Methodological guidelines for impedance cardiography

Impedance cardiography was introduced over 20 years ago as a noninvasive and unobtrusive technique for measuring systolic time intervals and cardiac output. Although our understanding of the physiological events reflected in the impedance cardiogram has become more refined, the technique's theoretical basis remains somewhat controversial and acceptance of its validity has relied heavily upon empirical validation. Largely as a consequence of this status, there have been inadequate grounds on which to develop sound methodological standardization. Currently, the methodological approaches that have been most frequently adopted may be viewed as representing the standard. The various aspects of impedance methodology are discussed, and alternative approaches described, with the objective of providing an informed basis for choosing among these methodological alternatives. It is recommended that studies utilizing impedance cardiography should be reported with clear and detailed methodological description. This should help clarify the extent to which methodological differences may underlie any discrepant research observations, as well as facilitate the emergence of improved methodological standards.

Intrathoracic impedance monitoring in patients with heart failure: correlation with fluid status and feasibility of early warning preceding hospitalization

BACKGROUND

Patients with heart failure are frequently hospitalized for fluid overload. A reliable method for chronic monitoring of fluid status is therefore desirable. We evaluated an implantable system capable of measuring intrathoracic impedance to identify potential fluid overload before heart failure hospitalization and to determine the correlation between intrathoracic impedance and standard measures of fluid status during hospitalization.

METHODS AND RESULTS

Thirty-three patients with NYHA class III and IV heart failure were implanted with a special pacemaker in the left pectoral region and a defibrillation lead in the right ventricle. Intrathoracic impedance was regularly measured and recorded between the lead and the pacemaker case. During hospitalizations, pulmonary capillary wedge pressure and fluid status were monitored. Ten patients were hospitalized for fluid overload 25 times over 20.7+/-8.4 months. Intrathoracic impedance decreased before each admission by an average of 12.3+/-5.3% (P<0.001) over an average of 18.3+/-10.1 days. Impedance reduction began 15.3+/-10.6 days (P<0.001) before the onset of worsening symptoms. There was an inverse correlation between intrathoracic impedance and pulmonary capillary wedge pressure (r=-0.61, P<0.001) and between intrathoracic impedance and net fluid loss (r=-0.70, P<0.001) during hospitalization. Automated detection of impedance decreases was 76.9% sensitive in detecting hospitalization for fluid overload, with 1.5 false-positive (threshold crossing without hospitalization) detections per patient-year of follow-up.

CONCLUSIONS

Intrathoracic impedance is inversely correlated with pulmonary capillary wedge pressure and fluid balance and decreased before the onset of patient symptoms and before hospital admission for fluid overload. Regular monitoring of impedance may provide early warning of impending decompensation and diagnostic information for titration of medication.

A new impedance cardiograph device for the non-invasive evaluation of cardiac output at rest and during exercise: comparison with the "direct" Fick method

The objectives of this study were to evaluate the reliability and accuracy of a new impedance cardiograph device, the Physio Flow, at rest and during a steady-state dynamic leg exercise (work intensity ranging from 10 to 50 W) performed in the supine position. We compared cardiac output determined simultaneously by two methods, the Physio Flow (QcPF) and the direct Fick (QcFick) methods. Forty patients referred for right cardiac catheterisation, 14 with sleep apnoea syndrome and 26 with chronic obstructive pulmonary disease, took part in this study. The subjects' oxygen consumption values ranged from 0.14 to 1.19 l x min(-1). The mean difference between the two methods (QcFick - QcPF) was 0.04 l x min(-1) at rest and 0.29 l x min(-1) during exercise. The limits of agreement, defined as mean difference +/- 2SD, were -1.34, +1.41 l x min(-1)] at rest and -2.34, +2.92 l x min(-1) during exercise. The difference between the two methods exceeded 20% in only 2.5% of the cases at rest, and 9.3% of the cases during exercise. Thoracic hyperinflation did not alter QcPF. We conclude that the Physio Flow provides a clinically acceptable and non-invasive evaluation of cardiac output under these conditions. This new impedance cardiograph device deserves further study using other populations and situations.

