Current Misconceptions in Lung Ultrasound: A Short Guide for Experts

Lung Ultrasound After COVID-19: A Pivotal Moment for Clinical Integration-Navigating Challenges and Seizing Opportunities

Lung ultrasound (LUS) has emerged as a valuable bedside decision-making tool, particularly since the COVID-19 pandemic, with applications in diagnosing pneumonia, managing fluid, and monitoring interstitial lung diseases (ILDs) and acute respiratory distress syndrome (ARDS), ultimately improving patient outcomes. Its repeatability, environmental safety, and reduced radiation exposure make it ideal for vulnerable populations and resource-limited settings. However, challenges such as inadequate documentation and a lack of standardized reporting formats limit its widespread adoption. The evolution of technology offers different possibilities, and improvements in software open up a range of possibilities, but this contrasts with the lack of postgraduate and undergraduate training and formal accreditation. This review addresses the impact of lung ultrasound through the course of air-liquid ratio impairment, crossing different clinical scenarios and exploring the challenges and opportunities for the implementation of lung ultrasound in the post-COVID era.

Value of lung ultrasound scores in assessing extravascular lung water in septic shock patients

The aim of this study was to explore the clinical value and accuracy of lung ultrasound in evaluating extravascular lung water (EVLW) in septic shock patients. Twenty-four septic shock patients who required mechanical ventilation and pulse indicating continuous cardiac output (PiCCO) monitoring in the Department of Critical Care Medicine of our hospital were included. Basic laboratory and demographic data for these patients were recorded. PiCCO monitoring was employed to measure EVLW at 0, 2, 6, 12, 24, and 48 h. The lung ultrasound score (LUS) was obtained via bedside transthoracic lung ultrasound (TTE), and the correlation between these two variables was analysed. Of 24 patients, 22 had satisfactory Doppler lung ultrasound results, and a strong correlation was detected between the LUS and EVLW measurements at the 0, 2, 6, 12, 24, and 48 h time points (all P < 0.001; ICC (interclass correlation coefficients) = 0.92, 0.91, 0.92, 0.90, 0.88, 0.71, respectively; all P < 0.001). The Bland‒Altman analysis revealed that only 4 (3.03%) points exceeded the limits of agreement. These findings suggest that pulmonary ultrasound scores can be utilized as an auxiliary metric for identifying EVLW in septic shock patients, suggesting that this technique is well suited for clinical application.

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.

Ten Questions on Using Lung Ultrasonography to Diagnose and Manage Pneumonia in the Hospital-at-Home Model: Part I-Techniques and Patterns

The hospital-at-home (HaH) model delivers hospital-level acute care, including diagnostics, monitoring, and treatments, in a patient's home. It is particularly effective for managing conditions such as pneumonia. Point-of-care ultrasonography (PoCUS) is a key diagnostic tool in the HaH model, and it often serves as a substitute for imaging-based diagnosis in the HaH setting. Both standard and handheld ultrasound equipment are suitable for lung ultrasound (LUS) evaluation. Curvelinear and linear probes are typically used. Patient positioning depends on their clinical condition and specific diagnostic protocols. To enhance sensitivity, we recommend using at least 10-point protocols supported by studies for pneumonia. Five essential LUS patterns should be identified, including A-line, multiple B-lines (alveolar-interstitial syndrome), confluent B-lines, subpleural consolidation, and consolidation with air bronchogram. Pleural effusion is common, and its internal echogenicity can indicate severity and the need for invasive procedures. The current evidence on various etiologies and types of pneumonia is limited, but LUS demonstrates good sensitivity in detecting abnormal sonographic patterns in atypical pneumonia, tuberculosis, and ventilator-associated pneumonia. Further LUS studies in the HaH setting are required to validate and generalize the findings.

Feline friendly POCUS: how to implement it into your daily practice

PRACTICAL RELEVANCE

Cats are great pretenders; they often hide illness until they are critical. This makes patients of this species challenging to assess and manage in the emergency setting where quick and stress-free diagnosis and treatment are necessary. Veterinary point-of-care ultrasound (POCUS) is a rapid, evidence-based, non-invasive, repeatable, cage-side ultrasonographic examination designed to answer clinically driven questions without compromising feline wellbeing. Integrating feline friendly POCUS as an extension of the physical examination to streamline diagnostic and therapeutic interventions, thereby limiting stress and improving overall patient care, is advocated by the authors of this article.

EQUIPMENT

Given the multitude of ultrasound machines and probes available that are portable, meaning they can be moved around the clinic and used patient-side, it should be possible for most practitioners to integrate POCUS into daily practice. The authors' preferred equipment for feline POCUS is a microconvex probe and a portable machine with a fixed pre-set. This set-up allows the clinician to complete all POCUS (abdominal, lung and pleural space, and heart) without needing to move the patient, change probes or restrain the patient in a particular position, ultimately saving time, personnel and cost while maintaining patient comfort and safety.

AIM

This review aims to serve as a valuable resource for veterinarians seeking to improve their feline patient care through the judicious utilisation of POCUS. In this article, the complex challenges posed by cats are addressed, and the different POCUS techniques, applications and clinical recommendations are discussed.

EVIDENCE BASE

This review draws on the published literature, as well as the authors' own collective experience when providing recommendations.

The application value of lung ultrasound scoring in assessing disease severity: Evaluation of small-scale outbreaks of COVID-19

PURPOSE

This study explored the use of transthoracic lung ultrasound for evaluating COVID-19 patients, compared it with computed tomography (CT), and examined its effectiveness using 8 and 12 lung regions.

METHODS

A total of 100 patients with COVID-19 and 40 healthy volunteers were assessed using 12 regions (bilateral upper/lower regions of the anterior/lateral/posterior chest) and simplified 8 zones (bilateral upper/lower regions of the anterior/lateral chest) transthoracic lung ultrasound. The relationships between ultrasound, CT, and clinical indicators were analyzed to evaluate the diagnostic value of ultrasound scores in COVID-19.

RESULTS

Increased disease severity correlated with increased 8- and 12-zone ultrasound and CT scores (all p < 0.05). The modified 8-zone method strongly correlated with the 12-zone method (Pearson's r = 0.908, p < 0.05). The 8- and 12-zone methods correlated with CT scoring (correlation = 0.568 and 0.635, respectively; p < 0.05). The intragroup correlation coefficients of the 8-zone, 12-zone, and CT scoring methods were highly consistent (intragroup correlation coefficient = 0.718, p < 0.01). The 8-zone ultrasound score correlated negatively with oxygen saturation (rs  = 0.306, p < 0.05) and Ca (rs  = 0.224, p < 0.05) and positively with IL-6 (rs  = 0.0.335, p < 0.05), erythrocyte sedimentation rate (rs  = 0.327, p < 0.05), alanine aminotransferase (rs  = 0.230, p < 0.05), and aspartate aminotransferase (rs  = 0.251, p < 0.05). The 12-zone scoring method correlated negatively with oxygen saturation (rs  = 0.338, p < 0.05) and Ca (rs  = 0.245, p < 0.05) and positively with IL-6 (rs  = 0.354, p < 0.05) and erythrocyte sedimentation rate (rs  = 0.495, p < 0.05).

