WO2017001955A1 - Photopléthysmographie de lumière verte en géométrie de transmission - Google Patents

Photopléthysmographie de lumière verte en géométrie de transmission Download PDF

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Publication number
WO2017001955A1
WO2017001955A1 PCT/IB2016/053254 IB2016053254W WO2017001955A1 WO 2017001955 A1 WO2017001955 A1 WO 2017001955A1 IB 2016053254 W IB2016053254 W IB 2016053254W WO 2017001955 A1 WO2017001955 A1 WO 2017001955A1
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WO
WIPO (PCT)
Prior art keywords
ppg
light
optical support
secured
component
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Application number
PCT/IB2016/053254
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English (en)
Inventor
Wouter Herman PEETERS
Egbertus Reinier JACOBS
Rick BEZEMER
Toeno VAN DER SAR
Jens Muehlsteff
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Koninklijke Philips N.V.
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Publication of WO2017001955A1 publication Critical patent/WO2017001955A1/fr

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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/145—Measuring characteristics of blood in vivo, e.g. gas concentration, pH value; Measuring characteristics of body fluids or tissues, e.g. interstitial fluid, cerebral tissue
    • A61B5/1455—Measuring characteristics of blood in vivo, e.g. gas concentration, pH value; Measuring characteristics of body fluids or tissues, e.g. interstitial fluid, cerebral tissue using optical sensors, e.g. spectral photometrical oximeters
    • A61B5/14551—Measuring characteristics of blood in vivo, e.g. gas concentration, pH value; Measuring characteristics of body fluids or tissues, e.g. interstitial fluid, cerebral tissue using optical sensors, e.g. spectral photometrical oximeters for measuring blood gases
    • A61B5/14552—Details of sensors specially adapted therefor
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/02—Detecting, measuring or recording pulse, heart rate, blood pressure or blood flow; Combined pulse/heart-rate/blood pressure determination; Evaluating a cardiovascular condition not otherwise provided for, e.g. using combinations of techniques provided for in this group with electrocardiography or electroauscultation; Heart catheters for measuring blood pressure
    • A61B5/024—Detecting, measuring or recording pulse rate or heart rate
    • A61B5/02416—Detecting, measuring or recording pulse rate or heart rate using photoplethysmograph signals, e.g. generated by infrared radiation
    • A61B5/02427—Details of sensor
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/68—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient
    • A61B5/6801—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient specially adapted to be attached to or worn on the body surface
    • A61B5/6813—Specially adapted to be attached to a specific body part
    • A61B5/6814—Head
    • A61B5/6819—Nose

Definitions

  • PPG photoplethysmography
  • pulse oximetry devices methods using same, and the like.
  • PPG and pulse oximetry finds application in PPG and pulse oximetry for medical monitoring generally, and finds particular application in PPG and pulse oximetry for patients with centralized perfusion.
  • Photoplethysmography is commonly used to monitor peripheral arterial blood in tissue.
  • the cardiac pulse rate can be derived from the pulsatile component of the PPG light signal which is caused by the pulsating arterial blood volume.
  • measurement of the oxygenation can be made based on the ratio of pulse amplitudes of red and infrared signals (e.g. 660 nm and 940 nm, respectively), due to difference in color (or absorption) between oxygen-bound and oxygen-unbound hemoglobin at red versus infrared wavelengths. This is known as the "ratio of ratios" technique.
  • Such a PPG sensor programmed to output both cardiac pulse and peripheral oxygen saturation values is referred to as a "pulse oximeter”.
  • a pulse oximeter is a clip-on unit secured to a fingertip or earlobe.
  • Light is emitted from a light source mounted at one side of the clip, transmits through the fingertip or earlobe and is detected by a sensor at the opposite side of the clip, so as to provide a light transmission measurement.
  • a problem with this design is that the PPG signal amplitude can be low for a subject with centralized perfusion, for example due to hypovolemia, hypothermia, Reynolds disease, cardiogenic shock, hypovolemic shock, septic shock, low cardiac output, high dose of vasopressor medication, cardiac arrest, tamponade, right atrial failure, trauma, heart failure, obesity, peripheral artery disease, or diabetes.
