The Senile Lung as a Possible Source of Pitfalls on Chest Ultrasonography and Computed Tomography

Role of NT-proBNP and lung ultrasound in diagnosing and classifying heart failure in a hospitalized oldest-old population: a cross-sectional study

AIM

Diagnosing and classifying heart failure (HF) in the oldest-old patients has technical and interpretation issues, especially in the acute setting. We assessed the usefulness of both N-terminal pro-brain natriuretic peptide (NT-proBNP) and lung ultrasound (LUS) for confirming HF diagnosis and predicting, among hospitalized HF patients, those with reduced ejection fraction (HFrEF).

METHODS

We performed a cross-sectional study on 148 consecutive patients aged ≥ 80 years admitted to our Internal Medicine and Geriatrics ward with at least one symptom/sign compatible with HF and NT-proBNP ≥ 125 pg/mL. We measured serum NT-proBNP levels and performed LUS and transthoracic echocardiography (TTE) on admission before diuretic therapy. We divided our cohort into three subgroups according to the left ventricular ejection fraction (LVEF): reduced (LVEF ≤ 40%), mildly-reduced (LVEF = 41-49%) and preserved (LVEF ≥ 50%).

RESULTS

The mean age was 88±5 years. Male prevalence was 42%. Patients with HFrEF were 19%. Clinical features and laboratory parameters did not differ between the three subgroups, except for higher NT-proBNP in HFrEF patients, which also had a higher number of total B-lines and intercostal spaces of pleural effusion at LUS. Overall, NT-proBNP showed an inverse correlation with LVEF (r = -0.22, p = 0.007) and a direct correlation with age, total pulmonary B-lines, and intercostal spaces of pleural effusion. According to the ROCs, NT-proBNP levels, pulmonary B-lines and pleural effusion extension were poorly predictive for HFrEF. The best-performing cut-offs were 9531 pg/mL for NT-proBNP (SP 0.70, SE 0.50), 13 for total B-lines (SP 0.69, SE 0.85) and one intercostal space for pleural effusion (SP 0.55, SE 0.89). Patients with admission NT-proBNP ≥ 9531 pg/mL had a 2-fold higher risk for HFrEF (OR 2.5, 95% CI 1.3-4.9), while we did not find any association for total B-lines ≥ 13 or pleural effusion ≥ 1 intercostal space with HFrEF. A significant association with HFrEF emerged for the combination of NT-proBNP ≥ 9531 pg/mL, total B-lines ≥ 13 and intercostal spaces of pleural effusion ≥ 1 (adjusted OR 4.3, 95% CI 1.5-12.9).

CONCLUSIONS

Although NT-proBNP and LUS help diagnose HF, their accuracy in discriminating HFrEF from non-HFrEF was poor in our real-life clinical study on oldest-old hospitalized patients, making the use of TTE still necessary to distinguish HF phenotypes in this peculiar setting. These data require confirmation in more extensive and longer prospective studies.

Evaluation of B-lines with 2 point-of-care lung ultrasound protocols in cats with radiographically normal lungs

OBJECTIVE

To compare 2 point-of-care lung ultrasound (LUS) protocols for quantification of B-lines in cats without evidence of respiratory disease based on history, physical examination, and thoracic radiography.

DESIGN

Prospective observational study.

SETTING

Single center, veterinary teaching hospital.

ANIMALS

Fifty-seven cats without respiratory disease based on history, physical examination, and thoracic radiographs.

INTERVENTIONS

All cats had 2 point-of-care LUS protocols performed bilaterally: a regional protocol (veterinary bedside lung ultrasound evaluation [VetBLUE]) and a more comprehensive vertical sweeping (VS) protocol. The total number of B-lines per cat, number of sites with B-lines, and maximal number of B-lines at each site were recorded and compared.

MEASUREMENTS AND MAIN RESULTS

Ten cats (18%) had at least 1 B-line identified with VetBLUE, versus 29 (51%) with VS. Comparing protocols, VS had a statistically higher total number of B-lines per cat, higher number of sites with B-lines, and higher maximal number of B-lines per site. B-lines that were too numerous to count were identified at a single location in 1 cat with VetBLUE and 2 cats with VS. A maximum of 3 B-lines were identified at all other positive sites regardless of the protocol used. On average, it took 1.79 times longer to complete VS bilaterally compared to VetBLUE (median [interquartile range]: 140 [33] and 78 [14] s, respectively) (P = 0.001).

CONCLUSIONS

This study demonstrates it is not uncommon to identify a single or even multiple B-lines in 1 or several sites on LUS in cats deemed to be clinically free of respiratory pathology-essential knowledge when using LUS as a screening test and to monitor intrathoracic lesions. In cats asymptomatic for respiratory disease, VS generally identifies more B-lines than VetBLUE, likely because it assesses a larger lung surface area. The sonographic identification of B-lines should be interpreted considering the LUS protocol used, history, and other diagnostics to determine their clinical significance.

Aging-Related Findings of the Respiratory System in Chest Imaging: Pearls and Pitfalls

Purpose of Review

The purpose of this review is to describe the main features of the aging chest, studied through different imaging modalities.

