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US 20170027456A1 us) United States 2) Patent Application Publication co) Pub. No.: US 2017/0027456 A1 oy oy ~ 3) ey @ (@) (60) 6) Kinast et al. (48) Pub. Date: Feb. 2, 2017 NON-INVASIVE BLOOD PRESSURE AiR 500 (2006.00) MEASUREMENT SYSTEM 4b 702 (2006.01) 461m 90228 (20060) Appicans:Erie Kael Kiast, Snta Ana CA (US), 4618 $0205 (2006.01) Valery G.Telfor, vine, CA (US) 2) US. CRC oc ABI $2125 (2013.01) AOU 502285 Inventors: Kinast, Santa Ana, CA (US), (2013.01); AGIB 542028 (2013.01); A6IB ery Ge Telfor, Irvine, CA (US) 50205 (201301), A6TB $/0402 (201501): ie ‘AGIB $7203 C13 0). BIB 877246 Assignee: Masimo Corporation, Irvine, CA (US) (2013.01); AGIB $/725 (2013.01); AGIB 742 ene ors A618 2 2013.01); A618 S245 Filed: Aug. 5, 2016 (57) ABSTRACT Related U.S. Application Dats individual's blood pressure is described. In certain embodi- Continuation of aplication No, 1/188396, le on ment the system esol polse wave transit tine tng Jul 2.2017, now Pat No. 9408 42, {wo scone sensor. The sytem ea inci ist conse Provisional application No, 61/3668, fed on Jl, SEBO configured to moniter Hear sounds ofthe patent 2, 20, peovsonl application No. 6469311, et Seeatic ansor confined to cna aerial pulse eee sound tan arterial location remote fro the eat. The System cin advntagcoslycaeulte a arterial pulse wave be Rd ‘transit time (PWTT) that does not include the pre-ejection Int Period time’ dey. In eerain embodiment, the spe GIB S021 (200601) firher ineudes & processor that calculates the aera “61 sz (200601) PACT obaine fom the scot sensors Te sytem ean A618 82 (200601) use this aerial PWT to determine whether To ager an ‘A61B 50402 (2006.01) Decisive cl meamirment ‘ oe Patent Application Publication Feb. 2,2017 Sheet 1 of 25 US 2017/0027456 Al yy ut 3 4 Hadi ee 2 j é 3 i aa iV a 8 3 ge Ba a 3s 53 & 2 ie18 ly Patent Application Publication Feb. 2,2017 Sheet 2 of 25 US 2017/0027456 Al a £ 3 é 8 as = 2 5 i 5 e &S i S & & 5 8 @ . oO YN 200A. US 2017/0027456 AI Feb. 2,2017 Sheet 3 of 25 Patent Application Publication oz 903 Ga UdesBowshyjold |_“ _| Md oz } sjuauodwiog oui, YSUBL| OABM OSIM a00z US 2017/0027456 AI Feb. 2,2017 Sheet 4 of 25 Patent Application Publication Ie Sib ove ed (esing pueH) ( Josueg onsnooy puz LiMd vez zee i vez, zez, (spunog yee) ‘\ doses ‘ousnooy Ise x JUOUIOINSeEY OUI] JSUEL| OEM O8INe C ‘2002 US 2017/0027456 AI Feb. 2,2017 Sheet 5 of 25 Patent Application Publication Gz 5Ib oz 903 oui ysuesy. pyoued ~ ogg (pnose9) 20805 onsnooy pug owl, suey) |euoNy ove (esind pueH) s08u9g ‘onsnooy 18z (spunog WeeH) Josueg ‘oysnooy 1S}, squouodwog owl, YSUEL] eABAA asINd US 2017/0027456 AI Feb. 2,2017 Sheet 6 of 25 Patent Application Publication £ DID sosse0dig te vie the Ze 3 ote 2 (s)s0sueg |} Jeouepadwioia ung | J 908 ainssaig pooig einpow sezkjeuy (S)s0sueg ainssaid Pooid }—| eunssaig pooja | | 904 S ‘NISEAUI-UON 'vOe oze (s)s0sueg fares eae es onsnooy y Zoe ole C. Patent Application Publication Feb. 2,2017 Sheet 7 of 25 US 2017/0027456 AI 432 FIG. 44 41 3 8 & Waveform ECG Waveform Patent Application Publication Feb. 2,2017 Sheet 8 of 25 US 2017/0027456 Al 4 a a 4 % FIG. 4B Bioimpedance Waveform EcG Waveform Patent Application Publication Feb. 2,2017 Sheet 9 of 25 US 2017/0027456 Al soos \ ) aa 520 580 sp p J J fa c c c ‘AUTOMATIC OCCLUSIVE EGG PROCESSOR OXIMETER, CUFF r 870 ip acoustic |~/ Pots 564A — sean | MODULE | 552, : | 87 sto 3628 FIG. SA Patent Application Publication Feb. 2,2017 Sheet 10 of 25 US 2017/0027456 Al 5008, _ ¢ a J 0 a sa j 5 C c c rouen oar = a a me Ta SETS come FIG. 5B Patent Application Publication Feb. 2,2017 Sheet 11 of 25 US 2017/0027456 Al FIG. 6 Patent Application Publication Feb. 2,2017 Sheet 12 of 25 US 2017/0027456 Al 700 Patent Application Publication Feb. 2,2017 Sheet 13 of 25 US 2017/0027456 Al US 2017/0027456 AI Feb. 2, 2017 Sheet 14 of 25 Patent Application Publication eu, be yout ¢—| una nur won Sarasa | pevog vcs “aul pens a ots pouod votpef3e1a unos, weoH ysi14 181g sue ‘oneM sind FEN wuojonenn ‘onsnooy }—— unojanem 903 le uuosenenn udesBowssyioid US 2017/0027456 AI Feb. 2, 2017 Sheet 15 of 25 Patent Application Publication v6 ew, ysuel, onem —] sing 1eueny ALM Fenus wos poueg uoroet ~ aig esgng, nem @sing [eM a6 5 \ roa uweiBopreo eouepedul uopsela-aue Ul0yOAe AA <——_ poved he joameosvowa [* ~ souspaduioig onal ~Bld s1BIMOIED ce j¢—— wiojenem 903 le few sued WO}EAe AA, udesBouKsuaia ‘006 US 2017/0027456 AI Feb. 2, 2017 Sheet 16 of 25 Patent Application Publication 6 Sib oun oc | esing leuouy ‘seunjpo4 WLOJOAEM, uaamjog soussayi ‘ou, oumuwisrog 26 \ WO}@AeNA unojonem, souspeduioia = beg souepaduioig eysnooy pisncoy so-ainjee, Anvep| o}onen ude sGowshyteta uuoyoAend joaineos Amuop, J — ydesBoushyoies » C ‘9006 US 2017/0027456 AI Feb. 2, 2017 Sheet 17 of 25 Patent Application Publication 6 Sib Uo}aAeNN ‘aging ansnooy LuuoyeaBja spunog |} uo onsncoy oun ‘seunyeo.y wuojonem .—! | ysueiy ene, <———| _usemyag eousieyig sing jeuowy ou euuueed fe — 626 a008 US 2017/0027456 AI Feb. 2, 2017 Sheet 18 of 25 Patent Application Publication Lima uly + emnpow vosuedwog ~9¢6 06 SID BLumd-e Vv Lime? wau SUB] oneN O8INd euouy ayeinayeo vou, —— Sue, OAEM OSIM apy 121M) J ar > \ gone uojenem esi, ‘onsnoay puz ‘uuojeneqy spunog, weaH onsnooy uojenem, ‘aging ansnooy 1s} US 2017/0027456 AI Feb. 2, 2017 Sheet 19 of 25 Patent Application Publication 986 uojonem souepeduiog uwojenenh ‘spunog weoH ansnooy wojenem 993 uojenem deuBowsAujoig “Lima 12100 empoyy + uosyedwog reveuy feu v5 Cc wwoyone nn [uma #-——__ ena ae ‘ysnoay pug reuaury sieinoyeq uuojanem spunog vm emcee reuewy eyein2|e9 wuojonenn ‘sing onsnooy Is S > \ \ 26 4008 Patent Application Publication Feb. 2,2017 Sheet 20 of 25 US 2017/0027456 Al 1000 »~ ) a ¢ Ne 1002 [MEASURE ARTERIAL PULSE WAVE — TRANSIT TIME AT A FIRST TINE ¥ 1004— [MEASURE ARTERIAL PULSE WAVE TRANSIT TIME AT A SECOND TIME ¥ 1006 — a DETERMINE A DIFFERENCE BETWEEN THE TWO ARTERIAL PTT MEASUREMENTS 1008 NEW BLOOD PRESSURE MEASUREMENT ? TRIGGER OCCLUSIVE CUFF TO TAKE NEW BLOOD PRESSURE MEASURENENT FIG. 10 Patent Application Publication Feb. 2,2017 Sheet 21 of 25 US 2017/0027456 Al 26 Minutes. FIG. 11 Wa ‘esi ‘SHU US 2017/0027456 AI Feb. 2, 2017 Sheet 22 of 25 Patent Application Publication era ow Sue ‘nem esing + aujoows Jeu BuiBesony fiddy & \ oz a Sib (suorourssee ere ateu weal BulBeveny 43 JO SORSHETS renipy azkieuy ( C \ » woz zoe eq ‘eu sues), anen asing ea eye uel} Patent Application Publication Feb. 2,2017 Sheet 23 of 25 US 2017/0027456 Al 1300. ~\ PRE-AMPLIFICATION FILTERS ‘8, 1310 ANALOG-TO.DIGITAL CONVERTER 138 FIG. 13 Patent Application Publication Feb. 2, 2017 Sheet 24 of 25 US 2017/0027456 Al 1400 START OBTAIN AT LEAST TWO BLOOD PRESSURE MEASUREMENTS OF A PATIENT AT DIFFERENT TIMES 1402 - 1404~ | MEASURE PULSE WAVE TRANSIT TIMES AT THE DIFFERENT TIMES OF THE BLOOD PRESSURE MEASUREMENTS "\_| DETERMINE A SLOPE CORRESPONDING ‘TO CHANGE IN PULSE WAVE TRANSIT TIME PER CHANGE IN BLOOD PRESSURE, 1406 Fig. 14 FIG. 144 Patent Application Publication 1450 S N\ Feb. 2,2017 Sheet 25 of 25 US 2017/0027456 A1 1408 | IDENTIFY INDIVIDUALIZED PATIENT CALIBRATION FACTOR BASED ON SLOPE + 1410 MEASURE PULSE WAVE TRANSIT TIME [4 + 1412— ESTIMATE CHANGE IN BLOOD PRESSURE BASED ON INDIVIDUALIZED CALIBRATION FACTOR 1414 BLOOD PRESSURE CHANGE, SIGNIFICANT ? YES 2 1416 NY OUTPUT SIGNAL TO PERFORM ACTION (E.G. TRIGGER CUFF) FIG. 14B US 2017/0027456 AI NON-INVASIVE BLOOD PRESSURE ‘MEASUREMENT SYSTEM. RELATED APPLICATIONS [0001] This application is a continuation of U.S. patent application Ser. No. 13/189,39, filed Jul. 22, 2011, entitled “Non-Invasive Blood Pressure Measurement Syste,” ‘which claims priority under 35 USC. §11%() to US. Provisional Application No. 61/366,862, fled Jul. 22, 2010, ‘entitled “System for Triggering a Non-invasive Blood Pres- sure Device” and 10 US. Provisional Application No. 61/469,511, fled Mar. 30, 2011, entitled “Non-Invasive Blood Pressure Measurement System,” the disclosures of ‘hich are hereby incorporated by reference in their entirety. BACKGROUND 10002] Prolonged reduction or loss of blood pressure in a patient severely limits the amount of tissue perfusion of the patient and therefore causes damage to or death of the tissue. Although some tissues can tolerate hypoperfusion for long periods of time, the brain, heart and kidneys are very Sensitive toa reduction in blood low. Thus, during and ater resical procedures and at other times, ood pressure is @ frequently monitored vital sign. [lood pressure can be alfeced by the type of medical procedure performed and by physiological factors such as the body's reaction to the medical procedure, Moreover, load pressure is often manipdlated and controlled using variows “medications Medical procedures, physiological factors, and medications ‘ean cause the blood pressure ofa patient to change rapidly. [0003] "The traditional method of measuring blood pres- sure is with a stethoscope, occlusive cuff, and pressure manometer. Blood pressure cult instruments make only & spot-check measurement, so repetitive interval measure rents are often used to trend patient stats. More frequent Jmervals improve vigilance at the expense of patient dis- ‘comfort, possible patent injury (et, due to occlusion of blood vessels), and excessive battery consumption SUMMARY, 10004} In certain embodiments, a method of monitoring blood pressure ofa patient includes receiving a physiol cal eletrcal signal from an electrical sensor coupled witha patie, The physiological elecsieal signal can reflect elec frical activity of the patient's heart. The method may also include receiving 1 eardiae ejection signal from a second sensor coupled with the patient, This eaiae eection signal ‘can rellect a cardiac ejection event associated Wit ‘of blood from the patient's heart. In addition, tt ‘may inelude receiving an seteril pulse signal few hid sensor eoupled with a limb of the patient. The method! ean alo inelude detemnining an arterial pulse wave transit time (PWTT) that compensates for a pre-sjection period of @ cardiac eyele associated with the patient's heart, hased at least partly onthe physiological electrical signal, the cardise ‘jection signal, and the arterial pulse signal. Moreover, the miehod may include triggering én occlasive blood pressure ‘culT to obiaina blood pressure measurement fom the patient responsive to a change in the arterial PWTT. [0005] For purposes of summarizing the disclosure, cer Iain aspects, advantages and novel features of the inventions have been described herein. It is to he understood that aot necessarily all such advantages can be achieved in accor Feb. 2, 2017 a of the inventio isclosed herein e be embodied of caried out in a mannee that achieves or ‘optimizes one advantage or group of advantages as taught herein without necessarily achieving other aivantages as ean be taught or suggested herein, BRIEF DESCRIPTION OF THE DRAWINGS [0006] Throughout the drawings, reference numbers ean be onnsed to indicate correspondence between referenced elements. The drawings ate provided to illustrate embod ‘ments ofthe inventions described herein and not to limit the scope thereof, [0007] FIG. 1 illustrtes an embodiment of a parameter calculation system: [0008] "FIGS. 24 and 2B illustrate plos of plethysmograph And electroeardiograph (ECG) waveforms that can be used to calculate pulse wave transit time (PWT), 0009] FIGS, 2C and 2D illustrate plots of acoustic wavee orms that can be used to calculate PWTT; [0010] FIG. 3 iustrates another embodiment of a blood presiure monitoring system: [0011] FIG. 44 illustrates a plot of acoustic and ECG ‘waveforms; [0012] FIG. 4B itusiraes a plot of bioimpedance and FCG waveforms; [0013] FIGS. 5A and 5B illustrate embodiments of blood pressure monitoring systems coupled to patient, [0014] FIG. 6 illustrates example positioning locations for the acoustic sensors that can be use in the various systems ‘nd methods described herein; [0015] FIG. 7 illustrates example positioning locations for acoustie, electrocandiograph (ECG), optical and bioimped- lance sensors that can be used