Abstract:
Detection of a discontinuity, a disconnection or loss of conductivity, of cables connected to a physiological signal recorder, in particular a Holter recorder of ECG signals by measuring an impedance of the line(s). To measure the impedance of the line comprising the connecting cable connecting an external electrode placed on a patient to a signal terminal ( 12 ) of the recorder ( 10 ), one generates a current impulse, applies this impulse to the line, measures the variation of voltage resulting on the terminal from the signal during the application duration of the current impulse, and determines the impedance of the line based upon the voltage variations thus measured. The current impulse is a biphasic impulse including two successive cycles of opposite polarities, the durations and the amplitudes of these two cycles being selected so as to define approximately equal respective loads and of contrary signs. A switch ( 36 ) connects the base of the pull-down resistance ( 32 ) of the signal terminal ( 12 ) to the output of a voltage or a current generator ( 38 ) during the impedance measurement, and connects it to the potential ground ( 34 ) during the remainder of time.

Description:
FIELD OF THE INVENTION  
         [0001]    The present invention relates to the recorders of physiological signals, such as the ambulatory recorders of the Holter type ensuring the recording of electrocardiographic (“ECG”) signals over a long period of time.  
         BACKGROUND OF THE INVENTION  
         [0002]    Recorders of physiological signals comprise an external case, carried by the patient, to which case one or more sensing electrodes are connected. The sensing electrodes are applied to the body of the patient and connected to the case at a signal input via connecting cables. The connecting cables typically include conductive wire and an insulating sheath. During frequent use, particularly with respect to recorders used for long durations, these cables are subjected to many stresses and end up being degraded. The degradation can go so far as to rupture the electric conductors internal to the cables.  
           [0003]    The state of the connecting cables therefore must be monitored. This can be automatically carried out by making an impedance measurement and identifying changes in impedances. It is known, for example, to make such a measurement by injecting a small current on the signal input to which the cable is to be connected (the return path of the current being provided by another measurement electrode or by a ground electrode) and measuring the voltage on the signal input during the current flow. From the measured voltage, one can determine the impedance of the line, to which are added the impedance of the electrodes and the impedance of the body of the patient between the two electrodes included in the current loop.  
           [0004]    One can thus highlight any defects of the electric conduction within the cables, as well as any defective connection of the electrodes (e.g., a badly inserted or loose cable or electrode, an internal break, etc.) by thus measuring, in place, the impedance of the line, and, in the case of a Holter recorder, of the lines of the various ECG cables.  
           [0005]    The impedance measurement can be carried out not only after installation of the electrodes at the time of putting the device in service, but also throughout the duration of the recording duration: Indeed, it is possible to detect a detachment of an electrode, the disconnection of a cable, etc., and to take account of this defect when recording signals or in the analysis of the acquired signals, or to even ask the patient being monitored to restore continuity by replacing the electrode (or cable) or by replugging a disconnected cable.  
           [0006]    The small current used in the impedance measurement is typically a microampere-current (“micro-current”) and is preferably of an impulse (pulsitile) nature. This is because a continuous micro-current would be likely to cause a polarization of the electrode-skin couple, and an alternating micro-current would involve a relatively significant consumption of energy because of the high frequency to be used, about 100 KHz, which must be higher than the components of the ECG signal (including the peaks of the stimulation pulses generated by a pacemaker eventually implanted in the patient), and of the signals which must be rejected.  
           [0007]    For this reason, the most recent apparatuses, such as the Syneflash and Synesis model recording devices available from Ela Medical, Montrouge, France, implement such an impulse process, in which the device injects a small quantity of current (on the order of a microampere) during a very short time (of about a microsecond) to measure the impedance of a line. The amplifier on which the input is connected amplifies the variation of voltage caused by the injection of this current and retransmits this variation to a digital measurement system (analog/digital converter and microcontroller) which memorizes and processes the impedance data, without (theoretically) deterioration of the collected signal.  
