US20070135724A1 - Methods and apparatus for heart failure treatment - Google Patents

Methods and apparatus for heart failure treatment Download PDF

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US20070135724A1
US20070135724A1 US10/575,197 US57519704A US2007135724A1 US 20070135724 A1 US20070135724 A1 US 20070135724A1 US 57519704 A US57519704 A US 57519704A US 2007135724 A1 US2007135724 A1 US 2007135724A1
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heart failure
pressure
treatment
patient
ventilation
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Anthony Ujhazy
Jonathan Wright
Glenn Richards
David Bassin
Michael Berthon-Jones
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    • A61B5/48—Other medical applications
    • A61B5/4836—Diagnosis combined with treatment in closed-loop systems or methods
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    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/08—Detecting, measuring or recording devices for evaluating the respiratory organs
    • A61B5/0826—Detecting or evaluating apnoea events
    • A—HUMAN NECESSITIES
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    • A61B5/08—Detecting, measuring or recording devices for evaluating the respiratory organs
    • A61B5/087—Measuring breath flow
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    • A61M2016/0018—Accessories therefor, e.g. sensors, vibrators, negative pressure inhalation detectors electrical
    • A61M2016/0021—Accessories therefor, e.g. sensors, vibrators, negative pressure inhalation detectors electrical with a proportional output signal, e.g. from a thermistor
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    • A61M2230/18—Rapid eye-movements [REM]
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    • A61M2230/43—Composition of exhalation
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    • A61M2230/63—Motion, e.g. physical activity

Definitions

  • the invention relates to methods and apparatus for diagnosing, managing and treating congestive heart failure.
  • Heart failure is a condition that is characterized by a reduced ability of the heart to circulate blood through the body.
  • an underlying disease such as high blood pressure (e.g., hypertension), clogged arteries (e.g., coronary artery disease), heart defect (e.g., cardiomyopathy, or valvular heart disease) or some other problem (e.g., diabetes, hyperthyroidism, or alcohol abuse) will lead to a decrease in circulation over time.
  • high blood pressure e.g., hypertension
  • clogged arteries e.g., coronary artery disease
  • heart defect e.g., cardiomyopathy, or valvular heart disease
  • some other problem e.g., diabetes, hyperthyroidism, or alcohol abuse
  • Heart failure may be identified by the phase of the heart cycle that is particularly associated with the nature of the circulatory problem. By this identification, two types of heart failure are known as systolic and diastolic. In systolic heart failure, the cardiac muscles' ability to contract decreases. This loss of contraction results in a decrease in the ability of the heart to force blood through the circulatory system of the body. In diastolic heart failure, the cardiac muscles' ability to relax diminishes. As the heart muscles become stiffer, the heart does not sufficiently fill with blood and thus each subsequent contraction circulates a lower volume of blood.
  • heart failure may be characterized by whether it stems from problems with the left or right side of the heart.
  • Left-sided heart failure occurs when the left ventricle does not sufficiently pump oxygenated blood to the body.
  • Right-sided heart failure occurs when the right ventricle does not pump adequately, which leads to fluid build-up in the veins.
  • congestive heart failure is more accurately descriptive of a symptom of heart failure relating to pulmonary congestion or fluid buildup in the lungs. This congestion is more commonly a symptom of systolic and left-sided heart failure.
  • increased blood volume near the input side of the heart changes the pressure at the alveolar arterial interface, an interface between the lung capillaries and the alveolar space of the lungs. The change in pressure at the interface causes blood plasma to push out into the alveolar space in the lungs.
  • Shortness of breath (“dyspnea”) and general fatigue are typical perceived manifestations of congestive heart failure.
  • CHF Congestive heart failure
  • Class I patients have no apparent symptoms and no physical activity limitations.
  • Class II patients experience some symptoms during moderate to severe physical activity.
  • Class III patients suffer symptoms at mild levels of physical activity.
  • Class IV patients experience symptoms with any form of physical activity as well as at rest.
  • diaretics is intended to reduce congestion by depleting the body of fluids.
  • Vasodilators such as ACE inhibitors are used to expand blood vessels and reduce resistance to blood circulation.
  • Beta blockers seek to reduce the work load on the heart by normalizing the rhythm of the heart.
  • Cardiotonic drugs are directed at increasing the force of the heart's contractions.
  • Surgical procedures include physical manipulation in an attempt to increase the internal size of constricted arteries, for example, by balloon angioplasty or stenting.
  • SDB Sleep Disordered Breathing
  • 33% of the patients may be classified as suffering from (a) Cheyne-Stokes respiration, a breathing condition characterized by waxing and waning breathing patterns or (b) central sleep apnea, a condition involving a cessation of airflow due to a cessation of patient respiratory effort.
  • Cheyne-Stokes respiration a breathing condition characterized by waxing and waning breathing patterns
  • central sleep apnea a condition involving a cessation of airflow due to a cessation of patient respiratory effort.
  • CPAP Continuous Positive Airway Pressure
  • U.S. Pat. No. 4,944,310 That patent describes continuous positive airway pressure being applied to a patient, through the patient's nares, to treat breathing disorders, including obstructive sleep apnea. It has been found that the application of pressure which exceeds atmospheric pressure, typically in the range 4 to 15 centimeters of H 2 O, is useful in treatment.
  • the pressure acts as a pneumatic splint to maintain upper airway patency to ensure free flow of air while the patient sleeps.
  • nasal CPAP treatment of Obstructive Sleep Apnea involves the use of an automated blower, such as the AUTOSET TTM device or AUTOSET SPIRITTM available from ResMed Ltd., to provide a constant supply of air or breathable gas at pressures in the range of 4 to 20 cm H 2 O to the airway of a patient via a mask.
