Pediatric Pulmonology 49:764771 (2014)

Challenging a Paradigm: Positional Changes in

Ventilation Distribution Are Highly Variable in Healthy
Infants and Children
Alison R. Lupton-Smith, BSc (Physio),1* Andrew C. Argent, FCPaeds (SA), MD,1,2
Peter C. Rimensberger, MD,3 and Brenda M. Morrow, PhD1,2
Summary. Rationale: Current understanding is that infants and children preferentially ventilate
non-dependent lungs, a reversal of that of adults, based on studies using krypton-81m ventilation
scanning. Participants in these studies had lung disease and were either sedated or ventilated.
There is little understanding of the distribution of ventilation in spontaneous breathing healthy
infants and children. Objectives: This study aimed to determine the effects of side lying on the
distribution of ventilation in healthy, spontaneously breathing infants and children between the
ages of 6 months and 9 years. Methods and Measurements: Measurements were taken using
electrical impedance tomography (EIT) in supine, left and right side lying. Distribution of ventilation
was described using end-expiratory to end-inspiratory relative impedance change. Results: Fifty-
six (31, 55% male) participants were studied. Nineteen (35%) participants consistently showed
greater ventilation in the non-dependent lung, eight (15%) consistently showed greater ventilation
in the dependent lung and 28 (51%) showed a varied pattern between left and right side lying.
Overall, left side lying resulted in significantly better mean ventilation of the right (non-dependent)
lung (P < 0.01). Distribution of ventilation in right side lying was relatively equal between left and
right lungs. Conclusions: This study demonstrates that the distribution of ventilation in
spontaneously breathing infants and children is not as straightforward as previously described.
The distribution of ventilation was variably affected by body position with no clear reversal of the
adult pattern evident. Pediatr Pulmonol. 2014; 49:764771. 2013 Wiley Periodicals, Inc.

Key words: electrical impedance tomography; body position; infants and children;
ventilation distribution.

Funding source: Medical Research Council of South Africa; Institute of Child Health, UCT;
Research Foundation of the South African Society of Physiotherapy

INTRODUCTION lungs, in healthy subjects, with respect to gravity thereby

Positioning is commonly used in ill and critically ill
patients in order to optimize ventilation and ventilation/
perfusion matching.1 Positioning is therefore, an impor-
tant component of the management of respiratory disease.
Different body positions change the orientation of the
affecting the distribution of ventilation.2 The distribution
of ventilation in response to different body positions in
adults has been well established, with greater ventilation
occurring in the dependent (lower) lung.3 Studies using
81-m krypton scanning,4,5 where majority of the
participants had lung disease and were mechanically

1
School of Child and Adolescent Health, University of Cape Town, Cape
Town, South Africa.
2
Paediatric Intensive Care Unit, Red Cross War Memorial Childrens
Hospital, Cape Town, South Africa.
3
Department of Paediatrics, University Hospital of Geneva, Pediatric and
Neonatal Intensive Care Unit, Geneva, Switzerland.
Presentations: Abstract presented at Critical4Africa, Combined meeting of
the Critical Care Society of Southern Africa (CCSSA), South African
Thoracic Society (SATS), South African Society for Parenteral and Enteral
Nutrition (SASPEN) and Trauma Society of South Africa (TSSA). S Afr J
Crit Care 2012;28(1):2836.
Conflict of Interest: None.


Correspondence to: Alison Lupton-Smith, BSc (Physio), UCT School of
Child and Adolescent Health, 5th Floor, Institute of Child Health Building,
Red Cross War Memorial Childrens Hospital, Klipfontein Road,
Rondebosch 7700, Cape Town, South Africa.
E-mail: alison.lupton-smith@uct.ac.za
Received 23 January 2013; Revised 17 July 2013; Accepted 17 July 2013.
DOI 10.1002/ppul.22893
Published online 5 September 2013 in Wiley Online Library
(wileyonlinelibrary.com).

