# Patent

## Title
Multimode device and method for controlling breathing

## Abstract

A device and method is provided for therapeutic stimulating, augmenting, manipulating and/or controlling breathing, in combination with stimulation of auxiliary respiratory nerves or muscles including the upper airway tract, chest wall muscles or abdominal muscles. Stimulation may be provided, for example, to augment breathing or to prevent closing of the upper airway during therapeutic stimulation. Stimulation may be also provided to the Hypoglossal nerve during exhalation.

## Background
RELATED APPLICATION DATA
This application is a continuation in part of U.S. application Ser. No. 11/271,726 filed Nov. 10, 2005 which is a continuation in part of U.S. application Ser. No. 10/966,484 filed Oct. 15, 2004; U.S. application Ser. No. 10/966,474, filed Oct. 15, 2004; U.S. application Ser. No. 10/966,421, filed Oct. 15, 2004; and U.S. application Ser. No. 10/966,472 filed Oct. 15, 2004 which are continuations in part of U.S. application Ser. No. 10/686,891 filed Oct. 15, 2003 entitled: BREATHING DISORDER DETECTION AND THERAPY DELIVERY DEVICE AND METHOD.


FIELD OF THE INVENTION
This invention relates to a device and method for treating respiratory and related disorders.
BACKGROUND OF THE INVENTION
There are several factors believed to contribute to the occurrence of obstructive respiratory events including anatomical deficiencies, deformities or conditions that increase the likelihood or occurrence of upper airway collapse; ventilatory instability; and fluctuations in lung volumes. There is believed to be a relationship between lung volume and the aperture of the upper airway with larger lung volume leading to greater upper airway patency.
Some obstructive sleep apnea (OSA) patients have increased upper airway resistance and collapsibility that may contribute to vulnerability to obstructive respiratory events. The pharyngeal airway is not supported by bone or cartilaginous structure and accordingly relies on contraction of the upper airway dilator muscles to maintain patency. The pharyngeal airway represents a primary site of upper airway closure.
Some OSA therapy has been based on a belief that OSA results from the size and shape of the upper airway muscles or conditions such as obesity that create a narrowing of the upper air passageway and a resulting propensity for its collapse.
In patients with obstructive sleep apnea, various treatment methods and devices have been used with very limited success.
CPAP machines have been used to control obstructive sleep apnea by creating a continuous positive airway pressure (CPAP) at night. External ventilatory control has been proposed including sensors that sense a cessation of breathing to determine when an obstructive sleep apnea event is occurring.
An implantable stimulator that stimulates the hypoglossal nerve after sensing an episode of obstructive sleep apnea has been proposed but has failed to provide satisfactory results in OSA patients.
Treating OSA has primarily relied on continuous treatment or detection of an obstructive respiratory event when it is occurring, i.e., when the upper air passageway has closed.
Drug therapy has not provided satisfactory results.
In central sleep apnea, as opposed to obstructive sleep apnea, it has been proposed to stimulate a patient's diaphragm or phrenic nerve to induce breathing where there is a lack of central respiratory drive. However, such therapy has be contraindicated for obstructive sleep apnea or respiratory events where there is an obstructive component, at least in part because stimulating a patient to breathe when the airway is obstructed is believed to further exacerbate the collapsing of the airway passage by creating a pressure that further closes the airway.
Accordingly, it would be desirable to provide an improved device and method for treating OSA.
It would also be desirable to provide treatment for various other respiratory and related disorders.
SUMMARY OF THE INVENTION
The present invention provides a novel approach to treating obstructive sleep apnea and other respiratory related disorders or conditions.
In accordance with one aspect of the invention, in a patient diagnosed with obstructive sleep apnea, tissue associated with the diaphragm or phrenic nerve is electrically stimulated to prevent obstructive respiratory events.
In accordance with one aspect of the invention stimulation of the diaphragm or phrenic nerve is provided to such obstructive sleep apnea patients to reduce the occurrence of upper airway collapse or upper airway flow limitation.
In accordance with one aspect of the invention, a device and method for increasing functional residual capacity (i.e., end expiratory lung volume) is provided.
In accordance with one aspect of the invention, a device and method for increasing upper airway patency is provided.
In accordance with one aspect of the invention, a device and method are provided for providing ventilatory stability in an obstructive sleep apnea patient.
In accordance with one aspect of the invention, an indicator of an impending obstructive respiratory event is detected prior to event onset.
In accordance with one aspect of the invention, a method for mitigating (i.e., preventing or lessening) obstructive respiratory events is provided.
In accordance with one aspect of the invention, a method and device is provided for synchronizing stimulation with one or more portions of an intrinsic breathing cycle.
In accordance with one aspect of the invention, a device and method for eliciting deep inspiration while avoiding airway closure are provided.
In accordance with one aspect of the invention, a device and method for normalizing peak flow while increasing tidal volume are provided.
In accordance with one aspect of the invention, a device and method for manipulating exhalation are provided.
In accordance with one aspect of the invention, a device and method for entraining breathing are provided.
In accordance with another aspect of the invention, a device detects when an obstruction has occurred to a particular extent and refrains from stimulating if the collapse has occurred to a particular extent.
In accordance with another aspect of the invention, a low level of stimulation is provided for therapeutic effects.
In accordance with another aspect of the invention, a low level of stimulation to the diaphragm or phrenic nerve is provided through or after airway closure to speed up airway opening and reduce arousal.
In accordance with another aspect of the invention respiration is controlled by causing a diaphragm response in coordination with activation of muscles associated with an upper airway of a subject.
In accordance with another object of the invention diaphragm stimulation therapy is augmented or optimized by activating the upper airway muscles to improve tonicity of the airway during the diaphragm stimulation.
In accordance with another aspect of the invention, a device is provided that will take over for a plurality of respiratory control functions. Such plurality of functions may include, for example, diaphragm control in coordination with upper airway control. The functions are controlled by providing an electrically stimulating signal that elicits a diaphragm response in combination with an electrically stimulating signal that controls the upper airway in a coordinated manner. The device may also control chest wall or abdominal muscles in combination with diaphragm control and/or upper airway control, in order to augment respiration and/or optimize intrapleural volume during diaphragm stimulation such as, e.g., a low level or bias stimulation.
According to another aspect of the invention, at least two groups of muscles associated with respiration may be controlled or coordinated. These groups may include diaphragm related muscles, chest wall related muscles, abdominal muscles and/or upper airway related muscles
These and other inventions are described herein and/or set forth in the claims herein.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1A is a schematic illustration of a device implanted in a subject in accordance with the invention.
FIG. 1B is a schematic illustration of a device implanted in a subject in accordance with the invention.
FIG. 2 is a schematic illustration of a processor unit of a sleep breathing disorder treatment device in accordance with the invention.
FIG. 3 is a schematic illustration of an external device of a stimulator in accordance with the invention.
FIG. 4A is a schematic illustration of respiration of an exemplary obstructive sleep apnea patient as the patient is going into an obstructive sleep apnea event.
FIG. 4B is a schematic illustration of respiration of an exemplary obstructive sleep apnea patient as the patient is going into an obstructive sleep apnea event.
FIGS. 4C and 4D are schematic illustrations respectively of respiration response and stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention in which the obstructive sleep apnea event illustrated in FIG. 4A is treated with deep inspiration stimulation.
FIG. 5A is a schematic illustration of respiration of an exemplary obstructive sleep apnea patient as the patient is going into an obstructive sleep apnea event.
FIGS. 5B and 5C are schematic illustrations respectively of respiration response and stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention in which the obstructive sleep apnea event illustrated in FIG. 5A is treated with deep inspiration stimulation.
FIGS. 6A, 6B and 6C are schematic illustrations respectively of airflow, tidal volume and corresponding stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention in which stimulation is applied during a portion of the respiration cycles.
FIGS. 7A and 7B are schematic illustrations respectively of tidal volume and corresponding stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention in which stimulation is applied during a portion of the respiration cycles.
FIGS. 8A and 8B are schematic illustrations respectively of tidal volume and corresponding stimulation waveforms illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIGS. 9A, 9B and 9C are schematic illustrations respectively of airflow, tidal volume and corresponding stimulation waveforms illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIGS. 10A, 10B and 10C are schematic illustrations respectively of airflow, tidal volume and corresponding stimulation waveforms illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIGS. 11A and 11B are schematic illustrations respectively of respiration response and stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention.
FIGS. 12A, 12B and 12C are schematic illustrations respectively of flow and tidal volume respiration response and stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention.
FIGS. 13A and 13B are schematic illustrations respectively of respiration response and stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention.
FIGS. 14A and 14B are schematic illustrations respectively of respiration response and stimulation waveforms illustrating a stimulation method using a stimulation device according to the invention.
FIG. 15 is a flow chart illustrating operation of a device in accordance with the invention.
FIG. 16A is a schematic of a signal processor of the processor unit in accordance with the invention.
FIG. 16B is a schematic example of a waveform of an integrated signal processed by the signal processor of FIG. 16A.
FIG. 16C is a schematic EMG envelope waveform.
FIG. 16D is a schematic waveform corresponding to or correlated with air flow.
FIG. 16E is a schematic waveform correlated to intrapleural pressure.
FIGS. 17A, 17B, 17C, 17D and 17E are schematic illustrations respectively of diaphragm EMG envelope; flow or inverse of upper airway pressure; tidal volume or inverse of intrapleural pressure; corresponding diaphragm stimulation; and corresponding hypoglossal stimulation illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIGS. 18A, 18B, 18C, 18D, 18E and 18F are schematic illustrations respectively of diaphragm EMG envelope; flow or inverse of upper airway pressure; tidal volume or inverse of intrapleural pressure; corresponding diaphragm stimulation; and corresponding hypoglossal stimulation illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIGS. 19A, 19B, 19C, 19D and 19E are schematic illustrations respectively of diaphragm EMG envelope; flow or inverse of upper airway pressure; tidal volume or inverse of intrapleural pressure; corresponding diaphragm stimulation; and corresponding hypoglossal stimulation illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIGS. 20A, 20B, 20C, 20D and 20E are schematic illustrations respectively of diaphragm EMG envelope; flow or inverse of upper airway pressure; tidal volume or inverse of intrapleural pressure; corresponding diaphragm stimulation; and corresponding hypoglossal stimulation illustrating a stimulation method using a stimulation device in which stimulation is applied in accordance with the invention.
FIG. 21 is a schematic illustration of a device or system according to the invention.



