Patent Application
20080077024
The present invention relates to a method and apparatus for non-invasively measuring certain physiological parameters of a subject. The invention is particularly useful in venous occlusion plethysmography (VOP) for measuring volumetric blood flow, or other physiological parameters derived from volumetric blood flow, as well as providing certain-quantitative indices of venous compliance, and is therefore described below with respect to such applications.
Venous occlusion plethysmography is a known method for non-invasively measuring a physiological parameter of a subject, particularly volumetric blood flow. It is based on the accumulation of blood in the veins of a body region that is distal or upstream from a venous occlusion device. In the venous occlusion plethysmography method, a pressure greater than the venous pressure, but less than the arterial pressure, is applied around a body region in order to cause venous blood to be accumulated in another body region located distally (or further away from the heart) to the one acted upon by the venous occlusion device. Changes in volume with respect to time of the distal region are measured and utilized to provide a measure of the blood flow, or other physiological parameters derived therefrom such as the relative volume accumulated at a given occlusion pressure level.
VOP is based on the following physiological properties of a subject's circulatory system:
1. the veins possess very high levels of compliance and are able to accommodate large amounts of blood at relatively low pressure;
2. there is a large pressure difference between systemic arterial and systemic venous blood pressure; and
3. blood flow in the systemic arteries propagates from the heart toward the periphery of the body, whereas it propagates in the opposite direction in the system veins, (i.e. from the periphery towards the heart).
At the present time, VOP measurements are generally made by inflating a segmental cuff, placed over the perimeter of a body region, to apply pressure over the entire circumference of the particular body region, to a pressure between venous and arterial pressure, and then measuring the volume of blood which accumulates distal to the cuff. As described more particularly below, when the venous occlusion pressure is intermittently raised in the cuff, the cumulative volume begins to increase with each pulse wave, until such time as the veins are unable to accommodate more volume.
As mentioned, the veins are characterized as having a very high degree of compliance compared to arterial blood vessels; that is, they are capable of undergoing a larger volume change for a given increase in pressure compared to equivalent sized arterial vessels. Compliance of the veins is especially high after they have initially been emptied. However as the veins become increasingly filled, and the venous wall begins to be stretched, the ability of the veins to expand without increasing the pressure of the contained blood tends to be reduced, upon pressure increases, thereby resulting in a non-linear pressure versus volume relationship. Nevertheless, a substantial portion of the volume of blood which the veins are able to accommodate from their fully emptied state, occurs without the venous wall being stretched, and this occurs at a very low level of pressure. The rate of change of the accumulated blood volume is the volumetric blood flow (BF). When the blood in the region distal to the occlusion cuff reaches the cuff pressure, further accumulation of blood ceases, and a steady state level of blood volume prevails. The volume of accumulated blood distal to the occlusion cuff at that point thus reaches a plateau which represents the venous capacitance (VC).
It is to be particularly noted that as the volume and pressure of the blood distal to the venous occlusion cuff increases, the compliance of the veins tends to decrease.
A major limitation of VOP, as it is currently practiced, is that it is restricted to measurements in body parts which are maintained above heart level, for the following reason: The combination of extremely high venous compliance described above, and the generation of hydrostatic gradients in the vascular system due to vertical displacement relative to heart level, means that the veins in body parts which are below heart level easily become filled with blood and therefore lose the capacity to freely accommodate additional volumes of blood. When venous blood vessels become filled due to hydrostatic pressure gradients, the partially filled veins cannot be accurately used for VOP measurements due to the relative reduction in the ability to further expand and the lack of linearity of the pressure volume relationship because of vessel wall stretching. For these reasons, VOP measurements have until now been strictly limited to the above heart position of the measured region.
While the filling of the veins due to such hydrostatic pressures can be prevented by the application of a sufficient level of external counter pressure to the measurement site (so as to counterbalance the intravenous pressure), traditional VOP volumetric collecting cups are mechanically incapable of being pressurized to any appreciable degree without being forced off the measurement site. They are therefore unable to provide the necessary degree of pressure to counterbalance the intra-venous pressure, and thus cannot be used to reliably measure BF below heart level. Substitute collecting devices, such as mercury in silastic rings or circumferential strain gauges, provide no actual pressure field to the bulk of the tissues distal to the venous occlusion cuff, so that resting venous distention cannot be counterbalanced by any of these methods. Furthermore, since they do not actually measure volume but rather an index of circumference, they are not capable of being accurately calibrated to provide an index of volume.