in the various systems and ‘methods deseribed herein; [0016] FIG. 8 illustrates an example acoustic sensor that fan be used in the vatious systems deseibed herein [0017] FIGS. 94 through 9F lustrte embodiments of calculating arterial PWTT, [0018] FIG, 10 illustrates an embodiment of a process for triggering an occlusive blood pressure measurement [0019] FIG. 1 ilostrates plots of PWTT and heart rate ‘waveforms; [0020] FIG. 12 ilustrates an embodiment of a dynamic PWT averaging system. [021] FIG. 13 illusates an embodiment of font end circuitry that can be used in the parameter calculation systems described herein to reduee phase impact on the [0022] FIGS. 144 and 148 iustrate an embodiment of a process for calibrating PWTT measurements based on an ‘ndividvalized patient calibration factor. DETAILED DESCRIPTION [0023] ‘The propayation time of an arterial pulse wave trom the heart to an extremity is related to blood press Currently available blood pressure monitoring systems ‘mate this propagation time by detcting a time difference between points on an electrocardiograph (ECG) waveform ‘anda photoplethysmograph waveform, This estimated propagation time i sometimes referred to as pulse wave transit time (PWT) or time difference of arival (TDOA). Currently availabe blood pressure monitoring systems trig US 2017/0027456 AI ter an automatic occlusive cu to take a blood pressure messurement based on detected changes in PWT. Whea the PWTT has not changed substantially, the blood pressure ‘monitoring system usually does not tigger an occlusive blood pressure measurement, AS a result, such a system automatically adjusts the frequency of oeclusive blood pres- sure measurements to obiain betier data while potentially reducing discomfort forthe patient 0024) _A drawback with existing blood pressure systems is that PWTT as calelated by these systems is not always un accurate indicator of blood pressure or changes in blood pressure, One reason for this inaccuracy is that eurrently= available systems do not aecount for patient's pre-jection period (PEP) when computing PWT. The PEP ean include the difference in time between an electrical tigger that iniates ventricular contraction (eas detected by an ECG sensor) and the actual ejection of blood from the ventricles Jno the aorta. Aecorlingly, the calculated PWTT does not socurately represent the actual propagation time of the ‘arterial pulse from the heat to an extremly, which ean result, jn inaccuracy in the blood pressure variability measure- ments 0025] | Another reason forthe inaccuracy af existing blood pressure systems is tat the photoplethysmograph wavefon typically oblained from an optical sensor coupled to finger of the patient. Studies have shown that pulse wave velocity slows greatly atthe transition from the arteries 10 the smaller vessels and capillaries, adding considerable ‘delay tothe arterial PWT. This time delay can account for up 10 509% of the arterial PWT. The use of an acoustic sensor positioned over an artery to monitor arterial pulse insta ‘of capillary flow can advantageously remove the ‘effect ofthe artery-to-capillary transition delay component ‘of the arterial pulse wave transit time measurements. 10026] This disclosure describes, among other Features, @ system for non-invasively determining at indication of aa individua’s blood pressure. In certain embodiments, the system dynamically. accounts for a patient's PEP when ‘calculating PWTT. The system can include an optical sensor that obtains plethysmograph infomation from patient. The system can fier inelnde an eleceical sensor, which can be ‘ny sensor tht obtains information relating o the electrical activity of the patients heart (such as an ECG sensor). Ia addition, the system can include another sensor, such as an ‘acoustic Sensor or a bioimpedance sensor, which ean obta Jnformation about cardiac ejections from the patients hear. In certain embodiments, the system further includes a pro- ‘essor that ealeulates PWTT compensated for PEP using the information obtained from the optical, electrical, acoustic, ‘and/or bivimpedance sensors, ‘The system can use this ‘compensated PWIT 10 determine whether to trigger an focclsive cull measurement [0027] In some embodiments the system determines an arterial pulse wave transit time measurement from features ‘of two acoustic waveforms. The system can include an ‘acoustic heart sounds sensor that obtains heart sound infor. mation from a patient. The system can furher include an ‘acoustic pulse sensor, which ean be placed at a location remote from the patients heart at which peripheral arterial pile pressure wave vibrations ean be monitored (such a8 at patient's wrist or nook) In addition, the system can include ‘one or more other sensors, suchas a second acoustic pulse sensor, ECG sensors, optical sensors, andior bioimpedance sensors. In certain embodiments, the system Further includes Feb. 2, 2017 ‘processor that caleulates arterial PWTT using the infor ‘mation obtained frm the acoustic andor other sensors, The system can use the arterial PWT measurements to estimate changes in blood pressure and wo ai in determining whether to trigger an occlusive cuff measurement. [0028] In some embodiments, the system also compen- sales PWTT data for noise. Por example, the system ean use A noise reference signal to reduce noise in the PWT data ‘The moise reference signal can be derived from the patient's heart rate. The system can reduce noise in the PWT, for ccample, by adaptively reducing the noise based on the noise reference signal or by dynamically adjusting an aver- aging time used 10 average the PWTT data, among other possible techniques. [0029] Moreover, in certain embodiments, the non-inva- sive blood pressure measurement system also calibrates PWT data based on an individualized patient calibration ‘actor. calibration fonetion or curve ean be determined that ‘maps PWT measurements to blood pressure values. The slope of the calibration curve can be determined experimen- tally and ean vary greatly from patient (© patent. In some embodiments, the system determines an individualized, or personalized, patient calibration facor based on the deter ‘mined slope, The patient calibration factor can then be used ‘o interpret subsequent PWTT measurements to estimate changes in blood pressure. The individualized patient cal bration can advantageously reduce the occurrence of uanee- essary blood pressure cult measurements andor false alarms System Overview [0030] FIG. 1 illastrtes an embodiment of a parameter calculation system 100, In certain embodimens, the param- cer calculation system 100 non-invasively obtains an in cation of changes in a patient's blood pressure. The param: cer calevlation system 100 can use the measured blood pressure changes fo tigger a blood pressure cuff 108 to ‘obtain ant occlusive blood pressure measurement, Advanta- sous, in certain embodiments, the parameter caleulation system 100 uses the arterial pulse wave transit ime, which ‘counts for a patient's pre-ejetion period (PEP) when calculating changes in blood pressure. The parameter cal- culation system 100 can therefore more accurately deter ‘mine when an occlusive blood pressure measurement is appropriate. [0031] In the depicted embodiment, the parameter calen- lation systems 100 includes a parameter calelator 110 and a display 120. ‘The parameter calculator 110 can inelude hardware (such as one or more processor), sohware. andlor fimware for measuring a physiological parameter sch as blood pressure. Inputs to the parameter calculator 110 ean include, among others, optical sensor data provided by an ‘optical Sensor 102, acoustic sensor data provided by one or more acoustic sensors 104, andlor additional sensor data provided by one or more additional sensors 106, The optical sensor 102 can be a pulse oximetry sensor, a eo-oximetty ‘Sensor, othe lke. The acoustic sensors 104 ean be biologie «al sound sensors. The biological sounds may include hear, breathing, and/or digestive system sounds, in addition 10 ‘many other physiological phenomena, The adlitional sen- sors 106 can include any sensing device that provides Physiological data to the parameter calculator 110, Tor ‘example, the additional sensors 196 can include an electrical US 2017/0027456 AI sensor configured to provide an ECG signal, an acoustic Sensor, andor a bioimpedance sensor, or any other sensing device. 10032] |The optical sensor 102 can use spectrophotometry Techniques to measure a variety of blood eonstitvents, including. for example, oxygen. saturation, hemoglobin, methemoglobin, carboxyhenioglobin, other hemoglobi species, concentrations ofthe sane, and th lke. In adition, the optical sensor 102 can also be used to measure a variety ‘of other physiological parameters, including pulse rate, perfusion, and the like. The optical sensor 102 can inelude ‘one oF more emitters that shine one or more wavelengths of Tight darouph tissue of a Tiving person, suet as through finger, toc, oF foot. One or more detectors can receive the transmitted light after attenuation by the tissue aod ea generate one or miore signals responsive to the attentt light 10033] In certain embodiments, the parameter calculator 110 derives a photoplethysmograph from the optical sensor data The photoplethysmograph (sometimes referred 10 herein a a “plethysmograph,” ‘photopleth” or “pleth”) can bea waveform that can represent changes in blood volume ‘as measured by one or more wavelengths of light irradiated tissue site ofa patient. The photoplethysmograph can be ‘caused by arterial pulsation, and as sock, ean be related 10 arterial blood pressure, Thus, in some embodiments, the parameter calculator 110 uses the optical sensor data to {rive an indication of blood pressure fora patient, 10034] In one embodiment, the parameter calculator 110 ‘can use the optical sensor data and the additional sensor data 106 to derive one or more indications oT blood pressure, For ‘eximple, a combination ofthe optical sensor data and data from electrical sensors), acoustic sensor(s) 104, andior bioimpedance sensors) can be used to determine an ‘amount of time that i takes for a pulse wo travel through aa artery from a patents heart toa measurement ite, This time ‘ean be refered to ab an arterial pulse-wave transit (PWT). Advantageously, in cerain embodiments, the prancter calulator 110 can more securely determine the S-PWTT based atleast in parton the additional sensor data 106 obiained from an acoustic (104) and/or bioimpedance sensor In particular, using the additional sensor data 106, the paranieter ealulator 110 can acount fora patient's cardiac pre-ejection period (PEP) when calculating «-PWTT. In ‘ther embodiments, the parameter calculator 110 uses the couse sensor data derived from acoustic sensors 104 alone to derive one oF more indications of blood pressure, Using the estimated changes in blood pressure. the parameter ‘caloulator 10 can tigger a blood pressure eulf 108 to obta fn occlusive blood pressure measurement 10035] The parameter calculator 10 ean ovtpot parameter data 13 indicative of the calculated parameters, including blood pressure, for presentation to user. The parameter data 113 can be displayed on a display device 120, In another ‘embouiiment, the parameter calculator 10 provides param- ‘eter Valtes as an output H12 to another device, for example, device providing an audible response, or over a network 10 ‘a remote device. For example, a remote device might be a ‘computer located at a nurses” sation oF a clinician's hand= held device [0036] The parameter caleulator 110 can also celeulate trend data reflecting trend information for the parameter data 113. The parameter calculator 110 can also synthesize oF scale waveform data, In addition to outputing the parameter Feb. 2, 2017 ata 113, the parameter caleulator 10 ean output tre data 114, synthesized, scaled, or actual wavelorms 118, clibra- ‘ion data 116, and alarms 117. The parameter calculator 100 can provide he outputs 113, 14, 18, 11610 the display 120. {oa separate patient monitoring device, or to another device configured to receive