CA2278193C - Impedance respiratory rate measuring edema monitor - Google Patents

Impedance respiratory rate measuring edema monitor Download PDF

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Publication number
CA2278193C
CA2278193C CA002278193A CA2278193A CA2278193C CA 2278193 C CA2278193 C CA 2278193C CA 002278193 A CA002278193 A CA 002278193A CA 2278193 A CA2278193 A CA 2278193A CA 2278193 C CA2278193 C CA 2278193C
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Prior art keywords
edema
impedance
value
respiratory rate
set forth
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CA2278193A1 (en
Inventor
Kenneth M. Riff
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Medtronic Inc
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Medtronic Inc
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    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00Measuring for diagnostic purposes; Identification of persons
    • A61B5/48Other medical applications
    • A61B5/4869Determining body composition
    • A61B5/4875Hydration status, fluid retention of the body
    • A61B5/4878Evaluating oedema
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00Measuring for diagnostic purposes; Identification of persons
    • A61B5/05Detecting, measuring or recording for diagnosis by means of electric currents or magnetic fields; Measuring using microwaves or radio waves 
    • A61B5/053Measuring electrical impedance or conductance of a portion of the body
    • A61B5/0535Impedance plethysmography
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00Measuring for diagnostic purposes; Identification of persons
    • A61B5/05Detecting, measuring or recording for diagnosis by means of electric currents or magnetic fields; Measuring using microwaves or radio waves 
    • A61B5/053Measuring electrical impedance or conductance of a portion of the body
    • A61B5/0537Measuring body composition by impedance, e.g. tissue hydration or fat content
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00Measuring for diagnostic purposes; Identification of persons
    • A61B5/08Detecting, measuring or recording devices for evaluating the respiratory organs
    • A61B5/0809Detecting, measuring or recording devices for evaluating the respiratory organs by impedance pneumography
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61NELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00Electrotherapy; Circuits therefor
    • A61N1/18Applying electric currents by contact electrodes
    • A61N1/32Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/362Heart stimulators
    • A61N1/37Monitoring; Protecting
    • A61N1/3702Physiological parameters
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61NELECTROTHERAPY; MAGNETOTHERAPY; RADIATION THERAPY; ULTRASOUND THERAPY
    • A61N1/00Electrotherapy; Circuits therefor
    • A61N1/18Applying electric currents by contact electrodes
    • A61N1/32Applying electric currents by contact electrodes alternating or intermittent currents
    • A61N1/36Applying electric currents by contact electrodes alternating or intermittent currents for stimulation
    • A61N1/362Heart stimulators
    • A61N1/3627Heart stimulators for treating a mechanical deficiency of the heart, e.g. congestive heart failure or cardiomyopathy

Abstract

An impedance monitor for discerning edema through evaluation of respiratory rate. Preferred embodiment includes edema monitor and trigger to initiate diagnostic reporting or corrective action when activated. Recording of Long Term Average and Short Term Average values for secondary edema measure based on DC signal level are described as are methods and apparatus for removing unwanted recurring noise.

Description

IMPEDANCE RESPIRATORY RATE MEASURING EDEMA MONITOR
BACKGROUND
This invention relates to irnplantable devices including but not limited to tissue stimulators having measurement capability for determining impedance measurements and is particularly well suited to measure long term edema variations within a living body.
Impedance monitoring has been used for determination of numerous physiologic conditions within th.e body with implanted devices and has been used in Io external monitoring de~rices as well. It is commonly understood that Transthoracic Impedance measurements give a good indication of the level of edema in patients.
Even as far back as 19',l l , in an article entitled "Transthoracic Electrical Impedance as a guide to Intravascc~lar Overload" by Berman et. al. (Archives surgery, V

P6i- 64 Jan. 1971), electrical impedance methods have been used to document the ~5 accumulation of fluid in the living; tissue.
What's important about long term impedance measurement and noting changes therein is that it is an valuable clinical indicator of the health of the living body which has heretofore been unavailable to physicians in a very useful form.
While edema is a sign oi= many other conditions it is also a sign of the failing 2o heart circulation which is our first concern. There are several mechanisms or diseases that can cause or affect edema. In general edema is a failure or over response of homeostatic process within the body. The body normally prevents the build up of fluids by maintaining adequate pressures and concentrations of salt and proteins, and by actively removing excess fluid. If a disease affects any of these 25 mechanisms the result c:an be edema. This includes heart failure, left sided MI(Myocardial Infarction), high blood pressure, altitude sickness, emphysema (all which affect pressures), and cancers that affect the lymphatic system, diseases . which disrupt the protein concentrations, ...etc. The list is large. The point is that by providing an adequate monitor of edema we can provide a physician and his 3o patient with a better tool to manage disease.

,i Unfortunately, ordinarily the first indication that a treating physician would have of the occurrence of edema is very late in the disease process when it becomes a physical manifestation with swelling or breathing difficulties so overwhelming as to be noticed by the patient who then proceeds to be examined by a physician.
For a cardiac heart failure (CHF) patient, hospitalization at such time would likely be required. A device and system as proposed in this application can obviate the need for proactive hospitalization simply to monitor a patient's progression of to edema as hospital stays are discouraged whenever possible under the emerging health care delivery system in the world today. Therefore a strong incentive or need exists for devices that can allow a patient to be monitored for disease symptoms over a long term without requiring hospitalization and allows for out-of hospital intervention when symptoms, in this case, due to edema suggest it.
t5 Additional need for this type of invention is found in the article "EFFECTS
OF PREHOSPITAL MEDICATIONS ON MORTALITY AND LENGTH OF
STAY IN CONGESTIVE HEART FAILURE," by Wuerz and Meador, ANNALS OF EMERGENCY MEDICINE, 21:6, June, 1992, pp 669-74, in which it is demonstrated that early pre-hospital treatment can save lives. A device that 2o establishes new indications before the patient can be hospitalized by allowing for a readout of accumulated and trend data can be seen as an improvement in the tools available to save lives from CHF.
There are numerous devices and teachings which describe or are capable of making impedance measurements including U.S. patents 5,534,018, 5,271,395, 25 5,370,6665, 5,233,985, and 5,282,840. Likewise, there are numerous mentions of the use of impedance for determination of levels of edema in the literature without the use of long term implantable devices which usually require significant and expensive monitoring, attention, and effort. Such monitoring and effort may not be available before hospitalization. However, there currently are no impedance 3o measurement devices suitable for providing an indication of when an edema is about to become a serious problem for a patient, nor for closely monitoring it over a protracted period of time. ConseQueatty, as patients become out of titer on their edema management medication (diuretics, for example) or after they unknowingly or unintentionally eat salty foods, hospitalization may be enhanced or possibly s avoided through the use of a device as described herein. Thus healthcare resources can be used more efficiently and effectively to help CIiF patients in particular as well as other patients which can benefit from similar information availability.
It should be noted that adaptations of scone technologies for performing some patient monitoring functions are developed as evidencxd by US Patems to 1o Yomotov, et al, Nos. 5,313,953 and 5,411,031.
However as yet there has not bees acceptance of implantable devices for monitoring purposes alone, and certainly none for simply monitoring edema per se, nor for edema as a partial indicator of health, nor for use of edema monitoring as an adjunct indicator for therapy modification. Accordingly it is is believed there is a large need for the teaching of this invention.
Additional measurements maybe particularly useful, including specifically Respiration rate. Additional data can be found is the respiration rate which can be monitored as a separate and independent indicator of edema onset and particularly of pulmonary edema or increased lung water, since patients are known to breath zo quickly when their Iungs fill with fluid. It is known, for instance that in extreme cases of pulmonary edema breathing rates of 60 per minute can occur. Because it would be impossible to clinically measure slight changes in long term breathing rates, for example a 5.5 to S.8 breath per minute change, but such monitoring is possible with an implanted device, by including a processor for sampling the rate of 25 breathing and comparing it to next sampled rates over time, substantial clinical benefit can be obtained by making this data available.
BHI~ D~C..~,~'I IU1V UP 1 j~: DRAWINGb.
Fig. 1 is a cut away view of the body having a implanted impedance measurement device for monitoring impedance within a body in accord with this 30 invention.

