Automatic sleep staging from ventilator signals in non-invasive ventilation

AbstractNon-invasive ventilation (NIV), a recognized treatment for chronic hypercapnic respiratory failure, is predominantly applied at night. Nevertheless, the quality of sleep is rarely evaluated due to the required technological complexity. A new technique for automatic sleep staging is here proposed for patients treated by NIV. This new technique only requires signals (airflow and hemoglobin oxygen saturation) available in domiciliary ventilators plus a photo-plethysmogram, a signal already managed by some ventilators. Consequently, electroencephalogram, electrooculogram, electromyogram, and electrocardiogram recordings are not needed. Cardiorespiratory features are extracted from the three selected signals and used as input to a Support Vector Machine (SVM) multi-class classifier. Two different types of sleep scoring were investigated: the first type was used to distinguish three stages (wake, REM sleep and nonREM sleep), and the second type was used to evaluate five stages (wake, REM sleep, N1, N2 and N3 stages). Patient-dependent and patient-independent classifiers were tested comparing the resulting hypnograms with those obtained from visual/manual scoring by a sleep specialist. An average accuracy of 91% (84%) was obtained with three-stage (five-stage) patient-dependent classifiers. With patient-independent classifiers, an average accuracy of 78% (62%) was obtained when three (five) sleep stages were scored. Also if the PPG-based and flow features are left out, a reduction of 4.5% (resp. 5%) in accuracy is observed for the three-stage (resp. five-stage) cases. Our results suggest that long-term sleep evaluation and nocturnal monitoring at home is feasible in patients treated by NIV. Our technique could even be integrated into ventilators

Non-invasive monitoring of vital signs using recliner chair and respiratory pattern analysis

In-home monitoring has the potential to help track health changes for older adults with chronic health conditions, thereby making early treatment possible when exacerbations arise. A recliner chair is often used by older adults, even for sleeping at night, for those with breathing difficulty, neck and back problems, or other pain. Here, we present a sensor system for recliner chairs that can be used to monitor heart rate and respiration rate. The system uses two accelerometers placed strategically to capture these vital signs noninvasively and without direct contact with the body, while at same time being hidden from view. The system was tested with 45 subjects, with an average age of 78.8 years for both upright and reclined configurations of the chair. We also tested the system on 6 different types of recliner models. An accuracy of 99% for heart rate and 93% for respiratory rate was obtained. An analysis of the error distribution patterns according to age, gender and recliner configurations are considered. A validation study of a commercially available sensor, Murata SCA11H, which is primarily designed for use on the bed is tested on the chair and the results are presented in this thesis. We have also developed a measure known as the "Breathing Pattern Index" that can be useful in determining the respiratory health of the occupants on the chair. Initial studies of the effectiveness of this index and algorithm are evaluated and the results are presented. This new system and index have the potential to help in identifying very early health changes and improve health outcomes for older adults.Includes bibliographical reference

Towards respiratory muscle-protective mechanical ventilation in the critically ill: technology to monitor and assist physiology

Inadequate delivery of ventilatory assist and unphysiological respiratory drive may severely worsen respiratory muscle function in mechanically ventilated critically ill patients. Diaphragm weakness in these patients is exceedingly common (>60% of patients) and associated with poor clinical outcomes, including difficult ventilator liberation, increased risks of intensive care unit (ICU) and hospital readmission, and mortality. The underlying mechanisms of diaphragm dysfunction were extensively discussed in this thesis. Pathways primarily include the development of diaphragm disuse atrophy due to muscle inactivity or low respiratory drive (strong clinical evidence), and diaphragm injury as a result of excessive breathing effort due to insufficient ventilator assist or excessive respiratory drive (moderate evidence, mostly from experimental work). Excessive breathing effort may also worsen lung injury through pathways that include high lung stress and strain, pendelluft, increased lung perfusion, and patient-ventilator dyssynchrony. Relatively little attention has been paid to the effects of critical illness and mechanical ventilation on the expiratory muscles; however, dysfunction of these muscles has been linked to inadequate central airway clearance and extubation failure. The motivation for performing the work presented in this thesis was the hypothesis that maintaining physiological levels of respiratory muscle activity under mechanical ventilation could prevent or attenuate the development respiratory muscle weakness, and hence, improve patient outcomes. This strategy, integrated with lung-protective ventilation, was recently proposed by international experts from different professional societies (this thesis), and is referred to as a combined lung and diaphragm-protective ventilation approach. Today, an important barrier for implementing and evaluating such an approach is the lack of feasible, reliable and well-understood modalities to assess breathing effort at the bedside, as well as strategies for assisting and restoring respiratory muscle function during mechanical ventilation. Furthermore, monitoring breathing effort is crucial to identify potential relationships between patient management and detrimental respiratory (muscle) function that can be targeted to improve clinical outcomes. In this thesis we identified and improved monitoring modalities for the diaphragm (Part I), we investigated the impact of mechanical ventilation on the respiratory pump, especially the diaphragm (Part II), and we evaluated a novel strategy for maintaining expiratory muscle activity under mechanical ventilation (Part III)

