CE: ; MCC/300107; Total nos of Pages: 10;

MCC 300107

REVIEW

C URRENT
OPINION Setting positive end-expiratory pressure by using
electrical impedance tomography
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM

z Frerichs, Dirk Sch€adler and Tobias Becher

Ine
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023

Purpose of review
This review presents the principles and possibilities of setting positive end-expiratory pressure (PEEP) using
electrical impedance tomography (EIT). It summarizes the major findings of recent studies where EIT was
applied to monitor the effects of PEEP on regional lung function and to guide the selection of individualized
PEEP setting.
Recent findings
The most frequent approach of utilizing EIT for the assessment of PEEP effects and the PEEP setting during
the time period from January 2022 till June 2023 was based on the analysis of pixel tidal impedance
variation, typically acquired during stepwise incremental and/or decremental PEEP variation. The most
common EIT parameters were the fraction of ventilation in various regions of interest, global inhomogeneity
index, center of ventilation, silent spaces, and regional compliance of the respiratory system. The studies
focused mainly on the spatial and less on the temporal distribution of ventilation. Contrast-enhanced EIT
was applied in a few studies for the estimation of ventilation/perfusion matching.
Summary
The availability of commercial EIT devices resulted in an increase in clinical studies using this bedside
imaging technology in neonatal, pediatric and adult critically ill patients. The clinical interest in EIT became
evident but the potential of this method in clinical decision-making still needs to be fully exploited.
Keywords
electrical impedance tomography, lung imaging, mechanical ventilation, ventilator-associated lung injury

INTRODUCTION oxygenation status, driving pressure, transpulmo-

Positive end-expiratory pressure (PEEP) is one of the
essential ventilator parameters that needs to be set
during mechanical ventilation. The selected PEEP
value affects the efficiency of pulmonary gas
exchange, the securing of which is the primary goal
of mechanical ventilation. It also influences the
extent of the injurious effects of artificial ventila-
tion. An optimum value of PEEP should enable the
realization of adequate gas exchange and at the
same time minimize the incidence of ventilator-
associated lung injury. Its setting clearly needs to
take the individual patient status and needs into
account. This task is particularly challenging in
critically ill patients with heterogeneous lung dis-
eases [1] requiring longer periods of ventilation
support.
The setting of PEEP relies strongly on the exper-
tise and experience of the attending physicians and
other medical personnel. Several additional meas-
urements, analyses and other tools are used or have
been proposed to facilitate the selection of the ‘best’
PEEP. The most frequent ones are the arterial
nary pressure, dynamic and static respiratory system
compliance (Crs), stress index, lung imaging and the
PEEP/FIO2 tables.
The medical decision-making is generally a com-
plex process requiring multiple inputs with subse-
quent integration and combination of the findings
that, in the next step, lead to concise interpretations
and decisions. It is therefore reasonable to presume
that the setting of PEEP would also rely on several
sources of information and would not be feasible
with just a single parameter input. Our article
describes the rationale why electrical impedance
Department of Anesthesiology and Intensive Care Medicine, University
Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
Correspondence to Prof. Dr. In

ez Frerichs, Department of Anesthesiol-
ogy and Intensive Care Medicine, University Medical Center Schleswig-
Holstein, Campus Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany.
Tel: +49 431 500 20801; fax: +49 431 500 20804;
e-mail: frerichs@anaesthesie.uni-kiel.de
Curr Opin Crit Care 2023, 29:000–000
DOI:10.1097/MCC.0000000000001117