Because of these limitations, traditional VOP devices are not able to modify the local venous transmural blood pressure so as to allow BF measurements or venous capacitance at specific pressure levels to be made when the measured body part is below heart level, and therefore, as noted above, VOP measurements have generally been limited to body regions which are located above the subject's heart or are deliberately elevated above heart level.
Further information regarding VOP measurements is available from the patent literature, e.g. U.S. Pat. Nos. 5,447,161 and 6,749,567, the contents of which are incorporated herein by reference. These patents also describe other physiological parameters derived from volumetric blood flow which may also be measured by the VOP method.
An object of the present invention is to provide a method having advantages in the above respects for non-invasively measuring physiological parameters, particularly volumetric blood flow and venous capacitance. A more particular object of the present invention is to provide a VOP measurement process which is not limited to body parts above the heart level of the subject, or those elevated to be above heart level. Another object of the present invention is to provide apparatus for making such non-invasive measurements in accordance with the novel method. Yet another object of the present invention is to provide apparatus for making such non-invasive measurements in a quantitative manner to provide data in standard physical units.
According to one aspect of the present invention, there is provided a method for non-invasively measuring a physiological parameter of a subject, comprising: applying to a body part of the subject a venous occlusion plethysmographic device including a first section having a first fluid chamber to engage a first region of the body part and a second section having a second fluid chamber to engage a second region of the body part, proximally located to the first region at the side thereof facing the heart of the subject; pressurizing the first fluid chamber to a pressure level exceeding the sum of the inherent venous pressure and the hydrostatic pressure prevailing within the given body part; intermittently raising and lowering the pressure in the second fluid chamber to a pressure above or equal to the pressure in the first chamber but below the arterial blood pressure; measuring changes in volume of the first region of the body part; and utilizing the measured changes in volume to provide a measure of the physiological parameter.
Preferably, the venous occlusion device used in the above method is a peripheral arterial tonometry (PAT) probe, such as described in previously issued U.S. Pat. Nos. 6,319,205; 6,322,515; 6,461,305 and 6,488,633, the contents of which are incorporated herein by reference, and several currently pending patent applications, all assigned to the same assignee as the present application. The preferred embodiments of the invention described below thus illustrate the utilization of such PAT probes.
According to further features in the described preferred embodiments, the volume changes are accumulated over a measured time period, and the rate of change is determined to thereby provide a measurement of volumetric blood flow. As indicated above, however, the method could also be used for measuring other physiological parameters derived from volumetric blood flow, e.g. the level of venous capacitance at specific venous pressure levels, venous pressure, arterial pressure, etc., as described for example in the above-cited U.S. Pat. No. 5,447,161.
According to another aspect of the present invention, there is provided a method for non-invasively measuring a physiological parameter of a subject, comprising: applying to a finger or toe of the subject a venous occlusion device including a first section having a first fluid chamber to engage the distal tip of the finger or toe including the distal most extremity of its tip, and a second section having a second fluid chamber to engage an annular region of the finger or toe inwardly of the distal tip; pressurizing first fluid chamber to a pressure below the venous occlusion pressure but sufficient to compensate for the hydrostatic pressure added to the venous pressure according to the vertical level of said finger or toe with respect to the subject's heart level; intermittently raising the pressure in said second fluid chamber to a pressure above or equal to the pressure within said first fluid chamber but below the arterial blood pressure; measuring changes in volume of said distal tip of the finger or toe; and utilizing said measured volume changes to provide a measure of the physiological parameter.
According to one described preferred embodiment, the annular region of the finger or toe is contiguous to the distal tip.
Another embodiment is described, however, wherein the annular region of the finger or toe is spaced from the distal tip by an intermediate annular region as described in U.S. Pat. No. 6,488,633. In this case, the venous occlusion device includes a third section between the first and second sections. The third section includes a third fluid chamber enclosing the annular region of the finger or toe between the first and second regions; and the third fluid chamber is pressurized to the same pressure as the first fluid chamber.
According to yet another aspect of the present invention there is provided apparatus for non-invasively measuring a physiological parameter of a subject, comprising: a venous occlusion device including a first section having a first fluid chamber to engage a first region of the body part, and a second section having a second fluid chamber to engage a second region of the body part, proximally located to the first region at the site thereof facing the heart of the subject; a pressurizing system for pressurizing the first fluid chamber to a pressure below the venous occlusion pressure but sufficient to compensate for the sum of the inherent venous pressure and hydrostatic pressure within the veins due to the vertical level of the body part with respect to the subject's heart level; and a control system for intermittently raising and lowering the pressure in the second fluid chamber to a pressure above or equal to the pressure in the first chamber but below the arterial blood pressure, for measuring changes in volume of the first region of the body part, and for utilizing the measured volume changes to provide a measure of the physiological parameter.
