Abstract:
Improved methods and devices are described for sensing the respiration pattern of a patient and controlling ventilator functions, particularly for use in an open ventilation system. An apparatus for sensing respiration and synchronizing a ventilator to the respiration of a patient is described. The apparatus may include a plurality of thermal breath sensors. At least one of the plurality of thermal breath sensors may be a heated thermal breath sensor.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims priority to U.S. Provisional Patent Application No. 61/071,251, entitled “Methods and Devices for Sensing Respiration and Controlling Ventilator Functions”, filed Apr. 18, 2008, the content of which is incorporated by reference in its entirety. 
    
    
     This application incorporates by reference in their entireties: U.S. patent application Ser. No. 10/771,803, entitled “Method and Arrangement for Respiratory Support for a Patient Airway Prosthesis and Catheter”, filed Feb. 4, 2004; U.S. patent application Ser. No. 11/523,518, entitled “Systems, Methods and Apparatus for Respiratory Support of a Patient”, filed Sep. 20, 2006; and U.S. patent application Ser. No. 11/523,519, entitled “Systems, Methods and Apparatus for Respiratory Support of a Patient”, filed Sep. 20, 2006. 
     FIELD OF THE INVENTION 
     This invention relates to ventilation therapy for persons requiring respiratory support from a ventilator. Conditions can include respiratory impairment and breathing disorders, such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, acute respiratory distress syndrome (ARDS), neuromuscular impairment, and sleep apnea, or anesthesia, emergency and the like. The present invention relates more specifically to measuring a patient&#39;s respiratory pattern using breath sensing approaches, and using that measured information from breath sensors to synchronize ventilator output to a breathing pattern of a patient. 
     BACKGROUND OF THE INVENTION 
     There are two general types of control systems for conventional ventilators. A first type delivers gas to a patient based on a frequency selected by the clinician that is independent of patient activity. This control system is used when the patient is non-alert, sedated, unresponsive or paralyzed. In this type of system, the ventilator is breathing for the patient. A second type of control system delivers gas to the patient in response to an inspiratory effort created by the patient. This type of ventilation helps the patient breathe. There are also ventilators and modes of ventilation that combine these two types of control systems. The present invention relates to ventilation systems and modes that respond to an inspiratory effort by the patient. 
     Control systems that respond to patient breathing efforts require breath sensors to detect inspiration. Conventional systems use pressure or flow sensors to detect the start of an inspiratory effort by the patient. The sensor is located somewhere in-line with the ventilation gas delivery circuit, either inside the ventilator, or in the tubing between the ventilator and the patient, or at the patient end of the tubing. In-line breath sensors are also used to measure the entire respiratory curve in addition to just the start of inspiration, however because the gas being delivered by the ventilator also moves past the sensor, the sensor during that time no longer measures the patient&#39;s respiration but rather the ventilator activity. In a closed ventilation system, the patient lung pressure and the gas delivery circuit pressure, while not necessarily identical, are typically very close. In an open ventilation system in which the patient is also spontaneously breathing, the patient lung pressure and the gas delivery circuit pressure can be very different. In this case a breath sensor in-line with the ventilation gas delivery circuit can be ineffective in measuring the entire respiratory pattern. 
     In ventilation systems in which the patient is expected to be breathing or partially breathing spontaneously, synchronization between the ventilator and the patient is important for comfort and efficacy. However, poor synchrony is still reported in some cases because of the demanding and exacting task of measuring all the different possible spontaneous breathing signals and the vast range of variations that exist. 
     Some attempts have been made to use sensors that are in parallel with the ventilation gas delivery system and are more directly coupled to the patient&#39;s actual respiration. The intent of these systems is to improve breath detection, to improve responsiveness of the ventilator, to improve the synchrony of the ventilator to the patient, or to reduce work of breathing required for a patient to trigger the ventilator. 
     For example, chest impedance sensors can be used to measure the entire respiratory curve of a patient and to use that signal to control the ventilator and synchronize the ventilator to the patient&#39;s breathing. However, this approach is technically challenging because the signal is prone to drift, noise and artifacts caused by patient motion and abdominal movement. In another technology, the neural respiratory drive measured with an esophageal catheter is used to measure the respiration of a patient. However, this technique requires an additional invasive device, and it does not monitor exhalation activity since that is a neurally passive function. 
     Thermal breath sensing is promising because it can be implemented such that the breath sensing can be placed in parallel with ventilation gas delivery and in-line with the spontaneous breathing airflow. If implemented correctly, thermal sensors can determine the complete breathing pattern of the patient and can generate a signal that is not disrupted by the ventilator gas flow. This is advantageous to optimize the synchrony of the ventilator to the patient&#39;s natural breath pattern, so that the patient is comfortable. Also, if the goal is to provide therapy during different portions of the respiratory curve, such as during the middle of inspiration, or during a particular part of the expiratory phase, then this method which accurately measures the entire respiratory curve is very beneficial. Another advantage of thermal sensing is that it is possible to correlate the signal to the patient&#39;s spontaneous breathing airflow, and knowledge of airflow can be useful to enhance ventilator control and therapy. 
     This breath sensing technology can, however, still be improved. Sensors that are in the airway of the patient can be prone to problems stemming from tissue interaction, patient-to-patient variability, variability within a given patient over time, variable outside environmental conditions such as temperature and humidity, and variable internal physiological conditions. For example, secretions in the airway could collect on the sensor and could cause signal artifacts and disrupt the sensor&#39;s ability to accurately and reliably measure the entire breath curve. Or, the sensor could come into contact with the tracheal wall which would disrupt the sensor&#39;s signal. In summary, existing systems have the one or more of the following disadvantages that require improvement: (1) they do not measure the complete breath cycle, (2) they are in-line with the channel used for ventilation gas delivery, (3) they have a limited reliability and robustness, and (4) do not provide an adequate determination of flow which can be useful for enhancing ventilator functions and optimizing therapy. 
     Therefore, the subject of this invention is to provide improved solutions to intra-airway thermal breath sensing. 
     SUMMARY OF THE INVENTION 
     The current invention is an improvement over existing breath sensing techniques for monitoring respiration and controlling ventilator functions. The invention may include temperature responsive breath sensors positioned in the airway or in proximity to an opening of the airway, in parallel with a ventilation circuit and in series with spontaneous airflow flowing in and out of a patient airway. Novel apparatus and methods for protecting and maintaining the sensor signal are also disclosed. 
     Various techniques for thermal-based breath sensing are described herein. In an exemplary embodiment, response times may be compared between multiple sensing elements to determine direction of airflow. In an exemplary embodiment, heated thermal-based sensors may be used to create a known and consistent offset and signal phase, so that prevailing temperature conditions due not effect the offset or phase. In an exemplary embodiment, a temperature signal may be converted to a volumetric flow rate or breathing volumes. In an exemplary embodiment, a heat source may be located near the thermal-based sensor or sensors to produce a signal response that consistently corresponds to flow direction. In an exemplary embodiment, a single thermal-based sensor may be used in which the offset value is adjusted to maintain a constant offset so that the signal does not drift due to changing prevailing temperature conditions. In an exemplary embodiment, multiple sensor locations may be used to provide reference and comparison values. In an exemplary embodiment, thermal sensors may be placed in a dedicated sensing lumen within the ventilation tube or catheter. In an exemplary embodiment, thermal-based sensors may be used in conjunction with pressure-based sensors in order to obtain both breathing airflow and breathing pressure. 
     Improved methods and devices are described for sensing the respiration pattern of a patient and controlling ventilator functions, particularly for use in an open ventilation system. An apparatus for sensing respiration and synchronizing a ventilator to the respiration of a patient is described. The apparatus may include a plurality of thermal breath sensors. At least one of the plurality of thermal breath sensors may be a heated thermal breath sensor. The plurality of thermal breath sensors may have attributes selected from the group consisting of: (1) the plurality of thermal breath sensors are joined in a bridge circuit; (2) the at least one heated thermal breath sensor is heated to maintain a desired baseline temperature compared to ambient temperature; (3) the at least one heated thermal breath sensor is heated using a heat source decoupled from the at least one heated thermal breath sensor; and (4) combinations thereof. The plurality of thermal breath sensors may have configurations selected from the group consisting of: (1) one thermal breath sensor is a sensing sensor and a second thermal breath sensor is an ambient reference sensor; (2) one thermal breath sensor is placed near the entrance to or in an airway, and a second thermal breath sensor is placed away from the airway as an ambient reference sensor; (3) two thermal breath sensors are in communication with spontaneous airflow and are joined in bridge circuit, and a third thermal breath sensor is not in communication with the spontaneous airflow and is a reference sensor; (4) at least one thermal breath sensor is positioned in a conduit that is in communication with spontaneous airflow, wherein the cross-section of the conduit and sensor signal are used to determine a volumetric flow rate; (5) two thermal breath sensors are separated by a barrier to create a directionally biased signal response phase shift between the signals of the two thermal breath sensors, wherein the phase shift directionality is used to determine the direction of airflow and the phase of respiration; and (6) combinations thereof. A DC shift of a signal from at least one of the plurality of thermal breath sensors may be controlled by (1) continually adjusting a source voltage or (2) auto-zeroing through a software feedback loop. The plurality of thermal breath sensors may be selected from the group consisting of: thermistors; polymer based thermally responsive materials; thermally responsive materials shaped like a bead, strip or ring; and combinations thereof. A signal from the plurality of thermal breath sensors may be correlated to flow, and the flow may be correlated to depth of breathing, inspiratory effort, inspiratory and expiratory flow, inspiratory and expiratory volume, and patient respiratory status. 
