Pediatric Pulmonology 50:1039–1050 (2015)

Review

Evaluation of Bedside Pulmonary Function in the Neonate:

From the Past to the Future
1 2,3
F. Reiterer, MD, * E. Sivieri, MSE, and S. Abbasi, MD2,3,4
Summary. Pulmonary function testing and monitoring plays an important role in the respiratory
management of neonates. A noninvasive and complete bedside evaluation of the respiratory
status is especially useful in critically ill neonates to assess disease severity and resolution and the
response to pharmacological interventions as well as to guide mechanical respiratory support.
Besides traditional tools to assess pulmonary gas exchage such as arterial or transcutaenous
blood gas analysis, pulse oximetry, and capnography, additional valuable information about global
lung function is provided through measurement of pulmonary mechanics and volumes. This has
now been aided by commercially available computerized pulmonary function testing systems,
respiratory monitors, and modern ventilators with integrated pulmonary function readouts. In an
attempt to apply easy-to-use pulmonary function testing methods which do not interfere with the
infantś airflow, other tools have been developed such as respiratory inductance plethysmography,
and more recently, electromagnetic and optoelectronic plethysmography, electrical impedance
tomography, and electrical impedance segmentography. These alternative technologies allow not
only global, but also regional and dynamic evaluations of lung ventilation. Although these methods
have proven their usefulness for research applications, they are not yet broadly used in a routine
clinical setting. This review will give a historical and clinical overview of different bedside methods
to assess and monitor pulmonary function and evaluate the potential clinical usefulness of such
methods with an outlook into future directions in neonatal respiratory diagnostics. Pediatr
Pulmonol. 2015;50:1039–1050. ß 2015 Wiley Periodicals, Inc.

Key words: pulmonary function testing; neonates; respiratory impedance

pneumography; electrical impedance tomography; respiratory
inductance plethysmography; review.

Funding source: None.

INTRODUCTION AND HISTORICAL OVERVIEW status of neonates with and without assisted ventilation.
With the better understanding of neonatal pulmonary
Pulmonary function testing and monitoring is an physiology and pathophysiology by researchers in the
objective clinical tool used to evaluate the pulmonary 1950s and 60s, especially in relation to lung surface

1
Division of Neonatology, Department of Pediatrics and Adolescence

Correspondence to: F. Reiterer, MD, Division of Neonatology, Department
Medicine, Medical University Graz, Graz, Austria. of Pediatrics and Adolescence Medicine, Medical University of Graz,
Auenbruggerplatz 30, 8036 Graz, Austria.
2
Section on Newborn Pediatrics, Pennsylvania Hospital, Philadelphia, E-mail: friedrich.reiterer@medunigraz.at
Pennsylvania.
Received 22 January 2015; Revised 1 April 2015; Accepted 8 May 2015.
3
Division of Neonatology, Department of Pediatrics, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania. DOI 10.1002/ppul.23245
Published online 2 July 2015 in Wiley Online Library
4
Department of Pediatrics, Perelman School of Medicine, University of (wileyonlinelibrary.com).
Pennsylvania, Philadelphia, Pennsylvania.

Conflict of interest: None

ß 2015 Wiley Periodicals, Inc.

