fig1 schematically illustrates the main components of a system used for the implementation of the present disclosure . the system includes a holter device 10 connected to various sensors or electrodes 12 , 14 , 16 , for measuring physiological signals such as heart rate , respiration , oxygen saturation , pulse wave , phonocardiogram , etc . in the following , we will focus mainly on the respiratory amplitude or respiratory pressure , which are simple parameters to obtasin . however , this measure is not intended to be restrictive and the disclosed systems and methods can be as well implemented from other physiological signals collected from the patient . the system further includes a kinesthetic stimulation device , with a generator housing 18 producing pulses for control of a stimulation kinesthetic effector 20 , consisting , for example , of a vibrator disposed in a sensitive region of the skin , typically ( in adults ) in the mastoid bone region near the ear . vibrotactile stimulation applied to the skin by the effector 20 is detected by the sensory receptors or mechanoreceptors of the body , and this information is transmitted through sensory nerves to the autonomous central nervous system . the effector 20 is , for example , a transducer such as c10 - 100 of precision microdrives or c2 tactor of engineering acoustics . the transducer is of a few grams which can emit vibrations due to an integrated vibrator excited by pulse trains of variable amplitude and length , typically at a frequency of 250 hz which is the nominal resonance frequency of this particular effector , and which is also the frequency at which the mechanoreceptors of the skin are the most sensitive . however , other types of effectors can also be used effectively . the control box 18 is controlled by a microcontroller which is configured to adjust the intensity ( i . e ., the energy ) of kinesthetic stimulation by controlled variation of the amplitude , the number , the duration , and / or the frequency of the stimulation pulse trains forming the signal applied to the effector 20 . the system also includes a housing 22 coupled to the holter device 10 and to the control box 18 by a respective wire or wireless connection 24 , 26 , to receive data from the holter device 10 , process such data and in response produce information of kinesthetic stimulation control to be transmitted to the control box 18 . alternatively , data processing and control of the control box 18 can be operated within the holter device 10 and transmitted directly by a link 28 to the housing 18 . finally , the system is configured to measure the respiratory rate , for example a nasal pressure cannula 30 ( and / or an oral cannula ) or other type of sensor such as a thermistor or a mechanical sensor of the abdomen and / or the thoracic cavity volume changes ( e . g ., by a belt equipped with sensors sensitive to stretching ). a ventilatory signal is delivered to the holter device 10 which is continuously analyzed in order to detect in real time the occurrence of an apnea or of a hypopnea . the system operates as follows : when apnea is detected by the holter device 10 , the control box 18 triggers a kinesthetic stimulus to trigger a response of the autonomic nervous system so that , in response , the autonomic nervous system causes a change in respiration and therefore triggers a respiratory reflex that stops the apnea . the energy with which the stimulation is performed determines the success of the therapy . if the stimulation energy is too low , it is not effective . if the stimulation energy is too high , there is a risk of waking the patient . if the stimulation energy is too repetitive , a habituation phenomenon can be created , which may in turn reduce the effectiveness of the stimulation . furthermore , the same energy may have a different effectiveness depending on the patient , the sleep stage or even the apneic event itself . the system as described with reference to fig1 is able to optimize the energy of kinesthetic stimulation to alleviate the above problems in real - time . it is understood that to modulate the “ energy ” of stimulation , the following parameters can be modified : the intensity of vibration stimulation , the frequency of occurrence , the number of pulses or pulse trains , the envelope shape , etc ., or any combination of these parameters . the optimization of the energy is carried out first with an initialization based on patient parameters . the initialization sets the initial stimulation energy . the efficiency of the same energy delivered under the same conditions ( e . g ., same episode of apnea , same sleep stage ) may change depending on the patient &# 39 ; s physical characteristics such as gender , age and body mass index ( bmi ). thus , the more the subject is aged , the larger the energy must be to achieve the same effectiveness . similarly , when the bmi increases , the energy must also be increased . the system is then able to adapt the energy needed for processing during the night and optionally in the same episode as a function of the effectiveness of the stimulation and of the risk of awakening . according to a particular implementation , and with reference to fig2 , by default an energy table based on these three parameters ( gender , age and bmi — fig2 showing a table for one gender only ) is established and stored according to clinical data available in the field . for this purpose , a population of patients with sleep apnea is subject to stimulation during polysomnography with varying stimulation energy , for example randomly varying . the effectiveness of the stimulation is measured and the analysis of the population allows for determining the minimum effective energies based on clinical patients characteristics . at the initiation of the stimulation system , the data is requested from the user and by default the energy value is then stored as the initial value based on the data . the ability to update the data is advantageously provided in the case where a significant drop or gain in patient weight occurs which may change the effectiveness of the therapy if the system does not modify the energy accordingly . fig2 shows , in addition to the value table , the modalities for determining the starting energy . the gender , bmi value and age are entered into the system using a user interface ( e . g ., touchscreen , keyboard - screen combination , etc .) either directly by the physician on the system during a consultation or , always by the physician , via a network connection , or via the patient himself ( e . g ., using a scale connected by local network such as bluetooth to the system ). the system then uses the data table above , stored in its memory , to determine the appropriate starting energy based on these parameters . from this initialization , the system is capable of varying the stimulation energy to maintain efficient energy but without causing the patient to awaken . thus , referring to fig3 , after switching on the apparatus ( step 100 ) the initialization of the stimulation energy value described above is implemented ( step 200 ). when an event to be processed ( apnea or hypopnea detection in step 300 ) occurs , an algorithm executed in the system control unit first determines an energy that will be used at the start of processing ( step 400 , detailed in fig4 c ). then , during the processing phase ( step 