electrical impedance tomography (eit) in paediatric intensive

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Academic Research Tool or Useful Clinical Device?

Electrical Impedance Tomography (EIT) in Paediatric Intensive Care

EIT has proven to deliver valuable information to individualize ventilation strategies in adult patients. But does EIT deliver the same value to the care of paediatric patients? Are there areas of application beyond supporting decisions on ventilation strategies? We explore multiple ways, EIT may bring value to daily clinical work on the paediatric ICU.


1. HISTORY AND TECHNICAL OVERVIEW

Electrical impedance tomography (EIT) has been applied for many years and is frequently being used in research and increasingly adopted in adult critical care. Although EIT offers substantial advantages, its use in paediatric critical care has remained rare so far. This overview will highlight the broad range of applications in paediatric critical care.

EIT is a non-invasive and radiation-free bedside tool that monitors regional conductivity changes. Invented over 30 years ago (Barber & Brown, 19892 ), a wide range of applications including monito-ring of brain function, breast tissue, gastric emptying, and lung function has been explored (Walsh & Smallwood, 201630). EIT technology analyses the electrical impedance changes between tissues, fluids, and air-filled spaces, therefore investiga-tion of lung tissue is an ideal application of EIT: pulmonary EIT images are clear and accurate. As the lung is located close to the measurement surface, changes in air volume during inspiration and expiration result in high changes in electrical conductivity and therefore in contrast (Davies & Silvestre, 20205).

The technology has been validated against several imaging tech-niques including computed tomography (CT), spirometry, single photon emission computed tomography, position emission tomo-graphy, and ventilation scintigraphy (Davies & Silvestre, 20205). EIT provides an opportunity to detect regional changes of lung ventilation like areas of overdistension or atelectasis in real time. It offers a large range of applications, especially in monitoring venti-lation as highlighted in the course of this article.

Research during the last years has pointed out the benefits of EIT in ventilation monitoring in adults. Also in children, there is growing evidence of the usefulness of this technique that will be the focus of this article.

2. SCOPE OF APPLICATION IN PAEDIATRIC CRITICAL CARE

Research during the last decades in adult patients has highligh-ted three main areas of thoracic EIT application (Frerichs et al., 20178): First, the monitoring of mechanical ventilation to prevent ventilator-associated lung injury. Second, monitoring of lung per-fusion, e.g. to detect regional hypoxic pulmonary vasoconstriction. And third, testing of pulmonary function in patients with lung di-seases like COPD, asthma or cystic fibrosis.

In paediatric care, there is an even stronger demand for a non-in-vasive, radiation-free bedside tool to monitor the respiratory status of children. In the following section we will highlight some impor-tant studies to illustrate the potential and broad range of the EIT technique in paediatric care (for a detailed review of EIT literature see Frerichs et al., 20178).

For detailed technical information of EIT technology please follow this link: https://www.draeger.com/en_uk/Hospital/Electrical-Impedance-Tomography

ELECTRICAL IMPEDANCE TOMOGRAPHY (EIT) IN PAEDIATRIC INTENSIVE CARE

EIT is a non-invasive bedside tool using electrical impe-dance of tissues to display real-time images. It has been validated against several imaging techniques and is best suited for monitoring lung function. In this article, we will highlight the use of EIT technology in paediatric care.


2.1. MECHANICAL VENTILATION

Most of the EIT-studies in children described this technology as a tool to visualise regional patterns of mechanical ventilation.

n The potential of EIT to monitor changes in end-expiratory lung volume (EELV) has been demonstrated in several studies. In preterm infants suffering from respiratory distress syndrome (RDS), EIT could demonstrate that stepwise lung recruitment in-creased EELV homogeneously during high-frequency ventilation (Martijn Miedema et al., 2011b21); surfactant therapy resulted in increased and stabilised regional EELV (Martijn Miedema et al., 2011a20); losses of EELV were rapidly regained after endotracheal tube suction (Hough et al., 201411); and EELV dropped after in-duction of anaesthesia and intubation (Humphreys et al., 201112).

n In ventilated children with acute lung injury, EIT could help to distinguish “responders” from “non-responders” of a recruitment manoeuvre, offering the potential to protect non-responders from further aggressive lung recruitment manoeuvres potentially causing lung overdistension (Wolf et al., 201231).

n Several studies using EIT have demonstrated the highly variable pattern of tidal ventilation in children depending on body positi-on/gravity (Lupton-Smith et al., 201416). EIT could also monitor the complex behaviour of tidal ventilation showing age-influenced breath-to-breath variability in preterm infants (Armstrong et al., 20111).