  • suitable nasal CPAP masks are the MIRAGETM nasal mask and the MIRAGETM full face mask also available from ResMed Ltd.
  • the AUTOSET TTM device continuously monitors the state of the patient's airway and determines an appropriate pressure to treat the patient, increasing it or decreasing it as necessary.
  • bilevel pressures are delivered to the patient as in the VPAP IITM devices also available from ResMed Ltd.
  • One form of pressure treatment is delivered in accordance with a smooth pressure waveform template and a continuous phase variable to provide comfortable pressure support substantially in phase with the patient's respiratory cycle.
  • the device is the subject of International Publication No. WO 98/12965.
  • the device is also the subject of U.S. patent application Ser. No. 08/935,785, now U.S. Pat. No. 6,532,957, the entire disclosure of which is hereby incorporated by reference.
  • Another form of pressure treatment is directed at treatment of Cheyne-Stokes breathing.
  • a device designated AUTOSET CSTM also provided by ResMed Ltd.
  • pressure support is varied in phase with patient respiration in such a manner to oppose the waxing and waning changes in patient respiration that characterize Cheyne-Stokes breathing.
  • the device is the subject of International Publication No. WO 99/61088.
  • the device is also the subject of a U.S. patent application Ser. No. 09/316,432, now U.S. Pat. No. 6,532,959, the entire disclosure of which is incorporated herein by reference.
  • U.S. Pat. No. 5,794,615 teaches a device to provide a level of pressure support to reduce cardiac pre-load and after load. However, the device is only taught to provide one continuous level of pressure during inspiration and another level during expiration. The patent does not suggest the provision of a waveform of cardiac pressure oscillations in phase with a patient's cardiac rhythm, a feature of the present invention as described below. Moreover, the device provides no assistance directed to alleviating Cheyne-Stokes breathing or distinguishing between obstructions due to vocal cord reflex and obstructions from typical OSA due to collapse of the upper airway during sleep.
  • the invention provides methods and apparatus for detecting reflex vocal cord closure.
  • the vocal cord closure detector derives a measure indicative of the closure.
  • the measure is indicative of a state of sleep and may be derived from respiratory airflow of the patient as a function of a minute ventilation and an elapsed time.
  • the delivery of positive airway pressure treatment is controlled as a function of the measure.
  • any apnea or obstructive event detected before about 30 minutes of sleep is determined to be vocal cord closure and treatment levels are not increased. Apneas detected after these thresholds are met and treated as a non-vocal cord obstructive apnea by an increase in pressure.
  • reflex vocal cord closure may be detected by distinguishing an incident of vocal cord closure from another type of airway obstruction based on a derived measure indicative of vocal cord closure.
  • the step of distinguishing may include detecting an obstructive event and conditioning an increase in treatment pressure in response to the detected obstructive event by an analysis of the derived measure of the closure. This analysis may include a comparison of the derived measure with a time limit of about 30 minutes.
  • the invention further includes methods and apparatus for providing a synchronized cardiac waveform to perform some work of the cardiac organ.
  • the cardiac waveform may be a square wave or sinusoidal wave in phase with detected cardiac rhythm and is preferably superimposed with continuous, bi-level or other oscillatory respiratory treatment pressure that supports the patient's respiration or maintains an open airway.
  • the cardiac waveform is preferably delivered with amplitudes in a range of approximately 1 to 2 cm H 2 O.
  • the invention also includes a means for calculating a heart treatment index to regulate or measure the dose of treatment to the heart from the synchronized oscillations.
  • the measure determines the index as a function of duration and delivered pressure and preferably accounts only for time that the treatment oscillations are actually delivered to the thorax by excluding treatment during closed airway apnea or periods of high leak.
  • the index is the product of an average pressure and the duration of treatment.
  • the invention includes methods and apparatus for assessing heart failure in a patient by calculation or determination of a heart failure indicator or index.
  • a heart failure indicator or index may be determined from respiratory airflow by assessing an extent of Cheyne-Stokes breathing in the patient.
  • Alternative embodiments of the indicator include measures of the duration of waxing and waning cycles or frequency analysis of components of a measure of airflow in a range of frequencies associated with Cheyne-Stokes breathing.
  • an appropriate indicator may be a measure of minute ventilation compared with a threshold of about 15 L/min. or alternatively a ratio of a minimum and maximum of a measure of ventilation, such as a minute ventilation or a tidal volume. Changes in such indicators taken by comparing or analyzing indicators from a current session with assigned thresholds or predetermined threshold values including indicators from prior sessions provide a diagnostic tool for assessing improvement or deterioration of the patient's condition.
  • FIG. 1 shows apparatus according to the invention
  • FIG. 2 is a flow chart of an embodiment of the invention for detecting vocal cord closure
  • FIG. 3 is a flow chart of an embodiment of the invention for delivering treatment based on the detection of vocal cord closure
  • FIG. 4 is a graph of one form of a synchronized cardiac pressure oscillations in accordance with the invention.
  • FIG. 5 is a graph of a respiratory treatment pressure waveform in accordance with the invention.
  • FIG. 6 is a graph of superimposed cardiac pressure oscillations with respiratory treatment pressure
  • FIG. 7 depicts several graphs relating to detection of Cheyne-Stokes breathing in a patient
  • FIG. 8A depicts a graph of minute ventilation determined from a flow signal from a patient experiencing Cheyne Stokes breathing and a graph of a frequency spectrum of the minute ventilation;
  • FIG. 8B depicts a graph of minute ventilation from a patient experiencing normal breathing and a graph of a frequency spectrum from the minute ventilation;
  • FIG. 9 illustrates a treatment protocol for distinguishing between vocal cord closure and upper airway obstruction
  • FIG. 10 illustrates a method of detecting obstruction from a measure of pressure and ventilation
  • FIG. 11 is a flow chart illustrating steps in a methodology for determining a positive pressure dose measure of the invention.
