Journal of Clinical Monitoring and Computing

https://doi.org/10.1007/s10877-020-00561-4

REVIEW PAPER

A concise overview of non‑invasive intra‑abdominal pressure

measurement techniques: from bench to bedside
Salar Tayebi1 · Adrian Gutierrez1 · Ikram Mohout1 · Evelien Smets1 · Robert Wise2,3 · Johan Stiens1 ·
Manu L. N. G. Malbrain4,5

Received: 29 February 2020 / Accepted: 14 July 2020

© The Author(s) 2020

Abstract
This review presents an overview of previously reported non-invasive intra-abdominal pressure (IAP) measurement tech-
niques. Each section covers the basic physical principles and methodology of the various measurement techniques, the
experimental results, and the advantages and disadvantages of each method. The most promising non-invasive methods for
IAP measurement are microwave reflectometry and ultrasound assessment, in combination with an applied external force.

Keywords Non-invasive measurement · Intra-abdominal pressure · Abdominal compartment syndrome · Intensive care
unit · Ultrasound · Microwave reflectometry

1 Introduction in abdominal compartment syndrome (ACS), a fatal con-

dition characterized by a sustained increase in IAP above
Around 25% of critically ill patients suffer from intra- 20 mmHg with new onset organ failure. Although the inci-
abdominal hypertension (IAH), defined as a sustained dence of ACS has decreased over the last decades and is cur-
increase in intra-abdominal pressure (IAP) equal to or rently estimated around 3–5% in general ICU patients, the
above 12 mmHg. More than half of the patients hospital- risk of ACS development should not be underestimated [2].
ized in intensive care units (ICUs) will develop IAH within Monitoring the IAP is thus absolutely necessary for patients
the first week [1]. The presence of IAH significantly affects hospitalized in the ICU, as measuring IAP is knowing and
perfusion to abdominal organs [2] and can result in dimin- understanding ACS.
ished organ perfusion, organ dysfunction, and depending Various direct and indirect techniques for IAP measure-
on the degree of IAP, potentially multiple organ failure and ment have been suggested. Presently, the gold standard for
death [3–5]. Furthermore, late detection of IAH can result IAP measurement advocated by the Abdominal Compart-
ment Society (WSACS, www.wsacs​.org, formerly known
as the World Society of the Abdominal Compartment Syn-
* Manu L. N. G. Malbrain
[email protected] drome) is an indirect measurement via the bladder, meas-
ured in the supine position after instilling a maximum of
Johan Stiens
[email protected] 25 ml into the bladder, with the zero reference level where
the mid-axillary line crosses the iliac crest. This measure-
1
Department of Electronics and Informatics, Vrije ment technique is cumbersome, non-continuous, and carries
Universiteit Brussel, Pleinlaan 2, 1050 Brussels, Belgium a potential risk for infection. Therefore, other less-invasive
2
Adult Intensive Care, John Radcliffe Hospital, Oxford indirect IAP measurement techniques have been suggested,
University Hospitals Trust, Oxford, England with a primary focus on accuracy and continuity [6, 7]. All
3
Discipline of Anaesthesia and Critical Care, School potential non-invasive IAP measurement techniques are
of Clinical Medicine, University of KwaZulu-Natal, Durban, reviewed in this paper. The first section examines the possi-
South Africa
bility of using a strain gauge, respiratory inductance plethys-
4
Intensive Care Unit, ICU Director, University Hospital mography, or abdominal tensiometer. The second section
Brussel (UZB), Laarbeeklaan 101, 1090 Jette, Belgium
relates to the application of ultrasound-based techniques for
5
Faculty of Medicine and Pharmacy, Vrije Universiteit IAP monitoring. The third section discusses bio-electrical
Brussel (VUB), Laarbeeklaan 103, 1090 Jette, Belgium

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 Journal of Clinical Monitoring and Computing

impedance and microwave reflectometry, while digital image

correlation and the use of a wireless motility capsule are
examined in the final section. Accordingly, this review paper
can be used as a guideline for future studies; to promote
research comparing the different existing techniques, and to
encourage researchers to further refine the most promising
techniques for non-invasive IAP measurement.

2 Methods

We included all clinical and medical aspects in relation to

the way how the intra-abdominal volume correlates with
IAP within the abdominal cavity, with a focus on IAP and Fig. 1  Wheatstone bridge strain gauge. In this circuit, Vin is the input
signal monitoring. A broad search of the English literature voltage, R1, R2, R3, and ­RS are resistors and Vout is the output voltage
that fluctuates according to the changes in RS
in PubMed and Medline using the terms of “intra-abdominal
pressure” or “abdominal pressure” and “non-invasive” was
performed. After analysis, the papers identified as relevant been implemented in numerous medical devices. They are
were included in this narrative review. used as a tool to assist monitoring the movement and force
applied to patients.
RS R3 − R1 R2
3 Results Vout = ( )( ) Vin (2)
RS + R2 R3 + R1