Non-invasive cardiac output evaluation during a maximal progressive exercise test, using a new impedance cardiograph device

One of the greatest challenges in exercise physiology is to develop a valid, reliable, non-invasive and affordable measurement of cardiac output (CO). The purpose of this study was to evaluate the reproducibility and accuracy of a new impedance cardiograph device, the Physio Flow, during a 1-min step incremental exercise test from rest to maximal peak effort. A group of 12 subjects was evaluated to determine the reproducibility of the method as follows: (1) each subject performed two comparable tests while their CO was measured by impedance cardiography using the new device (COImp1, COImp2), and (2) in a subgroup of 7 subjects CO was also determined by the direct Fick method (COFick) during the second test. The mean difference between the values obtained by impedance (i.e. COImp1-COImp2) was -0.009 l.min-1 (95% confidence interval: -4.2 l.min-1, 4.2 l.min-1), and CO ranged from 3.55 l.min-1 to 26.75 l.min-1 (n = 146). When expressed as a percentage, the difference (COImp1-COImp2) did not vary with increasing CO. The correlation coefficient between the values of COImp and COFick obtained during the second exercise test was r = 0.94 (P < 0.01, n = 50). The mean difference expressed as percentage was -2.78% (95% confidence interval: -27.44%, 21.78%). We conclude that COImp provides a clinically acceptable evaluation of CO in healthy subjects during an incremental exercise.

Non-invasive beat-to-beat cardiac output monitoring by an improved method of transthoracic bioimpedance measurement

The report describes a method of impedance cardiography using an improved estimate of thoracic volume. The formulas and their implementation in hardware and software are explained and new shortband electrodes are described which generate a good homogeneous thoracic field. Examples of stroke volume and cardiac output curves underline the capabilities of the monitoring system "Task Force Monitor". In several experiments, results are compared to thermodilution as well as to BioZ measurements: the new method excels in comparison with thermodilution and is comparable to the BioZ device. Compared to traditional electrodes, the new shortband electrodes are shown to provide better reproducibility.

Ambulatory monitoring of the impedance cardiogram

The growing need for more advanced ambulatory monitoring has led to the development of an ambulatory monitor for impedance cardiography (VU-AMD). This paper presents two studies addressing the validity of the VU-AMD. In the first study, the cardiovascular responses of 25 subjects during various conditions were simultaneously recorded with the VU-AMD and a standard laboratory impedance device. Correlations between the responses of the ambulatory and laboratory devices were high, both inter- and intraindividually, except for stroke volume and cardiac output during exercise. In the second study, 26 subjects underwent 24-hr monitoring with the VU-AMD. The values obtained with the VU-AMD were realistic and varied in a predictable way over activity and posture. It is concluded that the VU-AMD is a valid device for the measurement of systolic time intervals in real-life situations, but its applicability for absolute stroke volume and cardiac output determination remains to be established.

A software package for non-invasive, real-time beat-to-beat monitoring of stroke volume, blood pressure, total peripheral resistance and for assessment of autonomic function

The goal of the present study was to develop and evaluate algorithms for non-invasive, real-time, beat-to-beat monitoring of stroke index (SI), blood pressure (BP) and total peripheral resistance index (TPRI) which has a menu-driven interface, suitable for routine use by unskilled staff. In addition, it was our aim to include a meta-analysis for the evaluation of autonomic function derived from the above haemodynamic data. This includes spectral analysis of heart rate (HR), BP, SI and TPRI and the automatic calculation of baroreceptor reflex sensitivity. Impedance cardiography was used for beat-to-beat SI determination, Finapres corrected by an oscillometric blood pressure measurement (Dinamap) on the upper arm for beat-to-beat BP measurement. We demonstrate noise free recordings during physiological (head up tilt) and pharmacological intervention (alpha 1-, beta 2-adrenoreceptor agonists, insulin induced hypoglycemia). The newly developed software should prove valuable for physiological, pharmacological and clinical studies.