  • FIG. 12 is a flow chart illustrating steps in a methodology for determining a heart failure indicator or index.
  • the heart failure treatment invention involves an apparatus that includes a blower 2 , a flow sensor 4 f, pressure sensor 4 p, a mask 6 , and an air delivery conduit 8 for connection between the blower 2 and the mask 6 .
  • Exhaust gas is vented via exhaust 13 .
  • Mask flow is preferably measured using a pneumotachograph and differential pressure transducer to derive a flow signal F(t).
  • Mask pressure is preferably measured at a pressure tap using a pressure transducer to derive a pressure signal Pmask(t).
  • the pressure sensor 4 f and flow sensor 4 p have only been shown symbolically in FIG. 1 since it is understood that those skilled in the art would understand how to measure flow and pressure.
  • Flow F(t) and pressure Pmask(t) signals are sent to a controller or microprocessor 15 to derive a pressure request signal PRequest(t).
  • the controller or processor is configured to implement the methodology described in more detail herein and may include integrated chips, a memory and/or other instruction or data storage medium. Programmed instructions may be either coded on integrated chips in the memory of the device or may be loaded as software.
  • the apparatus further includes a communication port or module 10 , for example, a wireless communication transceiver and/or a network card, for communication with other devices or computers such as hand-held display and control devices 12 .
  • the apparatus optionally includes an oximeter in the main blower housing.
  • the apparatus may further include additional communications interface 16 for connection to additional diagnosis devices.
  • the diagnosis unit optionally includes a pulse oximeter 20 , respiratory movement sensors 22 , EEG & ECG 24 and/or EOG 25 .
  • the unit may also include a set of electrodes 28 for detecting cardiac rhythm.
  • the apparatus can interface with a variety of hand-held devices such as a Palm Pilot via wireless communication.
  • a physician may, for example, remotely monitor, analyze or record the status or data history of a patient or diagnose the severity of the patient's condition using the device.
  • remote devices may store heart failure indicators, such as in a database of patient heart failure recovery information for one or more patients, from data generated by use of the apparatus.
  • the treatment program that is being run on the patient can be monitored and changed remotely. In the event patient data is transmitted over open networks, the data may be encrypted for purposes of patient confidentiality.
  • the apparatus incorporates various treatment protocols.
  • One protocol is intended for treating obstructive apneas.
  • Another is for treating central apneas.
  • An additional protocol is for treating Cheyne-Stokes breathing. As described in more detail below, the apparatus determines treatment automatically.
  • the device provides a generally constant pressure throughout a breathing cycle, but may vary the pressure in accordance with indications of partial or complete obstruction of the airway.
  • One technique for accomplishing this using a combination of flow limitation and snore measurements is described in U.S. Pat. No. 5,704,345 (Berthon-Jones).
  • Other known alternative methods to vary the pressure for delivering CPAP treatment to a patient to treat obstructive apneas would be recognized by those skilled in the art and may be utilized as operating modes in the device.
  • the apparatus provides a higher pressure to the mask during the inspiratory portion of the breathing cycle, a so-called IPAP (inspiratory positive airway pressure), and a lower pressure to the mask during the expiratory portion of the breathing cycle, a so-called EPAP (expiratory positive airway pressure).
  • IPAP inspiratory positive airway pressure
  • EPAP expiratory positive airway pressure
  • the treatment delivered by the apparatus will smoothly vary in accordance with patient respiration to provide a smooth pressure waveform.
  • the device calculates a continuous phase variable to provide support in phase with the patient's breathing cycle and calculates the pressure to be delivered in accordance with a pressure waveform template.
  • the delivery of such pressure is disclosed in U.S. patent application Ser. No. 08/935,785.
  • pressure may be supplied in proportion to patient respiratory airflow.
  • pressure support is varied in phase with patient respiration in such a manner to oppose the waxing and waning changes in patient respiration that characterize Cheyne-Stokes breathing.
  • the methodology for such treatment is disclosed in U.S. patent application Ser. No. 09/316,432.
  • blower 2 may alternately generate different pressure levels in accordance with the varying pressure delivery methods just described, in an alternative version, a near-constant speed of blower 2 can be maintained and the pressure drops are achieved by venting with the inclusion of a controllable release valve.
  • the same apparatus can be used for many different therapies simply by adjusting the equation that is used to set the speed of the blower or to manipulate the venting with the release valve.
  • leak airflow may be determined by using a method such as taught in U.S. Pat. No. 6,152,129 (Berthon-Jones), the entire disclosure of which is incorporated herein by reference. Other known methods for determining leak may also be used by the device.
  • Positive pressure ventilation can be applied in the treatment of heart failure patients as further described herein.
  • Positive pressure addresses the symptoms of heart failure patients by (a) providing increased airflow to assist in drying fluid from the lungs; (b) reducing fluid transfer to the lungs by increasing the pressure in the alveolar space to offset the pressure differential across the alveolar arterial interface; (c) performing some work of the heart to assist with circulation by reducing the size of the heart to allow the heart to operate more efficiently as a result of increased pressure in the thoracic cavity adjacent to the heart or by providing a contracting assistance or oscillating force in the thoracic cavity, (d) supporting respiration to provide ventilatory assistance that compensates or prevents the waxing and waning cycles associated with Cheyne-Stokes breathing while also providing support to prevent or treat obstructive events; and (e) performs some portion of the work of breathing. Further objectives will be apparent to those skilled in the art based upon the disclosure herein.
  • a device of the invention is configured to automate a change of the treatment protocol based upon the likelihood of the occurrence of the various respiratory and airway abnormalities particularly associated with heart failure patients.
