Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress*. Crit Care Med. 2012;40:2064-2072. [PMID: 22584759 DOI: 10.1097/ccm.0b013e31824e68ae]

Negative extra-abdominal pressure (NEXAP)-based lung recruitment maneuver versus standard lung recruitment maneuver in the treatment of postoperative atelectasis after cardiac surgery: A single-center randomized controlled trial

OBJECTIVE

To evaluate the effect of negative extra-abdominal pressure (NEXAP)-based lung recruitment maneuver (LRM) for atelectasis after cardiac surgery, and compare it with stepwise positive end-expiratory pressure (PEEP)-based LRM.

METHODS

In this single-center randomized controlled clinical trial, patients were assigned to the NEXAP or PEEP groups. The primary outcome was the lung ultrasound score (LUSS) on global (LUSStot) and regional (LUSSp, posterior, LUSSa, anterior and LUSSl, lateral regions).

RESULTS

29 patients in the NEXAP group and 33 patients in the PEEP group were analyzed. The LUSStot was significantly decreased after LRM in both the NEXAP group (20.7 ± 3.2 vs. 15.6 ± 3.3; p < 0.001) and PEEP group (21.5 ± 4.2 vs. 17.1 ± 4.6; p < 0.001), and ΔLUSStot was significantly greater in the NEXAP group than PEEP group (-5.1 ± 2.3 vs. -3.8 ± 2.2, p = 0.020). Regional LUSS showed that NEXAP reduced LUSSl and LUSSp. PaO2/FiO2, PaO2, Vt, and Crs were significantly improved in the two groups.

CONCLUSION

NEXAP is an effective treatment for atelectasis after cardiac surgery, which significantly reduced patients' LUSS, improved pulmonary ventilation (especially in the lateral and posterior regions). NEXAP can further reduce LUSStot than the traditional PEEP-based LRM. Regional LUSS analyses reflecting the different mechanisms between the two methods of LRMs may require further investigation.

The 30-min diaphragm movement change rate for predicting weaning success in severe pneumonia patients requiring invasive ventilation

Purpose

This study evaluated the 30-min diaphragm excursion change rate (ΔDE30-0) as a novel predictor of weaning success compared to existing parameters in patients with severe pneumonia requiring invasive mechanical ventilation.

Methods

This retrospective cohort study enrolled patients with severe pneumonia requiring invasive mechanical ventilation (n = 100). The patients were divided into successful (n = 79) and failed (n = 21) extubation groups. Ultrasound measurements of diaphragm excursion (DE) were performed at baseline (DE0) and 30 min (DE30) during a spontaneous breathing trial. The ratio ΔDE30-0 was calculated as the absolute difference between DE30 and DE0 divided by DE0. Additional parameters including rapid shallow breathing index (Rapid Shallow Breathing Index, RSBI) and respiratory rate (RR) were also assessed. The predictive performance of ΔDE30-0 and other parameters was evaluated using receiver operating characteristic (ROC) curves.

Results

The extubation failure group had significantly higher ΔDE30-0 (0.40 ± 0.20 vs. 0.14 ± 0.12, p < 0.0001), RSBI (59.62 ± 21.77 vs. 47.7 ± 13.6, p = 0.0025), and RR (23.62 ± 2.25 vs. 20.34 ± 2.18, p < 0.0001) compared to the success group. ΔDE30-0 demonstrated the highest predictive performance with an area under the ROC curve of 0.924, sensitivity of 86.1%, and specificity of 95.2% at a cut-off value of 0.209.

Conclusions

ΔDE30-0 is a promising predictor of weaning success in severe pneumonia patients requiring invasive mechanical ventilation. It outperformed existing parameters and demonstrated high predictive accuracy.

Implications for clinical practice

Incorporating ΔDE30-0 into weaning protocols may improve decision-making, reduce complications, and optimize outcomes for patients requiring invasive mechanical ventilation due to severe pneumonia. This novel parameter can aid clinicians in identifying suitable candidates for extubation, potentially reducing the risk of weaning failure and associated adverse events.

ESICM-ESPNIC international expert consensus on quantitative lung ultrasound in intensive care

PURPOSE

To provide an international expert consensus on technical aspects and clinical applications of quantitative lung ultrasound in adult, paediatric and neonatal intensive care.

METHODS

The European Society of Intensive Care (ESICM) and the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) endorsed the project. We selected an international panel of 20 adult, paediatric and neonatal intensive care experts with clinical and research expertise in quantitative lung ultrasound, plus two non-voting methodologists. Fourteen clinical questions were proposed by the chairs to the panel, who voted for their priority (1-9 Likert-type scale) and proposed modifications/supplementing (two-round vote). All the questions achieved the predefined threshold (mean score > 5) and 14 groups of 3 mixed adult/paediatric experts were identified to develop the statements for each clinical question; predefined groups of experts in the fields of adult and paediatric/neonatal intensive care voted statements specific for these subgroups. An iterative approach was used to obtain the final consensus statements (two-round vote, 1-9 Likert-type scale); statements were classified as with agreement (range 7-9), uncertainty (4-6), disagreement (1-3) when the median score and ≥ 75% of votes laid within a specific range.

RESULTS

A total of 46 statements were produced (4 adults-only, 4 paediatric/neonatal-only, 38 interdisciplinary); all obtained agreement. This result was also achieved by acknowledging in the statements the current limitations of quantitative lung ultrasound.

CONCLUSION

This consensus guides the use of quantitative lung ultrasound in adult, paediatric and neonatal intensive care and helps identify the fields where further research will be needed in the future.

Associations Between Quantitative Lung Ultrasound and Successful Extubation in Infants

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lung Ultrasound in Mechanical Ventilation: A Purposive Review

Background/Objectives: Lung ultrasound (LUS) has emerged as a crucial bedside tool for evaluating and managing patients with respiratory failure, particularly those receiving mechanical ventilation (MV). Its ability to rapidly characterise lung pathology, including extent, severity, and progression, has established LUS as a key diagnostic and monitoring modality in both hospital and home-care settings. Methods: This narrative review analyses the specific applications of LUS in the assessment and management of patients undergoing MV, aiming to optimise ventilatory strategies. Results: We examine the role of LUS in (1) identifying patients requiring MV; (2) guiding ventilator settings (Positive End Expiratory Pressure selection, inspiratory pressure adjustment, and patient-ventilator synchrony optimisation); (3) performing and monitoring recruitment manoeuvres; (4) assessing parenchymal damage and evaluating the response to medical and ventilatory therapies; (5) detecting ventilation-associated complications; (6) facilitating weaning from MV; and (7) assisting with airway management procedures, specifically tracheostomy. The utility of Transesophageal Lung Ultrasound (TELU) is also briefly discussed. Conclusions: This review highlights the potential of LUS to improve clinical decision making and patient outcomes in the context of MV.

Lung Ultrasound in Critical Care: A Narrative Review

Lung ultrasound (LUS) has become a crucial part of the investigative tools available in the management of critically ill patients, both within the intensive care unit setting and in prehospital medicine. The increase in its application, in part driven by the COVID-19 pandemic, along with the easy access and use of mobile and handheld devices, allows for immediate access to information, reducing the need for other radiological investigations. LUS allows for the rapid and accurate diagnosis and grading of respiratory pathology, optimisation of ventilation, assessment of weaning, and monitoring of the efficacy of surfactant therapies. This, however, must occur within the framework of accreditation to ensure patient safety and prevent misinterpretation and misdiagnosis. This narrative review aims to outline the current uses of LUS within the context of published protocols, associated pathologies, LUS scoring systems, and their applications, whilst exploring more novel uses.

High Respiratory and Cardiac Drive Exacerbate Secondary Lung Injury in Patients With Critical Illness

The high respiratory and cardiac drive is essential to the host-organ unregulated response. When a primary disease and an unregulated secondary response are uncontrolled, the patient may present in a high respiratory and cardiac drive state. High respiratory drive can cause damage to the lungs, pulmonary circulation, and diaphragm, while high cardiac drive can lead to fluid leakage and infiltration as well as pulmonary interstitial edema. A "respiratory and cardiac dual high drive" state may be a sign of an unregulated response and can lead to secondary lung injury through the increase of transvascular pressure and pulmonary microcirculation injury. Ultrasound examination of the lung, heart, and diaphragm is important when evaluating the phenotype of high respiratory drive in critically ill patients. Ultrasound assessment can guide sedation, analgesia, and antistress treatment and reduce the risk of high respiratory and cardiac drive-induced lung injury in these patients.

Establishment of a prediction model for extubation failure risk in ICU patients using bedside ultrasound technology

BACKGROUND

Mechanical ventilation (MV) is crucial for managing critically ill patients; however, extubation failure, associated with adverse outcomes, continues to pose a significant challenge.

