International evidence-based recommendations for point-of-care lung ultrasound

Acute Pulmonary Interstitial Fibrosis Caused by Anti-GBM Disease Combined With ANCA-Associated Vasculitis-The Role of Combined Cardiopulmonary Ultrasound in Early Differential Diagnosis and Evaluation: A Case Report

Combined cardiopulmonary ultrasound (CCPUS) can be applied to bedside differential diagnosis of acute dyspnea. Pulmonary interstitial fibrosis is usually a chronic lung disease. However, some special diseases can cause pulmonary interstitial fibrosis with rapid progression. This study included a patient with unexplained dyspnea. We excluded cardiogenic pulmonary edema (CPE) by CCPUS and refused hemodialysis. The characteristics of lung ultrasound of the patient were similar to pulmonary interstitial fibrosis. Finally, the patient was diagnosed with antiglomerular basement membrane (anti-GBM) disease combined with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, causing acute progressive pulmonary interstitial fibrosis in lung tissue as a target organ.

Quantification of Residual Pulmonary Congestion Defined by B-Line Findings on Lung Ultrasound to Predict Cardiovascular Events in Acute Heart Failure : A Systematic Review and Meta Analysis

BACKGROUND

Pulmonary congestion detected by lung ultrasound (LUS) has emerged as a valuable prognostic marker in acute heart failure (AHF). This systematic review and meta-analysis aimed to evaluate the prognostic significance of residual B-lines identified by LUS before hospital discharge.

METHODS

A comprehensive literature search of PubMed, Cochrane Library, ScienceDirect, and ClinicalTrials.gov was conducted up to October 4, 2024. Studies assessing the association between residual B-lines and adverse clinical outcomes in hospitalized AHF patients were included, while studies involving ambulatory assessments were excluded. The primary outcome was a composite of all-cause mortality and heart failure (HF) rehospitalization. Secondary outcomes included all-cause mortality and HF rehospitalization individually. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Fifteen studies were included. Residual B-lines were significantly associated with an increased risk of composite outcomes (HR: 2.32; 95% CI: 1.91-2.82), all-cause mortality (HR: 3.01; 95% CI: 1.91-4.73), and HF readmission or cardiovascular events (HR: 4.01; 95% CI: 2.22-7.24). Risk increased with greater B-line burden. Prognostic impact was stronger in short-term follow-up (<6 months; HR: 3.57) than in longer-term follow-up (≥6 months; HR: 1.96).

CONCLUSIONS

Residual pulmonary congestion assessed by LUS at discharge is a strong independent predictor of adverse outcomes and may guide therapy decisions in AHF management.

Associations Between Quantitative Lung Ultrasound and Successful Extubation in Infants

OBJECTIVES

The aim is to evaluate the value of lung ultrasound (LUS) in the weaning of neonates from ventilators.

METHODS

This prospective observational study included hospitalized neonates who underwent invasive ventilation (excluding neonates ineligible for enrollment, eg, neonates with nonrespiratory conditions requiring mechanical ventilation). All the included neonates underwent LUS using a palm-sized ultrasound machine. After extubation, the neonates were divided into success and failure groups. Additionally, the neonates were divided into 2 groups according to gestational age (GA, <28 weeks and ≥28 weeks). Data on the main LUS signs and scores half an hour before and 2 hours after extubation were collected, and ultrasound scores were compared.

RESULTS

When LUS scores before and after extubation were used to predict weaning failure, the sensitivities were 83.3 and 94.6% (95% CI, 0.823-0.986; P < .05), and the specificities were 83.3 and 97.3% (95% CI, 0.819-0.995; P < .05), respectively. After grouping, for the <28-week group, the sensitivity was 84.6% both before and after extubation, and the specificities were 77.8 and 88.9%, respectively (before extubation: 95% CI, 0.653-1.013; P < .001; after extubation: 95% CI, 0.652-1.023; P < .001). In the ≥28-week group, the sensitivity was 80.0% both before and after extubation, and the specificities were 96.9 and 98.5%, respectively (before extubation: 95% CI, 0.724-1.051; P < .001; after extubation: 95% CI, 0.777-1.051; P < .001).

CONCLUSIONS

LUS can predict weaning failure in neonates with different respiratory diseases on the basis of LUS scores, with or without differences in GA. The use of palm-sized handheld portable ultrasound machines for LUS is feasible.

The role of early lung ultrasound score measurement in determining prognosis in COVID-19 ICU patients with respiratory failure

The utility of lung ultrasound (LUS) in evaluation of coronavirus disease (COVID-19) with pneumonia has not yet been elucidated. The main objective of study is to determine whether LUS can effectively predict the prognosis in intensive care unit (ICU), including mortality and disease severity. It's also aimed to determine whether LUS will provide a threshold value to predict mortality in COVID-19 cases. In this prospective observational study, 90 patients admitted to the ICU with COVID-19 pneumonia and respiratory failure were included. A LUS cutoff score of 21 on admission demonstrated sensitivity of 97% and specificity of 68% for predicting mortality. Baseline LUS scores were found to be significantly higher in nonsurvivor group(P < .001) whereas APACHE II, sequential organ failure assessment (SOFA), charlson comorbidity index (CCI), nutrition risk in critically ill (NUTRIC) scores, serum lactate, procalcitonin, ferritin, D-dimer levels and heart rate were also significantly found to be higher in nonsurvivor group(P < .05). Overall mean progression-free-survival (PFS) rate was significantly longer in patients with LUS scores < 21, (mean-survival 23.8 days) compared to those with LUS scores ≥ 21 (mean-survival 12.5 days) (P < .05). Multivariate Cox-regression analysis identified a LUS score ≥ 21 was an independent risk factor for mortality during ICU stay (P = .002). LUS performed at ICU admission can serve as a prognostic indicator for patients with COVID-19 pneumonia. By identifying high-risk groups and monitoring these patients closely using LUS, healthcare providers may enhance resource utilization and potentially improve patient outcomes.

Intraoperative Lung Ultrasound in the Detection of Pulmonary Nodules: A Valuable Tool in Thoracic Surgery

In the last two decades, there has been an increased interest in the application of lung ultrasound (LUS), especially intraoperatively, owing to its safety and simple approach to detecting and assessing pulmonary nodules. This review focuses on recent advancements in intraoperative lung ultrasound in detecting lung nodules. A systematic search was conducted using databases such as PubMed and Google Scholar. Keywords included "Lung ultrasound", "intraoperative lung ultrasound", and "video-assisted transthoracic surgery (VATS)". Articles published between 1963 and 2024 in peer-reviewed journals were included, focusing on the ones from the 2000s. Data on methodology, key findings, and research gaps were reviewed. Results indicated a significant advantage of intraoperative lung ultrasound (ILU) in the assessment of pulmonary nodules. ILU offers a noninvasive, real-time imaging modality that demonstrates up to 100% accuracy in detecting pulmonary nodules, with shorter time needed compared to other modalities, as well as less intraoperative periods and postoperative complications. However, some disadvantages were detected, such as operator dependency and a lack of specificity and knowledge of specific signs, as well as assisted localization via percutaneous puncture and its correct interpretation. The findings suggest that ILU has a promising future in pulmonary surgeries such as LUS-VATS but needs to be engaged more in clinical applications and modified with new techniques such as artificial intelligence (AI).

Diagnostic accuracy of multi-organ point-of-care ultrasound for pulmonary embolism in critically ill patients: a systematic review and meta-analysis

BACKGROUND

The clinical presentation of acute pulmonary embolism (PE) can range from mild symptoms to severe shock, circulatory arrest and even death, thereby presenting with a significant high mortality when undiagnosed. Computed tomography pulmonary angiography (CTPA) is the gold-standard imaging modality for diagnosing PE, however, it has several practical limitations and is not widely available in low-income country settings. In this context, point-of-care ultrasound (POCUS) has emerged as a valuable bedside, non-invasive diagnostic tool. This meta-analysis assesses the accuracy of multi-organ POCUS for diagnosing PE in critical care settings.

STUDY DESIGN AND METHODS

We conducted a systematic search of Pubmed, Embase, Scopus and the Cochrane Library databases for studies comparing multi-organ POCUS with CTPA or ventilation-perfusion scans for PE diagnosis in critical care departments. Two reviewers independently completed search, data abstraction and conducted quality assessment with QUADAS-2 tool. Heterogeneity was examined with I2 statistics. We used a bivariate model of random effects to summarize pooled diagnostic odds ratio (DOR), sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and summary receiver operating characteristic (SROC).

RESULTS

Four studies met the inclusion criteria, comprising 594 patients. The mean age of participants ranged from 55.2 to 71 years. Prevalence of PE ranged from 28 to 66.2%. CTPA was the primary reference standard used in most studies. Multi-organ POCUS for PE diagnosis demonstrated a pooled DOR of 25.3 (95% CI 4.43-82.9) with a pooled sensitivity of 0.90 (95% CI 0.85-0.94; I2 = 0%) and specificity of 0.69 (95% CI 0.42-0.87; I2 = 95%). The PLR was 3.35 (95% CI 1.43-8.02) and the NLR was 0.16 (95% CI 0.08-0.32). The SROC curve showed an AUC of 0.89 (95% CI 0.81-0.94).

CONCLUSIONS

Multi-organ POCUS has high diagnostic accuracy for PE diagnosis in critically ill patients. Further research is needed to validated these findings across different patient populations.

