Not all abolished lung sliding are pneumothorax: the case of a particular lung atelectasis

The Diagnostic Role of Lung Ultrasound and Contrast-Enhanced Ultrasound in Pulmonary Embolism

The diagnosis of pulmonary embolism (PE) relies essentially on a probabilistic approach that requires careful clinical assessments, targeted laboratory tests, and the use of appropriate imaging tools. Nowadays, the diagnostic gold standard is computed tomographic pulmonary angiography. Lung ultrasound (LUS) can play a role in the diagnosis of PE mainly by allowing the visualization of peripheral lung infarctions. Hypoechoic, pleural-based parenchymal consolidation is the most typical and common finding of pulmonary infarction. More than 85% of infarct lesions are wedge-shaped, extending to the pleural surface and are localized to where the patient complains of pleuritic chest pain. Contrast-enhanced ultrasound can be performed in addition to basic ultrasound examination to ascertain nonvascularization of the consolidation, thus confirming that the lesion is an infarct. The aim of this narrative review is to summarize the latest evidence on the application of LUS to the diagnosis of PE, focusing purely on thoracic/lung signs.

Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities

PURPOSE

While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US.

METHODS

In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes.

RESULTS

There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%.

CONCLUSION

Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

Ultrasound diagnosis of a pseudoaneurysm of the internal right mammary artery

One of the principles of managing trauma patients is that of their continuous re-evaluation over the hours and days. Even if the execution of the computed tomography method is classically recommended, especially in the most serious cases and in polytraumas with major dynamics, the clinician can use or request an ultrasound examination, especially in subsequent re-evaluations. Here we report a clinical case demonstrating how an ultrasound re-evaluation after the acute event can lead to a correct diagnosis of a rare complication of thoracic trauma. The findings were suggestive for a pseudoaneurysm of the internal right mammary artery. Subsequently, an ultrasound-guided injection of thrombin was carried out until complete interruption of the flow within the formation. At subsequent follow-up, no arterial or venous blush was highlighted.

Ultrasound-Assisted and Ultrasound-Guided Thoracentesis: An Educational Review

Thoracentesis is one of the most important invasive procedures in the clinical setting. Particularly, thoracentesis can be relevant in the evaluation of a new diagnosed pleural effusion, thus allowing for the collection of pleural fluid so that laboratory tests essential to establish a diagnosis can be performed. Furthermore, thoracentesis is a maneuver that can have therapeutic and palliative purposes. Historically, the procedure was performed based on a physical examination. In recent years, the role of ultrasound has been established as a valuable tool for assistance and guidance in the thoracentesis procedure. The use of ultrasound increases success rates and significantly reduces complications. The aim of this educational review is to provide a detailed and sequential examination of the procedure, focusing on the two main modalities, the ultrasound-assisted and ultrasound-guided form.

Infectious Pneumonia and Lung Ultrasound: A Review

The application of thoracic ultrasound examination has not long been developed because ultrasound's interaction with the lung does not generate an anatomical image but an artifactual one. Subsequently, the evaluation of pulmonary artifacts and their correlation to specific diseases allowed the development of ultrasound semantics. Currently, pneumonia still represents one of the main causes of hospitalization and mortality. Several studies in the literature have demonstrated the ultrasound features of pneumonia. Although ultrasound cannot be considered the diagnostic gold standard for the study of all lung diseases, it has experienced an extraordinary development and growth of interest due to the SARS-CoV-2 pandemic. This review aims to provide essential information on the application of lung ultrasound to the study of infectious pneumonia and to discuss the differential diagnosis.

Electrical impedance tomography to aid in the identification of hypoxemia etiology: Massive atelectasis or pneumothorax? A case report

Background

Bedside ultrasound is often used to determine the etiology of hypoxaemia, but not always with definitive results. This case reports the application of electrical impedance tomography (EIT) and saline injection to determine the etiology of hypoxaemia in a complex case that could not be identified by bedside ultrasound. The determination of the etiology of hypoxaemia by EIT and saline injection, regional ventilation and perfusion information can be used as a new clinical diagnostic method.

