Prone Positioning in COVID-19 ARDS: Comment.

Abstract

We read with interest the recent article by Zarantonello et al.1 on the physiologic effects of prone positioning on ventilation and perfusion distribution, oxygenation, and lung mechanics in COVID-19 acute respiratory distress syndrome patients. We would like to first congratulate the authors for the nicely conducted study that once again proved the clinical applicability of electrical impedance tomography for the assessment of ventilation–perfusion matching at the bedside. We acknowledge the clinical significance of the findings, but we wish to point out that several parts of the electrical impedance tomography methodology were incorrectly described in the article.In the Methods section, the authors described how the lung areas that were (1) perfused but not ventilated, (2) ventilated but not perfused, and (3) both ventilated and perfused were “divided by the sum of ventilated and perfused pixels” to calculate the corresponding relative fractions of the lung area in percentages, i.e., (1) “% shunt area,” (2) “% dead space area,” and (3) “% matched area,” respectively. However, the denominator must be the number of pixels that were ventilated or perfused, i.e., using the logical operator “or,” otherwise the calculated relative areas would be incorrect. The authors also determined “the percentage of total ventilated lung area that was located in the dorsal half of the thorax,” which they inaccurately termed as “dorsal ventilation.” According to the consensus electrical impedance tomography terminology and definitions,2 regional ventilation is determined as the sum of all pixel values of tidal impedance variation not as the pixel count, which defines just the ventilated area.The authors further introduced a new electrical impedance tomography parameter, the “homogeneity index,” which they “calculated as 1 – global inhomogeneity index,” based on the assumption of the global inhomogeneity index ranging from 1 to 0. However, the global inhomogeneity index values are commonly higher than 1 in patients with pronounced ventilation inhomogeneity, as shown already in some of the examined mechanically ventilated subjects in the original description of the global inhomogeneity index3 or recently in patients with exacerbated chronic lung disease.4 An example patient case is presented in figure 1, in which a global inhomogeneity index value of 2.59 was noted in the presence of pendelluft, which is a frequent cause of out-of-phase impedance variation both in spontaneously breathing and ventilated patients.5 The “homogeneity index” proposed by the authors would be negative in this case and assume the confusing value of –1.59. We therefore strongly advise against using the “homogeneity index” as a surrogate for the well established global inhomogeneity index.The authors pointed out that electrical impedance tomography perfusion assessment with saline bolus injection had been validated only in two animal studies. In fact, this technique of contrast-enhanced electrical impedance tomography has been studied in several other animal studies as well.6–9 Last, we agree with the authors that electrical impedance tomography images do not cover the whole lungs, but as summarized in the consensus paper on chest electrical impedance tomography,2 an electrical impedance tomography image does not originate from “only the area of the lung surrounded by the belt.”Electrical impedance tomography receives increasing attention due to its noninvasive bedside monitoring features. Correct description and implementation of the electrical impedance tomography technique and analysis procedures are crucial for further development and clinical use.Dr. Zhao receives a consulting fee from Dräger Medical (Lübeck, Germany). Dr. Frerichs reports funding from the European Union’s Framework program for Research and Innovation Horizon 2020 (WELMO, grant No. 825572).