PROSPERO REGISTRATION

CRD42024614328.

Diagnostic value of lung ultrasound B-lines for evaluating left ventricular filling pressure

BACKGROUND

The assessment of left ventricular (LV) diastolic function based on the American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) guidelines requires measurement of several echocardiographic indices. However, these assessments often yield inconclusive results owing to the absence of measurable parameters. Multiple B-lines on lung ultrasound have been proposed as a method for evaluating pulmonary congestion. We aimed to evaluate the association between B-lines and LV diastolic function and to examine whether B-lines show potential as an alternative to conventional indices for assessing LV diastolic function.

METHODS

This prospective study included 172 patients with pre-heart failure (HF) or HF. We investigated (i) the relationship between B-lines and LV diastolic function using echocardiography, (ii) the diagnostic accuracy of B-lines compared to echocardiography indices for estimating LV filling pressures and (iii) the relationship between B-lines and risk of hospitalisation for HF.

RESULTS

Among patients for whom the ASE/EACVI guideline algorithm for LV diastolic dysfunction was available (n = 89), the number of B-lines typically increased with the severity of diastolic dysfunction grade. In patients who underwent left heart catheterisation (n = 20), the LV filling pressure was significantly correlated with B-lines (r = 0.690, P < 0.001). The diagnostic accuracy of B-lines for detecting high LV filling pressure was comparable to that of tricuspid regurgitation peak gradient (TRPG). When TRPG was replaced with B-lines to diagnose grade II or III diastolic dysfunction using the ASE/ESCVI algorithm, sensitivity remained comparable (0.80); however, specificity improved (0.80 vs. 0.50). In patients who underwent lung ultrasound while they were hemodynamically stable and were followed up for prognosis (median, 730 days; n = 75), 14 hospitalisations for HF were observed. Kaplan-Meier analysis revealed that the high B-line group had a significantly higher incidence of hospitalisation events for HF (P = 0.036, log-rank test).

CONCLUSION

B-lines have shown potential as an alternative to conventional indices for assessing LV diastolic dysfunction.

Lung ultrasound for the diagnosis and monitoring of pneumonia in a tuberculosis-endemic setting: a prospective study

Lung ultrasound (LUS) has proven high diagnostic accuracy for community-acquired pneumonia (CAP) in developed countries. However, its diagnostic performance in resource-limited settings with high pulmonary tuberculosis (TB) incidence is less established. Additionally, the role of LUS in monitoring CAP progression remains underexplored.

OBJECTIVES

To validate the diagnostic performance, monitoring and prognostic utility of LUS for CAP in a high pulmonary TB incidence setting.

DESIGN

Prospective single-centre cohort study.

SETTING

Pulmonary department of a tertiary hospital in Vietnam.

PARTICIPANTS

A total of 158 patients suspected of having CAP were enrolled, with 136 (mean age 62 years, 72.8% male) included in the final analysis.

INTERVENTIONS

Patients underwent LUS and chest X-ray (CXR) within 24 hours of admission, with a follow-up LUS on days 5-8.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the diagnostic accuracy of LUS and CXR compared with discharge diagnosis. Secondary outcomes included the accuracy compared with CT scan results, changes in LUS parameters-consolidation size, number and Lung Ultrasound Score (LUSS)-and their association with in-hospital mortality.

RESULTS

LUS demonstrated higher sensitivity than CXR (96.0% (95% CI 90.0% to 99.0%) vs 82.8% (95% CI 73.9% to 89.7%)). LUS specificity was 64.9% (95% CI 47.5% to 80.0%), compared with 54.1% (95% CI 36.9% to 70.5%) for CXR. The moderate specificity for LUS was due to sonographic-similar conditions, notably TB in 5.1% of patients. Consolidation size and numbers showed marginal resolution, while LUSS showed more pronounced decreases over time. The baseline LUSS showed limited discriminative ability for predicting mortality (area under the curve, AUC 0.65, 95% CI 0.55 to 0.75), while follow-up LUSS and changes in LUSS (ΔLUSS) demonstrated higher levels of discrimination (AUC 0.81 (95% CI 0.71 to 0.89) and 0.89 (95% CI 0.80 to 0.95), respectively). For each one-point increase in ΔLUSS, the odds of in-hospital mortality went up by 70% (p=0.002). An improved LUSS effectively ruled out mortality (negative predictive value 97.4%).

CONCLUSION

Although LUS is highly sensitive for diagnosing CAP, its specificity in TB-endemic regions warrants further caution. Serial LUS assessments, particularly monitoring LUSS changes, are valuable for tracking disease progression and prognostication, with increasing LUSS indicating potential clinical deterioration.

Thoracic ultrasound in interstitial lung disease

B-lines and pleural line thickening on LUS are sensitive but nonspecific signs of ILD. LUS aids in early detection and monitoring, but HRCT and PFT remain the gold standards. Limitations include operator dependence and lack of standardised protocols. https://bit.ly/41vUQSn.

Lung ultrasound in children with cystic fibrosis - A new promising approach

BACKGROUND

Lung ultrasound is becoming increasingly important in the diagnosis of acute and chronic lung disease, especially in children and adolescents. In children with cystic fibrosis (CF), conventional radiography or computed tomography (CT) has been the main modality used to evaluate acute pneumonia or the progression of chronic lung disease. This Study aimed to evaluate Lung-Ultrasound as a diagnostic tool for children and adolescents with CF.

METHODS

We examined 30 CF patients with lung ultrasound before and after spirometry and compared them with lung ultrasounds of 15 lung-healthy children. We used a comprehensive and complete examination procedure with 12 probe positions to determine the best examination procedure in retrospect. In addition, an acceptance survey was conducted among the children and adolescents after the examination.

RESULTS

There was a significant difference in pleural irregularities, B-lines, consolidations and the adapted Peixoto et al. score between CF patients and healthy children before spirometry. We found excellent discrimination between patients and lung-healthy subjects using the Peixoto-score (AUC 0.968), pleural irregularities (AUC 0.890). CF patients had more B-lines, more consolidations, and a higher Peixoto score (mean difference 7.7 points). There was no significant difference in lung ultrasound results in children with CF before and after spirometry. Shortening our extended examination procedure would minimally compromise diagnostic accuracy. The lung ultrasound examination was well accepted by the children.

CONCLUSION

We could demonstrate that lung ultrasound is a sensitive and reliable method for assessing pulmonary changes in cystic fibrosis.

Advanced imaging techniques and artificial intelligence in pleural diseases: a narrative review

BACKGROUND

Pleural diseases represent a significant healthcare burden, affecting over 350 000 patients annually in the US alone and requiring accurate diagnostic approaches for optimal management. Traditional imaging techniques have limitations in differentiating various pleural disorders and invasive procedures are usually required for definitive diagnosis.

METHODS

We conducted a nonsystematic, narrative literature review aimed at describing the latest advances in imaging techniques and artificial intelligence (AI) applications in pleural diseases.

RESULTS

Novel ultrasound-based techniques, such as elastography and contrast-enhanced ultrasound, are described for their promising diagnostic accuracy in differentiating malignant from benign pleural lesions. Quantitative imaging techniques utilising pixel-density measurements to noninvasively distinguish exudative from transudative effusions are highlighted. AI algorithms, which have shown remarkable performance in pleural abnormality detection, malignant effusion characterisation and automated pleural fluid volume quantification, are also described. Finally, the role of deep-learning models in early complication detection and automated analysis of follow-up imaging studies is examined.

CONCLUSIONS

Advanced imaging techniques and AI applications show promise in the management and follow-up of pleural diseases, improving diagnostic accuracy and reducing the need for invasive procedures. However, larger prospective studies are needed for validation. The integration of AI-driven imaging analysis with molecular and genomic data offers potential for personalised therapeutic strategies, although challenges in data privacy, algorithm transparency and clinical validation persist. This comprehensive approach may revolutionise pleural disease management, enhancing patient outcomes through more accurate, noninvasive diagnostic strategies.

Characteristics of scores used for quantitative lung ultrasound in neonates: a systematic review

BACKGROUND

Quantitative lung ultrasound is increasingly being used in neonatology. The aim of this study is to identify the lung ultrasound scores (LUS) available for use in neonates, describe their characteristics and determine which LUS are most used and validated.

METHODS

A systematic review of the literature was conducted following PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols extension for reporting literature searches in systematic reviews) guidelines. Articles describing LUS in newborn animals and human neonates, published up to March 2024, were searched in the PubMed and Embase databases.

RESULTS

Out of 757 identified studies, 121 were included. Most of the articles were published in the past 5 years, predominantly by European investigators. They described 32 different LUS. Only 10 (31.4%) of these LUS had undergone at least one validation attempt and only 15 (48.4%) used the four-step scoring scale (i.e. scored from 0 to 3) based on classical lung ultrasound patterns originally described and well established in adult critical care medicine. The most common (49 (40.5%) of all the articles) neonatal score (published by Brat et al. in 2015) was based on this classical grading system. The most commonly used score was also validated using the greatest number of techniques and applied to all major neonatal respiratory disorders. Its simplified version is used to analyse six chest areas (anterior and lateral) to guide surfactant administration, while its extended version includes 10 areas by adding four posterior ones.

CONCLUSIONS

The most commonly used and validated score, consistent with adult critical care practice, should be the standard for assessing lung aeration in neonates.

