Method of driving a form of respiratory therapy

Abstract

A method of controlling a medical device is disclosed for delivering respiratory therapy to a user to treat sleep-disordered breathing, for instance obstructive sleep apnea, Cheyne-Stokes respiration etc. by estimating the user's CO2 percentage or concentration from a dynamic lung model driven by an observed respiration signal. The estimated user's CO2 percentage or concentration can be used to predict breathing events, such as hypopnea and apnea. The predictive capacity can be used for adjusting the respiratory therapy as required or for applying a ramp cycle therapy, in an attempt to reduce the prevalence and adverse effects of the breathing events. In other examples a variable ventilation therapy is provided in which pressure is supplied between first and second pressures, with the pressure being increased over more than one breath, and then dropped relatively rapidly, for example during expiration of a single breath.

Claims

1. A respiratory therapy device configured to supply a flow of breathable gas to a user via a breathing gas delivery conduit and a patient interface; the device comprising: a controller configured to control a pressure of the breathable gas supplied to the user; and wherein the controller is configured to control the device according to a variable ventilation profile to repeatedly: increase the pressure of the breathable gas supplied to the user from a first pressure to a second pressure over more than one breath; and in response to the second pressure being reached or maintained for a predetermined period of time, decrease the pressure of the breathable gas supplied to the user from the second pressure to the first pressure during a single period of exhalation.

2. The device of claim 1 wherein the controller is configured to increase the pressure of the breathable gas supplied to the user from the first pressure to the second pressure over a predetermined number of breaths.

3. The respiratory therapy device of claim 2, wherein the controller is configured to adjust the predetermined number of breaths over which the increased pressure is supplied in response to a characteristic of the user's breathing pattern.

4. The respiratory therapy device of claim 3 wherein the characteristic is a current CO.sub.2 level.

5. The device of claim 1 wherein the increased pressure is supplied asynchronously with the breathing pattern of the user, wherein a timing of the increased pressure is not synchronous with inspiratory and/or expiratory phases of the breath.

6. The device of claim 1 wherein the increased pressure is supplied semi-synchronously with the breathing pattern of the user, wherein a timing of the increased pressure is synchronous with part of inspiratory and/or expiratory phases of the breath.

7. The device of claim 1 wherein the increased pressure is supplied synchronously with the breathing pattern of the user, wherein a timing of the increased pressure is synchronous with inspiratory and/or expiratory phases of the breath.

8. The device of claim 1, wherein the controller is configured to control the device to increase the pressure of the breathable gas supplied to the user from the first pressure to the second pressure via a single step increase from the first pressure to the second pressure.

9. The device of claim 1, wherein the controller is configured to control the device to increase the pressure of the breathable gas supplied to the user from the first pressure to the second pressure via a plurality of step increases from the first pressure to the second pressure.

10. The device of claim 1, wherein the controller is configured to control the device to increase the pressure of the breathable gas supplied to the user from the first pressure to the second pressure via at least one ramped increase from the first pressure to the second pressure.

11. The device of claim 10 wherein the controller is configured to control the device to increase the pressure of the breathable gas supplied to the user from the first pressure to the second pressure via a plurality of ramped increases from the first pressure to the second pressure.

12. The device of claim 1, wherein the first pressure increases over successive cycles.

13. The device of claim 1, wherein the second pressure increases over successive cycles.

14. The respiratory therapy device of claim 1, further comprising one or more sensors configured to measure data relating to the user's breathing pattern, wherein the one or more sensors are configured to measure at least one respiration signal of the user, the at least one respiration signal indicative of any one or more of flow rate, pressure data, or thoracic movement of the user.

15. The respiratory device of claim 14 wherein the at least one respiration signal is indicative of any one of the following: a. an onset, duration and/or end of inspiration; b. an onset, duration and/or end of expiration; or c. a rise in a CO.sub.2 level by estimating a current CO.sub.2 level of the user by modeling the user's respiratory system based on the at least one respiration signal.

16. The respiratory therapy device of claim 1, wherein the controller is configured to increase the pressure supplied to the user from the first pressure to the second pressure by increasing the pressure by about 1 to 15 cm H.sub.2O.

17. A respiratory therapy device configured to supply a flow of breathable gas to a user via a breathing gas delivery conduit and a patient interface; the device comprising: a controller configured to control the flow of gas supplied to the user; and wherein the controller is configured according to a ramp cycle in which the pressure of the gases supplied to the user is increased between first and second threshold pressures over a predetermined number of breaths, and in response to the second threshold pressure being reached, the pressure of the gases supplied to the user is rapidly decreased to the first threshold pressure during an exhalation phase of one breath.

18. The device of claim 17 wherein the ramp cycle has a saw tooth profile, gradually ramping upwards and then dropping sharply during the exhalation phase.

19. A method of providing respiratory therapy using a device configured to supply a flow of breathable gas to a user via a breathing gas delivery conduit and a patient interface; comprising steps of: using a controller of the device to control the device according to a variable ventilation profile to: a) increase a pressure of the breathable gas supplied to the user from a first pressure to a second pressure over more than one breath; and b) in response to the second pressure being reached or maintained for a predetermined period of time, decrease the pressure of the breathable gas supplied to the user from the second pressure to the first pressure during a single period of exhalation.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) These and other features, aspects, and advantages of the present disclosure are described with reference to the drawings of certain embodiments, which are intended to schematically illustrate certain embodiments and not to limit the disclosure.

(2) FIG. 1 illustrates a schematic representation of an embodiment of a respiratory therapy device.

(3) FIG. 2A illustrates a flowchart of an embodiment of a method of estimating CO.sub.2 levels from a user's respiration signal.

(4) FIG. 2B illustrates exemplary flow rate and lung displacement volume patterns of a user.

(5) FIG. 3A illustrates a flowchart of an embodiment of a method of estimating CO.sub.2 levels from a user's respiration signal.

(6) FIG. 3B illustrates an exemplary user's respiration signal and exemplary estimated blood CO.sub.2 levels according to the method of FIG. 3A.

(7) FIG. 4 illustrates a flowchart of an exemplary application of the methods of estimating CO.sub.2 levels from a user's respiration signal of FIGS. 2 and 3A.

(8) FIG. 5A illustrates a flowchart of an exemplary application of the methods of estimating CO.sub.2 levels from a user's respiration signal of FIGS. 2 and 3A using a ramp cycle therapy.

(9) FIG. 5B illustrates an exemplary user's respiration signal, exemplary estimated blood CO.sub.2 levels and exemplary ramp cycle therapy pressure of FIG. 5A.