CONCLUSION

Lung ultrasound scores represent the clinical severity and have high clinical value for diagnosing COVID-19 pneumonia. The 8-zone scoring method can improve examination efficiency and reduce secondary injuries caused by patient movement.

Comparison of Ultrasound and CT Imaging for the Diagnosis of Coronavirus Disease and Influenza A Pneumonia

OBJECTIVE

The outbreak of coronavirus disease (COVID-19) coincided with the season of influenza A pneumonia, a common respiratory infectious disease. Therefore, this study compared ultrasonography and computed tomography (CT) for the diagnosis of the two diseases.

METHODS

Patients with COVID-19 or influenza A infection hospitalized at our hospital were included. The patients were examined by ultrasonography every day. The CT examination results within 1 day before and after the day of the highest ultrasonography score were selected as the controls. The similarities and differences between the ultrasonography and CT results in the two groups were compared.

RESULTS

There was no difference between the ultrasonography and CT scores (P = .307) for COVID-19, while there was a difference between ultrasonography and CT scores for influenza A pneumonia (P = .024). The ultrasonography score for COVID-19 was higher than that for influenza A pneumonia (P = .000), but there was no difference between the CT scores (P = .830). For both diseases, there was no difference in ultrasonography and CT scores between the left and right lungs; there were differences between the CT scores of the upper and middle lobes, as well as between the upper and lower lobes of the lungs; however, there was no difference between the lower and middle lobes of the lungs.

CONCLUSION

Ultrasonography is equivalent to the gold standard CT for diagnosing and monitoring the progression of COVID-19. Because of its convenience, ultrasonography has important application value. Furthermore, the diagnostic value of ultrasonography for COVID-19 is higher than that for influenza A pneumonia.

Relative hypoxemia at depth during breath-hold diving investigated through arterial blood gas analysis and lung ultrasound

Pulmonary gas exchange in breath-hold diving (BHD) consists of a progressive increase in arterial partial pressures of oxygen ([Formula: see text]) and carbon dioxide ([Formula: see text]) during descent. However, recent findings have demonstrated that [Formula: see text] does not consistently rise in all subjects. This study aimed at verifying and explaining [Formula: see text] derangements during BHD analyzing arterial blood gases and searching for pulmonary alterations with lung ultrasound. After ethical approval, 14 fit breath-hold divers were included. Experiments were performed in warm water (temperature: 31°C). We analyzed arterial blood gases immediately before, at depth, and immediately after a breath-hold dive to -15 m of fresh water (mfw) and -42 mfw. Signs of lung interstitial edema and atelectasis were searched simultaneously with a marinized lung ultrasound. In five subjects (-15 mfw) and four subjects (-42 mfw), the [Formula: see text] at depth seems to decrease instead of increasing. [Formula: see text] and lactate showed slight variations. At depth, no lung ultrasound alterations were seen except in one subject (hypoxemia and B-lines at -15 mfw; B-lines at the surface). Lung interstitial edema was detected in 3 and 12 subjects after resurfacing from -15 to -42 mfw, respectively. Two subjects developed hypoxemia at depth and a small lung atelectasis (a focal pleural irregularity of triangular shape, surrounded by thickened B-lines) after resurfacing from -42 mfw. Current experiments confirmed that some BH divers can experience hypoxemia at depth. The hypothesized explanation for such a discrepancy is lung atelectasis, which could not be detected in all subjects probably due to limited time available at depth.NEW & NOTEWORTHY During breath-hold diving, arterial partial pressure of oxygen ([Formula: see text]) and arterial partial pressure of carbon dioxide ([Formula: see text]) are believed to increase progressively during descent, as explained by theory, previous end-tidal alveolar gas measurements, and arterial blood gas analysis in hyperbaric chambers. Recent experiments in real underwater environment found a paradoxical [Formula: see text] drop at depth in some divers. This work confirms that some breath-hold divers can experience hypoxemia at depth. The hypothesized explanation for such a discrepancy is lung atelectasis, as suggested by lung ultrasound findings.

Assessment of lung injury severity using ultrasound in critically ill COVID-19 patients in resource limited settings

BACKGROUND

Lung ultrasound is a non-invasive tool available at the bedside for the assessment of critically ill patients. The objective of this study was to evaluate the usefulness of lung ultrasound in assessing the severity of SARS-CoV-2 infection in critically-ill patients in a low-income setting.

METHODS

We conducted a 12-month observational study in a university hospital intensive care unit (ICU) in Mali, on patients admitted for COVID-19 as diagnosed by a positive polymerase chain reaction for SARS-CoV-2 and/or typical lung computed tomography scan findings.

RESULTS

The inclusion criteria was met by 156 patients with a median age of 59 years. Almost all patients (96%) had respiratory failure at admission and many needed respiratory support (121/156, 78%). The feasibility of lung ultrasound was very good, with 1802/1872 (96%) quadrants assessed. The reproducibility was good with an intra-class correlation coefficient of elementary patterns of 0.74 (95% CI 0.65, 0.82) and a coefficient of repeatability of lung ultrasound score < 3 for an overall score of 24. Confluent B lines were the most common lesions found in patients (155/156). The overall mean ultrasound score was 23 ± 5.4, and was significantly correlated with oxygen saturation (Pearson correlation coefficient of - 0.38, p < 0.001). More than half of the patients died (86/156, 55.1%). The factors associated with mortality, as shown by multivariable analysis, were: the patients' age; number of organ failures; therapeutic anticoagulation, and lung ultrasound score.

CONCLUSION

Lung ultrasound was feasible and contributed to characterize lung injury in critically-ill COVID-19 patients in a low income setting. Lung ultrasound score was associated with oxygenation impairment and mortality.

Impact of lung ultrasound during the SARS-CoV-2 pandemic: Distinction between viral and bacterial pneumonia

INTRODUCTION

Lung Ultrasound is an accessible, low-cost technique that has demonstrated its usefulness in the prognostic stratification of COVID-19 patients. In addition, according to previous studies, it can guide us towards the potential aetiology, especially in epidemic situations such as the current one.