Understanding of Patients with Severe COVID-19 Using Lung Ultrasound

BACKGROUND

Lung ultrasound (LUS) has proven valuable in the initial assessment of coronavirus disease 2019 (COVID-19), but its role in detecting pulmonary fibrosis following intensive care remains unclear. This study aims to assess the presence of pulmonary sequelae and fibrosis-like changes using LUS in survivors of severe COVID-19 pneumonia one month after discharge.

METHODS

We prospectively enrolled patients with severe COVID-19 who required mechanical ventilation in the intensive care unit (ICU) and conducted LUS assessments from admission to the outpatient visit after discharge. We tracked changes in key LUS findings and applied our proprietary LUS scoring system. To evaluate LUS accuracy, we correlated measured LUS values with computed tomography scores.

RESULTS

We evaluated B-line presence, pleural thickness, and consolidation in 14 eligible patients. The LUS scores exhibited minimal changes, with values of 19.1, 19.2, and 17.5 at admission, discharge, and the outpatient visit, respectively. Notably, the number of B-lines decreased significantly, from 1.92 at admission to 0.56 at the outpatient visit (p<0.05), while pleural thickness increased significantly, from 2.05 at admission to 2.48 at the outpatient visit (p≤0.05).

CONCLUSION

This study demonstrates that LUS can track changes in lung abnormalities in severe COVID-19 patients from ICU admission through to outpatient follow-up. While pleural thickening and B-line patterns showed significant changes, no correlation was found between LUS and high-resolution computed tomography fibrosis scores. These findings suggest that LUS may serve as a supplementary tool for assessing pulmonary recovery in severe COVID-19 cases.

Diagnostic accuracy of prehospital ultrasound in detecting lung injury in patients with trauma: a systematic review and meta-analysis

BACKGROUND

Ultrasound is now readily available in the prehospital setting and its use has been highlighted as one of the top research priorities in prehospital care. Clinical examination remains the standard care for diagnosing lung injury in the prehospital setting, yet this can be challenging and has poor diagnostic accuracy. This review evaluates the accuracy of prehospital ultrasound for the diagnoses of pneumothorax, haemothorax and pulmonary contusions in patients with trauma.

METHODS

A systematic review and meta-analysis was conducted. MEDLINE/PubMed, CINAHL, Embase and the Cochrane Library were searched. Only papers reporting on the diagnostic accuracy of lung ultrasound for traumatic pneumothorax, haemothorax or pulmonary contusions; in a prehospital or helicopter emergency medical service setting; and with CT or operative findings as a reference standard, were included. Non-English studies or articles that reported on animal studies were excluded. The Quality Assessment of Diagnostic Accuracy Studies-2 was used to assess the methodological quality of the included studies.

RESULTS

Six observational studies, four with low risk of bias and two with some concerns, reporting on 1908 thoracic ultrasound examinations in patients with trauma, were included. For pneumothorax, meta-analysis yielded pooled sensitivity of 29% (95% CI 22% to 37%, I2=0%) and pooled specificity of 98% (95% CI 97% to 99%, I2=0%). Insufficient data were reported for a reliable meta-analysis on the presence of haemothorax. Only one study reported on the presence of pulmonary contusions and therefore no analysis was conducted.

CONCLUSION

Prehospital ultrasound is highly specific but has a lower sensitivity for the presence of pneumothorax when compared with hospital studies. Further research is required, alongside education and training of prehospital providers, to further explore the factors that account for the differences observed in this review.

PROSPERO REGISTRATION NUMBER

CRD42023365034.

Performance of a point-of-care ultrasound platform for artificial intelligence-enabled assessment of pulmonary B-lines

BACKGROUND

The incorporation of artificial intelligence (AI) into point-of-care ultrasound (POCUS) platforms has rapidly increased. The number of B-lines present on lung ultrasound (LUS) serve as a useful tool for the assessment of pulmonary congestion. Interpretation, however, requires experience and therefore AI automation has been pursued. This study aimed to test the agreement between the AI software embedded in a major vendor POCUS system and visual expert assessment.

METHODS

This single-center prospective study included 55 patients hospitalized for various respiratory symptoms, predominantly acutely decompensated heart failure. A 12-zone protocol was used. Two experts in LUS independently categorized B-lines into 0, 1-2, 3-4, and ≥ 5. The intraclass correlation coefficient (ICC) was used to determine agreement.

RESULTS

A total of 672 LUS zones were obtained, with 584 (87%) eligible for analysis. Compared with expert reviewers, the AI significantly overcounted number of B-lines per patient (23.5 vs. 2.8, p < 0.001). A greater proportion of zones with > 5 B-lines was found by the AI than by the reviewers (38% vs. 4%, p < 0.001). The ICC between the AI and reviewers was 0.28 for the total sum of B-lines and 0.37 for the zone-by-zone method. The interreviewer agreement was excellent, with ICCs of 0.92 and 0.91, respectively.

CONCLUSION

This study demonstrated excellent interrater reliability of B-line counts from experts but poor agreement with the AI software embedded in a major vendor system, primarily due to overcounting. Our findings indicate that further development is needed to increase the accuracy of AI tools in LUS.

Lung Ultrasound for the Assessment of Patients With Acute Respiratory Failure

ABSTRACT

Lung ultrasound has become a standard practice in acute care as an adjunct to the physical exam, providing valuable insights to guide clinical decision making at the point of care. Lung ultrasound can rapidly uncover anatomic detail, help resolve undifferentiated respiratory failure, and delineate equivocal findings on standard plain film without the need for transport to access additional diagnostic imaging. In the following review, basic concepts of lung ultrasound are reviewed including its role in detecting and assessing a variety of common problems.

Position statement on the use of point-of-care ultrasound in heart failure: recommendations from the Heart Failure and Atrial Fibrillation, and Clinical Ultrasound Working Groups of the Spanish Society of Internal Medicine (SEMI)

This document provides a comprehensive analysis of the use of point-of-care ultrasound in heart failure (HF), offering detailed recommendations on echocardiography, lung ultrasound, and venous ultrasound. These advanced imaging techniques allow for an accurate, detailed, and non-invasive evaluation of heart failure, facilitating rapid and effective clinical decision-making. Echocardiography enables a rapid assessment of cardiac function at the point of care, enhancing traditional physical examination and being essential for the management of heart failure (HF). Lung ultrasound provides a detailed view of the pulmonary status, crucial for diagnosing pulmonary congestion without using ionizing radiation, ideal for continuous monitoring. Venous ultrasound evaluates systemic congestion by measuring the inferior vena cava and other parameters, aiding in the estimation of right atrial pressure and monitoring pressure and volume overload, improving patient understanding and prognosis. Together, the use of these ultrasound modalities not only complements but enriches the traditional physical examination, establishing themselves as indispensable tools in the comprehensive and effective management of patients with heart failure. By incorporating these techniques into clinical practice, healthcare professionals can achieve better evaluation, diagnosis, and treatment, resulting in more personalized management of these patients.

A possible role of e-FAST in the hemodynamically stable polytrauma patient: results of a single trauma center preliminary restrospective study

PURPOSE

The purpose of this work is to evaluate whether EFAST can also play a role in the hemodynamically stable polytrauma patient, without delaying his arrival in the CT-scan room.

METHODS

In a period of seven month, 748 polytrauma patients were retrospective valued; we analyzed the findings of the CT exams of 485 haemodynamically stable patients for whom the EFAST investigation was not requested, highlighting the possible presence of findings that, if reported during the EFAST, could have changed the patient management.

RESULTS

52 hemodynamically stable patients with CT examination findings potentially detectable by ultrasound examination directly in the shock room, which represent a percentage of about 11% of all the hemodynamically stable patients analyzed; about 54% of CT findings are represented by the presence of pneumothorax.

CONCLUSION

Looking to the results and the sensitivity of thoracic ultrasound in identifying even small flaps of pneumothorax, the evaluation by EFAST ultrasound examination could be extended at least to all those patients with chest trauma or who require endotracheal intubation. The risk of generating a hypertensive pneumothorax following positive pressure intubation is widely known, and certainly the presence of a pre-existing layer of pneumothorax, even if of modest entity, further increases this possibility.

Appropriateness of respiratory physiotherapy positioning for acute lobar collapse

BACKGROUND

Positioning is an important physiotherapy treatment modality for the management of aeration loss associated with acute lobar atelectasis (ALA). Physiotherapists typically rely on lung auscultation and interpretation of chest x-ray (CXR) to inform treatment selection. These tools lack diagnostic accuracy, which could limit the ability of a physiotherapist to locate ALA and select an appropriate treatment position.

OBJECTIVES

The objectives of this study were to determine the number of clinical physiotherapist treatment positions found to be in agreement with lung ultrasound (LUS)-identified aeration loss and to determine the diagnostic accuracy of CXR and lung auscultation against LUS as the reference standard for locating aeration loss in mechanically ventilated patients with ALA.

METHODS

A prospective cohort study was conducted in a tertiary teaching hospital in Sydney. Mechanically ventilated adult patients in critical care with ALA were included. Physiotherapist-selected positions were compared against location of aeration loss based on LUS results to determine appropriateness. Location of aeration loss as identified by CXR results and lung auscultation was compared against LUS as the reference standard to determine diagnostic accuracy.