  • a reliable measurement of the pulsatile waveform by PPG is difficult with such patients.
  • the centralized perfusion has the consequence that limited arterial blood reaches the fingertip or earlobe, leading to low PPG signal amplitude. Disclosed herein are improvements that remediate the foregoing disadvantages and others.
  • a photoplethysmography (PPG) device comprises: a nasal mount including a first optical support and a second optical support and configured to be secured to a human nose with the nasal septum or an alar wing of the human nose interposed between the first optical support and the second optical support; a green PPG component including a light source secured to the first optical support and a light detector secured to the second optical support, the green PPG component configured to measure transmission of green light from the light source of the green PPG component to the light detector of the green PPG component; a red or near-infrared PPG component including a light source secured to one of the first optical support and the second optical support and a light detector secured to the other of the first optical support and the second optical support, the red or near-infrared PPG component configured to measure transmission of red or near-infrared light from the light source of the red or near-infrared PPG component to the light detector of the red or near-infrared PPG component; and an electronic data
  • a photoplethysmography (PPG) device comprises: a nasal mount including a first optical support and a second optical support and configured to be secured to a human nose with the nasal septum or an alar wing of the human nose interposed between the first optical support and the second optical support; a first PPG component including a light source secured to the first optical support and a light detector secured to the second optical support, the first PPG component configured to measure transmission of light in a first wavelength range from the light source of the first PPG component to the light detector of the first PPG component; and a second PPG component including a light source secured to one of the first optical support and the second optical support and a light detector secured to the other of the first optical support and the second optical support, the second PPG component configured to measure transmission of light in a second wavelength range from the light source of the second PPG component to the light detector of the second PPG component.
  • a nasal mount including a first optical support and a second optical support and configured to be secured to a human nose with the nasal septum or
  • the first wavelength range has an upper value of 590 nm or lower.
  • the second wavelength range has an upper value of 780 nm or lower and a lower value of 620 nm or higher.
  • the first wavelength range has an upper value of 580 nm or lower and a lower value of 530 nm or higher.
  • the second wavelength range has an upper value of 740 nm or lower and a lower value of 640 nm or higher.
  • a photoplethysmography (PPG) device comprises: a nasal mount including a first optical support and a second optical support and configured to be secured to a human nose with the nasal septum or an alar wing of the human nose interposed between the first optical support and the second optical support; and a green PPG component including a light source secured to the first optical support and a light detector secured to the second optical support.
  • the green PPG component is configured to measure transmission of green light from the light source of the green PPG component to the light detector of the green PPG component.
  • PPG photoplethysmography
  • pulse oximetry that is effective for patients, especially those with centralized perfusion.
  • Another advantage resides in providing PPG or pulse oximetry with improved signal intensity.
  • FIGURE 1 diagrammatically shows a pulse oximeter device mounted to measure transmission photoplethysmography (PPG) signals through the nasal septum in the red and green wavelength ranges.
  • PPG transmission photoplethysmography
  • FIGURE 2 shows a diagrammatic block diagram of the pulse oximeter device of FIGURE 1.
  • FIGURES 3 and 4 show isolation perspective views of the pulse oximeter device of FIGURES 1 and 2 configured as a clip-on nasal mount: FIGURE 3 illustrates the pulse oximeter device in its open (undipped) configuration and FIGURE 4 illustrates the pulse oximeter device in its closed (clipped-on) configuration.
  • FIGURE 5 shows a plot of absorption coefficient (in units of meter “1 ) as a function of wavelength (in units of nm) for hemoglobin (Hb) and oxygenated hemoglobin (HbCh), each at a concentration of 0.1125 mmol/liter.
  • FIGURE 6 shows a diagrammatic block diagram of a variant embodiment of a pulse oximeter device in which wavelength-selective filters are substituted for wavelength-specific light sources.
  • Photoplethysmography (PPG) and pulse oximeter devices disclosed herein measure photoplethysmography (PPG) by transmission through the nasal septum.
  • the nasal septum is oxygenated via a major arterial pathway from the heart, and hence is well-perfused even in the case of a patient with centralized perfusion.
