Abstract:
An improvement to a breathing therapy machine to detect and rate occurrences of periodic breathing and to alter the therapy delivered to a user of the device based on the rating.

Description:
FIELD OF THE INVENTION 
       [0001]    This invention relates generally to the field of breathing therapy machines of the type used to treat obstructive and/or central sleep disorders and specifically to the treatment of such sleep disorders when periodic breathing patterns are detected. 
       BACKGROUND OF THE INVENTION 
       [0002]    The term “periodic breathing” describes a respiratory pattern in which clusters of breaths exhibit a waxing and waning of the amplitude of the tidal volume of ventilation in a cyclic pattern, typically with a period of one minute or less, causing the subject to oscillate between hyperpnea and hypopnea with a crescendo-decrescendo pattern. Cyclic patterns with periods greater than one minute typically indicate a high likelihood of impaired cardiac systolic or diastolic function. In a more extreme version the clusters of breaths may be separated by periods of apnea, instead of hypopnea. Frequently the hypopneic or apneic episodes of periodic breathing contain both obstructive and central events. 
         [0003]    Although the exact cause of periodic breathing in adults has not been firmly established, it is thought that the cause may be related to excessive loop gain in the feedback control involved in the regulation of respiratory drive. In adults, periodic breathing is considered abnormal, and is often associated with subjects having neurologic dysfunction or heart failure. 
         [0004]    During CPAP therapy, detection of periodic breathing is crucial, as it may be desirable to alter the therapy delivered to the subject if periodic breathing is present. For example, a normal reaction to the detection of an obstructive apnea may be to gradually raise the pressure delivered to the subject until the apneas are eliminated or converted to hypopneas. However, this rise in pressure can actually aggravate a periodic breathing respiratory pattern. Thus, it may be desirable to alter the treatment delivered by the device when periodic breathing is detected. 
         [0005]    Current prior art devices are somewhat adept in detecting periodic breathing, but they lack sensitivity and the ability to distinguish between mild periodic breathing and severe periodic breathing. Therefore, it would be desirable to be able to detect periodic breathing with more sensitivity and to be able to distinguish between mild and severe periodic breathing such that delivered therapy may be adjusted accordingly. 
       SUMMARY OF THE INVENTION 
       [0006]    Detecting periodic breathing in a subject using a breathing therapy device is useful to ensure proper pressure therapy is administered to the subject, and to determine the ongoing suitability of breathing therapy for the subject. Periodic breathing exists in a range of patterns from obvious, almost mechanical rhythmic patterns to more visually obscure and less self-similar patterns which are nevertheless still biologically significant for the subject. The goal of the present invention is to detect periodic breathing with a sensitivity that detects a broad range of periodic breathing, from less obvious marginal periodic breathing to the obvious ‘text book’ periodic breathing, and to categorize the periodic breathing in multiple classes of severity, which is also useful in determining the overall severity of the subject&#39;s propensity to exhibit this pattern. 
         [0007]    The method of the present invention uses numerous signal processing techniques to detect periodic breathing patterns. Hilbert transforms are used to calculate analytical representations of a plurality of breathing measures. Ranking filters are used to remove “momentary” discontinuities in the periodic breathing crescendo/decrescendo signal, which allows periodic breathing detection to span across discontinuities in phase due to arousals. The method also grades the severity of the detected periodic breathing (none, mild, moderate, severe). 
         [0008]    The result is a method of detecting periodic breathing which is more sensitive than existing prior art methods. In addition, an apparatus consisting of a breathing therapy device implementing the method is also presented, which is capable of altering the therapy strategy based on the rated severity of the detected periodic breathing. 
     
    
     
       DESCRIPTION OF DRAWINGS 
         [0009]      FIG. 1   a  shows an example of generalized periodic breathing.  FIG. 1   b  shows an example of periodic breathing which would be classified as Cheyne-Stokes respiration. 
           [0010]      FIGS. 2-5  show a flow chart of the method of the present invention. 
           [0011]      FIG. 6  is a block diagram of a breathing therapy machine of the type in which the method of the present invention would be implemented. 
