Clinical applications of electrical impedance tomography

This article is a preliminary review of the possible clinical applications of electrical impedance tomography (EIT). The applications to, for example, the central nervous, respiratory, cardiovascular and digestive systems are covered. It is concluded that the area of greatest potential application of EIT is monitoring cardiopulmonary function, but that studies on much larger groups of patients than have been carried out hitherto are required to fully assess the potential of EIT as a clinical tool.

Noise and spatial resolution of a real-time electrical impedance tomograph

The Sheffield real-time electrical impedance tomograph produces 25 images per second, using 16 electrodes with adjacent-pair current drive and non-iterative image reconstruction. We describe the data acquisition timing of this instrument and present quantitative measurements of its signal-to-noise ratio and spatial resolution.

Blood flow imaging using electrical impedance tomography

It is shown that a real-time electrical impedance tomography (EIT) system can be used to image the flow of saline through the human vascular system. A 10 ml bolus of 0.9% saline injected intravenously distal to an EIT imaging plane allows venous flow to be observed. Measurements on a cylindrical tank with flow along axial conductive tubes have been used to establish that the area under a concentration against time curve can be obtained from the EIT images and used to determine the flow rate down the tube. In vivo results show that flow images of the venous system in a limb can be obtained and that there is adequate sensitivity to follow the passage of a saline bolus though the cardiac chambers.

Back-projection distortions in applied potential tomography images due to non-uniform reference conductivity distributions

An investigation was conducted to determine and quantify the distortions in applied potential tomography (APT) images reconstructed from data originating from bodies of non-uniform reference conductivity distributions. The results show that the distortions in the images are dependent on the reference conductivity distribution and on whether the images are formed by back projection along the assumed equipotentials of a uniform reference conductivity distribution or along the equipotentials of the true conductivity distribution. We believe that this last finding is significant since our previously held expectation, similar to that of Yorkey and Webster (1987), that back projection along the true equipotentials of the reference conductivity distribution should result in an accurate reconstruction, is shown to be incorrect.

Monitoring body fluid distribution in microgravity using impedance tomography (APT (applied potential tomography))

For an astronaut, the excitement of going into orbit is accompanied by a shift of 1 to 1.5 l of fluid from the legs into the upper body. Information on the way the redistributed fluid is handled by the body is very useful to space physiologists studying the process of adaptation to zero-gravity. Applied potential tomography (APT) can be used to image changes in fluid distribution. To ensure that the technique was capable of measuring fluid shifts induced by changing gravitational forces on the body, a standard Sheffield APT system was used to study several subjects during the eight ESA parabolic flight campaign. The results clearly demonstrated the feasibility of using APT for monitoring fluid redistribution during space flight. A battery-powered, body-worn APT system has now been developed for use in space. The equipment was tested on the eleventh parabolic flight campaign. The data collected with the miniaturised system was comparable to that obtained in the earlier experiment. Ergonomic tests indicated that the equipment is no more difficult to operate and maintain under weightless conditions than on earth. The system is undergoing space qualification tests in Munich. If no problems arise it will be used by German astronauts on missions to MIR and Skylab.

Trans-thoracic fluid shifts and endocrine responses to 6 degrees head-down tilt

A tomographic method of measuring electrical impedance known as Applied Potential Tomography (APT) has been used to image the impedance changes within the thoraxes of 8 healthy volunteers (4 male, 4 female) during 4-h periods of 6 degrees head-down tilt (HDT). A large decrease in impedance, reflecting an increase in thoracic fluid, was apparent within 1 min of tilting, peaked after 45 min, and was maintained throughout, although during the 4 h there was an 8% return towards baseline resistivity. Resistivity changes were most obvious in the region of the lungs. Simultaneous measurements of the key fluid regulating hormones revealed a significant increase in atrial natriuretic peptide (ANP) and a significant decrease in angiotensin II (AII) and aldosterone. There was no significant difference in plasma antidiuretic hormone level. These results illustrate the dynamic nature of fluid shifts during HDT, the spatial distribution of the fluid within the thorax and the associated endocrine responses.

