The role of lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia

Evaluation of the relationship of fetal lung elastography values with the development of postpartum respiratory distress in late preterm labor cases

OBJECTIVES

This study investigates the relationship between fetal lung elastography values and the development of postpartum respiratory distress syndrome (RDS) in late preterm neonates.

METHODS

A total of 88 singleton pregnancies between 34 and 37 weeks of gestation were analyzed. Fetal lung and liver elasticity measurements were performed using 2D shear wave elastography (SWE). Lung and liver elasticity values were compared between neonates who developed RDS and those who did not. The lung-liver elastography (LLE) ratio was also calculated.

RESULTS

The minimum, maximum, and median lung elastography values were significantly higher in neonates with RDS compared to the control group (p<0.05). However, liver elastography values were similar between groups. The LLE ratio was also significantly higher in the RDS group (p=0.014). Additionally, neonates with RDS had lower APGAR scores, higher NICU admission rates, and increased need for respiratory support.

CONCLUSIONS

Higher fetal lung elastography values and LLE ratios are associated with an increased risk of RDS in late preterm neonates. Fetal lung elastography may serve as a valuable non-invasive tool for predicting neonatal respiratory complications, potentially guiding perinatal management and treatment strategies. Further multicenter studies are needed to validate these findings.

Systematic review and meta-analysis of the accuracy of lung ultrasound and chest radiography in diagnosing community acquired pneumonia in children

Chest radiography (CXR) is commonly used for diagnosing childhood pneumonia, but concerns about radiation exposure have raised interest in using radiation-free lung ultrasound (LUS) as an alternative imaging modality. Therefore, we designed this meta-analysis to compare the accuracy of LUS and CXR for diagnosing childhood pneumonia. We searched 8 databases and 1 clinical trial registry for studies published from inception to March 2023. Studies assessing lung ultrasound and chest radiography for diagnosing childhood pneumonia were included. Two reviewers independently screened literature, extracted data, and assessed the risk of bias using the QUADAS-2 tool for each study. Meta-analysis was conducted using a random-effects model, and pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristic (SROC) curve were assessed. Statistical analyses were performed using Meta-Disc 1.4, RevMan 5.4, and Stata 17.0 software. Heterogeneity was examined, and subgroup analysis was conducted to explore the accuracy of lung ultrasound in diagnosing childhood pneumonia. Out of the 4089 screened articles, 30 studies were included, encompassing a total of 4546 children. Of those, 3257 were diagnosed with pneumonia, 3190 through LUS, and 2925 via CXR. The meta-analysis showed that the sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of LUS were 0.940 (95% CI 0.930-0.949), 0.855 (95% CI 0.835-0.873), 7.561 (95% CI 4.956-11.536), 0.08 (95% CI 0.056-0.113), and 110.77 (95% CI 62.156-197.40), respectively. The combined area under the SROC curve was 0.9712, Q index = 0.9218. For CXR, the sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.893 (95% CI 0.881-0.905), 0.906 (95% CI 0.889-0.921), 18.742 (95% CI 7.551-46.520), 0.105 (95% CI 0.062-0.180), and 237.43 (95% CI 74.080-760.99), respectively. The combined area under the SROC curve was 0.9810, Q index = 0.9391. Subgroup analysis showed that the implementation location, interval between lung ultrasound and chest radiography, and operator experience had no impact on the accuracy of lung ultrasound in diagnosing childhood pneumonia. Existing evidence suggests that lung ultrasound has high accuracy for diagnosing childhood community-acquired pneumonia. Compared with chest radiography, lung ultrasound has higher sensitivity, similar specificity, and advantages such as radiation-free, lower cost, simplicity of operation, and ease of follow-up, making it an important imaging modality for diagnosing childhood pneumonia.

Clinical utility of bedside Contrast-Enhanced Ultrasound (CEUS) in the diagnosis of pneumonia in elderly patients: Comparison with clinical, -radiological and ultrasound diagnosis

AIMS

to measure the clinical impact of contrast-enhanced ultrasound (CEUS) in the diagnosis of -community-acquired pneumonia (CAP), compared to clinical, radiological and ultrasound diagnosis.

METHODS

84 patients (47/37 males/females, mean age:78,57±11,7 Y) with clinical suspicion of pneumonia and with ultrasound findings of peripheral lung lesions, were investigated with CEUS for a better characterization. Final diagnosis of 65 cap was obtained with complete disappearance of symptoms and pulmonary nodule(s); 19 neoplasms: 16 patients performed histologically with bronchoscopy; 3 refused (non-invasive diagnosis with basal CT-scan and positron emission tomography (PET) with fluorodeoxyglucose (FDG)). Sensitivity, specificity, overall diagnostic accuracy (ODA) (and corresponding AUROC) of clinical-data (CD), chest X-ray(CXR), Lung-ultrasound(LUS), CEUS were calculated with SPSS 26.0 software.

RESULTS

Final diagnosis: 65 CAP, and 19 chest cancers. 9/65 (13%) patients died, of these 7/9 with older age and heart disease as comorbidity. CD: True-Positive (TP):23, True-negative (TN): 17; False-Positive (FP):2; False-negative (FN):42 (sens:35,4% spec:89,5% ODA10%: PPV:92%, NPV:28,8%) (AUROC±SEauc:0,46±0,076); CXR: TP: 36, TN:14; FP:5, FN:29; (sens: 55,4%; spec: 73,7%; ODA: 32%; PPV:87,5%, NPV:32,66%) (AUROC±SEauc:0,645±0,068). US: TP:59; TN: 14; FP:5, FN:6 (sens: 90,8%, spec: 73,7%, ODA: 84,9%, PPV:92,2%, NPV:70%) (AUROC±SEauc:0,9417±0,024); CEUS: TP: 63; TN: 19; FP:0; FN:2 (sens: 96,9%; spec: 100% ODA: 97,5%; PPV: 100%, NPV:90,5%) (AUROC±SEauc:0,98±0,01).

CONCLUSIONS

Clinical-data and chest X-RAYS are insufficient to obtain a correct diagnosis of CAP in elderly population; US demonstrated a good accuracy to establish CAP, but with a relatively low specificity; in these cases, CEUS is able to give a correct characterization, allowing you to save the need for a chest contrast-enhanced-CT (CECT).

POCUS literature primer: key papers on cardiac and lung POCUS

OBJECTIVE

Although point of care ultrasound (POCUS) use has become prevalent in medicine, clinicians may not be familiar with the evidence supporting its utility in patient care. The objective of this study is to identify the top five most influential papers published on the use of cardiac POCUS and lung POCUS in adult patients.

METHODS

A 14-member expert panel from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative used a modified Delphi process. Panel members are ultrasound fellowship trained or equivalent, are engaged in POCUS scholarship, and are leaders in POCUS locally and nationally in Canada. The modified Delphi process consisted of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers on cardiac POCUS and lung POCUS.

