) signals, acquired by means of capacitive accelerometers placed on left and right sides of the rib cage. Three methods were considered for asynchrony evaluation: Lissajous figure, Hilbert transform and Motto's algorithm. Bilateral asynchrony showed an increase at 20, 40 and 60% (values of normalized inspiratory pressure by their maximum value reached in the last inspiratory load) while the very severe group showed an increase at 20, 40, 80, and 100 % during the protocol. These increments in the phase's shift can be due to an increase of the inspiratory load along the protocol, and also as a consequence of distress and fatigue. In summary, this work evidenced the capability to estimate bilateral asynchrony in COPD patients. These preliminary results also showed that the use of capacitive accelerometers can be a suitable sensor for recording of respiratory movement and evaluation of asynchrony in COPD patients.

Respiratory rate detection by empirical mode decomposition method applied to diaphragm mechanomyographic signals

Non-invasive evaluation of respiratory activity is an area of increasing research interest, resulting in the appearance of new monitoring techniques, ones of these being based on the analysis of the diaphragm mechanomyographic (MMGdi) signal. The MMGdi signal can be decomposed into two parts: (1) a high frequency activity corresponding to lateral vibration of respiratory muscles, and (2) a low frequency activity related to excursion of the thoracic cage. The purpose of this study was to apply the empirical mode decomposition (EMD) method to obtain the low frequency of MMGdi signal and selecting the intrinsic mode functions related to the respiratory movement. With this intention, MMGdi signals were acquired from a healthy subject, during an incremental load respiratory test, by means of two capacitive accelerometers located at left and right sides of rib cage. Subsequently, both signals were combined to obtain a new signal which contains the contribution of both sides of thoracic cage. Respiratory rate (RR) measured from the mechanical activity (RR(MMG)) was compared with that measured from inspiratory pressure signal (RR(P)). Results showed a Pearson's correlation coefficient (r = 0.87) and a good agreement (mean bias = -0.21 with lower and upper limits of -2.33 and 1.89 breaths per minute, respectively) between RR(MMG) and RR(P) measurements. In conclusion, this study suggests that RR can be estimated using EMD for extracting respiratory movement from low mechanical activity, during an inspiratory test protocol.

Monitoring of children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference

OBJECTIVE

To critically review the potential role of monitoring technologies in the management of pediatric acute respiratory distress syndrome, and specifically regarding monitoring of the general condition, respiratory system mechanics, severity scoring parameters, imaging, hemodynamic status, and specific weaning considerations.

DESIGN

Consensus conference of experts in pediatric acute lung injury.

METHODS

A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. The monitoring subgroup comprised two experts. When published data were lacking a modified Delphi approach, emphasizing strong professional agreement was used.

RESULTS

The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the topics related to pediatric acute respiratory distress syndrome, 21 of which related to monitoring of a child with pediatric acute respiratory distress syndrome. All 21 recommendations had agreement, with 19 (90%) reaching strong agreement.

CONCLUSIONS

The Consensus Conference developed pediatric-specific recommendations related to monitoring children with pediatric acute respiratory distress syndrome. These include interpreting monitored values such as tidal volume using predicted body weight, monitoring tidal volume at the end of the endotracheal tube in small children, and continuous monitoring of exhaled carbon dioxide in intubated children with pediatric acute respiratory distress syndrome, among others. These recommendations for monitoring in pediatric acute respiratory distress syndrome are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Sources of methodological variability in phase angles from respiratory inductance plethysmography in preterm infants

RATIONALE

Better phenotypic descriptions are needed for chronic lung disease among surviving premature infants.

OBJECTIVES

The purpose of this study was to evaluate the potential usefulness of respiratory inductance plethysmography in characterizing respiratory system mechanics in preterm infants at 32 weeks postmenstrual age.

