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Tidal recruitment
Barotrauma was once the most frequent and easily recognized complication of mechanical ventilation. It is now evident, however, that barotrauma represents only one of the mechanisms underlying the broad category of ventilator-induced lung injury (VILI). http://emedicine.medscape.com/article/296625-
overview
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Lung collapseOverdistention
Lung recruitmentLung protective ventilation
75’000 patient deaths in USA due to ALI
Gold standard is CT image
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«densities»
At the present time the gold standard to compute the lung recruitability is the quantitative lung CT scan. Chiumello, Critical Care 2011
• Costly (fixed+variable)
• Risky (patient transport)
• Not continuous
• Dangerous
Swisstom technology makes lung function visible
without x-rays
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Respiratory therapy becomes easier and more effective because
results are immediately available.
In the end, clinicians can save more patients faster, administrators
can increase patient throughput, and hospitals become more efficient.
Difference between CT image and BB2 – monitor (1)
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1 CT exposure = 310 x-ray
1 image per day or even less
Non-invasive, radiation-free
Up to 50 images per second
Difference between CT image and BB2 – monitor (2)
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Ventilated areas vs. non-ventilated areas
Silent Spaces
Aereated vs. Non-aereated lung
Clinical benefits Swisstom solution BB2
15.04.2023 8*Acute Lung Injury: PaO2/FiO2<300mmHg, bi-lateral chest infiltrates, no congestive heart failure
• „Live“ view on lung ventilation, particularly SilentSpaces
• See the effects of recuitment manoevers and best PEEP setting
• Optimization of patient body positioning
• Optimization of ventilation strategy and spontaneous breathing (NAVA!)
• No radiation like x-rays
Main indication: acute lung injury intubated/mask/CPAP
Content
Systems overview
Underlying physiology
Technical background: Patient Interface
Data Analysis and display
Scientific literature
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Content
Systems overview
Underlying physiology
Technical background: Patient Interface
Data Analysis and display
Scientific literature
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Why is electrical-resistance changing in the lungs?
Breathing fills the lungs
Filled lungs have thinner walls
Thinner walls have higher electrical resistance
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Stretch and resistance: R = k * length / Area
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relaxed stretched consolidated
leng
th
Area
R
R
R
Content
Systems overview
Underlying physiology
Technical background: Patient Interface
Data Analysis and display
Scientific literature
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Patient Interface: Swisstom
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Shoulder straps
Positioning aids
Electrodes and electronics
Mounting loops
Velcro & Dock
ContactAgent
Patient Interface: integrated electronics
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Spacer fabric
Protective foil
Flexprint
Electrode connection
EIT-Chip
Electrodes, Z-Tex with Ag stripes
Clinical need: Swisstom solution BB2
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25 year old male, motor vehicle accident, • multiple fractures• on ventilator
Patient develops lung failure*
*Acute Lung Injury: PaO2/FiO2<300mmHg, bi-lateral chest infiltrates, no congestive heart failure
With Swisstom real-time Lung Monitoring
• Put SensorBelt on patient
• EIT guided recruitment and positioning
Shortens ICU stay and increases survival by 46% (Amato, NEJM)
Content
Systems overview
Underlying physiology
Technical background: Patient Interface
Data Analysis and display
Scientific literature
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Data Analysis Package of Swisstom BB2
15.04.2023 27*Acute Lung Injury: PaO2/FiO2<300mmHg, bi-lateral chest infiltrates, no congestive heart failure
• Real time images (movies)
• Quality monitor (electrode contact, etc.)
• Silent space analysis
• Trending of disease evolution and therapeutic effects
• Lung tissue stretch analysis
• Patient position monitoring
Real-time images at a rate of 50 /second
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Start InhalationEnd Inhalation
End ExhalationDifference
Image- =
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Silent space analysis Gold standard CT
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«densities»
??
dependent silent spaces
Non-dependent silent spaces
Contra-indications
Defibrillation: Remove SensorBelt before defibrillation
Open thorax
Uncovered wounds
In combination with internal or external pace makers
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Content
Systems overview
Underlying physiology
Technical background: Patient Interface
Data Analysis and display
Scientific literature
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EIT & Ventilation publications 2014
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1: Lehmann S, Tenbrock K, Schrading S, Pikkemaat R, Antink CH, Santos S, SpillnerJW, Wagner N, Leonhardt S. Monitoring of lobectomy in cystic fibrosis withelectrical impedance tomography - a new diagnostic tool. Biomed Tech (Berl). 2014Aug 5. pii: /j/bmte.ahead-of-print/bmt-2014-0019/bmt-2014-0019.xml. doi:10.1515/bmt-2014-0019. [Epub ahead of print] PubMed PMID: 25153206.
2: Bodenstein M, Boehme S, Wang H, Duenges B, Markstaller K. Hints for cyclicalrecruitment of atelectasis during ongoing mechanical ventilation in lavage andoleic acid lung injury detected by SpO2 oscillations and electrical impedancetomography. Exp Lung Res. 2014 Nov;40(9):427-38. doi:10.3109/01902148.2014.944719. Epub 2014 Aug 25. PubMed PMID: 25153803.