i1 : i Fig. 2 is an illustration of a common pacemaker device for use with this invention.
Fig. 3 is a block circuit diagram of a stimulation of an impedance measurement circuit for use with the invention as described herein.
Fig. 4 is a block circuit diagram in accord with a preferred embodiment with this invention.
Fig. 5 is a timing diagram for use with this invention.
Fig. 6 is a heuristic block diagram of a body, implanted devices and communication systems useful with this invention.
Fig. 7 is a block diagram for device alternatives to Fig. 1.
Fig. 8 is a circuit block diagram of a generalized version of this invention.
Fig. 9 is a flow diagram for a control for use with this invention.
Fig. 10 is a block diagram of a device in accord with the invention.
Fig. 11 is a flow diagram illustrating steps for evaluating edema using respiratory rate.
SUI~B~SARY OF THE INVENTION
In one aspect, the present invention provides an implantable edema monitoring device having: an impedance sensor for making impedance measurements in a living body into which said device is implanted, and memory and ~r~

4a evaluation circuitry means for monitoring said impedance measurements, and for generating a value representative of respiratory rate based on evaluation of said impedance measurement over time, edema value generator circuitry means for monitoring changes in said respiratory rate value, so as to generate an edema level value indicative of a measured value of edema in said living body based solely on said changes in said respiratory rate value.
In a second aspect, there is provided a method of determining patient pulmonary edema comprising: storing a history of respiratory rate in an implanted device, monitoring changes in the respiratory rate of the patient, determining a level of edema based on said changes in said respiratory rate that have occurred during said monitored history.
In a further aspect, there is provided a method of determining patient pulmonary edema comprising: storing a history of respiratory rate in an implanted device, monitoring changes in the respiratory rate of the patient, determining a level of patient health based on said changes in said respiratory rate that have occurred during said monitored history.
In another aspect, the invention provides an implantable edema monitoring device having: an impedance sensor for making impedance measurements in a living body into which said device is implanted, and memory and evaluation circuitry means for monitoring said impedance measurements, and for generating a value representative of respiratory rate based on evaluation of said impedance measurements over time, patient health value generator circuitry means for monitoring changes in said respiratory rate value, so as to generate a patient health level value i 4b indicative of general physical health in said living body based solely on said changes in said respiratory rate value.
A system for determining, generating, monitoring, and using signal representative of edema in a living body is described herein.
It includes an implantable apparatus for production of impedance measurement in a subcutaneous region of the living body having at least two electrically isolated electrodes, preferably but not necessarily on the outer surface of its housing and having within the housing an energy pulse delivery mechanism to deliver electrical pulses to living body and means for receiving electrical impulses on the surface of the housing so as to determine the impedance of the body between the two preferred or less preferred pair of electrodes.
The energy pulse delivery mechanism may advantageously be provided with an adjustment control that can be used to customize the output for a patient, assist in optimization of the Signal to Noise Ratio (SNR), and avoid local muscle stimulation. Automatic feedback control loops may be used for this purpose, but in the presently preferred embodiment, both the determination of the preferred pulse delivery electrodes and the values used for the impedance energy pulse to initiate measurement are either factory set or controlled by a telemetry link to the implant during the implant or adjustment procedure.
This invention can be used in conjunction with traditional pacemaker systems and implantable defibrillators, and other implantable devices, or may be incorporated into them. For example, the electrode configuration for impedance measurement may include a cardiac electrode tip in the heart and an electrode on the surface of a pacemaker blousing i:o~r one measure of impedance and an additional pair of electrodes both l~xated on t:he housing would enable the use of two different to measures of impedance ;end facilitate the use of comparisons between the resultant signals to refine the signal and provide additional information.
Additional means for discriminating impedance noise signals which are not representative of edema may be iincluded within the housing. Apparatus and method for determining long term and short term average values (LTA and STA
t5 values, respectively) and also for determining when to sample impedance measurements are included. In preferred embodiments trigger means for determining diagnostically significant events based on long term and short term average values are also iincluded..
Memory for storage andprocessors and signaling for managing the storage 2o so that optimal diagnostic data c<ln be stored based on edema measurement signals are also provided.
Enhancements include various ways to produce power within the device, programmable output v~ilues of impedance pulses, optimization of electrodes synchronization of stimulus pulses to physiologically recurring signals. Alarm 25 means, base station means, telephonic links, and diagnostic assistance may also be additionally provided.
For instantiation~~ where the invention is installed into pacemakers or drug pumps or other implantable devices, it can be used to alter the delivery of drugs and stimulation pulses to respond to the onset of edema automatically.

In Cardiac Heart Failure (CHF) patients the infusion of diuretics to manage edema automatically is a prime example of how this invention would be most useful.
Also, for providing additional useful data or for reference by automatic triggering apparatus to store data(in looping or non-looping memories) or generate alarms or take other actions based on significant events, ECG signal reading, pedal impact or other activity sensors, and sensors for measuring temperature, pressure, oxygen saturation, and so forth may advantageously be included. Where such triggers are used the device can be constructed to perform an appropriate device behavior from a range of preconditioned device behaviors.
Preferred embodiments of an implantable edema monitoring device have an impedance sensor for making impedance measurements in a living body into which said device is implanted, and memory and evaluation circuitry means for monitoring said impedance measurements, and for generating a value representative of respiratory rate based on evaluation of said impedance measurements over time, along with edema value generator circuitry for monitoring changes in said respiratory rate value, so as to generate an edema level value indicative of the amount and presence of edema in said living body based solely on said changes in said respiratory rate value. It can further store at least two edema values taken over time and comparing these at least two edema values to so as to determine whether and in what direction a change in this body edema may be occurring, as well as recording changes in said edema value for later transmission to a second device adapted to receive such information outside the body from said implanted monitoring device. It could have an alarm for generating an alarm based on predetermined changes in said edema level value. Further, the evaluation circuitry for monitoring said impedance measurements may sense DC changes in impedance indicative of interstitial fluid build-up from these measurements and generate a second edema level value signal indicative of the presence of edema, based solely on this DC change, with said respiratory rate filtered out, and may generate an alarm based on predetermined c:hinges in both said edema level value and said second edema level value.
Other determination circuitry means may determine if said respiration rate value exceeds a Cheyne-Stokes(CS) minimum value and if so, then determines if after a predetermined period of exceeding said minimum and if said respiration rate then falls substantially, to generate a CS episode indicator signal to indicate that an episode of Chyene- Stokes syndrome has occurred. Additionally, sensor and evaluation means for evaluating a level of patient activity independent from impedance based measurement .of respiratory rate and generating a value for said t o other activity level evaluation, and memory storage circuitry for storing respiratory activity and said activity level value or a ratio thereof over time may be included.
The device may also store a parameter that is a ratio or other relation representing respiratory rate and activity levels and a timing circuit may cause said parameter to be stored on a daily basis.
is Also, using this parameter and having a second physiologic indicator sensor circuit for generating a second physiologic sensor level signal for communication to a storage trigger circuit: and this trigger circuit can generate a trigger signal to cause said respiratory hate to activity level parameter to be stored in said storage circuit when said second sensor trigger circuit determines a second physiologic 2o indicator signal matches a predeae:rmined trigger condition.
This can also bf~ stored historically, longitudinally over time and the device may also have an edema level indicator circuit for monitoring said parameter level longitudinal history to ,generate a signal value representative of an amount of worsening or improving edema based on evaluation of said parameter history.
Zs Any of these various configurations can additionally have a circuit process for discriminating impedance noise signals generatable by said living body's electromyographic and motion signals so as to remove the noise such body activities would otherwise introduce into impedance measurement signals. This could comprise a rest cycle determinv:lg timing circuit means for generating a timing 3o signal to limit impedance measurements to times that the body is determined by said rest cycle timing and determining circuit means to be at rest. In general also the device memory means stores data related to significant events and history of impedance measurements. It can have power generator means for continuous long term operation of said device, programmable output values of impedance pulses, and even have the impedance measurement switchable between more than two electrodes to obtain best position for signal to noise.
The implantable device housing can additionally house or communicate with other implanted devices like Pacemaker, Implantable Defibrillator, Drug pump, Loop ECG recorder, and or heamodynamic parameter recorder/monitors.
to The device can use said activity sensor to remove from consideration those respiratory rate signals not taken at rest. It may further comprise an activation circuit for activating drug therapy responsive to impedance value changes.
In one form the implantable edema monitoring device has an impedance sensor for making impedance measurements in a living body into which said device is is implanted, memory and evaluation circuitry means for monitoring said impedance measurements, and for generating a value representative of respiratory rate based on evaluation of said impedance measurements over time,and a patient health value generator circuitry means for monitoring changes in said respiratory rate value, so as to generates a patient health level value indicative of general 2o physical health in said living body based solely on said changes in said respiratory rate value.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIM NTS
In the heuristic drawing of Fig. l, a section of a Body 11 is shown with a cut-away area 12 to allow for illustration of the inventive device 10. The device 10 25 has two electrodes 15a and 15b on the surface of its shell 14. Power is provided to the circuitry internal to the shell 14 by a power supply 18 which drives a stimulation circuit 16 which sends electrons through various pathways in the body (such pathways are heuristically illustrated as being primarily in the area surrounded by dotted line) 13 between electrodes 15a and 15b. An impedance measurement 3o device 17 determines the impedance of the circuit pathway 13.