Intrathoracic impedance monitoring to predict decompensated heart failure

Intrathoracic impedance measurement has been introduced in the InSync Sentry biventricular implantable cardioverter-defibrillator and may permit the early identification of pulmonary fluid accumulation secondary to left-sided heart failure (HF). An audible alarm (the OptiVol alert) can be triggered when the impedance index increases to greater than a predefined level of 60 Omega . day. The aim of this study was to evaluate the clinical value of the OptiVol alert and its prediction for decompensated HF. One hundred fifteen consecutive patients (mean New York Heart Association class 2.8 +/- 0.5, mean left ventricular ejection fraction 26 +/- 8%) who received InSync Sentry biventricular implantable cardioverter-defibrillators were included. When presenting with the OptiVol alert, current hemodynamic status was evaluated. During follow-up (mean 9 +/- 5 months), there were 45 presentations with the OptiVol alert in 30 patients. Clinical signs and symptoms of HF were present in only 15 patients (33%), whereas in the remaining patients, clinical signs of HF were absent (p <0.05). Receiver-operating characteristic curve analysis showed that increasing the threshold for the OptiVol alert provided a substantial increase in specificity for the detection of HF, with the optimal cut-off value identified at 120 Omega . day, yielding sensitivity of 60% and specificity of 73%. In conclusion, intrathoracic impedance measurement as present in the InSync Sentry biventricular implantable cardioverter-defibrillator may be a useful tool for monitoring pulmonary fluid status. The proposed threshold for the OptiVol alert of 60 Omega. day is very sensitive but not specific for the assessment of HF; adjustment of threshold settings may yield a superior balance between sensitivity and specificity.

Impedance pneumography: noise as signal in impedance cardiography

Thoracic impedance is modulated by events within the respiratory cycle, which represents a source of "noise" in impedance cardiography. Respiration itself, however, is a physiological rhythm of interest to psychophysiologists. We report here methods and validation for deriving impedance pneumographic measures of respiration from impedance cardiography signals, based on standard tetrapolar band electrodes. We recorded the change in impedance (delta Z), the first derivative of the change in impedance (dZ/dt), output from a strain-gauge respirometer, and criterion spirometry from eight healthy adults during rest, paced breathing, abdominal breathing, thoracic breathing, and a mental arithmetic task. Transfer function analyses revealed that a delta Zd signal (derived by integration of the dZ/dt signal) provided the best estimate of the criterion spirometric measure for all parameters (coherence, phase, and gain), accounting for almost 90% of the variance in respiratory waveform morphology. The results document the potential utility of impedance pneumography, as derived from standard impedance cardiography signals.

Comparison of impedance and inductance ventilation sensors on adults during breathing, motion, and simulated airway obstruction

The goal of this study was to compare the relative performance of two noninvasive ventilation sensing technologies on adults during artifacts. We recorded changes in transthoracic impedance and cross-sectional area of the abdomen (abd) and rib cage (rc) using impedance pneumography (IP) and respiratory inductance plethysmography (RIP) on ten adult subjects during natural breathing, motion artifact, simulated airway obstruction, yawning, snoring, apnea, and coughing. We used a pneumotachometer to measure air flow and tidal volume as the standard. We calibrated all sensors during natural breathing, and performed measurements during all maneuvers without changing the calibration parameters. No sensor provided the most-accurate measure of tidal volume for all maneuvers. Overall, the combination of inductance sensors [RIP(sum)] calibrated during an isovolume maneuver had a bias (weighted mean difference) as low or lower than all individual sensors and all combinations of sensors. The IP(rc) sensor had a bias as low or lower than any individual sensor. The cross-correlation coefficient between sensors was high during natural breathing, but decreased during artifacts. The cross correlation between sensor pairs was lower during artifacts without breathing than it was during maneuvers with breathing for four different sensor combinations. We tested a simple breath-detection algorithm on all sensors and found that RIP(sum) resulted in the fewest number of false breath detections, with sensitivity of 90.8% and positive predictivity of 93.6%.

