Influence of Device-assisted Suction Against Resistance (Mueller Maneuver) on Image Quality in CTPA for Suspected Lung Embolism

Overview

Journal Eur Radiol

Specialty Radiology

Date 2023 Jun 20

PMID 37338555

Authors

Niklas von Munchhausen

Sonja Janssen

Daniel Overhoff

Johann S Rink

Bram Geurts

Andreas Gutzeit

Mathias Prokop

Stefan O Schoenberg

Matthias F Froelich

Affiliations

Soon will be listed here.

Abstract

Objectives: To investigate the effect of a device-assisted suction against resistance Mueller maneuver (MM) on transient interruption of contrast (TIC) in the aorta and pulmonary trunk (PT) on computed tomography pulmonary angiogram (CTPA).

Methods: In this prospective single-center study, 150 patients with suspected pulmonary artery embolism were assigned randomly with two different breathing maneuvers (Mueller maneuver (MM) or standard end-inspiratory breath-hold command (SBC)) during routine CTPA. The MM was performed using a patented prototype (Contrast Booster™) which allows both the patient by means of visual feedback and the medical staff in the CT scanning room to monitor whether the patient is sucking sufficiently or not. Mean Hounsfield attenuation in descending aorta and PT was measured and compared.

Results: Overall, patients with MM showed an attenuation of 338.24 HU in the pulmonary trunk, compared to 313.71 HU in SBC (p = 0.157). In the aorta, the values for MM were lower compared to SBC (134.42 HU vs. 177.83 HU, p = 0.001). The TP-aortic ratio was significantly higher in the MM group at 3.86 compared to the SBC group at 2.26, p = 0.001. TIC phenomenon was absent in the MM group, whereas it was present in 9 patients (12.3%) in the SBC group (p = 0.005). Overall contrast was better on all levels for MM (p < 0.001). The presence of breathing artifacts was higher in the MM group (48.1% vs. 30.1%, p = 0.038), without clinical consequence.

Conclusions: Performing the MM with the application of the prototype is an effective way of preventing the TIC phenomenon during i.v. contrast-enhanced CTPA scanning compared to the standard end-inspiratory breathing command.

Clinical Relevance: Compared to standard end-inspiratory breathing command, the device-assisted Mueller maneuver (MM) improves contrast enhancement and prevents the transient interruption of contrast (TIC) phenomenon in CTPA. Therefore, it may offer optimized diagnostic workup and timely treatment for patients with pulmonary embolism.

Key Points: • Transient interruption of contrast (TIC) may impair image quality in CTPA. • Mueller Maneuver using a device prototype could lower the rate of TIC. • Device application in clinical routine may increase diagnostic accuracy.

References

Di Nisio M, van Es N, Buller H . Deep vein thrombosis and pulmonary embolism. Lancet. 2016; 388(10063):3060-3073. DOI: 10.1016/S0140-6736(16)30514-1. View

Heit J, Spencer F, White R . The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 2016; 41(1):3-14. PMC: 4715842. DOI: 10.1007/s11239-015-1311-6. View

Geersing G, Toll D, Janssen K, Oudega R, Blikman M, Wijland R . Diagnostic accuracy and user-friendliness of 5 point-of-care D-dimer tests for the exclusion of deep vein thrombosis. Clin Chem. 2010; 56(11):1758-66. DOI: 10.1373/clinchem.2010.147892. View

Stein P, Fowler S, Goodman L, Gottschalk A, Hales C, Hull R . Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 2006; 354(22):2317-27. DOI: 10.1056/NEJMoa052367. View

Konstantinides S, Meyer G, Becattini C, Bueno H, Geersing G, Harjola V . 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2019; 41(4):543-603. DOI: 10.1093/eurheartj/ehz405. View

Gosselin M, Rassner U, Thieszen S, Phillips J, Oki A . Contrast dynamics during CT pulmonary angiogram: analysis of an inspiration associated artifact. J Thorac Imaging. 2004; 19(1):1-7. DOI: 10.1097/00005382-200401000-00001. View

Wittram C, Yoo A . Transient interruption of contrast on CT pulmonary angiography: proof of mechanism. J Thorac Imaging. 2007; 22(2):125-9. DOI: 10.1097/01.rti.0000213566.78785.26. View

Gutzeit A, Roos J, Hergan K, von Weymarn C, Walti S, Reischauer C . Suction against resistance: a new breathing technique to significantly improve the blood flow ratio of the superior and inferior vena cava. Eur Radiol. 2014; 24(12):3034-41. DOI: 10.1007/s00330-014-3328-1. View

Gutzeit A, Froehlich J, Walti S, Roos J, Meissnitzer M, Hergan K . 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. 2015; 25(11):3133-42. DOI: 10.1007/s00330-015-3735-y. View

10.

Mortimer A, Singh R, Hughes J, Greenwood R, Hamilton M . Use of expiratory CT pulmonary angiography to reduce inspiration and breath-hold associated artefact: contrast dynamics and implications for scan protocol. Clin Radiol. 2011; 66(12):1159-66. DOI: 10.1016/j.crad.2011.06.012. View

11.

Chen Y, Velayudhan V, Weltman D, Balsam D, Patel N, Draves K . Waiting to exhale: salvaging the nondiagnostic CT pulmonary angiogram by using expiratory imaging to improve contrast dynamics. Emerg Radiol. 2008; 15(3):161-9. DOI: 10.1007/s10140-007-0695-9. View