           [0012]      FIG. 7  shows various intermediate waveforms generated by the method of the present invention. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0013]    The method of the present invention would typically be implemented as firmware in a breathing therapy device, such as a CPAP or Bi-PAP machine of the type shown in  FIG. 6 . Referring now to  FIG. 6 , there is shown a typical breathing gas delivery system. The breathing gas delivery system comprises a processor  10  having control software/firmware  12  stored in local memory. Motor control system  14  controls the speed of blower  16  under the control of processor  10 . Flow element  18  is connected to a patient interface (not shown) for the delivery of pressurized airflow. Mass flow sensor  20  senses the total flow (tidal volume) through flow element  18 , and pressure sensor  22  detects the system pressure. Both flow sensor  20  and pressure sensor  22  interface with processor  10  to provide feedback regarding the patient&#39;s breathing patterns. Using interface  24  allows a patient and/or therapist to control the device. 
         [0014]    The method of detecting periodic breathing will be described in reference to  FIGS. 2-5 . Now with reference to  FIG. 2 , in Step  1  of the process, in box  101 , raw total flow rate data from flow sensor  20  is sampled and A/C coupled. A Butterworth 2nd order, high-pass filter is applied to remove residual DC, which may be present due to bias flow and leakage, and which would interfere with subsequent signal processing steps. This results in a signal representing the patient flow data sampled at 250 Hz and labeled “A” on  FIG. 2 . An exemplary wave form of patient flow data can be  FIG. 7 , Reference “A”. 
         [0015]    In Step  2  of the process in  FIG. 2 , the patient flow signal is decimated or down-sampled to create a waveform more suitable for analytical processing. For example, the 250 Hz waveform may be down sampled at 32 Hz. At box  201 , the data is sampled at the lower rate and at box  202 , an additional high-pass filter is applied to filter out any additional DC that may be present. 
         [0016]    In Step  3  of the process in  FIG. 2 , the breathing signal is again down-sampled and filtered via a two point accumulator filter and a Butterworth 2nd order band pass filter is applied at boxes  301  with normal respiration upper and lower limit rates. In a preferred embodiment of the invention, the low-pass filter has a cut-off frequency of 1.25 Hz and the high-pass filter has a cut-off frequency of 0.2 Hz. This results in signal B, which is fed into Step  4  of the process, shown in  FIG. 3 . 
         [0017]    In Step  4  of the process, shown in  FIG. 3 , the true respiration is computed utilizing signal B as the input. Signal B is down sampled at 16 Hz in box  401  and the Hilbert Transformation is applied in box  402 . 2 The Hilbert Transformation applied in box  402  produces the envelope of respiration and represents the power of the respiration itself. This signal represents a continuous tidal volume. Further filtering is applied in box  403 , resulting in a signal that represents the true respiration power, which is used as input to Step  5  of the process. 
         [0018]    In Step  5  of the process, also shown in  FIG. 3 , the respiration power signal is again down-sampled using a four point accumulator, and the respiration power envelope is computed via a 7.5 second moving average. An example of this signal, labeled “C” in  FIG. 3 , is shown in  FIG. 7  as Reference C, and represents a true measure of respiration (in L/Min). Signal “D” is also produced in Step  5  of the process and is used as an input for Step  6 . 
         [0019]    In Step  6  of the process, shown in  FIG. 4 , signal “D” is used to create a second respiration power signal to be used as a long-term respiration reference signal. The signal is again down-sampled at box  601  and filtered at box  602 . The result is shown as signal “F” in  FIG. 4  and a example if this signal is shown in  FIG. 7  as Reference “F”. 
         [0020]    In Step  7  of the process, through a series of ranking filters and further band-pass filtering in the range of expected cyclic waning and waxing cycles, a ratio of a fast moving average vs. a slow moving average is computed resulting in a signal with normalized amplitude (and therefore adaptive to amplitude) representing waxing/waning cycles of periodic breathing. Referring to Step  7  on  FIG. 4 , the small moving average is calculated by boxes  701  and takes as input Signal “F” from Step  6 . The fast moving average is computed by boxes  702  using Signal C produced by Step  5  of the process. The ratio is calculated at box  703  and represents the normalized amplitude Signal “G”, which is utilized as an input to Step  8   a  and an example of which is shown in  FIG. 7  as Reference “G”. This signal represents the crescendo and decrescendo pattern of the patient flow signal A as a sine-like waveform. The presence of the sine-like waveform represents periods of periodic breathing. It can be seen in  FIG. 7  that the sine-like waveform goes away during the period of normal breathing shown in Signal “A”. 
