Patent Application
20230364366
Emergency advanced airway management is a challenging, multifaceted, and often high-stress procedure, typically performed on patients in a serious and often life-threatening medical condition. One very common method of advanced airway management, particularly in emergency situations, is Rapid Sequence Intubation (RSI), which involves administration of specific medications to rapidly establish favorable conditions for attempting to place an advanced airway (such as a tracheal tube). The procedure is common to several different emergency and critical care settings, including prehospital care provided by Emergency Medical Services (EMS), as well as in-hospital care settings such as the Emergency Department (ED) and Intensive Care Unit (ICU). Clinical research has demonstrated that the procedure is associated with a significant risk of severe physiologic complications, due both to the underlying disease severity and physiologic instability of the patients, as well as to the quality with which the procedure is performed. Deviations from procedural best practices, suboptimal clinical decision-making, and care process errors that can threaten patient safety are all known to occur during some proportion of emergency airway management procedures.
Examples of physiologic derangements that may occur during emergent attempts to establish an advanced airway include the development of oxygen desaturation, hypotension, bradycardia, or cardiac arrest. Research reveals that medical providers of all levels sometimes experience delayed or failed recognition of such physiologic derangements as they are occurring, and may also experience other manifestations of diminished situational awareness in the stress of the moment, such as a failure to accurately perceive time intervals. The potential for harm from a sub-optimally performed procedure, combined with the care process and cognitive process challenges associated with the stressful situations in which the procedure may need to be performed (potentially contributing to procedural errors and increased risk to patient safety) highlight the need for improved systems and methods for monitoring, auditing, and debriefing the emergency advanced airway management care process, and for summarizing important details of the physiologic response of the patient during the critical phases of such procedures.
Given the complexity and criticality of emergency advanced airway management procedures, particularly when performed in the prehospital environment, such cases may be reviewed or audited after the fact in an attempt to assess care quality, protocol adherence, and the occurrence of adverse events, as well as to attempt to identify quality improvement needs and opportunities. However, currently such reviews/audits are typically focused on review of text documentation captured in the patient care record, which is often documented by the providers that performed the procedure, at some time point after the procedure is complete, and at least partially based on the provider's recollection of what happened during the procedure. This documentation typically includes only sporadic and often questionably-accurate physiologic monitoring values, and by definition does not include any details that the documenting provider was not aware of as the event transpired. It is known from the published literature that chart documentation of critical care procedures, such as rapid sequence intubation, under-reports the incidence of procedural and physiologic complications, and inaccurately captures important details such as time intervals and the magnitude of physiologic derangements associated with the procedure. These inaccuracies in the data collected and its interpretation may prevent recognition of serious errors in the performance of the procedure (or in the performance of immediate post-procedure patient care), and may also preclude identification of important opportunities for improvement of patient care at the level of both the individual provider and the medical system (e.g. EMS agency or hospital department) within which the provider works.
What is desired are improved systems and methods for post-event assessment of an emergency advanced airway management process, such as a rapid sequence intubation, in order to provide more detailed and actionable insights that may be used to further the quality assurance and quality improvement needs of emergency medical personnel and care delivery systems. The following discloses various embodiments for such improved systems and methods, both individually and collectively.
Implementations of the present disclosure will be described with reference to the drawings, in which:
Various implementations described herein relate to techniques for monitoring a patient in an emergency (e.g., a prehospital setting). In emergency settings, rescuers perform rapid sequence intubation (RSI) in order to provide oxygen to a patient that can no longer breathe spontaneously. In particular cases, the rescuer inserts a tube (e.g., an “intubation tube”) into the trachea of the patient, and may connect the tube to a source of oxygenated air. The oxygenated air may be used to inflate the lungs of the patient during the emergency, which can enable the patient's blood, vital organs, and other tissues to remain oxygenated during the emergency. In various cases, the oxygenated air may be supplied manually, via a bag-valve-mask (BVM) operated by the rescuer. In some examples, the oxygenated air is supplied mechanically, via a mechanical ventilation device.
Problems during intubation and subsequent ventilation procedures can have significant impacts on the patient's health. For example, if an RSI procedure is performed but the patient does not in fact receive oxygen due to a problem with the RSI procedure or the subsequent ventilation, then the patient may experience hypoxemia. For example, a misplaced ventilation tube, a leak within a fluid circuit providing oxygenated air to the patient, or a failure to administer enough oxygenated air (e.g., by squeezing the BVM) may cause the patient to become hypoxemic. Hypoxemia, if sufficiently severe, can cause permanent damage to the patient's brain and other vital organs.
It can be very difficult for rescuers to identify problems during RSI or subsequent ventilation. In particular cases, a skilled rescuer who is not distracted with other emergency care procedures, can identify whether a patient is currently receiving sufficient oxygen by monitoring certain physiological parameters, such as a capnograph or photoplethysmograph, or a pulse oximetry value, which may be displayed on a monitor in real-time. However, in real-world emergency situations, rescuers are often distracted by other information relevant to other aspects of the patient's condition. For example, if the patient is experiencing acute respiratory failure in addition to having severe bleeding from an extremity, the rescuer may urgently apply a tourniquet to the extremity, during which the rescuer may be unable to independently review the screen of a monitor-defibrillator in order to determine whether the patient is also being sufficiently ventilated to avoid hypoxemia.
Furthermore, real-time physiological parameters do not adequately show whether a patient is about to, or currently, experiencing a hypoxemic injury. A patient, for instance, may temporarily have a low blood oxygen saturation (SpO2), without necessarily experiencing hypoxic injury. However, if the patient has a low blood oxygen saturation for an extended period of time, the accumulated hypoxemic injury experienced by the patient may be irreversible. Therefore, in order to monitor hypoxemia, and to understand the full potential for injury from hypoxemia, physiological parameters must be monitored and analyzed over an extended period of time. Such long-term monitoring corresponding to an accumulated hypoxemic injury is not feasible, particularly for many rescuers in high-stress emergency settings.
These and other problems are addressed in this disclosure. In various implementations of the present disclosure, an index is calculated based on one or more physiological parameters of a subject over time. For instance, an index may be calculated by integrating a physiological parameter over time. Various indices are described herein, including a hypoxemia dose index, a ventilation abnormality index, and the like.
Notably, in emergency settings, an index that monitors a physiological parameter over an unbounded time period may inadequately show a condition of the patient. For example, a medical device that monitors a parameter detected by a sensor before the sensor is coupled to the patient may estimate the patient's condition inaccurately. If an index is calculated based on a sensor reading that occurs before the patient is intubated, then the index may be an inaccurate estimation of the patient's condition. The index may accurately represent the condition of the patient, for instance, if it is calculated based on physiological parameters detected during a limited time interval that is relevant to the patient's care and condition. However, it can be challenging for a rescuer to manually keep track of relevant time intervals, particularly in complex emergency medical environments.
In various implementations of the present disclosure, these and other problems are addressed by calculating the index specifically based on sensor readings detected during a particular time interval. The index, for instance, is independent of the physiological parameter detected before or after that time interval. In some examples, the time interval begins when an RSI procedure is performed. For instance, the time interval may begin when the patient is administered a paralytic, a sedative, or other medication that prevents the patient from spontaneously breathing. By limiting the index to the time interval, the index may more accurately portray the condition of the patient.
Described herein are methods and systems for generating and using a post-event airway management report, incorporating specific Figures of Merit intended to better identify and quantify the quality with which an advanced airway management procedure was performed, as well as the patient's physiologic status and response to the procedure. As mentioned, emergency advanced airway management is a challenging, multifaceted, and often high-stress procedure, typically performed on patients in a serious and often life-threatening medical condition. The potential for harm from a sub-optimally performed procedure, combined with the care process and cognitive process challenges associated with the stressful situations in which the procedure may need to be performed (potentially contributing to procedural errors and increased risk to patient safety), highlight the need for improved systems and methods for monitoring, auditing, and debriefing the emergency advanced airway management care process, and for summarizing important details of the physiologic response of the patient during the critical phases of such procedures.
In some embodiments, the systems, apparatuses, and methods disclosed herein are directed to the collection and analysis of data related to a patient during an emergency advanced airway management process. The collected data may be obtained using various types of sensors, with the data collection process being managed or coordinated by a suitable system, such as a combination monitor-defibrillator. The monitor-defibrillator (alone or in combination with other system elements, such as a wired or wireless communications capability, a processor, data storage, etc.) may include a capability to process some or all of the acquired data, and in response to generate a summary report containing one or more figures-of-merit that may be of assistance in evaluating the airway management process. In some embodiments, the Figures of Merit (FOM) referred to or described herein may be considered: (1) the % of a time interval of specific and critical clinical significance where specific criteria (of either signals from one or more sensors, or parameters derived from those signals) are met, (2) a representation of the distribution of signal characteristics or parameter values within that time interval of specific and critical clinical significance, or (3) the minimum or maximum value, or maximum percent change, of a physiologic parameter measured during the time interval of specific and critical clinical significance.
In one or more embodiments, a summary report is disclosed herein that is generated at the end of a patient care event in which an airway management procedure was performed. In some cases, the care event includes an advanced airway procedure such as rapid sequence intubation (RSI) and positive pressure ventilation, performed on a patient not currently in cardiac arrest, and not receiving cardiopulmonary resuscitation (CPR). In some embodiments, the summary report graphically depicts physiologic trend data from multiple monitoring parameters (e.g. Heart Rate, Arterial Oxygen Saturation, Cerebral Oxygen Saturation, Respiration/Ventilation Rate, End-tidal CO2, Blood Pressure, etc.), as recorded by a multi-parameter physiologic monitor, which may be a combined monitor-defibrillator.
