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Secretion management in mechanically ventilated patients is a paramount task for clinicians. A better understanding of the mechanisms of flow bias and airway dynamic compression during airway clearance therapy may enable a more effective approach for this population. Ventilator hyperinflation, expiratory rib cage compression, a PEEP-ZEEP maneuver, and mechanical insufflation-exsufflation are examples of techniques that can be optimized according to such mechanisms. In addition, novel technologies, such as electric impedance tomography, may help improve airway clearance therapy by monitoring the consequences of regional secretion displacement on lung aeration and regional lung mechanics.

Transpulmonary driving pressure (DPL) corresponds to the cyclical stress imposed on the lung parenchyma during tidal breathing and, therefore, can be used to assess the risk of ventilator-induced lung injury (VILI). Its measurement at the bedside requires the use of esophageal pressure (Peso), which is sometimes technically challenging. Recently, it has been demonstrated how in an animal model of ARDS, the transpulmonary pressure (PL) measured with Peso calculated with the absolute values method (PL = Paw—Peso) is equivalent to the transpulmonary pressure directly measured using pleural sensors in the central-dependent part of the lung. We hypothesized that, since the PL derived from Peso reflects the regional behavior of the lung, it could exist a relationship between regional parameters measured by electrical impedance tomography (EIT) and driving PL (DPL). Moreover, we explored if, by integrating airways pressure data and EIT data, it could be possible to estimate non-invasively DPL and consequently lung elastance (EL) and elastance-derived inspiratory PL (PI). We analyzed 59 measurements from 20 patients with ARDS. There was a significant intra-patient correlation between EIT derived regional compliance in regions of interest (ROI1) (r = 0.5, p = 0.001), ROI2 (r = −0.68, p < 0.001), and ROI3 (r = −0.4, p = 0.002), and DPL. A multiple linear regression successfully predicted DPL based on respiratory system elastance (Ers), ideal body weight (IBW), roi1%, roi2%, and roi3% (R2 = 0.84, p < 0.001). The corresponding Bland-Altmann analysis showed a bias of −1.4e-007 cmH2O and limits of agreement (LoA) of −2.4–2.4 cmH2O. EL and PI calculated using EIT showed good agreement (R2 = 0.89, p < 0.001 and R2 = 0.75, p < 0.001) with the esophageal derived correspondent variables. In conclusion, DPL has a good correlation with EIT-derived parameters in the central lung. DPL, PI, and EL can be estimated with good accuracy non-invasively combining information coming from EIT and airway pressure.

In dredging project, the $\gamma$ -ray based source densitometer is widely used to measure the concentration in solid-liquid two-phase flow, whereas it is radiant, polluted, and inaccurate. Recently, electric densitometers based on Electric Impedance Tomography(EIT) technology has developed to replace the $\gamma$ -ray source densitometer. However, the calibration and velocity of electrical densitometer is very difficult since complex working conditions cannot be uniformly tested and reconstructed. In this paper, a simple and effective device is designed to calibrate the results of the electrical densitometer. Experiments show that the device can reconstruct typical working conditions in dredging projects and accomplish quantitative analysis.

This study explores the application of electric impedance tomography (EIT) to estimate tidal volume (VT) by measuring impedance change per breath (∆Zbreath). Seventeen healthy horses were anaesthetised and mechanically ventilated for elective procedures requiring dorsal recumbency. Spirometric VT (VTSPIRO) and ∆Zbreath were recorded periodically, up to six times throughout anaesthesia. Part 1 assessed these variables at incremental delivered VT of 10, 12 and 15 mL/kg. Part 2 estimated VT (VTEIT) in litres from ∆Zbreath at three additional measurement points using a line of best fit obtained from Part 1. During part 2, VT was adjusted to maintain end-tidal carbon dioxide between 45–55 mmHg. Linear regression determined the correlation between VTSPIRO and ∆Zbreath (part 1). Estimated VTEIT was assessed for agreement with measured VTSPIRO using Bland Altman analysis (part 2). Marked variability in slope and intercepts was observed across horses. Strong positive correlation between ∆Zbreath and VTSPIRO was found in each horse (R2 0.9–0.99). The agreement between VTEIT and VTSPIRO was good with bias (LOA) of 0.26 (−0.36–0.88) L. These results suggest that, in anaesthetised horses, EIT can be used to monitor and estimate VT after establishing the individual relationship between these variables.

