394

Electrical Impedance Tomography

E.L.V. Costa, R. Gonzalez Lima, and M.B.P. Amato

Introduction
Electrical impedance tomography (EIT) is a non-invasive, radiation-free monitoring
tool that allows real-time imaging of ventilation [1 – 3]. EIT was first used to monitor
respiratory function in 1983 and remains the only bedside method that allows
repeated, non-invasive measurements of regional changes in lung volumes [4, 5]. For
this reason, EIT has been used as a monitoring tool in a variety of applications in
critical care medicine, including monitoring of ventilation distribution [3, 6], assess-
ment of lung overdistension [7] and collapse [8, 9], and detection of pneumothorax
[10, 11], among others. In this chapter, we will provide a brief overview of the fun-
damentals of the EIT technique and review the use of EIT in critical care patients in
the light of recent literature.

How Electrical Impedance Tomography Works

X EIT uses injection of electricity in the thorax to obtain images of a cross section of
the lungs. Typically, the EIT device uses 16 or 32 electrodes distributed circumferen-
tially around the thorax to inject high-frequency and low-amplitude alternating elec-
trical currents (Fig. 1) [2, 10]. These currents travel through the thorax following
pathways that vary according to chest wall shape and distribution of impeditivities
inside the thorax. The resulting intrathoracic current densities determine electrical
potentials on the surface of the chest wall. The electrical potentials are measured and
used to obtain the electrical impedance distribution within the thorax using an esti-
mation algorithm that solves an ill-posed non-linear problem. Ill-posedness means
that, given a set of measured voltages on the chest-wall surface, the solution for intra-
thoracic impedances may not be unique or may be extremely unstable: Small errors
in voltage measurements may lead to drastically different solutions. This problem is
aggravated by the relatively small number of measurements made at the body surface
(because of limitations in the current technology, there is a minimum requirement
for electrode size and it is only possible to fit a relatively small number of electrodes
along the thoracic perimeter). In order to overcome the ill-posed nature of imped-
ance estimation, most EIT imaging algorithms make use of additional assumptions,
known as regularizations, such as smoothness of the intrathoracic impedance distri-
bution [12, 13]. These regularizations help the estimation algorithm to decide
between competing solutions, producing an image that is a reasonable estimation of
the true impedance distribution within the thorax, but at the expense of some
degraded spatial resolution or some attenuation of the maximum perturbation.
 Electrical Impedance Tomography 395

Fig. 1. Computed tomographic axial slice of the thorax of a patient with schematically drawn electrodes
and electrical current pathways through the thorax. One pair of electrodes injects electrical current at a
time while the remaining electrodes read the voltages produced as a result of electrical current passing
through the thorax. The injecting pair is alternated sequentially so that after a full cycle, all possible ad-
jacent electrodes serve as injectors. Each full cycle results in an image and 50 images are produced each
second.

Reconstruction Algorithms
Reconstruction or estimation algorithms refer to the computations that transform
the acquired voltages at the surface of the thorax into a cross-sectional image of
X
impedances (Fig. 2). To get a grasp of the complexity of EIT reconstruction algo-
rithms, it helps to compare EIT with X-ray computed tomography (CT). The recon-
struction of a CT image is relatively simple because X-rays pass through the thorax
as a straight beam, with negligible scattering of the energy. Thus, a localized change
in tissue density affects a few measurements (only the measures taken from the
detectors at the projection of the line connecting the X-ray beamer and the tissue
perturbation). In contrast, when an electrical current passes through the thorax, the
current spreads out in three dimensions, following a complex path that is deter-
mined by the place of current injection and also by the three-dimensional distribu-
tion of tissue impedances. Any local change in tissue impedance will affect all volt-
age measurements at the surface of the thorax in a non-linear fashion, producing a
voltage gradient that will depend on the complex distribution of current densities
across the thorax. Thus, the relationship between tissue impedance and voltages is
extremely complex, essentially non-linear, and depends on non-local phenomena.
The first algorithm used to generate images of ventilation using EIT was called
filtered backprojection [2], and used a linear approximation to solve the EIT prob-
lem. This approximation imposes some constraints in terms of the maximum
impedance variation that can be reliably measured. Many other linearized algo-
rithms have been developed since then in pursuit of an algorithm that is at the same
time fast and capable of providing images with good spatial resolution [14 – 16]. No
396 E.L.V. Costa, R. Gonzalez Lima, and M.B.P. Amato

Electrodes

Fig. 2. Finite element mesh used for image recon-

struction. From [10] with permission

single algorithm, however, stood out in terms of spatial resolution or speed, and dif-
ferent linearized algorithms are used in different EIT devices. For imaging the func-
tional changes in organs like the heart and lung, speed is important because the
ability of EIT to collect repeated data in time is one of the advantages of EIT over
other available imaging modalities with higher spatial resolution, such as CT. There-

X fore, iterative algorithms, although yielding more precise results because they take
into account the non-linearity of the EIT problem, have too high computational
costs and, at the moment, are not suitable for fast online imaging [13]. The two
types of algorithm are not mutually exclusive, though, and the output of iterative
algorithms could be used to improve the accuracy of linearized algorithms.

