PMU31 early cost-effectiveness analysis of continuous monitoring of lung-aeration with electrical impedance tomography in preterm neonates with respiratory distress syndrome

Objectives Respiratory distress syndrome (RDS) is relatively common in preterm neonates due to lung immaturity. Clinical management by respiratory support is associated with high complications rates. Guidance on appropriate lung-aeration is limited using conventional thorax X-ray monitoring. Electrical impedance tomography (EIT) allows radiation-free, continuous lung-aeration monitoring to guide effective respiratory support. EIT produces dynamic images of air volume changes whereas X-ray shows 2-D structure. Clinicians expect EIT implementation to reduce the number of patients requiring mechanical ventilation, overall complication rates and hospitalisation length. We conducted an early cost-effectiveness analysis of EIT-monitoring in preterm neonates with RDS versus standard care in the Netherlands. Methods A decision-analytic model was constructed comparing costs and effects of conventional X-ray versus EIT-monitoring for preterm neonates with RDS from the healthcare perspective with a time horizon of two years. Input parameters were based on literature and cost databases. The effects of EIT-monitoring were based on consensus by 6 clinical experts for two scenarios, (1) a conservative scenario assuming only a decrease of patients on mechanical ventilation under EIT-monitoring, and (2) an optimistic scenario including scenario (1) and assuming an additional 10% relative complication rate decrease in comparison to standard care. Main outcomes were total average costs per patient, number of patients with bronchopulmonary dysplasia (BPD), and mortality. One-way sensitivity analyses were conducted. Results EIT-monitoring was estimated to be cost-saving in both scenarios, mainly due to a shorter average hospital length of stay. Total incremental costs per patient for EIT-monitored care versus standard care were -€929 and -€10,706 for scenario (1) and (2), respectively. The number of patients with BPD and deaths were reduced. Results were robust to changes in input parameters. Conclusions EIT lung-aeration monitoring in preterm neonates is expected to result in cost-savings and lower mortality and BPD rates, in comparison to standard care, in a Dutch hospital setting. Copyright © 2019 Published by Elsevier Inc

Deep analysis of EIT dataset to classify apnea and non-apnea cases in neonatal patients

Electrical impedance tomography (EIT) is a non-invasive imaging modality that can provide information about dynamic volume changes in the lung. This type of image does not represent structural lung information but provides changes in regions over time. EIT raw datasets or boundary voltages are comprised of two components, termed real and imaginary parts, due to the nature of cell membranes of the lung tissue. In this paper, we present the first use of EIT boundary voltage data obtained from infants for the automatic detection of apnea using machine learning, and investigate which components contain the main features of apnea events. We selected 15 premature neonates with an episode of apnea in their breathing pattern and applied a hybrid classification model that combines two established methods; a pre-trained transfer learning method with a convolutional neural network with 50 layers deep (ResNet50) architecture, and a support vector machine (SVM) classifier. ResNet50 training was undertaken using an ImageNet dataset. The learnt parameters were fed into the SVM classifier to identify apnea and non-apnea cases from neonates' EIT datasets. The performance of our classification approach on the real part, the imaginary part and the absolute value of EIT boundary voltage datasets were investigated. We discovered that the imaginary component contained a larger proportion of apnea features

Electrical impedance tomography reveals pathophysiology of neonatal pneumothorax during NAVA

Pneumothorax is a potentially life‐threatening complication of neonatal respiratory distress syndrome (RDS). We describe a case of a tension pneumothorax that occurred during neurally adjusted ventilatory assist (NAVA) in a preterm infant suffering from RDS. The infant was included in a multicenter study examining the role of electrical impedance tomography (EIT) in intensive care and therefore continuously monitored with this imaging method. The attending physicians were blinded for EIT findings but offline analysis revealed the potential of EIT to clarify the underlying cause of this complication, which in this case was heterogeneous lung disease resulting in uneven ventilation distribution. Instantaneous increase in end‐expiratory lung impedance on the affected side was observed at time of the air leak. Real‐time bedside availability of EIT data could have modified the treatment decisions made

Deep Analysis of EIT Dataset to Classify Apnea and Non-apnea Cases in Neonatal Patients

