U.S. patent number 3,874,368 [Application Number 05/352,426] was granted by the patent office on 1975-04-01 for impedance plethysmograph having blocking system.
Invention is credited to Manfred Asrican.
United States Patent |
3,874,368 |
Asrican |
April 1, 1975 |
Impedance plethysmograph having blocking system
Abstract
An impedance plethysmograph has an oscillator for applying
constant current to the thorax of a patient. A detector circuit
connected to the patient provides an output corresponding to
thoracic impedance. Circuits responsive to detected impedance
provide signals corresponding to change of impedance and the first
time differential of impedance. Means are provided to block the
differential signal when it is meaningless, for example, due to
respiration.
Inventors: |
Asrican; Manfred (Greenwich,
CT) |
Family
ID: |
23385086 |
Appl.
No.: |
05/352,426 |
Filed: |
April 19, 1973 |
Current U.S.
Class: |
600/526;
600/547 |
Current CPC
Class: |
A61B
5/7239 (20130101); A61B 5/0535 (20130101) |
Current International
Class: |
A61B
5/053 (20060101); A61b 005/02 () |
Field of
Search: |
;128/2.6A,2.6B,2.6G,2.6R,2.1RB,2.1Z,2.5R |
References Cited
[Referenced By]
U.S. Patent Documents
Other References
Kubicek et al., "NASA Tech. Brief," No. 68-10220, June 1968, 2
pp..
|
Primary Examiner: Kamm; William E.
Attorney, Agent or Firm: Miller; Alfred E.
Claims
What is claimed is:
1. In a plethysmograph of the type including means for measuring an
impedance in a mammalian subject, means providing a first output
corresponding to impedance changes of said measured impedance and
means providing a second output corresponding to a time
differential of said measured impedance, the improvement comprising
a means responsive to said first output connected to inhibit said
second output when said first output exceeds a determined
magnitude.
2. In a plethysmograph for measuring cardiac output including a
source of alternating constant current, electrode means for
applying said constant current to a mammalian subject, amplifier
and detector means, further electrode means for connecting said
amplifier and detector means to the thorax region of said subject
for producing an impedance signal corresponding to thoracic
impedance, means responsive to said impedance signal for producing
a first signal corresponding to the change of said thoracic
impedance, and means responsive to said impedance signal for
producing a second signal corresponding to the first time
differential of said impedance; the improvement comprising means
responsive to the amplitude of said first signal for blocking said
second signal.
Description
The present invention relates to plethysmogragphs and particularly
to an impedance plethysmograph and process of using the same. The
invention is particularly useful in determining cardiac output.
U.S. Pat. No. 3,340,867 discloses a plethysmograph of the type to
which the present invention is directed. In accordance with this
patent, a current flux is distributed in the mammalian thorax by
the placement of electrodes at the neck and lower thorax. The
electrodes have the form of bands positioned to encircle the neck
and thorax. To these electrodes is applied a fluctuating excitation
current. The impedance of the thorax is then measured with either
the same electrodes or with different electrodes to obtain
information concerning cardiac activity and particularly cardiac
output. In accordance with this patent, the major portion of
excitation current flux is passed through the lung tissues, rather
than through the lower resistivity volume of the major thoracic
arteries veins, and the heart. Accordingly, it is possible to
measure the blood volume changes of the lungs and derive cardiac
output from the impedance changes. Impedance plethysmographic
waveforms obtained between the electrodes monitor the pulmonary
flow as reflected by impedance changes in the pulmonary vascular
bed.
In the system of this patent, the measurement of electrical
impedance changes in the thorax during application of a fluctuating
current (such as 100kc. current having RMS value of 5.0 ma.)
between electrodes placed on the surface of the thorax. This
procedure provides the advantage of minimum subject preparation and
constraint.
To verify the determination of cardiac output from impedance
measurements, an understanding of the physiological phenomena
responsible for the measured variations must be obtained. In
particular the excitation current flux paths in the thorax between
the excitation electrodes must be established.