3.1 Strain gauge, respiratory inductance Boudewyns et al. studied respiratory effort by implement-
plethysmography, and tensiometer ing strain gauges [9]. Strain gauges were used to detect rib
cage and abdominal movement. Thoracic and abdominal
3.1.1 Strain gauge strain gauges were positioned just below the axilla and at
the umbilicus. The objective was to characterize apneas and
A strain gauge is a device in which the electrical resistance examine the impact of sleep posture.
varies in proportion to the amount of force applied. It con- Boudewyns et al. also showed that strain gauges are suf-
verts force, pressure, and tension into a change in electri- ficiently reliable when describing apneas in most patient
cal resistance that can then be measured [8]. The working populations [9]. However, movement artifacts affect the
principle is based on an electrical resistance that changes as results, especially in obese patients. In approximately 10%
a function of deformation and is demonstrated practically of patients, the signal from the abdominal movement and
by a Wheatstone Bridge. The gauge factor (GF) is the fun- ribcage was very poor [9], revealing early pros and cons for
damental parameter that can be defined as a strain gauge’s this technique.
sensitivity to strain [8]. The GF is equal to the ratio of frac- Hodges et al. analyzed the effect of IAP on the human
tional change in electrical resistance to the fractional change spine [10], hypothesizing that an increase in IAP would
in length (strain): cause an extensor movement around ­L3 (third lumbar ver-
tebrae). IAP was increased in the test subjects by means of
ΔR∕R ΔR∕R
GF = = (1) tetanic stimulation of the phrenic nerve.
ΔL∕L 𝜀 Trunk extension was calculated by measuring the exten-
In Eq. (1), R and L are the electrical resistance and original sion force with a strain gauge (see Fig. 2a [10]). Also, the
length, respectively. correlation between IAP and trunk extension was investi-
𝜀 represents the strain which is defined as ΔL∕L. gated by measuring the IAP invasively.
In Fig. 1, RS is the resistor and its value is a function of Results showed a likely correlation between the ampli-
strain (ΔL∕L), multiplied by GF (see Eq. 1). On the other tude of the IAP (increase) and the amplitude of the exten-
hand, Vout represents a voltage value that fluctuates accord- sor torque at mid-lumbar level (correlation coefficient (R)
ing to the changes in RS (see Eq. 2). Finally, the data is dis- of 0.86 and p < 0.01) (see Fig. 2b [10]). This study dem-
played through the voltage value that represents the change onstrated that this strain gauge technique was capable of
of deformation over time. Nowadays, strain gauges have

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Journal of Clinical Monitoring and Computing

Fig. 2  Summary of results of the study about the effect of IAP on the measured by means of a strain gauge. Peak IAP values are achieved
human spine (adapted with permission from Hodges et al. [10]). a by using a pressure catheter which is known as the intragastric
Experimental set-up used in the study. By stimulating phrenic nerve, method b Normalized peak extensor torque as a function of peak IAP
IAP is increased and the extensor torque around mid-lumbar level is (R = 0.86, P < 0.01) (adapted from Hodges et al. [10])

providing valuable information (regarding IAP) despite 3.1.2 Respiratory inductance plethysmography (RIP)
artifacts.
Strain gauges are simple and low-cost devices. They Other techniques to study interactions between the abdo-
are capable of providing a great deal of interesting infor- men and thorax are combined thoracic and abdominal ple-
mation regarding patient position and further movement thysmography and electrical impedance tomography [12].
(e.g. a gyroscope). Negative aspects include motion arti- Respiratory inductance plethysmography (RIP) was first
facts and other forms of distortion that can affect results. introduced as a non-invasive respiratory assessment system
Strain gauges should not be used as standalone technol- in 1977 by Cohn. It consisted of two winding wire coils
ogy for measuring IAP as accuracy remains an issue. within elastic bands and encircling the rib cage (RC) and
Rather, they should be considered in combination with abdomen (AB) [13]. The inductance of the coils is a function
other technology, to enhance accuracy. of the cross-sectional area of AB and RC [14]. A general
schematic representation for a RIP setup is shown in Fig. 3

Fig. 3  The general principle of respiratory inductance plethysmogra- the length of AB and RC coils will be achieved (adapted with permis-
phy (RIP). Firstly, the coils should be positioned around the rib cage sion from Chen et al. [11])
(RC) and abdomen (AB). Finally, by data acquisition, the changes in

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[11]. Working with RIP allows the simultaneous recordings various compartments; 33% of the volume changes were
of pressure and volume excursions within the abdomen and linked to a decrease in lung volume, 40% to an increase in
thorax. These can be used to identify IAP and movements rib cage volume, and 26% to an increase in abdominal vol-
that can be caused by alterations in compliance of these ume. The authors concluded that the interactions between
compartments. The chest wall motions can be converted the rib cage, abdomen, and diaphragm aim to limit large
to volume changes. The relationship between RC and AB changes in end-expiratory lung volume, even in the face of
signals and tidal volume (TV), can be described by the fol- abdominal distension [16].
lowing equation: Several techniques such as electric impedance plethys-
mography (EIP), RIP, magnetometers/strain gauge sensors,
TV = 𝛼 × ΔL(RC) + 𝛽 × ΔL(AB) (3) and piezoresistive materials can be used as wearable respira-
Here, α and β are the coefficients describing the relation- tory monitoring to diagnose a variety of diseases. However,
ship between motion and volume changes in the rib cage and RIP has the advantage of better accuracy, sensitivity and
the abdominal compartment, and ΔL(RC) and ΔL(AB) are safety, compared with the other techniques [17–19]. Despite
the dimensional changes of the rib cage and abdomen. The these advantages, the simplicity and low-cost, it seems logi-
IAV can be calculated as follows: cal to combine RIP with another monitoring system for bet-
ter results.
IAV = k × [(𝛼∕𝛽) × ΔL(RC) + ΔL(AB)] (4)
3.1.3 Tensiometry
α/β is the weighting coefficient and κ is a factor converting
a change in dimension to volume in litres. In such a way, one
Tensiometry is another non-invasive technique for estima-
can determine IAP by dividing IAV by abdominal compli-
tion of IAP. The degree of indentation at the site where force
ance (Cab; defined as the change in IAV per change in IAP
is applied during palpation of the abdomen can be measured.
and expressed in ml/mmHg) [15]. Generally, measurement
Abdominal palpation examines intra-abdominal, passive and
of Cab is difficult at the bedside and can only be done in case
active muscle tension. Identifying increased muscle tension
of change in IAV. Finally, by plotting IAV versus IAP, the
may be useful as it can be a symptom of peritonitis. The
effects of the different actions of the thoracic and abdominal
force (F) necessary to make an indentation (d) in the abdom-
compartment can be studied (see Fig. 4).
inal wall is correlated with IAP as well as Cab:
In a study involving 5 normal subjects, C ab was
measured using RIP. In the supine position, C ab was F∕d ≈ IAP (5)
250 ± 100 ml(mmHg)−1. Changing to an upright position
reduced Cab to 48 ± 20 ml(mmHg)−1 [15]. In a preliminary study, van Ramshorst et al. [20] examined
In another study of three healthy subjects, fluid was abdominal wall tension (AWT) in 2 corpses (see Fig. 5 [20]).
instilled into the stomach and subsequently withdrawn. Vol- The abdominal cavity can be considered a cylindrical vessel
ume changes of abdomen, lung, and rib cage were assessed (t < R/4; with t = abdominal wall thickness and R = radius).
using magnetometry. In the 70° head-of-bed (HOB) posi- The tensile strength can thus be calculated by Eq. 6:
tion the mean Cab was 49 ± 20 ml (mmHg)−1. Interestingly, 𝜎w = [(Pi − Po ) R]∕t (6)
the gastric distension caused changes in the volume of the