2013 Wiley Periodicals, Inc.


ventilated, described greater ventilation occurring in the
non-dependent (upper) lung in the pediatric population,
opposite to that of adults. This is often described as the
pediatric pattern of ventilation and is thought to
continue into the second decade of life.6 These studies
currently guide clinical practice in the pediatric popula-
tion. However, recent studies in healthy, spontaneously
breathing neonates and infants under 6 months of age79
have questioned these previously reported findings. Two
of these studies reported that in neonates9 and infants up
to 6 months of age8 the distribution of ventilation in
supine and prone positions was similar to that found in
adults. Frerichs et al.7 also reported that neonates showed
greater ventilation of the dependent lung in right side
lying during spontaneous sighs. In order to correctly
understand how ventilation is distributed in different
disease states or during mechanical ventilation, and to
inform clinical practice; an understanding of what occurs
under normal circumstances is imperative. However,
there are no studies investigating the normal distribution
of ventilation in spontaneously breathing, healthy infants
and children beyond neonatal age.
Previous methods of determining the distribution of
ventilation in infants and children have proved difficult,
given the limited ability of children to co-operate with
testing procedures, as well as the lack of suitable testing
procedures that do not require sedation, radiation
exposure or invasive procedures. This makes baseline
studies on healthy infants and children difficult. Electrical
impedance tomography (EIT), however, allows for non-
invasive, radiation-free imaging, which may be particu-
larly suited to this population. EIT has been well validated
and has repeatedly been found to reliably detect changes
in ventilation within the lungs.1020 EIT can be used for
extended periods of time with no known harmful effects
or the need for sedation.7,13,21 Measurements can be
obtained at up to 40 scans per second,22 which is
particularly useful for the pediatric population where
irregular breathing is common. EIT measures changes in
impedance (resistance of biological tissues to alternating
current) in the lungs, by applying a small alternating
current through 16 electrodes around the thorax and
measuring the resulting potential differences.15,22 Imped-
ance increases during inspiration as a result of stretching
of the lung tissue as air flows into the lungs.11,15,22 The
reverse is true for expiration. Changes in impedance are,
therefore, closely related to tidal volume.23
Given the current lack of understanding of the
distribution of ventilation in the pediatric population in
response to different body positions, the aims of this study
ABBREVIATIONS:
EIT electrical impedance tomography
SD standard deviation
Effects of Side Lying on Ventilation in Children 765
were to determine the effects of left and right side lying on
the distribution of ventilation in healthy, spontaneously
breathing infants and children using EIT and to establish
whether there are age related differences in this
distribution.
METHODS
A cross-sectional observational study was conducted of
healthy, spontaneously breathing, unsedated infants and
children between the ages of 6 months and 9 years
attending out-patient clinics and day wards at Red Cross
War Memorial Childrens Hospital, Cape Town, South
Africa. Subjects were excluded if they had any respiratory
disease or other factors impacting on respiratory
mechanics.
A sample size of 40 subjects (10 in each age group: 6
12 months; 13 years; 46 years; 79 years) was
calculated as being required in order to detect a mean
difference in relative impedance change (DZ), in large
lung regions, of four with a standard deviation (SD) of 3.5
(alpha 0.5, power 0.8). A total of 56 subjects were
recruited in order to allow for the possibility of poor
quality data if participants did not cooperate fully. Ethical
approval was obtained from the Human Research Ethics
Committee of the University of Cape Town. Written
informed consent was obtained from the parent or legal
guardian of all participants and verbal or written assent
was obtained from participants where age-appropriate.
Procedure
EIT measurements were taken in the following three
body positions: supine with the head midline, left and right
side lying. The order chosen was one of convenience owing
to co-operation challenges in young, active children.
Sixteen neonatal sized electrodes (Blue Sensor
BR-50-K, Ambu, Ballerup, Denmark), connected to the
EIT device (Goettingen Goe-MF II EIT System; Viasys/
Carefusion, Hochberg, Germany), were placed around the