METHODS

Respiratory inductance plethysmography was used to obtain the phase angle, Φ, to describe rib cage and abdominal dyssynchrony in 65 infants born between 23 and 28 weeks gestation, all of whom were studied at 32 weeks postmenstrual age. Up to 60 breaths were evaluated for each subject. Sources of intrasubject variability in Φ arising from our methods were explored using mechanical models and by evaluating interobserver agreement.

MEASUREMENTS AND MAIN RESULTS

The mean Φ from infants ranged from 5.8-162.9°, with intrasubject coefficients of variation ranging from 11-123%. On the basis of the mechanical model studies, respiratory inductance plethysmography recording and analysis software added <2.3% to the intrasubject variability in Φ. Potential inconsistencies in breaths selected could have contributed 8.1%, on average, to the total variability. The recording sessions captured 22.8 ± 9.1 minutes of quiet sleep, and enough breaths were counted to adequately characterize the range of Φ in the session.

CONCLUSION

Φ is quite variable during even short recording sessions among preterm infants sleeping quietly. The intrasubject variability described herein arises from the instability of the rib cage and abdominal phase relationship, not from the recording and analytical methods used. Despite the variability, Φ measurements allowed the majority (80%) of infants to be reliably categorized as having relatively synchronous or dyssynchronous breathing. Respiratory inductance plethysmography is easy to use and should prove useful in quantifying respiratory mechanics in multicenter studies of preterm infants.

Respiratory inductance plethysmography calibration for pediatric upper airway obstruction: an animal model

BACKGROUND

We sought to determine optimal methods of respiratory inductance plethysmography (RIP) flow calibration for application to pediatric postextubation upper airway obstruction.

METHODS

We measured RIP, spirometry, and esophageal manometry in spontaneously breathing, intubated Rhesus monkeys with increasing inspiratory resistance. RIP calibration was based on: ΔµV(ao) ≈ M[ΔµV(RC) + K(ΔµV(AB))] where K establishes the relationship between the uncalibrated rib cage (ΔµV(RC)) and abdominal (ΔµV(AB)) RIP signals. We calculated K during (i) isovolume maneuvers during a negative inspiratory force (NIF), (ii) quantitative diagnostic calibration (QDC) during (a) tidal breathing, (b) continuous positive airway pressure (CPAP), and (c) increasing degrees of upper airway obstruction (UAO). We compared the calibrated RIP flow waveform to spirometry quantitatively and qualitatively.

RESULTS

Isovolume calibrated RIP flow tracings were more accurate (against spirometry) both quantitatively and qualitatively than those from QDC (P < 0.0001), with bigger differences as UAO worsened. Isovolume calibration yielded nearly identical clinical interpretation of inspiratory flow limitation as spirometry.

CONCLUSION

In an animal model of pediatric UAO, isovolume calibrated RIP flow tracings are accurate against spirometry. QDC during tidal breathing yields poor RIP flow calibration, particularly as UAO worsens. Routine use of a NIF maneuver before extubation affords the opportunity to use RIP to study postextubation UAO in children.

A Portable, PC-Based Monitor for Automated, On-line Cardiorespiratory State Classification

We have developed a monitor that acquires, classifies, annotates and displays patient cardiorespiratory data in an on-line and fully automated manner. The monitor is compact, portable and battery-operated; it applies automated methods that detect apnea and classify cardiorespiratory state on-line from non-invasive measurements of patient respiratory movements, blood oxygen saturation and heart rate, logging the raw and processed data. The monitor provides continuous, on-line, objective, standardized cardiorespiratory classification and has a graphical display and interface for patient monitoring by a clinician; it has immediate application in the clinical setting.

