Sources of inaccuracy in photoplethysmography for continuous cardiovascular monitoring

Photoplethysmography (PPG) is a low-cost, noninvasive optical technique that uses change in light transmission with changes in blood volume within tissue to provide information for cardiovascular health and fitness. As remote health and wearable medical devices become more prevalent, PPG devices are being developed as part of wearable systems to monitor parameters such as heart rate (HR) that do not require complex analysis of the PPG waveform. However, complex analyses of the PPG waveform yield valuable clinical information, such as: blood pressure, respiratory information, sympathetic nervous system activity, and heart rate variability. Systems aiming to derive such complex parameters do not always account for realistic sources of noise, as testing is performed within controlled parameter spaces. A wearable monitoring tool to be used beyond fitness and heart rate must account for noise sources originating from individual patient variations (e.g., skin tone, obesity, age, and gender), physiology (e.g., respiration, venous pulsation, body site of measurement, and body temperature), and external perturbations of the device itself (e.g., motion artifact, ambient light, and applied pressure to the skin). Here, we present a comprehensive review of the literature that aims to summarize these noise sources for future PPG device development for use in health monitoring

커프리스 방식의 착용형 연속 혈압 모니터링 시스템에 관한 연구

학위논문 (박사)-- 서울대학교 대학원 : 공과대학 협동과정 바이오엔지니어링전공, 2019. 2. 김희찬.고혈압의 조기 진단과 고혈압 환자의 혈압 관리를 위해서는 일상생활에서의 지속적인 혈압 모니터링이 중요하다. 맥파전달시간 (Pulse transit time, PTT) 기반의 혈압 추정 방식이 이를 가능케 하는 방법으로 가장 각광 받고 있지만, 맥파전달시간을 측정하기 위해서는 여러 측정 장치들이 필요하여 일상 생활에서의 사용에 제약이 있으며, 또한 맥파전달시간 만을 이용한 수축기 혈압(Systolic blood pressure, SBP) 추정 능력은 부족함이 있는 것으로 알려져 있다. 본 학위 논문의 첫 번째 목적은 맥파전달시간 측정 시스템을 착용형으로 개발하여 간편하게 맥파전달시간을 측정할 수 있도록 함으로써 일상 생활 중 맥파전달시간을 이용한 연속적인 혈압 모니터링이 가능케 하는 것이다. 이를 위해 광용적맥파 (Photoplethysmogram, PPG) 와 심진도 (Seismocardiogram, SCG)를 동시에 측정하는 가슴 착용형 단일 장치를 개발하여, 심진도로부터 대동맥 판막의 열리는 시점을, 광용적맥파로부터 맥파의 도착 시점을 특정하여 맥파 전달 시간을 측정하였다. 개발된 시스템은 낮은 전력 소모와 소형의 간편한 디자인을 통해 24시간 동안 연속적으로 사용할 수 있도록 설계되었다. 측정된 생체신호로부터 추출된 맥파전달시간 및 기타 혈압 관련 변수들이 기기의 반복 착용에도 변하지 않음을 급간내상관계수(Intra-class correlation, ICC) 분석을 통해 확인하였고 (ICC >0.8), 또한 본 시스템에서 사용된 심진도가 대동맥 판막의 열리는 시점의 레퍼런스가 될 수 있는지도 심저항신호(Impedancecardiogram, ICG)와의 비교를 통해 검증하였다(r=0.79±0.14). 둘째로, 개발된 시스템을 이용하여 기존의 맥파 전달 시간만을 이용한 혈압 추정 방식을 보완하여 수축기 혈압의 추정 능력이 향상된 알고리즘을 개발하였다. 이를 위해, 심진도의 진폭과 맥파 전달 시간을 같이 사용하는 다변수 모델을 수축기 혈압 추정을 위해 제안하였고, 다양한 방법으로 유도된 혈압 변화 상황에서, 기존의 맥파전달시간 혹은 맥파도달시간 (Pulse arrival time, PAT) 만을 이용한 모델과 그 성능을 비교하였다. 또한, 제안된 모델이 간단한 교정절차를 통해 여러 사람에게 적용될 수 있는 가능성을 살펴보았고 더 나아가 일상 생활에서의 사용 가능성에 대해서도 검증하였다. 그 결과로 제안된 모델은 (1) 기존의 맥파전달시간 혹은 맥파도달시간 만을 이용한 모델보다 수축기 혈압 추정 능력 측면에서 더 우수하였고, (각각의 평균절대오차는 4.57, 6.01, 6,11 mmHg 였다.) (2) 간단한 교정절차만을 통해서 여러 사람에게 적용 되었을 때의 추정 능력이 국제 기준에 부합하였으며, (3) 일상 생활에서도 사용자의 아무런 개입이나 제약 없이 지속적인 혈압 모니터링이 가능함을 확인하였다. 