Further features and advantages of the invention will be apparent from the description below.
The invention is herein described, by way of example only, with reference to the accompanying drawings, wherein:
a-1c include waveforms illustrating the basic venous occlusion plethysmography (VOP) process for measuring volumetric blood flow (BF) and venous capacitance or compliance; whereas
a illustrates an inherent drawback of the conventional VOP measurement systems presently in use in that in the absence of an appropriate level of externally applied counter pressure, the venous filling of the monitored site, e.g. a finger or toe, is progressively increased as the monitored site (arm or leg) is vertically lowered with respect to heart level. In contrast,
a and 4b are diagrams, corresponding to those of
and
It is to be understood that the foregoing drawings, and the description below, are provided primarily for purposes of facilitating understanding the conceptual aspects of the invention and possible embodiments thereof, including what is presently considered to be a preferred embodiment. In the interest of clarity and brevity, no attempt is made to provide more details than necessary to enable one skilled in the art, using routine skill and design, to understand and practice the described invention. It is to be further understood that the embodiments described are for purposes of example only, and that the invention is capable of being embodied in other forms and applications than described herein.
As briefly described above, the VOP method for measuring a physiological parameter of a subject is based on applying to the circumference of a body region of the subject a venous occlusion device; intermittently raising and lowering the pressure to cause intermittent venous occlusion, the magnitude of the venous occlusion pressure being below the arterial pressure; and measuring changes in volume of the body region distal or upstream (away from the heart) of the body region whose veins are occluded by the occlusion device to provide a measure of the physiological parameter. This process is illustrated in
Thus, when the venous occlusion pressure is intermittently raised by the occlusion device (
Generally speaking, the measured changes in volume are determined by measuring the volume change at some given pulsewave landmark over at least a single pulse cycle.
In practice, rate of change of the accumulated blood volume is determined by measuring the volume change at some given pulsewave landmark over a number of pulse cycles. Examples of appropriate pulse wave landmarks include the systolic peak, the foot of the pulse upstroke, the incisuria or dichrotic notch, and others. To allow for pulse to pulse volume change variability, it is common practice to determine a linear regression model line of best fit to optimally determine the volume changes for a multiplicity of pulse signals. The change of volume over time described by such a line of best fit represents the blood flow rate.
As shown in
As further described above, because of the hydrostatic pressure complement added to the venous pressure according to the vertical level of the measuring site with respect to the heart, the conventional VOP measurements have been limited to measurement of sites above the heart level.
As will be described more particularly below, according to the present invention the venous occlusion plethysmographic device is used, among other functions, to apply a pressure to the measurement site which counterbalances the combined inherent venous pressure plus the hydrostatic venous pressure at a given measurement site. This avoids venous distension due to the measurement site being below heart level, and depending on the level of pressure applied, thereby enables the VOP measurement method to be used at body regions at any level with respect to the heart level.
Thus, the apparatus illustrated in
The two chambers C1, C2 are connected via tubes 15 and 16, respectively, to a fluid pressurizing system 17, which is controlled by a pressure control system 18.
Volume measuring system 19 measures volume changes within chamber C1, and thereby volume changes within the distal tip of the finger enclosed by the chamber, during the pressurizing of the two chambers C1, C2, as described below. Volume measuring system 19 also processes those volume changes in the manner described below, to thereby produce a measurement of the desired physiological parameter, e.g. volumetric blood flow, as described above with respect to
The apparatus illustrated in
First, chambers C1 and C2 are pressurized to a pressure P at least sufficient to compensate for the inherent venous pressure added to the maximal hydrostatic pressure due to the maximal possible vertical displacement of the body part with respect to the subject's heart level. For example, if the body part is the subject's finger, chambers C1 and C2 would be pressurized by pressurizing system 17 to apply, over the entire surface of the finger contained within the probe, a uniform pressure field (P) sufficient to compensate for the maximal hydrostatic pressure added to the venous pressure at any vertical level of the finger tip.