Fig. 4  The tracings achieved by respiratory inductance plethysmogra- nal volume changes that have been assessed by thorax and abdomi-
phy (RIP). The first signal shows IAP in mmHg versus time in sec- nal respiratory inductance plethysmography (RIP). Sample tracings
onds. Peso is the esophageal pressure in mmHg that is shown as the obtained with BiCore monitor (Cardinal Health, Dublin, Ohio, United
second signal. The last two signals are related to thorax and abdomi- States)

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Fig. 5  Abdominal wall tensiom-

etry. Tensiometry is performed
by measuring force and distance
(indentation) at the site where
the punctual force is applied
(adapted with permission from
van Ramshorst et al. [20]). a
Initial abdominal wall tension
(AWT) measurement device b
Seven points were measured
during the initial study: three
on the linea alba, three on the
rectus abdominis muscle and
finally one over the lateral
transverse muscle. The meas-
urements were solely performed
on one half of the abdomen,
assuming abdominal symmetry

Where σw is stress in abdominal wall (tension), Pi is internal In a later study, the same authors examined the abdomens
pressure (IAP), and Po is external pressure. of 14 corpses that were insufflated with air [21]. The IAP
In Fig. 5a [20], force and distance were registered simul- was measured at intervals of 20 mmHg. At each interval,
taneously by using a CPU Gauge (Model RX Aikom, manu- abdominal wall tension (AWT) was measured five times
factured in Japan) and a position transducer (Series LWH, at six different areas on the abdomen (see Fig. 6 [21]). In
NovoTechnik, manufactured in Germany). Both sensors were 42 volunteers, AWT was measured at five points in supine,
supported by an assembly that enabled a device that applies sitting, and standing positions during various respira-
a force, connected to the measuring end of the force meter, tory maneuvers. The authors found significant correlation
to pass through an acrylic foot. The zero point was set as between IAP and AWT (the best correlation was found in the
the foot of the assembly and enabled the device to apply a epigastric region). In vivo measurements showed that AWT
force on the point of measurement, while the distant sensor was on average 31% higher in men compared to women and
measured the vertical displacement of the device [20]. increased from expiration to inspiration during valsalva

Fig. 6  Abdominal wall tension (AWT) measurement prototype used xiphoid bone (point 1), 5 cm cranial to the umbilicus (point 2), 5 cm
by van Ramshorst et al. (adapted with permission from van Ram- left to point 2 (point 3), 10 cm left to point 2 (point 4), 5 cm cranial
shorst et al. [21]). a New prototype of tensiometer connected to to the pubic bone (point 5), and an extra point, 5 cm left to point 5
smartphone b Six measurement points, derived from anatomical (point 6)
structures, were marked on each abdominal wall: 5 cm caudal to the

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maneuvers. AWT was highest in the standing position, fol-

lowed by the supine and sitting positions. The body mass
index (BMI) did not influence AWT.
Figure 6a [21] shows the prototype used for measuring
AWT, consisting of a built-in force and distance sensor,
attached to a handheld personal digital assistant (PDA, HP
IPAQ). The diameter of the circle-shaped base of the device
is 72 mm. The tip of the instrument is shaped like a half
sphere and has a diameter of 18 mm, with a total surface
area of 5.1cm2. The shape of the tip was chosen due to the
extensive use of this shape in industrial hardness measure-
ments of materials. The size of the tip was chosen due to its
comparability to the human finger, which is used to palpate
the abdominal wall. This device can measure the amount of Fig. 8  Correlation between abdominal wall tension (AWT) and uri-
force (N) needed to indent a specified amount (mm), which nary bladder pressure (UBP), performed by tensiometry. As can be
seen, an almost linear correlation was found between abdominal wall
is then visualized on the personal digital assistant (PDA)
thickness and the urinary bladder pressure (adapted from Chen et al.
with graphics [21]. [22])
In another study by Chen et al. tensiometry was used as a
non-invasive method for the assessment of urinary bladder
pressure (UBP) [22]. This prospective study monitored 51 used as a bedside modality in ICUs, referred to as point of
ICU patients with urethral catheters and studied the changes care ultrasound (POCUS) [23].
of AWT and UBP. UBP was in the range of 4 to 26 mmHg, There is limited research on ultrasound to measure IAP
and for each UBP value, the AWT was measured by a pro- or to detect IAH/ACS. The possibilities of ultrasound as
totype AWT measurement instrument shown in Fig. 7 [22]. a measurement tool for IAP are explored in the following
The tensiometer measured the required force to produce section.
displacement. Thus, the AWT can be calculated as thrust/
displacement (N/mm) [22]. The correlation between AWT 3.2.1 Ultrasound tonometry
and UBP is shown in Fig. 8 [22].
A significant linear correlation, with R = 0.986, P < 0.01, Ultrasound in combination with tonometry (or ultrasound-
was found between AWT and UBP. Overall, it is feasible to guided tonometry) is not a particularly familiar concept in
use tensiometry for IAP measurement. It is fast and inexpen- medicine. The principle is based on an ultrasound probe
sive with acceptable accuracy. However, as a new method, mounted onto an ultrasound transducer and connected to
the AWT measurement devices should be standardized for a pressure transducing system. This approach allows the
a more reliable and reproducible assessment. sonographer to account for the pressure one exerts on the
patient with the ultrasound probe. This technique was
3.2 Ultrasound‑based techniques recently examined using the Veinpress 2014 system (Vein-
press GmbH, 3110 Münsingen, Switzerland) as shown
Ultrasound is a common technique used in medicine. Health- in Fig. 9 [24] (available for research purposes only). The
care professionals and medical companies are already famil-
iar with the concept of using ultrasound-based devices to
aid diagnosis. Furthermore, ultrasound is increasingly being