As mentioned, given the complexity and criticality of emergency advanced airway management procedures, particularly when performed in the prehospital environment, such cases may be reviewed or audited after the fact in an attempt to assess care quality, protocol adherence, and the occurrence of adverse events, as well as to attempt to identify quality improvement needs and opportunities. Further, currently such reviews/audits are focused on review of text documentation captured in the patient care record, which is often documented by the providers that performed the procedure, at some time point after the procedure is complete, and at least partially based on the provider's recollection of what happened during the procedure. This documentation by definition does not include any details that the documenting provider was not aware of as the event transpired, even though such details may be of great significance in determining whether the procedure was performed optimally, and whether the patient's physiologic responses to the procedure were indicative of actual harm or “near miss” patient safety threats. These inaccuracies and omissions in the data collected and its interpretation may prevent recognition of errors in the emergency advanced airway management process, and may also preclude identification of important opportunities for improvement of patient care at the level of both the individual provider and the medical system (e.g. EMS agency or hospital department) within which the provider on other patients or in post-procedure patient care.
Thus, in some embodiments, the systems, apparatuses, and methods disclosed herein are directed to the improvement of emergency treatment for a patient. Further, the disclosed embodiments are also directed to the auditing review, risk management, continuum of care, training and/or evaluation of emergency rescuers. In this regard, the evaluation of the sensor data for one or for an aggregation of patients may indicate that a change in the care process is needed or would be an improvement.
In some embodiments, the systems, apparatuses, and methods disclosed herein are directed to the collection and analysis of data related to a patient during an emergency advanced airway management process. The collected data may be obtained using various types of sensors, with the data collection process being managed or coordinated by a suitable system, such as a combination monitor-defibrillator. The monitor-defibrillator (alone or in combination with other system elements, such as a wired or wireless communications capability, a processor, data storage, etc.) may include a capability to process some or all of the acquired data, and in response to generate a summary report containing one or more figures-of-merit that may be of assistance in evaluating the airway management process. In general, the Figures of Merit (FOM) referred to or described herein may be considered: (1) the % of a time interval of specific and critical clinical significance where specific criteria (of either signals from one or more sensors, or parameters derived from those signals) are met, (2) a representation of the distribution of signal characteristics or parameter values within that time interval of specific and critical clinical significance or (3) the minimum or maximum value, or the maximum percent change, of a physiologic parameter measured during the time interval of specific and critical clinical significance.
In one or more embodiments, the report depicts trend data for the entire interval that data are available, and for any and all of the monitored parameters. Typically for patient care events where an emergency advanced airway management procedure is performed, monitoring is performed (and thus recorded monitoring data are available) for all or a substantial portion of the time that a medical provider or team is attending to the patient, whereas the emergency airway management procedure itself (and thus its inherent physiologic hazards and the associated quality-of-care insights) only occupies a portion of the entire interval from which physiologic monitoring data are available. Thus in some embodiments, the report also includes one or more figures-of-merit (FOM), derived from one (or more) of the monitored parameters, and measured over a specific subset of the overall interval that the constituent parameter(s) contributing to the figure-of-merit were monitored. This sub-interval represents the portion of patient care process associated specifically with one or more stages of the emergency airway management procedure.
Options for determining/selecting the pertinent sub-interval include, but are not limited to, a software process automatically determining a relevant sub-interval or a user of the report software identifying one or more key time points from the process-of-care. In accordance with one or more rules, heuristics, or algorithms, a software process may automatically determine this sub-interval via utilization of one or more time-stamped process-of-care event markers recorded automatically by the monitor (or another communicatively-coupled device), or documented by a provider using a feature (such as an event marking feature) on the monitor (or on another communicatively-coupled electronic device). Examples of possible communicatively-coupled electronic devices include an electronic patient care reporting tablet, a smartphone app, a video laryngoscope, a ventilator, an IV infusion pump, and a computer-assisted dispatch system that tracks the status and/or location of an EMS response vehicle such as an ambulance. Alternately, a user of the report software may identify and demark this sub-interval within the report software based upon pertinent information available to them during the post-event review of the patient care event. Examples of such pertinent information may be a paper or electronic copy of a patient care report, or audio or video recordings of the patient care event which can be reviewed to determine the key process of care time points.
The time point(s) used to define the sub-interval generally consist of discrete events that occur a single time during the process of managing a patient's airway within a given patient encounter, and thus represent “boundaries” that distinguish critical stages of the emergency airway management process and that separate these stages from other portions of the overall patient care event, including portions not directly associated with the emergency advanced airway management procedure. Examples of such time points, in the context of an emergency advanced airway management procedure such as RSI, include, but are not limited to: induction of anesthesia (i.e. administration of the anesthesia medications), initiation of laryngoscopy, successful placement of the advanced airway, and hand-off of the patient to the next care location and/or team (e.g. EMS hand-off of the patient to the ED, or ED hand-off of the patient to the ICU). Note thus that these time points are not arbitrarily specified by a user, but rather are tied to specific key events within an emergency airway management process. Note also that with respect to providing insight into the quality of the airway management process, information (e.g., certain vital signs values, or derived metrics) may be of no particular significance on one side of the time point “boundary”, and of high (or relatively higher) significance on the other side of the “boundary”. Note also that the reliability, accuracy, or interpretation of the measured parameters may vary across the boundary due to one or more of several possible reasons; these reasons may include sensor or measurement device operating conditions, patient condition, relevance of parameter to patient condition, etc.
In some embodiments, the systems and methods described herein may be used to collect data prior to, during, and in some cases after the performance of an emergency advanced airway management procedure on a patient. In a typical scenario (although not in all cases where an embodiment may be used), a patient is being treated using a multi-parameter monitor-defibrillator of the type described with reference to
In some embodiments, the figures-of-merit (FOM), derived from one (or more) of the monitored parameters, and measured over a specific subset of the overall interval that the constituent parameter(s) contributing to the figure-of-merit were monitored may be presented to a service provider during the provision of a medical service. For example, in some embodiments, a ventilation abnormality index or hypoxemia dose index (both of which are described in greater detail herein) may be calculated or derived as a FOM and updated continuously or regularly during the provision of a medical service. This information may be used to provide a service provider with feedback regarding the patient condition or effectiveness of the medical service while the service is being provided. In response, the service provider may alter the care process, such as by introducing additional medication or performing a different procedure.
As shown in the figure, a portable multi-parameter monitor-defibrillator 100 has been brought close to the person 82. ECG electrodes 105-108 have been applied to the skin on each of the arms and legs of person 82, and ECG wires 101-104 connect those electrodes to the monitor-defibrillator 100, allowing the monitor-defibrillator 100 to monitor the person's ECG (electrocardiogram). Note that the number of ECG electrodes and associated wires utilized may vary, but typically will involve at least four ECG electrodes and associated wires. A pulse oximetry sensor 111 has been placed on a finger of person 82, and connected to the monitor-defibrillator via a cable 110, allowing pulse oximetry monitoring (monitoring of the oxygen saturation and pulse rate of person 82). Note that in other examples the pulse oximetry sensor could be placed on other parts of the body, such as the ear, forehead, nose, toe, etc. A non-invasive blood pressure (NIBP) cuff 121 has been attached to the arm of person 82, connected by tubing 120 to the monitor-defibrillator 100, allowing measurement of the blood pressure of person 82. Note that in other examples, the NIBP sensor may be of varying size and construction, and may be placed on other parts of the body, such as a wrist or finger. A capnography gas sampling adaptor 131 has been attached to the airway of person 82, connected by tubing 130 to the monitor-defibrillator 100, allowing measurement of capnography parameters such as end-tidal carbon dioxide concentration (EtCO2) along with breath rate or respiratory rate (RR). Note that in other examples the capnography gas sampling adaptor may instead be a capnography sensor, and the connecting tubing may instead be a connecting cable. In other words, capnography monitoring may be performed via either a “sidestream” or a “mainstream” approach; these two alternatives are familiar to those skilled in the art of capnography. Also the gas sampling adaptor or sensor may be attached in various ways to the patient's airway, depending on what airway device or management strategy is being utilized at a given time point during the patient care process. For example, the capnography adaptor/sensor could be attached between a manual resuscitation bag and a face mask, or between a manual resuscitation bag and a tracheal tube or supraglottic airway.
Note that the medical device 100 can be one of different types, each with a different set of features and capabilities. The set of capabilities of the device 100 is determined by planning who would use it, and the specific device capabilities those medical providers would be likely to require.
A first type of device 100 is generally called a defibrillator-monitor because it is typically formed as a single defibrillation unit in combination with a patient physiologic monitor. A defibrillator-monitor is sometimes called a monitor-defibrillator. A defibrillator-monitor is intended to be used in a pre-hospital or hospital setting, by persons in the medical professions, such as doctors, nurses, paramedics, emergency medical technicians, etc.
As a patient monitor, the device 100 has features additional to what is needed for operation as a defibrillator. These features can be for monitoring physiological indicators of a person in an emergency scenario. These physiological indicators are typically monitored as signals. For example, these signals can include a person's ECG (electrocardiogram) signal or impedance between two electrodes. Additionally, these signals can relate to the person's temperature, non-invasive blood pressure (NIBP), arterial oxygen saturation/pulse oximetry (SpO2), the concentration or partial pressure of carbon dioxide in the respiratory gases (known as capnography), and so on. These signals can be further stored and/or transmitted as patient data.
A second type of device 100 could be a physiologic monitor without any defibrillation capability. Such a device is often called a multi-parameter monitor or just called a monitor, and provides features for monitoring physiologic indicators as described above.
The monitor-defibrillator 300 will typically have several additional ports for purposes of collecting physiologic signals and measurements from a patient. These ports may include an ECG port 319, into which are plugged ECG leads, such as elements 101-104 of
The monitor-defibrillator 300 also typically includes a processor or processing element 330 (such as a central processing unit (CPU), controller, etc.) that may be implemented in a number of ways. Such ways include, by way of example and not limitation, digital and/or analog processors such as microprocessors and digital-signal processors (DSPs); controllers such as microcontrollers; computer-executable software being executed by a processor, apparatus or device; programmable circuits such as Field Programmable Gate Arrays (FPGAs), Field-Programmable Analog Arrays (FPAAs), Programmable Logic Devices (PLDs), Application Specific Integrated Circuits (ASICs), or any combination of one or more of these, etc.