     An apparatus may be provided for sensing respiration and synchronizing a ventilator to the respiration of a patient. The apparatus may include at least three thermal breath sensors. A first thermal breath sensor may measure temperature in an airway of the patient, a second thermal breath sensor may measure temperature at or near the opening of an airway of the patient, and a third thermal breath sensor may measure ambient temperature. Signals from the first thermal breath sensor and the second thermal breath sensor may be initially compared to a signal from the third thermal breath sensor to determine if inspired ambient air should be warmer or cooler than body temperature, and wherein the initial signal comparison defines an inspiratory phase and an expiratory phase associated with the signals from the first thermal breath sensor and the second thermal breath sensor. The signals from the first thermal breath sensor and the second thermal breath sensor are subsequently compared to each other to compensate for drift and artifacts, and wherein the subsequent signal comparison is used to determine true patterns, phases and timing of the patient&#39;s respiration. The at least three thermal breath sensors may have attributes selected from the group consisting of: (1) the first thermal breath sensor and the second thermal breath sensor are joined in a bridge circuit; (2) at least one of the first thermal breath sensor and the second thermal breath sensor are heated to maintain a desired baseline temperature compared to ambient temperature; (3) at least one of the first thermal breath sensor and the second thermal breath sensor are heated using a heat source decoupled from the at least one of the first thermal breath sensor and the second thermal breath sensor; and (4) combinations thereof. The at least three thermal breath sensors may have configurations selected from the group consisting of: (1) the first thermal breath sensor and the second thermal breath sensor are in communication with spontaneous airflow and are joined in a bridge circuit, and the third thermal breath sensor is not in communication with spontaneous airflow and is a reference sensor; (2) at least one of the at least three thermal breath sensors is positioned in a conduit that is in communication with spontaneous airflow, wherein the cross-section of the conduit and sensor signal are used to determine a volumetric flow rate; (3) the first thermal breath sensor and the second thermal breath sensor are separated by a barrier to create a directionally biased signal response phase shift between the signals of the first thermal breath sensor and the second thermal breath sensor, wherein the phase shift directionality is used to determine the direction of airflow and the phase of respiration; and (4) combinations thereof. A DC shift of a signal of at least one of the at least three thermal breath sensors may be controlled by (1) continually adjusting a source voltage or (2) auto-zeroing through a software feedback loop. The at least three thermal breath sensors may be selected from the group consisting of: thermistors; polymer based thermally responsive materials; thermally responsive materials shaped like a bead, strip or ring; and combinations thereof. A signal from one or both of the first thermal breath sensor and the second thermal breath sensor may be correlated to flow, and the flow may be correlated to depth of breathing, inspiratory effort, inspiratory and expiratory flow, inspiratory and expiratory volume, and patient respiratory status. 
     An apparatus may be provided for sensing respiration and synchronizing a ventilator to the respiration of a patient. The apparatus may include a ventilation tube to deliver gas to the patient, where the ventilation tube further includes a ventilation gas delivery channel to deliver gas to the patient. A breath sensing conduit may be in communication with an airway of the patient, where a thermal breath sensor is positioned in series with the breath sensing conduit. The thermal breath sensor may have attributes selected from the group consisting of: (1) the thermal breath sensor is joined with a second sensor in a bridge circuit; (2) the thermal breath sensor is heated to maintain a desired baseline temperature compared to ambient temperature; (3) the thermal breath sensor is heated using a heat source decoupled from the thermal breath sensor; and (4) combinations thereof. The apparatus may have configurations selected from the group consisting of: (1) the apparatus includes a second sensor that is an ambient temperature reference sensor; (2) the thermal breath sensor is placed near the entrance to an airway; (3) the thermal breath sensor is placed in an airway; (4) the thermal breath sensor is positioned in the sensing conduit near or in the patient&#39;s airway; and (5) combinations thereof. A DC shift of a signal of the thermal breath sensor may be controlled by (1) continually adjusting a source voltage or (2) auto-zeroing through a software feedback loop. The thermal breath sensor may be selected from the group consisting of: thermistors; polymer based thermally responsive materials; thermally responsive materials shaped like a bead, strip or ring; and combinations thereof. A signal from the thermal breath sensor may be correlated to flow, and the flow may be correlated to depth of breathing, inspiratory effort, inspiratory and expiratory flow, inspiratory and expiratory volume, and patient respiratory status. A signal from the thermal breath sensor may be correlated to flow using the signal and a cross sectional area of the sensing conduit, and the flow may be correlated to depth of breathing, inspiratory effort, inspiratory and expiratory flow, inspiratory and expiratory volume, and patient respiratory status. An intra-airway pressure sensing conduit may be provided, where at least one thermal breath sensor may be used to determine spontaneous breathing airflow, and the intra-airway pressure sensing conduit may be used to determine breathing pressure. 
     In certain embodiments, a method for breath sensing and controlling a ventilator may use two sensing systems, a thermal sensor for measuring tracheal airflow and a pressure sensor for measuring tracheal pressure. In certain embodiments, a method for breath sensing and controlling a ventilator may use two temperature sensitive elements where one element is exposed to ambient temperature and the other element is placed in the airway exposed to the intratracheal temperature. A method for breath sensing and controlling a ventilator may use three temperature sensitive elements, where one element is placed at the breathing entry point, for example the nose or mouth, and the other element is exposed to ambient temperature and the other element is placed in the airway exposed to the intratracheal temperature. A method and apparatus for sensing breathing and controlling a ventilator may use an array of temperature sensitive elements and comparing the temporal differences in the signals of the different elements to derive airflow direction and speed. A method and apparatus for sensing breathing and controlling a ventilator may use heated temperature-sensitive elements, and comparing the temporal differences in the signals. A method and apparatus for sensing breathing and controlling a ventilator may use a pair of temperature-sensitive elements arranged in a Wheatstone bridge, with one element heated. A method and apparatus for sensing breathing and controlling a ventilator may use a pair of temperature-sensitive elements arranged in a Wheatstone bridge, and while heating the pair of elements. A method for breath sensing and controlling a ventilator may use two temperature sensitive elements, with a heat source located near the elements. A method for breath sensing and controlling a ventilator may use two temperature sensitive elements arranged in a Wheatstone bridge configuration with a heat source located near the elements. A method for breath sensing and controlling a ventilator may use a single temperature sensitive element where the DC shift of the signal of the element is controlled by continually adjusting the source voltage or by auto-zeroing through software feedback loop. A method for breath sensing and controlling a ventilator may use a temperature sensitive element placed in an auxiliary sensing lumen in the gas delivery circuit. A method for breath sensing and controlling a ventilator may use a pair of temperature sensitive elements placed in an auxiliary sensing lumen in the gas delivery circuit, and optionally arranged in a Wheatstone bridge. A method for breath sensing and controlling a ventilator may use an array of sensing elements placed the trachea, the gas delivery circuit main lumen, and an auxiliary sensing lumen in the gas delivery circuit. A method and apparatus for sensing breathing and controlling a ventilator may use temperature-sensitive elements contained in a channel of known cross section, the signal from the elements used to determine airflow speed and volume using the known cross sectional dimension. A method and apparatus for sensing breathing and controlling a ventilator may use two sensing elements with a physical screen between the elements to bias the response time of each element due to the direction of flow. A method and apparatus for sensing breathing and controlling a ventilator may use two sensing elements on the inferior and superior aspects of the delivery cannula to create a physical barrier to bias the response time of each element that correlates to the direction of flow. A method and apparatus for sensing breathing and controlling a ventilator may use a inner and outer delivery cannula with an annular space between the inner and outer cannula and with a valve allowing for inspiratory flow through the annular space from ambient air but disallowing expiratory flow, and wherein a thermal breath sensing element placed in the annular space between the inner and outer cannula. A method and apparatus for sensing breathing and controlling a ventilator may use thermally sensitive sensing elements disposed in the airway. A method and apparatus for sensing breathing and controlling a ventilator may use thermally sensitive sensing elements disposed outside the airway. A method and apparatus for sensing breathing and controlling a ventilator may use thermally sensitive sensing elements disposed both inside and outside the airway. A method and apparatus for sensing breathing and controlling a ventilator may use thermally sensitive sensing elements disposed in a flow path between a two piece inner and outer ventilation tube. A method and apparatus for sensing breathing and controlling a ventilator may use thermally sensitive sensing elements disposed in a flow path between a stoma sleeve and a ventilation tube placed through the stoma sleeve. A method and apparatus for sensing breathing and controlling a ventilator may use thermally sensitive sensing elements disposed in the airway and comprising a flush system to delivery a fluid to the sensor to flush away debris. The flush system may flush the sensor continuously, intermittently, or when the sensor signal fades due to debris. The temperature sensitive element may be a thermistor. The temperature sensitive element may be a polymer based thermally responsive material. The sensing element may be a bead, a strip or a ring. The sensing element may be protected by a shield. The sensing element may be disposed in the inferior, superior, anterior, posterior or lateral sides of the ventilation tube, or combinations thereof. The pressure and flow data may be used to determine airway resistance, lung compliance, and an estimate of work of breathing. The ventilation tube may include an inflatable and deflatable cuff, and at least two sensing lumens with one lumen terminating distal to the cuff and one lumen terminating proximal to the cuff, wherein the pressures of the two sensing lumens are compared to provide an indication of the degree of obstruction being caused by the cuff. 
     Additional features, advantages, and embodiments of the invention are set forth or apparent from consideration of the following detailed description, drawings and claims. Moreover, it is to be understood that both the foregoing summary of the invention and the following detailed description are exemplary and intended to provide further explanation without limiting the scope of the invention as claimed. 
    