OBJECTIVE

The purpose of this prospective observational study was to develop and validate a predictive numerical model utilizing bedside ultrasound to forecast extubation outcomes in ICU patients.

METHODS

We enrolled 300 patients undergoing MV, from whom clinical variables, biomarkers, and ultrasound parameters were collected. Patients were randomly assigned to two groups at a 6:4 ratio: the derivation cohort (n = 180) and the validation cohort (n = 120). A nomogram prediction model was developed using significant predictors identified through multivariate analysis and its performance was assessed and validated by evaluating its discrimination, calibration, and clinical utility.

RESULTS

A total of 300 patients (mean age 72 years; 57.3 % male) were included, with an extubation failure rate of 26.7 %. The model, including diaphragm thickening fraction (OR: 0.890, P = 0.009), modified lung ultrasound score (OR: 1.371, P < 0.001), peak relaxation velocity (OR: 1.515, P = 0.015), and APACHE II (OR: 1.181, P = 0.006), demonstrated substantial discriminative capability, as indicated by an area under the receiver operating characteristic curve (AUC) of 0.886 (95 % CI: 0.830-0.942) for the derivation cohort and 0.846 (95 % CI: 0.827-0.945) for the validation cohort. Hosmer-Lemeshow tests yielded P-values of 0.224 and 0.212 for the derivation and validation cohorts.

CONCLUSIONS

We have established a risk prediction model for extubation failure in mechanically ventilated ICU patients. This risk model base on bedside ultrasound parameters provides valuable insights for identifying high-risk patients and preventing extubation failure.

Role of cardiac and lung ultrasonography in predicting weaning failure in patients with acute kidney injury requiring mechanical ventilation: A pilot study

PURPOSE

Acute Kidney Injury (AKI) has an incidence of 20-50 % in patients admitted in Intensive Care Unit. As weaning failure is associated with increased morbidity, its prediction and understanding of its physiological basis holds extreme importance in guided management and prognostication of these patients. We conducted this prospective, observational, single - center study to evaluate the efficacy of transthoracic echocardiography (TTE) and lung ultrasonography (LUS) in predicting weaning failure in patients with AKI requiring mechanical ventilation.

METHODS

We performed LUS and TTE before and 2 h after initiating spontaneous breathing trials (SBT) in 32 mechanically ventilated critically ill patients with AKI. Extubation was decided by an independent physician. LUS included global and anterior LUS scores. TTE included measurement of E/A and E/e' ratios to determine LV filling pressures.

RESULTS

Out of 32 patients included in this study, weaning failure was observed in 17 (n = 17, 53 %) patients (weaning success n = 15, 47%). Demographic and baseline laboratory parameters were comparable between the study groups. Fluid balance [+370 (250-530)] and SOFA score [8 (7-9)] on admission were significantly higher in weaning failure group (p < 0.001, p = 0.049). LUS scores and difference between LUS scores before and at the end of the SBT were significantly higher among the weaning failure group. The model consisting of baseline variables, SOFA score on the day of weaning and SBT induced changes in global lung score showed highest ability to predict weaning failure with AUC of 0.965, R2 = 61 %, p < 0.001.

CONCLUSION

In mechanically ventilated critically ill patients with AKI, LUS scores can predict weaning failure after SBT.

CTRI NUMBER

CTRI/2020/12/029565.

Assessment of Respiratory Muscles, Lung Parenchyma, and Cardiac Function by Ultrasound for Predicting Weaning Failure in Critically Ill Adults: A Prospective Observational Study

OBJECTIVES

The parasternal intercostal muscle activity, a marker of accessory muscle usage, is found to correlate inversely with the pressure-generating capacity of the diaphragm and level of support of mechanical ventilation. The primary objective of our study was to determine whether the parasternal intercostal muscle thickening fraction (PMTF) measured by ultrasonography can predict weaning. We also evaluated whether addition of lung ultrasound score and echocardiographic assessment can add on to predicting weaning failure.

METHODS

This prospective observational study conducted in a mixed medical-surgical intensive care unit, included 60 adult patients who were eligible for a spontaneous breathing trial (SBT) after being invasively mechanically ventilated for more than 48 hours. Ultrasound of respiratory muscles, lung parenchyma, and echocardiographic assessment were performed before and after 120 minutes of SBT. Parasternal intercostal muscles were imaged with a high frequency linear probe on the right second intercostal space 5 cm lateral to the sternal margin. PMTF was calculated as (maximum-minimum thickness)/minimum thickness.

RESULTS

Among 60 patients, SBT failure was seen in 11 patients and extubation failed in 8 patients. PMTF (%) was significantly higher in the weaning failure group (13.33 [8.33-19.05]) as compared to patients with successful weaning (6.67 [6.06-11.54]). Diaphragmatic thickening fraction (DTF) correlated inversely to PMTF in patients with weaning failure. A pre-SBT PMTF cut-off of ≥7.7% and post-SBT cut-off of ≥15.38% were good predictors of weaning failure and extubation failure, respectively.

CONCLUSIONS

PMTF has good discriminatory power to predict weaning outcomes (area under the receiver operating characteristic curve: 0.74 [0.59-0.88]). Pre-SBT PMTF had similar power as DTF to predict weaning failure.

Advances in Point-of-Care Ultrasound in Pediatric Acute Care Medicine

Pediatric point-of-care ultrasonography (POCUS) has grown in utilization and is now an integral part of pediatric acute care. Applications within the pediatric critical care, neonatology and pediatric emergency were once limited to evaluation of undifferentiated shock states, abdominal free fluid assessments in trauma resuscitation and procedural guidance. The body of pediatric POCUS literature is ever expanding and recently published international consensus guidelines are available to guide implementation into clinical practice. The authors present a review of emerging applications and controversies within thoracic, hemodynamic, neurologic, and ocular POCUS in pediatric acute care medicine.

Predicting extubation failure in neonates: The role of lung ultrasound and corrected gestational age in safe weaning in the NICU

To evaluate the accuracy of the lung ultrasound score (LUS) in predicting ventilatory weaning failure during neonatal hospitalization in the NICU and to identify factors associated with weaning failure, including corrected gestational age (CGA). This prospective, longitudinal, pragmatic and observational cohort study included neonates on mechanical ventilation for at least 48 h. The primary outcome was the accuracy of lung ultrasound in predicting 3-day weaning failure, with the ROC curve used to determine the best LUS cutoff (sensitivity and specificity). Among 55 neonates, the pre-extubation LUS did not show statistical significance in predicting weaning failure (AUC 0.61; 95% CI: 0.46-0.76, p = 0,169). In the subgroup analysis, a score ≥ 4 suggests the need for ventilatory support after extubation (area under the curve [AUC] = 0.91, 95% CI: 0.80-1.0, p < 0.001) in neonates with GA ≥ 28 weeks. In extremely preterm infants, the pre-extubation LUS was not statistically significant in predicting weaning failure (AUC = 0.38, 95% CI: 0-0.77, p = 0.535). In contrast, CGA ≥ 28.7 weeks at extubation was predictor of successful weaning within 3 days (AUC = 0.95, 95% CI: 0.85-1.0, p < 0.001).

CONCLUSION

LUS show promise in predicting weaning failure, though its accuracy may be limited in extremely preterm infants, highlighting the need for further well-powered studies. CGA at extubation also emerges as a key consideration in this population, warranting confirmation through robust future research.

WHAT IS KNOWN

• Identifying the optimal timing for extubation is crucial, as both prolonged mechanical ventilation and failed extubation are linked to increased morbidity. • Lung ultrasound plays a well-established role in diagnosing various neonatal lung pathologies, allowing clinicians to make rapid, bedside decisions for the treatment of newborns.

WHAT IS NEW

• LUS appears to be accurate in predicting weaning failure, though its accuracy may be lower in extremely preterm infants. • In extremely preterm infants, CGA may play an important role in extubation decision-making. • These findings are hypothesis-generating and warrant further investigation in future studies.

Value of combining lung ultrasound score with oxygenation and functional indices in determining weaning timing for critically ill pediatric patients

OBJECTIVE

This study aims to investigate the predictive effectiveness of bedside lung ultrasound score (LUS) in conjunction with rapid shallow breathing index (RSBI) and oxygenation index (P/F ratio) for weaning pediatric patients from mechanical ventilation.

