Non-invasive evaluation of coronary heart disease in patients with chronic kidney disease using photoplethysmography.

BACKGROUND: Chronic kidney disease (CKD) patients have an increased risk for coronary artery disease (CAD) and myocardial infarction. Therefore, there is a need to identify CKD patients at high risk of CAD. Coronary angiography, the gold standard for detecting CAD, carries a risk of serious adverse events. METHODS: Here, we assessed the validity of a novel non-invasive reflectance mode photoplethysmography (PPG) sensor for the evaluation of CAD in patients with advanced CKD. PPG signals were generated using green and infrared wavelengths and recorded from fingers of 98 patients. The detected signal has the shape of the pulse wave contour carrying information about the vascular system, that is, arterial stiffness. We studied four patient groups: (i) controls-patients without CKD or CAD; (ii) CKD alone; (iii) CAD alone (confirmed by coronary angiography); and (iv) CKD and CAD combined. RESULTS: With advancing age, we observed a steeper ascending signal during systole and greater signal decline during diastole (infrared wavelength: Slopes 4-6, P = 0.002, P = 0.003 and P = 0.014, respectively; green wavelength: Slopes 2-3, P = 0.006 and P = 0.005, respectively). Presence of CAD was associated with a slower signal decline during diastole in CKD patients compared with those without CAD (infrared wavelength: Slope 1, P = 0.012). CKD was associated with lower blood volume amplitude during each cardiac cycle compared with those without CKD (R-value, P = 0.022). CONCLUSIONS: PPG signal analyses showed significant differences between our groups, and it may be a potentially useful tool for the detection of CAD in CKD patients.

Noncontact Monitoring of Respiratory Rate in Newborn Infants Using Thermal Imaging.

Monitoring of respiratory rate (RR) is very important for patient assessment. In fact, it is considered one of the relevant vital parameters in critical care medicine. Nowadays, standard monitoring relies on obtrusive and invasive techniques, which require adhesive electrodes or sensors to be attached to the patient's body. Unfortunately, these procedures cause stress, pain, and frequently damage the vulnerable skin of preterm infants. This paper presents a "black-box" algorithm for remote monitoring of RR in thermal videos. "Black-box" in this context means that the algorithm does not rely on tracking of specific anatomic landmarks. Instead, it automatically distinguishes regions of interest in the video containing the respiratory signal from those containing only noise. To examine its performance and robustness during physiological (phase A) and pathological scenarios (phase B), a study on 12 healthy volunteers was carried out. After a successful validation on adults, a clinical study on eight newborn infants was conducted. A good agreement between estimated RR and ground truth was achieved. In the study involving adult volunteers, a mean root-mean-square error (RMSE) of ( 0.31 ±0.09) breaths/min and ( 3.27 ±0.72) breaths/min was obtained for phase A and phase B, respectively. In the study involving infants, the mean RMSE hovered around ( 4.15 ±1.44) breaths/min. In brief, this paper demonstrates that infrared thermography might become a clinically relevant alternative for the currently available RR monitoring modalities in neonatal care.

Non-Contact Remote Measurement of Heart Rate Variability using Near-Infrared Photoplethysmography Imaging.

Heart rate variability (HRV) is an important clinical parameter associated with the autonomous nervous system (ANS), age, as well as many diseases such as myocardial infarction, diabetes or renal failure. Gold standard for measurement of HRV is a high-resolution electrocardiogram (ECG). With the current trend towards non-contact and unobtrusive monitoring of vital signs, HRV has also become an interesting and important parameter for non-contact monitoring. In this paper, we present an approach towards non-contact and unobtrusive monitoring of heart rate variability using the camera-based technology of photoplethysmography imaging (PPGI). We investigated the suitability of invisible near-infrared illumination for PPGI, which would enable measurement of HRV in darkness. We compared results obtained using infrared illumination with those obtained using visible light as PPGI illumination and calculated both time-domain as well as frequency-domain HRV parameters. The results achieved with infrared illumination were on par with those using conventional illumination in the visible spectrum. We concluded that infrared illumination enables unobtrusive and non-contact remote HRV measurement in both darkness as well as regular daylight conditions using PPGI.

Estimation of respiratory rate from thermal videos of preterm infants.