결론적으로 본 연구에서 제안하는 착용형 연속 혈압 측정 시스템은 가슴에 부착하는 단일 기기 형태로 그 사용이 간편할 뿐 아니라 일상생활 중에서 맥파전달시간과 심진도의 진폭을 이용하여 향상된 수준의 연속 혈압 모니터링 성능을 제공하였는바, 이를 이용한 모바일 헬스케어 서비스의 가능성을 확인하였다.Continuous blood pressure (BP) monitoring is needed in daily life to enable early detection of hypertension and improve control of BP for hypertensive patients. Although the pulse transit time (PTT)-based BP estimation represents one of most promising approaches, its use in daily life is limited owing to the requirement of multi systems to measure PTT, and its performance in systolic blood pressure (SBP) estimation is not yet satisfactory. The first goal of this study is to develop a wearable system providing convenient measurement of the PTT, which facilitates continuous BP monitoring based on PTT in daily life. A single chest-worn device was developed measuring a photoplethysmogram (PPG) and a seismocardiogram (SCG) simultaneously, thereby obtaining PTT by using the SCG as timing reference of the aortic valve opening and the PPG as timing reference of pulse arrival. The presented device was designed to be compact and convenient to use, and to last for 24h by reducing power consumption of the system. The consistency of BP related parameters extracted from the system including PTT between repetitive measurements was verified by an intra-class correlation analysis, and it was over 0.8 for all parameters. In addition, the use of SCG as timing reference of the aortic valve opening was verified by comparing it with an impedance cardiogram (r = 0.79 ± 0.14). Secondly, the algorithm improving the performance of the SBP estimation was developed by using the presented system. A multivariate model using SCG amplitude (SA) in conjunction with PTT was proposed for SBP estimation, and was compared with conventional models using only PTT or pulse arrival time (PAT) in various interventions inducing BP changes. Furthermore, we validated the proposed model against the general population with a simple calibration process and verified its potential for daily use. The results suggested that (1) the proposed model, which employed SA in conjunction with PTT for SBP estimation, outperformed the conventional univariate model using PTT or PAT (the mean absolute errors were of 4.57, 6.01, and 6.11 for the proposed, PTT, and PAT models, respectively)(2) for practical use, the proposed model showed potential to be generalized with a simple calibrationand (3) the proposed model and system demonstrated the potential for continuous BP monitoring in daily life without any intervention of users or regulations. In conclusion, the presented system provides an improved performance of continuous BP monitoring in daily life by using a combination of PTT and SA with a convenient and compact single chest-worn device, and thus, it can contribute to mobile healthcare services.CONTENTS Abstract i Contents v List of Tables ix List of Figures xi List of Abbreviations xvi Chapter 1 1 General Introduction 1.1. Blood pressure 2 1.2. Pulse transit time 6 1.3. Thesis objective 12 Chapter 2 14 Development of the Wearable Blood Pressure Monitoring System 2.1. Introduction 15 2.2. System overview 17 2.3. Bio-signal instrumentation 21 2.4. Power management 24 2.5. PCB and case design 25 2.6. Software Design 27 2.7. Signal Processing 30 2.8. Experimental setup 34 2.8.1. Repeatability test 34 2.8.2. Verification of SCG-based PEP 35 2.9. Results and Discussion 38 2.9.1. Repeatability test 38 2.9.2. Verification of SCG-based PEP 40 Chapter 3 43 Enhancement of PTT based BP estimation 3.1. Introduction 44 3.2. Method 47 3.2.1. Principle of BP estimation 47 3.2.2. Subjects 49 3.2.3. Study protocol 50 3.2.4. Data collection 56 3.2.5. Data analysis 60 3.2.6. Evaluation standard 64 3.3. Results 67 3.4. Discussion 96 Chapter 4 113 Conclusion 4.1. Thesis Summary and Contributions 114 4.2. Future Direction 116 Bibliography 118 Abstract in Korean 128Docto

