text:
|Publication number
|Publication type
|Application number
|Publication date
|22 Jan 2008
|Filing date
|15 Dec 2003
|Priority date
|5 Nov 1993
|Fee status
|Also published as
|Publication number
|Michael Berthon-Jones
|Original Assignee
|Resmed Limited
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (108), Non-Patent Citations (1), Referenced by (19), Classifications (26), Legal Events (3)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a divisional of application Ser. No. 09/484,761, filed on Jan. 18, 2000, now U.S. Pat. No. 6,675,797 which is a continuation of application Ser. No. 08/950,322, filed on Oct. 14, 1997, now U.S. Pat. No. 6,029,665, which is a continuation of application Ser. No. 08/335,118 filed Nov. 4, 1994, now U.S. Pat. No. 5,704,345.
This invention relates to the detection of the occurrence of an apnea (i.e. the complete cessation of breathing) and to the determination of airway patency. The condition of patency of the airway is the converse of a total obstruction of the airway. The invention also relates to the detection of partial obstruction of the airway (i.e. obstructed breathing). The detection and monitoring of apneas, airway patency and obstruction is advantageous in the diagnosis and treatment of respiratory conditions that have adverse effects on a person's wellbeing.
The expression "airway" as used herein is to be understood as the anatomical portion of the respiratory system between the nares and the bronchii, including the trachea. The expression "respiration" is to be understood as the continually repeating events of inspiration (inhaling) followed by expiration (exhaling).
In the Sleep Apnea syndrome a person stops breathing during sleep. Cessation of airflow for more than 10 seconds is called an "apnea". Apneas lead to decreased blood oxygenation and thus to disruption of sleep. Apneas are traditionally (but confusingly) categorized as either central, where there is no respiratory effort, or obstructive, where there is respiratory effort. With some central apneas, the airway is patent, and the subject is merely not attempting to breathe. Conversely, with other central apneas and all obstructive apneas, the airway is not patent (i.e. occluded). The occlusion is usually at the level of the tongue or soft palate.
The airway may also be partially obstructed (i.e. narrowed or partially patent). This also leads to decreased ventilation (hypopnea), decreased blood oxygenation and disturbed sleep.
The dangers of obstructed breathing during sleep are well known in relation to the Obstructive Sleep Apnea (OSA) syndrome. Apnea, hypopnea and heavy snoring are recognised as causes of sleep disruption and risk factors in certain types of heart disease. More recently it has been found that increased upper airway resistance (Upper Airway Resistance syndrome) during sleep without snoring or sleep apnea also can cause sleep fragmentation and daytime sleepiness. It is possible there is an evolution from upper airway resistance syndrome to sleep apnea, accompanied by a worsening of clinical symptoms and damage to the cardiovascular system.
The common form of treatment of these syndromes is the administering of Continuous Positive Airway Pressure (CPAP). The procedure for administering CPAP treatment has been well documented in both the technical and patent literature. Briefly stated, CPAP treatment acts as a pneumatic splint of the airway by the provision of a positive pressure, usually in the range 4-20 cm H2O. The air is supplied to the airway by a motor driven blower whose outlet passes via an air delivery hose to a nose (or nose and/or mouth) mask sealingly engaged to a patient's face. An exhaust port is provided in the delivery tube proximate to the mask. More sophisticated forms of CPAP, such as bi-level CPAP and autosetting CPAP, are described in U.S. Pat. Nos. 5,148,802 and 5,245,995 respectively.
Various techniques are known for sensing and detecting abnormal breathing patterns indicative of obstructed breathing. U.S. Pat. No. 5,245,995, for example, describes how snoring and abnormal breathing patterns can be detected by inspiration and expiration pressure measurements while sleeping, thereby leading to early indication of preobstructive episodes or other forms of breathing disorder. Particularly, patterns of respiratory parameters are monitored, and CPAP pressure is raised on the detection of pre-defined patterns to provide increased airway pressure to, ideally, subvert the occurrence of the obstructive episodes and the other forms of breathing disorder.
As noted above, central apneas need not involve an obstruction of the airway, and often occur during very light sleep and also in patients with various cardiac, cerebrovascular and endocrine conditions unrelated to the state of the upper airway. In those cases where the apnea is occurring without obstruction of the airway, there is little benefit in treating the condition by techniques such as CPAP. Also, known automated CPAP systems cannot distinguish central apneas with an open airway from apneas with a closed airway, and may inappropriately seek to increase the CPAP splinting air pressure unnecessarily. Such unnecessary increases in pressure reflexly inhibit breathing, further aggravating the breathing disorder.
Other limitations associated with the prior art include the inability to detect airway patency and the absence of progressive, heirarchic response to increasingly severe indicators of airway obstruction for which the mask pressure should be increased.
It would be useful, however, to even more sensitively and reliably detect the conditions of partial obstruction, as well as apnea and patency, as this would assist in the design of equipment to prevent these conditions from occurring. In a similar way, means for detecting and monitoring mildly obstructed breathing would be useful in diagnosing and treating Upper Airway Resistance syndrome and monitoring that treatment is optimal.
In accordance with a first aspect the invention discloses a method for determining the occurrence of an apnea in a patient, the method comprising the steps of:
measuring respiratory air flow from the patient as a function of time;
determining the variance of said measured air flow; and
determining from said variance that an apnea is occurring.
The variance can be a moving average over the time window. Further, there can be a further step of comparing the variance with a threshold value, and if the variance falls below the threshold value then an apnea is occurring. The measured air flow can be expressed as an air flow signal. Advantageously, the respiratory air flow is sampled at equally spaced points in time to give a sampled air flow signal. Further, it can be the case that the variance must fall below the threshold value for a predetermined period of time before it is determined that an apnea is occurring. Advantageously the method can comprise the further step of either commencing continuous positive airway pressure (CPAP) treatment or increasing CPAP treatment pressure to the patient if an apnea is occurring.
In accordance with a further aspect the invention discloses a method for detecting partial obstruction of the airway of a patient, the method comprising the steps of:
measuring respiratory air flow from the patient;
detecting the inspiratory part of said air flow;
normalising said inspiratory part; and
determining an index value of a mid-portion of said normalised inspiratory part as a measure of partial obstruction.
Conveniently, the index value is determined from the amplitude of the mid-portion of the normalised inspiratory part. The index value can be determined as the arithmetic mean value of the amplitude in the mid-portion. Alternatively, the index value is determined from the flatness of the mid-portion. Yet further, the index value can be determined as the root mean square (RMS) deviation of the normalised inspiratory part in the mid-portion with respect to unity. The RMS deviation can be compared against a threshold value to determine the degree of obstruction. Still further, the step of normalising can include scaling the inspiratory part to unity duration and unity area. The determination also can be performed over a plurality of inspiratory events. In this way a moving mean value of amplitude or a moving RMS deviation can be formed. The respiratory air flow also can be sampled at spaced instants in time. Advantageously there is the further step of either commencing CPAP treatment or increasing CPAP treatment pressure to the patient if there is partial obstruction of the airway
The invention yet further discloses a method for determining the degree of obstruction of the airway of a patient receiving continuous positive airway pressure (CPAP) treatment by apparatus for supplying CPAP to the patient's airway, the method comprising the steps of:
measuring respiratory air flow from the patient to give an air flow signal;
filtering said air flow signal to reject components at least due to respiration to give a filtered air flow signal having components due to patient snoring and noise of said CPAP apparatus;
predicting a CPAP apparatus noise component of said filtered air flow signal; and
subtracting said predicted noise component from said filtered air flow signal to give a snore component signal as a measure of the degree of obstruction of the airway.
In a preferred form, the filtering step includes bandpass filtering also to reject high frequency noise components.
The invention yet further discloses a method for determining patency of the airway of a patient, the method comprising the steps of:
applying an oscillatory pressure waveform of known frequency to the patient's airway;
measuring respiratory air flow from the patient; and
determining that the airway is patent if there is a component of said air flow at said known frequency induced by said oscillatory pressure waveform.
Advantageously the air flow component is determined from the amplitude of the air flow signal, and there is the further step of comparing the magnitude with a threshold value and if the magnitude is greater than the threshold value then the airway is declared patent. Furthermore, the method can be performed when the patient is having an apnea and there is zero air flow. The step of determining can be said to identify modulation of the measured air flow by the oscillatory pressure waveform.
The invention yet further discloses a method for determining the degree of patency of the airway of a patient, the method comprising the steps of:
applying an oscillatory pressure waveform of known frequency and magnitude at an entrance to the patient's airway;
measuring respiratory air flow from the patient;
determining the magnitude of the component of said air flow at said known frequency induced by said oscillatory pressure waveform; and
determining the degree of patency as the ratio of said induced air flow magnitude and said oscillatory pressure waveform magnitude.
The measured air flow can be expressed as an air flow signal. Furthermore, the method can be performed when the patient is asleep, and further advantageously, when it previously has been determined that the patient is having an apnea. In the case of an apnea there is zero air flow.
The invention yet further discloses a method for determining patency of the airway of a patient, the method comprising the steps of:
measuring respiratory air flow from the patient;
analysing said air flow to detect the presence of cardiogenic air flow, and if said cardiogenic air flow is present then the airway is declared patent.
Again, the measured air flow can be expressed as an air flow signal. The respiratory air flow can be high pass filtered to reject components due to respiration. Further, the step of analysing detects the presence of a periodic component. The periodic component can include a fundamental component together with a sub-multiple or harmonic thereof. The step of analysing can further include performing a Fourier transformation on the air flow signal. Conveniently there can be the further step of detecting the patient's cardiac rate, and whereby the analysing step includes detecting a component of the air flow at the cardiac rate. Furthermore, the method can be performed when the patient is having an apnea and these is zero air flow.
The invention yet further discloses a method or controlling the administration of CPAP treatment to the airway of a patient by means controllable to supply breathable air to the patient's airway continually at a selectable pressure elevated above atmospheric pressure, the method comprising the step of:
The invention yet further discloses apparatus for determining the occurrence of an apnea in a patient, the apparatus comprising:
means for measuring respiratory air flow from the patient as a function of time;
means for determining the variance of said measured air flow; and
means for determining from said variance that an apnea is occurring.