           [0008]    This process has been found to present two disadvantages, however, in certain situations. First, in the case when an electrode is disconnected, the voltage level at the input on which the current is injected is parasitized (a situation that results from an illegible signal or an interference at the frequency of the power line), or falls to zero. If the level falls to zero, the device receives in fact on the amplifier the ECG signal of the other electrode. It thus amplifies this other signal in a monopolar mode, i.e., compared to the patient ground, thus giving a signal which seems very correct, although detected as abnormal by the microcontroller. In this situation, the system of current injection presents a major defect due to the fact that the load injected on the line which has a high impedance (because of the break in or disconnection of the cable). This impedance creates a voltage that is maintained for a relatively long time because of the input capacitors of the sensing circuit (these capacitors being useful for the passive filtering of the high frequencies). The sensed ECG signal is then very strongly disturbed by peaks caused with each injection of micro-current.  
           [0009]    Second, in the case of a patient carrying a pacemaker, the stimulation pulses (or peaks) produced by the implanted device can obstruct the impedance measurement of the external recorder, in two respects. First, if the stimulation peak occurs at the same time that measurement is taken, it can considerably deform the response and give a false value of the impedance. Second, when the voltage peak caused by the injection of current is significant, it can be wrongly interpreted as a stimulation peak by the recorder.  
         OBJECTS AND SUMMARY OF THE INVENTION  
         [0010]    It is, therefore, an object of the present invention to propose a new mode of testing the electrical continuity of a line by an impulse impedance measurement adapted to long duration recordings of physiological signals that overcomes the various above-mentioned disadvantages.  
           [0011]    To this end, the invention proposes an apparatus and a process of for testing the electrical continuity of a line by measuring the impedance of the line, the line having a cable connecting an external electrode placed on a patient to a signal terminal of a recorder of physiological signals, in particular of a Holter recorder of ECG signals, comprising the generation of an impulse of current and application of the impulse to the aforementioned line; the measurement of a voltage variation resulting on the signal terminal during the duration of the current impulse application; and determination of the impedance of the line based upon the voltage variation thus measured.  
           [0012]    According to a preferred embodiment of the invention, the current impulse is a biphasic impulse including two successive cycles of opposite polarities, the durations and the amplitudes of these two cycles being selected so as to define approximately equal respective loads of opposite signs.  
           [0013]    According to an advantageous embodiment of the invention, measurement of the voltage variation comprises the measurement of the of voltage variation at the end of the first cycle of the current impulse and the end of the second cycle of the current impulse of current, and more particularly the addition of the absolute values of these two variations of voltage.  
           [0014]    Preferably, the measurement of the voltage variation is operated in a concomitant manner to the collection of ECG signal. The ECG signal is thus sampled at a frequency producing a plurality of samples per cycle of measurement, with at least two samples for the measurement of the voltage variation at the end of the first current impulse cycle and the end of the second current impulse cycle, and at least one sample being used for the measurement of the level of ECG signal. In this last case, the ECG signal is advantageously sampled at a frequency that produces a plurality of samples for the measurement of the level of the ECG signal, and in which the measurement of the ECG signal is taken by averaging the plurality of samples, in particular at least two samples for the measurement of the variation of voltage at the end of the first cycle and the end of the second cycle of the current impulse, with eventually an intervening sample, and at least one sample usable for the measurement of the level of ECG signal.  
           [0015]    When the patient is equipped with an implanted pacemaker, it is further envisaged to include the elimination of the stimulation peaks mixed with the collected ECG signal, either by a preliminary detection of the stimulation peaks and definition of a temporal post-stimulation window during which the measurement of the line impedance will be implemented or by a preliminary memorizing of the voltage variation on the signal terminal during the application duration of the current impulse and subtraction of the memorized variation during the detection of a stimulation peak.  
           [0016]    In a preferred implementation, the measurement of the line impedance is advantageously reiterated, and it is then envisaged to have an evaluation and periodical memorizing of an impedance value based upon a plurality of preceding measurements, in particular by determining a median of a number of preceding measurements.  