PATIENTS AND METHODS

40 patients were prospectively recruited, 30 with confirmed SARS-CoV-2 pneumonia and 10 with community-acquired pneumonia (CAP). The patients included underwent both a chest X-ray and ultrasound.

RESULTS

There were no differences in the 2 groups in terms of clinical and laboratory characteristics. The main ultrasound findings in the SARS-CoV-2 group were the presence of confluent B lines and subpleural consolidations and hepatinization in the CAP group. Pleural effusion was more frequent in the CAP group. There were no normal lung ultrasound exams. Analysis of the area under the curve (AUC) curves showed an area under the curve for Lung Ultrasound of 89.2% (95% CI: 75%.0-100%, p < .001) in the identification of SARS-CoV-2 pneumonia. The cut-off value for the lung score of 10 had a sensitivity of 93.3% and a specificity of 80.0% (p < .001).

DISCUSSION

The combination of the findings of the Lung Ultrasound, with a Lung Score greater than 10, added to the rest of the additional tests, can be an excellent tool to predict the aetiology of the pneumonia.

[Impact of Lung Ultrasound dUring the SARS-CoV-2 Pandemic: Distinction Between Viral and Bacterial Pneumonia]

Introduction

Lung ultrasound is an accessible, low-cost technique that has demonstrated its usefulness in the prognostic stratification of COVID-19 patients. In addition, according to previous studies, it can guide us towards the potential aetiology, especially in epidemic situations such as the current one.

Patients and methods

40 patients were prospectively recruited, 30 with confirmed SARS-CoV-2 pneumonia and 10 with community-acquired pneumonia. The patients included underwent both a chest X-ray and ultrasound.

Results

There were no differences in the 2 groups in terms of clinical and laboratory characteristics. The main ultrasound findings in the SARS-CoV-2 group were the presence of confluent B lines and subpleural consolidations and hepatinization in the community-acquired pneumonia group. Pleural effusion was more frequent in the community-acquired pneumonia group. There were no normal lung ultrasound exams. Analysis of the area under the curve curves showed an area under the curve for lung ultrasound of 89.2% (95% CI: 75.0-100%, p < .001) in the identification of SARS-CoV-2 pneumonia. The cut-off value for the lung score of 10 had a sensitivity of 93.3% and a specificity of 80.0% (p < .001).

Discussion

The combination of the findings of the lung ultrasound, with a lung score greater than 10, added to the rest of the additional tests, can be an excellent tool to predict the aetiology of the pneumonia.

Lung Ultrasound Signs to Diagnose and Discriminate Interstitial Syndromes in ICU Patients: A Diagnostic Accuracy Study in Two Cohorts

OBJECTIVES

To determine the diagnostic accuracy of lung ultrasound signs for both the diagnosis of interstitial syndrome and for the discrimination of noncardiogenic interstitial syndrome (NCIS) from cardiogenic pulmonary edema (CPE) in a mixed ICU population.

DESIGN

A prospective diagnostic accuracy study with derivation and validation cohorts.

SETTING

Three academic mixed ICUs in the Netherlands.

PATIENTS

Consecutive adult ICU patients that received a lung ultrasound examination.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULT

The reference standard was the diagnosis of interstitial syndrome (NCIS or CPE) or noninterstitial syndromes (other pulmonary diagnoses and no pulmonary diagnoses) based on full post-hoc clinical chart review except lung ultrasound. The index test was a lung ultrasound examination performed and scored by a researcher blinded to clinical information. A total of 101 patients were included in the derivation and 122 in validation cohort. In the derivation cohort, patients with interstitial syndrome ( n = 56) were reliably discriminated from other patients based on the presence of a B-pattern (defined as greater than or equal to 3 B-lines in one frame) with an accuracy of 94.7% (sensitivity, 90.9%; specificity, 91.1%). For discrimination of NCIS ( n = 29) from CPE ( n = 27), the presence of bilateral pleural line abnormalities (at least two: fragmented, thickened or irregular) had the highest diagnostic accuracy (94.6%; sensitivity, 89.3%; specificity, 100%). A diagnostic algorithm (Bedside Lung Ultrasound for Interstitial Syndrome Hierarchy protocol) using B-pattern and bilateral pleural abnormalities had an accuracy of 0.86 (95% CI, 0.77-0.95) for diagnosis and discrimination of interstitial syndromes. In the validation cohort, which included 122 patients with interstitial syndrome, bilateral pleural line abnormalities discriminated NCIS ( n = 98) from CPE ( n = 24) with a sensitivity of 31% (95% CI, 21-40%) and a specificity of 100% (95% CI, 86-100%).

CONCLUSIONS

Lung ultrasound can diagnose and discriminate interstitial syndromes in ICU patients with moderate-to-good accuracy. Pleural line abnormalities are highly specific for NCIS, but sensitivity is limited.

Lung ultrasonography findings of coronavirus disease 2019 patients: Comparison between primary and secondary regions of China

BACKGROUND

An unexplained pneumonia occurred in Wuhan, China in December 2019, later identified and named coronavirus disease 2019 (COVID-19). This study aimed to compare the ultrasonographic features of the lung between patients with COVID-19 in Wuhan (the primary region) and those in Beijing (the secondary region) and to find the value of applying ultrasound in COVID-19.

METHODS

A total of 248 COVID-19 cases were collected, including long-term residents in Wuhan (138), those who had a short-term stay in Wuhan (72), and those who had never visited Wuhan (38). Ultrasound examination was performed daily; the highest lung ultrasound score (LUS) was the first comparison point, while the LUS of the fifth day thereafter was the second comparison point. The differences between overall treatment and ultrasonography of left and right lungs among groups were compared.

RESULTS

The severity decreased significantly after treatment. The scores of the groups with long-term residence and short-term stay in Wuhan were higher than those of the group that had never been to Wuhan.

CONCLUSION

Ultrasonography is effective for dynamic monitoring of COVID-19. The ultrasonographic features of patients in the Wuhan area indicated relatively severe disease. Thus, Wuhan was the main affected area of china.

Detection of residual pulmonary alterations with lung ultrasound and effects on postoperative pulmonary complications for patients with asymptomatic SARS-CoV-2 infection undergoing surgeries

BACKGROUND

For patients with a clinical course of active SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection, there may be a higher risk of perioperative complications. Our main objective is to detect the residual pulmonary alterations in asymptomatic patients after SARS-CoV-2 infection undergoing surgery and determine their relationship with the clinical course of SARS-CoV-2 infection. The secondary aim is to investigate whether the presence of residual pulmonary alterations have any affects on the severity of postoperative pulmonary complications.