I~ 3 A description of the application of impedance sensing for determining minute ventilation would be helpful to determine the scope of relevant variability available for using this invention with different electrode configurations, leads, Locations and test pulse characteristics. We recommend review of the book:
Clinical Cardiac Pacing, Kenneth Ellenbogen, et al, published by WB Saunders Company, copyright 1995, pages 219-233.
Because of the possible poor signal characteristics that may be found using to the same electrodes for generating the impedance test pulse signal and taking the measurement from the same electrodes, we prefer to measure in a uniform pan (or relatively noiseless area) of the field. Both the configuration of electrodes and the values of the test pulses should be programmable. One way to do this is usiag one electrode, electrically isolated from the large surface indifferent electrode(like the can or housing of a pacemaker, device 10, or other implant) to deliver the test pulse, and a second electrically isolated electrode to measure the voltage difference in the tissue between the indifferent electrode and this second electrode.
Another preferred arrangement would use two completely independent electrodes in the field to measure the impedance, thus having a quadripolar system. In various 2o configurations of this invention additional electrodes can be imagined for flexibility where needed or to use electrodes on leads locatable in specific places within the field created by the test (or as we sometimes call it the "excite") pulse.
This acceptable variety of configuration to achieve different edema measurement signal values is~ illustrated in Fig. 7 wherein an implantable device ID has electrodes e1, e2, eg and em and either electrodes e1 or e2 can be used for developing the test pulses. The value being measured (voltage or impedance of the tissue between these electrode pairs) is taken between another electrically isolated measuring electrode em and the indifferent or ground electrode eg; between em and e1; or between em and e2 in the preferred forms. Or, of course, the measurement could be taken between the two test pulse delivery electrodes a 1, and eg; or between e2 and eg in the least preferred forms.
As will be described with reference to various figures below, substantial variation can be used for each of the elements described with reference to Figs. 1 5 and 2, and still be within the scope of this invention.
In Fig. 2 an alternative apparatus for housing the invention is shown in a body (Body) having a heart. A pacemaker (IPG) is implanted on the right side and has a lead L extending through the Right Atrium (RA} and into the Right Ventricle {RV) of the heart. By using the circuits and teachings of this invention an apparatus 1o such as a pacemaker and lead combination implanted into a living body like that illustrated here can be used to implement this invention. Alternative types of implantable devices may also be used to house this invention including for example, defibrillators, drug infusion devices, spinal cord stimulators or any other implantable device having the minimum external number of electrodes and being provided with an impedance stimulation and measurement circuit.
So as to describe a workable device, a preferred form of the invention is described with reference to Fig. 3, in which a block diagram 30 is included which illustrates the addition of edema monitoring circuit to a dual chamber two lead pacemaker system. In Fig. 4. , a block diagram 40 is provided to describe elements 2o useful in finding diagnostically valuable edema signals. For additional beneficial data generation purposes other sensors may be included in the implanted device and data therefrom temporally matched with edema data to provide additionally beneficial diagnostic data. Each sensor can be thought of as a system for providing an indication of patient condition, either when it's output is taken alone or combined in manners known to those in the art to determine patient condition. Such included sensor systems or subsystems could include, for example, diurnal cycle indicators, position or posture indicators, resting indicators, heart beat cycle indicators, breathing indicators, movement indicators, and so forth, each providing a signal value that could be stored or used to trigger an activity of the implanted device.