Local blood volume changes in women with pelvic congestion measured by applied potential tomography

1. Applied potential tomography is a new, non-invasive technology for observing changes in blood volume. We have used it to study 12 women with lower abdominal pain caused by pelvic congestion, and 15 control subjects. 2. A significant increase in blood volume of 1.8% was observed in the pelvis of women with congestion when changing from the supine to the erect position, and of 2.7% in the control subjects (P less than 0.0002). The difference between the groups was not significant. 3. The distribution of the area over which blood volume changes took place was significantly different between the two groups (P less than 0.002). More of the posterolateral part of the pelvis was involved in women with pelvic congestion than in the control subjects. 4. Applied potential tomography distinguishes between normal women and those having pelvic congestion with a specificity of 87% and a sensitivity of 75%.

Electrical impedance assessment of muscle changes following exercise

Electrical impedance measurements have been assessed as a method of detecting changes in striated muscle following vigorous exercise. Transverse and longitudinal resistivities of the calf and thigh have been measured before and after four subjects ran a half marathon (21 km). No changes were observed in longitudinal resistivity but transverse resistivity rose by an average of 7% following the race. These results are consistent with changes in the muscle fibre membranes or interstitial fluid content.

Applied potential tomography

Applied Potential Tomography (APT) is a new method of imaging changes in the distribution of electrical resistivity within the human body. Such changes occur during respiration and, because of the movement of blood within the chest, during the cardiac cycle. Changes can also be observed due to redistribution of fluid within the body during simulated weightlessness. As very low electric currents are used to take measurements the method is safe. The equipment is simple and compact and ideal for use in space based measurement of physiological changes in the human body.

Possibilities and problems of real-time imaging of tissue resistivity

We show that the surface potential profiles used for electrical impedance tomography are largely determined by body shape and to a much lesser extent by internal resistivity distribution. The results of 2D finite element modelling show that changes of profile amplitude greater than a factor of four can be expected for the thorax. This offers the possibility of determining body shape from surface potential profiles and hence the determination of static images. Some of the other problems and possibilities of impedance imaging are discussed and in particular the design of a system for real time cardiac gated imaging.

Methods of cardiac gating applied potential tomography

Electrical impedance imaging of the heart, pulmonary perfusion and the great blood vessels can only be achieved by synchronising the data collection with cardiac activity. Due to low signal-to-noise ratio, temporal averaging is needed to improve the image quality. In this study several methods of ECG gating are attempted to synchronise the applied potential tomography (APT) serial data collection with the cardiac cycle. They allow us to collect sequential images time-locked with the R-wave of the patient, and hence image the pulsatile movement of blood. Different methods are examined for their sampling speeds, noise levels and ability to image before systole. A method of image data rearrangement in order to provide an apparent increase in speed is also discussed.

The effect of the skull of low-birthweight neonates on applied potential tomography imaging of centralised resistivity changes

An investigation is presented into the likely effects of the neonatal skull on impedance images produced by applied potential tomography (APT) by imaging impedance changes inside the skull of a human infant of occipito-frontal circumference 30 cm. Measurements have been made with the skull immersed in a tank of saline and electrodes fixed to the perimeter of the tank. Sensitivity measurements have been assessed for imaging a small target close to the centre of the skull as compared with images produced without the skull. The results obtained compare favourably with measurements on a more realistic model of the neonatal head constructed by filling the skull with agar jelly to leave only a thin exterior coating of jelly to simulate the scalp. These experiments suggest that in the central region of the head of a neonate, measured changes by the APT technique are about 44% of that expected from a homogeneous phantom, but that this might vary from 32% to 55% at different points in the image in a very complex manner.