500 , detailed in fig3 a ), the energy can change depending on the observed efficacy and on an upper limit related to the risk of awakening . after completing the event , the system is able to optimize the energy to be used during the update values phase ( step 600 , detailed in fig3 b ). details of this method are illustrated in fig3 a to 3d . first referring to fig3 a , which details the processing step 500 . once the initial energy has been determined and an apnea or hypopnea has been detected ( step 510 ), the system applies stimulation energy with the initial energy ( step 520 ). if the system detects a breathing disorder has stopped ( step 530 ), the system stores the energy as effective ( step 540 ). otherwise , the system increases the stimulation energy setpoint by a given increment ( step 560 ) and triggers a new stimulation ( return to step 520 ) with the new energy setpoint and continues the stimulation until the breathing disorder has stopped . between steps 530 and 560 , a step 550 is further provided to limit the stimulation energy applied to an admissible maximum energy , which can be an absolute energy value or can depend on criteria of gender , age , bmi index and possibly other criteria , including the patient &# 39 ; s sleep stage ( slow - wave sleep i , ii , iii , iv and rem sleep ), the maximum energy being a function of the sleep stage . step 550 may be improved by providing that in the case of achieving the maximum allowable energy value , the system identifies , using the different sensors 12 , 14 , 16 and 30 , if the episode of respiratory disorder is a serious episode ( e . g ., apnea too long , a desaturating episode , etc .) ( step 570 ). if so , the stimulation energy is again increased by one increment ( step 560 ) to exceed the maximum permissible value , and a new stimulation therapy is performed ( step 520 ), to ensure the disappearance of the disorder , but with the risk of waking the patient . fig3 b illustrates in detail the method 600 of updating the two variable energy values , i . e . the value of the energy considered effective to make the disorder disappear and the maximum allowable energy . this update is performed at the end of each therapy . in step 620 , the system determines if the effective energy value was incremented at step 560 during the previous therapy . if so , the starting setpoint energy for the next therapy is determined as the effective energy value after incremention ( step 630 ). if not , the setpoint energy is decreased to prevent upward drift ( step 640 ). regarding the maximum permissible value , the system determines if the previous processing stage 500 caused a patient awakening ( step 650 ) and , if so , determines at step 660 if the energy level that caused this awakening is or is not less than the maximum permissible value at the time of therapy . if so , the system has a new fixed maximum permissible energy value that caused the awakening ( step 670 ). the detection of the awakening may vary depending on the application . for example , the detection can be done by simply using an activator actuated by the patient when he wakes . the detection can also be done automatically using an actimetry sensor or through the study of the evolution of ventilation as described in ep 1317943 a1 ( sorin crm ), which is hereby incorporated by reference in its entirety . if , however , at the test of step 650 it is determined that the previous therapy phase 500 did not cause awakening , the system determines whether the stimulation energy at the end of therapy ( thus resulting in the cessation of disorder , without revival ) was greater than the current maximum permissible value ( step 680 ). if so , the system sets a new maximum permissible value as a value equal to the previous value increased by a given increment . it is understood that these two adjustments allow for optimization of the delivered stimulation energy , increasing the chances of reaching a cessation of the disorder episode while minimizing the risk of awakening . in this example , the optimization is done continuously during the night after each treated episodes . in a simplified version , it is also possible to optimize the delivered energy values only after a whole night , based on the success rate of therapy and the wakeup ratio of the previous night for application for the current night . fig3 c illustrates step 200 in detail , i . e . the method by which energy is determined during when starting a therapy according to the latest energy used and to the maximum permissible value . in step 410 , the system determines if a sleep disorder episode is the first episode of the night , which can be easily determined using an incremental counting of episodes . if so , the system uses the initially determined energy based on the parameters of gender , age and bmi index ( step 420 ) for the first therapy . if not , the system determines ( step 430 ) if the effective value used in a previous episode is less than the maximum permissible value used for the previous episode . if so , the initial energy value is set as the energy value that was effective in the previous episode ( step 440 ). if not , the system uses as a starting energy value the maximum permissible value used in the previous episode ( step 450 ). the above description is given as an example for an application considering only one type of respiratory disorder . depending on the types of respiratory disorders , e . g . apnea , central or obstructive hypopnea , flow rate limiting , etc ., it will be understood that the adjustment rules of the stimulation energy may be different . notably , the first issued energy level will be adjusted . as fig3 shows , an optional step 700 is provided between the steps 100 and 200 and the system determines the type of disorder , independently using the sensors 12 , 14 and 16 or by input made by the patient or by a caregiver treating the found type of disorder prior to start - up . fig3 d explains step 700 . three types of disorders can be selectively diagnosed ( steps 710 , 720 , 730 ). depending on the type of detected disorder , the system chooses a certain energy of initial stimulation ( steps 712 , 722 , 732 ), and then applies a kinesthetic therapy as before ( steps 714 , 724 , 734 ), and updates the values of admissible effective energy as before ( steps 716 , 726 , 736 ) for each of the types of disorders . the maximum permissible energy value can be commonly chosen for the different types of disorders ( step 740 ).
the disclosure relates to a device including a processor configured to detect a respiratory disorder episode and generate kinesthetic stimulation control signals in response to the detection of a respiratory disorder episode . the device further includes at least one kinesthetic effector adapted to be applied to a patient &# 39 ; s outer skin site and includes a vibrating electromechanical transducer capable of receiving stimulation control signals and outputting a kinesthetic stimulation energy determined by the stimulation control signals . the processor is further configured to determine the effectiveness of stimulation by detecting a cessation of the respiratory disorder episode . the processor is further configured to determine a stimulation energy by selecting an initial energy value and varying the energy value as a function of the effectiveness of previous stimulation .