Data-driven methods for analyzing ballistocardiograms in longitudinal cardiovascular monitoring

Cardiovascular disease (CVD) is the leading cause of death in the US; about 48% of American adults have one or more types of CVD. The importance of continuous monitoring of the older population, for early detection of changes in health conditions, has been shown in the literature, as the key to a successful clinical intervention. We have been investigating environmentally-embedded in-home networks of non-invasive sensing modalities. This dissertation concentrates on the signal processing techniques required for the robust extraction of morphological features from the ballistocardiographs (BCG), and machine learning approaches to utilize these features in non-invasive monitoring of cardiovascular conditions. At first, enhancements in the time domain detection of the cardiac cycle are addressed due to its importance in the estimation of heart rate variability (HRV) and sleep stages. The proposed enhancements in the energy-based algorithm for BCG beat detection have shown at least 50% improvement in the root mean square error (RMSE) of the beat to beat heart rate estimations compared to the reference estimations from the electrocardiogram (ECG) R to R intervals. These results are still subject to some errors, primarily due to the contamination of noise and motion artifacts caused by floor vibration, unconstrained subject movements, or even the respiratory activities. Aging, diseases, breathing, and sleep disorders can also affect the quality of estimation as they slightly modify the morphology of the BCG waveform.Includes bibliographical reference

Influence of photoplethysmogram signal quality on pulse arrival time during polysomnography

Intervals of low-quality photoplethysmogram (PPG) signals might lead to significant inaccuracies in estimation of pulse arrival time (PAT) during polysomnography (PSG) studies. While PSG is considered to be a “gold standard” test for diagnosing obstructive sleep apnea (OSA), it also enables tracking apnea-related nocturnal blood pressure fluctuations correlated with PAT. Since the electrocardiogram (ECG) is recorded synchronously with the PPG during PSG, it makes sense to use the ECG signal for PPG signal-quality assessment. (1) Objective: to develop a PPG signal-quality assessment algorithm for robust PAT estimation, and investigate the influence of signal quality on PAT during various sleep stages and events such as OSA. (2) Approach: the proposed algorithm uses R and T waves from the ECG to determine approximate locations of PPG pulse onsets. The MESA database of 2055 PSG recordings was used for this study. (3) Results: the proportions of high-quality PPG were significantly lower in apnea-related oxygen desaturation (matched-pairs rc = 0.88 and rc = 0.97, compared to OSA and hypopnea, respectively, when p < 0.001) and arousal (rc = 0.93 and rc = 0.98, when p < 0.001) than in apnea events. The significantly large effect size of interquartile ranges of PAT distributions was between low- and high-quality PPG (p < 0.001, rc = 0.98), and regular and irregular pulse waves (p < 0.001, rc = 0.74), whereas a lower quality of the PPG signal was found to be associated with a higher interquartile range of PAT across all subjects. Suggested PPG signal quality-based PAT evaluation reduced deviations (e.g., rc = 0.97, rc = 0.97, rc = 0.99 in hypopnea, oxygen desaturation, and arousal stages, respectively, when p < 0.001) and allowed obtaining statistically larger differences between different sleep stages and events. (4) Significance: the implemented algorithm has the potential to increase the robustness of PAT estimation in PSG studies related to nocturnal blood pressure monitoring

