The Feasibility of Deep Inspiration Breath-Hold in Children: Results of the TEDDI Pilot Study

Abstract

The use of deep inspiration breath-hold (DIBH) is recommended for radiotherapy (RT) of malignant lymphomas in the mediastinum in adults, however, no formalized studies have addressed the use of DIBH in children. TEDDI is a feasibility study introducing DIBH for pediatric patients within the NOPHO network. Prior to clinical implementation, the TEDDI pilot study was initiated to test if 1) children can perform a stable and comfortable DIBH, 2) the DIBH equipment is suitable for children, and 3) the information and coaching should be improved. The study aimed to recruit 30 children including both healthy volunteers and pediatric cancer patients not planned for radiotherapy. DIBH compliance was assessed during a 30 min coaching session at the linear accelerator with each child in a potential treatment position. The DIBH was voluntary, but monitored with an optical surface system providing a visual feedback of the respiration at the DIBH level. The child was declared DIBH compliant if he/she was able to perform 3 stable breath-holds of 20 seconds each. Patient compliance and coaching and DIBH equipment suitability were assessed from questionnaires and visual observations. A total of 27 volunteers were included at two separate institutions, 16 healthy and 11 cancer patients. The median age was 8 years (range: 5-15 years), and four were pre-school children. Nine volunteers (5 healthy, 4 patients) were found not to be suitable for RT in DIBH: one patient was not able to maintain a sufficient breath-hold, four volunteers (2 healthy, 2 patients) were not able to maintain the treatment position, and four volunteers (3 healthy, 1 patient) failed to do both. However, six volunteers (2 healthy, 4 patients) would have been able to comply with DIBH using custom made fixation and additional coaching-time. Of the 27 volunteers, only a 5-year old, healthy boy was not able to understand the DIBH concept. The DIBH equipment was deemed suitable for children, however, the visual feedback was changed from goggles to video screens. All volunteers reported that they were either very happy (10), fairly happy (15), or content (2) with the DIBH coaching and training. The TEDDI pilot study demonstrated that DIBH can be implemented for children older than 5 years, especially with sufficient coaching-time and proper visual feedback equipment. Consequently, the TEDDI feasibility study has been initiated.