Dräger PulmoVista 500 Manual
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Dräger PulmoVista 500 Manual

Electrical impedance tomography (eit) device handling, application tips and examples
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Mini-Manual
Electrical Impedance Tomography (EIT)
Device handling, application tips and examples
Christian Bozsak
Eckhard Teschner

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Summary of Contents for Dräger PulmoVista 500

  • Page 1 Mini-Manual Electrical Impedance Tomography (EIT) Device handling, application tips and examples Christian Bozsak Eckhard Teschner...
  • Page 3 ® This manual is intended to provide additional guidance for the use of PulmoVista 500. The information and data provided in this manual are subject to technical changes. For the use of the Dräger products, the instructions for use enclosed with the products always apply and are not in any way replaced or otherwise superseded by this manual.

  • Page 4: Table Of Contents

    Table of Contents Page IntroductIon 1. prepare the devIce for the clInIcal use 1.1. Start and Device Check 1.2. Selection and application of the electrode belt 1.2.1. Choosing the right belt size 1.2.2. Attach patient cable to electrode belt 1.2.3. Prepare the patient 1.2.4.
  • Page 5 Table of Contents Page 3. useful tools and tIps 3.1. Contour of ventilated area 3.2. Negative impedance changes 3.3. Filtration 3.4. Save screenshot and record EIT data 3.5. Coupling of a Dräger ventilator with Pulmovista ® 3.6. Frame rate 4. clInIcal applIcatIon 4.1.

  • Page 6: Introduction

    Introduction Welcome to the world of Electrical Impedance Tomography (EIT). PulmoVista 500 is the first clinical EIT device which up to date has been used ® in several thousand patients. EIT is a non-invasive imaging technique that gives you a special view inside the lungs. In a cross-sectional projection, the distribution of the tidal volume in the thorax is shown.

  • Page 7: Prepare The Device For The Clinical Use

    Prepare the device for the clinical use 1. Prepare the device for the clinical use 1.1. STarT and dEvICE ChECk Press the green power button in the lower left corner of the screen to turn on the device. The device check ensures that all components of the device and the trunk cable (cable from the device to the patient) function properly.

  • Page 8: Selection And Application Of The Electrode Belt

    3. Select Device Check › ‹ 4. Select Start and confirm with the Rotary Knob . › ‹ 5. The device check is running automatically. Wait for the test phase to finish. The device will announce the test result. If the device check fails, check the message and, if necessary, the connectors.
  • Page 9 Prepare the device for the clinical use How to find the right belt size a. Determine the proper belt size with the help of the measurement tape – Measure about 5 cm (two inches) below the armpit from axilla to axilla to 6 ICS).

  • Page 10: Attach Patient Cable To Electrode Belt

    10 | Electrode belt too long Electrode belt too short 1.2.2. attach patient cable to electrode belt Take the electrode belt and the corresponding patient cable and attach the patient cable to the electrodes in a zigzag pattern. Attach snap 1 of the patient cable to stud 1 of the electrode belt.

  • Page 11: Prepare The Patient

    | 11 Prepare the device for the clinical use When attaching the electrode cable avoid too tight bending radii, especially at the transition points between electrodes 4/5 and 12/13 (port left/right). Patient cable Electrode belt Right port Left port 1.2.3. Prepare the patient Before the electrode belt is put on, check the potential necessary preparations to position it well.

  • Page 12: Prepare The Electrode Belt

    12 | 1.2.4. Prepare the electrode belt To be ready for use as quickly as possible, it is advisable to moisten the electrodes of the electrode belt with a small amount of liquid (e.g. sterile saline solution, water or electrode gel), in particular with dry skin. 1.2.5.
  • Page 13 | 13 Prepare the device for the clinical use If tilting the bed or an upright patient position is not possible, the following methods for applying the electrode belt are available: Lifting method 1. Lift the patient’s head and put the mid position marker of the belt to the cervical spine.
  • Page 14 14 | rolling method 1. Turn the patient on one side, place one half of the belt around the chest (electrode on the left side of the patient) and hold the mid position marker on the spine in the area of the 4 to 6 ICS.
  • Page 15 | 15 Prepare the device for the clinical use The belt does not have to sit too tight, it is crucial that there is sufficient contact between the electrodes and the skin. An offset of the electrodes or an asymmetrically arranged belt can lead to image rotation.