1070-5295 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107
Respiratory system
KEY POINTS
 A significant increase in the number of experimental
and clinical studies using electrical impedance
tomography (EIT) for detection of positive end-
expiratory pressure (PEEP)-related changes in regional
lung function and for identifying individualized PEEP
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
levels was noted.
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023
 EIT monitoring can help find a PEEP level minimizing
alveolar collapse, tidal recruitment, overdistension,
shunt perfusion and dead space ventilation.
 Different approaches to EIT-guided PEEP setting have
been investigated, some based on the detection of
regional tidal volumes, while others utilized regional
pulmonary blood flow, changes in end-expiratory lung
volumes, or respiratory system mechanics.
 Only few of the recent studies exploited the information
on the temporal distribution of ventilation that can be
generated from EIT data along with its spatial
distribution.
 Further research investigating the long-term use of EIT in
the clinical setting is desirable.
tomography (EIT) generates information that is rel-
evant for PEEP adjustment. We also provide an
overview of the most important articles published
over the past 18 months (from January 1 2022 till
June 30 2023) that analyzed the PEEP effects using
EIT and/or used EIT for individualized PEEP setting.
PULMONARY EFFECTS OF POSITIVE END-
EXPIRATORY PRESSURE
During spontaneous quiet breathing, the inspira-
tion starts at the level of functional residual
capacity, the tidal volume is inhaled through the
active contraction of inspiratory muscles and
exhaled passively. During mechanical ventilation
in a lying patient with no spontaneous breathing
activity, the tidal volume is generated by the ven-
tilator. When no PEEP is applied, the volume of
air in the lungs by the end of expiration is lower
than during spontaneous breathing in an upright
position.
Alveolar collapse develops quickly when a
patient is ventilated without PEEP, mainly in the
gravity-dependent regions. Because these atelectatic
regions are not ventilated but still perfused, the
efficiency of pulmonary gas exchange is compro-
mised and the fraction of shunt perfusion is
increased. PEEP is therefore used to increase the
volume of air that stays in the lungs by the end of
expiration and to reduce the ventilation/perfusion
mismatch. If PEEP is inadequately set and its value
2 www.co-criticalcare.com
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
too low this may lead to cyclic alveolar opening and
closing, also known as ‘tidal recruitment’, which is
considered to promote alveolar tissue damage.
PEEP may also promote the development of
another deleterious effect of mechanical ventilation,
the cyclic or continuous alveolar overdistention. The
overdistended regions get injured through the high
mechanical stress they are exposed to. Besides, the
local blood flow is impeded, the regional ventilation
is wasted and the arterialization process is hampered.
All these phenomena lead to higher dead space ven-
tilation. Generally, the higher the PEEP, the higher
the probability of overdistension. The identification
of the PEEP value with the minimum overdistending
effect is not easy because it depends on the type of the
underlying lung disease and the degree of its hetero-
geneity as well as on other ventilator settings, e.g.
tidal volume. The regions that are most prone to the
development of overdistension are the nondepend-
ent lung regions.
All the described intrathoracic events, associ-
ated with the application of PEEP that are both
positive and negative need to be considered when
PEEP is being set. Moreover, the adequacy of PEEP
needs to be reassessed and readjusted over time, as
the patient’s status worsens or improves and the
therapy is modified.
HOW CAN ELECTRICAL IMPEDANCE
TOMOGRAPHY HELP IN SETTING
POSITIVE END-EXPIRATORY PRESSURE
EIT can detect and localize regional alveolar col-
lapse, tidal recruitment, overdistension, regional
increase or decrease in aeration and calculate the
distribution of ventilation and regional ventilation/
perfusion matching [2,3]. Moreover, EIT can gener-
ate this information continuously over protracted
&
periods of time spanning days [4 ]. Thus, EIT offers
quasi-continuously the unique possibility to pro-
vide all the information that needs to be considered
when deciding which PEEP value is the best in an
individual patient.
The capacity of EIT to generate this information
can be derived from the measuring principle of EIT.
EIT measures the electrical properties, i.e., the elec-
trical bioimpedance of thoracic tissues within a three-
dimensional transverse chest layer of a nonuniform
height. This is accomplished by probing the body
with minute electrical excitation currents and from
the repetitive measurements of electrical voltage dif-
ferences through an array of electrodes on the chest
surface. Because the measurements cause no harmful
effects to the body and the devices can be used
directly at the bedside, the scanning can be either
continuous or easily re-initiated when needed.
Volume 29  Number 00  Month 2023
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107
Setting positive end-expiratory pressure by using electrical impedance tomography Frerichs et al.
Detection of regional lung ventilation by
electrical impedance tomography
Pulmonary electrical bioimpedance varies quasi-
periodically over time as the result of ventilation.
The air entering the lungs distends the lung tissue
and elongates the pathways the EIT excitation cur-
rents need to pass during the examination. This is
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
detected by EIT as an increase in electrical impe-
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023
dance in the lung regions during inspiration. The
opposite happens during expiration. The amplitude
of the impedance change between end-expiration
and end-inspiration, i.e. the tidal impedance varia-
tion (TIV), can be calculated from each breath in
each image pixel. TIV is proportional to the local
tidal volume. Pixel TIV values are the basis for the
calculation of several measures characterizing the
spatial distribution of ventilation. If EIT is combined
with a simultaneous airway pressure measurement,
regional measures of respiratory system mechanics,
like regional Crs and its changes over time, can also
be determined.
Detection of spatial distribution of
ventilation and its use for positive end-
expiratory pressure setting
The changes in the spatial distribution of TIV with
different ventilator settings can provide informa-
tion on the presence of alveolar collapse or over-
distension. For instance, if PEEP is reduced and the
regional TIV in the dependent regions subsequently
falls and in the nondependent regions rises, this
may be the consequence of the lower PEEP value
leading to regional alveolar collapse and redistrib-
ution of ventilation toward the nondependent
regions. Or, if PEEP is increased and TIV falls in
the nondependent regions this may imply a higher
degree of overdistension in these regions. If TIV rises
in the dependent regions at the same time, then
alveolar recruitment in these regions is probable.
To quantify such distributional changes of ven-
tilation, EIT offers measures like the dorsal and
the ventral fraction of ventilation or the ventrodor-
sal center of ventilation (CoV). In case of right-to-
left asymmetry of the patient’s lung disease with
dissimilar response of the two lungs to a PEEP
change, analogous measures of right and left frac-
tion of ventilation and right-to-left CoV can be
utilized. For example, if PEEP is increased and the
previously collapsed dependent regions are success-
fully recruited in a supine patient, then the
dorsal fraction of ventilation will increase and
CoV will move toward the back. If the nondepend-
ent regions become overdistended in parallel, the
described change of both EIT parameters will further
be enhanced.
1070-5295 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
An experimental investigation studied the effect
of different PEEP values on the homogeneity of
ventilation during neurally-adjusted assisted venti-
lation using the dorsal fraction of ventilation to
identify the PEEP value leading to the highest degree
of ventral-dorsal balance [5]. The same parameter
was applied in obese surgery patients and identified
less dependent collapse at 12 than 4 cmH2O of PEEP
[6]. A well designed prospective clinical study in
postcardiac surgery patients determined PEEP by
analyzing a decremental PEEP trial with EIT with
the aim of avoiding ventilation loss in the depend-
&&
ent regions [7 ]. The EIT-guided PEEP setting pre-
vented alveolar collapse and improved oxygenation
and Crs.
When analyzing spatial distribution of ventila-
tion, it is also possible to classify the pixel TIV values
into two categories, typically with a threshold value
of 10% of the maximum TIV in the image, to iden-
tify lung regions exhibiting very low ventilation.
Such regions are also called ‘silent spaces’ and they
may be indicative of regional atelectasis or over-
distenstion. This method requires the definition
of lung regions in the EIT images, which is a difficult
issue in EIT and critical for the correct interpreta-
tion. Individualized regions are needed [8] which
has not been done so far. A new method has recently
been proposed that might improve the identifica-
&
tion of lung regions-of-interest [9 ]. Figure 1 shows
an example of changes in CoV and silent spaces
associated with a reduction of PEEP.
A study on patients with acute respiratory dis-
tress syndrome (ARDS) examined in prone and
supine positions and ventilated at two PEEP values
identified less dependent silent spaces without an
increase of nondependent ones at higher PEEP only
&
in recruiters and not in nonrecruiters [10 ]. In
another study, silent spaces were applied to identify
the PEEP level maintaining recruitment and mini-
mizing the overdistension by performing a 4-step
incremental/decremental PEEP trial in an experi-
mental study [11].
A different approach to characterizing the distri-
bution of pixel TIV that can be utilized in the process
of PEEP setting is based on the calculation of simple
quantitative measures like the coefficient of variation
or the global inhomogeneity (GI) index. These two
measures offer the information on the overall degree
of heterogeneity of ventilation distribution. How-
ever, unlike CoV, regional fractions of ventilation
or dependent and nondependent silent spaces men-
tioned above, they do not provide any information
on how this distribution is aligned with the ventro-
dorsal or right-to-left axis of the body.
Individualized PEEP was titrated by EIT during
an incremental PEEP trial and identified at the level
www.co-criticalcare.com 3
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107

