Ultrasound-induced lung hemorrhage is not caused by inertial cavitation

Best Practice Recommendations for the Safe use of Lung Ultrasound

The safety of ultrasound is of particular importance when examining the lungs, due to specific bioeffects occurring at the alveolar air-tissue interface. Lung is significantly more sensitive than solid tissue to mechanical stress. The causal biological effects due to the total reflection of sound waves have also not been investigated comprehensively.On the other hand, the clinical benefit of lung ultrasound is outstanding. It has gained considerable importance during the pandemic, showing comparable diagnostic value with other radiological imaging modalities.Therefore, based on currently available literature, this work aims to determine possible effects caused by ultrasound on the lung parenchyma and evaluate existing recommendations for acoustic output power limits when performing lung sonography.This work recommends a stepwise approach to obtain clinically relevant images while ensuring lung ultrasound safety. A special focus was set on the safety of new ultrasound modalities, which had not yet been introduced at the time of previous recommendations.Finally, necessary research and training steps are recommended in order to close knowledge gaps in the field of lung ultrasound safety in the future.These recommendations for practice were prepared by ECMUS, the safety committee of the EFSUMB, with participation of international experts in the field of lung sonography and ultrasound bioeffects.

A Review on Biological Effects of Ultrasounds: Key Messages for Clinicians

Ultrasound (US) is acoustic energy that interacts with human tissues, thus, producing bioeffects that may be hazardous, especially in sensitive organs (i.e., brain, eye, heart, lung, and digestive tract) and embryos/fetuses. Two basic mechanisms of US interaction with biological systems have been identified: thermal and non-thermal. As a result, thermal and mechanical indexes have been developed to provide a means of assessing the potential for biological effects from exposure to diagnostic US. The main aims of this paper were to describe the models and assumptions used to estimate the "safety" of acoustic outputs and indices and to summarize the current state of knowledge about US-induced effects on living systems deriving from in vitro models and in vivo experiments on animals. This review work has made it possible to highlight the limits associated with the use of the estimated safety values of thermal and mechanical indices relating above all to the use of new US technologies, such as contrast-enhanced ultrasound (CEUS) and acoustic radiation force impulse (ARFI) shear wave elastography (SWE). US for diagnostic and research purposes has been officially declared safe, and no harmful biological effects in humans have yet been demonstrated with new imaging modalities; however, physicians should be adequately informed on the potential risks of biological effects. US exposure, according to the ALARA (As Low As Reasonably Achievable) principle, should be as low as reasonably possible.

State of the Art in Lung Ultrasound, Shifting from Qualitative to Quantitative Analyses

Lung ultrasound (LUS) has been increasingly expanding since the 1990s, when the clinical relevance of vertical artifacts was first reported. However, the massive spread of LUS is only recent and is associated with the coronavirus disease 2019 (COVID-19) pandemic, during which semi-quantitative computer-aided techniques were proposed to automatically classify LUS data. In this review, we discuss the state of the art in LUS, from semi-quantitative image analysis approaches to quantitative techniques involving the analysis of radiofrequency data. We also discuss recent in vitro and in silico studies, as well as research on LUS safety. Finally, conclusions are drawn highlighting the potential future of LUS.

How Safe Is the Use of Ultrasound in Prenatal Medicine? Facts and Contradictions. Part 1 - Ultrasound-Induced Bioeffects

The "Ordinance on Protection Against the Harmful Effects of Non-Ionizing Radiation in Human Applications" will go into effect at the beginning of 2021 1. § 10 of this ordinance prohibits non-medical fetal ultrasound exposure thereby resulting in uncertainty, particularly among affected patients, with respect to the generally accepted theory regarding the lack of ultrasound side effects. Although not a single study has shown a detrimental effect on fetal or child development following exposure to ultrasound, the Federal Ministry for the Environment, Nature Conservation and Nuclear Safety has justified the ban with the purely hypothetical possibility of an unidentified side effect. The first part of the following study shows which ultrasound-induced biophysical effects are known and which dose-dependent threshold values must be taken into consideration. In particular, the study focuses on the well-researched heat effect with some in vivo measurements in humans showing that the actual temperature increase is less than the theoretically calculated values. The planned second part of this study will discuss the non-thermal effects and present the most important epidemiological studies.

Experimental Measurements of Ultrasound Attenuation in Human Chest Wall and Assessment of the Mechanical Index for Lung Ultrasound

Knowledge of the acoustic attenuation characteristics of the chest wall is necessary to estimate the acoustic exposure at the pleural surface during lung ultrasound and is useful in the prediction of bio-effects (e.g., pulmonary capillary hemorrhage) and the development of safe, effective lung imaging. Currently, this property is not well characterized in humans. The aim of this work was to characterize ultrasonic attenuation in human chest wall such that the ultrasound exposures of the lung can be estimated for clinically relevant conditions. In this study, we experimentally measured ultrasound transmitted through the intercostal tissue of 15 human cadaver chest wall samples relative to ultrasound transmitted through saline to determine attenuation coefficients for each sample. A GE Vivid 7 diagnostic ultrasound machine (GE Vingmed, Horten, Norway) and 3 S and 5 S phased array probes were used at center frequencies from 1.6 to 5 MHz. The chest wall samples varied in thickness from 2.3-5.5 cm with a median thickness of 3.8 cm. The frequency-normalized attenuation coefficient was approximately 1.44 dB/cm/MHz based on a linear best fit through all attenuation measurements. Attenuation characteristics varied appreciably between samples, and the sample-averaged linear attenuation coefficient was 1.43 ± 0.32 (mean ± standard deviation) dB/cm/MHz. This attenuation is higher than that previously measured in mammalian chest wall samples (1.1-1.3 dB/cm/MHz for mice and rats) and is much greater than that used by the mechanical index (0.3 dB/cm/MHz). Mechanical index values calculated using saline values de-rated by 0.3 dB/cm/MHz were up to 1.2 MPa/MHz^1/2 greater than those calculated using the measured through-tissue ultrasound waves. We conclude that the mechanical index overestimates exposures for lung ultrasound and thus may not be an appropriate dosimetry metric for pulmonary ultrasound.

Pulmonary Capillary Hemorrhage Induced by Acoustic Radiation Force Impulse Shear Wave Elastography in Ventilated Rats

OBJECTIVES

Diagnostic ultrasound (DUS) imaging can induce pulmonary capillary hemorrhage (PCH), possibly related to the ultrasonic radiation surface pressure arising from reflection at the lung blood-air interfaces. Acoustic radiation force impulse (ARFI) elastography is a relatively new DUS mode with high-energy "push pulses" used to move tissue and generate shear waves. The objective of this study was to characterize PCH induced by the ARFI elastographic mode for comparison with other previously tested DUS modes.

METHODS

Pulmonary capillary hemorrhage induction was examined for ARFI elastographic frames with 5.7-MHz push pulses (Acuson S3000; Siemens Medical Solutions, Mountain View, CA), which had a derated PRPA of 2.6 MPa. Groups of rats with tracheal tube placement had no ventilation (spontaneous breathing), intermittent positive pressure ventilation (IPPV), or IPPV plus 8 cm H₂ O of positive end-expiratory pressure (PEEP). Exposure was to 1 or 20 manually triggered image frame acquisitions. The PCH area was measured on the lung surface.

RESULTS

All 20-frame exposure groups, and even the single-frame group, had significant PCH relative to shams. Single-frame exposures produced significantly less PCH (P = .002) than 20-frame exposures in rats with a tracheal tube only (spontaneous breathing). The PEEP inhibited the PCH and produced about half of the PCH area induced for IPPV without PEEP (P = .014).