1040 Reiterer et al.
activity, along with the introduction of the first neonatal
ventilators, came an increased need for more comprehen-
sive assessment of neonatal respiratory function. Meas-
urements of lung function would provide valuable
additional information supplementing the traditional
physical examination, chest radiography, and invasive
arterial blood gas measurements.1–3
In the 1970s to 80s, transcutaneous blood gas monitor-
ing and pulse oximetry were introduced as noninvasive
clinical monitoring tools for pulmonary gas exchange.4–6
Also during this time period technical advances in
instrumentation adopted for use in neonates, such as
miniaturized airflow sensors and high-speed computer
technology, led to development of simplified mobile
instrumentation systems which facilitated measurement of
more technically demanding variables of lung function
such as pulmonary mechanics and energetics, as well as
lung volumes.7 Pulmonary function testing moved from
tightly controlled research settings to the infant’s bedside.
Clinical studies during mechanical ventilation showed that
bedside pulmonary function testing had the potential to
identify lung over distension and therefore lessen the
incidence of pneumothorax and intraventricular hemor-
rhage.8–10 Commercially available pulmonary function
test (PFT) equipment became increasingly popular in the
neonatal intensive care unit (NICU), but these systems
were not without limitations. Interpretation of data
collected with this equipment necessitated a thorough
understanding of physiological, clinical, and technical
aspects of the measurements.11–13 Additionally, such
bedside PFT’s provided only snapshot assessments of
respiratory mechanics which, by nature, could vary
significantly over short time periods. In the last decades
bedside “PFT carts” were more or less replaced by a new
generation of ventilators with their integrated measure-
ment capabilities to provide continuous real time display
and trending of several numerical and graphical parameters
of lung mechanics and ventilation. In addition, some of
ABBREVIATIONS:
PFT pulmonary function test
RIP respiratory inductance plethysmography
EIP electromagnetic impedance plethysmography
OEP optoelectronic plethysmography
SLP structured light plethysmograpy
EIT electrical impedance tomography
PNT pneumotachometer
HFOV high-frequency oscillatory ventilation
HFV high-frequency ventilation
LV lung volume
EELV end-expiratory lung volume
VT tidal volume
MV minute ventilation
FRC functional residual capacity
EtCO2 end-tidal CO2
Pediatric Pulmonology
these ventilators now also have closed-loop computer
control of physiologic target variables like tidal volume,
minute ventilation, or arterial hemoglobin saturation.14,15
Recently, in an attempt to reduce incidence of ventilator-
induced lung injury, there has been a trend toward
increased use of non-invasive forms of respiratory support
such as nasal continuous positive airway pressure
(NCPAP), nasal intermittent positive-pressure ventilation,
and heated and humidified high-flow nasal cannula
(HFNC). The requirement of a nasal interface for these
support modalities precludes the use of a traditional direct
airflow sensor at the infant’s airway. Hence, alternative
indirect techniques are being implemented which measure
tidal breathing parameters at the chest wall.
These alternative technologies include respiratory induc-
tance plethysmography (RIP) and more recently, electro-
magnetic inductance plethysmography (EIP), optoelectronic
plethysmography (OEP), electrical impedance tomography
(EIT), and segmentography (EIS).16–20 Although these
techniques are utilized in many research applications they
are not yet used in a broad clinical setting.
The purpose of this clinical review is to give an overview
of the different bedside PFT methodologies for assessment
of pulmonary function in intubated and unintubated
neonates and their potential clinical usefulness and
relevance, and finally, to give a personal outlook into future
directions in this important area of neonatal pulmonology.
MEASUREMENT METHODS OF PULMONARY
MECHANICS, ENERGETICS, AND VOLUMES:
THE CONVENTIONAL APPROACH
Conventional evaluation of pulmonary function is
based on simultaneous measurements of three respiratory
signals: airflow (V0 ), driving pressure (P), and volume (V)
in order to compute pulmonary compliance (C) and
resistance (R) as related by this simplified equation of
motion of the respiratory system:2,21,22
0
P ¼ V=C þ RV
The instrumentation needed to measure P, V0,
and V consists of pressure transducers, an airflow sensor,
and a means of recording and analyzing signals derived
from these devices. There are several technologies for
measuring airflow, including: flow-resistive type sensors
such as pneumotachometers, hot-wire anemometers, and
ultrasonic beam sensors. Tidal volume can be obtained by
either analog or digital integration of the tidal flow signal.
Driving or transpulmonary pressure, requires measure-
ment of the pressure differential between the intrapleural
space and the airway opening. Intrapleural pressure may
be estimated by measuring esophageal pressure either
with a balloon catheter, a liquid-filled open-ended
catheter or a solid-state micro-transducer tipped catheter.
Calculation of compliance and resistance, as well as work
 Bedside Pulmonary Function Testing in the Neonate
of breathing, is usually achieved using any of several
traditional manual methods or computerized regression
analysis algorithms employing some form of the above
equation.2325 Respiratory mechanics can also be mea-