Positive airway pressure and electrical stimulation methods for obstructive sleep apnea treatment: a patent review (2005-2014)

Producción CientíficaIntroduction. Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a major health problem with significant negative effects on the health and quality of life. Continuous positive airway pressure (CPAP) is currently the primary treatment option and it is considered the most effective therapy for OSAHS. Nevertheless, comfort issues due to improper fit to patient’s changing needs and breathing gas leakage limit the patient’s adherence to treatment. Areas covered. The present patent review describes recent innovations in the treatment of OSAHS related to optimization of the positive pressure delivered to the patient, methods and systems for continuous self-adjusting pressure during inspiration and expiration phases, and techniques for electrical stimulation of nerves and muscles responsible for the airway patency. Expert opinion. In the last years, CPAP-related inventions have mainly focused on obtaining an optimal self-adjusting pressure according to patient’s needs. Despite intensive research carried out, treatment compliance is still a major issue. Hypoglossal electrical nerve stimulation could be an effective secondary treatment option when CPAP primary therapy fails. Several patents have been granted focused on selective stimulation techniques and parameter optimization of the stimulating pulse waveform. Nevertheless, there remain important issues to address, like effectiveness and adverse events due to improper stimulation.Ministerio de Economía y Competitividad (TEC2011-22987)Junta de Castilla y León (VA059U13

Asleep and awake in the ICU

Sleep is essential for homeostasis, recovery and survival. The functional importance of sleep is perhaps best illustrated by observing the detrimental effects of sleep deprivation, as commonly experienced by hospitalized patients and occasionally by staff too. Our most vulnerable patients require intensive care around the clock, blurring the lines between day and night for those receiving and providing care. Meanwhile nurses, physicians, and researchers depend on legacy tools to expand our understanding of individual factors impacting sleep. Due to this limited understanding of the complex interplay between sleep, critical illness, circadian timekeeping, critical care, and environmental factors, broad efforts to improve patients’ sleep have seen limited success. Even well considered and targeted interventions may therefore be expected to interfere with natural sleep in unintended ways. This thesis describes a series of challenges and opportunities to improve our patients sleep when they may need it most

Telemedicine in home NIV: developing Health Informatics, assessing Physiological response, and Improving Patient Outcomes (THE HIPPO study)