Nasal airflow and thoracoabdominal motion in children using infrared thermographic video processing

The assessment of apnea and asynchronous breathing requires the application of a facemask connected to a pneumotachograph and inductive transducer bands placed around the chest wall. These contact devices may alter the breathing pattern and are difficult to implement, especially in infants and children. This study validates a contactless image-processing system that simultaneously retrieves breath-related thermal variations from nasal, ribcage, and abdomen regions of interest (ROI) from infrared thermographic video recordings of children. Thermographic videos were obtained in 17 supine, spontaneously breathing unsedated children (0.33-13.75 years), including 8 patients with respiratory pathology. Representative thermographic signals were obtained from each ROI on a frame-by-frame basis. Cronbach's Alpha reliability coefficient assessed the correlation between control nasal pressure period, the visually scored respiratory rate and the fundamental period in the frequency domain of thermographic signals. A cross-correlation function calculated the time delay and the phase angle between ribcage and abdomen variability. A Cronbach's Alpha value of 0.976 (0.992-0.944 95% CI) suggests a small-scale measurement error between thermographic and control periods. The ribcage-abdomen time delay in children with respiratory disease (-0.42 ± 0.707 sec) significantly differed from healthy children (0.22 ± 0.426 sec, P = 0.0125). This novel system reliably acquired time-aligned nasal airflow and thoracoabdominal motion estimates without relying on attached sensor performance and detected asynchronous breathing in pediatric patients.

Thoraco-abdominal asynchrony in children during quiet sleep using Hilbert transform

We present a technique based on the Hilbert transform to quantify the thoraco-abdominal asynchrony (TAA) based on the phase shift between ribcage (RC) and abdomenal (AB) breathing signals acquired using respiratory inductive plethysmography (RIP). We employed this method to investigate RIP during overnight polysomnography (PSG) in 40 healthy children for analysis of their breathing patterns in various stages of sleep (ss 2, 3, 4 and REM) and in two common sleeping positions (supine and lateral). RIP signals free of respiratory or movement artifacts were segmented into 30 second epochs. Those epochs with maximum power in the quiet breathing frequency range and positional invariance throughout were included for further processing. TAA was calculated from corresponding RC and AB excursions. We found a statistically significant influence of sleep position on the level of TAA in all stages of non-REM sleep. In conclusion, the Hilbert transform provides a simple tool for the quantification of thoraco-abdominal asynchrony.

Respiration rate monitoring methods: a review

Respiration rate is an important indicator of a person's health, and thus it is monitored when performing clinical evaluations. There are different approaches for respiration monitoring, but generally they can be classed as contact or noncontact. For contact methods, the sensing device (or part of the instrument containing it) is attached to the subject's body. For noncontact approaches the monitoring is performed by an instrument that does not make any contact with the subject. In this article a review of respiration monitoring approaches (both contact and noncontact) is provided. Concerns related to the patient's recording comfort, recording hygiene, and the accuracy of respiration rate monitoring have resulted in the development of a number of noncontact respiration monitoring approaches. A description of thermal imaging based and vision based noncontact respiration monitoring approaches we are currently developing is provided.

A telemedicine instrument for Internet-based home monitoring of thoracoabdominal motion in patients with respiratory diseases

Changes in thoracoabdominal motion are highly prevalent in patients with chronic respiratory diseases. Home care services that use telemedicine techniques and Internet-based monitoring have the potential to improve the management of these patients. However, there is no detailed description in the literature of a system for Internet-based monitoring of patients with disturbed thoracoabdominal motion. The purpose of this work was to describe the development of a new telemedicine instrument for Internet-based home monitoring of thoracoabdominal movement. The instrument directly measures changes in the thorax and abdomen circumferences and transfers data through a transmission control protocol∕Internet protocol connection. After the design details are described, the accuracy of the electronic and software processing units of the instrument is evaluated by using electronic signals simulating normal subjects and individuals with thoracoabdominal motion disorders. The results obtained during in vivo studies on normal subjects simulating thoracoabdominal motion disorders showed that this new system is able to detect a reduction in abdominal movement that is associated with abnormal thoracic breathing (p < 0.0001) and the reduction in thoracic movement during abnormal abdominal breathing (p < 0.005). Simulated asynchrony in thoracoabdominal motion was also adequately detected by the system (p < 0.0001). The experimental results obtained for patients with respiratory diseases were in close agreement with the expected values, providing evidence that this instrument can be a useful tool for the evaluation of thoracoabdominal motion. The Internet transmission tests showed that the acquisition and analysis of the thoracoabdominal motion signals can be performed remotely. The user can also receive medical recommendations. The proposed system can be used in a spectrum of telemedicine scenarios, which can reduce the costs of assistance offered to patients with respiratory diseases.

