Internet Connected Low Cost Healthcare Devices For Telemedicine in Rural India

Contents
1 Introduction 1
1.1 Background and Need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Problem Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Literature Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3.1 Multi-purpose HealthCare Telemedicine Systems with mobile commu-
nication link . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3.2 AC front end for ECG Transaction . . . . . . . . . . . . . . . . . . . . 4
1.3.3 Removal of power-line interference from the ECG: a review of the sub-
traction procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.4 Technology Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4.1 C# . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4.2 MySQL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.3 PHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4.4 Intrasystem communication - Wired . . . . . . . . . . . . . . . . . . . 8
2 Related Theory 9
2.1 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1.1 Clinical Significance of ECG . . . . . . . . . . . . . . . . . . . . . . . 12
2.2 Electronic Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.3 Pulse Oximeter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3 Related Concepts 24
3.1 Noise in ECG Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.2 FIR FILTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.3 Sallen-Key Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.4 Shielding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.5 ECG Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.6 Analog to Digital Converter . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
i
Contents Contents
4 ECG Module 37
4.1 Block Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.1.1 Input Transducers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.1.2 Shielded Cables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.1.2.1 Input Connectors . . . . . . . . . . . . . . . . . . . . . . . 39
4.1.2.2 Instrumentation Amplifier . . . . . . . . . . . . . . . . . . . 39
4.1.2.3 DC Blocking Circuit . . . . . . . . . . . . . . . . . . . . . . 40
4.1.2.4 Sallenkey Filter . . . . . . . . . . . . . . . . . . . . . . . . 42
4.1.2.5 Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.1.2.6 Level Shifter . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.2 Schematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.3 Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.4 Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
5 Electronic Stethoscope Module 48

5.1 Block Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.1.1 Preamplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.1.2 DC Blocking Circuit . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.1.3 Low Pass Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.1.4 Audio Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.2 Schematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.3 Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.4 Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
6 Pulse Measurement Module 54

6.1 Block Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.1.1 Input Transducer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
6.1.2 Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.1.3 Level Shifter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.1.4 DC Blocking Circuit . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.1.5 Low Pass Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
6.2 Schematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6.3 Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.4 Simulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
ii
Contents Contents
7 ADC Module 59
7.1 Block Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
7.1.0.1 Analog To Digital Converter . . . . . . . . . . . . . . . . . 60
7.1.0.2 Microcontroller Algorithm . . . . . . . . . . . . . . . . . . 61
7.2 Schematic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
7.3 Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
8 Internet Telemedicine System 65

8.1 Block Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.2 Screenshots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9 Graphical User Interface 69
10 Bill of Materials 71
10.1 ECG Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
10.2 ADC and Microcontroller Board . . . . . . . . . . . . . . . . . . . . . . . . . 72
10.3 Electronic Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
10.4 Pulse Measurement Module . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
11 Results and Conclusion 75

11.1 ECG Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
11.2 Pulse Measurement Module . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
11.3 Electronic Stethscope Module . . . . . . . . . . . . . . . . . . . . . . . . . . 77
12 Future Scope 78
iii
List of Figures
2.1 PQRST Waveform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.2 Eithoven Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.3 Commercial Electronic Stethoscope . . . . . . . . . . . . . . . . . . . . . . . 13
2.4 Pulse Oximetry Wavelengths . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.5 Schematic Representation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.1 Generic Sallen-Key Topology . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

3.2 Comparison of Shielded cables . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.3 Equivalent Circuit Model for Biopotential Electrode . . . . . . . . . . . . . . . 33
3.4 JFET input OPAMP for biopotential measurement . . . . . . . . . . . . . . . . 34
3.5 SAR architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
4.1 Block Diagram of ECG Module . . . . . . . . . . . . . . . . . . . . . . . . . 37

4.2 ECG Electrodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.3 Correct method for ac coupling an op-amp input for dual-supply operation . . . 41
4.4 Bode Plot of Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.5 Nyquist Plot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.6 Transient Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.7 Schematic of ECG Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.8 Layout of ECG Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.9 SPICE Simulation of ECG Amplifier . . . . . . . . . . . . . . . . . . . . . . . 47
5.1 Block Diagram Of Electronic Stethoscope Module . . . . . . . . . . . . . . . 48

5.2 Bode Plot of Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.3 Nyquist Plot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.4 Schematic of Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.5 Layout of Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.6 SPICE Simulation of Stethoscope . . . . . . . . . . . . . . . . . . . . . . . . 53
6.1 Block Diagram of Pulse Measurement Module . . . . . . . . . . . . . . . . . . 54
iv
List of Figures List of Figures
6.2 Schematic of Pulse Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

6.3 Layout of Pulse Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
6.4 SPICE Simulation of Pulse Amplifier . . . . . . . . . . . . . . . . . . . . . . 58
7.1 Block Diagram Of ADC and Microcontroller System . . . . . . . . . . . . . . 59

7.2 Schematic of ADC Module and Microcontroller Board . . . . . . . . . . . . . 63
7.3 Layout of ADC Module and Microcontroller Board . . . . . . . . . . . . . . . 64
8.1 Block Diagram of Internet Interface . . . . . . . . . . . . . . . . . . . . . . . 65

8.2 Add Study Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.3 List Patient Pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.4 Screenshots of hmads.in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9.1 ECG Interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

9.2 Pulse Measurement Interface . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
9.3 Audio Interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
11.1 ECG Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

11.2 Pulse Results obtained by HMAD system . . . . . . . . . . . . . . . . . . . . 77
11.3 Results from Electronic Stethscope . . . . . . . . . . . . . . . . . . . . . . . . 77
v
List of Tables
2.1 Eithoven Vectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.1 Transfer functions of four standard ideal filters . . . . . . . . . . . . . . . . . . 28
9.1 Summary of interface functions . . . . . . . . . . . . . . . . . . . . . . . . . . 70
10.1 ECG Amplifier BOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

10.2 ADC and Microcontroller Board BOM . . . . . . . . . . . . . . . . . . . . . . 72
10.3 Electronic Stethoscope BOM . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
10.4 Pulse Module BOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
vi
Acknowledgment
Every project requires proper guidance without which the project may not go in the right direc-
tion.
We would like to thank our Principal Dr. Varsha Shah for her support to our project. We would
like to thank our Head Of Department (Electronics) Prof. Nargis Shaikh,who has supported
us and provided us with laboratory facilities throughout the semester and has encouraged us at
every step.
Our guide, Mr Sachin Charbhe has been a source of inspiration to us. His pointers have been
invaluable and has helped the project progress and we appreciate him give us permission to use
facilities of the R&D Department of our college.
We would also like to thank lecturers Mr Amit Redkar, Mr Shiburaj Pappu, Mrs Dhanashree
Kangane, Mrs. Anuja Kamat, Mr. Ramkumar Maurya, Mr. Junaid Mandiwala, Mr. Rajan
Deshmukh for their invaluable inputs and solving our queries.
We would like to especially mention Mr. Ramkumar Maurya without whose wealth of knowl-
edge in analog electronics, industrial experience and practical solutions, the design and devel-
opment of this project would be very difficult indeed. From design to dubugging, he has been a
library of knowledge which we have extensively referred to.
The Electronics Department Laboratory assistants Mrs. Janhavi Khamkar, Mrs. Vedika Gulekar,
Mr. Tiwari have been have an invaluable source of information,helping us realist our designs and
providing an insight into the availability and types of components. They have often, very gen-
erously, provided us with components and tools. Our non-teaching staff Mr. Kiran G. Salunke
and Mr. Jeetendra Ahire have always extended co-operation and have stayed over-time, keeping
the labs open after college hours so that we could work on our project.
We would like to thank Texas Instruments, Maxim and Analog Co. for providing us with free
samples of expensive ICs and for their timely and meticulous packaging and delivery of compo-
vii
List of Tables List of Tables
nents which have significantly helped reduce our projects costs. We would like to mention our
fabricators WRIC laboratories, who have been of great help and support.
Initial need and requirement of such a project emerged from the conversations with Mr. Kaushik
Ray [TATA CANCER RESEARCH]. The urgency of such an endeavor became cogent with a
survey of literature released by the National Rural Health Mission and the WHO, citing the
apathy of rural health care in India.
Research work done by Prof. Dr. S. B. Ghungrad [ST. XAVIERS TECHNICAL INSTITUTE]
in RRV and his personal opinions made it clear that significant studies can be undertaken in the
domain. A major part of planning and feasibility information was sourced from Ms. Abhiruchi
Mehta [NMINS UNIVERSITY]. Finally the physiology of the ECG process was understood
from conversations with Dr. (Mrs) Swati Dutta [PHYSICIAN]. Mr. G. D. Patil [WRIC] has
been an enormous source of help and inspiration to us.
We thank our families and friends for their continued support, help and motivation throughout
the implementation of the project.
De Shaunak
Gadhia Karan
Kalbag Shrutika
Yadav Anil
viii
Abstract
Healthcare technology has made progress in leaps and bounds over the past couple of decades.
Yet sophisticated electronic test and measurement remain in the limited domains of large hospi-
tals and clinics, primarily owing to their prohibitive purchase and installation costs. Traditionally
monitoring equipment demanded specialized hardware which increase the cost of the apparatus
and make them inflexible. Telemetry is also not considered of primary importance in a hospital
environment owing to the nearness of the healthcare provider to the patient. The aim of this
project is to design and realize an economical, flexible healthcare telemetry system.
ix
1 Introduction
1.1 Background and Need
The availability of advanced healthcare apparatus are limited to medium to large healthcare cen-
ters only. Such facilities are almost always located solely in major urban centers, and are acces-
sible to a very limited section of the population. The quality of healthcare care services provided
at Rural Healthcare Centers (RHC) and small to medium clinics can be significantly ameliorated
if robust and economical test and measurement can be made available at these locations. The
need for telemedicine and remote diagnosis is also pressing in Rural India. Rural Medical Prac-
titioners, who provide about 80% of out patient care have no formal qualifications for their job.
[1] There is also a chronic shortage of experienced practitioners in rural Primary Healthcare
Centers (PHC), with even inexperienced healthcare professionals shunning rural postings in or-
der to practice in lucrative urban centers.[2] The penetration of computers and telephony in rural
areas can thus be leveraged to implement portable economic telemedicine units which will help
improve the general health and well being of the vast rural population, allowing them access to
experienced and qualified practitioners. Such systems can also be installed in ambulances and
in residences where care is typically provided by paramedics or nurses. An experienced practi-
tioner, or the monitoring software, can then provide a diagnosis and suggest a line of action to
the caregiver.
Development of low cost, easy to use and maintain hardware will provide an impetus to the
growth of a better all accessible healthcare infrastructure. Innovation in technology can play a
key role in reversing the scenario of both accessibility and manpower shortage. Convergence of
telecommunications and IT has changed the life of a rural citizen in the past few decades.
The technology available to us or in the process of development easily allows medical expertise
and critical advice to be delivered quickly to those in need. However due to the high costs and
lack of initiative, such endeavors are seldom undertaken. It is our belief that the pursuit of tech-
nology should eventually lead to the betterment of men and women, the society and country. The
1
1.1. BACKGROUND AND NEED CHAPTER 1. INTRODUCTION
availability of advanced healthcare apparatus are limited to medium to large healthcare centers
only. Such facilities are almost always located solely in major urban centers, and are accessible
to a very limited section of the population. The quality of healthcare care services provided at
Rural Healthcare Centers (RHC) and small to medium clinics can be significantly ameliorated
if robust and economical test and measurement can be made available at these locations. The
need for telemedicine and remote diagnosis is also pressing in Rural India. Rural Medical Prac-
titioners, who provide about 80% of out patient care have no formal qualifications for their job.
There is also a chronic shortage of experienced practitioners in rural Primary Healthcare Cen-
ters (PHC), with even inexperienced healthcare professionals shunning rural postings in order to
practice in lucrative urban centers. [1]
The recent penetration of computers and telephony in rural areas can thus be leveraged to imple-
ment portable economic telemedicine units which will help improve the general health and well
being of the vast rural population, allowing them access to experienced and qualified practition-
ers. Such systems can also be installed in ambulances and in residences where care is typically
provided by paramedics or nurses. An experienced practitioner, or the monitoring software, can
then provide a diagnosis and suggest a line of action to the caregiver. We need to develop a
healthcare monitoring system that will be efficient, economic as well as provide critical aid to
patients in rural areas. In ten years,its expected that healthcare will be available to all in rural
India but to provide it now in an efficient manner is a challenge we want to overcome.
Our method is simple. We need to make a system that ensures interaction of persons at the
rural healthcare center (RHC) with doctors in towns or cities in case of consultation or critical
opinions on reports that cannot be provided at the RHC. Our system involves sending ECG exam
sheets, electro-stethoscope audio files and results of the pulse-oximeter to the doctor at another
Center via the internet. This is done using C# and PHP technologies. This will ensure a smooth
user interface and also save critical time and provide an economical yet efficient solution to the
RHC and other hospitals.
2
1.2. PROBLEM DEFINITION CHAPTER 1. INTRODUCTION
1.2 Problem Definition
The major considerations kept in mind while designing and planning this project are as follows:
To Improvise existing technology and adapt it for domestic application. A lot of these
technologies may be available in developed nations where basic infrastructure is taken for
granted. This may not be the case in developing nations. The major target of the project
is to target this market.
The project has been visualized out of real life concerns to improve basic healthcare ser-
vices in developing nations. The act of saving human life is an act of nobility and there
can be no better application of technology.
Develop models and equipment to facilitate research. This apparatus should be low cost in
order to suit the budgets of domestic universities and researchers. Thus we aim to provide
a solid backbone for research applications.
Build dedicated or support applications related to patient care, which may not be vital to
healthcare, but improved the quality of care delivered to the patient.
3
1.3. LITERATURE SURVEY CHAPTER 1. INTRODUCTION
1.3 Literature Survey
1.3.1 Multi-purpose HealthCare Telemedicine Systems with mobile