Large-scale ensemble averaging of ambulatory impedance cardiograms

Impedance cardiography has been used increasingly to measure human physiological responses to emotional and mentally engaging stimuli. The validity of large-scale ensemble averaging of ambulatory impedance cardiograms was evaluated for preejection period (PEP), interbeat interval, and dZ/dt(min) amplitude. We tested whether the average of "classical" 60-sec ensemble averages across periods with fixed activity, posture, physical load, social situation, and location could be accurately estimated from a single large-scale ensemble average spanning these entire periods. Impedance and electrocardiograms were recorded for about 24-h from 21 subjects. Recordings were scored by seven raters, using both methods for each subject. Good agreement (average intraclass correlation coefficient was .91) between both ensemble averaging methods was found for all three cardiac function measures. The results indicate that for unambiguous ambulatory impedance cardiograms, large-scale ensemble averaging is valid, which makes measuring prolonged changes in cardiac sympathetic activity by measuring ambulatory PEP feasible even in large epidemiological samples.

Impedance imaging of lung ventilation: do we need to account for chest expansion?

Electrical impedance tomography (EIT) uses surface electrical measurements to image changes in the conductivity distribution within a medium. When used to measure lung ventilation, however, measurements depend both on conductivity changes in the thorax and on rib cage movement. Given that currently available reconstruction techniques assume that only conductivity changes are present, certain errors are introduced. A finite element model (FEM) is used to calculate the effect of chest expansion on the reconstructed conductivity images. Results indicate that thorax expansion accounts for up to 20% of the reconstructed image amplitude and introduces an artifact in the center of the image tending to "move" the reconstructed lungs closer together. Although this contribution varies depending on anatomical factors, it is relatively independent of inspiration depth. For certain applications in which one is only interested in changes in the level of physiological activity, the effect of the expansion can be neglected because it varies linearly with impedance changes. We conclude that chest expansion can contribute significantly to the conductivity images of lung ventilation and should be taken into account in the interpretation of these images.

Measurements of cardiac stroke volume in various body positions in pregnancy and during Caesarean section: a comparison between thermodilution and impedance cardiography

A total of 220 simultaneous pairs of measurements of cardiac stroke volume were made in twelve women before and during Caesarean section in order to compare impedance cardiography with the thermodilution method. A significantly higher coefficient of correlation was found before (r = 0.77) than during anaesthesia (r = 0.55). Further, there was a significant difference in the slope of the regression lines: before anaesthesia the slope was 1.07 and during anaesthesia with thiopentone, nitrous oxide, oxygen and suxamethonium it was 0.45. Significant changes in the intercept on the Y-axis were found before (-13.9 ml) and during anaesthesia (33.4 ml). When the uterus was displaced upwards and to the left from the 15 degrees tilt position the stroke volume and the cardiac output were increased when measured by both methods to nearly the same values as in the left lateral position. It is concluded that the impedance method is reliable for measuring cardiac stroke volume in late pregnancy under physiological conditions in the conscious patient, but that it cannot replace the thermodilution method in pharmacological studies.

Thoracic electrical bioimpedance measurement of cardiac output in postaortocoronary bypass patients

OBJECTIVE

To assess the degree of correlation and agreement between cardiac output by thermodilution and bioimpedance using the BoMed NCCOM3-R7 monitor in postaortocoronary bypass patients.

DESIGN

Prospective, randomized sampling.

SETTING

Military teaching hospital intensive care unit.

PATIENTS

Fifty patients undergoing coronary artery bypass surgery with thermodilution pulmonary artery catheters in place. Simultaneous determination of cardiac output by thermodilution and thoracic bioimpedance was performed. Readings were taken between 8 and 24 hrs after surgery. Forty patients were intubated; 19 patients had left-sided tube thoracotomy in addition to two mediastinal tubes, and 19 patients were obese.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The overall degree of correlation between the two measures was fair (r2 = .24). The bias and precision measurements were inaccurate as well (-0.33 +/- 3.14). Patients with normal body habitus or who were not receiving mechanical ventilation showed the best correlation (r2 = .40 and r2 = .45, respectively). Only 62% (31/50) of all patients had simultaneous measurements fall within 20% of each other, and there were no clinical features that made identification of those patients possible.

