Investigation of pulse transit time characteristics during single and recurrent obstructive respiratory events.

Conventional overnight polysomnography (PSG) used to determine the respiratory behaviour during sleep can be a complex and expensive procedure. Pulse transit time analysis (PTT) has shown potential to detect obstructive apnoeic and hypopnoeic events (OE) in adults. Due to abnormalities in central ventilatory control, recurring OE may occur. This study was undertaken to determine the potential of PTT to differentiate responses during upper airway obstruction in the paediatric population. This preliminary study included 11 children (10 male; aged 7.5 +/- 3.8 year) recruited to investigate PTT trend during single and recurrent OE. PTT measurements were evaluated against the corresponding PSG results pre-scored by two blinded observers. A total of 110 valid OE (47 single and 63 recurrent) were observed during these PSG studies. There were distinct PTT responses observed for these two types of OE with respect to those of tidal breathing (P < 0.05). For the tidal breathing events, the mean absolute standard deviation (SD) and maximal percentage (%) decrease (MAX) were 7.71 ms and 3.88% respectively. For the recurrent OE, the absolute SD, SD (%) and MAX were 52.21 ms, 8.52% and 55.08% accordingly while for the single OE, the absolute SD, SD (%) and MAX were 12.23 ms, 5.27% and 13.56% respectively. The findings herein can suggest that PTT can be a valuable clinical tool in the paediatric respiratory sleep studies.

Effect of ethnicity and growth on ratio-based transit time surrogate ankle-brachial index marker from a Chinese children's perception.

OBJECTIVE: Since its introduction, ankle brachial index (ABI) measurements have been used in numerous clinical studies for its diagnostic and epidemiological values. However, conventional methods to acquire ABI are known to have limitations such as their suitability on uncooperative children when multiple prolonged monitoring is required. A simple and non-occluding technique termed pulse transit time ratio (PTTR) has been recently proposed to be a surrogate ABI marker. This methodological approach is based on the working principle of pulse transit time (PTT). It is known that age and ethnicity have confounding effects on the body proportion but little is known about their effect on the PTTR value. METHODS AND RESULTS: In this study, 128 healthy subjects (43 Chinese adults, 55 Caucasian and 30 Chinese children) were recruited to assess the effect of the two physiologic parameters. Statistical analyses reveal that age and ethnicity have diverse effects on the acquired transit time-related measurements. Particularly, both the PTT and PTTR parameters were influenced by age (P < 0.05) but not ethnicity (P > 0.05). However, age did not have any effect on either parameter for the adult group (P > 0.05). CONCLUSIONS: Similar to the ABI concept, the PTTR is the quotient of the transit time acquired from the lower limb and upper limb that indirectly reflects the stiffness of the respective arterial wall. Hence, the findings herein suggest that the PTTR approach shows promise to be a surrogate ABI marker.

Effects of poorly perfused peripheries on derived transit time parameters of the lower and upper limbs.

A simple and non-intrusive approach termed the pulse transit time ratio (PTTR) has recently been shown to be a potential surrogate of the ankle-brachial index (ABI). PTTR is based on the principle of PTT, which is known to be temperature-sensitive. In this study, 23 healthy adults with normally perfused peripheries and 10 with poorly perfused peripheries were recruited. No significant change in PTTR was observed between those with cold (1.287+/-0.043) and normal (1.290+/-0.027) peripheries (p>0.05). A cold periphery may cause pulse waveform changes and indirectly affect PTT owing to poor skin microcirculation, but may have a limited effect on PTTR, which is useful as an ABI alternative.

Factors that affect pulse wave time transmission in the monitoring of cardiovascular system.