Background Prone positioning (PP) during veno-venous ECMO is feasible, but its physiological effects have never been thoroughly evaluated. Our objectives were to describe, through electrical impedance tomography (EIT), the impact of PP on global and regional ventilation, and optimal PEEP level. Methods A monocentric study conducted on ECMO-supported severe ARDS patients, ventilated in pressure-controlled mode, with 14-cmH2O driving pressure and EIT-based “optimal PEEP”. Before, during and after a 16-h PP session, EIT-based distribution and variation of tidal impedance, VTdorsal/VTglobal ratio, end-expiratory lung impedance (EELI) and static compliance were collected. Subgroup analyses were performed in patients who increased their static compliance by ≥ 3 mL/cmH2O after 16 h of PP. Results For all patients (n = 21), tidal volume and EELI were redistributed from ventral to dorsal regions during PP. EIT-based optimal PEEP was significantly lower in PP than in supine position. Median (IQR) optimal PEEP decreased from 14 (12–16) to 10 (8–14) cmH2O. Thirteen (62%) patients increased their static compliance by ≥ 3 mL/cmH2O after PP on ECMO. This subgroup had higher body mass index, more frequent viral pneumonia, shorter ECMO duration, and lower baseline VTdorsal/VTglobal ratio than patients with compliance ≤ 3 mL/cmH2O (P Conclusion Although baseline tidal volume distribution on EIT may predict static compliance improvement after PP on ECMO, our results support physiological benefits of PP in all ECMO patients, by modifying lung mechanics and potentially reducing VILI. Further studies, including a randomized–controlled trial, are now warranted to confirm potential PP benefits during ECMO.

To report on our clinical experience using EIT in individualized PEEP titration in ARDS. Using EIT assessment, we optimized PEEP settings in 39 ARDS patients. The EIT PEEP settings were compared with the physicians’ PEEP settings and the PEEP settings according to the ARDS network. We defined a PEEP difference equal to or greater than 4 cm H2O as clinically relevant. Changes in lung compliance and PaO2/FiO2-ratio were compared in patients with EIT-based PEEP adjustments and in patients with unaltered PEEP. In 28% of the patients, the difference in EIT-based PEEP and physician-PEEP was clinically relevant; in 36%, EIT-based PEEP and physician-PEEP were equal. The EIT-based PEEP disagreed with the PEEP settings according to the ARDS network. Adjusting PEEP based upon EIT led to a rapid increase in lung compliance and PaO2/FiO2-ratio. However, this increase was also observed in the group where the PEEP difference was less than 4 cm H2O. We hypothesize that this can be attributed to the alveolar recruitment during the PEEP trial. EIT based individual PEEP setting appears to be a promising method to optimize PEEP in ARDS patients. The clinical impact, however, remains to be established. Electronic supplementary material The online version of this article (10.1007/s10877-018-0164-x) contains supplementary material, which is available to authorized users.

Background High flow nasal cannula (HFNC) is known to increase global ventilation volume in healthy subjects. We sought to investigate the effect of HFNC on global and regional ventilation patterns in patients with hypoxia. Methods Patients were randomized to receive one of two oxygen therapies in sequence: nasal cannula (NC) followed by HFNC or HFNC followed by NC. Global and regional ventilation was assessed using electric impedance tomography. Results Twenty-four patients participated. Global tidal variation (TV) in the lung was higher during HFNC (NC, 2,241 ± 1,381 arbitrary units (AU); HFNC, 2,543 ± 1,534 AU; P < 0.001). Regional TVs for four iso-gravitational quadrants of the lung were also all higher during HFNC than NC. The coefficient of variation for the four quadrants of the lung was 0.90 ± 0.61 during NC and 0.77 ± 0.48 during HFNC (P = 0.035). Within the four gravitational layers of the lung, regional TVs were higher in the two middle layers during HFNC when compared to NC. Regional TV values in the most ventral and dorsal layers of the lung were not higher during HFNC compared with NC. The coefficient of variation for the four gravitational layers of the lung were 1.00 ± 0.57 during NC and 0.97 ± 0.42 during HFNC (P = 0.574). Conclusions In patients with hypoxia, ventilation of iso-gravitational regions of the lung during HFNC was higher and more homogenized compared with NC. However, ventilation of gravitational layers increased only in the middle layers. (Clinical trials registration number: NCT02943863).