The processor 330 can include a number of modules or elements, and may access a number of sets of software instructions that when executed, are used to implement particular functions, methods, processes, or operations. The set or sets of software instructions may be stored in a suitable non-transitory data storage medium, where non-transitory refers to a data or other form of storage medium other than a transitory waveform or similar medium. The processor receives information from various components or elements of the monitor-defibrillator, including from ports 310, 319, 321, 322, 323, and 324.
Monitor-defibrillator 300 optionally further includes a memory 338, which can work together with the processor 330. The memory 338 may be implemented in any number of ways. Such ways include, by way of example and not of limitation, nonvolatile memories (NVM), read-only memories (ROM), random access memories (RAM), any combination of these, and so on. The memory 338, if provided, can include programs or instruction sets to be executed by the processor 330, and so on. In addition, the memory 338 can store prompts for the user 380 and can store patient physiologic monitoring data, event data, and device status data, as needed.
The monitor-defibrillator 300 may also include a power source 340. To enable portability of the monitor-defibrillator 300, the power source 340 typically includes a battery. Such a battery can be implemented as a battery pack, which may be rechargeable or not. Sometimes, a combination is used, of rechargeable and non-rechargeable battery packs. Other embodiments of power source 340 can include AC power override that allows a rescuer to use AC power when such a source exists, but rely on the battery power if AC power is unavailable. In some embodiments, the power source 340 is controlled by the processor 330.
The monitor-defibrillator 300 further includes a user interface 370 for the user 380. For example, the interface 370 may include a screen to display physiologic monitoring waveforms and associated vital signs values, device status information, and data entry or device configuration windows, sub-displays, data entry fields, etc. The interface 370 may also include a speaker to issue voice prompts, alarms, audible alerts or otherwise audibly interact with the user and may additionally include various controls, such as pushbuttons, keyboards, and so on, as needed or desired.
The monitor-defibrillator 300 can optionally include other components. For example, a communication module 390 may be provided for communicating with other systems, networks, or devices. Such communication can be performed wirelessly (such as by WiFi or Bluetooth), via a wired connection, or by infrared communication, and so on. This way, data can be communicated, such as patient data, device usage and actions data, physiologic monitoring data, incident information, therapy attempted, CPR performance, and the like.
In general, the monitor-defibrillator 300 and/or associated components may include the ability to be networked with other devices, components, or systems used to monitor patient medical characteristics, provide patient-related data to medical professionals, generate graphs, images, or videos of a patient's measured characteristics, control data acquisition from sensors, and assist in diagnosing a patient's condition and applying the appropriate services or treatments. The “networking” may be the result of monitor-defibrillator 300 being capable of communications and/or data transfer with other devices, components, or systems over a wired and/or wireless network connection, using any suitable technology, mechanism, or protocols. For example, such technology, mechanism, or protocols may include (but are not limited to, or required to include) WiFi, Bluetooth, NFC, HTTP/TPC, etc. The systems or components that monitor-defibrillator 300 interacts with may include (but are not limited to, or required to include) other monitors, video laryngoscopes, ventilators, infusion pumps, electronic patient care documentation devices, printers, displays, communication devices, other processors, servers, etc.
Further, due to the ability to collect data from one or more sensors, various advanced data processing and analysis techniques may be used to process sensor data and to assist in diagnosing and treating a patient. For example, machine learning, statistical analysis, pattern matching, and other forms of data analysis may be used to derive useful information about a patient or their treatment from the collected data. In some cases, data collected from a set of patients or patient events may be used (typically in an anonymized, patient identification protected, or encrypted form) to evaluate the factors that are believed to be associated with a specific patient state or condition. For example, this may be useful in identifying previously unrecognized factors that are present when a patient undergoes a certain type of event or treatment.
In some embodiments, a monitor-defibrillator of the type described with reference to
To perform a review or audit of the patient encounter, and specifically, the advanced airway management component of the patient encounter, an individual associated with the EMS agency, such as the EMS medical director, a clinical supervisor or preceptor, or the EMS personnel who performed the emergency airway management procedure themselves, would typically access a downloaded monitor-defibrillator data file using the post-event data review functions and capabilities of embodiments of the system and methods described herein. The monitor-defibrillator data file may contain various information including: patient physiologic waveforms and vital signs measurements, device status and usage information, event information captured automatically by the device or marked by the device user, information on therapy delivered, audio and video data captured during a patient care event, and data acquired from a separate communicatively-coupled device in use during the patient care event, such as a video laryngoscope, a point-of-care ultrasound system, and IV infusion pump, or a ventilator.
The monitor-defibrillator data file may be transferred to various types of destinations, such as a computer, smartphone, electronic tablet, or website, for purposes of generating Figures of Merit and an Airway Management Report. In some embodiments, the post-event data review (incorporating the Airway Management Report and associated Figures of Merit of the present invention) may occur directly on the monitor-defibrillator itself, at the conclusion of the procedure or at the end of the patient care encounter, without any need to download or transmit the data to a remote location. In yet other embodiments, the post-event data review may occur on any communicatively coupled electronic device display, at any point in time after the conclusion of the procedure, with data from the monitor-defibrillator transmitted to a remote location (such as a cloud data storage and processing location) and with derived Figures of Merit and additional Airway Management Report content then transmitted to the communicatively coupled electronic device display.
With reference to
Examples of physiologic trend data may include: heart rate (HR), pulse rate (PR), arterial blood oxygen saturation (SpO2), breath rate (RR) (also known as respiratory rate or ventilation rate, depending on the source of the breaths), end-tidal carbon dioxide level (EtCO2), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP). Additional examples of trend data may include: regional tissue oxygen saturation (rSO2), ventilation tidal volume, ventilation airway pressure, or end-tidal oxygen level (EtO2).
In one embodiment, this physiologic trend data is collected during the course of a patient care event in which a Rapid Sequence Intubation (RSI) procedure was performed. In this context, RSI refers both to traditional RSI as well as variations on the procedure that have been given various names (e.g., Delayed Sequence Intubation, Rapid Sequence Airway, etc.) that all share the common characteristics of (1) one or more medications are administered to a patient to induce anesthesia, (2) an invasive airway device (e.g. tracheal tube, supraglottic airway) is placed in the patient's airway, and (3) positive pressure ventilation is subsequently provided to the patient.
As suggested by step or stage 204, next, a pertinent sub-interval of the collected data from which to derive one or more Figures of Merit (FOM) is identified. This sub-interval identification may be performed by any suitable method or process; options for determining/selecting the pertinent sub-interval include, but are not limited to, a software process automatically determining a relevant sub-interval based upon the data contained in the monitor-defibrillator memory or data file, or a user of the report software identifying one or more key time points from the process-of-care based upon information in the monitor-defibrillator data file, or in other available event documentation. These time points used to define the sub-interval generally consist of discrete events that occur a single time during the process of managing a patient's airway within an overall patient encounter, and effectively represent “boundaries” that distinguish key stages of the emergency airway management process, and that separate these stages from other portions of the overall patient care event, including portions not directly associated with the emergency advanced airway management procedure. Note thus that these time points are not arbitrarily specified by a user, but rather are tied to specific key events within an emergency airway management process.
Examples of data elements that may be available in the monitor-defibrillator memory or data file, and that may help either an automated software process or a user to manually identify such time points, include, but are not limited to: time-stamped event markers (e.g. an “induction medication administered” event) entered into the monitor-defibrillator (and/or entered into a communicatively-coupled device such as an electronic documentation or patient care reporting tablet, a smartphone app, or a different monitor) by a medical provider during the emergency advanced airway management procedure; audio or video data recorded by the monitor-defibrillator or a communicatively-coupled device; time-stamped events associated with changes made by the medical provider to the configuration or mode of the monitor-defibrillator (such as switching the monitor-defibrillator from a mode intended to optimally assist with the process of intubation, to a mode intended to optimally assist with the process of post-intubation ventilation); time-stamped events obtained from, and associated with the use of, another medical device during the patient care event, such as a video laryngoscope, a point-of-care ultrasound system, and IV infusion pump, or a ventilator.
Note also that with respect to providing insight into the quality of the airway management process, information (e.g., certain vital signs values, or derived metrics) may be of no particular significance on one side of the “boundary”, and of high (or relatively higher) significance on the other side of the “boundary”. Note also that the reliability accuracy, or interpretation of the measured parameters may vary across the boundary due to one or more of several possible reasons; these reasons may include sensor or measurement device operating conditions, patient condition, relevance of parameter to patient condition, etc.
In one embodiment, the important/useful process-of-care-related key time points (that typically only occur once each during the process of managing a patient's airway within an overall patient encounter) include at least: (1) induction of anesthesia, and (2) successful placement of the airway device (e.g., an endotracheal tube). A 3rd time point that may be useful specifically for an EMS-performed RSI would be the time of arrival at the emergency department (conclusion of patient transport). Additional time points of potential utility (depending on the medical care setting) may include: time of initiation of patient transport (for an EMS-performed RSI), time of initiation of pre-oxygenation, time of initiation of laryngoscopy, and time of hand-off of the patient to the next care location and/or team.