Respiratory system

(a) PEEP: 8 mbar (b) PEEP: 6 mbar

Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023

funconal lung size % nondependent % funconal lung size % nondependent %

0 0

75 25 75 25

50 50 50 50

25 75 25 75

0 0
% dependent % dependent

FIGURE 1. Presence of silent spaces (yellow image pixels) in predefined lung regions (bounded in green) at a positive end-
expiratory pressure (PEEP) value of 8 mbar (a) and after its reduction to 6 mbar (b). The white solid dot in each image marks
the location of the center of ventilation which shifted toward the left chest side and slightly toward the ventral side after the
PEEP decrease. The diagrams below the images show the percentages of poorly ventilated lung areas in the nondependent
and dependent lung regions as fractions of the area of both lung regions of interest. The reduction in PEEP resulted in a slight
fall of nondependent silent spaces, attributable to a small relief in overdistension, with a simultaneous and more pronounced
increase in the area of silent spaces in the dependent regions, attributable to lung collapse. The clinical implication of these
findings might be the reversal of the decision to reduce PEEP. (Data were acquired with the Sentec (Landquart, Switzerland) EIT
technology implemented in the Elisa 800VIT ventilator (L€ owenstein, Steinbach, Germany).)

resulting in the lowest GI index in ARDS patients
with underlying chronic obstructive pulmonary dis-
ease (COPD). In that study, the EIT-guided PEEP
level was found to be lower compared with the lower
&
PEEP/FIO2 table [12 ]. The same approach was used
in a study on obese patients during bariatric surgery
with the PEEP set either with or without a preceding
recruitment maneuver, showing higher intraopera-
tive Crs in the recruitment group but no differences
in the postoperative outcomes [13].
Detection of regional respiratory system
compliance and its changes as a tool for
setting positive end-expiratory pressure
When airway pressure is measured in parallel with the
EIT examination, regional Crs can be determined
from EIT data by dividing the TIV values with the
driving pressure. The most popular clinical applica-
tion has become its calculation during an incremen-
tal and/or decremental PEEP trial [14,15]. The
quantification of relative changes of pixel Crs in
the dependent and nondependent lung regions
during a decremental PEEP trial allows the generation
of curves presenting the increase of Crs toward lower
PEEP values (i.e., the compliance win due to relief of
overdistension) and the decrease in Crs toward lower
PEEP values (i.e., the compliance loss due to alveolar
collapse) (Fig. 2). The PEEP value at which the two
curves cross is considered to represent the situation
when the degrees of overdistension and collapse are
balanced. Following the maneuver, PEEP can be set
either at the value at which the crossover point
occurred or at a slightly higher value that prevents
the increase in atelectatic regions above a predefined
threshold value of relative collapse [16].
Several studies utilized the calculation of
regional Crs using EIT. The effect of the head-up
body tilt on the crossover point PEEP value deter-
mined from a decremental PEEP trial was examined
in patients with ARDS showing lower PEEP values,
better oxygenation and lower GI values in compar-
ison with the flat supine posture [17]. Regional
overdistension and collapse was determined based
on a decremental PEEP trial in patients with ARDS
and compared with a new approach based on the

