title: Reducing the within-patient variability of breathing for radiotherapy delivery in conscious, unsedated cancer patients using a mechanical ventilator.
abstract: OBJECTIVE
  Variability in the breathing pattern of patients with cancer during radiotherapy requires mitigation, including enlargement of the planned treatment field, treatment gating and breathing guidance interventions. Here, we provide the first demonstration of how easy it is to mechanically ventilate patients with breast cancer while fully conscious and without sedation, and we quantify the resulting reduction in the variability of breathing.
  
  
  METHODS
  15 patients were trained for mechanical ventilation. Breathing was measured and the left breast anteroposterior displacement was measured using an Osiris surface-image mapping system (Qados Ltd, Sandhurst, UK).
  
  
  RESULTS
  Mechanical ventilation significantly reduced the within-breath variability of breathing frequency by 85% (p < 0.0001) and that of inflation volume by 29% (p < 0.006) when compared with their spontaneous breathing pattern. During mechanical ventilation, the mean amplitude of the left breast marker displacement was 5 ± 1 mm, the mean variability in its peak inflation position was 0.5 ± 0.1 mm and that in its trough inflation position was 0.4 ± 0.0 mm. Their mean drifts were not significantly different from 0 mm min(-1) (peak drift was -0.1 ± 0.2 mm min(-1) and trough drift was -0.3 ± 0.2 mm min(-1)). Patients had a normal resting mean systolic blood pressure (131 ± 5 mmHg) and mean heart rate [75 ± 2 beats per minute (bpm)] before mechanical ventilation. During mechanical ventilation, the mean blood pressure did not change significantly, mean heart rate fell by 2 bpm (p < 0.05) with pre-oxygenation and rose by only 4 bpm (p < 0.05) during pre-oxygenation with hypocapnia. No patients reported discomfort and all 15 patients were always willing to return to the laboratory on multiple occasions to continue the study.
  
  
  CONCLUSIONS
  This simple technique for regularizing breathing may have important applications in radiotherapy.
  
  
  CONCLUSIONS
  Variations in the breathing pattern introduce major problems in imaging and radiotherapy planning and delivery and are currently addressed to only a limited extent by asking patients to breathe to auditory or visual guidelines. We provide the first demonstration that a completely different technique, of using a mechanical ventilator to take over the patients' breathing for them, is easy for patients who are conscious and unsedated and reduces the within-patient variability of breathing. This technique has potential advantages in radiotherapy over currently used breathing guidance interventions because it does not require any active participation from or feedback to the patient and is therefore worthy of further clinical evaluation.
authors.affiliation: 1 National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.|2 School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Parkes
authors.affiliation: 3 Hall Edwards Radiotherapy Research Group, Department of Medical Physics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Stuart
authors.initials: S
authors.lastname: Green
authors.affiliation: 4 Department of Oncology , University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Andrea M
authors.initials: AM
authors.lastname: Stevens
authors.affiliation: 3 Hall Edwards Radiotherapy Research Group, Department of Medical Physics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Sophia
authors.initials: S
authors.lastname: Parveen
authors.affiliation: 3 Hall Edwards Radiotherapy Research Group, Department of Medical Physics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Stephens
authors.affiliation: 1 National Institute for Health Research (NIHR)/Wellcome Trust Birmingham Clinical Research Facility, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.|5 Department Anaesthesia and Intensive Care Medicine , University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Clutton-Brock
mesh_terms: D000328:Adult; D000368:Aged; D001940:Breast / Q000503:physiopathology* / Q000528:radiation effects; D001943:Breast Neoplasms / Q000503:physiopathology* / Q000532:radiotherapy*; D005260:Female; D006801:Humans; D008875:Middle Aged; D009068:Movement; D056888:Patient Positioning / Q000379:methods; D061106:Radiotherapy Setup Errors / Q000517:prevention & control*; D015203:Reproducibility of Results; D012121:Respiration, Artificial / Q000379:methods*; D015656:Respiratory Mechanics; D012680:Sensitivity and Specificity