Our aim was to prospectively investigate whether the recently introduced suction/inspiration against resistance breathing method leads to higher computed tomography (CT) contrast density in the pulmonary artery compared to standard breathing.
Material and methods
The present study was approved by the Medical Ethics committee and all subjects gave written informed consent. Fifteen patients, each without suspicious lung emboli, were randomly assigned to four different groups with different breathing maneuvers (suction against resistance, Valsalva, inspiration, expiration) during routine CT. Contrast enhancement in the central and peripheral sections of the pulmonary artery were measured and compared with one another.
Peripheral enhancement during suction yielded increased mean densities of 138.14 Hounsfield units (HU) (p = 0.001), compared to Valsalva and a mean density of 67.97 HU superior to inspiration (p = 0.075). Finally, suction in comparison to expiration resulted in a mean increase of 30.51 HU (p = 0.42). Central parts of pulmonary arteries presented significantly increased enhancement values (95.74 HU) for suction versus the Valsalva technique (p = 0.020), while all other mean densities were in favour of suction (versus inspiration: p = 0.201; versus expiration: p = 0.790) without reaching significance.
Suction/Inspiration against resistance is a promising technique to improve contrast density within pulmonary vessels, especially in the peripheral parts, in comparison to other breathing maneuvers.
• Suction/Inspiration against resistance is promising to improve contrast density within the pulmonary artery.
• Patients potentially suffering pulmonary embolism are able to follow suction/inspiration against resistance.
• Contrast density after suction is superior in comparison to other breathing maneuvers.
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We thank Professor Dr. med. Georg Bongartz from the Department of Radiology and Nuclear Medicine of the University Hospital in Basel (Switzerland) for his valuable input during the ECR 2012 lecture concerning influencing factors regarding contrast enhancement using pulmonary CT. This served as the final impetus to perform this study.
We would especially like to thank Martin Hinnen (Head of the Technicians’ Service) and his CT Team of the Cantonal Hospital Winterthur for helping us manage and examine the patients.
Finally we want to thank Nicole Graf, who performed the statistical analysis (www.biostatistics.ch).
The scientific guarantor of this publication is Andreas Gutzeit. The authors of this manuscript declare relationships with the following companies: Author No. 2 is a consultant for Guerbet contrast media company. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. Several authors are experienced in statistics. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. Methodology: prospective, randomized controlled trial, performed at one institution.
Electronic supplementary material
Below is the link to the electronic supplementary material.
The video is merely supplementary to Fig. 6. It is intended to illustrate the dynamic processes during physiological inspiration and expiration under standardized suction against resistance and a standardized Valsalva maneuver. The video illustrates an MRI study, which was recently published  (AVI 5481 kb)
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Gutzeit, A., Froehlich, J.M., Wälti, S. et al. Suction/Inspiration against resistance or standardized Mueller maneuver : a new breathing technique to improve contrast density within the pulmonary artery: a pilot CT study. Eur Radiol 25, 3133–3142 (2015). https://doi.org/10.1007/s00330-015-3735-y
- Pulmonary embolism
- Computed tomography angiography
- Pulmonary vessel
- Contrast density