  • Page 16: Signal Check

    16 | 1.3. SIGnaL ChECk 1. Select Start / Stand-by screen and choose ›New patient‹. 2. Go to ›Signal check‹ page: the graph shows the skin electrode resistance for each electrode. The Signal check page. The electrode skin resistance is shown for every electrode.

  • Page 17: Settings Before Starting An Eit Measurement

    | 17 Prepare the device for the clinical use 1.4. SETTInGS BEFOrE STarTInG an EIT MEaSUrEMEnT Before starting the EIT session, it is recommended to go through these steps: 1. Choose ›New Patient‹. 2. Enter patient data. 3. Set frame rate and filter. 4.

  • Page 18: Check The Correct Electrode Belt Position

    18 | 1.6. ChECk ThE COrrECT ELECTrOdE BELT POSITIOn The following procedure will help you to check the belt position or to find the correct position. The belt is to be placed between the 4 and 6 ICS. For women, the belt should be placed onto the breast.
  • Page 19 | 19 Prepare the device for the clinical use Steps to identify whether the belt was placed too low: 1. Go to the Main View . 2. Click the ›Enhance contrast button‹. 3. If you can see purple regions (negative impedance changes) left and right of the lung regions (blue and white) it is very likely that the belt has been placed too low.

  • Page 20: Special Case: 15-Electrode Mode

    20 | 1.7. SPECIaL CaSE: 15-ELECTrOdE MOdE In the special case that one electrode does not have enough skin contact, the measurement can nevertheless be carried out reliably. The device uses a special mode for this purpose. If one electrode fails, the message ›Check electrode contact‹ appears, but the measurement can nevertheless be carried out without difficulty In the so-called 15-electrode mode, the inactive electrode in the virtual...

  • Page 21: Different Views And Their Special Properties

    | 21 Different views and their special properties Measurement in 15-electrode mode 2. different views and their special properties Different views are available for displaying and evaluating the EIT images and image information. – Main view – Fullscreen view – End-inspiratory trend view –...
  • Page 22 22 | you can change this to Minute Image (Setup). Real-time impedance curves represent ventilation over time. Changes in the overall cross-section are reflected by the Global Impedance Curve . This curve strongly correlates with the volume curve of the ventilator and with the applied/inhaled total volume. The regional impedance changes (i.e.

  • Page 23: Referencing

    | 23 Different views and their special properties Ventral Regions with ≤ 10 % of max. ventilation Regions with max. ventilation Dorsal Regions with > 10 % of max. ventilation Distribution of the tidal volume in a cross- sectional fullscreen view of the patient thorax in the caudal-cranial direction When looking at EIT images, it should be noted that these are, analogous to CT images, displayed in caudo-cranial projection.

  • Page 24: Regions Of Interest (Rois)

    24 | After activation, a new window, the Differential Image , appears instead of the Tidal Image. At the time of referencing, the reference Tidal Image is captured and moved under the Differential Image. Subsequent changes, however, will not be visible until the ›View Change‹ window is activated. In the Differential Image, the current status is compared with the reference status and the differences are displayed.
  • Page 25 | 25 Different views and their special properties In obese patients the size of the ROIs should be adapted to the smaller tidal image. healthy patient with Obese patient Adjust the window size to the normal weight smaller Tidal Image. The sum Window size unchanged, of the 4 regional tidal variations distribution of ventilation in %.

  • Page 26: Trend Views - End-Inspiratory And End-Expiratory

    26 | 2.2. TrEnd vIEwS – End-InSPIraTOrY and End-EXPIraTOrY The PulmoVista 500 trend views can be used to compare two different points ® in time. The End-inspiratory trend view is used to compare two different tidal images and their regional tidal volume distribution. It helps you identify inhomogeneities, recruitment, de-recruitment, overdistension and the redistribution of Vt.
  • Page 27 | 27 Different views and their special properties The End-expiratory trend view or ΔEELI-trend view is used to monitor regional changes of End Expiratory Lung Impedance (∆EELI). ∆EELI is strongly correlated with changes in End Expiratory Lung Volume (∆EELV). The ∆EELI trend is useful to asses changes in lung volume for example after changing the PEEP and after recruitment maneuvers for the re-opening of dorsal atelectases as well as for the detection of de-recruitment of individual lung areas.