Case presentation

A post-cardiac surgery patient under prolonged mechanical ventilation for lung emphysema developed sudden hypoxemia in the intensive care unit (ICU). A line pattern and lung sliding sign abolishment were found in the left lung, but there was no evidence of a lung point sign on bedside ultrasound. Hence, the initial diagnosis was considered to be a massive pneumothorax. To further define the etiology, EIT and saline bolus were used to assess regional ventilation and perfusion. A massive ventilation defect was found in the left lung, in which regional perfusion was maintained, resulting in an intrapulmonary shunt in the left lung. Finally, the conjecture of a pneumothorax was ruled out considering the massive atelectasis. After the diagnosis was clarified, hypoxaemia was corrected by restorative ventilation of the left lung after changing the patient's posture and enhancing sputum drainage with chest physiotherapy.

Conclusions

This was the clinical case involving EIT and saline bolus to establish the differential diagnosis and guide clinical decisions for patients with acute hypoxemia. This study highlighted that combination regional ventilation, EIT perfusion, and saline bolus provided helpful information for determining the etiology of hypoxemia. The results of this study contribute to the development of emergency patient management.

Limitations of Bedside Lung Ultrasound in Neonatal Lung Diseases

Lung ultrasound is a technique that has rapidly developed in recent years. It is a low-cost, radiation-free, and easy-to-operate tool that can be repeatedly performed at the bedside. Compared to chest X-ray, lung ultrasound has high sensitivity and specificity in the diagnosis of neonatal respiratory distress syndrome, transient tachypnoea of newborns and pneumothorax. Lung ultrasound has been widely used in neonatal intensive care units. However, due to the physical barriers of air, where ultrasonic waves cannot pass and therefore reflection artifacts occur, it has limitations in some other lung diseases and cannot fully substitute for chest X-rays or CT/MRI scanning. This review describes these limitations in detail and highlights that if clinical symptoms are not effectively alleviated after medical treatment or the clinical presentation is not compatible with the ultrasound appearances, then chest X-rays or CT/MRI scanning should be performed to avoid misdiagnosis and mistreatment.

One year of SARS-CoV-2 and lung ultrasound: what has been learned and future perspectives

A first screening by ultrasound can be relevant to set a specific diagnostic and therapeutic route for a patient with a COVID-19 infection. The finding of bilateral B-lines and white lung areas with patchy peripheral distribution and sparing areas is the most suggestive ultrasound picture of COVID-19 pneumonia. Failure to detect bilateral interstitial syndrome (A pattern) on ultrasound excludes COVID-19 pneumonia with good diagnostic accuracy, but does not exclude current infection. The use of shared semiotic and reporting schemes allows the comparison and monitoring of the COVID-19 pulmonary involvement over time. This review aims to summarise the main data on pulmonary ultrasound and COVID-19 to provide accurate and relevant information for clinical practice.

Role of shear-wave and strain elastography to differentiate malignant vs benign subpleural lung lesions

Elastosonography is a non-invasive diagnostic method to evaluate tissue stiffness. The aim of our study was to demonstrate the applicability and efficacy of elastosonography to differentiate benign vs malignant subpleural lung lesions compared to clinical, radiological and histological findings.We performed both strain and shear wave velocity (SWV) elastosonography on subpleural lung lesions. Moreover, we elaborated a composite score called "elasto index".Fourteen patients, 10 males and 4 females were recruited. On strain elastography, 9 lesions showed a hard pattern (type 3), 3 lesions showed an intermediate pattern (type 2), and 2 lesions a soft pattern (type 1). All lesions showed a mean SWV value of 4.46 ± 2.37 m/second. The mean SWV for malignant lesions (n = 6) was 5.92 ± 2.8 m/second. The mean SWV for benign lesions (n = 8) was 3.36 ± 1.20 m/second. SWV shows an area under the curve (AUC) of 0.792, and the Youden index shows a value of 3.6 m/second. The ROC curve elaborated for the diagnosis of malignancy by strain elastography showed an AUC of 0.688. ROC curve for the diagnosis of malignancy by elasto index demonstrated an AUC of 0.802.SWV values obtained by ARFI elastosonographic method are higher in malignant lung lesions (mean SWV: 5.92 m/second) than in benign ones (mean SWV: 3.36); a composite score (elasto index) is characterized by better statistical significance for the differentiation of the lesions.