The landscape of digital technology innovations which can assist healthcare provision has expanded rapidly over the past decade. With the adoption of consumer and healthcare-based technologies including mobile device and network access, the use of tele-monitoring in the management of chronic medical conditions will be incorporated into routine clinical care within this generation. Remote patient monitoring has an established role in the management of patients with obstructive sleep apnoea syndrome who require positive airway pressure support. However, the use of two-way remote monitoring via a cloud-based platform to initiate and optimise home non-invasive ventilation (NIV) is novel. Rising obesity rates and new evidence supporting the use of home NIV in patients with severe chronic obstructive pulmonary disease (COPD) and chronic hypercapnic respiratory failure has resulted in increased referrals for breathing support assessment and treatment. Chronic hypercapnic respiratory failure develops as a consequence of imbalance in the respiratory load capacity drive relationship and is associated with high morbidity and mortality. Advanced physiological measurements such as parasternal electromyography (EMG) to quantify neural respiratory drive and forced oscillometry technique to quantify airway resistance and reactance are well established in research but evidence for their clinical application in disease monitoring in patients with sleep disordered breathing and chronic hypercapnic respiratory failure is lacking. The anticipation is that big data from remote monitoring of home breathing support therapies and serial advanced physiological measurements will provide mechanistic insights of chronic respiratory failure, facilitate early optimisation of treatment, prompt early recognition of treatment failure and prioritise at risk patients to provide a personalised approach to the management of chronic respiratory disease. The aim of this thesis was to evaluate the adoption of two-way remote monitoring in patients with sleep disordered breathing and hypercapnic severe COPD and determine the feasibility of serial advanced physiological measurements in chronic respiratory disease. Methods A summary of the evolution of clinical pathways for two-way remote monitored breathing support and home ventilation in NHS Greater Glasgow and Clyde are detailed. A retrospective review of the clinical outcomes in observational cohorts of patients who were managed with two-way remote monitored home NIV for hypercapnic severe COPD and obesity related respiratory failure were evaluated. Clinical outcomes were compared to those of patients who survived a life-threatening exacerbation of COPD with persistent hypercapnic failure who were not referred for breathing support assessment (controls). Four physiological studies were performed. Firstly, the optimisation of parasternal EMG signals using different skin preparation and electrodes was explored. Secondly, inter-observer variability of parasternal EMG analysis between two UK based respiratory physiology research centres was assessed. Thirdly, the simplification of neural respiratory drive index analysis by using EMG signals to estimate respiratory rate to determine the feasibility of future omission of additional sensors improving accessibility. The fourth study explored the feasibility of serial advanced physiological measurements alongside standard care in a wide range of respiratory diseases. Results Clinical pathways for remote management of breathing support patients are now routine clinical care within NHS Greater Glasgow and Clyde. It is feasible and safe to use remote monitored home ventilation in patients with hypercapnic severe COPD. Continued use of two-way remote monitored home NIV prolonged time to re-admission or death in patients with hypercapnic severe COPD when compared to the control cohort. Continued use of remote monitored home NIV in hypercapnic severe COPD resulted in a median reduction of 14 occupied bed days per annum. Continued use of remote NIV prolonged time to re-admission or death in patients with obesity related respiratory failure compared to those non-adherent or discontinued NIV. Two-way remote home NIV can facilitate safe day case initiation of home NIV in patients with stable hypercapnic respiratory failure. It is feasible to use long term cardiac electrodes for parasternal electromyography measurements. Acceptable reproducibility of parasternal EMG analysis between two UK research centres has been demonstrated. The derivation of respiratory rate from parasternal EMG signals is feasible. Serial advanced physiological measurements can be incorporated into standard care in a wide range of respiratory diseases. Serial oscillometry measurements in patients with obstructive sleep apnoea syndrome has provided novel insight into the role a small airways disease. Conclusion The work undertaken in this thesis enabled significant service improvement within NHS Greater Glasgow and Clyde. The utilisation of remote monitoring in disease management provides realistic service provision with tangible service and cost efficiencies, addressing increased service demands and justifying future cost-effective analysis. This work has been a catalyst for ongoing digital innovation projects incorporating EHRs, ambulatory physiological monitoring and home device data into a multi-media multi-disciplinary platform for high-risk COPD patients. Serial advanced physiology data has advocated ongoing studies in acute respiratory failure secondary to COVID-19 infection. Adoption of these new technologies into routine clinical care will address increasing service demands, improve patient outcomes, and provide physiological insights into chronic respiratory failure and COVID-19 related respiratory failure

Intensive care unit depth of sleep:proof of concept of a simple electroencephalography index in the non-sedated

INTRODUCTION: Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with possible detrimental effects on short- and long- term outcomes. Investigation into the exact causes and effects of disturbed sleep has been hampered by cumbersome and time consuming methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep analysis, the ICU depth of sleep index (IDOS index), using single channel electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is shown in non-sedated ICU patients. METHODS: Polysomnographic (PSG) recordings of five ICU patients and 15 healthy outpatients were analyzed using the IDOS index, based on the ratio between gamma and delta band power. Manual selection of thresholds was used to classify data as either wake, sleep or slow wave sleep (SWS). This classification was compared to visual sleep scoring by Rechtschaffen & Kales criteria in normal outpatient recordings and ICU recordings to illustrate face validity of the IDOS index. RESULTS: When reduced to two or three classes, the scoring of sleep by IDOS index and manual scoring show high agreement for normal sleep recordings. The obtained overall agreements, as quantified by the kappa coefficient, were 0.84 for sleep/wake classification and 0.82 for classification into three classes (wake, non-SWS and SWS). Sensitivity and specificity were highest for the wake state (93% and 93%, respectively) and lowest for SWS (82% and 76%, respectively). For ICU recordings, agreement was similar to agreement between visual scorers previously reported in literature. CONCLUSIONS: Besides the most satisfying visual resemblance with manually scored normal PSG recordings, the established face-validity of the IDOS index as an estimator of depth of sleep was excellent. This technique enables real-time, automated, single channel visualization of depth of sleep, facilitating the monitoring of sleep in the ICU