Pressuring system 17 is then controlled by pressure control system 18 to intermittently raise and lower the pressure (P) within chamber C2 by a pressure increment (ΔP) sufficient to produce the venous occlusion but below the arterial blood pressure, and then to reduce the pressure back to the constant pressure level (P) in C1 as described above. As this is done, the changes in volume within chamber C1, and thereby within the distal region of the subject's finger enclosed by chamber C1, are measured by volume measuring system 19. Volume measuring system 19 also processes the measured volume changes within fluid chamber C1 to provide a measurement of the particular physiological parameter desired to be measured.
a-i c illustrate how the volume changes are measured and processed in order to produce a measurement of the quantitative blood flow. Thus,
The PAT probe illustrated in
The above-described PAT probe is ideally suited for performing VOP type measurements at any level of elevation relative to heart level since it is specifically designed to be able to apply a uniform pressure field over the entire surface of the body part under study, including its distal-most end (e.g. the distal tip of the finger in the above-described example) while remaining firmly attached to it. Thus, as shown in
The consequences of the presence and absence of hydrostatic pressure induced venous distensions on the compliance of the veins is illustrated in
a, 3b illustrate the points of intra-venous pressure and volume along the venous compliance curve at various levels of displacement of the measurement site with respect to the heart level. Here it can be seen that in the absence of external counter pressure applied by the probe (
Similarly, when an incremental pressure is applied to the proximal venous occlusion cuff (as shown in
a shows that when venous occlusion pressure is applied to a system that does not have enough pressure to counterbalance the intra-venous pressure level, the added volume will be dependent on the beginning position on the venous compliance curve, since less venous volume change occurs for a given venous pressure change as compliance is reduced. If however a sufficient level of probe pressure is applied to counterbalance the overall intra-venous pressure, then added venous distention due to the venous occlusion pressure will cease to be dependent on the level of displacement of the measurement site with respect to heart level. This would therefore facilitate the accurate determination of blood flow irrespective of the measurement site location as demonstrated in
Thus, probe 30 illustrated in
In this case, the two distal chambers C1 and C3 are maintained at a common pressure (P), sufficient to compensate for the maximal hydrostatic pressure due to vertical displacement, added to the inherent venous pressure. The proximal chamber C2 defined by housing section 12 serves, as in the probe of
It will thus be seen than the three-section probe illustrated in
An additional way in which the three compartment design can be used is to provide pressurizing means which would allow all three compartment to be independently pressurized, and to use the first two compartments (i.e. those corresponding to C3 and C2) in
In addition to the fingers or toes, other body regions may also be measured in accordance with any of the above described methods, using PAT probes of two or more compartments, particularly as described in our pending International Application (WO 02/080752) PCT/IL02/00249. The latter application describes the applicability of the multi-compartment probe in the measurement of more extensive body regions such as the upper and lower limbs.
ECG signal may be used for triggering the start of the venous occlusion to a defined point in time relative to the heart cycle.
There are several direct applications for which improved BF measurements in accordance with the present invention would be very useful;
A) In general research/clinical research spheres, BF determination without restriction of the vertical displacement of a finger or another body part being measured, would facilitate the study of the effect of drugs, in particular those with vasoactive effects, or any other interventions, as well as being particularly useful for measuring blood flow during natural orthostasis, tilt testing procedures, etc., in which the body undergoes changes in its orientation with respect to gravity.
B) During testing of endothelial function as described in our earlier U.S. Pat. No. 6,939,304, measuring BF immediately following blood flow occlusion could provide an objective index of the size of the acute peak hyperemic level. This would for example help normalize the subsequent post ischemic PAT response. Determining pre-occlusion BF, and the relative change following occlusion could also be useful to this end. Such evaluations would also be useful in relation to other stimuli for eliciting endothelial activity which are known to the art such as the intra-arterial injection of acetylcholine.
C) By monitoring both PAT signal amplitude and BF as determined in the above described manner, the predominant site of vascular responses (terminal versus more central) could be determined. This would be based on the concurrently measured relative changes of these two parameters since BF increase represents a reduction in the resistance of the smaller resistance vessels, whereas an increase in PAT signal amplitude at fixed level of BF represents a reduction in the resistance of the larger more central conducting vessels. If for example the relative increase in the PAT signal is greater than that of the BF, then it may concluded that the vascular effect was predominant in larger more central vessels, and vice-versa,
D) This method could be used to provide on-line feed back of the level of venous distention, thereby enabling the measurement system to be potentially able to avoid reaching a state of venous over-distention.
E) Combining PAT signal measurements and periodic BF measurements during the pre and post occlusion periods could be used to more comprehensively define the degree and nature of the induced vascular response.