(10) FIG. 6(a) illustrates an exemplary user's respiration signal in dashed line, with the solid line indicating the ventilatory assistance provided by a prior art respiratory therapy system.

(11) FIG. 6(b) illustrates an exemplary user's respiration signal in dashed line, with the solid line indicating the ventilatory assistance provided by another prior art respiratory therapy system.

(12) FIG. 7(a) illustrates an exemplary user's respiration signal in dashed line, with the solid line indicating the ventilatory assistance provided by a respiratory therapy system in accordance with the current disclosure.

(13) FIG. 7(b) illustrates the total ventilation of an exemplary user, being the sum of the exemplary user's respiration signal and the ventilatory assistance of FIG. 7A.

(14) FIG. 8(a) illustrates an exemplary user's respiration signal in dashed line, with the solid line indicating the ventilatory assistance provided by a respiratory therapy system in accordance with the current disclosure.

(15) FIG. 8(b) illustrates the total ventilation of an exemplary user, being the sum of the exemplary user's respiration signal and the ventilatory assistance of FIG. 8A.

(16) FIG. 9(a) illustrates an exemplary user's respiration signal in dashed line, with the solid line indicating the ventilatory assistance provided by a respiratory therapy system in accordance with the current disclosure.

(17) FIG. 9(b) illustrates the total ventilation of an exemplary user, being the sum of the exemplary user's respiration signal and the ventilatory assistance of FIG. 9A.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

(18) Although certain embodiments and examples are described below, those of skill in the art will appreciate that the disclosure extends beyond the specifically disclosed embodiments and/or uses and obvious modifications and equivalents thereof. Thus, it is intended that the scope of the disclosure herein disclosed should not be limited by any particular embodiments described below.

(19) A schematic representation of a respiratory therapy device is provided in FIG. 1. The respiratory therapy device can comprise, or be configured to be connected to, a breathable gas source such as a blower unit 6 in fluid communication with a humidifier 4 via a conduit 2. In other examples, the gas source may comprise a stored source of pressurized gas to which the device can be connected. An inspiratory or breathable gas delivery tube 3 can provide a flow of gases generated by the blower unit 6 and humidified by the humidifier 4 to a user 1 via a patient interface 5. The patient interface 5 can be a full face mask that can provide a flow of gases to the user's airways via the user's mouth and nose. The patient interface 5 can also be an oral interface or a nasal interface, or a tracheal interface. The nasal interface may comprise one or more nasal prongs. In some examples, the nasal prongs comprise nasal cushions or pillows configured to seal against the nares of the user. In nasal high flow (NHF) therapy, the prongs are configured not to seal against the patient's nares such that there is a leak flow path around the prongs. In some embodiments, the humidifier can be optional in the respiratory therapy device. General operation of the respiratory therapy device will be known to those skilled in the art and will not be described here in detail. In some embodiments, one or more controllers 7 can control the blower unit 6 to generate a gas flow of a desired flow rate and/or pressure. The gas flow can be directed through the conduit 2 to the humidifier 4 to be humidified. The humidified gas can be directed through the inspiratory tube 3 and the patient interface 5 to the user 1. The controller 9 can be programmed with or can determine a suitable flow rate and/or pressure. Sensors (not shown) can be placed in various locations in the respiratory therapy device. For example and not by way of limitation, the sensors can include any one or more of: flow, pressure, temperature, and/or humidity sensors. Output(s) from the sensors can be received by the controller 9 to assist the controller 9 to operate the respiratory therapy device in a manner that can provide the desired therapy. By ‘respiratory therapy device’ we include any device configured to supply breathable gas to a patient or user, and we include a ventilator as might be used in a hospital to supply all of the required volume of breathing gas to a patient, and any other type of device configured to supply any proportion of the required volume of breathing gas to a user.

Respiratory System and Metabolic Rate Model

(20) An aspect of the present disclosure is to provide a method of driving a respiratory therapy device to treat sleep-disordered breathing by estimating a user's blood or lung CO.sub.2 percentage composition from a dynamic lung model driven directly by an observed respiration signal measured in the respiratory therapy device. In some embodiments, the method can simulate the user's pulmonary system by taking a respiration signal, estimating a gas exchange rate, and determining a ratio of gases in the lungs for any given time. For example and not by way of limitation, the respiratory therapy device can be a CPAP machine. For example and not by way of limitation, the observed respiration signal can be a flow signal. Sleep-disordered breathing can include obstructive sleep apnea, Cheyne-Stokes respiration, etc. The method can comprise an input, which can be a measured parameter, a respiratory system simulator, and an output, which can be an estimated parameter.

(21) As shown in FIG. 2A, the input can be a respiration signal of a user connected to a CPAP machine or other medical device in a method 10 of estimating the user's CO.sub.2 levels. The respiration signal can be detected and measured 12 by one or more sensors 120. The sensors 120 can be built into the CPAP machine or the other medical device connected to the user, or stand-alone sensors. In some embodiments, the sensors 120 can be located in the inspiratory (and/or expiratory tubes, if present) of the CPAP machine. The respiration signal can be quantified by a measured flow rate of the CPAP device. In other embodiments, the respiration signal can be quantified by the user's airway pressure. In some embodiments, the input can be from a flow sensor in the respiratory device, determining a flow in the device. For example and not by way of limitation, the flow can be determined from a motor speed and/or a pressure within a flow path. In some embodiments, the input can be from a sensor attached to a thorax of the user, such as by inductance plethysmography. The sensor can estimate the flow by determining displacement of the user's chest, or by any known means of determining the flow. In some embodiments, the measured respiration signal can optionally be displayed 13. For example and not by way of limitation, the measured respiration signal can be displayed 13 graphically.

(22) With continued reference to FIG. 2A, the respiration signal, such as the flow rate, can be used by the respiratory dynamics simulator device 100 to simulate 14 the user's metabolic system. The respiratory dynamics simulator device 100 can be built into the CPAP machine or other medical device connected to the user, or a stand-alone hardware processor. The respiration signal can be input into a simulation processor 140 of the respiratory dynamics simulator device 100. The simulation processor 140 can be configured to simulate the user's metabolic system by utilizing at least one of the following parameters or combinations thereof: a total lung volume, a functional residual capacity of the lung, a tidal lung volume, a rate of infusion of O.sub.2 out of total lung volume, a rate of infusion of CO.sub.2 into total lung volume, a N.sub.2 content value, and a blood or lung CO.sub.2 percentage. One of ordinary skill in the art will appreciate from the disclosure herein that other suitable parameters can be included instead of or in addition to any of the above-referenced parameters. Details of those parameters are described below.