           [0017]    The present invention thus has as one aspect a process employing the aforementioned current impulse injection, voltage measurement, and voltage analysis process as described above, and as another aspect circuitry for implementing these functions. Regarding the apparatus of the latter aspect, the recorder can thus comprise, in particular a voltage or a current generator that is controlled by a microcontroller. The voltage output or the current output of this generator is then applied to the base of a pull-down resistance coupled to ground, in addition to the signal terminal, with means for placing the base of the pull-down resistance at the ground potential at times other than during the periods of application of the current or voltage output of the generator.  
           [0018]    The means for placing the base of the pull-down resistance at the ground potential advantageously includes a switch selectively controlled between a state of collection of the ECG signal, where the base of the pull-down resistance is connected to the ground potential, and a state of impedance measurement, where the base of the pull-down resistance is instead connected to the output of the generator.  
           [0019]    In an alternative embodiment, the means for placing the pull down resistor at ground potential, can include a resistance interposed between ground potential and the base of the pull-down resistance, such that the current or the voltage output of the generator is forced to a zero value except during the periods when the current impulse is to be applied for the impedance measurement.  
           [0020]    In yet another embodiment of the apparatus, the device can comprise a plurality of signal terminals, each one equipped with a respective pull-down resistance, and the voltage or the current output of the generator can be either:  
           [0021]    (i) applied simultaneously, either to the positive inputs or to the negative inputs, to the bases of these various pull-down resistances, such that the means for placing the base at ground potential apart from the periods of application being a common means, operating simultaneously on the aforementioned pull-down resistances, or  
           [0022]    (ii) applied independently to the bases of these various pull-down resistances, the means for placing the base at ground potential apart from the periods of current impulse application comprising a plurality of switches, with one switch for each signal terminal. 
       
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0023]    Further benefits, features and characteristics of the present invention will become apparent to a person of ordinary skill in the art in view of the following detailed description of a preferred embodiment of the invention, made with in reference to the annexed drawings, in which like reference characters refer to like elements, and in which:  
         [0024]    [0024]FIG. 1 is a schematic diagram of the circuits of a recorder in accordance with the present invention;  
         [0025]    [0025]FIG. 2 illustrates the chronograms of an injected current impulse injected and the resulting collected voltage signal in the case of a correct electric connection and a defective connection;  
         [0026]    [0026]FIG. 3 is a partial view illustrating an alternative of implementation of a portion of FIG. 1;  
         [0027]    [0027]FIG. 4 is a generalization of the circuit of FIG. 1 with the simultaneous measurement of the impedances on several inputs; and  
         [0028]    [0028]FIG. 5 illustrates selecting the sampling points of an ECG signal to interpose the impedance measurement while sampling an ECG signal. 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0029]    With reference to FIG. 1, a recorder case  10  is shown, equipped with signal inputs  12 , of which only one is represented, there typically being seven inputs  12  in the case of an ECG recording device. Each input is connected to a connecting cable (not represented) the other end of which is connected to a respective electrode applied to a patient to allow for the collection of physiological signals (not shown).  
         [0030]    Each signal input  12  has an associated a protection circuit  14  the output of which is connected to an input of a differential amplifier  16 . The other input of differential amplifier  16  is connected either to another signal input (for a bipolar measurement) or to a ground potential (for a monopolar measurement).  
         [0031]    The output of differential amplifier  16 , after conditioning by a conventional high-pass and low-pass filtering circuit (not shown), is converted by an analog/digital converter  18  into a signal that is applied to a microcontroller  20  ensuring the treatment (filtering, compression, recording, etc.) of the collected signal as well as that of the collected signals from the other electrodes placed on the patient (e.g., using a multiplexor, not illustrated), by software controlled signal processing techniques.  