RESULTS

Forty-three participants were included in this study. Four out of 43 patients (9.3%) were positioned appropriately. The rate of true positives for CXR and auscultation in locating aeration loss were highest in the lower lobes. Lung auscultation had higher sensitivities (16.7%-97.4%) than CXR (0%-59.5%) in a majority of lobes when detecting location of aeration loss. CXR had higher specificities (16.7%-100%) than lung auscultation (0%-64.9%) in a majority of lobes when detecting location of aeration loss.

CONCLUSIONS

Physiotherapists did not deliver appropriate positioning in a majority of cases. Overall, the diagnostic accuracy of lung auscultation and CXR in detecting location of ALA was low. Correctly locating lung aeration loss is imperative to ensure appropriate respiratory physiotherapy positions are selected. Physiotherapists should consider additional assessment tools such as LUS to increase their diagnostic ability.

Artificial Intelligence-Guided Lung Ultrasound by Nonexperts

Importance

Lung ultrasound (LUS) aids in the diagnosis of patients with dyspnea, including those with cardiogenic pulmonary edema, but requires technical proficiency for image acquisition. Previous research has demonstrated the effectiveness of artificial intelligence (AI) in guiding novice users to acquire high-quality cardiac ultrasound images, suggesting its potential for broader use in LUS.

Objective

To evaluate the ability of AI to guide acquisition of diagnostic-quality LUS images by trained health care professionals (THCPs).

Design, Setting, and Participants

In this multicenter diagnostic validation study conducted between July 2023 and December 2023, participants aged 21 years or older with shortness of breath recruited from 4 clinical sites underwent 2 ultrasound examinations: 1 examination by a THCP operator using Lung Guidance AI and the other by a trained LUS expert without AI. The THCPs (including medical assistants, respiratory therapists, and nurses) underwent standardized AI training for LUS acquisition before participation.

Interventions

Lung Guidance AI software uses deep learning algorithms guiding LUS image acquisition and B-line annotation. Using an 8-zone LUS protocol, the AI software automatically captures images of diagnostic quality.

Main Outcomes and Measures

The primary end point was the proportion of THCP-acquired examinations of diagnostic quality according to a panel of 5 masked expert LUS readers, who provided remote review and ground truth validation.

Results

The intention-to-treat analysis included 176 participants (81 female participants [46.0%]; mean [SD] age, 63 [14] years; mean [SD] body mass index, 31 [8]). Overall, 98.3% (95% CI, 95.1%-99.4%) of THCP-acquired studies were of diagnostic quality, with no statistically significant difference in quality compared to LUS expert-acquired studies (difference, 1.7%; 95% CI, -1.6% to 5.0%).

Conclusions and Relevance

In this multicenter validation study, THCPs with AI assistance achieved LUS images meeting diagnostic standards compared with LUS experts without AI. This technology could extend access to LUS to underserved areas lacking expert personnel.

Trial Registration

ClinicalTrials.gov Identifier: NCT05992324.

Lung ultrasound outperforms symptom-based screening to detect interstitial lung disease associated with rheumatoid arthritis

OBJECTIVES

Interstitial lung disease associated with rheumatoid arthritis (RA-ILD) is linked to high mortality. Currently, effective screening tools are lacking. We assessed the role of symptoms and lung ultrasound (LUS) as potential screening tools.

METHODS

116 adult patients with RA presenting to the rheumatology outpatient clinic underwent high-resolution CT (HRCT) scans, pulmonary function tests, LUS (72 zones) and completed a Visual Analogue Scale (VAS) for cough and modified Medical Research Council dyspnoea scale (mMRC). Kruskal-Wallis (KW) tests evaluated the correlation between clinical-radiological HRCT score (no ILD, non-specific abnormalities, subclinical ILD or ILD) and the B-lines on LUS, diffusion capacity (DLCO%pred), forced vital capacity (FVC%pred), VAS Cough and mMRC. Sensitivity and specificity analyses were performed to assess symptom-based questionnaires and the number of B-lines to detect RA-ILD. Area under the receiver operating characteristics (AUROC) for detecting clinical ILD and subclinical ILD were calculated.

RESULTS

In 11.8% of patients, an ILD was detected on HRCT. Additionally, in 5%, a diagnosis of subclinical interstitial lung changes was made. The number of B-lines was most strongly associated with the clinical-radiological score (KW χ²=41.2, p=<0.001). DLCO%pred was also significantly correlated with the clinical-radiological score (KW χ²=27.4, p=<0.001), but FVC%pred, mMRC and VAS cough were not. Cough and dyspnoea only weakly predicted the ILD score in the sensitivity-specificity analyses, while B-lines showed AUROCs>0.9 for predicting subclinical and clinical ILD.

CONCLUSION

LUS is a promising tool for early detection of RA-ILD, outperforming symptom-based questionnaires or the presence of dyspnoea or cough.

Relationship between lung consolidation size measured by ultrasound and outcome in ICU patients with respiratory failure

BACKGROUND

Lung ultrasound has been extensively used to assess the etiology of respiratory failure. Additionally, lung ultrasound-based scoring systems have been proposed to semi-quantify the loss of lung aeration in the ICU. The one most frequently used distinguishes four steps of progressive loss of aeration (scores from 0 to 3) and 3 scores mean tissue-like pattern. However, the burden of consolidation is not considered as tissue-like pattern is defined as 3 scores independently of its dimension. In this study, we present an ultrasound method for quantitative measurement of consolidation size and investigate the relationship between consolidation size and outcome in ICU patients with respiratory failure.

METHODS

A total of 124 patients in ICU were prospectively enrolled and 13 patients were excluded due to failure to obtain LUS measurements. Among the remaining 111 patients, 17 patients were non-intubated, and 94 patients under sedation and analgesia were intubated. All patients underwent lung ultrasound examination for the measurement of lung consolidation size between 24 and 48 h after ICU admission. Lung consolidation size was assessed by consolidation area index (CA), which was determined by tracing the maximum cross-sectional area of the region of consolidation. The Cox-regression model was constructed for 28- and 90-day mortality.

RESULTS

Consolidation size was successfully evaluated in all patients. The CA was 24.2cm2[15.9-36.6] (median [25th -75th percentiles]). CA was negatively correlated with PaO2/FiO2 ratio (r=-0.26, P < 0.0001). Upon univariate and multivariate analysis, only CA [Odds ratio (OR) 1.04, 95% CI 1.01-1.08, P = 0.004] and APACHEII (OR 1.14, 95% CI 1.05-1.25, P = 0.002) were the risk factors for ICU mortality. Patients with substantial CA (> 29.4cm2) had a higher risk of death in 28-day [Hazard ratio (HR) 4.35, 95%CI 1.70-11.11; Log-rank P = 0.017] and 90-day mortality (HR 4.10, 95%CI 1.62-10.39; Log-rank P < 0.01).

CONCLUSIONS

The proposed CA parameter, determined by lung ultrasound, was readily accessible at the bedside. It is noteworthy that a larger CA was correlated with impaired oxygenation and increased mortality rates among ICU patients. Further investigation is required to establish the merits of incorporating CA into lung ultrasound assessments in the ICU.

TRIAL REGISTRATION

ClinicalTrial.gov, Identifier NCT05647967, Date: Dec 13, 2022, retrospectively registered.

Transthoracic Lung Ultrasound in Systemic Sclerosis-Associated Interstitial Lung Disease: Capacity to Differentiate Chest Computed-Tomographic Characteristic Patterns

Background/Objectives: Even today, interstitial lung disease (ILD) is diagnosed by chest high-resolution computed tomography (lung HR-CT). Large amounts of data are available about the usefulness of transthoracic lung ultrasound (LUS) in ILD. This study aimed to evaluate the transthoracic LUS capacity to discriminate different ILD patterns in systemic sclerosis (SSc) patients, such as usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP) with ground glass opacification/opacity (GGO), and NSIP with GGO and reticulations, as well as the possibility of identifying progressive fibrosing ILD. Methods: We enrolled SSc-patients attending the outpatient Clinic of the Rheumatology Unit of Policlinico of Foggia and the Rheumatology Unit of Policlinico of Bari who satisfied these inclusion criteria: age older than 18 years; the satisfaction of ACR/EULAR 2013 classification criteria for SSc; chest HR-CT scan within three months before or three months after transthoracic LUS evaluation; and availability of recent and complete pulmonary function test. The exclusion criteria were as follows: history or recent reactivation of chronic obstructive pulmonary disease, lung cancer, lung infection, heart failure, pulmonary oedema, pulmonary arterial hypertension, acute respiratory distress syndrome and diffuse alveolar haemorrhage and thoracic surgery. All enrolled SSc-patients underwent transthoracic LUS, performed by an experienced sonographer. The ILD diagnosis and the respective patterns were assessed by chest HR-CT, which still represents the best diagnostic tool. Results: ILD was observed in 99 (63.5%) patients. Of these, 25% had the UIP pattern and 75% the NSIP pattern (46 with GGO, 28 with GGO and reticulations). By receiver operating characteristic (ROC) curve analysis, higher values of accuracy, sensitivity, specificity, and negative clinical utility index (CUI) were found for pleural line irregularity (0.84 (95% CI: 0.75-0.91), 96%, and 73.6%, p = 0.0001; 0.72), and pleural line thickness (0.84 (95% CI: 0.74-0.91), 72%, and 96.4%, p = 0.0001; 0.85) for detecting the UIP pattern. The best performance among transthoracic LUS signs for NSIP with the GGO pattern was observed for B-lines (accuracy: 0.88 (95% CI: 0.80-0.93), sensitivity: 93.4% and specificity: 82.4, p = 0.0001; CUI+: 0.75, CUI-: 0.77). LUS signs with higher accuracy, sensitivity, and specificity for NSIP with GGO and reticulations were pleural line irregularity (0.89 (95% CI: 0.80-0.95), 96.4%, and 82.4%, p = 0.0001) with CUI-: 0.72, and B-lines (0.89 (95% CI: 0.80-0.95), 96.4%, 82.4%, p = 0.0001), with CUI+: 0.80 and CUI-: 0.70. Furthermore, a total number of B-lines > 10 maximises LUS performance with 92.3% sensitivity, and an accuracy of 0.83 (p = 0.0001) for detecting the NSIP pattern, particularly GGO. A sample-restricted analysis (66 SSc patients) evidenced the presence of progressive fibrosing ILD in 77% of these patients. By binary regression analysis, the unique LUS sign associated with progressive fibrosing ILD was the presence of pleural line irregularity (OR: 3.6; 95% CI 1.08-11.9; p = 0.036). Conclusions: Our study demonstrated that transthoracic LUS presented a high capacity to discriminate the different patterns of SSc-ILD. Therefore, the hypothesis that transthoracic LUS is an effective screening method for the evaluation of the presence of SSc-ILD and establishing the correct timing of chest HR-CT, in order to avoid patients receiving excessive exposure to ionising radiation, is supported.

