Deep inspiration breath hold (DIBH) during radiation therapy

Radiation therapy is a breast cancer treatment that uses high-energy x-rays to destroy cancer cells. In some cases, the heart is within the area to receive radiation therapy – especially when the tumor was in the left breast. This is called left-sided breast radiation. Even a low dose of radiation to the heart can cause heart disease later.

To protect the heart during left-breast radiation therapy, doctors use a technique called deep inspiration breath hold (DIBH). Research shows that this breath-holding technique can minimize radiation exposure to the heart. Another study demonstrated that DIBH can also reduce the dose of radiation that reaches regional lymph nodes in and around the breast.

On this page, we’ll talk about how DIBH works and when it might be recommended.

In the video below, hear from radiation oncologist Karen Winkfield, MD, PhD, about the importance of protecting the heart during left-sided breast radiation therapy, and the technology and techniques that have been developed to make breast radiation therapy safe.

What is deep inspiration breath hold?

Deep inspiration breath hold (DIBH) is the practice of taking a deep breath and holding it for 20-40 seconds while radiation is delivered to the breast. Holding a deep breath expands the lungs, pulling the heart away from the chest wall. Studies of DIBH in left-sided breast radiation therapy show that DIBH can reduce the amount of radiation exposure to the heart.

DIBH is now used routinely in breast cancer radiation therapy. There are two main types of DIBH:

• Voluntary DIBH: In voluntary DIBH, you receive coaching to voluntarily hold your breath while radiation is delivered to the breast. With this approach, you’re in control of your breathing, and your healthcare team coaches you on when and how to take a breath.
• Moderate DIBH: In moderate DIBH, your healthcare team will use supportive tools to help you hold your breath during radiation. There are many types of DIBH, and equipment that can help make DIBH easier. Some hospitals provide helpful guidance through headphones or a speaker, letting you know when, and how deeply, to hold your breath. Another supportive option is to wear goggles connected to a computer system that provides an image (a line or wave) that represents your breathing pattern. Watching the image helps you know how deeply to breathe in, and how long to hold your breath.

When DIBH is used

DIBH is regularly used in breast cancer treatment, lymphoma treatment, and sometimes in the treatment of other tumors. In breast cancer treatment, DIBH is used to reduce the radiation dose to the heart when treating left-sided breast cancer. Doctors may recommend DIBH during breast radiation therapy on either side to limit how much radiation reaches your lungs.

Radiation therapy kills breast cancer cells using high-energy x-rays. The radiation can be directed to the whole breast or part of the breast. Common radiation therapy side effects include skin irritation and redness (a “sunburn”), and fatigue.

If the heart is in the path of the radiation, there is an increased risk for heart disease to develop at some point after the treatment. When left-sided radiation therapy-related heart disease does happen, it's usually diagnosed at least five years, and sometimes longer, after treatment ends.

It’s important to understand that not everyone receiving left-sided radiation therapy develops heart disease. The likelihood of radiation-related heart disease depends on many factors. For instance, if areas such as the internal mammary lymph nodes (closer to the heart than other lymph nodes) need to be treated with radiation, there is a higher risk of radiation reaching the heart. Other examples include radiation to a lumpectomy site that is close to the heart, and having an enlarged heart. While we don’t yet know the overall effect of DIBH on the development of heart disease and survival of heart disease, we do know that DIBH can minimize the dose of radiation to the heart.

Researchers have found that it’s possible to predict who may benefit from DIBH by using a CT scan and measuring the distance between the heart and the treatment target area of the chest wall.

While some people may benefit from DIBH, it is not for everyone.

• If you’re receiving partial breast radiation therapy, you may not need DIBH, although it can still be helpful.
• If you have asthma or any other condition that makes it hard to hold your breath, your doctor may not recommend DIBH.
• If you have certain types of heart disease or uncontrolled high blood pressure, your doctor may not recommend DIBH.

There may be other heart-sparing techniques available if DIBH isn’t right for you.

What to expect with DIBH

If your doctor has recommended DIBH for you during radiation therapy, you’ll likely be coached ahead of time so that you can get comfortable with the technique.

When your healthcare team is helping you hold your breath using supportive tools, you will have a practice session before actual radiation therapy treatment begins. During the practice session, your healthcare team will be there to coach and support you as you learn how to hold your breath using these tools. This could include practicing holding your breath when you hear guidance through headphones or a speaker. Or, it may mean learning to use video goggles that show you images to help you understand how deeply to breathe, and when to hold your breath. These are just two examples of the different kinds of tools hospitals may use to help you with DIBH.

When it’s time for treatment with DIBH, here’s a general look at what you can expect:

• In most cases, people receiving breast radiation therapy wear a hospital gown, but not a bra.
• A radiation technologist will position you on the treatment table. If you’re using supportive tools, you will get them now.
• You’ll receive direction to inhale and hold your breath as your doctor has coached you to do. You may receive this direction from the technologist on a speaker, from images on a screen, or from images you can watch through video goggles.
• While you hold your breath, the radiation treatment is given. After about 20-40 seconds of breath holding (this can vary), you will be directed to start breathing again.

Different hospitals may use different approaches and equipment with DIBH.

For more information on what it’s like to use DIBH with assistive technologies, you can watch this video from a company that created one of the systems used with DIBH.