Next, at step or stage 206, a Figure of Merit may be determined, calculated, generated, etc. As mentioned, the Figures of Merit (FOM) referred to or described herein may be considered: (1) the % of a time interval of specific and critical clinical significance where specific criteria (of either signals from one or more sensors, or parameters derived from those signals) are met, (2) a representation of the distribution of signal characteristics or parameter values within that time interval of specific and critical clinical significance or (3) the minimum or maximum value of a physiologic parameter measured during the time interval of specific and critical clinical significance. In one or more embodiments, the generated summary report depicts trend data for the entire interval that data are available, and for any and all of the monitored parameters. Thus, in some embodiments, the report includes one or more figures-of-merit (FOM), derived from one (or more) of the monitoring parameters, and measured over a specific subset of the overall interval that the constituent parameter(s) contributing to the figure-of-merit were monitored. The purpose/value of the Figures of Merit is that they reflect either: (1) patient stability and/or safety during the specified time interval (which, as noted, may be an interval of specific significance and meaningfulness, because it was derived based on the specific key care process events that define (serve as boundaries for) the important phases of the care process), or (2) an aspect of the quality (e.g. adherence to the clinical protocol, or to generally accepted best practices) with which the procedure was performed.
After calculation or determination of the Figure of Merit, the FOM is displayed, printed, and/or otherwise provided to a medical provider (as suggested by step or stage 208). This presentation may be in the form of a post event report that aggregates multiple FOMs, with optionally additional information such as described in
Examples of medical providers that may be provided with the FOM, and example actions they may consequently take include:
As another example, if a Figure of Merit describing the proportion of time that SpO2 values were below 90% during the critical sub-interval between induction of anesthesia and successful placement of an advanced airway reveals that SpO2 values were below 90% for a significant proportion of that critical sub-interval, then the medical supervisor may then identify that this episode of oxygen desaturation (which may have been unrecognized by the medical provider performing the procedure; published literature indicates that both oxygen desaturation, and provider unawareness of oxygen desaturation, are very common) was a consequence of, for example, inadequate pre-oxygenation duration, inappropriate pre-oxygenation technique, or an inappropriately prolonged intubation attempt. Performance improvement can then be achieved in future procedures by such quality improvement interventions as adjustments to pre-oxygenation strategy, establishing a minimum pre-procedural SpO2 threshold indicative of adequate pre-oxygenation as a requirement to proceed with the procedure, or assigning a different provider to continuously watch the SpO2 values and alert the provider performing the procedure immediately and continuously upon SpO2 falling below 90%.
An important aspect of the Figure(s) of Merit, and what enables them (and thus the overall Airway Management Report) to provide value to a user, is that they are only calculated once a critical sub-interval of significance to the emergency airway management procedure has been defined. This is because outside of this interval (e.g., prior to the induction of anesthesia or a boundary of another critical sub-interval), the Figure(s) of Merit may have an ambiguous meaning or may have no particular relevance to the safety and quality of the emergency airway management care process; it is only within the critical sub-interval that the Figure(s) of Merit have a clear, unambiguous, and clinically valuable meaning related to patient safety and/or to the quality of care in the emergency airway management process.
For example, the oxygen saturation values (or blood pressure values, etc.) prior to the time of induction of anesthesia represent an unknown combination of the patient's presenting state of illness, and initial attempts to treat and stabilize the patient. It is only after the time point at which the medical provider has decided they are going to perform an RSI procedure, and has progressed to the step of induction of anesthesia, that the oxygen saturation values (or blood pressure values, etc.) are unambiguously the responsibility of the medical provider. It is only during the critical sub-interval of the physiologic monitoring data collected from the overall patient encounter, bounded by this time point of induction of anesthesia, that any abnormalities or derangements in the physiologic monitoring values provide clear and direct insight into the quality of the emergency airway management process, and patient safety during that process.
With reference to
With reference to
As stated above, the source waveforms associated with some of the common physiological parameters monitored by a monitor-defibrillator may be compromised during portions of a patient monitoring episode (including during the critical sub-interval associated with the emergency airway management process), leading to potentially unreliable or inaccurate trend values. This can especially occur in the prehospital environment, where environmental variations, movements of the patient and EMS providers, and motion related to the ambulance transport of the patient, can decrease physiologic waveform signal quality and result in periods of inaccurate or less reliable physiologic trend values. Examples of ways in which the waveforms may be compromised, include, but are not limited to:
The ECG waveform is typically the source for heart rate values, and noise (e.g., electrical interference) or an artifact (e.g., an artifact from patient motion or tenuously attached electrodes) in the ECG signal can result in incorrect heart rate values;
The photo-plethysmograph waveform produced by a pulse oximeter is a source for pulse rate values, and also is a component of the information used to derive oxygen saturation (SpO2) values. Poor signal quality in the photo-plethysmograph (e.g., from a poorly placed or attached sensor, patient motion, or poor perfusion to the part of the patient's body where the sensor is placed) can result in the pulse oximeter reporting pulse rate and oxygen saturation values that are unreliable;
The capnography waveform (reflecting the concentration of carbon dioxide measured in the patient's airway continuously throughout the breathing cycle) is the source for end-tidal carbon dioxide (EtCO2) and breathing rate (RR) values. The capnography waveform can be impacted in ways that may make the EtCO2 and/or RR values inaccurate, for example when there is a leak in the airway, or some other cause of dilution of the sampled gas.
With reference to
In an alternate embodiment, the heart rate values during the periods of “low reliability/potential inaccuracy” would still be plotted in the trend graph, but an indication would be provided that those periods are less reliable and potentially inaccurate. Such indication could be by use of almost any common means of distinguishing portions of a line graph—e.g., colors, line style or thickness, shading, labels, etc.
A value of one or more embodiments that include this data qualification step stems from the fact that in the clinical circumstances in which emergency RSI and subsequent ventilation support is performed, environmental and scene conditions are highly variable, and there is frequently a lot of activity with and around the patient. Because of these factors, noisy/artifacted signals in the physiologic monitor are common, resulting in trend data values that are often unreliable or inaccurate for portions of time.
Next, as described with reference to
At step or stage 238, the FOMs are calculated using the qualified physiologic trend values from step or stage 234 (and not the raw values as in the embodiments described with reference to
Note that as suggested by step or stage 242, the portion of time within the interval defined in step 236 which was used to calculate the FOM is reported. For example, if there was noise affecting the ECG signal 10% of the time interval between the “induction of anesthesia” time point and the “arrival at the ED” time point, then heart rate data would be omitted/ignored from that 10% of time, meaning that any FOM incorporating heart rate data (e.g. lowest heart rate during the interval) would have been calculated using heart rate data from 90% of the interval. That 90% value would be reported in association with any ECG-derived FOMs on the Report. In an alternate embodiment, the portion of time excluded (rather than included) in the FOM calculation would be reported (i.e. 10%, in this example). As described with reference to
With reference to
As shown in
Note that the exact time point associated with any of the events that serve as boundaries to define a pertinent sub-interval may not be precisely known. For example, for purposes of generating an Airway Management Report from a specific patient encounter, the information used by the person generating the Report to identify the time at which the “induction of anesthesia” step was performed may be a written (or electronically documented) record of the procedure, and the time stamps used to document events in that record may be quantized to whole minute increments. So for example, the record of the procedure may indicate that “induction of anesthesia” was performed at 11:25 AM, but it was really performed at 11:25 and 34 seconds, with respect to the physiologic waveforms and trend data recorded by the monitor during the patient care event. Thus, there is inevitably a little bit of imprecision in the identification of the event time points used to bound the pertinent sub-interval for purposes of calculating the FOM(s). It should be appreciated that there are other potential sources of time stamp imprecision, depending on the method used to identify the time points for purposes of generating an Airway Management Report. For example, the clock used by the provider performing the procedure to note the time of “induction of anesthesia” may have been a wristwatch that was one minute behind the time on the physiologic monitor. Also, many of these events are not instantaneous actions, but rather an action that takes a certain period of time— e.g. “induction of anesthesia” involves drawing up several medications into syringes, and then administering those to the patient in sequence over a certain short (e.g., one minute) but not instantaneous period of time. In this example, the event time might variously be considered and/or recorded as the beginning of administering the first drug, the conclusion of administering the last drug, etc. This introduces uncertainty into the event times that are noted and hence into the identification of the critical interval(s).
Given the above, it is important to note that a time or time stamp being used to identify a stage of a particular event associated with treating a patient may not be completely accurate in terms of it being precisely the time when the stage or event occurred. Thus, some uncertainty in the accuracy of the times recorded and how they are used may be introduced. Thus, it should be understood that the times and time intervals being used in embodiments of the system and methods described herein may not correspond exactly to those of an actual event or stage of an event or treatment.
As described, in some embodiments, the software modules or processes executed by an electronic processor or processing element as part of the system and methods described herein generates an Airway Management Report, where such report may include, but is not limited to (or required to include), one or more of the following components:
In some embodiments, elements of an embodiment of the Airway Management Report may include:
a depiction or illustration of multi-parameter trend data from a patient care event;
an indication on (or alongside) the trend data of the time point(s) of one or more key events associated with the airway management process that occurred during the patient care event; or
one or more figures-of-merit (FOM) representative of an aspect of one or more of the airway management care process, care quality, or the patient's physiologic response to the airway management care, where the figure(s)-of-merit are derived from a specific sub-interval of the available trend data, with the specific sub-interval demarked by one or more of the indicated key events.
Note that the physiologic trend data may plot trend values as recorded by the monitor-defibrillator, or in some embodiments, the trend data depicted on the report may be (re)derived in the post-event software (or some other computing environment external to the monitor-defibrillator itself) by applying one or more algorithms to either the original trend data recorded by the monitor-defibrillator, or to the raw physiologic waveform data that is the basis for the trend data. Note that a value of re-deriving the trend data in the post-event software is one or more of: improving the accuracy and/or resolution of the trend data; removing noise and artifact(s) from the trend data; or deriving a variation of the monitoring parameter that is more clinically meaningful and actionable than the manner in which the parameter is derived and reported on the monitor-defibrillator itself.