RESULTS

A total of 66 relevant papers on cardiac POCUS and 68 relevant papers on lung POCUS were nominated by the panel. There was 100% participation by the panel members in all three rounds of the modified Delphi process. At the end of this process, we identified the top five most influential papers on cardiac POCUS and lung POCUS. Papers include studies supporting the use of POCUS for accurately assessing left ventricular systolic function, diagnosing pericardial effusion, clarifying its test characteristics for pulmonary embolism, identifying pulmonary edema and pneumonia, as well as consensus statements on the use of cardiac and lung POCUS in clinical practice.

CONCLUSION

We have created a list of the top five influential papers on cardiac POCUS and lung POCUS as an evidence-based resource for trainees, clinicians, and researchers. This will help trainees and clinicians better understand how to use POCUS when scanning the heart and lungs, and it will also help researchers better understand where to direct their scholarly efforts with future research.

Advancing healthcare through thoracic ultrasound research in older patients

This paper reports the proceedings of a meeting convened by the Research Group on Thoracic Ultrasound in Older People of the Italian Society of Gerontology and Geriatrics, to discuss the current state-of-the-art of clinical research in the field of geriatric thoracic ultrasound and identify unmet research needs and potential areas of development. In the last decade, point-of-care thoracic ultrasound has entered clinical practice for diagnosis and management of several respiratory illnesses, such as bacterial and viral pneumonia, pleural effusion, acute heart failure, and pneumothorax, especially in the emergency-urgency setting. Very few studies, however, have been specifically focused on older patients with frailty and multi-morbidity, who frequently exhibit complex clinical pictures needing multidimensional evaluation. At the present state of knowledge, there is still uncertainty on the best requirements of ultrasound equipment, methodology of examination, and reporting needed to optimize the advantages of thoracic ultrasound implementation in the care of geriatric patients. Other issues regard differential diagnosis between bacterial and aspiration pneumonia, objective grading of interstitial syndrome severity, quantification and monitoring of pleural effusions and solid pleural lesions, significance of ultrasonographic assessment of post-COVID-19 sequelae, and prognostic value of assessment of diaphragmatic thickness and motility. Finally, application of remote ultrasound diagnostics in the community and nursing home setting is still poorly investigated by the current literature. Overall, the presence of several open questions on geriatric applications of thoracic ultrasound represents a strong call to implement clinical research in this field.

Efficiency of Lung Ultrasonography in the Diagnosis and Follow-up of Viral Pneumonia in Newborn

OBJECTIVE

Lung ultrasonography (LUS) is a useful method for diagnosis of lung diseases such as respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, and pneumothorax in the neonatal period. LUS has become an important tool in the diagnosis and follow-up of lung diseases. LUS is easy to apply at the bedside and is a practical and low-cost method for diagnosing pneumonia.

STUDY DESIGN

This study was conducted in neonatal intensive care unit of Dr. Sami Ulus Obstetrics, Children's Health and Diseases Training and Research Hospital. From September 2019 to April 2020, 50 patients who were diagnosed with viral pneumonia were included in the study. Also, 24 patients with sepsis-related respiratory failure were included in the study as a control group. LUS was performed at the bedside three times, by a single expert, once each before treatment for diagnosis, on discharge, and after discharge in outpatient clinic control.

RESULTS

Before treatment, LUS findings were lung consolidation with air bronchograms (50/50), pleural line abnormalities (35/50), B-pattern (25/50), disappearance of lung sliding (21/50), lung pulse (5/50), and pleural effusion (9/50). During discharge, we found significant changes: lung consolidation with air bronchograms (6/50), pleural line abnormalities (7/50), B-pattern (12/50), and pleural effusion (1/50) (p < 0.05). Outpatient clinic control LUS findings were lung consolidation with air bronchograms (0/50), pleural line abnormalities (0/50), B-pattern (0/50), disappearance of lung sliding (0/50), and pleural effusion (0/50) (p < 0.05). Also, B-pattern image, disappearance of lung sliding, and pleural line abnormalities were higher in control group (p < 0.05).

CONCLUSION

Ultrasound gives no hazard, and the application of bedside ultrasonography is comfortable for the patients. Pneumonia is a serious infection in the neonatal period. Repeated chest radiography may be required depending on the clinical condition of the patient with pneumonia. This study focuses on adequacy of LUS in neonatal pneumonia.

KEY POINTS

· Lung ultrasound is a practical and low-cost method in diagnosing pneumonia.. · Neonatal pneumonia is a very important cause of morbidity and mortality in NICU.. · We can evaluate neonatal pneumonia with combination of clinical presentations and LUS findings..

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.

Lung ultrasound for the diagnosis of pulmonary atelectasis in both adults and pediatrics: A protocol for systematic review and meta-analysis

BACKGROUND

The use of lung ultrasound for the diagnosis of pulmonary atelectasis remains controversial. Therefore, we performed a protocol for systematic review and meta-analysis to evaluate the diagnostic accuracy of lung ultrasound for the diagnosis of pulmonary atelectasis both in adults and pediatrics.

METHODS

A comprehensive search of several databases from 1966 to October 2022 will be conducted. The databases include Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and PubMed. After screening and diluting out the articles that met inclusion criteria to be used for statistical analysis, the pooled evaluation indexes including sensitivity and specificity as well as hierarchical summary receiver operating characteristic curves with 95% confidence interval were calculated. All statistical analyses were calculated with STATA, version 12.0 (StataCorp, College Station, TX).

RESULT

We will synthesize the current studies to evaluate the diagnostic accuracy of lung ultrasound for the diagnosis of pulmonary atelectasis.

CONCLUSION

The result of this review will provide more reliable references to help clinicians make decisions for the diagnosis of pulmonary atelectasis.

Pleuro-pulmonary ultrasound in the diagnosis and follow-up of lung infections in children with cancer: a pilot study

PURPOSE

Febrile neutropenia and lung infections are common and potential fatal complications of pediatric cancer patients during chemotherapy. Lung ultrasound (LUS) has a good accuracy in the diagnosis of pneumonia in childhood, but there is no data concerning its use in the diagnosis and follow-up of pulmonary infection in children with cancer. The goal of this pilot study is to verify the feasibility of lung ultrasonography for the diagnosis and follow up of pneumonia in children and adolescents with cancer.

MATERIAL AND METHODS

This is a prospective observational case-control monocentric study conducted in the Pediatric Hematology and Oncology Department of University Hospital of Catania in patients aged < 18 years with cancer. Attending Physician used ultrasonography to detect pneumonia in cancer children with fever. As control group, cancer patients with no infection suspicion were also tested. LUS results were compared to chest X-ray (CXR) and/or chest CT scan, when these imaging techniques were performed, according to clinical indication.

RESULTS

Thirty-eight patients were studied. All underwent LUS, 16 underwent CXR, 3 chest CT. Statistical analysis showed LUS specificity of 93% (95% CI 84-100%), and sensitivity of 100%; CXR, instead, showed a specificity of 83% (95% CI 62-100%) and a sensitivity of 50% (95% CI 1-99%).