Studies have demonstrated that respiratory rate (RR) is a good predictor of the patient condition as well as an early marker of patient deterioration and physiological distress. However, it is also referred as "the neglected vital parameter". This is mainly due to shortcoming of current monitoring techniques. Moreover, in preterm infants, the removal of adhesive electrodes cause epidermal stripping, skin disruption, and with it pain. This paper proposes a new algorithm for estimation of RR in thermal videos of moderate preterm infants. It uses the temperature modulation around the nostrils over the respiratory cycle to extract this vital parameter. To compensate movement artifacts the approach incorporates a tracking algorithm. In addition, a new reliable and accurate algorithm for robust estimation of local (breath-to-breath) intervals was included. To evaluate the performance of this approach, thermal recordings of four moderate preterm infants were acquired. Results were compared with RR derived from body surface electrocardiography. The results showed an excellent agreement between thermal imaging and gold standard. On average, the relative error between both monitoring techniques was 3.42%. In summary, infrared thermography may be a clinically relevant alternative to conventional sensors, due to its high thermal resolution and outstanding characteristics.

Estimation of breathing rate in thermal imaging videos: a pilot study on healthy human subjects.

Diverse studies have demonstrated the importance of monitoring breathing rate (BR). Commonly, changes in BR are one of the earliest and major markers of serious complications/illness. However, it is frequently neglected due to limitations of clinically established measurement techniques, which require attachment of sensors. The employment of adhesive pads or thoracic belts in preterm infants as well as in traumatized or burned patients is an additional paramount issue. The present paper proposes a new robust approach, based on data fusion, to remotely monitor BR using infrared thermography (IRT). The algorithm considers not only temperature modulation around mouth and nostrils but also the movements of both shoulders. The data of these four sensors/regions of interest need to be further fused to reach improved accuracy. To investigate the performance of our approach, two different experiments (phase A: normal breathing, phase B: simulation of breathing disorders) on twelve healthy volunteers were performed. Thoracic effort (piezoplethysmography) was simultaneously acquired to validate our results. Excellent agreements between BR estimated with IRT and gold standard were achieved. While in phase A a mean correlation of 0.98 and a root-mean-square error (RMSE) of 0.28 bpm was reached, in phase B the mean correlation and the RMSE hovered around 0.95 and 3.45 bpm, respectively. The higher RMSE in phase B results predominantly from delays between IRT and gold standard in BR transitions: eupnea/apnea, apnea/tachypnea etc. Moreover, this study also demonstrates the capability of IRT to capture varied breathing disorders, and consecutively, to assess respiratory function. In summary, IRT might be a promising monitoring alternative to the conventional contact-based techniques regarding its performance and remarkable capabilities.

Active and Passive Optical Imaging Modality for Unobtrusive Cardiorespiratory Monitoring and Facial Expression Assessment.

Because of their obvious advantages, active and passive optoelectronic sensor concepts are being investigated by biomedical research groups worldwide, particularly their camera-based variants. Such methods work noninvasively and contactless, and they provide spatially resolved parameter detection. We present 2 techniques: the active photoplethysmography imaging (PPGI) method for detecting dermal blood perfusion dynamics and the passive infrared thermography imaging (IRTI) method for detecting skin temperature distribution. PPGI is an enhancement of classical pulse oximetry. Approved algorithms from pulse oximetry for the detection of heart rate, heart rate variability, blood pressure-dependent pulse wave velocity, pulse waveform-related stress/pain indicators, respiration rate, respiratory variability, and vasomotional activity can easily be adapted to PPGI. Although the IRTI method primarily records temperature distribution of the observed object, information on respiration rate and respiratory variability can also be derived by analyzing temperature change over time, for example, in the nasal region, or through respiratory movement. Combined with current research areas and novel biomedical engineering applications (eg, telemedicine, tele-emergency, and telemedical diagnostics), PPGI and IRTI may offer new data for diagnostic purposes, including assessment of peripheral arterial and venous oxygen saturation (as well as their differences). Moreover, facial expressions and stress and/or pain-related variables can be derived, for example, during anesthesia, in the recovery room/intensive care unit and during daily activities. The main advantages of both monitoring methods are unobtrusive data acquisition and the possibility to assess vital variables for different body regions. These methods supplement each other to enable long-term monitoring of physiological effects and of effects with special local characteristics. They also offer diagnostic advantages for intensive care patients and for high-risk patients in a homecare/outdoor setting. Selected applications have been validated at our laboratory using optical PPGI and IRTI techniques in a stand-alone or hybrid configuration. Additional research and validation is required before these preliminary results can be introduced for clinical applications.

Thermoregulation in premature infants: A mathematical model.