OBJECTIVES: Vascular transit time (VTT) can be defined as the first heart sound of the phonocardiography (PCG) signal to its arrival at the photoplethysmography (PPG). Studies have shown that monitoring VTT can be useful as an early prognosis of cardiac diseases. However, there is limited study conducted to understand the physiologic factors that affect VTT at the upper limb. In this study, the effect associated with difference in subject height, weight, heart rate, mean arterial pressure, systolic and diastolic blood pressure was assessed. METHODS: A study population of 31 healthy Chinese young adults (21 male; age range 20-33 yr) were recruited. PCG and PPG were recorded non-invasively from the fourth costal cartilage at the midclavicular line and right index finger, respectively. A single sample Kolmogorov-Smirnov (K-S) goodness-of-fit hypothesis test, a univariate linear regression analysis, and a multiple linear regression modelling were performed on the VTT measurements and the associated physiologic parameters. RESULTS: The results from the K-S test showed that the physiologic parameters and VTT measurements had a normal cumulative distribution function. Furthermore, all physiologic parameters were significantly and independently related to VTT (P < 0.05). Based on these physiological parameters, a VTT regression model was also derived (r (2) = 0.79). CONCLUSIONS: The findings herein suggest that the observed physiologic parameters have significant contributions to the nominal VTT value of a subject. Unlike pulse transit time, the VTT technique has the added advantage that the left ventricular isometric contraction time is not included in the timing derivation.

Pulse transit time in paediatric respiratory sleep studies.

Pulse transit time (PTT) has emerged over the recent decades as a simple and non-invasive measure to quantify inspiratory effort changes in adults with sleep disordered breathing (SDB). Hence, this shows promise to be an effective screening tool for the paediatrics. However, little is known about its utility and suitability until recent studies has been provided quantitative knowledge about its relevance in clinical investigations. In this review, the origins, normative values, current uses and technical issues in its application to paediatric monitoring, particularly during sleep are discussed. Preliminary findings from these investigations suggest favourably its potential as an important element to screen SDB in the children population.

Phonocardiographic signal analysis method using a modified hidden Markov model.

Auscultation is an important diagnostic indicator for cardiovascular analysis. Heart sound classification and analysis play an important role in the auscultative diagnosis. This study uses a combination of Mel-frequency cepstral coefficient (MFCC) and hidden Markov model (HMM) to efficiently extract the features for pre-processed heart sound cycles for the purpose of classification. A system was developed for the interpretation of heart sounds acquired by phonocardiography using pattern recognition. The task of feature extraction was performed using three methods: time-domain feature, short-time Fourier transforms (STFT) and MFCC. The performances of these feature extraction methods were then compared. The results demonstrated that the proposed method using MFCC yielded improved interpretative information. Following the feature extraction, an automatic classification process was performed using HMM. Satisfactory classification results (sensitivity > or =0.952; specificity > or =0.953) were achieved for normal subjects and those with various murmur characteristics. These results were based on 1398 datasets obtained from 41 recruited subjects and downloaded from a public domain. Constituents characteristics of heart sounds were also evaluated using the proposed system. The findings herein suggest that the described system may have the potential to be used to assist doctors for a more objective diagnosis.

A computational system to optimise noise rejection in photoplethysmography signals during motion or poor perfusion states.

Photoplethysmography (PPG) signals can be used in clinical assessment such as heart rate (HR) estimations and extraction of arterial flow waveforms. Motion artefact and/or poor peripheral perfusion can contaminate the PPG during monitoring. A computational system is presented here to minimise these two intrinsic weaknesses of the PPG signals. Specifically, accelerometers are used to detect the presence of motion artefacts and an adaptive filter is employed to minimise induced errors. Zero-phase digital filtering is engaged to reduce inaccuracy on the PPG signals when measured from a poorly perfused periphery. In this system, a decision matrix adopts the appropriate technique to improve the PPG signal-to-noise ratio dynamically. Statistical analyses show promising results (maximum error < 7.63%) when computed HR is compared to corresponding estimates from the electrocardiogram. Hence, the results here suggest that this dual-mode approach has potential for use in relevant clinical measurements.

Screening of obstructive and central apnoea/hypopnoea in children using variability: a preliminary study.