Patterns of Applying the Electrical Current

There are two general approaches for applying the electrical current. According to
the first approach, electrical current is injected simultaneously by all electrodes, and
the electrodes read the voltages produced at the same time electrical current is being
injected [13]. While this method tends to produce higher current densities inside the
thorax and thus higher signal-to-noise ratio, it has the drawback of introducing the
necessity to deal with skin-electrode contact impedances. In the ideal scenario, con-
tact impedance can be easily modeled [17], but when electrodes are not in perfect
contact with the skin, or when they partly come off during deep breaths, contact
impedance might become an important part of the impedance being measured.
The second approach consists of applying electrical current at one electrode pair
at a time, while the remaining electrodes function as voltage readers. The most com-
mon design injects electrical current at adjacent electrodes, but many other designs
are possible, including injection in every other electrode (Fig. 1) or in diametrically
opposite electrodes. The pair of active electrodes is alternated sequentially until all
possible pairs are used (according to the application pattern used). At the end of one
 Electrical Impedance Tomography 397

full cycle, there are N × (N-3) voltage measurements (N being the number of elec-
trodes) and these are used to feed the estimation algorithm and produce one image.
This approach has the advantage of not having to take into account skin-electrode
contact impedances because all voltage readings occur at near-zero current. Most
systems used for the study of lung function have used this second approach.

Absolute versus Difference Images

Thoracic shape can contribute as much as internal thoracic impedances to the mea-
sured voltages at the chest wall surface [13]. Consequently, reconstruction of the
absolute impedance distribution, albeit feasible, requires knowledge of the shape of
the thorax. To avoid taking thoracic geometry into account, Barber and Brown sug-
gested an approach based on the dynamic changes in impedance, i.e., relative
changes in impedance from time to time or during respiration [2], assuming that the
shape of the thorax did not change between measurements. This relative or differen-
tial approach cancels out most errors related to wrong assumptions about true tho-
racic shape (the same error is equally present in both images) and has proven its
validity in recent years. The use of normalized voltage measurements further
improves the robustness of such solution, which completely ignores the absolute val-
ues of impedance at the beginning of measurements. Typically, at a frequency of 10
KHz, the electrical impedance of the chest tissues is in the order of 2 – 4 Ωm, and the
average impedance of the lung is around 10 Ωm [18]. During respiration, while lung
impedance changes up to 300 % (from 7.2 to 23.6 Ωm in one report) [18], chest wall
impedance remains relatively constant.
Most currently available EIT devices and most publications in the field use the
relative approach and thus calculate difference impedance images in relation to a
reference. The output image of such algorithms is a 32 × 32 array from which each
element corresponds to a pixel on the image and contains the change in impedance
in relation to a reference frame, expressed as a percentage. The baseline impedance
cannot be recovered. Thus, breaths producing a change in lung impedance from 5 to
X
10 Ωm, or from 10 to 20 Ωm will produce exactly the same relative image. As we will
see below, this limitation is not worrisome as far as clinical applications are con-
cerned, because there is a well described and linear relationship between the amount
of air entering the voxel and the percent change in lung impedance [19].
One drawback of the use of difference images is that only regions of the thorax
that change their impedance over time are represented in EIT images. Consequently,
pre-existing consolidated areas of the lung (e.g., pneumonia or atelectasis), pleural
effusions or large bullae are not represented in difference EIT images. For this rea-
son, absolute images have the potential to bring additional and important informa-
tion and there is continuing research using iterative algorithms to improve the qual-
ity of absolute images. Although some progress has been made, with promising
results having been presented by Hahn et al. [11], the quality of the images is still
not good enough for meaningful clinical use. Further development in this area,
using estimations of electrode position and taking thoracic shape into account will
enable precise absolute image reconstruction.