Fig. 7  Abdominal wall tensiometer. Tensiometer used by Chen et al.

to measure the required thrust (N) to produce displacement (mm) Fig. 9  Veinpress system mounted on an ultrasound probe (adapted
(adapted with permission from Chen et al. [22]) with permission from Bloch et al. [24])

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Journal of Clinical Monitoring and Computing

system consists of an elastic silicone membrane filled with a ultrasound can be used, results for an externally applied pres-
fluid substance, translucent to ultrasound waves, and coupled sure of 40 mmHg (of ultrasound) showed the steepest ER
to a manometer. increase (10.6%, from baseline to 40 mmHg vs. 7.0%– 9.7%
There are multiple approaches to measuring compartment for the respective others). Thus the most accurate differentia-
pressure using ultrasound tonometry, however, this proposed tion of the intra-compartmental pressure (ICP) steps were
approach is based on the research of Bloch et al. [24]. First, achieved at 40 mmHg (see Fig. 11 [24]).
the elasticity ratio (ER) is calculated, which is the ratio of The resulting elastic ratios over a range of different ICPs
the compartment diameter with and without applying pres- are provided in more detail in Fig. 12 [24].
sure. The pressure was in this case manually applied, but The results showed a correlation between the elastic ratio
monitored by the Veinpress system. and the compartment pressure. An elastic ratio of 87.1%
The methodology of this experiment is shown in Fig. 10 had a sensitivity of 94.3% to detect a pressure of 30 mmHg
[24], in which six porcine legs were used. The tibial com- or higher [24]. However, as the pressure of the compart-
partment pressure was adjusted through a catheter that insuf- ment rose above 30 mmHg, the ER tended to flatten. This
flated fluid. Although different external pressure levels of

Fig. 10  Ultrasound-tonometry
set-up. Tonometry was per-
formed in combination with
ultrasound for intra-compart-
mental pressure (ICP) assess-
ment with an applied pressure
of 40 mmHg (right panel) com-
pared to the situation without
applied pressure (left panel) (d1,
d2: compartment diameters, T:
tibia, V: veinpress) (adapted
from Bloch et al. [24])

Fig. 11  Elastic ratio (ER) as a

function of the intra-compart-
mental pressure (ICP) for dif-
ferent external pressure values
(adapted with permission from
Bloch et al. [24])

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Fig. 12  Elastic ratio (ER) as a

function of the intra-compart-
mental pressure (ICP). The 95%
confidence interval was seen
at 40 mmHg external pressure
(adapted with permission from
Bloch et al. [24])

may have resulted when a certain rigidity was reached and (p-value < 0.02) [25]. All other ranges showed overlap and
it became difficult to compress the tissue further. indicated very poor accuracy. Knowing that IAP is only
The confidence intervals and the broad steps of 5 mmHg elevated when > 12 mmHg, and ACS generally occurs
indicate that further improvements are required before this above 20 mmHg, this device may only offer an indication
technology can be used as a bedside measurement device. of increased IAP (grade 2 and higher) without the ability
The ultrasound tonometry could indicate hypertension in to discriminate higher grades of IAH. A more reliable and
the tibial compartment, but does not suffice as a standalone accurate clinical measurement is required.
measurement. Also, the diameter of a porcine leg is signifi- Ultrasound tonometry has advantages in that it is non-
cantly smaller than the human abdominal cavity. The trade- invasive and easily reproducible, requires only minor
off between depth of ultrasound penetration and resolution changes to a classic ultrasound examination, and is rela-
may make the measurement difficult in a large abdominal tively inexpensive. It may also appeal to medical personnel,
cavity. Additionally, the organs and layers of tissue in the in that it is a safe and familiar modality. However, the need
abdominal cavity each have their own reflection coefficient. for coupling gel during an ultrasound examination limits
It is unclear if these measurements would be feasible in the this technology when adapting it to be a continuous process.
case of increased IAP from different causes, and particularly The major disadvantage of this technology is most nota-
difficult in the presence of abdominal gas. bly its lack of accuracy. However, the majority of research
Bloch et al., focused on measuring IAP, hypothesizing dates from 2017, and additional research may provide
that the vertical chamber diameter of the Veinpress system solutions.
may inversely correlate with IAP [25]. The workflow of the
experiment was similar to the previous one. A population 3.2.2 Ultrasound assessment of the abdominal wall
of seven pigs was used and the IAP increased by instilling in combination with external pressure
fluid into the abdominal cavity. Again, different pressure
levels were induced (22.5 mmHg and 37.5 mmHg) while the See et al. proposed an alternative ultrasound-based IAP
chamber diameter was examined as a function of different measurement technique [26]. A correlation was found
stages of IAH (Fig. 13) [25]. between IAP measurement using this ultrasound technol-
The results (Fig. 14) [25] showed a correlation between ogy and IAP measured by the standard intravesical method.
the IAP and the ultrasound tonometry measurements [25]. Two operators performed the ultrasonography and a third
The system was only able to discriminate between three operator used the intravesical method of IAP measurement.
pressure ranges, namely between baseline and 15 mmHg, A bottle filled with decreasing amounts of water was
between 15 and 25 mmHg, and between 25 and 40 mmHg used to apply a decremental pressure on the abdominal

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Fig. 13  Ultrasound tonometry concept for intra-abdominal pressure assessment. Labels “a” and “b” denote the vertical chamber diameter in two
different intra-abdominal pressure (IAP) values (adapted from Bloch et al. [25])

wall, while ultrasound was used to determine the peritoneal

rebound (see Fig. 15 [26]). The concept is based on the loss
of peritoneal rebound being a sign that the IAP is equal to
or more than the external pressure. In Fig. 15 [25], perito-
neal rebound is seen, indicating that the IAP is less than the
external pressure.
The results from the ultrasound operators showed a very
good correlation with the current gold standard for IAP
measurement (R = 0.982 and p < 0.001) and could be a clini-
cally reliable non-invasive technique in the future [26].