physiological parameter information. [0037] In an embodiment, the parameter calculator 110 is implemented in a single monitoring device. In an embodi- iment, the features of the parameter calculator 110 are distributed among separate device. In an embodiment, the parameter calculator 110 includes a processor, processor board or an Original Equipment Manufacture (OEM) board Tan embodiment, the parameter ealclator 10 is portable. Data communicated between the various components ofthe parameter calculation system 100 can be communicated ‘through cables or wirelessly. Other inputs and/or outputs ean be included with the system 100. [0038] The display 120 ofthe parameter calculation sys- ‘tem 100 can be pant of patent monitor (not shown), which can also inelude other components, sue as a speaker poser button, removable storage or memory (¢.,2flash card slot), ‘an AC power port, and one or more network interfaces, sch fs a universal serial bus interface or an Fihemet por. The ‘splay 120 can indicate a measurenient for blood prestre for example, a measurement of the systolic and diastolic blood pressure in mmflg. Other physiological parameter values, waveforms, trond data, calibration data, alarms, and the Tike ean also be output on the display 120, [039] Although the parameter caleulatar 110 is deseribed as calculating changes in blood pressure, in some embod ‘ments, the parameter calculator 110 calculates actual blood pressure values from the acoustic andlor additional sensor ata. In addition, the parameter calculation system 100 can also measure other physiological parameters besides blood pressure, sth os pulse ral, oxygen saturation (SpO,), hemoglobin, total hemoglobin, hemoglobin species (e8. ‘methemoglibin, carboxyhemoglobin, or the like), carbon monoxide or dioxide, perfusion, and glucose, among 2 varity of other parameters [0040] Further, in some embodiments, the parameter cal- eulator 110 uses acoustic sensor data (irom the acoustic sensor(s) 104) to detemnine any of a varity of respiratory parameters of a patient, including respiratory rate, inspi- {ory time, expinstory time, inspiratory to expiratory (LE) ratio, inspiratory’ flows, expiratory flow, tidal volume, minute volume, apnea duration, hypopaea duration, breath sounds (eg, miles, thoochi, and stridor), and changes in breath sounds such as decreased volume or change in airflow (Gither increase or decrease). In addition, in some cases the parameter calculator 110 monitors olber physiological Sounds from the acoustic sensor 104 daa, such as heart ale (ex, to help with probe off detection, heart sounds (SI, 82, 3, $4, and murmurs), and change in hear sounds such ‘normal to murmur of split Near sounds indicating uid overload. Moreover, a second acoustic sensor 104 may be placod over the chest for hetter heart sound detection. The parameter calculator 110 may keep user inputs to a mini- ‘mum (example, height) and use a Health Level 7 (HIL7) interface to automatically input patient demography. Example PWIT Calculations [041] FIG. 24 depicts an embodiment ofa plot 2004 that illustates an example PWTT calculation, In the plot 200A, ‘aplethysmograph Wavefonn 210 and an ECG waveform 220 US 2017/0027456 AI ‘are shown, The plethysmograph waveform 210 can be ‘obtained from an optical sensor 102 as described above. The ECG waveform 220 can be obtained from an eletsical 10042] The plethysmopraph waveform 210 can rellet changes in pultile flow of blood in body tissue ofa patient, The ECG waveform 220 can reflect electrical otivity of & patien’s heart. The CG waveform 220 can have features Including, for example, a Q-wave, an Rewave peak, and an Scwave, among others. A segment of the FCG waveform 220 from the Q point to the S point can be referred to 38 2 QRS complex, which can represent ventricular activation, [0043] Velocity of @ Blood pressure wave in Use arteries has a correlation with blood pressure. As the length of an artery is typically constant or approximately constant, the time that it takes for the blood pressure wave to travel from the heart to an extremity can be used to derive an indication ‘of blood pressure. In curently available monitoring systems, ‘a measure of seh time, refered to as PWTT, bas been used to infer changes in blood pressure. In some embodiments, the PWT can represent a difference in time between 3 Jeature of the plethysmograph waveform 210 and a festure ‘of the ECG waveform 220, For example, in one embodi- ment, the PW'TT ean be obtained from the difference in time between the Rawave peak on the ECG waveform 220 and @ oot point om the plelaysmograph waveform 210. The foot point of the plethysmowraph waveform 210 can correspond to the time of earliest onset of arrival of the pulse at @ Jocation away from the heart (eat a patients finger). In ‘other embodiments, the PWTT can be-obtainod from the “difference in time between either the Q-wave oF the S-wave ‘on the FCG waveform 220 anda feature on the plethysmo- raph waveform 210 (eg. foot point, peak, or some ether feature), 10044} Calculated inthis manner from the plethysmograpl and ECG waveforms 210, 220, PWTT canbe fairly accurate Tor some patients. However, ia some eases, using PWIT to measure changes in blood pressure provides inaccurate oF lunexpected results. Atleast a partial explanation of these ‘unexpected results can be seen in FIG. 28, 10045] In FIG. 2B, an example plot 200 is shown that includes 4 plethysmograph waveform 210 and an ECG Waveform 220, An overall PWT 212 can he caleulted from a point on the ECG waveform 220 10 a point of the plethysmograph waveform 210, as deseribed shove. Hom= ‘ever, the overall PWTT 212 can actually include at least 10 ‘components aa arterial pulse wave transit time (sometimes referred to as “s-PWIT") 214 and a pre-ejection period (PRP) 216, [0046] |The PEP 216 can be defined in different ways, For instance, in certain embodiments, the PEP 216 includes the difference in ine between venticular contraction and ear diac ejection of blood into the aorta, The PEP 216 can also be considered as measured interval from the onset of Ventricular depolarization, such as a Q-wave (or other fea- ture) ofan ECG, tothe beginning of meckanieal contraction ‘of the heart muscle. For example, the PEP 216 can represent the difference in time from the onset ofthe QRS complex of the ECG signal 220 to whea cardiac ejection actualy occurs Funher, the PEP 216 can alko be considered as the time interval from the beginning ofthe electrical aetivaton ofthe ventricles to the opening of the sortie valve [0047] The value of the PEP 216 can fluctuate based on patient condition, age, sex, and medications taken by the Feb. 2, 2017 among possibly other factors. In some patients, the ‘can account for a significant portion of the PWTT 212, including even as much as about 50% of the PWTT 212, Because PEP 216 ean eecouat for a significant portion of overall PWTT 212, including the PEP 216 in a PWTT measurement can result in inaccurate devenninations of changes in a patient’s blood pressure. In certain circum stances, this can even lead t0 not detecting a clinically significant change in blood pressure and ot initiating. an ‘occlusive cuff measurement for confirmation. FIG. 22 also illustrates that it can prove difficult 10 derive the PEP 216 irom & feature of a plelhysmogroph signal and a feature of an BCG signal [0048] ‘Thus, in certain embodiments, the arterial PWIT 214, which accounts forthe PEP 216, can more aceurately ‘correlate with changes in a patient's blood pressure than the ‘overall PWTT 212. Thus, it can bo advantageous to detect ‘changes inthe arterial PWTT 214 and t use these changes to trigger occlusive cuff measurements. The arterial PWIT 214 can be detemnined in some embodiments by ealeulating the PEP 216 and subinicting the PEP 216 value from the ‘overall PWIT 212, [0049] Tae PEP 216 can be derived, at least in part, from Another physiological signal, Such # physiological signal ‘a be indicative of cardia ejection. Example piysiological signals can inclode, but are not limited to, bioimpedance signals and acoustic signals. For example, in one embodi- ‘ment, the PEP 216 can be derived from & feature ofthe ECG Waveform 220 and a feature of another physiological signal. As another example, in another emboxiiment, the PEP 216 an be derived from a feature ofthe plthysmograph wave- orm 210 and a feature of another physiological signal. As yel another example, the PEP 216 can be accounted for by ‘eriving arterial PWTT direetly fom s feature ofan acoustic heart sound waveform and aa acoustic wavelorm om aa extremity, such as the hand, wrist, o Him [0050] FIG. 2C depicts an embodiment of plot 200C that illustrates an example PWT calculation that compensates {or PEP using multiple aeousti sensors. In te plot 200C, first acoustic waveform 230 and a second acoustic waveform 240 are shown, The first acoustic waveform 220 can be ‘obtained fom a fist acoustic sensor positioned proximate a heart ofa patient to monitor heart sounds ofthe patient. The bart sounds can be indicative of the closing of eat valves: the attoventricular valves (ata valve and tricuspid valve) and the semilunar valves (aortic valve apd. pulmonary valve). The closing of the heart valves corresponds 10 ventricular systole and diastole. The second acoustic wave- form 240 can be obiained feom a second acoustic sensor positioned at an arterial locaton avway from the heart and ‘configured to monitor peripheral pulse pressure wave vib tions oF sounds at the arterial location. For example, the second acoustie sensor can be positioned proximate a wrist anery (eg, radial artery, ulnar anery), proximate a carotid Anery on the nock of the patient, or proximate an artery of the leg. 0051} ‘The first acoustic waveform 230 can include heart sounels of the patient corresponding tothe closing ef heart valves st the transition between ventricular systole and iastole. For example, the heart sounds can include first heart sounds (eg, $1 heart sounds) 232 corresponding tothe closure of the alrioventricular Valves a the time ventricular systole begins and ventricular diastole ends and second heart sounds (eg. $2 beart sounds) 234 corresponding to the US 2017/0027456 AI ‘closure of the aortic valve and the pulmonary valve atthe time ventricular systole ends and ventricular diastole begins “The occurrence of the SI heart sound ean identify the stat time of ejection of blood from the heart and the occurrence ‘of the $2 heart sound ean mark the end time of approximate ‘end time of ejection of blood from the heart, Accordingly. the actual ejection of blood from the ventricles may’ occur for patents a the first heart sound (eg. atthe stat, peak, oF ‘end of the first heart sound), between the start of the first heart sound (he SI sound) and the start ofthe second heart sound (the S2 sound), or at the second heat sound (e3., sar, peak, or end of the second heart sound 100582] The second acoustic waveform 240 can include an arterial pulse at a second location remote from the hear (eg, at a pation’s wrist or neck). The second acoustic ‘waveform 240 shown in FIG, 2C includes odio information ‘of the peripheral arterial pulse ata patients wrist, hand, oF ‘arm (or foot, ankle, or leg). For convenience, although the Peripheral arterial pulse can be detected at a variety of Jocations onthe body, the wrist wil be used as an illustrative ‘example forthe reminder of this specification. The second acoustic waveform 240 may display a pressure. wave received at the patient's wrist some time prior to actual ‘artval ofthe blood atthe periphery 10083] In some embodiments, the arterial PWTT can rep- resent @ difference in time between a feature of the fist acoustic waveform (eg., heart sounds waveform) and Feature of the second acoustic waveform (e.g, wrist pulse waveform). For example, in one embodiment, the arterial PWT can be obsained from the ciferenee in time bersseen ‘a feature ofthe fist heart sound (the $1 sound) 232 on the seoustic heart sounds waveform 240 (e., start, maximum peak, end, soaie other Feature of the SI sound 242) and a Teature of the acoustic wrist pulse waveform 240 (e2. bottom onset or upstroke point 236 of the waveform 220 oF Sar, maximum peak, end, some othor feature of the wave- {orm 220). In other embodiments, the arterial PWTT can be ‘obtained {rom the difference in time between a determined ‘eniroid location of the SI sound 282 oF a locaton of the ‘centroid of the energy from the start of the SI sound 232, Until the stat of the S2 sound 234 and a feature on the acoustic wrist pulse waveform (et, bottom onset, a foot point, peak, or some other feature), In some embodiments, the envelope of the waveform 220 is obtained and used in the analysis deseribed herein, eg. by finding a feature ofthe ‘envelope rather than the waveform 220 itself. 