4 www.co-criticalcare.com Volume 29  Number 00  Month 2023

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107

Setting positive end-expiratory pressure by using electrical impedance tomography Frerichs et al.
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023

FIGURE 2. The waveforms of positive end-expiratory pressure (PEEP) (red), plateau pressure (Plateau) (blue) and global EIT
signal (Plethysmogram) (green) recorded during a decremental PEEP trial (a). Relative collapse (Coll) (red), hyperdistension
(Hyper) (blue) and compliance of the respiratory system (green) determined at each PEEP step of the decremental PEEP trial
(b). The crossover point between the curves of relative collapse and hyperdistension is marked by the vertical grey line. The
clinical implication of these findings might be to set the PEEP to a value of 6--7 cm H2O. (Data were acquired with the EIT
device Enlight 2100 (Timpel, Paran
a, Brazil).)

calculation of regional peak inspiratory flows, show-
ing comparable results between the two methods
[18]. The authors proposed that the latter method
might be of value during assisted ventilation. A
small clinical study demonstrated that the individ-
ualized PEEP derived from the decremental PEEP
trial reduced the mechanical power compared with
the high PEEP/FIO2 table [19]. Another small clinical
study titrated PEEP in prone and supine ARDS
patients with larger relative overdistension in the
prone and larger collapse in the supine position [20].
In a retrospective analysis of PEEP values set accord-
ing to the overdistension/collapse crossover point it
was shown that they differed by at least 2 cmH2O
from the initially set values according to the high
PEEP/FIO2 table in almost two-thirds of the analyzed
ARDS patients [21].
The determination of the crossover point of the
overdistension and collapse curves obtained during
an incremental PEEP trial was used to individualize
PEEP in patients undergoing thoracoscopic surgery
leading to higher dynamic Crs and reduced shunt
compared with controls [22]. It was also applied to
set PEEP using the decremental trial during extrac-
orporeal membrane oxygenation [23,24]. In another
study on ARDS patients, regional Crs was calculated

1070-5295 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 5

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107
Respiratory system
and ‘optimum’ PEEP selected so as to minimize
overdistension. The EIT-guided PEEP was then com-
pared to the PEEP level derived from lung ultra-
sound, with similar values [25]. Individualized
PEEP values derived from a decremental PEEP trial
showed comparable values in prone and supine
ARDS patients but a better ventilation-perfusion
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
match in the prone posture [26]. EIT monitoring
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023
in a large group of ARDS patients over the ICU stay
was used to guide PEEP setting using a decremental
PEEP trial and identify differences between survivors
&
and nonsurvivors [27 ]. The same authors showed
that the optimum PEEP values derived from the
crossover point of overdistension/collapse curves
and the GI index during an incremental and decre-
mental PEEP trial may differ from each other [28].
Another study showed that the individualized PEEP
values necessary to counteract atelectasis formation
or to equally balance overdistension and collapse
also differ from each other [16].
The relative popularity of the incremental but
mainly decremental PEEP trial for the setting of
PEEP can be explained by the fact that its principle
is easily comprehensible and its automated analysis
is implemented in commercially available EIT devi-
ces. But it needs to be mentioned that it does take
time to perform it and that the patient’s lungs are
exposed to relatively high and low PEEP values, the
choice of which moreover influences the exact posi-
tion of the crossover point of the overdistension-
collapse curves. An individualized placement of the
EIT belt might also be needed [29]. The use of the
decremental PEEP trial to set PEEP using EIT is help-
ful during the initial definition of the ventilator
settings before surgical interventions (as demon-
strated in several studies on patients undergoing
laparoscopic surgery [16,30,31]) or at the time of
admittance of a patient to the ICU. Rapid deterio-
ration of the respiratory function of a critically ill
patient is another meaningful indication for per-
forming an EIT decremental PEEP trial. In the course
of the patient’s ICU stay, less time-consuming and
less aggressive interventions analyzing the regional
Crs by EIT may be utilized (Fig. 3).
Detection of temporal distribution of
ventilation and its use for positive end-
expiratory pressure setting
Thanks to the very high scan rates of modern EIT
devices of about 50 primary EIT images/s, the proc-
ess of regional filling and emptying of air is meas-
ured dynamically and the subsequent analysis does
not need to be limited to the evaluation of only
those images that are acquired at the end-inspira-
tory and end-expiratory time points of tidal breaths
6 www.co-criticalcare.com
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
(or deeper inflation/deflation maneuvers). Specific
analysis tools utilize the whole intratidal sequence
of images and allow the assessment of the temporal
distribution of ventilation.
Several methods have been described in earlier
studies that characterized the dynamics of the filling
and emptying of lung regions like the intratidal
ventilation distribution [32,33], the curvilinearity
of regional inspiratory/expiratory EIT waveforms
(describing the progressively rising or falling rate
of air filling/emptying) [34,35], regional respiratory
time constants calculated from tidal breaths [36] or
after stepwise airway pressure changes [37], upper
and lower inflection points of regional pressure-
volume curves [38,39] or regional opening and clos-
ing pressures [40]. All of these could be used as
valuable decision inputs for PEEP setting, however,
their calculation is not implemented in the com-
mercial EIT devices and thus not easily accessible.
This is the most probable reason why these methods
were not applied in recent PEEP-related EIT studies.
The only parameter that was used to characterize the
effect of PEEP on the temporal distribution of ven-
tilation was the regional ventilation delay (RVD)
index available in one of the EIT devices. RVD
identifies the time points at which pixel impedance
waveforms reach a set relative threshold and com-
pares them with the time point when the same
threshold is detected in the global waveform [41].
The detection of long RVD during a low-flow infla-
tion maneuver is indicative of tidal recruitment in
the respective area. High heterogeneity in the spatial
distribution of RVD implies high temporal hetero-
geneity in the filling behavior of the lung tissue.
A study in ARDS patients with individualized
PEEP setting by EIT found smaller RVD values and
more dorsal ventilation with higher CoV in prone
compared to supine position in patients with higher
body mass index [42]. A retrospective analysis of EIT
data acquired during a decremental PEEP trial in obese
and nonobese patients showed that PEEP derived
from RVD was lower than when GI or a balanced
ventral and dorsal fraction of ventilation were used to
identify the optimum PEEP [43]. RVD, CoV and the GI
index were used to analyze the ventilation distribu-
tion in children with ARDS after EIT-guided PEEP
setting using the overinflation/collapse curves and
at maximum global Crs showing no significant differ-
ences between the two approaches [44].
Detection of regional lung perfusion
The quasi-periodic variation of pixel electrical bio-
impedance associated with the heart beat-related
changes in regional blood flow can also be detected
by EIT. This impedance variation is of much lower
Volume 29  Number 00  Month 2023
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107

