Determinants of pulmonary perfusion measured by electrical impedance tomography

Prone positioning improves ventilation-perfusion matching assessed by electrical impedance tomography in patients with ARDS: a prospective physiological study

BACKGROUND

The physiological effects of prone ventilation in ARDS patients have been discussed for a long time but have not been fully elucidated. Electrical impedance tomography (EIT) has emerged as a tool for bedside monitoring of pulmonary ventilation and perfusion, allowing the opportunity to obtain data. This study aimed to investigate the effect of prone positioning (PP) on ventilation-perfusion matching by contrast-enhanced EIT in patients with ARDS.

DESIGN

Monocenter prospective physiologic study.

SETTING

University medical ICU.

PATIENTS

Ten mechanically ventilated ARDS patients who underwent PP.

INTERVENTIONS

We performed EIT evaluation at the initiation of PP, 3 h after PP initiation and the end of PP during the first PP session.

MEASUREMENTS AND MAIN RESULTS

The regional distribution of ventilation and perfusion was analyzed based on EIT images and compared to the clinical variables regarding respiratory and hemodynamic status. Prolonged prone ventilation improved oxygenation in the ARDS patients. Based on EIT measurements, the distribution of ventilation was homogenized and dorsal lung ventilation was significantly improved by PP administration, while the effect of PP on lung perfusion was relatively mild, with increased dorsal lung perfusion observed. The ventilation-perfusion matched region was found to increase and correlate with the increased PaO₂/FiO₂ by PP, which was attributed mainly to reduced shunt in the lung.

CONCLUSIONS

Prolonged prone ventilation increased dorsal ventilation and perfusion, which resulted in improved ventilation-perfusion matching and oxygenation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04725227. Registered on 25 January 2021.

Lung Ultrasound and Electrical Impedance Tomography During Ventilator-Induced Lung Injury

OBJECTIVES

Lung damage during mechanical ventilation involves lung volume and alveolar water content, and lung ultrasound (LUS) and electrical impedance tomography changes are related to these variables. We investigated whether these techniques may detect any signal modification during the development of ventilator-induced lung injury (VILI).

DESIGN

Experimental animal study.

SETTING

Experimental Department of a University Hospital.

SUBJECTS

Forty-two female pigs (24.2 ± 2.0 kg).

INTERVENTIONS

The animals were randomized into three groups (n = 14): high tidal volume (TV) (mean TV, 803.0 ± 121.7 mL), high respiratory rate (RR) (mean RR, 40.3 ± 1.1 beats/min), and high positive-end-expiratory pressure (PEEP) (mean PEEP, 24.0 ± 1.1 cm H2O). The study lasted 48 hours. At baseline and at 30 minutes, and subsequently every 6 hours, we recorded extravascular lung water, end-expiratory lung volume, lung strain, respiratory mechanics, hemodynamics, and gas exchange. At the same time-point, end-expiratory impedance was recorded relatively to the baseline. LUS was assessed every 12 hours in 12 fields, each scoring from 0 (presence of A-lines) to 3 (consolidation).

MEASUREMENTS AND MAIN RESULTS

In a multiple regression model, the ratio between extravascular lung water and end-expiratory lung volume was significantly associated with the LUS total score (p < 0.002; adjusted R2, 0.21). The variables independently associated with the end-expiratory difference in lung impedance were lung strain (p < 0.001; adjusted R2, 0.18) and extravascular lung water (p < 0.001; adjusted R2, 0.11).

CONCLUSIONS

Data suggest as follows. First, what determines the LUS score is the ratio between water and gas and not water alone. Therefore, caution is needed when an improvement of LUS score follows a variation of the lung gas content, as after a PEEP increase. Second, what determines the end-expiratory difference in lung impedance is the strain level that may disrupt the intercellular junction, therefore altering lung impedance. In addition, the increase in extravascular lung water during VILI development contributed to the observed decrease in impedance.

