Electrical impedance tomography

Eduardo L.V. Costaa, Raul Gonzalez Limab and Marcelo B.P. Amatoa
a
Respiratory Intensive Care Unit, University of Sao
Paulo School of Medicine and bDepartment of
Mechanical Engineering, Escola Politecnica, University
of Sao Paulo, Sao Paulo, Brazil

Correspondence to Marcelo B.P. Amato, MD, PhD,

Respiratory Intensive Care Unit, University of Sao
Paulo School of Medicine, Av Dr Arnaldo 455, Room
2206 (2nd floor), 01246-903 Sao Paulo, Brazil
Tel: +55 11 3061 7361; fax: +55 11 3061 2492;
e-mail: amato@unisys.com.br
Current Opinion in Critical Care 2009,
15:1824

Purpose of review
Electrical impedance tomography (EIT) is a noninvasive, radiation-free monitoring tool
that allows real-time imaging of ventilation. The purpose of this article is to discuss the
fundamentals of EIT and to review the use of EIT in critical care patients.
Recent findings
In addition to its established role in describing the distribution of alveolar ventilation, EIT
has been shown to be a useful tool to detect lung collapse and monitor lung recruitment,
both regionally and on a global basis. EIT has also been used to diagnose with high
sensitivity incident pneumothoraces during mechanical ventilation. Additionally, with
injection of hypertonic saline as a contrast agent, it is possible to estimate ventilation/
perfusion distributions.
Summary
EIT is cheap, noninvasive and allows continuous monitoring of ventilation. It is gaining
acceptance as a valuable monitoring tool for the care of critical patients.
Keywords
electrical impedance tomography, imaging, lungs, monitoring
Curr Opin Crit Care 15:1824
2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5295

Introduction
Electrical impedance tomography (EIT) is a noninvasive,
radiation-free monitoring tool that allows real-time imaging of ventilation [13]. EIT is the only bedside method
that allows repeated, noninvasive measurements of
regional changes in lung volumes [4,5]. For this reason,
EIT has been used as a monitoring tool in a variety of
applications in critical care medicine, including monitoring of ventilation distribution [3,6], assessment of lung
hyperdistension [7] and collapse [8
,9
], detection of
pneumothorax [10
,11], among others. In this article,
we will discuss the fundamentals of EIT and review
the use of EIT in critical care patients in the light of
recent literature.

for intrathoracic impedances may not be unique or

may be unstable: small errors in voltage measurements
may lead to fairly different solutions. This problem is
aggravated by the small number of measurements made
at the body surface, because of the present technological
limitation on minimum electrode size (and thus maximal
electrode number). In order to overcome the ill-posed
nature of impedance estimation, most EIT imaging
algorithms make use of additional assumptions, known
as regularizations, such as smoothness of the intrathoracic
impedance distribution [12,13]. These regularizations
help the estimation algorithm to decide between competing solutions, producing an image that is a reasonable
estimation of the true impedance distribution within the
thorax, at the expense of degraded spatial resolution or
attenuation of maximum perturbations.

How electrical impedance tomography works

EIT uses injection of high frequency and low amplitude
electrical currents, typically through 16 or 32 electrodes
around the thorax, to obtain images of a cross section of
the lungs (Fig. 1) [1,10
]. These currents travel through
the thorax following pathways that vary according to
chest wall shape and thoracic distribution of impeditivities. The resulting electric potentials on the surface
of the chest wall are measured and used to obtain the
electric impedance distribution within the thorax using a
reconstruction algorithm that solves an ill-posed nonlinear problem. Ill-posedness means that the solution
1070-5295 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Absolute versus difference images

Thoracic shape can contribute as much as internal thoracic impedances to the measured voltages at the chest
wall surface [13]. Consequently, the reconstruction of the
absolute impedance distribution, albeit feasible, requires
knowledge of the shape of the thorax. Difference images,
described by Brown [13], can be generated without
precise knowledge of the thoracic geometry. Their reconstruction is based on relative changes in impedance in
relation to a reference, assuming that the shape of the
thorax is nearly rounded and did not change in between.
DOI:10.1097/MCC.0b013e3283220e8c