METHODS

This was a retrospective study. Eighty-two critically ill pediatric patients, who were admitted to the Pediatric Intensive Care Unit (PICU) and underwent mechanical ventilation from January 2023 to April 2024, were enrolled in this study. Prior to weaning, all patients underwent bedside LUS, with concurrent measurements of their RSBI and P/F ratio. Patients were followed up for weaning outcomes and categorized into successful and failed weaning groups based on these outcomes. Differences in clinical baseline data, LUS scores, RSBI and P/F ratios between the two groups were compared. The predictive value of LUS scores, RSBI and P/F ratios for weaning outcomes was assessed using receiver operating characteristic (ROC) curves and the area under the curve (AUC).

RESULTS

Out of the 82 subjects, 73 (89.02%) successfully weaned, while 9 (10.98%) failed. No statistically significant differences were observed in age, gender, BMI, and respiratory failure-related comorbidities between the successful and failed weaning groups (P > 0.05). Compared to the successful weaning group, the failed weaning group exhibited longer hospital and intubation durations, higher LUS and RSBI, and lower P/F ratios, with statistically significant differences (P < 0.05). An LUS score ≥ 15.5 was identified as the optimal cutoff for predicting weaning failure, with superior predictive power compared to RSBI and P/F ratios. The combined use of LUS, RSBI and P/F ratios for predicting weaning outcomes yielded a larger area under the curve, indicating higher predictive efficacy.

CONCLUSION

The LUS demonstrates a high predictive value for the weaning outcomes of pediatric patients on mechanical ventilation.

Ventilation distribution during spontaneous breathing trials predicts liberation from mechanical ventilation: the VISION study

BACKGROUND

Predicting complete liberation from mechanical ventilation (MV) is still challenging. Electrical impedance tomography (EIT) offers a non-invasive measure of regional ventilation distribution and could bring additional information.

RESEARCH QUESTION

Whether the display of regional ventilation distribution during a Spontaneous Breathing Trial (SBT) could help at predicting early and successful liberation from MV.

STUDY DESIGN AND METHODS

Patients were monitored with EIT during the SBT. The tidal image was divided into ventral and dorsal regions and displayed simultaneously. We explored the ventral-to-dorsal ventilation difference in percentage, and its association with clinical outcomes. Liberation success was defined pragmatically as passing SBT followed by extubation within 24 h without reintubation for 7 days. Failure included use of rescue therapy, reintubation within 7 days, tracheostomy, and not being extubated within 24 h after succesful SBT. A training cohort was used for discovery, followed by a validation cohort.

RESULTS

Among a total of 98 patients analyzed, 85 passed SBT (87%), but rapid liberation success occurred only in 40; 13.5% of extubated patients required reintubation. From the first minutes to the entire SBT duration, the absolute ventral-to-dorsal difference was consistently smaller in liberation success compared to all subgroups of failure (p < 0.0001). An absolute difference at 5 min of SBT > 20% was associated with failure of liberation, with sensitivity and specificity of 71% and 78% and positive predictive value 81% in a validation cohort.

CONCLUSION

During SBT, a large ventral-to-dorsal difference in ventilation indicated by EIT may help to rapidly identify patients at risk of liberation failure.

Basic Lung Ultrasound and Clinical Applications in General Medicine

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasonographic modeling of lung and diaphragm mechanics: clinical trial of a novel non-invasive method to evaluate pre-operative pulmonary function

Background

Pre-operative pulmonary function testing (PFT) plays a key role in predicting postoperative complications or functional impairment. However, PFT requires the subject and examiner to cooperate and the results are influenced by both technical and personal factors. In contrast, the use of ultrasound (US) for structural and functional assessments of the lungs and diaphragm is on the rise, as it requires minimal patient cooperation. Dyspnea is mainly caused by lung or pleural lesions but may also be caused by weak respiratory muscles. As the diaphragm is a primary respiratory muscle, combining lung ultrasonography (LUS) with diaphragm ultrasound (DUS) may enable a more comprehensive assessement of pulmonary function. This study aims to introduce a novel approach for assessing pulmonary function using a mathematical model based on LUS and DUS.

Methods

This prospective study was performed at the First Affiliated Hospital of Nanchang University between June 2021 and December 2021, 208 patients were recruited and underwent PFT, LUS, and DUS examinations. An experienced physician, blinded to the clinical history and PFT results, performed LUS and DUS and explored the correlations between a mathematical model (ultrasonographic modeling score (U-score)) using LUS combined with DUS and pulmonary function parameters. Univariate, multivariate, and logistic regression analyses were also performed.

Results

According to the univariate and multivariable analysis, diaphragm thickness fraction in deep breathing (D-DTF) (odds ratio (OR), 0.88; 95% confidence interval (CI) [0.83-0.94]; P < 0.001), and LUS score (OR, 1.44; 95% CI [1.16-1.80]; P < 0.001) were each independently associated with pulmonary function. According to the logistics equation, a U-score of -0.126 × D-DTF + 0.368 × LUS score was produced. The U-score showed a more significant negative correlation with forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) (r = -0.605, P < 0.001) than the LUS or DUS indices alone. The U-score (area under the curve (AUC) = 0.971) was greater than the other indices for assessing pulmonary function.

Conclusions

With validation, the U-score through both lung and diaphragm ultrasound measurements may assist in estimating pulmonary function. This approach facilitates the assessment of pulmonary function in patients who may be unable to reliably participate in PFT.

Lung ultrasound score and diaphragm ultrasound in weaning from mechanical ventilation: are they different in patients with and without COVID-19?

OBJECTIVE

To compare pre-extubation physiological characteristics and ultrasound variables between patients intubated for COVID-19 compared to a clinical population and those intubated for other reasons.

METHODS

This was a secondary analysis of a prospective cohort study of patients undergoing invasive mechanical ventilation (IMV) for more than 48 h. Patients were divided into two groups: those intubated for COVID-19-induced ARDS and those intubated for other clinical reasons. Ultrasound assessment of lung and diaphragm function was performed before extubation. The results were compared between the two groups of patients.

RESULTS

In comparison with the patients without COVID-19, those with the disease were younger (a median age of 58 [46-76] years vs. a median age of 75 [69-85] years; p = 0.01), had fewer comorbidities (a median Charlson Comorbidity Index of 2 [1-4] vs. a median Charlson Comorbidity Index of 5 [4-6]; p < 0.01), and were less severely ill at admission (a median APACHE II score of 9 [8-14] vs. a median APACHE II score of 18 [13-22]; p < 0.01). In addition, the median duration of IMV was longer in the COVID-19 patients (11 [9-23] days vs. 6 [3-8] days; p < 0.01). Although extubation success rates were similar between the COVID-19 and non-COVID-19 groups (22 [71%] vs. 35 [77.8%]), median lung ultrasound score differed between the two groups (23 [18-25] vs. 15 [11-18]; p < 0.01), as did median diaphragmatic excursion (2.1 [1.7-2.4] vs. 1.7 [1.2-2.0]; p < 0.01).

CONCLUSIONS

Although patients with COVID-19 requiring ventilatory support are younger and have fewer comorbidities than those intubated for other clinical reasons, they experience longer hospital stays. Although lung ultrasound score can differ between patients with and without COVID-19, these differences do not significantly translate into extubation success rates. Therefore, the utility of ultrasound scores in weaning COVID-19 patients from IMV needs further study.

Weaning of non COPD patients at high-risk of extubation failure assessed by lung ultrasound: the WIN IN WEAN multicentre randomised controlled trial

BACKGROUND

Postextubation respiratory failure (PRF) frequently complicates weaning from mechanical ventilation and may increase morbidity/mortality. Noninvasive ventilation (NIV) alternating with high-flow nasal oxygen (HFNO) may prevent PRF.

METHODS

Ventilated patients without chronic obstructive pulmonary disease (COPD) and at high-risk of PRF defined as a lung ultrasound score (LUS) ≥ 14 assessed during the spontaneous breathing trial, were included in a French-Chinese randomised controlled trial. PRF was defined by 2 among the following signs: SpO2 < 90%; Respiratory rate > 30 /min; hypercapnia; haemodynamic and/or neurological disturbances of respiratory origin. In the intervention group, prophylactic NIV alternating with HFNO was administered for 48 h following extubation. In the control group, conventional oxygen was used. Clinicians were informed on the LUS in the intervention group, those in the control group remained blind. The primary outcome was the incidence of PRF 48 h after extubation. Secondary outcomes were incidence of PRF and reintubation at day 7, number of ventilator-free days at day 28, length of ICU stay and mortality at day 28 and 90.