10053] In one embodiment, the arterial PWTT can be ‘obtained from the difference in time from a location bedween the SI and $2 heart sounds 2%2, 284 and/or between 9 ‘centroid of the enemzy ofthe Stand $2 sounds 232, 234 and the bottom onset of a corresponding pulse of an acoustic arterial pulse waveform (ean acoustic wrist pulse wave- orm of an acoustic carotid pulse waveform). In some ‘embodiments, an arterial PWIT determination based on Identified features of two mechanical acoustic waveforms ‘advaotageously provides a more sable result dan @ PWT ‘determination based on an identified festore ofan electrical waveform (¢., FCG waveform) and an identified feature of ‘mechanical waveform (eg., photoplethysmograph wave- orm) [0085] Turing to FIG. 20, » plot 2000 is shown that includes a set of four example waveform. The acoustic heart sounds waveform 230 and the acoustic wrist pulse waveform 240 are illustrated again, along with a third Feb. 2, 2017 acoustic waveform (an acoustic carotid pulse waveform) 250 and an ECG waveform 260. The plot 200D helps to illustrate the wo components that mike up an overall PWTT ‘caiurement in certain embodiments a pre-ejetion period (PEP) component and an arterial wansit time component ‘The use of to acoustic senson results ia PWIT or time. iference-of-arval calculations that, in certain embod ‘ments, more accurately reflect arterial pulse wave transit ‘ime, thereby allowing blood pressure measurements to be taken more ellcintly [0056] The acoustic carotid pulse waveform 250 can help to provide another measurement indicator (@.2, contro oF rojerence or another input component) that can be used 19 elermine the arterial pulse Wave teansit Time or other anerial properties because the distance is known between the two sensors. The acoustic carotid pulse waveform 280 or Any of the other waveforms ean provide an indication of patient breathing, as shown by the presence of noise 288 on the acoustic carotid ple waveform 250. In some imple- tions, the acoustic carotid pulse waveform 230 can be ted in place ofthe wrist pulse waveform 240 to determine the arterial PWTT [0057] In some embodiments, the PEP is derived from one ‘or mote features of one oF more acoustic signals. In one embodiment, the PEP is determined from the time of the Start ofthe SI heart sound 232 tothe time of the end of the SI heart sound 232, ln other embodiments, the PEP ean be derived from a feature of an ECG wavefoem 260 and Teature of another physiological signal (c.g. pth signal or ‘an acouste signal), One way fo measure PEP i o determine ie difference between an Ri wave peak of the ECG wave- orm 260 anda feature ofthe SI solnd 212.on the acoustic heart sounds waveform 230 (eg. a foot point, peak, cen- twoid, or other feature or derived focation). More generally. PEP can be determined asa difference in time between any feature of the FCG waveform 260 and any feature of the ‘acoustic heart sounds waveform 230, including in some ‘embodiments, a feature ofthe S2 heart sound 234, The PEP can vary depeading on patient pathotogy, and a determina- tion of PEP can provide information regarding heart condi- ‘ions to a clinician, In some embodiments, PEP is not calculated or used a all by the parameter calculation system 100 because the arterial PWTT is determined by the aeons [0058] FIG. 3 ustates an embodiment of a blood pee Sure monitoring system 300 that can determine PWTT ‘measurements (including a-PWTT measurements) from sig- tals roveived from various sensors. The blood pressure ‘monitoring system 300 can implement certain features ofthe parameter calculation system 100 deseribed above. In par- ‘cular, the system 300 can periodically measure. blood pressure using a blood pressure cull 320, whieh can be an Automatic occhisive cult ofthe lke. In addition, the system $300 can perform PWTT calculations to noninvasively detect ‘changes in patients blood pressure. The illustrated blood presiure monitoring system 300 includes sensors aad asso- tiated modules that ean advantageously be used to monitor blood pressure. The depicted modules ean be implemented in hardware andlor in software (¢.g., a8 executed by one or nore processors 380 or computing devices) [0059] In the depicted embodiment, the system 300 includes a parameter calculator 310, which ean be imple- ‘mented in hardware andor software. The parameter cal Jator 310 isa more detailed implementation of the parameter US 2017/0027456 AI ccaloulator 110 of FIG, 1 and can include all the Features theres! Various sensors communicate with the parameter ‘aleulator 310, These sensors include two oF more aeoustic Sensors 302, one or more ECG sensors 304, one oF more bioimpedance sensors 306, and one or more optical sensors 308, The acoustic sensors 302 eas include piezoeleceic Transducers or other acoustic transducers for measuring. & patient's body sounds, such as hreaing and heart sounds The ECG sensor(s) 304 can clude ECG leads or the like for reasuring the electrical activity ofthe heat. The bisimped- ance sensor(s) 306 can include electrodes placed on the neck ‘and/or thonix for measuring the impedance of electrical signals in the body. More detailed embodiments of these sensors are deseribed below with respect to FIGS, 5 [0060] ‘The example parameter calculator 310. shown ‘includes a blood pressure analyzer 312 and a noninvasive blood pressure module 314. The blood pressure analyzer 312 ‘can calculate arterial PWTT using the outputs of some or all, ‘of the various sensors 302, 304,306, and 08, ase at least in part on this aleulated PWT the blood pressure analyzer 312 can send a trigger signal to the noninvasive blood pressure module 314, In response to receiving this trigger ign. the notrinvasive Blood pressure module 314 can ‘cause the blood pressure cuff 320 10 take a blood pressure measurement. In some embodiments, the non-invasive blood pressure module 314 sa separate component from the parameter calculator 310, for example, on an Orginal Equipment Manufacture (OEM) board or the like [0061] In one embodiment, the acoustic sensor 302 is placed over the heart or near the heart ofa patient so as t0 ‘detect heart sounds ofthe patent. The acoustic sensor 302 ‘can be positioned on the chest, hack, neck, side, abdomen, ‘or other area of the body so a8 to detect the hear sounds Heart sounds can include, among others, first and second heart sounds. Te ist heat sound can correspond to syle, ofthe contrection of the ventricles and corresponding ejeo- tion of blood from the hear, PEP ean therefore be mes asa time difference between a feature of the FOG waveform ‘derived from the electrical sensors) 304 and a fist heart ound feature of an acoustic waveform derived from the ‘acoustic sensor 402, The second heart sound can correspond to the beginning of diastole. 0062], For example, refering to FIG. 44, an example scoutic wavefonn 410 and ECG wavelorm 412 are showa that illustrate one possible PEP calculation. The acoustic waveform 410 includes peaks 422, 424 that correspond to ‘example first and second heart sounds, respectively. The ECG wavelorm 412 includes a peak 432 corresponding to the R wave of the QRS complex. One way to measure PEP js to determine the difference betwen the R wave peak 432 and the first heart sound peak 422. In another embodiment, the PEP is measured as a difference between the R save peak 432 and a foot 4234 or 4236 of the acoustic waveform ‘410, More generally, PEP can be determined asa difference in time between any feature ofthe ECG waveform 412 and ‘any’ ature ofthe acoustie waveZorm 10, including in some ‘embodiments, a feature ofthe sscond heart sound peak 424, [0063] Referring again to FIG, 3, PWT measurements (eg, PEPora-PWTT measurements) can also be ealeulted using the one or more bioimpedance sensors 306, The bioimpedance sensors 306 can implement principles of impedance cardiography, which can also be refered 10 as thomcie electrical hioimpedance. The bioimpedance sensors 306 can measure the impedance ofa patient’ est cavity by Feb. 2, 2017 altematig (or diret) current dough the patieat’s The current tends to seck the path of last resistance, whieh isthe patients bloodsfilled aorta, The blood volume and velocity in the aorta ean change with each hearbeat resulting in corresponding changes in impedance measured by the bioimpodance electrodes. These changes in imped- ‘ance ean be used to derive PEP. [0064] For instance, referring to FIG. 4B, an example bioimpedance waveform 440 is shown together with the FCG waveform 412 of FIG. 44. The bioimpedance wave- ‘orm includes a peak 442 that corresponds to peak change jin impedance with respect to time. This peak 442 can correspond fo ejection of blood from the heat, correspond- jing to a current change in the sorta resulting from a heartbeat, This, PEP can be measured between a feature of the ECG waveform 412 and a featire ofthe bioimpedance ‘waveform 440, For instance, PEP ean be measured between the R wave peak 432 and a foot point 44 of the bioimped- ance waveform 440, This foot point 444 is sometimes referred o as the "2" point ofthe bicimpedance wavelorm 440 and corresponds 1 the maximum rate of change of the ‘wavelonm 440. The PEP can also be mensuced from the R ‘wave peak 432 (or another feature of the ECG waveform 4412) and the peak 442 of the bioimpedance waveform. [0068] Thus, in certain embodiments, the acoustic and/or bioimpedance seasors 302, 306 of FIG. 3 can be used in conjunction with the BCG sensors) 304 to ealeulate PEP. some implementations, only an acoustic sensor 302 and ECG sensor(s) 304 ar used to ealeulate PEP. Other insple- ‘meniations employ only bioimpedance sensor(s) 306 and ECG seasor(s) 304 to caleulate PEP. Still other embod ‘ments of the system 300 ean calculate PEP using acoustic sensor(s) 302 and separately calculate PEP using bioimped- ance seasor(s) 306, The blood pressure analyzer 312 can Average or otherwise combine the PEP calculations from these different seasors 302, 306 in some embodiments [0066] In other implementations, wo acoustic sensors 302 of FIG. 3 are used fo calculate PWTT measurements (©. a-PWTT or PEP measurements). In some implementations, ‘multiple techniques can be uscd to caleulate PEP or ‘&-PWTT, Insome embodiments, the blood pressure analyzer 312 ean average or otherwise combine the PWIT ealcula- ‘ions from these dillerent sensors. In other embodiments, PWTT measurements obtained from the one or more of sensors can be used to assess confidence in the PWTT ‘measurements obiained fom other of the sensors. Addi- ‘ional details will be Further deseribed below in connection with FIGS. 94:96, [0067] FIG. SA illustrates a more detailed embodiment of ‘blood pressure monitoring system SO0A including an acoustic sensor coupled to a patient, The blood pressure ‘monitoring system S00A can implement certain features of the blood pressure monitoring system 300 and parameter calculation system 100 described above, ‘he illustrated blood pressure monitoring system $004 includes sensors, associated modules, and a processor 530 that ean advan geously be used to monitor blood pressure. The depicted ‘modules canbe implemented in hardware andor in software (eg, as executed by the processor 530), [0068] The istated blood pressure monitoring system ‘500A is coupled to patient $10. The patient S10 is shown ‘with a cuff $22 attached to an upper arm. The cul $22 ean be implemented in combination with an automatic