Spatial and Temporal Resolution

Spatial resolution of EIT depends on the accuracy and noise of the measurements,
the number of electrodes, and the regularization used. For this reason, spatial reso-
398 E.L.V. Costa, R. Gonzalez Lima, and M.B.P. Amato

lution varies from one EIT device to another, and varies even within a single device
depending on the settings employed. In bench tests using tanks or phantoms, the
resolution is usually optimized because less regularization is required. At the bed-
side, however, noise and wrong assumptions about thoracic shape require stronger
regularizations and resolution is compromised. On average, for a 16-electrode sys-
tem, resolution is about 12 % of the thoracic diameter for regions in the periphery
of the lung and 20 % for central regions. By using a 32-electrode system, this resolu-
tion could be improved to 6 – 10 % of the thoracic diameter (Turri F, personal com-
munication). In a typical adult patient, this resolution corresponds to approximately
1.5 – 3 cm in the cross-sectional plane. The spatial resolution in the craniocaudal
direction is even lower, the slice thickness amounting to approximately 7 – 10 cm. In
fact, this characteristic is not necessarily a limitation; such thick slices are poten-
tially useful for representing lung behavior during mechanical ventilation, when the
detection of heterogeneities along the gravitational axis is the main target [20, 21].
Although it is possible to improve resolution, for example by increasing the num-
ber of electrodes or by improving hardware performance, it is unlikely that EIT will
ever reach the resolution of CT or magnetic resonance imaging (MRI) [22]. On the
other hand, modern EIT devices are characterized by high temporal resolution, with
some generating up to 50 images/s. It is thus possible to follow closely and on a
regional basis the time pattern of inflation and deflation of the lung. For example, it
is possible to show that some areas start to inflate after the others, reflecting either
tidal recruitment [23] or local auto-positive end-expiratory pressure (PEEP). Addi-
tionally, by use of brief periods of apnea or by filtering out ventilation [24], it is now
possible to monitor changes in intrathoracic impedance caused by perfusion. This
opens new horizons for the use of EIT with the perspective of studying at the bed-
side the intricate relationships between ventilation and perfusion in real-time.

X Clinical Applications
The body of literature on EIT has increased steadily over the last years. In the last 5
years, more than 200 papers have been published, representing an increase of almost
100 % in relation to the previous 5-year period. Initial EIT applications in critical
care medicine focused mainly on ventilation and its distribution; now other applica-
tions are being explored such as detection of pneumothorax, assessment of lung
recruitment and collapse, and lung perfusion. In this section, we will review the lit-
erature pertaining to respiratory and critical care medicine.

Assessment of Lung Recruitment and Lung Collapse

Careful titration of PEEP is of utmost importance for the success of ventilatory strat-
egies based on the open lung approach. Traditionally, global lung parameters, such
as pressure-volume curves [25, 26] or respiratory system compliance [27], have been
used, but they fail to represent what is happening to the lung on a regional basis
[28]. Collapsed and overdistended lung compartments commonly coexist, and a
method capable of assessing both, simultaneously, would be invaluable as a tool to
titrate PEEP. Our group described an EIT-based method for estimating alveolar col-
lapse at the bedside, pointing out its regional distribution. On an experimental
model in pigs, we found a good correlation between EIT and CT estimates of lung
collapse during decremental PEEP trials after a maximal lung recruitment maneuver
 Electrical Impedance Tomography 399

Fig. 3. Computed tomography (CT) of the thorax of a patient with right inferior lobe pneumonia (top fig-
ures) and electrical impedance tomography (EIT) maps (bottom figures) of lung hyperdistension (left) and
lung collapse (right) in a patient with acute respiratory distress syndrome (ARDS). The left-hand images
X
were obtained at PEEP of 25 cmH2O and those on the right, at a PEEP of 3 cmH2O.

[29]. Combining data obtained from EIT and respiratory mechanics, it is also possi-
ble to estimate the amount of overdistension during a PEEP trial, although valida-
tion of such estimates represents a challenge due to the lack of a gold standard to
compare to (Fig. 3) [30]. Meier et al. [9] recently used EIT to monitor regional tidal
volume during a PEEP titration maneuver in a model of surfactant depletion in pigs.
Looking at changes in regional tidal volumes that occurred with changes in PEEP,
they were able to detect the initiation of regional lung collapse and of regional lung
recruitment before global changes occurred in lung mechanics. Additionally, they
showed good correlation of ventilation estimated by EIT and CT, confirming the
results of Victorino et al. [3]. Their results bring an exciting possibility of bedside
titration of PEEP based on regional lung mechanics.
In a similar report, Luepschen et al. [31] extended the previous results by show-
ing that the center of gravity of ventilation images moves dorsally during lung
recruitment and ventrally during lung collapse. This EIT based parameter brought
additional information to a fuzzy controller of ventilation that optimized lung
recruitment based on oxygenation, ventilatory parameters and hemodynamics.
Other authors have also used the center of ventilation to assess lung recruitment
400 E.L.V. Costa, R. Gonzalez Lima, and M.B.P. Amato