METHODS

After approval by the Hospital's Ethical Committee, this prospective observational study included consecutive patients (n=103) undergoing various surgical procedures and anesthetic techniques with a history of past SARS-CoV-2 infection. On the day of surgery these patients remained asymptomatic and the polymerase chain reaction (PCR) test for SARS-CoV-2 was negative. The history, physical findings, and clinical course of SARS-CoV-2 infection were recorded. Lung ultrasound was performed before surgery to evaluate the possible residual pulmonary alterations (≥ 3 B-lines and pleural thickening), along with determitation of pulmonary static compliance values during surgery. Postoperative pulmonary complications were collected during hospital stay.

RESULTS

24.27% (n=25) patients presented ≥ 3 B-lines, and 28% (n=29) patients presented pleural thickening. For 15 patients (21.7%) the pulmonary compliance was < 40 mL/cm H₂O. Patients with pleural thickening had a higher incidence of pneumonia, acute respiratory syndrome distress, a need for vasoactive drugs and required more days of hospitalization during SARS-CoV-2 infection (p= 0.004, 0.001, 0.03, 0.00 respectively). Patients with ≥ 3 B-lines needed more days in an intensive care unit and vasoactive drugs during SARS-CoV2 infection (p= 0.04, 0.004 respectively). Postoperative pulmonary complications were observed in 5.8% (n=6) of the patients, and were more frequent in the presence of both, ≥ 3 B-lines and pleural thickening (p= 0.01).

CONCLUSIONS

In asymptomatic post-COVID-19 patients, pathological findings detected by lung ultrasound before surgery are associated with the severity of the SARS-CoV2 infection and resulted in more postoperative pulmonary complications. In these patients, the incidence of postoperative pulmonary complications appears similar to that described in the surgical population before the pandemic.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04922931). June 21, 2021. "Retrospectively registered".

Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients

BACKGROUND

Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE).

METHODS

We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available.

RESULTS

During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months).

CONCLUSIONS

B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03049995.

Ultrasound and Other Advanced Hemodynamic Monitoring Techniques in the Intensive Care Unit

The ideal device for hemodynamic monitoring of critically ill patients in the intensive care unit (ICU) or the operating room has not yet been developed. This would need to be affordable, consistent, have a very low margin of error (<30%), be minimally or noninvasive, and allow the clinician to make a reasonable therapeutic decision that consistently led to better outcomes. Such a device does not yet exist. This article will describe the distinct options we, as critical care physicians, currently possess for this Herculean endeavor.

Meta-analysis of Lung Ultrasound Scores for Early Prediction of Bronchopulmonary Dysplasia

RATIONALE

Lung ultrasound scores (LUS) might be useful in monitoring neonates with chronic pulmonary insufficiency of prematurity and in predicting bronchopulmonary dysplasia (BPD). Given their ease of use, accuracy and lack of invasiveness, LUS have been the subject of several recent studies.

OBJECTIVE

We sought to clarify whether LUS provide an accurate and early (within the first two weeks of life) prediction of BPD in preterm infants of gestational age <32weeks.

METHODS

Systematic review and diagnostic accuracy meta-analysis following PRISMA-P, PRISMA and QUADAS guidelines. Studies designed to predict BPD in the first two weeks of life using LUS were selected. A classical LUS (calculated for 6 chest areas) and its extended version (eLUS, 10 chest areas) were tested.

RESULTS

Seven studies (1027 neonates) were meta-analyzed. LUS and eLUS showed good diagnostic accuracy in predicting BPD at 7 and 14 days of life (AUC 0.85-0.87, pooled sensitivity 70-80%, pooled specificity 80-87%). The diagnostic accuracy of LUS and eLUS did not differ at any timepoint (AUC difference always p >0.05). Repeating the analyses without outliers or with moderate-to-severe BPD as outcome yielded similar results. Meta-regressions showed that prenatal steroid prophylaxis and sex were not significant effect confounders.

CONCLUSIONS

LUS are accurate for early prediction of BPD and moderate-to-severe BPD, in an average population of preterm infants <32weeks' gestation. The diagnostic accuracy is similar for LUS and eLUS, so the use of the simpler score should be advocated. Registration. PROSPERO CRD42021233010.

Lung ultrasound in a tertiary intensive care unit population: a diagnostic accuracy study

BACKGROUND

Evidence from previous studies comparing lung ultrasound to thoracic computed tomography (CT) in intensive care unit (ICU) patients is limited due to multiple methodologic weaknesses. While addressing methodologic weaknesses of previous studies, the primary aim of this study is to investigate the diagnostic accuracy of lung ultrasound in a tertiary ICU population.

METHODS

This is a single-center, prospective diagnostic accuracy study conducted at a tertiary ICU in the Netherlands. Critically ill patients undergoing thoracic CT for any clinical indication were included. Patients were excluded if time between the index and reference test was over eight hours. Index test and reference test consisted of 6-zone lung ultrasound and thoracic CT, respectively. Hemithoraces were classified by the index and reference test as follows: consolidation, interstitial syndrome, pneumothorax and pleural effusion. Sensitivity, specificity, positive and negative likelihood ratio were estimated.

RESULTS

In total, 87 patients were included of which eight exceeded the time limit and were subsequently excluded. In total, there were 147 respiratory conditions in 79 patients. The estimated sensitivity and specificity to detect consolidation were 0.76 (95%CI: 0.68 to 0.82) and 0.92 (0.87 to 0.96), respectively. For interstitial syndrome they were 0.60 (95%CI: 0.48 to 0.71) and 0.69 (95%CI: 0.58 to 0.79). For pneumothorax they were 0.59 (95%CI: 0.33 to 0.82) and 0.97 (95%CI: 0.93 to 0.99). For pleural effusion they were 0.85 (95%CI: 0.77 to 0.91) and 0.77 (95%CI: 0.62 to 0.88).

CONCLUSIONS

In conclusion, lung ultrasound is an adequate diagnostic modality in a tertiary ICU population to detect consolidations, interstitial syndrome, pneumothorax and pleural effusion. Moreover, one should be careful not to interpret lung ultrasound results in deterministic fashion as multiple respiratory conditions can be present in one patient. Trial registration This study was retrospectively registered at Netherlands Trial Register on March 17, 2021, with registration number NL9344.