PURPOSE: In 2010, approximately 14.9 million babies (11.1%) were born preterm. Because preterm infants suffer from an immature thermoregulatory system they have difficulty maintaining their core body temperature at a constant level. Therefore, it is essential to maintain their temperature at, ideally, around 37°C. For this, mathematical models can provide detailed insight into heat transfer processes and body-environment interactions for clinical applications. METHODS: A new multi-node mathematical model of the thermoregulatory system of newborn infants is presented. It comprises seven compartments, one spherical and six cylindrical, which represent the head, thorax, abdomen, arms and legs, respectively. The model is customizable, i.e. it meets individual characteristics of the neonate (e.g. gestational age, postnatal age, weight and length) which play an important role in heat transfer mechanisms. The model was validated during thermal neutrality and in a transient thermal environment. RESULTS: During thermal neutrality the model accurately predicted skin and core temperatures. The difference in mean core temperature between measurements and simulations averaged 0.25±0.21°C and that of skin temperature averaged 0.36±0.36°C. During transient thermal conditions, our approach simulated the thermoregulatory dynamics/responses. Here, for all infants, the mean absolute error between core temperatures averaged 0.12±0.11°C and that of skin temperatures hovered around 0.30°C. CONCLUSIONS: The mathematical model appears able to predict core and skin temperatures during thermal neutrality and in case of a transient thermal conditions.

Remote vital parameter monitoring in neonatology - robust, unobtrusive heart rate detection in a realistic clinical scenario.

Vital parameter monitoring of term and preterm infants during incubator care with self-adhesive electrodes or sensors directly positioned on the skin [e.g. photoplethysmography (PPG) for oxygen saturation or electrocardiography (ECG)] is an essential part of daily routine care in neonatal intensive care units. For various reasons, this kind of monitoring contains a lot of stress for the infants. Therefore, there is a need to measure vital parameters (for instance respiration, temperature, pulse, oxygen saturation) without mechanical or conductive contact. As a non-contact method of monitoring, we present an adapted version of camera-based photoplethysmography imaging (PPGI) according to neonatal requirements. Similar to classic PPG, the PPGI camera detects small temporal changes in the term and preterm infant's skin brightness due to the cardiovascular rhythm of dermal blood perfusion. We involved 10 preterm infants in a feasibility study [five males and five females; mean gestational age: 26 weeks (24-28 weeks); mean biological age: 35 days (8-41 days); mean weight at the time of investigation: 960 g (670-1290 g)]. The PPGI camera was placed directly above the incubators with the infant inside illuminated by an infrared light emitting diode (LED) array (850 nm). From each preterm infant, 5-min video sequences were recorded and analyzed post hoc. As the measurement scenario was kept as realistic as possible, the infants were not constrained in their movements in front of the camera. Movement intensities were assigned into five classes (1: no visible motion to 5: heavy struggling). PPGI was found to be significantly sensitive to movement artifacts. However, for movement classes 1-4, changes in blood perfusion according to the heart rate (HR) were recovered successfully (Pearson correlation: r=0.9759; r=0.765 if class 5 is included). The study was approved by the Ethics Committee of the Universal Hospital of the RWTH Aachen University, Aachen, Germany (EK 254/13).

Multisensor data fusion for enhanced respiratory rate estimation in thermal videos.

Scientific studies have demonstrated that an atypical respiratory rate (RR) is frequently one of the earliest and major indicators of physiological distress. However, it is also described in the literature as "the neglected vital parameter", mainly due to shortcomings of clinical available monitoring techniques, which require attachment of sensors to the patient's body. The current paper introduces a novel approach that uses multisensor data fusion for an enhanced RR estimation in thermal videos. It considers not only the temperature variation around nostrils and mouth, but the upward and downward movement of both shoulders. In order to analyze the performance of our approach, two experiments were carried out on five healthy candidates. While during phase A, the subjects breathed normally, during phase B they simulated different breathing patterns. Thoracic effort was the gold standard elected to validate our algorithm. Our results show an excellent agreement between infrared thermography (IRT) and ground truth. While in phase A a mean correlation of 0.983 and a root-mean-square error of 0.240 bpm (breaths per minute) was obtained, in phase B they hovered around 0.995 and 0.890 bpm, respectively. In sum, IRT may be a promising clinical alternative to conventional sensors. Additionally, multisensor data fusion contributes to an enhancement of RR estimation and robustness.

Robustness, specificity, and reliability of an in-ear pulse oximetric sensor in surgical patients.