Vertical distribution of specific ventilation in normal supine humans measured by oxygen-enhanced proton MRI

Specific ventilation (SV) is the ratio of fresh gas entering a lung region divided by its end-expiratory volume. To quantify the vertical (gravitationally dependent) gradient of SV in eight healthy supine subjects, we implemented a novel proton magnetic resonance imaging (MRI) method. Oxygen is used as a contrast agent, which in solution changes the longitudinal relaxation time (T1) in lung tissue. Thus alterations in the MR signal resulting from the regional rise in O(2) concentration following a sudden change in inspired O(2) reflect SV-lung units with higher SV reach a new equilibrium faster than those with lower SV. We acquired T1-weighted inversion recovery images of a sagittal slice of the supine right lung with a 1.5-T MRI system. Images were voluntarily respiratory gated at functional residual capacity; 20 images were acquired with the subject breathing air and 20 breathing 100% O(2), and this cycle was repeated five times. Expired tidal volume was measured simultaneously. The SV maps presented an average spatial fractal dimension of 1.13 ± 0.03. There was a vertical gradient in SV of 0.029 ± 0.012 cm(-1), with SV being highest in the dependent lung. Dividing the lung vertically into thirds showed a statistically significant difference in SV, with SV of 0.42 ± 0.14 (mean ± SD), 0.29 ± 0.10, and 0.24 ± 0.08 in the dependent, intermediate, and nondependent regions, respectively (all differences, P < 0.05). This vertical gradient in SV is consistent with the known gravitationally induced deformation of the lung resulting in greater lung expansion in the dependent lung with inspiration. This SV imaging technique can be used to quantify regional SV in the lung with proton MRI.

Nocturnal thoracoabdominal asynchrony in house dust mite-sensitive nonhuman primates

Nocturnal bronchoconstriction is a common symptom of asthma in humans, but is poorly documented in animal models. Thoracoabdominal asynchrony (TAA) is a noninvasive clinical indication of airway obstruction. In this study, respiratory inductive plethysmography (RIP) was used to document nocturnal TAA in house dust mite (HDM)-sensitive Cynomolgus macaques. Dynamic compliance (C_dyn) and lung resistance (R_L) measured in anesthetized animals at rest and following exposure to HDM allergen, methacholine, and albuterol were highly correlated with three RIP parameters associated with TAA, ie, phase angle of the rib cage and abdomen waveforms (PhAng), baseline effort phase relation (eBPRL) and effort phase relation (ePhRL). Twenty-one allergic subjects were challenged with HDM early in the morning, and eBPRL and ePhRL were monitored for 20 hours after provocation. Fifteen of the allergic subjects exhibited gradual increases in eBPRL and ePhRL between midnight and 6 am, with peak activity at 4 am. However, as in humans, this nocturnal response was highly variable both between subjects and within subjects over time. The results document that TAA in this nonhuman primate model of asthma is highly correlated with C_dyn and R_L, and demonstrate that animals exhibiting acute responses to allergen exposure during the day also exhibit nocturnal TAA.

Pressure-rate product and phase angle as measures of acute inspiratory upper airway obstruction in rhesus monkeys

RATIONALE

There are limited validated, objective, and minimally invasive techniques for the bedside evaluation of upper airway obstruction (UAO) in sick infants, despite its frequency in pediatric medicine. Prior techniques include pressure-rate product (PRP), a product of esophageal pressure and respiratory rate and phase angles (PAs), a measure of asynchrony between ribcage and abdominal respiratory movements in infants with UAO. The purpose of this study is to validate the PRP and compare it to a previously validated PA in rhesus monkeys.