         [0032]    The protection circuit  14  comprises a serial resistance  22 , about 100 KΩ, intended to limit the current circulating in the cable and via the electrode. A spark-gap component  24  ensures a limitation in voltage at the input, about 40 V, to take into account, in particular, the defibrillation shocks to be applied to the patient, so that the latter do not destroy the input circuits of the recorder. A suitable spark-gap component is the device sold by Cooper Electronics under the tradename SURGIX. The protection circuit  14  also comprises a connection capacitor  26  to block any possible continuous current (DC) component, as well as an RC network  28 ,  30  to filter the highest frequencies presented to differential amplifier  16 .  
         [0033]    Each input  12  is also equipped with a pull-down resistor  32  connected to the ground  34 , of high value (typically about 10 MΩ), mounted between the signal line, on the one hand, and ground  34 , on the other hand.  
         [0034]    For the impedance measurement, the invention proposes, instead of a permanent connection to the ground of pull-down resistance  32 , to connect the base of resistance  32  to a switch  36  that operates to connect the base either to ground  34  (the normal position for physiological signal acquisition) or to a generator of voltage or of current  38  (during the impedance measurement). The commutation (switching) is operated under the control of microcontroller  20 . For practical reasons, it is generally simpler to use a voltage generator for generator  38 , which devices are often available on conventional microcontrollers in the form of a digital to analog converter (D/A).  
         [0035]    More preferably, for the impedance measurement generator  38  provides, during a first cycle of short duration, for example, 1 ms, a voltage VT of a certain polarity. Then, during a second cycle of the same duration, a voltage of opposite polarity (cf the first line of the chronogram of FIG. 2, where the shape of the corresponding signal is illustrated at  40 ). This inversion of the polarities makes it possible to cancel the loads in the line, so that the measurement of the ECG signal will not be disturbed any more, even with a high line impedance, for example, because of a disconnected electrode.  
         [0036]    The relative amplitude of the positive and negative pulses of impulse  40  can be possibly optimized, by a learning mode wherein the microcontroller  20  learns to compensate for the shift caused by an absence of a cable, i.e. to compensate for the shift introduced by the measuring circuit, so as to adjust the return of the resulting signal to the base line signal in the absence of a cable, this adjustment being obtained by introducing a small dissymmetry between the two impulse cycles to compensate for the various shifts that are likely to be introduced into the measuring circuit.  
         [0037]    The value of the impedance is calculated based upon the voltage variations V S  measured at the output of the amplifier  16  at the end of the first cycle (variation ΔV 1 ) and at the end of the second cycle (variation ΔV 2 ). The measured signal V S  is illustrated into area  42  on the second line of the chronogram of FIG. 2, in the normal case, i.e. a not disconnected electrode or an intact connection wire. The voltage peak caused by the double injection of current has in this case an amplitude proportional to the impedance, and the variations of voltage ΔV 1  and ΔV 2  are in absolute value approximately equal, taking in account the errors of dissymmetry.  
         [0038]    To optimize the calculation of the impedance, it is possible to add the absolute values of the voltage variations ΔV 1  and ΔV 2 : As explained below in connection with FIG. 5, when the ECG signal is not null, it locally presents variations comparable to a slope which, if it is considered that the latter is stable over the short period of the impedance measurement, modifies the two values ΔV 1  and ΔV 2  in opposite directions; the total of these two values thus remains stable. In the case of a high impedance, corresponding to a situation of a disconnected or discontinuous (broken) cable, or of a disconnected electrode (i.e., one not properly coupled to the patient), the response to the current impulse  40  is very appreciably modified, as illustrated at area  44  on the second chronogram of FIG. 2: the load injected on the line with high impedance at the time of the first cycle of the current impulse  40  creates a high voltage, one that the microcontroller can immediately detect. In addition, injection of current in the opposite direction at the time of second cycle of current impulse  40  will cause cancellation of loads stored in the various input capacitors (loads that did not flow out (discharge) because of the high impedance between the signal terminal and the ground), thus allowing the return of the signal to the base line. That causes to place the entire system, from the point of view of the electric charges, in its former state.  
