Balthasar Eberle

Comparison of blood gases of ventilated patients during transport.

Three modes of ventilation during the transport of 30 ventilator-dependent patients were compared using blood gas variables. Ten were ventilated with a manually operated, ventilation bag (group C) and ten with a tidal volume meter at the exhalation valve of the ventilation bag (group V). Another ten patients (group O) were ventilated with a portable ventilator set to the minute volume (Ve) given in ICU. Ve was measured by volumetry as described above. Blood gases were analyzed in the ICU before and at the end of transport. In group C, significant decreases occurred in arterial (p < .01) and central venous (p < .05) Pco2, as well as in central venous Po2 (p < .01). Arterial (p < .05) and central venous (p < .01) pH increased. Group V showed no statistically significant changes. In group O, arterial (p < .01) and central venous (p < .05) Pco2 decreased whereas arterial (p < .01) and central venous (p < .05) pH increased. We conclude that Ve should be monitored during transport of ventilated patients.

Assessment of a single-acquisition imaging sequence for oxygen-sensitive 3He-MRI

MRI of the lungs using hyperpolarized helium‐3 (3He) allows the determination of intrapulmonary oxygen partial pressures (pO2). The need to separate competing processes of signal loss has hitherto required two different imaging series during two different breathing maneuvers. In this work, a new imaging strategy to measure pO2 by a single series of consecutive scans is presented. The feasibility of the method is demonstrated in three healthy human volunteers. Maps and histograms of intrapulmonary pO2 are calculated. Changes in the oxygen concentration of the inhaled gas mixture are well reproduced in the histograms. Monte Carlo (MC) simulations of the temporal evolution of 3He hyperpolarization within the lungs were performed to evaluate the accuracy of this measurement technique, and its limitations. Magn Reson Med 47:105–114, 2002.

Chronic thromboembolic pulmonary hypertension — assessment by magnetic resonance imaging

Chronic thromboembolic pulmonary hypertension (CTEPH) is a severe disease that has been ignored for a long time. However, with the development of improved therapeutic modalities, cardiologists and thoracic surgeons have shown increasing interest in the diagnostic work-up of this entity. The diagnosis and management of chronic thromboembolic pulmonary hypertension require a multidisciplinary approach involving the specialties of pulmonary medicine, cardiology, radiology, anesthesiology and thoracic surgery. With this approach, pulmonary endarterectomy (PEA) can be performed with an acceptable mortality rate. This review article describes the developments in magnetic resonance (MR) imaging techniques for the diagnosis of chronic thromboembolic pulmonary hypertension. Techniques include contrast-enhanced MR angiography (ce-MRA), MR perfusion imaging, phase-contrast imaging of the great vessels, cine imaging of the heart and combined perfusion-ventilation MR imaging with hyperpolarized noble gases. It is anticipated that MR imaging will play a central role in the initial diagnosis and follow-up of patients with CTEPH.

3He-MRI-based measurements of intrapulmonary pO2 and its time course during apnea in healthy volunteers: first results, reproducibility, and technical limitations

We applied a recently developed method of following the time course of the intrapulmonary oxygen partial pressure pO2(t) during apnea by 3He MRI to healthy volunteers. Using two imaging series with different interscan times during two breathholds (double acquisition technique), relaxation of 3He due to paramagnetic oxygen and depolarization by RF pulses were discriminated. In all four subjects, the temporal evolution of pO2 was found to be linear, and was described by an initial partial pressure p0 and a decrease rate R. Also, regional differences of both p0 and R were observed. A correlation between p0 and R was apparent. Finally, we discuss limitations of the double acquisition approach. Copyright

3He MRI in healthy volunteers: preliminary correlation with smoking history and lung volumes