The invention yet further discloses apparatus for detecting partial obstruction of the airway of a patient, the apparatus comprising:
means for measuring respiratory air flow from the patient;
means for detecting the inspiratory part of said air flow;
means for normalising said inspiratory part; and
means for determining an index value of a mid-portion of said normalised inspiratory part as a measure of partial obstruction.
The invention yet further discloses apparatus for determining the degree of obstruction of the airway of a patient receiving continuous positive airway pressure (CPAP) treatment by means for supplying CPAP to the patient's airway, the apparatus comprising:
means for measuring respiratory air flow from the patient to give an air flow signal;
means for filtering said air flow signal to reject components at least due to respiration to give a filtered air flow signal having components due to patient snoring and noise of said CPAP apparatus;
means for predicting a CPAP apparatus noise component of said filtered air flow signal; and
means for subtracting said predicted noise component from said filtered air flow signal to give a snore component signal as a measure of the degree of obstruction of the airway.
The invention yet further discloses apparatus for determining patency of the airway of a patient, the apparatus comprising:
means for applying an oscillatory pressure waveform of known frequency to the patient's airway;
means for measuring respiratory air flow from the patient; and
means for determining that the airway is patent if there is a component of said air flow at said known frequency induced by said oscillatory pressure waveform.
The invention yet further discloses apparatus for determining the degree of patency of the airway of a patient, the apparatus comprising:
means for applying an oscillatory pressure waveform of known frequency and magnitude to the patient's airway;
means for measuring respiratory air flow from the patient;
means for determining the magnitude of the component of said air flow at said known frequency induced by said oscillatory pressure waveform; and
means for determining the degree of patency as the ratio of said induced air flow magnitude and said oscillatory pressure waveform magnitude.
The invention yet further discloses apparatus for determining patency of the airway of a patient, the apparatus comprising:
means for measuring respiratory air flow from the patient; and
means for analysing said measured air flow to detect the presence of cardiogenic air flow, and if said cardiogenic air flow is present then the airway is declared patent.
The invention vet further discloses apparatus for controlling the administration of CPAP treatment to the airway of a patient comprising
means controllable to supply breathable air to the patient's airway continually at a selectable pressure elevated above atmospheric pressure;
controlling means for commencing or increasing CPAP treatment pressure if:
Embodiments of the invention will now be described with reference to the accompanying drawings, in which:
If the answer in step 14 is "Yes", an apnea is in progress and there then follows a determination of patency in step 20. If there is patency of the airway, a central apnea with an open airway is occurring, and, if desired, the event is logged in step 22. If the result of step 20 is that the airway is not patent, then a total obstructive apnea or a central apnea with closed airway is occurring, which results in the commencement or increase in CPAP treatment pressure in step 18. If desired, step 18 may include the optional logging of the detected abnormality.
If the answer in step 14 is "No", the Obstruction Index is compared with another Threshold value in step 16, by which the determination of obstruction of the airway is obtained. If "Yes" in step 16, then there is a partial obstruction, and if "No", there is no obstruction (normalcy).
Thus step 18 applies in the case of a complete or partial obstruction of the airway with a consequential increase in CPAP treatment pressure. In the instance of a central apnea with patent airway (steps 20,22) or normal breathing with no obstruction, the CPAP treatment pressure rather is reduced, in accordance with usual methodologies that seek to set the minimal pressure required to obviate, or at least reduce, the occurrence of apneas. The amount of reduction in step 17 may, if desired, be zero.
The methodology represented in
Interposed between the mask 30 and the exhaust 42 is a flow-resistive element 44. This can take the form of an iris across which a differential pressure exits. The mask side of the flow-resistive element 44 is connected by a small bore tube 46 to a mask pressure transducer 48 and to an input of a differential pressure transducer 50. Pressure at the other side of the flow-resistive element 44 is conveyed to the other input of the differential pressure transducer 50 by another small bore tube 52.
The mask pressure transducer 48 generates an electrical signal in proportion to the mask pressure, which is amplified by amplifier 52 and passed both to a multiplexer/ADC unit 54 and to the motor-servo unit 40. The function of the signal provided to the motor-servo unit 40 is as a form of feedback to ensure that the actual mask static pressure is controlled to be closely approximate to the set point pressure.
The differential pressure sensed across the flow-resistive element 44 is output as an electrical signal from the differential pressure transducer 50, and amplified by another amplifier 56. The output signal from the amplifier 56 therefore represents a measure of the mask or respiratory airflow rate. A large dynamic range can be achieved by using a flexible-vaned iris as the flow-resistive element 44.
The output signal from the amplifier 56 is low-pass filtered by the low-pass filter 58, typically with an upper limit of 10 Hz. The amplifier 56 output signal is also bandpassed by the bandpass filter 60, and typically in a range of 30-300 Hz. The outputs from both the low-pass filter 58 and the bandpass filter 60 are provided to the multiplexer/ADC unit 54. The multiplexed and digitized output from the multiplexer/ADC unit 54 is, in turn, passed to a controller 62, typically constituted by a micro-processor based device also provided with program memory and data processing storage memory. A component of the multiplexed output is a digitized and manipulated form of the air flow signal f(t), represented as fn.
Dependant upon the specific processing functions it performs, the controller 62 outputs a pressure request signal which is converted by a DAC 64, and passed to the motor-servo unit 40. This signal therefore represents the set point pressure (Pset(t)) to be supplied by the turbine 34 to the mask 30 in the administration of CPAP treatment.
The controller 62 is programmed to perform a number of processing functions, as presently will be described.
As an alternative to the mask pressure transducer 48, a direct pressure/electrical solid state transducer (not shown) can be mounted from the mask with access to the space therewithin, or to the air delivery tubing 32 proximate the point of entry to the mask 30.
Further, it may not be convenient to mount the flow transducer 44 at or near the mask 30, nor to measure the mask pressure at or near the mask. An alternative arrangement, where the flow and pressure transducers are mounted at or near the air pressure generator (in the embodiment being the turbine 34) is shown in
The pressure pg(t) occurring at the pressure generator 34 outlet is measured by a pressure transducer 70. The flow fg(t) through tubing 32 is measured with flow sensor 72 provided at the output of the turbine 34.
The pressure loss along tubing 32 is calculated in step 74 from the flow through the tube fg(t), and a knowledge of the pressure-flow characteristic of the tubing, for example by table lookup.
The pressure at the mask Pm is then calculated in subtraction step 76 by subtracting the tube pressure loss from Pg(t).
The pressure loss along tube 32 is then added to the desired set pressure at the mask pset(t) in summation step 78 to yield the desired instantaneous pressure at the pressure generator 34. Preferably, controller of the pressure generator 34 has a negative feedback input from the pressure transducer 70, so that the desired pressure from step 78 is achieved more accurately.
The flow through the exhaust 42 is calculated from the pressure at the mask (calculated in step 76) from the pressure-flow characteristic of the exhaust step 80, for example by table lookup.
Finally, the mask flow is calculated by subtracting the flow through the exhaust 42 from the flow through the tubing 32, in subtraction step 82.
The methodology put into place by the controller 62 will now be described with reference to the apparatus of
A. Determination of Apnea
This section generally corresponds to steps 10, 12, and 14 as shown in
Partial upper airway obstruction in untreated or partially treated Obstructive Sleep Apnea syndrome, and the related High Airway Resistance syndrome, leads to mid-inspiratory flow limitation, as shown in
As discussed previously, the respiratory air flow is determined by means of the differential pressure transducer 48, and a signal representing the air flow is continuously digitized and passed to the controller 62. If necessary, the controller 62 can linearise the flow signal, for example, by a table lookup. Occasionally, complete obstruction of the airway can occur unexpectedly for example in a previously untreated patient, without a period of preceding partial obstruction. Consequently, the processing steps 12, 14 shown in
This is achieved, for example as shown in
The Breathing Index at any given point in time is calculated as the square root of the variance of the digitized flow signal, fn:
The average variance calculated over a moving time window is compared with a Threshold by the level detector 127, to generate an "airflow-ceased" trigger. This starts the timer 128. If the trigger persists for more than 10 seconds, the comparator 129 declares an apnea. The Threshold may be a fixed value, typically 0.1 l/sec, or may be a chosen percentage (typically 10 or 20%) of the average ventilation over the last several minutes (typically 5 minutes). For convenience, instead of comparing the Threshold with the square root of the variance, one can square the Threshold, and compare with the variance directly.
Conversely, if airflow resumes before 10 seconds lapses, the timer 128 is reset and no apnea is declared. If an apnea is taking place, the patency of the airway must also be determined as an indicator of whether the apnea is of the central type with open airway, or otherwise. The processing performed by the controller 62 to achieve this determination will be discussed presently.
The method can, of course, be used instantaneously without requiring the elapse of a time interval before an apnea is declared.
The method is advantageous in comparison with known methods for detecting apnea, such as single zero crossing methods, because it is relatively insensitive to leaks. Furthermore, apneas are still detected in the presence of cardiogenic, as opposed to respiratory, air flow.
B. Determination of Airway Obstruction
The Obstruction Index is calculated in step 12. Either of two alternate Obstruction indices can be calculated. These will be referred to as shape factor 1 and shape factor 2.
The Obstruction Index is then compared with a threshold in step 16 of
As shown in
Conveniently, the scaled breaths are compared in a comparator 98 with a pre-stored template representing a normal unobstructed breath. The template is very similar to the curve for a normal inspiratory event as shown in
For data for which the test is satisfied, a moving average of the first such scaled point is calculated by the arithmetic processor 102 for the preceding several inspiratory events. This is repeated over the same inspiratory events for the second such point, and so on. Thus, sixty five scaled data points are generated by the arithmetic processor 102, and represent a moving average of the preceding several inspiratory events. The moving average of continuously updated values of the sixty five points are hereinafter called the "scaled flow", designated as fs(t). Equally, a single inspiratory event can be utilised rather than a moving average.
From the scaled flow two shape factors that directly relate to the determination of partial obstruction are calculated. Each shape factor equates to the Obstruction Index discussed above.