acclasive cul control unit $20, The eul'$22 ean be in communication US 2017/0027456 AI with the automatic occlusive euff control unit 520 via a eable 524. The control unit $20 ean contol the inflation of the cull 522 and receive signals {rom the eu S22 regarding systolic ‘and diastolic blood pressure. [0069] In adklition to the automatic occlusive cuff, ECG Sensors $62 und S62B can be coupled to the patient $10. The ECG sensors $624, 5628 can provide any ofthe ECG. signals described above. The ECG sensors $62 and 8623 ‘ean be implemented as dual electrodes or split electrodes. While the illustrated blood pressure monitoring system inchides two PCG sensors 862. and 8622, in other embodi- ments, only one ECC sensor ean be coupled to patent S10. In yet other embodiments, more than two ECG sensors ca be coupled tothe patient $10, such as three or mone sensors. In addition, ECG sensors can be placed at different mea- surement site(s) than illustrated ia FIG. SA. For example, ‘one or more ECG sensors cad be coupled to the back ofthe patient §10, 10070] The illustrated ECG sensors 862A, 628 can be ‘coupled 0 an ECC unit 560 via cables S644 and S642, respectively. The ECG unit $60 can interfe with the FCG sensors $624, 5628 and provide an ECG signal to the processor §30. In some embodiments, the ECG unit can ‘convert and output of ECG sensors 562A, 5628 from an ‘analog signal to a digital signal and/or perform other pre= processing. The PCG unit 560 ean be implemented separate from the processor 30 or alternatively as part of the processor $30, 10071] _An optical sensor 552 can also be coupled to the patient $10. The optical sensor $82 can provide any of the Plethysmograph waveforms ilustrated in FIGS. 2A and 2B ‘andlor the optical sensor data 104 described above ia ‘eonnetion with FIG. I. The illustrated optical sensor $52, ‘ean be coupled to oximeter unit $80 via cable $84. The ‘oximeter unit $60 can interface with the optical sensor 552 ‘and provide an optical signal to the processor $30. In some ‘embosiiments, the oximeter unit 850 ean conver and output ‘of optical sensor $2 from an analog signal toa digital signal andr perform other pre-processing. The oximeter unit 850 n be implemented separate lrom the processor 530 or temaively as part ofthe processor 830. It should be noted that in certain embodiments, the optical sensor 882 can provide data to a monitor other than a pulse oximeter 10072] An acoustic sensor $72 can also be coupled to the patient $10, The acoustic sensor 852 can provide any of the ‘scoustc signals and waveZorms described above. The illus trated acoustic sensor $72 is couple to the patent $10 at 2 ‘asurement site near the patients heat. In other embod ments, the acoustic sensor can be couple! 0 the patieat 510 lillerent measurement sites, so long. asthe acoustic sensor ‘ean provide useful information indicative of cardiac ejee tion, In other embodiments, more than one acoustie sensor 572 can be used. More detail regarding the acoustic sensor 8572 will be provided below in connection with FIG. 6 10073], The acoustic module $70 can be coupled to the acoustic sensor 872 via cable 874. The acoustic moxie $70 ‘can interface with the acoustic sensor S72 and provide aa scousie signal to the processor 830 In some embodiments, the aconstic module ean convert andl up ofthe aconstic sensor $72 from an analog signal toa digital signal andior perform other pre-processing. The acoustic module $70 can be implemented separste from the processor 830 oF alter natively as part of the processor 530. Feb. 2, 2017 10074] The procestor 830 can advantageously be used to ‘measure indicators of blood pressure, such as PTT, PEP, andor arterial PWTT, using information provided by the ECG unit $60, the oximeter unit $60, and the acoustic mexlale $70, The processor 530 eat include, for example, fone or more microprocessors, microcontrollers, cores digi ‘al signal processors (DSP), or the like, The processor $30 can store instctions in a computerreadable medium. The processor 530 can also perform other operations for the blood pressure monitoring system SOA that are not explic- itly deseribed herein. [0075] Tae processor $30 can also be coupled to the Auloniatic occlusive eu contol unit $20 via line 882, The processor 530 can receive information reganding a blood pressure measurement of the patient S10 from the auton fcclusive cull contol unit $20, and can activate the ‘matie occlusive cu contol unit §20 via the line 532 [0076] In certain embodiments, the processor $30 deter= ines the arterial PWTT, compensated for PEP. using the acoustic sensor 72, the ECG sensors 562A, and the optical sensor $52, The processor $30 can track changes in this anerial PWIT aud trigger the automatic occlusive cult ‘entrol unit §20 to take a blood pressure measurement Wilh the cuff $22, The PEP-compensated arterial PWTT ealeula- tions can be more ageurate than eurrently-avalable PWTT calculations that do not take PEP into account. Thus, ia certain embodiments, the blood pressure monitoring syste S00A can more ellectively monitor the patient's $10 blood pressure with potentially greater comfort forthe patent S10. [0077] FIG. 8B ilusrates another embodiment ofa blood pressure monitoring system S00B including bioimpedance sensors $82 coupled fo the patient $10, The blood pressure ‘monitoring system S00B can implement certain features of the blood pressure monitoring system 300 and parameter calculation system 100 described above, The sllustated blood pressure monitoring system SO0P can be substantially similar to the blood pressure moaitoring system S00A of FIG. 5A. However, bioimpedance sensors 5824, $828, '582C, $82D anda bioimpedance module $80 are included in place of the acoustic sensor $72 and the acoustic module 570. [0078] Tae bioimpedance sensors $824, $828, $82C ‘5820 ean be coupled tothe patent 510 at various measure ‘meat sites. For example, as illustrated, two bioimpedance sensors 582 and §82B can be coupled to the sides of the prlieat S10 and two bioimpedance sensors S82C and S82D ‘canbe coupled tothe neck of the patient $10. Other suitable ‘measurement sites can be used in other embodiments. The bioimpedance sensors $82A, $828, S82C, $820 can be used to provide the bioimpedance wavefonns destribed above ‘with respect to FIG. 48 andlor any ofthe adliional sensor ala 106 described above in connection with FIG. 1. Sui able bioimpedance sensors 582 can inhude electrodes othe Tike. [0079] The bioimpedance unit $80 can be coupled to one ‘or more of the bioimpedance sensors 582A, S821, 582C, 5821 via one or more eablos SBA, S84B, S84C, S84), respectively. The bioimpedance unit $80 can interface with fone oF more of the bioimpedanes sensors 582A, $82B, '582C, 582D and provide one or more bioimpedance signals to the processor 530. In some embodiments, the bioimped- ‘nce unit §80 can convert an output of one or more of the bioimpedance sensors 882A, $828, $82C, §82D from an ‘analog signal toa digital signal and/or perform other pre- US 2017/0027456 AI processing. The bioimpedance wit $80 can be cparate from the processor 530 or alterna the processor $30. 10080] In certain embodiments, the processor $30 deter mines the arterial PWTT, compensated for PEP, using the bioimpedance seasors S82, the ECG sensors 862A, 56213 ‘and the optical sensor 882. The procestor 830 can track ‘changes in this arerial PWI'T and trigger the automatic ‘occlusive cull control unit $20 to take a blood pressure measurement with the cuff $22. The PEP-compensated ‘arterial PWTT calculations ean be more accurate than eu rently-available PWTT calculations that do not take PEP Jno account, Thus, in certain embodiments, the blood pees sre monitoring system SO0E can more effectively monitor the patient's $10 blood pressure with potentially greater ‘comfort forthe patient $10, [0081] Although shown separately for ease of illustration, in certain embodiments the BCG sensors 562A, 5628 and the bioimpedance sensors 82 can be combined. For instance, the bioimpedance sensors $82 can obtain ECG data in some implementations, and vice versa [0082] _ FIG. 6ilustrates example positioning locations for the acoustic sensors that can he ws in the varius systems and methods described herein (suc as the parameter cal- culation system 100 and the blood pressure monitoring system 300). As described above, a fst acoustic sensor 602 ‘ean be placed over the heart or near the heart ofa patient so sto detect heart sounds of the patent. In some embod! mens, the acoustic heart sounds sensor 602 can be posi tioned over the heart in oF nea the second intercostal space; however, the sooustic heart sounds sensor 602 can be Positioned at other loeations (such as the chest, back, neck, fide, abdomen, or other area of the body) so 8 t0 more accurately detect particular heart sounds (e.the SI and S2 sounds). In some implementations, dhe acoustic heart sounds sensor 602 can be positioned ata location at which both the Stand S2 heart sounds ean be eflectively measured. In other ‘implementations, the acoustic heart sounds sensor 602 can be positioned at's location configured to obtain increased sna strength for a particular heat sound without regard to other heart sounds [0083] With continued reference to FIG. 6, a second acoustic sensor 604 can be placed ator neat an artery on oF fear the wrist ofa patient to measure am arterial pulse at @ distance from the heart, For example, the seoond acoustic sensor 604 ca be placed over the ulnar artery or the radial ‘artery 10 oblain information indicative of a wrist pulse. thind acoustic sensor 606 can be placed on neck of a patient ‘a a Toeation over oF near a carotid artery to obtain infor- mation indicative of a carotid pulse. In some implementa- tions, all three acoustic sensors are used. In other imple- ‘mentions, only the acoustic heart sounds sensor 602 and ‘one af the other two sensors are used. The sensors of FIG. 6 can be couple toa parameter calculation system (eg. the Parameter elevation system 100 or the blood pressure ‘monitoring system 300), FIG, 6 merely illustrates example Jocations for the types of sensors that can be used in various implementations; other suitable locations may also be used. {0084} FIG. 7ilustrates example positioning locations for acoustic, electroeardiograph (FCG), bioimpedanee and opti ‘eal sensors that ean be ised in the various systems and methods described herein (such as the blood pressure moni- toring system 300), The acoustic sensors T02A-702C are iustrated as circles, the ECG seasors TOKA-7O4C are ilus- nplemented iy as part of Feb. 2, 2017 ‘rated as squares, and the bioimpeslance sensors 706A-706D are illustrated as triangles. FIG. 7 als illustrates an optical sensor 708 and an occlusive blood pressure cull 740. The sensors of FIG. 7 can be coupled to a blood pressure ‘monitoring system (eg, the blood pressure monitoring system 300). Although FIG. 7 illustrates multiple sensors and multiple positioning locations ll of the sensors andor Positioning locations noed not be used: FIG. 7 mencly SIkistates example locations for the types of sensors that ean be used in various implementations. Tie number, locations, and type of sensors used ean vary [0085] The blood pressure cuff T10 can be attached to an ‘upper mm, The euif710 can be implemented in combination with an automatic occlusive cuff contol unit (not shown). ‘The cuff 710 can be in communication with the automatic ‘occlusive cuff control unit vis a cable andlor hose, The ‘contol unit ean control the iallation of the etlf 740 and receive signals from the cull 710 regarding systolic and Gasol blood pressure [0086] Te acoustic sensors 702A-702C can be coupled to fn acoustic module (not shown) via one or more cables oF wirelessly. The acoustic. module can interface with the ‘acoustic sensors 7OZA-702C and provide acoustic signals to the processor 330. In some embodiments, the acoustic ‘medlle can convert an output ofthe acoustic sensors 702- 7O2C from an analog signal to a digital signal andlor perform other pre-processing, The acoustic module ean be Implemented separate from the processor 330 o¢ alterna- tively