Lung Perfusion Assessment by Bedside Electrical Impedance Tomography in Critically Ill Patients

As a portable, radiation-free imaging modality, electrical impedance tomography (EIT) technology has shown promise in the bedside visual assessment of lung perfusion distribution in critically ill patients. The two main methods of EIT for assessing lung perfusion are the pulsatility and conductivity contrast (saline) bolus method. Increasing attention is being paid to the saline bolus EIT method in the evaluation of regional pulmonary perfusion in clinical practice. This study seeks to provide an overview of experimental and clinical studies with the aim of clarifying the progress made in the use of the saline bolus EIT method. Animal studies revealed that the saline bolus EIT method presented good consistency with single-photon emission CT (SPECT) in the evaluation of lung regional perfusion changes in various pathological conditions. Moreover, the saline bolus EIT method has been applied to assess the lung perfusion in a pulmonary embolism and the effect of positive end-expiratory pressure (PEEP) on regional ventilation/perfusion ratio (V/Q) and acute respiratory distress syndrome (ARDS) in several clinical studies. The implementation of saline boluses, data analyses, precision, and cutoff values varied among different studies, and a consensus must be reached regarding the clinical application of the saline bolus EIT method. Further study is required to validate the impact of the described saline bolus EIT method on decision-making, therapeutic management, and outcomes in critically ill patients.

Electrical impedance tomography detects changes in ventilation after airway clearance in spinal muscular atrophy type I

The effect of mechanical insufflation-exsufflation (MIE) for airway clearance in patients with spinal muscular atrophy type I (SMA-I) on the distribution of ventilation in the lung is unknown, as is the duration of its beneficial effects. A pilot study to investigate the feasibility of using three dimensional (3-D) electrical impedance tomography (EIT) images to estimate lung volumes pre- and post-MIE for assessing the effectiveness of mechanical insufflation-exsufflation (MIE) was conducted in 6 pediatric patients with SMA-I in the neuromuscular clinic at Children's Hospital Colorado. EIT data were collected before, during, and after the MIE procedure on two rows of 16 electrodes placed around the chest. Lung volumes were computed from the images and compared before, during, and after the MIE procedure to assess the ability of EIT to estimate changes in lung volume during insufflation and exsufflation. Images of pulsatile pulmonary perfusion were computed in subjects able to perform breath-holding. In four of the six subjects, lung volumes during tidal breathing increased after MIE (average change from pre to post MIE was 58.8±55.1 mL). The time-dependent plots of lung volume computed from the EIT data clearly show when the MIE device insufflates and exsufflates air and the rest periods between mechanical coughs. Images of pulmonary pulsatile perfusion were computed from data collected during breathing pauses. The results suggest that EIT holds promise for estimating lung volumes and ventilation/perfusion mismatch, both of which are useful for assessing the effectiveness of MIE in clearing mucus plugs.

Electrical impedance tomography in pulmonary arterial hypertension

The characterization of pulmonary arterial hypertension (PAH) relies mainly on right heart catheterization (RHC). Electrical impedance tomography (EIT) provides a non-invasive estimation of lung perfusion that could complement the hemodynamic information from RHC. To assess the association between impedance variation of lung perfusion (ΔZ_Q) and hemodynamic profile, severity, and prognosis, suspected of PAH or worsening PAH patients were submitted simultaneously to RHC and EIT. Measurements of ΔZ_Q were obtained. Based on the results of the RHC, 35 patients composed the PAH group, and eight patients, the normopressoric (NP) group. PAH patients showed a significantly reduced ΔZ_Q compared to the NP group. There was a significant correlation between ΔZ_Q and hemodynamic parameters, particularly with stroke volume (SV) (r = 0.76; P < 0.001). At 60 months, 15 patients died (43%) and 1 received lung transplantation; at baseline they had worse hemodynamics, and reduced ΔZ_Q when compared to survivors. Patients with low ΔZ_Q (≤154.6%.Kg) presented significantly worse survival (P = 0.033). ΔZ_Q is associated with hemodynamic status of PAH patients, with disease severity and survival, demonstrating EIT as a promising tool for monitoring patients with pulmonary vascular disease.

Regional Lung Perfusion Analysis in Experimental ARDS by Electrical Impedance and Computed Tomography

Electrical impedance tomography is clinically used to trace ventilation related changes in electrical conductivity of lung tissue. Estimating regional pulmonary perfusion using electrical impedance tomography is still a matter of research. To support clinical decision making, reliable bedside information of pulmonary perfusion is needed. We introduce a method to robustly detect pulmonary perfusion based on indicator-enhanced electrical impedance tomography and validate it by dynamic multidetector computed tomography in two experimental models of acute respiratory distress syndrome. The acute injury was induced in a sublobar segment of the right lung by saline lavage or endotoxin instillation in eight anesthetized mechanically ventilated pigs. For electrical impedance tomography measurements, a conductive bolus (10% saline solution) was injected into the right ventricle during breath hold. Electrical impedance tomography perfusion images were reconstructed by linear and normalized Gauss-Newton reconstruction on a finite element mesh with subsequent element-wise signal and feature analysis. An iodinated contrast agent was used to compute pulmonary blood flow via dynamic multidetector computed tomography. Spatial perfusion was estimated based on first-pass indicator dilution for both electrical impedance and multidetector computed tomography and compared by Pearson correlation and Bland-Altman analysis. Strong correlation was found in dorsoventral (r = 0.92) and in right-to-left directions (r = 0.85) with good limits of agreement of 8.74% in eight lung segments. With a robust electrical impedance tomography perfusion estimation method, we found strong agreement between multidetector computed and electrical impedance tomography perfusion in healthy and regionally injured lungs and demonstrated feasibility of electrical impedance tomography perfusion imaging.

