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Rationale: Despite its ability to reduce overall ventilation time, protocol-guided weaning from mechanical ventilation is not routinely used in daily clinical practice. Clinical implementation of weaning protocols could be facilitated by integration of knowledge-based, closed-loop controlled protocols into respirators. Objectives: To determine whether automated weaning decreases overall ventilation time compared with weaning based on a standardized written protocol in an unselected surgical patient population. Methods: In this prospective controlled trial patients ventilated for longer than 9 hours were randomly allocated to receive either weaning with automatic control of pressure support ventilation (automated-weaning group) or weaning based on a standardized written protocol (control group) using the same ventilation mode. The primary end point of the study was overall ventilation time. Measurements and Main Results: Overall ventilation time (median [25th and 75th percentile]) did not significantly differ between the automated-weaning (31 [19-101] h; n = 150) and control groups (39 [20-118] h; n = 150; P = 0.178). Patients who underwent cardiac surgery (n = 132) exhibited significantly shorter overall ventilation times in the automated-weaning (24 [18-57] h) than in the control group (35 [20-93] h; P = 0.035). The automated-weaning group exhibited shorter ventilation times until the first spontaneous breathing trial (1 [0-15] vs. 9 [1-51] h; P = 0.001) and a trend toward fewer tracheostomies (17 vs. 28; P = 0.075). Conclusions: Overall ventilation times did not significantly differ between weaning using automatic control of pressure support ventilation and weaning based on a standardized written protocol. Patients after cardiac surgery may benefit from automated weaning. Implementation of additional control variables besides the level of pressure support may further improve automated-weaning systems. Clinical trial registered with www.clinicaltrials.gov (NCT 00445289). [ABSTRACT FROM AUTHOR]

Objective . Since pulse wave transit time (PWTT) shortens as pulmonary artery pressure (PAP) increases it was suggested as a potential non-invasive surrogate for PAP. The state of tidal lung filling is also known to affect PWTT independently of PAP. The aim of this retrospective analysis was to test whether respiratory gating improved the correlation coefficient between PWTT and PAP. Approach . In each one of five anesthetized and mechanically ventilated pigs two high-fidelity pressure catheters were placed, one directly behind the pulmonary valve, and the second one in a distal branch of the pulmonary artery. PAP was raised using the thromboxane A2 analogue U46619 and animals were ventilated in a pressure controlled mode (I:E ratio 1:2, respiratory rate 12/min, tidal volume of 6 ml kg -1 ). All signals were recorded using the multi-channel platform PowerLab ® . The arrival of the pulse wave at each catheter tip was determined using a MATLAB-based modified hyperbolic tangent algorithm and PWTT calculated as the time interval between these arrivals. Main results . Correlation coefficient for PWTT and mean PAP was r = 0.932 for thromboxane. This correlation coefficient increased considerably when heart beats either at end-inspiration ( r = 0.978) or at end-expiration ( r = 0.985) were selected (=respiratory gating). Significance . The estimation of mean PAP from PWTT improved significantly when taking the respiratory cycle into account. Respiratory gating is suggested to improve for the estimation of PAP by PWTT., (Creative Commons Attribution license.)

Background: Gravity-dependent positioning therapy is an established concept in the treatment of severe acute respiratory distress syndrome and improves oxygenation in spontaneously breathing patients with hypoxemic acute respiratory failure. In patients with coronavirus disease 2019, this therapy seems to be less effective. Electrical impedance tomography as a point-of-care functional imaging modality for visualizing regional ventilation can possibly help identify patients who might benefit from positioning therapy and guide those maneuvers in real-time. Therefore, in this prospective observational study, we aimed to discover typical patterns in response to positioning maneuvers., Methods: Distribution of ventilation in 10 healthy volunteers and in 12 patients with hypoxemic respiratory failure due to coronavirus disease 2019 was measured in supine, left, and right lateral positions using electrical impedance tomography., Results: In this study, patients with coronavirus disease 2019 showed a variety of ventilation patterns, which were not predictable, whereas all but one healthy volunteer showed a typical and expected gravity-dependent distribution of ventilation with the body positions., Conclusion: Distribution of ventilation and response to lateral positioning is variable and thus unpredictable in spontaneously breathing patients with coronavirus disease 2019. Electrical impedance tomography might add useful information on the immediate reaction to postural maneuvers and should be elucidated further in clinical studies. Therefore, we suggest a customized individualized positioning therapy guided by electrical impedance tomography., (© 2022 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Pulse wave transit time (PWTT) shortens as pulmonary artery pressure (PAP) increases and was therefore suggested as a surrogate parameter for PAP. The aim of this analysis was to reveal patterns and potential mechanisms of ventilation-induced periodic changes in PWTT under resting conditions. To measure both PWTT and PAP in five healthy pigs, two pulmonary artery Mikro-Tip™ catheters were inserted into the pulmonary vasculature: one with the tip placed in the pulmonary artery trunk, and a second one placed in a distal segment of the pulmonary artery. Animals received pressure-controlled mechanical ventilation. Ventilation-dependent changes were seen in both variables, PWTT and mean PAP; however, changes in PWTT were not synchronous with changes in PAP. Thus, plotting the value of PWTT for each heartbeat over the respective PAP revealed a characteristic hysteresis. At the beginning of inspiration, PAP rose while PWTT remained constant. During further inspiration, PWTT started to decrease rapidly as mPAP was about to reach its plateau. The same time course was observed during expiration: while mPAP approached its minimum, PWTT increased rapidly. During apnea this hysteresis disappeared. Thus, non-synchronous ventilation-induced changes in PWTT and PAP were found with inspiration causing a significant shortening of PWTT. Therefore, it is suggested that the respiratory cycle should be considered when using PWTT as a surrogate for PAP.