3.2.3 Ultrasound Doppler tonometry

Doppler ultrasound is a non-invasive technique that meas-

ures flow through blood vessels, by making use of the fre-
Fig. 14  Vertical chamber diameter in relation to intra-abdom- quency shift of soundwaves reflecting off moving red blood
inal prerssure. Chamber diameter is expressed as a function of cells. The frequency change is in proportion to the blood
intra-abdominal pressure (IAP) stages at an external pressure of
22.5 mmHg and 37.5 mmHg, assessed with ultrasound tonometry flow velocity. However, classical doppler ultrasound faces
(adapted from Bloch et al. [25]) some challenges, most notably the velocity waveform is

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Fig. 15  Peritoneal rebound

visualized by ultrasound assess-
ment in combination with exter-
nal pressure. Loss of peritoneal
rebound visualization happens
when IAP is equal to or more
than external pressure (adapted
with permission from See et al.
[26])

affected by the pressure applied by the operator. The ultra- The idea of using ultrasound Doppler tonometry to
sound probe needs to be firmly in contact with the gel and measure IAP came from the theory that a correlation exists
skin surface, and maintaining this appropriate constant between blood flow in certain veins and the IAP. Gudmunds-
pressure by the operator is difficult. Doppler tonometry was son et al. investigated this further [28] through inducing IAP
introduced in an attempt to help overcome this problem. A on eight porcine subjects. Blood flow measurements were
force sensor is introduced to feedback any pressure informa- taken by transit-time flowmetry (Transonic Systems, HT
tion. Figure 16 [27] presents a block diagram of the basic 107) (Fig. 18) [28].
components of the doppler tonometry system. The objective was to investigate the correlation between
Akinin et al. designed and manufactured a Doppler inferior vena cava/right femoral vein flow and IAP. The
tonometer sensor system with a sub-resolution of 0.1 N. results showed a significant decrease in blood flow when
Multiple tests were performed including a study on a sub- IAP increased, and this was similar in both veins [28]. How-
ject’s arm [27]. A vein was located and cycles of increased ever, this method was inaccurate and only major changes in
and decreased pressure were implemented. Figure 17 [27] IAP were detected. Furthermore, there is no data on measur-
shows the applied force and corresponding velocity as a ing blood velocity as a function of IAP with a Doppler sound
function of time. tonometer sensor system. The system used by Gudmunds-
The graph shows that a relatively small force had a signif- son et al. was a transit time flowmeter that was solely used
icant effect on velocity, largely because veins, more so than on animals [28]. Unfortunately, there is a lack of data from
arteries, are susceptible to deformation. By decreasing the further studies. Moreover, as an indirect measurement of
cross-sectional area of a vessel, the velocity was increased. IAP, this method does not surpass the accuracy of ultrasound
Including force feedback could significantly improve the tonometry technology.
reliability of this measurement.

Fig. 16  Block diagram of a

Doppler tonometry system
(adapted with permission from
Akinin et al. [27])

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Fig. 17  Relationship between

applied force and measured
velocity as a function of time
(adapted with permission from
Akinin et al. [27])

Fig. 18  Doppler ultrasound. Relation between intra-abdominal pres- femoral vein b as a function of intra-abdominal pressure. * significant
sure (IAP) and venous transit time blood flow, performed by Doppler difference from the nearest left observation, ** significant difference
ultrasound. (adapted with permission from Gudmundsson et al. [28]). from the final IAP measurement (P < 0.05)
a Blood flow in the inferior vena cava vein and blood flow in the right

3.2.4 Laser‑ultrasound laser-ultrasound is based on the optical excitement of tis-

sue with a laser pulse. The absorbed light is converted into
Multiple problems arise when using ultrasound techniques heat and introduces temporal thermo-elastic pressure-waves.
to measure IAP. Laser-ultrasound was introduced to over- An ultrasound receiver then detects these pressure waves.
come the lack of accuracy and the problem of needing to The receiver in this case is not a typical piezo-electric trans-
use coupling gel. The photoacoustic working principle of ducer, but an optical microphone. Preißer et al. proposed a