CONCLUSIONS

Use of the BoMed NCCOM3-R7 bioimpedance monitor as a replacement for thermodilution-derived cardiac output cannot be recommended in postaortocoronary bypass patients. The distortions of patients' normal anatomy and physiology, coupled with the presence of endotracheal tubes and mechanical ventilation, mediastinal tubes and chest tubes, result in only fair correlation, significant bias, and poor precision between the two measures of cardiac output.

Reconstructions of chest phantoms by the D-bar method for electrical impedance tomography

The problem this paper addresses is how to use the two-dimensional D-bar method for electrical impedance tomography with experimental data collected on finitely many electrodes covering a portion of the boundary of a body. This requires an approximation of the Dirichlet-to-Neumann, or voltage-to-current density map, defined on the entire boundary of the region, from a finite number of matrix elements of the current-to-voltage map. Reconstructions from experimental data collected on a saline filled tank containing agar heart and lung phantoms are presented, and the results are compared to reconstructions by the NOSER algorithm on the same data.

Sensitivity distributions of impedance cardiography using band and spot electrodes analyzed by a three-dimensional computer model

Impedance cardiography (ICG) offers a safe, noninvasive, and inexpensive method to track stroke volume estimates over long periods of time. Several modified ICG measurement configurations have been suggested where for convenience or improved performance the standard band electrodes are replaced with electrocardiogram electrodes. This report assesses the sensitivity of the conventional and three modified ICG methods in detecting regional conductivity changes in the simulated human thorax. The theoretical analyses of the measurement sensitivity employ the reciprocity theorem and the lead field theory with a highly detailed, anatomically accurate, three-dimensional computer thorax model. This model is based on the finite-difference element method and the U.S. National Library of Medicine's Visible Human Man anatomy data. The results obtained indicate that the conventional four-band ICG is not specifically sensitive to detect conductivity changes in the region of the heart, aortas, and lungs. Analyzed modified electrode configurations do not reproduce exactly the measurement sensitivity distribution of the conventional four-band ICG. Thus, although the signals measured with modified spot arrangements may appear similar to the four-band configuration, the distribution of the signal origin may not be the same. Changing from band to spot electrodes does not overcome the methodological problems associated with ICG.

Fundamentals of intrathoracic impedance monitoring in heart failure

The primary objective of the first-generation implantable cardiac pacemakers was to provide critical heart rate support, but these devices did not have any diagnostic capabilities. In the intervening decades, the number, type, and complexity of implantable devices has greatly expanded. Today, implantable devices not only provide heart rate support but they also provide protection from sudden cardiac death with implantable cardioverter defibrillators (ICDs) and reduce symptoms and increase survival with cardiac resynchronization therapy (CRT). Furthermore, information on physiologic variables has been collected in patients with implanted devices for the purpose of providing sophisticated closed-loop optimization of their pacing and defibrillation algorithms. Thoracic fluid status monitoring via intrathoracic impedance is the newest device-based diagnostic capability. For those patients with heart failure who are already targeted to receive an ICD or CRT with defibrillator implant, the ability to monitor fluid status can provide additional insight into the difficult problem of evaluating and managing these patients. This article reviews the basics of measuring intrathoracic impedance via OptiVol fluid status monitoring (Medtronic, Inc., Minneapolis, MN), as well as clinical results regarding the utility of evaluating OptiVol intrathoracic impedance data trends.

