Design and Comparative Performance of a Robust Lung Auscultation System for Noisy Clinical Settings.

Chest auscultation is a widely used clinical tool for respiratory disease detection. The stethoscope has undergone a number of transformative enhancements since its invention, including the introduction of electronic systems in the last two decades. Nevertheless, stethoscopes remain riddled with a number of issues that limit their signal quality and diagnostic capability, rendering both traditional and electronic stethoscopes unusable in noisy or non-traditional environments (e.g., emergency rooms, rural clinics, ambulatory vehicles). This work outlines the design and validation of an advanced electronic stethoscope that dramatically reduces external noise contamination through hardware redesign and real-time, dynamic signal processing. The proposed system takes advantage of an acoustic sensor array, an external facing microphone, and on-board processing to perform adaptive noise suppression. The proposed system is objectively compared to six commercially-available acoustic and electronic devices in varying levels of simulated noisy clinical settings and quantified using two metrics that reflect perceptual audibility and statistical similarity, normalized covariance measure (NCM) and magnitude squared coherence (MSC). The analyses highlight the major limitations of current stethoscopes and the significant improvements the proposed system makes in challenging settings by minimizing both distortion of lung sounds and contamination by ambient noise.

Electronic Stethoscope Filtering Mimics the Perceived Sound Characteristics of Acoustic Stethoscope.

Electronic stethoscopes offer several advantages over conventional acoustic stethoscopes, including noise reduction, increased amplification, and ability to store and transmit sounds. However, the acoustical characteristics of electronic and acoustic stethoscopes can differ significantly, introducing a barrier for clinicians to transition to electronic stethoscopes. This work proposes a method to process lung sounds recorded by an electronic stethoscope, such that the sounds are perceived to have been captured by an acoustic stethoscope. The proposed method calculates an electronic-to-acoustic stethoscope filter by measuring the difference between the average frequency responses of an acoustic and an electronic stethoscope to multiple lung sounds. To validate the method, a change detection experiment was conducted with 51 medical professionals to compare filtered electronic, unfiltered electronic, and acoustic stethoscope lung sounds. Participants were asked to detect when transitions occurred in sounds comprising several sections of the three types of recordings. Transitions between the filtered electronic and acoustic stethoscope sections were detected, on average, by chance (sensitivity index equal to zero) and also detected significantly less than transitions between the unfiltered electronic and acoustic stethoscope sections ( ), demonstrating the effectiveness of the method to filter electronic stethoscopes to mimic an acoustic stethoscope. This processing could incentivize clinicians to adopt electronic stethoscopes by providing a means to shift between the sound characteristics of acoustic and electronic stethoscopes in a single device, allowing for a faster transition to new technology and greater appreciation for the electronic sound quality.

Digital auscultation in PERCH: Associations with chest radiography and pneumonia mortality in children.

BACKGROUND: Whether digitally recorded lung sounds are associated with radiographic pneumonia or clinical outcomes among children in low-income and middle-income countries is unknown. We sought to address these knowledge gaps. METHODS: We enrolled 1 to 59monthold children hospitalized with pneumonia at eight African and Asian Pneumonia Etiology Research for Child Health sites in six countries, recorded digital stethoscope lung sounds, obtained chest radiographs, and collected clinical outcomes. Recordings were processed and classified into binary categories positive or negative for adventitial lung sounds. Listening and reading panels classified recordings and radiographs. Recording classification associations with chest radiographs with World Health Organization (WHO)-defined primary endpoint pneumonia (radiographic pneumonia) or mortality were evaluated. We also examined case fatality among risk strata. RESULTS: Among children without WHO danger signs, wheezing (without crackles) had a lower adjusted odds ratio (aOR) for radiographic pneumonia (0.35, 95% confidence interval (CI): 0.15, 0.82), compared to children with normal recordings. Neither crackle only (no wheeze) (aOR: 2.13, 95% CI: 0.91, 4.96) or any wheeze (with or without crackle) (aOR: 0.63, 95% CI: 0.34, 1.15) were associated with radiographic pneumonia. Among children with WHO danger signs no lung recording classification was independently associated with radiographic pneumonia, although trends toward greater odds of radiographic pneumonia were observed among children classified with crackle only (no wheeze) or any wheeze (with or without crackle). Among children without WHO danger signs, those with recorded wheezing had a lower case fatality than those without wheezing (3.8% vs. 9.1%, p = .03). CONCLUSIONS: Among lower risk children without WHO danger signs digitally recorded wheezing is associated with a lower odds for radiographic pneumonia and with lower mortality. Although further research is needed, these data indicate that with further development digital auscultation may eventually contribute to child pneumonia care.