Setting positive end-expiratory pressure by using electrical impedance tomography Frerichs et al.
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023

FIGURE 3. Global EIT signal (white), peak inspiratory pressure (PIP) ( pink) and positive end-expiratory pressure (PEEP) (green)
waveforms recorded in a patient during ventilation at a PEEP value of 11 mbar (a) and 14 mbar (b). In each period, tidal
volume (VT) was temporarily decreased during five consecutive breaths and then increased back to the former value.
Functional EIT images plotted in the middle of each panel show the tidal impedance variation distribution before and during
the VT reduction. The second image from the left in the bottom part of each panel highlights the regional relative increase in
compliance (compliance win (CW)) and its decrease (compliance loss (CL)) after the VT reduction in turquoise and orange
colors, respectively. The CW/CL image in panel (a) indicates that the right ventral lung region was overdistended and the left
dorsal one experienced tidal recruitment before the VT reduction. The CW/CL image in panel (b) implies that tidal recruitment
was eliminated after the PEEP increase to 14 mbar but the overdistension in the right ventral lung region became more
pronounced. The clinical implication of these findings might be a small reduction in VT if possible, or the decrease of PEEP to
12--13 mbar. (Data were acquired with the EIT device PulmoVista 500 (Dr€ ager, L€
ubeck, Germany).)

1070-5295 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. www.co-criticalcare.com 7