RESULTS

Two hundred and forty patients were randomised and 227 analysed (intervention group = 128 and control group = 99). PRF at H48 was reduced in the intervention group compared to the control group: relative risk 0.52 (0.31 to 0.88), p = 0.01. The benefit persisted at day 7: relative risk 0.62 (0.44 to 0.96), p = 0.02. Weaning failure imposing reconnection to mechanical ventilation was not reduced. In patients who developed PRF and were treated by rescue NIV, reintubation was avoided in 44% of control patients and in 12% of intervention patients (p = 0.008). Other secondary outcomes were not different between groups. From a resource utilisation standpoint, prophylactic NIV alternating with HFNO was more demanding and costly than conventional oxygen with rescue NIV to achieve same clinical outcome.

CONCLUSIONS

Compared to conventional oxygenation, prophylactic NIV alternating with HFNO significantly reduced postextubation respiratory failure but failed to reduce reintubation rate and mortality in patients without COPD at high risk of extubation failure. Prophylactic NIV alternating with HFNO was as efficient as recue NIV to treat postextubation respiratory failure.

Effect of ultrasound-guided individualized positive end-expiratory pressure on the severity of postoperative atelectasis in elderly patients: a randomized controlled study

Postoperative pulmonary complications (PPCs) are common in patients undergoing general anesthesia, with atelectasis being a key contributor that increases postoperative mortality and prolongs hospitalization. Our research hypothesis is that ultrasound-guided individualized PEEP titration can reduce postoperative atelectasis. This single-center randomized controlled trial recruited elderly patients for laparoscopic surgery. Patients were randomly assigned to two group: the study group (individualized PEEP groups, PEEP Ind group) and the control group (Fixed PEEP group, PEEP 5 group). All patients in these two groups received volume-controlled ventilation during general anesthesia. Patients in the study group were given ultrasound-guided PEEP, while those in the control group were given a fixed 5 cmH2O PEEP. Bedside ultrasound assessed lung ventilation. The primary outcome was the severity of atelectasis within seven days post-surgery. Eighty-nine patients scheduled for elective laparoscopic radical surgery for colorectal cancer were enrolled in our study. Lung ultrasound scores (LUSs) in the study group during postoperative seven days was significantly decreased compared with that in the control group (P < 0.05). The severity of postoperative atelectasis in the study group was significantly improved. The incidence of PPCs during postoperative 7 days in the study group was significantly less than that in the control group (48.6% vs. 77.8%; RR = 0.625; CI = 0.430-0.909; P = 0.01). In elderly patients undergoing laparoscopic radical resection, lung ultrasound-guided individualized PEEP can alleviate the severity of postoperative atelectasis.Clinical trial number and registry URL: No. ChiCTR2200062979 ( https://www.chictr.org.cn ).

Diagnostic accuracy of lung ultrasound to predict weaning outcome: a systematic review and meta-analysis

Background

This systematic review and meta-analysis aim to systematically assess the diagnostic accuracy of lung ultrasound in predicting weaning failure from mechanical ventilation in critically ill patients.

Methods

We searched the relevant literature up to January 2024 in the databases Web of Science, Cochrane Library, Embase, and PubMed. Two researchers independently screened eligible studies and extracted data; disagreements, if any, were resolved through discussion or consultation with a third-party expert. The quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Statistical analyses were performed using Review Manager version 5.3 and Stata version 18.0, applying bivariate random-effects models to estimate sensitivity, specificity, diagnostic odds ratios, and their 95% confidence intervals, as well as to summarize receiver operating characteristic curves. Inter-study heterogeneity was assessed using the I-squared statistic, and potential sources of heterogeneity were explored by meta-regression analysis. The study follows the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses in reporting.

Results

Fourteen studies were included in the systematic review, of which 13 studies (totaling 988 patients) were included in the meta-analysis. The meta-analysis revealed an overall sensitivity of 0.86 (95% confidence interval: 0.77-0.91) and a specificity of 0.75 (95% confidence interval: 0.66-0.83) for lung ultrasound in predicting extubation failure. The area under the receiver operating characteristic curve was 0.87 (95% confidence interval: 0.84-0.89). Meta-regression analysis identified lung ultrasound thresholds, reference standards (extubation outcomes), and study flow and time bias as significant factors influencing diagnostic accuracy.

Conclusion

This systematic review and meta-analysis demonstrated that lung ultrasound has high diagnostic accuracy in predicting extubation failure in mechanically ventilated critically ill patients. Despite some study heterogeneity, lung ultrasound proved to be a reliable predictive tool for extubation failure. Future research should focus on standardizing the definition of extubation failure, exploring the impact of different thresholds on the predictive ability of lung ultrasound, and validating its application in various clinical settings to enhance its utility and accuracy in clinical practice.

Systematic review registration

This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42024555909). The study adhered to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Details of the PROSPERO protocol can be found in Supplementary Table 1.

Lung ultrasound score for the assessment of lung aeration in ARDS patients: comparison of two approaches

Purpose  A 4-step lung ultrasound (LUS) score has been previously used to quantify lung density. We compared 2 versions of this scoring system for distinguishing severe from moderate loss of aeration in ARDS: coalescence-based score (cLUS) vs. quantitative-based score (qLUS - >50% pleura occupied by artefacts). Materials and Methods   We compared qLUS and cLUS to lung density measured by quantitative CT scan in 12 standard thoracic regions. A simplified approach (1 scan per region) was compared to an extensive one (regional score computed as the mean of all relevant intercostal space scores). Results   We examined 13 conditions in 7 ARDS patients (7 at PEEP 5, 6 at PEEP 15 cmH2O-156 regions, 398 clips). Switching from cLUS to qLUS resulted in a change in interpretation in 117 clips (29.4%, 1-point reduction) and in 41.7% of the regions (64 decreases (range 0.2-1), 1 increase (0.2 points)). Regional qLUS showed very strong correlation with lung density (rs=0.85), higher than cLUS (rs=0.79; p=0.010). The agreement with CT classification in well aerated, poorly aerated, and not aerated tissue was moderate for cLUS (agreement 65.4%; Cohen's K coefficient 0.475 (95%CI 0.391-0.547); p<0.0001) and substantial for qLUS (agreement 81.4%; Cohen's K coefficient 0.701 (95%CI 0.653-0.765), p<0.0001). The agreement between single spot and extensive approaches was almost perfect (cLUS: agreement 89.1%, Cohen's kappa coefficient 0.840 (95%CI 0.811-0.911), p<0.0001; qLUS: agreement 86.5%, Cohen's kappa coefficient 0.819 (95%CI 0.761-0.848), p<0.0001). Conclusion   A LUS score based on the percentage of occupied pleura performs better than a coalescence-based approach for quantifying lung density. A simplified approach performs as well as an extensive one.

Predictive Value of Diaphragm and Lung Ultrasonography for Weaning Failure in Critically Ill Patients with Acute Respiratory Failure Due to COVID-19 Pneumonia

BACKGROUND

This study analyzed weaning characteristics and assessed the association of clinical and ultrasonographic indices-maximum inspiratory pressure (MIP), rapid shallow breathing index (RSBI), peak flow expiratory (PFE), diaphragm-thickening fraction (DTF), diaphragm thickness (DT), diaphragm excursion (DE), diaphragm-RSBI (D-RSBI), and lung ultrasound (LUS) patterns-with weaning failure.

METHODS

This retrospective cohort study included critically ill COVID-19 patients aged 18 and older who had been on invasive mechanical ventilation for at least 48 h and undergoing weaning. Exclusion criteria included absence of ultrasound assessments, neuromuscular diseases, and chronic cardio-respiratory dysfunction.

RESULTS

Among 61 patients, 44.3% experienced weaning failure, 27.9% failed the spontaneous breathing trial (SBT), 16.4% were re-intubated within 48 h, and 28% required tracheostomy. Weaning failure was associated with prolonged ventilation (29 vs. 7 days, p < 0.001), extended oxygen therapy, longer ICU stays, and higher ICU mortality. These patients had higher pressure support, lower oxygenation levels, a higher RSBI, and a lower MIP. While PEF, DTF, DE, and D-RSBI showed no significant differences, both right and left diaphragm thicknesses and the inspiratory thickness of the left diaphragm were reduced in failure cases. LUS scores were significantly higher before and after SBT in the failure group. Bivariate analysis identified RSBI [OR = 1.04 (95% CI = 1.01-1.07), p = 0.010], MIP [OR = 0.92 (95% CI = 0.86-0.99), p = 0.018], and LUS [OR = 1.15 (95% CI = 0.98-1.35), p = 0.025] as predictors of weaning failure; however, these associations were not confirmed in multivariate analysis.

CONCLUSIONS

Ultrasound provides supplementary information during weaning, but no definitive association between ultrasound indices and weaning failure was confirmed in this study.