communication link
Journal: BioMedical Engineering OnLine 2003, 2:7
The provision of effective emergency telemedicine and home monitoring solutions are the major
fields of interest discussed in this study. Ambulances, Rural Health Centers (RHC) or other
remote health location such as Ships navigating in wide seas are common examples of possible
emergency sites, while critical care telemetry and telemedicine home follow-ups are important
issues of tele-monitoring. In order to support the above different growing application fields
we created a combined real-time and store and forward facility that consists of a base unit and
a telemedicine (mobile) unit. This integrated system: can be used when handling emergency
cases in ambulances, RHC or ships by using a mobile telemedicine unit at the emergency site
and a base unit at the hospital-experts site, enhances intensive health care provision by giving
a mobile base unit to the ICU doctor while the telemedicine unit remains at the ICU patient site
and enables home telemonitoring, by installing the telemedicine unit at the patients home while
the base unit remains at the physicians office or hospital. The system allows the transmission of
vital biosignals (312 lead ECG, SPO2, NIBP, IBP, Temp) and still images of the patient. The
transmission is performed through GSM mobile telecommunication network, through satellite
links (where GSM is not available) or through Plain Old Telephony Systems (POTS) where
available. Using this device a specialist doctor can telematically "move" to the patients site and
instruct unspecialised personnel when handling an emergency or telemonitoring case. Due to
the need of storing and archiving of all data interchanged during the telemedicine sessions, we
have equipped the consultation site with a multimedia database able to store and manage the
data collected by the system. The performance of the system has been technically tested over
several telecommunication means; in addition the system has been clinically validated in three
different countries using a standardized medical protocol.
1.3.2 AC front end for ECG Transaction
IEEE transactions on biomedical engineering, vol. 50, no. 3, march 2003
AC coupling is essential in biopotential measurements. Electrode offset potentials can be several

orders of magnitude larger than the amplitudes of the biological signals of interest, thus limiting
4
1.3. LITERATURE SURVEY CHAPTER 1. INTRODUCTION
the admissible gain of a dc coupled front end to prevent amplifier saturation. A high-gain input
stage needs ac input coupling. This can be achieved by series capacitors, but in order to provide
a bias path, grounded resistors are usually included, which degrade the common mode rejection
ratio (CMRR). This paper proposes a novel balanced input ac coupling network that provides a
bias path without any connection to ground, thus resulting in a high CMRR. The circuit being
passive, it does not limit the differential dc input voltage. Furthermore, differential signals are ac
coupled, whereas common-mode voltages are dc coupled, thus allowing the closed-loop control
of the dc common mode voltage by means of a driven-right-leg circuit. This makes the circuit
compatible with common-mode dc shifting strategies intended for single-supply biopotential
amplifiers. The proposed circuit allows the implementation of high-gain biopotential amplifiers
with a reduced number of parts, thus resulting in low power consumption. An electrocardiogram
amplifier built according to the proposed design achieves a CMRR of 123 dB at 50 Hz.
1.3.3 Removal of power-line interference from the ECG: a review of the

subtraction procedure
Journal: BioMedical Engineering OnLine 2005, 4:50 doi:10.1186/1475-925X-4-50
Modern biomedical amplifiers have a very high common mode rejection ratio. Nevertheless,
recordings are often contaminated by residual power-line interference. Traditional analogue and
digital filters are known to suppress ECG components near to the power-line frequency. Differ-
ent types of digital notch filters are widely used despite their inherent contradiction: tolerable
signal distortion needs a narrow frequency band, which leads to ineffective filtering in cases of
larger frequency deviation of the interference. Adaptive filtering introduces unacceptable tran-
sient response time, especially after steep and large QRS complexes. Other available techniques
such as Fourier transform do not work in real time. The subtraction procedure is found to cope
better with this problem. The subtraction procedure was developed some two decades ago, and
almost totally eliminates power-line interference from the ECG signal. This procedure does not
affect the signal frequency components around the interfering frequency. Digital filtering is ap-
plied on linear segments of the signal to remove the interference components. These interference
components are stored and further subtracted from the signal wherever non-linear segments are
encountered. Results: Modifications of the subtraction procedure have been used in thousands
of ECG instruments and computer-aided systems. Other work has extended this procedure to
almost all possible cases of sampling rate and interference frequency variation. Improved struc-
ture of the online procedure has worked successfully regardless of the multiplicity between the
5
1.4. TECHNOLOGY AREAS CHAPTER 1. INTRODUCTION
sampling rate and the interference frequency. Such flexibility is due to the use of specific filter
modules. Conclusion: The subtraction procedure has largely proved advantageous over other
methods for power-line interference cancellation in ECG signals.
1.4 Technology Areas
Major focus will be on development and design of ultra low noise instrumentation amplifiers
and signal conditioning circuits. A variety of filters will also have to be implemented for data
processing. Implementation is to be done in C# to allow for real time procession. The software
backbone is also to be written in C#, designed to run in Microsofts .NET environment. Data
acquisition and wireless as well as Internet transfer will also have to be handled. The major tech-
nological challenges include amplifier and filter design, establishment of stable communication
links, database management and data acquisition.
1.4.1 C#
C# is a multi-paradigm programming language encompassing strong typing, imperative, declar-

ative, functional, generic, object-oriented (class-based), and component-oriented programming
disciplines. It was developed by Microsoft within its .NET initiative and later approved as a
standard by Ecma (ECMA-334) and ISO (ISO/IEC 23270). C# is one of the programming
languages designed for the Common Language Infrastructure. C# is intended to be a simple,
modern, general-purpose, object-oriented programming language. By design, C# is the pro-
gramming language that most directly reflects the underlying Common Language Infrastructure
(CLI). Most of its intrinsic types correspond to value-types implemented by the CLI framework.
The C# specification details a minimum set of types and class libraries that the compiler expects
to have available. In practice, C# is most often used with some implementation of the Com-
mon Language Infrastructure (CLI), which is standardized as ECMA-335 Common Language
Infrastructure (CLI). .NET The .NET Framework is a software framework that runs primarily
on Microsoft Windows. It includes a large library and supports several programming languages
which allows language interoperability (each language can use code written in other languages).
Programs written for the .NET Framework execute in a software environment (as contrasted to
hardware environment), known as the Common Language Runtime (CLR), an application virtual
machine that provides important services such as security, memory management, and exception
handling. The class library and the CLR together constitute the .NET Framework. The .NET
6
Frameworks Base Class Library provides user interface, data access, database connectivity,
cryptography, web application development, numeric algorithms, and network communications.
Programmers produce software by combining their own source code with the .NET Framework
and other libraries. The .NET Framework is intended to be used by most new applications
created for the Windows platform. Microsoft also produces a popular integrated development
environment largely for .NET software called Visual Studio.
1.4.2 MySQL
MySQL is a relational database management system (RDBMS) that runs as a server provid-
ing multi-user access to a number of databases. It is named after developer Michael Widenius
daughter, My. The SQL phrase stands for Structured Query Language. The MySQL develop-
ment project has made its source code available under the terms of the GNU General Public
License, as well as under a variety of proprietary agreements. MySQL was owned and spon-
sored by a single for-profit firm, the Swedish company MySQL AB, now owned by Oracle Cor-
poration. Free-software-open source projects that require a full-featured database management
system often use MySQL. For commercial use, several paid editions are available, and offer addi-
tional functionality. Applications which use MySQL databases include: TYPO3, Joomla, Word-
Press, MyBB, phpBB, Drupal and other software built on the LAMP software stack. MySQL
is also used in many high-profile, large-scale World Wide Web products, including Wikipedia,
Google (though not for searches), Facebook and Twitter.
1.4.3 PHP
PHP is a server-side scripting language, which can be embedded in HTML or used as a stan-
dalone binary (although the former use is much more common). Proprietary products in this
niche are Microsofts Active Server Pages, Macromedias ColdFusion, and Suns Java Server
Pages. Some tech journalists used to call PHP the open source ASP because its functionality
is similar to that of the Microsoft product although this formulation was misleading, as PHP
was developed before ASP. Over the past few years, however, PHP and server-side Java have
gained momentum, while ASP has lost market-share, so this comparison no longer seems ap-
propriate. PHP is a general-purpose server-side scripting language originally designed for web
development to produce dynamic web pages. For this purpose, PHP code is embedded into the
HTML source document and interpreted by a web server with a PHP processor module, which
7
generates the web page document. It also has evolved to include a command-line interface ca-
pability and can be used in standalone graphical applications. PHP can be deployed on most
web servers and as a standalone interpreter, on almost every operating system and platform free
of charge. A competitor to Microsofts Active Server Pages (ASP) server-side script engine and
similar languages, PHP is installed on more than 20 million websites and 1 million web servers.
PHP is commonly used as a bundle alongside Linux/Windows, Apache and MySQL. Together
PHP and MySQL provide a potent, scalable low cost solution that is easy to use and economical
to maintain. They bundle can be run on low end hardware or embedded systems.
1.4.4 Intrasystem communication - Wired
The major portion of the communication will be established by serial communication links. In
computing, a serial port is a serial communication physical interface through which information
transfers in or out one bit at a time (contrast parallel port). We intend to use either the USB or the
RS-232 port commonly available on personal computers for end point communication. Serial
ports use two-level (binary) signaling, so the data rate in bits per second is equal to the symbol
rate in bauds. A standard series of rates is based on multiples of the rates for electromechanical
teleprinters; some serial ports allow many arbitrary rates to be selected. The port speed and de-
vice speed must match. The capability to set a bit rate does not imply that a working connection
will result. Not all bit rates are possible with all serial ports. Some special-purpose protocols
such as MIDI for musical instrument control, use serial data rates other than the teleprinter se-
ries. Some serial port systems can automatically detect the bit rate. The speed includes bits for
framing (stop bits, parity, etc.) and so the effective data rate is lower than the bit transmission
rate. For example with 8-N-1 character framing only 80% of the bits are available for data (for
every eight bits of data, two more framing bits are sent). Common bit rates include 1200, 2400,
4800, 9600, 14400, 19200, 38400, 57600 and 115200 bit/s We shall be using 115200 for high
speed communication.
8
2 Related Theory
2.1 Electrocardiogram
The electrocardiograph is an instrument used to produce a graphic representation of the elec-

trical activity of the heart, the electrocardiogram (ECG or EKG), as measured by body surface
electrodes. It is an invaluable tool in the diagnosis of cardiovascular diseases, the monitoring
of patients while under anaesthesia, and occasionally used for the diagnosis of non-cardiac dis-
eases. It measures the rate and regularity of heartbeats, the position of the various chambers,
the existence of any damage to the heart and the effects of drugs and devices used to regulate
the heart. The potential created by the heart wall contraction spreads electrical currents from
the heart throughout the body. The spreading electrical currents create different potentials at
different points on the body. Leads are placed on the body in several pre-determined locations
to provide information about heart conditions. The cardiac signal, typically 5 mV peak to peak,
is an AC signal with a bandwidth of 0.05 Hz to 100 Hz. The ECG signal is characterized by six
peaks and valleys labeled with successive letters of the alphabet P, Q, R, S, T, and U.
The main purpose of the heart is to pump blood throughout the body. An electrical impulse
is necessary to cause the heart to contract. The Sino atrial Node (SA Node) is responsible
for producing these impulses. The impulse from the SA node stimulates the atrial muscles
causing both atria to contract and blood to flow into the ventricles. The signal then reaches the
Atrioventricular Node (AV node) where it is naturally delayed to allow the atria to contract and
fill the ventricles with blood. The signal continues down to a thick bundle of nerve fibres known
as the Bundle of His. The bundle branches out to the left and right and terminate in tiny fibres
known as Purkinje Fibres. These distribute the impulse to the cells of the heart muscle causing
ventricular stimulation.
The electrical activity can be represented as a dipole (a vector between two point charges). The
placement of the electrodes on the body determines the view of the vector as a function of time.
The following figure represents the most basic form of the electrode placement which is based
9
2.1. ELECTROCARDIOGRAM CHAPTER 2. RELATED THEORY
Figure 2.1: PQRST Waveform
on Einthovens triangle. This theoretical triangle is drawn around the heart with each apex of
the triangle representing where the fluids around the heart connect electrically with the limbs.
Lead I measures the differential potential between the right and left arms, Lead II between the
right arm and left leg, and Lead III between the left arm and left leg.
Einthovens law also states that the value of any point of the triangle can be computed as long
as values for the other two points are known. This point is crucial in the implementation of the
design. It simplifies the overall analogue design and reduces the component count (and most
importantly cost) as only two differential amplifiers are required. If any two leads (of the three
lead ECG) are generated using the front end hardware the third lead may be generated entirely by
software by simply subtracting (or adding) the two leads obtained from the analogue front end.
The equations presented below verify the above statement. The Einthoven limb leads (standard
leads) are defined as:
The ECG signal is susceptible to three major noise sources. As mentioned previously the ECG
signals are typically in the millivolt range, and are hence susceptible to large amounts of interfer-
ence, from a variety of sources. The interference sources can be divided into 3 distinct groups:
Noise originating from sources external to the patient. Interference originating from the patient.
10
2.1. ELECTROCARDIOGRAM CHAPTER 2. RELATED THEORY
Figure 2.2: Eithoven Diagram
Unwanted Potentials as well as interference originating from patient-electrode contact.
The ECG leads interface directly to the inputs of the differential amplifier. Since the ECG
signal is in the millivolt range, a highly sensitive differential amplifier is required for ECG
measurement. The differential amplifier is required to perform the necessary subtraction of
various potentials on the surface of the body. This subtraction action is required to generate
the three lead vectors. Any of the three lead vectors may be generated in hardware by simply
connecting the appropriate part of the body to the inputs of the differential amplifier.
Further noise reduction techniques however will have to be employed at the output of the differ-
ential amplifier to obtain noise free ECG trace. The amplifier is also required to provide amplifi-
cation to these millivolt range signals while strongly attenuating signals common to both inputs.
CMRR describes the ability of a differential amplifier to reject interfering voltages (VCM), com-
mon to both inputs, and to amplify only the difference between the inputs.
11
2.2. ELECTRONIC STETHOSCOPE CHAPTER 2. RELATED THEORY
Lead Name Vector Body Potential