F) Measurement of the tissue volume of the tissue mass from which the VOP is being measured may also be used to provide a blood flow rate measurement relative to the tissue mass, thus providing measurement values expressed as volume per unit tissue volume per unit time. Tissue mass and absolute volume can be measured in accordance with known techniques or those described in our pending International Application WO 2004/041079. The volumetric calibration of blood flow and of tissue volume will facilitate the accurate determination of blood flow in units of volume per time per unit tissue volume. Likewise the venous capacitance can be expressed in units of percentage change of the tissue volume.
The blood flow measurements may also be used in relation to the testing of reactive hyperemia in general, and reactive hyperemia in specific relation to endothelial function measurements.
Similarly, provided that sufficient time is allowed for the veins to reach a state of complete filling, venous capacity measurements may also be derived in relation to the testing of reactive hyperemia, as can be appreciated from Panels A and B in
Of special note, it may be further appreciated that an artifact associated with the mechanical perturbation due to the initiation of the venous occlusion process is apparent in all of the individual measurements. This transient change is a known phenomenon associated with VOP measurements. For calculating blood flow, this part of the signal is simply avoided and the calculation of blood flow is based on the signal following it.
With regard to the cumulative volume calculation, the artifact may be avoided by measuring the volume change occurring during the transition between a state of complete venous filling and subsequent venous emptying after the venous occlusion has been removed. This was illustrated in
It is to be noted that the measurements of peripheral arterial tone and of the blood flow were all derived from the same probe, wherein the pressure of the compartment nearest the heart was intermittently varied as shown in
Panel C of
Alternative ways of correcting for the extraneous influences which affect both control and test sites (not shown here), include subtracting the corresponding control value from that of the stimulated site. This may further be done by using absolute blood flow rate values, or by using blood flow rate values which are relative to their respective initial baselines.
While the general principles described herein have been illustrated with examples based on finger probe measurements, it will be understood that many other types of plethysmographic devices, such as those described in our above-cited International application published as International Publication No. WO 02/080752, can be used, and measurements can be made from a wide range of body sites as further described in that application.
The invention can be implemented in methods and apparatus for measuring a wide variety of physiological parameters with respect to a finger another body part without restriction of the vertical displacement relative to heart level, including: blood flow rate relative to tissue volume; venous capacity at a given pressure level; and venous capacity expressed as a percentage of the tissue volume per unit pressure. The invention may also be used: to facilitate the study of the effect of drugs, in particular those with vasoactive effects; to facilitate the study of blood flow during natural orthostasis, tilt testing procedures, or where the body undergoes changes in its orientation with respect to gravity; and in conjunction with a study of an eliciting stimulus to measure endothelial function. For example, a comparison may be made of blood flow before and after application of an eliciting stimulus such as a period of blood flow occlusion, to provide an objective index of the magnitude of the vascular response to the endothelial eliciting stimulus.
The invention may also be implemented in apparatus where measurements of peripheral arterial tone and blood flow are derived from the same probe, or wherein measurements of peripheral arterial tone and venous capacity are derived from the same probe.
Other possible applications of the invention include those wherein one probe is applied to a body location to receive a vasoactive stimulus, one probe is applied to a homologous or paired body part not to receive a vasoactive stimulus, and respective changes in the blood flow or venous capacity are used to compensate for spontaneous short-term shifts in the blood flow or venous capacity of local or systemic origin. The homologous or paired body parts receiving or not receiving the vasoactive stimulus for measuring respective changes in the blood flow or venous capacity therein could be corresponding fingers of opposite sided hands, or paired fingers, or toes of a hand or a foot when a test is performed on one of the fingers but not on the other. The changes in the blood flow or venous capacity in the body location to receive a vasoactive stimulus may be expressed as a function of the changes in the blood flow or venous capacity in the body location not to receive a vasoactive stimulus, to compensate for spontaneous short-term shifts in the blood flow or venous capacity of local or systemic origin.
The invention could also use comparative changes of peripheral arterial tone and blood flow to determine the predominant site of vascular responses, or to provide on-line feed-back of the level of venous distention to avoid reaching a state of venous over-distention. The comparison of blood flow before and after application of the eliciting stimulus may be expressed as an absolute difference, or as a relative change of the post-occlusion value to the baseline flow.
It will be appreciated, therefore, that the preferred embodiments of the invention described herein are set forth merely for purposes of example, and that many other variations, modifications and applications of the invention may be made.
| Filing Document | Filing Date | Country | Kind | 371c Date |
|---|---|---|---|---|
| PCT/IL05/00993 | 9/15/2005 | WO | 3/13/2007 |
| Number | Date | Country | |
|---|---|---|---|
| 60609813 | Sep 2004 | US |