DETAILED DESCRIPTION
In accordance with one aspect of the invention, a method and device for treating obstructive sleep apnea patients is provided. According to one embodiment, a device is provided that manipulates breathing according to one or more protocols, by stimulating the diaphragm or phrenic nerve to mitigate or prevent obstructive respiratory events including obstructive sleep apnea or other events with an obstructive component. The device may comprise a phrenic nerve or diaphragm stimulator and a sensor configured to sense a condition of a subject indicating a possibility that an obstructive respiratory event will occur or is occurring. In accordance with the invention, obstructive respiratory events are characterized by a narrowing of the air passageway, typically the upper air passageway. Examples of obstructive respiratory events include but are not limited to obstructive sleep apnea, obstructive hypopnea and other respiratory events with an obstructive component.
In another embodiment, stimulation is applied at a low level through or after an obstructive respiratory event has occurred.
In addition, in accordance with the invention stimulation techniques for controlling or manipulating breathing may be used for therapeutic purposes in other non-OSA patients.
In addition, in accordance with the invention stimulation techniques for controlling or manipulating breathing may coordinate stimulating a diaphragm response with controlling upper airway muscles.
FIGS. 1A and 2 illustrate a stimulator 20 comprising electrode assemblies 21, 22, each comprising a plurality of electrodes 21a-d and 22a-d respectively. The electrode assemblies 21, 22 are implanted in the diaphragm muscle so that one or more of electrodes 21a-d and of electrodes 22a-d are approximately adjacent to one or more junctions of the phrenic nerves 15, 16, respectively, with the diaphragm 18 muscle. Alternatively or additionally, electrodes or electrode assemblies may be implanted on the diaphragm from the thoracic side, at a location along the phrenic nerve in the thoracic region, neck region or other location adjacent a phrenic nerve (e.g. transvenously) where stimulating the phrenic nerve affects breathing and/or diaphragm movement of the subject. In addition, leads may be subcutaneously placed to stimulate at least a portion of the diaphragm or phrenic nerve. The electrode assemblies 21, 22, 31, 32, 41, 42 described herein are coupled to outputs of a pulse generator and are configured to deliver electrically stimulating signals to tissue associated with the implanted electrode assemblies.
The electrode assemblies 21, 22 (31, 32, 41, 42) may sense as well as pace or electrically stimulate at the diaphragm muscle or at the phrenic nerve. Electrode 51 may stimulate (as well as sense) at the upper airway muscles or hypoglossal nerve. Electrode 58 may stimulate (as well as sense) at the chest wall muscles or associated nerves. Electrode 59 may stimulate (as well as sense)at the abdominal muscles or associated nerves. Electrode assemblies 21, 22 may be implanted laparoscopically through the abdomen and into the muscle of the diaphragm 18 with needles, tissue expanding tubes, cannulas or other similar devices. The electrode assemblies 21, 22 may be anchored with sutures, staples, or other anchoring mechanisms. The electrode assemblies 21, 22 may be surface electrodes or alternatively intramuscular electrodes. The leads 23, 24 coupling the electrode assemblies 21, 22 to the control unit 100 are routed subcutaneously to the side of the abdomen where a subcutaneous pocket is created for the control unit 100. The electrode assemblies 21, 22 are each flexible members with electrodes 21a-d, assembled about 1-20 mm apart from one another and electrodes 22a-d assembled about 1-20 mm apart from one another. The electrode assemblies 21, 22 are coupled via leads 23, 24 to control unit 100. The stimulator 20 further comprises one or more sensors configured to sense one or more physiologic parameters. For example one or more sensors such as an accelerometer or movement sensor may sense information regarding movement pattern of the diaphragm muscles, intercostal muscles, and rib movement and thus determine overall respiratory activity and patterns. An electrode or electrodes may be used to sense the EMG of the diaphragm to determine respiration parameters. A flow sensor may be implanted in or near the trachea to sense tracheal air flow. A flow sensor 56 may be implanted in or near the mouth. An intrapleural pressure sensor 57 may be implanted on the top side of the diaphragm on its own or with one or more electrode assemblies 21, 22. The various sensors may be incorporated with electrode assemblies 21, 22, or may be separately implanted or otherwise coupled to the subject.
The control unit 100 is configured to receive and process signals corresponding to sensed physiological parameters, e.g., pressure, flow, nerve activity, diaphragm or intercostal muscle movement, and/or EMG of the diaphragm 18, to determine the respiratory parameters of the diaphragm 18. An EMG signal may be used or other sensed activity may also correspond with either tidal volume or airflow and may be used to identify different portions of a respiration cycle. An example of such signal processing or analysis is described in more detail herein with reference to a sensed respiration correlated signal, such as an EMG, flow, pressure or tidal volume correlated signal, in FIGS. 16A-16D.
The electrodes assemblies 21, 22 are coupled via leads 23, 24 to input/output terminals 101, 102 of a control unit 100. The leads 23, 24 comprise a plurality of electrical connectors and corresponding lead wires, each coupled individually to one of the electrodes 21a-d, 22a-d. Alternatively or in addition, electrodes 31, 32 implanted on or near the phrenic nerve in the thoracic region or electrodes 41, 42 implanted on or near the phrenic nerve in the neck region. Other locations at or near the phrenic nerve may be stimulated as well. Electrode(s) 51, may be placed at or near the hypoglossal nerve in accordance with a variation of the invention where stimulation of the diaphragm is coordinated with activation of upper airway muscles to open the airway passage just prior to stimulating the diaphragm muscles. Electrode(s) 51 is (are) coupled through lead(s) 52 to electronics in control unit 100. Control unit 100 is also configured to receive information from one or more sensors, including, for example upper airway pressure sensor 56 or intrapleural pressure sensor 57. Alternatively or in addition, electrode(s) 58 may be implanted at or near the chest wall muscles or associated nerves and may be used to stimulate chest wall muscles in coordination with diaphragm stimulation. According to one aspect, the chest wall stimulation may augment diaphragm stimulation to enhance breathing or lung volume control. Alternatively or in addition, electrode(s) 59 may be implanted at or near one or more abdominal muscle groups or associated nerves and may be used to stimulate abdominal muscles in coordination with diaphragm stimulation. According to one aspect, the abdominal muscle stimulation may augment diaphragm stimulation to enhance breathing or lung volume control.
The control unit 100 is implanted subcutaneously within the patient, for example in the chest region on top of the pectoral muscle. The control unit may be implanted in other locations within the body as well. The control unit 100 is configured to receive sensed nerve electrical activity from the sensors or electrode assemblies 21, 22, (31, 32, 41, 42, 51, 57, 58, 59) corresponding to respiratory effort or other respiration related parameters of a patient. The control unit 100 is also configured to receive information corresponding to other physiological parameters as sensed by other sensors. The control unit 100 delivers stimulation to the nerves 15, 16 or diaphragm as desired in accordance with the invention. The control unit 100 also delivers stimulation to the hypoglossal nerve 19. The control unit 100 may determine when to stimulate the diaphragm and/or hypoglossal nerve, as well as specific stimulation parameters, e.g., based on sensed information. The control unit 100 may determine when to stimulate the chest wall or abdominal muscles, as well as specific stimulation parameters, e.g., based on sensed information.
Additional sensors may comprise movement detectors 25, 26, in this example, strain gauges or piezo-electric sensors included with the electrode assemblies 21, 22 respectively and electrically connected through leads 23, 24 to the control unit 100. The movement detectors 25, 26 detect movement of the diaphragm 18 and thus the respiration parameters. The movement detectors 25, 26 sense mechanical movement and deliver a corresponding electrical signal to the control unit 100 where the information is processed by the processor 105. The movement information correlates to airflow and may accordingly be used to determine related respiration parameters. Upper airway pressure sensor 56 is positioned for example in the mouth or trachea and provides a signal that may be correlated to flow inverse of flow. Intrapleural pressure sensor 57 provides a signal that is schematically illustrated in FIG. 16E and is generally correlated to the inverse of tidal volume. The signal from the positive airway pressure sensor and the intrapleural pressure sensor may be processed and used for example, as described with respect to FIGS. 16A and 16B.
Electrodes may be selected from the plurality of electrodes 21a-d and 22a-d once implanted, to optimize the stimulation response. Electrodes may also be selected to form bipolar pairs or multipolar groups to optimize stimulation response. Alternatively electrodes may be in a monopolar configuration. Testing the response may be done by selecting at least one electrode from the electrodes in an assembly or any other combination of electrodes to form at least one closed loop system, by selecting sequence of firing of electrode groups and by selecting stimulation parameters. The electrodes may be selected by an algorithm programmed into the processor that determines the best location and sequence for stimulation and/or sensing nerve and/or EMG signals, e.g., by testing the response of the electrodes by sensing respiratory effort or flow in response to stimulation pulses. Alternatively, the selection process may occur using an external programmer that telemetrically communicates with the processor and instructs the processor to cause stimulation pulses to be delivered and the responses to be measured. From the measured responses, the external programmer may determine the optimal electrode configuration, by selecting the electrodes to have an optimal response to delivery of stimulation.
Alternative mapping techniques may be used to place one or more stimulation electrodes on the diaphragm. Examples of mapping the diaphragm and/or selecting desired locations or parameters for desired stimulation responses are described for example in U.S. application Ser. No. 10/966,484 filed Oct. 15, 2004 and entitled: SYSTEM AND METHOD FOR MAPPING DIAPHRAGM ELECTRODE SITES; in U.S. application Ser. No. 10/966,474, filed Oct. 15, 2004 entitled: BREATHING THERAPY DEVICE AND METHOD; in U.S. application Ser. No. 10/966,472 filed Oct. 15, 2004 entitled: SYSTEM AND METHOD FOR DIAPHRAGM STIMULATION; U.S. application Ser. No. 10/966,421 filed Oct. 15, 2004 entitled: BREATHING DISORDER AND PRECURSOR PREDICTOR AND THERAPY DELIVERY DEVICE AND METHOD; and in U.S. application Ser. No. 10/686,891 filed Oct. 15, 2003 entitled BREATHING DISORDER DETECTION AND THERAPY DELIVERY DEVICE AND METHOD, all of which are fully incorporated herein by reference.
FIG. 1B illustrates an alternative positioning of a stimulator 20′ in accordance with the invention. Electrodes 21′ and 22′ are microstimulating electrodes positioned on or adjacent the phrenic nerve branches 15, 16 respectively. Electrodes 21′, 22′ are in telemetric communication with the control unit 100′. Alternatively, electrodes 21′, 22′ may be nerve cuff electrodes or other electrodes coupled by a lead to the control unit 100′. Electrode 51′ also may either be a microstimulating electrode in telemetric communication with the control unit 100′ or may be coupled via a lead to control unit 100′. Control unit 100′ and electrodes 21′, 22′ and 51′ operate to control breathing in a manner similar to that described with respect to electrode assemblies 21, 22, electrode 51 and control unit 100 herein.
Any of the electrodes described in this application may be powered by an external source, e.g., an external control unit. Additionally, any of the electrodes herein may be microstimulators, including, for example, implanted microstimulators with electronic circuitry; and an external power source, e.g. an RF coupled source.
FIG. 2 illustrates an implantable control unit 100. The control unit 100 includes electronic circuitry capable of generating and/or delivering electrical stimulation pulses to the electrodes or electrode assemblies 21, 22, 31, 32, 41, 42, through leads 23, 24, 33, 34, 43, 44, respectively, to cause a diaphragm respiratory response in the patient. The control unit 100 electronic circuitry is also configured to generate and/or deliver electrical stimulation to electrode 51, through lead 52, to cause an upper airway response such as increased tonicity and/or opening of upper airway (electrode 51 may also comprise a pair of bipolar electrodes). For purposes of illustration, in FIG. 2, the control unit 100 is shown coupled through leads 23, 24 to electrode assemblies 21, 22 respectively. Other leads as described herein may be connected to inputs 101, 102 or other inputs.
The control unit 100 comprises a processor 105 for controlling the operations of the control unit 100. The processor 105 and other electrical components of the control unit are coordinated by an internal clock 110 and a power source 111 such as, for example a battery source or an inductive coupling component configured to receive power from an inductively coupled external power source. The processor 105 is coupled to a telemetry circuit 106 that includes a telemetry coil 107, a receiver circuit 108 for receiving and processing a telemetry signal that is converted to a digital signal and communicated to the processor 105, and a transmitter circuit 109 for processing and delivering a signal from the processor 105 to the telemetry coil 107. The telemetry coil 107 is an RF coil or alternatively may be a magnetic coil. The telemetry circuit 106 is configured to receive externally transmitted signals, e.g., containing programming or other instructions or information, programmed stimulation rates and pulse widths, electrode configurations, and other device performance details. The telemetry circuit is also configured to transmit telemetry signals that may contain, e.g., modulated sensed and/or accumulated data such as sensed EMG activity, sensed flow or tidal volume correlated activity, sensed nerve activity, sensed responses to stimulation, sensed position information, sensed movement information and episode counts or recordings.
