Deep Inspiration Breath hold and when it is beneficial to use.

It is our job as dosimetrists to achieve the lowest doses possible to critical structures. Deep
inspiration breath hold (DIBH) is a technique that was developed nearly 15 years ago. It is
typically applied when treating hypofractionated or high, single dose SBRT of the lung, liver,
upper abdominal lesions, esophageal cancer, and kidney tumors. It is also commonly used when
treating normal fractionated thoracic tumors of the lung, mediastinal lymph nodes and left breast
cancers. DIBH has shown to reduce heart and lung toxicity in supradiaphragmic Hodgkin
lymphoma.1
Patients with left sided breast cancer have an increase in cardiac mortality, increased rates of
major coronary events and cardiac deaths which is the result of increase mean heart dose from
radiation treatments. When used in treating breast cancer, DIBH increases the separation of the
heart and the chest wall when the lung expands with inspiration in order to decrease the doses
received by the heart.2 (Figure 2) The patient breathes in and holds that volume of air during
radiation which effectively minimizes the heart dose and volume when treated with tangential
ports. DIBH may serve as an alternative to prone breast positioning and studies have shown that
there is minimal setup error within 3-5mm regarding CW positioning.1 Studies have also shown
an achieved decrease in MHD of 25-67% and a decrease if 20-71 of dose to the left anterior
descending coronary artery. These numbers are substantial considering for every 1Gy there is a
4-7.4% increase in chance for heart disease.2
There are two types of DIBH: voluntary DIBH (vDIBH) or free breath hold and moderate DIBH.
During vDIBH patients are instructed to perform deep inspiration. This technique can be
employed without the need of additional equipment. The patient can be monitored by room
lasers and deviation away from their anterior and lateral marks. When the patient has the
prescribed lung volume the marks will align with the room lasers. Moderate DIBH uses
spirometry-based active breathing control devices (ABC Elekta). These devise monitor the
breathing cycle, reduce setup errors, and facilitate breath holds by stopping the flow of air at a
prescribed volume.2
4D gating CT to acquire breathing studies allow dosimetrists to form an internal target volume
(ITV) for tumor movement. A study performed noticed that breathing patterns change from day
to day and found that 4DCT over-estimated daily 3d motion in 39% of fractions and
underestimated motion in 53% of fractions.1 Using DIBH a smaller PTV could be used to spare
healthy lung tissue instead of a larger ITV to accommodate tumor motion. (Figure 3)
References
1. Boda-Heggemann J, Knopf AC, Simeonoca-Chergou A, et al. Deep inspiration breath
hold-based radiation therapy: a clinical review. Int J Radiat Oncol Biol Phys. 2016;
94(3):479-492.
2. Bellon JR, Wong JS, MacDonald SM, Ho AY. Radiation Therapy Techniques and
Treatment Planning for Breast Cancer. Switzerland: Springer; 2016.
3. Sixel KE, Aznar MC, Ung YC. Deep inspiration breath hold to reduce irradiated heart
volume in breast cancer patients. Int J Radiat Oncol Biol Phys. 2001; 49(1):199-204.
Additional pictures of ABC
https://www.elekta.com/radiotherapy/treatment-solutions/motion-management/active-breathing-
coordinator.html

Fig. 1. Pilot scan of patient acquired during (a) quiet respiration and (b) deep inspiration. 3

Fig. 2. Axial CT views at (a) quiet respiration and (b) deep inspiration The slices are taken at the same
couch index, i.e., the same patient level.3