Lead I V1 = l r l = Potential at the left arm
Lead II V2 = f r r =Potential at the right arm
Lead III V3 = f l f =Potential at the left foot
Table 2.1: Eithoven Vectors
2.1.1 Clinical Significance of ECG
From the ECG tracing, the following information can be determined: the heart rate the heart
rhythm whether there are conduction abnormalities (abnormalities in how the electrical im-
pulse spreads across the heart) whether there has been a prior heart attack whether there may be
coronary artery disease whether the heart muscle has become abnormally thickened. All of these
features are potentially important. If the ECG indicates a heart attack or possible coronary artery
disease, further testing is often done to completely define the nature of the problem and decide
on the optimal therapy. (These tests often include a stress test and/or cardiac cauterization.) If
the heart muscle is thickened, an echo-cardiogram is often ordered to look for possible valvular
heart disease or other structural abnormalities. Changes in the electrical pattern on the ECG may
give clues to the cause of syncopee (fainting), or may indicate underlying cardiac disease.
2.2 Electronic Stethoscope
The Problem
Conventional stethoscopes cannot function effectively unless ambient noise is maintained at

approximate examination-room levels. This serious limitation inhibits diagnosis and monitoring
of patients in a variety of common military medical situations: in field hospitals,in high ambient
noise environments such as ambulances,or in hyperbaric chamber treatment facilities. Trying to
measure blood pressure, determining if a faint heart-beat is present in a casualty, or listening to
respiratory events can be nearly impossible under field conditions.
The Approach
The objective of this project was to evaluate commercial off-the-shelf (COTS) products and
recommend one or several compact noise-reducing/canceling stethoscopes for field, medical-
transport, and shipboard use, in moderately noisy environments (up to 90 dB SPL). At the onset
12
of this project a working group was convened to assess Navy need and requirements for a noise-
reducing stethoscope for casualty care and general medical use. In general terms, given present
and projected state-of-the-art technology, a modular approach using a simpler device tailored to
the application, will be more cost-effective, for general-issue, than a single device. We selected
three such simpler devices for laboratory testing using both the listening-headsets provided, and
a highly accurate active noise cancellation (ANC)headset.
Figure 2.3: Commercial Electronic Stethoscope
The Findings
Laboratory data show exceptional performance of noise reduction stethoscopes in detection of

heart/lung sounds, especially in noisy environments up to around 95dB SPL. Of greater rele-
vance, a conventional device is unable to detect abnormal breath sounds when the noise field
exceeds about 76 dB SPL abnormal heart sounds can only be detected at levels below 81 dB
SPL. For one of the two best COTS devices, the detection advantage over a conventional stetho-
scope for these abnormal sounds is 17 dB for breath and 12 dB for heart. Evaluation of the
results from field data on normal heart/breath sounds confirmed their utility and provided user-
suggestions on possible improvements in design. Contracted pre-production prototypes address
several field-test recommendations. The Electrostethoscope The stethoscope has provided physi-
cians with an invaluable diagnostic tool. This simple sound-powered device acoustically couples
the small movements collected over a large area into relatively larger movements on the surface
of the eardrum. By virtue of the differences in surface area between eardrum (55-90 mm) and
the pickup, (1300 mm2) an acoustic gain is achieved.
This elegant device continues to be a mainstay diagnostic tool to the present day and is a readily
13
recognizable icon of the medical profession. It was originally designed for listening to sounds
in the chest, heart and abdomen but other uses have been developed since its invention.
Interfering noise
Emergency medical situations often occur in noise environments that preclude the use of the
conventional stethoscope. Brogan et al. reported that The Military Aircraft Command in 1966
recommended that an electronic stethoscope be developed for use "...aboard aero-medical evac-
uation aircraft, since listening procedures were extremely difficult, if not impossible with regular
stethoscopes." [7]
They reported their efforts to improve the signal-to-noise ratio by devising both an acoustically
shielded pickup transducer and headphones, and by band-limiting the amplified signal. The belt
mounted electronics package was quite large and clumsy at 6.75" x 6"and approximately 2"
thick. While they reported improved performance, no mention is made of actual noise attenua-
tion characteristics in their report.
In 1969 All red et al. Reported development and evaluation of two electronic stethoscopes of
novel design which they later incorporated into a single device of conventional size and shape.
The first design shifted the frequency of Korotkoff sounds and eliminated acoustic coupling
between pickup and earpieces.[8]
The second stethoscope eliminated all acoustic coupling but avoided frequency shifting.Pasic
and Poulton reported on the increasing use of aero-medical transportation and concomitant in-
creased intense noise exposure of helicopter pilots, aircrew and transported patients.
They warn, "Noise makes impossible the use of the standard stethoscope to auscultate breath
sounds, heart sounds or Korotkoffs sounds." In 1990 Bishop reported on the inability to detect
arterial sounds using a conventional stethoscope during a domestic commercial flight. This
was confirmed by Cottrell and Kohn , who reported similar findings derived from their earlier
1989 published study of emergency treatments during commercial flight. A study by Hunt et
al. attempted to assess the capabilities of a traditional and an amplified stethoscope during air
medical transport. They concluded "...flight nurses using a traditional or amplified stethoscope
are unable to hear normal breath sounds during flight in an MBB BO-105 helicopter"
Conventional stethoscopes (mechanical or electronic) cannot function effectively unless ambient

noise is maintained at normally encountered clinical levels (which are approximately 70 dB
SPL1). This serious limitation inhibits diagnosis and monitoring of patients in a variety of
14
common medical situations: in hospital emergency rooms and trauma facilities (65 dB SPL to
80 dB SPL); in emergency service vehicles such as ambulances, fixed and rotary wing aircraft
(85 to 140 dB SPL); or in areas where patients are attached to pulmonary ventilators, in neonatal
incubators, or in hyperbaric chamber treatment facilities (75 to 95 dB SPL).
As a result of these reports and technological advances in modern computer and digital tech-
nology, electronic stethoscopes of varied types and capabilities are currently at various stages
of development. The digital electronic stethoscope was introduced about 6 years ago. It is a
microphone-transducer-amplifier concept with a digital signal processing capability built into
the system. Unfortunately, it too has the same inability to function in noisy environments as the
analog stethoscope. The search for a more effective stethoscope for use in high noise conditions
persists
Currently available technology
Currently, cumbersome prototype electronic devices exist for ascultation in noisy environments.
Depending on how they reduce the noise, the devices are commonly referred to as:
active noise cancellation (ANC)
active noise reduction (ANR) and
noise reduction (NR) stethoscopes.
Within the group of acoustic devices that reduce noise using active means (electronic signal
modification), ANC devices use an inverted real-time analog signal from another microphone
directly to remove noise by cancellation .
In ANR devices a transfer function is digitally applied to the real-time sensor microphone to
mimic the response characteristics (bandwidth and spectral shape) of a conventional stethoscope-
head to actively reduce noise. The transfer function may be a fixed equation or it can be derived
from a control microphone that monitors signal and noise in real time. More elaborate proce-
dures such as those reported by Zachariaset al., Suzukiet al., and most recently by Patel et al.,
use adaptive filter techniques to modify the transfer function to compensate for differences in
the noise transmission path through different points on the body.
Other simpler NR electronic devices utilize pickup transducers immune to airborne noise for ex-
ample, by translation of skin torsional forces (via a piezoelectric thin-film sensor) to an acoustic
15
signal, or utilize noise attenuating materials around the sensor to reduce the interfering airborne
sound on the sensor.
Applying acoustic signals generated outside the range of human hearing, Kopczynski et al.
reported on an ultrasonic blood pressure monitoring device developed by USAF School of
Aerospace Medicine that employs the "Doppler shift principle to detect blood flow and arte-
rial wall motion... rather than detecting Korotkoff sounds." The device detects the Doppler shift
in the ultra-sonic signal and converts it into an audible sound indicating arterial wall motion.
The audible signals appear and disappear in equivalent manner to Korotkoff cues. They con-
cluded the device proved to be effective in eliminating the effects of in-flight noise and vibration
on blood pressure measurements.
As one might expect, the most sophisticated devices are costly and, by incorporating additional
processing hardware, are usually physically larger (far too large for field-pack applications). The
assessed devices all have specific advantages and drawbacks related to cost, size, and complexity
of transducer placement. Presently, no one device is ideal for universal use.
The majority of devices are either proof-of-concept prototypes using rack mount hardware, or in
Phase II (initial hardware development). They are not at a production stage. It should be noted
that all of the developers of the most elaborate multiple-sensor stethoscope devices have aban-
doned their efforts at further development while the simpler devices have evolved into marketed
products.
The modular approach
The near term noise-reducing electronic stethoscope must have the advantages of the acoustic
stethoscopes, without the limitations. Of primary importance, it must be small, dependable, and
simple to operate. There should be accurate and adjustable amplification, little ambient artifact
noise, and minimal instrument manipulation artifact noise. The earpieces or sound transducers
should be comfortable, adjustable, and provide excellent acoustic isolation from ambient sounds.
There could be a bell and a diaphragm-filtering mode or some equivalent.
It must also have an ergonomic design and, most important, it must be operationally accept-
able. Near-equally important, it must also be inexpensive enough for general-issue. More to the
point,it must be a compromise of general utility and dependability over high technology. One
of the best ways to that goal is a modular approach. We need a small dependable device that
wastes none of its power consumption or valuable component volume or cost on unnecessary
16
processing. For modular application, it must have an electrical signal output, but given modern
analog to digital processing, a clean analog output is all that is needed. Additional processing
can be done outboard to conserve battery power in our primary device. We need a primary device
that everyone can be issued and can not only operate more effectively with, but one that serves
as the noise-immune front-end for the rapidly evolving world of miniaturized signal-processing
hardware.
As a modular interfaced component, miniature hand-held CPU devices and software can in-
stantly upgrade without obsolescence. If a manufacturer can optimize such a sensor device,and
price it competitively it can become general-issue.
Design and implementation of Electronic-Stethoscope
A conventional stethoscope transmits sound via pressure waves travelling in the hollow tubing.
A tube or pipe is a natural acoustic filter talk through a tube, and the sound at the other end is
significantly modified. It is therefore apparent that to achieve perfect transmission, electronics
and wiring has to replace air. Replace pressure waves at the speed of sound with electrical
signals at the speed of light.
During our research, we wondered if some air tubing transmission would be acceptable. Could
we, for convenience, use the binaural headphones of a conventional stethoscope? The sound
would be electronic for most if the distance, but the last 10-12 inches (25-30cm) would be
acoustic tubing.
It would certainly make for a simpler headphone design, and almost every other electronic
stethoscope today uses air tubing for sound transmission, even if there is some electronic portion
in, say, the chest piece.
Probe
The Probe is critical to the feel of the stethoscope. Users have developed their favourite way
to hold a stethoscope fingers parted in a V, gripping between thumb and forefinger, or some
personal variation on these. We didnt want users to have to change their personal grip or han-
dling of the stethoscope. And so the Probe is reminiscent of a conventional 2-sided stethoscope
(Bell/Diaphragm). It is the same size, and feels naturally familiar in the hands of the user.
Machined aluminium alloy with (environmentally friendly lead-free) hard chrome plating main-
tained the solid metallic quality of a conventional chest piece, while adding to the acoustic per-
formance. The Probe housing would be the most expensive mechanical part of the stethoscope,
but the sense of quality is unmistakeable.
17
2.3. PULSE OXIMETER CHAPTER 2. RELATED THEORY
The digital control system
The control and signal processing electronics, and the Control Keys and Volume Control. At
first glance, it seems that controls should be on the Probe, facilitating one-handed operation. We
tried this on early prototypes. The problem we encountered was two-fold. First, the controls then
dictate that there is only one way to hold the Probe, and its not like any method currently used
by any practitioner. Second, adjusting the controls cause the user to move the Probe around on
the patients skin, press against the patient to activate a key, and so on. Both these problems were
anathema to our design priorities on user comfort and audio unadulterated by motion artifact.
AAA batteries were selected for their convenience. Two are used to provide the wattage to drive
the headphones with sufficient power to provide undistorted bass. The internal battery voltage is
boosted and regulated to ensure the same power regardless of battery voltage (until replacement
levels, of course).
Headphones
Like the metallic Probe, stethoscopes derive their sense oSallen-Keyf quality from the solid
metallic feel of the binaural headphones. This, and the need for durability, dictated the use of
stainless steel for the headphone tubing. Ear-tips are critical to stethoscope comfort. Wed like
to say that we used complex anatomical models to design the ear-tips. We then discovered that
due to the combination of amplification level and eartip softness, it was no longer necessary to
use severe force on the spring to push the ear-tips into the ears, as is done with conventional
stethoscopes. All we needed was a light spring, and the ear-tips sealed correctly. This was a
major advance in stethoscope comfort!
Our tests showed that the loudspeaker drivers have to be right at the eartips. The loudspeakers
also needed to be designed as essentially sub-woofers to reproduce heart murmurs which have
significant low frequency content. This required specific tuning of the loudspeaker cavity, and
the use of Neodymium magnets, which are used on most audiophile loudspeakers. The start-
ing point was to research the best way to capture heart, lung and other body sounds -clearly,
faithfully, and without noise or interference.
2.3 Pulse Oximeter
Pulse-oximetry is a non-invasive method allowing the monitoring of the oxygenation of a pa-