[32]. In sixteen newborn piglets with acute lung injury (ALI) induced by whole lung
lavage, Frerichs et al. showed that EIT allowed visualization of the effects of ALI,
lung recruitment, surfactant administration, and subsequent mechanical ventilation
strategy. They found that lung injury displaced the ventilation ventrally, and lung
recruitment restored the center of ventilation to the normal position. After surfac-
tant administration, ventilation was gradually shifted ventrally after 10 and 60 min,
but remained in the pre-injury position if surfactant administration was followed by
a recruitment maneuver.
Other indices to estimate lung recruitment using EIT have been proposed. In a
recent report [23], the authors compared EIT measures to dynamic CT in 18 pigs
divided into three groups (control, direct and indirect lung injury). EIT allowed
real-time monitoring of regional ventilation distribution. During an interposed slow
inflation, regional impedance time curves were used to calculate three indices: Area
under the curve, slope linearity (concavity or convexity), and time delay between
start of inspiration and start of regional inflation (ventilation delay index). These
investigators showed that recruitment could be detected by regional EIT and was
better described by the regional ventilation delay index, which also has the potential
to capture intra-tidal recruitment. Unfortunately, the other two indices did not cor-
relate with lung recruitment. Hinz et al. [33] used an index similar to the slope line-
arity described above and found different results. They monitored 20 mechanically
ventilated patients with ALI/acute respiratory distress syndrome (ARDS) during
tidal breathing and showed that the behavior of the impedance-time curve was het-
erogeneous within the lung suggesting the occurrence of hyperdistension and tidal
recruitment in different regions of the lung. These seemingly conflicting results
might be explained by simple methodological differences. First, Hinz et al. used
global EIT tidal volume on the x-axis instead of time. This is important, because it
eliminates the assumption that tidal volume is evenly distributed in the cephalocau-

X dal direction. Second, performing concavity analyses on large slow inflations (maxi-
mum airway pressure of 60 cmH2O) might be misleading because, at high lung vol-
umes, the rib cage limits further lung expansion on the transverse plane and the
additional lung inflation occurs mostly due to diaphragmatic displacement. Conse-
quently, concavity will be biased downwards.
Although careful titration of PEEP is important, one should bear in mind that
lung condition is constantly changing, and that a selected PEEP might not suffice to
keep the lung open at all times, especially if transient depressurization of the lung
takes place. Depressurization is particularly common when suctioning of the air-
ways is required for clearance of secretions. To assess the derecruitment caused by
closed-system suctioning, Wolf et al. [34] studied 6 children with ARDS on pressure
controlled ventilation and continuously monitored with EIT. They showed that lung
volumes decreased on average by 5.3 ml/kg after three suctioning maneuvers. Unex-
pectedly, they showed that the most dorsal regions of the lung were the least affected
by derecruitment; since the authors used difference EIT images, they could only
speculate that this region was atelectatic even before the suctioning maneuver.
Other authors have suggested that only open-system suctioning leads to signifi-
cant derecruitment. In pigs monitored with EIT after surfactant depletion [8], Lind-
gren et al. showed that endotracheal suctioning induced collapse of the lung and
decreased regional lung compliance during open-system suctioning, but not during
closed-system suctioning. The collapse was predominantly in the dorsal regions, but
recruitment was reestablished in less than 10 minutes by simple reconnection to the
ventilator. Nevertheless, it is important to bear in mind that the model of surfactant
 Electrical Impedance Tomography 401

depletion using whole lung lavage leads to lungs prone to collapse, but highly
recruitable. Therefore, these results need careful scrutiny before being extrapolated
to inflamed, edematous lungs of ARDS patients, on whom depressurization is best
avoided.
In a different report, the same authors used EIT to assess lung collapse during
bronchoscopic suctioning in mechanically ventilated patients with ALI [8]. They ele-
gantly showed that bronchoscopy initially leads to localized auto-PEEP due to the
reduced transverse area available for airflow, and that suctioning leads to a decrease
in lung aeration and decrease in lung compliance even when a closed suctioning sys-
tem is used. They obtained similar findings in volume-controlled and pressure-con-
trolled ventilation. In mechanically ventilated patients being submitted to broncho-
scopic procedures, EIT might prove to be a useful tool to quantify the amount of col-
lapse and to guide post-suctioning recruitment.