Electrical impedance tomography (EIT) is a non-invasive imaging modality that can provide information about dynamic volume changes in the lung. This type of image does not represent structural lung information but provides changes in regions over time. EIT raw datasets or boundary voltages are comprised of two components, termed real and imaginary parts, due to the nature of cell membranes of the lung tissue. In this paper, we present the first use of EIT boundary voltage data obtained from infants for the automatic detection of apnea using machine learning, and investigate which components contain the main features of apnea events. We selected 15 premature neonates with an episode of apnea in their breathing pattern and applied a hybrid classification model that combines two established methods; a pre-trained transfer learning method with a convolutional neural network with 50 layers deep (ResNet50) architecture, and a support vector machine (SVM) classifier. ResNet50 training was undertaken using an ImageNet dataset. The learnt parameters were fed into the SVM classifier to identify apnea and non-apnea cases from neonates’ EIT datasets. The performance of our classification approach on the real part, the imaginary part and the absolute value of EIT boundary voltage datasets were investigated. We discovered that the imaginary component contained a larger proportion of apnea features

Survey of milk protein polymorphism in the "Bovina Rossa Siciliana"

The “Rossa Siciliana” is an autochthonous small Sicilian dairy cattle population, accounting for 5-7,000 individuals.This breed is characterized by high ability to live on poor pasture lands, moderate milk production, and traditionally linked to cheese production. Aim of this work was to investigate milk protein polymorphisms in this population. A total of 62 individual milk samples were collected from 19 extensive farms spread in the “Parco dei Nebrodi” area (Messina). All samples were analyzed by isoelectrofocusing (IEF) with pH range 2.5-6. High variability was found at the CSN1S1, CSN2, CSN3, LGB and LALBA loci, while the CSN1S2 locus was monomorphic for the A allele. The allele frequencies and the Hardy-Weinberg equilibrium were estimated using the GENEPOP software, further the casein haplotype frequencies and the occurrence of the linkage disequilibrium were computed with the EH software, taking into account the association among loci. Joint analysis at all loci showed that the population is not in Hardy-Weinberg equilibrium (Chi-square=19.0, pvalue=0.0407), probably due to genetic drift. Of the three alleles detected at CSN1S1 locus, CSN1S1*B and CSN1S1*C had high frequencies (0.734 and 0.258 respectively), as reported for most breeds. The CSN1S1*D allele was detected with a low frequency (0.008). High frequencies were found for CSN2*A2 (0.573) and CSN3*B (0.637). High frequencies were observed for LALBA*B (0.903) and LGB*B (0.815). Strong linkage disequilibrium was detected for the polymorphic casein loci CSN1S1-CSN2-CSN3. For the casein haplotype only the hypothesis of association among loci was considered. Out of the 27 expected, only four haplotypes had a frequency higher than 0.10. The most frequent haplotype was BA2B (0.236), followed by CA2B (0.214), BA1A (0.168), BA1B (0.131), and BA2A (0.094). The high frequency of BA2B haplotype and the possible relation with production traits are under investigation

Chromosomal assignment of the ovine hairless (hr) gene by fluorescence in situ hybridization.

Congenital hypotrichosis in mammalian species consists of partial or complete absence of a hair coat at birth. Affected individuals having a partial hair coat at birth may loose it subsequently.The aim of this paper was to physically map the ovine hr gene using fluorescence in situ hybridization (FISH).A preliminary study on an internet data bank (http://www.informatics.jax.org) showed that the regions of the hr gene on murine chromosome 14 and human chromosome 8 present homology with ovine chromosome 2

Regional respiratory time constants during lung recruitment in high-frequency oscillatory ventilated preterm infants

To assess the regional respiratory time constants of lung volume changes during stepwise lung recruitment before and after surfactant treatment in high-frequency oscillatory ventilated preterm infants. A stepwise oxygenation-guided recruitment procedure was performed before and after surfactant treatment in high-frequency oscillatory ventilated preterm infants. Electrical impedance tomography was used to continuously record changes in lung volume during the recruitment maneuver. Time constants were determined for all incremental and decremental pressure steps, using one-phase exponential decay curve fitting. Data were analyzed for the whole cross section of the chest and the ventral and dorsal lung regions separately. Before surfactant treatment, the time constants of the incremental pressure steps were significantly longer (median 27.3 s) than those in the decremental steps (16.1 s). Regional analysis showed only small differences between the ventral and dorsal lung regions. Following surfactant treatment, the time constants during decremental pressure steps almost tripled to 44.3 s. Furthermore, the time constants became significantly (p <0.01) longer in the dorsal (61.2 s) than into the ventral (40.3 s) lung region. Lung volume stabilization during stepwise oxygenation-guided lung recruitment in high-frequency oscillatory ventilated preterm infants with respiratory distress syndrome is usually completed within 5 min and is dependent on the position of ventilation on the pressure volume curve, the surfactant status, and the region of interest of the lun