Respiratory failure due to SARS-CoV-2 may progress rapidly. During the course of COVID-19, patients develop an increased respiratory drive, which may induce high mechanical strain a known risk factor for Patient Self-Inflicted Lung Injury (P-SILI). We developed a novel Electrical Impedance Tomography-based approach to visualize the Dynamic Relative Regional Strain (DRRS) in SARS-CoV-2 positive patients and compared these findings with measurements in lung healthy volunteers. DRRS was defined as the ratio of tidal impedance changes and end-expiratory lung impedance within each pixel of the lung region. DRRS values of the ten patients were considerably higher than those of the ten healthy volunteers. On repeated examination, patterns, magnitude and frequency distribution of DRRS were reproducible and in line with the clinical course of the patients. Lung ultrasound scores correlated with the number of pixels showing DRRS values above the derived threshold. Using Electrical Impedance Tomography we were able to generate, for the first time, images of DRRS which might indicate P-SILI in patients suffering from COVID-19.Trial Registration This observational study was registered 06.04.2020 in German Clinical Trials Register (DRKS00021276)., (© 2021. The Author(s).)

Background: The current naming of ventilation modes in anesthesiology and critical care is characterized by manufacturer-specific inconsistent acronyms. This is confusing for users and potentially life-threatening for patients. The standard, published in August 2021 in its German version as DIN EN ISO 19223:2021, aims to introduce a uniform classification with corresponding nomenclature., Aim of the Work: To present the new standard and its consequences for the user., Material and Method: Review and summary of DIN EN ISO 19223:2021 with a critical appraisal of its strengths and weaknesses., Results: A simplified scheme shows the group classification of ventilation modes based on similar characteristics. These are further specified by additional variables. A reference table contrasts the new nomenclature of ventilation modes with those currently in use. Accordingly, the new classification scheme appears inconsistent and the variables are difficult to distinguish., Conclusion: Standardized terminology and semantics in respiratory care are necessary and desirable for error reduction. However, the recently presented standard fulfils these expectations only to some extent and in its current form will probably lead to further ambiguities and problems in the clinical routine. Accordingly, it is imperative that this first version of DIN EN ISO 19223:2021 be understood as the starting point for a discussion of its content, even outside the standards committees, so that its obvious weaknesses can be eradicated and the nomenclature made suitable for everyday use., (© 2022. The Author(s).)

For the non-invasive assessment of pulmonary artery pressure (PAP), surrogates like pulse wave transit time (PWTT) have been proposed. The aim of this study was to invasively validate for which kind of PAP (systolic, mean, or diastolic) PWTT is the best surrogate parameter. To assess both PWTT and PAP in six healthy pigs, two pulmonary artery Mikro-Tip™ catheters were inserted into the pulmonary vasculature at a fixed distance: one in the pulmonary artery trunk, and a second one in a distal segment of the pulmonary artery. PAP was raised using the thromboxane A2 analogue U46619 (TXA) and by hypoxic vasoconstriction. There was a negative linear correlation between PWTT and systolic PAP ( r = 0.742), mean PAP ( r = 0.712) and diastolic PAP ( r = 0.609) under TXA. During hypoxic vasoconstriction, the correlation coefficients for systolic, mean, and diastolic PAP were consistently higher than for TXA-induced pulmonary hypertension ( r = 0.809, 0.778 and 0.734, respectively). Estimation of sPAP, mPAP, and dPAP using PWTT is feasible, nevertheless slightly better correlation coefficients were detected for sPAP compared to dPAP. In this study we establish the physiological basis for future methods to obtain PAP by non-invasively measured PWTT.