sured passively by various occlusion or forced oscillation
techniques.26–28
The measurement of functional residual capacity (FRC),
a static lung volume, is mostly performed by different gas
dilution or washout techniques, mainly helium dilution and
nitrogen washout methods.11,22 More recently, a sulfur
hexaflouride washout method has been available in which a
very low concentration of this gas is measured with a
combined gas detector and ultrasonic flow sensor avoiding
many of the gas composition and accuracy constraints of
the earlier washout methods.29 Whole-body plethysmog-
raphy, although a standard modality for measuring thoracic
gas volumes, is not a practical technique to measure FRC in
the NICU, but it has been shown useful in the clinical
assessment of infants with bronchopulmonary diseases.30
The techniques described above all have some
limitations related to technical aspects. For example,
the reliability of intrapleural pressure is dependent on
proper esophageal catheter placement and response
characteristics, and the accuracy of tidal volume measure-
ments comprises airflow leakage around an uncuffed
endotracheal tube or an inadequately sealed facemask.7,31
Some other factors to be considered which also contribute
to a large inter- and intra-patient variability include the
patient’s tolerance, unstable spontaneous breathing
patterns, body and neck position, timing of the last
feeding, sleep state, sedation, and the interaction of
mechanical ventilator breaths with spontaneous breaths.
Standardized measurement conditions and testing of
equipment with a calibrated infant lung simulator are
advisable to ensure accuracy of data prior to analysis.32,33
As a guide for proper interpretation of PFT data in sick
patients, cross-sectional and longitudinal PFT’s were
performed during the neonatal period providing reference
values for healthy term and preterm infants.27,34–36
CLINICAL APPLICATIONS AND USEFULNESS OF
PULMONARY MECHANICS, VOLUMES, AND
GRAPHICS
Pulmonary function testing has been applied in studies
of acute and chronic neonatal respiratory disorders such
as respiratory distress syndrome (RDS) and bronchopul-
monary dysplasia (BPD), both occurring predominantly
in preterm neonates.37 RDS is characterized by significant
alterations in elastic and resistive properties and volumes
of the lung based on surfactant deficiency or dysfunction
typically resulting in stiff lungs with low-lung compliance
and FRC. BPD is a multifactorial chronic lung disease
characterized by prolonged oxygen dependency, in-
creased airway flow resistance and airway reactivity,
1041
decreased dynamic compliance, decreased FRC, and may
be associated with significant long-term morbidity in later
life. Pulmonary function testing using different methods
has been reported in numerous studies of neonates with
RDS and BPD to objectively evaluate baseline disease
severity, history, and disease predictive value38–41 as well
as the effect of interventions such as surfactant,42
steroids,43 theophylline,44 bronchodilators,45,46 diu-
retics,47 inhaled nitric oxide,48 and ventilation.49 A
state-of-the art critical review, focusing on respiratory
mechanics, has been published recently by Gappa et al. to
summarize and discuss available data on PFT’s performed
on neonates and infants with chronic lung disease.50 The
interpretation of many of these data is limited due to
incomplete evaluation of the pulmonary function status,
for example, the lack of simultaneous FRC measure-
ments, different testing methods and populations and
small numbers of study patients.51
Pulmonary function test values derived from current
neonatal ventilators, with their intergrated measurement
capabilities for lung mechanics and ventilation param-
eters, have become popular in recent years to guide
respiratory management in ventilated neonates, but this
usage also has its limitations. Under-reading of tidal
volumes and inaccuracy in compliance and resistance
measurements has been shown for several tested
ventilators in vitro and may lead to misinterpretation of
pulmonary status resulting in inadequate ventilator
adjustement and lung injury.31,33 This has to be
considered, for example, in the case of an endotracheal
tube leak and targeted tidal volume ventilation, a
ventilation mode which is highly recommended in the
management of neonates with RDS, as it shortens
duration of ventilation and reduces BPD.52,53 In general,
knowledge of basic physiology of the ventilated lung, the
influence of ventilator settings on lung function and the
interaction of spontaneous and mechanical ventilation is
essential for data interpretation.13,54–56 Recently, in an
effort to standardize testing methodology, Rigo et al.
suggested integration of automatic selection of optimal
respiratory cycles to improve the precision of pulmonary
function data.57
The fundamental measurable parameters of respira-
tion, P, V0, and V can be displayed as scalar waveforms
along a time axis or as x–y plots of relationships such
as volume-versus-pressure (V–P) or flow-versus-
volume (V0–V) loops. Previously reserved for special-
ized recording equipment these pulmonary graphics
representations can now be displayed continuously in
real time with modern graphics-display-based ventila-
tors. V–P loops have been used clinically to detect
ventilatory overdistension, lung atelectasis, endotra-
cheal tube leaks, and air trapping.8,58 V0–V loops have
been shown useful to detect and manage various types
of intrathoracic and extrathoracic airflow limitation.
Pediatric Pulmonology
1042 Reiterer et al.

