{"entity":{"id":"idea-pu-breath-hold-visual-feedback","kind":"idea","name":"Let the patient see their own breath-hold on a screen or in video glasses","aka":[],"tldr":"During breath-hold radiotherapy a camera or sensor measures how deep the breath is, but often only the radiographers see the trace. Showing it to the patient, on a screen or in video glasses with a target band to stay inside, made holds steadier and more repeatable in the clinical comparisons OnCo found, though none has yet measured whether it changes side effects.","summary":"The owner's example, and the one this file was written around. Breath-hold radiotherapy depends on the patient holding a breath of the same depth, in the same place, every time, often for 20 to 40 seconds and many times a session. The machine already measures this, by tracking the chest or abdomen with a camera, an infrared block or a surface scanner. The upgrade is to close the loop: give the patient the same trace, with a band marking the target, so they can see when they are in it and correct themselves.\n\nWhat the comparisons found. In 2009, five women with left breast cancer and fifteen volunteers performed breath-holds with and without visual coaching through video goggles fed by a three-dimensional surface camera: reproducibility improved from 2.1 to 0.5 millimetres and stability from 1.5 to 0.7 millimetres (p below 0.001 and below 0.01), with the largest gains in the people whose holds were worst. In a series of 43 women, chest-wall displacement on daily portal images was 0.59 millimetres on average with visual feedback against 2.09 with audio coaching alone (p below 0.001). In nine lung cancer patients scanned twice by MRI, audiovisual biofeedback improved the reproducibility of tumour position between sessions by 46 per cent, from 8.8 to 4.8 millimetres. Sixteen lung patients having stereotactic treatment through a monocular head-mounted display all tolerated it, with breath-hold variability of 1.5 and 1.2 millimetres within and between holds. Not every result points one way: in the earlier test of that head-mounted display in five healthy volunteers, feedback improved the reproducibility of breath-holds at the end of breathing out (0.63 against 0.96 millimetres, p equals 0.025) but not of deep breaths in (1.74 against 0.84 millimetres, not significant). In BRAVEHeart, 26 women analysed after randomisation between two feedback devices found both easy to follow, with no difference in accuracy or appointment length.\n\nWhat is not known. None of these studies was powered on a clinical outcome, most are small and single-centre, and the comparisons are of steadiness and position rather than of heart dose delivered over a course or of side effects. A multi-centre randomised phase II trial of audiovisual biofeedback in 75 lung cancer patients was registered in Australia in 2013 (ACTRN12613001177741); OnCo did not find its results published. Adoption is not measured by any survey OnCo found.","asOf":"2026-10-20","links":[{"label":"Cerviño et al., Using surface imaging and visual coaching to improve the reproducibility and stability of deep-inspiration breath hold for left-breast-cancer radiotherapy (Physics in Medicine and Biology 2009)","url":"https://doi.org/10.1088/0031-9155/54/22/007"},{"label":"Yamauchi et al., Assessment of visual feedback system for reproducibility of voluntary deep inspiration breath hold in left-sided breast radiotherapy (Journal of Medical Imaging and Radiation Sciences 2021)","url":"https://doi.org/10.1016/j.jmir.2021.08.018"},{"label":"Lee et al., Audiovisual biofeedback guided breath-hold improves lung tumor position reproducibility and volume consistency (Advances in Radiation Oncology 2017)","url":"https://doi.org/10.1016/j.adro.2017.03.002"},{"label":"Yoshitake et al., A clinical evaluation of visual feedback-guided breath-hold reproducibility of tumor location (Physics in Medicine and Biology 2009)","url":"https://doi.org/10.1088/0031-9155/54/23/009"},{"label":"Yoshitake et al., Breath-hold monitoring and visual feedback for radiotherapy using a charge-coupled device camera and a head-mounted display: system development and feasibility (Radiation Medicine 2008)","url":"https://doi.org/10.1007/s11604-007-0189-4"},{"label":"Byrne et al., Prospective randomized trial comparing 2 devices for deep inspiration breath hold management in breast radiation therapy: results of the BRAVEHeart trial (Advances in Radiation Oncology 