Computerized Lung Sound Screening for Pediatric Auscultation in Noisy Field Environments.

GOAL: Chest auscultations offer a non-invasive and low-cost tool for monitoring lung disease. However, they present many shortcomings, including inter-listener variability, subjectivity, and vulnerability to noise and distortions. This work proposes a computer-aided approach to process lung signals acquired in the field under adverse noisy conditions, by improving the signal quality and offering automated identification of abnormal auscultations indicative of respiratory pathologies. METHODS: The developed noise-suppression scheme eliminates ambient sounds, heart sounds, sensor artifacts, and crying contamination. The improved high-quality signal is then mapped onto a rich spectrotemporal feature space before being classified using a trained support-vector machine classifier. Individual signal frame decisions are then combined using an evaluation scheme, providing an overall patient-level decision for unseen patient records. RESULTS: All methods are evaluated on a large dataset with 1000 children enrolled, 1-59 months old. The noise suppression scheme is shown to significantly improve signal quality, and the classification system achieves an accuracy of 86.7% in distinguishing normal from pathological sounds, far surpassing other state-of-the-art methods. CONCLUSION: Computerized lung sound processing can benefit from the enforcement of advanced noise suppression. A fairly short processing window size (  s) combined with detailed spectrotemporal features is recommended, in order to capture transient adventitious events without highlighting sharp noise occurrences. SIGNIFICANCE: Unlike existing methodologies in the literature, the proposed work is not limited in scope or confined to laboratory settings: This work validates a practical method for fully automated chest sound processing applicable to realistic and noisy auscultation settings.

Listening panel agreement and characteristics of lung sounds digitally recorded from children aged 1-59 months enrolled in the Pneumonia Etiology Research for Child Health (PERCH) case-control study.

INTRODUCTION: Paediatric lung sound recordings can be systematically assessed, but methodological feasibility and validity is unknown, especially from developing countries. We examined the performance of acoustically interpreting recorded paediatric lung sounds and compared sound characteristics between cases and controls. METHODS: Pneumonia Etiology Research for Child Health staff in six African and Asian sites recorded lung sounds with a digital stethoscope in cases and controls. Cases aged 1-59 months had WHO severe or very severe pneumonia; age-matched community controls did not. A listening panel assigned examination results of normal, crackle, wheeze, crackle and wheeze or uninterpretable, with adjudication of discordant interpretations. Classifications were recategorised into any crackle, any wheeze or abnormal (any crackle or wheeze) and primary listener agreement (first two listeners) was analysed among interpretable examinations using the prevalence-adjusted, bias-adjusted kappa (PABAK). We examined predictors of disagreement with logistic regression and compared case and control lung sounds with descriptive statistics. RESULTS: Primary listeners considered 89.5% of 792 case and 92.4% of 301 control recordings interpretable. Among interpretable recordings, listeners agreed on the presence or absence of any abnormality in 74.9% (PABAK 0.50) of cases and 69.8% (PABAK 0.40) of controls, presence/absence of crackles in 70.6% (PABAK 0.41) of cases and 82.4% (PABAK 0.65) of controls and presence/absence of wheeze in 72.6% (PABAK 0.45) of cases and 73.8% (PABAK 0.48) of controls. Controls, tachypnoea, >3 uninterpretable chest positions, crying, upper airway noises and study site predicted listener disagreement. Among all interpretable examinations, 38.0% of cases and 84.9% of controls were normal (p<0.0001); wheezing was the most common sound (49.9%) in cases. CONCLUSIONS: Listening panel and case-control data suggests our methodology is feasible, likely valid and that small airway inflammation is common in WHO pneumonia. Digital auscultation may be an important future pneumonia diagnostic in developing countries.