Comparing lung aeration and respiratory effort using two different spontaneous breathing trial: T-piece vs pressure support ventilation

OBJECTIVE

To assess the changes in lung aeration and respiratory effort generated by two different spontaneous breathing trial (SBT): T-piece (T-T) vs pressure support ventilation (PSV).

DESIGN

Prospective, interventionist and randomized study.

SETTING

Intensive Care Unit (ICU) of Hospital del Mar.

PARTICIPANTS

Forty-three ventilated patients for at least 24 h and considered eligible for an SBT were included in the study between October 2017 and March 2020.

INTERVENTIONS

30-min SBT with T-piece (T-T group, 20 patients) or 8-cmH2O PSV and 5-cmH2O positive end expiratory pressure (PSV group, 23 patients).

MAIN VARIABLES OF INTEREST

Demographics, clinical data, physiological variables, lung aeration evaluated with electrical impedance tomography (EIT) and lung ultrasound (LUS), and respiratory effort using diaphragmatic ultrasonography (DU) were collected at different timepoints: basal (BSL), end of SBT (EoSBT) and one hour after extubation (OTE).

RESULTS

There were a loss of aeration measured with EIT and LUS in the different study timepoints, without statistical differences from BSL to OTE, between T-T and PSV [LUS: 3 (1, 5.5) AU vs 2 (1, 3) AU; p = 0.088; EELI: -2516.41 (-5871.88, 1090.46) AU vs -1992.4 (-3458.76, -5.07) AU; p = 0.918]. Percentage of variation between BSL and OTE, was greater when LUS was used compared to EIT (68.1% vs 4.9%, p ≤ 0.001). Diaphragmatic excursion trend to decrease coinciding with a loss of aeration during extubation.

CONCLUSION

T-T and PSV as different SBT strategies in ventilated patients do not show differences in aeration loss, nor estimated respiratory effort or tidal volume measured by EIT, LUS and DU.

Predicting Successful Weaning through Sonographic Measurement of the Rapid Shallow Breathing Index

Background: Diaphragmatic dysfunction correlates with weaning failure, highlighting the need to independently assess the diaphragm's effects on weaning. We modified the rapid shallow breathing index (RSBI), a predictor of successful weaning, by incorporating temporal variables into existing ultrasound-derived diaphragm index to create a simpler index closer to tidal volume. Methods: We conducted a prospective observational study of patients who underwent a spontaneous breathing trial in the medical intensive care unit (ICU) at Severance Hospital between October 2022 and June 2023. Diaphragmatic displacement (DD) and diaphragm inspiratory time (Ti) were measured using lung ultrasonography. The modified RSBI was defined as follows: respiratory rate (RR) divided by DD was defined as D-RSBI, and RR divided by the sum of the products of DD and Ti on both sides was defined as DTi-RSBI. Results: Among the sonographic indices, DTi-RSBI had the highest area under the receiver operating characteristic (ROC) curve of 0.774 in ROC analysis, and a correlation was found between increased DTi-RSBI and unsuccessful extubation in a multivariable logistic regression analysis (adjusted odds ratio 0.02, 95% confidence interval 0.00-0.97). Conclusions: The DTi-RSBI is beneficial in predicting successful weaning in medical ICU patients.

Lung ultrasound among Expert operator'S: ScOring and iNter-rater reliability analysis (LESSON study) a secondary COWS study analysis from ITALUS group

BACKGROUND

Lung ultrasonography (LUS) is a non-invasive imaging method used to diagnose and monitor conditions such as pulmonary edema, pneumonia, and pneumothorax. It is precious where other imaging techniques like CT scan or chest X-rays are of limited access, especially in low- and middle-income countries with reduced resources. Furthermore, LUS reduces radiation exposure and its related blood cancer adverse events, which is particularly relevant in children and young subjects. The score obtained with LUS allows semi-quantification of regional loss of aeration, and it can provide a valuable and reliable assessment of the severity of most respiratory diseases. However, inter-observer reliability of the score has never been systematically assessed. This study aims to assess experienced LUS operators' agreement on a sample of video clips showing predefined findings.

METHODS

Twenty-five anonymized video clips comprehensively depicting the different values of LUS score were shown to renowned LUS experts blinded to patients' clinical data and the study's aims using an online form. Clips were acquired from five different ultrasound machines. Fleiss-Cohen weighted kappa was used to evaluate experts' agreement.

RESULTS

Over a period of 3 months, 20 experienced operators completed the assessment. Most worked in the ICU (10), ED (6), HDU (2), cardiology ward (1), or obstetric/gynecology department (1). The proportional LUS score mean was 15.3 (SD 1.6). Inter-rater agreement varied: 6 clips had full agreement, 3 had 19 out of 20 raters agreeing, and 3 had 18 agreeing, while the remaining 13 had 17 or fewer people agreeing on the assigned score. Scores 0 and score 3 were more reproducible than scores 1 and 2. Fleiss' Kappa for overall answers was 0.87 (95% CI 0.815-0.931, p < 0.001).

CONCLUSIONS

The inter-rater agreement between experienced LUS operators is very high, although not perfect. The strong agreement and the small variance enable us to say that a 20% tolerance around a measured value of a LUS score is a reliable estimate of the patient's true LUS score, resulting in reduced variability in score interpretation and greater confidence in its clinical use.

Effect of lung volume preservation during spontaneous breathing trial on successful extubation in patients receiving mechanical ventilation: protocol for a multicenter clinical trial

BACKGROUND

In standard weaning from mechanical ventilation, a successful spontaneous breathing test (SBT) consisting of 30 min 8 cmH2O pressure-support ventilation (PSV8) without positive end-expiratory pressure (PEEP) is followed by extubation with continuous suctioning; however, these practices might promote derecruitment. Evidence supports the feasibility and safety of extubation without suctioning. Ultrasound can assess lung aeration and respiratory muscles. We hypothesize that weaning aiming to preserve lung volume can yield higher rates of successful extubation.

METHODS

This multicenter superiority trial will randomly assign eligible patients to receive either standard weaning [SBT: 30-min PSV8 without PEEP followed by extubation with continuous suctioning] or lung-volume-preservation weaning [SBT: 30-min PSV8 + 5 cmH2O PEEP followed by extubation with positive pressure without suctioning]. We will compare the rates of successful extubation and reintubation, ICU and hospital stays, and ultrasound measurements of the volume of aerated lung (modified lung ultrasound score), diaphragm and intercostal muscle thickness, and thickening fraction before and after successful or failed SBT. Patients will be followed for 90 days after randomization.

DISCUSSION

We aim to recruit a large sample of representative patients (N = 1600). Our study cannot elucidate the specific effects of PEEP during SBT and of positive pressure during extubation; the results will show the joint effects derived from the synergy of these two factors. Although universal ultrasound monitoring of lungs, diaphragm, and intercostal muscles throughout weaning is unfeasible, if derecruitment is a major cause of weaning failure, ultrasound may help clinicians decide about extubation in high-risk and borderline patients.

TRIAL REGISTRATION

The Research Ethics Committee (CEIm) of the Fundació Unió Catalana d'Hospitals approved the study (CEI 22/67 and 23/26). Registered at ClinicalTrials.gov in August 2023. Identifier: NCT05526053.

Lessons from the pandemic and the value of a structured system of ultrasonographic findings in the diagnosis of COVID-19 pulmonary manifestations

Implementing a structured COVID-19 lung ultrasound system, using COVID-RADS standardization. This case series exams revealed correlations between ultrasonographic and tomographic findings. Ventilatory assessments showed that higher categories required second-line oxygen. This replicable tool will aid in screening and predicting disease severity beyond the pandemic.

OBJECTIVE

We aimed to share our experience in implementing a structured system for COVID-19 lung findings, elucidating key aspects of the lung ultrasound score to facilitate its standardized clinical use beyond the pandemic scenario.

METHODS

Using a scoring system to classify the extent of lung involvement, we retrospectively analyzed the ultrasound reports performed in our institution according to COVID-RADS standardization.

RESULTS

The study included 69 thoracic ultrasound exams, with 27 following the protocol. The majority of patients were female (52%), with ages ranging from 1 to 96 years and an average of 56 years. Classification according to COVID-RADS was as follows: 11.1% in category 0, 37% in category 1, 44.4% in category 2, and 7.4% in category 3. Ground-glass opacities on tomography correlated with higher COVID-RADS scores (categories 2 and 3) in 82% of cases. Ventilatory assessment revealed that 50% of cases in higher COVID-RADS categories (2 and 3) required second-line oxygen supplementation, while none of the cases in lower categories (0 and 1) utilized this support.