  • perfusion of the nasal septum is partly supplied by the ethmoidal arteries, which are branches from the internal carotid artery which is fed directly from the main aortic artery from the heart.
  • the disclosed PPG and pulse oximeter devices further exclusively employ relatively short- wavelength light, e.g. 780 nm or shorter in wavelength in some embodiments, and operate in transmission mode.
  • Short wavelength light is generally not used for transmission measurements in human tissue due to the high optical absorption of human skin and like tissue at these short wavelengths.
  • light at wavelengths of 780 nm or shorter has sufficient transmission through the nasal septum to provide PPG measurements with high intensity and good signal-to-noise ratio (S R). Similar benefits can also be achieved by performing PPG measurements in transmission mode across the alar wing of a nostril.
  • a single-wavelength (or single light source) PPG device suitable for measuring heart rate
  • green light is used, in the range 590 nm or lower, and more preferably 530-580 nm.
  • All ranges recited herein are inclusive, e.g. the range 530-580 nm includes the endpoints 530 nm and 580 nm).
  • PPG signals at two different wavelengths are used in deriving the arterial blood oxygen saturation value. In pulse oximeter devices disclosed herein, both wavelengths are at wavelengths of 780 nm or shorter.
  • the two wavelengths are green light (590 nm or lower, and more preferably 530-580 nm) and red (or very near-infrared) light (620-780 nm, and more preferably 640-740 nm).
  • FIGURE 1 an illustrative photoplethysmography (PPG) device is diagrammatically shown mounted on a nose 1 (FIGURE 1), in block diagram format (FIGURE 2), and in isolation perspective views shown open for mounting (FIGURE 3) and closed (the state when secured to the nose, FIGURE 4).
  • the nose 1 is a human nose which, in accordance with normal human anatomy, includes first and second nostrils 2, 4 separated by a nasal septum 6 that runs from the tip of the nose 1 to the lip 8 and separates the nostrils 2, 4.
  • the PPG device is configured to be secured to the nose 1, and includes an exterior frame 10 that when secured is located on the exterior of the nose 1, and first and second optical supports 12, 14 which when secured are inserted into respective first and second nostrils 2, 4. These supports 12, 14 are mounted on respective extensions 16, 18 that are secured to the exterior frame 10 and, when secured to the nose 1, extend from the exterior frame 10 into the nostrils 2, 4 of the human nose 1. With the PPG device secured to the nose 1, the nasal septum 6 of the nose 1 is interposed between the first optical support 12 and the second optical support 14.
  • FIGURE 1 diagrammatically illustrates components 10, 12, 14, 16, 18 of the illustrative nasal mount.
  • FIGURES 3 and 4 show isolation perspective views of the illustrative PPG device including the exterior frame 10 and the first and second optical supports 12, 14 mounted on the respective extensions 16, 18.
  • the illustrative embodiment of the PPG device is designed as a mechanical clip, in which the first optical support 12 and the second optical support 14 are first and second ends of the clip and are configured to clip onto the nasal septum 6 of the human nose 1 to secure the PPG device to the nose 1.
  • the illustrative exterior frame 10 includes a spring-biased hinge 19 (e.g., with a bi-stable leaf spring or the like, not shown) which can be opened (FIGURE 3) to move the two supports 12, 14 away from each other in order to unclip the device, and can be closed (FIGURE 4) to bring the two supports 12, 14 together into sufficiently close proximity to each other to clip and hold the nasal septum 6 between the two supports 12, 14.
  • the PPG device is secured to the human nose 1 with the first optical support 12 and the second optical support 14 contacting opposite sides of the nasal septum 6.
  • the exterior frame 10 in its relaxed (unbiased) position has the two optical supports 12, 14 in close proximity to each other (as in FIGURE 4), and the exterior frame is springy, that is, has the ability to be manually opened to the open position of FIGURE 3 by pressing the supports 12, 14 away from each other in order to position the supports over the nasal septum 6, after which the force is removed and the springy frame acts to return to the shape of FIGURE 4 so as to clip the supports 12, 14 onto the nasal septum 6.