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commercially available optical hydrophone from XARION 3.3 Bio‑electrical impedance and microwave
Laser Acoustics GmbH (Vienna, Austria) [29]. However, reflectometry
for IAP measurement, a membrane free optical microphone
is more suited. 3.3.1 Bio‑electrical impedance
The theory involves the ultrasound pressure wave induc-
ing a density change in the medium of the optical sensor Electrical conductivity and permittivity are generic prop-
[29]. These changes are detected by a so-called Fabry-Pérot erties common to all materials. They define the in-phase
etalon, which is schematically shown in Fig. 19 [29] and, in and in-quadrature response of any material to applied AC
essence, is a compressed laser interferometer. (alternating current) and DC (direct current) electrical fields.
The ultrasound waves cause a density change, which Both material properties are tissue-specific (see Fig. 20
in turn cause a change in the refractive index of the mir- [30]) and can be determined by applying low-level AC and
rors. A laser sensor present in the etalon has its wavelength DC voltages and measuring the current (density) in phase
altered due to this phenomenon and, therefore, the ratio of and in quadrature, which is related to the complex-valued
the reflected light is increased. This effect is measured by a electrical impedance. For biological materials, one refers to
photodiode [29]. the bio-impedance characterization of tissues and organs.
This method could be implemented for IAP measurement. Bio-impedance measurements can be considered as a non-
The laser pulse could be introduced anteriorly and meas- destructive and non-invasive measurement technique. The
ured posteriorly on the patient. When IAP rises, the pressure study of the electromagnetic properties of specific body tis-
wave moving through the body will be altered introducing a sues can yield insights into physiological functioning and
change in the received signal (in dB). However, attenuation can therefore be used for disease correlations, such as IAP.
due to different tissues must be considered. Pressure waves David et al. published a pilot study where they performed
would travel back and forth through the numerous layers in non-invasive measurement of IAP using bioimpedance in
the body, and attenuation of these waves could have a seri- a porcine model [32]. It was assumed that changes in IAP
ous impact. It is unclear how this signal would be received. were directly correlated to the abdominal wall thickness.
Another approach would be to place both the emitter and The abdominal wall was seen as a compound of parallel
receiver anteriorly. The elastic properties of underlying tis- layers where the change in thickness of these layers affected
sue would be altered by the increase in IAP and this change the measured bioimpedance values, thus giving a value to
would be picked up by the laser-ultrasound receiver. To our the IAP.
knowledge no such experiments have yet been carried out The abdominal wall was modeled as a compound of five
for measurement of IAP. tissue layers [32]:
Laser-based ultrasound offers multiple advantages includ-
ing higher sensitivity compared to classic ultrasound tech- 1. Peritoneum
niques, no need for coupling gel or direct contact, and no 2. Muscles, including internal and external obliques, and
clamping or pressure forces required. Moreover, it operates transversus abdominis
in a vast dynamic range and offers good mechanical stability. 3. Fascia divided in Camper’s (fatty) and Scarpa’s (fibrous)
However, there is no published evidence of proof of concept fascia
yet, and this cannot be crowned as the ultimate solution. 4. Fascia transversalis
5. Skin and subcutaneous tissue

Fig. 19  Laser ultrasound.

Schematic representation of the
optical sensor and Fabry-Pérot
etalon as the main concept of
laser ultrasound (adapted with
permission from Preisser et al.
[29])

13
Journal of Clinical Monitoring and Computing

Fig. 20  Experimental data for

permittivity and conductivity
of muscle at body temperature
(adapted with permission from
Gabriel et al. [30])

Fig. 21  Bioimpedance analysis.

Results of the measured abso-
lute impedance for different
induced values of IAP. Drasti-
cally reduced sensitivity for val-
ues over 7 mmHg is observed
(adapted with permission from
David et al. [31])

The different layers of the abdominal wall were character- 𝜀∗1 (𝜔)𝜀∗2 (𝜔)
𝜀∗T (𝜔) = d1 + d2 ⋅ (8)
( )
ized by their overall dielectric permittivity function 𝜀∗T (𝜔). d2 𝜀∗1 (𝜔) + d1 𝜀∗2 (𝜔)
The dielectric permittivity of each layer mentioned above
were calculated by Eq. (7): The factors 𝜔 , 𝜀∗1 , d1, 𝜀∗2 and d2 are the frequency, dielec-
tric permittivity, and thickness of each layer, respectively.
𝜎(𝜔)
𝜀∗n (𝜔) = 𝜀n (𝜔) + (7) Although Eq. 8 is for a structure consisting of two layers,
j𝜔𝜀0
the general template of the equation is the same for structure
where ε0 , σ, and εn are the permittivity of vacuum, conduc- consisting of more layers.
tivity and relative permittivity studied by Gabriel et al. [30]. As a result, the overall complex-valued electrical imped-
The overall dielectric function for a structure consisting ance measured over the abdominal wall was a function of
of two layers is modeled in Eq. 8 [31]. the complex permittivity of each layer inside the multi-layer
structure. Due to the change in IAP and the elastic prop-
erties of each layer, the multi-layer structure was strained

13
 Journal of Clinical Monitoring and Computing

and thickness variations were induced. Finally, the induced five-layered model of the abdominal wall and assuming that
thickness variations were correlated with IAP changes. the IAP ultimately alters the thickness and electromagnetic
Bioimpedance has been previously used in a variety of properties (permittivity and conductivity) of the abdomi-
areas [32]. There was a strong correlation between IAP and nal wall, the reflection response to incident electromagnetic
absolute impedance for IAP up to 7 mmHg (see Fig. 21 waves was assumed to be different. In this study [31], por-
[31]). Although bioimpedance can be used as a completely cine subjects were studied with different IAP values.
non-invasive measurement technique for IAP levels up to When working with frequencies of a few GHz, the layered
7 mmHg, further research is needed to validate the sensitiv- anatomy was assumed to be a structure of lossy dielectric
ity of this method for higher pressures, before it becomes slabs. The reflection response for each interface was calcu-
clinically useful. lated by Eqs. (9) and (10) [31]:

3.3.2 Microwave reflection 𝜌i + Γi+1 e−2jki li

Γi = (9)
1 + 𝜌i Γi+1 e−2jki li
Microwaves are non-continuous electromagnetic waves in
the frequency spectrum of 300 MHz and 300 GHz. Micro- 𝜂i − 𝜂i−1
wave technology is widely used, with applications such as
𝜌i =
𝜂i + 𝜂i−1 (10)
wireless networks, radar, remote sensing and controlling,
and microwave ovens. Some advantages of microwaves are Factors Γi , 𝜌i , 𝜂i , ki and li represent the layer reflection
the larger bandwidth compared to lower frequency radio response, primary interface reflection coefficient, charac-
waves and better directive properties. This makes microwave teristic impedance, angular wavenumber and the thickness
high gain antennas easier to design and manufacture, and the of the ith slab, respectively.
use of higher frequencies allows for a decrease in the size of As a result, changes of IAP will change the thickness of
such antennas. Microwaves can be safely used in medicine each layer of the abdominal wall, and hence the reflection
for both diagnosis and treatment strategies. Several applica- response from the abdominal wall will be a function of the
tions have been developed for microwave characterization IAP [31].
of biological materials at molecular, cellular and tissue lev- The results of the study show a strong correlation between
els [33]. Some examples include the diagnosis of malignant IAP and the scattering parameter S ­ 11, corresponding to the
tumors, real-time body fluid analysis, and therapeutic and reflection coefficient of the multi-layer structure, for the
surgical applications. A widely developed healthcare appli- entire range of IAP measured (see Fig. 22 [31]). This was
cation of radiofrequency and microwaves is magnetic reso- different to the results of the same study for bioimpedance,
nance imaging (MRI), in which signal information is used which only showed correlation up until 7 mmHg. David
for reconstructing MRI images. et al. [31] thus demonstrated that microwave reflectometry
In the same study discussed previously in the bioim- measurement technique can be used to measure IAP. It is
pedance section, David et al. [31] studied the non-invasive continuous, non-invasive and sensitive enough to changes in
assessment of IAP using electromagnetic waves in the IAP. However, the quality of the measurement can be easily
microwave range, in particular at 4.25 GHz. Using the same

