C RIP educational_presentation

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Respiratory Inductance Plethysmography


RIP Applications

• Research

Over 1000 Research papers published.

Chimes Study

• ICU

Non Invasive Monitoring of FRC changes in Ventilated patients

Apnea monitoring

• SLEEP!!!

Adobe Acrobat Document


ASSM Scoring Rules


History

MOVEMENTS OF THE THORACIC CAGE AND DIAPHRAGM IN RESPIRATION by 0. L. WADE J. Physiol. (I954)

Fig. 1. Diagram showing the method of tracking diaphragmatic movement and of recordingvertical movements of the chest and changes of chest circumference. Inset diagramillustrates the geometric distortion for which corrections were made.


History

Measurement of the separate volume changes of rib cage and abdomen during breathing

KIMIO KONNO AND JERE MEAD J. Appl.Physiol. 22(3) : 407-422. I967


History

NIMS Respitrace Corp

Introduction of Respitrace Basic 1979

(still available from Ambulatory Care Inc)


History

Herman Watson 1/5/1982

Respitrace Corp

Respiratory Inductive Plethysmography


History

Herman Watson 2/15/1983

Respitrace Corp

Calibration of RIP

MARVIN A SACKNER, HERMAN WATSON, ANNE S. BELSITO, DREW FEINERMAN, MANUEL SUAREZ, GERARDO GONZALEZ,FRANKLIN BIZOUSKY, AND BRUCE KRIEGER.

September 8 1988

Calibration of respiratory inductiveplethysmography during natural breathing

QDCQualitative Diagnostic Calibration

History

QDC Calibration

To calibrate RIP to volume change (ΔV) the qualitative diagnostic calibration (QDC) procedure uses the equation ΔV = M * (K * ΔRIPrc + ΔRIPab), in which ΔRIPrc and ΔRIPab are the rib cage and abdominal RIP changes relative to the values at FRC, respectively. K is a calibration factor, indicating the relative contribution of both compartments to volume, and M scales the sum to volume and is expressed in ml. ( M is determined in a second stage Calibration to a pneumotach) In the QDC method, a number of undisturbed breaths are collected during 5 minutes uninterrupted mechanical ventilation. Breaths with similar tidal volume are selected, based on the uncalibrated sum signal (RIPrc+RIPab), including only breaths within one standard deviation of the mean. Then, the standard deviations of RIPrc and RIPab are determined over the selected breaths. Calibration factor K is estimated by SD(RIPab) / SD(RIPrc). M is determined by injection of a known volume, e.g. tidal volume. With M and K known, every pair of RIPab and RIPrc are converted to a calibrated volume.

5 Minutes of Normal Resting Breathing….


History

• NIMS

• September 1991 introduces Respitrace Plus

Respitrace Plus monitors breathing pattern and the electrocardiogram. It incorporates NIMS' patented Respitrace technology for assessment of respiratory frequency, changes of tidal volume, labored breathing and detection of central and obstructive apneas. Respitrace is the only commercially available technology that by itself is capable of monitoring these parameters