Ultrasound use in the ICU for interventional pulmonology procedures

Critical care ultrasound has shifted the paradigm of thoracic imaging by enabling the treating physician to acquire and interpret images essential for clinical decision-making, at the bedside, in real-time. Once considered impossible, lung ultrasound based on interpretation of artifacts along with true images, has gained momentum during the last decade, as an integral part of rapid evaluation algorithms for acute respiratory failure, shock and cardiac arrest. Procedural ultrasound image guidance is a standard of care for both common bedside procedures, and advanced procedures within interventional pulmonologist’s (IP’s) scope of practice. From IP’s perspective, the lung, pleural, and chest wall ultrasound expertise is a prerequisite for mastery in pleural drainage techniques and transthoracic biopsies. Another ultrasound application of interest to the IP in the intensive care unit (ICU) setting is during percutaneous dilatational tracheostomy (PDT). As ICU demographics shift towards older and sicker patients, the indications for closed pleural drainage procedures, bedside transthoracic biopsies, and percutaneous dilatational tracheostomies have dramatically increased. Although ultrasound expertise is considered an essential IP operator skill there is no validated curriculum developed to address this component. Further, there is a need for developing an educational tool that matches up with the curriculum and could be integrated real-time with ultrasound-guided procedures.

Usefulness of Lung Ultrasound Follow-up in Patients Who Have Recovered From Coronavirus Disease 2019

Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2 infection, which tends to be mild. Even in these cases, our understanding is still incomplete, particularly regarding its sequelae and long-term outcomes. We describe 3 recovered patients who had coronavirus disease 2019, with long-persisting symptoms after recovery, in whom chest computed tomographic and concurrent lung ultrasound examinations were performed. It is possible to correlate the findings from lung ultrasound with the symptoms and the fibrosis or residual abnormalities present on chest computed tomography. Lung ultrasound, which is easy to use, without side effects or radiation, helps monitor the disease resolution or assess early progression to lung fibrosis, as exemplified in the cases reported.

Lung Ultrasound: A "Biomarker" for Fluid Overload?

Fluid overload is associated with poor outcomes in patients with acute kidney injury as well as end-stage kidney disease. Lung ultrasound (LUS) has been used in many different settings and specialties including the emergency department, intensive care unit, trauma, cardiology, and nephrology. Although LUS has been a valuable tool in assessing pulmonary congestion, LUS findings may not always be pathognomonic for pulmonary congestion. Furthermore, the feasibility of doing an extensive LUS examination as has been done in research studies may be hard to implement within the clinical setting. This review will go over the use of LUS to evaluate for fluid overload, compare LUS with other markers of fluid overload, review limitations of LUS, and suggest potential future directions in the use of LUS in nephrology.

Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study

Background

The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound.

Methods

We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax.

Results

We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population .

Conclusions

Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions.

Trial registration

DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01454-6.

Lung Ultrasound: The Essentials

Although US of the lungs is increasingly used clinically, diagnostic radiologists are not routinely trained in its use and interpretation. Lung US is a highly sensitive and specific modality that aids in the evaluation of the lungs for many different abnormalities, including pneumonia, pleural effusion, pulmonary edema, and pneumothorax. This review provides an overview of lung US to equip the diagnostic radiologist with knowledge needed to interpret this increasingly used modality. Supplemental material is available for this article. © RSNA, 2021.

Bedside cardiopulmonary ultrasonography evaluates lung water content in very low-weight preterm neonates with patent ductus arteriosus

BACKGROUND

Patent ductus arteriosus (PDA) is a common congenital heart abnormality in preterm neonates with a high incidence in neonates with very low birth weights. When PDA persists, interstitial lung water content increases, which could lead to abnormal circulation hemodynamics and pulmonary edema. It is important to perform early and reliable assessment of lung water content in very low-weight preterm neonates with persistent PDA.

AIM

To evaluate the role of bedside cardiopulmonary ultrasonography in the lung water content assessment in very low-weight preterm neonates with persistent PDA.

METHODS

From January 2018 to March 2020, 69 very low-weight preterm neonates with echocardiography-confirmed PDA were selected as the PDA group. At the same time, 89 very low-weight preterm neonates without PDA were randomly selected as the control group. All neonates underwent echocardiography and 6-segment lung ultrasonography on the fourth day after birth. The clinical characteristics and main ultrasonography results were compared between the two groups. Pearson's analysis was used to analyze the correlation between lung ultrasonography score (LUS) and other related clinical and ultrasonography results in all neonates. In the PDA group, PDA diameters were recorded, and the correlation with LUS and left atrium to aortic (LA/AO) dimension ratio were also analyzed. LA/AO ratio is one of the ultrasonic diagnostic criteria for hemodynamically significant PDA. When the ratio is ≥ 1.5, it suggests the possibility of hemodynamic changes in persistent PDA. A receiver operating characteristic curve was established using the sensitivity of LUS to predict the hemodynamic changes in neonates with PDA as the ordinate and 1-specificity as the abscissa.

RESULTS

A total of 158 neonates were enrolled in this study, including 69 in the PDA group and 89 in the control group. There were no statistical differences in sex, gestational age, birth weight, ventilator dependence, hospitalization length and left ventricular ejection fraction between the two groups (P > 0.05). The LUS and LA/AO ratio in the PDA group were higher than those in the control group (P < 0.05), but there was no difference of LUS in neonates with or without use of the ventilator (t = 0.58, P = 0.16). In all cases, LUS was negatively correlated with gestational age (r = -0.28, P < 0.01) and birth weight (r = -0.36, P < 0.01), while positively correlated with the LA/AO ratio (r = 0.27, P < 0.01). In the PDA group, PDA diameter was positively correlated with the LA/AO ratio (r = 0.39, P < 0.01) and LUS (r = 0.31, P < 0.01). Receiver operating characteristic results showed that LUS had the moderate accuracy for predicting hemodynamic changes in PDA (area under the curve = 0.741; sensitivity = 93.75%; specificity = 50.94%).

CONCLUSION

Bedside cardiopulmonary ultrasonography can evaluate lung content in neonates with PDA and predict the possibility of hemodynamic changes in persistent PDA.

Clinical Impact of Vertical Artifacts Changing with Frequency in Lung Ultrasound

Background: This study concerns the application of lung ultrasound (LUS) for the evaluation of the significance of vertical artifact changes with frequency and pleural line abnormalities in differentiating pulmonary edema from pulmonary fibrosis. Study Design and Methods: The study was designed as a diagnostic test. Having qualified patients for the study, an ultrasound examination was performed, consistent with a predetermined protocol, and employing convex and linear transducers. We investigated the possibility of B-line artifact conversion depending on the set frequency (2 MHz and 6 MHz), and examined pleural line abnormalities. Results: The study group comprised 32 patients with interstitial lung disease (ILD) (and fibrosis) and 30 patients with pulmonary edema. In total, 1941 cineloops were obtained from both groups and analyzed. The employment of both types of transducers (linear and convex) was most effective (specificity 91%, specificity 97%, positive predictive value (PPV) 97%, negative predictive value (NPV) 91%, LR(+) 27,19, LR(−) 0.097, area under curve (AUC) = 0.936, p = 7 × 10⁻⁶). Interpretation: The best accuracy in differentiating the etiology of B-line artifacts was obtained with the use of both types of transducers (linear and convex), complemented with the observation of the conversion of B-line artifacts to Z-line.