Improving Maternal and Fetal Cardiac Monitoring Using Artificial Intelligence

Early diagnosis of possible risks in the physiological status of fetus and mother during pregnancy and delivery is critical and can reduce mortality and morbidity. For example, early detection of life-threatening congenital heart disease may increase survival rate and reduce morbidity while allowing parents to make informed decisions. To study cardiac function, a variety of signals are required to be collected. In practice, several heart monitoring methods, such as electrocardiogram (ECG) and photoplethysmography (PPG), are commonly performed. Although there are several methods for monitoring fetal and maternal health, research is currently underway to enhance the mobility, accuracy, automation, and noise resistance of these methods to be used extensively, even at home. Artificial Intelligence (AI) can help to design a precise and convenient monitoring system. To achieve the goals, the following objectives are defined in this research: The first step for a signal acquisition system is to obtain high-quality signals. As the first objective, a signal processing scheme is explored to improve the signal-to-noise ratio (SNR) of signals and extract the desired signal from a noisy one with negative SNR (i.e., power of noise is greater than signal). It is worth mentioning that ECG and PPG signals are sensitive to noise from a variety of sources, increasing the risk of misunderstanding and interfering with the diagnostic process. The noises typically arise from power line interference, white noise, electrode contact noise, muscle contraction, baseline wandering, instrument noise, motion artifacts, electrosurgical noise. Even a slight variation in the obtained ECG waveform can impair the understanding of the patient's heart condition and affect the treatment procedure. Recent solutions, such as adaptive and blind source separation (BSS) algorithms, still have drawbacks, such as the need for noise or desired signal model, tuning and calibration, and inefficiency when dealing with excessively noisy signals. Therefore, the final goal of this step is to develop a robust algorithm that can estimate noise, even when SNR is negative, using the BSS method and remove it based on an adaptive filter. The second objective is defined for monitoring maternal and fetal ECG. Previous methods that were non-invasive used maternal abdominal ECG (MECG) for extracting fetal ECG (FECG). These methods need to be calibrated to generalize well. In other words, for each new subject, a calibration with a trustable device is required, which makes it difficult and time-consuming. The calibration is also susceptible to errors. We explore deep learning (DL) models for domain mapping, such as Cycle-Consistent Adversarial Networks, to map MECG to fetal ECG (FECG) and vice versa. The advantages of the proposed DL method over state-of-the-art approaches, such as adaptive filters or blind source separation, are that the proposed method is generalized well on unseen subjects. Moreover, it does not need calibration and is not sensitive to the heart rate variability of mother and fetal; it can also handle low signal-to-noise ratio (SNR) conditions. Thirdly, AI-based system that can measure continuous systolic blood pressure (SBP) and diastolic blood pressure (DBP) with minimum electrode requirements is explored. The most common method of measuring blood pressure is using cuff-based equipment, which cannot monitor blood pressure continuously, requires calibration, and is difficult to use. Other solutions use a synchronized ECG and PPG combination, which is still inconvenient and challenging to synchronize. The proposed method overcomes those issues and only uses PPG signal, comparing to other solutions. Using only PPG for blood pressure is more convenient since it is only one electrode on the finger where its acquisition is more resilient against error due to movement. The fourth objective is to detect anomalies on FECG data. The requirement of thousands of manually annotated samples is a concern for state-of-the-art detection systems, especially for fetal ECG (FECG), where there are few publicly available FECG datasets annotated for each FECG beat. Therefore, we will utilize active learning and transfer-learning concept to train a FECG anomaly detection system with the least training samples and high accuracy. In this part, a model is trained for detecting ECG anomalies in adults. Later this model is trained to detect anomalies on FECG. We only select more influential samples from the training set for training, which leads to training with the least effort. Because of physician shortages and rural geography, pregnant women's ability to get prenatal care might be improved through remote monitoring, especially when access to prenatal care is limited. Increased compliance with prenatal treatment and linked care amongst various providers are two possible benefits of remote monitoring. If recorded signals are transmitted correctly, maternal and fetal remote monitoring can be effective. Therefore, the last objective is to design a compression algorithm that can compress signals (like ECG) with a higher ratio than state-of-the-art and perform decompression fast without distortion. The proposed compression is fast thanks to the time domain B-Spline approach, and compressed data can be used for visualization and monitoring without decompression owing to the B-spline properties. Moreover, the stochastic optimization is designed to retain the signal quality and does not distort signal for diagnosis purposes while having a high compression ratio. In summary, components for creating an end-to-end system for day-to-day maternal and fetal cardiac monitoring can be envisioned as a mix of all tasks listed above. PPG and ECG recorded from the mother can be denoised using deconvolution strategy. Then, compression can be employed for transmitting signal. The trained CycleGAN model can be used for extracting FECG from MECG. Then, trained model using active transfer learning can detect anomaly on both MECG and FECG. Simultaneously, maternal BP is retrieved from the PPG signal. This information can be used for monitoring the cardiac status of mother and fetus, and also can be used for filling reports such as partogram