Fig. 22  Microwave reflectom-

etry. Values of S11 (scattering
parameter) as a function of
IAP for the selected frequency
of 4.25 GHz, measured based
on microwave reflectometry
(adapted with permission from
David et al. [31])

13
Journal of Clinical Monitoring and Computing

affected. Further validation is required for this measurement position) of the object can be calculated. Applying the cor-
technique. relation algorithm can identify the position of each point of
the object. For effective measurements, the pixels should
3.4 Digital image correlation and wireless motility be easily recognizable and requires a special illumination
capsule technique. Figure 23 [34] illustrates a typical set-up for DIC
in the case of a uniaxial tensile test specimen.
3.4.1 Digital image correlation Although digital image correlation has not been used for
IAP measurement, Song et al. [35] used a similar concept
Digital image correlation (DIC) is an optical method that to investigate the mechanical properties of abdominal wall
uses tracking and image registration to obtain accurate meas- during insufflation (see Fig. 24 [35]).
urements of contour, deformation, and strain on almost any DIC is an accurate, but expensive technique. Moreover,
material. An unambiguous speckle pattern is sprayed on the keeping a random pattern placed around the patient’s abdo-
area of interest for tracking. The working principle is based men intact and visible, with an optimal view of the surface
on the localization of specific pixels using a stereoscopic for the camera, is not practical. Another troublesome aspect
sensor (camera) on each point of the object. A displacement of performing DIC in the ICU is the space required for the
field is then obtained from the correlation between consec- cameras. Positioning cameras from the ceiling is a possibil-
utive images based on the random speckle pattern. With ity, but there should still be easy access to the camera sys-
this data, the three-dimension position (or two-dimension tem for calibration, troubleshooting, and maintenance. The

Fig. 23  Digital image correla-

tion. Set-up of digital image
correlation (DIC) test for a
uniaxial tensile test of a cylin-
drical specimen. (adapted with
permission from [34])

Fig. 24  Markers placement on

the abdominal skin for digital
image correlation a Markers
configuration in normal IAP b
Markers configuration in IAH
(adapted with permission from
Song et al. [35])

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 Journal of Clinical Monitoring and Computing

accuracy of this technology is the greatest advantage, how-

ever, this does not outweigh the cost and additional problems
already highlighted.

3.4.2 Wireless motility capsule

Using smart pills seems a useful method for non-invasive

measurements of IAP. Rauch et al. evaluated IAP in a por-
cine model with a wireless motility capsule [36].
Generally, a motility capsule (Fig. 25) [36] is a wireless
smart pill that transmits pH, pressure, and temperature data
to a data recorder [35]. In this study, by means of a capsule
delivery device, a developed motility capsule (SmartPill™, Fig. 26  Intragastric pressure changes in an individual pig model dur-
SmartPill Corp., Buffalo, NY) was positioned endoscopi- ing 24 h measured by wireless motility capsule (adapted from Rauch
cally to the stomach of a porcine model to measure the intra- et al. [36])
gastric pressure. In Fig. 26 [36], intragastric pressure values
recorded by the motility capsule can be seen. In the end, the
results from the capsule were compared to the pressure val- compartment and monitoring IAP changes by motility cap-
ues achieved by intravesical method to study the correlation sules, we cannot comment on the usefulness of this device.
between these two different techniques. It may be considered as a potential IAP assessment tool in
This study reported an underestimation of IAP when the future.
using the motility capsule and measuring intragastic pres-
sure [36]. The discrepancies between the two methods could
be caused by gastric dilatation [36]. The poor correlation 4 Summary and conclusions
between intragastric and intravesical pressures seems to be
due to the location and not the measurement technique [36]. The advantages and disadvantages of the described non-
We believe further research should be done regarding invasive IAP measurement techniques are summarized in
this technique in order to critically evaluate the reliability Table 1 and Fig. 27.
of motility capsules in the detection of IAH. Since there Currently, wireless motility capsules, digital image cor-
is no study dealing with insufflation of the abdominal relation, and laser ultrasound cannot be proposed as the best
measurement techniques, mainly due to the lack of valida-
tion and clinical research. Respiratory inductance plethys-
mography, the use of a strain gauge and Doppler ultrasound
tonometry for IAP estimation are not reliable or accurate
enough to be used in clinical practice. As mentioned before,
it is better to combine these techniques with more accurate
ones. For instance, it might be useful to use these techniques
for the primary detection of IAH, in combination with a
standard transvesical measurement technique for confirma-
tion, and more accurate follow-up measurements. Tensiom-
etry showed acceptable results, however, since there is no
standardized tensiometer for IAP measurement, it seems
more pragmatic to focus on the remaining techniques. For
IAP measurement up to 7 mmHg, bioimpedance is one of
the best methods that can be used. But, as mentioned before,
this technique is not able to monitor clinically important IAP
changes (pressures > 12 mmHg). Finally, ultrasound assess-
ment in combination with external pressure and microwave
reflectometry seem the most promising non-invasive IAP
measurement methods that showed a good correlation with
Fig. 25  Wireless motility capsule. Components of a motility capsule
IAP as well as a relatively higher accuracy in the range of
for intragastric pressure measurement consists of a solid plastic head
and a soft polyurethane body incorporating the batteries and sensors the pressure values that are expected to occur in patients
(adapted with permission from Fernandes et al. [37]) hospitalized in the ICU. However, by ultrasound assessment,