n Especially in small children, every inch of displacement of the endotracheal tube might be harmful. EIT enabled recognition of correct placement of the endotracheal tube in children by comparing right to left lung symmetry (Steinmann et al., 201327).

n EIT offers potential to show the physiologic reaction to non-invasive respiratory support, like nasal CPAP, in paediatric care. For example, optimising nCPAP titration, which resulted in a more physiologic ventilation distribution with a homogeneous increase in EELV and tidal volume in preterm infants (M. Miedema et al., 201319).

n EIT is able to detect changes in distribution of ventilation dependent on the mode of ventilation and level of oxygenation im-pairment offering the possibility of proactive distribution-targeted mechanical ventilation strategies in children (Inany et al., 202013).

n In a case report, Rossi et al. describe the detection of pen-delluft by EIT in an infant. This may alert clinicians to consider effort-dependent lung injury even in a protective ventilation setting (Rossi et al., 201925).

2.2. LIMITED PULMONARY FUNCTION IN A ROUTINE SETTING

EIT can detect asymmetries in the distribution of ventilation. This offers the possibility to use EIT in the diagnosis of unilateral lung diseases like pneumothorax (M. Miedema et al., 201118; Rahtu et al., 201923) or atelectasis (van der Burg et al., 201429). Further-more, the EIT imaging was also applied to detect heterogeneities of paediatric lung function induced by lung diseases like bronchial asthma (Ngo et al., 201822) and cystic fibrosis (Lehmann et al., 201615). Recent studies have also described the use of EIT tech-nology in the detection of pneumonia (Mazzoni et al., 201722) and bronchospasm (de la Oliva et al., 20177).

First studies emerge using EIT to monitor paediatric diseases that do not originate from the lung. A first case report explored the use of EIT in space occupying lesions by mesenchymal hamartoma (Jardine et al., 201914). Another study reported of an infant with


This overview illustrates that EIT has a broad potential of applications in mechanical ventilation and is particu-larly suitable to monitor inhomogeneities of ventilation in children.


pulmonary Langerhans cell histiocytosis where the application of the EIT technique enabled the selection of a suitable ventilator strategy (Davies et al., 20184).

Taken together, all these studies demonstrate that EIT reliably pro-vides additional information on lung ventilation disorders in child-ren which can be quickly identified at the bedside. Future studies should substantiate the effectiveness of EIT on clinical practice in this context.

2.3. LUNG PERFUSION

Another emerging and promising field of EIT application appears to be the monitoring of lung perfusion. However, to date, there are only a limited number of studies using EIT to monitor the distribu-tion of lung perfusion.

In preterm infants, the EIT technique displayed age- and gravity-dependent differences in lung perfusion, demonstrating a grea-ter perfusion of the non-dependent lung (Carlisle et al., 20103). EIT has also been used to monitor the perfusion before and after ventricular septum defect surgery, opening the possibility of peri-operative assessment of the ventilation perfusion relation which is of clinical relevance in corrective open-heart surgery (Schibler et al., 201326). In a recent case of an infant with a complete left pulmonary artery thrombosis and lung infarction, EIT was able to detect perfusion and ventilation defects, suggesting EIT to be a promising tool to monitor ventilation-perfusion matching (Tingay et al., 201928).

3. CLINICAL RELEVANCE

3.1. BENEFITS OF EIT IN SPECIFIC CLINICAL SCENARIOS

As mentioned above, there is a broad range of paediatric EIT ap-plications, especially in monitoring mechanical ventilation in child-ren who are particularly prone to ventilator-associated lung injury. The technology has proved to be lung protective in the animal lab, mitigating lung pathology towards lung protection (Wolf et al., 201332). Furthermore, EIT has been shown to prospectively impro-ve gas exchange and lung protection (Rosemeier et al., 201924). This stresses the unique potential of EIT to prospectively guide and inform clinicians.

To illustrate some practical aspects of EIT, here, we want to high-light some specific examples for clinical use and the role of EIT in individualised medicine:In a recent report, Davies et al. presented several clinical scenari-os where they demonstrate the superiority of EIT in comparison to other means, highlighting the accurate, non-invasive way to obtain information with this technique (Davies et al., 20196):

n An 11-year-old boy with status asthmaticus ventilated on pres-sure control mode benefited from EIT monitoring because of the instant feedback on the global chest expansion that allowed the clinician to manage incipient gas trapping problems.

n In a child with pneumonitis on volume ventilation, EIT helped to decide if the patient was ready for weaning of ventilation. EIT was able to detect if the lungs were not yet able to cope with a loss of PEEP, indicating that the patient was not ready for extubation, or if the patient could maintain adequate expansion making him suitable for weaning of ventilation.

n A 2-year-old girl with pneumonia ventilated on pressure con-trol had frequent lobar collapses. Continuous monitoring by EIT allowed repositioning as soon as one lung showed signs of loss of ventilation and therefore optimal positioning and reinflation (for more examples see Davies et al., 20196).