CONCLUSION

Lung ultrasound has been widely utilized as a diagnostic tool owing to its availability and simplicity of application. In the context of the pandemic emergency, a pressing need for a focused and easily applicable assessment arose. The structured reporting system, incorporating ultrasound findings for stratification, demonstrated ease of replicability. This system stands as a crucial tool for screening, predicting severity, and aiding in medical decisions, even in a non-pandemic context. Lung ultrasound enables precise diagnosis and ongoing monitoring of the disease. Ultrasound is an effective tool for assessing pulmonary findings in COVID-19. Structured reports enhance communication and are easily reproducible.

Evaluation of a Lung Ultrasound Score in Hospitalized Adult Patients with COVID-19 in Barcelona, Spain

Background/Objectives: During the COVID-19 pandemic and the burden on hospital resources, the rapid categorization of high-risk COVID-19 patients became essential, and lung ultrasound (LUS) emerged as an alternative to chest computed tomography, offering speed, non-ionizing, repeatable, and bedside assessments. Various LUS score systems have been used, yet there is no consensus on an optimal severity cut-off. We assessed the performance of a 12-zone LUS score to identify adult COVID-19 patients with severe lung involvement using oxygen saturation (SpO2)/fractional inspired oxygen (FiO2) ratio as a reference standard to define the best cut-off for predicting adverse outcomes. Methods: We conducted a single-centre prospective study (August 2020-April 2021) at Hospital del Mar, Barcelona, Spain. Upon admission to the general ward or intensive care unit (ICU), clinicians performed LUS in adult patients with confirmed COVID-19 pneumonia. Severe lung involvement was defined as a SpO2/FiO2 ratio <315. The LUS score ranged from 0 to 36 based on the aeration patterns. Results: 248 patients were included. The admission LUS score showed moderate performance in identifying a SpO2/FiO2 ratio <315 (area under the ROC curve: 0.71; 95%CI 0.64-0.77). After adjustment for COVID-19 risk factors, an admission LUS score ≥17 was associated with an increased risk of in-hospital death (OR 5.31; 95%CI: 1.38-20.4), ICU admission (OR 3.50; 95%CI: 1.37-8.94) and need for IMV (OR 3.31; 95%CI: 1.19-9.13). Conclusions: Although the admission LUS score had limited performance in identifying severe lung involvement, a cut-off ≥17 score was associated with an increased risk of adverse outcomes. and could play a role in the rapid categorization of COVID-19 pneumonia patients, anticipating the need for advanced care.

Lung Ultrasound Score at Hospital Discharge as a Predictor of Emergency Department Visit and Hospital Readmission in Patients With Acute Heart Failure

Purpose The number of B-lines on lung ultrasound at hospital discharge in patients admitted with acute heart failure (AHF) is associated with poor outcomes. Assessing B-lines can be challenging to execute and replicate, depending on the clinical context. This study aims to determine whether the lung ultrasound score (LUS) at discharge predicts hospital readmission or emergency department (ED) visits in the 30 days after an AHF hospital admission. Methods  We conducted an observational study at the medical ward of the emergency unit of the Clinics Hospital of the Ribeirao Preto Medical School, University of Sao Paulo, a tertiary university hospital in Ribeirao Preto, Sao Paulo, Brazil, where consecutive adults admitted with AHF were included. On the day of hospital discharge, we measured the LUS and tracked these patients for up to 30 days to monitor emergency department visits, hospital readmission, and the number of days free from hospital stay. Results  A total of 46 patients were included in the study. A composite outcome of ED visits or hospital readmission in the 30 days after hospital discharge was achieved for 22 (47.8%) patients. The LUS at hospital discharge had a receiver operating characteristic (ROC) area of 0.93 (95% CI, 0.82-0.99) to predict the composite outcome, against 0.67 (95% CI, 0.52-0.81) for the clinical congestion score (CCS). A LUS ≥ 7 at discharge had a sensitivity of 95.5% and a specificity of 87.5% to predict the composite outcome. The average exam duration was 176±65 (sd) seconds. Conclusions The LUS at hospital discharge following admission for AHF proves to be an accurate tool for predicting the likelihood of return to the ED and/or hospital readmission within 30 days post discharge.

MUltiparametric Score for Ventilation Discontinuation in Intensive Care Patients: A Protocol for an Observational Study

BACKGROUND

Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity.

METHODS

This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score.

RESULTS

Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs.

CONCLUSION

This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.

Lung ultrasound in a nutshell. Lines, signs, some applications, and misconceptions from a radiologist's point of view. Part 2

In recent years, lung ultrasound (LUS) has developed rapidly, and it is gaining growing popularity in various scenarios. There are constant attempts to introduce it to new fields. In addition, knowledge regarding lung and LUS has been augmented by the recent COVID-19 pandemics. In the first part of this review we discuss lines, signs and pheno-mena, profiles, some applications, and misconceptions. An aim of the second part of the review is mainly to discuss some advanced applications of LUS, including lung elastography, lung spectroscopy, colour and spectral Doppler, contrast-enhanced ultrasound of lung, speckled tracking of pleura, quantification of pulmonary oedema, predicting success of talc pleurodesis, asthma exacerbations, detecting chest wall invasion by tumours, lung biopsy, estimating pleural effusion volume, and predicting mechanical ventilatory weaning outcome. For this purpose, we reviewed literature concerning LUS.

Lung Ultrasound Evaluation of Aeration Changes in Response to Prone Positioning in Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: An Observational Study

BACKGROUND

Prone positioning (PP) has been proven to be a beneficial approach in enhancing survival outcomes for patients with severe acute respiratory distress syndrome (ARDS) who need venovenous extracorporeal membrane oxygenation (V-V ECMO) support. The study utilized bedside lung ultrasound (LUS) to evaluate changes in lung aeration caused by PP in ARDS patients receiving V-V ECMO.

METHODS

This retrospective single-center study involved adult ARDS patients requiring V-V ECMO. The assessment of LUS involved examining specific dorsal lung regions, encompassing 16 areas, during three pre-defined time points: baseline (10 minutes prior), three-hour PP positioning, and 10-minute post-supine repositioning, all within the initial three days. Based on the oxygenation response to PP, patients were categorized into responder and non-responder groups. The primary outcome was LUS score changes during the initial three-day period. Secondary outcomes examined the impact of PP on the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) (P/F) ratio, V-V ECMO weaning success, length of ICU stay, and hospital survival.

RESULTS

Among the enrolled patients (27 in total), 16 were responders and 11 were non-responders. In the responder group, the global LUS score underwent a significant reduction from 26.38 ± 4.965 at baseline to 20.75 ± 3.337 (p < 0.001) after the first PP session, which further decreased to 15.94 ± 2.816 (p< 0.001) after three days. However, no significant differences were observed among PP non-responders. The oxygenation reaction yielded comparable results. There was a significant correlation between the duration of daily PP and the reduction in global LUS score among PP responders (r = -0.855, p < 0.001). In cases where the global LUS score decreased by > 7.5 after three days of PP, the area under the receiver operating characteristic curve (AUROC) for predicting ECMO weaning success was 0.815, while it was 0.761 for predicting hospital survival.

CONCLUSION

LUS has the potential to predict the response to PP and evaluate the prognosis of ARDS patients with V-V ECMO, although more studies are demanded in the future.

Lung Ultrasound Score on Postoperative Day 1 Is Predictive of the Occurrence of Pulmonary Complications after Major Abdominal Surgery: A Multicenter Prospective Observational Study

BACKGROUND

Postoperative pulmonary complications after major abdominal surgery are frequent and carry high morbidity and mortality. Early identification of patients at risk of pulmonary complications by lung ultrasound may allow the implementation of preemptive strategies. The authors hypothesized that lung ultrasound score would be associated with pulmonary postoperative complications. The main objective of the study was to evaluate the performance of lung ultrasound score on postoperative day 1 in predicting pulmonary complications after major abdominal surgery. Secondary objectives included the evaluation of other related measures for their potential prediction accuracy.

METHODS

A total of 149 patients scheduled for major abdominal surgery were enrolled in a bicenter observational study. Lung ultrasound score was performed before the surgery and on days 1, 4, and 7 after surgery. Pulmonary complications occurring before postoperative day 10 were recorded.

RESULTS

Lung ultrasound score on postoperative day 1 was higher in patients developing pulmonary complications before day 10 (median, 13; interquartile range, 8.25 to 18; vs. median, 10; interquartile range, 6.5 to 12; Mann-Whitney P = 0.002). The area under the curve for predicting postoperative pulmonary complications before day 10 was 0.65 (95% CI, 0.55 to 0.75; P = 0.003). Lung ultrasound score greater than 12 had a sensitivity of 0.54 (95% CI, 0.40 to 0.67), specificity of 0.77 (95% CI, 0.67 to 0.85), and negative predictive value of 0.74 (95% CI, 0.65 to 0.83). Lung ultrasound score greater than 17 had sensitivity of 0.33 (95% CI, 0.21 to 0.47), specificity of 0.95 (95% CI, 0.88 to 0.98), and positive predictive value of 0.78 (95% CI, 0.56 to 0.93). Anterolateral lung ultrasound score and composite scores using lung ultrasound score and other patient characteristics showed similar predictive accuracies.