2024)","url":"https://doi.org/10.1016/j.adro.2024.101572"},{"label":"Pollock et al., Audiovisual biofeedback breathing guidance for lung cancer patients receiving radiotherapy: a multi-institutional phase II randomised clinical trial, protocol (BMC Cancer 2015)","url":"https://doi.org/10.1186/s12885-015-1483-7"},{"label":"Jo et al., Assessment of the effectiveness of a visual coaching device combined with auditory instructions on reproducibility and stability in deep inspiration breath-hold radiotherapy (Journal of Clinical Medicine 2025)","url":"https://doi.org/10.3390/jcm14207259"}],"tags":["protocol-upgrade","upgrade:promising","evidence:moderate","precision"],"related":["idea-pu-breath-hold-left-breast-routine","idea-pu-breath-hold-coaching-before-planning"],"cancers":["breast-cancer","lung-cancer","nsclc"],"sections":["radiation"],"technologies":["respiratory-motion-management","respiratory-gating-tumour-tracking-systems","surface-guided-radiotherapy","patient-positioning-surface-guidance-systems","sbrt"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["deep-inspiration-breath-hold"],"trials":[],"people":[],"bottlenecks":["b-toxicity-qol","b-surgery-radiation-innovation"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Giving patients real-time visual feedback of their own breath-hold during breath-hold radiotherapy reduces the variation in breath-hold position across a course enough to allow smaller safety margins, and lowers the dose delivered to the heart or lung, compared with audio instruction alone.","rationale":"The measurement already exists in every department that does breath-hold. Every comparison OnCo found, in breast and lung, shows smaller variation when the patient can see it, the effect is largest in the patients who hold least well, and the hardware is a screen or a pair of video glasses.","test":"A multi-centre randomised trial in left-sided breast and in lung radiotherapy comparing visual feedback with audio instruction, with delivered heart or lung dose reconstructed from daily imaging as the primary endpoint and set-up time, patient experience and acute toxicity as secondary endpoints.","maturity":"early-clinical","actor":"clinic","cost":"small","horizonYears":3},"route":"/ideas/idea-pu-breath-hold-visual-feedback/","neighbours":{"idea":[{"id":"idea-pu-breath-hold-coaching-before-planning","kind":"idea","name":"Breath-hold coaching and home practice a week before the planning scan, in the patient's own language","route":"/ideas/idea-pu-breath-hold-coaching-before-planning/"},{"id":"idea-pu-breath-hold-left-breast-routine","kind":"idea","name":"Deep-breath-hold radiotherapy for every suitable person with left-sided breast cancer","route":"/ideas/idea-pu-breath-hold-left-breast-routine/"}],"cancer":[{"id":"breast-cancer","kind":"cancer","name":"Breast cancer (all types)","route":"/cancers/breast-cancer/"},{"id":"lung-cancer","kind":"cancer","name":"Lung cancer (all types)","route":"/cancers/lung-cancer/"},{"id":"nsclc","kind":"cancer","name":"Non-small-cell lung cancer","route":"/cancers/nsclc/"}],"section":[{"id":"radiation","kind":"section","name":"Radiation Therapy","route":"/fronts/radiation/"}],"technology":[{"id":"patient-positioning-surface-guidance-systems","kind":"technology","name":"Patient positioning and surface guidance systems (AlignRT, Catalyst, ExacTrac Dynamic)","route":"/technologies/patient-positioning-surface-guidance-systems/"},{"id":"respiratory-gating-tumour-tracking-systems","kind":"technology","name":"Respiratory gating and tumour tracking systems (RPM, ABC, Calypso, Synchrony)","route":"/technologies/respiratory-gating-tumour-tracking-systems/"},{"id":"respiratory-motion-management","kind":"technology","name":"Respiratory motion management (4D-CT, gating, breath-hold, tracking)","route":"/technologies/respiratory-motion-management/"},{"id":"sbrt","kind":"technology","name":"SBRT / SABR (stereotactic radiotherapy)","route":"/technologies/sbrt/"},{"id":"surface-guided-radiotherapy","kind":"technology","name":"Surface-guided radiotherapy (SGRT)","route":"/technologies/surface-guided-radiotherapy/"}],"term":[{"id":"deep-inspiration-breath-hold","kind":"term","name":"Deep inspiration breath-hold (DIBH)","route":"/terms/deep-inspiration-breath-hold/"}],"bottleneck":[{"id":"b-surgery-radiation-innovation","kind":"bottleneck","name":"Surgery and radiotherapy cure most, get least","route":"/bottlenecks/b-surgery-radiation-innovation/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}]}}