SCG variability and spectral energy distribution during normal breathing and breath hold at different lung volumes and airway pressures.

Seismocardiographic (SCG) signals are chest wall vibrations induced by cardiac activity and are potentially useful for cardiac monitoring and diagnosis. SCG waveform is observed to vary with respiration, but the mechanism of these changes is poorly understood as alterations in autonomic tone, lung volume, heart location and intrathoracic pressure are all varying during the respiratory cycle. Understanding SCG variability and its sources may help reduce variability and increase SCG clinical utility. This study investigated SCG variability during breath holding (BH) at two different lung volumes (i.e., end inspiration and end expiration) and five airway pressures (i.e., 0, ± 2-4, and ± 15-20 cm H2O). Variability during normal breathing was also studied with and without grouping SCG beats into two clusters of similar waveform morphologies (performed using the K-medoid algorithm in an unsupervised machine learning fashion). The study included 15 healthy subjects (11 Females and 4 males, Age: 21 ± 2 y) where SCG, ECG, and spirometry were simultaneously acquired. SCG waveform variability was calculated at each experimental state (i.e., lung volume and airway pressure). Results showed that breath holding was more effective in reducing the intra-state variability of SCG than clustering normal breathing data. For the BH states, the intra-state variability increased as the airway pressure deviated from zero. The subaudible-to-audible energy ratio of the BH states increased as the airway pressure decreased below zero which may be related to the effect of the intrathoracic pressure on cardiac afterload and blood ejection. When combining the BH waveforms at end inspiration and end expiration states (at the same airway pressures) into one group, the intra-state variability increased, which suggests that the lung volume and associated change in heart location were a significant source of variability. The linear trend between airway pressure and waveform changes was found to be statistically significant for BH at end expiration. To confirm these findings, more studies are needed with a larger number of airway pressure levels and larger number of subjects.

Postural and longitudinal variability in seismocardiographic signals.

Objective. Low frequency cardiovascular vibrations detectable on the chest surface (termed seismocardiography or SCG) may be useful for non-invasive diagnosis and monitoring of various cardiovascular conditions. A potential limitation of using SCG for longitudinal patient monitoring is the existence of intra-subject variability, which can contribute to errors in calculating SCG features. Improved understanding of the contribution of intra-subject variability sources may lead to improved SCG utility. This study aims to quantify postural and longitudinal SCG variability in healthy resting subjects during normal breathing.Approach. SCG and ECG signals were longitudinally acquired in 19 healthy subjects at different postures (supine, 45° head up, and sitting) during five recording sessions over five months. SCG cycles were segmented using the ECG R wave. Unsupervised machine learning was used to reduce SCG variability due to respiration by grouping the SCG signals into two clusters with minimized intra-cluster waveform heterogeneity. Several SCG features were assessed at different postures and longitudinally.Main results. SCG waveform morphological variability was calculated within each cluster (intra-cluster) and between two clusters (inter-cluster) at each posture and data collection session. The variabilities were significantly different between the supine and sitting but not between supine and 45° postures. For the 45° and sitting postures, the intra-cluster variability was not significantly different, while the inter-cluster variability difference was significant. The energy ratio between different frequency bands to total spectral energy in 0.5-50 Hz were calculated and were comparable for all postures. The combined cardiac timing intervals from the two clusters showed significant variation with postural changes. There was significant heart rate difference between the clusters and between postural positions. The SCG features were compared between longitudinal sessions and all features were not significantly different,Significance. Several SCG features significantly varied with posture suggesting that posture needs to be specified when comparing SCG changes over time. Longitudinally comparable SCG feature values suggests that significant longitudinal differences, if observed, may reflect true alternations in the cardiac functioning over time.

Noninvasive detection of elevated ICP using spontaneous tympanic membrane pulsation.

