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Abstract
Objective:Variability in the breathing pattern of patients with cancer during radiotherapy requires mitigation, including enlargement of the planned treatment field, treatment gating and breathing guidance interventions. Here, we provide the first demonstration of how easy it is to mechanically ventilate patients with breast cancer while fully conscious and without sedation, and we quantify the resulting reduction in the variability of breathing.Methods:15 patients were trained for mechanical ventilation. Breathing was measured and the left breast anteroposterior displacement was measured using an Osiris surface-image mapping system (Qados Ltd, Sandhurst, UK).Results:Mechanical ventilation significantly reduced the within-breath variability of breathing frequency by 85% (p < 0.0001) and that of inflation volume by 29% (p < 0.006) when compared with their spontaneous breathing pattern. During mechanical ventilation, the mean amplitude of the left breast marker displacement was 5 ± 1 mm, the mean variability in its peak inflation position was 0.5 ± 0.1 mm and that in its trough inflation position was 0.4 ± 0.0 mm. Their mean drifts were not significantly different from 0 mm min−1 (peak drift was −0.1 ± 0.2 mm min−1 and trough drift was −0.3 ± 0.2 mm min−1). Patients had a normal resting mean systolic blood pressure (131 ± 5 mmHg) and mean heart rate [75 ± 2 beats per minute (bpm)] before mechanical ventilation. During mechanical ventilation, the mean blood pressure did not change significantly, mean heart rate fell by 2 bpm (p < 0.05) with pre-oxygenation and rose by only 4 bpm (p < 0.05) during pre-oxygenation with hypocapnia. No patients reported discomfort and all 15 patients were always willing to return to the laboratory on multiple occasions to continue the study.Conclusion:This simple technique for regularizing breathing may have important applications in radiotherapy.Advances in knowledge:Variations in the breathing pattern introduce major problems in imaging and radiotherapy planning and delivery and are currently addressed to only a limited extent by asking patients to breathe to auditory or visual guidelines. We provide the first demonstration that a completely different technique, of using a mechanical ventilator to take over the patients' breathing for them, is easy for patients who are conscious and unsedated and reduces the within-patient variability of breathing. This technique has potential advantages in radiotherapy over currently used breathing guidance interventions because it does not require any active participation from or feedback to the patient and is therefore worthy of further clinical evaluation.
Highlights
Both the rate and depth of spontaneous breathing vary markedly,[1] for a number of complex reasons including anxiety 2 and the fact that as soon as subjects think about breathing, they voluntarily change it
Patients were sufficiently comfortable that sometimes they fell into a light sleep during mechanical ventilation, and this did not introduce any problems or disruption of their breathing pattern
Patients were content before mechanical ventilation, as evidenced by their resting mean systolic blood pressure (131 6 5 mmHg) and mean heart rate [75 6 2 beats per minute] being normal and not significantly different from those of our healthy untrained subjects,[9] nor from those of our trained subjects in previous studies.[629]
Summary
Both the rate and depth of spontaneous breathing vary markedly,[1] for a number of complex reasons including anxiety 2 and the fact that as soon as subjects think about breathing, they voluntarily change it. Variations in breathing pattern require management in imaging and radiotherapy planning and delivery, for breast cancer and potentially for all tumours in the thorax and abdomen This management will be especially important to make the best use of the imminent introduction of MR guidance into radiotherapy.[3] Koybasi et al[4] report that for irregular breathing patterns, four-dimensional CT may inaccurately characterize tumour motion and location, with negative consequences for treatment delivered with scanned proton beams. The correspondence between breathing motion assessed by four-dimensional CT at the planning stage and the actual motion during each daily treatment is so far measured only rarely in routine clinical practice. Gating methodologies appear to be accurate but are technologically complex and increase the duration of treatment slots
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