WO 98/33553 PCTlUS98/00040 Referring now t:o Fig. 3, it will be understood of those by ordinary skill in the art that a ventricular lead VL, will have a V tip electrode and a V ring electrode and an atria lead AL will have a A ring and an A tip electrode and that these electrodes are adapted to be inserted into the ventricle and atrium of a patient. A
case electrode (or neutral electrode as it may be called) is also provided to the circuit so that measurement may be made between any one of the four electrodes and the case, (or between any t:wo electrodes if it is desired not to measure the impedance between an extended lead electrode and the case). In any device having an electrode in the hea~~t and an electrode located substantially away from the heart to such as here with the case electrode in the pacemaker pocket, the kind of transthoracic impedance measurement that will be obtained provides a direct measurement of pulmonary ede:m~a.
(We also provide localized edema or impedance measurement ( see Fig. 7) in our most preferred e:mbodim~ents and compare these two values as described with t 5 reference to Fig. 4. ) Protection circuits are often provided in implanted devices such as circuits 31A and B in order to :protect the more sensitive electronics of the device from electrosurgical cautery in, or defibrillation of, the patient. A lead interface 32 (usually within the pacemaker shell itself and not in the connector block) provides 2o connection between the electrodes and sources of electrical stimulation as well as circuits for measurement. An excitation circuit 34 (usually associated with a current reference circuit 35) and ;~ control logic circuit 36 also supply input to the lead interface 32. As various switching circuits are well know to those of ordinary skill in the art the use of a large: scale line 33 {a control bus) to provide electrical 25 connection to the measurement block 37 is shown here to obviate the need to show all possible connections. This block 37 captures the resulting voltage from the excitation provided by circuit 34 and functions as a sample and hold circuit between measurements. The input impedance of this block is preferably very large compared to the excitation and measurement path so as not to affect the result.
3o Preferable values for capacitors C:l-C4 are substantially within the ranges of 2pF -SOpF based on the current excitation to allow complete charging in an excitation cycle and realization in a integrated circuit design. Measurement circuit 37 is run of course by a clock which in this embodiment has three signals, illustrated in this Fig. and in Fig. 5 as CLK 1, CLK 2, and CLK 3 to time the switches. During CLK 1 the top plate of capacitor C 1 is connected to the ring and the bottom plate is connected to the case ( the reference). The capacitor C3 top plate is connected to the tip electrode and its bottom plate is connected to the case. This arrangement and timing stores the positive peak voltage on capacitors C 1 and C3.
During CLK 2 the top plate of capacitor C2 is connected to the case to electrode and the bottom plate is connected to the ring. The capacitor C4 top plate is connected to the case electrode and the bottom plate is connected to the tip electrode. This results in the peak voltage during the negative phase of the excitation being stored on capacitors C2 and C4.
The clock signal phase CLK 3 connects the top plate of capacitors Cl to the top plate of capacitor of C2 with the reference connected to the ground. The top plate of capacitor C3 is also connected to the top plate of capacitor C4. This results in the peak-to-peak excitation voltage on capacitors C 1 plus C2 and peak-to-peak measurement voltage on capacitors C3 and C4.
Numerous alternative circuit arrangements are within the skill of the ordinary artisan and could be employed rather than the circuit described here, but it is believed that it will be advantageous to design the circuit with certain constraints.
Particularly relevant is having the test pulse delivery occur synchronously to the timing of the impedance measurement. Also depending on the location of the electrodes used for measurement, it is wise to consider synchronization to the heart beat cycle and the respiratory cycles or the variation in measurement resulting from measuring at inconsistent times within these cycles may cause insurmountable difficulties in extracting useful signal from the impedance changes created by these cycles.
For example, using the pacemaker as the vehicle for this invention the 3o transthoracic impedance measurement made between a ring or tip and can electrode pair will vary more dw°ing the lileart beat cycle than the expected range for significant edema indicative variation in the DC signal. The same will be true to a lesser extent for the breath cycle. If the impedance measurement is taken in some - other transthoracic vector, the breath cycle may be a greater influence than the heartbeat cycle on the noise. V~Jhere the implant is designed to measure only local edema these heartbeat ~~rld breath cycle noise sources will be less of a problem, especially where the device is to be located in an extremity, but one can certainly design in protections to filter out or otherwise obviate these sources.
(Exertion and movement noise source's are addressed later in this disclosure).
to In one preferred embodi.m.ent in which we want to filter out heart beat variation and/or breathing variation from the DC signal, we would employ a buffer filter circuit 38 so as to find both a excitation path baseline impedance, DCZ
and a measurement path trar~s-impedance DCZX . The impedance of DCZ ( Z) is equal to (Vring-Vcase)/ I ring to case). DCZX impedance is equal to (V tip -V case )/ I
(ring to case).
Filtering can be implemented in this block as desired. Preferably band pass poles of 0.05 Hz to 0.5 Hz can be realized and we prefer a switched capacitor bandpass filter.
Depending on the device configuration, it may be preferable to convert the 2o voltage values to digital values or to sum the values directly over time to eliminate the cardiac component;. in the impedance signal as well as other short duration impedance changes. Baseline impedance can be determined by the following equation.
Z Transthoracic = ~;DCZ+I)C:ZX/2n where n represents an ;adequate sampling over a extended period. The sampling period in preferred emlbodiments should be greater than the longest respiration cycle or at five breaths a minute, and the summation period should be at least twelve 3o seconds. A longer period of thirty two to sixty four seconds would further reduce the respiration component in the measurement signal. Impedance measurements can of course be made at sampling intervals appropriate to the device.
In taking a Long Term Average (LTA) signal especially but also for all signals, the potential for super-long term changes should be recognized and s compensated for as well. A specific example would be the effect of weight gain on the long term edema signal level, and it's differing effects on trans thoracic measurements and those of local measurements. The differences can be used to algorithmically process and remove or highlight the variance over time in the output data, and can then be used to more accurately asses the amount of tissue edema over i o the long term changing condition. This additional processing can be done manually or in a computer system outside the patient preferably, but as processing power needs decrease or clear trends in the data become available, it may become feasible to include this kind of processing to the implant itself, allowing for automatic recallibration over the long term and for additional indications of patient health to 15 be monitored.
In Fig. 5, the timing diagram for switching the CLK switches (CLK 1-3) and their timing in relation to the stimulation signal STIM, are shown. It should be recognized that the current (I) ranges from about 1mA peak-to-peak lOuA peak-to-peak and can be selected depending on the device used for the impedance measurement and other factors which would be apparent to one of ordinary skill in the art. The convenient current reference block 35 of Fig. 3 could be used for this adjustment.
Another preferred way to remove heart and breath cycle noise is to synchronize to the measurement so as to measure only at the same point in the 25 cycles. This is made possible in pacemakers that already use impedance measurements to detect Minute Ventilation (such as can be found in the Kappa 400) pacemakers by Medtronic, or the META DDDR by Telectronics/St. Jude Medical, since they keep track of the breathing cycle and the heart cycle already. By simply adding a trigger signal generator to signal the measurement circuits at a particular 3o value, and then storing the impedance at the time such signal is generated thereby designating it the DC impedance value, the required result is accomplished for that cycle. The trigger signal should preferably coincide with the nearest upcoming preprogrammed measurement tirr~e, preferably at 5 - 15 minute intervals, but anything up to each cy~~le or every hour would be reasonable. The value could be 5 stored and held so long as it doesn't change. (Many alternatives for filtering are available such as using a sampling rate that corresponds to a factor of one of the cycles and averaging the measurements, for example could be used for one or the other of these cyclic major noise sources.) If the filtered impedance value is seen to change sufficiently(most simply determined by comparing it to the last value 1 o accepted for an impedance measurement and determining whether the absolute value of the difference meets a predetermined value minimum), this change criterion can be used to generate a warning or just held for later data retrieval as an additional data point.
If other mean; or circuits are used to determine a propitious and consistent 1 s cycle moment for measurement (other than MV impedance testing pulses and internal cardiac cycle timing values as described generally in the preceding paragraph), such other circuits can be used to trigger a signal in any implanted device. For example, if the device is implanted in a surgically created chest pocket and measures breathing; cycles with a motion sensor, strain gauge on a diaphragm, or other activity sensor and uses electrodes to measure a subcutaneous ECG, the output of these sensors can be monitored to determine periodicity of these cycles and exclude measurements made or prevent measurements from being made during inconsistent parts of these cycles. These variations on the inventive concepts taught here are within the ordinary skill of the artisan in this field to implement without undue experimentation now that t:he invention has been revealed. In the memory and under program control, the device can then respond to the accumulated and processed data to determine appropriate device behavior from a range of preconditioned device behaviors. For example, if the edema level has changed greatly within a short period of time and the pressure values measured confirm that 3o there is a physiologic problem, a drug pump can add diuretic as well as blood pressure medicaments to the patient's body automatically, whereas if the blood pressure has not increased, only the diuretic can be added. These responses could be preprogrammed and modified as an overseeing physician directs.
Referring now to Fig. 4, a circuit block diagram 40 is shown having electrodes SOa-n either situated in leads or located directly on the housing depending on the configuration of the device connected to switching system 49.
The circuit 40 has a stimulation circuit 41 and a measurement circuit 42 connected to the electrodes as appropriate by the control circuit 51. (Of course, if only two or three electrodes are used the multiplexor design can be quite simple or reduced to 1 o a switch mechanism. ) The measurement circuit 42 is essentially the same circuit illustrated in Fig.
3 (circuit 39) wherein the value of the measurement impedance M 1 and the excitation impedance M2 are provided as outputs to a circuit 43 which in Fig.
4's circuit 40 provides a measure of the difference between the two (M1 and M2) to a is long term average circuit 44 and short term average 45. Manipulation of the stored values of long term and short term average circuits 44 and 45 which in the preferred embodiments are multiplace register circuits for holding digital values, is accomplished in a comparison circuit or combination circuit 46, which in the preferred embodiment subtracts the short term average value from the long term 2o average value providing as output a sign and absolute value to a physical event detection criteria circuit 47 which in turn provides an output signal to a output circuit 48 which enables the useful application of this value to the patients health.
The measurement circuit 42 is adapted to have input to the preferred embodiment from a synchronization circuit 52 and a trigger and /or sampling 25 frequency circuit 53.
The synchronization circuit can only exist in those preferred embodiments in which the device itself makes a determination of the timing of either respiration, Rwaves, or Pwaves so as to make the sample measurements at the same points in those cycles. A trigger device could be used if desired so that a patient may 3o activate the storage of a event (i.e.), these measurements were made around the time of the activation) a.t a given time or an attending physician or automatic device may be provided to do so. A sampling frequency circuit can be provided also based on a clocking device within the inventive device such that it determines the time appropriate to take a sample reading.
In all preferred embodiments we would prefer to make measurements during the rest periods of the patient, since this time obviates the need to remove muscle movement and body activity noise sources. Where this is not possible, the addition of activity sensors and common mode rejection of EGM or other signals from the measurements should be: employed.
to The control circuit 53 is preferably adapted to fire the stimulus circuit so as to deliver a programmable output and pulse width designed to obtain the maximum useful signal. If a circuit like circuit 40 is found in a pacemaker type device and Bipolar leads are used within thc: Atria and Ventricle, M1 is the value of the Unipolar impedance anal M2 is the value of Bipolar impedance. However if a unipoIar lead is used, NI2's value is zero.
Circuit 47 in the preferred embodiment operates by determining if the sign is positive and the value i;~ greater than a programmable percentage of the long term average (or some other programmable value determined to be appropriate) If this is true, circuit 47 will cause a detection signal to be generated. A memory circuit 2o may be provided to store short term and long term average values as well as data from any of the circuits, other sensor outputs, or output paths . These data may be useful for diagnostic purposes in the patients future.
It will now be apparent tlhat not only a single data point (LTA-STA) can be used to determine the extent and progression of the edema. A chart or history of the impedance (LTA-S7'A) versos time could be used to determine the effectiveness of drug therapy by including an index circuit or memory circuit with comparative values in the device. A determination of how severe the disease is by how quickly the edema progresses (i.e. if the change was seen over the course of two weeks, versus one day) becomes a measure that has value to the patient and physician and can be a stored value kept in a memory circuit by a device made in keeping with this invention.
With respect to configuration of the electrodes 50, preferred embodiments include four electrodes with one common electrode, three electrode's, and two electrodes. (Reference to other potential electrode configurations was described above at page 6) The determination of pulmonary edema or local edema will be based upon comparison of long term average impedance value compared to the short term average value. A discrimination of pulmonary edema from local edema (or the location of the edema) could be made by comparing the change in the 1o LTA-STA in the local (pocket located) electrodes compared to the change in the LTA-STA in transthoracic electrodes.
The number of samples for long and short term averages are dependent upon the sampling frequency. As we mentioned above it is up to the reader to chose a preferred sampling rate, but examples of sampling rates having some usefulness would include 5 minutes, 15 minutes, 1 hour, 2 hours, 1 day, and so forth. It depends on the capacity of the device battery to continue to make measurements and the period of time preferred to monitor that the selection of periodicity is based on.
If it is sufficient to sample only when the patient is asleep, once a day may be enough. Long term average preferably represents the number of days (in the most 2o preferred embodiment three to thirty) while the short term average represents the number of hours (preferably one to forty-eight). However, if the device is expected to detect very short term rises in impedance, a short term value should be measured in minutes and long term in less than a week. This kind of measurement timing set-up would accommodate the rapid rise that sometimes hospitalizes patients after 2s eating a salty meal, for example, allowing a warning to be generated or direct intervention started without the need for hospitalization. When the difference between the average signal value of the long term average storage circuit verses the value in the short term average storage circuit reaches a critical level (which should be programmable for the particular patient and adaptable during implant), a 3o determination is made that the edema is problematic. Other circuits or processes n :~ r could be used to make this kind of discrimination to avoid noise, whether cyclic or transient. In general these can be referred to as noise discrimination circuit processes since they may require use of data processing techniques or analog circuitry or both to implement the noisc reduction plan. Both types of design are known to those of skill in this art and suggestions for preferred forms have been suggested already.
It is~worth mentioning for completeness that any of the data stored in the device memory is read out by telemetry preferably. Many types of communication with implanted devices is lmown including telemetry from the pacemaker art, 1o including US Pat. No. 5,354,319, issued to Wyborny or 5,324 315 and 5,292,343 and x,117,825 issued to Grevious et al, amongst many others. For example, the US
Pat. No. 4,987,897 issued to Funke describes a communications system that uses the body as a transmissions medium. Since many are known and available, it is therefore sufficient to state that any means or apparatus system could be used to read out data collected by a device such as the ones described herein without deviating from the intent of this inventive teaching. We prefer the standard pacemaker telemetry approaches for our preferred embodiments but only because they are the most familiar.
2o It should also be noted that a patient trigger or activator can be used by a communications apparatus in conformity with the last paragraph to which a button or other patient manipulable device is attached to signal the implant to begin data readout, store a more complete form of data representing perhaps more measurements per unit time after the trigger is activated, and so forth. This kind of device could also be employed to enhance transtelephonic communication with a medical care provider if it only additionally included apparatus to connect the activator to the telephonic network.
Such a device could advantageously be like the device WD in Fig. 6. It would merely require a handy user interface like a button, switch or knob and 3o perhaps lights to acknowledge the trigger and so forth. Alternatively by tapping on the body in the vicinity of the device or holding a magnet over it or some other activation scheme known in the art may be used.
Additional triggers for storing data on measurements made at the time of a trigger signal could be automatic, based on regular measurements made by the 5 implanted device. For example, if a doctor believes a 10% change in LTA over a two week period should invoke hospitalization, he could set such a trigger in the implanted device memory. The device then would incorporate an automatic process for checking the data against the automatic trigger values, and when the comparison indicated a trigger condition, cause activation of either a readout, or an alarm or a to change in the type of measured data stored, depending on how the device were programmed. Alternatively, of course, this automatic trigger could be located in the external device that reads out the data from the implant. This would be preferable in most situations since the external device need not be as power constrained as the implant. Thus it could process the data more cheaply for a 15 determination of whether the automatic trigger values have been reached.
There are, of course many kinds of automatic rigger mechanisms that can be used, including the reaching of an absolute measurement value, pattern matching with an overall change in values plus reference to an absolute value in a limited time, absolute change between the LTA and STA values and so forth. Any of these can 2o be factory set or set by physicians/attendants in the field, and if transtelephonic communications are used, from remote locations.
Trend data retrieved from the implant's memory can be used to chart the variation over time between the two values (LTA and STA) or any other stored values, which could be used to enhance the diagnostic value of the data for the physician.
Refer now to Figs. 8 and 9 in which the more generalized forms of the invention are illustrated, a block diagram 80 having a similar input/output setup to circuit 40 of Fig. 4, such that the impedance stimulus pulses and measurements may be gathered through the same electrode system, that is, in Fig 8, electrodes 8Ia-n 3o and multipiexor or switching circuit 82. In this more generalized device, a bus or set of connections transports digital signals between functional elements of the device including the m.icrocontroller or processor 87/86, respectively, a memory 88, the impedance stimulus circuit 83, the impedance measurement circuit 85 and the other sensor circuits 89. With these parts a device can have the controller 87/86 schedule the delivery of any stimulation pulses needed and their intensity to each of the sensor systems 89a. or 89 when such stimulus is required and allow for the transport of measured data from such systems, as needed also. A control and storage mechanism ma.y be a unitary memory or a plurality of memories here illustrated as memory .88. The ~;.ontroller would allow sensor data to be routed to to memory for storage and later c:o nmunication to the world outside the implantable device through a telemetry subsystem 99. One of ordinary skill in the art is familiar with how to employ such components to build a system as described. In fact, some variation can be easily introduced, such as having all sensor subsystems communicate analog data to a single analog to digital converter(not shown).
The way it is illustrated in Fig. 8 A/L> conversion and it's converse are made part of the sensor subsystems as illustrated in the edema measurement subsystem 89a by having AID and D/A circuits in the measurement and stimulus circuits.
For convenient reference the kind of data available from sensor subsystems (89) would be ECG data, marker channel data, other device state data, pressure, 2o pedal impacts, activity, body position, temperature, heart rate, (or when compiled over time) heart rate variability, .heart events {fibrillation or tachyarrhythmia episodes and their frequency and duration), respiration, blood oxygen levels, patient symptoms monitor triggered measurements due to patient activation by a patient monitor activator (which could be a part of device WD in Fig 6, for example) as well as the described in detail pulmonary or transthoracic edema and local edema related impedance values or an,y other sensor subsystems and combinations thereof that are now available. It is ever. possible to use the inventive concepts described herein for these other sensor subsystems without edema if desired.
Fig. 9 illustrates the general flow 90 of progress in developing diagnostic 3o data from each of the sensor subsystems and can be incorporated into highly a complex algori~s for rrmltiple subsystems and for coordinating the storage and m~asuremen~t of all sensor data. Beginning with the data gang stage, if a stimulus pulse is roquirod it is given aid the measurement is made 91. No atimnlns pulse would be required for exa~le is an aarvity sensor that was self reporting.
s These values are scored in the dcvicx m~orlr 92, and then acted upon according to a program or circuit 93 that locates the u~a~sure~~t vahies in relation to or with r~pax to time and oth~i sensor measnran~ This program can have bras to alarms or initiation roaring to change the behavior of as implanted device basal on the values scared at this stage if desired. Iin this stage also,. calibration agaimt to ~ ' stored referee valves of stag upon near refer~oe vahies is handled.
If changes are raduired, say for example in the level of stimulus requira~ to elicit useful sensor response, they are detaminod at the neat step 94. Such changes in the value of the stimulus test pulses can be due to customizaation needs for a particular pati~t, to optimize the Signal-to Noise Ratio(SNR), to prevent accidental 1s or unwanted local muscle stimulation, etc. Alternatively, the excitation and ~asur~~at paths (which bodes are selocted for stimulus and measurement) should be switchable to determine the location of the edema and as part of the algorithm for detxting changes in edema, or simply to improve the.SNR. The program will then execute these changes, wait for the next appropriate time to take 2o a measurement from this sensor subsystem and return to step 91.
Fig. 6 Illustrate a patiatt body B having an implanted device in accord with the invention ID for determining a value of importance indicative of edema.
For example purposes also ilhtstrated implanrable device OD, as illustrated here, a pacanaker having a lead L.
25 In the clinical se~g the doctor will use a programmer device which is either a hand held unit like the PH unit which is held in proximity to the body B or a hand held device associated with a larger "programmer" which in common use is similar in power to a personal computer running an Intel 80486 or ~Pentium*
processor. 3'his unit is illustrated heuristically here with the numeral D2, connected 3o to the telem~ry containing head PH by a conaaxor cord C. S~bstanbal diagnostic *Trade-mark testing and processing .can be done, giving the patient stress testing, drug treatments, and so forth with the doctor in attendance since the immediate data from the implant can be acceased andl used by the physician to test the body's physiologic responses to various test conditions. Various configurations of D2 and PH with s respect to telemetric co~mmunic,ations to implants are well known and any such systems could be exploited for ~hi.s invention. The new data now available from the implanted inventive de~~ice ID enhances this physician function by providing an edema and edema history signal. containing data about the changes in the edema parameter over time to the physician. This data can be processed with data from other implanted sensor s which may be distributed between the implanted devices OD and ID, etc., or all from one device, such as a pacemaker like device OD.
It is already known in the ant to have and use implantable sensors to monitor and record data including activity sensed, heart rate, heart rate variability, respiration, minute ventilation and variability of, arrhythmia frequency and duration, averages of these 1s values over long term, pressure at various sensor locations, 02 saturation at various sensor locations, time located patient activated data records for holding various pieces of these data sets around a temporal marker set by a patient activated signaling device(which could be incorporated into a device such as WD, or some other convenient unit) for diagnosing patient symptoms, and so on. However, the 2o use of an impedance sensor dedicated to generate data specific to edema conditions and history has not heretofore been seen. Combining these edema measurements with any of these other signal data provides an enhanced diagnostic and patient management efficacy to all the devices that can be used in the Fig. 6 environments.
For example, the ID device could contain a looping memory activated by trigger 25 signals sent either through a patient activator (which advantageously can be located in device WD) or by physiolagic signals generated by one of the sensor systems (systems 89 or 89a of Fig. 8).
Continuing to refer to Fi:g. 6, the inventive implantable device ID can also be used in settings remote from direct physician contact to further its usefulness. A
3o wearable device WD can be used to extend the communications range without i~ l d ~ I ...._,_...