MRI with hyperpolarized helium‐3 (3He) provides high‐resolution imaging of ventilated airspaces. The first aim of this 3He‐study was to compare observations of localized signal defects in healthy smokers and non‐smokers. A second aim was to describe relationships between parameters of lung function, volume of inspired 3He and signal‐to‐noise ratio. With Ethics Committee approval and informed consent, 12 healthy volunteers (seven smokers and five non‐smokers) were studied. Imaging was performed in a 1.5 T scanner using a two‐dimensional FLASH sequence at 30V transmitter amplitude (TR/TE/α = 11 ms/4.2 ms/<10°). Known amounts of 3He were inhaled from a microprocessor‐controlled delivery device and imaged during single breath‐holds. Images were evaluated visually, and scored using a prospectively defined ‘defect‐index’. Signal‐to‐noise ratio of the images were correlated with localization, 3He volumes and static lung volumes. Due to poor image quality studies of two smokers were not eligible for the evaluation. Smokers differed from non‐smokers in total number and size of defects: the ‘defect‐index’ of smokers ranged between 0.8 and 6.0 (median = 1.1), that of non‐smokers between 0.1 and 0.8 (median = 0.4). Intraindividually, an anteroposterior gradient of signal‐to‐noise ratio was apparent. Signal‐to‐noise ratio correlated with the estimated amount of hyperpolarization administered (r = 0.77), but not with static lung volumes. We conclude that 3He MRI is a sensitive measure to detect regional abnormalities in the distribution of ventilation in clinically healthy persons with normal pulmonary function tests. Copyright

MRI in lung transplant recipients using hyperpolarized 3He: Comparison with CT

To elucidate the ability of 3He‐MRI to detect ventilation defects in lung transplant recipients, 3He‐MRI was compared to CT for concordance.

Dynamic 19F-MRI of pulmonary ventilation using sulfur hexafluoride (SF6) gas

A new method for dynamic imaging of pulmonary wash‐in and wash‐out kinetics of inhaled sulfur hexafluoride (SF6) gas was developed. Measurements at the fluorine‐19 Larmor frequency were performed in pigs using a gradient echo pulse sequence with 0.5 ms echo time and a measurement time of 9.1 s per image. Dynamic MRI was performed during wash‐in and wash‐out of SF6 gas in mechanically ventilated porcine lungs. A postprocessing strategy was developed for quantitative determination of wash‐out time constants in the presence of noise. Mean wash‐out constants were 4.78 ± 0.48 breaths vs. 4.33 ± 0.76 breaths for left and right lung when ventilation was performed with low tidal volume, and 1.73 ± 0.16 breaths vs. 1.85 ± 0.11 breaths with high tidal volume ventilation. In conclusion, breath‐hold MRI of SF6 gas is feasible in large animals. Moreover, regional wash‐in and wash‐out kinetics of SF6 can be determined noninvasively with this new method. Potential human applications are discussed. Magn Reson Med 45:605–613, 2001.

19F-MRI of perflubron for measurement of oxygen partial pressure in porcine lungs during partial liquid ventilation.

A method for in vivo measurement of oxygen partial pressure (pO2) in porcine lungs during partial liquid ventilation (PLV) with perflubron (PFOB) was developed. A pulse sequence for high‐resolution MRI of the distribution of PFOB in the lung after intratracheal administration was developed as well. Moreover, quantitative measurements of longitudinal relaxation time T1 of 19F resonances for assessment of regional pO2 are described. Due to the need to acquire data during a single expiratory breathhold, only low SNRs were achieved in vivo. Therefore, simulations were performed to investigate the influence of background noise on T1 values calculated from data with low SNR. Based on these simulations, a postprocessing strategy was developed to correct for systematic errors by background noise prior to quantitative analysis. Results of a pilot study in pigs under conditions of PLV are presented. Magn Reson Med 47:82–89, 2002.