  • the exterior frame 10 in its relaxed (unbiased) position has the two optical supports 12, 14 in close proximity to each other (as in FIGURE 4), and the exterior frame is springy, that is, has the ability to be manually opened to the open position of FIGURE 3 by pressing the supports 12, 14 away from each other in order to position the supports over the nasal septum 6, after which the force is removed and the springy frame acts to return to the shape of FIGURE 4 so as to clip the supports 12, 14 onto the nasal septum 6.
  • the illustrated PPG device mounting hardware is an example, and that more generally the PPG device may employ any mounting structure that is capable of being secured to a human nose with the nasal septum of the human nose interposed between a first optical support and a second optical support.
  • the PPG device mounting hardware is capable of being secured to a human nose with the alar wing 6' of a nostril of the human nose interposed between a first optical support and a second optical support.
  • one optical support is suitably located inside the nostril while the other is outside the nostril, with the alar wing interposed between the optical supports inside and outside the nostril, respectively.
  • transmission measurements are performed on both alar wings using two sets of optical supports, one for the alar wing of the left nostril and the other for the alar wing of the right nostril, and the transmission PPG measurements of the two alar wingsare suitably averaged.
  • FIGURE 1 illustrates the nose 1 and the exterior frame
  • the PPG device further includes a green PPG component including a green light source 20 secured to the first optical support 12 and a light detector 22 secured to the second optical support 14.
  • the green PPG component 20, 22 is configured to measure transmission of green light from the light source 20 of the green PPG component to the light detector 22 of the green PPG component. With these optical components 20, 22 alone, it is possible to measure cardiac pulse from a pulsatile component of the measured transmission of green light.
  • the green light is in a wavelength range of 590 nm or lower. In some embodiments, the green light is in a wavelength range of 530-580 nm.
  • Green light as used herein encompasses green light and primarily green light, and hence “green light” as used herein encompasses yellowish-green light (e.g. 580 nm) or bluish-green light (e.g. 495 nm).
  • the illustrative PPG device is a pulse oximeter device which can measure both pulse and arterial blood oxygen saturation (Sp0 2 ). To measure the latter, in addition to the green PPG component 20, 22 the PPG device further includes a red or near-infrared PPG component including a red or near-infrared light source 30 secured to either the first optical support 12 (as shown) or the second optical support, and a light detector 32 secured to the opposite optical support, e.g. the second optical support 14 as shown.
  • a red or near-infrared PPG component including a red or near-infrared light source 30 secured to either the first optical support 12 (as shown) or the second optical support, and a light detector 32 secured to the opposite optical support, e.g. the second optical support 14 as shown.
  • the red or near-infrared PPG component 30, 32 is configured to measure transmission of red or near-infrared light from the light source 30 of the red or near-infrared PPG component to the light detector 32 of the red or near-infrared PPG component.
  • the red or near-infrared light is in a wavelength range of 620-780 nm.
  • the red or near-infrared light is in a wavelength range of 640-740 nm.
  • “Red or near-infrared light” as used herein encompasses red light or near-infrared and primarily red light, and hence "green light” as used herein encompasses yellowish-green light (e.g.
  • a second, higher wavelength PPG component 30, 32 which includes a light source 30 secured to one of the first optical support 12 and the second optical support 14 and a light detector 32 secured to the other of the first optical support and the second optical support, the higher wavelength PPG component being configured to measure transmission of light at a higher wavelength than the green light from the light source 30 to the light detector 32. It is further contemplated to include more PPG components for more than two light wavelengths. For example, in some embodiments three PPG components are provided: the illustrated red and green PPG components 20, 22, 30, 32 and a third PPG component (not shown) operating in the infrared.
  • the red and infrared PPG components can be used to compute the Sp0 2 value, while the additional green PPG component can be used to measure a higher quality cardiac pulsatile component.
  • the Sp0 2 measurement may drop out due to poor red and infared signals, while a strong green pulsatile component can still be used to derive the cardiac pulse rate, or to do waveform analysis to infer estimates of the blood pressure and/or vascular tone of the patient.
  • an optical component may be secured to a support by being adhered to an exterior surface of the support by epoxy, glue, soldering to a circuit board of the support, or the like.
  • an optical component may be secured to a support by being embedded in the support or encapsulated by the support, with light coupling being provided by an opening or by an optically transparent window or lens.