CONCLUSION

This study shows for the first time that LUS allows physicians to diagnose pneumonia in children and young adults with cancer, with high specificity and sensitivity.

Comparison of lung ultrasound, chest radiographs, C-reactive protein, and clinical findings in dogs treated for aspiration pneumonia

Background

Comparison of clinical findings, chest radiographs (CXR), lung ultrasound (LUS) findings, and C‐reactive protein (CRP) concentrations at admission and serial follow‐up in dogs with aspiration pneumonia (AP) is lacking.

Hypothesis

Lung ultrasound lesions in dogs with AP are similar to those described in humans with community‐acquired pneumonia (comAP); the severity of CXR and LUS lesions are similar; normalization of CRP concentration precedes resolution of imaging abnormalities and more closely reflects the clinical improvement of dogs.

Animals

Seventeen dogs with AP.

Methods

Prospective observational study. Clinical examination, CXR, LUS, and CRP measurements performed at admission (n = 17), 2 weeks (n = 13), and 1 month after diagnosis (n = 6). All dogs received antimicrobial therapy. Lung ultrasound and CXR canine aspiration scoring systems used to compare abnormalities.

Results

B‐lines and shred signs with or without bronchograms were identified on LUS in 14 of 17 and 16 of 17, at admission. Chest radiographs and LUS scores differed significantly using both canine AP scoring systems at each time point (18 regions per dog, P < .001). Clinical and CRP normalization occurred in all dogs during follow up. Shred signs disappeared on LUS in all but 1 of 6 dogs at 1 month follow‐up, while B‐lines and CXR abnormalities persisted in 4 of 6 and all dogs, respectively.

Conclusion and Clinical Importance

Lung ultrasound findings resemble those of humans with comAP and differ from CXR findings. Shred signs and high CRP concentrations better reflect clinical findings during serial evaluation of dogs.

Lung Ultrasonography Beyond the Diagnosis of Pediatrics Pneumonia

Pneumonia is a prevalent disease with considerable morbidity and mortality among the pediatric population. Early diagnosis and swift commencement of the correct treatment are vital for a favorable clinical outcome. Along with history-taking and clinical examination, imaging modalities commonly used, lung ultrasound provides a bedside, less invasive, radiation-free alternative to diagnose pneumonia when compared with other images such as chest x-ray (CXR) and computed tomography (CT) scan. It is therefore of the utmost magnitude to inspect the evidence of its accuracy and reliability in the diagnosis of this condition. The goal of this study is to look into the available data supporting the use of lung ultrasound in the diagnosis of juvenile pneumonia, its relevance in distinguishing between viral and bacterial diseases, and its superiority as compared to other diagnostic methods. As mentioned, early detection and differentiation of the type of pneumonia can reduce unnecessary antibiotic prescriptions and provide patients with a better prognosis, as well as the ability to predict the course of the disease and the need for advanced care or the development of complications. An extensive literature search of two popular online medical websites (PubMed and Embase) was conducted in this review, concentrating on studies that examined the role of lung ultrasound in the diagnosis of pediatric pneumonia published in the last five years. Only studies published in the English language were included in this review. With high sensitivity and specificity, lung ultrasound appeared to be a promising tool not only for pediatric pneumonia diagnosis, but also for treatment guidance and disease follow-up, especially when combined with clinical presentation and laboratory findings.

Implementing Lung Ultrasound in the Outpatient Management of COVID-19 Pneumonia: A Pilot Study to Update Local Guidelines

Background: Lung ultrasound (LUS) has a good performance with a high sensitivity and specificity for the diagnosis of pneumonia compared with chest X-ray, and it has been extensively used to assess patients during the COVID-19 pandemic. This study aims to evaluate the potential advantages of the regular use of LUS for the assessment of the severity and prognosis of COVID-19 pneumonia and to propose an adapted protocol with its inclusion in current local validated and published guidelines.

Methods: This is a single-center prospective study conducted during the first (April–May 2020) and second (October 2020–January 2021) waves of the SARS-CoV2 pandemic in Switzerland. All adult patients presenting to dedicated test centers with a suspicion of mild-to-moderate COVID-19 pneumonia and not requiring hospitalization at the time of diagnosis were included. Patients with confirmed COVID-19 pneumonia were referred to an ambulatory follow-up unit at our institution for reassessment, with the inclusion of the use of LUS in a random selection. Descriptive statistics were calculated for demographics using percentages, means, and standard deviations according to the distribution of variables.

Results: Eighty-eight ambulatory patients with a confirmed COVID-19 pneumonia were included (men = 57 [59%]; mean age, 52.1 ± 13.5 years). Among these, 19 (21%) were hospitalized and none died. Twenty-five lung assessments by ultrasound were performed during the follow-up consultation. All were consistent with the clinical examination and confirmed the clinician's opinion.

Conclusion: The use of a standardized pleuro-pulmonary ultrasound protocol for ambulatory patients with COVID-19 could help to reduce the use of chest X-rays and improve overall management at the time of referral and eventual follow-up. However, a specific study including LUS in a systematic approach should be performed to evaluate the outcome of patients according to findings.

Community-acquired pneumonia

Community-acquired pneumonia is not usually considered a high-priority problem by the public, although it is responsible for substantial mortality, with a third of patients dying within 1 year after being discharged from hospital for pneumoniae. Although up to 18% of patients with community-acquired pneumonia who were hospitalised (admitted to hospital and treated there) have at least one risk factor for immunosuppression worldwide, strong evidence on community-acquired pneumonia management in this population is scarce. Several features of clinical management for community-acquired pneumonia should be addressed to reduce mortality, morbidity, and complications related to community-acquired pneumonia in patients who are immunocompetent and patients who are immunocompromised. These features include rapid diagnosis, microbiological investigation, prevention and management of complications (eg, respiratory failure, sepsis, and multiorgan failure), empirical antibiotic therapy in accordance with patient's risk factors and local microbiological epidemiology, individualised antibiotic therapy according to microbiological data, appropriate outcomes for therapeutic switch from parenteral to oral antibiotics, discharge planning, and long-term follow-up. This Seminar offers an updated view on community-acquired pneumonia in adults, with suggestions for clinical and translational research.

[Imaging in respiratory infections]

The conventional X‑ray image is the method of choice for suspected pneumonia. Computed tomography (CT) is indicated for treatment refractory or recurrent infiltrates, difficult differential diagnostics, suspected complications and in immunocompromised patients. Thoracic sonography can be used as an alternative method for initial diagnostics and in the intensive care unit to monitor progress. In addition to the detection of infiltrates the radiological classification can help to limit the pathogen spectrum. Radiologically, three forms of pneumonia can principally be differentiated: lobar pneumonia, bronchopneumonia and interstitial pneumonia. Furthermore, there are special forms of pneumonia with certain pathogens, such as aspergilloma, invasive mycosis, postprimary tuberculosis and nontuberculous mycobacteriosis or in a specific clinical context, such as aspiration pneumonia, postinfarction pneumonia, retention pneumonia and septic emboli. The most frequent complications of pneumonia are lung abscesses and pleural empyema. Both can sometimes but not always be seen in the X‑ray image. If clinically suspected the indications for CT should be generously applied. Certain pre-existing diseases, such as immunodeficiency or structural alterations of the lungs can predispose to pulmonary infections, frequently with unusual pathogens or manifestation forms and must be taken into account in the diagnostics.