CONCLUSIONS

The PCH results were comparable with those from a previous study using B-mode or color Doppler exposure for 5 minutes; however, these modes delivered many more pulses for continuous imaging frames, suggesting that the ARFI elastographic frames were individually much more effective.

Acoustic Fountains and Atomization at Liquid Surfaces Excited by Diagnostic Ultrasound

Pulmonary capillary hemorrhage (PCH) has been found in mammalian lungs exposed to diagnostic ultrasound (DUS), although the mechanism is poorly understood. This work investigates acoustic atomization and fountains at liquid-air interfaces subjected to DUS, which has been suggested as a possible PCH damage mechanism. Primarily using a SuperSonic Imagine Aixplorer DUS machine (SuperSonic Imagine, Aix-en-Provence, France), blood and water surfaces were excited in vitro by DUS and recorded with a high-speed camera. The surface was driven by B-mode, color Doppler, pulsed Doppler, and shear wave elastography imaging modes with center frequencies from 5.0-7.2 MHz and mechanical indexes (MI) up to 1.7. Fountains and atomization were only observed for SWE, for MI as low as 1.0. A comparison of the SWE waveforms with the surface dynamics suggests that fountains and atomization were driven by push-pulses and depended on pulse duration and intensity. However, we conclude that atomization and fountaining are unlikely primary mechanisms behind all DUS-induced PCH because neither phenomenon occurred for traditional diagnostic imaging modes.

Pulmonary Capillary Hemorrhage Induced by Diagnostic Ultrasound in Ventilated Rats

Pulmonary capillary hemorrhage (PCH) can be induced by diagnostic ultrasound-a potential safety issue. Anesthetized rats were intubated for intermittent positive-pressure ventilation (IPPV) with 0 end-expiratory pressure, +4 cm H₂O end-expiratory pressure (PEEP) and -4 cm H₂O end-expiratory pressure (NEEP). Rats were imaged at 7.6 MHz with a Philips HDI 5000 ultrasound machine. The output was low (mechanical index [MI] = 0.22) for aiming and then was raised for 5 min in 20 different exposure groups with n = 8. Peak rarefactional pressure amplitudes were measured in water and de-rated for chest attenuation. The PCH areas were measured on the lung surface. At 2.2 MPa, PCH was 9.3 ± 6.6 mm² for IPPV, 1.6 ± 3.2 mm² for PEEP (p <0.001) and 26.8 ± 6.4 mm² for NEEP (p <0.001). Thresholds were 1.3 MPa for IPPV, 2.1 MPa for PEEP and 1.0 MPa for NEEP. The small ventilator pressures subtracted or added to trans-capillary stress generated by diagnostic ultrasound pulses, virtually eliminating PCH for PEEP but enhancing PCH for NEEP.

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Mechanisms for Induction of Pulmonary Capillary Hemorrhage by Diagnostic Ultrasound: Review and Consideration of Acoustical Radiation Surface Pressure

Diagnostic ultrasound can induce pulmonary capillary hemorrhage (PCH) in rats and other mammals. This phenomenon represents the only clearly demonstrated biological effect of (non-contrast enhanced) diagnostic ultrasound and thus presents a uniquely important safety issue. However, the physical mechanism responsible for PCH remains uncertain more than 25 y after its discovery. Experimental research has indicated that neither heating nor acoustic cavitation, the predominant mechanisms for bioeffects of ultrasound, is responsible for PCH. Furthermore, proposed theoretical mechanisms based on gas-body activation, on alveolar resonance and on impulsive generation of liquid droplets all appear unlikely to be responsible for PCH, owing to unrealistic model assumptions. Here, a simple model based on the acoustical radiation surface pressure (ARSP) at a tissue-air interface is hypothesized as the mechanism for PCH. The ARSP model seems to explain some features of PCH, including the approximate frequency independence of PCH thresholds and the dependence of thresholds on biological factors. However, ARSP evaluated for experimental threshold conditions appear to be too weak to fully account for stress failure of pulmonary capillaries, gauging by known stresses for injurious physiologic conditions. Furthermore, consideration of bulk properties of lung tissue suggests substantial transmission of ultrasound through the pleura, with reduced ARSP and potential involvement of additional mechanisms within the pulmonary interior. Although these recent findings advance our knowledge, only a full understanding of PCH mechanisms will allow development of science-based safety assurance for pulmonary ultrasound.

Pulmonary Capillary Hemorrhage Induced by Fixed-Beam Pulsed Ultrasound

The induction of pulmonary capillary hemorrhage (PCH) by pulsed ultrasound was discovered 25 y ago, but early research used fixed-beam systems rather than actual diagnostic ultrasound machines. In this study, results of exposure of rats to fixed-beam focused ultrasound for 5 min at 1.5 and 7.5 MHz were compared with recent research on diagnostic ultrasound. One exposure condition at each frequency used 10-μs pulses delivered at 25-ms intervals. Three conditions involved Gaussian modulation of the pulse amplitudes at 25-ms intervals to simulate diagnostic scanning: 7.5 MHz with 0.3- and 1.5-μs pulses at 100- and 500-μs pulse repetition periods, respectively, and 1.5 MHz with 1.7-μs pulses at 500-μs repetition periods. Four groups were tested for each condition to assess PCH areas at different exposure levels and to determine occurrence thresholds. The conditions with identical pulse timing resulted in smaller PCH areas for the smaller 7.5-MHz beam, but both had thresholds of 0.69-0.75 MPa in situ peak rarefactional pressure amplitude. The Gaussian modulation conditions for both 7.5 MHz with 0.3-μs pulses and 1.5 MHz with 1.7-μs pulses had thresholds of 1.12-1.20 MPa peak rarefactional pressure amplitude, although the relatively long 1.5-μs pulses at 7.5 MHz yielded a threshold of 0.75 MPa. The fixed-beam pulsed ultrasound exposures produced lower thresholds than diagnostic ultrasound. There was no clear tendency for thresholds to increase with increasing ultrasonic frequency when pulse timing conditions were similar.

Dependence of thresholds for pulmonary capillary hemorrhage on diagnostic ultrasound frequency

Pulmonary ultrasound examination has become routine for diagnosis in many clinical and point-of-care medical settings. However, the phenomenon of pulmonary capillary hemorrhage (PCH) induction during diagnostic ultrasound imaging presents a poorly understood risk factor. PCH was observed in anesthetized rats exposed to 1.5-, 4.5- and 12.0-MHz diagnostic ultrasound to investigate the frequency dependence of PCH thresholds. PCH was detected in the ultrasound images as growing comet tail artifacts and was assessed using photographs of the surface of excised lungs. Previous photographs acquired after exposure to 7.6-MHz diagnostic ultrasound were included for analysis. In addition, at each frequency we measured dosimetric parameters, including peak rarefactional pressure amplitude and spatial peak, pulse average intensity attenuated by rat chest wall samples. Peak rarefactional pressure amplitude thresholds determined at each frequency, based on the proportion of PCH in groups of five rats, were 1.03 ± 0.02, 1.28 ± 0.14, 1.18 ± 0.12 and 1.36 ± 0.15 MPa at 1.5, 4.5, 7.6 and 12.0 MHz, respectively. Although the PCH lesions decreased in size with increasing ultrasonic frequency, owing to the smaller beam widths and scan lengths, the peak rarefactional pressure amplitude thresholds remained approximately constant. This dependence was different from that of the mechanical index, which indicates a need for a specific dosimetric parameter for safety guidance in pulmonary ultrasound.