  • Various combinations of different securing techniques may be used for the various optical components 20, 22, 30, 32.
  • additional components of the PPG device include a power source or connection to a power source and an electronic data processing device or operative connection with an electronic data processing device.
  • the PPG device is self-contained, and to this end includes an on-board battery 38 and an on-board electronic data processor 40, where the battery 38 powers the light sources 20, 30 and the electronic data processor 40 (e.g. a microprocessor, microcontroller, or other integrated circuit component).
  • Such a self-contained pulse oximeter may output the Sp0 2 and pulse values via a data cable or wireless transmitter (not shown), and/or may include an on-board display (not shown, e.g. a low-power LCD display).
  • the on-board battery 38 is omitted and the PPG device is powered by a connected power cable.
  • the on-board electronic data processor 40 is omitted and the outputs of the light detectors 22, 32 are communicated via a cable to an off-board processor, such as a multi-function patient monitor.
  • an off-board processor such as a multi-function patient monitor.
  • the electronic data processor 40 (or its off-board operational equivalent, e.g. a patient monitor connected with the PPG device) suitably determines pulse and (optionally) Sp0 2 as follows.
  • the cardiac pulse is readily determined by measuring the peak-to-peak time interval of the pulsatile component of either the green light transmission measured by the green PPG component 20, 22 or the red or near-infrared light transmission measured by the red or near-infrared PPG component 30, 32.
  • the measurement by the green PPG component 20, 22 is expected to be more accurate because the green light is more strongly absorbed by arterial blood in the very thin nasal septum 6. If both PPG components are available, the values can be averaged together to increase accuracy and/or may be used as validity cross-checks.
  • the arterial blood oxygen saturation (Sp0 2 ) value is suitably measured by the ratio-of-ratios method:
  • red or near-infrared light transmission measured by the red or near-infrared PPG component 30, 32
  • $DC longer ls tne non-pulsatile component of the longer wavelength light transmission measured by the red or near-infrared PPG component 30, 32
  • appropriate wavelength ranges 50, 52 for the green PPG component 20, 22 and the red or infrared PPG component 30, 32 can be chosen based on the absorption coefficients of hemoglobin (Hb) and oxygenated hemoglobin (Hb0 2 ).
  • FIGURE 5 plots absorption coefficient (in units of meter “1 ) as a function of wavelength (in units of nm) for Hb and Hb0 2 , each at a concentration of 0.1125 mmol/liter. It will be noted that for wavelengths longer than 780 nm the absorption coefficient of both Hb and Hb0 2 become small (note that the ordinate is a logarithmic scale). Additionally, there is a strong difference in absorption between Hb and Hb0 2 for the red to near-infrared light, whereas the difference in absorption between Hb and Hb0 2 for the green light is much less.
  • a difficulty with measuring arterial blood oxygen saturation (Sp0 2 ) using green light as one of the light components is that green light has high absorption in human skin.
  • the Hb and Hb0 2 absorption coefficients are one-to-two orders of magnitude higher for green light than for red to near-infrared light.
  • green light PPG is performed in reflection geometry.
  • attempting to measure arterial blood oxygen saturation in a reflection geometry using green light as one PPG signal and red or near-infrared light as the second PPG signal is difficult because the volume of tissue sampled differs greatly for the green PPG versus the red or near-infrared PPG due to the large difference in absorption coefficients for green versus red or near-infrared light.
  • the PPG device disclosed herein solves these problems by measuring arterial blood oxygen saturation in the nasal septum using green light and red or near-infrared light operating in transmission geometry.
  • This leverages multiple synergies: (1) the thinness of the nasal septum enables PPG using green light operating in a transmission geometry and conversely the strong absorption of green light provides good signal-to-noise ratio (SNR) for the PPG signal measured for the thin nasal septum; and (2) the transmission geometry means that the green and red/near-infrared PPG components sample the same volume; and (3) the nasal septum is well perfused with arterial blood even in the case of a subject with centralized perfusion because the nasal septum is supplied with arterial blood by the ethmoidal arteries which branch from the internal carotid artery which is fed directly from the heart via the main aortic artery.