  • CHF patients may experience Cheyne-Stokes breathing while a patient is awake. Patients may also experience Cheyne-Stokes breathing or central apneas in earlier stages of sleep particularly stage 1 and stage 2 sleep but not typically during REM sleep. Patients also experience obstructive apneas due to upper airway collapse. Such collapse is typically a result of the relaxed state of the patient induced by sleep. Therefore, these obstructive apneas may occur during the latter stages of sleep and are more likely to occur during REM sleep.
  • Obstructive events may be determined by analysis of patient flow to determine shape factors, flow flattening indices, roundness indices, etc.
  • a detected apnea e.g., a calculated variance falling below a threshold value
  • it can be determined whether the apnea constitutes airway obstruction or an absence of respiratory effort i.e., central apnea.
  • the apparatus when an apnea is detected as occurring, applies an oscillatory pressure waveform of known frequency and magnitude and assesses the patency of the airway from the flow that is induced in the airway. In one form, if the airway is patent during an apnea, then the apnea is judged to be central. However, if the airway is closed during an apnea, then the apnea is judged to be obstructive. In another technique, when an apnea is detected as occurring, the apparatus monitors the airflow for the presence of a signal of cardiac origin. If a cardiac signal is detected, then the airway is judged to be patent and the apnea classified as central. If no cardiac signal is detected, then the airway is judged to be closed and the apnea classified as obstructive.
  • An alternative method for determining the existence of obstructive events involves an analysis of the relationship between a measure of ventilation and changes in pressure support. For example, if a measure of minute ventilation does not increase or remains the same when support pressure is increased, this would indicate that the patient is experiencing an obstructive event. Thus, the failure of the measure of ventilation to increase in relation to increases in pressure support would tend to indicate that the patient's airway is obstructed.
  • the measure of minute ventilation is monitored to detect a decrease in the minute ventilation. When pressure ventilation is increased to compensate for the decrease in the measure of minute ventilation, if the measure of minute ventilation does not increase in this general time frame, the device interprets the condition as detecting an incident of obstruction. This method is illustrated in the graphs of FIG. 10 .
  • the graphs plot a continuously determined minute ventilation (e.g., the volume of air inspired by the patient during the previous 60 seconds) and pressure delivered at the mask with respect to a common time scale.
  • An obstructive event is determined when, after a decrease in minute ventilation shown at 100 , there is no increase in minute ventilation corresponding to an increase in pressure 102 . While the graph illustrates the method during delivery of a relatively constant CPAP pressure, those skilled in the art will recognize that the method may be accomplished in the presence of bi-level treatment or other pressure support which synchronizes smooth and comfortable pressure changes with the patients respiratory cycle by monitoring changes in end expiratory pressure.
  • Vocal cord closure may generally be considered an obstructive event that may be detected in the manner that upper airway occlusions at the level of the tongue or soft palate are detected.
  • Existing methods of obstruction detection as previously mentioned will detect both upper airway collapse and vocal cord closure but they cannot distinguish between these events.
  • the vocal cord event preferably is not treated like that of typical obstructive apneas, i.e., by increasing pressure, such as the end expiratory pressure, until the obstruction is opened. While vocal cord events may be treated by the same levels of pressure as other obstructive events, the treatment levels would not likely open the closure. Rather, such treatment is only likely to disturb the patient's sleep and prevent development of more stable deeper sleep. For these reasons, no increase in the treatment of reflex vocal cord closure is preferred.
  • a device of the invention preferably estimates or approximates whether the patient is awake or asleep, e.g., in some stage of sleep, and thus distinguishes between vocal cord closure and more typical obstructive events associated with sleep apnea.
  • a delivering step 30 a controlled supply of breathable gas at a pressure above atmospheric is supplied to the patient.
  • a deriving step 32 a flow derived measure indicative of a vocal cord closure in a patient is determined.
  • a detecting step 34 an incident of vocal cord closure is detected as a function of the indicator.
  • the device selects between different treatment regimes. For example, initially, Cheyne-Stokes breathing and central apneas are treated while the patient is awake or in the early stages of sleep by delivering variations in pressure in phase with patient respiration to meet a target ventilation. During this treatment period obstructive events are ignored. Alternatively, obstructive events may be detected by observing an absence of or substantial decrease in airflow but those obstructions that are likely to be vocal cord closure are preferably not treated according to the indicator. After satisfying a threshold comparison with the indicator, subsequent obstructive events that are detected will be treated by an increase in pressure, such as, by increasing end expiratory pressure. Such a methodology is illustrated in the flow chart of FIG. 3 .
  • a detection step 36 airway obstruction is detected.
  • an indicator of vocal cord closure is determined.
  • treatment is determined as a function of the indicator. If vocal cord closure is detected then pressure is maintained at the current level or decreased. If vocal cord closure is not detected then pressure is increased as in the case of a typical obstruction. Appropriate pressure responses to typical obstructive events is described in more detail in U.S. Pat. No. 5,704,345.
  • One such indicator relates to a measure of ventilation, for example, a minute ventilation, i.e., the volume of measured airflow over the course of a minute.
  • a ventilation measure falls below a certain threshold
  • the indicator may suggest that the patient is in a later stage of sleep. To this extent, it will serve as an indicator to distinguish between obstructive events of vocal cord closure as opposed to tongue and soft palate closure.
  • the minute ventilation preferably averaged over a period of time, e.g., five minutes, is in a range of about 5 to 10 liters per minute, the patient is likely in a later stage of sleep.
  • the accuracy of the indicator may be improved by making the threshold determination an additional function of time.
  • the measure of ventilation is below a certain level and a period of time has elapsed, such as about 30 minutes, the patient is more likely to be in a later stage of sleep.