For example, while the monitor-defibrillator may record Heart Rate trend data derived from a monitored ECG lead using an algorithm in the monitor-defibrillator, the Heart Rate data depicted in the trend data component of the post-event report might be derived by a different algorithm in the post-event report software, which may operate to process one or more of the available ECG signals and derive Heart Rate trend data that may differ from the Heart Rate trend data recorded during the event by the monitor-defibrillator. For example, the two types of data might differ because a different, more optimal, ECG lead was used for deriving Heart Rate in the post-event report, or because the ECG lead used for derivation of Heart Rate was dynamically adjusted by the software to always select the most optimal of the available ECG leads, or because a noise filtering/removal algorithm was applied to the ECG by the post-event software, or because an artifact detection algorithm was applied to the ECG by the post-event software, allowing it to suppress/avoid reporting of likely erroneous values during periods of critical artifact.
As another example, while the monitor-defibrillator may record “breath rate” (usually labelled RR for “Respiratory Rate” on monitors), trend data derived from the capnography CO2 waveform, the post-event report could depict a “breath rate” trend with different values than those displayed/recorded on the monitor, where the breath rate trend is derived by an algorithm in the post-event report software that processes the capnography CO2 waveform in a manner different from how the CO2 waveform is processed in the monitor-defibrillator. In this case, the algorithm in the post-event report software might be designed to allow better discrimination between true positive-pressure ventilations provided by the EMS personnel vs. spontaneous breathing efforts initiated by the patient. As a result, the post-event software could report breath rate values closer to the true rate of positive-pressure ventilations that were delivered by the medical provider, ignoring the interspersed spontaneous patient breaths that may also be incorporated into the RR which is reported on the monitor. Thus, the breath rate reported on the post-event report may be lower than the breath rate that was displayed in real time on the monitor, and the post-event breath rate would more specifically reflect the actual ventilation rate performed by the care provider, which is an important aspect of patient safety and care quality associated with the emergency advanced airway management procedure.
Figures-of-Merit (FOM) Derived from a Specific Subset of the Overall Monitoring Time
As recognized by the inventor, a variety of figures-of-merit (FOM(s)), representative of specific critical subsets of the overall time the patient was monitored, would assist in achieving the goal of facilitating improved audit of the airway management care process and the patient's physiologic response to that care. In one embodiment, these figures-of-merit are calculated in the post-event report software, and depicted on the post-event summary report, along with the physiologic trend data from the overall patient encounter. However, it should be appreciated that these figures-of-merit could instead comprise the entirety of the post-event summary report (i.e. without the accompanying trend data from the overall patient encounter), and/or that these figures-of-merit could be calculated and depicted on another computing device, including the monitor-defibrillator itself, or a communicatively-coupled documentation/event recording device such as an ePCR tablet, a smartphone app, etc.
In any of these embodiments, it should be appreciated that a key element of these figures-of-merit is that they are applied to/derived from a specific critical subset of the overall time interval that the patient was attached (via one or more sensors) to the multi-parameter monitor-defibrillator during the patient encounter. A value and importance of this source of a figure-of-merit is that the figure of merit has an unambiguous clinical significance during this defined sub-interval of time, while that same figure of merit may be deceptive and/or have an uncertain meaning with respect to an assessment of the emergency advanced airway management process when applied to a time interval that includes periods of time outside of this specific sub-interval. Note that the specific critical sub-interval is identified and demarked by one or more of the methods described earlier.
Specific examples of figures-of-merit that may be used to achieve the goal of summarizing the process and quality of an emergency advanced airway management procedure, and/or a patient's physiologic response to the airway management process, are listed below. Note that the list is not intended to be exhaustive or to indicate a required figure-of-merit. For each figure-of-merit, the following is described or intended to be a possible presentation of the information or use case:
Hypoxemia occurs during many emergency medical care events, and can result in profound harm to a patient. Due to the time-sensitive and chaotic nature of many emergencies, the true extent of hypoxemia can frequently be under-appreciated—it can last for longer, and achieve greater severity, than emergency care providers often recognize. For example, copious clinical research reveals that hypoxemia during rapid sequence induction of anesthesia and attempted endotracheal intubation is substantially more prevalent than appreciated by the EMS, Emergency Medicine, and Critical Care fields that perform emergency intubation. This lack of awareness, and lack of objective measurement of hypoxemia “dose” not only impacts the immediate patient being cared for, but also inhibits scientific progress in understanding the linkages between physiologic derangements such as hypoxemia early in the course of emergency care, and downstream consequences for patient course-of-care and outcomes.
In the current art, characterization of the depth and/or duration of hypoxemia is common. The concept of measuring the “area under the curve” (AUC) of a hypoxemia event has also been described in several publications. AUC provides a simple product of depth and duration, but it weights each increment of both depth and duration equally. Physiologically, the incremental risk of critical deterioration, and perhaps also overt harm, accumulated between 5 and 10 seconds of hypoxemia, vs. between 50 and 55 seconds of hypoxemia, is far from equivalent. Similarly, the incremental risk/harm posed by a desaturation from 90 to 85, vs. between 70 to 65 is likely not similar. Increases in duration and/or depth of hypoxemia thus have a relationship to patient hazard that is nonlinear over sequential increments of duration and/or depth. As a result, there would be value in an index of hypoxemia “dose” that better reflected the non-linearity of patient hazard associated with progression of hypoxemia in the duration and/or depth dimensions.
In this context, a FOM describing a mathematical index that responds in a non-linear fashion to incremental increases in the duration and/or depth of a hypoxemic episode may be of value. Such an index may be characterized or described by one or more of the following:
Note that in the following examples, the specific values shown represent pre-specified values that are intended to be adjustable/pre-configurable by the user of the post-event software and/or the monitoring device.
Examples include, but are not limited to:
Methods of reporting such a derived parameter as additional context added to the trend display of the source physiologic signal include, for example: shading the affected region of the trend display; changing the color or line thickness of the trend data within the affected region; placing indicator markings on or adjacent to the trend display; or adding a text annotation adjacent to the trend display.
A post-event summary report, automatically generated based on data recorded by a multi-parameter physiologic monitor such as a monitor-defibrillator, from a patient care event that involved positive pressure ventilation, and that depicts trended data from one or more monitored physiologic parameters, including at a minimum trended end-tidal CO2, and that provides a graphical indication (e.g., shading, color, line type, indicator marks, text annotation, etc.) associated with the end-tidal CO2 trend display demarking specific periods of time where the reported end-tidal CO2 values may be erroneously low due to patterns associated with one or more of: airway leak, non-plateauing waveforms, or spontaneous respiratory activity—such patterns being automatically detected by an algorithm in the post-event software, in the monitor that recorded the data, or in an intermediate computing location such as a cloud server;
A post-event summary report, automatically generated based on data recorded by a multi-parameter physiologic monitor such as a monitor-defibrillator, from a patient care event that involved positive pressure ventilation, that depicts trended data from one or more monitored physiologic parameters, including (at a minimum) trended breathing (respiratory/ventilatory) rate, and that provides a graphical indication (e.g., shading, color, line type, indicator marks, text annotation, etc.) associated with the breathing rate trend display demarking specific periods of time where the reported breathing rate values may overestimate the true rate of positive pressure ventilation being provided to the patient due to patterns associated with spontaneous respiratory activity—such patterns automatically detected by an algorithm in the post-event software, in the monitor that recorded the data, or in an intermediate computing location such as a cloud server;
A post-event summary report, automatically generated based on data recorded by a multi-parameter physiologic monitor such as a monitor-defibrillator, from a patient care event that involved positive pressure ventilation, that depicts trended data from one or more monitored physiologic parameters, including at a minimum trended breathing (respiratory/ventilatory) rate, that displays, simultaneously (e.g., superimposed on each other, or adjacent to each other), breathing rate trend data as derived from at least two different physiologic signals—for example CO2 waveform and airway pressure—or at least two different algorithms processing the same physiologic signal—for example “strict” and “tolerant” breath detection algorithms applied to the CO2 waveform, the “strict” algorithm measuring potentially lower breathing rates than the “tolerant” algorithm due to being designed to preferentially trigger on just positive pressure breaths and ignore breaths that are likely due to patient spontaneous respiratory activity;
A post-event summary report, automatically generated based on data recorded by a multi-parameter monitor-defibrillator system, which depicts end-tidal O2 trend data;
A post-event summary report, automatically generated based on data recorded by a multi-parameter physiologic monitor such as a monitor-defibrillator, from a patient care event that involved positive pressure ventilation, that graphically summarizes the distribution of breathing rates measured over a monitoring interval via three or more bins, each bin representing the aggregate absolute or percentage time that the breathing rate was measured to be within a discrete range (e.g., via a histogram);
Example Embodiments of FOMs Provided as Feedback to a Monitor-Defibrillator User During a Patient Care Event
In some embodiments, the previously described FOMs may be displayed as feedback to a medical provider during a patient care event, including during the portion of the patient care event associated with an emergency advanced airway management procedure. The FOMs may be displayed as a text and/or graphical indication, either on the monitor-defibrillator itself, or on any real-time communicatively coupled electronic display, such as a documentation or patient care reporting tablet, a smartphone, a display screen on a video laryngoscope, etc. The FOMs may be calculated based upon the currently elapsed portion of the critical sub-interval of the patient care event associated with the emergency advanced airway management process. In this manner, the FOM would be continuously (or regularly, or semi-continuously) recalculated and the display updated as time elapses during the critical sub-interval. Examples of aforementioned FOMs that may be provided as real-time feedback during a patient care event, and examples of actions that may be taken by the medical provider in response to the FOM feedback, include:
In the context of an emergency airway management process (and specifically the positive-pressure ventilation initiated promptly after the step of successful placement of an airway), the presence of such features provides specific and important insight into the status of the patient and/or the quality with which patient is being managed. Spontaneous respiratory activity during positive pressure ventilation could indicate that a patient requires administration of additional medication, such as a sedative and/or analgesic. In the context of an RSI (or other advanced airway management process involving administration of a paralytic agent), spontaneous respiratory activity indicates that the paralytic effect is wearing off. Knowledge of this development can thus serve, for example, as a valuable passage-of-time indicator for the medical provider, and may represent an indication for administration of additional medication. Airway leak indicates that the breathing circuit or system is not fully “closed”, and the effectiveness of ventilation may be compromised by gasses lost through the leak. Knowledge of the presence of a leak would allow the medical provider to assess the airway equipment and breathing system to find and fix the leak, thereby eliminating a potential cause of ineffective ventilation, and thus enhancing the safety and efficacy of the care they are providing the patient. Most importantly, all of the described features represent a situation where the EtCO2 value measured by and displayed on the monitor-defibrillator may be inaccurately low—a critical situation which if not recognized and accounted for, could lead a medical provider to make incorrect patient care decisions, and provide (or with-hold) treatments (e.g. medications, or a specific degree of ventilation) that risk harming the patient.
