Analysis and applications of respiratory surface EMG:report of a round table meeting

Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited—in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.</p

Analysis and applications of respiratory surface EMG:report of a round table meeting

Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited-in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.</p

Analysis and applications of respiratory surface EMG:report of a round table meeting

Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited-in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.</p

Analysis and applications of respiratory surface EMG:report of a round table meeting

Surface electromyography (sEMG) can be used to measure the electrical activity of the respiratory muscles. The possible applications of sEMG span from patients suffering from acute respiratory failure to patients receiving chronic home mechanical ventilation, to evaluate muscle function, titrate ventilatory support and guide treatment. However, sEMG is mainly used as a monitoring tool for research and its use in clinical practice is still limited—in part due to a lack of standardization and transparent reporting. During this round table meeting, recommendations on data acquisition, processing, interpretation, and potential clinical applications of respiratory sEMG were discussed. This paper informs the clinical researcher interested in respiratory muscle monitoring about the current state of the art on sEMG, knowledge gaps and potential future applications for patients with respiratory failure.</p

Polysomnography in stable COPD under non-invasive ventilation to reduce patient-ventilator asynchrony and morning breathlessness

Background: Stable severe chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure treated by nocturnal bi-level positive pressure non-invasive ventilation (NIV) may experience severe morning deventilation dyspnea. We hypothesised that in these patients, progressive hyperinflation, resulting from inappropriate ventilator settings, leads to patient-ventilator asynchrony (PVA) with a high rate of unrewarded inspiratory efforts and morning discomfort. Methods: Polysomnography (PSG), diaphragm electromyogram and transcutaneous capnography (PtcCO2) under NIV during two consecutive nights using baseline ventilator settings on the first night, then, during the second night, adjustment of ventilator parameters under PSG with assessment of impact of settings changes on sleep, patient-ventilator synchronisation, morning arterial blood gases and morning dyspnea. Results: Eight patients (61 ± 8years, FEV1 30 ± 8% predicted, residual volume 210 ± 30% predicted) were included. In all patients, pressure support was decreased during setting adjustments, as well as tidal volume, while respiratory rate increased without any deleterious effect on nocturnal PtcCO2 or morning PaCO2. PVA index, initially high (40 ± 30%) during the baseline night, decreased significantly after adjusting ventilator settings (p = 0.0009), as well as subjective perception of PVA leaks, and morning dyspnea while quality of sleep improved. Conclusion: The subgroup of COPD patients treated by home NIV, who present marked deventilation dyspnea and unrewarded efforts may benefit from adjustment of ventilator settings under PSG or polygraph

Development and validation of a sample entropy-based method to identify complex patient-ventilator interactions during mechanical ventilation

Patient-ventilator asynchronies can be detected by close monitoring of ventilator screens by clinicians or through automated algorithms. However, detecting complex patient-ventilator interactions (CP-VI), consisting of changes in the respiratory rate and/or clusters of asynchronies, is a challenge. Sample Entropy (SE) of airway flow (SE-Flow) and airway pressure (SE-Paw) waveforms obtained from 27 critically ill patients was used to develop and validate an automated algorithm for detecting CP-VI. The algorithm’s performance was compared versus the gold standard (the ventilator’s waveform recordings for CP-VI were scored visually by three experts; Fleiss’ kappa = 0.90 (0.87–0.93)). A repeated holdout cross-validation procedure using the Matthews correlation coefficient (MCC) as a measure of effectiveness was used for optimization of different combinations of SE settings (embedding dimension, m, and tolerance value, r), derived SE features (mean and maximum values), and the thresholds of change (Th) from patient’s own baseline SE value. The most accurate results were obtained using the maximum values of SE-Flow (m = 2, r = 0.2, Th = 25%) and SE-Paw (m = 4, r = 0.2, Th = 30%) which report MCCs of 0.85 (0.78–0.86) and 0.78 (0.78–0.85), and accuracies of 0.93 (0.89–0.93) and 0.89 (0.89–0.93), respectively. This approach promises an improvement in the accurate detection of CP-VI, and future study of their clinical implications.This work was funded by projects PI16/01606, integrated in the Plan Nacional de R+D+I and co-funded by the ISCIII- Subdirección General de Evaluación y el Fondo Europeo de Desarrollo Regional (FEDER). RTC-2017-6193-1 (AEI/FEDER UE). CIBER Enfermedades Respiratorias, and Fundació Parc Taulí

Maximum inspiratory pressure, a surrogate parameter for the assessment of ICU-acquired weakness