(23) Tidal Lung Volume V. The tidal lung volume can be a volume of air that is inhaled or exhaled in a single breath over and above the Functional Residual Capacity (discussed below). This volume is dependent on a state of the breath (inspiration, expiration).

(24) Functional Residual Capacity FRC, The functional residual capacity can be the volume of gas in the lungs at a resting expiratory level, that is, the volume of air present in the lungs at the end of passive expiration. The functional residual capacity of users can be about 2-4 L. In some embodiments, the simulation processor 140 can use a variable functional residual capacity ranging from about 0 L to about 5 L. The range of the functional residual capacity is not limiting and can be any range. In some embodiments, the user's functional residual capacity can be estimated by characteristics such as height and weight, or the altitude of the user's residence, or could be measured directly, for example, by nitrogen washout or helium dilution.

(25) Total Lung Volume VT=V+FRC, The total lung volume can be a dynamic variable representing the sum of the functional residual capacity and the tidal volume. The total lung volume can be greater or equal to 0 L, that is, VT≥0. In other words, the total lung volume can represent a total volume of fluid in the user's lungs at a given point in time of the respiratory cycle.

(26) Rate of infusion of CO.sub.2 into Total Lung Volume. This parameter can be the rate of infusion of CO.sub.2 into the instantaneous total lung volume as a result of gas exchange in the alveoli. In some embodiments, the rate of infusion of CO.sub.2 into the total lung volume can be an adjustable variable. In some embodiments, the rate of infusion of CO.sub.2 into the total lung volume can be set at a rate such that under a normal breathing pattern, the user's blood CO.sub.2 level is approximately 5%. This rate can correlate with and reflect the user's metabolic rate.

(27) Rate of infusion of O.sub.2 out of Total Lung Volume. This parameter can be the rate of infusion of O.sub.2 out of the instantaneous total lung volume as a result of gas exchange in the alveoli. In some embodiments, the rate of infusion of O.sub.2 out of the total lung volume can be an adjustable variable. In some embodiments, the rate of infusion of O.sub.2 out of the total lung volume can be set at a rate commensurate with an about 4-5% average blood CO.sub.2 level. This rate can be dependent at least in part on the user's metabolic rate.

(28) N.sub.2 Content Value. In some embodiments, the N.sub.2 content value can be a dynamic value based on the total lung volume, the CO.sub.2 levels, the O.sub.2 levels, and/or a flushing rate of gases present in the lungs. In some embodiments, the N.sub.2 content value can also be expressed as a value representing composition of respiratory gases other than O.sub.2 and CO.sub.2.

(29) Details of an embodiment of the simulation model that can be implemented by the simulation processor 140 will now be described with reference to FIG. 2B. FIG. 2B illustrates exemplary flow rate and lung displacement volume patterns of a user. In some embodiments, air can be inspired at ambient gases concentrations and exhaled at concentration of gases in the lung. Concentrations of the exhaled gases can vary over time depending on various factors including but not limited to a respiration rate and a gas exchange rate. In some embodiments, the ambient air is assumed to be composed of approximately 79.2% nitrogen (N.sub.2), 20.4% oxygen (O.sub.2), and 0.4% carbon dioxide (CO.sub.2). One of ordinary skill in the art would appreciate that these levels of gases could vary. For example and not by way of limitation, the ambient CO.sub.2 level may be assumed to be higher than 0.4% as CO.sub.2 levels rise in closed rooms due to exhalation by people in the closed rooms. In some embodiments, at the beginning of a therapy session, an assumed lung CO.sub.2 composition can be 5%. However, this assumed composition may vary, for example in a non-limiting range between about 4% and about 6%.

(30) As shown in FIG. 2B, a user's respiratory cycles can typically involve an inspiration phase I and an expiration phase E, with a peak of the lung displacement P indicating when the user transits from inspiration to expiration. An area under the flow rate A over an inhalation phase is a volume of air inhaled in that breath (hereinafter referred to as “maximum tidal volume” and corresponding to Vin the lung displacement pattern). While simple integration of the flow rate could be used to determine the volume of gases being inspired and exhaled, the simple integration does not take into account an anatomical dead space (i.e. the upper airways) when analyzing current gases concentrations in the inhaled air. The simple integration also may not take into account the dead space of a breathing circuit of the CPAP or bi-level machine, which can further increase the dead space over and above the dead space of the upper airways. On inhalation, the first gases that reach the lungs are from the dead space of upper airways, which typically has been exhaled from the lungs in a previous breath, and can have deviations from ambient air concentrations. The deviations can be taken into account in the simulation model in some embodiments. In one embodiment, volumes of a mask and/or a breathing tube can also be taken into account as dead spaces in the model.

(31) In some embodiments, the inspiration phase signal can be filtered to take into account the dead space of the upper airways and optionally of the mask and breathing tube. The exponential filter can have a time constant set to effectively model a delay caused by the additional upper airways volume and travelling of the air through the upper airway. The time constant can also take into account the physiology of the upper airways, such as a path length, volume, geometry, and the like. In a non-limiting example, the time constant may be adjusted to more accurately model the delay in air of ambient concentration reaching the lungs by taking into account that the patient has a larger anatomical dead space, or is using a full face mask over a nasal mask.

(32) The filtered inspiration phase signal can be integrated for each of N.sub.2, O.sub.2, and CO.sub.2 to determine a relative tidal volume of each of the three gases in the lungs. When calculating gases concentrations in the lungs, the model may take into account the volume of a functional residual capacity (illustrated as FRC in FIG. 2B), which is the volume of air still remaining in a user's lungs after passive expiration. The total volume in the lungs at an end of the inspiration phase can be a sum of the tidal volume at the end of the inspiration and the functional residual capacity, for example, as shown in FIG. 2B, where V.sub.T is the sum of V±FRC.

(33) Because the functional residual capacity can be an assumed parameter, the model can further include a feedback process to adjust an initial total volume to match an observed total volume. In some embodiments, the model can use a nominal functional residual capacity, which is the functional residual capacity and one half of the maximum tidal volume, based on an average over a period of time. In some embodiments, the model may not be critically dependent on the functional residual capacity. Alternatively, the model can use a simple fixed estimate of the functional residual capacity, for example, as shown in FIG. 9B.