To determine whether a classification based on the contour of the photoplethysmography signal (PPGc) can detect changes in systolic arterial blood pressure (SAP) and vascular tone. Episodes of normotension (SAP 90-140 mmHg), hypertension (SAP > 140 mmHg) and hypotension (SAP < 90 mmHg) were analyzed in 15 cardiac surgery patients. SAP and two surrogates of the vascular tone, systemic vascular resistance (SVR) and vascular compliance (Cvasc = stroke volume/pulse pressure) were compared with PPGc. Changes in PPG amplitude (foot-to-peak distance) and dicrotic notch position were used to define 6 classes taking class III as a normal vascular tone with a notch placed between 20 and 50% of the PPG amplitude. Class I-to-II represented vasoconstriction with notch placed > 50% in a small PPG, while class IV-to-VI described vasodilation with a notch placed < 20% in a tall PPG wave. 190 datasets were analyzed including 61 episodes of hypertension [SAP = 159 (151-170) mmHg (median 1st-3rd quartiles)], 84 of normotension, SAP = 124 (113-131) mmHg and 45 of hypotension SAP = 85(80-87) mmHg. SAP were well correlated with SVR (r = 0.78, p < 0.0001) and Cvasc (r = 0.84, p < 0.0001). The PPG-based classification correlated well with SAP (r = - 0.90, p < 0.0001), SVR (r = - 0.72, p < 0.0001) and Cvasc (r = 0.82, p < 0.0001). The PPGc misclassified 7 out of the 190 episodes, presenting good accuracy (98.4% and 97.8%), sensitivity (100% and 94.9%) and specificity (97.9% and 99.2%) for detecting episodes of hypotension and hypertension, respectively. Changes in arterial pressure and vascular tone were closely related to the proposed classification based on PPG waveform.Clinical Trial Registration NTC02854852.

To describe the principles and the first clinical application of a novel prototype automated weaning system called Evita Weaning System (EWS). EWS allows an automated control of all ventilator settings in pressure controlled and pressure support mode with the aim of decreasing the respiratory load of mechanical ventilation. Respiratory load takes inspired fraction of oxygen, positive end-expiratory pressure, pressure amplitude and spontaneous breathing activity into account. Spontaneous breathing activity is assessed by the number of controlled breaths needed to maintain a predefined respiratory rate. EWS was implemented as a knowledge- and model-based system that autonomously and remotely controlled a mechanical ventilator (Evita 4, Dräger Medical, Lübeck, Germany). In a selected case study (n = 19 patients), ventilator settings chosen by the responsible physician were compared with the settings 10 min after the start of EWS and at the end of the study session. Neither unsafe ventilator settings nor failure of the system occurred. All patients were successfully transferred from controlled ventilation to assisted spontaneous breathing in a mean time of 37 ± 17 min (± SD). Early settings applied by the EWS did not significantly differ from the initial settings, except for the fraction of oxygen in inspired gas. During the later course, EWS significantly modified most of the ventilator settings and reduced the imposed respiratory load. A novel prototype automated weaning system was successfully developed. The first clinical application of EWS revealed that its operation was stable, safe ventilator settings were defined and the respiratory load of mechanical ventilation was decreased.

Analysis methods of electrical impedance tomography (EIT) images based on different reconstruction algorithms were examined. EIT measurements were performed on eight mechanically ventilated patients with acute respiratory distress syndrome. A maneuver with step increase of airway pressure was performed. EIT raw data were reconstructed offline with (1) filtered back-projection (BP); (2) the Dräger algorithm based on linearized Newton-Raphson (DR); (3) the GREIT (Graz consensus reconstruction algorithm for EIT) reconstruction algorithm with a circular forward model (GR(C)) and (4) GREIT with individual thorax geometry (GR(T)). Individual thorax contours were automatically determined from the routine computed tomography images. Five indices were calculated on the resulting EIT images respectively: (a) the ratio between tidal and deep inflation impedance changes; (b) tidal impedance changes in the right and left lungs; (c) center of gravity; (d) the global inhomogeneity index and (e) ventilation delay at mid-dorsal regions. No significant differences were found in all examined indices among the four reconstruction algorithms (p > 0.2, Kruskal-Wallis test). The examined algorithms used for EIT image reconstruction do not influence the selected indices derived from the EIT image analysis. Indices that validated for images with one reconstruction algorithm are also valid for other reconstruction algorithms.