The “amount” of each of these features present in the CO2 waveform could be measured and quantified as an incidence or density over time (e.g. how many of the breath waveforms over the current elapsed interval exhibit the abnormal feature). In one embodiment, the “amount” of each of these features present in the CO2 waveform could be measured and quantified as a severity (e.g. an average severity across all pertinent breath waveforms) of the abnormality (e.g., for a given exhalation breath waveform in the CO2 signal, an “area under the curve” between the actual phase III of a breath waveform—also known as the alveolar plateau—and a line extrapolating the course of the plateau if it had not been afflicted with the abnormal feature). In other embodiments, the “amount” of each of these features could be measured and quantified as some combination of the incidence/density over time, and the severity of the abnormality. In yet other embodiments, the ventilation abnormality indicator or index could be measured based on a fixed-duration moving time window (e.g., the most recent 2 minutes) within the critical sub-interval of the patient care event associated with the emergency advanced airway management process. A medical provider being provided with this ventilation abnormality indicator or index would thus have access to real-time insight into aspects of the ongoing airway management/ventilation process that are of potentially critical significance to the quality and/or safety of patient care, and that are not reflected in the standard vital signs (e.g. HR, SpO2, RR, EtCO2, blood pressure).
It is well known from the clinical literature that oxygen desaturation (i.e., development of acute hypoxemia) is common during this critical interval of an emergency advanced airway management procedure, and it is also well known that medical providers commonly are unaware of the desaturation as it is happening. Even when providers are aware that a desaturation is occurring (or has occurred), they frequently remain unaware of clues to a worsening severity of the event (such as changes in Heart Rate or characteristics of the ECG), and they also may not appreciate the additive hazard of a concomitant physiologic insult, such as hypotension. Thus a hypoxemia dose index could be provided to a medical provider during an emergency advanced airway management procedure, providing them with significantly enhanced insight into the presence, severity and evolution of a common and commonly underappreciated physiologic hazard during such procedures. Based upon this hypoxemia dose index FOM, the provider may then take important actions that can impact patient morbidity or mortality, such as termination of a laryngoscopy attempt, or progression to a “failed airway” back-up plan (such as use of a different airway device, or an attempt at a surgical airway).
Each application module or sub-module may correspond to a particular function, method, process, or operation that is implemented by the module or sub-module. Such function, method, process, or operation may include those used to implement one or more aspects of the system and methods described herein.
The application modules and/or sub-modules may include any suitable computer-executable code or set of instructions (e.g., as would be executed by a suitably programmed processor, microprocessor, or CPU), such as computer-executable code corresponding to a programming language. For example, programming language source code may be compiled into computer-executable code. Alternatively, or in addition, the programming language may be an interpreted programming language such as a scripting language. The computer-executable code or set of instructions may be stored in (or on) any suitable non-transitory computer-readable medium. In general, with regards to the embodiments described herein, a non-transitory computer-readable medium may include almost any structure, technology or method apart from a transitory waveform or similar medium.
As described, the system, apparatus, methods, processes, functions, and/or operations for implementing an embodiment of the disclosure may be wholly or partially implemented in the form of a set of instructions executed by one or more programmed computer processors such as a central processing unit (CPU) or microprocessor. Such processors may be incorporated in an apparatus, server, client or other computing or data processing device operated by, or in communication with, other components of the system. As an example,
The monitor 606 is coupled to at least one airway sensor 608 configured to detect one or more airway parameters of the patient 604. The airway parameter(s) for instance, are measured from air in a fluidic circuit including an airway of the patient 604. Examples of airway parameters include a partial pressure of CO2, EtCO2, a capnograph, a pressure, a flow, a ventilation tidal volume, an oxygen level, and a RR. In various implementations, the airway sensor(s) 608 are configured to sample air in a fluidic circuit that includes an airway adapter and a gas source of a ventilation device. For instance, the airway adapter may include a face mask, a tracheal tube, or a supraglottic airway. In various cases, the gas source may include a manual resuscitation bag or mechanical ventilation gas source. The airway sensor(s) 608, in various cases, are configured to detect the airway parameter(s) in a mainstream of the ventilation device or a side stream of the ventilation device. The airway sensor(s) 608, in various examples, includes at least one infrared light source configured to transmit infrared light into the fluidic circuit and an infrared sensor configured to detect scattered light from air in the fluidic circuit. Based on the scattered light detected by the infrared sensor, the airway sensor(s) 608 may determine a partial pressure of CO2 in the air.
In some instances, the monitor 606 is further coupled to at least one oximetry sensor 610 configured to detect an oxygenation parameter of the patient 604. Examples of oxygenation parameters include oxygen saturation, oximetry, and pulse rate. In some implementations, the oximetry sensor(s) 610 includes a pulse oximetry (SpO2) sensor. In some cases, the oximetry sensor(s) 610 include a regional oximetry sensor. For example, the oximetry sensor(s) 610 include a light source configured to transmit light into blood of the patient 604 and to detect scatter of the light from the blood of the patient 604. Based on the scattered light, the oximetry sensor 610 may determine an oxygen saturation of the blood of the patient 604. In some cases, the oximetry sensor(s) 610 includes a sensor disposed on a finger, an ear, a forehead, a nose, a toe, or another portion of the patient 604.
In various cases, the monitor 606 is coupled to a blood pressure sensor 611 configured to detect a blood pressure of the patient 604. For instance, the blood pressure sensor 611 includes an inflatable cuff and a pressure sensor configured to detect a pressure within the inflatable cuff. When the inflatable cuff is disposed around an extremity (e.g., an arm) of the patient 604, the inflatable cuff may be inflated by a fluid. In various cases, the pressure within the inflatable cuff is related to the blood pressure (e.g., a diastolic and/or systolic blood pressure) of the patient 604. In various cases, the blood pressure sensor 611 is configured to output a signal and/or data indicative of the blood pressure of the patient 604 to the monitor 606.
In various implementations, the patient 604 is experiencing a medical emergency that prevents the patient 604 from breathing spontaneously. Accordingly, the rescuer 602 may at least attempt to ventilate the patient 604 using a ventilation device 612. In various implementations, the rescuer 602 initiates an emergency advanced airway management procedure, such as RSI, in order to facilitate assisted ventilation of the patient 604 by the ventilation device 612.
In various examples, the emergency advanced airway procedure includes predetermined steps or “stages” that are performed by the rescuer 602 and/or the ventilation device 612. First, the rescuer 602 administers one or more medications to the patient 604. The medication(s) may include a paralytic and/or a sedative. For instance, the rescuer 602 administers rocuronium and/or succinylcholine as well as ketamine and/or etomidate in order to render the patient 604 paralyzed and unconscious. In various cases, the administration of the medication(s) represents an induction of anesthesia. Second, the rescuer 602 intubates the patient 604 in order to place an airway adapter (e.g., an ET tube) in the airway of the patient 604. Intubation may be performed using a laryngoscope. Third, the patient 604 receives assisted ventilation from the ventilation device 612 via the airway adapter. Fourth, the patient 604 may arrive at a care location (e.g., a hospital) and/or be transferred to another care provider at the care location. Optionally, the emergency advanced airway procedure is associated with other steps, including initiation of transport of the patient 604 to the care location (e.g., the time at which the patient 604 is loaded onto a cot or into an ambulance) and the initiation of pre-oxygenation. In various cases, each one of these steps is associated with a particular time point. In some cases, each step is associated with a time interval (e.g., a time at which a step is initiated until a time at which another step is initiated). As used herein, the term “sub-interval,” and its equivalents, may refer to a time period extending between steps of an emergency advanced airway procedure.
During the emergency advanced airway procedure, it may be important to monitor the condition of the patient 604. For example, by monitoring the oxygenation or capnograph of the patient 604 while the patient 604 receives assisted ventilation from the ventilation device 612, the rescuer 602 may identify if there are any problems with the placement of the airway adapter, the function of the ventilation device 612, or other issues that could prevent the patient 604 from receiving sufficient assisted ventilation to avoid hypoxemic injury. In various implementations, the monitor 606 may report real-time values of the physiological parameters of the patient 604 to the rescuer 602. In some cases, the monitor 606 includes a display, speaker, or other type of output device configured to output the physiological parameters of the patient 604 in real-time. For instance, the display of the monitor 606 may visually present the physiological parameters within a second of their detection from the patient 604.
However, the rescuer 602 may be unable to watch the display of the monitor 606 constantly during the medical emergency. For instance, the rescuer 602 may be performing one or more steps of the emergency advanced airway procedure. In some cases, the rescuer 602 may prepare a therapy for the patient 604, such as a medication that is indicated by the condition of the patient 604. In some examples, the rescuer 602 may operate a defibrillator (e.g., the monitor 606) and administer an electrical shock to the heart of the patient 604, in order to treat an arrhythmia (e.g., VF) experienced by the patient 604. In various implementations, the monitor 606 may display numerous physiological parameters at once (e.g., greater than 3 physiological parameters). These and other real-world events may prevent the rescuer 602 from noticing that the ventilation device 612 is not supplying adequate oxygen to the patient 604 for one or more reasons.