Estimation of the acoustic impedance of lung versus level of inflation for different species and ages of animals

In a previous study, it was hypothesized that ultrasound-induced lung damage was related to the transfer of ultrasonic energy into the lungs (W. D. O'Brien et al. 2002, "Ultrasound-induced lung hemorrhage: Role of acoustic boundary conditions at the pleural surface," J. Acoust. Soc. Am. 111, 1102-1109). From this study a technique was developed to: 1) estimate the impedance (Mrayl) of fresh, excised, ex vivo rat lung versus its level of inflation (cm H(2)O) and 2) predict the fraction of ultrasonic energy transmitted into the lung (M. Oelze et al. 2003, "Impedance measurements of ex vivo rat lung at different volumes of inflation." J. Acoust. Soc. Am. 114, 3384-3393). In the current study, the same technique was used to estimate the frequency-dependent impedance of lungs from rats, rabbits, and pigs of various ages. Impedance values were estimated from lungs under deflation (atmospheric pressure, 0 cm H(2)O) and three volumes of inflation pressure [7 cm H(2)O (5 cm H(2)O for pigs), 10 cm H(2)O, and 15 cm H(2)O]. Lungs were scanned in a tank of degassed 37 degrees C water. The frequency-dependent acoustic pressure reflection coefficient was determined over a frequency range of 3.5-10 MHz. From the reflection coefficient, the frequency-dependent lung impedance was calculated with values ranging from an average of 1.4 Mrayl in deflated lungs (atmospheric pressure) to 0.1 Mrayl for fully inflated lungs (15 cm H(2)O). Across all species, deflated lung (i.e., approximately 7% of the total lung capacity) had impedance values closer to tissue values, suggesting that more acoustic energy was transmitted into the lung under deflated conditions. Finally, the impedance values of deflated lungs from different species at different ages were compared with the thresholds for ultrasound-induced lung damage. The comparison revealed that increases in ultrasonic energy transmission corresponded to lower injury threshold values.

Frequency dependence of kidney injury induced by contrast-aided diagnostic ultrasound in rats

This study was performed to examine the frequency dependence of glomerular capillary hemorrhage (GCH) induced by contrast-aided diagnostic ultrasound (DUS) in rats. Diagnostic ultrasound scanners were used for exposure at 3.2, 5.0 and 7.4 MHz, and previously published data at 1.5 and 2.5 MHz was also included. A laboratory exposure system was used to simulate DUS exposure at 1.0, 1.5, 2.25, 3.5, 5.0 and 7.5 MHz, with higher peak rarefactional pressure amplitudes (PRPAs) than were available from our DUS systems. The right kidneys of rats mounted in a water bath were exposed to intermittent image pulse sequences at 1 s intervals during infusion of diluted ultrasound contrast agent. The percentage of GCH was zero for low PRPAs, and then rapidly increased with increasing PRPAs above an apparent threshold, p(t). The values of p(t) were approximately proportional to the ultrasound frequency, f, such that p(t) /f was approximately 0.5 MPa/MHz for DUS and 0.6 MPa/MHz for laboratory system exposures. The increasing thresholds with increasing frequency limited the GCH effect for contrast-aided DUS, and no GCH was seen for DUS at 5.0 or 7.4 MHz for the highest available PRPAs.

The risk of exposure to diagnostic ultrasound in postnatal subjects: nonthermal mechanisms

This review examines the nonthermal physical mechanisms by which ultrasound can harm tissue in postnatal patients. First the physical nature of the more significant interactions between ultrasound and tissue is described, followed by an examination of the existing literature with particular emphasis on the pressure thresholds for potential adverse effects. The interaction of ultrasonic fields with tissue depends in a fundamental way on whether the tissue naturally contains undissolved gas under normal physiologic conditions. Examples of gas-containing tissues are lung and intestine. Considerable effort has been devoted to investigating the acoustic parameters relevant to the threshold and extent of lung hemorrhage. Thresholds as low as 0.4 MPa at 1 MHz have been reported. The situation for intestinal damage is similar, although the threshold appears to be somewhat higher. For other tissues, auditory stimulation or tactile perception may occur, if rarely, during exposure to diagnostic ultrasound; ultrasound at similar or lower intensities is used therapeutically to accelerate the healing of bone fractures. At the exposure levels used in diagnostic ultrasound, there is no consistent evidence for adverse effects in tissues that are not known to contain stabilized gas bodies. Although modest tissue damage may occur in certain identifiable applications, the risk for induction of an adverse biological effect by a nonthermal mechanism due to exposure to diagnostic ultrasound is extremely small.

Evaluation of the threshold for lung hemorrhage by diagnostic ultrasound and a proposed new safety index

In a recent report (O'Brien et al. (2006b), it was suggested that the current expression for the mechanical index (MI) was not well suited to its function of quantifying the likelihood of an adverse biological effect after exposure of the gas-filled lung to diagnostic ultrasound. The purpose of this study was to analyze the relatively large database of experimental thresholds for the induction of lung hemorrhage to: (i) determine which variable(s) best describe the data and (ii) use the resulting equation to obtain a new formulation for the MI for lung exposures. Data from 14 studies of lung hemorrhage in four common laboratory animals (mouse, rat, rabbit and pig) were tabulated with regard to five common acoustic variables: center frequency (f(c)), pulse repetition frequency (PRF), pulse duration (PD), exposure duration (ED) and the threshold in situ peak rarefactional pressure (p(r)). The 34 threshold data points were fit by linear regression to: (i) a multiplicative model of the other variables, p(r) = Af(c)(B)PRF(C)PD(D)ED(E), where A is a constant; (ii) 14 "reduced" models in which one or more variables were not included in the analysis; (iii) four models in which a multiplicative combination of variables has a common name e.g., duty factor; and (iv) the general form of the current expression for the MI. The MI was shown to provide a poor fit to the threshold data (r(2) = 0.382), as were three of the four named models. The best fits were found for the complete model and for three reduced models, all of which contain the exposure duration. Because the implementation of a time-dependent safety parameter would present significant practical difficulties, a different model, p(r) = Af(c)(B)PRF(C)PD(D), was chosen as the basis for the new MI. Thus, the expression for the lung-specific mechanical index, MI(Lung), includes several, rather than only one, of the relevant acoustic variables. This is the first potential safety index developed as a direct result of experimental measurements rather than theoretical analysis.

Hemorrhage near fetal rat bone exposed to pulsed ultrasound

Ultrasound-induced hemorrhage near the fetal rat skull was investigated to determine if the damage could be correlated with temporal-average intensity. A 0.92-MHz f/1 spherically focused transducer (5.1-cm focal length) was used to expose the skull of 18- to 19-day gestation exteriorized Sprague-Dawley rat fetuses (n = 197). There were four ultrasound-exposed groups (n = 36 each), one sham exposed group (n = 36) and one cage control group (n = 17). Three of the ultrasound-exposed groups had the same peak compressional (10 MPa)/peak rarefactional (6.7 MPa) pressure but different spatial-peak temporal-average intensities (I(TA)) of 1.9, 4.7 and 9.4 W/cm(2); the pulse repetition frequency (PRF) was varied (100, 250 and 500 Hz, respectively). The fourth ultrasound-exposed group had a peak compressional (6.7 MPa)/peak rarefactional (5.0 MPa) pressure and corresponding I(TA) of 4.6 W/cm(2); PRF was 500 Hz. Hemorrhage occurrence increased slightly with increasing I(TA), as well as peak rarefactional pressure and PRF, but the hemorrhage area did not correlate with any of the exposure parameters.