thorax at the level of the nipple line. Recordings were
taken for approximately 1 min in each position, EIT scans
were generated at 13 scans/sec. Positioning was standard-
ized, as far as possible, with the head supported on a
pillow in side lying, the upper limbs relaxed (with no
movement); the shoulders flexed forward, perpendicular
to the trunk and the lower limbs relaxed with hips and
knees flexed to ensure a stable pelvis. In supine, the arms
were dependent at the sides.
Off-Line Analysis
Analysis was performed off-line using Auspex Version
1.6 software (Viasys Healthcare, Amsterdam, Netherlands).
The data was filtered to eliminate the effect of the heart.21,24
A series of five reproducible tidal breaths, of similar
Pediatric Pulmonology
766 Lupton-Smith et al.
amplitude with no inspiratory or expiratory pauses, were
selected for analysis (Fig. 1a). Functional EIT (fEIT)
images (Fig. 2) were generated using the average of the end-
expiratory to end-inspiratory DZ (Fig. 1b). Calculations
were performed using the sum of pixel values of the fEIT
images for global DZ and regional DZ for regions of interest
(ROI). ROI were determined as described by Pulletz et al.25
with 20% of the regression coefficient being used to
determine the contour. In this case, ROI were the entire left
and right lung, respectively.
Mean DZ change was used to compare left and right
ROI, as well as globally, in different positions. The
difference in mean DZ change between non-dependent
and dependent positions in left and right lungs,
respectively, was calculated to determine the pattern
of ventilation and between- age group comparisons. In
addition, the proportion (%) of ventilation occurring in
each lung region relative to the global ventilation was
calculated for between- age group comparisons.
Statistical Analysis
Analysis was performed using Statistica version 10
(StatSoft, Tulsa, Oklahoma, USA). Data were tested for
normality using the Shapiro Wilks W-test and were found
to be normally distributed. Results are shown as means 
SD and 95% CI. Multi-way ANOVAs were used to
determine differences between age groups and ROI,
respectively in different positions. T-tests for dependent
and independent variables were used to determine
significant differences within and between groups.
P-values 0.05 were considered significant.
RESULTS
Fifty-six participants (31, 55.4% male) were included
in the study. Population characteristics are presented in
Table 1. Complete measurements were obtained in 55
subjects.
Fig. 1. Selection of reproducible tidal breaths (A) used for analysis indicated by vertical lines.
fEIT images were generated for the end-expiration and end-inspiration points are marked with
arrows (B) and are an indication of tidal volume.
Pediatric Pulmonology
Pattern of Ventilation
Nineteen (35%) subjects demonstrated greater ventila-
tion in the non-dependent lung and eight (15%)
demonstrated greater ventilation in the dependent lung
in both left and right side lying, whilst 28 (51%) followed
different patterns in left and right side lying.
Distribution of Ventilation in Left and Right Lungs
The global and regional DZ changes in supine and side
lying positions are presented in Table 2. There was no
significant difference in global ventilation between the
different positions. There was no difference in DZ
between left and right lungs in supine. Overall ventilation
of the right lung was greater than the left when lying on
the left side, while mean ventilation of both lungs was
equal in right side lying (Table 2).
The right lung showed greater ventilation when non-
dependent in 36 (65%) of the participants, whereas the left
lung showed better ventilation when non-dependent in 30
(55%) of participants.
Both left and right lungs showed greater ventilation
when non-dependent compared to dependent in side lying
(Table 2), although this was only significant in the right
lung. The difference between left and right lungs when
non-dependent approached significance (P 0.06; Ta-
ble 2). There was a significant decrease in ventilation in
both left (P 0.004) and right (P 0.02) lungs when
moving from supine position to side lying with that lung
dependent (Table 2). In left side lying there was a
significant difference in ventilation between left and right
lungs, with the right (non-dependent) lung being better
ventilated, whilst no difference was noted between left
and right lungs in right side lying (Table 2). The right lung
was better ventilated in left side lying when compared to
right side lying (P 0.02).
Comparison of the proportion of ventilation relative to
global ventilation, between left and right lungs, revealed
 Effects of Side Lying on Ventilation in Children 767