Lung ultrasound score predicts outcomes in COVID-19 patients admitted to the emergency department

BACKGROUND

During the COVID-19 pandemic, creating tools to assess disease severity is one of the most important aspects of reducing the burden on emergency departments. Lung ultrasound has a high accuracy for the diagnosis of pulmonary diseases; however, there are few prospective studies demonstrating that lung ultrasound can predict outcomes in COVID-19 patients. We hypothesized that lung ultrasound score (LUS) at hospital admission could predict outcomes of COVID-19 patients. This is a prospective cohort study conducted from 14 March through 6 May 2020 in the emergency department (ED) of an urban, academic, level I trauma center. Patients aged 18 years and older and admitted to the ED with confirmed COVID-19 were considered eligible. Emergency physicians performed lung ultrasounds and calculated LUS, which was tested for correlation with outcomes. This protocol was approved by the local Ethics Committee number 3.990.817 (CAAE: 30417520.0.0000.0068).

RESULTS

The primary endpoint was death from any cause. The secondary endpoints were ICU admission and endotracheal intubation for respiratory failure. Among 180 patients with confirmed COVID-19 who were enrolled (mean age, 60 years; 105 male), the average LUS was 18.7 ± 6.8. LUS correlated with findings from chest CT and could predict the estimated extent of parenchymal involvement (mean LUS with < 50% involvement on chest CT, 15 ± 6.7 vs. 21 ± 6.0 with > 50% involvement, p < 0.001), death (AUC 0.72, OR 1.13, 95% CI 1.07 to 1.21; p < 0.001), endotracheal intubation (AUC 0.76, OR 1.17, 95% CI 1.09 to 1.26; p < 0.001), and ICU admission (AUC: 0.71, OR 1.14, 95% CI 1.07 to 1.21; p < 0.001).

CONCLUSIONS

In COVID-19 patients admitted in ED, LUS was a good predictor of death, ICU admission, and endotracheal intubation.

Comparison of admission chest computed tomography and lung ultrasound performance for diagnosis of COVID-19 pneumonia in populations with different disease prevalence

PURPOSE

Chest computed tomography (CT) is considered a reliable imaging tool for COVID-19 pneumonia diagnosis, while lung ultrasound (LUS) has emerged as a potential alternative to characterize lung involvement. The aim of the study was to compare diagnostic performance of admission chest CT and LUS for the diagnosis of COVID-19.

METHODS

We included patients admitted to emergency department between February 21-March 6, 2020 (high prevalence group, HP) and between March 30-April 13, 2020 (moderate prevalence group, MP) undergoing LUS and chest CT within 12 h. Chest CT was considered positive in case of "indeterminate"/"typical" pattern for COVID-19 by RSNA classification system. At LUS, thickened pleural line with ≥ three B-lines at least in one zone of the 12 explored was considered positive. Sensitivity, specificity, PPV, NPV, and AUC were calculated for CT and LUS against real-time reverse transcriptase polymerase chain reaction (RT-PCR) and serology as reference standard.

RESULTS

The study included 486 patients (males 61 %; median age, 70 years): 247 patients in HP (COVID-19 prevalence 94 %) and 239 patients in MP (COVID-19 prevalence 45 %). In HP and MP respectively, sensitivity, specificity, PPV, and NPV were 90-95 %, 43-69 %, 96-72 %, 20-95 % for CT and 94-93 %, 7-31 %, 94-52 %, 7-83 % for LUS. CT demonstrated better performance than LUS in diagnosis of COVID-19, both in HP (AUC 0.75 vs 0.51; P < 0.001) and MP (AUC 0.85 vs 0.62; P < 0.001).

CONCLUSIONS

Admission chest CT shows better performance than LUS for COVID-19 diagnosis, at varying disease prevalence. LUS is highly sensitive, but not specific for COVID-19.

Management for the Drowning Patient

Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid." According to the World Health Organization, drowning claims the lives of > 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that > 90% of drownings are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of oxygen in different proportions. The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a noncardiogenic pulmonary edema. Salt and fresh water aspirations cause similar pathology. If the person is not rescued, aspiration continues, and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt ≤ 20% or Pao₂:Fio₂ ≥ 250. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essential steps from the first call to action until the best practice at the prehospital, ED, and hospitalization.

The Role of the Lung Ultrasound in Coronavirus Disease 2019: A Systematic Review

The coronavirus disease 2019 (COVID-19) pandemic has now infected six million people and is responsible for nearly four hundred thousand deaths. We review the potential role of the lung ultrasound to evaluate its benefits and potential roles to compare it to the current gold standard of computed tomography. A literature search was carried out utilizing electronic search engines and databases with COVID-19. Keywords related to the lung ultrasound (LUS) were used to refine this search - only the relevant articles found are cited. This review showed that there exists a strong correlation between the CT and LUS scan in COVID-19. Prominent features include the vertical B-lines, thicker pleural lines, and subpleural consolidation. Potential roles include reducing transmission between health-care workers and monitoring the progress of the disease. However, the current research is scarce compared to well-established imaging modalities, and as such, there is a necessity for more research to confirm the findings of this review.

Application of lung ultrasonography in critically ill patients with COVID-19

PURPOSE

Lung ultrasonography (LU) is useful to assess lung lesions and variations at bedside. To investigate the results of LU in severe and critical patients with coronavirus disease 2019 (COVID-19), we performed a single-institution study to evaluate the related lung lesions and variations, and prophylactic strategies, in a large referral and treatment center.

METHODS

We included 91 adult patients with severe and critical COVID-19, namely 62 males and 29 females, with an average age of 59 ± 11 years, who underwent LU. We collected the following patient information: sex, age, days in hospital, and days in ICU. In the ultrasound examinations, we recorded the presence of discrete B lines, confluent B lines, consolidation, pleural thickening, pleural effusion, and pneumothorax (PTX).

