Regional pleural strain measurements during mechanical ventilation using ultrasound elastography: A randomized, crossover, proof of concept physiologic study

Martin Girard, Marie-Hélène Roy Cardinal, Michaël Chassé, Sébastien Garneau, Yiorgos Alexandros Cavayas, Guy Cloutier, André Y Denault, Martin Girard, Marie-Hélène Roy Cardinal, Michaël Chassé, Sébastien Garneau, Yiorgos Alexandros Cavayas, Guy Cloutier, André Y Denault

Abstract

Background: Mechanical ventilation is a common therapy in operating rooms and intensive care units. When ill-adapted, it can lead to ventilator-induced lung injury (VILI), which is associated with poor outcomes. Excessive regional pulmonary strain is thought to be a major mechanism responsible for VILI. Scarce bedside methods exist to measure regional pulmonary strain. We propose a novel way to measure regional pleural strain using ultrasound elastography. The objective of this study was to assess the feasibility and reliability of pleural strain measurement by ultrasound elastography and to determine if elastography parameters would correlate with varying tidal volumes.

Methods: A single-blind randomized crossover proof of concept study was conducted July to October 2017 at a tertiary care referral center. Ten patients requiring general anesthesia for elective surgery were recruited. After induction, patients received tidal volumes of 6, 8, 10, and 12 mL.kg-1 in random order, while pleural ultrasound cineloops were acquired at 4 standardized locations. Ultrasound radiofrequency speckle tracking allowed computing various pleural translation, strain and shear components. We screened 6 elastography parameters (lateral translation, lateral absolute translation, lateral strain, lateral absolute strain, lateral absolute shear and Von Mises Strain) to identify those with the best dose-response with tidal volumes using linear mixed effect models. Goodness-of-fit was assessed by the coefficient of determination. Intraobserver, interobserver and test-retest reliability were calculated using intraclass correlation coefficients.

Results: Analysis was possible in 90.7% of ultrasound cineloops. Lateral absolute shear, lateral absolute strain and Von Mises strain varied significantly with tidal volume and offered the best dose-responses and data modeling fits. Point estimates for intraobserver reliability measures were excellent for all 3 parameters (0.94, 0.94, and 0.93, respectively). Point estimates for interobserver (0.84, 0.83, and 0.77, respectively) and test-retest (0.85, 0.82, and 0.76, respectively) reliability measures were good.

Conclusion: Strain imaging is feasible and reproducible. Future studies will have to investigate the clinical relevance of this novel imaging modality.

Clinical trial registration: www.Clinicaltrials.gov, identifier NCT03092557.

Keywords: general anesthesia; lung imaging; mechanical ventilalion; pulmonary strain; ultrasound elastography; ventilator-induced lung injury.

Conflict of interest statement

MG is a paid consultant for the point-of-care ultrasonography group of GE Healthcare. GC has an active commercial license with Rhéolution Inc. (Montréal, Canada) and a license option with Siemens Healthcare. AD reported non-financial educational material support from CAE Healthcare, research equipment grants from Edwards and was on Masimo’s speaker bureau. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Girard, Roy Cardinal, Chassé, Garneau, Cavayas, Cloutier and Denault.

Figures

FIGURE 1
FIGURE 1
Calculating lateral strain and lateral absolute strain values. (A) Instantaneous strain values are computed in all sub-ROIs between consecutive frames of a cineloop. (B) By averaging all instantaneous sub-ROI strain values in a single frame, instantaneous strain values for the whole ROI are plotted for all frames of the cineloop. (C) The summation of instantaneous strain values produces the cumulative strain of the pleura. Lateral strain is the range of the cumulative lateral strain experienced by the lung in the ROI. (D) On the other hand, by averaging all absolute sub-ROI instantaneous strain values in a single frame, instantaneous absolute strain values for the whole ROI are plotted for all frames of the cineloop. (E) The summation of the instantaneous absolute strain values produces the cumulative absolute strain of the pleura. Lateral absolute strain is the range of the cumulative lateral absolute strain experienced by the lung in the ROI.
FIGURE 2
FIGURE 2
Regression lines, 95% confidence bands and individual data points for all elastography parameters across the various tidal volumes stratified by gravity dependence. (A) Lateral translation. (B) Lateral absolute translation. (C) Lateral strain. (D) Lateral absolute strain. (E) Lateral absolute shear. (F) Von Mises strain. PBW, predicted body weight.
FIGURE 3
FIGURE 3
Slope estimates for elastography parameters in increasing order stratified by gravity dependence. Significant parameters are identified by an asterix.
FIGURE 4
FIGURE 4
Intraclass correlation coefficients and 95% confidence intervals for intraobserver, interobserver and test-retest reliability measures for elastography parameters. Intraclass correlation coefficients in the red panel indicate poor reliability, values in the orange panel indicate moderate reliability, values in the yellow panel indicate good reliability and values in the green panel indicate excellent reliability.

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