A narrative review of electrical impedance tomography in lung diseases with flow limitation and hyperinflation: methodologies and applications

Electrical impedance tomography (EIT) is a functional radiation-free imaging technique that measures regional lung ventilation distribution by calculating the impedance changes in the corresponding regions. The aim of the present review was to summarize the current literature concerning the methodologies and applications of EIT in lung diseases with flow limitation and hyperinflation. PubMed was searched up to May 2020 to identify studies investigating the use of EIT in patients with asthma, bronchiectasis, bronchitis, bronchiolitis, chronic obstructive pulmonary disease, and cystic fibrosis. The extracted data included study design, EIT methodologies, interventions, validation and comparators, population characteristics, and key findings. Of the 44 included studies, seven were related to simulation, animal experimentation, or reconstruction algorithm development with evaluation on patients; 27 studies had the primary objective of validating EIT technique and measures including regional ventilation distribution, regional EIT-spirometry parameters, end-expiratory lung impedance, and regional time constants; and 10 studies had the primary objective of applying EIT to monitor the response to therapeutic interventions, including various ventilation supports, patient repositioning, and airway suctioning. In pediatric and adult patients, EIT has been successfully validated for assessing spatial and temporal ventilation distribution, measuring changes in lung volume and flow, and studying regional respiratory mechanics. EIT has also demonstrated potential as an alternative or supplement to well-established measurement modalities (e.g., conventional pulmonary function testing) to monitor the progression of obstructive lung diseases, although the existing literature lacks prediction values as references and lacks clinical outcome evidence.

Dominant-Current Deep Learning Scheme for Electrical Impedance Tomography

OBJECTIVE

Deep learning has recently been applied to electrical impedance tomography (EIT) imaging. Nevertheless, there are still many challenges that this approach has to face, e.g., targets with sharp corners or edges cannot be well recovered when using circular inclusion training data. This paper proposes an iterative-based inversion method and a convolutional neural network (CNN) based inversion method to recover some challenging inclusions such as triangular, rectangular, or lung shapes, where the CNN-based method uses only random circle or ellipse training data.

METHODS

First, the iterative method, i.e., bases-expansion subspace optimization method (BE-SOM), is proposed based on a concept of induced contrast current (ICC) with total variation regularization. Second, the theoretical analysis of BE-SOM and the physical concepts introduced there motivate us to propose a dominant-current deep learning scheme for EIT imaging, in which dominant parts of ICC are utilized to generate multi-channel inputs of CNN.

RESULTS

The proposed methods are tested with both numerical and experimental data, where several realistic phantoms including simulated pneumothorax and pleural effusion pathologies are also considered.

CONCLUSIONS AND SIGNIFICANCE

Significant performance improvements of the proposed methods are shown in reconstructing targets with sharp corners or edges. It is also demonstrated that the proposed methods are capable of fast, stable, and high-quality EIT imaging, which is promising in providing quantitative images for potential clinical applications.

Evaluation of surrogate measures of pulmonary function derived from electrical impedance tomography data in children with cystic fibrosis

OBJECTIVE

Lung function monitoring by spirometry plays a critical role in the clinical care of pediatric cystic fibrosis (CF) patients, but many young children are unable to perform spirometry, and the outputs are often normal even in the presence of lung disease. Measures derived from electrical impedance tomography (EIT) images were studied for their utility as potential surrogates for spirometry in CF patients and to assess response to intravenous antibiotic treatment for acute pulmonary exacerbations (PEx) in a subset of patients.

APPROACH

EIT data were collected on 35 subjects (21 with CF, 14 healthy controls, 8 CF patients pre- and post-treatment for an acute PEx) ages 2 to 20 years during tidal breathing and also concurrently with spirometry on subjects over age 8. EIT-derived measures of FEV1, FVC, and FEV1/FVC were computed globally and regionally from dynamic EIT images.