It has been found that the only tenable theoretical flux
distribution path is that in which the majority of the current flux
passes from the band electrodes into the lung volume and tends to
avoid the heart blood volume regions. Consequently, this current
flux distribution implies that the measured impedance is an
indication of the total movement of blood in the pulmonary vascular
bed.
The impedance waveforms obtained with two band electrodes, one
positioned at the neck and the other about 2 cm. below the
xiphisternal joint reflect the pulmonary blood pulsations in the
lungs rather than the direct ventricular volume change.
Equipotential surfaces sketched from thorax potential measurements
indicated a flow of current from the blood volume regions. The
largest density of the current leaving a band electrode positioned
at the midsection of the thorax is found at the base of the lungs
on the posterior thorax. These results indicate that in an
electrode configuration including one band electrode about the neck
and another about the thorax, the majority of the current flux is
passed through the lungs, so that the major observed impedance
characteristics are controlled by the pulsating pulmonary volume
changes. The relatively accurate cardiac output determination made
by these impedance measurements are based on an indirect indication
of right ventricular stroke volume as reflected by the pulmonary
vascular bed.
In order to minimize the influence of respiratory and other effects
in the use of equipment of the above type, the first derivative of
the change in impedance of the thorax during the cardiac cycle is
generally used for computation. Thus, the normal respiration of a
patient produces periodic variation in the impedance, and the
computation on the basis of the first derivative of the impedance
can minimize the effect of such variation. Even when the first time
derivative of the impedance is employed, however, it has been found
that the best results are obtained when the subject is instructed
to hold his breath during the time that the measurements are taken.
For example, the patient may be required to hold his breath for
about six heart beats in order to avoid drift in the measurement of
the change of impedance and the first time differential of the
impedance recording. This technique of course requires that the
patient be conscious and otherwise capable of following
instructions to hold his breath during the measuring period. If the
patient is not capable of holding his breath, then great skill must
be employed in the interpretation of the recordings in order to
provide a reasonable determination of the meaning of the
recordings. In the event of erratic variation in the base
impedance, the interpretation of the recordings may be thus
exceedingly difficult if not impossible. It may be very difficult
to determine which portions of a recording produce valid results,
and which portions must be disregarded as meaningless.
In accordance with the present invention, this problem is overcome
by providing a method and apparatus for blocking out the reading of
an instrument of this type when the reading would be rendered
meaningless, for example, as a result of respiration.
The invention will now be more fully described with reference to
the accompanying drawings, in which:
FIG. 1 is a block diagram, illustrating the basic elements of an
impedance plethysmograph showing the interconnections thereof to a
human subject in use;
FIG. 2 is a block diagram of an impedance plethysmograph in
accordance with the invention;
FIG. 3 is a diagram showing a portion of a record of impedance
variation and the first time differential of the impedance for a
normal subject, in the use of an impedance plethysmograph; and
FIG. 4 is a diagram representing portion of a strip chart record
showing the impedance change and first time differential of the
impedance of a patient in which the variation of the base impedance
interferes with the interpretation of the recording.
Referring now to the drawings, and more in particular to FIG. 1, a
basis system or an impedance plethysmograph is comprised of a
constant current oscillator 10 providing, for example, a constant
sinusoidal alternating current of 4 milliamperes RMS, 100 KHz. The
output of the constant current generator 10 is connected between an
electrode 11 at the upper portion of the neck of the patient, and
an electrode 12 at the lower abdomen. The circuit also includes a
voltage pick up and detection circuit 13, the input of which is
connected between an electrode 14 at the base of the neck of the
patient, and an electrode 15 slightly below the xiphisternal joint
of the patient. The electrodes, for example, may encircle the
patient's body.