substantially it~sing ba~ay usage by the implant 1D for sending communication signals. A patent illust<atmg this concept is U.S. patent No. 5,113,869 showing that a wearable device ~uld be used in such a manner. As power considerations change and oommttnicatioa w implants b~oo~,s less costly, it is feasible to eliminate an intermediate device such as WD, btrt for the foracrable future such devices are eto be used for yoaic communications with implarus.
A borne monitor device such as D 1 may be kept in a location within range of the oo>mnuiueatiom c~abilities of the device WD anti oo~max to a tell lip TL
system to a telephony or cortnmuaications network T (which may be worldwide in ~ scope) or fbuough otlur communications c~am~els not shown to reach a devicx that is -located at a physician station, hospital or clinic and which can perform the same fumxions descn'bed for the pmdevice (D2) above.
Preferrably, devicx D3 can also comtaunic~te through the telephone or radio frequency chapel to the wearable device WD. In this way too, this communicated is information could be used to modify the functioning of the implanted devices, OD
and/or 1D. These changes could be modification to data collection methods, type of data collected or trigger release values for drug or swmrlation therapies.
In some preferred embodiment devices we would ttse the respiratory rate as an indicator of edema or lung water. This can be monitored long term like the DC
2o impedance signal, but instead of filtering out the respiration signals as noise, we would for these devices use the respiration varied impedance measures to determine breath rate. It is well known how to do this. Medtronic produced two pacemakers, the Legend bus*series and the Kappa*400 more rxe~tly that m~asvre mite -ventilation, which requires a ddermiaation of a breathing rate to provide a rate 2s response funcxioa. Another called the RDP3 or MB-1 was reported in "Rate responsive Pacing with a Pacemaker that detects respiratory rate (Biorate);
Clinical advantages and complications," by Lau et al, CLINICAL CARDIOLOGY, May, 1988, 11(5) p318 24, ISSN 0160=9289, Therefore it can readily be seen that determining respiration rate is not outside the skill of those of ordinary skill in this 30 -art. Ia our device we use the signals described above for counting breaths. An *Trade-mark equation representative. of how this function works is Respiratory Rate =
Minute Ventilation divided by TV, where TV is the maximum value of DCZ.
It is up to the designer of the device, of course, but alternative methods are available to generate a reliable respiration rate signal; for another example see 5 Plicchi and Canducci, US Pat. No. 4,576,183. All that is required is that a reasonably reliable count of respiration per unit time be maintained and reviewed on an ongoing basis to determine the change vector. A single memory element could be used to record whether each sample is moving up or down in rate if desired, but we prefer to keep some: value taken at several measurement so that the data can be to relayed to a doctor for careful analysis.
It is expected that measurement over sleep periods, with reduced muscle movement artifacts will yield a cleaner signal, so we prefer using an additional trigger to time the measurements to occur during the patient's sleep cycle. A
choice of a suitable sleep trigger is up to the designer, but it could be done in a t5 number of ways such a.s waitinl;(perhaps based on a timer and a timeout period) for a period of, say, 15 minutes in which no noise artifacts show up in the signal, timing the sampling periods tocorrespond with the patient sleep times using a hour clock in the device, and so forth. Many other devices and methods for determining sleep periods are known and may be applied here if desired.
2o A uniquely valuable enhancement would be the addition of an algorithm to detect Cheyne-Stokes respiration which often is present during sleep as a well known indicator of fluid build-up. By simply monitoring for rapid respiration rates and then closely observing the respiration signal after short episodes of rapid rates, one can easily generate: a marker in memory to indicate that such an episode has 25 occurred when shallow breathing or absence of breathing is detected after bursts of high respiration rate.
To exclude from consideration for edema monitoring those rises in respiration rate that occur because of patient exercise or other activity, we use an activity sensor like the activity crystal sensors or accelerometers commonly used for 3o activity measurement in modern pacemakers to generate a signal indicative of patient activity Level. If the level respiration rises only during or after periods of indicated increased patient activity, the value of a signal based on respiration rate should be decreased. The respiratory rate taken during periods of no activity is preferred to measure long-term breathing rate trends . In the preferred embodiment we use a Respiratory Rate/Activity or Accelerometer Parameter coefficient that is calculated on a daily basis . Thus two independent values are generated. One value is generated for activity and a value is generated for respiration rate and the ratio of these two is monitored. A change in this ratio causes an increase in the value used to indicate a troubling rise in edema. In other words, the change may indicate to more or less breathing during exertion, thus indicating an improvement or deterioration in lung fluid levels.
A device can be constructed using the respiration rate as described alone or in combination with the DC impedance measurement of edema described above.
If both are used a mixed value should ultimately be relied upon to indicate the level of edema the patient is subjected to. Many ways can be devised to combine these signals, including simply adding them throughout the potential range and using the total value for the indicator; relying on one measure only, in situations where it is superior, or simply recording both separately and reporting them out through telemetry for analysis together by a doctor or other attendant (human or automatic).
2o Alarms can be initiated thorough whatever patient or doctor communication system is used with the device at whatever level is programmed in for the variable or variables used to evaluate these measures of edema.
In our most preferred embodiment, we would use a combination of breathing rate rise over 10 % per 24 hour period with or without any indication of DC impedance measurement as sufficient to generate an alarm. Likewise a 20 %
rise in edema measured by DC filtered signal value should suffice to generate an edema alert alarm. Finally the presence of a newly discovered Chyene-Stokes episode or, if expected, perhaps the appearance of two Cheyne-Stokes episodes in one 24 hour period or one with either of the other just mentioned edema signal 3o value percentage changes should be sufficient to generate the alarm.