The leads 23, 24 are coupled to inputs 101, 102 respectively, of the control unit 100, with each lead 23, 24 comprising a plurality of electrical conductors each corresponding to one of the electrodes or sensors (e.g., movement sensor) of the electrode assemblies 23, 24. Thus the inputs 101, 102 comprise a plurality of inputs, each input corresponding to one of the electrodes or sensors. The signals sensed by the electrode assemblies 21, 22 are input into the control unit 100 through the inputs 101, 102. Each of the inputs are coupled to a separate input of a signal processing circuit 116 (schematically illustrated in FIG. 2 as one input) where the signals are then amplified, filtered, and further processed, and where processed data is converted into a digital signal and input into the processor 105. Each signal from each input is separately processed in the signal processing circuit 116.
The EMG/Phrenic nerve sensing has a dual channel sensor. One corresponding to each lung/diaphragm side. However, sensing can be accomplished using a single channel as the brain sends signals to the right and left diaphragm simultaneously. Alternatively, the EMG or phrenic nerve collective may be sensed using a single channel. Either a dual channel or single channel setting may be used and programmed.
The control unit 100 further includes a ROM memory 118 coupled to the processor 105 by way of a data bus. The ROM memory 118 provides program instructions to the control unit 100 that direct the operation of the stimulator 20. The control unit 100 further comprises a first RAM memory 119 coupled via a data bus to the processor 105. The first RAM memory 119 may be programmed to provide certain stimulation parameters such as pulse or burst morphology; frequency, pulse width, pulse amplitude, duration and a threshold or trigger to determine when to stimulate. The first RAM may also be programmed to provide coordination of stimulation to the diaphragm/phrenic nerve with the upper airway/hypoglossal nerve, chest wall muscles/nerves or abdominal muscles/nerves. A second RAM memory 120 (event memory) is provided to store sensed data sensed, e.g., by the electrodes of one or more electrode assemblies 21, 22 (EMG or nerve activity), position sensor 121, diaphragm movement sensors or strain gauges 25, 26, or the accelerometer 122 or other sensors such as a flow or tidal volume correlated sensors (e.g. using movement sensors or impedance plethysmography with a sensor positioned at one or more locations in the body such as on the control unit 100. These signals may be processed and used by the control unit 100 as programmed to determine if and when to stimulate or provide other feedback to the patient or clinician. Also stored in RAM memory 120 may be the sensed waveforms for a given interval, and a count of the number of events or episodes over a given time as counted by the processor 105. The system's memory will be programmable to store information corresponding to breathing parameters or events, stimulation delivered and responses, patient compliance, treatment or other related information. These signals and information may also be compiled in the memory and downloaded telemetrically to an external device 140 when prompted by the external device 140.
An example of the circuits of the signal processing circuit 116 corresponding to one or more of the sensor inputs is illustrated schematically in FIG. 16A. A sensor input signal correlating or corresponding to EMG, tidal volume or flow is input into an amplifier 130 that amplifies the signal. The signal is then filtered to remove noise by filter 131. The amplified signal is rectified by a rectifier 132, is converted by an A/D converter 133 and then is integrated by integrator 134 to result in an integrated signal from which respiratory information can be ascertained. A flow correlated signal may be input through A/D converter 133a and then input through the integrator 134. A signal corresponding to upper airway (or epiglossal) pressure may also be used as a flow correlated signal by inverting an upper airway pressure signal with inverter 133b and inputting the signal through A/D converter 133a. The signal output of the integrator 134 is then coupled to the processor 105 and provides a digital signal corresponding to the integrated waveform to the processor 105. A tidal volume correlated signal or an intrapleural pressure correlated signal may also be input to the signal processing circuit through A/D converter 134a at the output of the integrator 134. Intrapleural pressure may first be inverted through inverter 134b before inputting into A/D converter 134a. The signal output of the integrator 134 is coupled to a peak detector 135 that determines when the inspiration period of a respiratory cycle has ended and an expiration cycle has begun. The signal output of the integrator 134 is further coupled to a plurality of comparators 136, 137. The first comparator 136 determines when respiration has been detected based on when an integrated signal waveform amplitude has been detected that is greater than a percentage value of the peak of an intrinsic respiratory cycle or another predetermined amount (comp 1), for example between 1-25% of the intrinsic signal. In this example, the comparator is set at a value that is 10% of the waveform of an intrinsic respiratory cycle. The second comparator 137 determines a value of the waveform amplitude (comp 2) when an integrated signal waveform amplitude has been detected that is at a predetermined percentage value of the peak of an intrinsic respiratory cycle or another predetermined amount, for example between 75%-100% of the intrinsic signal. In this example, the comparator is set at a value that is 90% of the waveform of an intrinsic respiratory cycle. From this value and the comp 1 value, the slope of the inspiration period (between 10% and 90% in this example) may be determined. This slope may provide valuable diagnostic information as it shows how quickly a patient inhales.
In the case of a signal correlating to flow that is integrated or a signal correlated to tidal volume, after (or when) the peak detector detects the end of an inhalation period and the beginning of an exhalation period, the third comparator 138 determines an upper value for the waveform amplitude during active exhalation period, for example between 100% and 75% of the peak value detected by the peak detector 135. Then a lower value (comp 4) of the waveform during the exhalation period is determined by the fourth comparator 139, which compares the measured amplitude to a predetermined value, e.g. a percentage value of the peak amplitude. In this example, the value is selected to be 10% of the peak value. In one embodiment this value is selected to roughly coincide with the end of a fast exhalation period. From comp 3 and comp 4 values, the slope of the exhalation period (between 10% and 90% in this example) may be determined. This slope may provide valuable diagnostic information as it shows how quickly a patient exhales.
A non-integrated flow signal may also be used, for example in conjunction with EMG to detect airway closure where EMG is present in the absence of flow. An upper airway pressure signal is correlated with flow, so the absence of negative deflection corresponding to inhalation indicates airway closure.
The intrapleural pressure signal is generally the inverse of tidal volume. Intrapleural pressure may be used to provide diagnostic information such as lung volume information, duration of respiratory cycles, and rate of inhalation and exhalation.
Intrapleural pressure may be used by setting threshold levels used to determine different phases of a respiration cycle. For example, the negative peak 175a of intrapleural pressure correlates generally with the start of the exhalation cycle. This point 175a or other information derived from the sensed signal (FIG. 16E) may be used to trigger stimulation in accordance with one or more stimulation protocols of the embodiments of the invention described herein.
The information ascertained from the sensed signals may be used to determine triggers for providing stimulation. Examples of such triggers are described with reference to the various stimulation protocols and techniques described in the various embodiments herein.
FIG. 16B illustrates two sequential integrated waveforms of exemplary integrated signals corresponding to two serial respiratory cycles. An inspiration portion 172 may be observed using an EMG, flow or tidal volume correlated signal. An exhalation period 176 may be observed using a flow or tidal volume correlated signal. The waveform 170 has a baseline 170b, inspiration cycle 171, a measured inspiration cycle 172, a point of 10% of peak inspiration 173 (comp 1), a point of 90% of peak of inspiration 174 (comp 2), a peak 175 where inspiration ends and exhalation begins, and exhalation cycle 176 a fast exhalation portion 177 of the exhalation cycle 176, a 90% of peak exhalation point 178 (comp 3), a 10% of peak exhalation point 179 (comp 4), an actual respiratory cycle 180 and a measured respiratory cycle 181. 50% of exhalation (comp 5) may be used to trigger stimulation of the hypoglossal nerve to open the upper airway. The second waveform 182 is similarly shaped. The 10% inspiration 183 of the second waveform 182 marks the end of the measured respiratory cycle 181, while the 10% point 173 of the waveform 170 marks the beginning of the measured respiratory cycle 181.
FIG. 16C illustrates a schematic EMG envelope corresponding to an inspiration portion e.g., 172 of a respiration cycle. FIG. 16D illustrates a schematic flow correlated signal corresponding to a respiration cycle.
The upper airway pressure sensed with sensor 56 provides a signal correlated to the inverse of flow. The inverse of the upper airway signal may be processed as a flow correlated signal as set forth herein to provide respiration information.
Intrapleural pressure may be sensed with sensor 57 to provide a signal as schematically set forth in FIG. 16E. This may processed similar to an integrated flow (or Tidal Volume signal) as described herein to provide exhalation cycle information or lung volume information. Exhalation cycle information or lung volume information may be used as a trigger for stimulation as set forth herein.
In FIG. 3 a circuit for an external device 140 is illustrated. The external device 140 comprises a processor 145 for controlling the operations of the external device. The processor 145 and other electrical components of the external device 140 are coordinated by an internal clock 150 and a power source 151. The processor 145 is coupled to a telemetry circuit 146 that includes a telemetry coil 147, a receiver circuit 148 for receiving and processing a telemetry signal that is converted to a digital signal and communicated to the processor 145, and a transmitter circuit 149 for processing and delivering a signal from the processor 145 to the telemetry coil 146. The telemetry coil 147 is an RF coil or alternatively may be a magnetic coil depending on what type of coil the telemetry coil 107 of the implanted control unit 100 is. The telemetry circuit 146 is configured to transmit signals to the implanted control unit 100 containing, e.g., programming or other instructions or information, programmed stimulation protocols, rates and pulse widths, electrode configurations, and other device performance details. The telemetry circuit 146 is also configured to receive telemetry signals from the control unit 100 that may contain, e.g., sensed and/or accumulated data such as sensed information corresponding to physiological parameters, (e.g., sensed EMG activity, sensed nerve activity, sensed responses to stimulation, sensed position information, sensed flow, or sensed movement information). The sensed physiological information may be stored in RAM event memory 158 or may be uploaded and through an external port 153 to a computer, or processor, either directly or through a phone line or other communication device that may be coupled to the processor 145 through the external port 153. The external device 140 also includes ROM memory 157 for storing and providing operating instructions to the external device 140 and processor 145. The external device also includes RAM event memory 158 for storing uploaded event information such as sensed information and data from the control unit, and RAM program memory 159 for system operations and future upgrades. The external device also includes a buffer 154 coupled to or that can be coupled through a port to a user-operated device 155 such as a keypad input or other operation devices. Finally, the external device 140 includes a display device 156 (or a port where such device can be connected), e.g., for display visual, audible or tactile information, alarms or pages.
The external device 140 may take or operate in, one of several forms, e.g. for patient use, compliance or monitoring; and for health care provider use, monitoring, diagnostic or treatment modification purposes. The information may be downloaded and analyzed by a patient home unit device such as a wearable unit like a pager, wristwatch or palm sized computer. The downloaded information may present lifestyle modification, or compliance feedback. It may also alert the patient when the health care provider should be contacted, for example if there is malfunctioning of the device or worsening of the patient's condition.
Other devices and methods for communicating information and/or powering stimulation electrodes as are know in the art may be used as well, for example a transcutaneously inductively coupled device may be used to power an implanted device.
According to one aspect of the invention, the stimulator operates to stimulate and/or manipulate breathing to mitigate (i.e., avoid or reduce effects of) an obstructive respiratory event by stimulating the phrenic nerve, diaphragm or associated tissue according to one or more protocols, to elicit a respiratory response. Examples of such stimulation protocols are described herein with reference to FIGS. 4A-23D. In accordance with another aspect of the invention, such stimulation is provided prior to the onset of an obstructive respiratory event or prior to airway obstruction to prevent an obstructive respiratory event from occurring or the airway from fully closing. In accordance with another aspect of the invention, stimulation is provided at a low level following obstructive sleep apnea or effective airway closure.