The constant current from the oscillator 10 is passed
longitudinally through the thorax of the patient between the
electrodes 11 and 12. The product of this current multiplied by the
thoracic impedance generates a voltage E=IZ.sub.o between the
electrodes 14 and 15. This voltage is picked up by the voltage pick
up and detection circuit 13, which employs a high input impedance
linear amplifier in its input stage. The circuit 13 also includes
detection, balancing, and calibration circuits, and provides the
outputs Z.sub.o ,.DELTA.Z, dz/dt. z.sub.o is the base impedance of
the thorax, and provides a direct numerical measurement of fluid
changes in the chest. .DELTA.Z represents the gross impedance
change during the cardiac cycle, and is a parameter which may be
employed in the measurement of peripheral circulation. The time
derivative dz/dt is the first derivative of .DELTA.Z, and is the
parameter which is employed in the measurement of stroke volume and
the cardiac output.
Referring now to FIG. 2, therein is illustrated a block diagram of
a circuit in accordance with the invention. The circuit is
comprised of a constant current sinusoidal oscillator 10, of
conventional nature, which is connected to the electrodes 11 and 12
as above-described. The base impedance Z.sub.o of the thorax
appears between the electrodes 13 and 14, as above-described. The
electrode 14 may be connected to a ground reference, and the
electrode 13 is connected a high input impedance AC amplifier 15.
The output of the amplifier 15 is connected to a detector 16. The
output of detector 16 is connected to a digital read-out circuit 17
which, after suitable filtering provides a digital read-out
corresponding to the base impedance Z.sub.o. The circuit 17, for
example, may comprise filtering circuits for filtering the DC
output of the detector 16, followed by an analog to digital
converter and a digital indicator. In a normal subject, the base
level indicated by the digital read-out circuit 17 will be about 25
ohms. The output of the detector 16 may also be applied to a
terminal Z.sub.o for external use.
The output of the detector 16 is also applied to an amplifier 20 by
way of a switch 21, and to a differentiator and filter circuit 22
by way of a gate circuit 23 and switch 24. The output of the
amplifier 20 is applied to a terminal .DELTA.Z, to produce an
output corresponding to the change in the impedance Z.sub.o from
its base level.
As one example, the amplifier 20 may be comprised of a differential
amplifier, the second input of which is derived from the oscillator
10 by way of a potentiometer 30, an amplifier 31, a detector 32,
and a switch 33. With this arrangement, the potentiometer 30 may be
adjusted to an impedance corresponding to the impedance of the
thorax at the base level, so that the output of the amplifier 20
reflects changes in the thoracic impedance from this level. A
system of this general type is disclosed in U.S. Pat. No.
3,340,867, for example. Alternatively, the amplifier 20 may include
a sample and hold circuit having an automatic re-set, for providing
the desired output corresponding to the difference impedance.
The differentiator and filter circuit 22 is of conventional nature,
and provides an output at the terminal dz/dt corresponding to the
first time differential of the base impedance.
In addition, the circuit of FIG. 2 includes a calibration generator
40 for generating calibration signals for the .DELTA.Z and dz/dt
outputs. The nature of the calibration signal will be more fully
disclosed in the following paragraphs. One output of the
calibration generator 40 is applied to the amplifier 20 by way of
the switches 21 and 33, and another output of the calibration
generator is applied to the differentiator and filter circuit 22 by
way of the switch 24.
The above-described circuit, with the exception of the gate 23, is
conventional, and has been employed in the past for the measurement
of thoracic impedance.
FIG. 3 illustrates a portion of a strip chart recording of the
outputs dz/dt and .DELTA.Z from the arrangement of FIG. 2 with a
normal subject. Trace 50, corresponding to the change of impedance
Z.sub.o from its base level, is shown with a constant base line,
i.e., without the influence of respiratory or other effects. The
vertically extending portions 51 of this curve correspond to the
maximum decreasing impedance slope during systole. The pulmonary
flow rate is a function of the rate of change of impedance, and
hence of the slope of the portions 51 of the curve 50. This slope
is determined by differentiating the impedance Z.sub.o, for example
in the circuit 22 of FIG. 2, to provide the wave form 53. The
amplitude of the peaks 54 from a calibration base line 55 thus
corresponds to the pulmonary flow rate.