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Electrical impedance tomography Costa et al. 19

Figure 1 Disposition of electrodes around the thorax and electrical current injection

Computerized tomography (CT) of the thorax of a patient with schematically drawn electrodes and electrical current pathways through the
thorax. One pair of electrodes injects electrical current at a time whereas
the remaining electrodes read the voltages produced as a result of
electrical current passing through the thorax. The injecting pair is
alternated sequentially so that after a full cycle, all possible adjacent
electrodes serve as injectors. Each full cycle results in an image and 50
images are produced each second.

This relative or differential approach cancels out most

errors related to wrong assumptions about the true thoracic shape (the same error is equally present in both
images) and has proven its validity in the last years.
The use of normalized voltage measurements further
improves the robustness of such solution, which ignores
the absolute values of impedance at the beginning of the
measurements. Typically, at a frequency of 10 kHz, the
electrical impedance of the chest tissues is in the order of
24 Vm, and the average impedance of the lung is around
10 Vm [14]. During respiration, whereas lung impedance
changes up to 300% (from 7.2 to 23.6 Vm in one report)
[14], chest wall impedance remains relatively constant.
Most currently available EIT devices in clinical practice
and most publications in the field use the relative
approach and thus calculate difference impedance
images in relation to a reference. The output image of
such algorithms is usually a 32  32 or a 64  64 array
(which might be later interpolated) from which each
element corresponds to a pixel on the image and contains
the change in impedance in relation to a reference frame,
expressed as a percentage. The baseline impedance
cannot be recovered. Thus, breaths producing a change
in lung impedance from 5 to 10 Vm, or from 10 to 20 Vm
will produce exactly the same relative image. As we will
see later, this limitation is not worrisome as far as clinical
applications are concerned, because there is a well
described and linear relationship between the amount

of air entering the voxel and the percentage change in

lung impedance [15,16].
One drawback of the use of difference images is that only
regions of the thorax that change their impedance over
time are represented in EIT images. Consequently,
preexisting consolidated areas of the lung (e.g., pneumonia or atelectasis), pleural effusions or large bullae are not
represented in difference EIT images. For this reason,
absolute images have the potential to bring additional
and important information and there is continuing
research to improve the quality of absolute images.
Although some progress has been made, with promising
results presented by Hahn et al. [11], the quality of the
images is still not good enough for meaningful clinical
use. Further development in this area, using estimations
of electrode position and taking thoracic shape into
account will enable precise absolute image reconstruction.

Spatial and temporal resolution

Spatial resolution of EIT depends on the accuracy and
noise of the measurements, the number of electrodes,
and the regularization used. For this reason, spatial resolution varies from one EIT device to another, and even
within a single device depending on the settings
employed. In bench tests, the resolution is usually
optimized because less regularization is required. At
the bedside, however, noise and wrong assumptions
about thoracic shape require stronger regularizations
and resolution is compromised. On average, in 16-electrode systems, resolution is 12% of the thoracic diameter
for regions in the periphery of the lung and 20% for
central regions. In 32-electrode systems, this resolution
can be improved to 610% of the thoracic diameter
(Turri F, personal communication). In a typical adult
patient, this resolution corresponds to approximately
1.53 cm in the cross-sectional plane. The spatial resolution in the craniocaudal direction is lower, the slice
thickness amounting to approximately 710 cm. Such
thick slices can be useful for studying the lung behavior
during mechanical ventilation, when the detection of
heterogeneities along the gravity axis is the main target
[17,18].
Although it is possible to improve spatial resolution, for
example, by increasing the number of electrodes or by
improving hardware performance, it is unlikely that EIT
will ever reach the resolution of CT or MRI [19]. On the
contrary, modern EIT devices are characterized by high
temporal resolution, with some generating 50 images/s. It
is thus possible to follow closely the time pattern of
regional inflation and deflation of the lung. For example,
it is possible to show that some areas start to inflate after
others, reflecting either tidal recruitment [20
] or local

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20 Respiratory system

auto-PEEP. Additionally, by use of brief periods of apnea

or by filtering out ventilation [21
], high temporal resolution allows for monitoring of changes in intrathoracic
impedance caused by perfusion.