3: van der Burg PS, Miedema M, de Jongh FH, van Kaam AH. Unilateral atelectasisin a preterm infant monitored with electrical impedance tomography: a casereport. Eur J Pediatr. 2014 Aug 23. [Epub ahead of print] PubMed PMID: 25146419.
4: Grychtol B, Elke G, Meybohm P, Weiler N, Frerichs I, Adler A. Functionalvalidation and comparison framework for EIT lung imaging. PLoS One. 2014 Aug11;9(8):e103045. doi: 10.1371/journal.pone.0103045. eCollection 2014. PubMedPMID: 25110887; PubMed Central PMCID: PMC4128601.
5: Zhang J, Patterson R. Variability in EIT Images of Lung Ventilation as aFunction of Electrode Planes and Body Positions. Open Biomed Eng J. 2014 Jun27;8:35-41. doi: 10.2174/1874120701408010035. eCollection 2014. PubMed PMID:25110529; PubMed Central PMCID: PMC4126188.
6: Blankman P, VAN DER Kreeft SM, Gommers D. Tidal ventilation distributionduring pressure-controlled ventilation and pressure support ventilation inpost-cardiac surgery patients. Acta Anaesthesiol Scand. 2014 Sep;58(8):997-1006. doi: 10.1111/aas.12367. Epub 2014 Jul 15. PubMed PMID: 25039666.
7: Schaefer MS, Wania V, Bastin B, Schmalz U, Kienbaum P, Beiderlinden M,Treschan TA. Electrical impedance tomography during major open upper abdominalsurgery: a pilot-study. BMC Anesthesiol. 2014 Jul 5;14:51. doi:10.1186/1471-2253-14-51. eCollection 2014. PubMed PMID: 25018668; PubMed Central PMCID: PMC4094413.
8: Pomprapa A, Schwaiberger D, Pickerodt P, Tjarks O, Lachmann B, Leonhardt S.Automatic protective ventilation using the ARDSNet protocol with the additionalmonitoring of electrical impedance tomography. Crit Care. 2014 Jun 23;18(3):R128.doi: 10.1186/cc13937. PubMed PMID: 24957974.
9: Blankman P, Hasan D, Erik G, Gommers D. Detection of 'best' positiveend-expiratory pressure derived from electrical impedance tomography parametersduring a decremental positive end-expiratory pressure trial. Crit Care. 2014 May 10;18(3):R95. doi: 10.1186/cc13866. PubMed PMID: 24887391; PubMed Central PMCID: PMC4095609.
10: Zhao Z, Frerichs I, Pulletz S, Müller-Lisse U, Möller K. The influence ofimage reconstruction algorithms on linear thorax EIT image analysis ofventilation. Physiol Meas. 2014 Jun;35(6):1083-93. doi:10.1088/0967-3334/35/6/1083. Epub 2014 May 20. PubMed PMID: 24845059.
11: Grychtol B, Adler A. Choice of reconstructed tissue properties affectsinterpretation of lung EIT images. Physiol Meas. 2014 Jun;35(6):1035-50. doi:10.1088/0967-3334/35/6/1035. Epub 2014 May 20. PubMed PMID: 24844670.
12: Bläser D, Pulletz S, Becher T, Schädler D, Elke G, Weiler N, Frerichs I.Unilateral empyema impacts the assessment of regional lung ventilation byelectrical impedance tomography. Physiol Meas. 2014 Jun;35(6):975-83. doi:10.1088/0967-3334/35/6/975. Epub 2014 May 20. PubMed PMID: 24844247.
13: Pikkemaat R, Lundin S, Stenqvist O, Hilgers RD, Leonhardt S. Recent advances in and limitations of cardiac output monitoring by means of electrical impedance tomography. Anesth Analg. 2014 Jul;119(1):76-83. doi:10.1213/ANE.0000000000000241. PubMed PMID: 24810260.
14: Bodenstein M, Boehme S, Bierschock S, Vogt A, David M, Markstaller K.Determination of respiratory gas flow by electrical impedance tomography in ananimal model of mechanical ventilation. BMC Pulm Med. 2014 Apr 29;14:73. doi:10.1186/1471-2466-14-73. PubMed PMID: 24779960; PubMed Central PMCID: PMC4012093.
15: Li Y, Tesselaar E, Borges JB, Böhm SH, Sjöberg F, Janerot-Sjöberg B.Hyperoxia affects the regional pulmonary ventilation/perfusion ratio: anelectrical impedance tomography study. Acta Anaesthesiol Scand. 2014Jul;58(6):716-25. doi: 10.1111/aas.12323. Epub 2014 Apr 25. PubMed PMID:24762189.
16: Frerichs I, Becher T, Weiler N. Electrical impedance tomography imaging ofthe cardiopulmonary system. Curr Opin Crit Care. 2014 Jun;20(3):323-32. doi:10.1097/MCC.0000000000000088. PubMed PMID: 24739268.