    
     
       BRIEF DESCRIPTION OF THE INVENTION 
       The accompanying drawings, which are included to provide a further understanding of the invention and are incorporated in and constitute a part of this specification, illustrate preferred embodiments of the invention and together with the detailed description serve to explain the principles of the invention. In the drawings: 
         FIG. 1  shows prior art breath sensing in series with breathing circuit for ventilator control. 
         FIG. 1A  shows graphical representation of the respiration signal masked by the ventilator gas delivery pressure. 
         FIG. 2  shows prior art breath sensing for ventilator control using chest impedance. 
         FIG. 2A  shows a graphical representation of the ventilation gas delivery pressure and the respiration sensor signal. 
         FIG. 3  shows intra-airway breath sensing for ventilator control. 
         FIG. 3A  shows graphical representation of the ventilation gas delivery pressure and the respiration sensor signal. 
         FIG. 4A  shows graphically conventional breath sensing. 
         FIG. 4B  shows graphically breath sensing described in this invention. 
         FIG. 4C  shows graphically chest impedance breath sensing. 
         FIG. 5  shows breath sensing using an array of temperature sensitive elements and comparing the temporal differences in the signals of the different elements to derive airflow direction and speed. 
         FIG. 5A  shows graphically the signal tracings from the sensors of  FIG. 5  indicating the temporal difference used to distinguish inspiration from exhalation. 
         FIG. 6  shows breath sensing using heated temperature-sensitive elements, and comparing the temporal differences in the signals. 
         FIG. 6A  shows graphically the signal tracings from the sensors of  FIG. 6  indicating the resultant signal when the sensor elements are heated. 
         FIG. 7  shows breath sensing using temperature-sensitive elements contained in a conduit of known cross section used to correlate the signal to airflow speed and volume using the known cross sectional dimension. 
         FIG. 7A  describes an alternate configuration to that shown in  FIG. 7  in which the sensors are placed inside a channel of a ventilation tube, with the channel acting as the flow conduit. 
         FIG. 7B  shows the resultant signals of the system of  FIG. 7  used to compute flow rate. 
         FIG. 8  shows breath sensing using a pair of temperature-sensitive elements arranged in a Wheatstone bridge, with one element heated. 
         FIG. 8A  shows the bridge circuit of the sensor array shown in  FIG. 8 . 
         FIG. 8B  shows the resultant signals of the sensing elements of  FIG. 8 . 
         FIG. 9  shows breath sensing using a pair of temperature-sensitive elements arranged in a Wheatstone bridge, and while heating the pair of elements. 
         FIG. 9A  shows the sensor signal tracings from the sensing elements shown in  FIG. 9 , before and after the elements are heated. 
         FIG. 9B  shows the sensor signal tracing of the bridge output signal of the sensor array shown in  FIG. 9 , at a high and low ambient temperature, indicating similar bridge output amplitude and offset regardless of ambient temperature conditions. 
         FIG. 10  shows breath sensing using two temperature sensitive elements, with a heat source located near the elements. 
         FIG. 10A  shows the sensor signal tracings at a high ambient temperature condition of the sensing system shown in  FIG. 10 . 
         FIG. 10B  shows the sensor signal tracings at a low ambient temperature condition of the sensing system shown in  FIG. 10 . 
         FIG. 11  shows breath sensing using two temperature sensitive elements arranged in a Wheatstone bridge configuration with a heat source located near the elements. 
         FIG. 11A  shows the bridge output signal and the differential over time of the bridge output signal of the sensing system shown in  FIG. 11 . 
         FIG. 12  shows breath sensing using a single temperature sensitive element where the DC shift of the signal of the element is controlled by continually adjusting the source voltage or by auto-zeroing through software feedback loop. 
         FIG. 12A  shows the circuit diagram of the sensing system described in  FIG. 12 . 
         FIG. 12B  shows the signal tracing of the sensor described in  FIG. 12 , without compensation for drift. 
         FIG. 12C  shows the signal tracing of the sensor described in  FIG. 12 , with compensation for drift. 
         FIG. 12D  describes an alternative to the sensing system of  FIG. 12  in which the sensing element is heated. 
         FIG. 12E  describes an alternative to the sensing system of  FIG. 12  in which the sensor is configured in an electrical bridge circuit. 
         FIG. 13  shows a graphical representation of breath sensing using two temperature sensitive elements where one element is exposed to ambient temperature and the other element is placed in or in proximity to an airway and exposed to airway temperature, and the comparison provides breath phase information. 
         FIG. 13A  shows the system of  FIG. 13  in which the ambient temperature is greater than body temperature indicating that a decreasing signal of the airway temperature sensor indicates exhalation phase. 
         FIGS. 14A-D  shows breath sensing using three temperature sensitive elements, where one element is placed at the breathing entry point, for example the nose or mouth, and the other element is exposed to ambient temperature and the other element is placed in the airway exposed to the intratracheal, intra-oral, or intra-nasal temperature. 
         FIG. 14A  shows the ambient sensing signal tracing of the system shown in  FIG. 14D . 
         FIG. 14B  shows the nasal, oral or tracheotomy sensing signal tracing of the system shown in  FIG. 14D . 
         FIG. 14C  shows the intra-tracheal, intra-nasal, or intra-oral sensor signal tracing of the system shown in  FIG. 14D . 
         FIG. 14D  shows the patient interface configuration indicating an ambient sensor, an intra-airway sensor, and a proximal airway sensor positioned near the airway entrance. 
         FIG. 15  shows breath sensing using a temperature sensitive element placed in an auxiliary sensing lumen in the gas delivery circuit. 
         FIG. 15A  shows a detailed view of location A of the interface shown in  FIG. 15 , indicating the sensing element positioned in a sensing channel. 
         FIG. 15B  shows graphically the signal tracing from the sensor of  FIG. 15 . 
         FIG. 16  shows breath sensing using a pair of temperature sensitive elements placed in an auxiliary sensing lumen in the gas delivery circuit, and optionally arranged in a Wheatstone bridge. 
         FIG. 16A  shows a detailed view of location B of the interface shown in  FIG. 16 , indicating the sensing element positioned in a sensing channel. 
         FIG. 16B  shows graphically the signal tracings from the two sensing elements of  FIG. 16 , indicating a phase shift and amplitude difference between the two signals. 
         FIG. 17  shows breath sensing using combinations of sensing elements placed the trachea, the gas delivery circuit main lumen, and an auxiliary sensing lumen in the gas delivery circuit. 
         FIG. 17A  shows a detailed view of area C of  FIG. 17 . 
         FIG. 17B  shows graphically the signal tracings from the sensing elements shown in  FIG. 17 . 
         FIG. 18  shows breath sensing using two sensing elements with a physical screen between the elements to bias the response time of each element due to the direction of flow. 
         FIG. 18A  shows the signal tracings of the sensors of  FIG. 18  in which the phase shift indicates inspiratory phase. 
         FIG. 18B  shows the signal tracings of the sensors of  FIG. 18  in which the phase shift indicates expiratory phase. 
         FIG. 19  shows breath sensing using two sensing elements on the inferior and superior aspects of the delivery cannula to create a physical barrier to bias the response time of each element that correlates to the direction of flow. 
         FIG. 19A  shows the signal tracings of the sensors of  FIG. 18  in which the phase shift indicates inspiratory phase. 
         FIG. 19B  shows the signal tracings of the sensors of  FIG. 18  in which the phase shift indicates expiratory phase. 
         FIG. 20  shows breath sensing using two sensing systems, a thermal sensor for measuring tracheal airflow and a pressure sensor for measuring tracheal pressure. 
         FIG. 20A  shows resultant flow and pressure signals for the system described in  FIG. 20 , showing determination of compliance, resistance and a surrogate for work of breathing. 