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107
Respiratory system
amplitude than the ventilation-related variation.
Because it primarily results from the changing vessel
dimensions between systole and diastole its evalua-
tion is not considered to be the ideal approach for
quantifying regional lung perfusion [45]. Neverthe-
less, methodological studies still aim at improving
this approach [46]. For direct visualization of pul-
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
monary perfusion, the method of contrast-
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023
enhanced EIT is used during which an electrically
conductive agent is injected through a central
venous line as a bolus [47]. The resulting regional
dilution curves are analyzed in individual image
pixels to provide regional measures of blood flow.
Typically, hypertonic saline solution has been used
for contrast-enhanced EIT measurements but new
&
agents are also being investigated [48 ].
An experimental study analyzed the ventilation-
perfusion matching at differing tidal volume, cardiac
output and four incremental PEEP values to identify
the settings with the highest ventilation-perfusion
match [49]. A clinical study examined regional ven-
tilation and perfusion at two PEEP levels showing
better ventilation-perfusion matching at higher PEEP
in ARDS patients with recruitable lungs [50].
Detection of regional aeration changes
The analysis of end-expiratory lung impedance
(EELI) values and their changes over a longer
sequence of breaths may be applied to identify
the adequacy of the newly set PEEP level [51]. If
EELI falls over time, derecruitment may be postu-
lated and the chosen PEEP regarded as too low. If
EELI rises, this may imply recruitment.
EELI has not been often used in the recent
studies, probably because its values reflect not only
the state of lung aeration but are influenced by other
factors as well (e.g. pulmonary fluid/blood content
[52] or the EIT electrode-skin contact [53]). Under
controlled experimental conditions it could be
adequately used to individualize PEEP based on an
incremental PEEP trial [54]. Regional changes in
EELI acquired in ARDS patients during a rapid PEEP
trial were successfully utilized to identify PEEP res-
ponders and nonresponders using a novel method
for calculation of dependent and nondependent
&
respiratory system elastance [55 ]. Another study
used the regional EELI values (along with TIV) to
quantify dynamic relative regional strain at three
PEEP values compared with the highest PEEP in an
experimental ARDS model [56].
CONCLUSION
A multitude of experimental and clinical studies on
the use of EIT to detect the effects of PEEP on regional
lung function and for individualized setting of PEEP
8 www.co-criticalcare.com
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
has recently been conducted. EIT has been shown to
reliably describe the distribution of ventilation and
aeration changes in the chest and to detect regional
alveolar collapse, tidal recruitment, overdistension,
strain and ventilation/perfusion mismatch. This
information can be applied to guide the clinical
decision on the ‘best’ PEEP for individual patients
during the whole period of their ICU treatment when
mechanical ventilator support is needed. In the
reviewed 18-month period, the EIT measures of ven-
tilation distribution and regional Crs acquired during
incremental and decremental PEEP trials were pre-
dominantly utilized. In the future, this approach
might be accompanied by more frequent use of EIT
measures describing also the temporal distribution of
ventilation. Short and less aggressive interventions,
automated analyses, long-term instead of short-term
EIT monitoring, and large randomized controlled
outcome trials proving or refuting the clinical advan-
tages of EIT-based PEEP setting are needed.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
I.F. reports funding from the European Commission
(project WELMO, grant no. 825572). D.S. reports no
conflict of interest. TB reports consulting fees from
Lo€wenstein Medical Innovation for institutional funding
and lecture fees from Vyaire Medical.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Bastia L, Roze H, Brochard LJ. Asymmetrical lung injury: management and
outcome. Semin Respir Crit Care Med 2022; 43:369–378.
2. Frerichs I, Amato MB, van Kaam AH, et al. Chest electrical impedance
tomography examination, data analysis, terminology, clinical use and recom-
mendations: consensus statement of the TRanslational EIT developmeNt
stuDy group. Thorax 2017; 72:83–93.
3. Piraino T. An introduction to the clinical application and interpretation of
electrical impedance tomography. Respir Care 2022; 67:721–729.
4. Becher TH, Miedema M, Kallio M, et al. Prolonged continuous monitoring of
& regional lung function in infants with respiratory failure. Ann Am Thorac Soc
2022; 19:991–999.
A large prospective multicenter clinical study demonstrating the feasibility and
safety of long-term continuous EIT monitoring of up to 72 h in 200 critically ill
neonates and infants.
5. Widing H, Chiodaroli E, Liggieri F, et al. Homogenizing effect of PEEP on tidal
volume distribution during neurally adjusted ventilatory assist: study of an
animal model of acute respiratory distress syndrome. Respir Res 2022;
23:324.
6. Ellenberger C, Pelosi P, de Abreu MG, et al. Distribution of ventilation and
oxygenation in surgical obese patients ventilated with high versus low positive
end-expiratory pressure: a substudy of a randomised controlled trial. Eur J
Anaesthesiol 2022; 39:875–884.
Volume 29  Number 00  Month 2023
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107
Setting positive end-expiratory pressure by using electrical impedance tomography Frerichs et al.
7. Bito K, Shono A, Kimura S, et al. Clinical implications of determining
&& individualized positive end-expiratory pressure using electrical impedance
tomography in postsardiac surgery patients: a prospective, nonrandomized
interventional study. J Clin Med 2022; 11:3022.