In accordance with one aspect of the invention as described with respect to FIGS. 4A-4D, 5A-5C, 7A-7B, 8A-8B, 9A-9C, 10A-10C and 12A-12B, stimulation of the phrenic nerve or diaphragm is provided to increase functional residual capacity, i.e., end expiratory volume, at least until onset of a subsequent respiration cycle. In accordance with the invention, an increased functional residual capacity is believed to assist in maintaining an airway passage open to a sufficient degree to prevent or reduce airway collapse that results in an obstructive respiratory event.
In accordance with another aspect of the invention, as described with respect to FIGS. 4A-4D, 5A-5B, 6A-6B, 10A-10C, 11A-11B, 12A-12B or 14A-14B, stimulation of the phrenic nerve or diaphragm is provided to increase tidal volume sufficiently to increase upper airway patency. It is believed that increasing the tidal volume may contribute to stiffening the upper airway. Preferably the same or a lower peak flow with respect to intrinsic flow is provided to avoid an increase in negative pressure applied to the upper airway that would decrease upper airway patency. Therapy may be delivered to increase flow in the case where flow is below normal. In cases where flow is normal, or limited by obstruction, tidal volume may be increased through extension of the inspiration duration. An upper airway hysteresis effect may also occur where the volume of a breath is increased above a normal tidal volume and the stiffening of the upper airway during inspiration does not return entirely to a relaxed resting state. It is accordingly additionally believed that an upper airway hysteresis effect would stiffen the upper air passageway for subsequent breaths and will thereby prevent or mitigate airway narrowing or collapse that results in obstructive sleep apnea.
In accordance with one aspect of the invention, as described with respect to FIGS. 9A-9C, 11A-11B, 13A-13B and 14A-14B, stimulation is provided to create ventilatory stability and to thereby reduce fluctuations in the upper airway passage muscles that may lead to upper airway collapse where ventilatory drive is low or unstable. “Ventilatory instability is defined herein to mean varying breathing rate and/or tidal volume outside of normal variations.” Ventilatory stability associated with obstructive respiratory events, as opposed to periodic breathing or Cheynes-Stokes respiration, include, for example, variations in breathing rate and/or tidal volume associated with sleep onset, change in sleep state, and REM sleep.
In accordance with another aspect of the invention, as described with respect to FIGS. 4A-4D, 6A-6C, 9A-9C and 10A-10C, 11A-11B, 12A-12B, and 14A-14B, stimulation of the phrenic nerve or diaphragm is provided during intrinsic breathing during or at the end of an intrinsic inspiration portion of a breathing cycle. For purposes of the invention herein, the intrinsic cycle may be detected near onset of inspiration. Other portions of a breathing cycle may be identified for breathing stimulation. Alternatively, the beginning of the breathing cycle or a portion of the breathing cycle may be predicted, e.g., based on a typical breathing pattern of an individual patient.
A stimulation signal may be provided during inspiration of intrinsic breathing for various purposes. In accordance with a variation of the invention, stimulation is provided during intrinsic inspiration to provide initial and more gradual control of breathing according to a protocol. Then, breathing control protocols may be applied so that airway closure due to stimulation is avoided. Tidal volume is increased gradually so as to balance out an increase in upper airway resistance that can occur with stimulation during intrinsic inspiration. Stimulation of breathing during intrinsic inspiration in accordance with variations of the invention is configured to contribute to creating the effect of increasing functional residual capacity. In some variations of the invention, stimulation during intrinsic breathing is configured to stiffen the upper airway, thereby increasing upper airway patency. Stimulating during inspiration in accordance with a protocol of the invention may also increase upper airway hysteresis. In one embodiment, breathing is stimulated at least in part during intrinsic inspiration so that the resulting tidal volume is greater than intrinsic normal volume, while peak flow is maintained near normal peak flow to avoid upper airway closure. Stimulating during intrinsic inspiration may also be used to normalize breathing in an obstructive sleep apnea patient and to increase ventilatory stability associated with airway obstructions. Stimulating at least in part during intrinsic inspiration may increase inspiration duration which may allow increase of tidal volume without significantly increasing the peak flow. (Increasing peak flow may increase the possibility of airway closure.) According to one embodiment, peak flow is provided at, near or below intrinsic peak flow.
While stimulating breathing during intrinsic inspiration is described herein in use with a device and method of treating obstructive sleep apnea, other breathing or related disorders may be treated by stimulating breathing during intrinsic inspiration in accordance with another aspect of the invention.
In accordance with another aspect of the invention and as illustrated in FIGS. 4A-4D, and 5A-5C the phrenic nerve or diaphragm is stimulated to provide deep inspiration therapy to a subject. Deep inspiration therapy involves stimulating a breath that is of a greater tidal volume than a normal breath. According to a preferred embodiment, deep inspiration stimulation provides a breath having a greater inspiration duration than that of a normal breath. Rather than substantially increasing peak flow or rather than increasing the magnitude of diaphragm contraction, the increase in inspiration duration to increase tidal volume is believed to reduce the likelihood of airway closure with stimulation. Deep inspiration stimulation may be provided intermittently throughout the night or a portion of the night while a patient sleeps, thus preventing an obstructive respiratory event. While deep inspiration therapy is described herein in use with a device and method of treating obstructive sleep apnea, other breathing or related disorders may be treated by deep inspiration therapy.
In accordance with another aspect of the invention as described with respect to FIGS. 6A-6B, 7A-7B, 8A-8B, 9A-9C, 10A-10C and 12A-12B, the exhalation cycle is manipulated to provide a therapeutic effect. According to one aspect of the invention, increased functional residual capacity is provided by manipulating the exhalation phase. Manipulation of the exhalation phase may be provided using stimulation during the exhalation phase. The exhalation phase may also otherwise be manipulated in length or duration.
In accordance with another aspect of the invention as described with respect to FIGS. 7A-7B 8A-8B, 9A-9C, and 10A-10C, a low level stimulation is applied during all or a portion of the respiration cycle. Among other therapeutic effects such stimulation may increase functional residual capacity. Such low level stimulation may be directed to provide an increased tidal volume during a rest phase of a respiration cycle by sustaining a low level contraction of the diaphragm. Typically such low level stimulation would be lower than the relative threshold for eliciting breathing. This level may vary from patient to patient and may be determined on an individual basis. It may also depend on electrode type and placement. Typically the stimulation is lower than 8 mA.
In accordance with another aspect of the invention, as described with respect to FIGS. 9A-9C, 12A-12B, 13A-13B, and 14A-14B, stimulation of the phrenic nerve or diaphragm is provided to control breathing. According to one aspect of the invention, breathing is controlled either by inhibiting respiratory drive, entraining breathing or other mechanisms. Controlling breathing according to one variation comprises stimulating to control or manipulate the central respiratory drive. Controlling breathing may include taking over breathing to control one or more parameters of a stimulated breath. Entraining breathing may include stimulating at a rate greater than but close to, or equal to the intrinsic respiratory rate until the central pattern generator activates the respiration mechanisms, which includes those of the upper airway, in phase with the stimulation. As an alternative or in addition, inspiration duration may be increased with respect to the total respiration cycle or exhalation. While controlling breathing is described herein in use with a device and method of treating obstructive sleep apnea, other breathing or related disorders may be treated by controlling breathing in accordance with another aspect of the invention.
According to another aspect of the invention stimulation is used to provide ventilatory stability. Examples of providing ventilatory stability are shown in FIGS. 9A-9C, 10A-10B, 11A-11B, 13A-13B and 14A-14B. Ventilatory stability may be provided by stimulating breathing to increase a falling tidal volume towards that of a normal breath. Ventilatory stability may also be provided by controlling breathing in a manner that creates stability. Ventilatory stability may also be provided by entraining breathing. Instability in ventilatory rate that indicates the onset of obstructive sleep apnea may be treated by controlling breathing for a preset period of time as described with respect to FIGS. 9A-9B, 13A-13B or FIGS. 14A-14B. Instability in ventilatory rate may also be treated by normalizing tidal volume using stimulation as described with respect to FIGS. 10A-10B or 11A-11B.
Referring to FIGS. 4A-4D, stimulation and respiration waveforms illustrating a method using a device in accordance with one aspect of the invention are illustrated. A device and method creates increased functional residual capacity and upper airway patency by providing deep inspiration. In this particular embodiment, deep inspiration is provided by stimulating during a portion of an inspiration cycle. Stimulation may extend beyond the duration of an intrinsic breath. The stimulation is provided to increase tidal volume by extending the duration of the inspiration cycle. (While preferably maintaining peak flow at or near intrinsic peak flow, i.e. normalizing flow.) In accordance with a protocol, stimulation through one or more electrodes associated with the diaphragm or phrenic nerve is provided to cause the diaphragm to contract to cause a deep inspiration breath. Stimulation may be provided when a characteristic preceding an obstructive respiratory event is detected. For example, if erratic breathing occurs or if the tidal volume drops below a given threshold level, then stimulation is provided. The resulting breath comprises a deep inhalation breath (i.e., a greater tidal volume than a normal, intrinsic breath.) A deep inspiration breath may then be repeated periodically to prevent further drop in tidal volume by increasing the functional residual capacity and creating upper airway stiffening. The device may also be programmed to repeat the deep breath a given number of times before ceasing the stimulation.
One possible characteristic of breathing in obstructive sleep apnea patients is a decreasing tidal volume. The ultimate closure of an air passageway in an obstructive sleep apnea event thus may be preceded by a gradual decrease in ventilatory volume. Another possible characteristic of breathing in obstructive sleep apnea patients is an erratic breathing pattern. In a patient who is diagnosed with obstructive sleep apnea, respiration may be monitored using EMG or other sensors that sense respiration parameters corresponding to tidal volume or flow (for example, diaphragm movement which corresponds to airflow may be sensed; impedance plethysmography may be used; or flow itself may be sensed using a sensor implanted in the trachea.) FIGS. 16A-16D illustrate monitoring or detection of various aspects or parameters of respiration on a breath by breath basis. Tidal volume is monitored and a decrease in tidal volume characteristic (FIG. 4A) or an erratic breathing pattern (FIG. 4B) in an obstructive sleep apnea patient is detected. (Monitored tidal volume as used herein may also include a monitored tidal volume correlated signal). Estimated minute ventilation (i.e., determined by multiplying respiratory rate times volume of a breath) may also be used to determine the impending onset of an obstructive respiratory event.
For purposes of detecting a threshold volume on a breath-by-breath basis or in real time, a programmed threshold may be set. The threshold value may be determined when initializing the device as the value at or below which preventative or mitigating treatment is required or is otherwise optimal. This value may be programmed into the device. A minimum safety threshold value may also be established below which stimulation is inhibited to prevent airway closure. As such, the minimum safety threshold may be set as a value sufficiently above a tidal volume where stimulation treatment if provided would further close an air passageway.
When monitoring tidal volume, the area under the inspiration flow curve or EMG envelope of an individual breath may be monitored to determine tidal volume of a breath. The tidal volume is compared to a threshold value for a particular patient. Other parameters may be used to identify when tidal volume has dropped below a predetermined threshold, for example baseline tidal volume rate variance over a period of time may be monitored and compared to a normal variance. The normal variance may be determined on a patient-by-patient basis and programmed into the device.
FIG. 4A illustrates a breathing pattern where a decrease in tidal volume ultimately ends in an obstructive sleep apnea event. Accordingly, tidal volume of intrinsic breaths 411-415 of an obstructive sleep apnea patient is shown in FIG. 4A. The tidal volume of breaths 411-415 gradually decreases until the airway narrows ultimately leading to an airway obstruction. An obstructive respiratory event occurs with total airway closure after breath 415. An obstructive respiratory event may also be an airway narrowing, e.g., hypopnea. An obstructive respiratory event may be detected by monitoring a decrease in tidal volume, for example as a predetermined percentage of normal or intrinsic tidal volume. The threshold 450 below which treatment is to be provided by the device is shown in FIGS. 4A-4D. FIG. 4D illustrates a stimulation protocol corresponding to the resulting tidal volume waveforms of FIG. 4C.