         FIG. 21  shows breath sensing using an intra-airway sensor and a flush lumen and flush port in the delivery tube to maintain a contamination-free sensor. 
         FIG. 21A  shows a detailed view of area E of  FIG. 21 . 
         FIG. 22  shows breath sensing using an intra-airway sensor and a flush port connected to the gas delivery channel to maintain a contamination-free sensor. 
         FIG. 23A  shows an alternate location of the flush port described in  FIG. 21 , wherein the sensor and flush port are located on the anterior or inferior side of the ventilation tube. 
         FIG. 23B  shows an alternative configuration of the flush port described in  FIG. 21 , wherein the sensor and flush port are located on the posterior or superior surface of the ventilation tube and the flush port is positioned so that the flush media is directed in a retrograde direction at the sensor. 
         FIG. 24A  shows a graphical description of a constant steady state flushing pressure profile. 
         FIG. 24B  shows a graphical description of an intermittent flushing pressure profile in which flushing occurs as needed or intermittently. 
         FIG. 24C  shows a graphical description of a cyclical flushing pressure profile, optionally in synchrony with the patient&#39;s respiration pattern. 
         FIG. 25  shows breath sensing and ventilation system in which a ventilation tube is placed into a outer sleeve, such as a tracheostomy tube, stomal guide, nose guide or oral guide, with breath sensors, and optionally a heat moisture exchanger, bacterial filter, and breathing port and inspiratory valve positioned in the annular space between the tube and outer sleeve. 
         FIG. 25A  shows the ventilation tube of  FIG. 25 . 
         FIG. 25B  shows the outer sleeve of  FIG. 25 . 
         FIG. 25C  shows a cross sectional view through line C-C of  FIG. 25 . 
         FIG. 25D  shows a cross sectional view through line D-D of  FIG. 25 . 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       FIG. 1  (prior art) describes a conventional ventilator system in which the breath sensor is in line with the ventilation gas being delivered in the breathing circuit. The Ventilator V delivers gas to the patient Pt through the ventilation gas delivery circuit, dual limb  21  and ventilation tube  25 . A pressure tap  23  in series or in line with the ventilator gas flow senses a negative pressure created by a patient inspiratory effort. Alternatively, a flow sensor can be used in series with the ventilation circuit to detect when the patient inspires. The signal from the breath sensor is delivered to a ventilator control unit  20  in the ventilator V. As seen in  FIG. 1A  these in-series sensor systems measure the start of a patient inspiratory effort  63 , but after the ventilator V is triggered to deliver a mechanical breath to the patient Pt, the sensor signal predominantly indicates the ventilator activity in the form of a ventilator gas delivery pressure tracing  52 , and not the patient activity. 
       FIG. 2  describes a ventilator breath sensing triggering system in which the breath sensor is a chest impedance sensor system, as described in U.S. Publication No. 2005/0034721. In this case, the sensor is placed in parallel with the ventilation circuit. A chest impedance band  62  is connected to the ventilator V control unit  20  by chest impedance wires  60 . As shown in  FIG. 2A , the patient spontaneous respiration curve  58  is not masked by the pressure waveform in the ventilator gas delivery pressure tracing  52 . Although an improvement over prior art, the impedance sensor can have a tendency to register motion of the person which is not related to breathing and hence can include artifacts. 
       FIG. 3  describes an overall configuration of an embodiment of the present invention, including a ventilator V, a ventilation gas delivery circuit, single limb  24 , ventilation tube  25  and sensor or pressure sensing port S 1  positioned to measure intra-airway tracheal air flow or breathing pressures or nasal or oral air flow, positioned inside or near the airway. While the following exemplary embodiments are described for intra-airway tracheal air flow, similar concepts may apply to nasal and oral air flow. The breath sensor or sensing port S 1  may be an intra-tracheal sensor, conduit or port located in the tracheal airway TA in the path of the patient&#39;s airflow, and in parallel with the ventilation circuit  24 . The sensor, conduit or sensing port is typically but not always part of or attached to the ventilation tube  25 . The signal may be delivered to the ventilator control unit  20  by means of wires or sensing conduits, or alternate transmission means such as fiber optic or wireless. The ventilator V may have one or more processors  10  for receiving and analyzing signals from the sensors. The processor  10  may process receive and process signals from the sensors and compute relevant parameters as described below. The processor  10  may then output the signals and/or the results of computations. The processor  10 , ventilator V, and/or ventilator control unit  20  may then output the signals, the results of the analyzing and/or control ventilation based upon the analysis. As seen in  FIG. 3A , this may be an improvement over conventional in-series breath sensing systems in that the actual breathing signal  58  is not masked by the ventilation gas delivery pressure signal  52 , and the sensor measures both the patient&#39;s true breathing activity  58  as well as the effect that the ventilation gas delivery has on the patient&#39;s lung pressure and airway breath flow. This is especially important in open ventilation systems. Also, as will be explained in later sections, the present invention describes improvements related to signal drift, artifacts, and disturbance caused by patient movement and changing temperature conditions. 
     It should be noted that while in  FIG. 3  and in the following descriptions, the sensing system is typically described in conjunction with a transtracheal ventilation catheter, the transtracheal ventilation catheter is exemplary only and other interfaces are included in the invention, such as but not limited to: a trans-nasal catheter, a trans-oral catheter, transtracheal tube catheters, percutaneous catheters, oral cannula, nasal cannula, non-invasive mask oral and/or nasal interfaces, open nasal and open oral cannula interfaces. For simplicity, the following embodiments are typically described with a transtracheal catheter; however the invention is also applied to the other interfaces stated above. 
       FIGS. 4A-C  graphically describes the difference between using intra-airway sensors which directly measure tracheal airflow and respiration, versus conventional in-line ventilator sensing systems.  FIG. 4A  describes a conventional system in which the flow sensor measures a patient inspiratory effort  63  but then measures the ventilator gas flow  52 . As one example of the disadvantages of this conventional system, the resultant inspiratory time determined by the ventilator is the inspiratory time set by the user on the ventilator, and not the true patient&#39;s spontaneous inspiratory time determined by a spontaneous breathing sensor, and for example as a result the patient&#39;s exhalation curve  66  begins later than the patient&#39;s true start of exhalation.  FIG. 4B  describes mechanical augmented ventilation in which airway airflow is measured at all times, hence during the period of ventilation gas delivery, the waveform accurately shows the combined effect in the lung or airway of spontaneous breathing and artificial ventilation.  FIG. 4C  shows a system with a chest impedance sensor which shows an artificial trigger of the ventilator gas delivery  52  due to an artifact in the signal  77  occurring before the true start of inspiration. 
     In  FIG. 5 , two thermal sensing elements Tp, Td may be positioned on a ventilation tube  25  and spaced apart by a distance. As seen in  FIG. 5A , the phase of the two signals defined by the difference between t1 and t2 may be compared to determine direction of airflow. During inspiration, the proximal thermistor Tp may respond to a change in temperature slightly sooner than the distal thermistor Td. By comparing the temporal differences in the inflection points of the two signals, the direction of airflow may be determined. For example, if the proximal sensor signal is seen to respond sooner than the distal sensor signal, it can be deduced that the airflow is moving in the inspiratory direction, and the sensing algorithms may declare that portion of the breath waveform as inspiration  200 . If the proximal sensor signal is seen to respond later than the distal sensor signal, it can be deduced that the airflow is moving in the expiratory direction, and the sensing algorithms may declare that portion of the breath waveform as expiration  202 . Ventilator gas flow  204  may pass through a ventilation gas delivery circuit, a ventilation catheter flange, and the ventilation tube  25 . 