  • Page 28: Diagnostic View

    28 | 2.3. dIaGnOSTIC vIEw 2.3.1. COndUCT anaLYSIS dIaLOGUE wIndOw The Diagnostic View allows the analysis of regional compliance changes and delays in regional ventilation in addition to the evaluation of ventilation distribution. Every selected time period is called a “section”. The ›Conduct analysis‹...
  • Page 29 | 29 Different views and their special properties Global impedance waveform. If available, trend parameters from the ventilator are displayed: PEEP in green and EIP in pink. Sections with alphabetically sorted labels (incl. the respective PEEP if available). Automatic section selection. Manual section selection (add or remove sections and position them using the touchscreen or rotary knob).

  • Page 30: Results Of The Analysis

    30 | 2.3.2. rESULTS OF ThE anaLYSIS The results of the PEEP trial analysis support the selection and personalization of PEEP. Regional compliance images show the influence of PEEP on lung mechanics. The ›Customized analysis‹ can be used to evaluate various therapeutic interventions. At constant driving pressures an increase/decrease in ventilation can be interpreted as an increase/decrease of regional compliance (C).
  • Page 31 | 31 Different views and their special properties The RVD parameter can be displayed in 2 different configurations: as the standard deviation of the RVD (RVD SD) for every section or as the RVD Ratio. RVD SD, indicated as % of Ti, describes how inhomogeneous the regional inspiration within the contour of the ventilated area is.

  • Page 32: Useful Tools And Tips

    32 | Colour maps – Customized analysis Compliance Loss /Compliance Win Dark Grey: Pixels with no change against Reference. Orange: CL - Decrease of compliance against Reference CL = 13 means, that in this image there was a cumulative decrease of 13 % in those (orange) regions.
  • Page 33 | 33 Useful Tools and Tips Grey areas indicate lung regions that are not ventilated at time Ref or C but have been ventilated at a different time within the selected observation period. In the picture above, the grey area at time Ref identifies the recruitable lung area at time C .

  • Page 34: Negative Impedance Changes

    34 | 3.2. nEGaTIvE IMPEdanCE ChanGES Negative impedance changes (in black/purple) represent inverted waveforms and are often caused by fluid accumulations inside the thorax. The following conditions might cause negative impedance changes: – Heart activity – Pleural effusion – Movement of the diaphragm (belt placed too low, see page 18) –...

  • Page 35: Filtration

    | 35 Useful Tools and Tips 3.3. FILTraTIOn By default, PulmoVista 500 processes unfiltered raw data and ® displays it accordingly. Since even smallest changes are detected with this technology, it is also possible to display simultaneous superimposed effects. Thus, e.g. pulmonary function as well as cardiac or perfusion related impedance changes are displayed.
  • Page 36 36 | Filter menu Unfiltered EIT data Filtered EIT data with low pass filter at HR -20 Please note that low-pass and band-pass filtering may cause a phase shift and thus a delayed display of impedance curves. With activated bandpass filtering the tidal rate will no longer be displayed. Filter and boundary frequency settings only affect the display of data, not on the data recording.

  • Page 37: Save Screenshot And Record Eit Data

    | 37 Useful Tools and Tips 3.4. SavE SCrEEnShOT and rECOrd EIT daTa You can take screenshots and record entire EIT measurements (EIT data). For creating screenshots, insert a USB flash drive into one of the side USB ports in the C500 monitor. After pressing the key ›Export Screenshot‹ the current view will be transferred directly onto the flash drive.

  • Page 38: Coupling Of A Dräger Ventilator With Pulmovista ® 500

    38 | 3.5. COUPLInG OF a drÄGEr vEnTILaTOr wITh PULMOvISTa ® PulmoVista 500 allows a synchronous import of EIT information and the current ® ventilation settings, waveforms, and trends. Data is imported via the Medibus / Medibus.X interface. The necessary settings can be found in the menu under ›Screen layout / Data Import‹.

  • Page 39: Frame Rate

    | 39 Cllinical Application 3.6. FraME raTE The dynamic EIT image continuously shows relative impedance changes. The high temporal resolution of this method allows for very precise analysis of individual phases during inspiration and expiration as well as the detection of rapid changes in intrathoracic processes.