FIG. 4C illustrates tidal volume of a patient treated using a deep inspiration stimulator. The stimulator detects the drop in tidal volume (breath 413) below a threshold level as described above with respect to FIGS. 4A-4B. During the subsequent breath 414, stimulation 434 (schematically illustrated as an envelope of a burst of pulses) is provided by the stimulator to provide a deep inspiration breath 424 with the breath 414. The deep inspiration breath 424 comprises a breath that has a tidal volume greater than the tidal volume of a normal or intrinsic breath. After one or more deep inspiration breath stimulations, the tidal volume is expected to return to normal or close to normal, e.g. at breaths 425-429. Synchronization is provided whereby the onset of inspiration is detected and stimulation is provided during the breath. According to one variation, a tidal volume that is greater than or equal to a predetermined percentage of a normal inspiration is detected (e.g. 10% of tidal volume as described with respect to FIGS. 16A-16E). Then when the onset of the next inspiration is detected, stimulation is provided. Additional periodic delivery of deep inspiration paced breaths may be provided synchronously or asynchronously with the intrinsic breathing, to prevent or mitigate drops in tidal volume. In accordance with this aspect of the invention, as illustrated in FIG. 4D an additional pacing pulse or burst of pulses 439 is provided to stimulate deep inspiration breath 419. Thus, the therapy described with reference to FIG. 4D may prevent a further drop in tidal volume, thereby reducing the occurrence of obstructive respiratory events or other breathing related disorders.
FIGS. 5A-5C illustrate use of a deep inspiration stimulator in accordance with the invention. FIG. 5A illustrates a breathing pattern where a decrease in tidal volume ultimately ends in an obstructive respiratory event. Accordingly, tidal volume of intrinsic breaths 511-515 of an obstructive sleep apnea patient is shown in FIG. 5A with the airway ultimately closing after breath 515. In FIG. 5A, no treatment is provided. Other pre-obstructive breathing characteristics may also be used to determine when an OSA event is likely to be imminent.
A threshold 550 below which treatment is to be provided by the device is shown in FIGS. 5A and 5B. This threshold may be determined in a manner similar to that described with respect to FIGS. 4A-4C. FIG. 5C illustrates a stimulation protocol corresponding to the resulting tidal volume waveforms of FIG. 5B. FIG. 5B illustrates the tidal volume of a patient treated using a deep inspiration stimulator who would otherwise have had a breathing pattern shown in FIG. 5A. The stimulator detects the drop in tidal volume (breath 513) below a threshold level 550 in a manner similar to that described above with respect to FIGS. 4A-4D. Prior to what would have been the subsequent breath 514, i.e., at some point during the intrinsic exhalation period or rest period, the stimulator provides stimulation 533 to elicit a deep inspiration breath 523 (FIG. 5B). The deep inspiration breath 523 comprises a breath with a tidal volume greater than the tidal volume of an intrinsic or normal breath. Preferably, the peak flow remains relatively normal while inspiration duration increases thus increasing tidal volume. After one or more deep inspiration breath stimulations, the tidal volume returns to normal, e.g., at breaths 524-525. At breaths 526, 527 a slight decrease in respiratory drive is shown with a decreased tidal volume. Periodic delivery of deep inspiration breaths may be provided to prevent or mitigate drops in tidal volume. In accordance with this aspect of the invention, as illustrated in FIG. 5C an additional pacing pulse or burst of pulses 538 is provided prior to the onset of the next intrinsic breath to stimulate deep inspiration breath 528 which is then followed by a normal breath 529. The deep inspiration breaths 523 or 528 are intended to increase the functional residual capacity of the lung and/or enhance upper airway patency. Thus, the therapy may prevent further drop in tidal volume, thereby reducing the incidence of obstructive sleep apnea or other breathing related disorders.
FIGS. 6A-6B illustrate stimulation and inspiration waveforms corresponding to a variation of stimulation device and method of the invention. The stimulation protocol of FIGS. 6A-6B provides stimulation at the end of an inspiration cycle increasing inspiration duration, thereby increasing tidal volume. A resulting normalized peak flow and increased tidal volume is believed to stiffen or lengthen the upper airway and may create an upper airway hysteresis effect. Increased tidal volume may provide more time and volume for gas exchange. Among other effects, normalized peak flow and increased tidal volume are believed to prevent airway collapse attributable to obstructive sleep apnea.
FIG. 6A illustrates normal inspiration duration 610 of an intrinsic breath and increased inspiration duration 620 that would result from stimulation 650 shown in FIG. 6B. Stimulation 650 is provided at the end of an inspiration period for a predetermined amount of time T6 to maintain flow and prolong inspiration for the additional period of time T6. The end of the inspiration period may be determined in a manner as described with reference to FIGS. 16A-16D herein. The time T6 may be selected and/or programmed into the device. The time may be determined to elicit a desired response. A short stimulation period, for example, as short as 0.1 seconds may be used.
FIGS. 7A-7B illustrate stimulation and inspiration waveforms corresponding to a variation of a stimulation device and method of the invention. The stimulation protocol of FIGS. 7A-7B provides low level stimulation at the beginning or the end of an exhalation portion of a respiration cycle, or at some time within the exhalation portion of the respiration cycle. This is believed to preserve lung volume prior to the next inspiration. The manipulation of the exhalation cycle is thus believed to increase functional residual capacity. FIG. 7A illustrates tidal volume 730 that would result from stimulation 750 shown in FIG. 7B. Stimulation 750 is provided at an end portion of an exhalation cycle to preserve some volume 740 for the next inspiration cycle thus increasing the functional residual capacity. The end of the exhalation cycle may be determined by determining the end of inspiration and then based on a known respiration rate, estimating the time of the end of the exhalation cycle. Alternatively, flow correlated respiration parameters may be sensed and the desired portion of the exhalation cycle may be determined. FIGS. 16A-16D illustrate manners for determining portions of a respiration cycle.
FIGS. 8A-8B illustrate stimulation and inspiration waveforms corresponding to a variation of a stimulation device and method or the invention. The stimulation protocol of FIG. 8B provides a low level of a continuous stimulation to cause the diaphragm to remain slightly contracted, thereby increasing functional residual capacity. FIG. 8B illustrates stimulation provided while FIG. 8A illustrates tidal volume. As shown, the tidal volume is elevated during the end portion of the exhalation cycle 840 (FIG. 8A) relative to end expiratory tidal volume before the stimulation.
FIGS. 9A-9C illustrate stimulation and inspiration waveforms corresponding to a variation of a stimulation device and method of the invention. The stimulation protocol provides a combination of therapies or protocols including increasing functional residual capacity and controlling breathing. The stimulation protocols manipulate exhalation and control breathing. The stimulation protocol of FIGS. 9A-9C provides a low current stimulation 950 as shown in FIG. 9C during the exhalation phase of a respiration cycle and a stimulated breath 951 delivered at the end of exhalation. The stimulated breath 951 is provided at a higher rate R2 than the intrinsic rate R1. The stimulation 950 is applied between the end of inspiration cycles 920, 921, 922 and the onset of the next inspiration cycles, 921, 922, 923 respectively to increase functional residual capacity. Stimulation 951 produces inspiration cycles 920, 921, 922, 923. Flow waveforms 930, 931, 932, 933 respectively of respiration cycles 920, 921, 922, 923 are shown in FIG. 9A. Tidal volume waveforms 940, 941, 942, 943 respectively of respiration cycles 920, 921, 922, 923 are shown in FIG. 9B.
FIGS. 10A-10B illustrate stimulation and inspiration waveforms corresponding to a variation of a stimulation device and method of the invention. Stimulation is provided during the inspiration cycle in a manner shown in FIGS. 7A-7B to increase inspiration duration and tidal volume (with normalized peak flow) in order to stiffen the upper airway. Also, a low level stimulation is provided to increase lung capacity at the end of inspiration and until the beginning of the next inspiration cycle to increase the functional residual capacity. A first intrinsic respiration cycle 1020 is illustrated. At the onset of exhalation 1021 of the respiration cycle 1020, a low level stimulation 1050 is applied until the onset of the inspiration cycle of the next respiration cycle 1022. At the detection of the onset of the next respiration cycle 1022 (as described in FIGS. 16A-16E), stimulation 1055 is provided. The stimulation 1055 is applied at least in part during the inspiration cycle 1022. The corresponding tidal volumes 1040, 1042 of respiration cycles 1020, 1022 respectively are illustrated in FIG. 10A. The corresponding flows 1030, 1032 of respiration cycles 1020, 1022 respectively are shown in FIG. 10B.
Referring to FIGS. 11A and 11B, stimulation and inspiration waveforms illustrate a stimulation device and method of the invention. Stimulation is provided in a manner similar to that described with reference to FIGS. 4A-4D. In accordance with FIGS. 11A and 11B, stimulation is provided to prevent or mitigate obstructive sleep apnea by stabilizing the tidal volume. FIG. 11A schematically shows the tidal volume as sensed by EMG sensors and illustrates the intrinsic breathing 1111-1117 of a subject, as well as the resulting breathing 1124, 1125. FIG. 11B illustrates the stimulation pulse envelopes 1160 of stimulation applied to the diaphragm or phrenic nerve of a subject in accordance with one aspect of the invention. Referring to FIG. 11A, the tidal volume from intrinsic breathing gradually decreases (1111, 1112) until it falls below a threshold level 1150 (1113-1115) and then resumes normal tidal volume (1116-1117) after treatment. After breath 1113 is detected below threshold level 1150, a stimulation pulse 1160 is provided during and in synchronization with the subsequent breath 1114, 1115 to thereby provide the resulting breath. The resulting breaths have waveforms 1124, 1125 with tidal volumes increased to a level of normal breathing. According to one variation, stimulation is provided with the goal of stabilizing or normalizing breathing. After stimulating for a given period of time or number of breaths, breathing is monitored to determine if it is normalized (for example with breaths 1116, 1117) at which time the stimulation may be discontinued.
FIGS. 12A-12B illustrate stimulation and inspiration waveforms corresponding to a variation of a stimulation device and method of the invention. The stimulation protocol of FIGS. 12A-12B provides a long rising stimulation during at least the inspiration portion of a respiration cycle to increase inspiration time of the cycle with respect to expiration time(or total percentage of the cycle that corresponds to inspiration). Using breathing control therapy to lengthen the inspiratory duration, expiratory time is reduced and the baseline relaxation lung volume is not completely restored, leading to an increased functional residual capacity. The stimulation protocol thereby manipulates or shortens the length of the exhalation portion of the respiration cycle. In addition, the respiration rate is increased to shorten the exhalation portion of the respiration waveform. Thus, the protocol is directed to increasing the functional residual capacity of the lungs by manipulating the expiration phase of the respiration cycle.
FIG. 12A illustrates flow and FIG. 12B illustrates corresponding stimulation. Referring to FIG. 12A a first intrinsic breath 1210 is shown with an intrinsic inspiration volume VII and an intrinsic expiration volume VIE. Prior to time T12A, breathing may be entrained (for example, as described with respect to FIGS. 13A and 13B herein) at a rate slightly faster than the intrinsic rate but at approximately a normal tidal volume and waveform 1210. Thereafter, stimulation 1240 is applied during a rest period (i.e. at an end portion of the exhalation phase) of a respiration cycle 1220 following breath 1210. The stimulation is provided using a long rising pacing pulse so that the respiration cycle is lengthened by a time T12B to prevent full expiration before the next inspiration cycle of the next breath 1230 which is provided by stimulation 1250. Stimulation 1250 is provided at a rate slightly faster than the previous stimulation 1240. Thus, exhalation is shortened, preventing exhalation portion 1260, and thus increasing the functional residual capacity of the lungs.
Referring to FIGS. 13A-13B, stimulation and respiration waveforms illustrating a stimulation method using a stimulation device in accordance with one aspect of the invention are illustrated. According to FIGS. 13A-13B, breathing is stabilized by stimulating to control or manipulate breathing. FIGS. 13A-13B illustrate a variation of a technique for controlling breathing.
FIG. 13A illustrates the flow of air representing respiration waveforms over time. Breathing control may be used for a number of different purposes. It may be done with or without sensing a condition that indicates a respiratory disturbance is present or occurring. It may be done for a predetermined period of time or during certain times of day or during certain sleep cycles. It may be done to stabilize breathing.