Hepatocardiorenal Syndrome: Integrating Pathophysiology with Clinical Decision-Making via Point-Of-Care Ultrasound

BACKGROUND

Accumulating evidence has challenged the traditional model of the liver-kidney connection in hepatorenal syndrome. Cirrhosis can significantly impact cardiac function, leading to cirrhotic cardiomyopathy. Recent understanding reveals how cardiac dysfunction plays a pivotal role in the development of renal dysfunction in this setting, suggesting that disturbances traditionally categorized under hepatorenal syndrome may actually represent a hepatic form of cardiorenal syndrome - hepatocardiorenal syndrome - where the liver affects the kidney through cardiorenal pathways.

SUMMARY

Effective management of hepatocardiorenal syndrome and acute kidney injury in cirrhosis relies on accurately assessing a patient's hemodynamic and volume status. Point-of-care ultrasound, including lung and focused cardiac ultrasound, is a valuable diagnostic tool that provides crucial data on fluid tolerance, subclinical pulmonary congestion, and left ventricular filling pressures. This objective, bedside approach offers a comprehensive assessment that directly influences patient management and therapeutic decisions.

KEY MESSAGES

Point-of-care ultrasound plays an essential role in evaluating and managing hepatocardiorenal syndrome, providing insights into the underlying pathophysiology. By assessing hemodynamic parameters, it helps guide therapy and monitor patient responses, ensuring more accurate and effective treatment of patients with cirrhosis and acute kidney injury.

Lung Ultrasound in Hemodialysis Patients-Which Protocol Is More Accurate and Informative in Daily Clinical Practice: A Systematic Review

Lung ultrasound can detect hidden lung congestion in hemodialysis (HD) patients, even though they present no symptoms of hypervolemia. The 28-zone protocol is the one mainly assessed in the majority of studies. However, it is quite time consuming, making its integration into daily clinical practice difficult. Alternative approaches have been proposed that require fewer scanning zones. This systematic review used various combinations of the following keywords: "Lung ultrasound", "Hemodialysis", "Scanning protocols", "Scanning zones", "28-points", and "28-zones" via PubMed's and Google Scholar's search engines. Six relevant studies were obtained, five of which refer to the adult population and one to children. Initially, the first published study compared the 28-zone protocol to the 8-zone protocol, while three studies compared the 28-zone protocol to the 8-zone, 6-zone, and 4-zone protocols. Another study compared the 16-zone protocol to the 12-zone and 8-zone protocols. Finally, one study compared the 28-zone protocol to the 8-zone protocol in children. There are several alternatives in the literature for applying abbreviated versions of the 28-zone protocol to save time in daily clinical practice. However, none of these protocols provide the same accuracy as the 28-zone protocol. Therefore, it should be preferred when the clinical question regarding pulmonary congestion remains. Further multicenter studies are required to determine whether any shorter version of the 28-zone protocol can sufficiently replace it in daily clinical practice.

Potential for Lung Recruitment Maneuvers Estimated by the Cytokines in Bronchoalveolar Lavage Fluid in Acute Respiratory Distress Syndrome

Objective: Lung recruitment maneuvers (RMs) is an important treatment for acute respiratory distress syndrome (ARDS) patients; however, assessing lung recruitability is imperative to avoid biotrauma and hemodynamic instability. This study aims to investigate whether the cytokine levels in the bronchoalveolar lavage fluid (BALF) of ARDS patients can serve as an indicator of their lung recruitability. Methods: This study included ARDS patients who received mechanical ventilation for over 24 h. Patients were categorized into lung recruitment maneuver effective (RM-E) group and lung recruitment maneuver noneffective (RM-N) group. Interleukin-6 (IL-6), interleukin-8 (IL-8) and interleukin-10 (IL-10) in BALF, lung ultrasound (LUS) scores, and the oxygenation index (P/F) were measured. The differences in cytokine levels between the two groups were compared, and correlations between changes in cytokine levels (ΔIL-6, ΔIL-8, and ΔIL-10), ΔLUS, and ΔP/F were analyzed. Results: Sixty-two patients were included in this study (38 in the RM-E group and 24 in the RM-N group). After the RM, compared with the RM-N group, an increase was observed in ΔIL-6 (p=0.013), ΔIL-8 (p=0.045), ΔIL-10 (p=0.039), and ΔLUS (p=0.045) in the RM-E group. A positive linear correlation was found between ΔIL-6 and ΔLUS (r = 0.504, p < 0.001). The area under the lung recruitment potential curve (AUC) predicted by ΔIL-6 was 0.794, the sensitivity was 94.7%, and the specificity was 70.8%. A positive linear correlation was found between ΔIL-6 and ΔLUS (r = 0.504, p < 0.001). The lung recruitment potential curve's AUC predicted by ΔIL-6 was 0.794, with a sensitivity of 94.7% and specificity of 70.8%. Conclusion: Lower levels of cytokines in BALF were observed in the RM-E group. It is possible that the cytokines in BALF, especially IL-6, could be used to determine the need for RM on the basis of lung recruitability.

Transfer of POCUS Skills of Anesthesia Trainees from the Simulation Laboratory to Clinical Practice: A Follow-Up Pilot Evaluation After ABC US Protocol Training

Background/objectives: Point-of-care ultrasound (POCUS) in the intensive care unit (ICU) has gained much attention in the last few years as an alternative to the classic ways of assessing and diagnosing life-threatening conditions in critical patients. During the COVID-19 pandemic, we proposed a POCUS protocol based on the airway, breathing, and circulation (ABC) approach to quickly evaluate and diagnose life-threatening diseases in critical patients with acute respiratory failure and shock, and later, we used it as a curriculum to teach POCUS to anesthesia and intensive care trainees. Methods: We developed an evaluation protocol where evaluators with experience in POCUS in critically ill patients had to assess the trainee's ultrasound scan; this was based on the ABC protocol taught in the simulation laboratory and applied in a clinical setting at the bedside. Results: Statistically significant differences were observed in some categories evaluated regarding independence and diagnosis. Conclusion: Initial POCUS simulation-based training using an ABC POCUS protocol (that demonstrated good results in the simulation laboratory) is useful when transferring US skills to the bedside and is applicable in daily clinical practice with good results in terms of operator independence.

[Sonography of the pleura - step by step]

Pleural ultrasonography enables the rapid and reliable detection of pneumothoraces, pleural effusions, and other lung pathologies. Its advantages - such as high image resolution and ease of bedside use - make it particularly popular in acute and intensive care medicine. Despite its limitations in examining deeper structures, it offers many benefits compared to other imaging modalities.

Predictive Value of Lung Ultrasound Combined With ACEF Score for the Prognosis of Acute Myocardial Infarction

BACKGROUND

Lung ultrasound (LUS) and the ACEF score (age, creatinine, and ejection fraction) have been shown to be pivotal in predicting an unfavorable prognosis in acute myocardial infarction (AMI).

HYPOTHESIS

The aim of this study is to investigate the prognostic value of LUS combined with ACEF score in AMI.

METHODS

The ACEF score and the total number of B-lines in eight thoracic regions of LUS were calculated. Adverse events were recorded during hospitalization and follow-up, defined as all-cause death and other cardiovascular events. Multivariate logistic regression identified predictors of adverse events during hospitalization. Multivariate Cox regression identified predictors of adverse events during follow-up.

RESULTS

We enrolled 204 patients. The B-lines (adjusted OR 1.08, [95% CI: 1.03-1.13], p < 0.01) and the ACEF score (adjusted OR 2.71 [95% CI: 1.07-6.81], p < 0.05) independently predicted adverse events during hospitalization. The C-index values were 0.81 (p < 0.01) for the ACEF score, 0.81 (p < 0.01) for LUS, and 0.86 (p < 0.01) for their combination. One hundred seventy-one patients were followed up for 12 months (IQR, 8.13-15.93). Both the B-lines (adjusted HR 1.06 [95% CI: 1.03-1.09], p < 0.05) and the ACEF score (adjusted HR 1.95 [95% CI: 1.10-3.43], p < 0.05) remained associated with an increased risk of adverse events during follow-up. The C-index values were 0.74 (p < 0.01) for the ACEF score, 0.73 (p < 0.01) for LUS, and 0.80 (p < 0.01) for their combined predictive ability.