In situations where the device is communicating with or a part of a therapy delivery device, response to edema levels, however measured may be used to trigger or adapt therapies, in any situation described above with reference to the alarm.
In Fig. 10, an idealized implantable device 110 is illustrated heuristically with a body compatible shell 110b (which could of course be composed of Titanium or ceramic, or any other body compatible material suitable for housing an implant in a living body) surrounding its component circuits 111-124 and any others desired (but not shown here) by the designer of the device 110 to supplement the inventive 1o circuitry arrangement described herein. For evaluation of impedance measurements to derive a respiratory ,rate signal one requires an impedance measurement circuit 111 connected to an electrode means on the shell or a lead or similar appendage attached to the shell (he;re illustrated as two bumps 110a) and a circuit to evaluate changes in the value of the impE:dance measurements over time. As is well known is in the art (and mentioned above implemented in present pacemakers), The impedance measurement can find a value for a respiratory rate signal from counting breaths represented by an approximation of a sinusoidal variation in the impedance occurring within the pa~tential range of breathing rates. In Fig 10, this determination of respiration ratf: occurs in the circuit 114. It should be understood 2o that this ability to determine breathing rate is known in the art through at least the methods described in L:~S Pat. I\fo. 4,576,183 (Plicchi and Canducci) and 5,271,395 (Wahlstrand et al.). Generally in block 114 a circuit should provide conversion of an AC impedance signal from the change in impedance tot a respiration rate through bandpass filtering, zero-crossing detection, and if desired, template matching of the 25 digitized waveform. Any design that gives a fairly accurate assessment of respiration rate is acceptable, however.
For completeness(in some embodiments), a DC value of Z may be maintained to take advantage of the potential for determining edema directly from the changes in the impf;dance signal as described above, and this function occurs in 3o Fig 10 in circuit 112.