(34) At all times a running total of the ratio of the three gases can be tracked. Gas exchange occurs continuously in the lung alveoli. O.sub.2 can diffuse out of the lungs and into the bloodstream, and CO.sub.2 can diffuse out of the blood stream and into the lungs. Gas exchange occurs regardless of breathing, and changes the concentration of these gases in the lungs. A gas exchange rate within the lungs can vary depending on a metabolic demand of the patient. Diffusion rates of the gases used in the model can be set by calibrating the model. Predetermined breath parameters can be fed into the model for the calibration, and the O.sub.2 and CO.sub.2 alveoli exchange rates can be adjusted to achieve approximately 5% CO.sub.2 level in the lung volume. In some embodiments, the predetermined parameters can include a 500 ml tidal volume at 15 breaths/min. In one embodiment, a ratio of O.sub.2 to CO.sub.2 exchange rates can be set at 0.8.

(35) In other embodiments, the CO.sub.2 and O.sub.2 exchange rates may be set at an assumed rate in litres per minute. While an assumed rate is used, the rate could be set by a clinician based on a patient's physical traits, for example age, height, weight, or other physical traits that can affect metabolic rate. The rates could also be measured experimentally in a sleep lab before the patient commences therapy. These assumptions may also change with time, and the model may dynamically change over several nights of therapy as data is gathered.

(36) As described above, the exhalation phase signal can be isolated from the respiration signal. The exhalation phase signal can be integrated to determine a volume of gases being exhaled. The ratio of gases can be changing during exhalation as gas exchange occurs continuously in the lung. The CO.sub.2 concentration can rise slightly during exhalation.

(37) By modeling the inspiration and expiration phase signals along with the gas exchange in the lungs, a real-time estimate of the patient's CO.sub.2 level can be determined. As previously described, a higher CO.sub.2 level can correlate with higher probability of a breathing event. As such, a CPAP or bi-level controller can be configured to respond to the changing CO.sub.2 level by increasing the therapeutic pressure above the set pressure, or using a ramp cycle therapy before a breathing event occurs, which will be described in greater detail below. One of ordinary skill in the art would appreciate that other ways of responding to the increased CO.sub.2 levels may be possible.

(38) Returning to FIG. 2A, the output of the method can be the user's estimated lung or blood CO.sub.2 level in some embodiments. Other indicators of the user's metabolic rate can also be estimated. For example and not by way of limitation, the user's estimated blood CO.sub.2 level can be the blood CO.sub.2 percentage composition, concentration, or any other suitable indicator of the blood CO.sub.2 level. The blood CO.sub.2 level can be estimated 16 by the simulation processor 140 using one or more of the above-referenced parameters. The blood CO.sub.2 level can correlate with and be an indicator of the user's metabolic rate. The estimated blood CO.sub.2 level can be displayed 18 on the display device 180. For example and not by way of limitation, the estimated blood CO.sub.2 level can be displayed 13.

(39) Turning to FIG. 3A, in addition to features of the method 10 described above, a method 20 of driving a medical device to treat sleep-disordered breathing can further include an additional output. For example and not by way of limitation, the medical device can be a CPAP machine. In some embodiments, the additional output can be a prediction of breathing events. The predicted breathing events can include but are not limited to, hyperpnea, hypopnea, and/or apnea. The simulation processor 140 can use the estimated blood or lung CO.sub.2 level to predict 15 occurrences of the breathing events. In some embodiments, the predicted breathing events can be displayed 17 on the display device 180. For example and not by way of limitation, the predicted breathing events can be displayed 17 graphically and/or in text on the display device 180. In some embodiments, the respiratory signal, the estimated blood CO.sub.2 level, and/or the breathing events can be displayed concurrently. For example and not by way of limitation, graphs of the respiratory signal, the estimated blood CO.sub.2 level, and/or the breathing events can be superposed on each other. The concurrent displays can advantageously show a relationship among the respiratory signal, the estimated blood CO.sub.2 level and/or the breathing events. In some embodiments, the respiratory signal, the estimated blood CO.sub.2 level, and/or the breathing events can be displayed separately or sequentially. One of ordinary skill in the art would appreciate that a display device may not be required because the user would normally use the respiratory therapy device during sleep and need not see the display.

(40) FIG. 3B illustrates an example user's flow signal 220 and example estimated blood CO.sub.2 levels 260 with respect to time according to the method of FIG. 3A. FIG. 3B further shows the predicted events 250.

(41) The relationship among the flow signal 220, the estimated blood CO.sub.2 level 260 and/or the breathing events 250 can be seen in FIG. 3B. For example, hypopnea as indicated by a region of small-amplitude peaks 222 and small amplitude valleys 224 of the flow signal 220. The hypopnea can be preceded by and can coincide with a rise 262 in the estimated CO.sub.2 level. The rise 262 of the estimated CO.sub.2 level can culminate at a peak at the marker 264, when the user awakens and begins to draw deeper breaths, as shown by a region of larger-amplitude peaks 226 and larger-amplitude valleys 228 of the flow signal 220 after the marker 225. The deeper breaths can provide greater tidal lung volume for flushing the CO.sub.2 from in the user's body and can therefore coincide with a decrease 266 and stabilizing of the estimated CO.sub.2 level 260.

Example Applications of the Methods

(42) Example applications of the methods described above will now be discussed. The methods described above can be run on-board the CPAP machine or other medical device. Blowers or flow generators of the CPAP machine or other medical device can be used to assist in adjusting therapy parameters. In some embodiments, the pressure can be increased or adjusted. In other embodiments, the pressure can be increased slowly to a predetermined level in cycles. The methods described above may also be run on separate devices.

Example Applications to Existing Therapies

(43) FIG. 4 illustrates an example application 30 of the methods 10, 20 shown in FIGS. 2 and 3A to influence existing treatments. As shown in FIG. 4, the simulator 100 can be operably coupled to the respiratory therapy device 100 that can provide therapeutic pressure to the user at an operating pressure of the respiratory therapy device 100. In this application, “operably coupled” can refer to devices being connected by one or more cables/wires, and/or wireless connections using any existing wireless technology. In addition to features of the methods 10, 20 as shown in FIGS. 2 and 3A, after predicting 15 the breathing event, the respiratory therapy device 110 can adjust and/or change 11 an existing treatment configuration based on the predicted breathing events. In some embodiments, the respiratory therapy device 110 can also adjust and/or change 11 an existing treatment configuration based on the estimated blood CO.sub.2 level. Adjusting and/or changing 11 the existing treatment configuration can include increasing the operating pressure of the respiratory therapy device so that the user can receive a greater therapeutic pressure. For instance, when high CO.sub.2 levels can be estimated and/or when hypopnea can be predicted, the respiratory therapy device 110 can increase its operating pressure. The greater therapeutic pressure delivered to the user can attempt to further open the user's airway and to induce deeper breathing.