     In  FIG. 6 , a transtracheal tube is described similar to that described in  FIG. 5  except the temperature sensing elements Tp, Td are heated at a time t h , as indicated by the arrow in  FIG. 6A , to a desired temperature that may always be higher than the possible conditions encountered in the patient Pt. In this case, the signal of the sensor during iso-flow conditions to the right of t h  is maintained at a constant level regardless of patient temperature or ambient temperature. This may be in contrast to the non-heated case in  FIG. 5  where the sensor signal can shift even during iso-flow conditions based on environmental or patient temperature changes. Thus, the direction of change in response to inspiration and exhalation may be consistent throughout the different temperature ranges potentially encountered by the patient Pt. Inspiration is reflected by a cooling of the sensor starting at t1 and t2 and ending at t3 and t4, and the start of exhalation is reflected by the returning of the signal to its baseline starting at t3 and t4 and ending at t5 and t6, which reflects the end of exhalation. 
     In  FIG. 7 , another embodiment of the present invention is described in which temperature sensing element S 1  is placed in a flow conduit  206  in or near the airway TA, which allows inspiratory and expiratory flow to pass through. The conduit  206  may be positioned on the ventilation catheter  25  such that the proximal and distal openings of the conduit  206  are in line with the axis of the tracheal or airway airflow  200 . A ventilation gas flow lumen  210  may pass through the ventilation tube  25 . The conduit  206  of known cross sectional area then can be used to correlate the sensor signal to airflow rate, based on for example known correlation factors and look up tables. For example, the slope of the sensor signal a/b, as shown in  FIG. 7B , divided by the cross sectional area of the conduit may give a value in units of [(volts*[cross sectional area]^2)/time] which can be correlated to liters per minute based on a correlation factor of volts to distance. The resultant value is the flow rate Q(c) though the conduit  206 . Q(c) can then be correlated to the flow rate in the trachea or airway by a correlation factor correlating the conduit size with the tracheal lumen size or airway size. Therefore, this may provide a breathing waveform of the inspiratory and expiratory breathing curves useful in deriving the patient&#39;s spontaneous inspiratory and expiratory flow rates and breathing volumes. Inspiratory and expiratory flow rate can be useful in determining the breathing effort of the patient and titrating the ventilation therapeutic level to the needs of the patient.  FIG. 7A  shows a variation of  FIG. 7  in which two sensors S 1  and S 2  are disposed in a channel wherein the channel is within the ventilation tube, and in which airway airflow passes through the channel and past the sensors S 1  and S 2  via a fenestration  102  or via the main lumen of the ventilation tube. 
     In  FIG. 8 , another embodiment of the present invention is described with a ventilation tube including two temperature sensing elements T 1  and T H  arranged in a Wheatstone bridge circuit, where one element Th may be heated to a temperature above the maximum temperature anticipated in the trachea or airway. This may offset the bridge signal so that the direction of airflow is easier to determine.  FIG. 8A  shows a bridge circuit diagram W of the sensing system shown in  FIG. 8 , with T 1  and T H  in the circuit with two balancing resistors Re.  FIG. 8B  shows the signal tracings from the sensors T 1  and T H , with T H  at a higher amplitude than that of T 1 . Therefore, comparing the two signals together can determine inspiratory and expiratory phase regardless of ambient temperature. 
       FIG. 9  describes two temperature sensitive sensors, for example thermistors, arranged in a Wheatstone bridge configuration in which both thermistors may be heated to a temperature greater than that anticipated in the trachea or airway, for example to 130° F. surface temperature.  FIG. 9A  describes the signal of each sensor T H1  and T H2  before and after being heated at time t h .  FIG. 9B  describes the bridge output signal at a high and low ambient temperature condition, before and after T H1  and T H2  are heated at time t h . The output of the Wheatstone bridge during iso-flow conditions may be balanced, however, when flow occurs, and the signal may change in response to cooling. In this case cooling is represented by an increase in amplitude of the signal. An increase of the signal, or cooling, may occur in both inspiration and exhalation since the outside air and the lung air temperature may be less than 130° F. The phase of respiration can be detected by another means, such as predictive algorithms or other sensors, such as a pressure sensor. When the elements are heated at time t h , as depicted by the arrow in  FIGS. 9   a  and  9   b , the signals of each element shift up ( FIG. 9   a ). As can be seen in  FIG. 9   b , after the bridge circuit output rebalances from the heating of the elements (shown by the bounce after when the heater is turned on), the bridge circuit output signal may be the same characteristic when the ambient temperature is 20° C. or 50° C. Therefore, changing ambient temperature conditions may not affect the phase or characteristic of the signal. The sensors&#39; surface, at 130° F., may compromise the tracheal wall tissue if there is prolonged contact, hence, a means to shut off the heating of the sensor may be provided if contact with the tissue is sensed. This would be detected by a certain characteristic signal response and frequency response of the sensor being in contact with a 98° F. object. In addition the sensor surfaces can be protected to avoid contact with the tracheal wall, for example with a guard or a shape of the catheter, as shown. 
       FIG. 10  describes a ventilation tube  25  that may include two temperature sensing elements T 1 , T 2  and a heat source H located near the temperature sensing elements T 1 , T 2 . The heat source H may produce a temperature gradient  212  above the temperature which would be anticipated in the trachea or nasal or oral airway, for example 120° F., but below the temperature that would be irritating or damaging to the user&#39;s skin or airway tissue. Ideally the heat source is placed on a location of the ventilation tube that does not come into contact with the skin or airway tissue. The heat from the heat source is drawn to the sensing elements during inspiration. Therefore, the sensing elements T 1 , T 2  may always register an increase in temperature during inspiration regardless of ambient temperature. As can be seen in the tracings of the signals from T 1  and T 2  shown in  FIGS. 10A and 10B , the signals are similar when ambient temperature is above and below body temperature. The heater can alternatively be placed in between the elements or on either side of the elements and the signal interpreted accordingly. The elements can be independently operated or can be arranged in a Wheatstone bridge configuration as previously described. Phase shift between the signals, or a comparison between the signals can be used to obtain flow information. 
       FIG. 11  describes a variation on the embodiment described in  FIG. 10  in which the two temperature sensitive elements T 1 , T 2  are arranged in a Wheatstone bridge circuit that may correct for drift in the signals. The output signal of the bridge circuit, as shown in  FIG. 11A  may be differentiated to correct of offset and to obtain a signal that is in phase with the breathing flow curve. This overall arrangement may produce a consistent and normalized signal throughout different ambient temperature conditions. The heater H may include a protective spacer to insure that the heater does not come into contract with the tracheal, nasal or oral tissue for prolonged periods. 
