Thoracic Electrical Impedance Tomography-The 2022 Veterinary Consensus Statement

Validation of three-dimensional thoracic electrical impedance tomography of horses during normal and increased tidal volumes

Objective. Data from two-plane electrical impedance tomography (EIT) can be reconstructed into various slices of functional lung images, allowing for more complete visualisation and assessment of lung physiology in health and disease. The aim of this study was to confirm the ability of 3D EIT to visualise normal lung anatomy and physiology at rest and during increased ventilation (represented by rebreathing).Approach. Two-plane EIT data, using two electrode planes 20 cm apart, were collected in 20 standing sedate horses at baseline (resting) conditions, and during rebreathing. EIT data were reconstructed into 3D EIT whereby tidal impedance variation (TIV), ventilated area, and right-left and ventral-dorsal centres of ventilation (CoVRLand CoVVD, respectively) were calculated in cranial, middle and caudal slices of lung, from data collected using the two planes of electrodes.Main results. There was a significant interaction of time and slice for TIV (p< 0.0001) with TIV increasing during rebreathing in both caudal and middle slices. The ratio of right to left ventilated area was higher in the cranial slice, in comparison to the caudal slice (p= 0.0002). There were significant effects of time and slice on CoVVDwhereby the cranial slice was more ventrally distributed than the caudal slice (p< 0.0009 for the interaction).Significance. The distribution of ventilation in the three slices corresponds with topographical anatomy of the equine lung. This study confirms that 3D EIT can accurately represent lung anatomy and changes in ventilation distribution during rebreathing in standing sedate horses.

Evaluation of adjacent and opposite current injection patterns for a wearable chest electrical impedance tomography system

Objective.Wearable electrical impedance tomography (EIT) can be used to monitor regional lung ventilation and perfusion at the bedside. Due to its special system architecture, the amplitude of the injected current is usually limited compared to stationary EIT system. This study aims to evaluate the performance of current injection patterns with various low-amplitude currents in healthy volunteers.Approach.A total of 96 test sets of EIT measurement was recorded in 12 healthy subjects by employing adjacent and opposite current injection patterns with four amplitudes of small current (i.e. 1 mA, 500 uA, 250 uA and 125 uA). The performance of the two injection patterns with various currents was evaluated in terms of signal-to-noise ratio (SNR) of thorax impedance, EIT image metrics and EIT-based clinical parameters.Main results.Compared with adjacent injection, opposite injection had higher SNR (p< 0.01), less inverse artifacts (p< 0.01), and less boundary artifacts (p< 0.01) with the same current amplitude. In addition, opposite injection exhibited more stable EIT-based clinical parameters (p< 0.01) across the current range. For adjacent injection, significant differences were found for three EIT image metrics (p< 0.05) and four EIT-based clinical parameters (p< 0.01) between the group of 125 uA and the other groups.Significance.For better performance of wearable pulmonary EIT, currents greater than 250 uA should be used in opposite injection, 500 uA in adjacent one, to ensure a high level of SNR, a high quality of reconstructed image as well as a high reliability of clinical parameters.

Thoracic electrical impedance tomography identifies heterogeneity in lungs associated with respiratory disease in cattle. A pilot study

Respiratory disease in cattle is a significant global concern, yet current diagnostic methods are limited, and there is a lack of crush-side tests for detecting active disease. To address this gap, we propose utilizing electrical impedance tomography (EIT), a non-invasive imaging technique that provides real-time visualization of lung ventilation dynamics. The study included adult cattle from farms in Western Australia. The cattle were restrained in a crush. A standardized respiratory scoring system, which combined visual, auscultation, and clinical scores, was conducted by two non-conferring clinicians for each animal. The scores were blinded and averaged. During assessment, an EIT electrode belt was placed around the thorax. EIT recordings of ten suitable breaths were taken for analysis before the cattle were released back to the herd. Based on the combined examination scoring, the cattle were categorized as having healthy or diseased lungs. To allow visual interpretation of each breath and enable the creation of the quartile ventilation ratio (VQR), Flow/Tidal Impedance Variation curves (F/TIV) were generated for each breath. The analysis focused on two EIT variables: The novel VQR over time during inhalation and exhalation and global expiratory impedance (TIVEXP) adjusted by breath length. A mixed effects model was used to compare these variables between healthy and diseased cattle. Ten adult cattle of mixed ages were used in the current analysis. Five cattle were scored as healthy and five as diseased. There was a significant difference in the examination scores between the healthy and diseased group (P = 0.03). A significant difference in VQR during inhalation (P = 0.03) was observed between the healthy and diseased groups. No difference was seen in VQR over time during exhalation (P = 0.3). The TIVEXP was not different between groups (P = 0.36). In this study, EIT was able to detect differences in inhalation mechanics when comparing healthy and diseased cattle as defined via clinical examination, highlighting the clinical utility of EIT.