Ultrasound-biophysics mechanisms

Ultrasonic biophysics is the study of mechanisms responsible for how ultrasound and biological materials interact. Ultrasound-induced bioeffect or risk studies focus on issues related to the effects of ultrasound on biological materials. On the other hand, when biological materials affect the ultrasonic wave, this can be viewed as the basis for diagnostic ultrasound. Thus, an understanding of the interaction of ultrasound with tissue provides the scientific basis for image production and risk assessment. Relative to the bioeffect or risk studies, that is, the biophysical mechanisms by which ultrasound affects biological materials, ultrasound-induced bioeffects are generally separated into thermal and non-thermal mechanisms. Ultrasonic dosimetry is concerned with the quantitative determination of ultrasonic energy interaction with biological materials. Whenever ultrasonic energy is propagated into an attenuating material such as tissue, the amplitude of the wave decreases with distance. This attenuation is due to either absorption or scattering. Absorption is a mechanism that represents that portion of ultrasonic wave that is converted into heat, and scattering can be thought of as that portion of the wave, which changes direction. Because the medium can absorb energy to produce heat, a temperature rise may occur as long as the rate of heat production is greater than the rate of heat removal. Current interest with thermally mediated ultrasound-induced bioeffects has focused on the thermal isoeffect concept. The non-thermal mechanism that has received the most attention is acoustically generated cavitation wherein ultrasonic energy by cavitation bubbles is concentrated. Acoustic cavitation, in a broad sense, refers to ultrasonically induced bubble activity occurring in a biological material that contains pre-existing gaseous inclusions. Cavitation-related mechanisms include radiation force, microstreaming, shock waves, free radicals, microjets and strain. It is more challenging to deduce the causes of mechanical effects in tissues that do not contain gas bodies. These ultrasonic biophysics mechanisms will be discussed in the context of diagnostic ultrasound exposure risk concerns.

What is ultrasound?

This paper is based on material presented at the start of a Health Protection Agency meeting on ultrasound and infrasound. In answering the question 'what is ultrasound?', it shows that the simple description of a wave which transports mechanical energy through the local vibration of particles at frequencies of 20 kHz or more, with no net transport of the particles themselves, can in every respect be misleading or even incorrect. To explain the complexities responsible for this, the description of ultrasound is first built up from the fundamental properties of these local particle vibrations. This progresses through an exposition of the characteristics of linear waves, in order to explain the propensity for, and properties of, the nonlinear propagation which occurs in many practical ultrasonic fields. Given the Health Protection environment which framed the original presentation, explanation and examples are given of how these complexities affect issues of practical importance. These issues include the measurement and description of fields and exposures, and the ability of ultrasound to affect tissue (through microstreaming, streaming, cavitation, heating, etc.). It is noted that there are two very distinct regimes, in terms of wave characteristics and potential for bioeffect. The first concerns the use of ultrasound in liquids/solids, for measurement or material processing. For biomedical applications (where these two processes are termed diagnosis and therapy, respectively), the issue of hazard has been studied in depth, although this has not been done to such a degree for industrial uses of ultrasound in liquids/solids (sonar, non-destructive testing, ultrasonic processing etc.). However, in the second regime, that of the use of ultrasound in air, although the waves in question tend to be of much lower intensities than those used in liquids/solids, there is a greater mismatch between the extent to which hazard has been studied, and the growth in commercial applications for airborne ultrasound.

Threshold estimation of ultrasound-induced lung hemorrhage in adult rabbits and comparison of thresholds in mice, rats, rabbits and pigs

The objective of this study was to assess the threshold and superthreshold behavior of ultrasound (US)-induced lung hemorrhage in adult rabbits to gain greater understanding about species dependency. A total of 99 76 +/- 7.6-d-old 2.4 +/- 0.14-kg New Zealand White rabbits were used. Exposure conditions were 5.6-MHz, 10-s exposure duration, 1-kHz PRF and 1.1-micros pulse duration. The in situ (at the pleural surface) peak rarefactional pressure, p(r(in situ)), ranged between 1.5 and 8.4 MPa, with nine acoustic US exposure groups plus a sham exposure group. Rabbits were assigned randomly to the 10 groups, each with 10 rabbits, except for one group that had nine rabbits. Rabbits were exposed bilaterally with the order of exposure (left then right lung, or right then left lung) and acoustic pressure both randomized. Individuals involved in animal handling, exposure and lesion scoring were blinded to the exposure condition. Probit regression analysis was used to examine the dependence of the lesion occurrence on in situ peak rarefactional pressure and order of exposure (first vs. second). Likewise, lesion depth and lesion root surface area were analyzed using Gaussian tobit regression analysis. Neither probability of a lesion nor lesion size measurements was found to be statistically dependent on the order of exposure after the effect of p(r(in situ)) was considered. Also, a significant correlation was not detected between the two exposed lung sides on the same rabbit in either lesion occurrence or size measures. The p(r(in situ)) threshold estimates (in MPa) were similar to each other across occurrence (3.54 +/- 0.78), depth (3.36 +/- 0.73) and surface area (3.43 +/- 0.77) of lesions. Using the same experimental techniques and statistical approach, great consistency of thresholds was demonstrated across three species (mouse, rat and rabbit). Further, there were no differences in the biologic mechanism of injury induced by US and US-induced lesions were similar in morphology in all species and age groups studied. The extent of US-induced lung damage and the ability of the lung to heal led to the conclusion that, although US can produce lung damage at clinical levels, the degree of damage does not appear to be a significant medical problem.

Lesions of ultrasound-induced lung hemorrhage are not consistent with thermal injury

Thermal injury, a potential mechanism of ultrasound-induced lung hemorrhage, was studied by comparing lesions induced by an infrared laser (a tissue-heating source) with those induced by pulsed ultrasound. A 600-mW continuous-wave CO2 laser (wavelength approximately 10.6 microm) was focused (680-microm beamwidth) on the surface of the lungs of rats for a duration between 10 to 40 s; ultrasound beamwidths were between 310 and 930 microm. After exposure, lungs were examined grossly and then processed for microscopic evaluation. Grossly, lesions induced by laser were somewhat similar to those induced by ultrasound; however, microscopically, they were dissimilar. Grossly, lesions were oval, red to dark red and extended into subjacent tissue to form a cone. The surface was elevated, but the center of the laser-induced lesions was often depressed. Microscopically, the laser-induced injury consisted of coagulation of tissue, cells and fluids, whereas injury induced by ultrasound consisted solely of alveolar hemorrhage. These results suggest that ultrasound-induced lung injury is most likely not caused by a thermal mechanism.

Overview of experimental studies of biological effects of medical ultrasound caused by gas body activation and inertial cavitation

Ultrasound exposure can induce bioeffects in mammalian tissue by the nonthermal mechanism of gas body activation. Pre-existing bodies of gas may be activated even at low-pressure amplitudes. At higher-pressure amplitudes, violent cavitation activity with inertial collapse of microbubbles can be generated from latent nucleation sites or from the destabilization of gas bodies. Mechanical perturbation at the activation sites leads to biological effects on nearby cells and structures. Shockwave lithotripsy was the first medical ultrasound application for which significant cavitational bioeffects were demonstrated in mammalian tissues, including hemorrhage and injury in the kidney. Lithotripter shockwaves can also cause hemorrhage in lung and intestine by activation of pre-existing gas bodies in these tissues. Modern diagnostic ultrasound equipment develops pressure amplitudes sufficient for inertial cavitation, but the living body normally lacks suitable cavitation nuclei. Ultrasound contrast agents (UCAs) are suspensions of microscopic gas bodies created to enhance the echogenicity of blood. Ultrasound contrast agent gas bodies also provide nuclei for inertial cavitation. Bioeffects from contrast-aided diagnostic ultrasound depend on pressure amplitude, UCA dose, dosage delivery method and image timing parameters. Microvascular leakage, capillary rupture, cardiomyocyte killing, inflammatory cell infiltration, and premature ventricular contractions have been reported for myocardial contrast echocardiography with clinical ultrasound machines and clinically relevant agent doses in laboratory animals. Similar bioeffects have been reported in intestine, skeletal muscle, fat, lymph nodes and kidney. These microscale bioeffects could be induced unknowingly in diagnostic examinations; however, the medical significance of bioeffects of diagnostic ultrasound with contrast agents is not yet fully understood in relation to the clinical setting.

Superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse repetition frequency and pulse duration

OBJECTIVE

The purpose of this study was to enhance the findings of an earlier ultrasound-induced lung hemorrhage study (Ultrasound Med Biol 2003; 29:1625-1634) that estimated pressure thresholds as a function of pulse duration (PD: 1.3, 4.4, 8.2, and 11.6 micros; 2.8 MHz; 10-s exposure duration [ED]; 1-kHz pulse repetition frequency [PRF]). In this study, the roles of PRF and PD were evaluated at 5.9 MPa, the peak rarefactional pressure threshold near that of the ED50 estimate previously determined.

METHODS

A 4 x 4 factorial design study (PRF: 50, 170, 500, and 1700 Hz; PD: 1.3, 4.4, 8.2, and 11.6 mus) was conducted (2.8 MHz; 10-s ED). Sprague Dawley rats (n = 175) were divided into 16 exposure groups (10 rats per group) and 1 sham group (15 rats); no lesions were produced in the sham group. Logistic regression analysis evaluated significance of effects for lesion occurrence, and Gaussian tobit analysis evaluated significance for lesion depth and surface area.

RESULTS

For lesion occurrence and sizes, the main effect of PRF was not significant. The interaction term, PRF x PD, was highly significant, indicating a strong positive dependence of lesion occurrence on the duty factor. The main effect of PD was almost significant (P = .052) and thus was included in the analysis model for a better fit.

CONCLUSIONS

Compared with the findings from a PRF x ED factorial study (J Ultrasound Med 2005; 24:339-348), a function that considers PRF, PD, and ED might yield a sensitive indicator for consideration of a modified mechanical index, at least for the lung.

Acoustic output as measured by mechanical and thermal indices during routine obstetric ultrasound examinations

OBJECTIVE

The purpose of this study was to quantify the acoustic output of clinical ultrasound instruments, as expressed by the thermal index (TI) and mechanical index (MI), during routine obstetric examinations.

METHODS

A prospective, observational study was conducted. Sonographers were unaware of the data being sought. Data were collected regarding duration of the examination and specific duration spent at each MI and TI.

RESULTS

A total of 11 first-trimester, 14 second-trimester, and 12 third-trimester examinations were evaluated. The mean duration of the first-trimester examination was 8.9 minutes. The mean MI was 0.73 (range, 0.3-1.3), and the mean TI was 0.34 (0.1-1.7). The mean duration of the second-trimester examination was 31.8 minutes. The mean MI was 1.04 (0.5-1.5), and the mean TI was 0.28 (0.1-2.4). The mean duration of the third-trimester examination was 16.3 minutes. The mean MI was 1.06 (0.2-1.5), and the mean TI was 0.32 (0.1-2.4). Statistical significance existed across trimesters with regard to examination durations and MI (P < .001). However, no statistical significance existed in the TI across trimesters. During the third trimester, 3.5% of the examinations had a TI of greater than 1.0. Of these, 2.4% were between 1.0 and 1.49 and 1.1% were greater than 1.5. These changes (of TI > or = 1) were brief (mean +/- SD, 0.17 +/- 0.08 minutes) and were observed during the short periods of color Doppler imaging.

CONCLUSIONS

Output levels during routine obstetric ultrasound examinations, as expressed by the MI and TI, are generally low. However, higher output levels, particularly TI levels of greater than 1.5, can be achieved, although they account for only a very small proportion of examination time.

Superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse repetition frequency and exposure duration revisited

OBJECTIVE

The purpose of this study was to augment and reevaluate the ultrasound-induced lung hemorrhage findings of a previous 5 x 3 factorial design study (Ultrasound Med Biol 2001; 27:267-277) that evaluated the role of pulse repetition frequency (PRF: 25, 50, 100, 250, and 500 Hz) and exposure duration (ED; 5, 10, and 20 s) on ultrasound-induced lung hemorrhage at an in situ (at the pleural surface) peak rarefactional pressure [pr(in situ)] of 12.3 MPa; only PRF was found to be significant. However, saturation (response plateau) due to the high pr(in situ) might have skewed the results. In this follow-up 3 x 3 factorial design study, a wider range of PRFs and EDs were used at a lower pr(in situ).

METHODS

Sprague Dawley rats (n=198) were divided into 18 ultrasonically exposed groups (10 rats per group) and 6 sham groups (3 per group). The 3 x 3 factorial design study (PRF: 17, 170, and 1700 Hz; ED: 5, 31.6, and 200 s) was conducted at 2 frequencies (2.8 and 5.6 MHz). The p(r(in situ)) was 6.1 MPa. Logistic regression analysis evaluated lesion occurrence, and Gaussian tobit analysis evaluated lesion depth and surface area.

RESULTS

Frequency did not have a significant effect, so the analysis combined results for the 2 frequencies. For lesion occurrence and sizes, the main effects for PRF and ED were not significant. The interaction term was highly significant, indicating a strong dependence of lesion occurrence and size on the total number of pulses (PRF x ED).

CONCLUSIONS

The results of both studies are consistent with the hypothesis that the total number of pulses is an important factor in the genesis of ultrasound-induced lung hemorrhage.

Effect of contrast agent on the incidence and magnitude of ultrasound-induced lung hemorrhage in rats

OBJECTIVE

To test the hypothesis that inertial cavitation in the vasculature of the lung is not the physical mechanism responsible for ultrasound-induced lung hemorrhage.

METHODS

A factorial design was used to study the effects of two types of injected agents (IA; 0.25 ml per rat of saline or Optison given intravenously) and two levels of pulsed ultrasound exposure (UE; in situ peak rarefactional pressures of 2.74 and 5.86 MPa; respective mechanical indices of 1.02 and 2.14) on the incidence and size of lung lesions. Ten 10-to-11-week-old Sprague-Dawley rats were exposed to pulsed ultrasound at each of the four combinations of IA and UE at a center frequency of 3.1 MHz, exposure duration of 10 s, pulse repetition frequency of 1,000 Hz and pulse duration of 1.2 micros. In addition, nine rats served as shams in which no lung hemorrhage occurred.

RESULTS

Rats administered contrast agent prior to exposure did not have an increase in lesion occurrence or size compared to rats that received saline with no contrast agent.

CONCLUSIONS

These results provide further evidence that the mechanism for production of lung hemorrhage is not inertial cavitation.

Mechanical Bioeffects of Ultrasound

Ultrasound is used widely in medicine as both a diagnostic and therapeutic tool. Through both thermal and nonthermal mechanisms, ultrasound can produce a variety of biological effects in tissues in vitro and in vivo. This chapter provides an overview of the fundamentals of key nonthermal mechanisms for the interaction of ultrasound with biological tissues. Several categories of mechanical bioeffects of ultrasound are then reviewed to provide insight on the range of ultrasound bioeffects in vivo, the relevance of these effects to diagnostic imaging, and the potential application of mechanical bioeffects to the design of new therapeutic applications of ultrasound in medicine.