tients haemoglobin. A sensor is placed on a thin part of the patients body, usually a finger-
18
tip or earlobe, or in the case of an infant, across a foot. Light of two different wavelengths is
passed through the patient to a photodetector.
The changing absorbance at each of the wavelengths is measured, allowing determination of

the absorbances due to the pulsing arterial blood alone, excluding venous blood, skin, bone,
muscle, fat, and (in most cases) fingernail polish. With NIRSit is possible to measure both
oxygenated and deoxygenated hemoglobin on a periperhal scale (possible on both brain and
muscle).[11]
Reflectance pulse oximetry may be used as an alternative to transmissive pulse oximetery de-
scribed above. This method does not require a thin section of the patients body and is therefore
well suited to more universal application such as the feet, forehead and chest. Pulse oximetry
was developed in 1972, by Takuo Aoyagi and Michio Kishi, bioengineers, at Nihon Kohden us-
ing the ratio of red to infrared light absorption of pulsating components at the measuring site.
Susumu Nakajima, a surgeon, and his associates first tested the device in patients, reporting it in
1975. [9]
It was commercialized by Biox in 1981 and Nellcor in 1983. Biox was founded in 1979, and
introduced the first pulse oximeter to commercial distribution in 1981. Biox initially focused on
respiratory care, but when the company discovered that their pulse oximeters were being used
in operating rooms to monitor oxygen levels, Biox expanded its marketing resources to focus
on operating rooms in late 1982. A competitor, Nellcor (now part of Covidien, Ltd.), began to
compete with Biox for the U.S. operating room market in 1983.
Prior to its introduction, a patients oxygenation could only be determined by arterial blood gas, a
single-point measurement that takes a few minutes of processing by a laboratory. (In the absence
of oxygenation, damage to the brain starts within 5 minutes with brain death ensuing within
another 1015 minutes). In the U.S. alone, approximately $2 billion was spent annually on
this measurement. With the introduction of pulse oximetry, a non-invasive, continuous measure
of patients oxygenation was possible, revolutionizing the practice of anesthesia and greatly
improving patient safety.
Prior to its introduction, studies in anesthesia journals estimated U.S. patient mortality as a
consequence of undetected hypoxemia at 2,000 to 10,000 deaths per year,[10] with no known
estimate of patient morbidity. By 1987, the standard of care for the administration of a gen-
eral anesthetic in the U.S. included pulse oximetry. From the operating room, the use of pulse
oximetry rapidly spread throughout the hospital, first to the recovery room, and then into the
various intensive care units. Pulse oximetry was of particular value in the neonatal unit where
19
the patients do not thrive with inadequate oxygenation, but also can be blinded with too much
oxygen.
Furthermore, obtaining an arterial blood gas from a neonatal patient is extremely difficult. In
1995, Masimo introduced Signal Extraction Technology (SET) that could measure accurately
during patient motion and low perfusion. Some have termed newer generation pulse oximetry
technologies as high resolution pulse oximetry (HRPO). One area of particular interest is the
use of pulse oximetry in conducting portable and in-home sleep apnea screening and testing.
In 2009, the worlds first Bluetooth-enabled fingertip pulse oximeter was introduced by Nonin
Medical, enabling clinicians to remotely monitor patients pulses and oxygen saturation levels.
It also allows patients to monitor their own health through online patient health records and
home telemedicine system.
Principles of Pulse Oximetry Technology
The principle of pulse oximetry is based on the red and infrared light absorption characteristics
of oxygenated and de-oxygenated haemoglobin. Oxygenated haemoglobin absorbs more infra-
red light and allows more red light to pass through. De-oxygenated (or reduced) haemoglobin
absorbs more red light and allows more infra-red light to pass through. Red light is in the 600-
750 nm wavelength light band. Infra-red light is in the 850-1000 nm wavelength light band.
Pulse oximetry uses a light emitter with red and infra-red LEDs that shines through a reasonably
translucent site with good blood flow. Typical adult/paediatric sites are the finger, toe, pinna
(top) or lobe of the ear. Infant sites are the foot or palm of the hand and the big toe or thumb.
Opposite the emitter is a photo detector that receives the light that passes through the measuring
site.
There are two methods of sending light through the measuring site: transmission and reflectance.
In the transmission method, as shown in the figure on the previous page, the emitter and photo
detector are opposite of each other with the measuring site in-between. The light can then pass
through the site. In the reflectance method, the emitter and photo-detector are next to each other
on top the measuring site. The light bounces from the emitter to the detector across the site.
The transmission method is the most common type used and for this discussion the transmission
method will be implied.
After the transmitted red (R) and infra-red (IR) signals pass through the measuring site and are
received at the photo-detector, the R/IR ratio is calculated. The R/IR is compared to a "look- up"
table (made up of empirical formulas) that convert the ratio to an SpO2 value.
20
Figure 2.4: Pulse Oximetry Wavelengths
Most manufacturers have their own look-up tables based on calibration curves derived from
healthy subjects at various SpO2 levels.
Typically a R/IR ratio of 0.5 equates to approximately 100% SpO2 , a ratio of 1.0 to approxi-
mately 82% SpO2 , while a ratio of 2.0 equates to 0% SpO2 .
The major change that occurred from the 8-wavelength Hewlett Packard oximeters of the 70s to
the oximeters of today was the inclusion of arterial pulsation to differentiate the light absorption
in the measuring site due to skin, tissue and venous blood from that of arterial blood.
At the measuring site there are constant light absorbers that are always present. They are skin,
tissue, venous blood, and the arterial blood. However, with each heart beat the heart contracts
and there is a surge of arterial blood, which momentarily increases arterial blood volume across
the measuring site. This results in more light absorption during the surge. If light signals re-
ceived at the photo-detector are looked at as a waveform, there should be peaks with each
heartbeat and troughs between heartbeats. If the light absorption at the trough (which should
include all the constant absorbers) is subtracted from the light absorption at the peak then, in the-
ory, the resultants are the absorption characteristics due to added volume of blood only; which is
arterial. Since peaks occur with each heartbeat or pulse, the term "pulse oximetry" was coined.
This solved many problems inherent to oximetry measurements in the past and is the method
used today in conventional pulse oximetry.
Still, conventional pulse oximetry accuracy suffered greatly during motion and low perfusion
and made it difficult to depend on when making medical decisions. Arterial blood gas tests have
been and continue to be commonly used to supplement or validate pulse oximeter readings. The
21
Figure 2.5: Schematic Representation
advent of "Next Generation"pulse oximetry technology has demonstrated significant improve-

ment in the ability to read through motion and low perfusion; thus making pulse oximetry more
dependable to base medical decisions on.
How to interpret your pulse oximeter readings
The best place to get the answer to this question is in your doctors office. Your pulse oximetry
normal values are dependent on your health condition, respiratory rate, percentage of oxygen in
the air, activities you are performing, and other factors.
Here are some general guidelines to understand oximeter readings. For a regular healthy person,
the normal blood oxygen saturation level (SpO2 ) should be around 94% to 99%. For patients
with mild respiratory diseases, the SpO2 should be 90% or above. Supplementary oxygen should
be used if SpO2 level falls below 90%, which is unacceptable for a prolonged period of time.
Medicare will pay for oxygen supply if your reading is below 88%. If you fall into this abnormal
range, consult with a doctor immediately. Many doctors want their patients to have their SpO2
above 90%. Sleep apnea may affect your SpO2 level. In fact,best place to get the answer
to this question is in your doctors office. Your pulse oximetry normal values are dependent
on your health condition, respiratory rate, percentage of oxygen in the air, activities you are
performing, and other factors. Pay attention to the trend. If you see anything unusual, it is
time to consult your friendly doctor. Under certain special conditions, a pulse oximeter may not
give accurate results. You need to be aware of these limitations when interpreting the result.
Regardless of the reading, one should treat the patient first. The reading is only one of several
important assessment criterion. Watch for symptoms of hypoxia or hypoxaemia. Furthermore,
pulse oximeter measures oxygen saturation, not breathing and does not indicate the removal of
carbon dioxide from blood. Along with SpO2 , one needs to record the respiratory rate to get
an indication on breathing. If the patient is having supplementary oxygen, track the amount of
oxygen also. Take appropriate actions if the patient is not feeling OK. Emergency care may
be required. Monitor your pulse rate along with your SpO2 . They are predictors of health
problems. If you have abnormal readings even for a short period of time, see a doctor. Low
or high pulse rate can indicate heart problems. According to Dr. Fred Furgang in his article
22
"Hypoxia, Oxygen, and Pulse Oximetry," a pilot should use supplemental oxygen if the oximeter
reading is below 90%, maintain at 91-92% level when doing remedial tasks and above 93% with
increased workload. The amount of oxygen in the air, which decreases at higher altitude, would
have a significant effect on a persons SpO2 . A person may have a reading of 98% at sea level; it
may decrease to 95% at 5,000 ft. and further to 90% at 10,000 ft. At altitude above 10,000 ft., a
person may fail to adjust to the low level of oxygen and his SpO2 may drop below 80% resulting
in hypoxic conditions.
23
3 Related Concepts
3.1 Noise in ECG Signals
ECG signals may be corrupted by various kinds of noise. The main sources of noise are:
power-line interference: 5060 Hz pick up and harmonics from the power mains
electrode contact noise: variable contact between the electrode and the skin, causing base-
line drift
motion artefacts: shifts in the baseline caused by changes in the electrode-skin impedance
muscle contraction: electro myogram- type signals (EMG) are generated and mixed with
the ECG signals
respiration, causing drift in the baseline
electromagnetic interference from other electronic devices, with the electrode wires serv-
ing as antennas, and
noise coupled from other electronic devices, usually at high frequencies.
For diagnostic quality ECG recordings, signal acquisition must be noise free. Since ECG sig-
nals are only of the order of 1mV in amplitude, the ECG acquisition is susceptible to many
types of noises In fact the waveforms of interest are sometimes so heavily masked by noise that
their presence can only be revealed after the applications of appropriate signal processing tools.
Common to all types of ECG analysis - whether it concerns resting ECG interpretation, stress
testing, ambulatory monitoring or intensive care monitoring the first step is to remove the noise
and Power line interference is one of them. Many types of analog and Digital Filters have been
proposed/ suggested by the researchers. Solution is combination technique of three methods i.e.
the Moving Averages technique, IIR Notch and Wavelets to reduce the Powerline interference.
24
3.1. NOISE IN ECG SIGNALS CHAPTER 3. RELATED CONCEPTS
The ECG signal is represented as PQRST waveform The first phase of cardiac muscle activation
is the stimulation of the right and left atria by an electrical signal generated from SA node.
The depolarization of atria appears as the P-wave on the ECG waveform. The electrical signal
generated, originally generated by the SA node, then spreads through the Atrio ventricular (AV)
node, the bundle of HIS, and the Purkinje fibers to finally reach and stimulate the ventricles. The
spread of electrical signal through ventricles causes ventricular contraction. The phase of re-
polarization of atria and depolarization of ventricles appears as the characteristic QRS complex
on ECG waveform. Finally, the re-polarization of two ventricles appears as the T-wave on ECG
waveform.
Many methods have been suggested or proposed to remove powerline interference:
1. Alireza K Ziarani,Adaibert Konrad have proposed Non linear Adaptive method of elimi-
nation of power line interference in ECG signals.
2. S.Pooranchandra, N.kumarave have used the wavelet coefficient threshold based hyper
shrinkage function to remove power line frequency.
3. Santpal Singh Dhillon and Saswat Chakrabarti have used a simplified lattice based adap-
tive IIR Notch filter to remove power line interference.
4. Mahesh S. Chavan, R.A. Aggarwala, M.D.Uplane have used Digital FIR Filters based on
Rectangular window for the powerline noise reduction.
5. ChavdarLevkov, Georgy Mihov, Ratcho Ivanov, Ivan Daskalov, Ivaylo Christov, and Ivan
Dotsinsky have used the subtraction procedure to remove the powerline noise
6. Ziarani AK, KonardA used a nonlinear adaptive method to remove noise.
7. LIN Yue-Der, YU HEN HU have proposed a PLI detector that employs an optimal linear
discriminant analysis (LDA). G. Mihov, Iv Dotsinsky, Ts Georgieva have proposed sub-
traction procedure for powerline interference removing from ECG which is extended to
almost all possible cases of sampling rate and interference frequency variation.
8. K.Daqrouq has removed ECG baseline wandering using Discrete Wavelet Transform.
9. P.E.Tikkane has applied Non linear wavelet and wavelet packet for denoising of electro-
cardiogram signal.
25
3.2. FIR FILTERS CHAPTER 3. RELATED CONCEPTS
Moving Average Method
Moving Averages algorithm is applied in cases where a given waveform is cluttered with noise,
where a mean needs to be extracted from a periodic signal or where a slowly drifting baseline
needs to be eliminated from a higher frequency signal. A moving average filter smooths data
by replacing each data point with the average of the neighbouring data points defined within
the span the algorithm accomplishes a moving average by taking two or more number of data
points from the waveform data, adding them, dividing their sum by the total number of data
points added, replacing the first data point of the waveform with the average just computed
and repeating the steps with the second, third and so on data points until the end of the data
is reached. The result is a second or generated waveform consisting of the averaged data and
having the same number of points as the original waveform. The appropriate smoothing factor
has been taken determined by dividing one waveform period with the channels sample interval.
3.2 FIR FILTERS
FIR filters are digital filters with finite impulse response. They are also known as non-recursive
digital filters as they do not have the feedback (a recursive part of a filter), even though recursive
algorithms can be used for FIR filter realization. FIR filters can be designed using different
methods, but most of them are based on ideal filter approximation. The objective is not to achieve
ideal characteristics, as it is impossible anyway, but to achieve sufficiently good characteristics
of a filter. The transfer function of FIR filter approaches the ideal as the filter order increases,
thus increasing the complexity and amount of time needed for processing input samples of a
signal being filtered. The system introduces a phase shift of 0 radians at the frequency of w,
and p radians at three times that frequency. Input signal consists of natural frequency w and one
harmonic with the same amplitude at three times that frequency.
If we assume that the input is a speech signal whose phase characteristic is not of the essence,
such distortion in the phase of the signal would be unimportant. In this case, the system satisfies
all necessary requirements. However, if the phase characteristic is of importance, such a great
distortion mustnt be allowed. In order that the phase characteristic of a FIR filter is linear, the
impulse response must be symmetric or anti-symmetric, which is expressed in the following
way:
Symmetric impulse response (about its middle element):
26
3.2. FIR FILTERS CHAPTER 3. RELATED CONCEPTS
h[n] = h[N n 1]
Anti-symmetric impulse response (about its middle element):
h[n] = h[N n 1]
One of the drawbacks of FIR filters is a high order of designed filter. The order of FIR filter
is remarkably higher compared to an IIR filter with the same frequency response. This is the
reason why it is so important to use FIR filters only when the linear phase characteristic is very
important. A number of delay lines contained in a filter, i.e. a number of input samples that
should be saved for the purpose of computing the output sample, determines the order of a filter.
For example, if the filter is assumed to be of order 10, it means that it is necessary to save 10
input samples preceding the current sample. All eleven samples will affect the output sample of
FIR filter.
The transform function of a typical FIR filter can be expressed as a polynomial of a complex
variable z-1 . All the poles of the transfer function are located at the origin. For this reason, FIR
filters are guaranteed to be stable, whereas IIR filters have potential to become unstable.
Effect of the poles and zeros of the transfer function
The location of zeros and poles of the transfer function is very important for discrete time system
analyses and synthesis. According to their position it is possible to test stability of a discrete-
time system, detect round-off errors made due to software implementation of a filter as well as
errors in the coefficients encountered during hardware implementation of a filter. In order that
a discrete-time system is stable, all poles of the discrete-time system transfer function must be
located inside the unit circle. If this requirement is not satisfied, the system becomes unstable,
which is very dangerous. The location of zeros doesnt affect the stabilty of discrete-time sys-
tems. Recalling that FIR filters do not have a feedback, which further means that the transfer
function has no poles. This causes a FIR filter to be always stable. Filter stability will be dis-
cussed in more details along with IIR filters which have potential to become unstable because
of the feedback they have. This property of FIR filters actually represents their essential advan-
tage. An error in coefficient representation is always produced due to software and hardware
27
3.3. SALLEN-KEY FILTER CHAPTER 3. RELATED CONCEPTS
implementation. In software implementation, an error is triggered by the finite word-length