An impedance cardiography system: a new design

An IBM compatible impedance cardiac output monitoring prototype system has been developed for use at the bedside on patients in the ICU, CCU, ER, Cath. Lab, and OR, etc. This impedance cardiographic (ICG) system, whose operation is completely technician-free, provides a continuous display with digital results and four channel color waveforms on an Enhanced Graphics Display screen. The software is written in C language with several special segments in assembly code where speed is essential. In this prototype system, a real-time algorithm was introduced to modify the ensemble averaging technique so that it averages nonperiodic signals such as: ECG, dZ/dT, delta Z, etc. Also, a real-time algorithm was developed to adaptively detect R spikes from conventional ECG signals. A signal preprocessor was developed to process signals digitally before any further work is done. This procedure reduces muscle noise, 60 Hz interference, and ventilatory movement. A special digital filter was designed to cope with the cases in which pacemakers are used. A special algorithm was also developed to further reduce the ventilation artifacts so that a period of apnea is unnecessary during the performance of the measurements. An anatomically specified electrode configuration has been defined enabling precise and reproducible positioning of the electrodes--hopefully leading to electrode standardization. At the present time, this prototype system has been compared with standard hand calculation and correlated with the clinical "gold standard," the Swan-Ganz thermodilution cardiac output. Using 144 sets of data from 10 healthy volunteers, 4 critically ill patients, and 8 healthy exercising volunteers, calculations of cardiac output were made using our system and the standard hand calculation of stroke volume, based upon Kubicek's equation; there was a relatively high and stable correlation: r = 0.93, p less than 0.005 (healthy); r = 0.94, p less than 0.002 (ill), r = 0.95, p less than 0.002 (exercise). From 20 patients at two different hospitals all with Swan-Ganz catheters in their hearts, 65 correlation studies between our system and the standard thermodilution technique were performed; the results were encouraging in terms of accuracy and consistency (r1 = 0.84, p less than 0.01, n = 10 CCU patients), and (r2 = 0.93, p less than 0.01, n = ICU patients). These results along with a growing body of data from other investigators indicate that this noninvasive and technician-free system for measuring cardiac output could have a significant role in patient care.

Comparison of impedance cardiographic measurements using band and spot electrodes

The comprehensive assessment of cardiac function using impedance cardiography has led to increasingly widespread use of the technique in psychophysiology. Disposable adhesive band electrodes have been the most widely used electrode type, but spot electrode configurations present attractive alternatives in terms of convenience and subject comfort. The present study was designed to evaluate whether one such spot electrode configuration yielded the same information as the more standard band electrodes for cardiac output and systolic time interval measurement. Male and female healthy adult subjects (N = 20) were tested. Comparisons between spot and band electrodes were made for the absolute magnitude of cardiac output and systolic time intervals, as well as for responses to the highly reproducible effects of bicycle exercise. Consistent with previous findings, systolic time interval measurements were unaffected by electrode type. However, for cardiac output measurements, differences between spot and band electrode measurements were found. Under resting conditions, the absolute magnitudes of cardiac output values measured using spot electrodes were smaller than for band electrodes. Subtle, yet significant differences were also found for cardiac output responses to exercise, with spot electrodes indicating greater increases in cardiac output than band electrodes. At the same time, anticipated gender differences found for cardiac output at rest and in response to exercise were unaffected by electrode type. Overall, these findings suggest that when comparing the results of studies that have utilized different impedance electrode types, it would be prudent to remain alert to the possibility of confounding influences.

Thoracic impedance changes measured via defibrillator pads can monitor ventilation in critically ill patients and during cardiopulmonary resuscitation

OBJECTIVE

Monitoring of ventilation performance during cardiopulmonary resuscitation would be desirable to improve the quality of cardiopulmonary resuscitation. To investigate the potential for measuring ventilation rate and inspiration time, we calculated the correlation in waveform between transthoracic impedance measured via defibrillator pads and tidal volume given by a ventilator.

DESIGN

Clinical study.

SETTING

Emergency department of a tertiary care university hospital.

PATIENTS

A convenience sample of mechanical ventilated patients (n = 32), cardiac arrest patients (n = 20), and patients after restoration of spontaneous circulation (n = 31) older than 18 were eligible.

INTERVENTIONS

The Heartstart 4000SP defibrillator (Laerdal Medical Cooperation, Stavanger, Norway) with additional capabilities of recording thoracic impedance changes was used.

MEASUREMENTS AND MAIN RESULTS

The relationship between impedance change and tidal volume (impedance coefficient) was calculated. The mean (sd) correlations between the impedance waveform and the tidal volume waveform in the patient groups studied were .971 (.027), .969 (.032), and .967 (.035), respectively. The mean (sd) impedance coefficient for all patients in the study was .00194 (.0078) Omega/mL, and the mean (sd) specific (weight-corrected) impedance coefficient was .152 (.048) Omega/kg/mL. The measured thorax impedance change for different tidal volumes (400-1000 mL) was approximately linear.