Fig. 2. fEIT images in right side lying from two different participants (both between the ages of 4
and 6 years). Lighter portions indicate areas of greater ventilation. (A) Indicates greater
ventilation in the non-dependent (left) lung and (B) indicates greater ventilation in the dependent
(right) lung.

that the right lung had a significantly greater proportion of
ventilation (P < 0.001) than the left lung in left side lying,
whilst there was no difference in right side lying (P 0.9).
The Effect of Age
The distribution of ventilation in the left and right
lungs, as well as globally, was similar between age groups
in the different positions (Fig. 3); however, significant
age-related changes were found in the proportion of
ventilation in the left and right lungs (Fig. 4) in side lying.
Significant age-related differences were found when
comparing the DZ change in the left lung between side
lying positions. The 612 months group favourably
ventilated the left lung when non-dependent, whereas the
older age groups (13 and 79 years) favourably
ventilated the left lung when dependent. No age-related
differences were found in the right lung (Table 3 and
Fig. 5).
A significantly greater proportion of ventilation
occurred in the right (nondependent) lung compared to
the left lung in left side lying, amongst all age groups
(Fig. 4). In right side lying, the 612 months age group
demonstrated a significantly greater proportion of
ventilation in the left (non-dependent) lung, while the
13 years age group had a greater proportion of
ventilation in the right (dependent) lung. The 46 years
and 79 years age groups demonstrated relatively equal
ventilation between left and right lungs in right side lying
(Fig. 4).
DISCUSSION
This study examined the regional distribution of
ventilation in spontaneously breathing, healthy infants
and children in response to side lying positions, using EIT.
Our results show that the distribution of ventilation in
healthy, spontaneously breathing, nonsedated infants and
children is complex, with the pattern of ventilation not
being uniform as previously reported.4,5 A high degree of
variability was found between participants with approxi-
mately half showing a different pattern of ventilation
distribution between right and left lungs in side lying
positions. Only about one-third of the children conformed
to the previously described pattern of consistently greater
ventilation in the non-dependent lung.4,5,26 Age related
differences were primarily noted in the left lung, and
between those younger and older than 12 months, with
those under 12 months demonstrating better ventilation in
the non-dependent lung.

TABLE 1 Population Characteristics (Mean  SD)

TABLE 2 Mean DZ  SD of Lung Regions in Different
Gender Positions
(male: Respiratory rate
Age group Number female) Age (years) (breath per minute) Lung region Supine Left side lying Right side lying


,
612 months 10 6:4 0.85  0.11 47.00  7.42 Left 16.8  9.0 14.1  7.3 15.6  9.3ll
13 years 18 11:7 2.76  0.94 26.78  5.34 Right 17.8  7.9 18.4  7.5,,ll 15.7  7.0,
46 years 18 7:11 5.59  0.94 21.94  3.62 Global 34.6  16.3 32.6  13.5 31.5  14.3
79 years 10 7:3 8.72  0.85 19.90  2.85
Total 56 31:25 Comparisons are marked as significant.


P 0.004; P 0.02; P 0.002; P 0.02; llP 0.06.

Pediatric Pulmonology
768 Lupton-Smith et al.

Fig. 3. Mean relative tidal impedance change (DZ) in left (A) and right (B) lungs between age
groups in left side lying (sd ly), supine and right side lying. Points represent means and vertical
bars denote 95% CI.

This is the first study of postural effects on ventilation
distribution in normal, healthy children. The majority of
participants in previous studies4,5 displayed abnormal
chest radiographs and were either mechanically ventilat-
ed or most likely required sedation. These factors may all
affect respiratory mechanics and may predispose to
favourable ventilation of the non-dependent lung,7,9,27
accounting for the difference between our findings.
The most notable effect of position on the distribution
of ventilation was in left side lying, with a significantly
larger proportion of ventilation in the non-dependent
(right) lung. This is in keeping with the pattern described
by Davies et al.4 In right side lying, however, both the
distribution and proportion of ventilation remained
relatively equal between the left and right lungs, although
there was a trend towards greater ventilation in the non-
dependent lung. These findings are in keeping with those
of Frerichs et al.7
The marked difference between left and right side lying
is not unexpected given the asymmetry of the chest and
related organs, particularly the heart, which occupies the
left ventral compartment.28 In left side lying the
gravitational effect on the heart, the heaviest structure
in the thorax, would likely limit left lung expansion. This
is supported by the suggestion that changes in the
distribution of ventilation in different positions are
primarily attributed to movement of thoracic tissue in
response to gravity.2931 To our knowledge, there are no
reports on the effect of left side lying on the distribution of
ventilation in infants and children.