13
 Table 1  Potential non-invasive intra-abdominal pressure (IAP) measurement techniques
Measurement technique Concept behind the measurement Advantages Disadvantages Compatibility with the specific ICU
technique environment

Strain gauge Correlation between IAP and external Simple High motion sensitivity Restricted applications due to patient
torque around mid-lumbar level Low-cost Low signal to noise ratio positioning during IAP measurement
Respiratory Inductance Plethysmog- Correlation between IAP and IAV Simple Lack of reliability Compatible
raphy Low-cost Motion sensitivity
Journal of Clinical Monitoring and Computing

Tensiometry Correlation between AWT and IAP Fast Lack of standardized tensiometer Compatible
Inexpensive
High accuracy
Ultrasound tonometry Correlation between IAP and applied Relatively inexpensive Need of coupling gel Compatible
force on the ultrasound probe Fast Low accuracy
Easily reproducible
Ultrasound assessment in combina- Correlation between IAP and external Fast The need of coupling gel Measure- Compatible
tion with external pressure force on abdominal wall Inexpensive ment limitations
Reproducible
Doppler ultrasound Correlation between IAP and blood Relatively inexpensive Lack of accuracy Compatible
flow Fast
Laser ultrasound Correlation between IAP and wave- No need for coupling gel, vast Relatively expensive, lack of proof of Contactless and ideal for use in ICU
length of the reflected/transmitted dynamic range for measure- concept
pulse ment
Bioimpedance Correlation between IAP and electri- High accuracy Lack of sensitivity for IAP values Restricted applications due to the
cal impedance of abdominal wall higher than 7 mmHg impedance electrode placement
Microwave reflectometry Correlation between IAP and reflec- High accuracy Contactless The need for further validations Contactless and ideal for use in ICU
tion response (S11) of microwaves
Digital Image Correlation Optical tracking and image registra- High accuracy Expensive Restricted applications due to its equip-
tion of abdominal compartment Complex set-up ment placement in ICU
Lack of proof of concept
Wireless motility capsule Direct measurement of intragastric – Expensive Compatible
pressure Low accuracy

The second column manifests the logic behind each measurement technique, while the advantages and disadvantages of each method are shown in the third and fourth column, respectively. The
last column is also related to the possibility of using each measurement method in the specific conditions of ICU (compatibility with other medical equipment, monitoring systems, etc.). Intra-
abdominal volume, abdominal wall, and abdominal wall tension are abbreviated as IAV, AW, and AWT, respectively
AWT​abdominal wall tension, IAP intra-abdominal pressure, IAV intra-abdominal volume, ICU intensive care unit

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 Journal of Clinical Monitoring and Computing

Fig. 27  Summary of characteristics of the different non-invasive IAP measurement techniques. (DIC: digital image correlation, US: ultrasound)

we can only monitor the IAP that is equal to the external Author contributions Conceptualization was done by Manu L.N.G.
pressure exerted on the abdominal wall, since the peritoneal Malbrain. Material preparation, data collection and analysis were
performed by the collaboration of all authors. The first draft of the
rebound occurs only when the IAP is equal to or above the manuscript was written by Salar Tayebi, and all authors commented on
external pressure. Furthermore, the external pressure exerted previous versions of the manuscript. Supervision was done by Manu
on the abdominal wall needs to be standardized in the future. L.N.G. Malbrain and Johan Stiens. All authors read and approved the
This is another downside of this measurement method that final manuscript.
restricts its broad application at the bedside.
Funding This research received no external funding.
Also, it should be pointed out that all these reviewed
techniques are able to monitor the IAP changes rather than Data Availability All data generated or analyzed during this study are
estimating the absolute IAP value. Thus, we need to know included in this review paper (and its supplementary information files).
the initial IAP value in order to monitor the IAP trend. In
our perspective, estimation of the initial IAP can be done Compliance with ethical standards
based on (for instance) the initial thickness of the different
layers of the abdominal wall in combination with a gold Conflicts of interest MLNGM is a member of the medical advisory
standard reference method (e.g. bladder pressure). However, Board of Pulsion Medical Systems (now fully integrated in Getinge,
Solna, Sweden) and Serenno Medical (Tel Aviv, Israel), consults for
more investigation needs to be done in the future looking for Baxter, Maltron, ConvaTec, Acelity, Spiegelberg and Holtech Medi-
correlations between specific body parameters and IAP in cal. The other authors declare no conflict of interest in relation to the
order to predict the baseline IAP value with high accuracy content of this review.
and reliability.
Open Access This article is licensed under a Creative Commons Attri-
Acknowledgements The authors of the ETRO-department acknowl- bution 4.0 International License, which permits use, sharing, adapta-
edge the Vrije Universiteit Brussel (VUB) through the SRP-project tion, distribution and reproduction in any medium or format, as long
M3D2 and the ETRO-IOF project. MLNGM is a member of the Exec- as you give appropriate credit to the original author(s) and the source,
utive Committee of the Abdominal Compartment Society, formerly provide a link to the Creative Commons licence, and indicate if changes
known as the World Society of Abdominal Compartment Syndrome were made. The images or other third party material in this article are
(https​://www.wsacs​.org/). He is former president, co-founder and cur- included in the article’s Creative Commons licence, unless indicated
rent Treasurer of WSACS. He is also co-founder of the International otherwise in a credit line to the material. If material is not included in
Fluid Academy (IFA). The IFA is integrated within the not-for-profit the article’s Creative Commons licence and your intended use is not
charitable organization iMERiT, International Medical Education and permitted by statutory regulation or exceeds the permitted use, you will
Research Initiative, under Belgian law. The content of the IFA web- need to obtain permission directly from the copyright holder. To view a
site (https​://www.fluid​acade​my.org ) is based on the philosophy of copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/.
FOAM (Free Open Access Medical education – #FOAMed).

13
Journal of Clinical Monitoring and Computing

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