An assessment of dynamic images by applied potential tomography for monitoring pulmonary perfusion

Applied potential tomography (APT) images can be collected at a rate of 24 per second and data collection can be synchronised with the ECG. Images thus obtained from a thoracic plane allow the spatial separation of impedance changes originating in the heart, aorta and lungs and have raised the possibility of detecting pulmonary perfusion abnormalities from the cardiac-related impedance changes in the lungs. We have recently started a study to compare isotope perfusion scans with APT images and present here a few initial examples which suggest that further investigation of this field may prove rewarding.

Applied potential tomography: a new technique for monitoring pulmonary function

An electrical impedance tomographic imaging system has been developed which can monitor changes in the resistivity of the thorax at a rate of 5 frames per second. There is a high correlation (r greater than 0.95) between changes in resistivity of the lungs and the volume of air inspired. Calibration of the system allows continuous monitoring of the level of ventilation on exercise up to a minute volume of 45 l min-1. The volumetric accuracy of the system is generally within +/- 10% of spirometric measurements. Studies of the effect of changes in posture on the calibration of the system show changes of between +9.5% and -3.8% in normal male subjects. The performance of the system compares favourably with existing techniques for the noninvasive monitoring of ventilation.

Errors in reconstruction of resistivity images using a linear reconstruction technique

Reconstruction of electrical impedance images using the filtered back projection method of Barber and Brown makes several important assumptions about the object being imaged. These are principally that the object has a circular boundary, is two-dimensional and of impedance close to uniform, and has electrodes equally spaced on its boundary. In practice few of these assumptions are met, yet the method appears to give sensible and useful images. This paper looks at errors of reconstruction produced by non-ideal placement of the electrodes and shows that the reconstruction method is insensitive to such placement errors.

Problems of cardiac output determination from electrical impedance tomography scans

Impedance variations within the thorax related to cardiac activity have been localised using cardiac gated electrical impedance images. Since quantitative measurements of local variations can be made from those images, electrical impedance tomography gives more valuable information than impedance cardiography (ICG). However, because of the three-dimensional (3D) and non-uniform nature of the sensitivity function, localised measurements from electrical impedance tomography (EIT) scans are related to the position and geometry of the regions in which a resistivity change occurs. For accurate determination of volume changes from conductivity variations, the 3D sensitivity distribution needs to be known.

Comparison of applied potential tomography and impedance epigastrography as methods of measuring gastric emptying

Two new non-invasive methods of measuring gastric emptying, impedance epigastrography (IE) and applied potential tomography (APT) have been compared. Measurements in vitro showed that there is a good correlation between the square of the radius of a glass rod placed in the centre of a tank and values obtained by IE or APT. However, if the rod is moved anteriorly in the tank IE values increase markedly, whereas APT values are unchanged. Both APT and IE can be used to follow gastric emptying of liquid meals; however, the results obtained using APT are more reproducible and have a better correlation with those obtained simultaneously by scintigraphy. Neither method was able accurately to follow gastric emptying unless gastric acid secretion was inhibited by cimetidine.

Determination of upper arm muscle and fat areas using electrical impedance measurements

An electrical impedance technique is described which enables the cross-sectional areas of fat and muscle in the upper arm to be recorded. By making comparisons with measurements obtained using the x-ray technique of computerised tomography (CT) scanning it is shown that fat can be determined to a mean accuracy of 2.3 cm2 and muscle to a mean accuracy of 1.5 mm2. These results are more accurate than a parallel set of measurements made using the traditional anthropometric technique.

Limitations in hardware design in impedance imaging

The collection of data suitable for impedance imaging is a well defined task. Once the number of electrodes is chosen, it is possible to specify the number of independent measurements which must be made. Having done so, a data collection system can be designed; preferably with the view to both maximising the speed of data collection and minimising the noise on the measurements. The former is desirable to eliminate aliasing when taking measurements on regions in which the conductivity varies with time, the latter to ensure maximum image quality. When designing such a system many practical problems become apparent. Some are a result of the electrical components used. In principle these can be overcome, although in practice they will always be important. Other problems arise from the nature of the measurements and the way in which they must be taken. These problems do not depend on how the hardware is implemented. They impose fundamental constraints on the quality of the measurements. The problems in the design of a data collection system are considered here. The design is analysed at the functional rather than electronic level, so the results are of general use. Factors considered include the number of measurements, speed of data collection, noise, bandwidth, isolation, common mode feedback, dynamic range, and quantisation.