For example, if tidal volume falls below a predetermined threshold, stimulation may begin. Stimulation may also be provided periodically or at times of greater vulnerability to obstructive sleep apnea or other disorders associated with breathing disorders. FIG. 13B illustrates envelopes 1340 of stimulation pulses provided to control breathing during the course of stimulation. FIG. 13A illustrates the breaths 1360 resulting from the stimulation illustrated in FIG. 13B.
According to this embodiment, the stimulator first takes over breathing by providing stimulation 1340 (as illustrated in FIG. 13B) at a time during an end portion 1320 of the exhalation phase of an intrinsic respiration cycle, prior to the onset of the next respiration cycle (As illustrated in FIG. 13A). The stimulation 1340 is provided at a rate greater than the intrinsic rate, i.e., where the cycle length T1 is less than the intrinsic cycle length T1+x. As illustrated the duration of the intrinsic respiration cycle is T1+x. The duration of the respiration cycles of the stimulated breathing begins at T1 to take over breathing. After a period of time of taking over breathing, the respiration cycle length is then gradually increased to T1+m, t1+n, and T1+o where m<n<o<x and where o approaches x in value. Breathing is thereby controlled and ventilation is accordingly stabilized.
According to one aspect of the invention, breathing is believed to be controlled by stimulating for a period of time at a rate greater than but close to the intrinsic respiratory rate. Breathing may be controlled through inhibition of the central respiratory drive or entrainment. In order to entrain breathing, stimulation may be provided until the central pattern generator activates the respiration mechanisms, which includes those of the upper airway, in phase with the stimulation through various feedback mechanisms. It is believed that breathing may be entrained when the central respiratory drive is conditioned to adapt to stimulation. When breathing is entrained, it may be possible to further slow respiration rate or the respiration cycle length so that it is longer than the intrinsic length 1320.
Some methods for controlling breathing are described for example in U.S. application Ser. No. 10/966,474, filed Oct. 15, 2004 and incorporated herein by reference.
Referring to FIGS. 14A and 14B inspiration flow waveforms and stimulation pulse envelope waveforms are shown corresponding to a variation of a stimulation device and method of the invention. In accordance with this variation, the stimulation device stimulates during intrinsic breaths 1411, 1412, 1413 to provide resulting breaths 1421, 1422, 1423. The intrinsic breaths occur at a rate B1 as illustrated in FIG. 14A. The first stimulation 1451 is applied at a delay D1 from the onset of intrinsic breath 1411. The next stimulation 1452 is provided at a delay D2 from the onset of intrinsic breath 1412 and the subsequent stimulation pulse 1453 is provided at a delay D3 from the onset of intrinsic breath 1413. The time between the first and second stimulation 1451 and 1452 is T1+Δ a while the time between the second and third stimulation 1452 and 1453 is T1, i.e., shorter. Thus stimulation is provided gradually closer and closer to the onset of stimulation to gently take over breathing with stimulation at least in part during intrinsic inspiration. The stimulation 1453 is essentially synchronous with the start of the intrinsic inspiration 1413, to create the resulting breath 1423. Stimulation may be delivered at this rate for a period of time. Then the next stimulus 1454 is delivered at a rate faster than normal at a respiration cycle length timed to thereby elicit paced breath 1424. The next stimulus 1455 is delivered at the interval T2, to induce another paced breath 1425, and this may be continued for some time in order to control breathing. This may lead to the entrainment of the central respiratory control system. Also, rate may be increased gradually until no intrinsic breaths occur between the paced breaths. When control of respiratory rate is achieved (and possibly entrainment), if a slowing of the breathing rate is desired, the pacing rate can be decreased gradually as shown schematically in the Figure by stimuli delivered at a cycle length of T2+x, followed by T2+2x, inducing paced breaths 1426 and 1427. It is believed that if entrained, if desired, the stimulation rate may bring the respiration rate slower than the intrinsic rate and tidal volume may be manipulated. After a period of time or after breathing has been controlled as desired, the intrinsic breathing may be allowed to resume, for example, as shown with breath 1418. The patient may be weaned off stimulation, for example, as described herein.
In accordance with another aspect of the invention, the phrenic nerve or diaphragm may be stimulated using the low level stimulation as described herein, through an OSA event after obstructive sleep apnea event has occurred
The stimulation described or shown herein may be comprised of several stimulation parameters. For example a burst of pulses may form a square pulse envelope or may ramp up or down in amplitude or a combination thereof. The frequencies may vary or may be varied depending upon a desired result. In accordance with one embodiment, the burst frequency ranges between 5-500 Hz and more preferably between 20-50 Hz. However, other frequency ranges may be used as desired. Low level pulses or continuous stimulation may comprise stimulation at about 8 mA or less or may be determined on a case-by-case basis. However, other amplitudes and frequencies may be used as desired. The stimulation may be monophasic or may be biphasic. Stimulation may be provided in response to sensing respiration or other parameters. Alternatively, stimulation may be provided periodically or during specific times, for example during sleep, during sleep stage transitions, or during non-REM sleep.
Stimulation may also be slowly phased out. That is the patients may be weaned from stimulation slowly. In general, when paced breathing is ongoing, and the therapy is to be stopped, it may be beneficial to wean the patient off the therapy to avoid creating apnea that may lead to obstructions or arousals. Weaning off would involve a gradual decrease in rate, until an intrinsic breath is detected. Once an intrinsic breath is detected, the device would discontinue pacing and would return to monitoring mode. An example of a protocol for weaning a patient off from stimulation is described, for example, in U.S. application Ser. No. 10/686,891 filed Oct. 15, 2003. Other variations of weaning patients off are also possible.
FIG. 15 is a flow chart illustrating operation of a system or device in accordance with the invention. An implanted device is initialized during an initialization period 1510. During the initialization period, among other things, the thresholds may be set up for triggering or inhibiting therapy. The thresholds may be set up by observing patient breathing over time. Therapy modalities may also be chosen, for example by testing various stimulation protocols to optimize therapy. For example, information obtained from one or more breaths can be used to set pacing parameters for subsequent therapies. Examples of data that can be obtained from one or a series of breaths include: rate, tidal volume, inspiration duration, flow parameters, peak flow, and/or duty-cycle. In the case of paced breathing therapies or breathing control (and possible entrainment), the rate of intrinsic breathing could be measured, and then paced breathing could be delivered, for example, at a faster rate than the measured rate. As another example, one could measure the inspiration duration of previous intrinsic breaths, and induce a breath to create an inspiration duration longer (or shorter) than the previous intrinsic breaths. During initialization or when updating the device, test stimulation signals and measured responses may be used to determine appropriate stimulation parameters.
During operation, the therapy is turned on 1520. This may be done automatically or manually. Therapy is delivered 1530 as is determined to be appropriate for a particular patient in accordance with one or more protocols, for example as described herein.
Referring to FIGS. 17A-17E combination diaphragm/phrenic nerve and upper airway stimulation and respiration related waveforms illustrate a stimulation device and method in accordance with the invention. A low level continuous stimulation 1750 is applied (FIG. 17D) to the diaphragm or phrenic nerve in a manner similar to that described with reference to FIGS. 8A and 8B. The low level or volume bias stimulation may be provided for a predetermined period of time or on-demand, based on sensed information, for example, that indicates a greater likelihood of a respiratory disorder event occurring, for example by identifying a breathing pattern prior to onset of OSA or other disorder, or by identifying a flow limitation from an EMG.
FIG. 17E illustrates a stimulation signal 1760 applied to the hypoglossal nerve or upper airway. In accordance with the invention, it is believed that a combined effect of providing a volume bias stimulation and stimulating the upper airway or hypoglossal nerve provides improved upper airway tonicity and/or patency. Also, in accordance with the invention, the upper airway is preactivated prior to the contraction of the diaphragm. Accordingly, the airway may be prepared for negative pressure caused by diaphragm contraction which may have a collapsing effect on the upper airway.
Stimulation of the hypoglossal nerve (or upper airway) as illustrated in FIG. 17E may be triggered a number of ways. FIG. 17A illustrates the sensed EMG envelope 1720 corresponding to a subject stimulated in accordance with FIGS. 17D and 17E. The EMG signal 1720 may be processed to identify the end 1725 of an EMG envelope corresponding to a first breath 1730. The end 1725 of the EMG envelope of the first breath 1730 may be used to trigger hypoglossal nerve stimulation 1770 prior to a second breath 1735. The system may be programmed to wait a predetermined amount of time 1765 following the detected end 1725 of the EMG envelope of the first breath 1730 to stimulate the hypoglossal nerve. The system, for example may wait a percentage of an intrinsic exhalation period. This intrinsic exhalation period may be determined a number of ways. For example, the duration of an intrinsic inspiration period may be subtracted from the duration of an intrinsic respiration cycle. Alternatively, an intrinsic exhalation period may be determined by measuring the duration of one or more intrinsic expiration cycles using a flow correlated signal.
FIG. 17B illustrates an upper airway pressure waveform 1740 that may be sensed (or an other flow correlated signal), for example using sensor 86 positioned in the mouth (epiglossal). The sensed pressure corresponds to the breathing of the subject as indicated by the EMG envelope 1710 of FIG. 17A. The upper airway pressure waveform 1740 may be used to trigger hypoglossal nerve stimulation. The peak negative pressure trigger point 1747 may be detected by analyzing the waveform 1740 as described with respect to FIGS. 16A-16E. The peak negative pressure 1741 occurs at a time during exhalation that generally corresponds to 50% of exhalation (see comp 5, FIG. 16B). Similarly, tidal volume or intrapleural pressure (generally correlated with inverse of tidal volume) may be used to trigger hypoglossal nerve stimulation. FIG. 17C schematically illustrates a tidal volume or inverse intrapleural pressure waveform 1745. Trigger point 1746 is detected at 50% of exhalation (see comp 5 FIG. 16B). Stimulation 1760 may be provided after a predetermined delay 1755 from detection of trigger point 1741 (FIG. 17B) or 1746 (FIG. 17C). While 50% of exhalation is described with respect to the illustrated examples, generally stimulation of the hypoglossal nerve is provided before substantial diaphragm contraction. This is done by detecting a trigger point corresponding to a preceding inspiration cycle and most preferably during the exhalation cycle or rest period of a preceding inspiration cycle. Alternatively, a continuous hypoglossal nerve stimulation may be provided for a predetermined time, number of breaths, or may be triggered on or offAs is generally known, the EMG envelope is generally correlated to tidal volume. EMG amplitude is correlated to respiratory effort which increases during flow limitation and when no flow limitation exists is correlated to tidal volume.
Referring to FIGS. 18A-18F combination diaphragm/phrenic nerve, upper airway, abdominal and chest wall stimulation and respiration related waveforms illustrate a stimulation device and method in accordance with the invention.
FIG. 18A illustrates the EMG envelopes 1820 corresponding to a subject's breathing. FIG. 18B illustrates flow or the inverse of an upper airway pressure waveform 1830. The upper airway pressure waveform may be sensed, for example using sensor 86 positioned in the mouth. The sensed pressure corresponds to the breathing of the subject as indicated by the EMG envelope 1820 of FIG. 18A.
A low level discrete stimulation, i.e. lung volume bias stimulation 1850 is applied (FIG. 18D) to the diaphragm or phrenic nerve. The bias stimulation 1850 may be provided at or during a particular portion of an intrinsic respiration cycle. For example, the bias stimulation 1850 may be triggered at the beginning of the downward slope 1823 of the EMG envelope 1820 (FIG. 18A), at the peak 1832 of flow or inverse of upper airway pressure 1830 (FIG. 18B), or at approximately the 50% point 1843 of increasing tidal volume or inverse of intrapleural pressure 1840 (FIG. 18C). These points may be determined by analyzing the waveforms, for example, as described with respect to FIGS. 16A-16E. The bias stimulation may be provided for a predetermined period of time based on a subject's innate respiration cycle. While a specific trigger point and bias stimulation duration are described with reference to FIGS. 18A-18F, the discrete bias may be timed in a number of manners. The timing of the stimulation may be determined by analyzing the respiration waveform, e.g., EMG, flow, upper airway pressure, intrapleural pressure, tidal volume, or other respiration cycle correlated parameter, to determine the appropriate trigger threshold. The bias stimulation may be initiated during a portion of an inspiration cycle, at the end of the inspiration cycle or just prior to a subsequent inspiration cycle. The bias stimulation is provided during at least a portion of the exhalation cycle. The bias stimulation 1850 may be provided until or overlapping with the hypoglossal stimulation 1860 which is provided to open the upper airway prior to initiation of a subsequent inspiration cycle.