For many years, pulse oximetry has been widely used in the clinical environment for a reliable monitoring of oxygen saturation ( SpO2) and heart rate. But since common sensors are mainly placed to peripheral body parts as finger or earlobe, it is still highly susceptible to reduced peripheral perfusion, e.g., due to centralization. Therefore, a novel in-ear pulse oximetric sensor (placed against the tragus) was presented in a prior work which is deemed to be independent from perfusion fluctuations due to its proximity to the trunk. Having demonstrated the feasibility of in-ear SpO2 measurement with reliable specificity in a laboratory setting, we now report results from a study on in-ear SpO2 in a clinical setting. For this, trials were performed on 29 adult patients undergoing surgery. In-ear SpO2 data are compared with SaO2 data obtained by blood gas analysis, and with three reference pulse oximeters applied to the finger, ear lobe, and forehead. In addition, we derived an SpO2-independent perfusion index by means of the wavelengths used. The feasibility and robustness of in-ear SpO2 measurement is demonstrated under challenging clinical conditions. SpO2 shows good accordance with SaO2, a high level of comparability with the reference pulse oximeters, and was significantly improved by introducing a new algorithm for artifact reduction. The perfusion index also shows a good correlation with the reference data.

Hybrid optical imaging technology for long-term remote monitoring of skin perfusion and temperature behavior.

Photoplethysmography imaging (PPGI) and infrared thermography imaging (IRTI) are contactless camera-based measurement methods for monitoring a wide range of basic vital parameters. In particular, PPGI enhances the classical contact-based photoplethysmography. Approved evaluation algorithms of the well-established PPG method can easily be adapted for detection of heart rate, heart rate variability, respiration rate (RR), respiratory variability (RV), and vasomotional activity with PPGI. The IRTI method primarily records temperature distribution of the observed object, but information on RR and RV can also be derived from IRTI by analyzing the development of temperature distribution in the nasal region. The main advantages of both monitoring methods are unobtrusive data acquisition and the possibility of assessing spatial assignment between vital parameters and body region. Hence, these methods enable long-term monitoring or the monitoring of effects with special local characteristics. Because the two systems supplement each, a combined hybrid application is proposed and its feasibility discussed.

Evaluating Innovative In-Ear Pulse Oximetry for Unobtrusive Cardiovascular and Pulmonary Monitoring During Sleep.

Homecare is healthcare based on the principle "outpatient before inpatient," with the aim of moving at least some care-delivery to the home. But reliable determination of vital signs at home requires new, smart sensors, which can be used by the patients themselves. We present a novel pulse oximetry sensor worn in the ear channel. It was previously shown that measurement of heart rate, arterial oxygen saturation and related respiratory information can be performed with reliable accuracy under laboratory conditions. The present study explores the clinical feasibility of the sensor system for cardiovascular monitoring during sleep, with the aim to diagnose sleep apnea. For this, human trials were performed in a sleep laboratory including patients with a clinical suspicion of sleep apnea. Besides a general analysis of the sensor's signal quality during sleep, the evaluation focuses on heart rate dynamics and time-variant oxygen saturation. In addition, several methods to derive respiration rate from photoplethysmographic signals are examined and discussed. Results from the in-ear sensor are compared with standard polysomnography monitoring and demonstrate that this novel system allows long-term nocturnal measurement of heart rate, oxygen saturation and respiratory rate with sufficient accuracy.

Advances in reflective oxygen saturation monitoring with a novel in-ear sensor system: results of a human hypoxia study.

Pulse oximetry is a well-established, noninvasive photoplethysmographic method to monitor vital signs. It allows us to measure cardiovascular parameters, such as heart rate and arterial oxygen saturation, and is considered an essential monitoring tool in clinical routine. However, since many of the conventional systems work in transmission mode, they can only be applied to the thinner or peripheral parts of the body, such as a finger tip. This has the major disadvantage that, in case of shock-induced centralization and a resulting drop in perfusion, such systems cannot ensure valid measurements. Therefore, we developed a reflective in-ear sensor system that can be worn in the ear channel like a headphone. Because the sensor is integrated in an ear mold and positioned very close to the trunk, reliable measurement is expected even in case of centralization. An additional advantage is that the sensor is comfortable to wear and has considerable resistance to motion artifacts. In this paper, we report on hypoxia studies with ten healthy participants which were performed to analyze the system with regard to the detection of heart rate and arterial oxygen saturation. It was shown earlier that, due to the high signal quality, heart rate can easily be detected. Using the conventional calculation principle, based on Beer-Lambert's law combined with a single-point calibration method, we now demonstrate that the detection of arterial oxygen saturation in the human ear canal is possible using reflective saturation sensors.