MAIN RESULTS

Global EIT-derived FEV1/FVC showed good correlation with spirometry FEV1/FVC values (r  =  0.54, p  =  0.01), and were able to distinguish between the groups (p  =  0.01). Lung heterogeneity was assessed through the spatial coefficient of variation (CV) of EIT difference images between key time points, and the CVs for EIT-derived FEV1 and FVC showed significant correlation with the CV for tidal breathing (r  =  0.47, p  =  0.01 and r  =  0.50, p  =  0.01, respectively). Global EIT-derived FEV1/FVC was better able to distinguish between groups than spirometry FEV1 (F-values 776.5 and 146.3, respectively, p  <  0.01.) The same held true for the CVs for EIT-derived FEV1, FVC, and tidal breathing (F-values 215.93, 193.89, 204.57, respectively, p  <  0.01).

SIGNIFICANCE

The strong correlation between the CVs for tidal breathing, FEV1, and FVC, and the statistically significant ability of CV for tidal breathing to distinguish between healthy subjects and CF patients, and between the studied CF disease states suggests that the CV may be useful for measuring the extent and severity of structural lung disease.

Estimation of Stroke Volume and Stroke Volume Changes by Electrical Impedance Tomography

BACKGROUND

Electrical impedance tomography (EIT) is a noninvasive imaging method that identifies changes in air and blood volume based on thoracic impedance changes. Recently, there has been growing interest in EIT to measure stroke volume (SV). The objectives of this study are as follows: (1) to evaluate the ability of systolic impedance variations (ΔZsys) to track changes in SV in relation to a baseline condition; (2) to assess the relationship of ΔZsys and SV in experimental subjects; and (3) to identify the influence of body dimensions on the relationship between ΔZsys and SV.

METHODS

Twelve Agroceres pigs were instrumented with transpulmonary thermodilution catheter and EIT and were mechanically ventilated in a random order using different settings of tidal volume (VT) and positive end-expiratory pressure (PEEP): VT 10 mL·kg and PEEP 10 cm H2O, VT 10 mL·kg and PEEP 5 cm H2O, VT 6 mL·kg and PEEP 10 cm H2O, and VT 6 mL·kg and PEEP 5 cm H2O. After baseline data collection, subjects were submitted to hemorrhagic shock and successive fluid challenges.

RESULTS

A total of 204 paired measurements of SV and ΔZsys were obtained. The 4-quadrant plot showed acceptable trending ability with a concordance rate of 91.2%. Changes in ΔZsys after fluid challenges presented an area under the curve of 0.83 (95% confidence interval, 0.74-0.92) to evaluate SV changes. Conversely, the linear association between ΔZsys and SV was poor, with R from linear mixed model of 0.35. Adding information on body dimensions improved the linear association between ΔZsys and SV up to R from linear mixed model of 0.85.

CONCLUSIONS

EIT showed good trending ability and is a promising hemodynamic monitoring tool. Measurements of absolute SV require that body dimensions be taken into account.

Electrical impedance tomography: Amplitudes of cardiac related impedance changes in the lung are highly position dependent

BACKGROUND

Electrical impedance tomography (EIT) is used on the thorax to measure impedance changes due to the presence of air and blood in the lung. This experimental study was performed to investigate the effect of posture on cardiac and respiratory related impedance changes.

METHODS

EIT measurements were performed on 14 healthy subjects in left-, right lateral, prone, supine and upright positions. Simultaneously, tidal volume was recorded with an ultrasonic flowmeter. For image reconstruction, the classic Sheffield back-projection and three variants of the modern GREIT algorithm were applied with two different reference frames. Amplitudes of cardiac- and respiratory impedance changes were extracted and compared between the positions.

RESULTS

We found significant differences in both cardiac and respiratory amplitudes between postures. Especially, supine and upright positions showed dramatic changes in amplitude. These differences between postures were unaffected by the change of reference frames in all reconstruction methods except of the classic Sheffield back projection. Possible sources that explain the observed posture dependency are discussed.

CONCLUSION

Researchers and clinicians need to be aware of this phenomenon when comparing EIT amplitudes in different body positions.

A Real-time D-bar Algorithm for 2-D Electrical Impedance Tomography Data

The aim of this paper is to show the feasibility of the D-bar method for real-time 2-D EIT reconstructions. A fast implementation of the D-bar method for reconstructing conductivity changes on a 2-D chest-shaped domain is described. Cross-sectional difference images from the chest of a healthy human subject are presented, demonstrating what can be achieved in real time. The images constitute the first D-bar images from EIT data on a human subject collected on a pairwise current injection system.