         [0039]    The impedance measurement is preferably determined by microcontroller  20  at regular intervals, for example, several times per minute, or even several times per second.  
         [0040]    The impedance measurement will take into account the various components of the protection circuit  14  against high and low frequency interference. In this regard, the components do not obstruct the impedance measurements, but they must be taken into account in the measurements. Thus, serial resistance  22  placed at input  12  to limit the current that can circulate in the line when a high voltage is applied to an electrode, for example, in the case of a defibrillation shock, comes to be added to the impedance measurement. As for capacitor  26  charged to cutoff the very low frequencies, it does not intervene in calculation owing to the fact that it completely transmits the measurement current to the line. Moreover, it has the advantage of removing possible DC components that are likely to decrease the precision of the signal injected by generator  38 .  
         [0041]    To make the measurement impedance reliable, the recorder must avoid taking into account aberrant values. For that, it can practice several successive measurements and then keep only one of them, for example, employ an average or a median of a plurality of measurements taken. By this technique one thus eliminates from the risk of recording an aberrant measurement if, for example, a high frequency artifact appears during the impedance measurement cycle. For one example, if the device takes ten measurements during a one minute interval, it can record each minute a median value of these ten measurements: the value of the impedance is thus updated once per minute.  
         [0042]    Various alternatives and improvements of the process of the invention can be considered. For example, it is possible to test simultaneously two lines by using signals that are opposite in phase. The current will circulate between the two electrodes, and this minimizes any risk of false measurement if the ground electrode becomes disconnected (the final balance of loads reminds null).  
         [0043]    In an alternative embodiment, as illustrated in FIG. 3, it is possible to remove switch  36 , leave generator  38  permanently connected to the base of resistance  32 , and interpose a resistance  46  between resistance  32  and ground  34 . In this embodiment, between the phases of measurement, instead of switching the switch  36  to connect resistance  32  to ground  34  as in the preceding embodiment, microcontroller  20  imposes on generator  38  a zero output voltage, which is equivalent to putting the base of resistor  32  to ground potential. This solution, which is purely static, makes it possible to avoid recourse to using a controlled switch  36 ; it however presents the disadvantage of requiring a permanent operation of the generator  38 , which thus always consumes a certain current because of the resistance network employed. The embodiment of FIG. 1 by contrast, differs in that use of switch  36  makes it possible to completely stop generator  38  except during the impedance measurement, thus making for an economy of the power supply of generator  38 .  
         [0044]    In addition, it is possible to carry out the impedance measurement on several amplifiers  16  simultaneously. Thus, as illustrated in FIG. 4, recorder  10  typically comprises a plurality of inputs  12 , each one connected, via a corresponding plurality of protection circuits  14 , to the positive input of a respective amplifier  16 . In the same way, inputs  12 ′ are respectively connected to the negative input of these same amplifiers  16 . Each positive input  12  is connected by its respective base resistance  32 , via a common trunk  48 , with a single switch  36  (or alternatively a single resistance  46 , as in the case of the embodiment of FIG. 3). In the same way, the negative inputs are connected to another common switch (not shown). The lines are thus tested alternately, positive inputs first, and then negative inputs, for example.  
         [0045]    Because the impedance measurement is realized during a very short time period, it is possible to carry out this measurement without stopping the collection of an ECG signal. FIG. 5 illustrates the corresponding manner of proceeding. To be able to measure the impedance, it is necessary to have an amplifier having a sufficiently short time-constant in regard to the measurement cycles. This constant must in particular be shorter than that which is usually used for a sampling at 200 s −1  (that is to say approximately 10 ms).  
         [0046]    The invention therefore proposes to associate a shorter time-constant, for example, 2 ms instead of 10 ms, with a faster sampling cycle, for example, 1 KHz, by averaging the signal over several points. FIG. 5 illustrates an ECG signal with the various points of sequential sampling such as  50  . . .  58  and  60  . . .  68 . The value of the ECG signal is obtained by averaging five points of sequential sampling  50 ,  52 ,  54 ,  56  and  58 . The samples being digitized each millisecond, this operation gives 1000/5=200 points a second (a frequency that is an acquisition frequency value usually used in the existing recorders, which allow for sampling frequencies generally ranging between 128 and 256 Hz).  