Shape factor 1 is the ratio of the mean of the middle thirty-two scaled flow points to the mean overall sixty-five scaled flow points. This is thus a determination of the reduction of the magnitude (depression) of the mid-portion of the scaled inspiratory event(s). Since the mean for all sixty five points is unity, the division need not actually be performed.
Mathematically, it is expressed as:
which reduces simply to
For a normal inspiratory event this ratio will have an average value in excess of unity, because a normal such inspiratory event is of higher flow in the middle than elsewhere, as can be seen from
In other embodiments the number of sampled points, number of breaths and number of middle points can be varied, and still achieve a meaningful determination of whether partial obstruction is occurring. The Threshold value similarly can be a value other than 1.17.
Alternatively, the second shape factor is calculated as the RMS deviation from unit scaled flow, taken over the middle thirty two points. This is essentially a measure of the flatness of the mid-portion of the scaled respiratory event(s). Expressed mathematically, this is:
For a totally flow-limited breath, the flow amplitude vs. time curve would be a square wave and the RMS deviation would be zero. For a normal breath, the RMS deviation is approximately 0.2 units, and this deviation decreases as the flow limitation becomes more severe. A threshold value of 0.15 units is used in step 16 of
Both shape factors discussed above can be utilised independently in implementing the methodology carried by the apparatus of
In either case, if the results of the comparison is "No", then those results are ANDed in the AND gate 122. That is, an output will only be achieved if both Threshold criteria are not satisfied. In this case, there is no partial obstruction, or partial obstruction has subsided, in which case, as indicated in block 124, it is appropriate to decrease the CPAP pressure.
This arrangement avoids any peculiarities affecting either algorithm. For example, the presence of an initial non-flow-limited period early in a breath can permit an early sharp peak in the flow-time curve. This means that the scaled flow during the middle half of the breath may be below unity. For very severely obstructive breaths, the RMS deviation from unity may therefore rise again, and shape factor 2 will fail to recognise such breaths. They will, however, be correctly identified by the now desensitized shape factor 1. Some normal breaths can involve an inspiratory flow-time waveform approximating a right triangle, where the mean flow during the middle half of the inspiration is close to unity. Such a waveform correctly triggers neither shape factor 1 nor shape factor 2. That is, the instantaneous flow during the middle half of the inspiration is only unity at a single point, and above or below unity elsewhere, so the RMS deviation from unit scaled flow will be large.
In summary, the shape factors provide an Index of the state of the airway. They provide a sensitive warning of an airway becoming unstable, and allow early CPAP treatment to occur. Continuing calculation of the moving average shape, and thus the shape factors, provides an accurate on-going assessment of the degree of any such apnea that is not subverted by CPAP treatment in order that modified appropriate treatment or corrective action can be taken.
The shape factors discussed above provide the most sensitive indication of upper airway stability and therefore result in the smallest increase in the CPAP pressure that should restore stability to the airway and similarly a correspondingly small decrease in the CPAP pressure when stability has so been restored. By being able to maintain the increases to such a small level, the patient is less likely to be woken, and will also benefit from avoiding apneas with their associated health risks.
For example, when shape factor 1 is below 1.0, the CPAP pressure is increased in proportion to the amount of the ratio being below 1.0. An increase of 1 cm H2O per breath per unit below a ratio of 1.0 has been found particularly effective. Conversely, if the ratio is above 1.0, the CPAP pressure is gradually reduced with a time constant of 20 minutes. If shape factor 2 is below 0.2, the CPAP pressure is increased at a rate of 1 cm H2O per breath per unit below 0.2. Conversely, if the shape factor is above 0.2 units, the pressure is gradually lowered with a time constant of 20 minutes.
An example of experimental validation involved a subject with severe Obstructive Sleep Apnea syndrome placed on nasal CPAP therapy. A catheter tip pressure transducer was placed in the hypopharyngeal space, below the site of upper airway obstruction, and the peak upper airway pressure gradient (UAP) from hypopharynx to mask calculated for each breath.
The CPAP pressure was intentionally reduced from time to time during stable sleep, in order to produce partial upper airway obstruction. For each breath taken during the night, the two shape factors were calculated, and plotted against the UAP, measured in cm H2O. The results are shown in
In this patient there was an 83% correlation between shape factor 1 (
The function achieved by shape factor 1 also can be achieved by an improved methodology in the detection of snoring.
Prior art U.S. Pat. No. 5,245,995 describes signal processing of the mask flow signal to determine a snore characteristic, particularly as shown in FIGS. 9 and 10 of that document. The respiratory air flow signal is bandpass filtered in the range 30-300 Hz. Snoring exhibits characteristic frequencies in this range, and as described in the prior art reference the sound intensity of snoring is indicative of almost complete obstruction of the airway. Thus CPAP pressure is increased if the snore signal is in excess of a snore threshold value. This then corresponds to the degree of obstruction otherwise detected by shape factor 1.
Although the snore detector and CPAP treatment effected in consequence of the occurrence of snoring operates satisfactorily there is still scope for improvement. Once particular problem comes in that some CPAP apparatus caused wind noise occurs in the 30-300 Hz range, as does background noise due to the motor driving the blower.
As described herein, the digitized flow signal fn has been arrived at in a similar manner to that described in prior art U.S. Pat. No. 5,245,995, and thus includes snore component frequencies.
The methodology to improve performance of the snore detector firstly involves a determination of the blower motor speed. This can be achieved by a tachometer located on the motor. Then follows a determination of an expected flow signal such as would occur in the absence of snoring. This is calculated as a function of motor speed and airflow by the following formula:
where ω is the motor speed signal and f is the flow signal. The constants k1-k4 are determined empirically. The predicated signal is then subtracted from the measured flow signal to obtain the snore signal. Thus the corrected snore signal more accurately reflects the occurrence and extent of snoring, and when compared against the snore threshold results in an increase in the CPAP pressure.
C. Determination of Airway Patency
If the outcome of step 14 is "Yes", then an apnea in progress. In accordance with the methodology of
1. Cardiogenic Airflow
With each beat of the heart, of the order of 66 ml of blood is ejected from the chest over about 0.3 sec, producing a pulsatile blood flow out of the chest of the order of 0.22 l/sec peak flow. If the chest wall were rigid this would create a partial vacuum in the chest cavity, and, if the upper airway were open and of zero resistance, a similar quantity of air would be sucked in through the trachea.
In practice, the chest wall is not totally rigid, and the upper airway has a finite resistance. Consequently the observed airflow with each beat of the heart is of the order of 0.02 to 0.1 l/sec. If there is a central apnea with an open airway, there will be a very small pulsatile airflow of the order of 0.02 to 0 l/sec in time with the heart beat. Conversely, if the airway is closed, there will be no pulsatile airflow in time with the heart beat.
The methodology firstly records the airflow, f(t), using by the flow transducer 48 shown in
If required, the flow signal, fn, is digitally bandpass filtered by the bandpass filter 130 between 0.1 and 6 Hz to remove low frequency components (leak) and high frequency components (noise) to yield a clean respiratory air flow signal.
The occurrence of an apnea will have previously been determined by, for example, the Breathing Index derived in
A Discrete Fourier-transform (DFT) is performed, by the processing element 132, of the airflow signal fn during the apnea. Only terms up to 6 Hz need to be calculated. In the case where the heart rate is not known, processing is as follows: if the amplitude of the DFT exceeds a Threshold value of 0.01 L/sec, as determined by the peak height detector 136 and the subsequent comparator element 138, at any frequency between 0.75 and 3 Hz (bandpass element 134), the airway is declared open; otherwise it is declared closed. Patency Index 1 represents the output of the peak height detector 136.
If an electrocardiogram or other indicator of heartbeat, such as a pulse oximeter is available, then an appropriate method is to:
(1) Use a digital or electronic trigger to trigger on each heart beat.
(2) Accumulate the respiratory airflow signal at time nT after receipt of each trigger into element n of an array, summing with previous values at time nT for the duration of the apnea.
(3) Divide by the number of heartbeats to obtain the average air flow as a function of time into the heartbeat.
(4) Calculate the first two terms of the DFT of this signal (fundamental and first harmonic) and inspect for an amplitude of the order of 0.1 l/sec.
In such a case where the heart rate is known, then only the amplitudes at the heart rate and its first harmonic need be considered, leading to a more accurate estimation.
Instead of using the DFT, any suitable mathematical method of detecting a rhythmic oscillation with a frequency of the anticipated heart rate and its first harmonic (0.75 to 3 Hz) will suffice. Such methods could include measuring the regularity of peak heights and zero crossings, autocorrelation, or other digital filtering methods.
2. Externally Induced Oscillations
If the airway is open, but the respiratory muscles are relaxed (i.e. a central apnea with open airway), then small externally originating fluctuations in the mask pressure will induce a small respiratory airflow by inflating and deflating the lungs, and by compressing and decompressing the gas in the lungs. Conversely, if the airway is closed, no airflow will be induced.
Approximately 5-seconds into the apnea a 2 Hz, 1 cm H2O pressure oscillation is induced (applied) for 6 seconds (i.e. between t=14 s to t=20.5 s). It can be seen that this pressure modulation induces a corresponding 2 Hz modulation in the respiratory air flow signal.
Conversely, in
The procedure is typically, at 4-6 seconds into the apnea, the CPAP pressure generator output pressure supplied to the motor-servo unit 40 is controlled to produce a modulated pressure output. As shown in
As further shown in
Apneas are classified as "airway open" if the mean induced signal is more then 0.03 l/sec, and "airway closed" if the mean induced signal is less than 0.03 l/sec. Alternatively, the mean induced signal could be divided by the amplitude of the inducing pressure to yield the conductance (degree of openness) as a continuous variable.