Variable Ventilation—Ramp Cycle Therapy Example

(44) FIG. 5A illustrates an example ramp cycle therapy 40 which may provide a greater rate of flushing of CO.sub.2 from the user's lungs. As described above, one or more sensors can detect 42 a respiration signal from the respiratory therapy device 400 connected to the user 490 or directly from the user 490 as described above. For example and not by way of limitation, the respiration signal can be flow data. A respiratory system simulator 420 can use the respiration signal from the sensor(s) to simulate the user's metabolic rate. In the illustrated embodiment, the simulator 420 can estimate 46 the user's lung or blood CO.sub.2 level as an output. In other embodiments, other indicators of the user's metabolic rate can be estimated. The flow generator of the respiratory therapy device 410 can be controlled based on the estimated lung or blood CO, level. The flow generator of the respiratory therapy device 410 can generate a ramp cycle therapy pressure 470 based on the estimated lung or blood CO.sub.2 level (and/or predicted breathing events). The ramp cycle therapy pressure 470 can cyclically rise above an operating pressure of the respiratory therapy device 410 to attempt to increase a volume of the user's lungs for flushing CO.sub.2 from the user's lungs and subsequently fall to the operating pressure more rapidly than the rise in pressure, for example during one exhalation, thereby advantageously reducing an abnormally high CO.sub.2 level. With the ramp cycle therapy, the effective increase in the CO.sub.2 flushing volume of the user's lungs can be about 5% to about 15% depending on the rate of increase and a volume of the user's lungs for flushing the CO.sub.2.

(45) Details of the ramp cycle therapy 40 will now be described. The ramp cycle therapy can, in some examples, be based on a principle that introducing a higher proportion of ambient air into the lungs can dilute the concentration of CO.sub.2 in the lungs, as the CO.sub.2 concentration of ambient air (0.4%) is much lower than a typical lung CO.sub.2 concentration. In some embodiments, the CO.sub.2 concentration of ambient air can be about 0.4% and the lung CO.sub.2 concentration can be about 5%, or higher if CO.sub.2 levels have built up over time.

(46) Further, introducing the higher volume of ambient air into the lungs could result in more air being expelled from the lungs when the therapy pressure 470 is reduced to the operating pressure. Whenever an additional volume of air is expelled, the lung CO.sub.2 concentration can be reduced by between about 5-15% from the initial concentration, depending on the flushing volume. Repeated flushing of the lungs with ambient air could prevent or mitigate the CO.sub.2 build-up in the lungs and advantageously prevent a sleep disordered breathing event from occurring.

(47) In some embodiments, the ramp cycle therapy 40 could be initiated by the respiratory therapy device 400 when the estimated CO.sub.2 levels are above a threshold, are increasing, or are increasing above a predetermined rate. In other embodiments, the ramp cycle therapy 40 could run continuously throughout the therapy over and above a set point pressure or therapeutic pressure as determined by other algorithms. In one embodiment, the algorithm can be an auto PAP algorithm, which can change pressure provided to the patient after detecting the breathing events. A rate of increase, an amplitude, and/or a frequency of the ramp cycle therapy pressure may be adjusted based on the estimated CO.sub.2 levels as described above. In some embodiments, the ramp cycle therapy may be used with other methods of measuring or estimating CO.sub.2 levels.

(48) Further, the user's lung compliance can affect the ramp cycle therapy. The lung compliance can be defined as an ability of the user's lungs to stretch and expand. The lung compliance of the user can be determined over time through therapy data. In some embodiments, the lung compliance of the user can be determined by looking at the exhalation volume at the end of each ramp cycle and by determining how much the increase in pressure contributed to an increase in lung volume. The respiratory therapy device 400 can dynamically update the user's lung compliance to create a more accurate ramp cycle therapy 40. In a non-limiting example, if the therapy data determines that the lung's ability to stretch is lower than an assumed amount for each cm H.sub.2O increase in pressure, the increase in the ramp cycle therapy pressure 470 over the set point pressure may be increased to compensate for the lower lung compliance.

(49) As described above, the ramp cycle therapy pressure 470 can be provided in cycles. In other embodiments, the ramp cycle therapy pressure 470 can have other variations and/or patterns. FIG. 5B illustrates an example waveform of the ramp cycle therapy pressure 470. The waveform on the left of the marker 425 indicates a user's respiration signal when the user is sleeping and the waveform on the right of the marker 425 indicates the respiration signal after the user wakes up as a result of the sleep disordered breathing event. As shown in FIG. 5B, the ramp cycle therapy pressure 470 can be a sawtooth wave, gradually ramping upwards and then dropping sharply. The ramp cycle therapy pressure 470 can have an increase 472 from a first threshold 474 to a second threshold 476 over a predetermined number of breaths taken by the user. The increase can be one or more of linear, exponential, stepped function increases, or a combination thereof. The thresholds can depend on the therapeutic pressure set by the clinician. For example and not by way of limitation, the therapeutic pressure set by the clinician can be in the range of 4-20 cm H.sub.2O. This therapeutic pressure may also change throughout the therapy in response to the breathing events such as apneas and the like. When an apnea is sensed, the respiratory therapy device can increase the therapeutic pressure as described above. In some embodiments, the first threshold can be the therapeutic pressure. The second threshold can be between about 1 and about 5 cm H.sub.2O above the therapeutic pressure. The ramp therapy can be seen as slow ventilation over a number of breaths over and above the set CPAP therapeutic pressure. In some embodiments, the first threshold 474 can be about 0 cm H.sub.2O and the second threshold 476 can be about 4-6 cm H.sub.2O. In some embodiments, the increase 472 of pressure can increase the volume of the user's lungs by approximately 100 mL/cm H.sub.2O. For example, the increase 472 from about 0 to about 5 cm H.sub.2O can increase the volume of the lungs for flushing the CO.sub.2 by about 0.5 L. One of ordinary skill in the art would appreciate that the increase in the volume of the user's lungs may vary. In some embodiments, each ramp cycle can increase the pressure by about 3 to about 5 cm H.sub.2O, thereby increasing the lung volume by about 300 to about 500 ml. Further, the increase 472 can stop when the ramp cycle therapy pressure 470 reaches the second threshold 476. The ramp cycle therapy pressure 470 can return to the first threshold 474 during an exhalation phase of one breath. When the pressure is rapidly dropped back to the first threshold 474 during exhalation, the additional volume of air in the lung can be exhaled. This exhalation can flush the lung. Dropping the ramp cycle therapy pressure 470 over one breath can minimize opportunities for CO.sub.2 to build up in the decreasing lung volume and ensures more flushing of the lungs. In other embodiments, the return to the first threshold 474 could be over more than one breath. In a non-limiting example, the return to the first threshold 474 can be over two breaths.