A prospective clinical study demonstating the benefits of individually titrated PEEP
using EIT at the bedside by minimizing alveolar collapse in the dependent lung
regions.
8. Yang L, Fu F, Frerichs I, et al. The calculation of electrical impedance
tomography based silent spaces requires individual thorax and lung contours.
Physiol Meas 2022; 43:; 09NT02.
9. Borgmann S, Linz K, Braun C, et al. Lung area estimation using functional tidal
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
& electrical impedance variation images and active contouring. Physiol Meas
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023
2022; 43:075010.
A prospective methodological clinical study on 68 lung-healthy subjects proposing
an improved method for identification of lung and heart regions in functional EIT
images.
10. Taenaka H, Yoshida T, Hashimoto H, et al. Personalized ventilatory strategy
& based on lung recruitablity in COVID-19-associated acute respiratory distress
syndrome: a prospective clinical study. Crit Care 2023; 27:152.
A prospective clinical study on 43 patients where EIT was used to confirm lung
recruitability at two PEEP levels in prone and supine body positions.
11. Ambrosio AM, Sanchez AF, Pereira MAA, et al. Assessment of regional
ventilation during recruitment maneuver by electrical impedance tomography
in dogs. Front Vet Sci 2021; 8:815048.
12. Liu X, Liu X, Meng J, et al. Electrical impedance tomography for titration of
& positive end-expiratory pressure in acute respiratory distress syndrome pa-
tients with chronic obstructive pulmonary disease. Crit Care 2022; 26:339.
A small prospective clinical study comparing the outcomes of individualized EIT-
guided PEEP vs. PEEP/FIO2 table between ARDS patients with and without
COPD comorbidity.
13. Wang ZY, Ye SS, Fan Y, et al. Individualized positive end-expiratory pressure
with and without recruitment maneuvers in obese patients during bariatric
surgery. Kaohsiung J Med Sci 2022; 38:858–868.
14. Dargaville PA, Rimensberger PC, Frerichs I. Regional tidal ventilation and
compliance during a stepwise vital capacity manoeuvre. Intensive Care Med
2010; 36:1953–1961.
15. Costa EL, Borges JB, Melo A, et al. Bedside estimation of recruitable alveolar
collapse and hyperdistension by electrical impedance tomography. Intensive
Care Med 2009; 35:1132–1137.
16. Dargvainis M, Ohnesorge H, Schadler D, et al. Recruitable alveolar collapse
and overdistension during laparoscopic gynecological surgery and mechan-
ical ventilation: a prospective clinical study. BMC Anesthesiol 2022; 22:251.
17. Marrazzo F, Spina S, Zadek F, et al. PEEP titration is markedly affected by
trunk inclination in mechanically ventilated patients with COVID-19 ARDS: a
physiologic, cross-over study. J Clin Med 2023; 12:3914.
18. de Jongh SAM, Heines SJH, de Jongh FHC, et al. Regional peak flow as a
novel approach to assess regional pulmonary mechanics by electrical im-
pedance tomography: an observational validation study. Ann Transl Med
2023; 11:253.
19. Jimenez JV, Munroe E, Weirauch AJ, et al. Electric impedance tomography-
guided PEEP titration reduces mechanical power in ARDS: a randomized
crossover pilot trial. Crit Care 2023; 27:21.
20. Otahal M, Mlcek M, Borges JB, et al. Prone positioning may increase lung
overdistension in COVID-19-induced ARDS. Sci Rep 2022; 12:16528.
21. Somhorst P, van der Zee P, Endeman H, Gommers D. PEEP-FiO2 table versus
EIT to titrate PEEP in mechanically ventilated patients with COVID-19-related
ARDS. Crit Care 2022; 26:272.
22. Zha J, Yu YJ, Li GR, et al. Lung protection effect of EIT-based individualized
protective ventilation strategy in patients with partial pulmonary resection. Eur
Rev Med Pharmacol Sci 2023; 27:5459–5467.
23. Di Nardo M, Fischer M, Ranieri VM. Electrical impedance tomography to set
positive end expiratory pressure during pediatric extracorporeal membrane
oxygenation for respiratory failure. . . Is it feasible? ASAIO J 2022; 68:
e136–e138.
24. Di Pierro M, Giani M, Bronco A, et al. Bedside selection of positive end
expiratory pressure by electrical impedance tomography in patients under-
going veno-venous extracorporeal membrane oxygenation support: a com-
parison between COVID-19 ARDS and ARDS from other etiologies. J Clin
Med 2022; 11:1639.
25. Theerawit P, Pukapong P, Sutherasan Y. Relationship between lung ultra-
sound and electrical impedance tomography as regional assessment tools
during PEEP titration in acute respiratory distress syndrome caused by
multilobar pneumonia: a pilot study. J Clin Monit Comput 2023; 37:889–897.
26. Zarantonello F, Sella N, Pettenuzzo T, et al. Early physiologic effects of prone
positioning in COVID-19 acute respiratory distress syndrome. Anesthesiol-
ogy 2022; 137:327–339.
27. Heines SJH, van Bussel BCT, Jong MJA, et al. Pulmonary pathophysiology
& development of COVID-19 assessed by serial electrical impedance tomo-
graphy in the MaastrICCht cohort. Sci Rep 2022; 12:14517.
A large prospective clinical study with daily individualizion of PEEP based on the
measurement of regional respiratory system compliance and balancing regional
relative overdistension and alveolar collapse.
28. Heines SJH, de Jongh SAM, Strauch U, et al. The global inhomogeneity index
assessed by electrical impedance tomography overestimates PEEP require-
1070-5295 Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ment in patients with ARDS: an observational study. BMC Anesthesiol 2022;
22:258.
29. Zhao Z, Chen TF, Teng HC, et al. Is there a need for individualized adjustment
of electrode belt position during EIT-guided titration of positive end-expiratory
pressure? Physiol Meas 2022; 43:064001.
30. Buonanno P, Marra A, Iacovazzo C, et al. Electric impedance tomography and
protective mechanical ventilation in elective robotic-assisted laparoscopy
surgery with steep Trendelenburg position: a randomized controlled study.
Sci Rep 2023; 13:2753.
31. Zhang W, Liu F, Zhao Z, et al. Driving pressure-guided ventilation improves