Impedance measurements of ex vivo rat lung at different volumes of inflation

A previous study [J. Acoust. Soc. Am. 111, 1102-1109 (2002)] showed that the occurrence of ultrasonically induced lung hemorrhage in rats was directly correlated to the level of lung inflation. In that study, it was hypothesized that the lung could be modeled as two components consisting of air and parenchyma (contiguous tissue [pleura and septa]). The speed of sound and lung impedance would then depend on the fractional volume of air in the lung. According to that model, an inflated lung should act like a pressure-release surface for sound incident from tissue onto a tissue-lung boundary. A deflated lung containing less air should allow more acoustic energy into the lung tissue because the impedance was more closely matched to the contiguous tissues. In the study reported herein, a measurement technique was devised to calculate the impedance of seven rat lungs, ex vivo, under deflation (atmospheric pressure) and three volumes of inflation pressure (7-cm H2O, 10-cm H2O, and 15-cm H2O). Lungs were dissected from rats and immediately scanned in a tank of degassed 37 degrees C water. The frequency-dependent acoustic pressure reflection coefficient was measured over a frequency range of 3.5 to 10 MHz. From the reflection coefficient, the frequency-dependent lung impedance was calculated with values ranging from an average of 1 Mrayls in deflated lungs to 0.2 Mrayls for fully inflated lungs. Lung impedance calculations showed that deflated lungs had an impedance closer to water (1.52 Mrayls) than inflated lungs. At all volumes of inflation, the lungs acted as pressure-release surfaces relative to the water. The average of the four lung impedance values (deflated, 7-cm H2O, 10-cm H2O, and 15-cm H2O) at each level of inflation was statistically different (p<0.0001).

Threshold estimates and superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse duration

The study objective was to estimate the pressure threshold (ED(05), effective dose, or in situ peak rarefactional pressure associated with 5% probability of lesions) of ultrasound (US)-induced lung hemorrhage as a function of pulse duration (PD) in adult rats. A total of 220 10- to 11-week-old 250-g female Sprague-Dawley rats (Harlan) were randomly divided into 20 ultrasonic exposure groups (10 rats/group) and one sham group (20 rats). The 20 ultrasonic exposure groups (2.8-MHz; 10-s exposure duration; 1-kHz PRF; -6-dB pulse-echo focal beam width of 470 microm) were divided into four PD groups (1.3, 4.4, 8.2 and 11.6 micros) and, for each PD group, there were five in situ peak rarefactional pressures (range between 4 and 9 MPa). Rats were weighed, anesthetized, depilated, exposed, and euthanized under anesthesia. The left lung was removed and scored for the occurrence of hemorrhage. If hemorrhage was present, the lesion surface area and depth were measured. Individuals involved in animal handling, exposure and lesion scoring were "blinded" to the exposure conditions. Logistic regression analysis was used to examine the dependence of the lesion occurrences, and Gaussian tobit regression analysis was used to examine the dependence of the lesion surface areas and depths on in situ peak rarefactional pressure and PD. Threshold results are reported in terms of ED(05). For PDs of 1.3, 4.4, 8.2 and 11.6 micros, respectively, lesion occurrence ED(05)s were 3.1, 2.8, 2.3 and 2.0 MPa with standard errors around 0.6 MPa. Lesion size ED(05)s showed similar values. A mechanical index (MI) of 1.9, the US Food and Drug Administration (FDA) regulatory limit of diagnostic US equipment, is equivalent to the adult rat's in situ peak rarefactional pressure of 4.0 MPa. PDs of 8.2 and 11.6 micros had ED(05)s more than 2 standard errors below 4.0 MPa, indicating that the ED(05)s of these two PDs are statistically significantly different from 4.0 MPa. The ED(05) threshold levels for a PD of 1.3 micros are consistent with previous US-induced lung hemorrhage studies. As the PD increases, the ED(05) levels decrease, suggesting greater likelihood of lung damage as the PD increases. All of the ED(05)s are less than the FDA limit.

Effect of pulse polarity and energy on ultrasound-induced lung hemorrhage in adult rats

The objective of this study was to further assess the role of inertial cavitation in ultrasound-induced lung hemorrhage by examining the effect of pulse polarity at a common in situ (at the lung surface) peak rarefactional pressure [pr(in situ)] and at a common in situ pulse intensity integral (PII(in situ)). A total of 60 rats was divided into three experimental groups of 20 animals per group and randomly exposed to pulsed ultrasound. The groups were exposed as follows: Group 1 to 0 degree polarity pulses (compression followed by rarefraction) at a pr(in situ) of 3.48 MPa and a PII(in situ) of 4.78 Ws/m2, group 2 to 180 degree polarity pulses (rarefraction followed by compression) at a pr(in situ) of 3.72 MPa and a PII(in situ) of 2.55 Ws/m2, and group 3 to 180 degree polarity pulses at a pr(in situ) of 4.97 MPa and a PII(in situ) of 4.79 Ws/m2. For all experimental groups, the frequency was 2.46 MHz, the exposure duration was 240 s, the pulse repetition frequency was 2.5 kHz, and the pulse duration was 0.42 micros. Six sham animals were also randomly distributed among the experimental animals. The lesion surface area and depth were determined for each rat as well as lesion occurrence (percentage of rats with lesions) per group. It was found that lesion occurrence and size correlated better with PII(in situ) than with pr(in situ), suggesting that a mechanism other than inertial cavitation was responsible for the damage.

Superthreshold behavior and threshold estimation of ultrasound-induced lung hemorrhage in pigs: role of age dependency

Age-dependent threshold and superthreshold behavior of ultrasound-induced lung hemorrhage were investigated with 116 2.1 +/- 0.3-kg neonate crossbred pigs (4.9 +/- 1.6 days old), 103 10 +/- 1.1-kg crossbred pigs (39 +/-5 days old), and 104 20+/-1.2-kg crossbred pigs (58 +/- 5 days old). Exposure conditions were: 3.1 MHz, 10-s exposure duration, 1-kHz pulse repetition frequency (PRF), and 1.2-micros pulse duration. The in situ (at the pleural surface) peak rarefactional pressure ranged between 2.2 and 10.4 MPa with either eight or nine acoustic pressure groups for each of the three pig ages (12 pigs/exposure group) plus sham exposed pigs. There were no lesions in the shams. Pigs were exposed bilaterally with the order of exposure (left then right lung, or right then left lung) and acoustic pressure both randomized. Pig age was not randomized. Individuals involved in animal handling, exposure, and lesion scoring were blinded to the exposure condition. Logistic regression analysis was used to examine the dependence of the lesion incidence rates on in situ peak rarefactional pressure, left versus right lung exposure, order of exposure (first versus second), and age in three age groups. Likewise, lesion depth and lesion root surface area were analyzed using Gaussian tobit regression analysis. A significant threshold effect on lesion occurrence was observed as a function of age; younger pigs were less susceptible to lung damage given equivalent in situ exposure. Overall, the oldest pigs had a significantly lower threshold (2.87 +/- 0.29 MPa) than middle-aged pigs (5.83 +/- 0.52 MPa). The oldest pigs also had a lower threshold than neonate pigs (3.60 +/- 0.44 MPa). Also, an unexpected result was observed. The ultrasound exposures were bilateral, and the threshold results reported above were based on the lung that was first exposed. After the first lung was exposed, the pig was turned over and the other lung was exposed to the same acoustic pressure. There was a significant decrease (greater than the confidence limits) in occurrence thresholds: 3.60 to 2.68, 5.83 to 2.97, and 2.87 to 1.16 MPa for neonates, middle-aged, and oldest pigs, respectively, in the second lung exposed. Thus, a subtle effect in lung physiology resulted in a major effect on lesion thresholds.