Fig. 4. Proportion of ventilation (relative to global ventilation) in left and right lungs, depicted as
means, 95% CI and minmax values, in left (A) and right (B) side lying. Comparisons marked as
significant
P 0.03 between left and right lungs; P < 0.001 between left and right lungs;

P 0.003 between left and right lungs; P < 0.001;

P 0.02 between left and right lungs.
ll
P 0.01 within left and right lungs, respectively between age groups; P 0.01 within left and
right lungs, respectively, between age groups; P 0.02 within left and right lungs, respectively
between age groups.

Pediatric Pulmonology

TABLE 3 Mean  SD Difference in DZ in Left and Right
Lungs, Respectively, When Moving From Non-Dependent to
Dependent
Age group Left lung Right lung

,
612 months 4.9  5.9 1.3  9.0
13 years 0.3  4.7
5.0  5.3
46 years 2.8  15.0 0.4  9.3
79 years 2.0  4.8 4.6  8.5
A positive value indicates greater ventilation of the non-dependent
lung, whilst a negative value indicates greater ventilation of the
dependent lung. Comparisons are marked as significant.

The longer the resting length, the better the contraction
P 0.04; P 0.01.
Authors of previous studies4,5 attributed the difference
between ventilation distribution in adults towards the
dependent lung3 and the trend towards better ventilation
of the non-dependent lung in infants and children to
differences in respiratory mechanics. Ventilation is
determined by a complex interplay between chest wall,
lung, respiratory muscle and pleural dynamics. In adults
the changes in the distribution of ventilation are primarily
due to differences in pleural pressure, which become
progressively more positive down the vertical axis of the
thorax as a result of gravity.32,33 These changes in pleural
pressures result from increased superimposed pressures
on the dependent lung by the weight of the lung above
it.31,34 Consequently, the dependent lung has lower
resting volumes and expands more during inspiration
than the non-dependent lung.31 Children differ from
adults in that they have higher chest wall compliance35; as
a result the resting pleural pressure is more positive. This
results in a lower functional residual capacity which nears
closing volumes.4,5,35,36 The higher resting pleural
pressure, in addition to the gravitational effects on the
intrapleural pressure,32 is likely to result in airway closure
Fig. 5. The proportion of participants in different age groups
demonstrating better ventilation of the left and right lungs when
either dependent or non-dependent. The left lung is dependent
in left side lying and non-dependent in right side lying. This is
reversed for the right lung.
Effects of Side Lying on Ventilation in Children 769
in dependent lung portions and therefore, greater
ventilation in the non-dependent lung. Most of the
changes in the chest wall and respiratory musculature
occur up to the age of 2 years, coinciding with motor
development where a more upright posture is as-
sumed.37,38 After about 2 years of age the chest wall
and respiratory musculature are similar to that of adults.37
Heaf et al.5 also postulated that the side lying position
places the dependent hemidiaphragm at a mechanical
disadvantage. Contractility of the diaphragm is governed,
in part, by the resting length of the muscle fibres (preload).
and therefore greater ventilation to the lung.39 In adults, in
side lying, there is greater preload on the dependent
hemidiaphragm as a result of pressure from the abdominal
contents, hence better ventilation of the dependent lung.
Davies et al.4 and Heaf et al.5 postulated that due to the
narrower abdomen in infants, the difference in preload of
the dependent and non-dependent diaphragm is less,
resulting in greater ventilation of the non-dependent lung5
or a smaller difference between lungs.4 These factors may
explain the overall trend to greater ventilation in the non-
dependent lung in our study, particularly in infants under