These examples underline the ability of EIT to support the shift from evidence-based medicine towards a more individualised me-dicine. Children with acute lung injury respond in a very individual way towards ventilation strategies. Therefore, individualising ven-tilation by EIT might offer benefits for this vulnerable group of patients (Rosemeier et al., 201924; Wolf et al., 201231).


There are some promising results in detection of lung perfusion by EIT in children which should be substanti-ated in further studies to identify if EIT might serve as a clinical tool for lung perfusion in the future.

EIT may offer a simple method to detect heterogeneities of lung function in a routine setting.


To classify the clinical benefits of EIT, clinicians were recently asked for their opinion: In a survey among neonatologists and paediatricians with previous experience of EIT, the current users were asked to rate several EIT parameters regarding their clinical usefulness (Frerichs & Becher, 20194). Parameters of ventilation and aeration distribution (GI, SS, ΔEELI, CoVvd) were conside-red to be particularly useful. In addition to that the survey results highlighted the usefulness of EIT in the detection of pathological findings with ventilation asymmetry like pneumothorax or endo-tracheal tube malposition (Frerichs & Becher, 20199). These sub-jective assessments are invaluable and should be substantiated by evidence-based data of future studies.

However, despite all the proven and potential advantages of EIT in paediatric critical care and the recent availability of dedicated electrode belts, broad adoption into clinical routine still seems to be limited by concerns of time and resources, meaning personnel and budgets. To meet these concerns, it is suggested that the technique is (at first) best used for individuals with severe lung diseases where adjusted ventilation can decrease morbidity, mor-tality, length of ventilation and stay in intensive care (Davies & Silvestre, 20205). On top of that, the range of application areas and the advantages of this technique offer the potential for a broad implementation in clinical use.

3.2. ADVANTAGES AND CURRENT LIMITATIONS OF EIT IN PAEDIATRIC CRITICAL CARE

EIT technology is a reliable, safe, and highly reproducible tool that allows prompt real-time assessment of lung characteris-tics with almost no side effects (Frerichs et al., 20178; Walsh & Smallwood, 201630). The technique offers advantages that are particularly important in the vulnerable population of paediatric patients: it is non-invasive and radiation-free, and as a bedside tool there is no need for patient transport. In comparison to other well-established techniques, EIT has several advantages: compared to CT scanning or X-Rays, EIT is radiation-free and can be applied at the bed-side; EIT allows regional lung assessment that cannot be gained by ventilator spirometry; and it provides images of higher resolution than ultrasound in a continuous way (Davies et al., 20196). Although interpretation of images requires some training, it is a very visual monitoring that may be utilised by a multidisciplinary team, e.g. to guide physiotherapy management (Davies et al., 20196).

For optimal application, further aspects have to be addressed. One important goal should be the implementation of a consis-tent terminology, image analysis and interpretation (Frerichs et al., 20178) that allows a standardised use across research groups and in clinical routine.

Furthermore, it should be kept in mind that the images can be affected by several factors like changes in position of electrodes and body movement, especially in children, where movement artefacts might be higher and skin integrity impaired; banda-ges or wire sutures as well as interference with other medical devices may alter the EIT signal, particularly in the small torso of infants (Davies et al., 20196; Frerichs et al., 20178). Although no relevant side effects are reported (Inany et al., 202013), local pressure marks or skin irritations may occur dependent on the period of use and there are limited data on long-term application.

Several clinical scenarios demonstrate the benefits of EIT, especially in the scope of individualised medicine.

Although some aspects must be kept in mind, the EIT technique offers many advantages as a reliable, safe, real-time bedside-tool.



3.3. CALL FOR PROSPECTIVE STUDIES AND FUTURE PERSPECTIVES

Despite all the promising clinical approaches, EIT technology is a relatively new tool in daily clinical use and still has to demonstrate if the physiological benefits translate to long-term outcome benefits. A few prospective studies have already shown the capability of EIT to improve outcome in animal models (Hochhausen et al., 201710; Wolf et al., 201332), adult patients (Zhao et al., 201933), and also in children with acute lung injury (Rosemeier et al., 201924). Based on these promising results, large randomised controlled clinical trials should be constructed to validate improvements in outcome compared to standard care. This will show if EIT can find its place next to the ‘gold standard’ technologies in paediatric care.