METHODS

Calibrated resistors were applied to the inspiratory limb of 10 anesthetized, intubated, and spontaneously breathing rhesus monkeys (weight 8.7 +/- 2.5 kg). Airway pressure, respiratory rate, PAs, heart rate, and oxygen saturation were recorded. Obstruction was applied in random order as 0, 5, 20, 200, 500, and 1,000 cmH(2)O/L/sec for 2-min periods, the last 15 sec (10-20 breaths) were analyzed for each timeframe.

RESULTS

PA increased significantly at the 200 cmH(2)O/L/sec level but it reached a plateau above 500 cmH(2)O/L/sec. PRP rose progressively and was significantly different at all levels of obstruction. Esophageal pressure change was progressively and statistically significantly different from baseline and each other at 200, 500, and 1,000 cmH(2)O/L/sec (P < 0.001).

CONCLUSIONS

In this model of UAO, PRP tracks increasing inspiratory load better than PA. PRP continued to be linear up through the highest inspiratory resistance where the change in PA reached a plateau before the highest load. The assessment of esophageal pressure changes may offer the simplest objective measure of UAO.

Microgravity alters respiratory abdominal and rib cage motion during sleep

The abdominal and rib cage contributions to tidal breathing differ between rapid-eye-movement (REM) and non-NREM sleep. We hypothesized that abdominal relative contribution during NREM and REM sleep would be altered in different directions when comparing sleep on Earth with sleep in sustained microgravity (microG), due to conformational changes and differences in coupling between the rib cage and the abdominal compartment induced by weightlessness. We studied respiration during sleep in five astronauts before, during, and after two Space Shuttle missions. A total of 77 full-night (8 h) polysomnographic studies were performed; abdominal and rib cage respiratory movements were recorded using respiratory inductive plethysmography. Breath-by-breath analysis of respiration was performed for each class: awake, light sleep, deep sleep, and REM sleep. Abdominal contribution to tidal breathing increased in microG, with the first measure in space being significantly higher than preflight values, followed by a return toward preflight values. This was observed for all classes. Preflight, rib cage, and abdominal movements were found to be in phase for all but REM sleep, for which an abdominal lead was observed. The abdominal leading role during REM sleep increased while deep sleep showed the opposite behavior, the rib cage taking a leading role in-flight. In microG, the percentage of inspiratory time in the overall breath, the duty cycle (T(I)/T(Tot)), decreased for all classes considered when compared with preflight, while normalized inspiratory flow, taking the awake values as reference, increased in-flight for light sleep, deep sleep, and REM. Changes in abdominal-rib cage displacements probably result from a less efficient operating point for the diaphragm and a less efficient coupling between the abdomen and the apposed portion of the rib cage in microG. However, the preservation of total ventilation suggests that short-term adaptive mechanisms of ventilatory control compensate for these mechanical changes.

Regional ventilation distribution in non-sedated spontaneously breathing newborns and adults is not different

BACKGROUND

In adults, ventilation is preferentially distributed towards the dependent lung. A reversal of the adult pattern has been observed in infants using radionuclide ventilation scanning. But these results have been obtained in infants and children with lung disease. In this study we investigate whether healthy infants have a similar reverse pattern of ventilation distribution.

STUDY DESIGN

Measurement of regional ventilation distribution in healthy newborn infants during non-REM sleep in comparison to adults.

METHODS

Twenty-four healthy newborns and 13 adults were investigated with electrical impedance tomography (EIT) in supine and prone position. Regional ventilation distribution was assessed with profiles of relative impedance change. The phase lag between dependent and non-dependent ventilation was calculated as a measure of asynchronous ventilation.