In various implementations of the present disclosure, the monitor 606 may generate an index based on one or more of the physiological parameters. The index, for instance, is representative of whether the patient 604 has, or is in danger of developing, a hypoxemic injury. The index may be based on at least one physiological parameter over time. The index is a more accurate indication of a condition of the patient 604 than a single, real-time physiological parameter alone. Further, it may be easier for the rescuer 602 to discern the condition of the patient using the index, rather than multiple physiological parameters. In some cases, it may be impossible for the rescuer 602 to accurately discern the condition of the patient 604 in real-time using multiple physiological parameters, but the index may enable the rescuer 602 to accurately discern the condition of the patient 604.
In some examples, the index is calculated based on an amount of time that a physiological parameter is above an upper threshold or is below a lower threshold. For example, the index may be proportional to an amount of time that a partial pressure of CO2 in the airway or a blood oxygenation of the patient 604 is below a predetermined threshold.
In some cases, the index is calculated based on an integral of a metric over time. That is, the index is based on an “area under the curve” of a metric based on one or more physiological parameters over time. For instance, a metric representing a depth of a physiological parameter (e.g., a partial pressure of CO2 in the airway, a blood oxygenation, etc.) under a threshold is calculated. The threshold, for instance, is associated with hypoxemia. The index, for instance, is determined by calculating the integral of the metric during time intervals at which the metric is positive (i.e., when the physiological parameter is below the threshold). Because the severity of hypoxemia is dependent on the time at which the physiological parameter is below the threshold and the depth of the physiological parameter below the threshold, the integral may provide a more accurate indication of hypoxemia than displaying the physiological parameter alone.
In various implementations, the index is based on a percentage. For example, the index may be based on a percentage of the time that a physiological parameter (e.g., a partial pressure of CO2 in the airway, a blood oxygenation, etc.) is below a threshold during a predetermined time period.
In some cases, the index is indicative of a maximum or minimum change in the physiological parameter detected by the monitor 606. For instance, the index may be based on a maximum percent change of a physiological parameter during a monitored time period.
According to various cases, the index has a nonlinear relationship with the magnitude of a physiological parameter. For example, the hypoxemic injury caused by a physiological parameter at one level (e.g., an oxygenation at 70%) may be much more severe than the hypoxemic injury caused by the physiological parameter at another level (e.g., an oxygenation at 90%). In various cases, the index is nonlinearly related to a metric based on at least one physiological parameter. For instance, the index is nonlinearly dependent on the absolute value of a difference between a physiological parameter (e.g., an amount of CO2 in the airway, a blood oxygenation, etc.) and a predetermined threshold associated with hypoxemia.
In some cases, the index determined by the monitor 606 is a hypoxemia dose index. In various implementations, the hypoxemia dose index is calculated based on a blood oxygenation of the patient 604 over time. In some examples, the hypoxemia dose index is determined based on an amount of time that the blood oxygenation of the patient 604 is below a threshold oxygenation. According to various cases, the hypoxemia dose index is determined based on an extent to which the blood oxygenation of the patient 604 is below the threshold oxygenation. In some cases, the hypoxemia dose index varies nonlinearly with respect to the amount of time that the blood oxygenation of the patient 604 is below the threshold oxygenation and/or with respect to the extent to which the blood oxygenation of the patient 604 is below the threshold oxygenation. For instance, the hypoxemia dose index may be calculated based on the following Equation:
∫t
wherein t is time, t1 is a time at which the blood oxygenation of the patient 604 initially falls below the threshold oxygenation, t2 is a time at which the blood oxygenation of the patient 604 rises above the threshold oxygenation (or a current time if the blood oxygenation of the patient 604 has not yet risen above the threshold oxygenation), κt(t) is a weight function with respect to time, κd(t) is a weight function with respect to time related to a difference between the blood oxygenation of the patient 604 and the threshold oxygenation, and f(t) is the blood oxygenation of the patient 604 at time t.
According to some implementations, κt(t) increases as the time at which the blood oxygenation of the patient 604 is below the threshold oxygenation increases. Further, in some cases, κd(t) increases as the time at which the difference between the current oxygenation of the patient 604 and the threshold oxygenation increases. For instance, the time spent with a blood oxygenation below 80% could be weighted double the time spent with a blood oxygenation between 80% and 90%. In some implementations, the hypoxemia dose index is representative of multiple episodes in which the blood oxygenation of the patient 604 falls below the threshold oxygenation. For instance, the total hypoxemia dose index of the patient 604 is a sum of the hypoxemia dose index determined for each instance in which the blood oxygenation of the patient 604 falls below the threshold oxygenation.
In some cases, the hypoxemia dose index is based on additional physiological parameters. For instance, κt(t) and/or κd(t) may further be functions based on the presence of an arrhythmia, like VF, (e.g., as indicated in the ECG of the patient 604) and/or a blood pressure of the patient 604. In some cases, κt(t) and/or κd(t) may be based on a previous condition of the patient 604, such as anemia, cardiac disease, or pulmonary disease. In various implementations, the hypoxemia dose index is based on arterial oxygen saturation and/or regional oxygen saturation. In various implementations, the monitor 606 is configured to calculate κt(t) and/or κd(t) based on one or more physiological parameters of the patient 604.
According to some cases, the monitor 606 generates an index based on values of the physiological parameter(s) detected during a particular time interval of interest (also referred to as a “sub-interval”). For instance, the monitor 606 detects the index based on physiological parameter(s) detected during a particular sub-interval of an emergency advanced airway management procedure. In various cases, the index may be independent of one or more physiological parameters detected before the beginning of the sub-interval or after the end of the sub-interval. In various implementations, the index is independent of any physiological parameters detected outside of the time interval.
In various examples, the monitor 606 detects a first event at a first time. The monitor 606 may calculate the index based on physiological parameter(s) detected from the patient 604 after the first time. For instance, the first event may be a first step of the emergency advanced airway procedure (e.g., administration of one or more medications, intubation, etc.). In various cases, the monitor 606 may detect the physiological parameter(s) before the first time, but may refrain from applying the physiological parameter(s) detected before the first time to the index. In some implementations, the monitor 606 is configured to report the index, or output an alert based on the index, after the first time.
In some cases, the monitor 606 detects a second event at a second time. For instance, the second event may be a second step of the emergency advanced airway procedure (e.g., arrival at a care location, such as a hospital). In some implementations, the monitor 606 is configured to calculate the index based on physiological parameter(s) detected between the first time and the second time. For instance, the index may be independent of one or more physiological parameters detected after the second time.
The monitor 606 detects the first time, the second time, or the time interval, using one or more techniques. In some examples, the monitor 606 includes an input device that receives an input signal from the rescuer 602. For instance, the rescuer 602 may press a button on the monitor 606. The input signal indicates the first time, the second time, or the time interval, according to some examples.
In some implementations, the monitor 606 detects the first time, the second time, or the time interval, based on the physiological parameter(s). In some implementations, the monitor 606 detects an artifact in the detected physiological parameter(s) indicating that the patient 604 has been intubated. For instance, an RSI procedure may cause a significant artifact in a photoplethysmography waveform. In some cases, the monitor 606 detects that a medication has been administered to the patient 604 in response to detecting that a motion artifact associated with patient movement is omitted from the physiological parameter(s).
In some cases, the monitor 606 detects the first time, the second time, or the time interval, based on another type of sensor. For example, the monitor 606 may detect that an ET tube has been inserted into an airway of the patient 604 based on a pressure detected by a pressure sensor integrated with a laryngoscope (not illustrated) used to place the ET tube. For instance, the laryngoscope may be configured to transmit or otherwise output an indication of the pressure detected by the pressure sensor to the monitor 606, which may thereby detect the placement of the ET tube. In some cases, the monitor 606 includes a location sensor configured to detect that the patient 604 has arrived at a hospital.
According to various cases, the monitor 606 outputs a signal to the rescuer 602 and/or to an external device based on the index. For instance, the monitor 606 visually presents the index on a display. In some cases, the monitor 606 compares the index to a threshold and outputs an alert based on the comparison to the threshold. The alert, for instance, may indicate that the rescuer 602 should perform one or more procedures to immediately prevent permanent hypoxic injury of the patient 604. Accordingly, in various cases, the alert may enable the rescuer 602 to prioritize ventilation to the patient 604 above treating other conditions (e.g., arrhythmias) when the patient 604 is in danger of developing a hypoxemic injury. In some cases, the monitor 606 transmits data indicative of the index to an external device. For example, the index may be reviewed by a medical director or other individual evaluating the rescuer 602.
In various implementations of the present disclosure, the index determined by the monitor 606 cannot be determined in the mind of the rescuer 602, or using pen and paper. For instance, Equation 1 cannot be solved in the mind of the rescuer 602, particularly in real-time. Further, in cases where the index is limited to a critical time interval of an emergency advanced airway management procedure, the rescuer 602 may be unable to calculate a physiological parameter-dependent index while also physically performing the steps of the procedure.
At 702, the entity detects measurements of a physiological parameter of a patient. In various implementations, the entity includes a sensor configured to detect the physiological parameter. The sensor, for example, may generate the measurements by sampling the physiological parameter at a sampling frequency. In various cases, the measurements can be represented as a waveform representing the physiological parameter over time. In some cases, the entity displays the waveform, such as on a screen. In various cases, the physiological parameter includes an airway parameter (e.g., an amount of CO2 in the airway of the patient over time) or an oxygenation parameter (e.g., SpO2).