CONCLUSIONS

An elevated lung ultrasound score on postoperative day 1 is associated with the occurrence of pulmonary complications within the first 10 days after major abdominal surgery.

EDITOR’S PERSPECTIVE

Development of an Automated Ultrasound Signal Indicator of Lung Interstitial Syndrome

OBJECTIVES

The number and distribution of lung ultrasound (LUS) imaging artifacts termed B-lines correlate with the presence of acute lung disease such as infection, acute respiratory distress syndrome (ARDS), and pulmonary edema. Detection and interpretation of B-lines require dedicated training and is machine and operator-dependent. The goal of this study was to identify radio frequency (RF) signal features associated with B-lines in a cohort of patients with cardiogenic pulmonary edema. A quantitative signal indicator could then be used in a single-element, non-imaging, wearable, automated lung ultrasound sensor (LUSS) for continuous hands-free monitoring of lung fluid.

METHODS

In this prospective study a 10-zone LUS exam was performed in 16 participants, including 12 patients admitted with acute cardiogenic pulmonary edema (mean age 60 ± 12 years) and 4 healthy controls (mean age 44 ± 21). Overall,160 individual LUS video clips were recorded. The LUS exams were performed with a phased array probe driven by an open-platform ultrasound system with simultaneous RF signal collection. RF data were analyzed offline for candidate B-line indicators based on signal amplitude, temporal variability, and frequency spectrum; blinded independent review of LUS images for the presence or absence of B-lines served as ground truth. Predictive performance of the signal indicators was determined with receiving operator characteristic (ROC) analysis with k-fold cross-validation.

RESULTS

Two RF signal features-temporal variability of signal amplitude at large depths and at the pleural line-were strongly associated with B-line presence. The sensitivity and specificity of a combinatorial indicator were 93.2 and 58.5%, respectively, with cross-validated area under the ROC curve (AUC) of 0.91 (95% CI = 0.80-0.94).

CONCLUSION

A combinatorial signal indicator for use with single-element non-imaging LUSS was developed to facilitate continuous monitoring of lung fluid in patients with respiratory illness.

Lung Ultrasound Score as a Predictor of Failure to Wean COVID-19 Elderly Patients off Mechanical Ventilation: A Prospective Observational Study

Background

The lung ultrasound score was developed for rapidly assessing the extent of lung ventilation, and it can predict failure to wean various types of patients off mechanical ventilation. Whether it is also effective for COVID-19 patients is unclear.

Methods

This single-center, prospective, observational study was conducted to assess the ability of the 12-region lung ultrasound score to predict failure to wean COVID-19 patients off ventilation. In parallel, we assessed whether right hemidiaphragmatic excursion or previously published predictors of weaning failure can apply to these patients. Predictive ability was assessed in terms of the area under the receiver operating characteristic curve (AUC).

Results

The mean age of the 35 patients in the study was (75 ± 9) years and 12 patients (37%) could not be weaned off mechanical ventilation. The lung ultrasound score predicted these failures with an AUC of 0.885 (95% CI 0.770-0.999, p < 0.001), and a threshold score of 10 provided specificity of 72.7% and sensitivity of 92.3%. AUCs were lower for previously published predictors of weaning failure, and right hemidiaphragmatic excursion did not differ significantly between the two groups.

Conclusion

The lung ultrasound score can accurately predict failure to wean critically ill COVID-19 patients off mechanical ventilation, whereas assessment of right hemidiaphragmatic excursion does not appear helpful in this regard.

Trial Registration

https://clinicaltrials.gov/ct2/show/NCT05706441.

Lung ultrasound and supine chest X-ray use in modern adult intensive care: mapping 30 years of advancement (1993-2023)

In critically ill patients with acute respiratory failure, thoracic images are essential for evaluating the nature, extent and progression of the disease, and for clinical management decisions. For this purpose, computed tomography (CT) is the gold standard. However, transporting patients to the radiology suite and exposure to ionized radiation limit its use. Furthermore, a CT scan is a static diagnostic exam for the thorax, not allowing, for example, appreciation of "lung sliding". Its use is also unsuitable when it is necessary to adapt or decide to modify mechanical ventilation parameters at the bedside in real-time. Therefore, chest X-ray and lung ultrasound are today's contenders for shared second place on the podium to acquire a thoracic image, with their specific strengths and limitations. Finally, electrical impedance tomography (EIT) could soon have a role, however, its assessment is outside the scope of this review. Thus, we aim to carry out the following points: (1) analyze the advancement in knowledge of lung ultrasound use and the related main protocols adopted in intensive care units (ICUs) over the latest 30 years, reporting the principal publications along the way, (2) discuss how and when lung ultrasound should be used in a modern ICU and (3) illustrate the possible future development of LUS.

The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients

Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.

B-lines by lung ultrasound as a predictor of re-intubation in mechanically ventilated patients with heart failure

Introduction

There have been few studies on predictors of weaning failure from MV in patients with heart failure (HF). We sought to investigate the predictive value of B-lines measured by lung ultrasound (LUS) on the risk of weaning failure from mechanical ventilation (MV) and in-hospital outcomes.

Methods

This was a single-center, prospective observational study that included HF patients who were on invasive MV. LUS was performed immediate before ventilator weaning. A positive LUS exam was defined as the observation of two or more regions that had three or more count of B-lines located bilaterally on the thorax. The primary outcome was early MV weaning failure, defined as re-intubation within 72 h.

Results

A total of 146 consecutive patients (mean age 70 years; 65.8% male) were enrolled. The total count of B-lines was a median of 10 and correlated with NT-pro-BNP level (r2 = 0.132, p < 0.001). Early weaning failure was significantly higher in the positive LUS group (9 out of 64, 14.1%) than the negative LUS group (2 out of 82, 2.4%) (p = 0.011). The rate of total re-intubation during the hospital stay (p = 0.004), duration of intensive care unit stay (p = 0.004), and hospital stay (p = 0.010) were greater in the positive LUS group. The negative predictive value (NPV) of positive LUS was 97.6% for the primary outcome.

Conclusion

B-lines measured by LUS can predict the risk of weaning failure. Considering the high NPV of positive LUS, it may help guide the decision of weaning in patients on invasive MV due to acute decompensated HF.

The value of lung ultrasound score in neonatal respiratory distress syndrome: a prospective diagnostic cohort study

Rationale

The accurate diagnosis of critically ill patients with respiratory failure can be achieved through lung ultrasound (LUS) score. Considering its characteristics, it is speculated that this technique might also be useful for patients with neonatal respiratory distress syndrome (NRDS). Thus, there is a need for precise imaging tools to monitor such patients.

Objectives

This double-blind randomized cohort study aims to investigate the impact of LUS and related scores on the severity of NRDS patients.

Methods

This study was conducted as a prospective double-blind randomized study. Bivariate correlation analysis was conducted to investigate the relationship between LUS score and Oxygenation Index (OI), Respiratory Index (RI), and Sequential Organ Failure Assessment (SOFA) score. Spearman's correlation coefficient was used to generate correlation heat maps, elucidating the associations between LUS and respective parameters in different cohorts. Receiver Operating Characteristic (ROC) curves were employed to calculate the predictive values, sensitivity, and specificity of different scores in determining the severity of NRDS.

Results

This study ultimately included 134 patients admitted to the intensive care unit (ICU) between December 2020 and June 2022. Among these patients, 72 were included in the NRDS cohort, while 62 were included in the Non-NRDS (N-NRDS) cohort. There were significant differences in the mean LUS scores between NRDS and N-NRDS patients (p < 0.01). The LUS score was significantly negatively correlated with the OI (p < 0.01), while it was significantly positively correlated with the RI and SOFA scores (p < 0.01). The correlation heatmap revealed the highest positive correlation coefficient between LUS and RI (0.82), while the highest negative correlation coefficient was observed between LUS and OI (-0.8). ROC curves for different scores demonstrated that LUS score had the highest area under the curve (0.91, 95% CI: 0.84-0.98) in predicting the severity of patients' conditions. The combination of LUS and other scores can more accurately predict the severity of NRDS patients, with the highest AUC value of 0.93, significantly higher than using a single indicator alone (p < 0.01).