The 2023 wearable photoplethysmography roadmap

Photoplethysmography is a key sensing technology which is used in wearable devices such as smartwatches and fitness trackers. Currently, photoplethysmography sensors are used to monitor physiological parameters including heart rate and heart rhythm, and to track activities like sleep and exercise. Yet, wearable photoplethysmography has potential to provide much more information on health and wellbeing, which could inform clinical decision making. This Roadmap outlines directions for research and development to realise the full potential of wearable photoplethysmography. Experts discuss key topics within the areas of sensor design, signal processing, clinical applications, and research directions. Their perspectives provide valuable guidance to researchers developing wearable photoplethysmography technology

Wearable and Nearable Biosensors and Systems for Healthcare

Biosensors and systems in the form of wearables and “nearables” (i.e., everyday sensorized objects with transmitting capabilities such as smartphones) are rapidly evolving for use in healthcare. Unlike conventional approaches, these technologies can enable seamless or on-demand physiological monitoring, anytime and anywhere. Such monitoring can help transform healthcare from the current reactive, one-size-fits-all, hospital-centered approach into a future proactive, personalized, decentralized structure. Wearable and nearable biosensors and systems have been made possible through integrated innovations in sensor design, electronics, data transmission, power management, and signal processing. Although much progress has been made in this field, many open challenges for the scientific community remain, especially for those applications requiring high accuracy. This book contains the 12 papers that constituted a recent Special Issue of Sensors sharing the same title. The aim of the initiative was to provide a collection of state-of-the-art investigations on wearables and nearables, in order to stimulate technological advances and the use of the technology to benefit healthcare. The topics covered by the book offer both depth and breadth pertaining to wearable and nearable technology. They include new biosensors and data transmission techniques, studies on accelerometers, signal processing, and cardiovascular monitoring, clinical applications, and validation of commercial devices