A memory circuit is provided in device 110 which herein is illustrated as being in 4 potential parts, memory circuits 113, 115, 119 and 123. Of course the designer may subdivide or consolidate a memory circuit in any way desired and this is indicated in Fig 10 by the dotted line 116, suggesting by way of illustration that the configuration of the memory circuitry is best left to the final designer of a particular implementation of this invention.
A timing or clock circuit 125 should be provided to coordinate the storage of data related to each evaluation so that histories of such data can be maintained. As illustrated here, the DC impedance is stored as a secondary or second value set of edema values in memory I13, the respiratory rate values in memory 115 and the respiratory rate change that indicates an edema value (here a primary or first edema value)is stored in memory 119.
An alternate and independent activity sensor and associated signal value generation circuit I22(any known kind could be used) may be provided for a preferred embodiment. This activity sensor and value generator can have its own historical values stored in a piece of memory too, here memory 123.
At any time desired in accord with the needs of the preferred design, the current value of any one of the stored values can be compared to a current or past value of either the same the same or any other one of the stored values. This means 2o that the change in rate, as found in circuit 117 can be used to evaluate the respiration rate, and that the respiration rate can be compared. If desired a memory controller 127 can coordinate these evaluations according to a program that may also be in software stored in the memory, but currently in preferred designs hardwired circuitry (not shown) cycles through comparisons required by the particular design. In this way the illustrated flexibility is compromised for cost reasons. The comparitor circuit 117 output should be qualified by an evaluation circuit 120, preferably each time a comparison is made to determine if the results of that comparison indicate a need to generate other signals that trigger an alarm or a readout or a therapy, depending on the configuration of the device. For example, if 3o the respiratory rate has risen very quickly (thus meeting a criteria stored in or accessible to circuit 120, a signal should be sent to the Cheyne Stokes indicator circuit 121 to see if the change should generate an alarm. If circuit 121 determines that it is appropriate it :should send a signal to the transceiver circuit 12b to perform its function suitable to receiving a signal from said CS indicator circuit 121. Circuit 126 may be a circuit to transmit data through telemetry to a device adapted to receive such telemetered data outside the body as illustrated in earlier Figs., or it could be a simple alarm. that vibrates or generates a sound from within the patient.
It can be triggered by the evaluation circuit any time appropriate criteria are met by the output of the comparitor circuit 117, all of which are described above.
to Additionally circuit 12E~ may readout the memory contents or parts thereof on receiving an inquiry signal from an external device, or automatically telemeter out data based on an the ex~?iry of a timer or other signal generated by clock circuit 125.
As with any imylanted device there should be a source of power, here illustrated as power supply 124, which of course could be a battery or power generator of any kind suitable for powering implanted devices, so as to supply power to the circuits used in the device and to generate pulses for impedance measurement.
In Fig. 11 a flow diagram 130 illustrates a method for using the measure of 2o respiratory rate over time to generate an evaluation of edema or lung water. It is assumed that he impedance measures are made in the thoracic region of the body by an implanted device as ~describeci above.
Step l la measures the impedance and stores the history, repeating itself continuously as indicated by the curved arrow. In Step l 1b, each breath count is determined by review of the history of impedance measurements. A rate is then determined and stored as a current in Step i lc. On their own appropriate cycle times, as would be app~irent to one of skill in this art, both steps llb and l lc iterate and store their determined value, as history. As can easily be appreciated, the past history of a prior step rnay be il;nored once a new datapoint is generated by a later step if the only data desired is that determined in the later step. Thus history memory circuitry can be conserved.
In Step l 1d, the history of respiratory rate from l lc is evaluated. Here a determination is made as to whether it is tending faster or slower and whether it 5 meets preestablished criteria to proceed to step 11 a and to generate an alarm. If the device in which this method is used does more than generate an alarm, it should readout the storage for analysis by a health professional, Step l 1f. The preestablished criteria can be stored in the device during manufacture or may be set and reset by an attending physician depending on patient conditions. They may, of 1o course, be comparative criteria indicating simply a vector of edema measurements or may be combined with other physiologic indicators as described above to establish more complex or more reliable criteria.
An easy way to turn the data into diagnostically useful data is to store a respiratory rate to activity level parameter history longitudinally over time.
Then t5 an edema level indicator circuit can generate a signal value representative of whether edema or lung water is worsening or improving, based on evaluation of said parameter history. The doctor can simply look at the change in this value over time to assist in his care of the patient. This could be called simply a measure of patient health, rather than edema since respiratory rate may correspond to other 2o simultaneously occurring changes in patient physiologic condition.
The invention as described and illustrated herein is only limited by the following appended claims.

