Unilateral empyema impacts the assessment of regional lung ventilation by electrical impedance tomography

Clinical Applicability of Electrical Impedance Tomography in Patient-Tailored Ventilation: A Narrative Review

Electrical Impedance Tomography (EIT) is a non-invasive bedside imaging technique that provides real-time lung ventilation information on critically ill patients. EIT can potentially become a valuable tool for optimising mechanical ventilation, especially in patients with acute respiratory distress syndrome (ARDS). In addition, EIT has been shown to improve the understanding of ventilation distribution and lung aeration, which can help tailor ventilatory strategies according to patient needs. Evidence from critically ill patients shows that EIT can reduce the duration of mechanical ventilation and prevent lung injury due to overdistension or collapse. EIT can also identify the presence of lung collapse or recruitment during a recruitment manoeuvre, which may guide further therapy. Despite its potential benefits, EIT has not yet been widely used in clinical practice. This may, in part, be due to the challenges associated with its implementation, including the need for specialised equipment and trained personnel and further validation of its usefulness in clinical settings. Nevertheless, ongoing research focuses on improving mechanical ventilation and clinical outcomes in critically ill patients.

Electrical impedance tomography in perioperative medicine: careful respiratory monitoring for tailored interventions

BACKGROUND

Electrical impedance tomography (EIT) is a non-invasive radiation-free monitoring technique that provides images based on tissue electrical conductivity of the chest. Several investigations applied EIT in the context of perioperative medicine, which is not confined to the intraoperative period but begins with the preoperative assessment and extends to postoperative follow-up.

MAIN BODY

EIT could provide careful respiratory monitoring in the preoperative assessment to improve preparation for surgery, during anaesthesia to guide optimal ventilation strategies and to monitor the hemodynamic status and in the postoperative period for early detection of respiratory complications. Moreover, EIT could further enhance care of patients undergoing perioperative diagnostic procedures. This narrative review summarizes the latest evidence on the application of this technique to the surgical patient, focusing also on possible future perspectives.

CONCLUSIONS

EIT is a promising technique for the perioperative assessment of surgical patients, providing tailored adaptive respiratory and haemodynamic monitoring. Further studies are needed to address the current technological limitations, confirm the findings and evaluate which patients can benefit more from this technology.

Regional pulmonary effects of bronchoalveolar lavage procedure determined by electrical impedance tomography

Background

The provision of guidance in ventilator therapy by continuous monitoring of regional lung ventilation, aeration and respiratory system mechanics is the main clinical benefit of electrical impedance tomography (EIT). A new application was recently described in critically ill patients undergoing diagnostic bronchoalveolar lavage (BAL) with the intention of using EIT to identify the region where sampling was performed. Increased electrical bioimpedance was reported after fluid instillation. To verify the accuracy of these findings, contradicting the current EIT knowledge, we have systematically analysed chest EIT data acquired under controlled experimental conditions in animals undergoing a large number of BAL procedures.

Methods

One hundred thirteen BAL procedures were performed in 13 newborn piglets positioned both supine and prone. EIT data was obtained at 13 images before, during and after each BAL. The data was analysed at three time points: (1) after disconnection from the ventilator before the fluid instillation and by the ends of fluid (2) instillation and (3) recovery by suction and compared with the baseline measurements before the procedure. Functional EIT images were generated, and changes in pixel electrical bioimpedance were calculated relative to baseline. The data was examined in the whole image and in three (ventral, middle, dorsal) regions-of-interest per lung.

Results

Compared with the baseline phase, chest electrical bioimpedance fell after the disconnection from the ventilator in all animals in both postures during all procedures. The fluid instillation further decreased electrical bioimpedance. During fluid recovery, electrical bioimpedance increased, but not to baseline values. All effects were highly significant (p < 0.001). The fractional changes in individual regions-of-interest were posture-dependent. The regional fall in electrical bioimpedance was smaller in the ventral and larger in the dorsal regions after the fluid instillation than after the initial disconnection to ambient pressure in supine animals (p < 0.001) whereas these changes were of comparable amplitude in prone position.