Neurological conditions such as traumatic brain injury (TBI) and hydrocephalus may lead to intracranial pressure (ICP) elevation. Current diagnosis methods rely on direct pressure measurement, while CT, MRI and other expensive imaging may be used. However, these invasive or expensive testing methods are often delayed because symptoms of elevated ICP are non-specific. Invasive methods, such as intraventricular catheter, subdural screw, epidural sensor, lumbar puncture, are associated with an increased risk of infection and hemorrhage. On the other hand, noninvasive, low-cost, accurate methods of ICP monitoring can help avoid risks and reduce costs while expediting diagnosis and treatment. The current study proposes and evaluates a novel method for noninvasive ICP monitoring using tympanic membrane pulsation (TMp). These signals are believed to be transmitted from ICP to the auditory system through the cochlear aqueduct. Fifteen healthy subjects were recruited and TMp signals were acquired noninvasively while the subjects performed maneuvers that are known to change ICP. A custom made system utilizing a stethoscope headset and a pressure transducer was used to perform these measurements. Maneuvers included head-up-tilt, head-down-tilt and hyperventilation. When elevated ICP was induced, significant TMp waveform morphological changes were observed in each subject (p < 0.01). These changes include certain waveform slopes and high frequency wave features. The observed changes were reversed by the maneuvers that decreased ICP (p < .01). The study results suggest that TMp waveform measurement and analysis may offer an inexpensive, noninvasive, accurate tool for detection and monitoring of ICP elevations. Further studies are warranted to validate this technique in patients with pathologically elevated ICP.

Sound transmission in human thorax through airway insonification: an experimental and computational study with diagnostic applications.

Pulmonary diseases and injury lead to structural and functional changes in the lung parenchyma and airways, often resulting in measurable sound transmission changes on the chest wall surface. Additionally, noninvasive imaging of externally driven mechanical wave motion in the chest (e.g., using magnetic resonance elastography) can provide information about lung stiffness and other structural property changes which may be of diagnostic value. In the present study, a comprehensive computational simulation (in silico) model was developed to simulate sound wave propagation in the airways, parenchyma, and chest wall under normal and pathological conditions that create distributed structural (e.g., pneumothoraces) and diffuse material (e.g., fibrosis) changes, as well as a localized structural and material changes as may be seen with a neoplasm. Experiments were carried out in normal subjects to validate the baseline model. Sound waves with frequency content from 50 to 600 Hz were introduced into the airways of three healthy human subjects through the mouth, and transthoracic transmitted waves were measured by scanning laser Doppler vibrometry at the chest wall surface. The computational model predictions of a frequency-dependent decreased sound transmission due to pneumothorax were consistent with experimental measurements reported in previous work. Predictions for the case of fibrosis show that while shear wave motion is altered, changes to compression wave propagation are negligible, and thus, insonification, which primarily drives compression waves, is not ideal to detect the presence of fibrosis. Results from the numerical simulation of a tumor show an increase in the wavelength of propagating waves in the immediate vicinity of the tumor region. Graphical abstract.

Extraction of Peak Velocity Profiles from Doppler Echocardiography Using Image Processing.

The objective of this study is to extract positive and negative peak velocity profiles from Doppler echocardiographic images. These profiles are currently estimated using tedious manual approaches. Profiles can be used to establish realistic boundary conditions for computational hemodynamic studies and to estimate cardiac time intervals, which are of clinical utility. In the current study, digital image processing algorithms that rely on intensity calculations and two different thresholding methods were proposed and tested. Image intensity histograms were used to guide threshold choices, which were selected such that the resulting velocity profiles appropriately represent Doppler shift envelopes. The resulting peak velocity profiles contained artifacts in the form of sudden velocity changes and possible outliers. To reduce these artifacts, image smoothing using a moving average process was then implemented. Bland-Altman analysis suggested good agreement between the two thresholding methods. Artifacts decreased when image smoothing was performed. Results also suggested that one thresholding method tended to provide the lower limit (i.e., underestimate) of velocities, while the second tended to provide the velocity upper limit (i.e., overestimate). Combining estimates from both methods appeared to provide a smoother peak velocity profile estimate. The proposed automated approach may be useful for objective estimation of peak velocity profiles, which may be helpful for computational hemodynamic studies and may increase the efficiency of current clinical diagnostic tools.

Recent Advances in Seismocardiography.