RESULTS

In newborns and adults the geometric center of ventilation was centrally located in the lung at 52.2 +/- 6.2% from anterior to posterior and at 50.5 +/- 14.7%, respectively. Using impedance profiles, ventilation was equally distributed to the dependent and non-dependent lung regions in newborns. Ventilation distribution in adults was similar. Phase lag characteristics of the impedance signal showed that infants had slower emptying of the dependent lung than adults.

CONCLUSION

The speculated reverse pattern of regional ventilation distribution in healthy infants compared to adults could not be demonstrated. Gravity had little effect on ventilation distribution in both infants and adults measured in supine and prone position.

Effectiveness of a photogrammetric model for the analysis of thoracoabdominal respiratory mechanics in the assessment of isovolume maneuvers in children

OBJECTIVE

To test the applicability of a geometric model, adapted to the supine position, for the analysis of respiratory mechanics regarding changes in lateral thoracoabdominal areas in children with asthma.

METHODS

Nineteen children (mean age, 11.26 +/- 1.28 years) performed isovolume maneuvers (IVMs) after maximal inspiration, followed by glottal closure and alternation of airflow between the abdominal and thoracic compartments. The maneuvers were recorded in a digital video camera placed perpendicularly to the movement plane, and the images of interest were selected. The geometric model was traced on each image based on surface landmarks of anatomical references. The traced areas were calculated using a computer program, and the results were converted into metric units (cm(2)) using a surface landmark of a known area. Relative contributions (RCs) of the subcompartments in relation to their original compartments and to the chest wall (CW) were calculated.

RESULTS

The model was based on 55 thoracic IVM images and 55 abdominal IVM images. Areas and subareas were compared between the maneuvers. There were significant differences in all subcompartments (p < 0.001). All of the RCs were significantly different for the CW (p < 0.001) but not for the ratios between the subcompartments and their original compartments.

CONCLUSIONS

This geometric model, applied in children and adapted to the supine position, was effective in profiling changes in the thoracoabdominal silhouette during the IVMs, and the selected subdivisions were useful for the identification of areas contributing the most and the least to CW composition.

Respiratory measurement utilizing a novel laser displacement technique: normal tidal breathing

A novel technique for achieving plethysmography measurements utilizing noncontact laser displacement sensors is described. This method may have utility in measuring respiratory and pulmonary function similar to that of respiratory inductive plethysmography. The authors describe the apparatus and method and provide results of a validation study comparing respiratory excursion data obtained by (1) the laser sensor technique, (2) standard respiratory inductive plethysmography (RIP), and (3) lung volume measurements determined by pressure variations in a control volume. Six healthy volunteers (five female, one male, ages ranging from 19 to 23 years) were measured for tidal breathing excursions simultaneously via all three measurement techniques.

RESULTS

Excellent correlation between the techniques was shown. Pairwise comparisons among all three measurement techniques across all subjects showed intraclass correlation coefficients of 0.995 in each case. These results indicate the laser plethysmograph (LP) system provides results that are, at a minimum, equivalent to those of the RIP at the two sites commonly measured by RIP. Use of the LP system has the potential to provide much more extensive and precise measurements of chest wall function and the respiratory musculature.

Assessment of thoraco-abdominal asynchrony

Thoraco-abdominal asynchrony is often observed in many respiratory disorders and/or respiratory muscle dysfunctions and clinically assessed as a sign of respiratory distress and increased work of breathing. This review describes the assessment of thoraco-abdominal asynchrony by respiratory inductance plethysmography. Visual inspection of the Konno-Mead plot yields information about the relative contribution of the RC and the ABD to respiration and about respiratory muscle dysfunction in selected patients. The monitoring of thoraco-abdominal asynchrony is a useful, non-invasive indicator of respiratory muscle load or respiratory muscle dysfunction and can be used to determine response to therapy in individual patients. The technique is limited by the fact that it does not detect respiratory muscle fatigue and that the occurrence of TAA does not always correspond to a clinically relevant respiratory problem, especially in the neonatal period.