Lung ultrasound compared to chest X-ray for the diagnosis of CAP in children

BACKGROUND

Community-acquired pneumonia (CAP) represents one of the most common infectious diseases among children. Diagnosis of CAP is mainly clinical. Chest X-ray (CXR) remains the gold standard for the diagnosis in severe or controversial conditions. Recently, some authors have focused on the application of ultrasound in lung diseases but the role of lung ultrasound (LUS) in the diagnosis of CAP is still debated. We aimed to study the concordance between LUS and CXR in evaluating specific signs of CAP. As a secondary aim, we sought to determine the sensitivity and specificity of LUS in CAP diagnosis compared with CXR. Finally, we evaluated the role of LUS during the follow up.

METHODS

We enrolled 68 children (<16 years old) hospitalized from October 2018 to September 2019 with a clinical and radiological diagnosis of CAP (cases: N = 41), or with no respiratory diseases (controls: N = 27), in whom a CXR was performed for clinical indications. All the children underwent LUS during hospitalization. The average time needed to perform LUS was 5-10 min for each child, and 19/41 cases were re-evaluated by LUS and CXR 30 days after discharge.

RESULTS

Lung ultrasound confirmed CAP diagnosis in 40/41 patients. Concordance between the two techniques was K = 0.88 for the right lung and K = 0.70 for the left lung. Lung ultrasound showed a sensitivity of 97% and a specificity of 96% compared with CXR. At the follow up, sensitivity increased to 100% while specificity was 94%.

CONCLUSIONS

Our study showed a potential benefit of LUS compared with CXR in the diagnosis and the follow up of CAP.

Can lung ultrasound differentiate between bacterial and viral pneumonia in children?

PURPOSE

This study evaluates whether LUS can differentiate between bacterial and viral pneumonia in children and thus affect their management.

METHODS

The prospective, cross-sectional, analytical study included 200 children under 12 years of age (excluding neonates) with clinical suspicion of pneumonia who had undergone a chest radiograph (CR). The CR and LUS findings were classified as bacterial or viral pneumonia. The final diagnosis was made on the basis of a combination of clinical profile, available routine laboratory investigations and CR diagnosis which was taken as the gold standard for the study and LUS was compared with the gold standard.

RESULTS

LUS has a high sensitivity (91%; 95% CI [84-96]) and specificity (91.3%; 95% CI [84-96]) in diagnosing bacterial pneumonia with a high positive predictive value (91.9%; 95% CI [85-96]) and negative predictive value (90.3%; 95% CI [82-95]). For diagnosing viral pneumonia, the sensitivity of LUS was 78.4%; (95% CI [68-86]), specificity was high (90.4%; 95% CI [83-95]) and so was the positive predictive value (87.3%; 95% CI [78-94]) and negative predictive value (91.3%; 95% CI [84-96]).

CONCLUSION

LUS has a high accuracy in differentiating between bacterial and viral pneumonia in children and can help in their management by avoiding an ill-advised use of antibiotic therapy.

Air bronchogram integrated lung ultrasound score to monitor community-acquired pneumonia in a pilot pediatric population

Aims

Chest ultrasound is a non-invasive method for evaluating children with suspected community-acquired pneumonia (CAP). We evaluated the prognostic role of change of ultrasonographic (US) air bronchogram in management of CAP in terms of: rate of complicated CAP, change of empiric antibiotic therapy, relationship to defervescence time, and length of hospitalization.

Methods

Patients with CAP and radiographic evidence of lung consolidation were prospectively enrolled. Chest US examinations were performed within 12 h from admission and after 48 h. A new grading system (USINCHILD score) based on presence and features of air bronchogram was adopted.

Results

Thirty six patients were stratified into two groups according to the presence of an increase of at least 1 grade of US score (Δ US grade), expression of an improvement of lung consolidation. Δ US grade after 48 h ≥ 1 was associated with an increased risk of complicated CAP (p value 0.027) and a longer defervescence time (p value 0.036). Moreover, Δ US grade ≥ 1 was predictive of a short hospitalization (p value 0.008).

Conclusions

USINCHILD score could be an innovative biotechnology tool for the management of pediatric CAP.

Trial registration number and date of registration

NCT03556488, June 14, 2018.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s40477-020-00547-7) contains supplementary material, which is available to authorized users.

Point-of-care ultrasound by the pediatrician in the diagnosis and follow-up of community-acquired pneumonia

OBJECTIVES

To review, analyze, and present the available evidence on the usefulness of point-of-care pulmonary ultrasound in the diagnosis and monitoring of community-acquired pneumonia (CAP), aiming to facilitate its potential inclusion into pediatric clinical reference guidelines.

SOURCE OF DATA

A non-systematic research was carried out in the MEDLINE (PubMed), LILACS, and SciELO databases, from January 1985 to September 2019. The articles that were considered the most relevant were selected.

SYNTHESIS OF DATA

CAP is a relevant cause of morbidity and mortality in pediatrics and its clinical management remains a major challenge. The systematic use of chest X-ray for its diagnosis is controversial because it exposes the child to ionizing radiation and there are interobserver differences in its interpretation. Recently, the use of point-of-care pulmonary ultrasound by the pediatrician has been presented as an alternative for the diagnosis and monitoring of CAP. A great deal of evidence has disclosed its high sensitivity and diagnostic specificity, with the advantages of no ionizing radiation, relatively low cost, immediate results, portability, and the possibility of repetition according to the requirements of disease evolution. Moreover, its use can help rule out possible bacterial etiology and thus prevent inappropriate antibiotic treatments that favor bacterial resistance.

CONCLUSIONS

Point-of-care ultrasonography represents an opportunity to improve the diagnosis and monitoring of CAP. However, as an operator-dependent technique, training is required for adequate image acquisition, correct interpretation, and integration with clinical data for correct decision-making.

Ultrasound Elastography for Lung Disease Assessment

Ultrasound elastography (US-E) is a noninvasive, safe, cost-effective and reliable technique to assess the mechanical properties of soft tissue and provide imaging biomarkers for pathological processes. Many lung diseases such as acute respiratory distress syndrome, chronic obstructive pulmonary disease, and interstitial lung disease are associated with dramatic changes in mechanical properties of lung tissues. Nevertheless, US-E is rarely used to image the lung because it is filled with air. The large difference in acoustic impedance between air and lung tissue results in the reflection of the ultrasound wave at the lung surface and, consequently, the loss of most ultrasound energy. In recent years, there has been an increasing interest in US-E applications in evaluating lung diseases. This article provides a comprehensive review of the technological advances of US-E research on lung disease diagnosis. We introduce the basic principles and major techniques of US-E and provide information on various applications in lung disease assessment. Finally, the potential applications of US-E to the diagnosis of COVID-19 pneumonia is discussed.