12 months of age.
The variability found amongst different children is
difficult to explain, although it may relate in part to
normal physiological principles in which energy is likely
to be conserved by varying patterns of respiratory muscle
use.40 Irregular respiratory rates and patterns may also
contribute to this variability. The lack of variability
described in earlier studies of mostly ventilated children
with lung pathology,4,5 may reflect a diseased state in
which normal fluctuations of breathing pattern are not
possible. Intersubject variability may also be due, in part,
to differences in developmental levels given that the chest
wall is similar to that of adults by the age of 2 years and
may result in a similar distribution of ventilation to that of
adults. Coinciding with the changes in the chest wall are
changes in respiratory muscle strength and function38 and
chest wall compliance.35 The vertical height of the lungs
(size of the child) may also affect the distribution of
ventilation, and possibly explain some of the variability
found in our study, based on findings of Agostoni and
DAngelo41 that the vertical pleural pressure gradient
decreases with increasing size (height of the lung). These
suggestions require further investigation, particularly
considering that we were unable to show clear age-
related differences in ventilation distribution.
It is possible that the relative impedance measured also
reflected changes in perfusion, which is known to be
affected by gravity. However, it has been noted that changes
in perfusion account for <5% of the recorded relative
impedance.42 Perfusion is related to cardiac frequency. By
filtering the data to exclude the heart noise,24 effects of
perfusion on the readings were likely reduced.
Pediatric Pulmonology
770 Lupton-Smith et al.
Our results suggest that in clinical practice it cannot be
assumed that every spontaneously breathing child without
respiratory disease will better ventilate the non-dependent
lung. The high degree of variability found in this study,
provides a persuasive argument for of the use of real-time
imaging, such as EIT, in choosing the optimal position for
a child in the clinical situation; particularly if the childs
response to a given position is not clear when using
conventional means such as respiratory rate and pattern,
oxygen saturation and auscultation.
There are several limitations to this study. This study
would have been strengthened had direct measurements
of tidal volume and end-expiratory lung volume been
taken. The order of positions proved difficult to
randomize due to co-operation challenges. We were
unable to determine whether the order of positions chosen
had any effect on the distribution of ventilation.
Positioning, although reproducible, was not absolutely
standardized, given that these were unsedated, healthy
children. Owing to co-operation challenges some young
infants had to be held in position. We cannot confirm
whether this influenced ventilation distribution. Repro-
ducibility in each position was not measured. Although
previous studies in adults,3,16 animals14 and neonates43
have shown EIT to be highly reproducible, future studies
on different population groups should include measures
of reproducibility as this could account for some of the
variability observed. Due to the short periods of
measurement time in each position, we were unable to
determine if the distribution of ventilation changes over
time in each new position. Whilst we have postulated
possible explanations for the observed variability in
ventilation distribution, these were not directly examined
in this study and require further investigation.
This study has provided new insights into the
distribution of ventilation in side lying in healthy,
spontaneously breathing infants and children and ques-
tions the underlying assumptions currently guiding
clinical practice. The distribution of ventilation was