Attenuation coefficient and propagation speed estimates of rat and pig intercostal tissue as a function of temperature

Attenuation coefficient and propagation speed of intercostal tissues were estimated as functions of temperature (22, 30, and 37 degrees C) from fresh chest walls from eight 10- to 11-week-old female Sprague-Dawley (SD) rats, eight 21- to 24-week-old female Long-Evans (LE) rats, and ten 6- to 10-week-old mixed sex Yorkshire (York) pigs. The primary purpose of the study was to estimate the temperature dependence of the intercostal tissue's attenuation coefficient so that accurate estimates of the in situ (at the pleural surface) acoustic pressure levels could be made for our ultrasound-induced lung hemorrhage studies. The attenuation coefficient of intercostal tissue for both species was independent of the temperature at the discrete frequencies of 3.1 MHz (-0.0076, 0.0065, and 0.016 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively) and 6.2 MHz (-0.015, 0.014, and 0.014 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively). However, the temperature-dependent regressions yielded a significant temperature dependency of the intercostal tissue attenuation coefficients in SD and LE rats (over the 3.1 to 9.6 MHz frequency range); there was no temperature dependency in York pigs (over the 3.1 to 8.6 MHz frequency range). There was no significant temperature dependency of the intercostal tissue propagation speed in SD rats; there was a temperature dependency in LE rats and York pigs (-0.59, -1.6, and -2.9 m/s/degrees C for SD rats, LE rats, and York pigs, respectively). Even though the attenuation coefficient's temperature dependency was significant from the linear regression functions, the differences were not very great (-0.040 to -0.13, 0.011 to 0.18, and 0.055 to 0.10 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively, over the data frequency range). These findings suggest that it is not necessary to determine the attenuation coefficient of intercostal tissue at body temperature (37 degrees C), but rather it is sufficient to determine the attenuation coefficient at room temperature (22 degrees C), a much easier experimental procedure.

Attenuation coefficient and propagation speed estimates of intercostal tissue as a function of pig age

Attention coefficient and propagation speed of intercostal tissues were estimated from chest walls removed postmortem (pm) from 15 5.3+/-2.3-day-old, 19 31+/-6-day-old, and 15 61+/-3-day-old crossbred pigs. These ultrasonic propagation properties were determined from measurements through the intercostal tissues, from the surface of the skin to the parietal pleura. The chest walls were placed in a 0.9% sodium chloride solution, sealed in freezer bags, and stored at -15 degrees C prior to measurements. When evaluated, chest-wall storage time ranged between 1 and 477 days pm. All chest walls were allowed to equilibrate to 22 degrees C in a water bath prior to evaluation. There was an age dependency of the intercostal tissue propagation speed, with the speed increasing with increasing age. The attenuation coefficient of intercostal tissue was shown to be independent of the age of the pig at the discrete frequencies of 3.1 and 6.2 MHz. For pig intercostal tissues, the estimated attenuation coefficient over the 3.1-9.2 MHz frequency range was A = 1.94f(0.90) where A is in decibels per centimeter (dB/cm) and f is the ultrasonic frequency in megahertz. In order to determine if there was an effect of storage time pm on estimates of attenuation coefficient, a second experiment was conducted. Five of the youngest pig chest walls measured on day 1 pm in the first experiment were stored at 4 degrees C prior to the first evaluation then stored at -15 degrees C before being measured again at 108 days pm. There was no difference in the estimated intercostal tissue attenuation coefficient as a function of storage time pm.

Ultrasound-induced lung hemorrhage: role of acoustic boundary conditions at the pleural surface

In a previous study [J. Acoust. Soc. Am. 108, 1290 (2000)] the acoustic impedance difference between intercostal tissue and lung was evaluated as a possible explanation for the enhanced lung damage with increased hydrostatic pressure, but the hydrostatic-pressure-dependent impedance difference alone could not explain the enhanced occurrence of hemorrhage. In that study, it was hypothesized that the animal's breathing pattern might be altered as a function of hydrostatic pressure, which in turn might affect the volume of air inspired and expired. The acoustic impedance difference between intercostal tissue and lung would be affected with altered lung inflation, thus altering the acoustic boundary conditions. In this study, 12 rats were exposed to 3 volumes of lung inflation (inflated: approximately tidal volume; half-deflated: half-tidal volume; deflated: lung volume at functional residual capacity), 6 rats at 8.6-MPa in situ peak rarefactional pressure (MI of 3.1) and 6 rats at 16-MPa in situ peak rarefactional pressure (MI of 5.8). Respiration was chemically inhibited and a ventilator was used to control lung volume and respiratory frequency. Superthreshold ultrasound exposures of the lungs were used (3.1-MHz, 1000-Hz PRF, 1.3-micros pulse duration, 10-s exposure duration) to produce lesions. Deflated lungs were more easily damaged than half-deflated lungs, and half-deflated lungs were more easily damaged than inflated lungs. In fact, there were no lesions observed in inflated lungs in any of the rats. The acoustic impedance difference between intercostal tissue and lung is much less for the deflated lung condition, suggesting that the extent of lung damage is related to the amount of acoustic energy that is propagated across the pleural surface boundary.

Superthreshold behavior and threshold estimates of ultrasound-induced lung hemorrhage in adult rats: role of beamwidth

It is well documented that ultrasound-induced lung hemorrhage can occur in mice, rats, rabbits, pigs, and monkeys. The objective of this study was to assess the role of the ultrasound beamwidth (beam diameter incident on the lung surface) on lesion threshold and size. A total of 144 rats were randomly exposed to pulsed ultrasound at three exposure levels and four beamwidths (12 rats per group). The three in situ peak rarefactional pressures were about 5, 7.5, and 10 MPa. The four 19-mm-diameter focused transducers had measured pulse-echo -6-dB focal beamwidths of 470 microm (2.8 MHz; f/1), 930 microm (2.8 MHz; f/2), 310 microm (5.6 MHz; f/1), and 510 microm (5.6 MHz; f/2). Exposure durations were 10 s, pulse repetition frequencies were 1 kHz, and pulse durations were 1.3 micros (2.8 MHz; f/1), 1.2 micros (2.8 MHz; f/2), 0.8 micros (5.6 MHz; f/1) and 1.1 micros (5.6 MHz; f/2). The lesion surface area and depth were measured for each rat as well as the percentage of rats with lesions per group. Logistic regression analysis and Gaussian-Tobit analysis methods were used to analyze the data. The effects of in situ peak rarefactional pressure and beamwidth were highly significant, but ultrasonic frequency was not significant. In addition, the estimated interaction between in situ peak rarefactional pressure and beamwidth was positive and highly significant. The ultrasound beamwidth incident on the lung surface was shown to strongly affect the percentage and size of ultrasound-induced lung hemorrhage lesions. Even though ultrasonic frequency was an experimental variable, it was not shown to affect the lesion percentage or size.