       FIG. 12  describes a ventilation tube  25  that includes a single temperature sensing element T 1  arranged in a modified Wheatstone bridge circuit W′, shown in  FIG. 12A . To prevent drift of the signal due to the variable conditions, auto-correction may be made by adjusting the input to an amplifier, where the adjustment is determined in software in the microprocessor μP, as shown in  FIG. 12A . Alternately, the current of voltage supplied to the sensor may be periodically adjusted such that the DC component of the sensor output is held hear the center of the element&#39;s operating range. The DC component may be computed by low pass filtering the sensor output. When a DC offset correction is made, detection of airflow direction and speed may be momentarily suspended until the DC offset correction settles.  FIG. 12B  describes the output of the sensor shown in  FIG. 12  without software or DC drift compensation, showing a floating signal.  FIG. 12C  describes the output of the circuit shown in  FIG. 12A  in which the signal has a steady offset without drift.  FIG. 12D  describes where the temperature sensing element described in  FIG. 12  is heated to a temperature above that which would be anticipated in the trachea, for example to 120° F., and arranged in the modified bridge circuit described in  FIG. 12E . In this configuration, drift is corrected by the bridge circuit, and the effect of changing ambient temperature conditions is negated by the heating of the element. 
       FIGS. 13 and 13A  describe an embodiment in which the airway temperature and ambient temperature are monitored as part of a breath sensing system, and in which the airway temperature is used to determine spontaneous breathing airflow. If the ambient temperature is low, as shown by Tamb in  FIG. 13 , an increasing slope of the Taw signal implies expiratory phase and a decreasing slope implies inspiratory phase. If the ambient temperature is high, as shown in Tamb in  FIG. 13A , the converse of  FIG. 13  is true. 
       FIGS. 14A-14D  describe an embodiment in which temperature sensing elements measure intra-airway temperature Taw, temperature at the point of gas entry to the patient, T 1 , and ambient temperature Tamb. Locations of the sensing elements are described in  FIG. 14D . Comparison of these three temperature signals may provide information required to correlate the Taw signal to an inspiratory and expiratory flow signal. The Tamb signal may determine if inspiratory airflow is warmer or cooler than expiratory airflow, and the T 1  signal may provide a comparison to Taw in order to compensate for drift and artifacts. 
       FIG. 15  describes another embodiment of the present invention in which a ventilation tube  25  comprises a gas delivery lumen  210  and a sensing lumen  208 .  FIG. 15A  shows a detailed view of area B in  FIG. 15 . A thermal sensing element T 1  is disposed in the sensing lumen or conduit  208 . When the patient inhales or exhales, some airflow flows out of and into the sensing lumen  208  and past the sensing element T 1 . In this manner, the phases of breathing can be detected by the sensing element T 1 . The machine end of the sensing lumen  208  may optionally be open to atmosphere in order to enhance the amount of flow flowing through the sensing lumen  208  and past the sensing element T 1 . The temperature of the inspired air in the sensing lumen  208  should be slightly cooler than the temperature of the exhaled air and hence the resultant signal, T 1  as shown in  FIG. 15B , can be correlated to flow direction and the breath cycle. The sensing element can be heated or can be arranged in a bridge circuit as described in previous embodiments to compensate for drift and ambient temperature ranges. 
       FIG. 16  describes an option to the embodiment of  FIG. 15  in which there are two temperature sensing elements, T 1  and T 2 , placed in the sensing lumen  208 .  FIG. 16A  shows a detailed view of area B in  FIG. 16 . The two signals from T 1  and T 2  may provide more information than just one element, and can be used to help determine the direction of flow. For example one element can possess different thermal properties compared to the other element to dampen or shift the resultant signal, so that the direction of flow can be determined by signal comparison. As can be seen in  FIG. 16B , the signals from T 1  and T 2  are different in phase and amplitude. The signal differences can be used to correct for noise, drift and other artifacts, as well as determine air flow direction and airflow strength. As previously described one or both sensing elements can be heated or the elements can be arranged in a Wheatstone bridge circuit, to compensate for signal drift and/or negate the effect of changing ambient temperature conditions. 
       FIG. 17  describes an optional embodiment in which an array of thermal sensors S 1 , S 2  and S 3  are placed in the airway TA, in a sensing lumen  208  as described in  FIG. 16 , and in the gas delivery circuit  24 . Optionally, the sensing lumen  208  can be open to ambient air AMB at or near the ventilator end of the system, in order to enhance spontaneous breathing air flow flowing through the sensing lumen.  FIG. 17A  describes a detailed view of area C in  FIG. 17 , indicating S 1  placed in the airway of the patient, S 2  placed in a sensing lumen  208  that is part of the ventilation tube  25 . The resultant signals are described in  FIG. 17B , which show that the signal from S 1  is the strongest spontaneous breathing signal, S 2  is a weaker spontaneous breathing signal, and the signal form S 3  shows both the ventilation delivery as well as spontaneous breathing when the ventilator is not active. Information from these three sensors can be used to understand what the breathing and ventilator conditions are at any given time, and can be used to cross check each other. In the case in which the ventilation parameters create entrainment of ambient air that is induced by ventilation gas delivered through and exiting the gas delivery channel  210 , the airway sensor S 1  can be used to measure entrainment of ambient airflow. Again, the sensing elements can be heated or arranged in bridge circuits to compensate for ambient temperature conditions and drift. 
       FIG. 18  describes an embodiment of the invention in which a ventilation tube  25  includes a physical screen or barrier  214  separating two sensing elements S 1  and S 2 . The screen  214  provides a dampening or phase shift between the signals from the two sensors S 1  and S 2 . As air flows in one direction, for example, inspiration I, as shown in  FIG. 18A , the signal strength of S 1  is relatively strong and undampened, and the strength of S 2  is relatively weak and dampened due to the dampening effect that the screen  214  has on airflow. When air flows in the direction of exhalation E, as shown in  FIG. 18B , signal S 2  is stronger and more responsive thus indicating expiratory phase. Temporal and amplitude differences in the signal can be used to determine the direction of airflow. These sensing elements can be temperature sensitive elements or may work on other principles such as pressure, sound, ultrasound, optical, or other. 
     Alternatively to  FIG. 18 ,  FIG. 19  describes a ventilation tube  25  in which the sensors S 1  and S 2  are separated by the tube itself, achieving a similar result as described in the graphs shown in  FIGS. 19A and 19B . 
     In another embodiment of the present invention,  FIG. 20  describes a ventilation tube  25 , which includes both a temperature sensing element T 1  and a pressure sensor or pressure sensing port P 1 , in order to obtain both an airflow signal Q and a tracheal pressure signal P 1  as shown in  FIG. 20A . Optionally, two temperature sensing elements T 1  and T 2  can be used in a sensing array or Wheatstone bridge arrangement as previously described. The pressure signal P 1  can be used to determine breath phase as well as airway pressure (i.e., negative pressure corresponding to inspiration), and this breath phase detection can be used to calibrate the temperature element signal to the correct phase of breathing, so inspiratory airflow can be distinguished reliably from expiratory airflow, regardless of the prevailing temperature conditions and ambient conditions. If two temperature sensing elements are used, they can be combined in a circuit as previously described and differentiated to normalize the signal and compensate for drift. The information obtained by this sensing configuration can be used to determine lung compliance, airway resistance and an estimate of work of breathing by establishing a correlation between airway pressure and pleural pressure. The flow signal can also be used to determine inspiratory and expiratory effort and depth of breathing, which can be used to titrate the ventilation parameters to the needs of the patient in a biofeedback loop. 