AIM: Polysomnography (PSG) is the current standard protocol for sleep disordered breathing (SDB) investigation in children. Presently, there are limited reliable screening tests for both central (CE) and obstructive (OE) respiratory events. This study compared three indices, derived from pulse oximetry and electrocardiogram (ECG), with the PSG gold standard. These indices were heart rate (HR) variability, arterial blood oxygen de-saturation (SaO2) and pulse transit time (PTT). METHODS: 15 children (12 male) from routine PSG studies were recruited (aged 3-14 years). The characteristics of the three indices were based on known criteria for respiratory events (RPE). Their estimation singly and in combination was evaluated with simultaneous scored PSG recordings. RESULTS: 215 RPE and 215 tidal breathing events were analysed. For OE, the obtained sensitivity was HR (0.703), SaO2 (0.047), PTT (0.750), considering all three indices (0) and either of the indices (0.828) while specificity was (0.891), (0.938), (0.922), (0.953) and (0.859) respectively. For CE, the sensitivity was HR (0.715), SaO2 (0.278), PTT (0.662), considering all indices (0.040) and either of the indices (0.868) while specificity was (0.815), (0.954), (0.901), (0.960) and (0.762) accordingly. CONCLUSIONS: Preliminary findings herein suggest that the later combination of these non-invasive indices to be a promising screening method of SDB in children.

Estimation of breathing interval from the photoplethysmographic signals in children.

Two important parameters that are generally under continual observation during clinical monitoring are heart rate (HR) variability and breathing interval (BI) of patients. Current HR monitoring during night-long childhood respiratory sleep studies is well tolerated but BI monitoring requires instrumentation, like nasal cannula, that can be less accommodating for children. In this study, BI was extracted from the photoplethysmographic (PPG) signals using a two-stage signal processing technique termed zero-phase digital filtering. Eight children (7 male) aged 8.6 +/- 2.6 years were recruited to perform two breathing activities: during tidal and with customized externally applied inspiratory resistive loading (IRL). The accuracy of BI derived from the PPG signals was compared with that estimated by a calibrated air pressure transducer in children. Statistical analysis revealed that mean BI attained from the PPG signals were significantly related during tidal breathing (r(2) = 0.76; range 0.61-0.83; p < 0.05) and with the IRL (r(2) = 0.79; range 0.68-0.85; p < 0.05) in the absence of motion artefacts. Preliminary findings herein suggest that besides having the capability to monitor HR and arterial blood oxygen saturation measurements, the PPG signals can be used to derive BI for children. This can be an attractive alternative for children who are more disturbed by intrusive techniques in prolonged clinical monitoring.

Pulse transit time changes observed with different limb positions.

Pulse transit time (PTT) is a non-invasive measure of arterial compliance. It can be used to assess instantaneous blood pressure (BP) changes in continual cardiovascular measurement such as during overnight respiratory sleep studies. In these studies, periodic changes in limb position can occur randomly. However, little is known about their possible effects on PTT monitored on the various limbs. The objective of this study was to evaluate PTT differences on all four limbs during two positional changes (lowering and raising of a limb). Ten healthy adults (seven male) with a mean age of 27.0 years were recruited in this study. The results showed that the limb that underwent a positional change had significant (p < 0.05) local PTT differences when compared to its nominal baseline value, whereas PTT changes in the other remaining limbs were insignificant (p > 0.05). The mean PTT value measured from a vertically-raised limb increased by 42.7 ms, while it decreased by 28.1 ms with a half-lowered limb. The PTT differences observed during positional change can be contributed to by the complex interactions between hydrostatic pressure changes, autonomic and local autoregulation experienced in these limbs. Hence the findings herein suggest that PTT is able to reflect local circulatory responses despite changes in the position of other limbs. This can be useful in prolonged clinical observations where limb movements are expected.

Use of pulse transit time to distinguish respiratory events from tidal breathing in sleeping children.

