BB2

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

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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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Basic principle:

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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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Alveolar walls are stretched

15.04.2023 13Nopp et.al. 1997

Stretch and resistance: R = k * length / Area

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relaxed stretched consolidated

leng

th

Area

R

R

R

Flow of electrical current: inspiration

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~~

Flow of electrical current: expiration

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~

Scanning example

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Creating two dimension out of one dimension

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Movie

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50 images per second

Content

Systems overview

Underlying physiology

Technical background: Patient Interface

Data Analysis and display

Scientific literature

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Patienten Interface: early attempts

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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)

Swisstom BB2

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SensorBeltConnector

Instrument BB2

SensorBelt

Trolley

ContactAgent

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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Lung tissue stretch analysis

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30

Quantification of silent spaces

dependent silent spaces

Non- dependent silent spaces

Silent space analysis Gold standard CT

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«densities»

??

dependent silent spaces

Non-dependent silent spaces

SilentSpaces trending

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Contra-indications

Defibrillation: Remove SensorBelt before defibrillation

Open thorax

Uncovered wounds

In combination with internal or external pace makers

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Certification: CE and CB

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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

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Together

we change

Intensive Care Medicine