Conclusion

Our double-blind randomized cohort study demonstrates that LUS, RI, OI, and SOFA scores can effectively monitor the lung ventilation and function in NRDS. Moreover, these parameters and their combination have significant predictive value in evaluating the severity and prognosis of NRDS patients. Therefore, these results provide crucial insights for future research endeavors.

Setting positive end-expiratory pressure: lung and diaphragm ultrasound

PURPOSE OF REVIEW

The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed.

RECENT FINDINGS

Lung ultrasound can accurately diagnose the cause of acute respiratory failure, including acute respiratory distress syndrome and can identify focal and nonfocal lung morphology in these patients. This is essential in determining optimal ventilator strategy and PEEP level. Assessment of the effect of PEEP on lung recruitment using lung ultrasound is promising, especially in the perioperative setting. Diaphragm ultrasound can monitor the effects of PEEP on the diaphragm, but this needs further validation. In patients with an acute exacerbation of chronic obstructive pulmonary disease, diaphragm ultrasound can be used to predict noninvasive ventilation failure. Lung and diaphragm ultrasound can be used to predict weaning outcome and accurately diagnose the cause of weaning failure.

SUMMARY

Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.

Mechanical Ventilation, Past, Present, and Future

Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.

Lung ultrasound score and in-hospital mortality of adults with acute respiratory distress syndrome: a meta-analysis

BACKGROUND

Lung ultrasound (LUS) score could quantitatively reflect the lung aeration, which has been well applied in critically ill patients. The aim of the systematic review and meta-analysis was to evaluate the association between LUS score at admission and the risk of in-hospital mortality of adults with acute respiratory distress syndrome (ARDS).

METHODS

Toachieve the objective of this meta-analysis, we conducted a thorough search of PubMed, Embase, Cochrane Library, and the Web of Science to identify relevant observational studies with longitudinal follow-up. We employed random-effects models to combine the outcomes, considering the potential influence of heterogeneity.

RESULTS

Thirteen cohort studies with 1,022 hospitalized patients with ARDS were included. Among them, 343 patients (33.6%) died during hospitalization. The pooled results suggested that the LUS score at admission was higher in non-survivors as compared to survivors (standardized mean difference = 0.73, 95% confidence interval [CI]: 0.55 to 0.91, p < 0.001; I2 = 25%). Moreover, a high LUS score at admission was associated with a higher risk of in-hospital mortality of patients with ARDS (risk ratio: 1.44, 95% CI: 1.14 to 1.81, p = 0.002; I2 = 46%). Subgroup analyses showed consistent results in studies with LUS score analyzed with 12 or 16 lung regions, and in studies reporting mortality during ICU or within 1-month hospitalization.

CONCLUSION

Our findings suggest that a high LUS score at admission may be associated with a high risk of in-hospital mortality of patients with ARDS.

Assessment of Pulmonary Circulation of Critically Ill Patients Based on Critical Care Ultrasound

Pulmonary circulation is crucial in the human circulatory system, facilitating the oxygenation of blood as it moves from the right heart to the lungs and then to the left heart. However, during critical illness, pulmonary microcirculation can be vulnerable to both intrapulmonary and extrapulmonary injuries. To assess these potential injuries in critically ill patients, critical point-of-care ultrasound can be used to quantitatively and qualitatively evaluate the right atrium, right ventricle, pulmonary artery, lung, pulmonary vein, and left atrium along the direction of blood flow. This assessment is particularly valuable for common ICU diseases such as acute respiratory distress syndrome (ARDS), sepsis, pulmonary hypertension, and cardiogenic pulmonary edema. It has significant potential for diagnosing and treating these conditions in critical care medicine.

Lung Imaging and Artificial Intelligence in ARDS

Artificial intelligence (AI) can make intelligent decisions in a manner akin to that of the human mind. AI has the potential to improve clinical workflow, diagnosis, and prognosis, especially in radiology. Acute respiratory distress syndrome (ARDS) is a very diverse illness that is characterized by interstitial opacities, mostly in the dependent areas, decreased lung aeration with alveolar collapse, and inflammatory lung edema resulting in elevated lung weight. As a result, lung imaging is a crucial tool for evaluating the mechanical and morphological traits of ARDS patients. Compared to traditional chest radiography, sensitivity and specificity of lung computed tomography (CT) and ultrasound are higher. The state of the art in the application of AI is summarized in this narrative review which focuses on CT and ultrasound techniques in patients with ARDS. A total of eighteen items were retrieved. The primary goals of using AI for lung imaging were to evaluate the risk of developing ARDS, the measurement of alveolar recruitment, potential alternative diagnoses, and outcome. While the physician must still be present to guarantee a high standard of examination, AI could help the clinical team provide the best care possible.

The role of lung ultrasound for detecting atelectasis, consolidation, and/or pneumonia in the adult cardiac surgery population: A scoping review of the literature

OBJECTIVES

Postoperative pulmonary complications (PPCs) frequently occur after cardiac surgery and may lead to adverse patient outcomes. Traditional diagnostic tools such as auscultation or chest x-ray have inferior diagnostic accuracy compared to the gold standard (chest computed tomography). Lung ultrasound (LUS) is an emerging area of research combating these issues. However, no review has employed a formal search strategy to examine the role of LUS in identifying the specific PPCs of atelectasis, consolidation, and/or pneumonia or investigated the ability of LUS to predict these complications in this cohort. The objective of this study was to collate and present evidence for the use of LUS in the adult cardiac surgery population to specifically identify atelectasis, consolidation, and/or pneumonia.

REVIEW METHOD USED

A scoping review of the literature was completed using predefined search terms across six databases which identified 1432 articles. One additional article was included from reviewing reference lists. Six articles met the inclusion criteria, providing sufficient data for the final analysis.

DATA SOURCES

Six databases were searched: MEDLINE, Embase, CINAHL, Scopus, CENTRAL, and PEDro. This review was not registered.

REVIEW METHODS

The review followed the PRISMA Extension for Scoping Reviews.

RESULTS

Several LUS methodologies were reported across studies. Overall, LUS outperformed all other included bedside diagnostic tools, with superior diagnostic accuracy in identifying atelectasis, consolidation, and/or pneumonia. Incidences of PPCs tended to increase with each subsequent timepoint after surgery and were better identified with LUS than all other assessments. A change in diagnosis occurred at a rate of 67% with the inclusion of LUS and transthoracic echocardiography in one study. Pre-established assessment scores were improved by substituting chest x-rays with LUS scans.

CONCLUSION

The results of this scoping review support the use of LUS as a diagnostic tool after cardiac surgery; however, they also highlighted a lack of consistent methodologies used. Future research is required to determine the optimal methodology for LUS in diagnosing PPCs in this cohort and to determine whether LUS possesses the ability to predict these complications and guide proactive respiratory supports after extubation.

The use of diaphragm and lung ultrasound in acute respiratory physiotherapy practice and the impact on clinical decision-making: A systematic review and meta-analysis

OBJECTIVES

Diaphragm and lung ultrasound (DLUS) is emerging as an important point-of-care respiratory assessment tool and is being used in clinical care by trained respiratory physiotherapists, both in Australia and internationally. However, the impact of DLUS on physiotherapists' clinical decision-making remains largely unknown. This systematic review aims to review the evidence for implementing DLUS in acute respiratory physiotherapy management.

REVIEW METHOD USED

We conducted a systematic review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, CENTRAL, and Scopus from inception to 18th April 2023 for all original clinical studies reporting on the physiotherapy clinical decision-making, following a DLUS examination and/or where DLUS was used to evaluate the effect of respiratory physiotherapy, in adults over 18 years of age.

REVIEW METHODS

Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the Newcastle-Ottawa Scale, and certainty in outcomes was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework.

RESULTS

A total of seven observational studies (n = 299) were included, all of which were in the intensive care setting. DLUS changed physiotherapy diagnosis, management, and treatment in 63.9% (50-64%), 16.8% (15-50%), and 48.4% (25-50%) of patients, respectively. There was a significant improvement in the lung ultrasound score post respiratory physiotherapy treatment (mean difference -2.31, 95% Confidence Interval (95% CI) -4.42 to -0.21; very low certainty) compared to before respiratory physiotherapy treatment. Moderate risk of bias was present in six studies, and there was variance in the DLUS methodology across included studies.

CONCLUSIONS

The findings of this review suggest DLUS influences physiotherapy clinical decision-making and can be used to evaluate the effects of acute respiratory physiotherapy treatment. However, the available data is limited, and further high-quality studies are needed.

TRIAL REGISTRATION

This study is registered with the International Prospective Register of Systematic Reviews; CRD42023418312.