Conclusions

The results of this study show a regionally dissimilar initial fall in electrical bioimpedance caused by non-uniform aeration loss at the beginning of the BAL procedure. They also confirm a further pronounced fall in bioimpedance during fluid instillation, incomplete recovery after suction and a posture-dependent distribution pattern of these effects.

Electronic supplementary material

The online version of this article (10.1186/s40635-019-0225-6) contains supplementary material, which is available to authorized users.

Characteristic pattern of pleural effusion in electrical impedance tomography images of critically ill patients

BACKGROUND

Electrical impedance tomography (EIT) is increasingly used for continuous monitoring of ventilation in intensive care patients. Clinical observations in patients with pleural effusion show an increase in out-of-phase impedance changes. We hypothesised that out-of-phase impedance changes are a typical EIT finding in patients with pleural effusion and could be useful in its detection.

METHODS

We conducted a prospective observational study in intensive care unit patients with and without pleural effusion. In patients with pleural effusion, EIT data were recorded before, during, and after unilateral drainage of pleural effusion. In patients with no pleural effusion, EIT data were recorded without any intervention. EIT images were separated into four quadrants of equal size. We analysed the sum of out-of-phase impedance changes in the affected quadrant in patients with pleural effusion before, during, and after drainage and compared it with the sum of out-of-phase impedance changes in the dorsal quadrants of patients without pleural effusion.

RESULTS

We included 20 patients with pleural effusion and 10 patients without pleural effusion. The median sum of out-of-phase impedance changes was 70 (interquartile range 49-119) arbitrary units (a.u.) in patients with pleural effusion before drainage, 25 (12-46) a.u. after drainage (P<0.0001) and 11 (6-17) a.u. in patients without pleural effusion (P<0.0001 vs pleural effusion before drainage). The area under the receiver operating characteristics curve was 0.96 (95% limits of agreement 0.91-1.01) between patients with pleural effusion before drainage and those without pleural effusion.

CONCLUSIONS

In patients monitored with EIT, the presence of out-of-phase impedance changes is highly suspicious of pleural effusion and should trigger further examination.

Regional lung response to bronchodilator reversibility testing determined by electrical impedance tomography in chronic obstructive pulmonary disease

Patients with obstructive lung diseases commonly undergo bronchodilator reversibility testing during examination of their pulmonary function by spirometry. A positive response is defined by an increase in forced expiratory volume in 1 s (FEV1). FEV1 is a rather nonspecific criterion not allowing the regional effects of bronchodilator to be assessed. We employed the imaging technique of electrical impedance tomography (EIT) to visualize the spatial and temporal ventilation distribution in 35 patients with chronic obstructive pulmonary disease at baseline and 5, 10, and 20 min after bronchodilator inhalation. EIT scanning was performed during tidal breathing and forced full expiration maneuver in parallel with spirometry. Ventilation distribution was determined by EIT by calculating the image pixel values of FEV1, forced vital capacity (FVC), tidal volume, peak flow, and mean forced expiratory flow between 25 and 75% of FVC. The global inhomogeneity indexes of each measure and histograms of pixel FEV1/FVC values were then determined to assess the bronchodilator effect on spatial ventilation distribution. Temporal ventilation distribution was analyzed from pixel values of times needed to exhale 75 and 90% of pixel FVC. Based on spirometric FEV1, significant bronchodilator response was found in 17 patients. These patients exhibited higher postbronchodilator values of all regional EIT-derived lung function measures in contrast to nonresponders. Ventilation distribution was inhomogeneous in both groups. Significant improvements were noted for spatial distribution of pixel FEV1 and tidal volume and temporal distribution in responders. By providing regional data, EIT might increase the diagnostic and prognostic information derived from reversibility testing.