Temporal and spatial evaluation of lesion reparative responses following superthreshold exposure of rat lung to pulsed ultrasound

This study characterized the reparative responses in rat lung. Forty-five adult female rats were exposed at two sites over the left lung to 3.1-MHz superthreshold pulsed ultrasound. The repair of lung lesions was evaluated from 0 through 44 days postexposure. Macroscopic lesions at 0 days postexposure were large bright red ellipses of hemorrhage. By 1 and 3 days postexposure, lesions were the same size and dark red to red-black, but, by 3 days postexposure, lesions had a raised surface appearance. From 5 to 10 days postexposure, lesions grew smaller in size, progressed from red-gray to yellow-brown, and retained a raised surface appearance. From 13 through 44 days postexposure, lesions gradually decreased in size, had a faint yellow-brown discoloration, and gradually lost the raised surface appearance. By 37 and 44 days postexposure, lung returned to near normal morphology, but had small areas of light yellow-brown discoloration in the areas where lung was exposed. Microscopic lesions at 0 and 1 days postexposure were areas of acute alveolar hemorrhage. By 3 days postexposure, lesions had loss of alveolar erythrocytes and the formation of hemoglobin crystals. From 5 through 44 days postexposure, iron in degraded erythrocytes was processed to hemosiderin and was negligible in quantity at 44 days postexposure. The proliferation of resident cells (likely alveolar epithelial cells, fibroblasts and endothelial cells) and the infiltration of inflammatory cells in lesions declined in intensity as the lesions aged and was minimal by 44 days postexposure. Under the superthreshold exposure conditions described, lesions induced by ultrasound do not seem to have long-term residual effects in lung.

Attenuation coefficient estimates of mouse and rat chest wall

Attenuation coefficients of intercostal tissues were estimated from chest walls removed postmortem (pm) from 41 6-to-7-week-old female ICR mice and 27 10-to-11-week-old female Sprague-Dawley rats. These values were determined from measurements through the intercostal tissues, from the surface of the skin to the parietal pleura. Mouse chest walls were sealed in plastic wrap and stored at 4 degrees C until evaluated, and rat chest walls were sealed in Glad-Lock Zipper sandwich bags, and stored at -15 degrees C. When evaluated, chest wall storage time ranged between 1 and 2 days pm for mice and between 41 and 110 days pm for rats. All chest walls were allowed to equilibrate to 22 degrees C in a water bath prior to evaluation. For both mouse and rat intercostal tissues, the estimated frequency normalized attenuation coefficient was 1.1 dB/cm-MHz. In order to determine if there was an effect of storage time on estimates of attenuation coefficient, an independent experiment was conducted. The intercostal tissues from six mouse chest walls were evaluated at three time points (1, 22, and 144 days pm), and from six rat chest walls were evaluated at four time points (1, 22, 50, and 125 days pm). There was no difference in the estimated intercostal tissue attenuation coefficient as a function of time postmortem.

Superthreshold behavior and threshold estimation of ultrasound-induced lung hemorrhage in adult mice and rats

Threshold estimates and superthreshold behaviors for ultrasound-induced lung hemorrhage were investigated as a function of species (adult mice and rats) and ultrasound frequency (2.8 and 5.6 MHz). A total of 151 6-to-7-week-old female ICR mice and 160 10-to-11-week-old female Sprague-Dawley rats were randomly divided into two ultrasonic frequency groups, and further randomly divided into seven or eight ultrasonic peak rarefactional pressure groups. Each group consisted of about 10 animals. Animals were exposed to pulsed ultrasound at either 2.8-MHz center frequency (1-kHz PRF, 1.42-microsecond pulse duration) or 5.6-MHz center frequency (1-kHz PRF, 1.17-microsecond pulse duration) for a duration of 10 seconds. The in situ (at the pleural surface) peak rarefactional pressure levels ranged between 2.5 and 10.5 MPa for mice and between 2.3 and 11.3 MPa for rats. The mechanical index (MI) ranged between 1.4 and 6.3 at 2.8 MHz for mice and between 1.1 and 3.1 at 5.6 MHz for rats. The lesion surface area and depth were measured for each animal as well as the percentage of animals with lesions per group. The characteristics of the lesions produced in mice and rats were similar to those described in previous studies by our research group and others, suggesting a common pathogenesis in the initiation and propagation of the lesions at the gross and microscopic levels. The percentage of animals with lesions showed no statistical differences between species or between ultrasound frequencies. These findings suggest that mice and rats are similar in sensitivity to ultrasound-induced lung damage and that the occurrence of lung damage is independent of frequency. Lesion depth and surface area also showed no statistically significant differences between ultrasound frequencies for mice and rats. However, there was a significant difference between species for lesion area and a suggestive difference between species for lesion depth. The superthreshold behavior of lesion area and depth showed that rat lung had more damage than mouse lung, and the threshold estimates showed a weak, or lack of, frequency dependency, suggesting that the MI is not consistent with the observed findings.

Superthreshold behavior of ultrasound-induced lung hemorrhage in adult mice and rats: role of pulse repetition frequency and exposure duration

Superthreshold behavior for ultrasound-induced lung hemorrhage was investigated in adult mice and rats at an ultrasound center frequency of 2.8 MHz to assess the role of pulse repetition frequency and exposure duration. One hundred fifty, 6-7-week-old female ICR mice and 150 10-11-week-old female Sprague-Dawley rats were each divided into 15 exposure groups (10 animals per group) for a 3 x 5 factorial design (3 exposure durations of 5, 10, and 20 s and 5 pulse repetition frequencies of 25, 50, 100, 250, and 500 Hz). The in situ (at the pleural surface) peak rarefactional pressure of 12.3 MPa and the pulse duration of 1.42 micros were the same for all ultrasonically-exposed animals. In addition, 15 sham exposed mice and 15 sham exposed rats were included into both studies. In each study of 165 animals, the exposure conditions were randomized. The lesion depth and surface area were measured for each animal, as well as the percentage of animals with lesions per group. The characteristics of the lesions produced in mice and rats were similar to those described in studies by our research group and others, suggesting a common pathogenesis for the initiation and propagation of the lesions at the gross and microscopic levels. The proportion of lesions in both species was related statistically to pulse repetition frequency (PRF) and exposure duration (ED), with the exception that PRF in rats was not quite significant; the PRF x ED interaction (number of pulses) for lesion production was not significant for either species. The PRF, but not ED, significantly affected lesion depth in both species; the PRF x ED interaction for depth was not significant for either species. Both PRF and ED significantly affected lesion surface area in mice, while neither affected area in rats; the PRF x ED interaction for surface area was not significant for either species.

Ultrasound-induced lung hemorrhage is not caused by inertial cavitation

In animal experiments, the pathogenesis of lung hemorrhage due to exposure to clinical diagnostic levels of ultrasound has been attributed to an inertial cavitation mechanism. The purpose of this article is to report the results of two experiments that directly contradict the hypothesis that ultrasound-induced lung hemorrhage is caused by inertial cavitation. Elevated hydrostatic pressure was used to suppress the involvement of inertial cavitation. In experiment one, 160 adult mice were equally divided into two hydrostatic pressure groups (0.1 or 1.1 MPa), and were randomly exposed to pulsed ultrasound (2.8-MHz center frequency, 1-kHz PRF, 1.42-micros pulse duration, 10-s exposure duration). For the two hydrostatic pressure groups (80 mice each), 8 in situ peak rarefactional pressure levels were used that ranged between 2.82 and 11.8 MPa (10 mice/group). No effect of hydrostatic pressure on the probability of hemorrhage was observed. These data lead to the conclusion that lung hemorrhage is not caused by inertial cavitation. Also, the higher hydrostatic pressure enhanced rather than inhibited the impact of ultrasonic pressure on the severity (hemorrhage area, depth, and volume) of lesions. These counterintuitive findings were confirmed in a second experiment using a 2 x 5 factorial design that consisted of two ultrasonic pressure levels and five hydrostatic pressure levels (100 mice, 10 mice/group). If inertial cavitation were the mechanism responsible for lung hemorrhage, then elevated hydrostatic pressures should have resulted in less rather than more tissue damage at each ultrasonic pressure level. This further supports the conclusion that the pathogenesis of ultrasound-induced lung hemorrhage is not caused by inertial cavitation.