At 704, the entity identifies a sub-interval that begins in response to an event. In various cases, the measurements detected by the entity at 702 are at least partially detected before the beginning of the sub-interval. In various cases, the sub-interval is defined after a first time. In some cases, the sub-interval is defined before a second time, which may also correspond to the occurrence of an event. Various events can be used to define the first time and/or the second time, such as administration of one or more medications, intubation (e.g., RSI), patient arrival at a secondary care location (e.g., a hospital), transfer between care providers, or during other emergency medical procedures.
At 706, the entity identifies a portion of the measurements detected during the sub-interval. In various cases, the portion of the measurements omits measurements detected before the first time and/or after the second time. Accordingly, the entity may avoid analyzing measurements that may be irrelevant to the hypoxemic state of the patient.
At 708, the entity determines, by analyzing the portion of the measurements, an index of the patient. For instance, the index is a hypoxemia dose index. In some implementations, the index is based on (e.g., proportional to) an integral, with respect to time, of a difference between the physiological parameter and a predetermined threshold associated with hypoxemia. In some cases, the index is based on an amount and/or a percentage of time that the physiological parameter is below the threshold. In various implementations, the index is based on a time that the physiological parameter is below the threshold and/or an extent (e.g., a depth) to which the physiological parameter is below the threshold. In some cases, the index is proportional to a percentage of the sub-interval at which the portion of the measurements is below a first threshold or above a second threshold.
In some cases, the entity determines the index based on additional information. For instance, the index may be based on an integral, with respect to time, of a difference between another physiological parameter (e.g., another airway parameter, another oxygenation parameter, blood pressure, or the like) and another predetermined threshold associated with hypoxemia. In some cases, the index is based on an amount and/or a percentage of time that the additional physiological parameter is below the threshold. In various examples, the index is based on a time that the additional physiological parameter is below the threshold and/or an extent (e.g., a depth) to which the additional physiological parameter is below the threshold.
In some cases, the entity determines the index by determining a condition of the patient, such as a condition of the patient during the sub-interval. The condition, in various examples, is relevant to the severity of a hypoxemic injury experienced by the patient. For example, the entity may analyze the ECG to determine that the patient has an arrhythmia (e.g., VF) that inhibits effective blood circulation through the patient's body during the sub-interval. Based on the detected arrhythmia, the entity may adjust the index to indicate that the potential hypoxemic injury by the patient is more severe than it would be without detecting the arrhythmia. In some cases, the entity may determine that the patient has anemia, cardiac disease, or pulmonary disease.
At 710, the entity compares the index to a threshold. At 712, the entity outputs, based on the comparison of the index to the threshold, an alert or report. For example, the alert may indicate that ventilation of the patient should be immediately prioritized in order to avoid permanent and debilitating hypoxic injury. In various cases, the report may indicate whether the patient developed a permanent and debilitating hypoxic injury during the sub-interval. In various implementations, the alert or report includes an instruction to change an intubation protocol. For example, the alert or report may include an instruction to check for a leak between a ventilation device and the airway of the patient, to change a ventilation frequency, to change a ventilation timing, or the like.
In some cases, the entity may adjust a ventilation parameter based on the index. For example, the entity may administer, or cause administration of, mechanical ventilation at a higher rate based on determining that the index is below the threshold. Accordingly, the entity may automatically treat the patient based on the index, in some examples.
Any of the software components, processes or functions described in this application may be implemented as software code to be executed by a processor using any suitable computer language such as, for example, Java, JavaScript, C++ or Perl using, for example, conventional or object-oriented techniques. The software code may be stored as a series of instructions, or commands in (or on) a non-transitory computer-readable medium, such as a random-access memory (RAM), a read only memory (ROM), a magnetic medium such as a hard-drive or a floppy disk, or an optical medium such as a CD-ROM. In this context, a non-transitory computer-readable medium is almost any medium suitable for the storage of data or an instruction set, aside from a transitory waveform. Any such computer readable medium may reside on or within a single computational apparatus, and may be present on or within different computational apparatuses within a system or network.
According to one example implementation, the term processing element or processor, as used herein, may be a central processing unit (CPU), or conceptualized as a CPU (such as a virtual machine). In this example implementation, the CPU or a device in which the CPU is incorporated may be coupled, connected, and/or in communication with one or more peripheral devices, such as display.
The non-transitory computer-readable storage medium referred to herein may include a number of physical drive units, such as a redundant array of independent disks (RAID), a floppy disk drive, a flash memory, a USB flash drive, an external hard disk drive, thumb drive, pen drive, key drive, a High-Density Digital Versatile Disc (HD-DV D) optical disc drive, an internal hard disk drive, a Blu-Ray optical disc drive, or a Holographic Digital Data Storage (HDDS) optical disc drive, synchronous dynamic random access memory (SDRAM), or similar devices or other forms of memories based on similar technologies. As mentioned, with regards to the embodiments described herein, a non-transitory computer-readable medium may include almost any structure, technology or method apart from a transitory waveform or similar medium.
Certain implementations of the disclosed technology are described herein with reference to block diagrams of systems, and/or to flowcharts or flow diagrams of functions, operations, processes, or methods. It will be understood that one or more blocks of the block diagrams, or one or more stages or steps of the flowcharts or flow diagrams, and combinations of blocks in the block diagrams and stages or steps of the flowcharts or flow diagrams, respectively, can be implemented by computer-executable program instructions. Note that in some embodiments, one or more of the blocks, or stages or steps may not necessarily need to be performed in the order presented, or may not necessarily need to be performed at all.
These computer-executable program instructions may be loaded onto a general-purpose computer, a special purpose computer, a processor, or other programmable data processing apparatus to produce a specific example of a machine, such that the instructions that are executed by the computer, processor, or other programmable data processing apparatus create means for implementing one or more of the functions, operations, processes, or methods described herein. These computer program instructions may also be stored in a computer-readable memory that can direct a computer or other programmable data processing apparatus to function in a specific manner, such that the instructions stored in the computer-readable memory produce an article of manufacture including instruction means that implement one or more of the functions, operations, processes, or methods described herein.
The features disclosed in the foregoing description, or the following claims, or the accompanying drawings, expressed in their specific forms or in terms of a means for performing the disclosed function, or a method or process for attaining the disclosed result, as appropriate, may, separately, or in any combination of such features, be used for realizing implementations of the disclosure in diverse forms thereof.
As will be understood by one of ordinary skill in the art, each implementation disclosed herein can comprise, consist essentially of or consist of its particular stated element, step, or component. Thus, the terms “include” or “including” should be interpreted to recite: “comprise, consist of, or consist essentially of.” The transition term “comprise” or “comprises” means has, but is not limited to, and allows for the inclusion of unspecified elements, steps, ingredients, or components, even in major amounts. The transitional phrase “consisting of” excludes any element, step, ingredient or component not specified. The transition phrase “consisting essentially of” limits the scope of the implementation to the specified elements, steps, ingredients or components and to those that do not materially affect the implementation. As used herein, the term “based on” is equivalent to “based at least partly on,” unless otherwise specified.
Unless otherwise indicated, all numbers expressing quantities, properties, conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term “about.” Accordingly, unless indicated to the contrary, the numerical parameters set forth in the specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained by the present disclosure. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. When further clarity is required, the term “about” has the meaning reasonably ascribed to it by a person skilled in the art when used in conjunction with a stated numerical value or range, i.e. denoting somewhat more or somewhat less than the stated value or range, to within a range of ±20% of the stated value; ±19% of the stated value; ±18% of the stated value; ±17% of the stated value; ±16% of the stated value; ±15% of the stated value; ±14% of the stated value; ±13% of the stated value; ±12% of the stated value; ±11% of the stated value; ±10% of the stated value; ±9% of the stated value; ±8% of the stated value; ±7% of the stated value; ±6% of the stated value; ±5% of the stated value; ±4% of the stated value; ±3% of the stated value; ±2% of the stated value; or ±1% of the stated value.
Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the disclosure are approximations, the numerical values set forth in the specific examples are reported as precisely as possible. Any numerical value, however, inherently contains certain errors necessarily resulting from the standard deviation found in their respective testing measurements.
The terms “a,” “an,” “the” and similar referents used in the context of describing implementations (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., “such as”) provided herein is intended merely to better illuminate implementations of the disclosure and does not pose a limitation on the scope of the disclosure. No language in the specification should be construed as indicating any non-claimed element essential to the practice of implementations of the disclosure.
Groupings of alternative elements or implementations disclosed herein are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other members of the group or other elements found herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasons of convenience and/or patentability. When any such inclusion or deletion occurs, the specification is deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.
Certain implementations are described herein, including the best mode known to the inventors for carrying out implementations of the disclosure. Of course, variations on these described implementations will become apparent to those of ordinary skill in the art upon reading the foregoing description. The inventors expect skilled artisans to employ such variations as appropriate, and the inventors intend for implementations to be practiced otherwise than specifically described herein. Accordingly, the scope of this disclosure includes all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above-described elements in all possible variations thereof is encompassed by implementations of the disclosure unless otherwise indicated herein or otherwise clearly contradicted by context.
This application is a continuation in part of U.S. patent application Ser. No. 16/478,817, entitled “Systems and Methods of Managing and Evaluating Airway Procedures,” filed Jul. 17, 2019, which is a 371 filing of International Patent Application No. PCT/US2018/014565, entitled “Systems and Methods of Managing and Evaluating Airway Procedures,” filed Jan. 19, 2018, which claims the benefit of U.S. Provisional Patent Application Ser. No. 62/448,934, entitled “Post-Event Assessment of the Emergency Advanced Airway Management,” filed Jan. 20, 2017, the contents of each of which are incorporated by reference herein in their entirety.
| Number | Date | Country | |
|---|---|---|---|
| 62448934 | Jan 2017 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 16478817 | Jul 2019 | US |
| Child | 18227248 | US |