  • a period of time has elapsed, such as about 30 minutes
  • the mask has been on the patient for more than about 30 minutes and the minute ventilation averaged over a period of about five minutes is less than about 12 liters per minute, a later stage of sleep is indicated. This would also indicate that any detected obstructive events are of the more typical upper airway collapse of traditional obstructive sleep apnea rather than reflex vocal cord closure.
  • Swing is the difference between inspiration and expiration pressure levels as delivered by the apparatus in keeping with the effort of the patient's respiratory cycle.
  • pressure swing is in the range of about 3 to 10 cm H 2 O.
  • Higher pressure swings in the range near about 10 cm H 2 O may be indicative of Cheyne-Stokes breathing.
  • a threshold for example, about 8 cm H 2 O or less
  • a measure of time may serve to detect vocal cord closure by distinguishing between obstructive apneas and vocal cord closure based on this measure.
  • any detected obstructive events prior to the expiration of a period of time are considered to be vocal cord closure and not treated.
  • some start event such as the initiation of a treatment session (e.g., when the machine is turned on or when the mask pressure first raises above ambient pressure) or by some other resetting or starting of a timer
  • these detected events would be considered vocal cord closure.
  • Those events that are detected after expiration of the time period would then be considered treatable upper airway obstruction.
  • an alternative methodology may simply abstain from detecting obstructive events prior to the expiration of the time period. In this methodology, all events after the expiration of the time period are determined to be treatable upper airway obstructive events.
  • FIG. 9 A preferred treatment protocol for responding to obstructive events in a manner that distinguishes between upper airway obstructive events and vocal cord closure is illustrated in FIG. 9 .
  • obstructive events detected by any method are determined to be vocal cord closure. No increase in pressure from an initial pressure setting is permitted.
  • detected obstructive events are treated by a step up in end expiratory pressure (EEP), for example, about 1-2 cm H 2 O, which may be fixed or user selectable.
  • EEP end expiratory pressure
  • additional increases in pressure for detected obstructive events may be limited by the expiration of additional time periods.
  • a subsequent step in the EEP upon detection of another obstructive event would not be permitted until after about 10 minutes.
  • increases in the EEP would not be permitted beyond a maximum pressure level.
  • the initial EEP pressure is 5 cm H 2 O and increases in pressure step about 2 cm H 2 O and these steps are permitted after about 30 minutes have elapsed from the time that the patient has begun using the mask. Additional steps are permitted at about ten minute intervals thereafter. The limitation imposed by the additional intervals can be phased out after a sufficient time has elapsed which will substantially suggest that the patient is fully asleep, e.g., after about 1 to 2 hours of sleep, preferably after 100 minutes.
  • vocal cord closure may also be determined by an insertable camera proximate to the patient's vocal cords, due to issues of comfort and equipment cost it is preferred to determine an indicator of closure as described above from a measure of respiratory airflow as a function of time.
  • additional indicators may be based upon sleep data from EEG signals (electroencephalography) and/or EOG signals (electro-oculographic) or any other equipment used to determine sleep. Those skilled in the art would understand the nature of data from these devices for the purpose of distinguishing between the various stages of sleep that a subject will experience.
  • the preferred device calculates an index that represents the dose of treatment for the heart.
  • a physician may prescribe a certain quantity of treatment. Compliance then can be monitored by the pressure treatment apparatus so that the physician and patient can be certain that a treatment regimen is being satisfied.
  • Steps in such a methodology are illustrated in the flow chart of FIG. 11 .
  • a delivery step 1102 a supply of breathable gas is delivered at a pressure above atmospheric to the airway of the patient.
  • the pressure is controlled to perform work of the heart of the patient.
  • a heart treatment index representative of a dose of heart treatment experienced by the patient's heart is determined.
  • the index may be viewed as having a pressure component and a time component.
  • the preferred pressure component of the index is an average value of the pressure.
  • the average pressure taken over the time period of treatment multiplied by the length of the time period can serve as a measure of dose. For example, if the average pressure delivered to the patient during a 5 hour treatment period is 7 cm H 2 O, the dose is 35 cm H 2 O—hours.
  • higher treatment pressures are weighted more than lower treatment pressures for purposes of determining compliance.
  • a patient receiving an average 9 cm H 2 O of support 7 pressure would satisfy the 35 cm H 2 O —hours dose in approximately 3.9 hours.
  • the index may be derived as the root mean square value of the pressure delivered during the treatment period. Such an index will more accurately provide an indicator of the pressure delivered given the pressure swings when compared with, for example, a median pressure.
  • the total time duration that the device delivers pressure support is not necessarily sufficient to accurately measure the treatment actually experienced by a subject's heart. Rather, it is preferred to consider the time period during which pressure is actually delivered to the thorax by excluding periods of closed airway obstruction.
  • the preferred heart failure treatment dose index is a measure of delivered pressure during a time period that excludes duration of obstructive apneas and reflex vocal cord closures.
  • the dose index is a product of the average of the delivered pressure and an estimate of the number of hours that pressure is delivered to the thorax.
  • the total number of hours of machine use is reduced to exclude the total time associated with airway obstructive events as these events are detected during treatment.
  • the device quantifies periods of detected obstruction from the start of each obstruction through a point when the obstruction is alleviated. For example, an obstruction timer may commence when an obstructive apnea is detected if a calculated airflow variance falls below a threshold value. The obstruction timer will continue to track time until the calculated variance rises again above the threshold value.
  • the time of the event may be excluded if it is determined to be a central apnea since the thorax will still be treated during a central apnea.
  • Those skilled in the art will recognize other methods for quantifying the time period of the obstructive events that prevent pressure treatment of the thorax.