FIG. 18E illustrates a stimulation signal 1860 applied to the hypoglossal nerve or upper airway. In accordance with the invention, it is believed that a combined effect of providing a bias diaphragm stimulation and stimulating the upper airway or hypoglossal nerve provides improved upper airway tonicity and/or patency. Also, in accordance with the invention, the upper airway is preactivated prior to the contraction of the diaphragm. Accordingly, the airway may be prepared for negative pressure caused by diaphragm contraction which may have a collapsing effect on the upper airway.
Stimulation of the hypoglossal nerve (or upper airway) as illustrated in FIG. 18E may be triggered a number of ways. The end 1821 of the EMG envelope 1820 of the first breath 1825 (FIG. 18A), the zero crossing point 1831 of decreasing flow or inverse of upper airway pressure 1830 (FIG. 18B), or the peak 1841 of tidal volume or inverse of intrapleural pressure 1840 (FIG. 18C) may be used to trigger hypoglossal nerve stimulation 1860 prior to a second breath 1826. The system may be programmed to wait a predetermined amount of time 1865 following the detected end 1821 of the EMG envelope (FIG. 18A), zero crossing point 1831 of decreasing flow or inverse of upper airway pressure 1830 (FIG. 18B), or peak 1841 of tidal volume or inverse of intrapleural pressure 1840 (FIG. 18C) to stimulate the hypoglossal nerve. The system, for example may wait a percentage of an intrinsic exhalation period. This intrinsic exhalation period may be determined a number of ways. For example, the duration of an intrinsic inspiration period may be subtracted from the duration of an intrinsic respiration cycle. Also, the intrinsic exhalation period may be determined by measuring the duration of one or more intrinsic expiration cycles using a flow correlated signal or tidal volume correlated signal.
FIG. 18F illustrates a stimulation protocol of either a chest wall or abdominal muscles (muscles or associated nerves). Stimulation is provided, e.g. using electrodes 58 or 59, to augment diaphragm stimulation. A stimulation signal 1870, may be provided prior to onset of a subsequent inspiration, for example, during inspiration, at the end of inspiration or during exhalation.
A stimulation signal 1870 may be synchronized as illustrated by providing stimulation a preset period 1872 following beginning of bias stimulation 1850. A stimulation signal may also be provided at some time during an EMG envelope 1820 or at the end 1821 of and EMG envelope (FIG. 18A); during positive flow or at the beginning 1831 of negative flow of a breath or a correlated signal (FIG. 18B); or before during or after the peak 1841 of tidal volume or a correlated signal (FIG. 18C). It is believed that such stimulation may assist in controlling lung volume prior to a subsequent inspiration, or may assist in supplementing functional residual capacity. A stimulation signal 1875 may also be triggered during inspiration, e.g. at the beginning of an EMG envelope (FIG. 18A), at the beginning of positive flow or correlated signal (FIG. 18B), or at the beginning of the upward slope of tidal volume or a correlated signal (FIG. 18C). It is believed that such stimulation may augment diaphragm stimulation, or augment inspiration
FIGS. 19A-19E illustrate a combination diaphragm/phrenic nerve and upper airway stimulation and respiration related waveforms illustrating a stimulation device and method in accordance with the invention.
Natural breathing is controlled by augmenting breathing with a stimulation signal 1950 (FIG. 19D). Prior to augmentation, hypoglossal nerve (or upper airway) stimulation 1960 (FIG. 19E) is provided to prevent the upper airway from collapsing when stimulation signal 1950 is provided.
The stimulation signal 1950 is applied to the diaphragm or phrenic nerve during intrinsic breathing at the end of an inspiration cycle in a manner similar to that described with respect to FIGS. 6A to 6C. Stimulation may also be applied during intrinsic breathing in other manners for various therapeutic purposes, for example, as described herein with respect to FIGS. 4A-4D, and 10A-10C, 11A-11B, and 14A-14B. The stimulation may be triggered to be provided at or during a particular portion of an intrinsic inspiration or respiration cycle. The stimulation signal 1950 illustrated in FIG. 19D is triggered either at the peak 1922 of the EMG envelope 1920 (FIG. 19A), the peak 1932 of flow or inverse airway pressure 1930 (FIG. 19B), or at about 50% 1941 of tidal volume or inverted intrapleural pressure 1940 (FIG. 19C). These threshold points may be determined by analyzing the EMG, flow, upper airway pressure, tidal volume, or intrapleural pressure waveforms, for example, in a manner set forth with respect to FIGS. 16A-16E herein.
The bias stimulation 1955 (FIG. 19D) may also be provided at other times in the respiration cycle depending on the amount of augmented flow or inspiration duration that is desired. The low level stimulation 1955 may be provided at times of the inspiration cycle when augmentation is not provided. It may also be provided continuously.
FIG. 19E illustrates a stimulation signal 1960 applied to the hypoglossal nerve or upper airway. In accordance with the invention, it is believed that a combined effect of providing a stimulation to augment or control breathing, with stimulation to the upper airway or hypoglossal nerve provides improved upper airway tonicity and/or patency that reduces the possibility of upper airway collapse when controlling breathing. Also, in accordance with the invention, the upper airway is preactivated prior to the contraction of the diaphragm. Accordingly, the airway may be prepared for negative pressure caused by diaphragm contraction particularly when stimulating to augment or control breathing, which may have a collapsing effect on the upper airway.
Stimulation of the hypoglossal nerve as illustrated in FIG. 19E may be triggered a number of ways. The end 1921 of the EMG envelope 1920 of the first breath 1925 (FIG. 19A), the zero crossing point 1931 of decreasing flow or inverse of upper airway pressure 1930 (FIG. 19B), or the peak 1941 of tidal volume or inverse of intrapleural pressure 1940 (FIG. 19C) may be used to trigger hypoglossal nerve stimulation 1960 prior to a second breath 1926. The system may be programmed to wait a predetermined amount of time 1965 following the detected end 1921 of the EMG envelope (FIG. 19A), zero crossing point 1931 of decreasing flow or inverse of upper airway pressure 1930 (FIG. 19B), or peak 1941 of tidal volume or inverse of intrapleural pressure 1940 (FIG. 19C) to stimulate the hypoglossal nerve. The system, for example may wait a percentage of an intrinsic exhalation period. This intrinsic exhalation period may be determined a number of ways. For example, the duration of an intrinsic inspiration period may be subtracted from the duration of an intrinsic respiration cycle. Also, the intrinsic exhalation period may be determined by measuring the duration of one or more intrinsic expiration cycles using a flow correlated signal or tidal volume correlated signal.
Hypoglossal nerve stimulation 1960 is provided prior to onset of a breath 1926 where stimulation signal 1950 is provided. The hypoglossal nerve stimulation 1960 may also be continued for the duration of the stimulation signal 1950.
FIGS. 20A-20E illustrate a combination diaphragm/phrenic nerve and upper airway stimulation and respiration related waveforms illustrating a stimulation device and method in accordance with the invention.
A stimulation signal 2050 is applied (FIG. 20D) to the diaphragm or phrenic nerve to elicit paced breathing for one or more of various therapeutic purposes, for example, as described herein with respect to FIGS. 5A-5C, 9A-9C and, 11A-11B, 12A-12B, 13A-13B and 14A-14B. The stimulation may be triggered to be provided at or during a particular portion of an intrinsic inspiration or respiration cycle. As illustrated in FIG. 20D, stimulation is triggered at a time during an exhalation phase or rest period of a previous intrinsic breath 2010.
FIG. 20E illustrates a stimulation signal 2060 applied to the hypoglossal nerve or upper airway. In accordance with the invention, it is believed that a combined effect of providing a stimulation to control breathing with stimulation to the upper airway or hypoglossal nerve provides improved upper airway tonicity and/or patency that reduces the possibility of upper airway collapse when controlling breathing. Also, in accordance with the invention, the upper airway is preactivated prior to the contraction of the diaphragm. Accordingly, the airway may be prepared for negative pressure caused by diaphragm contraction particularly when stimulating to control breathing, which may have a collapsing effect on the upper airway.
Stimulation of the hypoglossal nerve as illustrated in FIG. 20E may be initially triggered a number of ways. FIG. 20A illustrates the sensed EMG envelope 2020 corresponding to a subject stimulated in accordance with FIGS. 20D and 20E. The EMG signal 2020 may be processed to identify the end 2021 of an EMG envelope corresponding to a first intrinsic breath 2010. The end 2021 of the EMG envelope of the intrinsic breath 2010 may be used to trigger combined hypoglossal nerve stimulation 2060 and breathing stimulation 2050. The system may be programmed to wait to stimulate the hypoglossal nerve for a predetermined amount of time 2065 following the detected end 2021 of the EMG envelope of the intrinsic breath 2010. The system may be further programmed to wait a predetermined amount of time 2055 from the stimulation of the hypoglossal nerve to stimulate a paced breath. The zero crossing point 2031 of decreasing flow or inverse of upper airway pressure 2030 (FIG. 20B), or peak 2041 of tidal volume or inverse of intrapleural pressure 2040 (FIG. 20C) to stimulate the hypoglossal nerve may be used as triggers as well. While specific trigger points are illustrated with respect to FIGS. 20A-20E, a variety of other trigger points may be used. Hypoglossal stimulation 2060 preferably is provided or initiated prior to paced breathing stimulation 2050. According to one embodiment, hypoglossal stimulation 2060 is provided or initiated between 200-500 ms prior to paced breathing stimulation 2050. According to another aspect, the hypoglossal nerve stimulation continues through the inspiration period of a paced breath (FIG. 23E).
According to another aspect of the invention, a bias stimulation 2057 may be provided during an exhalation phase or rest period of the paced breathing. The bias stimulation 2057 may be provided for a predetermined amount of time 2058, prior to initiation of hypoglossal stimulation 2060. Alternatively the bias stimulation maybe 2057 be provided for the entire duration between paced breathing stimulation 2050.
While hypoglossal or upper airway stimulation is illustrated herein in combination with diaphragm stimulation, it is also contemplated that the hypoglossal stimulation may be provided alone and triggered to begin during exhalation and prior to beginning of a subsequent inspiration cycle as set forth herein.
FIG. 21 schematically illustrates a device and system in accordance with the invention. A central controller 2100 controls stimulation, for example in accordance with one or more stimulation protocols as described herein. Diaphragm stimulation 2120 is controlled by the controller. Hypoglossal nerve stimulation or upper airway stimulation 2110 may be provided as set forth in the protocols herein to provide or increase airway patency. The controller coordinates the timing of the hypoglossal nerve stimulation 2110 and the diaphragm stimulation 2120. Additionally or alternatively, the controller 2100 coordinates stimulation of the chest wall 2130 and/or stimulation of the intra-abdominal muscles 2140 with diaphragm stimulation 2120 and/or hypoglossal nerve/upper airway stimulation 2110. Sensor input 2150 may provide information on the patient status, e.g., relating to likelihood of onset of breathing disorder, or relating to respiration, e.g., EMG, flow or tidal volume correlated signals. This information may be used by the controller to coordinate or control stimulation 2110, 2120, 2130, 2140, for example, in accordance with one or more protocols described herein.
The protocols set forth herein may vary or other stimulation protocols are contemplated herein and may be used in accordance with the invention to treat respiration related disorders.
While the invention has been described with respect to treating obstructive sleep apnea, various aspects of the invention are not limited to use in obstructive sleep apnea patients. The various techniques for controlling breathing as disclosed herein may be used in other therapeutic applications where controlling breathing is desired, for example in various breathing related disorders.
For example, stimulating breathing during intrinsic inspiration may be useful in any treatment involving control of breathing. Stimulating during intrinsic inspiration may be used as a technique to gradually begin to control or manipulate breathing parameters such as breathing rate, inspiration duration and tidal volume. Simulation during intrinsic breathing may be used with a number of breathing control protocols to initiate control of breathing, e.g., to gradually take over or to entrain breathing and to gradually control or manipulate breathing parameters.
The various techniques used to increase functional residual capacity maybe used in connection with any therapy where an increase in functional residual capacity results in a desired benefit.
Likewise, therapy described herein that stiffen the upper airway may also be used in any therapy for a breathing related disorder where the effects of improving upper airway patency are beneficial.
Similarly the techniques for controlling or entraining breathing as described herein may be used in other therapeutic applications where controlling or entraining breathing is desired.
Similarly, techniques for creating ventilatory stability as described herein may be used in other therapeutic application where stabilization is beneficial.
Stimulation may be provided at various times during sleep or various sleep stages or sleep transitions, including but not limited to, for example: prior to sleep, at sleep onset, upon detection of dropping tidal volume, upon detection of transition into REM or non-REM or during REM or non-REM sleep, or upon changes in breathing patterns, including but not limited to breathing rate.
The various stimulation protocols described herein may be combined in a variety of manners to achieve desired results.