effect, whereas in hardware implementation, it occurs due to impossibility of representing the
coefficients with absolute accuracy.
The result in both cases is that the value of coefficients differs from their value obtained in design
process. Such errors cause frequency deviation of discrete-time system designed. Frequency
deviation depends on the spacing between the zeros of the FIR filter transfer function. FIR filter
coefficient error affects more the frequency characteristic as the spacing between the zeros of
the transfer function narrows. This property is particularly typical of high order filters because
their zeros are very close each other. However, slight errors in coefficient representation may
cause large frequency deviations.
Following are the transfer functions of four standard ideal filters:
Table 3.1: Transfer functions of four standard ideal filters
3.3 Sallen-Key Filter
The SallenKey topology is an electronic filter topology used to implement second-order active
filters that is particularly valued for its simplicity. It is a degenerate form of a voltage-controlled
28
3.3. SALLEN-KEY FILTER CHAPTER 3. RELATED CONCEPTS
voltage-source (VCVS) filter topology. A VCVS filter uses a super-unity-gain voltage amplifier
with practically infinite input impedance and zero output impedance to implement a 2-pole (12
dB/octave) low-pass,high-pass, or bandpass response. The super-unity-gain amplifier allows for
very high Q factor and passband gain without the use of inductors. A SallenKey filter is a
variation on a VCVS1 filter that uses a unity-gain amplifier (i.e., a pure buffer amplifier with
0dB gain). It was introduced by R.P. Sallen and E. L. Key of MIT Lincoln Laboratory in 1955.
Because of its high input impedance and easily selectable gain, an operational amplifier in a
conventional non-inverting configuration is often used in VCVS implementations. Implementa-
tions of SallenKey filters often use an operational amplifier configured as a voltage follower;
however,emitter or source followers are other common choices for the buffer amplifier. VCVS
filters are relatively resilient to component tolerance, but obtaining high Q factor may require
extreme component value spread or high amplifier gain. Higher-order filters can be obtained by
cascading two or more stages.
Figure 3.1: Generic Sallen-Key Topology
Suppose you had a large interfering signal you needed to get rid of. To get lots of attenuation,
you could cascade several RC filters. Unfortunately, the impedance of one RC section affects
the next. This means that the knee or transition between the pass and stop bands wont be
very sharp. A sharp knee helps you reduce the interfering signal without degrading your desired
signals. In this situation, the Sallen-Key active filter can save the day. This circuit implements a
2-pole filter. Cascading several stages can give you a steep attenuation curve with a very sharp
knee.
In theory, the response in the stop band should keep decreasing as frequency increases. Instead,
1 Voltage Controlled Voltage Source
29
3.4. SHIELDING CHAPTER 3. RELATED CONCEPTS
the response actually will begin rising again at some high frequency. Why? A properly func-
tioning op amp is essential to the filters operation. However, real world op amps lose voltage
gain at some frequency due to their finite bandwidth.
3.4 Shielding
Industrial applications such as the factory floor are typically electrically noisy environments.
Electrical noise, either radiated or conducted as electromagnetic interference (EMI), can seri-
ously disrupt the proper operation of other equipment. Insulation protects a cable mechanically
from scraps and abrasion and environmentally from moisture and spills. But insulation is trans-
parent to electromagnetic energy and offers no protection. Shielding is needed to combat the
effects of EMI. Cables can be a main source of transfer for EMI, both as a source and receiver.
As a source, the cable can either conduct noise to other equipment or act as an antenna radiating
noise. As a receiver, the cable can pick up EMI radiated from other sources. A shield works on
both. The table below gives general guidelines as to the areas which are subject to these gener-
alized noise levels. Notice that switching heavy loads, inductive heaters, large transformers can
all present high levels of both conducted and radiated EMI.
Placing signal cables next to power cables can also allow power-line noise to couple onto the
signal lines. The primary way to combat EMI in cables is through the use of shielding. The
shield surrounds the inner signal- or power-carrying conductors. The shield can act on EMI in
two ways. First, it can reflect the energy. Second, it can pick up the noise and conduct it to
ground. In either case, the EMI does not reach the conductors. In either case, some energy still
passes through the shield, but it is so highly attenuated that it doesnt cause interference.
Cables come with various degrees of shielding and offer varying degrees of shielding effec-
tiveness. The amount of shielding required depends on several factors, including the electrical
environment in which the cable is used, the cost of the cablewhy pay for more shielding than
you need?and issues like cable diameter, weight, and flexibility.
There are two types of shielding typically used for cables: foil and braid.
Foil shielding used a thin layer of aluminum, typically attached to a carrier such as polyester to
add strength and ruggedness. It provides 100% coverage of the conductors it surrounds, which
is good. It is thin, which makes it harder to work with, especially when applying a connector.
30
3.5. ECG ELECTRODES CHAPTER 3. RELATED CONCEPTS
Figure 3.2: Comparison of Shielded cables
Usually, rather than attempting to ground the entire shield, the drain wire is used to terminate
and ground the shield.
A braid is a woven mesh of bare or tinned copper wires. The braid provides a low-resistance
path to ground and is much easier to termination by crimping or soldering when attaching a con-
nector. But braided shields do not provide 100% coverage. They allow small gaps in coverage.
Depending on the tightness of the weave, braids typically provide between 70% and 95% cov-
erage. When the cable is stationary, 70% is usually sufficient. In fact, you wont see an increase
in shielding effectiveness with higher percentages of coverage. Because copper has higher con-
ductivity than aluminum and the braid has more bulk for conducting noise, the braid is more
effective as a shield. But it adds size and cost to the cable.
For very noisy environments, multiple shielding layers are often used. Most common is using
both a foil and a braid. In multi conductor cables, individual pairs are sometimes shielded with
foil to provide crosstalk protection between the pairs, while the overall cable is shielded with
foil, braid, or both. Cables also use two layers of foil or braid.
3.5 ECG Electrodes
Electrocardiography (ECG), electromyography (EMG), and electroencephalography (EEG) sys-