Claims (25)

CLAIMS:
1. An implantable edema monitoring device having:
an impedance sensor for making impedance measurements in a living body into which said device is implanted, and memory and evaluation circuitry means for monitoring said impedance measurements, and for generating a value representative of respiratory rate based on evaluation of said impedance measurement over time, edema value generator circuitry means for monitoring changes in said respiratory rate value, so as to generate an edema level value indicative of a measured value of edema in said living body based solely on said changes in said respiratory rate value.
2. An implantable device as set forth in claim 1 further comprising edema evaluation circuitry for storing at least two edema values taken over time and comparing these at least two edema values to so as to determine whether and in what direction a change in edema may be occurring.
3. An implantable device as set forth in claim 1 further comprising edema memory circuitry means for recording changes in said edema value for later transmission to a second device adapted to receive such information outside the body from said implanted monitoring device.
4. An implantable device as set forth in claim 1 further comprising an alarm means for generating an alarm based on predetermined changes in said edema level value.
5. An implantable device as set forth in claim 1 wherein said memory and evaluation circuitry means for monitoring said impedance measurements senses DC changes in impedance indicative of interstitial fluid build-up and generates a second edema level value signal indicative of the presence of edema, based solely on this DC change, with said respiratory rate filtered out.
6. An implantable device as set forth in claim 5 wherein said device further comprises an alarm generator means for generating an alarm based on predetermined changes in both said edema level value and said second edema level value signal.
7. An implantable device as set forth in claim 1 and further comprising determination circuitry means to determine if said respiration rate value exceeds a Cheyne-Stokes (CS) minimum value and if so, then determines if after a predetermined period of exceeding said minimum and if said respiration rate then falls substantially, to generate a CS episode indicator signal to indicate that an episode of Cheyne-Stokes syndrome has occurred.
8. An implantable device as set forth in claim 1 further comprising:
sensor and evaluation means for evaluating a level of patient activity independent from impedance based measurement of respiratory rate and generating a value for said level of patient activity, and memory storage circuitry means for storing respiratory activity and said activity level value or a ratio thereof over time.
9. An implantable device as set forth in claim 5 further comprising:

sensor and evaluation means for evaluating a level of patient activity independent from impedance based measurement of respiratory rate and generating a value for said level of patient activity, and memory storage circuitry means for storing respiratory activity and said activity level value or a ratio thereof over time.
10. An implantable device as set forth in claim 9 wherein said device further comprises a storage circuit for storing a respiratory rate to activity level parameter.
11. A device as set forth in claim 10 wherein said parameter is a ratio and a timing circuit causes said parameter to be stored on a daily basis.
12. A device as set forth in claim 10 wherein said parameter is a ratio and having a second physiologic indicator sensorcircuit for generating a second physiologic sensor level signal for communication to a storage trigger circuit for generating a trigger signal to cause said respiratory rate to activity level parameter to be stored in said storage circuit when said second physiologic indicator sensor circuit determines a second physiologic indicator signal matches a predetermined trigger condition.
13. An implantable device as set forth in claim 10 wherein said device further comprises a storage circuit means for storing said respiratory rate to activity level parameter historically, longitudinally over time and having an edema level indicator circuit for monitoring said parameter level longitudinal history to generate a signal value representative of an amount of worsening or improving edema based on evaluation of said parameter history.
14. An implantable device as set forth in claim 1 and having a circuit process for discriminating impedance noise signals generatable by said living body's electromyographic and motion signals so as to remove the noise signals such body activities would otherwise introduce into said impedance measurement signals.
15. An implantable device as set forth in claim 14 wherein said circuit process for discriminating impedance noise signals comprises a rest cycle determining timing circuit means for generating a timing signal to limit impedance measurements to times that the body is determined by said rest cycle timing and determining circuit means to be at rest.
16. An implantable device as set forth in claim 1 wherein said memory means stores data related to significant events and history of impedance measurements.
17. An implantable device as set forth in claim 1 and having power generator means for continuous long term operation of said device.
18. An implantable device as set forth in claim 1 and having programmable output values of impedance pulses.
19. An implantable device as set forth in claim 1 and wherein the impedance measurement is switchable between more than two electrodes to obtain best position for signal to noise.
20. An implantable device as set forth in claim 1 wherein said device housing additionally houses or communicates with an implanted device of the kind listed:
Pacemaker, Implantable Defibrillator, Drug pump, Loop ECG
recorder, hemodynamic parameter recorder/monitor.
21. A device as set forth in claim 9 wherein said sensor and evaluation means is used to remove from consideration those respiratory rate signals not taken at rest.
22. A device as set forth in claim 1 further comprising an activation circuit for activating drug therapy responsive to impedance value changes.
23. A method of determining patient pulmonary edema comprising:
storing a history of respiratory rate in an implanted device, monitoring changes in the respiratory rate of the patient, determining a level of edema based on said changes in said respiratory rate that have occurred during said monitored history.
24. A method of determining patient pulmonary edema comprising:
storing a history of respiratory rate in an implanted device, monitoring changes in the respiratory rate of the patient, determining a level of patient health based on said changes in said respiratory rate that have occurred during said monitored history.
25. An implantable edema monitoring device having:

an impedance sensor for making impedance measurements in a living body into which said device is implanted, and memory and evaluation circuitry means for monitoring said impedance measurements, and for generating a value representative of respiratory rate based on evaluation of said impedance measurements over time, patient health value generator circuitry means for monitoring changes in said respiratory rate value, so as to generate a patient health level value indicative of general physical health in said living body based solely on said changes in said respiratory rate value.
CA002278193A 1997-01-31 1998-01-08 Impedance respiratory rate measuring edema monitor Expired - Fee Related CA2278193C (en)

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US08/792,204 1997-01-31
US08/792,204 US5876353A (en) 1997-01-31 1997-01-31 Impedance monitor for discerning edema through evaluation of respiratory rate
PCT/US1998/000040 WO1998033553A1 (en) 1997-01-31 1998-01-08 Impedance respiratory rate measuring edema monitor

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