Applications of applied potential tomography (APT) in respiratory medicine

Impedance pneumography, electrical impedance measurements of the lung, is a technique which has been widely used to monitor respiration non-invasively and more recently, the onset of pulmonary oedema. Attempts have been made to try to localise the changes in impedance using electrode arrays and electrode guarding. These techniques allow localisation to a particular hemithorax, but the resolution of the majority of the systems remains poor. To assess the performance and possible clinical applications of APT, measurements have been made following increases in lung volume and pulmonary blood volume. During inspiration an increase in both the area and the magnitude of the impedance changes over the area of the lungs was observed. Numerical analysis of the impedance changes in normal subjects reveals a consistently high correlation between the volume of air inspired and the magnitude of the impedance changes. The resolution of the system is sufficient to monitor differences in ventilation in the right and left lung and to measure variations in these levels with posture. Preliminary clinical work suggests that APT may be used to detect ventilatory defects in certain types of lung disease. APT measurements show a decrease in resistivity over the area of the lungs when the pulmonary blood volume is increased by the intravenous infusion of 1.5 litres of isotonic saline. Similar changes in the volume of fluid in the lungs are known to occur in pulmonary oedema. APT measurements of lung impedance may detect the onset of pulmonary oedema in high risk patients.

Localisation of cardiac related impedance changes in the thorax

The existence of variations of normal human thoracic impedance, during the cardiac cycle to high frequency electrical current is well known. Since the impedance variations within the thorax are synchronous with the electrocardiogram (ECG), they are attributed to cardiac activity. They can arise from the change of either the rate of blood flow or the blood volume in the heart chambers, the great blood vessels and the lungs. However, their relative contribution is not known. Many investigators have worked on the non-invasive determination of some cardiac parameters using surface electrode impedance measurements on the thorax. Since the relationships between the measurement results and the pulsatile circulation of blood in various organs inside the chest are not well known, the information determined by surface impedance measurements is not as accurate as the results of invasive techniques. Recent advances in the clinical use of applied potential tomography (APT), or electrical impedance imaging, showed that the APT system gives a good soft-tissue contrast and has good sensitivity to resistivity changes. It is therefore concluded that the origin of thoracic impedance changes related to cardiac activity can be deduced from APT images. Our initial studies of ECG gated dynamic APT images of the thorax show that cardiac related thoracic impedance variations originating from different organs can be separated. Sequential APT images of the thorax during the cardiac cycle are presented. The movement of blood from the ventricles to the lungs and vascular system and back to the ventricles is observable in these images.(ABSTRACT TRUNCATED AT 250 WORDS)

Applied potential tomography: a new non-invasive technique for assessing gastric function

Applied potential tomography is a new, non-invasive technique that yields sequential images of the resistivity of gastric contents after subjects have ingested a liquid or semi-solid meal. This study validates the technique as a means of measuring gastric emptying. Experiments in vitro showed an excellent correlation between measurements of resistivity and either the square of the radius of a glass rod or the volume of water in a spherical balloon when both were placed in an oval tank containing saline. Altering the lateral position of the rod in the tank did not alter the values obtained. Images of abdominal resistivity were also directly correlated with the volume of air in a gastric balloon. Profiles of gastric emptying of liquid meals obtained using APT were very similar to those obtained using scintigraphy or dye dilution techniques provided that acid secretion was inhibited by cimetidine. Profiles of emptying of a mashed potato meal using APT were also very similar to those obtained by scintigraphy. Measurements of the emptying of a liquid meal from the stomach were reproducible if acid secretion was inhibited by cimetidine. Thus, APT is an accurate and reproducible method of measuring gastric emptying of liquids and particulate food. It is inexpensive, well tolerated, easy to use and ideally suited for multiple studies in patients, even those who are pregnant. A preliminary study is also presented that assesses the technique as a means of measuring gastric acid secretion. Comparison of resistivity changes with measured acid secretion following the injection of pentagastrin shows good correlations. APT might offer a non-invasive alternative to the use of a nasogastric tube and acid collection.