STUDY OBJECTIVES: Currently, esophageal pressure monitoring is the "gold standard" measure for inspiratory efforts, but its invasive nature necessitates a better tolerated and noninvasive method to be used on children. Pulse transit time (PTT) has demonstrated its potential as a noninvasive surrogate marker for inspiratory efforts. The principle velocity determinant of PTT is the change in stiffness of the arterial wall and is inversely correlated to BP. Moreover, PTT has been shown to identify changes in inspiratory effort via the BP fluctuations induced by negative pleural pressure swings. In this study, the capability of PTT to classify respiratory events during sleep as either central or obstructive in nature was investigated. SETTING AND PARTICIPANTS: PTT measure was used in adjunct to routine overnight polysomnographic studies performed on 33 children (26 boys and 7 girls; mean +/- SD age, 6.7 +/- 3.9 years). The accuracy of PTT measurements was then evaluated against scored corresponding respiratory events in the polysomnography recordings. RESULTS: Three hundred thirty-four valid respiratory events occurred and were analyzed. One hundred twelve obstructive events (OEs) showed a decrease in mean PTT over a 10-sample window that had a probability of being correctly ranked below the baseline PTT during tidal breathing of 0.92 (p < 0.005); 222 central events (CEs) showed a decrease in the variance of PTT over a 10-sample window that had a probability of being ranked below the baseline PTT of 0.94 (p < 0.005). This indicates that, at a sensitivity of 0.90, OEs can be detected with a specificity of 0.82 and CEs can be detected with a specificity of 0.80. CONCLUSIONS: PTT is able to categorize CEs and OEs accordingly in the absence of motion artifacts, including hypopneas. Hence, PTT shows promise to differentiate respiratory events accordingly and can be an important diagnostic tool in pediatric respiratory sleep studies.

Variability in time delay between two models of pulse oximeters for deriving the photoplethysmographic signals.

Pulse oximetry is commonly used as an arterial blood oxygen saturation (SaO2) measure. However, its other serial output, the photoplethysmography (PPG) signal, is not as well studied. Raw PPG signals can be used to estimate cardiovascular measures like pulse transit time (PTT) and possibly heart rate (HR). These timing-related measurements are heavily dependent on the minimal variability in phase delay of the PPG signals. Masimo SET Rad-9 and Novametrix Oxypleth oximeters were investigated for their PPG phase characteristics on nine healthy adults. To facilitate comparison, PPG signals were acquired from fingers on the same hand in a random fashion. Results showed that mean PTT variations acquired from the Masimo oximeter (37.89 ms) were much greater than the Novametrix (5.66 ms). Documented evidence suggests that 1 ms variation in PTT is equivalent to 1 mmHg change in blood pressure. Moreover, the PTT trend derived from the Masimo oximeter can be mistaken as obstructive sleep apnoeas based on the known criteria. HR comparison was evaluated against estimates attained from an electrocardiogram (ECG). Novametrix differed from ECG by 0.71+/-0.58% (p<0.05) while Masimo differed by 4.51+/-3.66% (p>0.05). Modern oximeters can be attractive for their improved SaO2 measurement. However, using raw PPG signals obtained directly from these oximeters for timing-related measurements warrants further investigations.

Predictive regression equations and clinical uses of peripheral pulse timing characteristics in children.

Studies have shown that increased arterial stiffening can be an indication of cardiovascular diseases like hypertension. In clinical practice, this can be detected by measuring the blood pressure (BP) using a sphygmomanometer but it cannot be used for prolonged monitoring. It has been established that pulse wave velocity (PWV) is a direct measure of arterial stiffening but its usefulness is hampered by the absence of non-invasive techniques to estimate it. Pulse transit time (PTT) is a simple and non-invasive method derived from PWV. However, limited knowledge of PTT in children is found in the present literature. The aims of this study are to identify independent variables that confound PTT measure and describe PTT regression equations for healthy children. Therefore, PTT reference values are formulated for future pathological studies. Fifty-five Caucasian children (39 male) aged 8.4 +/- 2.3 yr (range 5-12 yr) were recruited. Predictive equations for PTT were obtained by multiple regressions with age, vascular path length, BP indexes and heart rate. These derived equations were compared in their PWV equivalent against two previously reported equations and significant agreement was obtained (p < 0.05). Findings herein also suggested that PTT can be useful as a continuous surrogate BP monitor in children.