Cardiovascular disease is a major cause of death worldwide. New diagnostic tools are needed to provide early detection and intervention to reduce mortality and increase both the duration and quality of life for patients with heart disease. Seismocardiography (SCG) is a technique for noninvasive evaluation of cardiac activity. However, the complexity of SCG signals introduced challenges in SCG studies. Renewed interest in investigating the utility of SCG accelerated in recent years and benefited from new advances in low-cost lightweight sensors, and signal processing and machine learning methods. Recent studies demonstrated the potential clinical utility of SCG signals for the detection and monitoring of certain cardiovascular conditions. While some studies focused on investigating the genesis of SCG signals and their clinical applications, others focused on developing proper signal processing algorithms for noise reduction, and SCG signal feature extraction and classification. This paper reviews the recent advances in the field of SCG.

Adverse Hemodynamic Conditions Associated with Mechanical Heart Valve Leaflet Immobility.

Artificial heart valves may dysfunction, leading to thrombus and/or pannus formations. Computational fluid dynamics is a promising tool for improved understanding of heart valve hemodynamics that quantify detailed flow velocities and turbulent stresses to complement Doppler measurements. This combined information can assist in choosing optimal prosthesis for individual patients, aiding in the development of improved valve designs, and illuminating subtle changes to help guide more timely early intervention of valve dysfunction. In this computational study, flow characteristics around a bileaflet mechanical heart valve were investigated. The study focused on the hemodynamic effects of leaflet immobility, specifically, where one leaflet does not fully open. Results showed that leaflet immobility increased the principal turbulent stresses (up to 400%), and increased forces and moments on both leaflets (up to 600% and 4000%, respectively). These unfavorable conditions elevate the risk of blood cell damage and platelet activation, which are known to cascade to more severe leaflet dysfunction. Leaflet immobility appeared to cause maximal velocity within the lateral orifices. This points to the possible importance of measuring maximal velocity at the lateral orifices by Doppler ultrasound (in addition to the central orifice, which is current practice) to determine accurate pressure gradients as markers of valve dysfunction.

Sound transmission in porcine thorax through airway insonification.

Many pulmonary injuries and pathologies may lead to structural and functional changes in the lungs resulting in measurable sound transmission changes on the chest surface. Additionally, noninvasive imaging of externally driven mechanical wave motion in the chest (e.g., using magnetic resonance elastography) can provide information about lung structural property changes and, hence, may be of diagnostic value. In the present study, a comprehensive computational simulation (in silico) model was developed to simulate sound wave propagation in the airways, lung, and chest wall under normal and pneumothorax conditions. Experiments were carried out to validate the model. Here, sound waves with frequency content from 50 to 700 Hz were introduced into airways of five porcine subjects via an endotracheal tube, and transmitted waves were measured by scanning laser Doppler vibrometry at the chest wall surface. The computational model predictions of decreased sound transmission with pneumothorax were consistent with experimental measurements. The in silico model can also be used to visualize wave propagation inside and on the chest wall surface for other pulmonary pathologies, which may help in developing and interpreting diagnostic procedures that utilize sound and vibration.

A model of lung parenchyma stress relaxation using fractional viscoelasticity.

Some pulmonary diseases and injuries are believed to correlate with lung viscoelasticity changes. Hence, a better understanding of lung viscoelastic models could provide new perspectives on the progression of lung pathology and trauma. In the presented study, stress relaxation measurements were performed to quantify relaxation behavior of pig lungs. Results have uncovered certain trends, including an initial steep decay followed by a slow asymptotic relaxation, which would be better described by a power law than exponential decay. The fractional standard linear solid (FSLS) and two integer order viscoelastic models - standard linear solid (SLS) and generalized Maxwell (GM) - were used to fit the stress relaxation curves; the FSLS was found to be a better fit. It is suggested that fractional order viscoelastic models, which have nonlocal, multi-scale attributes and exhibit power law behavior, better capture the lung parenchyma viscoelastic behavior.

Experimental and Computational Studies of Sound Transmission in a Branching Airway Network Embedded in a Compliant Viscoelastic Medium.

Breath sounds are often used to aid in the diagnosis of pulmonary disease. Mechanical and numerical models could be used to enhance our understanding of relevant sound transmission phenomena. Sound transmission in an airway mimicking phantom was investigated using a mechanical model with a branching airway network embedded in a compliant viscoelastic medium. The Horsfield self-consistent model for the bronchial tree was adopted to topologically couple the individual airway segments into the branching airway network. The acoustics of the bifurcating airway segments were measured by microphones and calculated analytically. Airway phantom surface motion was measured using scanning laser Doppler vibrometry. Finite element simulations of sound transmission in the airway phantom were performed. Good agreement was achieved between experiments and simulations. The validated computational approach can provide insight into sound transmission simulations in real lungs.