Background: Bronchial asthma is not always easily diagnosed in children because of poor compliance performing spirometric manoeuvres. Little is known about the distribution of pulmonary regional ventilation in these patients. Electric Impedance Tomography (EIT) is a technique where the electrical conductivity and impedance of ventilation is inferred from surface electrodes to form a tomographic image. Objectives: This study aims to determine the role of EIT to investigate the distribution of ventilation during methacholine challenge test (MCT) in order to discriminate healthy from asthmatic patients. Methods: Patients from 5 to 16 years old were enrolled. Positive MCT was defined as a reduction of FEV1 ≥20%. For each patient, spirometry and EIT were assessed at baseline (B), at PD20 (or Step 6 of the MCT) and 10 minutes after administration of the bronchodilator. Results: 36 positive and 7 negative patients were found. Positive group at PD20 showed a significant air trapping (550 ±180 ml, p Conclusions: EIT is a good tool to evaluate regional pulmonary ventilation without requiring collaboration. It could be useful to identify an early air trapping in patients with methacholine challenge test and, possibly, discriminate severe asthmatic in order to administer specific therapy.

The WELCOME system was an innovative telemonitoring solution for management of COPD patients with major comorbidities. It consisted of a sensors-vest capable of recording numerous vital parameters in real time and transmitting them to the cloud via wireless connection. In addition, peripheral devices recorded extra physiological data coupled with responses to validated health questionnaires that the patients responded to via a tablet. A dedicated medical Decision Support System (DSS) and a medical doctor user interface supported the system in providing automated detection of abnormalities/ disease deteriorations. The obtained signals included Heart and Respiratory Rate, Body Posture, SpO 2 , multi-lead ECG, Auscultation and Electric Impedance Tomography. The system was tested with pilot studies in Greece and UK. Results from the Greek pilot study are presented in this paper, highlighting the route from data collection to applied translational medicine through the first operational use of the WELCOME infrastructure.

Introduction: Early assessment of weaning failure and prediction of extubation failure are crucial for management of invasively ventilated patients. Aim: Evaluating whether changes in end-expiratory lung impedance (dEELI) and tidal impedance variation (TIV) by electrical impedance tomography (EIT) may predict weaning failure early in the course of the spontaneous breathing trial (SBT) and extubation failure soon after tube removal. Methods: Multicentre study planning enrolment of 80 invasively ventilated ICU patients. dEELI and TIV are computed averaging 5 consecutive minutes during mechanical ventilation (baseline), at SBT initiation (SBT_0) and end (SBT_30), immediately (SB_0) and 30 minutes after extubation (SB_30). Data comparisons are made between subgroups stratified for weaning and extubation outcome. Results: So far, we enrolled 46 patients. Compared to baseline, patients (n=11) failing SBT, as opposed to those succeeding, show dEELI significantly more negative at SBT_0 (-281 [-1048; -119] vs. -126 [-241; 18] ml, p=0.015) and SBT_30 (-279 [-1396; -156] vs. -73 [-247; 116] ml, p=0.008). No significant loss of dEELI (p= 0.172 at SB_30) was observed in the patients who failed extubation(n=14), compared to those who succeeded (n=21). TIV was no significantly different in any comparisons. Conclusions: While changes in TIV are unhelpful for assessing the risk of both weaning and extubation failure, early fall of dEELI occurs in patients failing SBT, as opposed to those succeeding. The values of dEELI are not significantly different between the patients failing extubation and those succeeding, despite a trend toward a greater reduction in the formers, which makes necessary achieving the planned sample size.