tems measure heart, muscle, and brain activity (respectively) over time by measuring electric
31
potentials on the surface of living tissue. Nervous stimuli and muscle contractions can be de-
tected by measuring the ionic current flow in the body. This is accomplished using a biopotential
electrode.
A negatively charged ion is an anion and a positively charged ion is a cation. The current flow
in the human body is due to ion flow, not electrons. A biopotential electrode is a transducer
that senses ion distribution on the surface of tissue, and converts the ion current to electron
current. An electrolyte solution/jelly is placed on the side of the electrode that comes into
contact with tissue; the other side of the electrode consists of conductive metal attached to a
lead wire connected to the instrument. A chemical reaction occurs at the interface between the
electrolyte and the electrode.
An Introduction to the Electrolyte-Electrode Interface
Current can pass from an electrolyte to a nonpolarized electrode. (Polarized electrodes act more
like a capacitor and current is displaced but does not move freely across the electrolytic inter-
face). Current crosses the interface as the atoms in the electrode oxidize to form cations and
electrons. The cations are discharged into the electrolyte, and the electrons carry charge through
the lead wires. Similarly, the anions in the electrolyte travel toward the interface to deliver free
electrons to the electrode.
A voltage known as the half-cell potential develops across the interface due to an uneven distri-
bution of anions and cations. It appears as a dc offset in ECGs, EMGs and EEGs.
A very popular electrode is silver/silver choloride (Ag/AgCl) because of its very low half-cell
potential of approximately 220 mV and its ease of manufacturability. Ag/AgCl electrodes are
nonpolarized electrodesthey allow current to pass across the interface between the electrolyte
and the electrode. Nonpolarized electrodes are better than polarized electrodes in terms of their
rejection of motion artifacts and their response to defibrillation currents. Both motion artifacts
and defibrillation events can charge up the capacitance from the electrolyte and electrode inter-
face.
Figure above shows an equivalent electrical model. The AgCl layer lowers the impedance of the
electrode. This is important at low frequencies near dc, where ECG and EEG measurements are
taken.
32
Figure 3.3: Equivalent Circuit Model for Biopotential Electrode
Patient Preparation Challenges Are Relevant to System Design
Clinicians face practical challenges when making biopotential measurements. They must prep
a patients skin to make a good contact with the electrode. Dry and/or old skin creates a high
impedance, which makes it difficult to acquire good readings. In addition, electrode to skin
impedances vary due to ethnicity, age, and gender. Clinicians rub the skin with a mild abrasive to
remove the thin layer of dead skin to enable better ion flow between the tissue and the electrolyte
on the electrode. This ensures better measurements but takes time. Problems also occur when the
electrolyte dries over the course of several hours. This increases the impedance in the electrolyte,
which steadily increases the dc offset that, in turn, expends the dynamic range of the instrument.
Both challenges are relevant to system designers. Skin to electrode impedances at 10 Hz using
silver/silver chloride electrodes, with the skin properly prepared, are typically about 5 kW. This
impedance will vary from manufacturer to manufacturer.
When designing ECGs and other biopotential front-end circuits, the designer must remember
that an impedance of 500 kW can be encountered frequently.
Many clinicians never take the time to prepare the skin for attaching the electrode unless they are
having problems acquiring good signals. In addition, gold electrodes with paste are commonly
used in EEG recordings, and these yield much higher impedances than silver/silver chloride
electrodes. Placing the electrodes on the thoracic cavity will yield skin to electrode impedances
approximately 2.5 lower than if the electrodes are placed on the limbs.
Designing with Overpotentials
An overpotential is the difference between the half-cell potential and the zero potential. It ap-
pears as a dc offset to the measurement instrument.
33
In the case of an ECG, the differential voltage across a persons chest (the cardiac signal) is
typically 1.8 mV in amplitude riding on a dc offset of up to 300 mV. The enormity of the
dc offset, compared to the cardiac signal, limits the amount of gain applied to the front-end
amplifiers. For example, applying a gain of 100 would increase a 5 mV cardiac signal to 500
mV but would also increase a 300 mV dc offset to 30 V.
Amplifiers that operate on wide supply voltages such as 5 V are commonly used to take ad-
vantage of the larger input voltage range. In addition, the designer is able to apply more gain.
Designers often use large rails of 7.5 V to handle the severe environment that the ECG device
has to work in, such as operating rooms (ORs).
Figure 3.4: JFET input OPAMP for biopotential measurement
Figure above shows JFET input op amps such as Analog Devices AD8625/AD8626/AD8627
and AD8641/AD8642/AD8643 that have input bias currents of less than 1 pA. JFET input in-
strumentation amplifiers such as the AD8220 and AD8224 have input bias currents under 20
pA.
Understanding the electrochemical interaction in electrodes helps clarify their behavioral nu-
ances. In addition, it enables designers to understand the challenges clinicians face when plac-
ing electrodes on patients. A thorough understanding of the electrode to skin interface ensures
that the signal acquisition is correct and reliable, enabling the clinician to correctly diagnose the
patients condition.
34
3.6. ANALOG TO DIGITAL CONVERTER CHAPTER 3. RELATED CONCEPTS
3.6 Analog to Digital Converter
ADC2 s convert voltages that represent real-world signals into bits that microprocessors and soft-
ware use to manipulate test data and control test equipment. Even if you work on digital signals
exclusively, you probably use an ADC in an oscilloscope to look at the analog characteristics
of your signals. ADCs come in several basic architectures, although many variations exist for
each type. Different types of test equipment need different types of ADCs. For example, a
digital oscilloscope needs high digitizing speeds but can sacrifice resolution. Some PC-plug-in
digitizers and RF test equipment use subranging ADCs, which provide better resolution than
flash converters, but at the expense of speed. General-purpose data-acquisition equipment usu-
ally falls between scopes and DMMs for sample speed and resolution. This type of equipment
uses successive-approximation register (SAR) or sigma-delta converters. A digital multimeter
(DMM) needs fine resolution and can sacrifice high measurement speeds.
SAR converters
When you need resolution from 12, 14, or 16 bits, but you dont need the speed of a subranging
ADC and you want to use a lower cost device that draws less power, look for equipment that
contains an SAR. SAR converters are by far the most popular ADCs in measurement products. If
you use a PC plug-in data-acquisition board or PC-external data-acquisition system, you proba-
bly use an SAR converter. Some SAR converters have less than 12 bits of resolution, but theyre
generally not used in test equipment.
Figure 3.5: SAR architecture
2 Analog to Digital Converter
35
3.6. ANALOG TO DIGITAL CONVERTER CHAPTER 3. RELATED CONCEPTS
Currently, SAR converters resolve voltages to 16 bits with sampling speeds of about 100 ksam-
ples/s .Some 12-bit SAR converters digitize at speeds faster than 1 Msamples/s. At the start of
a conversion, the SAR converter sets its successive-approximation registers output so that all
bits except the MSB produce logic 0. That sets the DACs output to one-half of the devices
full-scale input.
The comparator sets its output based on the difference between the DACs output and the sam-
pled voltage.For example, consider an 8-bit SAR converter . The registers output starts at
10000000. If the input voltage is less than one-half of the ADCs full range, then the compara-
tors output goes (or stays) low. That forces the registers output to 01000000, which changes
the DACs output voltage to the comparator. If the comparators output stays low, then the reg-
isters output changes to 00100000, and so on. SAR converters, therefore, need one cycle for
each output bit, or N cycles for an N-bit converter. A 16-bit SAR converter takes longer than
twice the conversion time of an 8-bit SAR converter, because the output must settle to one bit in
65,536, where an 8-bit ADC needs to settle to one bit in 256.
36
4 ECG Module
4.1 Block Diagram
Electrocardiogram is an instrument used to study and record electrical signals that originate from
the heart. The Electrocardiograph (ECG) signal is an electrical signal generated by the hearts
beating, which can be used as a diagnostic tool for examining some of the functions of the heart.
It has a principal measurement range of 0.5 to 4 mV and signal frequency range of 0.01 to 250
Hz.
Figure 4.1: Block Diagram of ECG Module
37
4.1. BLOCK DIAGRAM CHAPTER 4. ECG MODULE
At the heart of this module, lies an Instrumentation Amplifier with moderate gain and high
Common Mode Rejection Ratio [CMRR]. This instrumentation amplifier receives differential
input from electrodes attached to the patients skin. This signal is given moderate amplification
and passed through a series of filters for noise reduction. After filtering, further amplification is
provided and it is passed to a level shifter block. The level shifter converts the 18V peak to peak
input to a 0-5V signal centered about 2.5 V.
4.1.1 Input Transducers
The ECG is converted to electrical voltage by electrodes. Ag/AgCl electrodes are used for this
purpose. These electrodes are available in circular, disposable packages. The center part of
the electrodes contains the Ag/AgCl gel and it is surrounded concentrically by a self adhesive
surface. These electrodes are attached directly to the patients skin and can be easily removed.
Such a setup is shown below.
Figure 4.2: ECG Electrodes
ECG measurements may be corrupted by various types of electrode contact noise. Electrode
contact noise is caused by variations in the position of the heart with respect to the electrodes
and changes in the propagation medium between the heart and the electrodes. This causes sud-
den changes in the amplitude of the ECG signal, as well as low frequency baseline shifts. In
addition, poor conductivity between the electrodes and the skin both reduces the amplitude of
the ECG signal and increases the probability of disturbances (by reducing SNR). The underlying
mechanism resulting in these baseline disturbances is electrode-skin impedance variation. The
larger the electrode-skin impedance, the smaller the relative impedance change needed to cause
a major shift in the baseline of the ECG signal. If the skin impedance is extraordinarily high,
it may be impossible to detect the signal features reliably in the presence of body movement
[3][4]. Sudden changes in the skin-electrode impedance induce sharp baseline transients which
decay exponentially to the baseline value. This transition may occur only once or rapidly several
38
times in succession. To suppress this noise source, it is crucial to make sure electrode adheres
securely to the skin.
4.1.2 Shielded Cables
We are using a set of shielded cables to make the electrical connections from the electrodes to
the circuit. The shielded cables have a crocodile connector clip at one end and a RCA Jack
(Male) at the other. The cable itself is a single core, multistrand, single shield cable. These help
suppress 50 Hz noise which would otherwise be picked up by an unshielded core from power
lines.[5] The cable itself is selected so it is thin and light enough so as not to cause discomfort
to the patient and be a cause of the electrodes loosing contact with skin.
4.1.2.1 Input Connectors
The connectors used are of a RCA female type. In the most normal usage, cables have a standard
plug on each end, consisting of a central male connector, surrounded by a ring. The ring is often
segmented for flexibility. Devices mount the socket (female jack), consisting of a central hole
with a ring of metal around it. The ring is slightly smaller in diameter and longer than the ring
on the plug, allowing the plugs ring to fit tightly over it. The jack has a small area between
the outer and inner rings which is filled with an insulator, typically plastic (very early versions,
or those made for use as RF connectors used ceramic). These help make a secure connection
to both the core of the cable as well as its shielding or cladding. These are designed to carry
and connect high speed video signals hence have a very low junction capacitance and are well
suited for bio-potential signal acquisition. Connections are made by pushing the cables plug
into the female jack on the device. The signal-carrying pin protrudes from the plug, and often
comes into contact with the socket before the grounded rings meet, resulting in a noise spike if
the circuit components are powered while making connections. Continuous noise can occur if
the plug partially falls out of the jack, breaking ground connection but not the signal.
4.1.2.2 Instrumentation Amplifier
ECG applications require an instrumentation amplifier with a very high common mode rejection
ratio. The small AC signal voltage (less than 5mV) picked up by the sensor is accompanied by
a large common mode AC component (upto 1.5V) and a large variable DC component (upto
39
300mV). The common mode rejection ratio specified by the Association for the Advancement
of Medical Instrumentation (AAMI) for standard ECG is 89dB minimum and for Ambulatory
ECG, 60dB minimum. The selected instrumentation amplifier device is the AD620.
The AD620 is a low cost, high accuracy instrumentation amplifier that requires only one exter-
nal resistor to set gains of 1 to 1000. Furthermore, the AD620 features 8-lead SOIC and DIP
packaging that is smaller than discrete designs, and offers lower power (only 1.3 mA max sup-
ply current), making it a good fit for battery powered, portable (or remote) applications. The
AD620, with its high accuracy of 40 ppm maximum non-linearity, low offset voltage of 50 V
max and offset drift of 0.6 V/C max, is ideal for use in precision data acquisition systems,
such as weigh scales and transducer interfaces. Furthermore, the low noise, low input bias cur-
rent, and low power of the AD620 make it well suited for medical applications such as ECG and
noninvasive blood pressure monitors. The low input bias current of 1.0 nA max is made possible
with the use of Superbeta processing in the input stage. The AD620 works well as a preamplifier

due to its low input voltage noise of 9 nV/ Hz at 1 kHz, 0.28 V p-p in the 0.1 Hz to 10 Hz band,