CONCLUSIONS

The B-lines and ACEF score are associated with adverse events in AMI patients. When combined, they provide increasing value in assessing the risk of adverse events, which has significant implications for risk stratification.

Potential role of lung ultrasonography in outpatient follow-up of patients with COVID-19. A systematic review

INTRODUCTION AND AIM

Currently, the usefulness of lung ultrasound in the follow-up of patients after hospital discharge for SARS-CoV-2 pneumonia is not well known. The main objective of this systematic review is to investigate the persistence of alterations in lung ultrasound of patients who have had COVID-19 pneumonia.

METHODS

A systematic review has been carried out following the PRISMA regulations in the PubMed, EMBASE, Web of Science and Google Scholar database from January 2020 to May 2023 using the combination of MeSH terms: "lung ultrasound", "ultrasonography", "lung alterations", "persistence", "follow-up", "consequences", "hospital discharge", "COVID", "COVID-19", "SARS-CoV-2". Studies were selected that described alterations in the lung ultrasound of patients after having suffered from COVID-19 pneumonia. The JBI Critical Appraisal Tools were used to assess the risk of bias of the studies. No meta-analysis techniques were performed, the results being compared narratively.

RESULTS

From two to six months after COVID-19 pneumonia, pulmonary ultrasound abnormalities appear frequently and are proportional to the intensity of the initial episode. The most frequent anomalies are irregularities in the pleural line, the presence of B lines and/or subpleural consolidations, predominantly in the basal regions of the thorax. These findings seem to correlate with those of the chest CT.

CONCLUSIONS

Lung ultrasound offers technical and economic advantages that should be considered for the study of patients after hospital discharge for COVID-19.

The diagnostic value and efficacy evaluation of lung ultrasound score in neonatal respiratory distress syndrome: a prospective observational study

Objective

To evaluate the diagnostic efficacy and determine the optimal cut-off values of lung ultrasound score for diagnosing neonatal respiratory distress syndrome and its accuracy in assessing the efficacy of neonatal respiratory distress syndrome.

Method

This prospective study included 100 neonates with suspected neonatal respiratory distress syndrome. Each patient underwent both the 14-zone and 12-zone lung ultrasound methods, as well as a chest x-ray, performed after birth and before initiating drug treatment. Surfactant replacement therapy was administered to patients who were diagnosed with neonatal respiratory distress syndrome and met the criteria for medication. Lung ultrasound was conducted and recorded at the 24th hour, the 48th hour, the 72nd hour, and the 7th day after drug administration. ROC curve analysis, Kappa statistics, and ANOVA were utilized to identify the optimal cut-off values for the lung ultrasound scores in diagnosing neonatal respiratory distress syndrome.

Results

89 neonates were diagnosed with respiratory distress syndrome, of whom 64 received surfactant replacement therapy. The mean scores of 12-zone lung ultrasound score, 14-zone lung ultrasound score, and chest x-ray score are 18.22 ± 7.15, 38.92 ± 9.69, and 2.15 ± 0.97, respectively. The diagnostic AUC for the 12-zone lung ultrasound score is 0.84 (95% CI: 0.73-0.95), with an optimal cut-off value of 13.5 for diseased vs. not diseased, while the AUC for the 14-zone lung ultrasound score is 0.88 (95% CI: 0.76-0.99), with an optimal cut-off value of 34 for diseased vs. not diseased. There is significant concordance between the neonatal lung ultrasonography scores and the chest x-ray score for diagnosis respiratory distress syndrome (P < 0.01). The optimal cut-off values for the grading diagnosis of neonatal respiratory distress syndrome using the 14-zone lung ultrasound score are identified as 36.5, 40.5, and 44.5. The 12-zone lung ultrasound score does not have a significant difference between the 12th hour after receiving surfactant replacement therapy and the 48th hour after treatment (P = 0.08). All other comparisons demonstrated significant differences.

Conclusion

The 14-zone lung ultrasound score demonstrates higher diagnostic efficacy in diagnosing neonatal respiratory distress syndrome and can accurately evaluate the early efficacy of surfactant replacement therapy in neonates.

Dynamic pathophysiological features of early primary blast lung injury: a novel functional incapacity pig model

INTRODUCTION

While there is evidence supporting the use of ultrasound for real-time monitoring of primary blast lung injury (PBLI), uncertainties remain regarding the timely detection of early PBLI and the limited data correlating it with commonly used clinical parameters. Our objective is to develop a functional incapacity model for PBLI that better addresses practical needs and to verify the early diagnostic effectiveness of lung ultrasound in identifying PBLI.

METHODS

We selected six healthy male pigs to develop an animal model using a bio-shock tube (BST-I). The injuries were induced at a pressure of 4.8 MPa. We monitored the animals before and after the injury using various methods to detect changes in vital signs, lung function, and hemodynamics.

RESULTS

The experimental peak overpressure was measured at 405.89 ± 4.14KPa, with the duration of the first positive peak pressure being 50.01ms. The mortality rate six hours after injury was 50%. The average Military Combat Injury Scale was higher than 3. Significant increases were observed in heart rate (HR), shock index (SI), alveolar-arterial oxygen gradient (AaDO2), lung ultrasound scores(LUS), and pulmonary vascular permeability index (PVPI) at 0.5 h, 3 h, and 6 h after-injury (p < 0.05). Conversely, there were notable decreases in average arterial pressure(MAP), oxygenation index (OI), stroke volume per heartbeat(SV), cardiac output power index(CPI), global end-diastolic index (GEDI), and intrathoracic blood volume index (ITBI) during the same time periods (p < 0.05). Meanwhile, the extrapulmonary water index (ELWI) showed a significant increase at 0.5 h and 6 h after injury (p < 0.05). At 6 h after injury, pulmonary ultrasound scores were positively correlated with HR (R = 0.731, p < 0.001), AaDO2 (R = 0.612, p = 0.012), SI (R = 0.661, p = 0.004), ELWI (R = 0.811, p < 0.001), PVPI (R = 0.705, p = 0.002). In contrast, these scores were negatively correlated with SpO2 (R = -0.583, p = 0.007),OI (R = -0.772, p < 0.001), ITBI (R = -0.637, p = 0.006).

CONCLUSION

We have successfully developed a novel, and highly reproducible animal model for assessing serious PBLI functional incapacity. This model displays immediate symptoms of hypoxia, decreased cardiac output, decreased blood volume, and abnormal lung ultrasound findings within 0.5 h of injury, with syptoms lasting for up to 6 h. Lung ultrasound evaluation is crucial for the early assessment of injuries, and is comparable to commonly used clinical parameters.

The value of lung ultrasound score combined with echocardiography in assessing right heart function in patients undergoing maintenance hemodialysis and experiencing pulmonary hypertension

AIMS

This study explores the clinical application of lung ultrasound scoring(LUS) combined with echocardiography in assessing right heart function in patients undergoing maintenance hemodialysis(MHD) and those with elevated pulmonary artery systolic pressure(PASP), as well as the correlation between LUS and right ventricular(RV) function.

METHODS

Eighty five patients who underwent MHD combined with elevated PASP, at the First Central Hospital of Baoding City were selected. Divided into three groups based on PASP, and perform echocardiography and lung ultrasound examinations. Compare the right heart function parameters and LUS among the three groups. Using Pearson correlation analysis to examine the relationship between LUS and right heart function parameters. Perform multivariate logistic regression analysis to identify predictive factors for RV systolic dysfunction. A receiver operating characteristic (ROC) curve and calculate the area under the curve(AUC) to compare the diagnostic efficacy of various parameters.

RESULTS

Patients undergoing MHD exhibited varying degrees of reduced left ventricular (LV) and RV systolic function. Correlation analysis revealed that Tricuspid annular plane systolic excursion (TAPSE), Fractional area change (FAC), and Tricuspid annular peak systolic velocity(S') were negatively correlated with LUS(r = -0.81, -0.86, -0.69), while Right ventricular free wall longitudinal strain(RVFWLS) was positively correlated with LUS (r = 0.85, P < 0.05). The ROC curve indicated that the combination of LUS and RVFWLS had the highest area under the curve (AUC = 0.963), followed by the combination of LUS and TAPSE (AUC = 0.847), LUS and FAC(AUC = 0.937), and LUS combined with S'(AUC = 0.940). All combinations demonstrated higher AUC values than the individual indicators.

CONCLUSIONS

Patients with MHD combined with elevated PASP, the RV function parameters are associated with LUS, which may serve as a valuable reference indicator for assessing RV function. The use of LUS to evaluate right heart function in these patients, alongside traditional two-dimensional parameters, holds significant clinical value.