  • the determination of the average pressure may be suspended so that the pressure readings during this period do not affect the average pressure calculation.
  • time periods of high or significant mask leak may similarly be excluded from the computation of thorax treatment time and average pressure. Such periods may be considered ineffective treatment.
  • the volume of measured airflow taken over a single breath cycle may be compared to a threshold value to determine if significant or high leak exists.
  • the time period from such a comparison indicating high leak until the time that the comparison no longer indicated high leak could be excluded from the total treatment time and average pressure calculation.
  • a pressure treatment device may optionally be implemented to accept as input a prescribed dose as a set-point index or prescribed threshold before use of the device. Then during treatment, the actual delivered dose is calculated and compared to the prescribed threshold to assess whether the actual delivered does satisfies the prescribed threshold. When the threshold is reached, the device may automatically cease delivery of pressure treatment. Preferably, the extent of the compliance with the prescribed dose may be recorded in the device for use by or transmission to the patient's physician. In one embodiment, the device may indicate that the dose has been achieved by generating a message, warning or alarm to the user or physician to advise the user that the dose has been reached and no further treatment is required.
  • positive pressure can be applied to a subject's respiratory system to provide an oscillating force in the thorax proximate to the wall of the heart to assist with the work of the heart.
  • positive pressure may be supplied to the subject's lungs to cause compression on the heart by increasing pressure during the systolic phase when the cardiac muscles contract. By reducing delivered pressure during the diastolic phase, treatment will more readily allow the cardiac muscles to relax.
  • a cardiac pressure waveform with peak amplitude in the chosen range is superimposed on a level of positive pressure delivered in accordance with CPAP, bi-level pressure support or other pressure support variant such as the pressure delivered in accordance with a smooth pressure waveform template as disclosed in U.S. patent application Ser. No. 08/935,785.
  • the cardiac treatment pressure waveform cycles to increase and decrease in phase with the cycle of the heart.
  • FIG. 4 One such synchronized cardiac waveform is illustrated in FIG. 4 .
  • the peak pressure amplitudes associated with the systolic phase are in a range of about 1 to 4 cm H 2 O.
  • FIG. 4 depicts a clipped sinusoidal waveform, other waveform shapes may be used.
  • an oscillatory square wave may also serve to provide support for the contractions of the heart.
  • the device determines the phase of the heart and triggers the cardiac pressure oscillations.
  • cardiac rhythm is detected from an output signal from either an electrocardiogram (ECG) or a set of electrodes.
  • ECG electrocardiogram
  • Such electrodes each include a signal wire from the device which is attached to a metallic or otherwise conductive skin contact that can detect an electric charge.
  • Electrical current generated by the heart in a person's chest flows to the surface and at the skin produces differences in electrical voltage which can be measured between pairs of electrodes placed at two points on the skin. Data from such electrodes is analyzed to time the delivery of each increase in pressure to generate the cardiac pressure waveform.
  • cardiac rhythm may be determined from an airflow signal as described in U.S. Pat. No. 5,704,345 or otherwise estimated from the patient's pulse by an automated pulse rate detector on the wrist or finger of the patient.
  • FIGS. 4, 5 and 6 An example of the superposition of a cardiac pressure waveform and a respiratory pressure level or waveform is illustrated with reference to FIGS. 4, 5 and 6 .
  • the waveform shown in FIG. 5 depicts a hypothetical bi-level respiratory treatment pressure waveform with an IPAP generated for the inspiratory portions of a subject's respiratory cycle and an EPAP generated for the expiratory portions of the subject's respiratory cycle.
  • the waveform depicted in the graph of FIG. 6 illustrates the superposition of the synchronized cardiac treatment pressure waveform of FIG. 4 with the respiratory treatment pressure waveform of FIG. 5 .
  • Another difficulty involving the treatment of heart failure patients relates to disease management.
  • the preferred device determines or calculates one or more heart failure indicators or indices to indicate a change in heart failure condition or to rate a degree of severity of the heart failure condition.
  • the changing value of such an indicator or index may provide a diagnostic tool for the physician to assess the state of the patient's health.
  • the indicator may provide information to inform the physician that the dosage of pharmacological agents given to the patient ought to be changed. If the index indicates that heart failure was stabilizing then it may be appropriate to reduce or maintain the dosage in use.
  • the device may begin to provide a specific dose of superimposed cardiac oscillations to perform some work of the patient's heart as previously described.
  • the index may be used to monitor the efficacy or effectiveness of a drug protocol.
  • the index may be monitored for a group of patients. This may include the storing of multiple indices in a database of patient information. By an analysis of such data, it may be determined that a drug is safe and/or appropriate as a treatment for heart failure in general.
  • an index determined in accordance with the invention may be used by a physician in conjunction with other known methods of analyzing the health of the patient.
  • an index or indicator in accordance with the invention may be used in conjunction with changes in weight, medication dosage or lung fluid levels to detect changes in a subject's condition.
  • Such an index may also be part of a battery of indicators for diagnosing whether or not a patient is suffering from heart failure in the first instance.
  • levels of B Natriuretic Peptide (BNP) a protein present in the blood that is secreted by heart muscle that is failing, which may be determined by a blood test and recorded by the apparatus and associated with the periods of use of the device as well as the indicators determined by the device.
  • the apparatus prompts for input from a user so that the user can enter weight changes, medication dosage, number of apneas or hypopneas, or other heart failure monitoring characteristics, such as levels of BNP.
  • the device also serves as a database for recording heart failure monitoring characteristics.
  • the device then may periodically transmit such data relating to the patient's condition to a centralized system for physician analysis.
  • transmissions of such data may be performed on physician prescribed times or intervals or based on certain event criteria being met, such as a transmission trigger based upon recorded data meeting certain thresholds (e.g., the total number of apneas or hypopneas exceeding a certain threshold level or a change in a heart failure indicator compared with prior indices.)