Clinical applications
Initial EIT applications on critical care medicine focused
mainly on ventilation and its distribution; now other
applications are being studied such as detection of pneumothorax, assessment of lung recruitment and collapse,
and lung perfusion.
Assessment of lung recruitment and lung collapse

Careful titration of PEEP is of utmost importance for the

success of ventilatory strategies based on the open lung
approach. Global lung parameters, such as pressurevolume curves [22,23] or respiratory system compliance
[24] fail to represent what is happening to the lung on a
regional basis [25]. Collapsed and overdistended lung
compartments commonly coexist, and a method capable
of assessing both, simultaneously, would be invaluable as
a tool to titrate PEEP. Our group described an EIT-based
method for estimating alveolar collapse at the bedside,
pointing out its regional distribution. On an experimental
model in pigs, we found a good correlation between EIT
and CT estimates of lung collapse during decremental

PEEP trials after a maximal lung recruitment maneuver

[26]. Combining data obtained from EIT and respiratory
mechanics, it is also possible to estimate the amount of
overdistension during a PEEP trial, although validation
of such estimates represents a challenge due to the lack of
a gold standard to compare with (Fig. 2) [27]. Meier et al.
[9
] recently used EIT to monitor regional tidal volume
during a PEEP titration maneuver in a model of surfactant depletion in pigs. Looking at changes in regional
tidal volumes that occurred with changes in PEEP, they
were able to detect the initiation of regional lung collapse
and of regional lung recruitment before global changes
occurred in lung mechanics. Additionally, they showed
good correlation of ventilation estimated by EIT and CT,
confirming the results of Victorino et al. [3]. Together,
these results bring an exciting possibility of bedside
titration of PEEP based on regional lung mechanics.
In a similar report, Luepschen et al. [28
] showed that the
center of gravity of ventilation images moves dorsally
during lung recruitment and ventrally during lung collapse. This EIT-based parameter brought additional
information to a fuzzy controller of ventilation that optimized lung recruitment based on oxygenation, ventilatory parameters and hemodynamics. Other authors also
used the center of gravity of ventilation to assess lung
recruitment [29]. In 16 newborn piglets with acute lung

Figure 2 Estimation of collapse and overdistension

Computerized tomography (CT) of the thorax of a patient with right inferior lobe pneumonia (top figures) and EIT maps (bottom figures) of lung
hyperdistension (left) and lung collapse (right) in a patient with ARDS. The left-hand images were obtained at PEEP of 23 cmH2O and those on the
right, at a PEEP of 3 cmH2O. In these images, CT slice thickness was 1 cm, and EIT slice thickness was approximately 7 cm.

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Electrical impedance tomography Costa et al. 21

injury induced by whole lung lavage, Frerichs et al.