Background: The electrical impedance tomography (EIT)-based global inhomogeneity (GI) index was introduced to quantify tidal volume distribution within the lung. Up to now, the GI index was evaluated for plausibility but the analysis of how it is influenced by various physiological factors is still missing. The aim of our study was to evaluate the influence of proportion of open lung regions measured by EIT on the GI index., Methods: A constant low-flow inflation maneuver was performed in 18 acute respiratory distress syndrome (ARDS) patients (58 ± 14 years, mean age ± SD) and 8 lung-healthy patients (41 ± 12 years) under controlled mechanical ventilation. EIT raw data were acquired at 25 scans/s and reconstructed offline. Recruited lung regions were identified as those image pixels of the lung regions within the EIT scans where local impedance amplitudes exceeded 10% of the maximum amplitude during the maneuver. A series of GI indices was calculated during mechanical lung inflation, based on the differential images obtained between different time points. Respiratory system elastance (Ers) values were calculated at 10 lung volume levels during low-flow maneuver., Results: The GI index decreased during low-flow inflation, while the percentage of open lung regions increased. The values correlated highly in both ARDS (r2 = 0.88 ± 0.08, p < 0.01) and lung-healthy patients (r2 = 0.92 ± 0.05, p < 0.01). Ers and GI index were also significantly correlated in 16 out of 18 ARDS (r2 = 0.84 ± 0.13, p < 0.01) and in 6 out of 8 lung-healthy patients (r2 = 0.84 ± 0.07, p < 0.01). Significant differences were found in GI values between two groups (0.52 ± 0.21 for ARDS and 0.41 ± 0.04 for lung-healthy patients, p < 0.05) as well in Ers values (0.017 ± 0.008 cmH2O/ml for ARDS and 0.009 ± 0.001 cmH2O/ml for lung-healthy patients, p < 0.01)., Conclusions: We conclude that the GI index is a reliable measure of ventilation heterogeneity highly correlated with lung recruitability measured with EIT. The GI index may prove to be a useful EIT-based index to guide ventilation therapy.

Background: Due to the ill-posed problem, the electrical impedance within the thorax cannot be exactly reconstructed., Objective: The aim of our study was to prove that reconstruction with individual thorax geometry improved the quality of EIT (electrical impedance tomography) images., Methods: Seven mechanically ventilated patients with acute respiratory distress syndrome were examined by EIT. The thorax contours were determined from routine computed tomography (CT) images based on automatic threshold filtering. EIT raw data was reconstructed offline with (1) back-projection with circular forward model; (2) GREIT reconstruction method with circular forward model and (3) GREIT with individual thorax geometry. The resulting EIT images were compared to rescaled CT images. The distance between the lung contour and the thorax contour was calculated for each method and the differences to that in CT were denoted as position differences. Shape differences was defined as the ratio of thorax (or lungs) size in EIT and that in rescaled CT., Results: Method (3) has the smallest position differences (6.6 ± 2.8, 5.3 ± 3.3, 2.3 ± 1.4 in pixel, for each reconstruction method respectively; mean ± SD). The thorax and lungs sizes in the transformed CT images were 514 ± 73 and 177 ± 39. Shape differences of thorax were 1.81 ± 0.26, 1.81 ± 0.26, 1.10 ± 0.12 and that of lungs were 1.69 ± 0.45, 1.52 ± 0.45, 1.34 ± 0.35 for each method respectively., Conclusion: The reconstructed images using the GREIT method with individual thorax geometry were more realistic. Improvement of EIT image quality may foster the acceptance of EIT in routine clinical use.

Introduction: Lung-protective ventilation aims at using low tidal volumes (VT) at optimum positive end-expiratory pressures (PEEP). Optimum PEEP should recruit atelectatic lung regions and avoid tidal recruitment and end-inspiratory overinflation. We examined the effect of VT and PEEP on ventilation distribution, regional respiratory system compliance (C(RS)), and end-expiratory lung volume (EELV) in an animal model of acute lung injury (ALI) and patients with ARDS by using electrical impedance tomography (EIT) with the aim to assess tidal recruitment and overinflation., Methods: EIT examinations were performed in 10 anaesthetized pigs with normal lungs ventilated at 5 and 10 ml/kg body weight VT and 5 cmH2O PEEP. After ALI induction, 10 ml/kg VT and 10 cmH2O PEEP were applied. Afterwards, PEEP was set according to the pressure-volume curve. Animals were randomized to either low or high VT ventilation changed after 30 minutes in a crossover design. Ventilation distribution, regional C(RS) and changes in EELV were analyzed. The same measures were determined in five ARDS patients examined during low and high VT ventilation (6 and 10 (8) ml/kg) at three PEEP levels., Results: In healthy animals, high compared to low VT increased C(RS) and ventilation in dependent lung regions implying tidal recruitment. ALI reduced C(RS) and EELV in all regions without changing ventilation distribution. Pressure-volume curve-derived PEEP of 21±4 cmH2O (mean±SD) resulted in comparable increase in C(RS) in dependent and decrease in non-dependent regions at both VT. This implied that tidal recruitment was avoided but end-inspiratory overinflation was present irrespective of VT. In patients, regional C(RS) differences between low and high VT revealed high degree of tidal recruitment and low overinflation at 3±1 cmH2O PEEP. Tidal recruitment decreased at 10±1 cmH2O and was further reduced at 15±2 cmH(2)O PEEP., Conclusions: Tidal recruitment and end-inspiratory overinflation can be assessed by EIT-based analysis of regional C(RS).