Pneumothorax effects on pulmonary acoustic transmission.

Pneumothorax (PTX) is an abnormal accumulation of air between the lung and the chest wall. It is a relatively common and potentially life-threatening condition encountered in patients who are critically ill or have experienced trauma. Auscultatory signs of PTX include decreased breath sounds during the physical examination. The objective of this exploratory study was to investigate the changes in sound transmission in the thorax due to PTX in humans. Nineteen human subjects who underwent video-assisted thoracic surgery, during which lung collapse is a normal part of the surgery, participated in the study. After subjects were intubated and mechanically ventilated, sounds were introduced into their airways via an endotracheal tube. Sounds were then measured over the chest surface before and after lung collapse. PTX caused small changes in acoustic transmission for frequencies below 400 Hz. A larger decrease in sound transmission was observed from 400 to 600 Hz, possibly due to the stronger acoustic transmission blocking of the pleural air. At frequencies above 1 kHz, the sound waves became weaker and so did their changes with PTX. The study elucidated some of the possible mechanisms of sound propagation changes with PTX. Sound transmission measurement was able to distinguish between baseline and PTX states in this small patient group. Future studies are needed to evaluate this technique in a wider population.

Comparison of Poroviscoelastic Models for Sound and Vibration in the Lungs.

Noninvasive measurement of mechanical wave motion (sound and vibration) in the lungs may be of diagnostic value, as it can provide information about the mechanical properties of the lungs, which in turn are affected by disease and injury. In this study, two previously derived theoretical models of the vibroacoustic behavior of the lung parenchyma are compared: (1) a Biot theory of poroviscoelasticity and (2) an effective medium theory for compression wave behavior (also known as a "bubble swarm" model). A fractional derivative formulation of shear viscoelasticity is integrated into both models. A measurable "fast" compression wave speed predicted by the Biot theory formulation has a significant frequency dependence that is not predicted by the effective medium theory. Biot theory also predicts a slow compression wave. The experimentally measured fast compression wave speed and attenuation in a pig lung ex vivo model agreed well with the Biot theory. To obtain the parameters for the Biot theory prediction, the following experiments were undertaken: quasistatic mechanical indentation measurements were performed to estimate the lung static shear modulus; surface wave measurements were performed to estimate lung tissue shear viscoelasticity; and flow permeability was measured on dried lung specimens. This study suggests that the Biot theory may provide a more robust and accurate model than the effective medium theory for wave propagation in the lungs over a wider frequency range.

A comprehensive computational model of sound transmission through the porcine lung.

A comprehensive computational simulation model of sound transmission through the porcine lung is introduced and experimentally evaluated. This "subject-specific" model utilizes parenchymal and major airway geometry derived from x-ray CT images. The lung parenchyma is modeled as a poroviscoelastic material using Biot theory. A finite element (FE) mesh of the lung that includes airway detail is created and used in comsol FE software to simulate the vibroacoustic response of the lung to sound input at the trachea. The FE simulation model is validated by comparing simulation results to experimental measurements using scanning laser Doppler vibrometry on the surface of an excised, preserved lung. The FE model can also be used to calculate and visualize vibroacoustic pressure and motion inside the lung and its airways caused by the acoustic input. The effect of diffuse lung fibrosis and of a local tumor on the lung acoustic response is simulated and visualized using the FE model. In the future, this type of visualization can be compared and matched with experimentally obtained elastographic images to better quantify regional lung material properties to noninvasively diagnose and stage disease and response to treatment.

Sound transmission in the chest under surface excitation: an experimental and computational study with diagnostic applications.