Adaptive Noise Suppression of Pediatric Lung Auscultations With Real Applications to Noisy Clinical Settings in Developing Countries.

GOAL: Chest auscultation constitutes a portable low-cost tool widely used for respiratory disease detection. Though it offers a powerful means of pulmonary examination, it remains riddled with a number of issues that limit its diagnostic capability. Particularly, patient agitation (especially in children), background chatter, and other environmental noises often contaminate the auscultation, hence affecting the clarity of the lung sound itself. This paper proposes an automated multiband denoising scheme for improving the quality of auscultation signals against heavy background contaminations. METHODS: The algorithm works on a simple two-microphone setup, dynamically adapts to the background noise and suppresses contaminations while successfully preserving the lung sound content. The proposed scheme is refined to offset maximal noise suppression against maintaining the integrity of the lung signal, particularly its unknown adventitious components that provide the most informative diagnostic value during lung pathology. RESULTS: The algorithm is applied to digital recordings obtained in the field in a busy clinic in West Africa and evaluated using objective signal fidelity measures and perceptual listening tests performed by a panel of licensed physicians. A strong preference of the enhanced sounds is revealed. SIGNIFICANCE: The strengths and benefits of the proposed method lie in the simple automated setup and its adaptive nature, both fundamental conditions for everyday clinical applicability. It can be simply extended to a real-time implementation, and integrated with lung sound acquisition protocols.

Developing a reference of normal lung sounds in healthy Peruvian children.

PURPOSE: Lung auscultation has long been a standard of care for the diagnosis of respiratory diseases. Recent advances in electronic auscultation and signal processing have yet to find clinical acceptance; however, computerized lung sound analysis may be ideal for pediatric populations in settings, where skilled healthcare providers are commonly unavailable. We described features of normal lung sounds in young children using a novel signal processing approach to lay a foundation for identifying pathologic respiratory sounds. METHODS: 186 healthy children with normal pulmonary exams and without respiratory complaints were enrolled at a tertiary care hospital in Lima, Peru. Lung sounds were recorded at eight thoracic sites using a digital stethoscope. 151 (81%) of the recordings were eligible for further analysis. Heavy-crying segments were automatically rejected and features extracted from spectral and temporal signal representations contributed to profiling of lung sounds. RESULTS: Mean age, height, and weight among study participants were 2.2 years (SD 1.4), 84.7 cm (SD 13.2), and 12.0 kg (SD 3.6), respectively; and, 47% were boys. We identified ten distinct spectral and spectro-temporal signal parameters and most demonstrated linear relationships with age, height, and weight, while no differences with genders were noted. Older children had a faster decaying spectrum than younger ones. Features like spectral peak width, lower-frequency Mel-frequency cepstral coefficients, and spectro-temporal modulations also showed variations with recording site. CONCLUSIONS: Lung sound extracted features varied significantly with child characteristics and lung site. A comparison with adult studies revealed differences in the extracted features for children. While sound-reduction techniques will improve analysis, we offer a novel, reproducible tool for sound analysis in real-world environments.

Characterization of noise contaminations in lung sound recordings.

Lung sound auscultation in non-ideal or busy clinical settings is challenged by contaminations of environmental noise. Digital pulmonary measurements are inevitably degraded, impeding the physician's work or any further processing of the acquired signals. The task is even harder when the patient population includes young children. Agitation and/or crying are captured into the recordings, additionally to any existing ambient noise. This study focuses on characterizing the different types of signal contaminations, expected to be encountered during lung sound measurements in non-ideal environments. Different noise types were considered, including background talk, radio playing, subject's crying, electronic interference sounds and stethoscope displacement artifacts. The individual characteristics were extracted, discussed and further compared to characteristics of clean segments. Additional exploration of discriminatory features led to a spectro-temporal signal representation followed by a standard SVM classifier. Although pulmonary and ambient sounds were both dominant in most sound clips, such a complex representation was deemed to be adequate, capturing most of the signal's distinguishing characteristics.