Background: Lung tissue of patients with acute respiratory distress syndrome (ARDS) is heterogeneously damaged and prone to develop atelectasis. During inflation, atelectatic regions may exhibit alveolar recruitment accompanied by prolonged filling with air in contrast to regions with already open alveoli with a fast increase in regional aeration. During deflation, derecruitment of injured regions is possible with ongoing loss in regional aeration. The aim of our study was to assess the dynamics of regional lung aeration in mechanically ventilated patients with ARDS and its dependency on positive end-expiratory pressure (PEEP) using electrical impedance tomography (EIT)., Methods: Twelve lung healthy and twenty ARDS patients were examined by EIT during sustained step increases in airway pressure from 0, 8 and 15 cm H2O to 35 cm H2O and during subsequent step decrease to the corresponding PEEP. Regional EIT waveforms in the ventral and dorsal lung regions were fitted to bi-exponential equations. Regional fast and slow respiratory time constants and the sizes of the fast and slow compartments were subsequently calculated., Results: ARDS patients exhibited significantly lower fast and slow time constants than the lung healthy patients in ventral and dorsal regions. The time constants were significantly affected by PEEP and differed between the regions. The size of the fast compartment was significantly lower in ARDS patients than in patients with healthy lung under all studied conditions., Conclusion: These results show that regional lung mechanics can be assessed by EIT. They reflect the lower respiratory system compliance of injured lungs and imply more pronounced regional recruitment and derecruitment in ARDS patients.

Electrical impedance tomography (EIT) is a functional imaging modality capable of tracing continuously regional pulmonary gas volume changes. The aim of our study was to determine if EIT was able to assess spatial and temporal heterogeneity of ventilation during pulmonary function testing in 14 young (37 ± 10 yr, mean age ± SD) and 12 elderly (71 ± 9 yr) subjects without lung disease and in 33 patients with chronic obstructive pulmonary disease (71 ± 9 yr). EIT and spirometry examinations were performed during tidal breathing and a forced vital capacity (FVC) maneuver preceded by full inspiration to total lung capacity. Regional inspiratory vital capacity (IVC); FVC; forced expiratory volume in 1 s (FEV(1)); FEV(1)/FVC; times required to expire 25%, 50%, 75%, and 90% of FVC (t(25), t(50), t(75), t(90)); and tidal volume (V(T)) were determined in 912 EIT image pixels in the chest cross section. Coefficients of variation (CV) were calculated from all pixel values of IVC, FVC, FEV(1), and V(T) to characterize the ventilation heterogeneity. The highest values were found in patients, and no differences existed between the healthy young and elderly subjects. Receiver-operating characteristics curves showed that CV of regional IVC, FVC, FEV(1), and V(T) discriminated the young and elderly subjects from the patients. Frequency distributions of pixel FEV(1)/FVC, t(25), t(50), t(75), and t(90) identified the highest ventilation heterogeneity in patients but distinguished also the healthy young from the elderly subjects. These results indicate that EIT may provide additional information during pulmonary function testing and identify pathologic and age-related spatial and temporal heterogeneity of regional lung function.

Purpose: In acute lung injury (ALI), the application of positive end-expiratory pressure (PEEP) is known to prevent the alveoli from cyclic collapse and reopening and to homogenize ventilation. The setting of adequate PEEP could be optimized by the knowledge of regional lung opening and closing pressures at the bedside. The aim of our study was to determine regional opening and closing pressures in ventilated patients by electrical impedance tomography (EIT)., Materials and Methods: Eight patients with healthy lungs and 18 patients with ALI were studied. A low-flow inflation and deflation maneuver with constant gas flow was performed. Regional opening and closing pressures were calculated for every pixel of the EIT scan. These pressures were defined as those values of global airway pressure at which the lung areas opened up or started to close., Results: Injured lungs exhibited significantly higher regional opening pressures compared with healthy lungs (P < .05). In ALI, significantly higher opening pressures were found in the dependent lung regions. Regional closing pressures did not significantly differ between healthy and injured lungs., Conclusions: Regional lung opening and closing pressures can be assessed by EIT. This information may facilitate the setting of adequate PEEP levels in patients in future., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We show the first clinical results using the level-set-based reconstruction algorithm for electrical impedance tomography (EIT) data. The level-set-based reconstruction method (LSRM) allows the reconstruction of non-smooth interfaces between image regions, which are typically smoothed by traditional voxel-based reconstruction methods (VBRMs). We develop a time difference formulation of the LSRM for 2D images. The proposed reconstruction method is applied to reconstruct clinical EIT data of a slow flow inflation pressure-volume manoeuvre in lung-healthy and adult lung-injury patients. Images from the LSRM and the VBRM are compared. The results show comparable reconstructed images, but with an improved ability to reconstruct sharp conductivity changes in the distribution of lung ventilation using the LSRM.