  • SNR signal-to-noise ratio
  • the green PPG component achieves green light sensitivity because the light source 20 outputs green light
  • the red or near-infrared PPG component achieves red or near-infrared light sensitivity because the light source 30 outputs red or near-infrared light
  • the light detectors 22, 32 are optionally not wavelength-selective, e.g. they may be optically broadband detectors, so long as the geometry of the light sources 20, 30 and detectors 22, 32 is such that optical cross-talk is negligible.
  • Optical cross-talk can be reduced, for example, by having a relatively large separation between the green PPG component 20, 22 and the red or near-infrared PPG component 30, 32.
  • the green and red/near-infrared detectors 22, 32 can optionally include green-selective and red/near-infrared-selective filters, respectively.
  • An advantage of the embodiment of FIGURES 1-4 is that the single- wavelength or narrowband-wavelength light sources 20, 30 can be embodied by low-power light sources such as light emitting diodes (LEDs) or semiconductor lasers, and there is little or no "wasted" light emitted outside of the target green or red/near-infrared spectral bands.
  • the separate green and red/near-infrared light sources 20, 30 are replaced by a broadband light source 60 which outputs over a spectrum encompassing both green and red or near-infrared light.
  • the broadband light source 60 may be a white light source such as a white LED comprising a blue/ultraviolet group Ill-nitride LED coated with a phosphor that outputs white phosphorescence.
  • the light detector 22 of the green PPG component must be provided with a green-selective filter 62, and likewise the light detector 32 of the red or near-infrared PPG component must be provided with a red (or near-infrared) selective filter 64.
  • both light detectors 22, 32 must be secured to the same one of the two optical supports, e.g. to the second optical support 14 in the illustrative example, so as to both be illuminated by the common light source 60.
  • the PPG device embodiment of FIGURE 6 is generally less energy efficient than the embodiment of FIGURES 1-2 due to some "wasted" light being emitted outside of the target green or red/near-infrared spectral bands. However, if the PPG device is externally powered, e.g. via a power cable running to the PPG device from a patient monitor, then this reduced energy efficiency may be acceptable.
  • the disclosed PPG device is specifically configured to measure PPG in the nasal septum using green light (and optionally also using a longer wavelength PPG component to provide data for Sp0 2 via the ratio-of-ratios method).
  • green light and optionally also using a longer wavelength PPG component to provide data for Sp0 2 via the ratio-of-ratios method.
  • the disclosed PPG device and measurement techniques may be applied to other areas in which the tissue may be thin enough to provide for green PPG in transmission geometry, such as between the web skin (i.e. interdigital fold) between the forefinger (i.e. index finger) and thumb.

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Abstract

Dans un dispositif de photopléthysmographie (PPG), un support nasal comprend des premier et second supports optiques (12, 14) fixés à un nez (1) avec la cloison nasale (6) ou une aile alaire (6') entre les supports optiques. Un composant vert de PPG mesurant la transmission de lumière verte à travers le septum nasal comprend une source de lumière (20, 60) fixée sur le premier support optique et un détecteur de lumière (22, 62) fixé sur le deuxième support optique. Un composant rouge ou proche infrarouge de PPG mesurant la transmission de lumière rouge ou proche infrarouge à travers la cloison nasale comprend une source de lumière (30, 60) fixée à un support optique et un détecteur de lumière (32, 64) fixé à l'autre support optique. Un processeur de données électroniques calcule la saturation en oxygène du sang artériel (SpO2) à partir d'un rapport d'intensités de la transmission mesurée de la lumière verte et de la transmission mesurée de la lumière rouge ou proche infrarouge.
PCT/IB2016/053254 2015-06-30 2016-06-03 Photopléthysmographie de lumière verte en géométrie de transmission WO2017001955A1 (fr)

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Cited By (2)

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KR20190117205A (ko) * 2018-04-06 2019-10-16 재단법인 아산사회복지재단 광용적맥파를 이용한 통증심도 측정 방법 및 장치
WO2021064212A1 (fr) * 2019-10-02 2021-04-08 Biosency Procédé et système d'évaluation de la qualité du rapport de valeurs de rapports

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