Effectiveness of Lung Ultrasound in Comparison with Chest X-Ray in Diagnosis of Lung Consolidation

BACKGROUND:

Lung ultrasound (US) is an available and inexpensive tool for the diagnosis of community-acquired pneumonia (CAP); it which has no hazards of radiation and can be easily used.

AIM:

To evaluate the efficacy of lung ultrasound in the diagnosis and follow-up of CAP.

PATIENTS AND METHODS:

100 patients aged from 40 to 63 years with a mean age of 52.3 ± 10 years admitted to the Critical Care Department, Cairo University with pictures of CAP. Lung US was performed for all patients initially, then a plain chest X-ray (CXR) was performed. Another lung ultrasound was performed on the 10th day after admission.

RESULTS:

Initial chest X-ray was correlated with the initial chest ultrasound examination in CAP diagnosis (R-value = 0.629, P < 0.001). Cohen’s κ was run to determine if there is an agreement between the findings of the initial chest X-ray findings and those of the initial chest ultrasound in CAP diagnosis. A moderate agreement was found where κ = .567 (95% CI, 0.422 to 0.712) and P < 0.001. Upon initial examination, the CXR diagnosed CAP in 48.0% of patients, while lung US diagnosed the disease in 70% of patients. Moreover, lung US was more sensitive than CXR (P-value < 0.001). Compared to the accuracy of computed tomography (CT) chest (100%) which is the gold standard for CAP diagnosis, the accuracy of lung US was 95.0%, while the accuracy of CXR was 81.0%.

CONCLUSION:

This study proved the effectiveness of lung ultrasound in CAP diagnosis.

The Geriatric Patient: The Ideal One for Chest Ultrasonography? A Review From the Chest Ultrasound in the Elderly Study Group (GRETA) of the Italian Society of Gerontology and Geriatrics (SIGG)

OBJECTIVES

To investigate the current evidence on the use of point-of-care chest ultrasonography in older patients and geriatric settings and present the current state of the art of chest ultrasound applications.

DESIGN

Special article based on a literature review with narrative analyses and expert clinical knowledge.

SETTING AND PARTICIPANTS

All studies performed in a geriatric setting were included. Observational and intervention studies and meta-analyses including participants aged ≥70 years were also considered, even if not specifically focused on a geriatric setting.

MEASURES

Data on participant characteristics, diagnostic accuracy of chest ultrasonography, and outcomes were collected for each considered study. Data were analyzed and discussed with a particular focus on the possible applications and advantages of chest ultrasonography in geriatric medicine, underlining the possible areas of future research.

RESULTS

We found only 5 studies on the diagnostic accuracy and prognostic relevance of chest ultrasonography in geriatrics. However, several studies performed in emergency departments, intensive care units, and internal medicine wards included a large number of participants ≥70 years old; they suggest that chest ultrasonography may represent a valid aid to the diagnostics of acute dyspnea, pneumonia, acute heart failure, pneumothorax, and pleural diseases, with an accuracy in some cases superior to standard x-rays, especially when mobility limitation is present. Diaphragm ultrasonography may also represent a valid tool to guide mechanical ventilation weaning in older patients with acute respiratory failure.

CONCLUSIONS AND IMPLICATIONS

Chest ultrasonography may represent a valid bedside diagnostic aid to the management of acute respiratory diseases in older patients. However, specific evidence is lacking for geriatric patients. Future research will need to focus on defining the reference standards and the diagnostic accuracy for older patients with frailty and multimorbidity, cost-efficacy and cost-effectiveness of the technique, its impact for clinical outcomes, and role for follow-up in the post-acute care.

Tabla: A Proof-of-Concept Auscultatory Percussion Device for Low-Cost Pneumonia Detection

Pneumonia causes the deaths of over a million people worldwide each year, with most occurring in countries with limited access to expensive but effective diagnostic methods, e.g., chest X-rays. Physical examination, the other major established method of diagnosis, suffers from several drawbacks, most notably low accuracy and high interobserver error. We sought to address this diagnostic gap by developing a proof-of-concept non-invasive device to identify the accumulation of fluid in the lungs (consolidation) characteristic of pneumonia. This device, named Tabla after the percussive instrument of the same name, utilizes the technique of auscultatory percussion; a percussive input sound is sent through the chest and recorded with a digital stethoscope for analysis. Tabla analyzes differences in sound transmission through the chest at audible frequencies as a marker for lung consolidation. This paper presents preliminary data from five pneumonia patients and eight healthy subjects. We demonstrate 92.3% accuracy in distinguishing between healthy subjects and patients with pneumonia after data analysis with a K-nearest neighbors algorithm. This prototype device is low cost and simple to implement and may offer a rapid and inexpensive method for pneumonia diagnosis appropriate for general use and in areas with limited medical infrastructure.

[Use of pocket-sized ultrasound in internal medicine (hospitalist) practice: Feedback and perspectives]

INTRODUCTION

Point of care ultrasound (POCUS) is routinely used by intensivists and emergency physicians for many years. Its interest is not arguable any more for these specialists, despite the large variety of diseases they care. Hospitalists and internists also should find some interest in POCUS, which convenience and wide range of indications responds well to the variety of their practice. However, it is still not widely used in internal medicine departments.

METHODS

We here report our experience of using a pocket-sized ultrasound device in a French internal medicine department. The device used was a Vscan Dual Probe, GE, whose two probes and presets allow for cardiac, abdominal, pulmonary, obstetric, vascular, pulmonary, and superficial soft tissue exploration. One physician of the ward received a course for POCUS that was initially dedicated for emergency physicians. This study reports on the results of the examinations made between January and September 2015. For each examination performed, clinical usefulness was assessed at the time of patient discharge, by two independent physicians who reviewed the clinical course and the results of conventional imaging and rated their evaluation on a Likert scale.

RESULTS

One hundred and four examinations were evaluated. The mean duration of the ultrasound examination was 9±5minutes. The POCUS conclusions were corrected by disease course or the results of conventional imaging in 10 (9.6%) cases. The presets of the device: heart, soft tissue, lung, abdomen and vascular were used respectively in 32, 30, 21, 12 and 5% of the examinations. The main indications of POCUS examination were for identification of pleural, pericardial or peritoneal effusion, and to assess the central venous pressure by inferior vena cava examination. Eighteen examinations were performed for puncture of effusion. The retrospectively evaluated clinical benefit was clearly demonstrated in 78% of cases. The agreement between the two blinded assessors was good (kappa coefficient at 0.82).