When it is desired to determine the state of the airway in the presence of typical CPAP treatment, it is preferable to take into account the effect of mask leaks. A leak between the mask and the face can produce a false positive induced air flow signal. As shown in
The flow signal is also low pass filtered (typically 0.1 Hz) by the low pass filter 150 to derive a measurement of leak. The value calculated in step 142 represents the sum of the induced signal due to modulation of respiratory air flow and the induced signal due to modulation of flow through the leak. The induced signal due to modulation of flow through the leak is then calculated by arithmetic element 154, as:
This is then subtracted by the subtractor 156 from the uncompensated Patency Index to produce a leak-compensated Patency Index. The leak-compensated Patency Index can optionally be divided by the inducing oscillation amplitude to yield airway conductance, as described previously.
In the case of either methodology utilised to determine patency, if the result of that determination (step 20) is "No", then as was the case for a partial obstruction, the CPAP treatment pressure is increased. If the result is "Yes", then a central apnea with an open airway is occurring, and it is inappropriate to increase CPAP pressure. Instead the event is only logged, and step 17 follows, whereby CPAP pressure is reduced, as has previously been discussed.
3. Extensions to the Methodology of Determining Patency
(1) Instead of declaring the airway open or closed, the airway can be declared open to a certain degree. For example, if the peak amplitude of the DFT was 50% of the threshold, the airway is taken as being patent to degree 0.5. Similarly with the externally induced oscillation method.
(2) Instead of using the entire duration of the apnea, calculations can be performed on a moving window of appropriate duration, such as 10 seconds. In this way, mixed apneas, in which the airway is open for only part of the apnea, can be detected.
(3) Other methods of measuring or inferring respiratory airflow can be utilised. For example, instead of measuring mask airflow with a flow-resistive element and differential pressure transducer, mask airflow could be measured using an ultrasonic flow transducer, or inferred from mask pressure, using a single ended pressure transducer. Alternatively, measurements of chest wall and/or abdominal movement (such as magnetometers, inductance plethysmography, or strain gauges) could be used.
D. A Combined System for Automatic Adjustment of CPAP Pressure
The mask pressure is initially set to a low pressure, typically 4 cm H2O. Whenever the apnea detector 168 detects an apnea, the airway patency detector 170 determines whether the airway is open or closed by the forced oscillation method, and if closed, the mask pressure is increased, typically by 1 cm H2O per 15 seconds of apnea. If a central apnea is occurring, no increase in CPAP pressure is instructed.
If a snore is detected by the snore detector 172 (such as that disclosed in U.S. Pat. No. 5,245,995) the mask pressure is also increased. If the snore index on the given breath exceeds a critical threshold value, the pressure is increased by 1 cm H2O per unit above the threshold value. The defaults threshold for the snore index is 0.2 units, corresponding approximately to a snore that can only just be reliably detected by a technician standing at the bedside. The rate of rise in pressure is limited to a maximum of 0.2 cm H2O per second, or 12 cm H2O per minute.
In some patients, it is not possible to prevent the occasional snore, even at maximum pressure. Consequently, above pressures of 10 cm H2O, a heuristic methodology is used to perform a trade-off between the possible advantage of increasing the pressure and the disadvantage of increased side effects. Thus the threshold is adjusted as follows:
Pressure (cm H2O)
Threshold (snore units)
very soft
If the shape factor 2 is less than the threshold value, the mask pressure also is increased. The default threshold value is 0.15 units. The default rate of increase of pressure is such that a severely abnormal shape factor of 0.05 units will produce a rise in pressure of 0.3 cm H2O per breath, or approximately 4.5 cm H2O per minute.
The lips and tongue can sometimes act like a one-way valve, forming a seal during inspiration when the pharyngeal pressure is lowest but failing during early to mid-expiration when the pressure is highest. Large leaks, and particularly valve-like leaks, can cause the shape factor to read low, falsely implying flow limitation. To compensate for this, the default threshold is increased according to an empiracal heuristic technique if there is a large leak, or if there is a valve-like leak. This is to avoid the treatment pressure being increased unnecessarily. Consequently, in the presence of a large leak, more reliance is placed on the snore and apnea detectors.
In some patients, the shape factor does not become normal even at maximum pressure. Consequently, a further heuristic trade-off is made between possible increases in patency within increasing pressure, versus increasing side effects.
The heuristics used are as follows:
(i) If the leak exceeds 0.7 l/sec, the critical threshold for the shape factor is 0. In the range 0.3-0.7 l/sec, the threshold is decreased proportionately, so that as the leak increases more severe flattening is required before the pressure will rise.
(ii) An index of the presence of valve-like leaks is calculated as the ratio of the peak flow during the first 0.5 seconds of expiration to the mean flow during the second 0.5 seconds of expiration. If this ratio exceeds 5:1, the threshold is 0. In the range 4:1 to 5:1, the threshold is reduced proportionately.
(iii) If the mask pressure is 20 cm H2O, the threshold is 0, and is reduced proportionately in the range 10-20 cm H2O. For example, if the leak is 0.4 l/sec. and the mask pressure is 15 cm H2O, the threshold is reduced by 25% because of the leak, and a further 50% because of the already high treatment pressure so that the new threshold is 0.056 units. Conversely, if no abnormality is detected on a particular breath (block 176), the mask pressure is reduced with an appropriate time constant typically 10-20 minutes per cm H2O for snore or shape factor changes, and preferably about 40 minutes per cm H2O following apneas.
The preferred embodiment of the combined system for automatic adjustment of CPAP treatment pressure described above was used to treat 28 patients with previously untreated obstructive sleep apnea syndrome. CPAP pressure commenced at 4 cm H2O, and increased automatically in response to closed airway apneas, snoring, and inspiratory air flow limitation. The following table compares results with those obtained in the same subjects without treatment:
(mean � SEM)
(mean � SEM)
Apnea Index (events/hr)
35.5 � 5.9
1.5 � 0.32
Time in Apnea (Percent of night)
24.5 � 4.7
1.0 � 0.37
Slow Wave Sleep (Percent of night)
7.0 � 1.6
20.0 � 2.2
REM Sleep (Percent of night)
9.4 � 1.4
20.3 � 2.1
Arousal Index (Events/hr)
55.9 � 5.3
10.8 � 1.9
Respiratory Arousals (Events/hr)
5l.5 � 5.4
4.2 � 1.5
There was a dramatic reduction in the number of apneas per hour, and the percentage of time in apnea. There was a large increase in the percentage of deep restorative sleep (slow wave and REM sleep). There was a dramatic reduction in the number of arousals from sleep, particularly those of a respiratory origin. These results confirm that the combined system produces excellent results in treating obstructive sleep apnea syndrome.
The system described can also be utilised in a diagnostic mode, typically where nasal cannulae are utilized in the place of a mask arrangement sealed to the patient's face. In this mode, measurements of apneas, patency, and partial obstruction are logged, but no CPAP treatment is effected. The nasal cannulae are connected to one side of the flow sensor 50 in
Numerous alterations and modification, as would be apparent to one skilled in the art, can be made without departing from the basic inventive concept.
More complex variants of CPAP therapy, such as bi-level CPAP therapy or therapy in which the mask pressure is modulated within a breath, can also be monitored and/or controlled using the methods described herein.
The moving average variance apnea detector, as described, can be extended to include a hypopnea detector by adding a second comparator set at a higher threshold, so that it will respond to partial reductions in ventilation.
|Cited Patent
|Filing date
|Publication date
|4 Mar 1957
|15 Sep 1959
|Shane Sylvan M
|Breathing indicator
|19 Sep 1967
|2 Feb 1971
|Potter James A
|Respiration meter having several modes of operation
|27 Nov 1968
|27 Jul 1971
|Heron Michael W
|Flow line break alarm device
|28 Oct 1968
|12 Oct 1971
|Respiration monitor
|3 Sep 1971
|9 Apr 1974
|Lang V
|Device for combined monitoring and stimulation of respiration
|11 Dec 1972
|18 Jun 1974
|Puritan Bennett Corp
|Flow responsive respiration apparatus
|11 Dec 1973
|13 May 1975
|Jacobs Harvey Barry
|Low-Cost Pneumatic Apnea or Respiration Monitor
|24 Jan 1974
|9 Sep 1975
|Sandoz Ag
|Automatically calibrated respiratory ventilation monitor
|11 Feb 1974
|28 Oct 1975
|Banner Philip M
|Liquid flow indicating and flow control means
|17 Jul 1974
|13 Jan 1976
|Western Engineering & Mfg. Co.
|Variable pitch axial fan
|3 Sep 1974
|8 Jun 1976
|Hoffmann-La Roche Inc.
|Automatic regulation of respirators
|27 May 1975
|12 Oct 1976
|Milton Roy Company
|Constant pressure pump
|5 Mar 1975
|2 Nov 1976
|Siemens Aktiengesellschaft
|Flow measuring device
|17 Sep 1975
|8 Feb 1977
|National Semiconductor Corporation
|Flow meter
|19 Oct 1976
|7 Mar 1978
|H. B. W. Medical Instruments Manufacturing Company, Inc.
|Breathing equipment such as resuscitators
|21 Mar 1977
|11 Apr 1978
|Research Development Corporation
|Variable orifice gas flow sensing head
|2 Sep 1980
|26 Jan 1982
|United Technologies Corporation
|Sensor and meter for measuring the mass flow of a fluid stream
|10 Mar 1980
|23 Mar 1982
|Instrumentarium Oy
|Apparatus in medicine for the monitoring and or recording of the body movements of a person on a bed, for instance of a patient
|27 Jun 1980
|30 Mar 1982
|Respiratory Care, Inc.
|Temperature control system with alarm and shut down for non-tracking condition of dual thermometers
|19 Jun 1981
|28 Dec 1982
|Medicon, Inc.
|Method of monitoring patient respiration and predicting apnea therefrom
|27 Feb 1981
|3 May 1983
|Douglas David W
|Method and apparatus for detecting apnea
|6 Apr 1981
|14 Jun 1983
|Kearns Kenneth L
|Respiration monitor and x-ray triggering apparatus
|1 May 1981
|28 Feb 1984
|Hochstein Peter A
|Method and assembly for monitoring respiration and detecting apnea
|16 Dec 1981
|3 Apr 1984
|Medical Graphics Corporation
|Respiratory analyzer system
|2 Jul 1982
|15 May 1984
|Sensormedics Corporation
|Respiratory gas analysis instrument having improved volume calibration method and apparatus
|14 Apr 1983
|19 Feb 1985
|Litton Systems, Inc.