17: Moens Y, Schramel JP, Tusman G, Ambrisko TD, Solà J, Brunner JX, Kowalczyk L,Böhm SH. Variety of non-invasive continuous monitoring methodologies includingelectrical impedance tomography provides novel insights into the physiology oflung collapse and recruitment – case report of an anaesthetized horse. VetAnaesth Analg. 2014 Mar;41(2):196-204. PubMed PMID: 24734295.
18: Crabb MG, Davidson JL, Little R, Wright P, Morgan AR, Miller CA, Naish JH,Parker GJ, Kikinis R, McCann H, Lionheart WR. Mutual information as a measure of image quality for 3D dynamic lung imaging with EIT. Physiol Meas. 2014May;35(5):863-79. doi: 10.1088/0967-3334/35/5/863. Epub 2014 Apr 8. PubMed PMID: 24710978; PubMed Central PMCID: PMC4059506.
19: Wi H, Sohal H, McEwan AL, Woo EJ, Oh TI. Multi-frequency electrical impedancetomography system with automatic self-calibration for long-term monitoring. IEEE Trans Biomed Circuits Syst. 2014 Feb;8(1):119-28. doi:10.1109/TBCAS.2013.2256785. PubMed PMID: 24681925.
20: Krause U, Becker K, Hahn G, Dittmar J, Ruschewski W, Paul T. Monitoring ofregional lung ventilation using electrical impedance tomography after cardiacsurgery in infants and children. Pediatr Cardiol. 2014 Aug;35(6):990-7. doi:10.1007/s00246-014-0886-6. Epub 2014 Feb 26. PubMed PMID: 24569885.
21: Zhao Z, Pulletz S, Frerichs I, Müller-Lisse U, Möller K. The EIT-based globalinhomogeneity index is highly correlated with regional lung opening in patientswith acute respiratory distress syndrome. BMC Res Notes. 2014 Feb 6;7:82. doi:10.1186/1756-0500-7-82. PubMed PMID: 24502320; PubMed Central PMCID: PMC3922336.
22: Shi C, Boehme S, Bentley AH, Hartmann EK, Klein KU, Bodenstein M, BaumgardnerJE, David M, Ullrich R, Markstaller K. Assessment of regional ventilationdistribution: comparison of vibration response imaging (VRI) with electricalimpedance tomography (EIT). PLoS One. 2014 Jan 27;9(1):e86638. doi:10.1371/journal.pone.0086638. eCollection 2014. PubMed PMID: 24475160; PubMedCentral PMCID: PMC3903564.
23: Marinho LS, Sousa NP, Barros CA, Matias MS, Monteiro LT, Beraldo Mdo A, CostaEL, Amato MB, Holanda MA. Assessment of regional lung ventilation by electricalimpedance tomography in a patient with unilateral bronchial stenosis and ahistory of tuberculosis. J Bras Pneumol. 2013 Nov-Dec;39(6):742-6. doi:10.1590/S1806-37132013000600013. English, Portuguese. PubMed PMID: 24473768;PubMed Central PMCID: PMC4075903.
24: Durlak W, Kwinta P. Role of electrical impedance tomography in clinicalpractice in pediatric respiratory medicine. ISRN Pediatr. 2013 Dec25;2013:529038. doi: 10.1155/2013/529038. eCollection 2013 Dec 25. Review. PubMedPMID: 24455294; PubMed Central PMCID: PMC3886230.
25: Karsten J, Krabbe K, Heinze H, Dalhoff K, Meier T, Drömann D. Bedsidemonitoring of ventilation distribution and alveolar inflammation incommunity-acquired pneumonia. J Clin Monit Comput. 2014 Aug;28(4):403-8. doi:10.1007/s10877-014-9549-7. Epub 2014 Jan 17. PubMed PMID: 24435618.
26: Czaplik M, Antink CH, Rossaint R, Leonhardt S. Application of internalelectrodes to the oesophageal and tracheal tube in an animal trial: evaluation ofits clinical and technical potentiality in electrical impedance tomography. JClin Monit Comput. 2014 Jun;28(3):299-308. doi: 10.1007/s10877-013-9536-4. Epub2013 Nov 27. PubMed PMID: 24281746.
27: Karsten J, Meier T, Iblher P, Schindler A, Paarmann H, Heinze H. Thesuitability of EIT to estimate EELV in a clinical trial compared to oxygenwash-in/wash-out technique. Biomed Tech (Berl). 2014 Feb;59(1):59-64. doi:10.1515/bmt-2012-0076. PubMed PMID: 24114891.
28: Karsten J, Heinze H, Meier T. Impact of PEEP during laparoscopic surgery onearly postoperative ventilation distribution visualized by electrical impedancetomography. Minerva Anestesiol. 2014 Feb;80(2):158-66. Epub 2013 Jul 23. PubMedPMID: 23877309.
EIT is probably a revolution in mechanical ventilation. Constantin et.al. Crit. Care 2014, 16:164