  • Page 40: Identify Responder Or Non-Responder To A Recruitment-Maneuver (Rm)

    40 | 4.1. IdEnTIFY rESPOndEr Or nOn-rESPOndEr TO a rECrUITMEnT-ManEUvEr (rM) Step 1: Perform a rM Open the Main View: Set the Regions of Interest to ›layers‹ (adjust their height if required: in obese patients, adjust the height of the ROIs, so that ROI 1 properly represents ventral ventilation) –...
  • Page 41 | 41 Cllinical Application EXaMPLE: 40:40 ManEUvEr 40 mbar Inspiratory hold: Inspiratory pressure of 40 mbar for 40 s 40 s Recruitment-Maneuver Objective: – Re-expand collapsed lung tissue – Maintain sufficient PEEP to prevent de-recruitment after RM How-to: – Increase end-inspiratory pressure (Pinsp) for a short time –...
  • Page 42 42 | 2. Identify responder or non-responder: Responder: TV in ROI 4 is significantly higher during the RM than before (e.g. TV ROI 4 – 10 %, and the differential image shows light blue color in ROI 4. Non-Responder: Small or no change in ROI 4 (± 0 – 2 %) What to look for in the End-inspiratory Trend View? The following table shows two different results of a recruitment maneuver.

  • Page 43: Identify Possible De-Recruitment And Overdistension

    | 43 Cllinical Application 4.2. IdEnTIFY POSSIBLE dE-rECrUITMEnT and OvErdISTEnSIOn Principle: Comparison of regional compliance at different PEEP levels Use the PEEP trial analysis to interpret the loss of compliance. Step 1: Perform a decremental PEEP trial According to hospital standards. EXaMPLE: dECrEMEnTaL PEEP TrIaL –...
  • Page 44 44 | Definition of overdistension: The term overdistension describes an excessive expansion of the alveoli, which is very often caused by either high tidal volumes and / or high end-expiratory lung volumes resulting from high PEEP levels. In EIT, overdistension can be expected whenever a major loss of ventilation is observed during PEEP trials in the non-dependent lung areas towards higher airway pressures.

  • Page 45: Influence Of Positioning On The Distribution Of Ventilation

    | 45 Cllinical Application 2. Perform analysis Compliance changes during PEEP trials are conveniently displayed as a series of images and a diagram. At lower PEEP levels, those compliance changes may indicate collapse, at higher PEEP levels overdistension, respectively. Based on this information, an individualized PEEP level can be chosen, where the loss of compliance and the underlying adverse effects are minimized.

  • Page 46: Patient Proning

    46 | Gravity vector Supine position Lateral position right Lateral position left 4.4. PaTIEnT PrOnInG PulmoVista 500 allows the visualization of ventilated and non-ventilated ® lung areas. It is therefore also suitable for visualizing and tracking changes in ventilation following the application of any therapeutic intervention, such as after patient proning.

  • Page 47: Intubation Check

    | 47 Cllinical Application 4.5. InTUBaTIOn ChECk PulmoVista 500 can help to detect a faulty tube position. Real-time ® information helps EIT identify the correct tube position during the intervention. Example: ET tube inserted too deeply  ventilation visible only in right lung 4.6.

  • Page 48: Δeeli-Trend After Suction

    48 | 4.7. ΔEELI-TrEnd aFTEr SUCTIOn The ∆EELI trend is predestined to visualize and evaluate end-expiratory events in the lungs. In this case, a secretion suction was performed, which initially resulted in a sharp drop in end-expiratory lung impedance (EELI) (-2,58 x TV C1).

  • Page 49: Eit-Terminology

    | 49 EIT-Terminology 5. EIT-Terminology Baseline: Sets the reference for the next breath or sequence of breaths (changes in impedance). The virtual baseline EIT image in the different views is black. Globale Impedance Curve ΔEELI = Changes of EELI: Changes in end-expiratory lung impedance in the EIT sensitivity region. Absolute impedance measurements cannot be directly related to end- expiratory lung impedance.
  • Page 50 50 | FrC = functional residual capacity: FRC is a physiological parameter that describes the residual volume of lung capacity at the end of passive expiration (against ambient pressure). EELV (or FRC) describes the volume of air that can contribute to gas exchange between breaths.

  • Page 51: Contraindications

    – Patients with pacemakers, defibrillators or other electrically active implants – Patients with damaged skin or impaired skin contact of the electrodes due to wound dressings (PulmoVista 500 could also work in “15-electrode mode”) – Patients where the attachment of the patient belt could pose a risk to the patient, e.g.
  • Page 52 52 |...
  • Page 53 | 53 Notes...
  • Page 54 54 |...
  • Page 55 | 55 Notes...
  • Page 56 Not all products, features, or services are for sale in all countries. Mentioned Trademarks are only registered in certain countries and not necessarily in the country in which this material is released. Go to www.draeger.com/trademarks to find the current status. COrPOraTE hEadqUarTErS Drägerwerk AG &...

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