History

• NIMS – SensorMedics Agreement

• August 2 1994

• Respitrace PT2

• Respitrace Plus

• Respitrace Cardio

• Respibands


History

• SensorMedics / VIASYS– April 1999

– Qualitative Diagnostic Calibration• 5 minutes Normal Resting Breathing

– Calibrated SUM channel

– FVL with RespiEvents Software

– dVt Channel (Derived Flow) in 2002

– FVL integrated into Somnostar in 2002


History

• Compumedics• David Burton• Jiang Hong Tan• Patent # 6142953 November 2000

A device for reliably and non-invasively measuring respiration rates and effort by encircling the patient's chest with a device having a large section of inelastic belt attached to a small section of elastic material. The elastic material having two magnetic tapes with wire windings thereon proximate each other with an insulation material therebetween. The wire windings are electrically connected to each other. The magnetic tapes have opposite ends attached to the elastic material such that when the elastic material expands and contracts the wire windings move relative to each. A toroidal transformer is connected to the wire windings. When a carrier signal is introduced to the transformer and the magnetic tapes move relative to each other on the elastic material when the patient breathes a mutual inductance in the wire windings modulates the carrier signal and thus measures the expansion and contraction of the patient's chest which is directly related to the patient's respiration rate. The electronics connected to the device for monitoring respiration also measures belt shifting for diameter changes during monitoring by measuring the central amplitude during a breath cycle and comparing the initial belt diameter conditions to later conditions. The electronics can then compensate for amplitude variations in the signal caused by belt shifting which may be confused with shallower breathing in uncompensated devices.


History

• Compumedics 2000• • Inductive plethysmography technology• • Linear response to changes in effort• • Balanced SUM channel output• • Continuous, automatic channel balancing• • Operates with any PSG amplifier system• • 800 hours of operation from a small low-cost battery• • Long lasting, reusable sensor bands• • Cost effective and easy to use


History

• Embla 2005• • XFlow™ is a semi-quantitative measure of inspiratory and• expiratory flow, providing a complementary flow signal• for studies without airflow sensors. X-flow is a reliable• backup and great tool for titrations.• • XSum™ is the summation of the abdominal and thoracic• signals providing a semi-quantitative measurement of• lung volume.• • RMI™ (Respiratory Mechanics Instability) is a proprietary• algorithm that assesses the severity of Sleep Disordered• Breathing by analyzing the phase relationship between• the abdomen and thorax.• • Phase Analysis displays (in degrees) the phase relationship• between the abdomen and the thorax for evaluation and• analysis of paradoxical breathing.


History

• Pro Tech June 2005• zRIP

– Compatible with all PSG systems– Washable belts– Non-calibrating SUM channel


History

• Braebon 2006• Q-RIP

– Compatible with all PSG systems– Non-calibrating SUM channel


History

• Sleepmate 2007• RIPmate

– Compatible with all PSG systems– Non-calibrating SUM channel

The RIPmate system is designed with a washable one-size-fits-all belt and buckle that is comfortable and stays in place. The RIPmate Inductance Processor module plugs directly into the AC input of any headbox with no additional software needed. The system provides a reliable effort signal that eliminates the problems of effort signal loss and false paradoxical signals.


Comparison Piezo Belts

– Poor QUALITATIVE grading of waveform• NOT Quantitative

– False Paradox due to low signal

– Must be readjusted throughout night

– Loss of signal due to position shift


Comparison Non Calibrated RIP

•False paradox eliminated (if reference and signal inputs must be connected with the same polarity).

•Excellent signal quality

•Small interface device (usually battery operated)

•Sum channel not equal to true RC + ABD volume change


Comparison Calibrated RIP

• False paradox eliminated

•Excellent signal quality

•Larger driver/interface device (usually AC operated)

•Sum channel equal to true RC + ABD volume change

•dVt

•FVL

•Konno Mead Loops

• QUANTITATIVE


Device Comparison


Obstructive Apnea

No Flow

Paradoxical Effort


Central Apnea

No Flow! No Volume! No Patient Effort


Hypopneas - Non Calibrated RIP


Hypopneas – Calibrated RIP with FVL


Hypopnea

• Take the guess-work out of Hypopneas!

• Quantify the difference of percentage of breaths against the Baseline Breath


Inspiratory Flow Limitation - UARS

• Flattening on the Inspiratory Side of the Flow Volume Loop

vs.

• Chest and Abdomen out of Phase


Inspiratory Flow Limitation - UARS

Flattening of Chest Signal

Flattening of dVt Channel

Flattening of Inspiratory Curve

Increased I:E Ratio


CPAP TITRATION

The first step to compliance is proper Titration

Eliminate all obstructive and events• Gross titration by stepwise increases in PAP until no events are

observed via Thermocouple/Nasal Pressure and effort belts.Elimination of UARS

• Fine titration of stepwise increases in PAP until Airway is splinted open observed via Flow Volume Loops or Esophageal Pressure.