An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Advanced analyses of physiological signals and their role in Neonatal Intensive Care

Preterm infants admitted to the neonatal intensive care unit (NICU) face an array of life-threatening diseases requiring procedures such as resuscitation and invasive monitoring, and other risks related to exposure to the hospital environment, all of which may have lifelong implications. This thesis examined a range of applications for advanced signal analyses in the NICU, from identifying of physiological patterns associated with neonatal outcomes, to evaluating the impact of certain treatments on physiological variability. Firstly, the thesis examined the potential to identify infants at risk of developing intraventricular haemorrhage, often interrelated with factors leading to preterm birth, mechanical ventilation, hypoxia and prolonged apnoeas. This thesis then characterised the cardiovascular impact of caffeine therapy which is often administered to prevent and treat apnoea of prematurity, finding greater pulse pressure variability and enhanced responsiveness of the autonomic nervous system. Cerebral autoregulation maintains cerebral blood flow despite fluctuations in arterial blood pressure and is an important consideration for preterm infants who are especially vulnerable to brain injury. Using various time and frequency domain correlation techniques, the thesis found acute changes in cerebral autoregulation of preterm infants following caffeine therapy. Nutrition in early life may also affect neurodevelopment and morbidity in later life. This thesis developed models for identifying malnutrition risk using anthropometry and near-infrared interactance features. This thesis has presented a range of ways in which advanced analyses including time series analysis, feature selection and model development can be applied to neonatal intensive care. There is a clear role for such analyses in early detection of clinical outcomes, characterising the effects of relevant treatments or pathologies and identifying infants at risk of later morbidity

Separator fluid volume requirements in multi-infusion settings

INTRODUCTION. Intravenous (IV) therapy is a widely used method for the administration of medication in hospitals worldwide. ICU and surgical patients in particular often require multiple IV catheters due to incompatibility of certain drugs and the high complexity of medical therapy. This increases discomfort by painful invasive procedures, the risk of infections and costs of medication and disposable considerably. When different drugs are administered through the same lumen, it is common ICU practice to flush with a neutral fluid between the administration of two incompatible drugs in order to optimally use infusion lumens. An important constraint for delivering multiple incompatible drugs is the volume of separator fluid that is sufficient to safely separate them. OBJECTIVES. In this pilot study we investigated whether the choice of separator fluid, solvent, or administration rate affects the separator volume required in a typical ICU infusion setting. METHODS. A standard ICU IV line (2m, 2ml, 1mm internal diameter) was filled with methylene blue (40 mg/l) solution and flushed using an infusion pump with separator fluid. Independent variables were solvent for methylene blue (NaCl 0.9% vs. glucose 5%), separator fluid (NaCl 0.9% vs. glucose 5%), and administration rate (50, 100, or 200 ml/h). Samples were collected using a fraction collector until <2% of the original drug concentration remained and were analyzed using spectrophotometry. RESULTS. We did not find a significant effect of administration rate on separator fluid volume. However, NaCl/G5% (solvent/separator fluid) required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). Also, G5%/G5% required significantly less separator fluid than NaCl/NaCl (3.6 ± 0.1 ml vs. 3.9 ± 0.1 ml, p <0.05). The significant decrease in required flushing volume might be due to differences in the viscosity of the solutions. However, mean differences were small and were most likely caused by human interactions with the fluid collection setup. The average required flushing volume is 3.7 ml. CONCLUSIONS. The choice of separator fluid, solvent or administration rate had no impact on the required flushing volume in the experiment. Future research should take IV line length, diameter, volume and also drug solution volumes into account in order to provide a full account of variables affecting the required separator fluid volume