Computed tomography-based tracheobronchial image reconstruction allows selection of the individually appropriate double-lumen tube size

OBJECTIVES To determine whether individualized selection of double-lumen tubes or alternatives based on three-dimensional reconstruction of the tracheobronchial image from routine preoperative computed tomography (CT) scans leads to clinically appropriate choices. DESIGN Prospective observational study; comparison to historic controls. SETTING Anesthesia and radiology facilities of a university medical center. PARTICIPANTS Forty-nine patients undergoing thoracic surgery requiring one-lung ventilation. INTERVENTIONS Three-dimensional image reconstruction of individual tracheobronchial anatomy was performed from routine preoperative spiral CT scans as well as from scans of five left-sided and four right-sided double-lumen tubes. Results of image-based tube size selection were compared with literature recommendations. Prospectively, individualized tube selection was performed by superimposition of printed transparencies of tubes over the tracheobronchial system and was validated using bronchoscopic and clinical criteria (n = 24). MEASUREMENTS AND MAIN RESULTS Three-dimensional reconstruction visualized individual anatomy with good accuracy and resolution. Correlations between patient morphology and tracheobronchial dimensions were weak (height versus mainstem bronchial diameters: r < 0.50). In 11 of 48 patients (23%). CT-fitted double-lumen tube sizes would have differed from a conventional height-based and gender-based selection. Individual, prospective, CT-based double-lumen tube selection was associated with (1) good fit and positioning confirmed by fiberoptic bronchoscopy, (2) adequate bronchial cuff seal volumes, (3) complete lung separation, and (4) oxygenation and ventilation parameters during one-lung ventilation similar to those with conventional size selection. In one patient, three-dimensional CT study allowed noninvasive evaluation of a tracheal stenosis precluding double-lumen tube placement. CONCLUSION Individualized selection of double-lumen tube size using CT-based reconstructions of tracheobronchial anatomy leads to clinically appropriate choices. Risks resulting from variations in tracheobronchial morphology are recognized in advance.

Reduced inotropic support after aprotinin therapy during pediatric cardiac operations

BACKGROUND Several reports indicate that aprotinin treatment before and during cardiopulmonary bypass (CPB) might have a protective effect on the myocardium. We evaluated the hemodynamic effects of perioperative aprotinin treatment. METHODS We conducted a randomized, double-blind, placebo-controlled trial in 34 infants (mean age, 2.5 years) who had cardiac operations. Half of the patients received high-dose aprotinin therapy. There were no significant differences between the aprotinin and placebo groups with respect to age, weight, sex, aortic cross-clamp time, and CPB time. The following data were recorded at arrival in the intensive care unit 6, 12, 24, and 48 hours after termination of CPB: heart rate, blood pressure, left atrial pressure, central-peripheral temperature difference, arterial-central venous oxygen saturation difference, urine output, serum creatinine, lactate and neutrophil elastase levels, the Doppler echocardiographic factors shortening fraction and preejection period/left-ventricular ejection time, and cumulative doses of catecholamines (epinephrine), enoximone, and furosemide. RESULTS No hemodynamic variable showed any significant difference between aprotinin and placebo groups. Urine output, creatinine, lactate, and elastase levels, as well as the cumulative doses of furosemide and epinephrine were not significantly different. Twelve hours after CPB 10 patients in the placebo group and 4 in the aprotinin group had received enoximone (p<0.05). The placebo group had received significantly larger doses of enoximone than the aprotinin group at arrival in the intensive care unit (0.13+/-0.05 versus 0 mg/kg), 12 hours after CPB (0.58+/-0.14 versus 0.18+/-0.09 mg/kg), 24 hours after CPB (1.11+/-0.24 versus 0.42+/-0.16 mg/kg), and 48 hours after CPB (1.61+/-0.40 versus 0.86+/-0.28). At 6 hours the difference did not reach statistical significance. CONCLUSIONS Clinical and hemodynamic status of the aprotinin-treated patients was similar to that of the placebo-treated patients in the first 48 hours after CPB. The placebo group, however, required significantly more inotropic support by enoximone than the aprotinin group to achieve this goal.