CONCLUSION

Pocket-sized ultrasound device could be used in internal medicine wards. However, its limited performance compared to more sophisticated echography limits the possible explorations and their reliability, which encourages caution and makes critical the question of the initial training of doctors and medical students.

Long-term sequelae after lung abscess in children - Two tertiary centers' experience

AIM

The aim of the study was to describe the epidemiology and clinical characteristic of children hospitalized with pneumonia complicated by lung abscess, as well as to evaluate the long-term sequelae of the disease.

METHODS

A retrospective review of medical records of all patients treated for pulmonary abscess in two tertiary centers was undertaken. Pulmonary function tests and lung ultrasound were performed at a follow-up.

RESULTS

During the study period, 5151 children with pneumonia were admitted, and 49 (0.95%) cases were complicated with lung abscess. In 38 (77.5%) patients, lung abscess was treated solely with antibiotics, and in nine cases (16.3%) surgically. In 21 (51.21%) children complete radiological regression was documented. The mean time for radiological abnormalities regression was 84.14 ± 51.57 days, regardless of the treatment mode. Fifteen patients were followed up at 61.6 ± 28.3 months after discharge. Lung ultrasound revealed minor residual abnormalities: pleural thickening, subpleural consolidations and line B artefacts in 11 (73.3%) children. Pulmonary function tests results were abnormal in eight (53.3%) patients, the most frequent abnormality being hyperinflation. We did not find a restrictive disorder in any of the children. There were no deaths in our study.

CONCLUSIONS

Lung abscess is a rare but severe complication of pneumonia in children. Most children recover uneventfully with no significant long-term pulmonary sequelae.

Lung ultrasonography to diagnose community-acquired pneumonia in children

Background

Early diagnosis of community-acquired pneumonia (CAP) is essential to reduce the total burden of this disease. Traditionally, chest radiography (CR) is used to identify true CAP. However, CR is not a perfect diagnostic test for CAP. The use of lung ultrasonography (LUS) has been suggested as an alternative to overcome the problems associated with CR and increase the feasibility and accuracy of CAP diagnosis. LUS has largely been used for the diagnosis of several lung problems, including CAP, in adult patients with satisfactory results. Experience with LUS in children has grown over recent years. The main aim of this paper is to discuss the advantages and limits of LUS in the diagnosis of paediatric CAP.

Discussion

The presence of a consolidation pattern during LUS may represent pneumonia or atelectasis, although this conclusion is operator dependent. An overall agreement between LUS and CR was observed in most of the studies that were examined. In most reports where a disagreement between the two methods was found, CR was not able to identify the cases that were correctly diagnosed by LUS, particularly when CR was performed only with postero-anterior/antero-posterior projection and consolidation was observed in lung areas that are poorly visualized by CR. However, the lack of standardized LUS methods is problematic. Finally, the real advantage of LUS for the diagnosis of CAP in children remains unclear.

Summary

LUS is an interesting diagnostic modality that appears a useful first imaging test in children with suspected CAP. However, the methods used to perform LUS in children are not precisely standardized, and the diagnosis of interstitial CAP is inaccurate. Further studies are needed before LUS can be routinely used in everyday paediatric practice.

A case of Legionella pneumophila evaluated with CT and ultrasound

A 36-year-old man was admitted to the emergency department of "SS Annunziata" hospital in Chieti complaining of a sharp chest pain arisen some hours before admission. On examination, the patient looked sweaty; his vital signs showed tachycardia and augmented breath rate; sinus tachycardia and normal ventricular repolarization were observed on ECG, and no abnormalities were observed in the echoscan of the hearth. According to the clinical and electrocardiographic findings, and to previous episode of DVT in anamnesis, a thorax CT scan was performed in order to rule out pulmonary embolism. It showed an "area of parenchymal consolidation involving almost all the left lower lobe with patent bronchial structures"; given the patient's CURB 65 score, he was then admitted to the pneumology ward where empiric treatment with levofloxacin (750 mg PO once daily) was initiated. Thoracic ultrasound was performed using a multifrequency convex transducer, and the posterior left area was examined through intercostal approach, placing the patient in a sitting position. A subpleural patchy hypoechoic lesion with irregular boundaries was detected; the maximum diameter was 11 cm, and the multiple hyperechoic spots inside it (elsewhere defined as "air bronchogram") showed no Doppler signal. Given the positive result of the Legionella urinary antigen test, antibiotic treatment was switched to Levofloxacin 1000 mg PO once daily and Claritromicin 500 mg PO twice daily. After 3 days, his clinical conditions improved dramatically. Ultrasound performed after 5 days from the diagnosis showed decreased dimensions of the lesion previously identified (maximum diameter 8.25 cm) and a marked reduction of the hyperechoic spots in it. The patient was discharged in good clinical conditions, and both thorax CT scan obtained after 1 and 4 months from the diagnosis showed radiological resolution of the parenchymal consolidation. The key to ultrasound visualization of pneumonia is its contact with the pleural surface (86-98% in cases of CAP) and the relative loss of aeration of the portion involved by the infection and a concomitant increase in the fluid content. A paradigmatic US image for parenchymal inflammatory infiltrate has not been established yet; anyway, some typical findings, when combined with the clinical features, can confirm the diagnostic hypothesis.

Can Chest Computed Tomography Be Replaced by Lung Ultrasonography With or Without Plain Chest Radiography in Pediatric Pneumonia?

PURPOSE

The purpose of this study was to answer the following question: can chest computed tomography (CT) requested by pediatricians be replaced by lung ultrasonography (US) with or without chest radiography in pediatric pneumonia?

MATERIALS AND METHODS

A total of 98 children with suspected pneumonia who were referred by pediatricians for CT examinations were prospectively studied. Levels of agreement between CT findings and plain radiography, lung US, and chest radiography plus lung US results were investigated.

RESULTS

CT defined pneumonia in 84 patients, among which 26 cases were complicated. κ values between radiography and CT findings were 0.82 in complicated cases, 0.67 in uncomplicated cases, and 0.72 overall. The corresponding values between US and CT findings were 1, 0.52, and 0.62, respectively, and between radiography plus US and CT findings were 1, 0.86, and 0.88, respectively.

CONCLUSIONS

CT can be replaced by US when complex effusions are present in children with pneumonia. In case of an ambiguous diagnosis of pediatric pneumonia with or without complex effusions, a combination of chest radiography and US is a reliable surrogate for chest CT.

Evaluation of the Diagnostic Role of Bedside Lung Ultrasonography in Patients with Suspected Pulmonary Embolism in the Emergency Department

Background:

Despite the existence of detailed consensus guidelines, challenges remain regarding efficient, appropriate, and safe imaging methods for the diagnosis of suspected pulmonary embolism.

Aims:

To investigate the role of the wedge sign, B-lines, and pleural effusion seen on bedside lung ultrasound in the diagnosis of pulmonary embolism.

Study Design:

Diagnostic accuracy study.