Detection of Pneumothorax and Pleural Effusion

Pneumothorax is a relatively common complication in critical care patients receiv-
ing mechanical ventilation or submitted to invasive procedures such as central
venous line placement or thoracocentesis. Costa et al. [10] created an algorithm for
the detection of pneumothoraces using EIT. In a first set of 10 pigs, they created the
algorithm which was subsequently tested in 29 pigs. EIT showed a sensitivity of
100 % (CI 93 – 100 %) to detect pneumothoraces as small as 20 ml (Fig. 4.). The
major limitation of this study was the need for a baseline measurement before the
occurrence of the pneumothorax, limiting the application to monitoring of situa-
tions at high risk of developing pneumothorax, such as central venous line place-
ments or mechanical ventilation with high alveolar pressures.

Fig. 4. Computed tomography (CT), ventilation map, and aeration change map obtained at baseline and
after the induction of a 100 ml pneumothorax in a pig with partial atelectasis of the lungs. The arrows
point to the accumulation of air in the pleural space. From [10] with permission
402 E.L.V. Costa, R.G. Lima, and M.B.P. Amato

Another group of investigators [11] studied the combined use of dynamic and abso-
lute images for the diagnosis of pneumothorax and pleural effusion. They studied
five pigs and showed reproducible results with the development of pneumothorax
consisting of increased impedance and decreased ventilation. Pleural effusions,
being more conductive than the lung, produced a decrease in impedance associated
with decreased ventilation. They further acquired images in four patients and
showed that EIT absolute images were compatible with CT images.
The use of EIT as a sensitive monitoring tool for the detection of pneumothorax
and pleural effusions [10, 11, 35] is appealing but probably will not be applied in
clinical practice until systematic studies in patients are performed.

Correct Placement of Endotracheal Tube

Steinmann et al. [36] studied 40 patients requiring one-lung ventilation for surgical
procedures. EIT monitoring started before intubation and continued throughout the
protocol. All clinical decisions were based on fiberoptic bronchoscopy and EIT
investigators were blinded to bronchoscopy findings. EIT reliably identified left and
right one-lung ventilation, correctly diagnosing misplacement of the tube in the
contralateral main bronchus. Nevertheless, using EIT parameters, they could not
identify misplacement of the endobronchial cuff, suggesting that EIT cannot replace
bronchoscopy as a guide to one-lung ventilation. Although not designed to address
this question, this study suggests that EIT can be used to diagnose selective intuba-
tion or endotracheal tube displacement during conventional two-lung ventilation.

Potential Future Applications of Clinical Relevance

X In addition to the above established applications, EIT can also be used to study lung
perfusion [24, 37 – 39]. One of the goals of mechanical ventilation is to ensure ade-
quate gas exchange, and the efficiency of gas exchange depends not only on ventila-
tion, but also on pulmonary perfusion. Using dynamic filtering processes, or by
means of a short period of apnea, it is possible to separate ventilation and cardiac
related changes in lung impedance [24]. The amplitude of cardiac-related oscilla-
tions seen in the EIT signals, however, has not been shown to correspond to the
amount of local perfusion, and further studies are necessary to explore its precise
physiological meaning. A different approach to measuring lung perfusion involves
the injection of small volumes (5 – 10 ml) of hypertonic saline in a central vein [39].
Hypertonic saline is more conductive than blood and produces regional decreases in
lung impedance that vary according to regional lung perfusion. Although the above
techniques offer exciting new ways to monitor pulmonary perfusion at the bedside,
clinical data on these techniques are limited. Clinical validation of these techniques
is warranted before they can be used in clinical practice.

Conclusion
EIT is gradually gaining acceptance as a valuable monitoring tool for critically ill
patients. It is cheap, non-invasive and, up to now, has been show to reliably track
changes in regional ventilation, describe regional ventilation distribution and
regional lung mechanics, detect pneumothoraces, and monitor lung recruitment and
 Electrical Impedance Tomography 403

derecruitment. Other applications such as monitoring of lung perfusion and of ven-

tilation/perfusion distribution are feasible but still require further studies.

Acknowledgement: Financial support by grants from “Fundação de Amparo à Pes-

quisa do Estado de São Paulo (FAPESP)” and “Financiadora de Estudos e Projetos
(FINEP)”.

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