|Selector valve for an aircraft on board oxygen generation system with high pressure oxygen backup
|3 Dec 1982
|26 Mar 1985
|Kircaldie, Randall And Mcnab
|Method and apparatus for rectifying obstructive apnea
|29 Aug 1983
|5 Nov 1985
|Grant Graham C
|Fluid flowmeter
|15 Jul 1982
|5 Nov 1985
|Mcewen James A
|Method and apparatus for detection of breathing gas interruptions
|16 May 1984
|17 Dec 1985
|Erich Jaeger Gmbh & Co.
|Testing of the airways and pulmonary tract of a patient, particularly for sensitivity to aerosols
|25 Mar 1985
|18 Feb 1986
|Kircaldie, Randall And Mcnab (As Trustee)
|Respirating gas supply method and apparatus therefor
|6 May 1983
|18 Mar 1986
|Manus Eugene A
|Respiration and heart rate monitoring apparatus
|12 Oct 1984
|8 Apr 1986
|Aequitron Medical, Inc.
|Apnea monitoring system
|18 Aug 1982
|29 Jul 1986
|Plasmedics, Inc.
|Physiological detector and monitor
|5 Mar 1985
|23 Dec 1986
|Dan Atlas
|Apnea monitoring apparatus
|3 May 1985
|10 Mar 1987
|Brigham And Women's Hospital
|Respiration detector
|13 Jun 1986
|10 Mar 1987
|Respitrace Corporation
|Method for detecting and differentiating central and obstructive apneas in newborns
|6 Oct 1983
|7 Apr 1987
|New York University
|Method and apparatus for the treatment of obstructive sleep apnea
|16 Oct 1985
|7 Jul 1987
|The University Of Auckland
|Method of dispensing and/or a dispenser
|2 Sep 1986
|18 Aug 1987
|Tottori University
|Breath synchronized gas-insufflation device and method therefor
|10 Apr 1985
|18 Aug 1987
|Tri Fund Research Corporation
|Multi-channel ventilation monitor and method
|26 Nov 1985
|9 Feb 1988
|Beran Anthony V
|Endotracheal tube connector
|9 May 1983
|19 Apr 1988
|Thatcher John B
|Apnoea monitor
|17 Feb 1987
|18 Oct 1988
|Respitrace Corporation
|Method and apparatus for distinguishing central obstructive and mixed apneas by external monitoring devices which measure rib cage and abdominal compartmental excursions during respiration
|18 Jun 1987
|18 Oct 1988
|Mckenna Kevin
|Respiration monitor
|24 Aug 1987
|3 Jan 1989
|Cobe Laboratories, Inc.
|Condition responsive pump control utilizing integrated, commanded, and sensed flowrate signals
|2 Sep 1987
|7 Feb 1989
|Sentel Technologies, Inc.
|Sleep apnea monitor
|24 Oct 1986
|7 Feb 1989
|Hudson Oxygen Therapy Sales Co.
|Ventilator monitor and alarm apparatus
|20 Oct 1987
|11 Apr 1989
|Siemens Aktiengesellschaft
|Method and apparatus for delivering aerosol to the airways and/or lungs of a patient
|18 Apr 1988
|25 Apr 1989
|Smith Richard F M
|Demand oxygen controller and respiratory monitor
|13 Nov 1987
|2 May 1989
|Societe Anonyme Drager
|Pheumatic alarm for respirator
|2 Mar 1988
|9 May 1989
|L'air Liquide
|Process and device for supplying respiratory oxygen
|26 Oct 1987
|13 Jun 1989
|Gibeck-Dryden Corporation
|Gas sampling lumen for breathing system
|14 Nov 1988
|4 Jul 1989
|Luciano Gattinoni
|Pulmonary pressure and volume measurement
|14 Jan 1987
|29 Aug 1989
|Respitrace Corp.
|Noninvasive method for measuring and monitoring intrapleural pressure in newborns
|12 Jun 1987
|3 Oct 1989
|Litton Systems, Inc.
|Backup breathing gas supply for an oxygen concentrator system
|16 Mar 1988
|19 Dec 1989
|Beatty Robert F
|Apparatus for and method of spectral analysis enhancement of polygraph examinations
|23 Dec 1987
|10 Apr 1990
|N. Visveshwara, M.D., Inc.
|Ventilation synchronizer
|25 Apr 1989
|3 Jul 1990
|Trudell Medical
|Inhalation chamber in ventilator circuit
|16 Oct 1987
|3 Jul 1990
|Puritan-Bennett Corporation
|Inspiration oxygen saver
|10 May 1988
|18 Sep 1990
|Sipin Anatole J
|Gas delivery means
|1 May 1989
|2 Oct 1990
|Pennock Bernard E
|Method and apparatus for measuring respiratory flow
|11 Feb 1985
|20 Nov 1990
|Pearce Stephen D
|Transducer for detecting apnea
|9 Jun 1988
|27 Nov 1990
|Vital Signals, Inc.
|Method and apparatus for precision monitoring of infants on assisted ventilation
|30 Nov 1988
|8 Jan 1991
|Dr. Madaus Gmbh
|Diagnostic apnea monitor system
|7 Nov 1989
|22 Jan 1991
|Etela-Hameen Keuhkovammayhdistys R.Y.
|Respiration therapy apparatus
|14 Oct 1989
|5 Feb 1991
|Battelle Development Corporation
|26 Jan 1989
|5 Feb 1991
|Puritan-Bennett Corporation
|Dual lumen cannula
|31 Mar 1988
|4 Jun 1991
|Cardiopulmonary Corporation
|Circulatory assist method and apparatus
|30 Jan 1989
|18 Jun 1991
|Dietz Henry G
|Apparatus for inhalation therapy using triggered dose oxygenator employing an optoelectronic inhalation sensor
|25 Oct 1988
|1 Oct 1991
|Dietz Henry G
|Method and apparatus for using an inhalation sensor for monitoring and for inhalation therapy
|27 Oct 1988
|12 Nov 1991
|Etala-Hameen Keuhkovammayhdistys R.Y.
|Ultrasonic atomizer
|22 Dec 1987
|19 Nov 1991
|New York University
|Method and apparatus for the treatment of obstructive sleep apnea
|31 Aug 1990
|3 Dec 1991
|Mcdonald Jr Lewis D
|Respiration sensor set
|22 Jan 1990
|25 Feb 1992
|The University Of Melbourne
|Electronic transducer
|23 Jan 1989
|14 Apr 1992
|Nippon Kayaku Kabushiki Kaisha
|Method and apparatus for correlating respiration and heartbeat variability
|6 Jun 1991
|28 Apr 1992
|Bear Medical Systems, Inc.
|Ventilator control system using sensed inspiratory flow rate
|21 Dec 1990
|4 Aug 1992
|Puritan-Bennett Corporation
|Inspiratory airway pressure system with admittance determining apparatus and method
|19 Mar 1991
|15 Sep 1992
|Medtronic, Inc.
|Demand apnea control of central and obstructive sleep apnea
|22 Sep 1989
|22 Sep 1992
|Respironics Inc.
|Method and apparatus for maintaining airway patency to treat sleep apnea and other disorders
|5 Mar 1991
|10 Nov 1992
|Flow sensor system
|24 Sep 1991
|24 Nov 1992
|Bird F M
|Ventilator and oscillator for use therewith and method
|22 Oct 1991
|15 Dec 1992
|Sherwood Medical Company
|Pulmonary function tester
|28 May 1991
|29 Dec 1992
|Medtronic, Inc.
|Airway feedback measurement system responsive to detected inspiration and obstructive apnea event
|11 Sep 1990
|12 Jan 1993
|Walstrom Dennis R
|Drug delivery device
|16 Sep 1991
|12 Jan 1993
|Sackner Marvin A
|System for non-invasive detection of changes of cardiac volumes and aortic pulses
|17 Sep 1991
|2 Mar 1993
|Healthdyne, Inc.
|Thermistor airflow sensor assembly
|13 Feb 1991
|23 Mar 1993
|Hok Instrument Ab
|Acoustic respiration detector
|12 Dec 1991
|6 Apr 1993
|Sullivan Colin E
|Device for monitoring breathing during sleep and control of CPAP treatment that is patient controlled
|14 Jun 1991
|20 Apr 1993
|Board Of Regents, The University Of Texas System
|Method and apparatus for controlling sleep disorder breathing
|7 Oct 1991
|3 Aug 1993
|Minnesota Mining And Manufacturing
|Method of and apparatus for the aerosol administration of medication
|3 Sep 1991
|10 Aug 1993
|Medtronic, Inc.
|Method and apparatus for apnea patient screening
|27 May 1992
|21 Sep 1993
|Rescare Limited
|Device and method for monitoring breathing during sleep, control of CPAP treatment, and preventing of apnea
|9 Apr 1992
|9 Nov 1993
|Puritan-Bennett Corporation
|Inspiratory airway pressure system controlled by the detection and analysis of patient airway sounds
|5 Nov 1992
|25 Jan 1994
|Paul Ritzau Pari-Werk Gmbh
|Device in particular and inhalating device for treating the lung and the respiratory tracts
|1 Aug 1991
|15 Mar 1994
|Geomet Technologies, Inc.
|Emergency breathing apparatus
|26 Sep 1991
|22 Mar 1994
|Sam Technology, Inc.
|Non-invasive human neurocognitive performance capability testing method and system
|6 Jul 1992
|19 Apr 1994
|Dragerwerk Aktiengesellschaft
|Method for detecting the respiratory phases of a patient during an assisted ventilating process
|17 Nov 1992
|17 May 1994
|Peter Stasz
|Breath sensing apparatus
|11 Oct 1991
|24 May 1994
|University Of Pittsburgh Of The Commonwealth System Of Higher Education
|Endotracheal™ tube for topical substance delivery and associated method of use
|24 Jan 1991
|21 Jun 1994
|Vortran Medical Technology, Inc.