Purpose: High-frequency oscillatory ventilation (HFOV) is usually considered not indicated for treatment of patients with chronic obstructive pulmonary disease (COPD) because of the theoretical risk of air trapping and hyperinflation. The aim of our study was to establish whether HFOV can be safely applied in patients with acute exacerbation of COPD and hypercapnic respiratory failure., Methods: Ten patients (age, 63-83 years) requiring intensive care treatment who failed on noninvasive ventilation were studied. After initial conventional mechanical ventilation (CMV) of less than 72 hours, all patients were transferred to HFOV for 24 hours and then back to CMV. Arterial blood gases, spirometry, and hemodynamic parameters were repeatedly obtained in all phases of CMV and HFOV at different settings. Regional lung aeration and ventilation were assessed by electrical impedance tomography., Results: High-frequency oscillatory ventilation was tolerated well; no adverse effects or severe hyperinflation and hemodynamic compromise were observed. Effective CO(2) elimination and oxygenation were achieved. Ventilation was more homogeneously distributed during HFOV than during initial CMV. Higher respiratory system compliance and tidal volume were found during CMV after 24 hours of HFOV., Conclusions: Our study indicates that short-term HFOV, using lower mean airway pressures than recommended for acute respiratory distress syndrome, appears safe in patients with COPD while securing adequate pulmonary gas exchange., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Electrical impedance tomography (EIT) is expected to become a valuable tool for monitoring mechanically ventilated patients due to its ability to continuously assess regional lung ventilation and aeration. Several sources of interference with EIT examinations exist in intensive care units (ICU). Our objectives are to demonstrate how some medical nursing and monitoring devices interfere with EIT measurements and modify the EIT scans and waveforms, which approaches can be applied to minimize these effects and how possible misinterpretation can be avoided. We present four cases of EIT examinations of adult ICU patients. Two of the patients were subjected to pulsation therapy using a pulsating air suspension mattress while being ventilated by high-frequency oscillatory or conventional pressure-controlled ventilation, respectively. The EIT signal modulation synchronous with the occurrence of the pulsating wave was 2.3 times larger than the periodic modulation synchronous with heart rate and high-frequency oscillations. During conventional ventilation, the pulsating mattress induced an EIT signal fluctuation with a magnitude corresponding to about 20% of the patient's tidal volume. In the third patient, interference with EIT examination was caused by continuous cardiac output monitoring. The last patient's examination was disturbed by impedance pneumography when excitation currents of similar frequency to EIT were used. In all subjects, the generation of functional EIT scans was compromised and interpretation of regional ventilation impossible. Discontinuation of pulsation therapy and of continuous cardiac output and impedance respiration monitoring immediately improved the EIT signal and scan quality. Offline processing of the disturbed data using frequency filtering enabled partial retrieval of relevant information. We conclude that thoracic EIT examinations in the ICU require cautious interpretation because of possible mechanical and electromagnetic interference.

Background and Objective: Reliable assessment of regional lung ventilation and good reproducibility of electrical impedance tomography (EIT) data are the prerequisites for the future application of EIT in a clinical setting. The aims of our study were to determine (i) the reproducibility of repeated EIT measurements and (ii) the effect of the studied transverse chest plane on ventilation distribution in different postures., Methods: Ten healthy adult subjects were studied in three postures on two separate days. EIT and spirometric data were obtained during tidal breathing and slow vital capacity (VC) manoeuvres. EIT data were acquired in two chest planes at 13 scans/s. Reproducibility of EIT findings was assessed by Bland-Altman analysis and Pearson correlation in 16 regions of interest in each plane. Regional ventilation distribution during tidal breathing and deep expiration was determined as fractional ventilation in four quadrants of the studied chest cross-sections., Results: Our study showed a good reproducibility of EIT measurements repeated after an average time interval of 8 days. Global tidal volumes and VCs determined by spirometry on separate days were not significantly different. Regional ventilation in chest quadrants assessed by EIT was also unaffected. Posture exerted a significant effect on ventilation distribution among the chest quadrants during spontaneous breathing and deep expiration in both planes. The spatial distribution patterns in the two planes were not identical., Conclusions: We conclude that regional EIT ventilation findings are reproducible and recommend that the EIT examination location on the chest is carefully chosen especially during repeated measurements and follow-up., (© 2011 The Authors. Respirology © 2011 Asian Pacific Society of Respirology.)