showed that EIT allows visualization of the effects of
acute lung injury, lung recruitment, surfactant administration, and mechanical ventilation strategy. They found
that lung injury displaces the ventilation ventrally, and
lung recruitment restores the center of ventilation to the
normal position. After surfactant administration, ventilation shifts ventrally over 1060 min, but remains in the
preinjury position if surfactant administration is followed
by a recruitment maneuver.
Other methods to estimate lung recruitment using EIT
have been proposed. In a recent report [20
], the authors
compared EIT measures to dynamic CT in 18 pigs
divided into three groups (control, direct, and indirect
lung injury). EIT allowed real-time monitoring of
regional ventilation distribution. During an interposed
slow inflation, regional recruitment was detected by using
the time delay between start of inspiration and start of
regional inflation (ventilation delay index). Hinz et al.
[30
] monitored 20 mechanically ventilated patients
during with acute lung injury/acute respiratory distress
syndrome (ARDS) during tidal breathing and showed
that the behavior of regional impedance over time was
heterogeneous and significantly different from that of the
whole lung. The findings suggested the occurrence of
hyperdistension and tidal recruitment in different regions
of the lung (Fig. 2).
Although a careful titration of PEEP is important, lung
conditions frequently change, and a selected PEEP
might not suffice to keep the lung open at all times,
especially if transient depressurization of the lung occurs.
Depressurization is particularly common when suctioning of the airways is required for clearance of secretions.
To assess the derecruitment caused by closed-system
suctioning, Wolf et al. [31
] studied six children with
ARDS, on pressure controlled ventilation and continuously monitored with EIT. They showed that lung
volumes decreased on average by 5.3 ml/kg after three
suctioning maneuvers. Unexpectedly, they showed that
the most dorsal regions of the lung were the least affected
by derecruitment; as the authors used difference EIT
images, they could only speculate that this region was
atelectatic even before the suctioning maneuver. Another
possibility might be suggested in this context, which is
the presence of air trapping in dependent lung regions. In
pigs monitored with EIT after surfactant depletion,
Lindgren et al. [8
] found different results. They showed
that endotracheal suctioning induced collapse of the lung
and decreased regional lung compliance during opensystem suctioning but not during closed-system suctioning. The collapse was predominantly in the dorsal
regions, but recruitment was reestablished in less than
10 min by simple reconnection to the ventilator. Nevertheless, it is important to bear in mind that the model of

surfactant depletion using whole lung lavage leads to

lungs prone to collapse, but highly recruitable. Therefore, these results need careful scrutiny before being
extrapolated to inflamed, edematous lungs of ARDS
patients, on whom depressurization can cause long-term
effects and should be avoided.
On a different report, the same authors used EIT to
assess lung collapse during bronchoscopic suctioning
in patients mechanically ventilated with acute lung
injury [32
]. They elegantly showed that bronchoscopy
initially leads to localized auto-PEEP due to the reduced
transverse area available for airflow, and that suctioning
leads to a decrease in lung aeration and compliance even
when a closed suctioning system is used. They obtained
similar findings both in volume-controlled and pressurecontrolled ventilation. In mechanically ventilated
patients being submitted to bronchoscopic procedures,
EIT might prove to be a useful tool to quantify the
amount of collapse and guide postsuctioning recruitment.
Detection of pneumothorax and pleural effusion

Pneumothorax is a relatively common complication in

critical care patients under mechanical ventilation or
submitted to invasive procedures such as central venous
line placement or thoracocentesis. Costa et al. [10
]
created an algorithm for the detection of pneumothoraces using EIT. The algorithm was created in a first
set of 10 pigs, and subsequently tested in 29 pigs. EIT
showed a sensitivity of 100% (CI 93100%) to detect
pneumothoraces as small as 20 ml (Fig. 3). The major
limitation of this study was the need for a baseline
measurement before the occurrence of the pneumothorax, limiting the application to monitoring of situations with high risk of developing pneumothorax, such
as central venous line placements or mechanical ventilation with high alveolar pressures.
Another group of investigators [11] studied the combined
use of dynamic and absolute images for the diagnosis of
pneumothorax and pleural effusion. They studied five
pigs and showed reproducible results with the development of pneumothorax consisting of regional increase in
absolute impedance and decreased ventilation. Pleural
effusions, being more conductive than the lung, produced a regional decrease in impedance associated with
decreased ventilation. They further acquired images in
four patients and showed that EIT absolute images were
compatible with CT images.
The use of EIT as a sensitive monitoring tool for the
detection of pneumothorax and pleural effusions
[10
,11,33] is appealing but probably will not be applied
in clinical practice until systematic studies in patients
are performed.

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22 Respiratory system
Figure 3 Detection of pneumothorax
Computerized tomography (CT), ventilation
map, and aeration change map obtained at
baseline and after the induction of a 100 ml
pneumothorax in a pig with partial atelectasis
of the lungs.