|Intermittent signal actuated nebulizer synchronized to operate in the exhalation phase, and its method of use
|22 Jan 1993
|12 Jul 1994
|The Johns Hopkins University
|Polygraph automated scoring systems
|7 May 1992
|9 Aug 1994
|New York University
|Method and apparatus for continuous adjustment of positive airway pressure for treating obstructive sleep apnea
|21 Sep 1992
|11 Oct 1994
|Miles Laughton E
|Cardio-respiratory control and monitoring system for determining CPAP pressure for apnea treatment
|18 Nov 1992
|1 Nov 1994
|Campbell Jr William G
|Respiratory and cardiac monitor
|16 Sep 1991
|3 Jan 1995
|Cardiopulmonary Corporation
|Cardiac synchronous ventilation
|9 Dec 1992
|14 Feb 1995
|Roberts; Josephine A.
|Positive-pressure ventilator system with controlled access for nebulizer component servicing
|21 Jul 1993
|7 Mar 1995
|Respironics, Inc.
|Physiological monitoring system
|Citing Patent
|Filing date
|Publication date
|9 Jun 2005
|11 Jan 2011
|Nexense Ltd.
|High-sensitivity sensors for sensing various physiological phenomena, particularly useful in anti-snoring apparatus and methods
|10 Apr 2007
|5 Apr 2011
|General Electric Company
|Method and system for detecting breathing tube occlusion
|23 Apr 2008
|17 Jun 2014
|General Electric Company
|System and method for mobilizing occlusions from a breathing tube
|22 Jan 2010
|16 Jun 2015
|Koninklijke Philips N.V.
|Automatic pressure titration
|20 Dec 2006
|16 Feb 2016
|General Electric Company
|Respiratory monitoring with differential pressure transducer
|11 Mar 2013
|7 Jun 2016
|Covidien Lp
|Methods and systems for managing a patient move
|8 Nov 2012
|28 Jun 2016
|Covidien Lp
|Systems and methods for monitoring, managing, and/or preventing fatigue during ventilation
|20 May 2015
|29 Aug 2017
|Koninklijke Philips N.V.
|Automatic pressure titration
|20 Dec 2006
|7 Jun 2007
|General Electric Company
|Respiratory monitoring with differential pressure transducer
|10 Apr 2007
|16 Oct 2008
|General Electric Company
|Method and system for detecting breathing tube occlusion
|9 Jun 2005
|11 Dec 2008
|Arie Ariav
|High-Sensitivity Sensors for Sensing Various Physiological Phenomena, Particularly Useful in Anti-Snoring Apparatus and Methods
|23 Apr 2008
|29 Oct 2009
|General Electric Company
|System and method for mobilizing occlusions from a breathing tube
|24 Aug 2009
|10 Jun 2010
|Nihon Kohden Corporation
|Gas flow system, meter, and method
|18 Mar 2010
|22 Sep 2011
|Yungkai Kyle Lai
|Methods and devices for continual respiratory monitoring using adaptive windowing
|22 Jan 2010
|8 Dec 2011
|Koninklijke Philips Electronics N.V.
|Automatic pressure titration
|25 Mar 2014
|4 Feb 2016
|Technion Research & Development Foundation Ltd.
|Apnea and hypoventilation analyzer
|1 Mar 2011
|21 Sep 2011
|System and method for managing torque capability in electric motor system
|1 Mar 2011
|23 Apr 2014
|System and method for managing torque capability in electric motor system
|22 Jan 2010
|2 Sep 2010
|Koninklijke Philips Electronics, N.V.
|Automatic pressure titration
|U.S. Classification
|128/204.23, 128/205.23, 128/204.18, 128/204.21, 128/205.11
|International Classification
|Cooperative Classification
|European Classification
|15 Dec 2003
Owner name: RESMED LIMITED, AUSTRALIA
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text:
Scott Jagow: Congress has passed a law designed to stop terrorists from using container ships as part of an attack. But a report out of Europe this morning says that law is bad for the global trade business. From London, Stephen Beard reports.
Stephen Beard: Under the new law, every shipping container entering the U.S. -- and there are 20 million of them a year -- will be scanned at the port of departure. The image will be sent to the U.S. for checking.
Congress passed the measure out of concern that terrorists might use containers like a Trojan Horse. But a report by a French University out today says there's a downside. The measure, which comes into force in 2012, could delay shipments, hitting global growth without improving security.
Andrew Bounds of the Financial Times:
Andrew Bounds: Now is not the time, people say, when we have fears of protectionism, fears of slowdown, the credit crunch is biting, now is not the time to put more obstructions in the way of world trade and world growth.
Opponents of the measure also complain it shifts the cost of American security onto foreign ports. But supporters argue that everyone benefits from avoiding the damage to world trade that would follow a successful sea-borne terrorist attack.
In London, this is Stephen Beard for Marketplace.

subset: commoncrawl


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At HRBR we specialise in the treatment of male and female pattern hair loss, tailoring treatment plans to each patient's specific needs. Every patient who attends HRBR is seen by a qualified doctor, not a salesperson. Patients are given independent advice as to their options; the decision to proceed with surgery is that of the patient.
The team of hair restoration specialists at HRBR extends to our experienced surgeons, nurses and technicians involved in hair loss treatment and the hair transplant procedure. Our team is led by Irish surgeon Dr Maurice Collins FRCSI, who has over twenty years' experience in microscopic surgery. Dr. Collins is Medical Director and Team Principal of Hair Restoration Blackrock.
In our organisation we are totally focussed on our patients. We strive for perfection, recognising the challenges that this presents. We aim to attract, train and retain the talented staff who shape our values. Our work is very specialised and we are committed to operating as an efficient team to provide competent, compassionate care to all those we serve.
Further Reading
Follicular Unit Extraction
The team at HRBR are experts in the FUE technique of hair transplantation, with over 10 years' experience in the procedure.
FUE involves follicular units being taken individually from the donor area of the scalp without the need for a linear incision. Instead, a 1mm specialist punch tool is used to extract the individual follicles from the scalp. This method differs from FUT where a donor strip of skin is taken and the follicular units are microscopically dissected from that strip.
Follicular Unit Transplantation
Also known as URFUT (Ultra Refined Follicular Unit Transplantation)
HBRB are experts in Ultra Refined Follicular Unit Transplantation (URFUT), also known as FUT. FUT has many advantages, one of which is producing a high yield of grafts for transplantation.
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Before and After
Move your cursor over the images to the right to see the difference before and after treatment at HRBR
Before and After
Tap to the left and right of the images to view the difference before and after treatment at HRBR.
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Aonghus McAnally Interview – Limerick Fm
Aonghus McAnally is a well-known RTE presenter and producer. In this interview Aonghus discuss his decision to have a hair transplant and how having the surgery made him more self confident.Listen
Aonghus McAnally on Today with Maura and Daithi, RTÉ – HRBR
Aonghus McAnally on Today with Maura and Daithi. Thursday 6th October 2016. RTÉ. On the show Aonghus talks about his upcoming series, the loss of his mother and hair loss.Watch Video
Male pattern baldness: The stars fighting to keep their locks
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text:
Forward Steven Lawless hopes a solid pre-season campaign will help him shine in the Premiership next term.
Lawless enjoyed a decent first season in Scotland's top flight last time out and put pen-to-paper on a new deal at Firhill after helping Partick Thistle retain their Premiership place.
A series of niggling injuries too often halted his progress as he ended the campaign with five goals to his credit.
And the 23-year-old is determined to make an even bigger impact this time around.
Lawless said: "Last year was a bit up-and-down for me but it was my first real taste of the league and I was pleased with how I did overall.
"I am really looking forward to the new season now. I want to get myself in my team and hopefully score a few more goals this year.
"I started the season well and then had a bit of a dip. I was carrying an injury. I know this year not to put myself in that position again.
"I know what to expect from the league this year and that will help me. I was feeling a problem in my ankle and I ended up having it for the full year, I went over on it in certain games and it kept coming back.
"The gaffer gave me a break round about the halfway stage and when I came back in I felt good. Hopefully I am over it all this year and I can play and score more regularly."
Thistle will continue preparing for the new campaign with a friendly against Fleetwood Town this afternoon.
Boss Alan Archibald put his squad through their paces in a bounce game against Rangers in midweek and will see them in action against Sunderland on Wednesday night.
And Lawless is feeling the benefit of his match action so far this summer.
He said: "I played the last half-hour or so against Rangers and it was good to get on and get a run out.
"I am feeling good and fit. I have come back fit this year.Hopefully I can push on now and do well for the team.
"It is all geared up for the start of the season and we are all in good shape."
One of Lawless' main rivals for a starting spot this term is forward Ryan Stevenson after his switch from Hearts.
And the former Motherwell kid is pleased to have Stevenson on board as Thistle look to improve on their 10th-place finish last time out.
He said: "It wouldn't bother me if someone else came in, it just means you need to keep improving to get in the team.
"Stevo has come in and he is a good player. He is a bit of a weirdo but a good guy!
"Some of the songs he puts on in the changing room aren't the best but we are letting him away with that just now.
"He had a great season last year with Hearts and has played at this level for a number of years so his experience will be crucial for us."


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Ed Miliband: 'Big Six' energy firms too close to ministers
Lobbyists employed directly by the energy companies should be reined in and their dealings with the Government made more open, Labour leader Ed Miliband has said.
In an interview with The Independent, Miliband accused ministers of being too close to the Big Six energy companies. Analysis reveals that ministers from the Department of Energy and Climate Change have met representatives from the energy giants on 128 occasions since the Coalition was formed in 2010, yet have held talks with the main groups representing energy consumers only 26 times during the same period.
Labour will table amendments to the Lobbying Bill, which returns to the Commons tomorrow, that would force all lobbyists to join the register proposed by the Government, including in-house lobbyists employed by the energy companies. The Bill currently covers professional "third-party" lobbyists who contact ministers and aides directly.