Thirteen serum biochemical indexes and five whole blood coagulation indices in a point-of-care testing analyzer: ideal protocol for evaluating pulmonary and critical care medicine

The accurate and timely detection of biochemical coagulation indicators is pivotal in pulmonary and critical care medicine. Despite their reliability, traditional laboratories often lag in terms of rapid diagnosis. Point-of-care testing (POCT) has emerged as a promising alternative, which is awaiting rigorous validation. We assessed 226 samples from patients at the First Affiliated Hospital of Guangzhou Medical University using a Beckman Coulter AU5821 and a PUSHKANG POCT Biochemistry Analyzer MS100. Furthermore, 350 samples were evaluated with a Stago coagulation analyzer STAR MAX and a PUSHKANG POCT Coagulation Analyzer MC100. Metrics included thirteen biochemical indexes, such as albumin, and five coagulation indices, such as prothrombin time. Comparisons were drawn against the PUSHKANG POCT analyzer. Bland-Altman plots (MS100: 0.8206‒0.9995; MC100: 0.8318‒0.9911) evinced significant consistency between methodologies. Spearman correlation pinpointed a potent linear association between conventional devices and the PUSHKANG POCT analyzer, further underscored by a robust correlation coefficient (MS100: 0.713‒0.949; MC100: 0.593‒0.950). The PUSHKANG POCT was validated as a dependable tool for serum and whole blood biochemical and coagulation diagnostics. This emphasizes its prospective clinical efficacy, offering clinicians a swift diagnostic tool and heralding a new era of enhanced patient care outcomes.

Diagnostic performance of prehospital EFAST in predicting CT scan injuries in severe trauma patients: a multicenter cohort study

BACKGROUND

The early mortality of trauma patients, mainly from hemorrhagic shock, raises interest in detecting the presence of non-exteriorized bleeding. Intra-hospital EFAST (Extended Focused Assessment with Sonography for Trauma) has demonstrated its utility in the assessment and management of severe trauma patients (STP). However, there is a lack of data regarding the diagnostic performance of prehospital EFAST (pEFAST). The main objective of our study was to evaluate the pEFAST performance to predict a positive CT scan in STP.

METHODS

This was a retrospective, multicenter, database-driven study. All severe trauma patients managed by a prehospital medical team were included. The results of pEFAST were compared with the admission CT scan.

RESULTS

Data from 495 patients were included. The pEFAST had sensitivity of 27% (95% CI 22; 32) and specificity of 94% (95% CI 90; 97) for predicting the presence of a lesion on CT scan at hospital admission. The area under the curve (AUC) was 0.66 (95% CI 0.57; 0.63), the positive predictive value 84% (95% CI 75; 87), the negative predictive value was 51% (95% CI 44; 66), the positive likelihood ratio was 4.24 (95% CI 2.46; 7.3) and the negative likelihood ratio 0.78 (95% CI 0.72; 0.85).

CONCLUSION

Prehospital EFAST has an excellent specificity but a poor sensitivity for predicting a positive CT scan on hospital admission. We do not know whether this low sensitivity is secondary to the delay between the two examinations or to the poor performance of pEFAST. Therefore, a negative pEFAST should not be reassuring. A positive pEFAST is highly informative, as it predicts a lesion and enables hospital management to be prepared accordingly.

Point-of-Care Lung Ultrasound in Small Animal Emergency and Critical Care Medicine: A Clinical Review

Thoracic point-of-care ultrasound (T-POCUS) has grown in popularity and usage in small animal emergencies and critical care settings due to its non-invasive nature, mobility, and ability to acquire images in real time. This review summarizes current understanding about T-POCUS in dogs and cats with respiratory illnesses, including normal thoracic ultrasonography appearance and numerous pathological situations. The basics of T-POCUS are covered, including equipment, scanning procedures, and picture settings. Practical applications in patients with respiratory distress are discussed, with an emphasis on pleural space abnormalities and lung diseases. Ultrasound results define pulmonary disorders such as pneumonia, atelectasis, cardiogenic and non-cardiogenic pulmonary edema, lung lobe torsion, pulmonary fibrosis, pulmonary thromboembolism, pulmonary neoplasms, and pulmonary bleeding. The evaluation focuses on T-POCUS diagnostic skills in a variety of clinical settings. Limitations and the need for more study to standardize techniques, establish agreed terminology, and create specialized educational routes are highlighted.

Thoracic Ultrasound in Cattle: Methods, Diagnostics, and Prognostics

Thoracic ultrasonography (TUS) has emerged as a critical tool in the diagnosis and management of respiratory diseases in cattle, particularly bovine respiratory disease (BRD), which is one of the most economically significant health issues in feedyard operations. The objective of this review is to explore TUS in veterinary medicine, including the historical development, methodologies, and clinical applications for diagnosing and prognosing respiratory diseases. This review also emphasizes the importance of operator training, noting that even novice operators can achieve diagnostic consistency with proper instructions. Ultrasound was introduced in the mid-20th century for back-fat thickness measurements; TUS has evolved to offer a non-invasive, real-time imaging modality that allows for the detection of lung and pleural abnormalities such as consolidations, pleural effusions, and B-lines. These features are vital indicators of respiratory disease, and their early identification through TUS can significantly improve clinical outcomes. Compared to traditional diagnostic methods like auscultation or radiography, TUS provides superior accuracy in detecting both subclinical and advanced respiratory conditions, particularly in high-risk populations. Furthermore, TUS has demonstrated strong prognostic value, with studies showing that the extent of lung consolidation correlates with higher relapse risk, reduced growth performance, and increased mortality.

Integrated Lung, Diaphragm and Lower Limb Muscular Ultrasound: Clinical Correlations in Geriatric Patients with Acute Respiratory Illness

Background/Objectives: Point-of-care lung ultrasonography (LUS) represents an accurate diagnostic tool in older patients with respiratory failure. The integration of LUS with ultrasonographic assessment of diaphragm thickness and excursion, right vastus lateralis (RVL) muscle thickness and cross-sectional area (CSA) could provide real-time information on frailty and sarcopenia. The primary aim of this proof-of-concept prospective study was to evaluate clinical correlates of thoracic, diaphragmatic, and muscular ultrasound to characterize the associations between frailty, respiratory failure, and sarcopenia in older patients hospitalized for acute respiratory complaints. Methods: Each of 52 participants (age median 84, IQR 80-89 years old) underwent integrated LUS, diaphragm and RVL ultrasound examination upon admission (T0) and after 72 h of hospitalization (T1). LUS score was used to estimate lung interstitial syndrome severity. Diaphragm excursion, thickness, RVL thickness and CSA were measured following a standardized protocol. Frailty was assessed with the PC-FI (Primary Care-Frailty Index). Results: All patients exhibited multifactorial causes of respiratory symptoms. The LUS score on T0 predicted 3-month rehospitalization. Frail patients exhibited higher LUS scores on T1. Diaphragm excursion on T0 was reduced in patients with COPD and heart failure and in those developing delirium during hospitalization. Diaphragm excursion on T1 was negatively associated with PC-FI. Diaphragm thickness, RVL thickness, and CSA exhibited a positive association with obesity. Right vastus lateralis CSA on T1, however, was also negatively associated with PC-FI. Conclusions: Integrated lung, diaphragm, and RVL ultrasound shows clinical correlations with several aspects of frailty that may help to improve the management of geriatric patients with respiratory illness.

Role of pulmonary ultrasonography in diagnosis of acute heart failure

BACKGROUND

One of the most prevalent causes of emergency room visits is acute dyspnea. Several etiologies, including cardiac, pulmonary, metabolic, psychogenic etc… may be involved. Acute heart failure (AHF) is among the most common causes. This study aims to evaluate, in patients presenting with acute dyspnea to the emergency departement (ED), the accuracy of a diagnostic approach combining Lung ultrasonography (LUS) and clinical assessment as compared to the traditional AHF diagnostic work-up.

METHODS

This is a bi-centric cross-sectional observational study, conducted at the Emergency and Cardiology Department of both the Hedi Chaker Hospital in Sfax and the Habib Thameur Hospital in Tunis for the period extending from 01/07/2022 to 30/09/2023. The diagnostic performance of pulmonary ultrasonography was studied and the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were compared with those of clinical examination, chest X-Ray, NT-pro -BNP and the Transthoracic echocardiography (TTE) which was the reference exam.

RESULTS

The most common cause of acute dyspnea is acute heart failure (79.3 %). LUS had a sensitivity of 94,2 % in diagnosing AHF and a specificity of 77,5 %. Its PPV and NPV were respectively 92 % and 81 %. The area under curbe (AUC) of B-Lines required for the diagnosis of interstitial pulmonary syndrome was excellent (92 %). There was a moderate significant positive correlation between the number of B-Lines and NT-Pro-BNP levels r = 0.51, P < 0.001. Also, there was a very strong significant positive relationship between the pulmonary congestion assessed by LUS and Left atrium - pressure r = 0.788, P < 0.001 CONCLUSION: LUS is an excellent test both to confirm and exclude the diagnosis of AHF in patients consulting the emergency room for acute dyspnea and therefore deserves to be performed systematically.

Ultrasound-guided deep versus superficial continuous serratus anterior plane block for pain management in patients with multiple rib fractures: A prospective randomized double-blind clinical trial

Background

Efficient analgesia is the cornerstone in multiple rib fractures (MRFs) management. The serratus anterior plane block (SAPB) shows promising outcomes. However, it is still provocative whether the superficial or deep approach is more effective in the SAPB procedure. We hypothesized that the deep approach of ultrasound (US)-guided continuous SAPB could be superior for MRFs pain management.