Methods:

During the first evaluation of patients with suspected pulmonary embolism, bedside lung ultrasound was performed, and the B-lines, wedge sign, and pleural effusion were investigated. Computed tomography angiography was used as a confirmatory test and was compared with the lung ultrasound findings.

Results:

Pulmonary embolism was detected in 38 (38%) patients. In the comparison of bedside lung ultrasound results, statistically significant differences were found between the groups in terms of the B-lines and wedge sign (p=0.005 and p<0.001, respectively). There were no significant differences in terms of effusion (p=0.234). Comparison of these findings with computed tomography angiography of the chest showed weak negative correlations between the groups in terms of B-lines (r=-0297) and a moderately positive correlation in terms of the wedge sign (r=0.523). The sensitivity, specificity, and positive and negative predictive values of lung ultrasound findings alone were low. In the logistic regression analysis, the wedge sign (p<0.01, OR=69.45, 95% CI=6.94-695.17) and B-line (p=0.033, OR=1.96, 95% CI=0.41-8.40) were found to be effective in the diagnosis of pulmonary embolism.

Conclusion:

Although the role of lung ultrasound has been increasing in the management of critically ill patients, its value is limited and cannot replace the gold standard tests in the diagnosis of pulmonary embolism.

The role of transthoracic ultrasonography in predicting the outcome of community-acquired pneumonia in hospitalized children

CONCLUSION

TUS findings of fluid bronchogram, multifocal involvement, and pleural effusion were associated with adverse outcomes, including longer hospital stay, ICU admission, and tube thoracotomy in hospitalized CAP children. Therefore, TUS is a novel tool for prognostic stratifications of CAP in hospitalized children.

Routine application of lung ultrasonography in the neonatal intensive care unit

The aim of this study was to study the features of lung ultrasonography (LUS) in lung disease and to evaluate the usefulness of LUS in the neonatal intensive care unit (NICU).All of 3405 neonates included in this study underwent an LUS examination. Diagnoses were based on medical history, clinical manifestation, laboratory examination, and signs on chest radiography (CR) and/or computed tomography (CT). A single expert physician performed all LUS examinations.There were 2658 cases (78.9%) with lung disease and 747 cases (21.9%) without lung disease. The main signs of neonates with lung disease on LUS were as follows: absence of A-lines, pleural-line abnormalities, interstitial syndrome, lung consolidation, air bronchograms, pulmonary edema, and lung pulse. These abnormal signs were reduced or eliminated on LUS as patient conditions improved. There were 81 cases that could not be diagnosed as lung disease by CR but were discovered as pneumonia, respiratory distress syndrome (RDS), or transient tachypnea of newborn (TTN) on LUS. Likewise, 23 cases misdiagnosed as RDS by CR were diagnosed as TTN on LUS. Among 212 cases of long-term oxygen dependence (LTOD) that failed to yield signs of pulmonary edema and lung consolidation on CR, 103 cases showed abnormal signs on LUS. Among 747 cases without lung disease, B-lines of 713 neonates (95.4%) could be found within 3 days after birth, and 256 neonates (34.3%) could be observed from 3 days to 1 week after birth. B-lines of 19 cases could be detected from 1 to 2 weeks after birth. The longest time at which B-lines could still be observed was 19 days after birth.LUS has clinical value for the diagnosis of lung disease and the discrimination of causes of LTOP in premature infants, particularly for the diagnosis and identification of RDS and TTN. Moreover, LUS has additional advantages, including its lack of radiation exposure and its ability to noninvasively monitor treatment progress. Therefore, LUS should be routinely used in the NICU.

Lung Ultrasound as First-Line Examination for the Diagnosis of Community-Acquired Pneumonia in Children

OBJECTIVES

The diagnosis of pediatric community-acquired pneumonia (CAP) is based on clinical criteria. Even though chest x-ray (CXR) is only recommended in severe cases, it is often requested from physicians in mild cases, thus increasing radiation exposure. Lung ultrasound (LUS) is not included in the diagnostic workup. The objective of this study was to evaluate the diagnostic performance of LUS against CXR.

METHODS

Children who presented to the emergency department with clinical signs suggesting CAP and had already been evaluated with a CXR were included in the study. Availability of a pediatric sonographer expert in LUS was also considered a criterion for participation. Chest x-ray and LUS were considered positive for CAP in cases of alveolar or interstitial pattern of disease. The diagnostic criterion standard was the ex post diagnosis of pneumonia, made by an independent senior expert pediatrician, after evaluation of the complete medical chart.

RESULTS

Sixty-nine children were enrolled in the study, with 66 of 69 positive for CAP. Receiver operating characteristic curve analysis results for CXR were 95.5% sensitivity and 100% specificity, whereas for LUS, sensitivity was reported 92.42% and specificity 100%. Comparison of the 2 receiver operating characteristic curves revealed no difference in the diagnostic value of the 2 methods for the diagnosis of pneumonia (P = 0.658). However, LUS classified more cases as alveolar disease compared with CXR.

CONCLUSIONS

Lung ultrasound plays a significant role in the detection of CAP, not inferior to CXR. The aim of this study was to encourage the use of ultrasound as a first-line examination for CAP in children.

Lung Ultrasound Will Soon Replace Chest Radiography in the Diagnosis of Acute Community-Acquired Pneumonia

Acute community-acquired pneumonia should be diagnosed early to avoid most complications. The common diagnostic tools were represented by blood tests and chest X-ray with CT scan coming as a second-line exploration. The presence of air in the pulmonary parenchyma has long been thought of as not explorable by ultrasound. However, since the 1990s, several teams have described a semiology of ultrasonography of pulmonary diseases. Moreover, the safety of the technique and the development of mobile and ultra-portable devices have offered it as a first-line examination by a non-radiologist physician. The authors describe in this article ultrasonography as a way of learning the technique, and the main results observed in the literature. In conclusion, they propose it as the first-line examination instead of chest X-ray, and to reserve chest CT scan for complicated cases.

Lung ultrasound and chest x-ray for detecting pneumonia in an acute geriatric ward

BACKGROUND

Our aim was to compare the accuracy of lung ultrasound (LUS) and standard chest x-ray (CXR) for diagnosing pneumonia in older patients with acute respiratory symptoms (dyspnea, cough, hemoptysis, and atypical chest pain) admitted to an acute-care geriatric ward.

METHODS

We enrolled 169 (80 M, 89 F) multimorbid patients aged 83.0 ± 9.2 years from January 1 to October 31, 2015. Each participant underwent CXR and bedside LUS within 6 hours from ward admission. LUS was performed by skilled clinicians, blinded to CXR results and clinical history. The final diagnosis (pneumonia vs no-pneumonia) was established by another clinician reviewing clinical and laboratory data independent of LUS results and possibly prescribing chest contrast-enhanced CT. Diagnostic parameters of CXR and LUS were compared with McNemar test on the whole cohort and after stratification for Rockwood Clinical Frailty Scale.