Comparative analysis of phase difference estimation methods quantifying asynchronies between compartmental chest wall volume signals

Asynchronous breathing movements may be observed in the presence of pulmonary disease, such as chronic obstructive pulmonary disease (COPD). This study was undertaken in an attempt to propose a reliable methodology to quantify this asynchrony. Five methods for estimating phase differences between two signals, based on the phase angle of the Fourier Transform (PhD(FT)), paradoxical motion (PhD(PM)), the Lissajous figure (PhD(LF)), maximal linear correlation (PhD(P)) and least-squares filtering (PhD(LS)), were compared. Frequency-modulated signals, simulating compartmental chest wall volumes, were used to evaluate the methods. Breathing asynchrony was quantified in two ways; by estimating (a) a single PhD value for the entire recording and (b) time-varying PhDs, representing non-stationarities of human breathing. PhD(PM) and PhD(LF) had the lowest average errors (4%), and PhD(LS) had a slightly higher error. PhD(FT) had zero error when estimating a single PhD value but a considerable error when estimating time-varying PhDs. PhD(P) presented the highest errors in all cases. An application of this methodology is proposed in real compartmental chest wall volume signals of normal and COPD subjects. Preliminary results indicate that the methodology is promising in quantifying differences in asynchronous breathing between thoracic volumes of COPD patients and healthy controls.

Electrical impedance tomography in extremely prematurely born infants and during high frequency oscillatory ventilation analyzed in the frequency domain

Functional electrical impedance tomography (EIT) measures relative impedance change that occurs in the chest during a distinct observation period and an EIT image describing regional relative impedance change is generated. Analysis of such an EIT image may be erroneous because it is based on an impedance signal that has several components. Most of the change in relative impedance in the chest is caused by air movement but other physiological events such as cardiac activity change in end expiratory level or pressure swings originating from a ventilator circuit can influence the impedance signal. We obtained EIT images and signals in spontaneously breathing healthy adults, in extremely prematurely born infants on continuous positive airway pressure and in ventilated sheep on conventional mechanical or high frequency oscillatory ventilation (HFOV). Data were analyzed in the frequency domain and results presented after band pass filtering within the frequency range of the physiological event of interest. Band pass filtering of EIT data is necessary in premature infants and on HFOV to differentiate and eliminate relative impedance changes caused by physiological events other than the one of interest.

Different breathing patterns in healthy and asthmatic children: responses to an arithmetic task

Asthma patients have been reported to be sensitive to breathlessness, independent of the degree of airway obstruction. Paying attention and task performance may induce changes in breathing pattern and these in turn may mediate such a feeling. The present experiment investigates whether strained breathing induced by an arithmetic task was different in children with asthma compared to healthy children.

METHODS

Seven healthy and eight asthmatic but symptom-free school children were equipped with electrodes for surface electromyographic (EMG) measurements of diaphragm, abdominal and intercostal (IC) muscles and with a strain gauge to monitor the pattern of breathing at rest and during an arithmetic task. The relative duration of exhalation and the relative speed of exhalation are used as measures of straining. The phase angle of maximal respiratory muscle activities relative to the maximal chest extension (MCE) are additional discriminating parameters.

RESULTS

Asthmatic children breathed more slowly and already at rest the phase of their respiratory muscle activity appears to be different. While in healthy children the maximal activity of the (left)abdominal muscles occurred 5+/-29% later than the MCE, in children with asthma the maximal activity occurred 26+/-30% of the cycle earlier than MCE. In children with asthma the activity of the IC muscles starts weaning already at 10+/-30% before MCE, in contrast to the healthy children in which intercostal muscle weaning starts only at 1+/-24% after MCE. During arithmetic, the significant difference between the groups in this respect disappeared.

CONCLUSION

Children with asthma show, even at rest, signs of respiratory muscle straining, probably in order to keep close control over the airflow in a similar way as healthy children during mental tasks. Such a 'careful' breathing pattern may work to prevent airway irritation also when they are free of symptoms.