Compressive sensing in electrical impedance tomography for breathing monitoring

Continuous functional thorax monitoring using EIT has been extensively researched. A limiting factor in high temporal resolution, three dimensional, and fast EIT is the handling of the volume of raw impedance data produced for transmission and storage. Owing to the periodicity of breathing that may be reflected in EIT boundary measurements, data dimensionality may be reduced efficiently at the time of sampling using compressed sensing techniques. Measurements using a 32-electrode 48-frame-per-second EIT system from 30 neonates were post-processed to simulate random demodulation acquisition method on 2000 frames for compression ratios (CRs) ranging from 2-100. Sparse reconstruction was performed by solving the basis pursuit problem using SPGL1 package. The global impedance data was used in the subsequent studies. The signal to noise ratio (SNR) for the entire frequency band (0 Hz - 24 Hz) and three local frequency bands were analysed. A breath detection algorithm was applied to traces and the subsequent error-rates were calculated while considering the outcome of the algorithm applied to a down-sampled and linearly interpolated version of the traces as the baseline. SNR degradation was proportional with CR. The mean degradation for 0 Hz - 8 Hz was below ~15 dB for all CRs. The error-rates in the outcome of the breath detection algorithm in the case of decompressed traces were lower than those of the associated down-sampled traces for CR≥25, corresponding to sub-Nyquist rate for breathing. For instance, the mean error-rate associated with CR = 50 was ~60% lower than that of the corresponding down-sampled traces. To the best of our knowledge, no other study has evaluated compressive sensing on boundary impedance data in EIT. While further research should be directed at optimising the acquisition and decompression techniques for this application, this contribution serves as the baseline for future efforts. [Abstract copyright: Creative Commons Attribution license.

Clinical performance of a novel textile interface for neonatal chest electrical impedance tomography

Objective: Critically ill neonates and infants might particularly benefit from continuous chest electrical impedance tomography (EIT) monitoring at the bedside. In this study a textile 32-electrode interface for neonatal EIT examination has been developed and tested to validate its clinical performance. The objectives were to assess ease of use in a clinical setting, stability of contact impedance at the electrode–skin interface and possible adverse effects. Approach: Thirty preterm infants (gestational age: 30.3 ± 3.9 week (mean ± SD), postnatal age: 13.8 ± 28.2 d, body weight at inclusion: 1727 ± 869 g) were included in this multicentre study. The electrode–skin contact impedances were measured continuously for up to 3 d and analysed during the initial 20-min phase after fastening the belt and during a 10 h measurement interval without any clinical interventions. The skin condition was assessed by attending clinicians. Main results: Our findings imply that the textile electrode interface is suitable for long-term neonatal chest EIT imaging. It does not cause any distress for the preterm infants or discomfort. Stable contact impedance of about 300 Ohm was observed immediately after fastening the electrode belt and during the subsequent 20 min period. A slight increase in contact impedance was observed over time. Tidal variation of contact impedance was less than 5 Ohm. Significance: The availability of a textile 32-electrode belt for neonatal EIT imaging with simple, fast, accurate and reproducible placement on the chest strengthens the potential of EIT to be used for regional lung monitoring in critically ill neonates and infants

Surfactant replacement and open lung concept – Comparison of two treatment strategies in an experimental model of neonatal ARDS

Background: Several concepts of treatment in neonatal ARDS have been proposed in the last years. The present study compared the effects of open lung concept positive pressure ventilation (PPVOLC) with a conventional ventilation strategy combined with administration of two different surfactant preparations on lung function and surfactant homoeostasis. Methods: After repeated whole-lung saline lavage, 16 newborn piglets were assigned to either PPVOLC(n = 5) or surfactant treatment under conventional PPV using a natural bovine (n = 5) or a monomeric protein B based surfactant (n = 6). Results: Comprehensive monitoring showed each treatment strategy to improve gas exchange and lung function, although the effect on PaO2and pulmonary compliance declined over the study period in the surfactant groups. The overall improvement of the ventilation efficiency index (VEI) was significantly greater in the PPVOLCgroup. Phospholipid and protein analyses of the bronchoalveolar lavage fluid showed significant alterations to surfactant homoeostasis in the PPVOLCgroup, whereas IL-10 and SP-C mRNA expression was tendentially increased in the surfactant groups. Conclusion: The different treatment strategies applied could be shown to improve gas exchange and lung function in neonatal ARDS. To which extent differences in maintenance of lung function and surfactant homeostasis may lead to long-term consequences needs to be studied further