       FIG. 21  describes another embodiment of the present invention in which the sensor S 1  is flushed with flow exiting a flush port  220 .  FIG. 21   a  describes a detailed view of area E in  FIG. 21 , and shows a dedicated flush lumen  224  leading to the flush port  220 . 
       FIG. 22  describes an alternative embodiment wherein the flush lumen  224  branches off of the main gas delivery lumen  210 . 
       FIG. 23A  describes an alternative embodiment in which the sensor and flush port are located on the inferior or anterior side of the ventilation tube, as opposed to the superior or posterior side. In addition, the sensor and flush port can be located on the lateral side, on the superior side, or on the inferior side of the ventilation tube (not shown).  FIG. 23B  describes an alternate configuration in which the flush port is located distal to the sensor and flushes in the reverse direction back at the sensor. 
       FIGS. 24A-24C  describe alternate pressure or flow delivery profiles of the flushing media being delivered, for example continuous as in  FIG. 24A , pulsatile as in  FIG. 24C , intermittent as in  FIG. 24B , or as needed when the sensor signal appears degraded. The flush media can be a respiratory gas such as oxygen, a therapeutic gas such as helium, humidified air, or a liquid such as saline, a mucolytic or a medicant. 
       FIGS. 25-25D  describe an embodiment where a ventilation and breath sensing system includes a ventilator V, a gas delivery circuit  24 , and a ventilation catheter  26  or ventilation tube  25  placed into an outer sleeve  28 ,  29  such as a tracheostomy tube or stomal sleeve, or airway guide such as a nasal sleeve or oral sleeve.  FIG. 25  describes the overall system of this embodiment. FIG.  25 A describes the ventilation tube.  FIG. 25B  describes the outer sleeve.  FIG. 25C  describes a cross sectional view through line C-C of  FIG. 25  showing the pressure sensor P 1  and thermal airflow sensor T 1  and optional inspiratory valve  122 .  FIG. 25D  describes a cross sectional view through line D-D of  FIG. 25  showing the optional heat moisture exchanger  118  and bacterial filter  120 . In addition to the patient inspiring spontaneously through the upper airway  200 , the patient can also inspire from ambient air through the annular space between the ventilation catheter  26  or ventilation tube  25  and the outer sleeve and optionally through an inspiratory flow valve  122  and/or outer cannula breathing flow port  116 . A tracheostomy tube neck flange  112  and/or a tracheostomy tube ventilation circuit connector  111  may be provided. A heat moisture exchanger  118  and a bacterial filter  120  are optionally provided in the annular space. Further, breath sensors can optionally be placed in the annular space, for example a thermal sensor T 1  for detecting inspiratory flow and/or expiratory flow and a pressure sensor or sensing port P 1  for measuring airway pressure. 
     The embodiments described above are exemplary and certain features can be combined. The sensors can be disposed on the ventilation catheter or ventilation tube or on an outer sleeve, and can be placed on the anterior, inferior, lateral, superior, or posterior sides or combinations thereof. The ventilation catheter or tube can be inserted directly into a stoma or airway, or into a tracheal sleeve, such as a tracheostomy tube, stoma guide or stent, or an airway sleeve such as a nasal or oral guide. The ventilation catheter or tube and the sleeve, if used, can be comprised of a variety of shapes and curves, and can include protective features to protect the sensors and centering features to center the catheter or tube in the airway. In the case that the ventilation catheter or tube is placed directly in through the stoma, shapes and protective features are employed to prevent the sensing element from contacting the tracheal wall and signal disruption. In the case that the ventilation catheter or tube is placed into a sleeve such as a tracheostomy tube, the sensors can be inside the tracheostomy tube for protection. Typically the tracheostomy tube is fenestrated so that there is adequate airflow past the sensors during inspiration and exhalation. 
     In addition, while the embodiments have been described typically in conjunction with a transtracheal interface, they can also be endrotracheal, oral, nasal, or face or nose masks interfaces. For example, the patient interface can be a trans-nasal or trans-oral catheter entering the airway from the nose or mouth. Or, the patient interface can be a open oral or open nasal cannula or catheter, in which the distal end of the cannula or catheter can be adapted to be positioned slightly inside the oral or nasal cavity, or at the entrance to the oral or nasal airway, or outside of the oral or nasal airway directed at the entrance to the airway. Or, the patient interface can be an oral and/or nasal mask. In the case of the more invasive interfaces or catheters, the tip of the catheter can be located in any of the lung airways. In the case of the less invasive interfaces, the tip of the catheter can penetrate the airway barely. In the case of non-invasive interfaces, the tip of the tube, cannula, or mask can be outside of the airway. 
     The ventilation tube or tracheostomy tube may comprise an inflatable and deflatable cuff, and the sensors or sensing lumens can be provided on the distal and proximal side of the cuff (not shown) to sense pressures or flows on both sides of the cuff, to provide an indication of the resistance being caused by the cuff. For example if the cuff is not completely deflated, the data from the two sensors or sensing ports will register a higher than expected pressure drop, indicating to the user that the cuff is not fully deflated for upper airway breathing, or the tube is too big for that particular patient or situation. Optionally the two sensors can be used to monitor cuff inflation if and when closed ventilation is being applied to the patient. 
     The thermal sensing elements described are typically thermistor elements, however can be thermally response polymers, or other thermally responsive materials. They can be negative coefficient or positive coefficient, or both. 
     The ventilation therapy described in the embodiments can be augmented ventilation in which the patient is receiving a portion of their tidal volume from the ventilator, can be open ventilation in which the patient is spontaneously breathing through their upper airway, or can be closed or partially closed ventilation in which the patient&#39;s effort triggers the ventilator. The delivery circuit can be a single limb breathing circuit or dual limb breathing circuit. The invention can be applied to respiratory insufficiencies such as COPD, forms of neuromuscular weakness and paralysis, or airway disorders such as sleep apnea therapy. The therapy can be applied to adults, pediatrics and neonates. 
     The information made available by the breath sensors described herein can be used to synchronize ventilator functions to the patient&#39;s breath cycle, but can also be used to automatically adjust ventilator output and can be used for diagnostic purposes and trending analysis. The ventilator functions being controlled by the sensor information can be (1) delivery timing of gas from the ventilator, for example at a certain point of the inspiratory phase, a certain point of the expiratory phase, etc.; (2) amplitude, speed or waveform shape of ventilator output; or (3) frequency of ventilator output; or (4) composition of ventilator output, or combinations of the above. 
     Typical dimensions of the embodiments, assuming a transtracheal catheter interface are listed below. Dimensions for other interfaces, such as oral or nasal catheters or cannula include the requisite dimensional adjustments: 
     1. Ventilation tube or catheter: 2 mm OD to 12 mm OD, preferably 3-5 mm, 0.5-6 mm ID, preferably 1-3 mm ID. Insertion length 10 mm to 150 mm, preferably 30-100 mm. Curved such that there is a distal straight section aligned with the lumen of the trachea. Durometer 40-80 Shore D. 
     2. Single limb ventilation circuit: 4 mm OD to 12 mm OD, preferably 5-8 mm OD, 24-48 inches in length. 
     3. Gas delivery lumen: 0.5-6 mm ID, preferably 1-3 mm ID 
     4. Sensing lumen: 0.25-3 mm ID, preferably 0.5-1.75 mm and most preferably 0.75-1.5 mm. 
     5. Thermal sensing element: 0.25 mm-1.5 mm cross sectional dimension, 1-5 mm length. The thermal sensing element can also be a circumferential band around the diameter of the ventilation tube, or a strip of material. 
     6. Flow conduit: 0.5-2.0 mm ID, preferably 1-1.5 mm ID. 
     7. Flush port: 0.25-2 mm width or length or diameter. 
     8. Flush lumen: 0.2 mm-1.0 mm, preferably 0.25-0.5 mm. 
     