We recently described how spontaneous effort during mechanical ventilation can cause "pendelluft," that is, displacement of gas from nondependent (more recruited) lung to dependent (less recruited) lung during early inspiration. Such transfer depends on the coexistence of more recruited (source) liquid-like lung regions together with less recruited (target) solid-like lung regions. Pendelluft may improve gas exchange, but because of tidal recruitment, it may also contribute to injury. We hypothesize that higher positive end-expiratory pressure levels decrease the propensity to pendelluft and that with lower positive end-expiratory pressure levels, pendelluft is associated with improved gas exchange but increased tidal recruitment.Crossover design.University animal research laboratory.Anesthetized landrace pigs.Surfactant depletion was achieved by saline lavage in anesthetized pigs, and ventilator-induced lung injury was produced by ventilation with high tidal volume and low positive end-expiratory pressure. Ventilation was continued in each of four conditions: positive end-expiratory pressure (low or optimized positive end-expiratory pressure after recruitment) and spontaneous breathing (present or absent). Tidal recruitment was assessed using dynamic CT and regional ventilation/perfusion using electric impedance tomography. Esophageal pressure was measured using an esophageal balloon manometer.Among the four conditions, spontaneous breathing at low positive end-expiratory pressure not only caused the largest degree of pendelluft, which was associated with improved ventilation/perfusion matching and oxygenation, but also generated the greatest tidal recruitment. At low positive end-expiratory pressure, paralysis worsened oxygenation but reduced tidal recruitment. Optimized positive end-expiratory pressure decreased the magnitude of spontaneous efforts (measured by esophageal pressure) despite using less sedation, from -5.6 ± 1.3 to -2.0 ± 0.7 cm H2O, while concomitantly reducing pendelluft and tidal recruitment. No pendelluft was observed in the absence of spontaneous effort.Spontaneous effort at low positive end-expiratory pressure improved oxygenation but promoted tidal recruitment associated with pendelluft. Optimized positive end-expiratory pressure (set after lung recruitment) may reverse the harmful effects of spontaneous breathing by reducing inspiratory effort, pendelluft, and tidal recruitment.

BACKGROUND A bedside tool for monitoring changes in end-expiratory lung volume (ΔEELV) would be helpful to set optimal positive end-expiratory pressure (PEEP) in acute lung injury/acute respiratory distress syndrome patients. The hypothesis of this study was that the cumulative difference of the inspiratory and expiratory tidal volumes of the first 10 breaths after a PEEP change accurately reflects the change in lung volume following a PEEP alteration. METHODS Changing PEEP induces lung volume changes, which are reflected in differences between inspiratory and expiratory tidal volumes measured by spirometry. By adding these differences with correction for offset, for the first 10 breaths after PEEP change, cumulative tidal volume difference was calculated to estimate ΔEELV(VT) ((i-e)) . This method was evaluated in a lung model and in patients with acute respiratory failure during a PEEP trial. In patients, ΔEELV(VT) ((i-e)) were compared with simultaneously measured changes in lung impedance, by electric impedance tomography (EIT), using calibration vs. tidal volume to estimate changes in ΔEELV(EIT) . RESULTS In the lung model, there was close correlation (R(2) = 0.99) between ΔEELV(VT) ((i-e)) and known lung model volume difference, with a bias of -4 ml and limits of agreement of 42 and -50 ml. In 12 patients, ΔEELV(EIT) was closely correlated to ΔEELV(VT) ((i-e)) (R(2) = 0.92), with mean bias of 50 ml and limits of agreement of 131 and -31 ml. Changes in EELV estimated by EIT (ΔEELV(EIT) ) exceeded measurements by spirometry (ΔEELV(VT) ((i-e)) ), with 15 (±15)%. CONCLUSIONS We conclude that spirometric measurements of inspiratory-expiratory tidal volumes agree well with impedance changes monitored by EIT and can be used bedside to estimate PEEP-induced changes in EELV.