Typical examples of such use is in patients with Capnometry

obstructive airway disease as in chronic lung disease or
tracheobronchomalacia are shown in Figure 1.59 An
overview of clinical applications of PFT´s is given in
Table 1.
RESPIRATORY MONITORING OF OXYGENATION
AND PARTIAL PRESSURE OF CARBON DIOXIDE
The assessment of adequate oxygenation and ventila-
tion is the main goal during respiratory support in the
delivery room and in the NICU. Pulse oximetry, a well-
proven and popular noninvasive bedside technology,
provides the clinician instantaneous, and continuous
information about peripheral oxygen saturation (SpO2)
and heart rate, but is not without limitations such as the
lack of data accuracy during hypoxemia, hyperoxemia,
peripheral hypoperfusion, and body movements.60 The
assessment and management of ventilation also requires
bedside information on tidal volume and CO2 levels in
order to evaluate the effectiveness of pulmonary gas
exchange. This can be done invasively by capillary or
arterial blood gas determination, and by several continu-
ous noninvasive methods including:
The measurement of CO2 concentration in an exhaled
breath to determine end-tidal CO2 (EtCO2) displayed as a
numerical readout. Capnography displays the expired
CO2 level graphically over the time course for each
breath. Measurements of EtCO2 have been reported
useful in assessing lung aeration and ventilation in
preterm and term infants requiring respiratory support
immediatley after birth.61–63 Depending on the capnog-
raphy technology used and the severity of lung disease,
EtCO2 measurements may also be useful for bedside
monitoring in ventilated neonates in the NICU and have
been shown to correlate well with arterial pCO2 values.64
In spontaneously breathing infants, measurement of
EtCO2 has been used for assessment of functional lung
alterations related to BPD.65
Colorimetric Devices
These provide a qualitative indication of several ranges
of EtCO2 by displaying color changes on a chemical
indicator strip rather than a numerical readout. Because of
their ease of use, colorimetric devices may be of particular
benefit for preterm infants in the delivery room and during

Fig. 1. Flow-volume tracings in a patient with severe congenital tracheobronchomalacia. At PEEP

level of 2, and 4 cm H20 there is almost complete flow interruption during exspiration, at PEEP of 6
there is moderate, and at PEEP of 8 cm H2O there is no flow interruption.59

Pediatric Pulmonology
 Bedside Pulmonary Function Testing in the Neonate 1043
TABLE 1— Clinical Applications of Pulmonary Function Testing

1 Assessement of pulmonary airway and tissue disease severity and resolution

2 Assessement of efficiency of mechanical ventilatory support: tidal volume, tracheal airflow, optimum CPAP, time constants of respiratory
system, and ventilation distribution
3 Assessement of weaning efficiency from mechanical ventilation and readiness for extubation
4 Assessement of pharmacological interventions: surfactant, bronchodilators, methyl-xanthines, diuretics, steroids, and inhaled nitric oxide
5 Assessement of the effect of posture on airway resistance and delivered tidal volume
6 Sequential follow-up of chronic lung disease