Introduction: Interventional lung assist (ILA), based on the use of a pumpless extracorporeal membrane oxygenator, facilitates carbon dioxide (CO2) elimination in acute respiratory distress syndrome (ARDS). It is unclear whether an ILA system should be clamped during cardiopulmonary resuscitation (CPR) in patients with ARDS or not. The aim of our study was to test the effects of an ILA on haemodynamics and gas exchange during CPR on animals with ARDS and to establish whether the ILA should be kept open or clamped under these circumstances., Methods: The study was designed to be prospective and experimental. The experiments were performed on 12 anaesthetised and mechanically ventilated pigs (weighing 41 to 58 kg). One femoral artery and one femoral vein were cannulated and connected to an ILA. ARDS was induced by repeated bronchoalveolar lavage. An indwelling pacemaker was used to initiate ventricular fibrillation and chest compressions were immediately started and continued for 30 minutes. In six animals, the ILA was kept open and in the other six it was clamped., Results: Systolic and mean arterial pressures did not differ significantly between the groups. With the ILA open mean +/- standard deviation systolic blood pressures were 89 +/- 26 mmHg at 5 minutes, 71 +/- 28 mmHg at 10 minutes, 63 +/- 33 mmHg at 20 minutes and 83 +/- 23 mmHg at 30 minutes. The clamped ILA system resulted in systolic pressures of 77 +/- 30 mmHg, 90 +/- 23 mmHg, 72 +/- 11 mmHg and 72 +/- 22 mmHg, respectively. In the group with the ILA system open, arterial partial pressure of CO2 was significantly lower after 10, 20 and 30 minutes of CPR and arterial partial pressure of oxygen was higher 20 minutes after the onset of CPR (191 +/- 140 mmHg versus 57 +/- 14 mmHg). End-tidal partial pressure of CO2 decreased from 46 +/- 23 Torr (ILA open) and 37 +/- 9 Torr (ILA clamped) before intervention to 8 +/- 5 Torr and 8 +/- 10 Torr, respectively, in both groups after 30 minutes of CPR., Conclusions: Our results indicate that in an animal model of ARDS, blood pressures were not impaired by keeping the ILA system open during CPR compared with the immediate clamping of the ILA with the onset of CPR. The effect of ILA on gas exchange implied a beneficial effect.

Background: Electrical impedance tomography (EIT) is able to detect variations in regional lung electrical impedance associated with changes in both air and blood content and potentially capable of assessing regional ventilation-perfusion relationships. However, regional lung perfusion is difficult to determine because the impedance changes synchronous with the heart rate are of very small amplitude., Objectives: The aim of our study was to determine the redistribution of lung perfusion elicited by one-lung ventilation using EIT with a novel region-of-interest analysis., Methods: Ten patients (65 +/- 9 years, mean age +/- SD) scheduled for elective chest surgery were studied after intubation with a double-lumen endotracheal tube during bilateral and unilateral ventilation of the right and left lungs. EIT data were acquired at a rate of 25 scans/s. Relative impedance changes synchronous with the heart rate were evaluated in the right and left lung regions., Results: During bilateral ventilation, the mean right-to-left lung ratio of the sum of heart rate-related impedance changes was 1.12 +/- 0.20, but the ratio significantly changed (0.81 +/- 0.16 and 1.48 +/- 0.37) during unilateral left- and right-lung ventilation with reduced perfusion of the non-ventilated lung. Increased perfusion most likely occurred in the ventilated lung because the impedance values summed over both regions did not change (0.62 +/- 0.23 vs. 0.58 +/- 0.22) compared with bilateral ventilation., Conclusions: Our results indicate that redistribution of regional lung perfusion can be assessed by EIT during one-lung ventilation. The performance of EIT in detecting changes in lung perfusion in even smaller lung regions remains to be established., (Copyright 2009 S. Karger AG, Basel.)