Chest physical examination often includes performing chest percussion, which involves introducing sound stimulus to the chest wall and detecting an audible change. This approach relies on observations that underlying acoustic transmission, coupling, and resonance patterns can be altered by chest structure changes due to pathologies. More accurate detection and quantification of these acoustic alterations may provide further useful diagnostic information. To elucidate the physical processes involved, a realistic computer model of sound transmission in the chest is helpful. In the present study, a computational model was developed and validated by comparing its predictions with results from animal and human experiments which involved applying acoustic excitation to the anterior chest, while detecting skin vibrations at the posterior chest. To investigate the effect of pathology on sound transmission, the computational model was used to simulate the effects of pneumothorax on sounds introduced at the anterior chest and detected at the posterior. Model predictions and experimental results showed similar trends. The model also predicted wave patterns inside the chest, which may be used to assess results of elastography measurements. Future animal and human tests may expand the predictive power of the model to include acoustic behavior for a wider range of pulmonary conditions.

Investigating a compact phantom and setup for testing body sound transducers.

Contact transducers are a key element in experiments involving body sounds. The characteristics of these devices are often not known with accuracy. There are no standardized calibration setups or procedures for testing these sensors. This study investigated the characteristics of a new computer-controlled sound source phantom for testing sensors. Results suggested that sensors with different sizes require special phantom requirements. The effectiveness of certain approaches on increasing the spatial and spectral uniformity of the phantom surface signal was studied. Non-uniformities > 20 dB were removable, which can be particularly helpful in comparing the characteristics of different size sensors more accurately.

Comparison of hemodialysis access flow measurements using flow dilution and in-line dialysance.

Measurement of hemodialysis (HD) access flow (QA) is a noninvasive approach for arteriovenous graft or fistula surveillance. Flow dilution (FD) and in-line dialysance (DD) are two common methods for measuring QA. In a randomized fashion, we prospectively evaluated QA using FD and DD in 48 HD patients during three separate HD sessions over a span of 3 months. The measurement of QA was similar (1,016 +/- 412 ml/min for FD and 1,009 +/- 425 ml/min for DD, p = 0.44 and 0.79 for the mean and standard deviation, respectively). While FD successfully measured QA >or=2,000 ml/min, DD "saturated" (indicating a QA >or=2,000 ml/min without providing a numerical QA value) (n = 17). The correlation coefficient for QA 2,000 ml/min, FD provided a quantitative QA measure, and is therefore a potentially useful tool for QA above this threshold, while DD is not.

Identification of endotracheal tube malpositions using computerized analysis of breath sounds via electronic stethoscopes.

Endotracheal tube (ETT) malpositioning into a mainstem bronchus or the esophagus may result in significant hypoxemia. Current methods to determine correct ETT position include auscultation, radiography, and bronchoscopy, although the current acceptable standard procedure for proper endotracheal (versus esophageal) intubation is detection of end-tidal carbon dioxide (ETco(2)) by capnography, capnometry, or colorimetric ETco(2) devices. Unfortunately, capnography may be unavailable or unreliable in nonhospital/emergency settings or in low cardiac output states, and it does not detect endobronchial intubation. The purpose of this study was to quantify and assess breath sound characteristics using electronic stethoscopes placed over each hemithorax and epigastrium to determine their ability to detect ETT malposition. We recorded breath sounds in 19 healthy, non-obese adults before general surgical procedures. After intubation of the trachea, the ETT was bronchoscopically positioned 3 cm above the carina, after which 3 breaths of 500 mL were given and breath sounds were recorded. A second ETT was placed in the esophagus and the same series of breaths and recordings were performed. Finally, the tracheal ETT was advanced into the right mainstem bronchus and breath sounds were recorded. Using computerized analysis, breath sounds were digitized and filtered to remove selected frequencies, and acoustic signals and energy ratios were obtained for all 3 positions. Total energy ratios using band-pass filtering of the acoustic signals accurately identified all esophageal and endobronchial intubation (P < 0.001). These preliminary results suggest that this technique, when incorporated into a 3-component, electronic stethoscope-type device, may be an accurate, portable mechanism to reliably detect ETT malposition in adults when ETco(2) may be unavailable or unreliable.

Infantile cystinosis presenting as chronic constipation.

An infant presented with persistent constipation as the first clinical symptom of cystinosis before evidence of renal Fanconi's syndrome. The history of muscle weakness, failure to thrive, polydipsia, and polyuria prompted subsequent clinical and laboratory evaluations, leading to the correct diagnosis of cystinosis. Primary and persistent constipation as an initial manifestation of cystinosis has not been reported previously. Although rare, cystinosis should be considered in the differential diagnosis of constipation if other suggestive signs or symptoms are present.