SGRT Birmingham 2022 SimRT: Workflows and optimizing DIBH planning Julie Kilkenny  Technical Lead Practitioner (Pre-treatment)- Radiotherapy, QE, University Hospitals Birmingham

1. Sim RT: Optimizing practice
and DIBH workflows
Julie Kilkenny
Pre-Treatment Technical Lead, QEH Birmingham

2. Our Clinical uses of Sim RT
• 4DCT – Lungs
• For DIBH coaching and scanning on Left Breast
patients
• Ad hoc to control extent of inhale/exhale breath hold
scans to prevent an exaggerated extent of motion
About to explore it for the use of Abdominal 4DCT in
compression as we explore the move to Gated RT

3. DIBH - What are we looking for?
• Breath hold of 25 seconds
• No arching, hunching, tensing
• No huge breaths… but a distinct movement
• Reproducible each time
• Sustainable for the BH duration
• No leaking
No matter what the method – SGRT, pen marks..
So why is SGRT better?

4. Using Sim RT for DIBH
• Real Time Coach • Patient Side

5. Advantages Sim RT for DIBH – Staff uses:
Patient side
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required

6. Advantages Sim RT for DIBH – Staff uses:
Patient side (1)
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required

7. Advantages Sim RT for DIBH – Staff uses:
Patient side
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required
• Assess the reproducibility of the Breath Hold (reaching
the same point?)

8. Advantages Sim RT for DIBH – Staff uses:
Patient side
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required
• Assess the reproducibility of the Breath Hold (reaching
the same point?)

9. Advantages Sim RT for DIBH – Staff uses:
Patient side
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required
• Assess the reproducibility of the Breath Hold (reaching
the same point?)
• Assess the suitability of the Breath Hold (leaking?
Suitable amplitude?)

10. Advantages Sim RT for DIBH – Staff uses:
Patient side
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required
• Assess the reproducibility of the Breath Hold (reaching
the same point?)
• Assess the suitability of the Breath Hold (leaking?
Suitable amplitude?)

11. Advantages Sim RT for DIBH – Staff uses:
Patient side
• Use the amplitude axis of the graph to coach the patient
into a smaller or bigger Breath Hold as required
• Assess the reproducibility of the Breath Hold (reaching
the same point?)
• Assess the suitability of the Breath Hold (leaking?
Suitable amplitude?)
• Use the threshold function to allow the patient to use the
RTC to achieve their Breath Hold
• Use the threshold function to time the breath hold and
ensure reproducibility

12. Threshold function – staff use

13. Threshold Function – Patient use with RTC

14. Advantages Sim RT for DIBH – Patient uses:
RTC
• Confidence of knowing they are ‘reaching the right spot’
• Gives them a focus to ensure no leaking to hold the BH
• Feeling ‘in control’
• Measurable BH to reach in terms of ‘a little bit more’ or ‘a
little bit less’
• Allows feedback between Radiographer and Patient

15. Rescan data
• Rescans usually due to BH amplitude – unmeasurable
Audit over a 10 week period:
Pre Sim RT - 14.9% rescan rate
With Sim RT – 2.3% rescan rate

16. *Disclaimer..
• We use the RTC to scan, but this isn't how we were
trained. We explored how to use the system further with
the bed moving and the ramp up times required