Adik

09/30/2010
Mrs. Ma. Margarita Maraña

NCM 103 Lecturer
Level III
Dear Mrs. Maraña,
I would like to inform you that I will be joining the group 1 Team B Section Bravo
1for the case presentation. I failed to join my group for case presentation because of my
previous hospitalization last Sept. 3-7, 2010. This is the reason why I wasn’t able to
comply with my case presentation duty hours during our scheduled duty.
Our case presentation will be this coming Tuesday dated Oct. 5, 2010. I am
hoping for your kind consideration
Respectfully Yours,
Sheena Rose A. Tales
Noted By:
Mrs Ma. Margarita Maraña

Level III Lecturer
Approved By:
Liza T. Chan
Level III Chairman
generally known as electrode motion artifact, an intermittent and
generally aperiodic signal component which results from
mechanical deformation of the electrode/skin interface.
Summary
Knowledge of respiratory patterns would be clinically useful in

many situations in which the ECG, but not respiration, is routinely
Several years ago, Pinciroli[1] began studying methods
monitored. We describe a signal-processing technique which
for determining the direction of the axis, in order to create ``virtual
derives respiratory waveforms from ordinary ECGs, permitting
ECG leads'' which would represent what might be obtained from
reliable detection of respiratory efforts. Central and mixed apnea,
electrodes fixed in position relative to the heart. We expected that
hypopnea, and tachypnea may be identified with confidence. In
fluctuations in axis direction measurements would reflect the
many cases, obstructive apnea and changes in tidal volume are also
physical influences of respiration on the ECG, and began a study to
clearly visible in the ECG-derived respiratory signal (EDR). We
determine if these measurements could be used to derive
compare examples of the EDR with conventional respiration
information about respiration.
measurements. In the context of multiple-lead arrhythmia
detectors, the additional computation required for recovery of the
EDR is insignificant. The technique is applicable to both real-time ECG-derived respiratory signals
monitors and tape systems, requires no supplementary transducers
or hardware modifications, and yields significant information of
This relationship was confirmed by comparing axis direction
clinical value.
measurements with simultaneously recorded measurements of
chest circumference using a mercury strain gauge; later studies
Relationships of cardiac and respiratory rhythms used pneumatic respiration transducer (PRT) measurements. Axis
direction measurements based on chest electrodes correlate better
with chest circumference and impedance than with abdomen
The clinical significance of certain cardiac arrhythmias can be
measurements, or with direct measurements.
understood only with reference to respiration. The normal
respiratory cycle is accompanied by changes in autonomic tone
which modulate heart rate, causing sinus arrhythmia. Apnea may Although many techniques for measuring the direction of the axis
be associated with tachycardia, increased ventricular ectopy, or work well, we found that shown in figure 2 both accurate and
asystole. Stress, congestive heart failure, and chronic lung disease computationally simple. After subtracting the baseline, the area of
may result in both tachypnea and tachyarrhythmia. Thus, each normal QRS complex in each of two leads is measured over a
simultaneous observation of the ECG and the respiratory cycle fixed window (the width of which is determined during the
over long periods is often clinically useful. learning phase of the ECG analysis program to match the interval
from the PQ junction to the J-point of a normal QRS). Area
measurements such as these are made routinely by many
Respiration monitoring techniques
arrhythmia detectors, either for direct use in feature-extraction
approaches, or for normalization in template-matching methods.
Methods of respiration monitoring fall into two categories. Devices Since the window width is fixed, the area is proportional to the
such as spirometers and nasal thermocouples measure air flow into mean amplitude of the signal, hence to the projection of the mean
and out of the lungs directly. Respiration can also be monitored cardiac electrical vector on the lead axis. Assuming that the leads
indirectly, by measuring body volume changes; transthoracic are orthogonal, the arctangent of the ratio of the areas measured in
inductance and impedance plethysmographs, strain gauge the two leads gives the angle of the mean axis with respect to one
measurement of thoracic circumference, pneumatic respiration of the lead axes. If the leads are not orthogonal, a systematic but
transducers, and whole-body plethysmographs are examples of harmless error in axis direction estimation results from this
indirect techniques. Each method has unique advantages and computationally convenient assumption.
disadvantages. Direct measurements are the most accurate, but
interfere with normal respiration. The whole-body plethysmograph
In order to evaluate the technique, and to explore its limitations,
can be highly accurate and does not interfere with respiration, but
simultaneous recordings of EDR and respiration signals were made
requires immobilizing the patient. Other techniques require
in the sleep laboratory at Beth Israel Hospital in Boston. Two
frequent recalibration but the transducers (belts or electrodes) do
roughly orthogonal ECG chest leads, and chest and abdomen PRT
not significantly burden a stationary patient; these are the only
signals, were recorded for each of seven patients who were
methods suitable for ambulatory respiration monitoring.
referred to the laboratory with diagnosed or suspected sleep
apneas. Of this group, obstructive apneas were recorded in four
Measurement of mean axis direction patients, including one who also had mixed apneas; central apneas
were observed in a fifth patient, hypopneas in a sixth, and the
seventh patient had normal respiration. Twenty-nine hours of
ECGs recorded from the surface of the chest are influenced by recordings were analyzed using a two-lead arrhythmia detector[2]
motion of the electrodes with respect to the heart, and by changes which had been modified to calculate the EDR.
in the electrical impedance of the thoracic cavity. The expansion
and contraction of the chest which accompanies respiration results
in motion of chest electrodes. Short-term changes in thoracic Figure 5 shows a central apnea, as seen from the chest PRT and
impedance reflect the filling and emptying of the lungs, a from the EDR. The central apneas observed were easily
phenomenon which is the basis of impedance plethysmography. identifiable in both signals.
These physical influences of respiration result in amplitude

variations in the observed ECG (figure 1). In terms of the
equivalent dipole model of cardiac electrical activity, respiration
induces an apparent modulation in the direction of the mean
cardiac electrical axis. This phenomenon is independent of what is

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09/30/2010

Mrs. Ma. Margarita Maraña

Dear Mrs. Maraña,

Sheena Rose A. Tales

Mrs Ma. Margarita Maraña

Knowledge of respiratory patterns would be clinically useful in

These physical influences of respiration result in amplitude

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