0.1 pA/ hz input current noise. Also, the AD620 is well suited for multiplexed applications with
its settling time of 15 s to 0.01% and its cost is low enough to enable designs with one inamp
per channel. The low current noise of the AD620 allows its use in ECG monitors where high
source resistances of 1 MW or higher are not uncommon. The AD620s low power, low supply
voltage requirements, and space-saving 8-lead mini-DIP and SOIC package offerings make it an
excellent choice for battery powered data recorders. Furthermore, the low bias currents and low
current noise coupled with the low voltage noise of the AD620 improve the dynamic range for
better performance.
Thus the device is well-suited for the purpose.
4.1.2.3 DC Blocking Circuit
A standard C-R differentiator is used to block the DC component of the signal. If this component
is not blocked it may saturate subsequent stages. Consider a small DC component of 70mV. If
this is passed through an amplifier of gain 1000, it will be amplified to 70V which will saturate
the amplifier, assuming it is fed by a standard 9V supply. This is sometimes also refereed to as
capacitive coupling or AC coupling.
A high value resistance is connected in shunt to maintain DC return path for bias current in
ac-coupled operational or instrumentation-amplifier circuits. This should be especially useful
40
in high-gain applications, where even a small dc voltage at an amplifiers input can limit the
dynamic range, or even result in output saturation. However, capacitive coupling into a high-
impedance input, without providing a dc path for current flowing in the + input, will lead to
circuit failure.
Figure 4.3: Correct method for ac coupling an op-amp input for dual-supply operation
What actually happens is that the input bias currents will flow through the coupling capacitor,
charging it, until the common-mode voltage rating of the amplifiers input circuit is exceeded or
the output is driven into limits. Depending on the polarity of the input bias current, the capacitor
will charge up toward the positive supply voltage or down toward the negative supply. The bias
voltage is amplified by the closed-loop dc gain of the amplifier.
This process can take a long time. For example, an amplifier with a field-effect-transistor (FET)
input, having a 1-pA bias current, coupled via a 0.1-mF capacitor, will have a charging rate, I/C,
of 1012/107 = 10 mV/s, or 600 mV per minute. If the gain is 100, the output will drift at 0.06
V per minute. Thus, a casual lab test (using an ac-coupled scope) might not detect this problem,
and the circuit will not fail until hours later. Obviously, it is very important to avoid this problem
altogether.[6]
41
4.1.2.4 Sallenkey Filter
This filter is used to block high frequency noise present in the signal. This noise usually orig-
inates from muscle movement. The Sallen-key filter is of the low pass type with a cut off
frequency of fc = 284.20525 Hz.
The filter has been designed on the okawa-denshi simulator [8] have the following specifications:
It is a second order filter with a maximally flat response. Its transfer function is given as:
3188775.5102
G(s) =
s2 + 3571.42857143s + 3188775.5102
Its designed quality factor is Q = 0.5.
Damping ratio is designed as z = 1.00.
The filter has non significant overshoot.
Final value of the step response (on the condition that the system converged when t goes
to infinity) is g() = 1.
The Bode, Nyquist and Transient Plots of the filter are:
42
Figure 4.4: Bode Plot of Filter
Figure 4.5: Nyquist Plot
43
Figure 4.6: Transient Response
4.1.2.5 Amplifier
This amplifier block is used to provide further amplification to the filtered signal. This amplifier
is a two stage cascade amplifier. The gain of the first stage can be adjusted upto 200 and the
second stage has fixed gain of 2.2. The amplifier thus has a total gain of 440.
4.1.2.6 Level Shifter
The level shifter circuit consists of summing inverting amplifier followed by an unity inverting
buffer. The summing amplifier is centered at a magnitude of 2.5 V. This block converts a 9V
signal to a 5V signal centered at 2.5 V. This is suitable for conversion by the microcontrollers
ADC which cannot tolerate bipolar signals.
44
4.2. SCHEMATIC CHAPTER 4. ECG MODULE
4.2 Schematic
Figure 4.7: Schematic of ECG Amplifier
45
4.3. LAYOUT CHAPTER 4. ECG MODULE
4.3 Layout
Figure 4.8: Layout of ECG Amplifier
46
4.4. SIMULATION CHAPTER 4. ECG MODULE
4.4 Simulation
Figure 4.9: SPICE Simulation of ECG Amplifier
47
5 Electronic Stethoscope Module
5.1 Block Diagram
Figure 5.1: Block Diagram Of Electronic Stethoscope Module
5.1.1 Preamplifier
A preamplifier (preamp) is an electronic amplifier that prepares a small electrical signal for
further amplification or processing. A preamplifier is often placed close to the sensor to reduce
the effects of noise and interference. It is used to boost the signal strength to drive the cable to
the main instrument without significantly degrading the signal-to-noise ratio (SNR).
Pre-amplifier is used to provide high input impedance and a moderate voltage gain. This pre-
vents loading of previous stages. A TL072 Operational Amplifier is used for the purpose. The
48
5.1. BLOCK DIAGRAM CHAPTER 5. ELECTRONIC STETHOSCOPE MODULE
JFET-input operational amplifiers in the TL07_ series are designed as low-noise versions of the
TL08_ series amplifiers with low input bias and offset currents and fast slew rate. The low
harmonic distortion and low noise make the TL07_ series ideally suited for high-fidelity and
audio preamplifier applications. Each amplifier features JFET inputs (for high input impedance)
coupled with bipolar output stages.
The preamplifier has a gain of 20.
5.1.2 DC Blocking Circuit
the amplifier, assuming it is fed by a standard 9V supply.
5.1.3 Low Pass Filter
This filter is used to block high frequency noise present in the signal. This noise usually origi-
nates from contact noise with the patients skin and microphone defects. The LPF is designed as
a Sallenkey type of filter and has a maximally flat response. Its cut off frequency is designed to
be fc = 159.1549 Hz.
The filter has been designed on the okawa-denshi simulator [8] have the following specifications:
It is a second order filter with a maximally flat response. Its transfer function is given as:
1000000
G(s) =
s2 + 2000s + 1000000
Its designed quality factor is Q = 0.5.
Damping ratio is designed as z = 1.00.
The filter has non significant overshoot.
Final value of the step response (on the condition that the system converged when t goes
to infinity) is g() = 1.
49
5.1. BLOCK DIAGRAM CHAPTER 5. ELECTRONIC STETHOSCOPE MODULE
The Bode, Nyquist and Transient Plots of the filter are:
Figure 5.2: Bode Plot of Filter
Figure 5.3: Nyquist Plot
5.1.4 Audio Amplifier
This amplifier uses the LM386N IC. LM386 is a power amplifier designed for use in low voltage
consumer applications. The gain is internally set to 20 to keep external part count low, but the
addition of an external resistor and capacitor between pins 1 and 8 will increase the gain to any
value from 20 to 200. The inputs are ground referenced while the output automatically biases
to one-half the supply voltage. The quiescent power drain is only 24 milliwatts when operating
from a 6 volt supply, making the LM386 ideal for battery operation.
50
5.2. SCHEMATIC CHAPTER 5. ELECTRONIC STETHOSCOPE MODULE
5.2 Schematic
Figure 5.4: Schematic of Stethoscope
51
5.3. LAYOUT CHAPTER 5. ELECTRONIC STETHOSCOPE MODULE
5.3 Layout
Figure 5.5: Layout of Stethoscope
52
5.4. SIMULATION CHAPTER 5. ELECTRONIC STETHOSCOPE MODULE
5.4 Simulation
Figure 5.6: SPICE Simulation of Stethoscope
53
6 Pulse Measurement Module
6.1 Block Diagram
Figure 6.1: Block Diagram of Pulse Measurement Module
6.1.1 Input Transducer
The input Transducer used is an infra-red transmission - reception system. An infra-red diode
is used to pulse infra-red light into a patients finger. The reflected radiation is collected by
the infra-red receiver and is used for further measurement. The intensity of reflected signal is
proportional to the amount of blood in region. The IR diode is connected in reverse bias.
54
6.1. BLOCK DIAGRAM CHAPTER 6. PULSE MEASUREMENT MODULE
6.1.2 Amplifier
This amplifier block is used to provide further amplification to the input signal. It has a small
signal gain of 10.
6.1.3 Level Shifter
The level shifter circuit consists of summing inverting amplifier followed by an unity inverting
buffer. The summing amplifier is centered at a magnitude of 2.5 V. This block converts a 9V
signal to a 5V signal centered at 2.5 V. This is suitable for conversion by the microcontrollers
ADC which cannot tolerate bipolar signals.
6.1.4 DC Blocking Circuit
the amplifier, assuming it is fed by a standard 9V supply.
6.1.5 Low Pass Filter
This filter is used to block high frequency noise present in the signal. This is sporadic noise re-
sulting from minor variations in finger pressure on sensor or trembling of the patient. It contains
no clinically significant signal and must be discarded. Its cut off frequency is fc = 159.1549 Hz
55
6.2. SCHEMATIC CHAPTER 6. PULSE MEASUREMENT MODULE
6.2 Schematic
Figure 6.2: Schematic of Pulse Amplifier
56
6.3. LAYOUT CHAPTER 6. PULSE MEASUREMENT MODULE
6.3 Layout
Figure 6.3: Layout of Pulse Amplifier
57
6.4. SIMULATION CHAPTER 6. PULSE MEASUREMENT MODULE
6.4 Simulation
Figure 6.4: SPICE Simulation of Pulse Amplifier
58
7 ADC Module
7.1 Block Diagram
Figure 7.1: Block Diagram Of ADC and Microcontroller System
The system is centered around the versatile AVR ATMEGA microcontroller series. The AVR is
a modified Harvard architecture 8-bit RISC single chip microcontroller which was developed by
Atmel in 1996. The AVR was one of the first microcontroller families to use on-chip flash mem-
ory for program storage, as opposed to one-time programmable ROM, EPROM, or EEPROM
used by other microcontrollers at the time.
The AVR is a modified Harvard architecture machine where program and data are stored in sep-
arate physical memory systems that appear in different address spaces, but having the ability to
read data items from program memory using special instructions. Flash, EEPROM, and SRAM
59
7.1. BLOCK DIAGRAM CHAPTER 7. ADC MODULE
are all integrated onto a single chip, removing the need for external memory in most applica-
tions. Some devices have a parallel external bus option to allow adding additional data memory
or memory-mapped devices. Almost all devices have serial interfaces, which can be used to
connect larger serial EEPROMs or flash chips.
7.1.0.1 Analog To Digital Converter
The AVR ADC allows the AVR microcontroller to convert analog voltages to digital values with
few to no external parts. The ADC1 built into the ATMega 8 is capable of 10 bit resolution. The
ATMega 8 microcontroller has 8 ADC channels, allowing up to 8 analog sources to be attached
to the microcontroller. The 8 ADC channels are connected to the internal DAC through a device
called a multiplexer. The multiplexer connects the 8 ADC channels to the internal ADC. One
channel at a time is passed through the multiplexer to the ADC. The ADC has its own power
supply, labeled AVCC. This pin needs to be connected to a power source within .3 volts of the
chips VCC supply. The 10 bit resolution allows measuring voltages from 0 to 5 volts with a
resolution of 5/1024 volts, or 4.88 mV. The ADC contains a Sample and Hold circuit which
ensures that the input voltage to the ADC is held at a constant level during conversion.
1 Analog to Digital Converter
60
7.1.0.2 Microcontroller Algorithm
Algorithm 7.1 Convert And Transmit
The AVR is initialized with appropriate registers for operation of the ADC, serial transmission
hardware and Timer.
The timer is programed to overflow every 1mS. Due to the odd valued crystal of 11.0592 Mhz
crystal, there is an error of 0.02% in the timing. This is well within acceptable limits for the
application. When the timer overflows, it triggers an interrupt.
The ISR2 of the timer interrupt initiates the conversion process. The ADC is programmed in
single shot mode. A normal conversion takes 13 ADC clock cycles. The first conversion after
the ADC is switched on (ADEN in ADCSRA is set) takes 25 ADC clock cycles in order to
2 Interrupt Service Routine
61
initialize the analog circuitry. The 10 bit binary output of the ADC is formatted for transmission.
The natural binary output is segmented into a 4-BCD3 code. This is then transmitted serially.
The stream is interleaved with a CR or carriage return character every 4 bytes to facilitate
data recovery at receiver end. Serial transmission takes advantage of the AVRs USART4 . It is
clocked by a 11.0592 Mhz crystal that allows an error free transmission at a baud rate of 115200
bps5 . After transmission, the device returns to idle mode, waiting for next interrupt.
3 BinaryCoded Decimal
4 UniversalAsynchronous Receiver/Transmitter
5 Baud Per Second
62
7.2. SCHEMATIC CHAPTER 7. ADC MODULE
7.2 Schematic
Figure 7.2: Schematic of ADC Module and Microcontroller Board
63
7.3. LAYOUT CHAPTER 7. ADC MODULE
7.3 Layout
Figure 7.3: Layout of ADC Module and Microcontroller Board
64
8 Internet Telemedicine System
8.1 Block Diagram
Figure 8.1: Block Diagram of Internet Interface
System entails PHP based uploading forms and a backend databases onto the website. These
forms might be to Add Patients or Add Doctors or Add a study. This can be uploaded by a
Technician who has the permission to add content by filling these forms. The screenshot below
show a PHP form used to add patients to the HMAD-ITS database.
Consider the technician wants to add an ECG study, he or she will login into www.hmads.in and
click on Add Study and fill out the form. The data will then be uploaded on our website. All
requesite details are stored to a MySQL database at the back end.
65
8.1. BLOCK DIAGRAM CHAPTER 8. INTERNET TELEMEDICINE SYSTEM
Figure 8.2: Add Study Form
Patients and Doctors registered with HMAD-ITS have unique IDs and can login into our website
and view their details.
The Doctor can view the patients (only of the patients assigned to them) form and related
ECG, ElectroScope readings and Pulse Oximeter Readings attached to their form and give their
opinions and diagnose the patient as per the readings. The Technician and Doctor can access
the Patient details as per the permissions assigned to them. Patients have the permission to view
only their listings and doctors comments (if any).
Figure 8.3: List Patient Pages
An effective Internet Telemedicine can improve the access to Doctors and improve healthcare
66
8.1. BLOCK DIAGRAM CHAPTER 8. INTERNET TELEMEDICINE SYSTEM
and add transparency to the whole process, making it organised and efficient and above all cost-
effective.
67
8.2. SCREENSHOTS CHAPTER 8. INTERNET TELEMEDICINE SYSTEM
8.2 Screenshots
Figure 8.4: Screenshots of hmads.in
68
9 Graphical User Interface
Figure 9.1: ECG Interface
Figure 9.2: Pulse Measurement Interface
69
CHAPTER 9. GRAPHICAL USER INTERFACE
Figure 9.3: Audio Interface
A intuitive and easy to use GUI system was developed to allow any user to fully utilize the sys-
tem efficiently, without the need for familiarization. A high degree of uniformity was maintained
across interfaces to allow any user familiar with one module to productively use any other mod-
ule. The interface is both intuitive, minimal and functional. The main features of the interface
are summarized in the table below.
Control Instruction
Start Button It starts the communication with HMAD-iTS hardware and plots
the acquired samples in graph area
Stop Button It stops the communication and retains the last plot
Save Button It saves the current plot in the graph into a file with an appropriate
extension
Load Button It loads the saved file and plots in the graph area
Clear Button It clears the graph area
Transmit Button It uploads the file into the database of hmads.in from where user or
doctor can access them whenever required.
Filter Menu Filter length and type of plot can be selected (filtered, unfiltered,
superimposed)
Select COM Port This drop down menu lists names of all connected serial ports.
User have to choose the desired COM ports through which the
HMAD-iTS hardware is connected
Table 9.1: Summary of interface functions
70
10 Bill of Materials
10.1 ECG Module
Sr.No Name of component Quantity Per unit rate(Rs.) Total cost(Rs.)