Lung ultrasound monitoring of CPAP effectiveness on SARS-CoV-2 pneumonia: A case report

SARS-CoV-2 infection is characterized by extremely heterogeneous features, going from cases with few symptoms to severe respiratory failures. Chest Computed Tomography (CT) is currently the gold-standard imaging method, although burdened by the risk of exposure to ionizing radiation and management / organizational concerns. In particular, the critical patient undergoing ventilation (invasive or not) seems to be difficult to monitor by repeated CT scan over time. We report the case of a 55-year-old male patient subjected to Continuous Positive Airway Pressure (CPAP) and prone positioning, in which the use of ultrasound monitoring allowed to verify the effectiveness of the pressure support used in recruiting previously atelectasis lung areas. Lung ultrasound can guide pulmonary recruitment and pronation maneuvers in patients undergoing non-invasive ventilation. Ultrasound can identify atelectatic lung areas, which demonstrate an alveolar re-expansion following the setting of high PEEP values, as underlined by the reappearance of pleural/air interface.

Thoracic ultrasound and SARS-COVID-19: a pictorial essay

Thoracic ultrasound seems to adapt to the screening for lung involvement of patients with suspected or ascertained SARS-COVID-19 infection due to its characteristics of easy applicability. It can be also a relevant method in monitoring patients. B lines are early finding of COVID-19, even in mild-symptomatic subjects; in the most serious cases such as pre-ARDS or ARDS, the B lines end up filling the ultrasound image almost completely, until it merges, so as to create a single hyperechoic image named as "white lung", with distortion and irregularity of the pleural line. In advanced stage, lung consolidations are present, representing pulmonary pathological areas that are no longer normally ventilated.

Lung-ultrasound objective structured assessment of technical skills (LUS-OSAUS): utility in the assessment of lung-ultrasound trained medical undergraduates

Purpose

Recently, some attempts have been made to integrate lung ultrasound (LUS) teaching into medical curricula. However, current education studies of LUS are extremely heterogeneous due to the lack of evidence-based guidelines on LUS education. In particular, the assessment of competencies is poorly standardized and mostly relies on non-validated scales. A new validated tool, the objective structured assessment of lung ultrasound skills (LUS-OSAUS), has the potential to overcome these limitations. Therefore, we adopted the LUS-OSAUS tool to assess the competencies of a group of LUS-trained undergraduates. Existing no prior practical applications of the LUS-OSAUS, our aim was to investigate the practical utility of this tool and its applicability in the evaluation of US-trained medical students.

Methods

Eight undergraduates (two males, six females) were enrolled on a voluntary basis to receive a theoretical and practical training in LUS. Once completed their training, each student performed an LUS examination on a different patient hospitalized for respiratory symptoms. The same eight patients were also scanned by a senior resident in emergency medicine for a comparison with students’ results. Students and the senior resident were tested by an examiner using the LUS-OSAUS tool. We compared the scores obtained by operators in all areas of competence of the LUS-OSAUS, the total scores, and the time needed to complete the sonographic task.

Results

Median students’ score in the single items of the scale was significantly lower than the ones obtained by the senior resident (4.0 [3.3–5.0] vs. 5.0 [5.0–5.0]; p < 0.0001). Students scored significantly lower than the senior resident in each item, except for B-line identification, choice of the correct transducer, and suggested focused questions. Median total score was also lower for students compared to the senior resident (70.5 [61.0–74.8] vs. 84.0 [83.5–84.3] (p = 0.0116). Median time required to complete the examination was significantly higher for students (14.1 [12.8–16.1] vs. 4.7 [3.9–5.2] min, p = 0.0117).

Conclusions

The LUS-OSAUS tool allowed for a standardized and comprehensive assessment of student’s competencies in lung ultrasound, and helped to discriminate their level of expertise from that of a more experienced operator. The scale also specifically tests the theoretical knowledge of trainees, thus making redundant the use of questionnaires designed for this purpose.

Electronic supplementary material

The online version of this article (10.1007/s40477-020-00454-x) contains supplementary material, which is available to authorized users.

From an abdominal ultrasound to a lung disease passing through the diaphragm: a case of idiopathic pulmonary fibrosis

RATIONALE

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease characterized by abnormal and excessive deposition of collagen in the pulmonary interstitium (fibrosis) with minimal associated inflammation evolving into progressive and irreversible decline in lung function.

PATIENT CONCERNS

Patient referred discomfort, bilateral upper quadrant abdominal pain, and progressive exertional dyspnea (shortness of breath with exercise).

DIAGNOSIS

Exertional dyspnea due to idiopathic pulmonary fibrosis (IPF).

INTERVENTION

Sonographic evaluation demonstrated an alteration of diaphragm excursion together with a relevant alteration of the pleural line and multiple irregular and confluent B lines.

CONCLUSIONS

Lung and diaphragm ultrasound could be employed as a screening or first-line diagnostic tool in the suspicion of interstitial lung disease.