neonatal transport as well as in the perioperative setting to
verify correct endotracheal tube positioning.
Transcutaneous CO2
This technology utilizes specialized skin surface
sensors to estimate arterial CO2. This method is not as
popular in the NICU as it requires regular calibration and
positional changes of the skin sensor and is prone to
artifacts during unstable hemo-dynamic conditions.
However, during stable infant conditions, transcutaneous
pCO2 measurements have been shown to have good
agreement with corresponding arterial measurements
even in extremely low-birth weight infants.66
RESPIRATORY PLETHYSMOGRAPHY AND
ELECTRICAL IMPEDANCE TECHNIQUES
RIP
Respiratory inductance plethysmograph (RIP), a rather
simple commercially available technique has been in use
for several decades in pediatric sleep laboratories to
describe thoracic and abdominal movements. The RIP
apparatus consists of sinusoidally arranged coils embed-
ded in soft elastic bands which are placed around the
thorax and abdomen. As an infant breathes, changes in the
rib cage and abdominal cross-sectional areas circum-
scribed by the bands are transduced into electrical signals
(Fig. 2). This technology has been used to evaluate infant
breathing asynchrony by providing a continuous display
of the phase angle, or phase delay, between abdominal and
thoracic excursions which may vary between 08 (com-
plete synchrony) and 1808 (paradoxical breathing) as
illustrated in Figure 3. Phase angle, as an index of
thoracoabdominal asynchrony (TAA), has been shown to
be useful in detection of airway obstruction and for sleep
apnea monitoring.67–69 Other RIP-derived asynchrony
and work of breathing indices include: the labored
breathing index (LBI), defined as the ratio of the sum of
maximal ribcage and abdominal excursions to the actual
tidal volume, with values >1 indicating increased
breathing effort; phase relation total breath (PhRTB),
defined as the percentage time in a single breath spent in
asynchrony; control of breathing and timing parameters
such as the ratio of time to peak tidal expiratory flow to
expiratory time (tPTEF/tE).70–73 In a number of studies,

Fig. 2. Schematic of respiratory inductance plethysmograph (RIP) bands and the recorded
ribcage and abdominal waveforms. The ribcage-to-abdominal phase angle is calculated using
the equation as shown using measurements from the x–y plot of the ribcage versus abdominal
display, where m ¼ the loop diameter at the1/2 ribcage excursion, and s ¼ maximal abdominal
excursion.

Pediatric Pulmonology
1044 Reiterer et al.

Fig. 3. Phase delay between rib cage and abdominal motion during respiratory cycles of varying
asynchrony displayed as idealized plots of the ribcage versus abdominal signals obtained using
respiratory inductance plethysmography (RIP).

RIP has been used to evaluate the effectiveness of invasive has been shown to be accurate for measuring tidal
and noninvasive ventilatory strategies on thoracoabdo- breathing parameters in term- and pre-term infants.17,89,90
minal asynchrony and tidal volumes in preterm infants
who have very compliant rib cages and are prone to chest OEP
wall distortions especially with underlying lung dis-
Optoelectronic plethysmography (OEP), estimates
eases.74–77 RIP has also been used to measure relative
chest wall volume by measuring the three-dimensional
end-expiratory lung volume changes at different levels of
(3D) position of several reflective markers placed on the
NCPAP.78 In another study, RIP was used to detect a high
patient’s thorax by an automatic motion analyzer getting
breath-to-breath variability in healthy as well as in sick
input signals from several cameras.18 It has been recently
premature infants with respiratory support.79
tested in spontaneously breathing term and preterm
If properly calibrated, RIP may also be used to
neonates, validated in comparison to mask pneumo-
accurately measure tidal volume, and several calibration
tachograyphy and provided accurate measurements of
techniques have been developed for this purpose.80–82 In
lung volume changes and tidal volumes. It is an
general, all such calibration schemes require a period of
interesting, futuristic technique, requiring no previous
restful breathing with close to constant tidal volumes to
calibration, but besides other potential errors, the
generate appropriate weighing factors for the different
complexity of its bedside setup mainly limits its routine
ribcage and abdominal contributions to the total tidal
clinical application at the moment.18,91
volume. A period of breathing through a calibrated flow
A recently developed method also in the field of 3D
sensor, such as a pneumotachometer, is also required to
optical technology is structured light plethysmograpy
scale the final RIP signal to known reference volumes.
(SLP).92,93 This is a completely non-contact technology
Consistent accuracy is usually achieved while the subject
in which a structured light checkerboard pattern is
remains in a single postural position.83,84 When thus
projected onto the frontal thoracoabdominal surface. Two
calibrated, the RIP technique has been used to estimate
camera images, the moving surface and generate a 3D
respiratory mechanics and work of breathing measures in
reconstruction giving an estimate of chest wall volume
infants in which direct airflow measurement at the airway
over time. The system is calibrated by simply scanning an
would interfere with a nasal/oral interface device used, for
object with precisely known physical dimensions.
example, with NCPAP or HFNC therapy.85–88
Currently, although a commercially available version
(PneumaCare Limited, Cambridge, UK) of this technolo-
EIP gy is available for use with adults and children, there is as
yet no known adaptation of this system for use with
Electromagnetic inductance plethysmography (EIP), a
neonates.
newer method, measures volume changes from chest and
abdomen during respiration via changes in the electro-
EIT
magnetic field, generated by a weakly electrified vest worn
by the infant. Although the required bedside equipment for Electrical impedance tomography (EIT) is a relatively
this technology may be bulky (at the time of this writing), it new radiation-free technique in the neonatal field that can
does not require subject dependent calibration, which detect regional changes in lung volumes. This is
allows measurement of truly undisturbed tidal breathing. It accomplished by generating cross-sectional images of