  • the heart failure indices are determined from an analysis of the patient's breathing characteristics or by the machines' responses to the patient's breathing patterns.
  • the indices may be determined in conjunction with a protocol for delivering treatment pressure or without such treatment pressure, for example, by simply monitoring patient respiratory airflow.
  • Such indices serve as heart failure indicators to show patient improvement or relapse as detailed below.
  • Such indicators may be recorded over various sessions with the device. In subsequent sessions, a current indicator or an average of such indicators may be compared with an indicator or average of such indicators from one or more prior sessions to analyze changes in the indicators.
  • Steps in such a methodology for evaluating heart failure in a patient are illustrated in the flow chart of FIG. 12 .
  • breathable gas is delivered to the patient at a pressure above atmospheric.
  • the respiratory airflow of the patient is measured.
  • a heart failure indicator representing information about the patient's heart condition is derived from the respiratory airflow.
  • One such index is based upon a measure of the extent of the subject's Cheyne-Stokes breathing or a so-called “Cheyne-Stokiness” of the patient.
  • heart failure patients typically experience periods of the waxing and waning defined as Cheyne-Stokes breathing.
  • the cycle of the waxing and waning typically will vary in the range of about 30 to 90 seconds, or even as high as 120 seconds. By examining variations or changes in the cycle, such as periodicity, it can serve as an indicator of the degree of severity or change in heart failure condition.
  • the envelope period or duration of each waxing and waning cycle may be measured and compared to the time for one or more previous cycles or an average of prior cycles.
  • a decrease may suggest that the patient's heart failure condition is improving.
  • an increase may suggest that the patient's heart failure condition is destabilizing.
  • a current cycle time would be compared to a threshold, e.g., based on previously determined cycle times.
  • the difference between current and prior measurements or a ratio of current and prior measurement may also serve as such an indicator.
  • One method for determining the duration of Cheyne-Stokes breathing is to determine the start time of a hyperapnea or hyperventilation and the end time of a subsequent apnea or hypopnea as shown in respiratory graph 70 of FIG. 7 .
  • the start of the cycle may be indicated by an increase in a short-term measure of ventilation, for example, an instantaneous ventilation or a volume of airflow measured over a period of several seconds or less.
  • it may be determined from an increase in peak values of airflow.
  • the duration would then include the time period of the increase, the time period of a subsequent decrease in the short-term ventilation measure or decrease in peak airflow, and may include the duration of a possible period of cessation of airflow.
  • Other methods for detecting each of these events i.e., hyperapnea or hyperventilation, hypopnea and central apnea, are known in the art.
  • duration may be determined by identifying a particular point in one cycle and the similar point in the subsequent cycle.
  • One such method involves a measure of instantaneous ventilation and a measure of recent average ventilation as disclosed in U.S. patent application Ser. No. 09/316,432.
  • an estimate of cycle time for Cheyne-Stokes breathing may be determined. For example, by monitoring the intersections of an instantaneous ventilation and an average ventilation and determining the time between two similar intersections or otherwise measuring the time between two such intersections, the duration of a Cheyne-Stokes cycle may be estimated.
  • FIG. 7 This method is illustrated in FIG. 7 .
  • the figure shows three graphs.
  • the first graph of respiratory airflow depicts a number of cycles of Cheyne-Stokes breathing.
  • the second graph shows a plot of one instantaneous ventilation (Instantaneous Ventilation 1 ) as measured in accordance with U.S. patent application Ser. No. 09/316,432.
  • the third graph is a plot of another measure of instantaneous ventilation (Instantaneous Ventilation 2 ).
  • the duration of the Cheyne-Stokes cycle on the respiratory graph 70 may be determined by measuring the duration on the ventilation graph 72 .
  • a timer may be reset to zero at the moment instantaneous ventilation changes from less than to greater than the recent average ventilation and the time elapsed is assessed when that condition is again true.
  • the time of these points may be recorded and cycle time maybe derived by calculation to determine the difference between the recorded times.
  • the heart failure indicator may be an indication of Cheyne-stokes breathing determined from an average of a flow signal adjusted to remove leak. For example, if a measure of ventilation which, for preference, is an average minute ventilation or inspired volume over a one minute period, exceeds about 15 L/min, it is likely that the patient is experiencing an episode of Cheyne-Stokes breathing. The total number of these events can be logged. The changing value of such a heart failure indicators or indices may provide a diagnostic tool for the physician to assess the state of the patient condition. Thus, the information may be recorded over several sessions and increases or decreases in this number or durations from prior sessions, or averages from prior sessions, may then be determined, recorded and transmitted to the physician for review and analysis.
  • the minimum measure of ventilation may be near 0, it is preferred that the minimum be divided by the maximum to avoid a divide by zero operation.
  • the indicator may be based on the ratio of minimum and maximum tidal volumes (i.e., a measure of ventilation of the patient taken during the inspiratory portion of a respiratory cycle.) For patients experiencing Cheyne-Stokes breathing, the tidal ventilation may vary from 0 up to 1.5 or as much as 2.5 liters.
  • Another method for determining an appropriate heart failure indicator which is intended to assess the extent of Cheyne-Stokes breathing, is to measure a volume of airflow, e.g., a minute ventilation or a filtered measure of airflow with a time constant of about 10 seconds, and record the resulting waveform or sampled data representing the waveform over time.
  • a period of measurement such as one treatment episode or various intervals during one such episode, the data or waveform is analyzed to isolate the frequencies typically associated with Cheyne-Stokes waxing and waning periods.