RESULTS

Diagnostic accuracy for pneumonia (96 patients) was significantly higher in LUS (0.90, 95% confidence interval [CI] 0.83-0.96) compared with CXR (0.67, 95%CI 0.60-0.74, P < 0.001). LUS had a better sensitivity (0.92, 95%CI 0.86-0.97 vs 0.47, 95%CI 0.37-0.57) and negative predictive value (0.95, 95% CI 0.83-0.96 vs 0.57, 95%CI 0.48-0.56). In those patients with frailty (n = 87 with Rockwood Clinical Frailty Scale ≥5), LUS maintained a high diagnostic accuracy, but CXR did not (P = 0.0003). Interobserver agreement for LUS, calculated in a subsample of 29 patients, was high (k = 0.90).

CONCLUSIONS

In multimorbid patients admitted to an acute geriatric ward, LUS was more accurate than CXR for the diagnosis of pneumonia, particularly in those with frailty. A wider use of LUS should be implemented in this setting.

Thoracic ultrasound: Potential new tool for physiotherapists in respiratory management. A narrative review

The use of diagnostic ultrasound by physiotherapists is not a new concept; it is frequently performed in musculoskeletal physiotherapy. Physiotherapists currently lack accurate, reliable, sensitive, and valid measurements for the assessment of the indications and effectiveness of chest physiotherapy. Thoracic ultrasound may be a promising tool for the physiotherapist and could be routinely performed at patients' bedsides to provide real-time and accurate information on the status of pleura, lungs, and diaphragm; this would allow for assessment of lung aeration from interstitial syndrome to lung consolidation with much better accuracy than chest x-rays or auscultation. Diaphragm excursion and contractility may also be assessed by ultrasound. This narrative review refers to lung and diaphragm ultrasound semiology and describes how physiotherapists could use this tool in their clinical decision-making processes in various cases of respiratory disorders. The use of thoracic ultrasound semiology alongside typical examinations may allow for the guiding, monitoring, and evaluating of chest physiotherapy treatments. Thoracic ultrasound is a potential new tool for physiotherapists.

Detection of abnormalities in ultrasound lung image using multi-level RVM classification

The classification of abnormalities in ultrasound images is the monitoring tool of fluid to air passage in the lung. In this study, the adaptive median filtering technique is employed for the preprocessing step. The preprocessed image is then extracted the features by the convoluted local tetra pattern, histogram of oriented gradient, Haralick feature extraction and the complete local binary pattern. The extracted features are selected by applying particle swarm optimization and differential evolution feature selection. In the final stage, classifiers namely relevance vector machine (RVM), and multi-level RVM are employed to perform classification of the lung diseases. The diseases respiratory distress syndrome (RDS), transient tachypnea of the new born, meconium aspiration syndrome, pneumothorax, bronchiolitis, pneumonia, and lung cancer are used for training and testing. The experimental analysis exhibits better accuracy, sensitivity, specificity, pixel count and fitness value than the other existing methods. The classification accuracy of above 90% is accomplished by multi-level RVM classifier. The system has been tested with a number of ultrasound lung images and has achieved satisfactory results in classifying the lung diseases.

The irregular diaphragmatic pleural interface: a novel sonographic sign facilitating the diagnosis of pneumonia

Pneumonia, a disease that has been reported to be the sixth leading cause of death in the United States, has worsening mortality with delays in diagnosis. As the history and physical examination are excessively inaccurate in the diagnosis of pneumonia, we often rely on chest radiography to rule in or out disease. However, it is found to lack sufficient accuracy when computed tomography is used as the reference standard. Sonography has emerged as a viable alternative to chest radiography in the diagnosis of pneumonia. Here, we describe a novel sonographic sign that can be used to assist in the diagnosis of pneumonia.

The utility of thoracic ultrasound in patients with acute eosinophilic pneumonia

Thoracic ultrasound (TUS) is an easy-to-use imaging modality that aids physicians in the differential diagnosis of respiratory diseases. However, no data exist on the TUS findings of acute eosinophilic pneumonia (AEP) or their clinical utility in patients with AEP. Thus, we performed an observational study on TUS findings and their clinical utility for follow-up in patients with AEP. We prospectively screened patients who visited the emergency department for acute respiratory symptoms at the Armed Forces Capital Hospital in South Korea between February 2014 and July 2014. Of them, patients suspected to have AEP underwent an etiological investigation, including flexible bronchoscopy with bronchoalveolar lavage and TUS, and we evaluated TUS findings and serial changes on TUS during the treatment course compared with those from chest radiographs. In total, 22 patients with AEP were identified. The TUS examinations reveled that all patients exhibited multiple diffuse bilateral B-lines and lung sliding, with (n = 5) or without pleural effusion, which was consistent with alveolar-interstitial syndrome. B-line numbers fell during the course of treatment, as the lines became thinner and fainter. A-lines were evident in 19 patients on day 7 of hospitalization, when B-lines had disappeared in 13 patients, and all pleural effusion had resolved. All patients exhibited complete ultrasonic resolution by day 14, along with clinicoradiological improvement. Chest radiographs of five patients taken on day 7 seemed to show complete resolution, but several abnormal B-lines were evident on TUS performed the same day. As a result, our data show common TUS findings of AEP and suggest that AEP may be included as a differential diagnosis when multiple diffuse bilateral B-lines with preserved lung sliding are identified on a TUS examination in patients with acute symptoms, and that TUS is a useful modality for evaluating the treatment response in patients with AEP.

[Lung ultrasonography for the diagnosis of pneumonia in pregnant women with blood system tumors]

AIM

To estimate the informative value of ultrasonography (USG) in the diagnosis of lung injuries in pregnant women with blood system tumors.

SUBJECTS AND METHODS

Lung ultrasound was performed in 5 pregnant patients with blood cancers. The women's age was 29-38 years; gestational age was 14-33 weeks. Four women had different types of acute leukemia; one had primary mediastinal large B-cell lymphoma. All the women received chemotherapy for blood cancer. When there were signs of lung injury, USG was conducted, the results of which necessitated therapy or bronchoalveolar lavage (BAL).

RESULTS

Three patients developed acute respiratory failure; 2 of them required noninvasive ventilation. Based on the detection of consolidation with a dynamic air bronchogram and pleural effusion, the authors diagnosed bilateral pneumonia and alveolar-interstitial syndrome in 1 patient, right-sided pneumonia in 1, left-sided one in 1, and transfusion-related pulmonary edema in 1. Lung ultrasound did not verify the diagnosis of pneumonia in 1 patient. According to USG data, BAL procedures were performed in 2 patients; one of them was diagnosed as having Pneumocystis pneumonia; the other was found to have no pathogens in lavage fluid. Treatment resulted in clinical improvements and normalization of the lung ultrasound pattern in all the pregnant women. Later on, 4 women delivered via cesarean section done at 32-34 weeks' gestation and gave birth to healthy babies. One patient died from infectious complications after chemotherapy.

CONCLUSION

Lung sound may be used to diagnose lung injury in pregnant women with blood cancers.