A multiresolution analysis for detection of abnormal lung sounds.

Automated analysis and detection of abnormal lung sound patterns has great potential for improving access to standardized diagnosis of pulmonary diseases, especially in low-resource settings. In the current study, we develop signal processing tools for analysis of paediatric auscultations recorded under non-ideal noisy conditions. The proposed model is based on a biomimetic multi-resolution analysis of the spectro-temporal modulation details in lung sounds. The methodology provides a detailed description of joint spectral and temporal variations in the signal and proves to be more robust than frequency-based techniques in distinguishing crackles and wheezes from normal breathing sounds.

Decision support in heart failure through processing of electro- and echocardiograms.

OBJECTIVE: Signal and imaging investigations are currently key components in the diagnosis, prognosis and follow up of heart diseases. Nowadays, the need for more efficient, cost-effective and personalised care has led to a renaissance of clinical decision support systems (CDSSs). The purpose of this paper is to present an effective way of achieving a high-level integration of signal and image processing methods in the general process of care, by means of a clinical decision support system, and to discuss the advantages of such an approach. From the wide range of heart diseases, heart failure, whose complexity best highlights the benefits of this integration, has been selected. METHODS: After an analysis of users' needs and expectations, significant and suitably designed image and signal processing algorithms are introduced to objectively and reliably evaluate important features involved in decisional problems in the heart failure domain. Then, a CDSS is conceived so as to combine the domain knowledge with advanced analytical tools for data processing. In particular, the relevant and significant medical knowledge and experts' knowhow are formalised according to an ontological formalism, suitably augmented with a base of rules for inferential reasoning. RESULTS: The proposed methods were tested and evaluated in the daily practice of the physicians operating at the Department of Cardiology, University Magna Graecia, Catanzaro, Italy, on a population of 79 patients. Different scenarios, involving decisional problems based on the analysis of biomedical signals and images, were considered. In these scenarios, after some training and 3 months of use, the CDSS was able to provide important and useful suggestions in routine workflows, by integrating the clinical parameters computed through the developed methods for echocardiographic image segmentation and the algorithms for electrocardiography processing. CONCLUSIONS: The CDSS allows the integration of signal and image processing algorithms into the general process of care. Feedback from end-users has been positive.

The morphological classification of heartbeats as dominant and non-dominant in ECG signals.

Surface electrocardiography (ECG) is the art of analyzing the heart's electrical activity by applying electrodes to certain positions on the body and measuring potentials at the body surface resulting from this electrical activity. Usually, significant clinical information can be obtained from analysis of the dominant beat morphology. In this respect, identification of the dominant beats and their averaging can be very helpful, allowing clinicians to carry out the measurement of amplitudes and intervals on a beat much cleaner from noise than a generic beat selected from the entire ECG recording. In this paper a standard clustering algorithm for the morphological grouping of heartbeats has been analyzed based on K-means, different signal representations, distance metrics and validity indices. The algorithm has been tested on all the records of the MIT-BIH Arrhythmia Database (MIT-BIH AD) obtaining satisfying performances in terms of averaged dominant beat estimation, but the results have not been fully satisfactory in terms of sensitivity and specificity. In order to improve the clustering accuracy, an ad hoc algorithm based on a two-phase decision tree, which integrates additional specific knowledge related to the ECG domain, has been implemented. Similarity features extracted from every beat have been used in the decision trees for the identification of different morphological classes of ECG beats. The results, in terms of dominant beat discrimination, have been evaluated on all annotated beats of the MIT-BIH AD with sensitivity = 99.05%, specificity = 93.94%, positive predictive value = 99.32% and negative predictive value = 91.69%. Further tests have shown a very slight decrement of the performances on all detected beats of the same database using an already published QRS detector, demonstrating the validity of the algorithm in real unsupervised clustering situations where annotated beat positions are not available but beats are detected with a high-performance beat detector.