Hyperoxia affects the regional pulmonary ventilation/perfusion ratio: an electrical impedance tomography study

BACKGROUND

The way in which hyperoxia affects pulmonary ventilation and perfusion is not fully understood. We investigated how an increase in oxygen partial pressure in healthy young volunteers affects pulmonary ventilation and perfusion measured by thoracic electrical impedance tomography (EIT).

METHODS

Twelve semi-supine healthy male volunteers aged 21-36 years were studied while breathing room air and air-oxygen mixtures (FiO2) that resulted in predetermined transcutaneous oxygen partial pressures (tcPO2) of 20, 40 and 60 kPa. The magnitude of ventilation (ΔZv) and perfusion (ΔZQ)-related changes in cyclic impedance variations, were determined using an EIT prototype equipped with 32 electrodes around the thorax. Regional changes in ventral and dorsal right lung ventilation (V) and perfusion (Q) were estimated, and V/Q ratios calculated.

RESULTS

There were no significant changes in ΔZv with increasing tcPO2 levels. ΔZQ in the dorsal lung increased with increasing tcPO2 (P = 0.01), whereas no such change was seen in the ventral lung. There was a simultaneous decrease in V/Q ratio in the dorsal region during hyperoxia (P = 0.04). Two subjects did not reach a tcPO2 of 60 kPa despite breathing 100% oxygen.

CONCLUSION

These results indicate that breathing increased concentrations of oxygen induces pulmonary vasodilatation in the dorsal lung even at small increases in FiO2. Ventilation remains unchanged. Local mismatch of ventilation and perfusion occurs in young healthy men, and the change in ventilation/perfusion ratio can be determined non-invasively by EIT.

Direct EIT reconstructions of complex admittivities on a chest-shaped domain in 2-D

Electrical impedance tomography (EIT) is a medical imaging technique in which current is applied on electrodes on the surface of the body, the resulting voltage is measured, and an inverse problem is solved to recover the conductivity and/or permittivity in the interior. Images are then formed from the reconstructed conductivity and permittivity distributions. In the 2-D geometry, EIT is clinically useful for chest imaging. In this work, an implementation of a D-bar method for complex admittivities on a general 2-D domain is presented. In particular, reconstructions are computed on a chest-shaped domain for several realistic phantoms including a simulated pneumothorax, hyperinflation, and pleural effusion. The method demonstrates robustness in the presence of noise. Reconstructions from trigonometric and pairwise current injection patterns are included.

Development of an Anatomically Realistic Forward Solver for Thoracic Electrical Impedance Tomography

Electrical impedance tomography (EIT) has the potential to provide a low cost and safe imaging modality for clinically monitoring patients being treated with mechanical ventilation. Variations in reconstruction algorithms at different clinical settings, however, make interpretation of regional ventilation across institutions difficult, presenting the need for a unified algorithm for thoracic EIT reconstruction. Development of such a consensual reconstruction algorithm necessitates a forward model capable of predicting surface impedance measurements as well as electric fields in the interior of the modeled thoracic volume. In this paper, we present an anatomically realistic forward solver for thoracic EIT that was built based on high resolution MR image data of a representative adult. Accuracy assessment of the developed forward solver in predicting surface impedance measurements by comparing the predicted and observed impedance measurements shows that the relative error is within the order of 5%, demonstrating the ability of the presented forward solver in generating high-fidelity surface thoracic impedance data for thoracic EIT algorithm development and evaluation.

A direct D-bar reconstruction algorithm for recovering a complex conductivity in 2-D

A direct reconstruction algorithm for complex conductivities in W^2,∞ (Ω), where Ω is a bounded, simply connected Lipschitz domain in ℝ², is presented. The framework is based on the uniqueness proof by Francini [Inverse Problems 20 2000], but equations relating the Dirichlet-to-Neumann to the scattering transform and the exponentially growing solutions are not present in that work, and are derived here. The algorithm constitutes the first D-bar method for the reconstruction of conductivities and permittivities in two dimensions. Reconstructions of numerically simulated chest phantoms with discontinuities at the organ boundaries are included.