Correct placement of endotracheal tube

Steinmann et al. [34 ] studied 40 patients requiring onelung ventilation for surgical procedures. EIT monitoring
started before intubation and continued throughout the
protocol. All clinical decisions were based on fiberoptic
bronchoscopy and EIT investigators were blinded to
bronchoscopy findings. EIT correctly identified left
and right one-lung ventilation, but could not identify
misplacement of the endobronchial cuff, suggesting that
EIT cannot fully replace bronchoscopy as a guide to onelung ventilation. Although not designed to address this
question, this study suggests that EIT can be used to
diagnose selective intubation or endotracheal tube displacement during conventional two-lung ventilation.

hold maneuver [36
,37]. Using this technique, we conducted a study (Borges JB, unpublished data) to compute
regional VA/Q ratios in a pig model of ARDS and compared them to VA/Q ratios computed with single photon
emission tomography. Ventilation was calculated using
the concept of functional images, as previously described
[2]. Regional perfusion estimations were based on the
time-signal intensity curve (or first-pass contrast curve)
observed in each pixel after the bolus of hypertonic
saline. A gamma curve, which models the indicator
washin, was fitted to sequential impedance measurements of each pixel during the passage of the contrast.
We found that it is possible to derive meaningful VA/Q
maps from EIT data (Fig. 4) (Borges JB, unpublished
data).

Perfusion and ventilation/perfusion ratios

The relationship between ventilation and perfusion

(VA/Q) is important in the pathophysiology of a number
of clinical conditions, such as pulmonary thromboembolism, advanced chronic obstructive pulmonary disease and
ARDS. Additionally, in the ICU, VA/Q relationships
can change quite fast following changes that occur in
cardiac output and alveolar ventilation [35
]. Better
understanding of the VA/Q relationships could potentially
help guide treatment decisions and optimize gas
exchange. It is possible to use EIT to study lung perfusion through intravenous injection of hypertonic saline,
which serves as a contrast agent for EIT images (because
of its extremely low impeditivity), together with a breath

Recently Deibele et al. [21
] used a combination of

techniques including signal filtering and principal components analysis to separate the respiratory from the
cardiac signal in real time without the need for breath
holding. The authors were able to decompose the EIT
signal and to produce images from the cardiac oscillations.
This technique has the advantage over the hypertonic
saline technique in that it allows continuous monitoring
of cardiac-related oscillations. The amplitude of cardiac
related oscillations seen in the EIT signals, however, has
not been shown to correspond to the amount of local
perfusion, and further studies are necessary to explore its
precise physiological meaning [38].

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Electrical impedance tomography Costa et al. 23

Figure 4 Ventilation/perfusion maps

Computed tomography, ventilation/perfusion (VA/Q) map and distribution of ventilation and blood flow derived from electrical impedance tomography
data. On the color scale for the VA/Q maps, red indicates shunt, green indicates VA/Q 1, and white indicates dead space ventilation. Shunt is shown
by the closed circle at VA/Q 0. Panels a, b and c are from a mechanically ventilated pig with normal lungs and panels d, e and f are from the same
animal after induction of atelectasis of the left lung. CT, computed tomography. Adapted with permission from (Borges JB, unpublished data).

Conclusion
EIT is gradually gaining acceptance as a valuable
monitoring tool for the care of critical patients. It is cheap,
noninvasive and, up to now, has been shown to reliably
track changes in regional ventilation, describe regional
ventilation distribution and regional lung mechanics,
detect pneumothoraces, and monitor lung recruitment
and derecruitment. Other applications such as monitoring
of lung perfusion and of ventilation/perfusion distribution are feasible but still require further studies.

Acknowledgements
Financial support by grants from Fundacao de Amparo a` Pesquisa do
Estado de Sao Paulo (FAPESP) Sao Paulo State Research Support
Foundation and Financiadora de Estudos e Projetos (FINEP)
Studies and Projects Financial Support Provider.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
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of special interest


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