Pediatric Pulmonology
 Bedside Pulmonary Function Testing in the Neonate 1045

the changes in distribution of electrical impedance within
the thorax measured by electrocardiography electrodes
placed on the thorax just above the nipple line.19
Connected to a special EIT system, data are continuously
acquired, analyzed, and visualized. An application of
electrical impedance measurement, which has been
specifically developed for use in neonates, electrical
impedance segmentography (EIS) or quadrant impedance
monitoring (QIM), differs from EIT in that it determines
impedance changes in four quadrants of the thorax
(Fig. 4) and also allows quantification of impedance
changes of the lung expressed as absolute tidal volumes
when calibrated with known volumes using a pneumo-
tachometer.20 Clinical and experimental studies using
EIT and EIS/QMI have already shown their usefulness in
several clinical areas including: detection of small
pneumothoraces,94 evaluation of distribution of ventila-
tion in different conditions, e.g., during endotracheal
suctioning,95 endotracheal tube placement,96 body posi-
tioning,97–99 pulmonary recruitment maneuvers,99–102
pulmonary assessment prior to extubation,103 and pre,
during, and post surfactant therapy.104–106 This method-
ology has also been used to study ventilation inhomoge-
neity in chronic lung disease.107,108 The first prospective
study of EIT in surfactant-treated neonates showed not
only an increase in lung aeration but also reduced right-to-
left asymmetry and increased ventilation of dependent
regions after surfactant.104 A summary of nine EIT
publications from 1995 to 2003 in preterm and term
neonates with a gestational age range of 27–42 weeks is
given in a study by Pillow et al.107 reporting issues related
to practical factors such as: applicability and feasibility of
the EIT-system, data comparison with adults, maturation-
al lung function changes, and effect of breathing patterns
and posture.
EIT or EIS technology is commercially available but
not yet routinely used in a clinical setting. Some
limitations in its use are the lack of standardized
measurement protocols, the somewhat difficult placement
of the electrodes, especially in VLBW infants, the low
resolution of the generated images, the applicability and
usefulness for different lung diseases, the lack of
appropriate reference values that take gestational age
into account, and the lack of experience with long-term
monitoring. In addition to respiratory applications, the
different aspects of EIT imaging for cardiopulmonary
imaging and monitoring have also been recently reviewed
by Frerichs et al.108
A summary of more recent clinical studies on EIP, OEP,
and EIT is shown in Table 2.
CONCLUSIONS AND FUTURE DIRECTIONS
Pulmonary function testing and monitoring plays an
important role in the evaluation and management of
neonates with respiratory compromise. Being predomi-
nantly a research tool in the past and limited to a few
clinical bedside applications, present-day NICU’s are
offered a number of newer, noninvasive, methods to
assess clinically relevant respiratory parameters even in
very premature infants. Pulmonary function testing has
been shown to be useful in studying basic pulmonary
physiology and the natural course of development of the
immature lung. Routine PFT’s have also been useful in

Fig. 4. Electrical Impedance Segmentography (Angelie EIS system, EMS Biomedical, Korneuburg
Austria) from a preterm neonate showing the ventilation pattern in four segments of the lung over
time. UR, upper right segment; UL, upper left segment; LR, lower right segment; LL, lower left
segment. The values given inthe circles of the lung window indicate percent changes in each
quadrant’s capacity compared to a baseline start point.