a part of the processor 330 or even as part of one or sone of the sensors 702A-702C [0087] ‘The BCG sensors 7044-704C can provide any of the ECG signals deseribed herein, The ECG sensors TA4A- 7704C can be implemented as dus! electrodes oF split elec- trodes. While the patient 700 in FIG. 7 has three ECG sensors TOMA-TO4C, in other embodiments, only one ECG ‘Sensor or t¥0 ECG sensors an be coupled te the patient 700 Inyet other embodiments, more than three ECG sensors can bbe coupled to the patient 700, such as four or more sensors In addition, ECG sensors can be placed at different mea- surement site(s) than illustrated in FIG. 7, For example, one ‘oF more BCG sensors could be coupled tothe back of the patient 700. [0088] The illustrated! ECG sensors 7O4A-704C can be ‘coupled to an ECG unit (aot shown) via cables or wirelessly ‘The ECG unit can interface with the ECG sensors TO4A- ‘TNAC and provide an ECG signal t a processor 330, In some ‘embodiments, the ECG unit can conver an ontput of ECG sensors 7044-TIMC from an analog signal toa digital signal andor perform other pre-processing, The BCG unit ean be implemented separate from the processor 330 or alterna- tively as part of the processor 390. [0089] ‘The bioimpedance sensors 706A-706D ean be coupled tothe patient 700 at various messurement sites. For example, sillsteated, wo bioimpedance sensors 706A and ‘70613 can be coupled to the sides ofthe patient 700 aad Wo bioimpedance sensors 706C and 706D ean be coupled to the peck of the patient 700. Other suitable measurement sites can be used in other embodiments. The bioimpedance sen- sors 706A-706D can be used 10 provide bioimpedance ‘waveforms that can be used in detemining meastirements indicative of blood pressure (eg, overall PWTT, PEP, anerial PWT). Suitable bioimpedaace sensors 7064-7061) fan include electrodes or the like US 2017/0027456 AI 10090] The bioimpedance sensors 706A-706D can be ‘coupled to bioimpodance unit (aot shown). The bird face unit can interove with one or more of the bioitiped- lance sensors 706A-706D and. provide one oF more boimpedance signals tthe processor 330. n some embod rents, the biompedance unit can convert a output of one ‘or more of the bioimpedance sensors 706A-706D from an fnalog signal to digital signal andor perform other pre~ processing. The bioimpedanee unit can be implemented Separate from the procemor 330 or alleratively as part of the processor 830. 0091] Although shown separately for ease of istration, Jn certain embodiments the ECG season TOAA-TOMC and thebiimpedance sensors T06A-706D can be combined For instance, the bioimpedance sensors 7064-706D cas obtain ECG data in some implementations, and vice ves 10092] Aa optical sensor 708 can alto be coupled wo the pation! 700 (eg. ta pation’ finger). Theillsrated optical $eosor 708 can be eaupled to an oximeter unit (ant shown) ‘inva cable or wircesly. The oximeter tit can interlace withthe optical sensor 708 ad provide un optical signal to 2 processor 380. In some embodiments, the oximeter unit ‘et convert an ouput of opie seasor 708 fom an analog signal 0 digital signal andlor perfoan. other pre-process- ing. The oximeter uit canbe iplemeated separate fom the processor 390 or ltematively a pat of the processor 330 Te should be noted that i certain embodiments, the optical sensor 708 can provide dats to 8 monitor other than pulse oximeter. 10093] The procesor 390 of FIG, 3 can advantageously be used measute indicators of blood presre, sucas PWT, PEP. andlor artecal PWT, using information provided by the acoustic mode, the CG unt the oximeter uni nor the bicimpedance unit. The processor 330 can inch, for ‘example, a microprocessor, mieooontolet, a core, digital Signal processor (DSP), oF the ike. The processor 330 ca store instructions in a computerseadsble medium. The pro- ‘cessor 330 ca also perform other operations forthe blood pressure monitoring system 300 that are not explicitly Aeseribod her. 10094} The processor 330 ean also be coupled tthe sutomatie acchnive cu contra wit. Te pressor 330 ca receive infomation regarding 4 blood pressure meastre~ ‘ent of the patent 700 from the automatic aelisve call ‘control unit, and ean aetvate the automat occlusive cll ‘ont uit 10095] In certain embodiments, the processor 380 deter mines the arterial PWT, using two of the acoustic sensors TW2A-702C, independenily or in conjunction with an addi- tional acoustic sensor, one or more of the BCG sensors 704A-704C, one or more bioimpedance sensors T06A- 7061), and the optical sensor 708, In sme embodiments, the processor 330 determines the arterial PWIT using a com- bination of one oF more acoustic sensors and one oF more non-acoustie sensors (Tor example, using to bioimpedance sensors aud one acoustic sensor). The processor 330 can track changes in this arterial PWIT and teigger the auto- matic oechasive eff control unit to take @ Blood pressure ‘measurement sith the cult 710, The arterial PWTT caleu- lations obtained ean be more aceurate than eurrently-avil able PWTT caleulatons that do not take PEP into acoouato subimetion of the PEP to determine the arterial Feb. 2, 2017 [0096] FIG. 8 illustrates an example acoustic Sensor sys- tem 800 that can be used ia any of the blood pressire ‘monitoring systems described herein, such as the stems 100 and 300, FIG. 8 is top perspective ofa sensor system £800 including an acoustic sensor assembly 801 suitable for use as any acoustic sensor deseribed herein and a monitor cable 811, The sensor assembly 801 can include an acoustic sensor 815, a cable assembly 817, and a connector 808. The sensor 81, in one embodiment, can include a sensor sub- assembly 802 and an attachment subassembly 804. The cable assembly 817 of one embodiment can include a eable 807 and a patient anchor 803. The various components can be conncefed to one another via the sensor cable 807. The sensor connector subassembly 80S can be removably famtached to a monitor connector 809, which can be con- ‘ected to parameter calculator or other physilogical moni- tor (not shown) via the monitor eable 811. In one embed the sensor assembly 801 can communicate with the physiological monitor wirolessl. [097] In an embodiment, the sensor assembly 801 can Include a sensing element, such as, for example, a piezo- clectri device or otlier acoustic sensing device, The sensing ‘clement can generate a vollage tht is responsive to vibri- tions geverated by the patient, and the sensor ean inelude circuitry to transmit the voltage generated by the sensing element toa processor for processing. In an emboxliment, the fcoustic sensor assembly BDI can inchide circuitey for Selecting and transmiting information related to biological sound toa physiological monitor. These biological sounds may include heart, breathing, and/or digestive system sound, in addition to many other physiological phenomena ‘The acoustic sensor B15 in certain embodiments can be @ biological sound sensor, such as the sensors deseribed herein. In some embodiments, the biological sound sensor is ‘one of the sensors stich as those deseribed inthe USS. patent application Ser. No. 12044 885, filed Mar 7, 2008, eattled ‘ystems and Methods for Determining # Physiological Condition Using an Acoustic Monitor” which is incorpo- sited in its entirely by reference herein. In other embodi- ‘ments, the acoustic sensor 818 ean include a biological sound sensor such a those deseribed in US. Pat. No. 8,661,161, which is incorporated by reference herein, Other embodiments inlude othr suitable acoustic sensors [0098] The attachment sub-assembly 804 can inchude a tit elongate portion 806 aad a second elongate portion 808, ‘The first elongate portion 806 and the second elongate portion 808 can include patient adhesive (ex, in some embodiments tape, glue, a suction device, ec) attached 10 ‘an elongate member 810, The adbesive on the elongate portions 806, S08 can be used fo secure the sensor suhus- sembly 802 to a patient's skin, The elongate member 810 an beneficially bias the sensor subassembly 802 in tension ‘against the patient's skin and reduce stress on the connection between the patient adhesive and the skin. A removable ‘aeking ean be provided withthe patient adhesive to protect the adhesive surface prior to afliing to patient's skin [0099] ‘The sensor eable 807 can be electrically coupled to the sensor subassembly 802 via a printed circuit board CPCB") (not shown) in the sensor subassembly 802 Through this contact, signals can be communicated fom the sensor subassembly to the physiological monitor via the Sensor cable 807 and the eable BIL [0100] In various embodiments, not all ofthe components illustrated in FIG. 8 are ilu i the Sensor systems 800. US 2017/0027456 AI 10 For example, in various embodiments, one or more of the patient anchor 903 ad the attachment subassembly 804 are hot included, Ia one embostiment, for example, 2 bindage oF lupe is used insted of the allachavent subassembly 804 attach the sensor subassembly 602 to a measurement ste Moreover, such bandages or pes may be a variety of ‘different shapes including generally elongate, circular and oval, for example [0101] FIGS. 9A, 98, and 9C illustrate embodiments of processes 900A, 90013 and 900C for calculating PWTT values compensated for PEP. The processes 900A, 9008, 900C can be implemented as part of any of the blood pressure monitoring systems deseribed herein, soc as the blood pressure monitoring systems 100, 300, SO0A, and 5008. More particularly, the process 900A illustrates an ‘embodiment of obtaining compensated PWT using infor. ‘ation obtained fom an aeoustie sensor. The process 9007. ‘ustrates an embodinent of PWIT caleation using bioimpedance sensors. The process 900C: illustrates an ‘embodiment of calculating PWIT without using an ECG. [0102] Referring specifically o FIG. 9A, plethysmograph, ECG, and acoustic waveforms are received by the process ‘900A. At block 902, an inital PWTT is calculated from the plelhysmograph and ECG waveforms, This initial PTT is ‘determined in one embodiment by determining 2 time dif Terence between Features of the ECG and plethysmograpl ‘waveforms, Features on these waveforms ean be determined, using signal processing techniques including, but not Finite 'o, taking derivatives ofthe waveforms, detecting peaks and troughs of the waveform, comparing the waveforms 10 models andor thresholds, and the like. For example, an Rewave peak on an ECG waveform cat be determined by detecting a point at which the ECG signal is above a (potentially adaptive) threshold and the derivative of the FCG signal is zero, As another example, «foot point on & pleiysmograph waveform can be identified by the point at ‘which the derivative of the plethysmograph waveform is oro in atime window defined afer an Rewave peak. Such sgnal processing can be performed dynamically in real ne. Altematively or additionally, svc signal processing ‘can be performed during post processing of data 10103] As described above, tis initial PWTTT ean include the arterial PWIT as well as the PEP. Thus, to obtain the ‘arterial PWIT, further blocks of the process 900A. ca determine PEP so a compensate the initial PWT forthe PEP. At block 904, a fist heart sound is detected from the ‘acoustic waveform. The PEP is then calculated ut block 906 by determining a time difference between a feature of the ECG waveform and a featre of the frst hear sound. The feature used on the ECG waveform wo caleulate the PEP 906 ‘can be the same feature used t calculate the initial PWT at block 902. Altematively, different ECG features ean be tied to calculate PEP and the init PWTT. At block 908, the PEP is subtracted from the intial PWT t produce an ‘arterial PTT value, This arterial PWT value ean be sed jn determining i an automatic occlusive cuff shoud tke @ blood pressure measurement from patient (see FIG. 10), 10108) Advantageously, in certain embodiments, the pro- ‘ess 900 can be performed eontinvously or substantially ‘continsously so as to monitor patient's arterial PWT over time. The process 900A can therefore dynamically deter ‘ine a patient's changing PEP over ime