1 Capacitor 0.1u 4 2 8
2 Capacitor 470nf 2 2 4
3 Battery connector AB9v 2 3 6
4 Stand-off 4 6 24
5 RCA jack 4 12 48
6 Resistor 220E 2 0.5 1
7 Resistor 1k 3 0.5 1.5
8 Resistor 2k2 2 0.5 1
9 Resistor 5.6k 2 0.5 1
10 Resistor 1M 2 0.5 1
11 Resistor 200k 2 0.5 1
12 Resistor 56k 2 0.5 1
13 Resistor 36k 2 0.5 1
14 Resistor 10k 1 0.5 0.5
15 AD620N 1 150 150
16 OP07CN 2 15 30
17 TL072-P 2 20 40
Total 319
Table 10.1: ECG Amplifier BOM
71
10.2. ADC AND MICROCONTROLLER BOARD CHAPTER 10. BILL OF MATERIALS
10.2 ADC and Microcontroller Board
Sr. No Name of Component Quantity Per unit rate (Rs.) Total cost (Rs.)
2 Capacitor 10u 5 2 10
5 Capacitor 22pf 2 2 4
6 Stand-off 4 6 24
7 RCA jack 1 12 12
8 Battery connector AB9V 1 3 3
9 1N4148 1 2 2
10 Resistor 4k7 1 0.5 0.5
11 Crystal 11.0592 Mhz 1 10 10
12 Serial Connector 1 15 15
13 Tactile switch 1 1 1
14 LM7805 1 5 5
15 Atmega168 1 180 180
16 Max232 1 25 25
Total 305.5
Table 10.2: ADC and Microcontroller Board BOM
72
10.3. ELECTRONIC STETHOSCOPE CHAPTER 10. BILL OF MATERIALS
10.3 Electronic Stethoscope
Sr.No Name of the component Quantity Per unit rate (Rs.) Total cost (Rs.)
3 Battery connector AB9v 2 3 6
4 Stand-off 4 6 24
5 Resistor 10k 2 0.5 1
6 Resistor 47k 1 0.5 0.5
7 Resistor 3.9E 1 0.5 0.5
8 Resistor 1k 1 0.5 0.5
9 Resistor 2.2k 1 0.5 0.5
10 2.3 mm jack 3 15 45
11 TL072-P 1 20 20
12 TL071-P 1 20 20
13 LM386N 1 8 8
Total 134
Table 10.3: Electronic Stethoscope BOM
73
10.4. PULSE MEASUREMENT MODULE CHAPTER 10. BILL OF MATERIALS
10.4 Pulse Measurement Module
Sr. No Name of component Quantity Per unit rate (Rs.) Total cost (Rs.)
3 Capacitor 470nF 2 2 4
4 Stand-off 4 6 24
5 RCA jack 1 12 12
6 Resistor 33k 1 0.5 0.5
7 Resistor 68k 2 0.5 1
8 Resistor 1M 2 0.5 1
9 Resistor 56k 3 0.5 1.5
10 Resistor 10k 1 0.5 0.5
11 Resistor 47k 1 0.5 0.5
12 Resistor 150E 1 0.5 0.5
13 Resistor 680k 1 0.5 0.5
14 Resistor 36k 2 0.5 1
15 OP07CN 2 15 30
16 TL072-P 1 20 20
Total 105
Table 10.4: Pulse Module BOM
74
11 Results and Conclusion
The aforementioned hardware was built and tested. Following iterative testing and re-designing
our modules, we have performed and obtained the desired outputs of our modules viz. ECG,
Pulse Measurement and Electronic Stethoscople. Results with fair degree of clinical significance
have been obtained. Our project has been cost effective but we havent compromised on the
quality of our modules. Distinct output waveforms obtained from our modules can be studied
and analysed by the Doctors and diagnose the patients effectively.
Module wise results are described as follows:
11.1 ECG Module
The ECG records the electrical activity that results when the heart muscle cells in the atria and
ventricles contract. Atrial contractions show up as the P wave. Ventricular contractions show as
a series known as the QRS complex.The third and last common wave in an ECG is the T wave.
This is the electrical activity produced when the ventricles are recharging for the next contraction
(re-polarizing). Interestingly, the letters P, Q, R, S, and T are not abbreviations for any actual
words but were chosen many years ago for their position in the middle of the alphabet. The
electrical activity results in P, QRS, and T waves that are of different sizes and shapes. When
viewed from different leads, these waves can show a wide range of abnormalities of both the
electrical conduction system and the muscle tissue of the hearts 4 pumping chambers.
The U wave is a wave on an electrocardiogram that is not always seen. It is typically small,
and, by definition, follows the T wave. U waves are thought to represent re-polarization of the
papillary muscles or Purkinje fibers.
The P wave is visible and clearly defined, as is the QRS complex and T wave. U wave, although
not absent, is sometimes lost in the baseline wander. However the U wave is not clinically
significant, and is only useful of research purposes.
75
11.2. PULSE MEASUREMENT MODULE CHAPTER 11. RESULTS AND CONCLUSION
The results can be further improved if more number of channels are considered. To do this, the
input hardware would have to be duplicated and all outputs would need to be summed in an
summing amplifier.
(a) Ideal ECG wave
(b) Obtained from the HMAD system
Figure 11.1: ECG Results
11.2 Pulse Measurement Module
The Pulse Measurement Module we designed and tested has proved to be an effective pulse mea-
surement tool. We obtained pulse readings by placing the patients finger along the transmitter
and receiver IR LEDs. We also obtained successful readings when the finger was placed along
the transmitter IR LED and RED LED. The ratio of the above two readings can indicate the
oxygen saturation in the patients bloodstream. An effective housing made by us has proved to
improve the efficiency of the module.
76
11.3. ELECTRONIC STETHSCOPE MODULE
CHAPTER 11. RESULTS AND CONCLUSION
Figure 11.2: Pulse Results obtained by HMAD system
11.3 Electronic Stethscope Module
The Electro-Stethoscope built by us has proved to be successful and its amplification and quality
is much better than an analog stethoscope. The design standards were maintained and we built
and modified the amplifier to improve the efficiency of the Electronic Stethoscope.
Figure 11.3: Results from Electronic Stethscope
77
12 Future Scope
This project would greatly benefit from the inclusion of a blood pressure measurement module.
There are two methods of sensing blood pressure - invasive and non invasive. The noninva-
sive auscultatory and oscillometric measurements are simpler and quicker than invasive mea-
surements, require less expertise, have virtually no complications, are less unpleasant and less
painful for the patient. However, noninvasive methods may yield somewhat lower accuracy
and small systematic differences in numerical results. Noninvasive measurement methods are
more commonly used for routine examinations and monitoring. Measuring pressure invasively,
by penetrating the arterial wall to take the measurement, is much less common and usually re-
stricted to a hospital setting.
The portability and usefulness can be further augmented with the embedding of project. All code
developed under the .NET architecture will readily run on a Windows CE platform powered by
an Intel Atom processor. The inclusion of a PCI bus based RS232 interface in the target sys-
tem would help improve serial throughput increasing the number of samples deliverable. Many
algorithms and DSP blocks can additionally be implemented to improve the nature, characteris-
tics and usefulness of the results, by reducing noise and emphasizing or annotating appropriate
segments in the resultant display.
Finally the patient modules and the computer can be decoupled by implementation of a wire-
less communication link. This would improve patient safety and prevent a catastrophic reverse
current from flowing to the patient.
78
Index
.NET, 6 hypoxic, 23
AAMI, 40 impedance, 38
AD620, 40 Instrumentation, 38
Ag/AgCl, 38
Korotkoff, 16
Ambulatory, 40
ANC, 15 MySQL, 7
ANR, 15
ATMEGA, 59 Neodymium, 18
AVR, 61 noise, ECG, 24
NR, 15
baseline, 38
PHP, 7
C#, 6 Pulse-oximetry, 18
C-R, 40
closed-loop, 41 RCA, 39
CMRR, 38 registers, 61
RHC, 1
ECG, 9 RS-232, 8
EEPROM, 60
Einthoven, 10 SallenKey, 28
Electrocardiograph, 37 shunt, 40
electrocardiograph, 9 SOIC, 40
Electronic-Stethoscope, 17 SpO2, 20
stethoscopes, 12
field-effect-transistor, 41
FIR, 26 Telemedicine, 66
Flash, 59 timer, 61
transmission, 62
haemoglobin, 20
79
References
[1]
[2]
[3]
80
Bibliography
[1] Arvind Panagariya, India: The Crisis in Rural Health Care, The Economic Times, January
24, 2008
[2] S. Viswanathan, Health care woes: need for doctors and funds, The Hindu, April 18, 2010
[3] Muris Mujagic, Characterization of ECG Noise Sources, 2002
[4] D. L. Carlo, Surface Electromyography: Detection and Recording, 2002
[5] Matti Aksela, Biomedical Signal Processing, 2004
[6] Charles Kitchin, Avoid Common Problems When Designing Amplifier Circuits, Analog
Devices INC.
[7] Brogan et al, The Military Aircraft Command, 1966
[8] Red et al, Electroinc Stethoscope, 1969
[9] Takuo Aoyagi and Michio Kishi, Pulse Oximetry, 1972
[10] Principles of pulse oximetry Anaesthesia, UK 11 Sept 2004
[11] Brand TM, Brand ME, Jay GD. Enamel nail polish does not interfere with pulse oximetry
among normoxic volunteers J Clin Monit Comput. 2002 Feb;17(2):936.
[12] Alireza K Ziarani, Adaibert Konrad have proposed Non linear Adaptive method of elimi-
nation of power line interference in ECG signals.
[13] S.Pooranchandra, N.kumarave have used the wavelet coefficient threshold based hyper
shrinkage function to remove power line frequency.
[14] Santpal Singh Dhillon and Saswat Chakrabarti have used a simplified lattice based adaptive
IIR Notch filter to remove power line interference.
81
Bibliography Bibliography
[15] Mahesh S. Chavan, R.A. Aggarwala, M.D.Uplane have used Digital FIR Filters based on
Rectangular window for the powerline noise reduction.
[16] ChavdarLevkov, Georgy Mihov, Ratcho Ivanov, Ivan Daskalov, Ivaylo Christov, and Ivan
Dotsinsky have used the subtraction procedure to remove the powerline noise
[17] Bio-Semi Research et al, 1999 - 2012
[18] C.W. Hesse, E. Seiss, R.M. Bracewell, P. Praamstra, Absence of gaze direction effects on
EEG measures of sensorimotor function. Clinical Neurophysiology 115 (2004)
[19] Shawn Stevenson, Implementation of FIR Filtering in C, 2002
[20] PCB504 Instrumentation, Oxford University, 2006
[21] Shawn Charson, ECG Measurement System, University Press, Columbia, 2003
82

Internet Connected Low Cost Healthcare Devices For Telemedicine in Rural India

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Internet Connected Low Cost Healthcare Devices For Telemedicine in Rural India

Загружено:

Авторское право:

Доступные форматы

Contents

5 Electronic Stethoscope Module 48

6 Pulse Measurement Module 54

8 Internet Telemedicine System 65

9 Graphical User Interface 69

11 Results and Conclusion 75

2.1 PQRST Waveform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

3.1 Generic Sallen-Key Topology . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

4.1 Block Diagram of ECG Module . . . . . . . . . . . . . . . . . . . . . . . . . 37

5.1 Block Diagram Of Electronic Stethoscope Module . . . . . . . . . . . . . . . 48

6.1 Block Diagram of Pulse Measurement Module . . . . . . . . . . . . . . . . . . 54

6.2 Schematic of Pulse Amplifier . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

7.1 Block Diagram Of ADC and Microcontroller System . . . . . . . . . . . . . . 59

8.1 Block Diagram of Internet Interface . . . . . . . . . . . . . . . . . . . . . . . 65

9.1 ECG Interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

11.1 ECG Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

2.1 Eithoven Vectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3.1 Transfer functions of four standard ideal filters . . . . . . . . . . . . . . . . . . 28

9.1 Summary of interface functions . . . . . . . . . . . . . . . . . . . . . . . . . . 70

10.1 ECG Amplifier BOM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

1.1 Background and Need

1.2 Problem Definition

1.3 Literature Survey

1.3.1 Multi-purpose HealthCare Telemedicine Systems with mobile

Journal: BioMedical Engineering OnLine 2003, 2:7

1.3.2 AC front end for ECG Transaction

IEEE transactions on biomedical engineering, vol. 50, no. 3, march 2003

AC coupling is essential in biopotential measurements. Electrode offset potentials can be several

1.3.3 Removal of power-line interference from the ECG: a review of the

Journal: BioMedical Engineering OnLine 2005, 4:50 doi:10.1186/1475-925X-4-50

1.4 Technology Areas

C# is a multi-paradigm programming language encompassing strong typing, imperative, declar-

1.4.4 Intrasystem communication - Wired

The electrocardiograph is an instrument used to produce a graphic representation of the elec-

Figure 2.1: PQRST Waveform

Figure 2.2: Eithoven Diagram

Unwanted Potentials as well as interference originating from patient-electrode contact.

Lead Name Vector Body Potential

Table 2.1: Eithoven Vectors

2.1.1 Clinical Significance of ECG

2.2 Electronic Stethoscope

Conventional stethoscopes cannot function effectively unless ambient noise is maintained at

Figure 2.3: Commercial Electronic Stethoscope

Laboratory data show exceptional performance of noise reduction stethoscopes in detection of

Conventional stethoscopes (mechanical or electronic) cannot function effectively unless ambient

Currently available technology

active noise cancellation (ANC)

active noise reduction (ANR) and

noise reduction (NR) stethoscopes.

The modular approach

Design and implementation of Electronic-Stethoscope

The digital control system

2.3 Pulse Oximeter

Pulse-oximetry is a non-invasive method allowing the monitoring of the oxygenation of a pa-

The changing absorbance at each of the wavelengths is measured, allowing determination of

Principles of Pulse Oximetry Technology

Figure 2.4: Pulse Oximetry Wavelengths

Figure 2.5: Schematic Representation

advent of "Next Generation"pulse oximetry technology has demonstrated significant improve-

How to interpret your pulse oximeter readings

3.1 Noise in ECG Signals

respiration, causing drift in the baseline

noise coupled from other electronic devices, usually at high frequencies.