RESULTS

Among the 91 severe and critical patients, 59 cases had scattered B lines, 56 cases had confluent B lines, 58 cases had alveolar-interstitial syndrome (AIS), 48 cases had lung consolidation, six cases had pleural thickening, 39 cases had pleural effusion (average depth of the pleural effusion: 1.0 ± 1.5 cm), and 20 patients developed PTX. In the Cox multivariate analysis, there were significant differences in age, hospitalization days, ICU days, and lung consolidation.

CONCLUSION

Lung ultrasonography performed at the bedside can detect lung diseases, such as B lines, PTX, pulmonary edema, lung consolidation, pleural effusion, and variations of these findings. Our findings support the use of LU and measurements for estimating factors, and monitoring response to therapy in severe and critical COVID-19 patients.

The "pandemic" increase in lung ultrasound use in response to Covid-19: can we complement computed tomography findings? A narrative review

Coronavirus disease of 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has rapidly spread to a global pandemic in March 2020. This emergency condition has been putting a severe strain on healthcare systems worldwide, and a prompt, dynamic response is instrumental in its management. While a definite diagnosis is based on microbiological evidence, the relationship between lung ultrasound (LU) and high-resolution computed tomography (HRCT) in the diagnosis and management of COVID-19 is less clear. Lung ultrasound is a point-of-care imaging tool that proved to be useful in the identification and severity assessment of different pulmonary conditions, particularly in the setting of emergency and critical care patients in intensive care units; HRCT of the thorax is regarded as the mainstay of imaging evaluation of lung disorders, enabling characterization and quantification of pulmonary involvement. Aims of this review are to describe LU and chest HRCT main imaging features of COVID-19 pneumonia, and to provide state-of-the-art insights regarding the integrated role of these techniques in the clinical decision-making process of patients affected by this infectious disease.

Could It Be Pneumonia? Lung Ultrasound in Children With Low Clinical Suspicion for Pneumonia

Supplemental Digital Content is available in the text.

Background:

Community-acquired pneumonia (CAP) is a significant cause of pediatric morbidity and mortality worldwide. Emergency department point of care ultrasound (POCUS) is a first-line modality for diagnosis of CAP. The current coronavirus disease 2019 pandemic creates a unique opportunity to incorporate lung POCUS into the evaluation of a broader range of children. It has increased the utility of lung POCUS in both evaluation and follow-up of pediatric coronavirus cases. An increased use of lung POCUS creates an opportunity for earlier diagnosis while allowing the opportunity for overdiagnosis of small infiltrates and atelectasis. We collated a case series to demonstrate the benefit of lung POCUS in a very broad range of children.

Methods:

We collected a case series of 5 patients between December 2018 and December 2019 who presented nonclassically and were diagnosed with CAP on POCUS by a pediatric emergency physician.

Conclusion:

Routine lung POCUS in ill children will allow treating physicians to identify and follow a pulmonary infiltrate consistent with CAP quickly. We anticipate that early and more frequent use of POCUS and earlier diagnosis of CAP may improve outcomes by decreasing healthcare encounters within the same illness and by reducing the incidence of late sequelae of pneumonia such as empyema and effusions. However, we acknowledge that this may come at the expense of the overtreatment of viral infiltrates and atelectasis. Further study is required to improve the specificity of lung POCUS in the evaluation of CAP.

Point-of-care ultrasound in pediatric anesthesia: perioperative considerations

PURPOSE OF REVIEW

To review the perioperative applications of point-of-care ultrasound (POCUS).

RECENT FINDINGS

The role of point-of-care ultrasonography for perioperative care is expanding with respect to perioperative application. The imaging approach can complement the physical exam and provide additional information for decision-making in pediatric perioperative medicine. This review will focus on applications in the following organ systems: airway, cardiac, pulmonary and gastric. Specifically, POCUS of the airway has been used to optimize endotracheal tube depth, aid in tube size selection and predict difficulty with laryngoscopy and intubation. Lung POCUS has been used to assess for causes hypoxemia as well as to optimize ventilatory mechanics. Cardiac POCUS has been used for assessment of hemodynamics, valvular and ventricular function. Gastric ultrasound has emerged as an evaluative mechanism of gastric content in the setting of fasting as well as to confirm placement of gastric tubes. The applications of POCUS in the perioperative setting continue to evolve as a reliable diagnostic tool that can assist in timely diagnosis, improve procedural safety and has the potential to improve patient outcomes.

SUMMARY

The utility of perioperative POCUS has been well demonstrated, specifically for examination of the airway, stomach and cardiopulmonary system. It is advisable for the novice sonographer to perform POCUS within the guidelines set by the American Society of Echocardiography regarding basic POCUS. As with all diagnostic modalities, understanding the limitations of ultrasound and POCUS as well as continuous self-assessment is crucial.

Lung Ultrasound Score Predicts the Extravascular Lung Water Content in Low-Birth-Weight Neonates with Patent Ductus Arteriosus

BACKGROUND Patent ductus arteriosus (PDA) is a common congenital cardiac abnormality in premature infants. In low-birth-weight infants weighing less than 2500 g, if the PDA continues to open, abnormal circulation hemodynamics and pulmonary edema may occur. This study aimed to investigate the role of lung ultrasound score in the assessment of pulmonary edema in low-weight neonates with PDA. MATERIAL AND METHODS Two hundred and twenty-one neonates with low birth weight were selected as the subjects, children with PDA as the observation group, and children with closed ductus arteriosus as the control group. On the fourth postnatal day, lung ultrasound examination and 6-segment lung ultrasound scoring were performed. RESULTS All 221 infants (94 in the observation group, 127 controls) underwent ultrasound examinations of the lungs. Intergroup differences in gestational age, birth weight, length of hospital stay, and left ventricular ejection fraction were not statistically significant. There was a significant difference in lung ultrasound score (t=0.005, P=0.000) and aortic root ratio to left atrial (t=0.085, P=0.000), which was negatively correlated with gestational age (r=-0.235, P=0.000) and positively correlated with PDA diameter (r=0.261, P=0.011). CONCLUSIONS Low-birth-weight children often have PDA. Its continued opening changes the circulation hemodynamics in children. Lung ultrasound score can semi-quantitatively evaluate the extravascular lung water content, identifying the need to intervene and follow up the hemodynamic significance of PDA over time.

The lung ultrasound: facts or artifacts? In the era of COVID-19 outbreak

Ultrasound is the most disruptive innovation in intensive care life, above all in this time, with a high diagnostic value when applied appropriately. In recent years, point-of-care lung ultrasound has gained significant popularity as a diagnostic tool in the acutely dyspnoeic patients. In the era of Sars-CoV-2 outbreak, lung ultrasound seems to be strongly adapting to the follow-up for lung involvement of patients with ascertaining infections, till to be used, in our opinion emblematically, as a screening test in suspected patients at the emergency triage or at home medical visit. In this brief review, we discuss the lung ultrasound dichotomy, certainties and uncertainties, describing its potential role in validated clinical contexts, as a clinical-dependent exam, its limits and pitfalls in a generic and off-label clinical context, as a virtual anatomical-dependent exam, and its effects on the clinical management of patients with COVID-19.