Automated Estimation of the Phase Between Thoracic and Abdominal Movement Signals

This paper presents a new procedure for the automated estimation of the phase relation between thoracic and abdominal breathing signals measured by inductance plethysmography (RIP). This estimation is achieved using linear filters, binary converters and an exclusive-or gate. The filters are designed offline from prior knowledge of the spectrum of subjects' respiration, reducing computational complexity and providing on-line processing capabilities. Some numerical results based on simulated time series and infant respiration data are provided, showing that the new method is less biased than the Pearson correlation method, commonly used for assessment of thoracoabdominal asynchrony. Our method offers further advantages: 1) it works with uncalibrated measurements; 2) it provides quantitative phase estimates with no need to estimate the underlying frequency of the breathing signals; 3) it does not require nonconvex optimization search algorithms; and 4) it is easy to implement and to automate.

Breath-to-breath analysis of abdominal and rib cage motion in surfactant-depleted piglets during high-frequency oscillatory ventilation

OBJECTIVE

To assess the value of monitoring abdominal and rib cage tidal displacement as an indicator of optimal mean airway pressure (Paw) during high-frequency oscillatory ventilation (HFOV).

DESIGN AND SETTING

Prospective observational study in a university research laboratory.

ANIMALS

Eight piglets weighing 12.0+/-0.5 kg, surfactant depleted by lung lavage.

INTERVENTIONS

Compliance of the respiratory system (C(rs)) was calculated from a quasistatic pressure volume loop. After initiation of HFOV lung volume was recruited by increasing Paw to 40 cmH(2)O. Then mean Paw was decreased in steps until PaO(2)/FIO(2) was below 100 mmHg. Proximal pressure amplitude remained constant.

MEASUREMENTS AND RESULTS

Abdominal and rib cage tidal displacement was determined using respiratory inductive plethysmography. During HFOV there was maximum in tidal volume (Vt) in seven of eight piglets. At maximal mean Paw abdominal and rib cage displacement were in phase. Phase difference between abdominal and rib cage displacement increased to a maximum of 178+/-28 degrees at minimum mean Paw. A minimum in abdominal displacement and a maximum of Vt was found near the optimal mean Paw, defined as the lowest mean Paw where shunt fraction is below 0.1.

CONCLUSIONS

During HFOV abdominal and rib cage displacement displayed mean Paw dependent asynchrony. Maximal Vt and minimal abdominal displacement coincided with optimal C(rs), oxygenation, and ventilation, suggesting potential clinical relevance of monitoring Vt and abdominal displacement during HFOV.

Scope of linear estimators of tidal and occluded volumes using thoracoabdominal indications of breathing movement coordination

The basic theory for respiratory inductive plethysmography (RIP) applications was re-examined, refined and tested. A realistic model of the RIP interpretation of respiratory mechanics related tidal volumes (VT) to a linear combination of ribcage and abdomen movements. Lissajous plots of asynchronous thoracoabdominal movements revealed their net effect equivalent to the superposition of synchronous and antipathetic respiration modes at right angles, along the principal axes specific to the combined motion. Predictors of relative changes in VT, degree of asynchrony and volume thus being occluded were developed via least squares estimation theory, with an optional validation facility. The approach enabled clinically adequate analysis of 452 h of RIP data from 29 postoperative patients. Correct identification of only seven complete apnoeas in 111 incidences of obstruction during periodic, variable, asynchronous or paradoxical natural breathing was substantiated via non-invasive airflow monitoring. The modelling helped clarify RIP limitations--the possibility of misleading indications from obese or abnormal physiques or movement artefacts degrading its otherwise nearly optimal performance. Nevertheless, our uncalibrated predictors had better theoretical basis, improved reliability and more convenient practical utility than the traditional approach of calibrating RIP by spirometry prior to non-invasive monitoring and identifying and classifying apnoeas.