A novel non-invasive technique for monitoring fluid content in the human bladder is described. Specifically, a precommercial electric impedance tomograph (EIT) was applied to measure and visualize impedance changes in the lower torso due to changes in bladder volume. Preliminary measurements were conducted during routine urodynamic tests of nine male paraplegic patients, in whom a contrast agent was slowly infused into the bladder for diagnostic purposes. In some patients, a good correlation between bladder volume and EIT measurements was found, whereas in others the correlation was still good but inverted, presumably due to a poor electrode positioning. These preliminary results indicate that a sufficiently accurate finite element modeling of the impedance distribution in the abdomen, and proper electrode positioning aids, are important prerequisites to enable this technology to be used for routine measurement of bladder volume.

Summary Background & aims Continuous nasogastric infusion is commonly used to deliver enteral feed but current methods used to assess tolerance based on aspiration and measurement of gastric residual volume have been criticised. Electric impedance tomography (EIT) measures gastric emptying by monitoring changes in epigastric impedance when a meal progressively empties from the stomach. Aims: (1) to establish whether EIT was a valid method for measuring gastric emptying during continuous nasogastric infusion by comparing it with gamma scintigraphy (GS) and (2) to provide data on gastric emptying patterns during continuous nasogastric infusion. Methods Gastric emptying of 400 ml of enteral feed given over 200 min was measured simultaneously using EIT and GS in 10 healthy volunteers (five male and five female). Results Gastric emptying curves were obtained in 10 subjects by EIT but only eight by GS. Visual examination of the curves showed reasonable agreement. Patterns of emptying and filling during continuous nasogastric infusion were variable between individuals; the prevailing pattern was a trend towards a steady-state volume of approximately 50–125 ml. Conclusions While EIT does not provide an accurate estimate of gastric volume during continuous infusion, it does show patterns of gastric emptying over time. With further development this could make it a useful tool for monitoring gastric emptying in patients at risk of gastroparesis.

To evaluate the efficacy of different lung recruitment maneuvers using electric impedance tomography.Experimental study in animal model of acute lung injury in an animal research laboratory.Fourteen pigs with saline lavage induced lung injury.Lung volume, regional ventilation distribution, gas exchange, and hemodynamics were monitored during three different recruitment procedures: (a) vital capacity maneuver to an inspiratory pressure of 40 cmH2O (ViCM), (b) pressure-controlled recruitment maneuver with peak pressure 40 and PEEP 20 cmH2O, both maneuvers repeated three times for 30 s (PCRM), and (c) a slow recruitment with PEEP elevation to 15 cmH2O with end inspiratory pauses for 7 s twice per minute over 15 min (SLRM).Improvement in lung volume, compliance, and gas exchange were similar in all three procedures 15 min after recruitment. Ventilation in dorsal regions of the lungs increased by 60% as a result of increased regional compliance. During PCRM compliance decreased by 50% in the ventral region. Cardiac output decreased by 63+/-4% during ViCM, 44+/-2% during PCRM, and 21+/-3% during SLRM.In a lavage model of acute lung injury alveolar recruitment can be achieved with a slow lower pressure recruitment maneuver with less circulatory depression and negative lung mechanic side effects than with higher pressure recruitment maneuvers. With electric impedance tomography it was possible to monitor lung volume changes continuously.

Magnetic resonance electrical impedance tomography (MR-EIT) is an emerging imaging technique that reconstructs conductivity images using magnetic flux density measurements acquired employing MRI together with conventional EIT measurements. In this study, experimental MR-EIT images from phantoms with conducting and insulator objects are presented. The technique is implemented using the 0.15 T Middle East Technical University MRI system. The dc current method used in magnetic resonance current density imaging is adopted. A reconstruction algorithm based on the sensitivity matrix relation between conductivity and only one component of magnetic flux distribution is used. Therefore, the requirement for object rotation is eliminated. Once the relative conductivity distribution is found, it is scaled using the peripheral voltage measurements to obtain the absolute conductivity distribution. Images of several insulator and conductor objects in saline filled phantoms are reconstructed. The L2 norm of relative error in conductivity values is found to be 13%, 17% and 14% for three different conductivity distributions.