Elimination of Central Events caused by over titration•Observe FVLs for hyperinflation

Elimination of increased WOB / increased Expiratory Resistance•Treat Flattening of expiratory curve with Pressure

Release


How can cRIP Help ?

Flow Volume Loops– Breath used as the “Signature Breath”

• Select a Baseline Breath at Sleep Onset

– Compare breaths to the Baseline Breath• CPAP Titrations

– Titrate sleep patients back to their “Signature Breath

• UARS Visualize Inspiratory Flow Limitation1

• Hypopnea Events– Show a difference or a percentage as compared to the

Baseline Breath

– Differentiate between Mixed, Obstructive and Central Hypopneas2

1 Daniel Loube, MD, FCCP, Teotimo Andrada, MS. Pulmonary/Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC, USA COMPARISON OF RESPIRATORY INDUCTANCE PLETHYSMOGRAPHY AND ESOPHAGEAL PRESSURE MONITORING IN THE DETECTION OF UPPERAIRWAY RESISTANCE SYNDROME

2 Classification of a hypopnea as obstructive, central or mixed should not be performed without a quantitative assessment of ventilatory effort (esophageal manometry, calibrated respiratory inductance plethysmography, or diaphragmatic/intercostal EMG) ASSM Manual for the Scoring of Sleep and Associated Events


Konno Mead Loops– Work of Breathing

• Visualize accessory muscle use vs. diaphragmatic effort

• Monitor Increased Expiratory Resistance during titrations

– Chest/Abdominal Asynchrony• Phase Angle shift

– Central vs. Obstructive events• True Paradox

How can cRIP Help ?


Konno Mead Loop Breakdown

Rib Cage

Abdomen

Inspiration

Expiration


Breath by Breath Tabular View– Monitor I:E Ratios Inspiratory/Expiratory times

• Inverse I:E ratios indicate increased Inspiratory Resistance

– Pif-Mif Peak Inspiratory Flow/Mean Inspiratory Flow • Peak flow greater than the mean flow implies a work rate

greater than a constant flow1. <1.5 = inspiratory flow limitation1

– Selection of multiple breaths for comparison and printing

1. Lafortuna CL, Minetti AE, Mognoni P. Inspiratory pattern inhumans. J Appl Physiol 1984;57:1111-1119.

How can cRIP Help ?


PAP Titration with cRIP

Select a reproducible breath

Normal FVL



Titrate to Eliminate Events



Titrate PAP to Open Loop

Inspiratory Resistance (UARS)

Inverse I:E ratio

Increased WOB

Eliminate UARS



• Titrate Inspiratory and Expiratory curves separately to Baseline Breath with Bi-Level

• Optimize Expiratory Pressure Release to decreased expiratory resistance using FVLs and decrease WOB with Konno Mead Loops



Titrate Bi-Level to Eliminate Hypoventilation

Titrate EPAP to Eliminate Events

Titrate IPAP to increase Vt



Expiratory Resistance

Eliminate Expiratory Resistance

Titrate Pressure Release to Open Loop

Increased WOB



Eliminate Central Apneas Caused by Over Titration

Reduce Pressure to Decrease Vt

Central Apneas


Successful Titration with cRIP

Titrated Loops = Baseline Loop

Elimination of Events

Elimination of UARS

WOB returns to Baseline LevelNo Hyperinflation

Successful Titration = Better Compliance = Satisfied Customer


Summary

• Long History of Research and Development

• Validated technique

• Available calibrated and uncalibrated

• Accurate event detection

• A better way to measure Effort

• Enhanced software packages with FVL and Konno Mead Loops

• A better tool for titration

C RIP educational_presentation

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changes of tidal volume

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