## Claims

1. A device for manipulating breathing of a subject comprising:
a phrenic nerve and/or diaphragm tissue stimulation element comprising at least a first electrode;
an upper airway stimulation element comprising at least a second electrode;
a controller in communication with the first and second electrodes and programmed to supply a first stimulation signal through the first electrode during at least one existing breath to a phrenic nerve and/or diaphragm tissue to elicit a diaphragm response without initiating a new breath during a respiratory cycle of the subject having intrinsic respiration and to further supply a second stimulation signal through the second electrode during at least one existing breath to tissue associated with an upper airway of the subject during said respiratory cycle to elicit a response of an upper airway musculature; and,
a sensor in communication with the controller, wherein the sensor is configured to detect at least one parameter of the respiratory cycle,
wherein the controller is further programmed to coordinate the first and second stimulation signals provided by the phrenic nerve and/or diaphragm tissue stimulation element and upper airway stimulation element with respect to each other to supply diaphragm stimulation and upper airway stimulation such that the breath is supplemented, and
wherein the controller is also programmed to adjust a waveform of the first stimulation signal in response to the sensed parameter of the respiratory cycle.

2. The device of claim 1 wherein the controller is further programmed to stimulate the upper airway via the upper airway stimulation element during a first respiratory cycle prior to inspiration of a next respiratory cycle.

3. The device of claim 2 wherein the controller is further programmed to stimulate the upper airway via the upper airway stimulation element during an exhalation cycle of a first respiratory cycle prior to inspiration of the next respiratory cycle.

4. The device of claim 3 wherein the controller is further programmed to provide the first stimulation signal via the phrenic nerve and/or diaphragm tissue stimulation element to stabilize an airway and a subsequent stimulation signal via the phrenic nerve and/or diaphragm tissue stimulation element.

5. The device of claim 4 wherein the controller is further programmed to provide an increased lung volume beyond a baseline via the phrenic nerve and/or diaphragm tissue stimulation element.

6. The device of claim 1 wherein the controller is further programmed to provide stimulation via the phrenic nerve and/or diaphragm tissue stimulation element to supplement an intrinsic breath of said next respiratory cycle.

7. The device of claim 1 wherein the controller is further programmed to increase a functional residual capacity of the subject by providing a stimulation via the phrenic nerve and/or diaphragm tissue stimulation element while stiffening the airway.

8. The device of claim 1 wherein the controller is further programmed to provide stimulation via the diaphragm stimulation element to augment or supplement a tidal volume of the intrinsic respiration of a subsequent respiratory cycle.

9. The device of claim 1 wherein the controller is further programmed to provide stimulation via the phrenic nerve and/or diaphragm tissue stimulation element to increase lung volume.

10. A device for manipulating breathing of a subject comprising:
a phrenic nerve and/or diaphragm tissue stimulation element comprising at least a first electrode;
an upper airway stimulation element comprising at least a second electrode;
a controller in communication with the first and second electrodes and programmed to supply a low-level stimulation signal through the first electrode during at least one existing breath to a phrenic nerve and/or diaphragm tissue of the subject having intrinsic respiration to elicit a diaphragm response without initiating a new breath and to further supply a stimulation signal through the second electrode during at least one existing breath to tissue associated with an upper airway of the subject to elicit a response of an upper airway musculature; and,
a sensor in communication with the controller, wherein the sensor is configured to detect at least one parameter of the respiratory cycle,
wherein the controller is further programmed to coordinate the first and second stimulation signals provided by the phrenic nerve and/or diaphragm tissue stimulation element and upper airway stimulation element with respect to each other to supply diaphragm stimulation and upper airway stimulation such that the functional residual capacity is supplemented, and
wherein the controller is also programmed to adjust a waveform of the first stimulation signal in response to the sensed parameter of the respiratory cycle.

11. The device of claim 10 wherein the controller is further programmed to supply an electrical stimulation signal via the upper airway stimulation element during an exhalation portion of a first respiratory cycle prior to an inspiration portion of an inspiration portion of a next respiratory cycle.

12. The device of claim 10 wherein the controller is further programmed to provide the low-level stimulation signal via the phrenic nerve and/or diaphragm tissue stimulation element to stabilize an airway and a subsequent stimulation signal via the phrenic nerve and/or diaphragm tissue stimulation element to elicit a breath.

13. A device for manipulating breathing of a subject comprising:
a phrenic nerve and/or diaphragm tissue stimulation element comprising at least a first electrode;
an auxiliary stimulation element comprising at least a second electrode;
a controller in communication with the first and second electrodes and programmed to supply a stimulation signal through the first electrode during at least one existing breath to a phrenic nerve and/or diaphragm tissue of the subject having intrinsic respiration to elicit a diaphragm response without initiating a new breath during a respiratory cycle of the subject and to further supply a stimulation signal through the second electrode during at least one existing breath to tissue associated with an auxiliary musculature associated with the subject's respiratory system during said respiratory cycle to elicit an auxiliary response of the auxiliary musculature; and,
a sensor in communication with the controller, wherein the sensor is configured to detect at least one parameter of the respiratory cycle,
wherein the controller is further programmed to coordinate the first and second stimulation signals provided by the phrenic nerve and/or diaphragm tissue stimulation element and auxiliary stimulation element with respect to each other to supply diaphragm stimulation and auxiliary stimulation such that the breath is augmented, and
wherein the controller is also programmed to adjust a waveform of the first stimulation signal in response to the sensed parameter of the respiratory cycle.

14. A method for manipulating breathing of a subject comprising the steps of:
providing a phrenic nerve and/or diaphragm tissue stimulation element comprising at least a first electrode and an upper airway stimulation element comprising at least a second electrode;
monitoring a respiratory parameter of the subject;
supplying a first stimulation signal through the first electrode during an existing breath to a phrenic nerve and/or diaphragm tissue of the subject to elicit a diaphragm response without initiating a new breath during intrinsic respiration of the subject, wherein the first stimulation signal has a waveform which elicits the diaphragm response and which is adjusted in response to the monitored respiratory parameter;
supplying a second stimulation signal through the second electrode during the existing breath to tissue associated with an upper airway of the subject to elicit a response of an upper airway musculature; and
coordinating the first and second stimulation signals respectively provided by the diaphragm stimulation element and upper airway stimulation element to avoid upper airway collapse during diaphragm stimulation such that the breath is supplemented.

15. A method for manipulating breathing of a subject comprising the steps of:
providing a phrenic nerve and/or diaphragm tissue stimulation element comprising at least a first electrode and an upper airway stimulation element comprising at least a second electrode;
monitoring a respiratory parameter of the subject;
supplying a first stimulation signal through the first electrode during an existing breath to a phrenic nerve and/or diaphragm tissue of the subject to elicit a diaphragm response without initiating a new breath during intrinsic respiration of the subject, wherein the first stimulation signal has a waveform which elicits the diaphragm response and which is adjusted in response to the monitored respiratory parameter;
supplying a second stimulation signal through the second electrode during the existing breath to tissue associated with an upper airway of the subject to elicit a response of an upper airway musculature; and
stimulating the upper airway musculature during an exhalation cycle of a first respiratory cycle prior to an inspiration portion of a next respiratory cycle.

16. The method of claim 15 wherein the step of supplying a first stimulation signal comprises eliciting the diaphragm response by augmenting an intrinsic breath.

17. The method of claim 16 wherein the step of augmenting an intrinsic breath comprises augmenting the breath during said next respiration cycle.

18. The method of claim 15 wherein the step of supplying a first stimulation signal comprises eliciting the diaphragm response by providing a lung volume bias stimulation without eliciting a respiratory cycle.

19. A method for manipulating breathing of a subject comprising the steps of:
providing a phrenic nerve and/or diaphragm tissue stimulation element comprising at least a first electrode and an auxiliary stimulation element comprising at least a second electrode;
monitoring a respiratory parameter of the subject;
supplying a first stimulation signal through the first electrode during an existing breath to a phrenic nerve and/or diaphragm tissue to elicit a diaphragm response without initiating a new breath during a respiratory cycle of the subject having intrinsic respiration, wherein the first stimulation signal has a waveform which elicits the diaphragm response and which is adjusted in response to the monitored respiratory parameter;
supplying a second stimulation signal through the second electrode during the existing breath to tissue associated with an auxiliary musculature associated with the subject's respiratory system during said respiratory cycle to elicit an auxiliary response of an auxiliary musculature; and
coordinating the first and second stimulation signals respectively provided by the diaphragm stimulation element and auxiliary stimulation element with respect to each other such that the breath is augmented.

20. The method for manipulating breathing of claim 19 wherein the step of coordinating the first and second stimulation signals comprises coordinating the diaphragm stimulation with one or more of upper airway stimulation, chest wall stimulation and abdominal stimulation.