With this approach, EIT can develop into a widely-used decision support tool with the potential to drive clinical care and to improve the patient’s outcome. Looking further ahead, the user group of paediatric intensivists might be expanded and there could be fu-ture potential of EIT to guide respiratory care during anaesthesia for surgery, or in ambulatory settings, e.g., as a monitoring tool for children with cystic fibrosis. Until then, EIT offers already now a large spectrum of applications and several advantages in compari-son to other standard tools. Clinicians should consider the use of EIT at least in their most complex ventilated children, keeping in mind the potential of this technique for further use. EIT is an at-tractive technology that may prove to be a useful bedside tool and may become a routine part of paediatric clinical care in the future.

Further work is needed to validate the superiority of EIT over traditional methods in the clinical context with the long-term goal to provide a useful therapeutic bedside tool in routine clinical care.


Four questions toPD Dr. med. Gerhard Wolf

n Head of the Department of Paediatrics, Children’s Hospital Traunstein, Kliniken Südost-bayern, Academic teaching hospital of Ludwig Maximilian University Munich, Germany

n Member of the TRanslational EIT developmeNt stuDy (TREND) group consisting of pre-eminent researchers and clinical leaders using chest EIT collaborating on the clinical promotion of EIT

1For what purpose do you use EIT

technology in your clinic?

In our intensive care unit, we attempt to use EIT to facilitate lung protection in children with Acute Respiratory Distress Syndrome (ARDS). We try to include every eligible child with ARDS in our research studies to advance the scientific knowledge of this technology. We consider it an advantage that EIT offers real-time information about the ventilation status of the lung, to which the clinician can react instantly. With this information, persona-


lized ventilation could be one step closer: For every patient, the percentage of areas of atelectasis as well as the areas of overdistension could be quantified at the bed-side. With this knowledge, settings like PEEP and tidal volume can be optimized. In our studies, we were able to demon-strate that with EIT, ventilated patients can be ventilated at their optimal individual ventilation status with a minimum of atelectatic or overdistended lung areas.

2What is your practical experience

with EIT, how is it accepted by physi-cians, nursing staff, and patients?

Our study team is adequately trained in all practical aspects of the EIT – application and evaluation. But also the rest of our clinical staff like physicians, nursing staff and physiotherapists are well informed and are interested in the visual display of lung ventilation. For example, our team of phy-siotherapists may get a real-time feedback on their interventions, such as opening lung areas by positional changes and physical therapy. And of course we pass on all the insights from our study results to our team. Regarding the handling: the new pediatric belts are easy to attach and our patients did not yet show intolerances such as pressure sores or allergies. In small children, there might be some problems of space with ECG electrodes, or if a chest tube is inserted. But all in all, the EIT- technique is easy to apply and is well accepted in our ICU.

3Would you share an anecdotic

experience, where EIT showed an anticipated or even unexpected

benefit?

In one of our studies, we included an adolescent patient with acute ARDS. He was emergently intubated, placed on a ventilator, and simultaneously placed on EIT, and we started lung recruitment immediately with the help of EIT. In real-time, we were able to observe how atelec-tatic areas opened, while we increased PEEP. This caused overdistension of other areas, so we stepwise reduced the PEEP to a degree that overdistension was reversed but atelectatic areas remained open. After a few hours, we had achieved an optimal ventilation status for this patient with maximal lung recruitment. I suppose, without the EIT technique we wouldn’t have achieved this status so ra-pidly, because we would have been forced to rely on the usual parameters like gas exchange and lung mechanics. With EIT, we do no longer have to guess if the lung is optimally recruited, but instead we can visually monitor and quantify the venti-lation status in real-time.

4What are the fields of

application where you see most potential of the EIT technique

in the future?

To take advantage of the full potential of EIT, the broad application and long-term usage of EIT at the bedside would be desirable. Similar to measuring the oxygen saturation transcutaneously, it would be great to monitor the ventilation status by EIT permanently, displaying the EIT on the monitor of the ventilator. The highlight would be a closed-loop system that would recommend how to adjust the PEEP, peak pressure, and tidal volume, depending on the state of lung recruitment. Intubated ARDS patients could benefit from this technique, but also for non-invasively ventilated patients, it would be attractive to perma-nently monitor ventilation by EIT in real time.


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electrical impedance tomography (eit) in paediatric intensive

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