variably affected by body position, with no clear
pediatric pattern of ventilation or age related differ-
ences in ventilation distribution. This study provides a
baseline to which future studies can be compared. Future
research should be directed at determining the effects of
mechanical ventilation, respiratory disease states and
respiratory muscle function on the distribution of
ventilation in the pediatric population. It would also be
beneficial for clinical practice to determine if there is
a time-dependent component to the distribution of
ventilation.
ACKNOWLEDGMENT
Inez Frerichs for training in EIT application.
Pediatric Pulmonology
REFERENCES
1. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M,
Schonhofer B, Stiller K, van de Leur H, Vincent JL. Physiotherapy
for adult patients with critical illness: recommendations of the
European respiratory society and European society of intensive
care medicine task force on physiotherapy for critically ill
patients. Intensive Care Med 2008;34:11881199.
2. Bryan AC, Milic-Emili J, Pengelly D. Effect of gravity on the
distribution of pulmonary ventilation. J Appl Physiol 1966
21:778784.
3. Riedel T, Richards T, Schibler A. The value of electrical
impedance tomography in assessing the effect of body position
and positive airway pressures on regional lung ventilation in
spontaneously breathing subjects. Intensive Care Med 2005;31:
15221528.
4. Davies H, Kitchman R, Gordon I, Helms P. Regional ventilation in
infancy. N Engl J Med 1985;313:16261628.
5. Heaf D, Helms P, Gordon I, Turner H. Postural effects on
gas exchange in infants. N Engl J Med 1983;308:15051508.
6. Davies H, Helms P, Gordon I. Effect of posture on regional
ventilation in children. Pediatr Pulmonol 1992;12:227232.
7. Frerichs I, Schiffmann H, Oehler R, Dudykevych T, Hahn G, Hinz
J, Hellige G. Distribution of lung ventilation in spontaneously
breathing neonates lying in different body positions. Intensive
Care Med 2003;29:787794.
8. Pham T, Yuill M, Dakin C, Schibler A. Regional ventilation
distribution in the first 6 months of life. Eur Respir J 2011;37:919
924.
9. Schibler A, Yuill M, Parsley C, Pham T, Gilshenan K, Dakin C.
Regional ventilation distribution in non-sedated spontaneously
breathing newborns and adults is not different. Pediatr Pulmonol
2009;44:851858.
10. Victorino JA, Borges JB, Okamoto VN, Matos GFJ, Tucci MR,
Caramez MPR, Tanaka H, Sipmann FS, Santos DCB, Barbas
CSV, Carvalho CRR, Amato MBP. Imbalances in regional
lung ventilation. Am J Respir Crit Care Med 2004;169:791
800.
11. Frerichs I, Braun P, Dudykevych T, Hahn G, Genee D, Hellige G.
Distribution of ventilation in young and elderly adults determined
by electrical impedance tomography. Respir Physiol Neurobiol
2004;143:6375.
12. Frerichs I, Dargaville P, Dudykevych T, Rimensberger P. Electrical
impedance tomography: a method for monitoring regional lung
aeration and tidal volume distribution? Intensive Care Med
2003;29:23122316.
13. Bodenstein M, David M, Markstaller K. Principles of electrical
impedance tomography and its clinical application. Crit Care Med
2009;37:713724.
14. Frerichs I, Schmitz G, Pulletz S, Schadler D, Zick G, Scholz J,
Weiler N. Reproducibility of regional lung ventilation distribution
determined by electrical impedance tomography during mechani-
cal ventilation. Physiol Meas 2007;28:S261S267.
15. Moerer O, Hahn G, Quintel M. Lung impedance measurements to
monitor alveolar ventilation. Curr Opin Crit Care 2011;17:260
267.
16. Reifferscheid F, Elke G, Pulletz S, Gawelczyk B, Lautenschlager I,
Steinfath M, Weiler N, Frerichs I. Regional ventilation distribution
determined by electrical impedance tomography: reproducibility
and effects of posture and chest plane. Respirology 2011;16:
523531.
17. Kunst PW, Vonk Noordegraaf A, Hoekstra OS, Postmus PE, de
Vries PM. Ventilation and perfusion imaging by electrical
impedance tomography: a comparison with radionuclide scan-
ning. Physiol Meas 1998;19:481490.