Imaging regional PAO2 and gas exchange

Several methods allow regional gas exchange to be inferred from imaging of regional ventilation and perfusion (V/Q) ratios. Each method measures slightly different aspects of gas exchange and has inherent advantages and drawbacks that are reviewed. Single photon emission computed tomography can provide regional measure of ventilation and perfusion from which regional V/Q ratios can be derived. PET methods using inhaled or intravenously administered nitrogen-13 provide imaging of both regional blood flow, shunt, and ventilation. Electric impedance tomography has recently been refined to allow simultaneous measurements of both regional ventilation and blood flow. MRI methods utilizing hyperpolarized helium-3 or xenon-129 are currently being refined and have been used to estimate local PaO(2) in both humans and animals. Microsphere methods are included in this review as they provide measurements of regional ventilation and perfusion in animals. One of their advantages is their greater spatial resolution than most imaging methods and the ability to use them as gold standards against which new imaging methods can be tested. In general, the reviewed methods differ in characteristics such as spatial resolution, possibility of repeated measurements, radiation exposure, availability, expensiveness, and their current stage of development.

Electrical Impedance Tomography for hemodynamic monitoring

Electrical Impedance Tomography (EIT) is a known technique to monitor impedance changes in a cross-section of a body segment, which recently gained increasing interest for regional ventilation monitoring. In this paper, we focus on hemodynamic monitoring using EIT. Past and ongoing research activities to obtain cardiac related signals and regional perfusion information from EIT image streams are summarized. Finally, we present some preliminary results on stroke volume estimation using EIT.

Regional lung perfusion estimated by electrical impedance tomography in a piglet model of lung collapse

The assessment of the regional match between alveolar ventilation and perfusion in critically ill patients requires simultaneous measurements of both parameters. Ideally, assessment of lung perfusion should be performed in real-time with an imaging technology that provides, through fast acquisition of sequential images, information about the regional dynamics or regional kinetics of an appropriate tracer. We present a novel electrical impedance tomography (EIT)-based method that quantitatively estimates regional lung perfusion based on first-pass kinetics of a bolus of hypertonic saline contrast. Pulmonary blood flow was measured in six piglets during control and unilateral or bilateral lung collapse conditions. The first-pass kinetics method showed good agreement with the estimates obtained by single-photon-emission computerized tomography (SPECT). The mean difference (SPECT minus EIT) between fractional blood flow to lung areas suffering atelectasis was -0.6%, with a SD of 2.9%. This method outperformed the estimates of lung perfusion based on impedance pulsatility. In conclusion, we describe a novel method based on EIT for estimating regional lung perfusion at the bedside. In both healthy and injured lung conditions, the distribution of pulmonary blood flow as assessed by EIT agreed well with the one obtained by SPECT. The method proposed in this study has the potential to contribute to a better understanding of the behavior of regional perfusion under different lung and therapeutic conditions.

The role of imaging techniques in the assessment of pulmonary circulation

Knowledge of the structure and function of pulmonary circulation has evolved considerably in the last few decades. The use of non-invasive imaging techniques to assess the anatomy and function of the pulmonary vessels and heart has taken on added importance with the recent advent of novel therapies. Imaging findings not only constitute a diagnostic tool but have also proven to be essential for prognosis and treatment follow-up. This article reviews the myriad of imaging methods currently available for the assessment of pulmonary circulation, from the simple chest X-ray to techniques that are more complex and promising, such as electrical impedance tomography.

Electrical impedance tomography and heterogeneity of pulmonary perfusion and ventilation in porcine acute lung injury

BACKGROUND

The heterogeneity of pulmonary ventilation (V), perfusion (Q) and V/Q matching impairs gas exchange in an acute lung injury (ALI). This study investigated the feasibility of electrical impedance tomography (EIT) to assess the V/Q distribution and matching during an endotoxinaemic ALI in pigs.

METHODS

Mechanically ventilated, anaesthetised pigs (n=11, weight 30-36 kg) were studied during an infusion of endotoxin for 150 min. Impedance changes related to ventilation (Z(V)) and perfusion (Z(Q)) were monitored globally and bilaterally in four regions of interest (ROIs) of the EIT image. The distribution and ratio of Z(V) and Z(Q) were assessed. The alveolar-arterial oxygen difference, venous admixture, fractional alveolar dead space and functional residual capacity (FRC) were recorded, together with global and regional lung compliances and haemodynamic parameters. Values are mean+/-standard deviation (SD) and regression coefficients.

RESULTS

Endotoxinaemia increased the heterogeneity of Z(Q) but not Z(V). Lung compliance progressively decreased with a ventral redistribution of Z(V). A concomitant dorsal redistribution of Z(Q) resulted in mismatch of global (from Z(V)/Z(Q) 1.1+/-0.1 to 0.83+/-0.3) and notably dorsal (from Z(V)/Z(Q) 0.86+/-0.4 to 0.51+/-0.3) V and Q. Changes in global Z(V)/Z(Q) correlated with changes in the alveolar-arterial oxygen difference (r(2)=0.65, P<0.05), venous admixture (r(2)=0.66, P<0.05) and fractional alveolar dead space (r(2)=0.61, P<0.05). Decreased end-expiratory Z(V) correlated with decreased FRC (r(2)=0.74, P<0.05).