CONCLUSIONS

The impedance sensor of a defibrillator is accurate in identifying tidal volumes, when chest compressions are interrupted. This also allows quantifying ventilation rates and inspiration times. However this technology, at its present state, provides only limited practical means for exact tidal volume estimation.

Non-invasive measurement of cardiac output by thoracic electrical bioimpedance: a study of reproducibility and comparison with thermodilution

The performance and reproducibility of the BoMED NCCOM3 thoracic electrical bioimpedance cardiograph (TEB) has been evaluated in volunteers and patients. In resting supine volunteers, we determined the coefficient of variability over short time periods (30 min) and over several days, and examined the effects of differences in electrode type and electrode placement. The mean (range) intra-subject coefficients of variation (CV) for thoracic fluid index (TFI) and stroke volume (SV) were 1.0% (0.4-1.8%) and 4.7% (2.1-8.5%), respectively over a 30-min period. The corresponding CV were 5.6% (2.3-10.9%) and 10.9% (6.1-14.8%) for measurements made at rest on four separate occasions. Use of different electrode types (RedDot and Medicotest) resulted in differences in TFI (P less than 0.01), but not in mean values for SV or cardiac output (Q); their use in individual subjects revealed differences of up to 20% in SV and Q. Alterations in electrode placement by 5 cm in the horizontal and diagonal planes produced no significant changes in TFI, SV or Q; changes in the longitudinal plane produced a graded change. Increases of 5 cm and 10 cm in thoracic length produced mean increases in TFI of 9.8% and 39.8%, respectively, and mean decreases in Q of 8.4% and 16.7% and SV of 7.5% and 15.8%. TEB measurements of Q and SV were compared with thermodilution (TD) in 16 intensive care patients. Mean (SEM) Q by TEB was 5.63 (1.10) litre min-1 compared with TD 4.38 (0.72) litre min-1 (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamics associated with breathing through an inspiratory impedance threshold device in human volunteers

OBJECTIVE

Increased negative intrathoracic pressure during spontaneous inspiration through an impedance threshold device (ITD) causes elevated arterial blood pressure in humans. This study was performed to determine whether the acute increase in blood pressure induced by breathing through an ITD is associated with increased stroke volume and cardiac output.

DESIGN

Randomized, blinded, controlled trial.

SETTING

Laboratory.

SUBJECTS

Ten women and ten men.

INTERVENTIONS

We measured hemodynamic and respiratory responses during two separate ITD conditions: 1) breathing through a face mask with an ITD (impedance of 6 cm H2O [0.59 kPa]) and 2) breathing through the same face mask with a sham ITD (control). Stroke volume was measured by thoracic bioimpedance.

MEASUREMENTS AND MAIN RESULTS

Compared with the control condition, ITD produced higher stroke volume (124 +/- 3 vs. 137 +/- 3 mL; p = .013), heart rate (63 +/- 3 vs. 68 +/- 3 beats/min; p = .049), cardiac output (7.69 vs. 9.34 L/min; p = .001), and systolic blood pressure (115 +/- 2 to 122 +/- 2 mm Hg [15.33 +/- 0.3 to 16.26 +/- 0.3 kPa]; p = .005) without affecting expired minute ventilation (6.2 +/- 0.4 to 6.5 +/- 0.4 L/min; p = .609).

CONCLUSIONS

Breathing with an ITD at relatively low impedance increases systolic blood pressure by increasing stroke volume and cardiac output. The ITD may provide short-term protection against cardiovascular collapse induced by orthostatic stress or hemorrhage.

Multi-frequency imaging and modelling of respiratory related electrical impedance changes

Two studies concerning multi-frequency impedance measurements are presented. The first uses tetrapolar measurements made on the thorax and the second electrical impedance tomography images, also made from the thorax. The way in which the impedance and the changes in impedance with ventilation depend upon frequency are investigated using Cole-Cole modelling and also a physiological model of lung tissue. There is an excellent fit to the Cole-Cole model, and the results show that it should be possible to identify tissue on the basis of the impedance spectrum and the spectrum of the changes in impedance during breathing.