(50) The ramp cycle therapy 40 can use the estimated blood CO.sub.2 level (and/or the predicted breathing events) to adjust a rate of the increase 472 of the ramp cycle therapy pressure. If an increased risk of a breathing event is predicted from the CO.sub.2 level, the increasing pressure phase 472 of the ramp cycle may be adjusted to occur over a reduced number of breaths. In a non-limiting example, the ramp cycle can be reduced to 5 breaths from 10 breaths. A shorter ramp cycle can advantageously provide more effective and frequent flushing and to bring down the lung CO.sub.2 level in advance of a breathing event, thereby preventing the breathing event from occurring or mitigating the breathing events. For example, as shown in FIG. 5B, the increase 472 can be from about 0 to about 5 cm H.sub.2O over a course of about 12-13 breaths when the estimated blood CO.sub.2 level 460 can be substantially constant or normal. When the estimated blood CO.sub.2 level begins to rise 462, the rate of the increase 472 can be higher so that the ramp cycle therapy pressure 470 can rise from the first threshold 474 to the second threshold 476 in fewer breaths. For example and not by way of limitation, the ramp cycle therapy pressure 470 can rise from the first threshold 474 to the second threshold 476 in about five to six breaths of the user.

(51) Adjusting a length of the ramp cycle based on the estimated CO.sub.2 level (and/or the predicted breathing events) can advantageously allow the ramp cycle therapy pressure 470 to be controlled with respect to the user's respiratory cycle. That control may be such as to control some or all of the ramp cycle therapy to be asynchronous with a particular phase or part of a user's respiratory cycle. That control may be such as to control some or all of the ramp cycle therapy to partially synchronize, or to fully synchronize, with some or all of the user's actual respiratory cycle and to mitigate effects of the breathing events. Broadly, the ramp cycle may be controlled so as to begin in synchrony with the start of an inspiratory portion of a breath, to continue for more than one breath, and to end during an expiratory portion of a breath. For example and not by way of limitation, the effects of the breathing events can include a rise 462 in the blood CO.sub.2 level when there is hypopnea. A hypopnea may also be preceded by a rise in the CO.sub.2 level. As shown in FIG. 5B, the shorter ramp cycle 478 can be delivered, for example, when a hypopnea is detected and/or predicted. The blood CO.sub.2 level can decrease after the shorter ramp cycle because more CO.sub.2 can have been flushed from the user's body. The more effective increase in the therapeutic pressure can also induce the user to deeper breaths.

(52) In other examples, the ramp cycle may be controlled by time or rate so as to be independent of any particular number of breathing cycles. Thus, the ramp cycle may be controlled to provide approximately two to 10 cycles per minute, regardless of how many breathing cycles occur during that time. More preferably the ramp cycle may be controlled to provide approximately three to six cycles per minute, and in some cases three to four cycles per minute.

(53) In examples where the pressure drop is triggered by expiration so as to drop at the start of, or at least during, an expiratory portion of a breath, the variable ventilation profile may be controlled to automatically trigger the pressure drop in the event of a time out or period in which expiration should have started but has not. Thus, the profile may be such as to automatically initiate the pressure drop after a set or predetermined time period, even if expiration has not actually begun.

Asynchronous, Partially Synchronous and Fully Synchronous Variable Ventilation

(54) With additional reference to FIGS. 6 to 9, further methods of providing respiratory therapy are provided using some of the principles described above. For example, some examples provide variable ventilation using a ramp cycle similar to those discussed above in relation to FIGS. 5A and 5B. Others examples of variable ventilation in accordance with this disclosure use a cycle incorporating a single or multiple stepped change between first and second pressure thresholds. The methods of FIGS. 5A and 5B, and FIGS. 7A to 9B control the flow of breathable gas to the user such that the pressure is increased from first to second pressure thresholds over multiple sequential breathing cycles, and subsequently reduced from the second to the first pressure thresholds during expiration. Thus, for example, the pressure may be increased over three or four breaths, and then dropped over a single expiration.

(55) In these examples a respiratory therapy device, for example as described above, is configured to supply a flow of breathable gas to a user via a breathing gas delivery conduit and a patient interface; and comprises a controller configured to control a pressure of the gas supplied to the user; and one or more sensors configured to measure data relating to a patient's breathing pattern. The controller is configured to control the device to increase the pressure of the breathable gas supplied to the user from a first pressure to a second pressure over a predetermined number of breaths. The controller is further configured, after the second pressure is reached or maintained, to decrease the pressure of the gas supplied to the user from the first pressure to the therapeutic pressure during one or more periods of exhalation.

(56) In these examples, variable ventilation is achieved by the increase in pressure from the first to second pressure thresholds and this can be asynchronous with the breathing cycle of the patient in the sense that delivery of the increased and/or decreased pressure need not be synchronized with the start of inspiration or expiration. In these examples, the total ventilation does not always follow the pattern of natural breaths of the user, as it is only the total amount of gas moved in and out that determines the elimination of CO.sub.2. Thus any cyclic change in volume (including the resting FRC) will accomplish some ventilation and contribute to the clearance of CO.sub.2.

(57) A variable ventilation profile, examples of which are described above and below, may itself comprise a sole ventilation profile providing assisted ventilation to the user, or may be superimposed with one or more further ventilation profiles so as to provide a composite ventilation profile to the user. In the latter example, the variable ventilation profile may form a baseline ventilation profile which may be supplemented by one or more further profiles.

(58) As mentioned above, examples of conventional breathing modes include: 1. Total controlled ventilation—the respiratory therapy device delivers a set number of fixed volume or pressure cycles that determine total ventilation without regard for patient efforts. This is often used on paralyzed or deeply sedated subjects, but is generally uncomfortable in conscious patients. 2. Intermittent mandatory ventilation (IMV)—the respiratory therapy device delivers fixed numbers of volume or pressure cycles that cause a minimum number of controlled or augmented breaths, mixed in with spontaneous breaths initiated by the patient. However, between each breath (including the mandatory breaths) the patient is allowed to return to FRC. 3. Backup ventilation or rate—the respiratory therapy device switches to total controlled ventilation when the patient experiences either a respiratory pause of a pre-set duration, or when the total average ventilation falls below a pre-set level. At other times, the patient is allowed to breathe at will. 4. Assisted ventilation (e.g. pressure support)—the respiratory therapy device, on a patient triggered breath, delivers a set amount of additional volume, pressure or some combination.

(59) These modes are all based on providing individual breaths at a frequency generally in the range of 10-25/min, with return to FRC between breaths.