Pediatric Pulmonology
 1046

TABLE 2— Clinical Studies With Electrical Impedance and Plethysmographic Techniques

Pediatric Pulmonology
No. of Study Authors refs. year of
Reiterer et al.

Method GA (weeks) infants population Study aim Main results publication

EIP 40  1.3 10 Healthy Validation of measurement system Tidal parameters correlated closely Olden et al. 201089
29  4.6 11 BPD oxygen with facemask measurements in
dependent healthy neonates, differed from BPD
EIP 35  4 (28–42) 49 Healthy Normative data of tidal breathing parameters VT and MV decreased with advancing PCA Pickerd et al. 201317
EIP 28  2 (23–33) 29 CPAP clinical Compare effects of three CPAP devices at MV/kg similar between all devices, Pickerd et al. 201490
stable different pressure settings on tidal decreasing difference for VT/kg over
breathing, assess changes during weaning time on and off CPAP
OEP 34  5 (29–41) 20 Healthy Appropriate experimental setup, system validation Accurate measurement of lung Dellaca et al. 201018
with PNT volume changes
EIT 28.3 median (25.3–31.9) 15 RDS on HFOV Immediate and regional effects of surfactant Surfactant increased LV by 61  39%, Miedema et al.
on LV, mechanics and ventilation stabilization most prominent in 2011100
dependent lung regions, ventilation not
affected by surfactant
EIT 28.1  2.6 (24–33) 14 On CMV Evaluation of PEEP-levels (5–8 cm H2O) on air Best homogenous air distribution with Rossi et al. 2013103
distribution before extubation PEEP 6.3 þ 1.1 cm H2O
EIT 27.9 median (25.6–31.4) 15 RDS on open Measurement of EELV comparison to RIP Significant correlation va der Burg et al.
lung HFV 201419
EIT 30.94  2.38 (27–35) 17 RDS on CMV Global and regional lung function changes before More homogenous air distribution after Chatzioannidis et al.
and after surfactant surfactant, improvement in global 2013104
lung function
EIT 32 20 RDS on CMV Assess the extent and duration of change in EEL Significant LV increase (for at least 90 min) Hough et al. 201495
from endotracheal suction

EIP, Electromagnetic impedance plethysmography; OEP, Optoelectronic plethysmography; EIT, Electrical impedance tomography.
GA data are mean  SD if not otherwise indicated, ranges in parenthesis.
 Bedside Pulmonary Function Testing in the Neonate
evaluating the response to pharmacological interventions,
and in guiding ventilator management. But nonetheless,
pulmonary function testing has not been proven to have a
significant impact on short- or long-term pulmonary
outcomes in adequately designed clinical studies. As lung
injury may already occur during neonatal resuscitation,
the focus of respiratory function monitoring has recently
moved to the delivery room. There, respiratory function
monitors and capnography are being used to access and
optimize tidal volumes and lung aeration during positive
pressure ventilation, which is considered key to success-
ful resuscitation. Whether or not this new focus will have
an impact on pulmonary outcome needs to be tested with
further and larger prospective randomized clinical
trials.109,110
In contrast to traditional “snapshot” measurements of
respiratory function, the newer noninvasive bedside tools,
like EIT or EIS, will enable continuous monitoring of
regional lung volume and ventilation changes as well as
measures of breathing efficiency such as thoracoabdo-
minal asynchrony. For this, it will be necessary to
establish standardized calibration techniques, measure-
ment conditions, and criteria for data analysis and
interpretation. In addition, the reliability and accuracy
of these newer systems needs to be validated in different
clinical settings and in a sufficient number of stable and
unstable patients. In the meantime, our goal should be a
comprehensive clinical assessment and early application
of the least invasive and most practical techniques for
pulmonary as well as circulatory evaluation and
management.
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