         [0047]    At the time of an impedance measurement, the injection of the biphasic current impulse will result in two points of sampling  60  and  62  deviating from the base line, and corresponding to amplitudes ΔV 1  and ΔV 2  of the signal in response, as illustrated in FIG. 2. These two data sample points  60  and  62  will be used for the impedance measurement and, on the five successive samples, there will remain at least two sample points  66 ,  68  to deliver a value of the ECG signal (sample point  64  which follows immediately sample points  60  and  62  is not preserved for the calculation of the average value, by precaution). So the determination of the ECG signal will not be, or at least will be very little, modified during the impedance measurement phase. The only difference being that during this particular cycle the evaluation of the ECG signal will be done by averaging only two points, instead of five in the normal case—but the measurement of the ECG signal will not be stopped, even during only one cycle, due to the impedance measurement.  
         [0048]    This manner of proceeding is of course not restrictive, and other alternatives can be considered, for example, the measurement of a number of data points (e.g., three or four points) per cycle, instead of five, by retaining only the last point as value of the ECG signal in the case of a cycle including an impedance measurement, by using different sampling frequencies, etc.  
         [0049]    One now will consider the particular case of a patient carrying a pacemaker. In this case, the peaks of stimulation emitted by the pacemaker disturb the operation of the impedance measurement by the recorder. Indeed, these peaks are of an amplitude and a duration of the same order of magnitude as the voltage variations related to the measurement of impedance; the measuring circuit can thus confuse the signal collected during the impedance measurement (e.g., the signal illustrated on the second line of FIG. 2) with a stimulation peak. Until now, this difficulty was circumvented by removing any impedance measurement in the recorders carried by patients equipped with a pacemaker.  
         [0050]    The invention proposes to resolve this difficulty, by proposing two methods authorizing impedance measurements by the recorder even when the patient carries a pacemaker. The first method concerns synchronizing the impedance measurement cycle on the recognized stimulation peaks. For that, the recorder seeks the presence of peaks (analyzing signals at 1000 Hz by use of software or a specific peak detecting circuit), and delivers temporal windows placed after the peaks (for example, 10 ms), during which it will be confident that the pacemaker will not emit other stimulation pulses. When the recorder wants to take the impedance measurement, it awaits a window of measurement and performs the measurement as previously described, without being likely to be disturbed. If no peak is detected in the ECG signal for one relatively significant length of time (e.g., a few seconds), the recorder considers that the pacemaker is in an inhibited mode (the so-called “demand” mode) and that it can thus launch its measurement of impedance; there remains however a risk (low) to be in synchronism with a peak, if a stimulation starts at this time.  
         [0051]    The second method concerns rebuilding the signal at 1000 Hz: during a first measurement, the response to the current impulse is memorized. Under normal operation, with each impedance measurement, the ECG signal is collected and, using a subtraction algorithm, the previously recorded first measurement response is removed from the detected signal. One thus obtains a signal free of the impedance measurement artifacts, and on which one can seek the stimulation peaks (the proper response at the injection of the measurement signal is obtained starting from the preceding cycles, and eventually the following cycles).  
         [0052]    Known devices where the invention might be practiced have been cited in the present disclosure, namely the Syneflash™ and Synesis™ devices available from ELA Medical. Circuits for implementing the aforementioned functions for controlling the generator output and operating switches are known to persons of ordinary skill in the art. Similarly, software suitable for operating the microcontroller to in turn operate the switches, generator and temporal window, as well as analog to digital and digital to analog converters, are believed to be within the abilities of a person of ordinary skill in the art to prepare and implement.  
         [0053]    One skilled in the art will appreciate that the present invention can be practiced by other than the described embodiments, which are presented for purposes of illustration and not of limitation.