The Opposition will also demand a code of conduct with "real sanctions" and moves to prevent conflicts of interest when people switch between government and lobbying firms. The energy firms regularly "second" staff to Whitehall departments including the Department of Energy and Climate Change (Decc), while some civil servants spend time working in the industry. The Big Six are drawing up a campaign to lobby against Mr Miliband's pledge to freeze gas and electricity prices for 20 months if Labour wins power.
Mr Miliband said: "The Government's Lobbying Bill will not capture the big energy lobbyists, who will continue to escape scrutiny. We will bring in a universal register of all professional lobbyists, along with a code of conduct backed by sanctions."
The Labour leader sees the crackdown on lobbyists as the next stage of his campaign to stand up to the "vested interests" in the energy industry.
Mr Miliband claimed: "We have an energy market that isn't working for ordinary families and businesses. Yet rather than act, this Tory-led Government is letting energy firms overcharge millions of families who are struggling to pay their ever-rising energy bills." He added: "With a cost of living crisis gripping Britain, hardworking people need a government that fights for them. Instead we have a Prime Minister who always stands up for a privileged few."
The Independent's analysis found that since May 2010, Decc ministers have held talks with Centrica, the owner of British Gas, on 30 occasions; met Scottish Power 26 times; EDF 21; SSE 19; RWE npower 17 and E. on 15. In contrast, the ministers met Consumer Focus 13 times; Which? on 10 occasions; Energy Action twice and held one session with "consumer groups".
The Bill was long-delayed despite Mr Cameron's warning before the last election that lobbying was "the next big scandal waiting to happen". But the measure has won few friends because of its narrow scope.
After warnings by the industry that most lobbyists who meet ministers will be unaffected, Labour's amendments say that anyone who meets the definition of lobbying, whether working on behalf of a client or an employer, should be required to join the register. Labour would also require lobbyists to declare the approximate value of their activity and to list the individuals involved.
Labour proposes an "enforceable code of conduct", including a ban on inappropriate financial relationships between lobbyists and MPs or peers. Tough sanctions for breaches of the code of would include preventing the worst offenders from practising by removing them from the register.
The Opposition also wants to prevent conflicts of interests arising from the "revolving door" when ministers or officials join lobbying companies or lobbyists move to a job in government. It says appointments should be scrutinised by a committee, which could attach conditions to prevent those involved using their new role to further other interests.
Decc insisted on Sunday taht its links with the energy companies are "entirely above board", saying that steps were taken to avoid any conflict of interest and details of meetings were published. A Decc spokesman said: "Keeping the lights on and delivering value to consumers is a vital job and it is perfectly normal for Decc ministers and officials regularly to meet with energy suppliers as well as independent players and environmental and consumer groups to discuss energy issues."
The Government insists that it has listened to critics of the Bill. Andrew Lansley, the Commons Leader who is responsible for it, has announced changes after charities complained that they could be "gagged" by proposed curbs on political campaigning before elections. But umbrella groups representing these bodies said the amendments do not go far enough.
Belfast Telegraph Digital


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About Piatti - Danville
Ristorante Piatti features a menu with recipes complimenting the various regions of Italy. It has a casual yet sparkling atmosphere with authentic regional Italian cuisine. Piatti's success can be attributed to its staff and its approach to food, wine, and the dining experience.
Danville, CA 94526
Dining Style:
Casual Elegant
Hours of Operation:
Sunday: 10:00am-9:00pm; -Monday: 11:30am - 9:00pm; Tuesday - Friday: 11:30am -10:00pm; Saturday 11:30 am - 10:00 pm. On Sundays, Brunch is served from 10:00am - 3:00pm.
Cross Street:
San Ramon
Dress Code:
Business Casual
Price Range:
$30 and under
Payment Options
AMEX, Diners Club, MasterCard, Visa
Phone Number:
(925) 838-2082
Executive Chef:
Dan Reighley
Private Party Facilities:
Piatti is the ideal venue for private parties, receptions and corporate events. We offer several menus at different price points, as well as an extensive wine list to complement your menu selections.
Private Party Contact:
Tami Morgan: (925) 389-1548
Bar/Lounge, Beer, Counter Seating, Full Bar, Outdoor dining, Wheelchair Access, Wine
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Piatti - Danville Ratings and Reviews
Always good. We dine with a couple friends who have rather peculiar food preferences and request substitutions and changes in preparation. Piatti always accommodates them with a smile. Have been coming here at least once a month for years and plan on more visits. Could use a couple more rosés on their wine list, particularly French ones.
They acknowledged my request for a particular table and that it was a birthday celebration through my open table reservation and I was really happy with that. The server on the other hand seemed to be rushing us from the start, but then when he clearly got the message (body language) that we didn't want to be rushed, he was much better with our service and we chalked it up to he may have been new on the wait staff. All in all we had a good experience.
I have been to Piatti's many times and the food has always been good. However, last Thursday night, it was below standard. I was a little embarrassed as entertaining tow out of town clients. One ordered the fish special. There were two small pieces of fish and not much else. I had the Hanger Steak. It was cooked to order but very little else on the plate. Presentation was poor. A disappointing meal
Piatti's, you did it again! You exceeded my expectations in every way. Last summer my ladies group had a birthday party for thirteen at your restaurant. It went off without a hitch. Several of us had special dietary requests that were accommodated without question, and we had separate checks! Yesterday my cousin and I celebrated our mutual birthday's together at Piatti's , and lunch was outstanding. My cousin miss ordered and our server, who was fantastic in every way, graciously replaced her meal. I cannot say enough good things about Piatti's. Each experience with you is as good or better than the last.
We've been here several times. I'll still go back, but will likely limit my selections to appetizers, salad, pizza and pasta.
We ordered a bottle of sangiovese, but the glass I tasted it from still had some soap residue in it, which I could smell and obviously it affected the taste of the wine. The server took it away, and I accepted the wine, but really they should have brought another full bottle, OR they should have at least brought another glass on the house since some of the wine had to be thrown away. (Our server actually asked if I wanted the wine from the tainted glass poured into the new glass he brought - seriously???)
We ordered the cauliflower soup. It was supposed to be topped with a drizzle of truffle oil, but the oil on top was definitely not truffle oil. No aroma of truffles whatsoever. In addition, when I ate the soup I came across several particles that seemed like they were from a pastry brush or something - they were thin and fibrous, and I ended up having to deposit them on my bread plate - so I definitely won't be ordering that again.
The pizza was excellent, as was the beet and arugula salad. So maybe I'll come back for those, and order wine by the glass.
We have been going to Piatti for years and this was the first time that we were disappointed in it. My husband order the fritto misto and the batter was soggy and the calamari was tough. It normally is very good. The salads were good but not great. We just felt that overall the food was not as good as in the past.
This was a disappointing birthday for my sister. Our waitress, Maggie, was highly distracted and disorganized. We had to ask for lemons several times. The brussel sprout salad was too cool and tasted like it had been sitting on the counter a while. The cheeseburger was kind of warm (not hot), though well done as requested. The lemon cheese raviolis, our favorite dish at Piatti's, had to be sent back because they were just very cold. We didn't have time to wait for another plate of 8. The waitress ignored nearby diners as they attempted to get her attention, and even after calling for her several times, people still waited for their check. The only time she was on time was to pick up her tip.
Our sever, Jacob, was excellent! Funny, polite, attentive yet not intrusive. The bread is always to die for! The asparagus soup was delicious. The veggies that accompanied the salmon were way too hard but the manager swiftly brought out the creamiest, hot mashed potatoes...and amazing shaved Brussel Sprouts....without taking away my guests salmon dish....and without drawing attention to her or asking a bunch of questions. Very professional! I had the special, cod with risotto. The lemon butter sauce was good but the cod and rice were quite bland.
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Set in a 400-year-old boys' boarding school in London, a chilling gothic thriller by the author of the critically acclaimed A Good and Happy Child....
A fierce and jealous ghost....
A young man's fight for his life....
The Harrow School is home to privileged adolescents known as much for their distinctive dress and traditions as for their arrogance and schoolboy cruelty. Seventeen-year-old American Andrew Taylor is enrolled in the esteemed British institution by his father, who hopes that the school's discipline will put some distance between his son and his troubled past in the States.
But trouble - and danger - seem to follow Andrew. When one of his schoolmates and friends dies mysteriously of a severe pulmonary illness, Andrew is blamed and is soon an outcast, spurned by nearly all his peers. And there is the pale, strange boy who begins to visit him at night. Either Andrew is losing his mind, or the house legend about his dormitory being haunted is true.
When the school's poet-in-residence, Piers Fawkes, is commissioned to write a play about Byron, one of Harrow's most famous alumni, he casts Andrew in the title role. Andrew begins to discover uncanny links between himself and the renowned poet. In his loneliness and isolation, Andrew becomes obsessed with Lord Byron's story and the poet's status not only as a literary genius and infamous seducer but as a student at the very different Harrow of two centuries prior - a place rife with violence, squalor, incurable diseases, and tormented love affairs.
When frightening and tragic events from that long-ago past start to recur in Harrow's present, and when the dark and deadly specter by whom Andrew's been haunted seems to be all too real, Andrew is forced to solve a 200-year-old literary mystery that threatens the lives of his friends and his teachers - and, most terrifyingly, his own.
©2011 Justin Evans (P)2011 HarperCollins Publishers
"Eerie tale, well read"
I'm walking the dog in broad daylight, listening to the book and when the narrator makes this sound - the sound of the antagonist's labored breathing - I stop, hunch up and start looking over my shoulder. Wonderfully eerie, adept job of narration with one of the best American accents I've heard from a British narrator. The book serves up some serious suspense, with an amazingly creepy scene (where a female character is infected with - oh wait - better not spoil the plot for you) that still disturbs me when I inadvertently remember it.
"Not recommended for adults"
I don't recommended this book for anyone with a mental age above 13 who is not titillated by teen sex scenes and references to buggery. No suspense (ghosts are not scary when they have no subtlety), nothing very interesting about Byron, which is what I was hoping for. I couldn't maintain enough to interest to finish it. The reader is okay but I disagree with the first reviewer about his American accent. The "Southern" accent that the father speaks is just awful. His rendering of the son is better, but one has to wonder why the father is Southern and the boy isn't.