Comparison of electrical impedance tomography and spirometry-based measures of airflow in healthy adult horses

Electrical impedance tomography (EIT) is a non-invasive diagnostic tool for evaluating lung function. The objective of this study was to compare respiratory flow variables calculated from thoracic EIT measurements with corresponding spirometry variables. Ten healthy research horses were sedated and instrumented with spirometry via facemask and a single-plane EIT electrode belt around the thorax. Horses were exposed to sequentially increasing volumes of apparatus dead space between 1,000 and 8,500 mL, in 5-7 steps, to induce carbon dioxide rebreathing, until clinical hyperpnea or a tidal volume of 150% baseline was reached. A 2-min stabilization period followed by 2 minutes of data collection occurred at each timepoint. Peak inspiratory and expiratory flow, inspiratory and expiratory time, and expiratory nadir flow, defined as the lowest expiratory flow between the deceleration of flow of the first passive phase of expiration and the acceleration of flow of the second active phase of expiration were evaluated with EIT and spirometry. Breathing pattern was assessed based on the total impedance curve. Bland-Altman analysis was used to evaluate the agreement where perfect agreement was indicated by a ratio of EIT:spirometry of 1.0. The mean ratio (bias; expressed as a percentage difference from perfect agreement) and the 95% confidence interval of the bias are reported. There was good agreement between EIT-derived and spirometry-derived peak inspiratory [-15% (-46-32)] and expiratory [10% (-32-20)] flows and inspiratory [-6% (-25-18)] and expiratory [5% (-9-20)] times. Agreement for nadir flows was poor [-22% (-87-369)]. Sedated horses intermittently exhibited Cheyne-Stokes variant respiration, and a breath pattern with incomplete expiration in between breaths (crown-like breaths). Electrical impedance tomography can quantify airflow changes over increasing tidal volumes and changing breathing pattern when compared with spirometry in standing sedated horses.

Computed Tomographic and Histopathologic Studies of Lung Function Immediately Post Natum in Canine Neonates

BACKGROUND

The lung tissue in newborn canine neonates is still in a morphologically and functionally immature, canalicular-saccular stage. True alveoli are only formed postnatally. The aim of this study was to analyze the spatial and temporal development of the ventilation of the lung tissue in vital canine neonates during the first 24 h post natum (p.n.).

METHODS

Forty pups (birth weight Ø 424 g ± 80.1 g) from three litters of large dog breeds (>20 kg live weight) were included in the studies. Thirty-three pups (29 vital, 2 vitally depressed, 2 stillborn neonates) originated from controlled, uncomplicated births (n = 3); moreover, six stillborn pups as well as one prematurely deceased pup were birthed by other dams with delivery complications. Computed tomography (CT) was used in 39 neonates, and histopathologic tissue classification techniques (HALO) were used in 11 neonates (eight stillborn and three neonates died early post natum, respectively) to quantify the degree of aerated neonatal lung tissue.

RESULTS

It was shown that, in vital born pups, within the first 10 min p.n., the degree of ventilation reached mean values of -530 (±114) Hounsfield units (HU) in the dorsal and -453.3 (±133) HU in the ventral lung area. This is about 75-80% of the final values obtained after 24 h p.n. for dorsal -648.0 (±89.9) HU and ventral quadrants -624.7 (±76.8) HU. The dorsal lung areas were always significantly better ventilated than the ventral regions (p = 0.0013). CT as well as histopathology are suitable to clearly distinguish the nonventilated lungs of stillborns from neonates that were initially alive after surviving neonatal respiratory distress syndrome but who died prematurely (p = 0.0398).

CONCLUSION

The results of this study are clinically relevant since the lung tissue of canine neonates presents an aeration profile as early as 10 min after birth and continues progressively, with a special regard to the dorsal lung areas. This is the basis for resuscitation measures that should be performed, preferably with the pup in the abdomen-chest position.

Impact of sedation, body position change and continuous positive airway pressure on distribution of ventilation in healthy foals

Background

This study aimed to compare the distribution of ventilation measured by electrical impedance tomography (EIT), in foals under varying clinical conditions of sedation, postural changes, and continuous positive airway pressure (CPAP). To support the interpretation of EIT variables, specific spirometry data and F-shunt calculation were also assessed.

Materials and methods

Six healthy Thoroughbred foals were recruited for this sequential experimental study. EIT and spirometry data was recorded: (1) before and after diazepam-sedation, (2) after moving from standing to right lateral recumbency, (3) in dorsal recumbency during no CPAP (CPAP₀) and increasing levels of CPAP of 4, 7, and 10 cmH₂O (CPAP₄, ₇, ₁₀, respectively). Ventral to dorsal (COV_VD) and right to left (COV_RL) center of ventilation, silent spaces, tidal impedance variation, regional ventilation distribution variables and right to left lung ventilation ratio (R:L) were extracted. Minute ventilation was calculated from tidal volume (V_T) and respiratory rate. F-Shunt was calculated from results of arterial blood gas analysis. Statistical analysis was performed using linear mixed effects models (significance determined at p < 0.05).