homogeneity in lung gas distribution for gynecological laparoscopy: a rando-
mized controlled trial. Sci Rep 2022; 12:21687.
32. Lowhagen K, Lundin S, Stenqvist O. Regional intratidal gas distribution in
acute lung injury and acute respiratory distress syndrome-assessed
by electric impedance tomography. Minerva Anestesiol 2010; 76:
1024–1035.
33. Blankman P, Shono A, Hermans BJ, et al. Detection of optimal PEEP for equal
distribution of tidal volume by volumetric capnography and electrical impe-
dance tomography during decreasing levels of PEEP in post cardiac-surgery
patients. Br J Anaesth 2016; 116:862–869.
34. Frerichs I, Dudykevych T, Hinz J, et al. Gravity effects on regional lung
ventilation determined by functional EIT during parabolic flights. J Appl Physiol
2001; 91:39–50.
35. Hinz J, Gehoff A, Moerer O, et al. Regional filling characteristics of the lungs in
mechanically ventilated patients with acute lung injury. Eur J Anaesthesiol
2007; 24:414–424.
36. Strodthoff C, Kahkonen T, Bayford RH, et al. Bronchodilator effect on regional
lung function in pediatric viral lower respiratory tract infections. Physiol Meas
2022; 43:104001.
37. Pulletz S, Kott M, Elke G, et al. Dynamics of regional lung aeration determined
by electrical impedance tomography in patients with acute respiratory distress
syndrome. Multidiscip Respir Med 2012; 7:44.
38. Frerichs I, Dargaville PA, Rimensberger PC. Regional respiratory inflation and
deflation pressure-volume curves determined by electrical impedance tomo-
graphy. Physiol Meas 2013; 34:567–577.
39. Scaramuzzo G, Spadaro S, Waldmann AD, et al. Heterogeneity of regional
inflection points from pressure-volume curves assessed by electrical impe-
dance tomography. Crit Care 2019; 23:119.
40. Pulletz S, Adler A, Kott M, et al. Regional lung opening and closing pressures
in patients with acute lung injury. J Crit Care 2012; 27:323; e11-8.
41. Wrigge H, Zinserling J, Muders T, et al. Electrical impedance tomography
compared with thoracic computed tomography during a slow inflation man-
euver in experimental models of lung injury. Crit Care Med 2008;
36:903–909.
42. Mi L, Chi Y, Yuan S, et al. Effect of prone positioning with individualized
positive end-expiratory pressure in acute respiratory distress syndrome using
electrical impedance tomography. Front Physiol 2022; 13:906302.
43. Girrbach F, Zeutzschel F, Schulz S, et al. Methods for determination of
individual PEEP for intraoperative mechanical ventilation using a decremental
PEEP trial. J Clin Med 2022; 11:3707.
44. Ren H, Xie L, Wang Z, et al. Comparison of global and regional compliance-
guided positive end-expiratory pressure titration on regional lung ventilation in
moderate-to-severe pediatric acute respiratory distress syndrome. Front Med
(Lausanne) 2022; 9:805680.
45. Borges JB, Suarez-Sipmann F, Bohm SH, et al. Regional lung perfusion
estimated by electrical impedance tomography in a piglet model of lung
collapse. J Appl Physiol 2012; 112:225–236.
46. Zhang K, Li M, Liang H, et al. Deep feature-domain matching for cardiac-
related component separation from a chest electrical impedance tomography
image series: proof-of-concept study. Physiol Meas 2022; 43:125005.
47. Frerichs I, Hinz J, Herrmann P, et al. Regional lung perfusion as determined by
electrical impedance tomography in comparison with electron beam CT
imaging. IEEE Trans Med Imaging 2002; 21:646–652.
48. Muders T, Hentze B, Leonhardt S, Putensen C. Evaluation of different contrast
& agents for regional lung perfusion measurement using electrical impedance
tomography: an experimental pilot study. J Clin Med 2023; 12:2751.
A small animal experimental study exploring novel contrast agents for lung
perfusion measurements using bolus contrast-enhanced EIT.
49. Pan P, Li L, Xie F, et al. Physiological regulation of pulmonary microcirculation
under mechanical ventilation at different cardiac outputs and positive end-
expiratory pressures in a porcine model. J Pers Med 2023; 13:107.
50. Pavlovsky B, Pesenti A, Spinelli E, et al. Effects of PEEP on regional
ventilation-perfusion mismatch in the acute respiratory distress syndrome.
Crit Care 2022; 26:211.
51. Eronia N, Mauri T, Maffezzini E, et al. Bedside selection of positive end-
expiratory pressure by electrical impedance tomography in hypoxemic pa-
tients: a feasibility study. Ann Intensive Care 2017; 7:76.
52. Becher T, Wendler A, Eimer C, et al. Changes in electrical impedance
tomography findings of ICU patients during rapid infusion of a fluid bolus:
a prospective observational study. Am J Respir Crit Care Med 2019;
199:1572–1575.
53. Frerichs I, Pulletz S, Elke G, et al. Patient examinations using electrical
impedance tomography-sources of interference in the intensive care unit.
Physiol Meas 2011; 32:L1–10.
www.co-criticalcare.com 9
CE: ; MCC/300107; Total nos of Pages: 10;
MCC 300107

Respiratory system

54. Mlcek M, Borges JB, Otahal M, et al. Real-time effects of lateral positioning on
regional ventilation and perfusion in an experimental model of acute respira-
tory distress syndrome. Front Physiol 2023; 14:1113568.
55. Grivans C, Stenqvist O. Gas distribution by EIT during PEEP inflation: PEEP
& response and optimal PEEP with lowest trans-pulmonary driving pressure can
be determined without esophageal pressure during a rapid PEEP trial in
patients with acute respiratory failure. Physiol Meas 2022; 43:114001.
Downloaded from http://journals.lww.com/co-criticalcare by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/15/2023
A small clinical study proposing a new method for identifying responders
and nonresponders to PEEP and for setting PEEP based on the
calculation of respiratory system elastance in dependent and nondependent
regions.
56. Gogniat E, Madorno M, Rodriguez PO, et al. Dynamic relative regional lung
strain estimated by electrical impedance tomography in an experimental
model of ARDS. Respir Care 2022; 67:906–913.

10 www.co-criticalcare.com Volume 29  Number 00  Month 2023

Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.