and ean compen- sate initial PWTT values according to this changing PEP. Feb. 2, 2017 [0105] It should farther be noted that the process 900A shown eat also be more accurate than processes that eae Jate the areal PWTT without using an ECG waveform. ocanse of its prominent R-wave peak, the ECG wavetorm can bea more reliable triggering point than cardiac ejection signals such as heart sounds or bioimpedance signals. Accordingly the ECG signal ean be used to identify relevant ‘ardiae ejection signal, For example, the subsequent cardiac jection signal aller an ECG signal may be the next carding ejection signa of interest [0106] Another advantage of using the PCG as a trigger- ing signal for calculating PWTT is related tothe occasional ambiguity of the canlise ejection signal. In some cases, it may be dificult or impossible to distinguish a cardi jection signal from noise, In such cases, the parameter calculator 110 oF 310 can use the previous PEP value as the fcurent PEP value and calculate arterial PWET as the dierence between the ECG-to-arteralpolse signal and the previous PEP value, As PEP values may change intie- ‘quently, this substitution may be aceurate, [0107] Further, because the occurrence andor location of | the cardive ejection signal can be ambignous, it can be benctcial to more aggressively average the PEP measure- meats over time (© compensate for this ambiguity. For ample, a atively slower averaging filter which may Jnclude longer time window of data points, may be applied to the PEP values. In contrat, the overall PWTT values may change more rapidly (see, e.g. FIG, 11), and it may be bbencticial to apply a relatively faster averaging filter having a relatively shorter time window to these vale. [0108] FIG. 9B illustrates another embodiment of a pro- cess 900B that uses bioimpedance information to eaeulate ‘aerial PWT. The process 9001 is substantially similar to the process 900A, except that the process 900B analyzes bioimpedance waveZorm insteud of an acoustic waveform, [0109] Like the process 900A, the process 900BB receives 4 plethysmograph waveform and an ECG waveform, At block 912, an initial PTT is calelated from these wave- orm in the manner deseribod above with respect to FIG. 9A. At block 914, the bioimpedance waveform (or imped- ance cardiogram) is analyzed to detect a feature, such as a ‘oot point, a peak change in impedance, an infletion point, ‘or the like. At block 916, the PEP is caleulated as a time tilerence between a feature ofthe ECG waveform and the Teature on the bioimpedanee waveform. For example, the point of maximum impedance change can be compared with 4 feature of the ECG waveform Wo determine the PEP. At block 918, the calculated PEP value is subtracted form the inital PWTT to determine the arterial PWTT. This aneral PWT value can be used in determining if an automatic ‘eclusive cuff should take a blood pressure measurement from 8 patient (see FIG. 10), 0110] Like the process 900A, the process 9008 ean be performed continuously or substantially continuously so as {fo monitor a patient's arterial PWTT overtime. The process 9008 can therefore dynamically determine a. patient's changing PEP over time and can compensate initial PWTT values aecording 10 this changing PEP. The process 9008 can therefore, in ceriin embodiments, calculate more aceu- rate PWIT than cureatly-available devices. US 2017/0027456 AI [OLLI] FIG, 9€ illustrates another embodiment of a pro- ‘cess 900C for calculating PWTT. However, the process ‘900C can advantageously calculate PWTT using an optical ‘and aooubtie signal oF an optical and bioimpedance signal, ‘without using an ECG signal. Thus, the process 990C uses ewer sensors to calelate arterial PWTT, [0112] The process 900C receives a plethysmograph and acoustic waveform, or a plethysmograph and bioimpedance waveform, At block 922, a feature of the pledyysmograph ‘waveform is identified. At block 924, a feature of the ‘acoustic or bioimpedance waveform is identified. Candine jection can proce the arrival of the resulting pulse at an ‘extremity. Ths, a feature from the plethysmograph wave orm obtained at the extremity can be identified when it ‘occurs ata Later time than the identified feature from the soountie oF bioimpedance waveform, [0113] At block 926, atime difference between the iden- tified waveform features is determined. This time is the ‘arterial PWIT, This arterial PWIT value can be used ia determining if an automatic occlusive cull should take a blood pressure measurement from patient (see FIG. 10), [0114] Like the processes 900A and 900R, the process ‘900C can be performed continuously oF substantially con tinvously so as to monitor a patients arterial PWTT over time. The process 900C can therefore dynamically deter mine a patien’s changing PEP over time and ean compen- sate initial PWTT values according to this changing PEP. ‘The process 900C can therefore, in certain embodiments, caleulate more accuse PWIT than curreatly-available doves, [0118] The process 900C can be modified in one embodi- rent fo receive an PCG signal input to assist with identi ‘ving the feature ofthe plethysmograph waveform at block ‘922. It can be dificult to propery identify features from the plethysmograph waveform de to the double-peak nature of the waveform, aswell ar due to noise. An ECG signal, on the ‘other hand, ean have clearly-idenifiable landanavks, includ ing the wave peak, among others. An ECG signal can therefore be used as a gating function to determine whieh feature ofthe plethysmograph waveform should be consid- ‘ered andor which feature of the acoustic oF bioimpedance ‘waveform should be considered. In one embodiment, the first peak, foot point, or other feature in the plethysmogeaph ‘occuring alter feature identified from the ECG signal aa be identified as the relevant plethysmograph feature. Si fist foot peak, or other feature of the acoustic oF bioimpedance waveform occurring alter a feature identified from the ECO signal ean he identified asthe relevant cardiac ‘jection signa feature. The FCG signal can therefore resolve ambiguities inthe plethysmograph waveform, thereby improving noise immunity andor nose reduction, Similary, the ECG signal can also be used as a reliable identifier of ‘cardiae ejection signal, thereby improving the accuracy of the arterial PWTT calculation [0116] FIGS. 9D-.9F illustrate adgitional embodiments of processes 8000, 900E:, 900F for calculating arterial PWTT values, refining calculated arterial PWIT values, andor determining confidence of arterial PWTT valves. In some ‘implementations arterial PW'TT values are determined from ‘acoustic waveforms of signals from only two acorstic sensors, as described in eonnection with FIG. 9D. In other implementations, arterial PWTT values are determined tising waveforms of signals from three of more acoustic sensors (as described in eonaeetion with FIG. 9E) or from Feb. 2, 2017 Each ofthe depieted blocks or modules ofthe processes 900 can be implemented by hardware and/or soflvare modules [0117] With reference to FIG. 9D, the process 990D can advantageously calculate arterial PWTT ising two acoustic Signals, without using an ECF signal, Thus, the process 900D uses wo mechanical signals rather thua one eleteical signal and one mechanical signa, thereby improving stabi ity and aceuraey of the arterial PWTT calculations. The use of the two acoustic signals also removes the necessity 10 sublract out the PEP component of the overall PWIT ad instead relcts the atrial PWTT alone. [0118] The process 900D receives an acoustic heart sounels waveform and an acoustic pulse waveform. The Acoustic pulse waveform can he, for example, an acoust ‘wrist pulse waveform or an acoustic earotid pulse waveform, as described above; however, the acoustic pulse waveform fan be received from an acoustie sensor positioned at other locations as well, At block 927, a feature of the acoust heart sounds waveform is identified. At block 928, a featare ofthe acoustic pulse waveform is identified. The Teature of the acoustic heart sounds waveform can camespond to the time of cardiac ejection, which precedes the time of arrival of the resulting pulse ata location of the acoustic sensor {rom which the acoustic pulse waveform is penerated, [0119] Features on these waveforms can be determined ‘using signal processing techniques ineluding, but not Timited ‘o, taking derivatives ofthe waveforms, detecting peaks and ‘woughs of the waveform, comparing the waveforms 10 models andlor thresholds, determining the centroid of a ‘eature ofthe waveform, taking an envelope ofa portion of the waveform and identifying a fenture of the envelope, combinations of the same, and the like. For example, foot point on an acoustic waveform can be ientilied by the pont ft which the derivative of the avoustie waveform is zero in a time window defined after an electical wigger (eg. as identified by an ECG sensor). As another example, 4 cen- {mid oF “middle” of a pulse, burst or wave of an acoustic ‘waveform can be determined. In some embodiments, the ceatroid ean be determined by constricting an amplinide envelope of the pulse, sound burst, or pressure wave and then performing 8 nonalized weighting of each time point according tothe envelope amplitude, with the highest energy point of the envelope being the cent time ofthe pulse oF ‘Sound (¢, heart sound). The eentroid determination can be performed inthe time domi or frequency domain. In some fmbodiments, the centroid determination ineludes sampling andor fering ofthe pulse, sound burst, or pressure wave. Such signal processing can be performed dynamically, in real time, ANeratively or additionally, such signal process: ‘ng can be performed during post processing of data [0120] At block 929, a time difference between the iden- tified wavefoom features is detemined. This time ean be ‘considered tobe the srteril PWT ia.one embodiment. This anerial PWTT value ean be used in determining if an ‘utonsatic occlusive eull should take a blood pressure mea- Sstrement from a patient (see PIG. 8). The process 9001) can be performed continuously or substantially continuously $0 fs to monitor a patient's arterial PWT aver time. Altrna- tively, the process 9000 can be performed as a spot-check ‘pon occurence of predetermined conditions or at prode- termined time intervals US 2017/0027456 AI {0121} The process 8000 can be modified in one es rent to roeive a ECG signal inp to assis ith ‘ing the feature ofthe acoustic heat sounds wavelora at block 927. It can be dillcul to properly deny features from acoustie waveforms dhe to noise oF other characteris ties. An ECG signal, om the other hand, can have clearly- identifiable landmarks, including the R wave peak among ‘thers. An ECG signal can therefore be uscd ax & gating function to determine which hear sound should he consid cre none embedineat, th first heart sound of the acoustic hea sounds waveform occuring after a festure Mentified from the ECG signal can be identified sx the relevant acostie heat sounds festre. The ECG signal can therfore resolve ambiguities is the acoustic waveforms, therchy improving noise immunity and/or noise reduction. Tn some embodiments, the ECG signal can be used 1 Sealy the teansiion from electrical to mechanical behaviog. The ime ‘ela between the ECG signal and theft heat sound (8, Si sound) detected bythe acoustic heat sounds sensor ean provide an indication of the hells of the heart oF other Potential pathological conditions tht may warrant medial ‘Mtcaion, However, the ECG signal input is not Used or nosed in other embodiments 0122] FIGS. 98 and 9F illstate embodiments of pro- ‘exsses 9002 900C for determining PWT values, refining ‘calculated PWTT vals, andor determining confidence of PWT values. More particu the proces 9005 illu: tetes an embodiment of a process for calculating, eins ‘orassesing PWTT values Using information objained fom multiple coustc sensors, one of which is an acoustic heat Sounds sensor. The process 900C iustates an embodiment ‘of a syst for arterial PWT calculation, refinement, or ‘assessment using aot sensors ia conjunction witha tonal sensors, sch 8 ECG sensors, optical sensors, andor bioimpedance sensors. The processes 900, 9906 ean be inuplemented spar o the parameter calculation system 100 ‘rite blood pressure monitoring sytem 300, ch of the ‘epicted Blocks or modules of the processes 900 can be Jniplemented by hardware andoe stare modules. 