Point-of-Care Lung Ultrasound Findings in Patients with COVID-19 Pneumonia

Patients with novel coronavirus disease (COVID-19) typically present with bilateral multilobar ground-glass opacification with a peripheral distribution. The utility of point-of-care ultrasound has been suggested, but detailed descriptions of lung ultrasound findings are not available. We evaluated lung ultrasound findings in 10 patients admitted to the internal medicine ward with COVID-19. All of the patients had characteristic glass rockets with or without the Birolleau variant (white lung). Thick irregular pleural lines and confluent B lines were also present in all of the patients. Five of the 10 patients had small subpleural consolidations. Point-of-care lung ultrasound has multiple advantages, including lack of radiation exposure and repeatability. Also, lung ultrasound has been shown to be more sensitive than a chest radiograph in detecting alveolar-interstitial syndrome. The utilization of lung ultrasound may also reduce exposure of healthcare workers to severe acute respiratory syndrome-coronavirus-2 and may mitigate the shortage of personal protective equipment. Further studies are needed to evaluate the utility of lung ultrasound in the diagnosis and management of COVID-19.

Thoracic ultrasound evaluation and B-type natriuretic peptide value in elective cesarean section under spinal anesthesia

BACKGROUND

Pregnancy-induced changes in cardiovascular status make women more susceptible to pulmonary edema. During cesarean section, to counterbalance the effect of hypotension caused by spinal anesthesia, anesthesiologists must choose between two fundamental approaches to maintain the hemodynamic state-intravenous fluids or vasopressors-and this choice will depend upon their particular opinions and experience. We aim to assess for any correlations between thoracic ultrasound A- and B-line artifacts, brain natriuretic peptide (BNP) levels, and the amount of intraoperative fluids administered.

RESULTS

From December 2016 to August 2018, at the University-Hospital of Udine, we enrolled 80 consecutive pregnant women undergoing cesarean section. We observed a statistically significant difference in the volume of fluids administered in the first 24 h (p = 0.035) between the patients presenting B-lines in at least one basal area of their thoracic ultrasound and patients with no evident B-lines (AUC 66.4%; IC 0.49-0.83). Dividing the population on whether their BNP levels were higher or less than 20 pg/mL, no statistically significant difference was revealed with regard to fluids administered in the first 24 h (p = 0.537).

CONCLUSIONS

Thoracic ultrasound is a non-invasive and easy-to-use tool for detecting fluid intolerance in pregnant women undergoing cesarean section. BNP levels were slow to rise following the cesarean section and did not show any clear correlation with fluid volumes administered.

Lung ultrasound in pediatric radiology - cons

In the 1990s, intensivists suggested a new type of sonography: lung ultrasound, based on artefacts that receive information even from physical acoustic phenomena not directly convertible into images of the human body. They compared the artefacts from the lung zones with no acoustic window with various computed tomography (CT) patterns. They used and still use US as a tool to evaluate patients bedside, i.e. monitoring of lung recruitment. They included Lung ultrasound in what was termed POCUS (Point-of-Care Ultrasound). Lung ultrasound has been progressively extended to paediatrics in general. The most appealing novelty has been the diagnosis of pneumothorax. Lung ultrasound was developed as a support tool for critical patients. Extrapolation with mass diffusion, in the absence of appropriate training, has led to misunderstandings and dangerous therapeutic diagnostic drifts.

Lung Ultrasound for the Diagnosis and Management of Acute Respiratory Failure

For critically ill patients with acute respiratory failure (ARF), lung ultrasound (LUS) has emerged as an indispensable tool to facilitate diagnosis and rapid therapeutic management. In ARF, there is now evidence to support the use of LUS to diagnose pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia, and acute pulmonary embolism. In addition, the utility of LUS has expanded in recent years to aid in the ongoing management of critically ill patients with ARF, providing guidance in volume status and fluid administration, titration of positive end-expiratory pressure, and ventilator liberation. The aims of this review are to examine the basic foundational concepts regarding the performance and interpretation of LUS, and to appraise the current literature supporting the use of this technique in the diagnosis and continued management of patients with ARF.

Emergency bedside ultrasound: benefits as well as caution – part 1. General

Purpose of review

The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed.

Recent findings

Despite its widespread use, definitive studies demonstrating improved patient outcomes are limited. The list of indications for POCUS nonetheless is increasing as practitioners acknowledge clinical benefits, and technological advancement improves diagnostic accuracy and efficiency of use.

Summary

We believe that a core level of POCUS should be achievable by practicing clinicians. Ultimately, the integration of POCUS findings into a patient management strategy must be holistic, and hence requires prudent consideration of the clinical scenario.

Morpho-functional evaluation of lung aeration as a marker of sickle-cell acute chest syndrome severity in the ICU: a prospective cohort study

Background

Acute chest syndrome (ACS) is the main cause of morbi-mortality in patients with sickle-cell disease in the intensive care unit (ICU). ACS definition encompasses many types of lung damage, making early detection of the most severe forms challenging. We aimed to describe ACS-related lung ultrasound (LU) patterns and determine LU performance to assess ACS outcome.

Results

We performed a prospective cohort study including 56 ICU patients hospitalized for ACS in a tertiary university hospital (Paris, France). LU and bedside spirometry were performed at admission (D0) and after 48 h (D2). Complicated outcome was defined by the need for transfusion of ≥ 3 red blood cell units, mechanical ventilation, ICU length-of-stay > 5 days, or death. A severe loss of lung aeration was observed in all patients, predominantly in inferior lobes, and was associated with decreased vital capacity (22 [15–33]% of predicted). The LU Score was 24 [20–28] on D0 and 20 [15–24] on D2. Twenty-five percent of patients (14/56) had a complicated outcome. Neither oxygen supply, pain score, haemoglobin, LDH and bilirubin values at D0; nor their change at D2, differed regarding patient outcome. Conversely, LU re-aeration score and spirometry change at D2 improved significantly more in patients with a favourable outcome. A negative LU re-aeration score at D2 was an independent marker of severity of ACS in ICU.

Conclusions

ACS is associated with severe loss of lung aeration, whose resolution is associated with favourable outcome. Serial bedside LU may accurately and early identify ACS patients at risk of complicated outcome.