       
         
               
             
               
               
             
           
               
                   
               
               
                 List of Reference Symbols: 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Amb:  
                 Ambient 
               
               
                 Amp:  
                 Amplifier of Wheatstone bridge output 
               
               
                 A/D:  
                 Analog to digital comparator 
               
               
                 D/A:  
                 Digital to analog comparator 
               
               
                 E:  
                 Expiratory 
               
               
                 H:  
                 Heater 
               
               
                 I:  
                 Inspiratory 
               
               
                 L:  
                 Lung(s) 
               
               
                 P1, P2, P3:  
                 pressure transducer 1, 2 and 3 
               
               
                 PS:  
                 Power supply for Wheatstone bridge 
               
               
                 Pt:  
                 Patient 
               
               
                 Pf:  
                 Flush pressure level 
               
               
                 Q:  
                 Tracheal airflow trace 
               
               
                 R:  
                 Respiration trace 
               
               
                 R1, R2, R3:  
                 Bridge circuit resistors 
               
               
                 Re:  
                 Resistor in Wheatstone bridge 
               
               
                 S:  
                 Breath sensor signal trace 
               
               
                 S1, S2, S3:  
                 Sensing elements 
               
               
                 TA:  
                 Tracheal airway 
               
               
                 t:  
                 Time 
               
               
                 Tp:  
                 Proximal thermal sensing element 
               
               
                 Td:  
                 Distal thermal sensing element 
               
               
                 TH:  
                 Heated sensing element 
               
               
                 T1:  
                 Thermal sensing element one 
               
               
                 T2:  
                 Thermal sensing element two 
               
               
                 TH1:  
                 Heated sensing element one 
               
               
                 TH2:  
                 Heated sensing element two 
               
               
                 Taw:  
                 Airway temperature 
               
               
                 Tamb:  
                 Ambient temperature 
               
               
                 uP:  
                 Microprocessor 
               
               
                 V:  
                 Ventilator 
               
               
                 V1, V2:  
                 Voltage 
               
               
                 V+:  
                 Output voltage from bridge circuit 
               
               
                 V−:  
                 Input voltage to bridge output amplifier 
               
               
                 W:  
                 Wheatstone bridge circuit 
               
               
                 W′:  
                 Modified Wheatstone bridge circuit 
               
               
                  10:  
                 Processor 
               
               
                  20:  
                 Ventilator control unit 
               
               
                  21:  
                 Ventilation gas delivery circuit, dual limb 
               
               
                  23:  
                 Ventilation circuit pressure tap 
               
               
                  24:  
                 Ventilation gas delivery circuit, single limb 
               
               
                  25:  
                 Ventilation tube 
               
               
                  26:  
                 Ventilation catheter 
               
               
                  28:  
                 Tracheostomy tube outer cannula 
               
               
                  29:  
                 Stoma sleeve, guide or stent 
               
               
                  52:  
                 Ventilator gas delivery pressure tracing 
               
               
                  58:  
                 Patient spontaneous respiration curve 
               
               
                  60:  
                 Chest impedance wires 
               
               
                  62:  
                 Chest impedance band 
               
               
                  63:  
                 Patient inspiratory effort 
               
               
                  66:  
                 Patient exhalation tracheal flow/pressure curve 
               
               
                  77:  
                 Chest impedance tracing 
               
               
                 102:  
                 Ventilation catheter fenestration(s) 
               
               
                 111:  
                 Tracheostomy tube ventilation circuit connector 
               
               
                 112:  
                 Tracheostomy tube neck flange 
               
               
                 116:  
                 Ventilation catheter - outer cannula breathing flow port 
               
               
                 118:  
                 Ventilation catheter - outer cannula heat moisture exchange 
               
               
                 120:  
                 Ventilation catheter - outer cannula filter 
               
               
                 122:  
                 Inspiratory valve 
               
               
                 200:  
                 Inspiratory flow 
               
               
                 202:  
                 Expiratory flow 
               
               
                 204:  
                 Ventilator gas flow 
               
               
                 206:  
                 Sensor flow conduit 
               
               
                 208:  
                 Sensing lumen 
               
               
                 210:  
                 Ventilator gas flow lumen 
               
               
                 212:  
                 Temperature gradient 
               
               
                 214:  
                 Sensor physical barrier 
               
               
                 220:  
                 Sensor flush port 
               
               
                 224:  
                 Flush lumen 
               
               
                   
               
             
          
         
       
     
     Although the foregoing description is directed to the preferred embodiments of the invention, it is noted that other variations and modifications will be apparent to those skilled in the art, and may be made without departing from the spirit or scope of the invention. Moreover, features described in connection with one embodiment of the invention may be used in conjunction with other embodiments, even if not explicitly stated above.