The measurement of regional lung ventilation by electrical impedance tomography (EIT) has been evaluated in many experimental studies. However, EIT is not routinely used in a clinical setting, which is attributable to the fact that a convenient concept for how to quantify the EIT data is missing. The definition of region of interest (ROI) is an essential point in the data analysis. To date, there are only limited data available on the different approaches to ROI definition to evaluate regional lung ventilation by EIT. For this survey we examined ten patients (mean age +/- SD: 60 +/- 10 years) under controlled ventilation. Regional tidal volumes were quantified as pixel values of inspiratory-to-expiratory impedance differences and four types of ROIs were subsequently applied. The definition of ROI contours was based on the calculation of the pixel values of (1) standard deviation from each pixel set of impedance data and (2) the regression coefficient from linear regression equations between the individual local (pixel) and average (whole scan) impedance signals. Additionally, arbitrary ROIs (four quadrants and four anteroposterior segments of equal height) were used. Our results indicate that both approaches to ROI definition using statistical parameters are suitable when impedance signals with high sensitivity to ventilation-related phenomena are to be analyzed. The definition of the ROI contour as 20-35% of the maximum standard deviation or regression coefficient is recommended. Simple segmental ROIs are less convenient because of the low ventilation-related signal component in the dorsal region.

Introduction: The aim of the study was to test the hypothesis that a pumpless arteriovenous extracorporeal membrane oxygenator (interventional lung assist (ILA)) does not significantly improve oxygenation in a lavage model of acute lung injury., Methods: The study was designed as a prospective experimental study. The experiments were performed on seven pigs (48-60 kg body weight). The pigs were anesthetized and mechanically ventilated. Both femoral arteries and one femoral vein were cannulated and connected with ILA. Acute lung injury was induced by repeated bronchoalveolar lavage until the arterial partial pressure of O2 was lower than 100 Torr for at least 30 minutes during ventilation with 100% O2., Results: ILA was applied with different blood flow rates through either one or both femoral arteries. Measurements were repeated at different degrees of pulmonary gas exchange impairment with the pulmonary venous admixture ranging from 35.0% to 70.6%. The mean (+/- standard deviation) blood flow through ILA was 15.5 (+/- 3.9)% and 21.7 (+/- 4.9)% of cardiac output with one and both arteries open, respectively. ILA significantly increased the arterial partial pressure of O2 from 64 (+/- 13) Torr to 71 (+/- 14) Torr and 74 (+/- 17) Torr with blood flow through one and both femoral arteries, respectively. O2 delivery through ILA increased with extracorporeal shunt flow (36 (+/- 14) ml O2/min versus 47 (+/- 17) ml O2/min) and reduced arterialization of the inlet blood. Pulmonary artery pressures were significantly reduced when ILA was in operation., Conclusion: Oxygenation is increased by ILA in severe lung injury. This effect is significant but small. The results indicate that the ILA use may not be justified if the improvement of oxygenation is the primary therapy goal.

Impairment of the intestinal microcirculation has been recognized as an important factor in the pathogenesis of endotoxin related sepsis syndrome. We investigated the effects of endotoxemia on the variability of intestinal microvascular blood flow (IMBF) and arterial blood pressure (BP) in a prospective, randomized, controlled animal study. Recordings of IMBF (laser Doppler fluxmetry) and BP were performed before, two and four hours after i.v. injection of either placebo or endotoxin (5 mg/kg b.w. lipopolysaccharide from E. coli, serotype O55:B5). Control experiments were performed with systemic (clonidine) and local intestinal (surgery) sympathectomy. Spectral analysis was performed using the autoregressive approach. Spectral power was determined in two frequency bands (low frequency (LF): 0.27-0.74 Hz; high frequency (HF): 0.76-3.00 Hz). Two hours after endotoxin challenge a significant decrease in IMBF was observed. LF spectral power of IMBF and BP increased significantly in the endotoxin challenged group, while no effects were observed in the placebo group. Four hours after endotoxin administration IMBF decreased further and LF spectral power of IMBF and BP remained elevated. Denervation prevented the decrease in IMBF but did not abolish the LF power increase. Clonidine administration attenuated the IMBF decrease and significantly diminished the increase in LF spectral power of IMBF and BP. We conclude that endotoxemia is associated with increased sympathetic outflow to the systemic vasculature, as indicated by the increase in LF spectral power of arterial blood pressure. The increase in LF variability of IMBF is secondary to the increase in LF spectral power of BP, since it could be attenuated by systemic and not by local intestinal sympathectomy.

New molecular markers of coagulation and fibrinolysis activation have been developed and used to identify patient subgroups that frequently develop increased procoagulant turnover and, hence, disseminated intravascular coagulation and organ dysfunction. The idea of inhibiting the coagulation hyperactivation by the administration of antithrombin has led to experimental findings that pinpoint an anti-inflammatory action of antithrombin. Preliminary clinical trials of high-dose antithrombin administration in sepsis are promising. Point-of-care coagulation testing remains controversial since a variety of perioperative therapeutic regimens such as aprotinin administration obviously do not require 'on-line' coagulation monitoring.