The following conditions are optimal for obtaining an adequate number of informative images by electric impedance tomography: a) patient seated or standing with hands at the nape of the neck; b) breathing at rest; c) recording of at least 300 images (at a frequency of 10 Hz), and d) readings taken at the sixth intercostal space.

In the current clinical practice the primary diagnostic method for testing for prostate cancer is ultrasound-guided biopsy. In this paper we consider using a sonolucent array of electrodes, printed on a thin Kapton layer and positioned on the imaging window of a transrectal ultrasound probe, as a method for providing coregistered electrical an ultrasound imaging of the prostate. As the electrical properties of malignant tissues have been shown to differ significantly to from benign tissues, the estimation of the electrical properties is expected to be helpful in distinguishing certain begin pathologies from cancer and in improving the detection rate that current biopsy methods provide. One of the main difficulties in estimating electrical properties of tissues with this electrode configuration is the rapid decay of the sensitivity with distance from the sensing array. In order to partially overcome this difficulty we propose to use prior information from US. Specifically we intend to delineate the boundaries of the prostate from US, to subdivide the organ in a small number of voxels and to estimate the conductivity as constant on each of these subvolumes. In the present work we use a 3D forward model based on the finite element method for modeling the probe and three different electrode array designs. Array designs presents a tradeoff choice: larger electrodes, having a larger area, result in a better contact with the tissues; electrodes which are too large result in small inter- electrode gaps, increasing the amount of current that is shunted by the array and thus reduce the sensitivity. We study the sensitivity of the three designs and show that one of these designs presents a good tradeoff in terms of area and sensitivity.

In vivo measurements of equivalent resistivities of skull (/spl rho//sub skull/) and brain (/spl rho//sub brain/) are performed for six subjects using an electric impedance tomography (EIT)-based method and realistic models for the head. The classical boundary element method (BEM) formulation for EIT is very time consuming. However, the application of the Sherman-Morrison formula reduces the computation time by a factor of 5. Using an optimal point distribution in the BEM model to optimize its accuracy, decreasing systematic errors of numerical origin, is important because cost functions are shallow. Results demonstrate that /spl rho//sub skull///spl rho//sub brain/ is more likely to be within 20 and 50 rather than equal to the commonly accepted value of 80. The variation in /spl rho//sub brain/ (average = 301 /spl Omega/ /spl middot/ cm, SD = 13%) and /spl rho//sub skull/ (average = 12230 /spl Omega/ /spl middot/ cm, SD = 18%) is decreased by half, when compared with the results using the sphere model, showing that the correction for geometry errors is essential to obtain realistic estimations. However, a factor of 2.4 may still exist between values of /spl rho//sub skull///spl rho//sub brain/ corresponding to different subjects. Earlier results show the necessity of calibrating /spl rho//sub brain/ and /spl rho//sub skull/ by measuring them in vivo for each subject, in order to decrease errors associated with the electroencephalogram inverse problem. We show that the proposed method is suited to this goal.

Lung function monitoring should provide basic physiological information on gas transport from the air via the lung into the blood and should — depending on the level of care — provide parameters which make a differentiation of the cause of the disturbance in gas exchange possible (Table 1).

Electric impedance tomography (EIT) images have been recorded from the upper thorax of 10 normal subjects and from two patients with pulmonary emboli. The Sheffield Mk2 system was used to obtain the EIT images during quiet tidal breathing and the images were then analysed to extract the cardiac and respiratory related components. In the 10 normal subjects the mean measured change in resistivity during tidal breathing was 9% (SD 3%) with no significant difference in four lung regions. The mean changes during the cardiac cycle were different in the four regions, ranging from -0.9% to -2.6%. The two patients showed very different cardiac related changes from those found in the normals in the posterior lung regions. The sign of the changes was positive, whereas it was negative in the normals. The changes in the anterior lung regions were within the range found in the authors' normal group.