The curves 50 and 53 are typical curves obtained in operation of
the instrument, and these curves are shown to the left of a
vertical line 56, representing an arbitrary time at which the
switches 21, 24, and 33 were switched from their operating
position, as shown in FIG. 2, to the output of the calibration
generator 40. As illustrated to the right of the line 56, the
calibration signal for the .DELTA.Z amplifier, which will be
generally unchanged in shape from the output thereof, consists of a
series of pulses 57 having leading edges with calibrated slopes.
Since the normal variation of impedance is around 0.1 ohm, the
pulses 57 have amplitudes corresponding to such value. The
calibration signal establishes a base line 59 corresponding to the
base impedance. Pulses similar to the pulses 57 are applied to the
differentiator and filter circuit 42, whereby the output of this
circuit has a wave form 61 with pulses 62 having amplitudes
corresponding to the slope of the leading edges of the pulses 57.
For example, the amplitudes of the pulses 62 may correspond to an
impedance change rate of one ohm per second. The curve 61 also
establishes the base line 55 for the curve 53.
As above stated, in the normal process of taking measurements with
an impedance plethysmograph, the patient is instructed to hold his
breath, for example for six heart beats, in order that variations
of the base impedance, for example, due to respiration, do not
interfere with the output of the device. In the presence of
respiration, the curve 50 corresponding to the change of impedance
is superimposed on a cyclically varying base which may correspond
to impedance changes greater than those resulting from pulmonary
flow. As a consequence, the slope of the impedance change during
each systole will not correspond exactly to the pulmonary flow
rate, and the amplitudes of the pulses 54 will consequently not
accurately correspond to the flow rate. While this effect may be
minimized by having the patient hold his breath, some
interpretation may still be necessary by the operator to ascertain
which of the pulses 54 provide an accurate indication of the flow
rate. While this technique is of course possible when a patient is
conscious and able to understand and follow instructions to hold
his breath, it is of course impossible when the patient is not
capable of holding his breath in this manner. In such cases, in the
past, it has been necessary to employ great skill in interpretation
of the recording in order to ascertain the flow rate. In some
cases, particularly when the variations in the base line were
erratic, it has not been possible to ascertain the pulmonary flow
rate with any degree of accuracy. A portion of a strip chart
recording of an abnormal patient is illustrated in FIG. 4. In this
figure, the curve 50 corresponding to the change of impedance has
been superimposed upon a base line of unknown or erratic variation,
so that it is difficult to visually pick out the portions of the
curve corresponding to a systole. The curve 53, due to the
variations in slopes of the curve 50 resulting from the variation
in the base line, therefore exhibits peaks 54 of widely differing
amplitudes. The selection of the peaks 54 corresponding to the true
pulmonary flow rate is consequently difficult.
In order to overcome this problem, in accordance with the
invention, means are provided for blocking the presentation of a
recording corresponding to the dz/dt signal whenever this signal
has a meaningless value. Specifically, the signal is difficult to
interpret whenever the base line upon which the difference
impedance .DELTA.Z is superimposed exceeds a given value.
Therefore, in accordance with the invention, referring to FIG. 2, a
threshold circuit 65 is provided connected to the output of the
amplifier 20, for providing an output signal whenever the output
thereof exceeds a given value. The circuit 65, may for example, be
Schmitt trigger circuit. Since it is desirable to block out the
dz/dt signal for the entire stroke, the output of the threshold
circuit 65 may be applied to a gate generator circuit 66, for
example monostable multivibrator. The output of the gate generator
66 is applied as a control signal to the gate 23, to thereby block
the gate 23 upon the occurrence of a signal input to the threshold
circuit exceeding the determined value. As a consequence, whenever
the base line has fluctuated to an extent such that the output of
the differentiator and filter circuit 22 would be meaningless or
difficult to interpret, this output is blocked by the gate 23, and
hence the output appears merely as a straight line. The operator is
then presented only with a recording that is sufficiently accurate
to be subject to correct interpretation without difficulty.
While the invention has been disclosed and described with reference
to a single embodiment, it will be apparent that many variations
and modifications may be made therein within the scope of the
invention, and it is therefore intended in the following claims to
cover each such variation and modification as falls within the true
spirit and scope of the invention.
* * * * *