         [0021]    In Step  8   a , also shown on  FIG. 4 , the true waxing and waning power is computed as the envelope of the normalized amplitude Signal “G” via the application of a Hilbert Transform in box  801 . This signal is shown as Signal “H” in  FIG. 4  and an example of this signal is shown in  FIG. 7  as Reference “H”. Signal “H” is used as an input to Step  9  of the process to compute the severity of the periodic breathing. It should be noted that the higher the value of this signal, the higher the severity of the periodic breathing. 
         [0022]    In Step  8   b  of the process, also shown in  FIG. 5 , a moving cyclic variance calculation is performed on the normalized amplitude to Signal “G” to create an analytical representation of cyclic regularity. This is shown as Signal “I” in  FIG. 7  and represents the variance in the zero crossings between the sign-like waveform of Signal “G” and a true sine waveform. In general, the lower this number, the more regular the periodic breathing. 
         [0023]    In Step  9  of the process, also shown in  FIG. 5 , the two input signals, namely the crescendo-decrescendo envelope Signal “H” and the crescendo-decrescendo zero crossing variance Signal “I” are input to a minimal distance statistical classification technique that classifies the inputs with four degrees of periodic breathing. (i.e., none, mild, moderate and severe). The final output signal of the process is shown as Signal “J” in  FIG. 7 . In this particular case, during the periods of patient flow data shown as Signal “A” in  FIG. 7 , the algorithm has rated the periodic breathing as moderate, while the regular breathing is noted as having no periodic breathing component. 
         [0024]    The calculation of the rating of the severity of the periodic breathing used as Signal “H” (the crescendo-decrescendo envelope) and Signal “I” (the crescendo-decrescendo zero crossing variance) as inputs. For each of these signals, a band of values is defined representing each of the four categories of the severity of periodic breathing. The membership of each data point from Signals H and I are analyzed using a minimal distance estimation technique, which is a statistical method for fitting a mathematical model to empirical data. The algorithm may be tweaked by changing the values that define the bands for Signals H and I. In general, the larger the value for the crescendo-decrescendo envelope (Signal H) and the lower the crescendo-decrescendo zero crossing variance (Signal I), the more severe and/or the more likelihood of period breathing being present. 
         [0025]    The Applicants note that the algorithm presented is optimized for one minute cycles. However, this can be easily changed by varying the parameters of the filtering which is applied to the signals. Also note that in the preferred embodiment of the invention, Butterworth 2nd order filters are used throughout, however, any other type of filter producing a suitable result may be used. In addition, the cutoff values for the filters have been selected to capture the vast majority of periodic breathing scenarios. 
         [0026]    Also, as part of this invention, as implemented in a breathing therapy machine, the therapy pressure may be varied based upon the detection of periodic breathing. For example, if periodic breathing is determined to be mild and respiratory events are detected, then the machine may not respond to the respiratory events by increasing pressure. Therefore, when obstructive apnea, for example is detected, when it is time to make a pressure change decision, if periodic breathing is also present, no increases in pressure may be implemented. In the event that the periodic breathing transitions to moderate or severe, if it stays there for a minimum period of time, then the therapy pressure may be dropped. As it is known that increased pressure may aggravate periodic breathing. The actual method of altering the therapy pressure based upon the presence or lack thereof of periodic breathing may be tweaked based upon desired outcomes. However, the decision to change or not change the therapy pressure utilizes the presence or lack thereof of the periodic breathing as an input to that decision. 
         [0027]    Although a specific embodiment of the process has been described herein, it should be realized by one of skill in the art that many implementations are possible which would fall within the scope of the invention, which is represented by the following claims.