CONCLUSIONS

EIT can be used to assess the heterogeneity of regional pulmonary ventilation and perfusion and V/Q matching during endotoxinaemic ALI, identifying pivotal pathophysiological changes.

Effect of domain shape modeling and measurement errors on the 2-D D-bar method for EIT

The D-bar algorithm based on Nachman's 2-D global uniqueness proof for the inverse conductivity problem (Nachman, 1996) is implemented on a chest-shaped domain. The scattering transform is computed on this chest-shaped domain using trigonometric and adjacent current patterns and the complete electrode model for the forward problem is computed with the finite element method in order to obtain simulated voltage measurements. The robustness and effectiveness of the method is demonstrated on a simulated chest with errors in input currents, output voltages, electrode placement, and domain modeling.

Electrical impedance tomography applied to assess matching of pulmonary ventilation and perfusion in a porcine experimental model

INTRODUCTION

Electrical impedance tomography (EIT) can be used to measure impedance changes related to the thoracic content of air and blood. Few studies, however, have utilised EIT to make concurrent measurements of ventilation and perfusion. This experimental study was performed to investigate the feasibility of EIT to describe ventilation/perfusion (V/Q) matching after acute changes of pulmonary perfusion and aeration.

METHODS

Six mechanically ventilated, anaesthetised pigs in the supine position were studied at baseline, after inflation of a balloon in the inferior caval vein (Binfl) to reduce cardiac output and after an increased positive end-expiratory pressure (PEEP) of 20 cmH2O (PEEP20) to increase pulmonary aeration. EIT measurements were performed at the mid-thoracic level to measure the amplitude of impedance changes related to ventilation (ZV) and perfusion (ZQ), both globally and in four defined regions of interest (ROI) extending from the ventral to dorsal distance.

RESULTS

A largely parallel distribution of ZV and ZQ in all four ROIs during baseline conditions corresponded to a bell-shaped frequency distribution of ZV/ZQ ratios with only moderate scatter. Binfl and PEEP20 with unchanged tidal volumes significantly increased the mismatch of regional ZV and ZQ, the scatter of ZV/ZQ ratios and the heterogeneity of the ZV/ZQ frequency distribution. Significant positive and negative correlations were demonstrated between fractional alveolar dead space (r2 = 0.63 [regression coefficient]) and venous admixture (r2 = 0.48), respectively, and the global ZV/ZQ ratio.

CONCLUSIONS

EIT may be used to monitor the distribution of pulmonary ventilation and perfusion making detailed studies of V/Q matching possible.

Monitoring pulmonary perfusion by electrical impedance tomography: an evaluation in a pig model

BACKGROUND

Electrical impedance tomography (EIT) is a non-invasive technique that generates images of impedance distribution. Changes in the pulmonary content of air and blood are major determinants of thoracic impedance. This study was designed to evaluate EIT in monitoring pulmonary perfusion in a wide range of cardiac output.

METHODS

Eight anaesthetised, mechanically ventilated pigs were fitted with a 16-electrode belt at the mid-thoracic level to generate EIT images that were analysed to determine pulse-synchronous systolic changes in impedance (DeltaZ(sys)). Stroke volume (SV) was derived using a pulmonary artery catheter. Reductions in cardiac pre-load, and thus pulmonary perfusion, were induced either by inflating the balloon of a Fogarty catheter positioned in the inferior caval vein or by increasing the positive end-expiratory pressure (PEEP). All measurements were performed in a steady state during a short apnoea.

RESULTS

Pulse-synchronous changes in DeltaZ(sys) were easily discernable during apnoea. Balloon inflation reduced SV to 36% of the baseline, with a corresponding decrease in DeltaZ(sys) to 45% of baseline. PEEP reduced SV and DeltaZ(sys) to 52% and 44% of the baseline, respectively. Significant correlations between SV and DeltaZ(sys) were demonstrated during all measurements (rho=0.62) as well as during balloon inflation (rho=0.73) and increased PEEP (rho=0.40). A Bland-Altman comparison of relative changes in SV and DeltaZ(sys) demonstrated a bias of -7%, with 95% limits of agreement at -51% and 36%.

CONCLUSIONS

EIT provided beat-to-beat approximations of pulmonary perfusion that significantly correlated to a wide range of SV values achieved during both extra and intrapulmonary interventions to change cardiac output.