Theoretical limits to sensitivity and resolution in impedance imaging

In any practical impedance imaging system it is important to be able to predict the image quality which can be expected from particular measurements. It is of interest both to establish the smallest object that can be detected for a certain noise level and to determine the maximum resolution for a certain number of electrodes. In impedance imaging this is not straightforward. The reason is that the resolution and the accuracy of an image which represents a conductive region are related to the number of electrodes and to the noise on the measurements. They also vary with position in the image and depend on the particular distribution of conductivity itself. It is therefore not possible, in general, to make quantitative statements about the resolution and accuracy. It is of course possible to make qualitative statements, but they are not of much use in any particular situation. Formulations are presented here which do allow quantitative assessment of the resolution and accuracy in a certain class of conductive regions. The regions to which they apply are two-dimensional and have a circular boundary shape. The details of the approach are included, both mathematically and descriptively. The quantitative improvement in image quality which can be obtained by reducing the noise, is shown both in terms of accuracy and resolution. The limit to the improvement in quality which can be obtained by taking unlimited independent measurements (i.e. using an unlimited number of electrodes) is calculated. It is shown how to predict the smallest sized object that can just be detected by measurements with a known level of noise.

The Sheffield data collection system

Because of the intrinsically low sensitivity of any surface potential measurement to resistivity changes within a volume conductor, any data collection system for impedance imaging must be sensitive to changes in the peripheral potential profile of the order of 0.1%. For example, whilst the resistivity changes associated with lung ventilation and the movement of blood during the cardiac cycle range from 3 to 100% the changes recorded at the surface are very much less than this. The Sheffield data collection system uses 16 electrodes which are addressed through 4 multiplexers. Overall system accuracy is largely determined by the front-end equivalent circuit which is considered in some detail. This equivalent circuit must take into account wiring and multiplexer capacitances. A current drive of 5 mA p-p at 5 kHz is multiplexed to adjacent pairs of electrodes and peripheral potential profiles are recorded by serially stepping around adjacent electrode pairs. The existing Sheffield system collects the 208 data points for one image in 79 ms and offers 10 image data sets per second to the microprocessor. For a homogeneous circular conductor the ratio of the maximum to minimum signals within each peripheral potential profile is 45:1. The temptation to increase the number of electrodes in order to improve resolution is great and an achievable performance for 128 electrodes is given. However, any improvement in spatial resolution can only be made at the expense of speed and sensitivity which may well be the more important factors in determining the clinical utility of APT.

Applied potential tomography. A new noninvasive technique for measuring gastric emptying

Applied potential tomography is a new, noninvasive technique that yields sequential images of the resistivity of gastric contents after subjects have ingested a liquid or semisolid meal. This study validates the technique as a means of measuring gastric emptying. Experiments in vitro showed an excellent correlation between measurements of resistivity and either the square of the radius of a glass rod or the volume of water in a spherical balloon when both were placed in an oval tank containing saline. Altering the lateral position of the rod in the tank did not alter the values obtained. Images of abdominal resistivity were also directly correlated with the volume of air in a gastric balloon. Profiles of gastric emptying of liquid meals obtained using applied potential tomography were very similar to those obtained using scintigraphy or dye dilution techniques, provided that acid secretion was inhibited by cimetidine. Profiles of emptying of a mashed potato meal using applied potential tomography were also very similar to those obtained by scintigraphy. Measurements of the emptying of a liquid meal from the stomach were reproducible if acid secretion was inhibited by cimetidine. Thus, applied potential tomography is an accurate and reproducible method of measuring gastric emptying of liquids and particulate food. It is inexpensive, well tolerated, easy to use, and ideally suited for multiple studies in patients, even those who are pregnant.