Methods

Sixty-two adult patients having unilateral MRFs, were randomized into two groups to receive continuous superficial SAPB (group S, n = 31) or continuous deep SAPB (group D, n = 31). As a primary outcome, we compared pain numeric rating scale (NRS), while total analgesic consumption, incentive spirometer volume (IS-V), lung ultrasound score (LUSS), basal and 24-h serum beta-endorphin (BE) levels, and any adverse events were secondary outcomes.

Results

There was a significant reduction in NRS in favor of group D when compared to group S at 30 minutes (P = 0.001) until 12 hours (P = 0.029); total analgesic consumption was significantly lower in group D (P = 0.005). A significant increase in the median IS-V in group D compared to group S at 90 minutes (P = 0.02) and 12h postblock (P = 0.004) LUSS was significantly lower in D group at 90 min, 12 h, and 24 h (P = 0.04, 0.001, 0.031). No significant differences as regards serum BE levels. No adverse events were noted.

Conclusion

Either superficial or deep continuous SAPB can be used safely and effectively in managing pain related to MRFs. Notably, the deep approach offered superior analgesia and improved deep breathing compared to the superficial.

Integrated Multi-Organ Ultrasound

Integrated multi-organ ultrasound is increasingly used across various medical specialties. It should be performed in conjunction with history, physical examination, and other investigations in the diagnostic process to enhance the detection of conditions in the lung, heart, and abdomen. Multi-organ ultrasound has been shown to improve diagnostic accuracy in a sizeable portion of patients, potentially altering treatment plans. Specifically, it aids in assessing shock, sepsis, dyspnea, delirium, and in the perioperative setting, contributing to a more comprehensive patient assessment process.

Lung ultrasound in neonates and children with cardiac diseases with focus on post cardiac surgical period: time for systematic use-an expert opinion report by the Association for European Paediatric and Congenital Cardiology Imaging Working Group

Background

Despite lung ultrasound (LUS) gaining consensus for the diagnosis of pulmonary complication in paediatric acute care setting and in adult cardiology, its use in paediatric cardiology remains limited.

Aim

The aim of the present investigation is to provide an expert opinion on the applications of LUS in neonates and children with congenital heart disease, with a special focus on the post-surgical period.

Methods and Results

A complete guide for identification of landmarks and major signs (A and B lines) and their characteristics is provided. Diagnostic criteria, tips, and tricks for the diagnosis, and differential diagnosis of common pulmonary diseases such as pleural effusion, pneumonia, and consolidation are provided. To perform diagnosis of pneumothorax is illustrated. Applications of LUS for evaluation of hemidiaphragm motility and for a comprehensive assessment of retrosternal area are also discussed. The use of LUS for guidance of minor, common interventional procedures such as lung recruitment and drainage insertion is also described. The report also highlights current gaps of knowledge, including the difficulty for quantitative estimation of pleural effusion and atelectasis, and future prospective.

Conclusion

There is sufficient evidence to support a systematic use of LUS for the diagnosis and follow-up of neonates and children with cardiac disease especially those undergoing paediatric cardiac surgery. LUS is an easy, accurate, fast, cheap, and radiation-free tool that should become a routine in daily practice.

Integrative assessment of congestion in heart failure using ultrasound imaging

In heart failure (HF), congestion is a key pathophysiologic hallmark and a major contributor to morbidity and mortality. However, the presence of congestion is often overlooked in both acute and chronic settings, particularly when it is not clinically evident, which can have important clinical consequences. Ultrasound (US) is a widely available, non-invasive, sensitive tool that might enable clinicians to detect and quantify the presence of (subclinical) congestion in different organs and tissues and guide therapeutic strategies. In particular, left ventricular filling pressures and pulmonary pressures can be estimated using transthoracic echocardiography; extravascular lung water accumulation can be evaluated by lung US; finally, systemic venous congestion can be assessed at the level of the inferior vena cava or internal jugular vein. The Doppler evaluation of renal, hepatic and portal venous flow can provide additional valuable information. This review aims to describe US techniques allowing multi-organ evaluation of congestion, underlining their role in detecting, monitoring, and treating volume overload more objectively.

Cardiopulmonary Ultrasound to Predict Care Escalation in Early Sepsis: A Pilot Study

BACKGROUND

It is challenging to identify emergency department (ED) patients with sepsis who will require resources such as positive-pressure ventilation, vasopressors, or intensive care unit (ICU) admission.

OBJECTIVES

Describe the correlation of cardiopulmonary ultrasound (CPUS) with need for care escalation.

METHODS

Single center, prospective, observational study of adult patients with suspected sepsis. CPUS assessed left ventricular systolic function (LVF), right ventricular (RV) size and function, inferior vena cava (IVC) collapsibility, and thoracic B lines. The primary composite outcome was need for care escalation within 12 hours of ED presentation defined as: ICU admission or positive-pressure ventilation or vasopressor infusion.

RESULTS

A total of 92 patients were enrolled; 18 (19.6%) required care escalation. A logistic regression model identified the presence of ≥4 thoracic B-lines as a statistically significant predictor of care escalation (OR 7.8, 95% CI [1.3-26.4], p = 0.002). Other features positively correlated with care escalation were: reduced LVF (OR 4.26, 95% CI [0.06-12.9], p = 0.14), and dilated RV size (OR 2.8, 95% CI [0.4-11.8], p = 0.16). A retrospective stepwise regression model incorporating these three variables to predict care escalation showed an AUROC = 0.75 (95% CI [0.63-0.88]). When 2 or more variables were abnormal the model showed excellent specificity of 95% (LR+ 6.2), but low sensitivity of 33% (LR- 0.7).

CONCLUSIONS

In patients with concern for sepsis early findings of ≥4 B-lines is associated with care escalation. Combining this finding with LVF and RV size assessment improves the positive predictive power and may be useful in rapid identification of patients likely to require care escalation.

Basic Lung Ultrasound and Clinical Applications in General Medicine

Proficiency in basic lung ultrasound is highly recommended for clinicians in general and internal medicine. This article will review and provide guidance for novice users on how to use lung ultrasound in clinical practice, through a pathology-oriented approach. The authors recommend a 12-zone protocol and describe how to perform and apply it in clinical practice while examining patients with clinical suspicion for the following diseases: pleural effusion, heart failure, pneumonia (bacterial and viral), interstitial lung disease, and pneumothorax.

LUDT-ADHF trial: Lung ultrasound-guided diuretic therapy for hospitalized patients with acute decompensated heart failure: An open-label clinical trial

Background Acute Decompensated Heart Failure (ADHF) constitutes a major reason for hospital admissions and significantly contributes to increased morbidity and mortality. Limited research indicates that lung ultrasound (LUS) may enhance the care for patients with ADHF. Objectives The purpose of this study was to evaluate the impact of LUS-guided diuretic therapy on reducing length of hospital stay (LOS) and 90-day readmissions among patients with ADHF. Methods This open-label, non-randomized clinical trial included patients with ADHF managed with diuretics based on LUS findings of B-lines and pleural effusion (LUS group) compared to those receiving standard care (control group). The primary outcome was LOS during the index admission, and secondary outcomes included 90-day ADHF readmissions, all-cause readmissions, and safety parameters like acute kidney injury, hypokalemia, and hypotension. Results The study included a total of 77 patients, segregated into two groups: control and LUS. The median age of the patients was 68 years, with women slightly outnumbering men (53.25%, n=41). The most prevalent comorbidities were hypertension (88.31%, n=68), diabetes mellitus (59.74%, n=46), and chronic kidney disease (66.23%, n=51). The LUS group had a shorter LOS, though not statistically significant (4 vs five days, p= 0.175). Patients in the LUS group had significantly fewer 90-day ADHF readmissions compared to the control group (10.53% vs. 35.9%; p<0.01). Survival analysis demonstrated that the LUS group had a longer time to 90-day ADHF readmissions, with a hazard ratio (HR) of 0.24 (95% CI: 0.08-0.75, p=0.014). For 90-day all-cause readmissions, the LUS group also showed a longer time to readmission compared to controls, with an HR of 0.45 (95% CI: 0.200-1.005, p=0.046). For other safety measures, there was no significant difference in the incidence of adverse events, including acute kidney injury, hypokalaemia, or hypotension, between the LUS and control groups. Conclusion LUS might reduce in-hospital mortality and readmissions among adults with acute decompensated HF. However, further double-blinded randomized clinical trials are needed to confirm these preliminary results.

The development of point-of-care ultrasound (POCUS): Worldwide contributions and publication trends

PURPOSE

Point-of-care ultrasound (POCUS) concept is widely used in both emergency medicine (EM) and intensive care medicine (ICM). This study aimed to analyze the scientific articles on POCUS published by statistical methods and to evaluate the subject holistically.

METHODS

This study is bibliographical, descriptive, and analytical in nature. POCUS-related publications published were downloaded from the Web of Science (WoS) database and analyzed using statistical methods. Network visualization maps were used to identify trending topics.

RESULTS

The literature search revealed 5714 publications on POCUS in the WoS database. According to the WoS categorization of publications, the most common categories were emergency medicine (1751; 30.6%). The topics studied in recent years were deep learning, artificial intelligence, COVID-19, acute kidney injury, heart failure, and telemedicine.

CONCLUSION

This study on POCUS, we summarized 5714 publications published. According to our results, the trending topics in POCUS research in recent years include deep learning, artificial intelligence, COVID-19, acute kidney injury, heart failure and telemedicine. Our study can be a valuable resource for clinicians and scientists who are working on POCUS or will be working on POCUS in the future.