Results

(1) Respiratory rate was lower after sedation (p = 0.0004). (2) In right lateral recumbency (compared to standing), the COV_VD (p = 0.0012), COV_RL (p = 0.0057), left centro-dorsal (p = 0.0071) and dorsal (p < 0.0001) regional ventilation were higher, while the right ventral (p = 0.0016) and dorsal (p = 0.0145) regional ventilation, and R:L (p = 0.0017) were lower. (3) Data of two foals for CPAP₁₀ was excluded from statistical analysis due to prolonged apnea. Stepwise increase of CPAP led to increases of COV_VD (p = 0.0028) and V_T (p = 0.0011). A reduction of respiratory rate was detected with increasing CPAP levels (p < 0.0001).

Conclusions

(1) In healthy foals, diazepam administration did not alter distribution of ventilation or minute ventilation, (2) lateral recumbency results in collapse of dependent areas of the lung, and (3) the use of CPAP in dorsal recumbency at increasing pressures improves ventilation in dependent regions, suggesting improvement of ventilation-perfusion mismatch.

Management of refractory hypoxemia using recruitment maneuvers and rescue therapies: A comprehensive review

Refractory hypoxemia in patients with acute respiratory distress syndrome treated with mechanical ventilation is one of the most challenging conditions in human and veterinary intensive care units. When a conventional lung protective approach fails to restore adequate oxygenation to the patient, the use of recruitment maneuvers and positive end-expiratory pressure to maximize alveolar recruitment, improve gas exchange and respiratory mechanics, while reducing the risk of ventilator-induced lung injury has been suggested in people as the open lung approach. Although the proposed physiological rationale of opening and keeping open previously collapsed or obstructed airways is sound, the technique for doing so, as well as the potential benefits regarding patient outcome are highly controversial in light of recent randomized controlled trials. Moreover, a variety of alternative therapies that provide even less robust evidence have been investigated, including prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and unconventional ventilatory modes such as airway pressure release ventilation. With the exception of prone positioning, these modalities are limited by their own balance of risks and benefits, which can be significantly influenced by the practitioner's experience. This review explores the rationale, evidence, advantages and disadvantages of each of these therapies as well as available methods to identify suitable candidates for recruitment maneuvers, with a summary on their application in veterinary medicine. Undoubtedly, the heterogeneous and evolving nature of acute respiratory distress syndrome and individual lung phenotypes call for a personalized approach using new non-invasive bedside assessment tools, such as electrical impedance tomography, lung ultrasound, and the recruitment-to-inflation ratio to assess lung recruitability. Data available in human medicine provide valuable insights that could, and should, be used to improve the management of veterinary patients with severe respiratory failure with respect to their intrinsic anatomy and physiology.

The optimal PEEP after alveolar recruitment maneuver assessed by electrical impedance tomography in healthy horses

Background

Electrical impedance tomography (EIT) has been an essential tool for assessing pulmonary ventilation in several situations, such as the alveolar recruitment maneuver (ARM) in PEEP titration to maintain the lungs open after atelectasis reversion. In the same way as in humans and dogs, in horses, this tool has been widely used to assess pulmonary aeration undergoing anesthesia, mechanical ventilation, recruitment maneuver, standing horses, or specific procedures.

Objectives

The present study aimed to evaluate the distribution of regional ventilation during ARM based on lung monitoring assessment by EIT, with a focus on better recruitment associated with less or no overdistention.

Methods

Fourteen horses of 306 ± 21 kg undergoing isoflurane anesthesia in dorsal recumbency were used. The animals were mechanically ventilated with a tidal volume of 14 ml kg^-1 and a respiratory rate of 7-9. An alveolar recruitment maneuver was instituted, increasing the PEEP by five cmH₂O every 5 min until 32 cmH₂O and decreasing it by five cmH₂O every 5 min to 7 cmH₂O. At each step of PEEP, arterial blood samples were collected for blood gas analysis, EIT images, hemodynamic, and respiratory mechanics.

Results

Associated with the CoV-DV increase, there was a significant decrease in the DSS during the ARM and a significant increase in the NSS when PEEP was applied above 12 cmH₂O compared to baseline. The Compl_ROI showed a significant increase in the dependent area and a significant decrease in the non-dependent area during ARM, and both were compared to their baseline values. The driving pressure decreased significantly during the ARM, and Cst, PaO₂, and PaO₂/FiO₂ ratio increased significantly. The V_D/V_T decreased significantly at DEPEEP17 and DEPEEP12. There was an HR increase at INPEEP27, INPEEP 32, and DEPEEP17 (p < 0.0001; p < 0.0001; and p < 0.05, respectively), those values being above the normal reference range for the species. The SAP, MAP, DAP, CI, and DO₂I significantly decreased INPEEP32 (p < 0.05).

Conclusion

The ARM by PEEP titration applied in the present study showed better ventilation distribution associated with better aeration in the dependent lung areas, with minimal overdistention between PEEP 17 and 12 cmH₂O decreasing step. Those changes were also followed by improvements in static and regional compliance associated with increased oxygenation and pulmonary ventilation. ARM promoted a transitory decrease in arterial blood pressure and depression in CI with a concomitant drop in oxygen delivery, which should be best investigated before its routine use in clinical cases.