<p>Abstract</p> <p>Background</p> <p>Physical examination has been advocated as a primary determinant of ICU-acquired weakness (ICU-AW). The purpose of the study is to investigate ICU-AW development by using Maximum Inspiratory Pressure (MIP) as a surrogate parameter of the standardized method to evaluate patients' peripheral muscle strength.</p> <p>Methods</p> <p>Seventy-four patients were recruited in the study and prospectively evaluated in a multidisciplinary university ICU towards the appearance of ICU-AW. APACHE II admission score was 16 ± 6 and ICU stay 26 ± 18 days. ICU-AW was diagnosed with the Medical Research Council (MRC) scale for the clinical evaluation of muscle strength. MIP was measured using the unidirectional valve method, independently of the patients' ability to cooperate.</p> <p>Results</p> <p>A significant correlation was found between MIP and MRC (r = 0.68, p < 0.001). Patients that developed ICU-AW (MRC<48) had a longer weaning period compared to non ICU-AW patients (12 ± 14 versus 2 ± 3 days, p < 0.01). A cut-off point of 36 cmH₂O for MIP was defined by ROC curve analysis for ICU-AW diagnosis (88% sensitivity,76% specificity). Patients with MIP below the cut-off point of 36 cmH₂O had a significant greater weaning period (10 ± 14 versus 3 ± 3 days, p = 0.004) also shown by Kaplan-Meier analysis (log-rank:8.2;p = 0.004).</p> <p>Conclusions</p> <p>MIP estimated using the unidirectional valve method may be a potential surrogate parameter for the assessment of muscle strength compromise, useful for the early detection of ICU-AW.</p

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

Evaluation of Respiratory Muscle Activity by Means of Concentric Ring Electrodes

© 2021 IEEE. Personal use of this material is permitted. Permissíon from IEEE must be obtained for all other uses, in any current or future media, including reprinting/republishing this material for advertisíng or promotional purposes, creating new collective works, for resale or redistribution to servers or lists, or reuse of any copyrighted component of this work in other works.[EN] Surface electromyography (sEMG) can be used for the evaluation of respiratory muscle activity. Recording sEMG involves the use of surface electrodes in a bipolar configuration. However, electrocardiographic (ECG) interference and electrode orientation represent considerable drawbacks to bipolar acquisition. As an alternative, concentric ring electrodes (CREs) can be used for sEMG acquisition and offer great potential for the evaluation of respiratory muscle activity due to their enhanced spatial resolution and simple placement protocol, which does not depend on muscle fiber orientation. The aim of this work was to analyze the performance of CREs during respiratory sEMG acquisitions. Respiratory muscle sEMG was applied to the diaphragm and sternocleidomastoid muscles using a bipolar and a CRE configuration. Thirty-two subjects underwent four inspiratory load spontaneous breathing tests which was repeated after interchanging the electrode positions. We calculated parameters such as (1) spectral power and (2) median frequency during inspiration, and power ratios of inspiratory sEMG without ECG in relation to (3) basal sEMG without ECG (R-ins/noise), (4) basal sEMG with ECG (R-ins/cardio) and (5) expiratory sEMG without ECG (R-ins/exp). Spectral power, R-ins/noise and R-ins/cardio increased with the inspiratory load. Significantly higher values (p < 0.05) of R-ins/cardio and significantly higher median frequencies were obtained for CREs. R-ins/noise and R-ins/exp were higher for the bipolar configuration only in diaphragm sEMG recordings, whereas no significant differences were found in the sternocleidomastoid recordings. Our results suggest that the evaluation of respiratory muscle activity by means of sEMG can benefit from the remarkably reduced influence of cardiac activity, the enhanced detection of the shift in frequency content and the axial isotropy of CREs which facilitates its placement.This work was supported in part by the CERCA Program/Generalitat de Catalunya, in part by the Secretaria d'Universitats i Recerca de la Generalitat de Catalunya under Grant GRC 2017 SGR 01770, in part by the Spanish Grants RTI2018-098472-B-I00, RTI2018-094449-A-I00-AR (MCIU/AEI/FEDER, UE) and DPI2015-68397-R (MINECO/FEDER), and in part by the Biomedical Research Networking Centre in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN, Instituto de Salud Carlos III/FEDER). The first author was supported by the IFARHU-SENACYT Scholarship Program from the Panama Government under Grant 270-2012-273.Estrada-Petrocelli, L.; Torres, A.; Sarlabous, L.; Ràfols-De-Urquía, M.; Ye Lin, Y.; Prats-Boluda, G.; Jané, R.... (2021). Evaluation of Respiratory Muscle Activity by Means of Concentric Ring Electrodes. IEEE Transactions on Biomedical Engineering. 68(3):1005-1014. https://doi.org/10.1109/TBME.2020.3012385S1005101468