0123] Referring specially 10 FIG. 9F, the proces 9008 receives three aoouslic waveforms, These Ue acoustic ‘waveforms ean include an acoustic heart sounds waveform ‘and wo cout pulse waveforms (fist pulse wavelomm and a second pulse wavelorm. For example, the acoustic Pulse wavelorms can inchide a st pulse waveform and 2 ‘aroid pulse waveform. The acoustic heart sounds Wave- Toms nf pulse waveoras e wrist pulse wavelors) ‘eat he received by PWT determination block 982 and the ‘oust heart sounds waveform aad a second pulse wave- form can be received by PWIT determination block 934 The PWT detemnination block 982 can calculate ist antral PWTT (a-PWTT A) value rom the acoustic beat sounds waveform and the first acouste pulse waveform. The PWTT determination block 934 can caleulate 4 second ‘aceial PWIT (@-PWIT B) vale Irom the acoustic heart sounds waveform and the second acoustie pulse waveform. ‘These initial atrial PWTT measurements se determined ‘one embodiment by determining atime difference between Teanuns of the acoustic heart sounds wavetorm and the acoustic pulse waveform (as decebed in connection with FIG. 9A) [0124] In some implementations, thesia anril PWT values (@-PWTT A tad a-PWTT B) can be provided to 8 ‘comparison module 986, The comparison mele 906 a Feb. 2, 2017 analyze the two initial arterial PWIT values to generate @ final arterial PWTT output value. Ia some implementations, the comparison module 936 can compare the 10 initial arterial PWTT valves wo determine a dillerence between the ‘wo values. The comparison module 936 can derive a confidence value from the calculated diference. In other ‘implementations, the comparison module 936 ean average ‘orothenvise combine the two intial arterial PWTT values to ‘output refined final aresal PWT output value. In some embodiments, the two intial arterial PWIT values are ‘weighted. In yet other implementations, the comparison sadule 936 can seloet one ofthe two initial arterial PWTT values to output a the final aerial PWT ouput wale, The ‘comparison module 936 can make this selection based oa confidence values, based on comparison to historical data or thresholds, based on patient-specific factors, and/or the Tike [0125] In some embodiments, the second pulse acoustic ‘waveform ean simply be used to provide another reference for gating point in identilying a feature of the fist pulse fcoustc waveform, In other embodiments, the second pulse Acoustic waveform can be used 10 idenify other patent characteristics (eg. patent breaths, respiratory rate, resp ratory pause, oF other respiratory conklitons, as discussed above). [0126] FIG. 9F illustrates an embodiment of 9 process ‘900C that wses information obtained from one oF more on-acoustie sensors in addition t0 one or more acovst sensors to calculate, refine, or assess arterial PWT stremens [0127] Like the process 900E; the process 900E can cal- culate wo arterial PWTT values (a-PWTT.A and a-PWTT |B) at PWTT determination blocks 932 and 934, respectively. The process 9O0C can also receive am ECG signal inp, & plethysmograph signal input, andor a bioimpedance signal input in addition to the acoustic signal inputs. An overall PWT value (including antrial PWTT and PEP compo- ents) ean be calelated at PWTT determination block 937 by detemnining a time difference between a feature of a plethysmograph waveform and a feature of an ECG wave- orm. Further blocks ofthe process 900C can determine PEP 0 ao compensate the overall PWTT for the PEP. The PEP js caleuated at block 938 by determining atime difference between a Feature of the ECG wavelonm and a feature ofthe ‘acoustic heart sounds wavefom or a bioimpedance wave- orm in the mannee described above, The featuee used on the ECG waveform to calculate the PEP 938 can be the same Teature used to calculate the overall PWTT at block 936. Alternatively, different ECG features can he ust calen late PEP and the overall PTT. At block 940, the PEP is subtracted from the inital PWTT to produce a third arterial PWTT value (@-PWIT ©). [0128] In other embodiments, the thint arterial PWIT value can be derived from a time difference between 2 {ature of an acomntie waveform or a bioimpedance wave- form and a pleth waveform such that PEP need not be calculated, as deseribed above, [0129] Similar to the process 900E, the three arterial PWTT values can be received by’ the comparison module 936 and analyzed to outpat a final arterial PWT wal. in some implementations, the comparison module 936 can ‘compare the thre initial arterial PWTT values to determine differences between any two ofthe three values. The com- parison modile 936 can derive a confidence value from the calculated differences. In other implementations, the com- US 2017/0027456 AI parison module 936 can average or otherwise combine the {hace intl steral PWT vais to output refined inal ‘atrial PTT output vale. In some emnediments, te three inital arte PWTT values are weighted. In yet othee implementations, the comparison mele 936 can sleet one ‘ofthe thre iil atrial PWIT vals to output othe fil faccrial PWTT ouput valve, The comparison movie 936 ‘ca make this scleton based on confidence vals, based ‘oncomparison t historical data oF thresholds, based on patient-specific factor, andor the ike [0130] In other embodiments, aerial PWTT values ean be calulated sing one oF more non-scovstic sensor ia ‘combination with one of more acoustic sensors For ‘cxample, atrial PWT valucs can be calcite from time Aiferences between feature ofa bioimpedance waveform (eq, genre from signals recive from two bisimpede ance seusor) aod a Ratre of an acoustic wavefomn (68, roccived fom an acotstie pulse sensor positioned over or proximate a wes, eg or eid arte). [0131] FIG. 10 illustrates an embodiment of a process 1000 for determining whether otager an alternative blood pressure measurement. This process 1000 can be imple- fuente by any of the systems 100, 300, described above Aavantagevtss in cetan embodiments, the process 1000 ‘ean determine, based at lest partly on non-invasive PWT measurements, whsther t tager an automatic occhsive ‘ull As result, contindous. or substantially continuous ‘monitoring of a Uses blood pressure can occur, allowing the frequeney of occlusive calf meastrementso poeatlly be reduced 10132] AC block 1002, frst oterial PWTT measurement js determined at ist point in time. The aerial PWTT ean be determined using any ofthe techaigues above, such as by caleulating PEP and by compensating an overall PWIT Nalue with the PEP. Similarly. a sesond arterial PWIT Imeasurement is taken at @ second point in time ot block 41004, These arterial PWTT measurements canbe take fea successive. heartbeats in one embodiment. In another ‘ehoiment, the first and second arterial PWTT vals each represent arcrial PWTT values averaged over multiple hestbets 10133] Ax lock 1006, a dsference between the to are- rial PWIT measurements is determined. It is then deter fined at decision block 1008 whether 3 new blood prssire ressurement i required, In certain embodiments, this dei Sion can be made by deicrmining whether the uillrence between dhe two measurement is greater dan threshold Adilleeace greater than a treshold can be indicative of & ‘hange in a patients blood pressure. Therefore, if the ‘ference js preter han the thresold, an occlusive cus triggered to take anew blod pressure measurement t block 1010. Ire diferece isnot renter than the reso, thea the process 1000 loops bock to Block 1002. Ffestively, the process 1000 therlore can trigger occlusive cull measur ments when the threshold i exceeded and can continue ‘monitoring arterial PWIT meastrements oberwise 10134) _Incenain embodiments, te process 1000 analyzes ‘hpges in aerial PWTT measurements using an absolute ‘ference technique ora moving diffrence tshnigus, With the absofote diference technique, the process 1000 mea- sores the PWT at fist fined! time. Subsesient atrial PWIT measurements (@p. the second measurement at Dock 108) ae compared the initial atrial PWT atthe first fixed time to determine whether the difference betwee Feb. 2, 2017 these measurements exceeds a threshold, With the moving ilerence technique, the fst and second arterial PTL measurements are compared for suecessive points in time. ‘The first arterial PWT measurement is therefore 20t taken ata fixed time but instead changes over time, Thus, the ‘moving dlference technique can approximate a derivativeof the arterial PWIT measurements, The moving difference can be compared oa threshold at block 1008. An advantage fof using the moving difference technique is that it ean tially ignore drifts in arterial PWTT measurements due {o calibration changes or other enor. [0138] Thus, in cerain embodiments, the process 1000 can refrain from triggering an occlusive cuff until the ‘non-invasive measurement dilfers enough to trigger such a ‘measurement. Advantageously, in certain embodiments, the pracess 1000 can therefore allow # user to postpone the siscomfort and potential physiological damage associated with occlusive blood presse measurements, while the ‘non-invasive measurement (eg, arterial PWET)is within a ceriain tolerance [0136] Although the PWTT measurements have been Ueseribed herein as being used 10 tigger an occlusive cull, in certain embodiments the PWTT measurements can also oF instead be used to derive an estimate of blood pressure, A calibration function or curve ean be detemained that maps PWT measurements to blood pressure values. The slope and intereept of the calibration curve ean be determined experimentally, PWLT Noise Compensation [0137] _As described above, in addition to compensating PWT for PEP. the parameter ealeuation system 100 can also compensate PWIT data for noise. FIGS. M1 and 12 illustrate embodiments for compensating PWIT data for noise. By compensating PWTT data for noise, more accurate PWIT meastrements can be obiained. ‘The features described with respect to FIGS. 11 and 12 can be used in combination with any of the features described herein [0138] FIG. 14 depicts an example pot 1100 that illus teates noise in a set of arterial PWTT data. In the example lot 1100, PWIT valves taken over time are represented as a PWT waveform I110. Variability in the PWT wavelorm 1110 reflects noise in the PWTT waveform 1110. Noisy PWT data can load 10 lower quality PWTT measurements, resulting in too Frequent or to infrequent triggering of @ blood pressure cull. In certain ciumstances, noisy PWT can even lead to missing a clinically significant change in blood presse 10139] One technique to reduce the effets of noise in the PWT data is to average the PWIT data overtime. time-averaged PWT waveform 1120 is shown in FIG. 11 ‘The average can be caleulted from PWT data points taken cover a certain time period. PWI'T data points can be averaged by applying & smoothing filter, sch ax a low pass filer Determining a number of PWTT data points and/or an averaging time to include in an average ean involve ‘radeolls. A longer averaging time ean reduce the presence ‘of noise in the PWIT data, However, @ longer averaging time can also reduce the benefits of using PWTT 35 an indicator of blood pressure to trigger an occlusive cuff For cxample, a long averaging time can cause rapidly-changing Teatures on a Waveform to be missed. In contrast, a shorter averaging time using fewer data PWT datapoints may not sulicently filter out noise, US 2017/0027456 AI [0140] In certain embodiments, averaging can be ‘improved by dynamically adjusting the averaging. time acconting othe amount of noise present in the PWTT data, a higher level of noise s presen a longer averaging time ‘canbe selected. Conversely if ess noises present, a shorter ‘averaging time can be used. However, it ean be dificult 10

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