18. Richard JC, Pouzot C, Gros A, Tourevieille C, Lebars D, Lavenne
F, Frerichs I, Guerin C. Electrical impedance tomography
compared to positron emission tomography for the measurement
of regional lung ventilation: an experimental study. Crit Care
2009;13:R82.
19. Smit HJ, Handoko ML, Vonk Noordegraaf A, Faes A, Postmus TJ,
de Vries PE, Boonstra A. Electrical impedance tomography to
measure pulmonary perfusion: is the reproducibility high enough
for clinical practice? Physiol Meas 2003;24:491499.
20. de Lema JB, Serrano E, Feixas T, Calaf N, Camacho MV, Riu PJ,
Casan P. Assessment of differential lung function by electrical
impedance tomography. Arch Bronconeumol 2008;44:408412.
21. Heinrich S, Schiffmann H, Frerichs A, Klockgether-Radke A,
Frerichs I. Body and head position effects on regional lung
ventilation in infants: an electrical impedance tomography study.
Intensive Care Med 2006;32:13921398.
22. Calzia E, Hahn G, Hellige G. Electrical impedance tomography:
looking behind the secrets of regional lung function. Intensive
Care Med 2005;31:14741475.
23. Frerichs I, Hinz J, Herrmann P, Weisser G, Hahn G, Quintel M,
Hellige G. Regional lung perfusion as determined by electrical
impedance tomography in comparison with electron beam CT
imaging. IEEE Trans Med Imaging 2002;21:646652.
24. Zadehkoochak M, Blott BH, Hames TK, George RF. Pulmonary
perfusion and ventricular ejection imaging by frequency domain
filtering of EIT (electrical impedance tomography) images. Clin
Phys Physiol Meas 1992;13:191196.
25. Pulletz S, van Genderingen HR, Schmitz G, Zick G, Schadler D,
Scholz J, Weiler N, Frerichs I. Comparison of different methods to
define regions of interest for evaluation of regional lung ventilation
by EIT. Physiol Meas 2006;27:S115S127.
26. Bhuyan U, Peters A, Gordon I, Davies H, Helms P. Effects of
posture on the distribution of pulmonary ventilation and perfusion
in children and adults. Thorax 1989;44:480484.
27. Hatch D, Fletcher M. Anaesthesia and the ventilatory system in
infants and young children. Br J Anaesth 1992;68:398410.
28. Drake RL. Grays Basic Anatomy. Philadelphia, PA: Churchill
Livingston/Elsevier; 2012.
29. Grant CA, Pham T, Hough J, Riedel T, Stocker C, Schibler A.
Measurement of ventilation and cardiac related impedance
changes with electrical impedance tomography. Crit Care
2011;15:R37.
Effects of Side Lying on Ventilation in Children 771
30. Petersson J, Rohdin M, Sanchez-Crespo A, Nyren S, Jacobsson H,
Larsson SA, Lindahl SG, Linnarsson D, Neradilek B, Polissar NL,
Glenny RW, Mure M. Posture primarily affects lung tissue
distribution with minor effect on blood flow and ventilation.
Respir Physiol Neurobiol 2007;156:293303.
31. Frerichs I, Hahn G, Hellige G. Gravity-dependent phenomena in
lung ventilation determined by functional EIT. Physiol Meas
1996;17:A149A157.
32. West JB. Respiratory Physiology the Essentials. 9th revised
edition. Philadelphia/US: Lippincott Williams and Wilkins; 2011.
33. Galvin I, Drummond GB, Nirmalan M. Distribution of blood flow
and ventilation in the lung: gravity is not the only factor. Br J
Anaesth 2007;98:420428.
34. Gattinoni L, Pelosi P, Vitale G, Pesenti A, DAndrea L,
Mascheroni D. Body position changes redistribute lung comput-
ed-tomographic density in patients with acute respiratory failure.
Anesthesiology 1991;74:1523.
35. Papastamelos C, Panitch HB, England SE, Allen JL. Develop-
mental changes in chest wall compliance in infancy and early
childhood. J Appl Physiol 1995;78:179184.
36. Mansell A, Bryan C, Levison H. Airway closure in children. J Appl
Physiol 1972;33:711714.
37. Openshaw P, Edwards S, Helms P. Changes in rib cage geometry
during childhood. Thorax 1984 39:624627.
38. Gaultier C. Respiratory muscle function in infants. Eur Respir J
1995;8:150153.
39. Pengelly LD, Alderson AM, Milic-Emili J. Mechanics of the
diaphragm. J Appl Physiol 1971;30:797805.
40. Hutten GJ, van Eykern LA, Latzin P, Kyburz M, van Aalderen
WM, Frey U. Relative impact of respiratory muscle activity on
tidal flow and end expiratory volume in healthy neonates. Pediatr
Pulmonol 2008;43:882891.
41. Agostoni E, DAngelo E. Comparative features of the
transpulmonary pressure. Respir Physiol 19701971;11:76
83.
42. Frerichs I, Pulletz S, Elke G, Reifferscheid F, Schadler D, Scholz J,
Weiler N. Assessment of changes in distribution of lung perfusion
by electrical impedance tomography. Respiration 2009;77:282
291.
43. Frerichs I, Schiffmann H, Hahn G, Hellige G. Non-invasive
radiation-free monitoring of regional lung ventilation in critically
ill infants. Intensive Care Med 2001;27:13851394.
Pediatric Pulmonology