(60) Respiratory therapy methods and devices in accordance with the present disclosure may be operative according to an algorithm configured to provide variable ventilatory assistance which combines existing spontaneous ventilation (or any of the above continuous cyclic modes of synchronous mechanical assistance) with a background variable profile of relatively slow artificial breaths that are created by slowly inflating the lung over multiple spontaneous breaths and then allowing the lung to empty down to FRC. This can also be described as slowly (e.g. 2-5 L/min) increasing the FRC and then allowing the lung to deflate passively, without relationship to the spontaneous breathing pattern. This variable ventilation is thus independent of spontaneous breaths/tidal volumes and contributes an independent and predictable amount of respiratory therapy device driven ventilation to the total ventilation received by the user. The remainder of ventilation can be supplied by the spontaneous breathing of the patient or by conventional ventilator modes acting at a different rate that enlarge breaths or provide additional breaths.

(61) With reference to FIGS. 6A and 6B, these illustrate prior art assisted ventilation in which spontaneous regular breathing shown in dotted line is supplemented with machine assistance shown in solid line. FIG. 6A shows a ventilation profile which provides assistance to the size of each tidal volume (e.g. pressure support). FIG. 6B shows a ventilation profile that provides extra breaths (backup frequency) in between the user's breaths.

(62) With reference to FIGS. 7A and 7B, a variable ventilation profile is shown of a respiratory therapy method or device in accordance with the present disclosure. In this example, variable ventilation, shown in solid line, is provided in which a single stepped pressure increase from a first pressure threshold to a second higher pressure threshold is provided. Pressure is maintained at the second, higher pressure threshold for a predetermined number of breath cycles and then controlled to drop back to the lower first pressure threshold during a single expiration. This ventilation profile therefore comprises a relatively slow cycle with a relatively long inspiratory period during which ventilatory assistance is provided at the second pressure threshold, and a relatively short withdrawal of ventilatory assistance during expiration to allow the lungs to drop to FRC between asynchronous breaths. FIG. 7B shows the sum of patient spontaneous patient breaths and asynchronous breaths resulting in total ventilation to the user, which is potentially greater than user spontaneous ventilation. In this example the first pressure, and the second pressure, are constant over multiple cycles of the ventilation profile. In this example, the pressure increase is timed to begin at the start of an inspiratory cycle, to continue for multiple breaths, and the pressure drop is timed to begin at the start of an expiratory cycle, after the predetermined number of multiple breaths.

(63) With reference to FIGS. 8A and 8B, another ventilation profile is shown of a respiratory therapy method or device in accordance with the present disclosure. In this example, variable ventilation, shown in solid line, is provided in which there is a single, relatively gradual, ramped pressure increase from a first pressure threshold to a second higher pressure threshold, similar to the ramped ventilation profile of FIG. 5B. The pressure increases from the first pressure threshold over a number of breath cycles. Once the pressure reaches the second, higher pressure threshold, pressure is then controlled to drop back to the lower first pressure threshold during a single expiration. In this example at least one of the first pressure, and the second pressure, are constant over multiple cycles of the ventilation profile. This ventilation profile therefore comprises a relatively slow ramping cycle of FRC with a relatively long increase time and a relatively short withdrawal of assistance to allow the lungs to drop to FRC between asynchronous breaths. The sum of patient spontaneous patient and asynchronous changes in FRC results in total ventilation which is potentially greater than patient spontaneous ventilation. In this example, the pressure increase is timed to begin at the start of an inspiratory cycle, to continue increasing for multiple breaths, and the pressure drop is timed to begin at the start of an expiratory cycle, after the predetermined number of multiple breaths.

(64) With reference to FIGS. 9A and 9B, a further ventilation profile is shown of a respiratory therapy method or device in accordance with the present disclosure. In this example, variable ventilation, shown in solid line, is provided in which a plurality of stepped pressure increases are provided from a first pressure threshold to a second higher pressure threshold. Pressure is increased in steps over a number of breath cycles, and is maintained at the second, higher pressure threshold for a predetermined time period which may be a proportion of a breath cycle, a single breath cycle, or over a predetermined plurality of breath cycles. Pressure is then controlled to drop back to a lower pressure during a single, or small number of, expiration period(s). The lower pressure may be the first pressure threshold or may be a pressure higher than the first pressure threshold and lower than the second pressure threshold. This ventilation profile therefore provides variable, partially synchronous, ventilation in a relatively slow cycle with a relatively long inspiratory time and a relatively short withdrawal of assistance to allow the lungs to drop to FRC between asynchronous breaths, similar to the profile of FIGS. 8A and 8B. However, in this example, increases in FRC are accomplished with individual step rises in pressure support timed with inspiration (IPAP), instead of a continuous increase in pressure, cycled with progressive rises in end-expiratory pressure (EPAP) that prevent full exhalation. The sum of spontaneous patient breaths and asynchronous ventilation results in total ventilation which is potentially greater than patient spontaneous ventilation. In this example, each stepped pressure increase is timed to begin at the start of an inspiratory cycle, to continue increasing for multiple breaths, and the pressure drop is timed to begin at the start of an expiratory cycle, after the predetermined number of multiple breaths.

(65) The variable ventilation comprising part of the current disclosure may include any one or more of the following benefits: 1. Timing of mechanical breathing assistance is less dependent on detecting user efforts, which can be a problem in non-invasive mask ventilation. 2. Small cycles of changing FRC may be imperceptible to the user, and thus more comfortable than large breaths continuously. This may help to reduce arousals during sleep. 3. Slowly changing FRC may inhibit breathing (this is known as the Hering Breuer reflex) less than continuous large changes in volume from larger breaths. As a result the user may then continue to provide their own ventilatory efforts fully, rather than being suppressed as mechanical ventilatory support is added. 4. Slowly varying cyclical changes in FRC can be combined with other types of ventilation such as CPAP, bi-level and timed modes of ventilation, as well as modes that detect the awake state of the user and turn ventilation on and off with arousal. Ventilation in accordance with the current disclosure may therefore comprise a secondary or base line ventilation which can be supplemented with, and superimposed with, other types of ventilation to provide a composite ventilation to the patient. 5. Because changes in the pressure provided by the asynchronous assistance are relatively slow and thus minimally affect the waveform of inspiration within a single breath, algorithms that are dependent on inspiratory shape (e.g. detection of flow-limitation in autoCPAP) can function with little modification and less corruption than during large pressures used to assist breath size externally.