  • This frequency analysis involves a Fourier Transform such as a DFT or FFT to examine a frequency range of about 5 ⁇ 10-2 Hz to 1.1 ⁇ 10-2 Hz since the period for a typical Cheyne-Stokes cycle is in the range of about 20 to 90 seconds in duration.
  • a Fourier Transform such as a DFT or FFT to examine a frequency range of about 5 ⁇ 10-2 Hz to 1.1 ⁇ 10-2 Hz since the period for a typical Cheyne-Stokes cycle is in the range of about 20 to 90 seconds in duration.
  • a quantitative measure of the extent of Cheyne-Stokes breathing may be extracted. Since normal patient respiratory cycles would be reflected at much higher frequencies, the chosen range would be indicative of Cheyne-Stokes cycles.
  • An example of a frequency spectrum 80 is shown in FIG.
  • FIG. 8A depicting a frequency analysis of components of a measure of airflow in the range of frequencies generally associated with Cheyne-Stokes breathing.
  • the bottom graph of FIG. 8A illustrates the existence of Cheyne-Stokes breathing in the minute ventilation signal of the top graph of FIG. 8A .
  • the bottom graph of FIG. 8B illustrates the lack of Cheyne-Stokes breathing in the minute ventilation signal of the top graph of FIG. 8B .
  • an embodiment of the invention quantifies components in the range of Cheyne-Stokes frequencies as one or more indices and/or generates a visual frequency spectrum of the Cheyne-Stokes frequencies to show a graphical pattern of the patient's Cheyne-Stokes breathing.
  • Such indicators may be based upon analyses or quantifications of the spectrum that include a determination of a total power, for example, a sum of amplitudes or magnitudes of components at all frequencies in the entire band of frequencies or a portion thereof, a determination of magnitudes or a measure of a peak value at one or more separate frequencies, a determination of a measure of central tendency or standard deviation, or similar.
  • the indicators may then serve as indicators of a change in heart failure condition. For example, if the magnitudes or patterns indicate that the patient's Chenye-Stokes breathing is increasing in duration, becoming more frequent or otherwise increasing in intensity, it may indicate that the patient's heart failure condition is destabilizing and a different treatment approach (medicinal or otherwise) to the patient's condition may be warranted. Alternatively, a decrease in the duration, frequency or intensity of such breathing may indicate that the current treatment approach is appropriate.
  • these quantifications e.g., duration, a magnitude, sum of magnitudes, or standard deviation
  • the threshold may be a pre-determined acceptable level or a quantification derived from a previous analysis in a current session or from a previous treatment session with the device.
  • a warning such as an audible alarm or other visual signal is generated or this information may be transmitted to a system for access by a physician. For example, if the current heart failure indicator including a duration is greater than a prior indicator or a desired threshold of change in the indicator, a warning is generated. The alarm or warning is intended to alert a care provider or user to the potential destabilization of the patient if a change in the indicator suggests such destabilization.
  • indicators may be recorded over time to provide long-term statistical analysis of the patient's condition subsequent to treatment with the device. For example, such indicators may be recorded over various sessions with the device in a database or other information storage medium.
  • the device may respond to the onset of one or more periods of Cheyne-Stokes breathing by reducing pressure support to permit data from a Cheyne-Stokes breathing event to be recorded in the absence any significant treatment pressure that might impact or change the nature of the pattern of breathing. For example, if a Cheyne-Stokes breathing event is detected, the amplitude of pressure support may be reduced by about 50% for a particular period of time, for example, about 10 minutes, so that data during the event may be recorded. A limit on the number of these untreated data collection sessions may also be implemented so that the patient's Cheyne-Stokes breathing does not go completely untreated during any treatment session with the apparatus.
  • the device may record data for three Cheyne-Stokes events during any single treatment session.
  • This reduced treatment data collection process may be performed consecutively for each consecutively detected Cheyne-Stokes event up to the optional limit.
  • a certain number of detected Cheyne-Stokes events one or more, may be fully treated by an appropriate support pressure response before a subsequently detected event will be evaluated in a reduced treatment data collection process.
  • a full treatment process and reduced treatment data collection process may alternate over a number of detected Cheyne-Stokes events.
  • the indicator may be utilized as an input to an automated pressure adjustment algorithm that can serve to provide additional treatment for the heart.
  • the indicator may be utilized to increase end expiratory pressure.
  • the pressure may be increased by a small quantity, for example about 1 cm H 2 O.
  • any additional changes to the treatment pressure based on the indicator would not take place until expiration of a predetermined time period, such as about 10 minutes.
  • the pressure may be increased by a small degree, e.g., about 1 cm H 2 O.
  • the pressure may be increased as follows: If MIN(tidal volume)/MAX(tidal volume) ⁇ a threshold in a range of about 0.04 to 0.25, preferably about 0.1 to 0.2, for example, about 0.15, after a period of about 10 minutes then increase the pressure by about 1 cm H 2 O.
  • the aforementioned indicators or the measures on which they are based may be filtered with a time constant of about 5 or 10 minutes. Such an operation permits the filtering out of the consequences of short term changes in these continuously determined measures.

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WO2005037355A1 (fr) 2005-04-28
US10856802B2 (en) 2020-12-08
US20060084877A1 (en) 2006-04-20
EP2450074A2 (fr) 2012-05-09
EP1680166A1 (fr) 2006-07-19
US20130118494A1 (en) 2013-05-16
EP1680166B1 (fr) 2019-09-18
US9283341B2 (en) 2016-03-15
US20160151014A1 (en) 2016-06-02
EP1680166A4 (fr) 2010-08-25
US20100258126A1 (en) 2010-10-14
EP2450074A3 (fr) 2014-01-22
US8356594B2 (en) 2013-01-22
EP2450074B1 (fr) 2015-12-09
US20100043795A1 (en) 2010-02-25

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