Robust Algorithms for Unattended Monitoring of Cardiovascular Health

Cardiovascular disease is the leading cause of death in the United States. Tracking daily changes in one’s cardiovascular health can be critical in diagnosing and managing cardiovascular disease, such as heart failure and hypertension. A toilet seat is the ideal device for monitoring parameters relating to a subject’s cardiac health in his or her home, because it is used consistently and requires no change in daily habit. The present work demonstrates the ability to accurately capture clinically relevant ECG metrics, pulse transit time based blood pressures, and other parameters across subjects and physiological states using a toilet seat-based cardiovascular monitoring system, enabled through advanced signal processing algorithms and techniques. The algorithms described herein have been designed for use with noisy physiologic signals measured at non-standard locations. A key component of these algorithms is the classification of signal quality, which allows automatic rejection of noisy segments before feature delineation and interval extractions. The present delineation algorithms have been designed to work on poor quality signals while maintaining the highest possible temporal resolution. When validated on standard databases, the custom QRS delineation algorithm has best-in-class sensitivity and precision, while the photoplethysmogram delineation algorithm has best-in-class temporal resolution. Human subject testing on normative and heart failure subjects is used to evaluate the efficacy of the proposed monitoring system and algorithms. Results show that the accuracy of the measured heart rate and blood pressure are well within the limits of AAMI standards. For the first time, a single device is capable of monitoring long-term trends in these parameters while facilitating daily measurements that are taken at rest, prior to the consumption of food and stimulants, and at consistent times each day. This system has the potential to revolutionize in-home cardiovascular monitoring

Photoplethysmography-Based Biomedical Signal Processing

In this dissertation, photoplethysmography-based biomedical signal processing methods are developed and analyzed. The developed methods solve problems concerning the estimation of the heart rate during physical activity and the monitoring of cardiovascular health. For the estimation of heart rate during physical activity, two methods are presented that are very accurate in estimating the instantaneous heart rate at the wrist and, at the same time, are computationally efficient so that they can easily be integrated into wearables. In the context of cardiovascular health monitoring, a method for the detection of atrial fibrillation using the video camera of a smartphone is proposed that achieves a high detection rate of atrial fibrillation (AF) on a clinical pre-study data set. Further monitoring of cardiovascular parameters includes the estimation of blood pressure (BP), pulse wave velocity (PWV), and vascular age index (VAI), for which an approach is presented that requires only a single photoplethysmographic (PPG) signal. Heart rate estimation during physical activity using PPG signals constitutes an important research focus of this thesis. In this work, two computationally efficient algorithms are presented that estimate the heart rate from two PPG signals using a three axis accelerometer. In the first approach, adaptive filters are applied to estimate motion artifacts that severely deteriorate the signal quality. The non-stationary relationship between the measured acceleration signals and the artifacts is modeled as a linear system. The outputs of the adaptive filters are combined to further enhance the signal quality and a constrained heart rate tracker follows the most probable high energy continuous line in the spectral domain. The second approach is modest in computational complexity and very fast in execution compared to existing approaches. It combines correlation-based fundamental frequency indicating functions and spectral combination to enhance the correlated useful signal and suppress uncorrelated noise. Additional harmonic noise damping further reduces the impact of strong motion artifacts and a spectral tracking procedure uses a linear least squares prediction. Both approaches are modest in computational complexity and especially the second approach is very fast in execution, as it is shown on a widely used benchmark data set and compared to state-of-the-art methods. The second research focus and a further major contribution of this thesis lies in the monitoring of the cardiovascular health with a single PPG signal. Two methods are presented, one for detection of AF and one for the estimation of BP, PWV, and VAI. The first method is able to detect AF based on a smartphone filming the finger placed on the video camera. The algorithm transforms the video into a PPG signal and extracts features which are then used to discriminate between AF and normal sinus rhythm (NSR). Perfect detection of AF is already achieved on a data set of 326 measurements (including 20 with AF) that were taken at a clinical pre-study using an appropriate pair of features whereby a decision is formed through a simple linear decision equation. The second method aims at estimating cardiovascular parameters from a single PPG signal without the conventional use of an additional electrocardiogram (ECG). The proposed method extracts a large number of features from the PPG signal and its first and second order difference series, and reconstructs missing features by the use of matrix completion. The estimation of cardiovascular parameters is based on a nonlinear support vector regression (SVR) estimator and compared to single channel PPG based estimators using a linear regression model and a pulse arrival time (PAT) based method. If the training data set contains the person for whom the cardiovascular parameters are to be determined, the proposed method can provide an accurate estimate without further calibration. All proposed algorithms are applied to real data that we have either recorded ourselves in our biomedical laboratory, that have been recorded by a clinical research partner, or that are freely available as benchmark data sets