(66) It will be appreciated that the above disclosure incorporates any type of ventilation profile which provides an increase in pressure over a plurality of, or at least more than one, breathing cycles, and which reduces the pressure more quickly, that is, in less time than the duration of the pressure increase. In some examples, the pressure is decreased over a single expiratory cycle. Thus, in some embodiments, the pressure may be increased rapidly, maintained over multiple breathing cycles, and dropped quickly. In other embodiments, the pressure may be increased slowly over multiple breathing cycles and then dropped quickly. The start and end pressures during the increasing pressure phase may be kept constant, or may increase or otherwise vary over successive cycles of the ventilatory profile. For example, the second pressure to which the pressure is increased may itself increase over successive cycles. Likewise the first pressure to which the pressure drops during expiration may increase over successive cycles. Further, a combination of one or more stepped and/or ramped pressure changes may be used during one or both of the pressure increase and decrease phases.

(67) A further example of a variable ventilation profile in accordance with the current disclosure is similar to the stepped increase described with reference to FIG. 9, is a profile in which pressure is increased over each inspiration and subsequently paused during at least one expiration. Thus, the pressure continues to increase over sequential breathing cycles, but is held constant during each, or at least some, expiration period(s).

(68) Another example of a variable ventilation profile in accordance with the current disclosure incorporates a variation to one or both of the pressure increase and pressure decrease to account for the awake/asleep state of the patient. The ventilation profile may therefore be configured to reduce the magnitude of, the rate of change of, pressure between the first and second pressures, or to alter the first and second pressures, if the patient or user is determined to be awake.

(69) Whilst the above examples discuss ventilation profiles based on pressure control, whereby a controller of a respiratory therapy device is configured to control the pressure of breathable gas supplied to the user, the disclosure includes similar ventilation profiles based on flow control, whereby a controller of a respiratory therapy device is configured to control the flow of breathable gas supplied to the user. Suitable pressure and/or flow sensors and/or control algorithms may be provided accordingly. In any of the above examples and/or ventilation profiles the control of the ventilation profile by the or each controller is automatic in that it may occur without any patient intervention or external input, and/or may be recurring for any time duration required and/or for any number of breathing cycles required.

(70) Although this disclosure has been described in the context of certain embodiments and examples, it will be understood by those skilled in the art that the disclosure extends beyond the specifically disclosed embodiments to other alternative embodiments and/or uses and obvious modifications and equivalents thereof. In addition, while several variations of the embodiments of the disclosure have been shown and described in detail, other modifications, which are within the scope of this disclosure, will be readily apparent to those of skill in the art. It is also contemplated that various combinations or sub-combinations of the specific features and aspects of the embodiments may be made and still fall within the scope of the disclosure. For example, features described above in connection with one embodiment can be used with a different embodiment described herein and the combination still fall within the scope of the disclosure. It should be understood that various features and aspects of the disclosed embodiments can be combined with, or substituted for, one another in order to form varying modes of the embodiments of the disclosure. Thus, it is intended that the scope of the disclosure herein should not be limited by the particular embodiments described above. Accordingly, unless otherwise stated, or unless clearly incompatible, each embodiment of this invention may comprise, additional to its essential features described herein, one or more features as described herein from each other embodiment of the invention disclosed herein.

(71) Features, materials, characteristics, or groups described in conjunction with a particular aspect, embodiment, or example are to be understood to be applicable to any other aspect, embodiment or example described in this section or elsewhere in this specification unless incompatible therewith. All of the features disclosed in this specification (including any accompanying claims, abstract and drawings), and/or all of the steps of any method or process so disclosed, may be combined in any combination, except combinations where at least some of such features and/or steps are mutually exclusive. The protection is not restricted to the details of any foregoing embodiments. The protection extends to any novel one, or any novel combination, of the features disclosed in this specification (including any accompanying claims, abstract and drawings), or to any novel one, or any novel combination, of the steps of any method or process so disclosed.

(72) Furthermore, certain features that are described in this disclosure in the context of separate implementations can also be implemented in combination in a single implementation. Conversely, various features that are described in the context of a single implementation can also be implemented in multiple implementations separately or in any suitable subcombination. Moreover, although features may be described above as acting in certain combinations, one or more features from a claimed combination can, in some cases, be excised from the combination, and the combination may be claimed as a subcombination or variation of a subcombination.

(73) Moreover, while operations may be depicted in the drawings or described in the specification in a particular order, such operations need not be performed in the particular order shown or in sequential order, or that all operations be performed, to achieve desirable results. Other operations that are not depicted or described can be incorporated in the example methods and processes. For example, one or more additional operations can be performed before, after, simultaneously, or between any of the described operations. Further, the operations may be rearranged or reordered in other implementations. Those skilled in the art will appreciate that in some embodiments, the actual steps taken in the processes illustrated and/or disclosed may differ from those shown in the figures. Depending on the embodiment, certain of the steps described above may be removed, others may be added. Furthermore, the features and attributes of the specific embodiments disclosed above may be combined in different ways to form additional embodiments, all of which fall within the scope of the present disclosure. Also, the separation of various system components in the implementations described above should not be understood as requiring such separation in all implementations, and it should be understood that the described components and systems can generally be integrated together in a single product or packaged into multiple products.

(74) For purposes of this disclosure, certain aspects, advantages, and novel features are described herein. Not necessarily all such advantages may be achieved in accordance with any particular embodiment. Thus, for example, those skilled in the art will recognize that the disclosure may be embodied or carried out in a manner that achieves one advantage or a group of advantages as taught herein without necessarily achieving other advantages as may be taught or suggested herein.

(75) Conditional language, such as “can,” “could,” “might,” or “may,” unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to convey that certain embodiments include, while other embodiments do not include, certain features, elements, and/or steps. Thus, such conditional language is not generally intended to imply that features, elements, and/or steps are in any way required for one or more embodiments or that one or more embodiments necessarily include logic for deciding, with or without user input or prompting, whether these features, elements, and/or steps are included or are to be performed in any particular embodiment.

(76) Language of degree used herein, such as the terms “approximately,” “about,” “generally,” and “substantially” as used herein represent a value, amount, or characteristic close to the stated value, amount, or characteristic that still performs a desired function or achieves a desired result. For example, the terms “approximately”, “about”, “generally,” and “substantially” may refer to an amount that is within less than 10% of, within less than 5% of, within less than 1% of, within less than 0.1% of, and within less than 0.01% of the stated amount. Additionally, as used herein, “gradually” has its ordinary meaning (e.g., differs from a non-continuous, such as a step-like, change).

(77) The scope of the present disclosure is not intended to be limited by the specific disclosures of preferred embodiments in this section or elsewhere in this specification, and may be defined by claims as presented in this section or elsewhere in this specification or as presented in the future. The language of the claims is to be interpreted broadly based on the language employed in the claims and not limited to the examples described in the present specification or during the prosecution of the application, which examples are to be construed as non-exclusive.