Performance of electrical impedance tomography in detecting regional tidal volumes during one-lung ventilation

BACKGROUND

Electrical impedance tomography (EIT) is becoming a new medical imaging modality for continuous monitoring of regional lung function in the intensive care unit or operating room. The aim of our study was to evaluate the performance of EIT in detecting regional tidal volumes in patients during volume-controlled mechanical ventilation of one or both lungs.

METHODS

Ten adult patients undergoing elective thoracic surgery were included. EIT measurements were performed with the Goe-MF II EIT system. Data were collected before surgery during ventilation of both, the right and left lungs. Tidal volumes of 800 and 400 ml were applied during bilateral and unilateral ventilation, respectively.

RESULTS

Ventilation-related impedance changes determined in the whole chest cross-section during the right and left lung ventilation did not significantly differ from each other and were equal to 47.6+/-5.6% and 48.5+/-7.8% (mean+/-SD) of the value determined during bilateral ventilation. During unilateral ventilation, EIT clearly separated the ventilated and non-ventilated lung regions; nevertheless, ventilation-related impedance changes were also detected at the non-ventilated sides in areas corresponding to 3.4+/-4.1% and 12.4+/-6.9% of the scan halves during ventilation of the left and right lung, respectively. Changes in global tidal volumes were adequately detected by EIT during both bilateral and unilateral lung ventilation.

CONCLUSION

Although good separation of the ventilated and non-ventilated sides of the chest was possible, the data indicate that reliable quantification of regional tidal volumes during asymmetric or inhomogeneous distribution patterns requires regions-of-interest analysis.

Assessment of the Pulmonary Volume Pulse in Idiopathic Pulmonary Arterial Hypertension by Means of Electrical Impedance Tomography

BACKGROUND

Electrical impedance tomography (EIT) is a non-invasive imaging technique which can be used to measure the blood volume changes in the pulmonary vascular bed during the cardiac cycle.

STUDY OBJECTIVES

This study was performed to evaluate the differences in the EIT signal of the pulmonary vascular bed between healthy subjects and patients with idiopathic pulmonary arterial hypertension (IPAH), who are known to have a remodelled pulmonary vascular bed.

PATIENTS AND METHODS

Twenty-one patients (17 females, 4 males) with IPAH and 30 healthy controls (5 females, 25 males) were measured. EIT measurements were performed in duplicate, on the same day as right heart catheterization to obtain haemodynamic data. The maximal impedance change during systole (Delta Z(sys)) was used as a measure of the pulmonary volume pulse and expressed in arbitrary units (AU). Total lung capacity, spirometric values and diffusion capacity for carbon monoxide were measured as well.

RESULTS

Mean Delta Z(sys) was 215 +/- 58 x 10(-2) AU (95% CI 193 x 10(-2) to 236 x 10(-2)) in the healthy subjects and 78 +/- 27 x 10(-2) AU (95% CI 66 x 10(-2) to 91 x 10(-2)) in the IPAH patient group (p < 0.0001). No significant correlation was found between Delta Z(sys) and any of the haemodynamic or lung function data.

CONCLUSION

The impedance pulsation of the pulmonary vascular bed is reduced in IPAH in comparison with controls, indicating a reduced volume pulse. This might represent the reduced cross section area, as well as the reduced compliance and number of the pulmonary vessels in these patients.

Noninvasive assessment of lung volume: respiratory inductance plethysmography and electrical impedance tomography

OBJECTIVE

Respiratory inductance plethysmography (RIP) and electrical impedance tomography (EIT) are two monitoring techniques that have been used to assess lung volume noninvasively.

METHODS

RIP uses two elastic bands around the chest and abdomen to assess global changes in lung volume. In animal models, RIP has been shown to detect changes in lung mechanics during high-frequency oscillatory ventilation and has the potential to quantify lung volumes noninvasively. EIT measures regional impedance changes with 16 electrodes around the patient's chest, each of them injecting and receiving small currents. Impedance changes have been correlated with volume changes in animal models and in humans. In a recent animal model, EIT was shown to be capable of tracking lung volume changes during high-frequency oscillatory ventilation.

CONCLUSION

The promise of monitoring techniques such as RIP and EIT is that they will guide lung protective ventilation strategies and allow the clinician to optimize lung recruitment, maintain an open lung, and limit overdistension. EIT is the only bedside method that allows repeated, noninvasive measurements of regional lung volumes. In the future, it will be important to standardize the definitions of alveolar recruitment and ultimately demonstrate the superiority of EIT-guided ventilator management in providing lung protective ventilation.