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Many of the programs installed on your PC may have, by default, set themselves to run each time your PC starts. These programs will take up system resources (memory, processor cycles etc) even though you're not using them. Check your system tray right after your PC starts and see how many icons are showing – this can be a good (but not definitive) indication of what's starting each time you turn on your computer.
For each of these programs, check the settings or configuration screen for a box labeled "Run at Windows Startup" (or similar). By manually starting programs as you need them, rather than having them start automatically when you turn your PC on, your start time will decrease and your system will run much faster. It is important to note that not all programs that start on their own will have an icon in the system tray. Stopping these programs from running at start up can be a bit more difficult. Microsoft has built a program into Windows 98, 98SE, ME and XP called msconfig. This program allows you to change which programs will run when your PC starts. It is very important to note that using msconfig can cause serious problems with your PC if the wrong things are changed. It is strongly recommended that only users who are very comfortable using some of the more advanced aspects of their PC should attempt to alter settings via the msconfig utility. Some sites that will guide you in using msconfig have been provided below.
Microsoft Windows XP resource
How to prevent programs from automatically starting when Windows starts
- Click Start and choose Run
- In the Open field, type msconfig
- Click OK
- Click on the Startup
- Uncheck the box next to any programs you wish to disable from starting when Windows starts
- Click OK
Note: You must restart Windows before the changes will take effect


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Hi everyone, just a quick update. I decided to use the ATD Mod (primarily so I could figure out what I was deleting). I loaded it up with IOS249 and went into the 00010005 (Downloadable Game Content). I had used the previous free DLC hack and found my wads there. I deleted them all one by one, occasionally encountering the ret-106 error. When I tried to use low-level delete to finish the job, it would eventually disappear. That happened with two of the WADs (SZFE and SZAE, if I remember right). After that, the problem disappeared!
Problem solved.


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NuGroove Records will release Feelin' It by Freddie Fox July 7, 2009. Fans will remember Fox from the Grammy-winning song "Morning" with George Benson & Al Jarreau or for his studio work with smooth jazz notables like Marion Meadows, Warren Hill and Walter Beasley.
Feelin' It is a showcase of contemporary jazz who's who with appearances by have Nelson Rangell, Najee, Walter Beasley, Michael Lington, Luis Conte, and Freddie's wife Evelyn "Champagne" King on lead vocals on "Happy Feelings"!
The first single to go to radio is "U Turn." Hans Bernd-Hulsman "HBH" of Smooth-Jazz.de said, "Walking on George Benson's path No U Turn showcases Freddie's full knowledge of guitar magic and melody." Get your FREE download of "No U Turn" at http://www.thenugroove.com/freddiefox/NoUTurn.mp3
For more information on Freddie Fox:


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Does your small dog ALWAYS want to play fetch? With the iFetch Interactive Dog Fetch Toy, he can. Even when you're away or busy doing other things, iFetch keeps launching tennis balls for your dog to retrieve until he simply needs a nap.
The small, yet powerful iFetch automatic ball launcher - designed for smaller dogs - eliminates doggie boredom, keeps him occupied, and lets you accomplish even more throughout your day while ensuring that your dog gets the mental and physical exercise he needs. Plus, you can say goodbye to sore arm muscles from repeated throws.
The iFetch Interactive Dog Fetch Toy is extremely easy to use. Simply plug it in, choose your launching distance (10 ft, 20 ft, or 30 ft) using the button on the back of the unit, drop in a ball, and let your dog fetch to his heart's content. The iFetch Interactive Dog Fetch Toy runs almost silently and will not disturb you or your dog. Rubber feet help keep the toy in place. Streamlined plastic design. Requires 6 C-cell batteries (not included), or plugs into a standard wall outlet. Includes 3 miniature (1.5" dia) tennis balls and an A/C adapter with 5-ft cord. White with blue trim. The iFetch Interactive Dog Fetch Toy measures 10.5" x 7" x 7.5" high, with a 6.5" dia top ball return cone and a 1-5/8" dia ball launching hole.
Replacement tennis balls also available.
Shop all fetching toys for dogs.
Please click on "More Information" for usage instructions, training tips, and additional details.


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JET 187618 6 Ton 5' Lift 187618
The 187618 includes:
- 1x JET 187618 JLP-600A-5 6 Ton 5' Lift
- Weston Style Dual Pawl Brake System- Double pawl design increases safety
- Alloy Steel Hooks- Industrial rated hooks rotate 360 degrees for easy rigging. Hooks slowly stretch to indicate an overload situation increasing jobsite safety
- Durability
- Needle Bearing Design- Promotes long hoist life with low wear reducing downtime
- Grade 80 Load Chain- Grade 80 black oxide coated load chain for durability
- All Steel Construction- Impact resistant covers that provide durability and protection
- Compact Design- Smaller body and lightweight design for low headroom applications and use in confined areas
JET JLP-A Series lever hoists combine safety, reliability, and durability that are designed to perform in light duty industrial applications. Safety features such as optional overload protection prevents the lever hoist from lifting or pulling damaging loads above its rated capacity. JET also offers the option of shipyard hooks, virtually eliminating stretched hooks caused by point or tip loading. The JET JLP-A lever hoist is available in 1/4 ton to 6 ton capacities with standard lifts of 5, 10, 15, 20 and 30 feet (custom lifts available). The JET JLP-A is the perfect choice for a contractor grade lever hoist.
For all JET warranty issues, please visit thier warranty site.
Tech Specs:
- Brand: JET
- Model: JLP-600A-5
- Type: Lift
- Load Capacity (Tons): 6
- Lift (Ft.): 5
- Overload Protection: No
- Shipyard Hooks: No
- Package Qty.: 1
This item is covered by WMH's 5 Year Warranty and Jet's Red Assurance Protection Plan.
WMH Stands behind every product it sells with outstanding customer service and support. Their multitude of service repair centers offer quick turnarounds and most of the time they can authorize warranty repair, assist you in locating replacement parts, and perform routine maintenance and large repairs on your tools and machinery. To find a service center near you, please visit Jet's service center page.


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After all the hard work that high school seniors have put in over their four years, many want a clean break from the daily stress of school and to get a taste of being part of the workforce to garner real world experience. That is exactly what the Weston High School Internship Program strives to provide.
The internship program is an opportunity for qualified seniors to explore an area of interest and gain work experience outside the school setting during the last four to five weeks of their senior year.
"Our goal is to provide all students with opportunities to explore careers as they receive an up-close look at the world of work," said Meredith Starzyk, director of the high school Guidance Department and the head of the internship program.
Program growth
The program is in its fifth year of existence with more than 120 out of 207 seniors participating this time around. It started as a pilot with just 10 students but has received more interest with each passing year.
Students have the opportunity to obtain an internship in anything that interests them. Senior Daniel Muller, a political enthusiast, chose to intern at the offices of 4th District U.S. Congressman Jim Himes in Bridgeport.
"I've always been fascinated by politics and I wanted to see how it works at the local level because I didn't have much previous knowledge about it," Daniel said.
As an intern, his responsibilites consisted of helping the constitutents service representatives with anything they needed, which included answering phones, attending staff events or a field trip to Mr. Himes' district. "I did the nitty-gritty stuff to ensure that everything was running smoothly," Daniel said.
He strongly believes the internship program is beneficial to high school seniors. "It gives seniors the opportunity to, first of all, unwind a little bit at the end of the year, but also an opportunity to explore a career field that we might not otherwise have the opportunity to explore," the senior said.
At town hall
Daniel wasn't the only senior to choose politics as his area of interest for the internship program. Seniors Aaron Pomerance and Dani Narins chose to intern locally at Weston Town Hall. They have attended meetings in Hartford, typed up pieces for the town website and done clerical work, including recording mortgages.
"It's interesting to see how the town works behind the scenes and how much work goes into the little things. There's a lot of paperwork," Aaron said with a laugh.
Dani and Aaron both believe that the internship program is successful.
"You are able to experience the work environment and that will be helpful later in life," Dani said.
'Authentic learning'
Lisa Wolak, Weston High School principal, echoed the same views as the town hall interns. "The internship program is wonderful for students to explore an area of interest in a particular field or career. It is an incredible 'authentic learning' opportunity," Ms. Wolak said.
In the future, Ms. Starzyk is hoping to see the number of participants continue to grow. "Our goal is to have even more students next year. Based on the increase in student participation, I view this program to be a success," she said.
Other changes she would like to see is for the high school to "capture these experiences through media such as video clips, journal entries, and photos to display for both faculty and students moving forward." She also sees the need to reach out to more local businesses and organizations in order for the program to continue to expand.
Ms. Wolak also would like students' efforts to be highlighted in some fashion and suggested graduation as a venue.
Daniel said he would like to see the internship program run longer but understands with Advanced Placement (AP) testing — which takes place nationwide in mid-May — it would be difficult to do so.
Overall, the internship program is an opportunity for high school seniors to gain experience in a field of interest and apply skills they have been working on since kindargarten.
"Through this program, our seniors develop communication skills, appriopriate work attitude, technology skills, and good work habits that will serve them well for life beyond WHS," Ms. Staryzk said.


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WXII 12 News - Piedmont Triad Breaking News and Weather
About WXII 12 News - Piedmont Triad Breaking News and Weather
Take the WXII 12 News app with you everywhere you go and be the first to know of breaking news happening in Winston-Salem and the surrounding area. Always stay up to date with the latest local news, national, sports, traffic, political, entertainment stories and much more. Download the WXII 12 News app for free today.
Our Local News, Weather and Sports App Features Include:
- Winston-Salem breaking news alerts with push notifications
- Live streaming breaking news updates from our WXII 12 News reporters when it happens, where it happens
- Local news submission area for breaking news, news tips and the ability to email your news photos and videos right to our newsroom to be featured on air
- Up to date, current local weather conditions, hourly Winston-Salem weather updates, and 7 day forecasts
- An interactive radar that lets you zoom in and out to street level and watch storms as they approach. Move the map around to see major weather activity
- Share stories via email or your social media pages
- Winston-Salem weather alerts and updates, weather videocasts and more