Recent Findings

Aging-related changes of the respiratory system are inevitable. Therefore, it is mandatory to be familiar with the para-physiological changes that occurs, in order to avoid inappropriate interpretation of radiological findings that put patients at risk of over or undertreatment.

Summary

The role of the radiologist is fundamental in evaluating aging-related processes affecting the respiratory system and in distinguishing them from frank diseases.

Usefulness of lung ultrasound for selecting asymptomatic older patients with COVID 19 pneumonia

Clinical and prognostic differences between symptomatic and asymptomatic older patients with COVID-19 are of great interest since frail patients often show atypical presentation of illness. Lung Ultrasound (LUS) has been proven to be a reliable tool for detecting early-phase COVID-19 pneumonic alterations. The current prospective bicentric study aimed to compare LUS score and 3-month overall mortality between asymptomatic and symptomatic older patients with COVID-19, according to frailty status. Patients were stratified according to LUS score tertiles and Clinical Frailty Scale categories. Survival rate was assessed by telephone interviews 3 months after discharge. 64 symptomatic (24 women, aged 80.0 ± 10.8 years) and 46 asymptomatic (31 women, aged 84.3 ± 8.8 years) were consecutively enrolled. LUS score resulted an independent predictor of 3-month mortality [OR 2.27 (CI95% 1.09-4.8), p = 0.03], and the highest mortality rate was observed in symptomatic and asymptomatic pre-frail and frail patients (70.6% and 66.7%, respectively) with greater LUS abnormalities (3rd tertile). In conclusion, LUS identified an acute interstitial lung involvement in most of the older asymptomatic patients. Mortality rate progressively increased according to clinical frailty and LUS score degree, resulting a reliable prognostic tool in both symptomatic and asymptomatic patients.

Lung Ultrasound for Identification of Patients Requiring Invasive Mechanical Ventilation in COVID-19

OBJECTIVES

Indication for invasive mechanical ventilation in COVID-19 pneumonia has been a major challenge. This study aimed to evaluate if lung ultrasound (LUS) can assist identification of requirement of invasive mechanical ventilation in moderate to severe COVID-19 pneumonia.

MATERIALS AND METHODS

Between April 23 and November 12, 2020, hospitalized patients with moderate to severe COVID-19 (oxygen demand ≥4 L/min) were included consecutively. Lung ultrasound was performed daily until invasive mechanical ventilation (IMV-group) or spontaneous recovery (non-IMV-group). Clinical parameters and lung ultrasound findings were compared between groups, at intubation (IMV-group) and highest oxygen demand (non-IMV-group). A reference group with oxygen demand <4 L/min was examined at hospital admission.

RESULTS

Altogether 72 patients were included: 50 study patients (IMV-group, n = 23; non-IMV-group, n = 27) and 22 reference patients. LUS-score correlated to oxygen demand (SpO₂ /FiO₂ -ratio) (r = 0.728; p < .0001) and was higher in the IMV-group compared to the non-IMV-group (20.0 versus 18.0; p = .026). Based on receiver operating characteristic analysis, a LUS-score of 19.5 was identified as cut-off for requirement of invasive mechanical ventilation (area under the curve 0.68; sensitivity 56%, specificity 74%). In 6 patients, LUS identified critical coexisting conditions. Respiratory rate and oxygenation index ((SpO₂ /FiO₂ )/respiratory rate) ≥4.88 identified no requirement of invasive mechanical ventilation with a positive predictive value of 87% and negative predictive value of 100%.

CONCLUSIONS

LUS-score had only a moderate diagnostic value for requirement of invasive mechanical ventilation in moderate to severe COVID-19. However, LUS proved valuable as complement to respiratory parameters in guidance of disease severity and identifying critical coexisting conditions.

Point-of-Care Lung Ultrasound Pattern in Healthy Parturients: Prevalence of Pulmonary Interstitial Syndrome Following Vaginal Delivery, Elective and Unplanned Intrapartum Cesarean Delivery

BACKGROUND

Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmonary edema, with the risk of fluid extravasating into the pulmonary interstitium being potentially at a maximum during the early postpartum period. Data on the impact of labor and peripartum hemodynamic strain on lung ultrasound (LUS) are limited, and the prevalence of subclinical pulmonary interstitial syndrome in peripartum women is poorly described. The primary aim of this exploratory study was to estimate the prevalence of pulmonary interstitial syndrome in healthy term parturients undergoing vaginal (VD), elective (eCD), and unplanned intrapartum cesarean deliveries (uCD). Secondary aims were to estimate the prevalence of positive lung regions (≥3 B-lines on LUS per region) and to assess the associations between positive lung regions and possible contributing factors.

METHODS

In this prospective observational cohort study, healthy women at term undergoing VD, eCD, or uCD were enrolled. Following international consensus recommendations, a LUS examination was performed within 4 hours after delivery applying an 8-region technique. Pulmonary interstitial syndrome was defined by the presence of 2 or more positive lung regions per hemithorax. Ultrasound studies were reviewed by 2 blinded reviewers and assessed for interobserver reliability.

RESULTS

Seventy-five women were assessed (n = 25 per group). No pulmonary interstitial syndrome was found in the VD and eCD groups (each 0 of 25; 0%, 95% confidence interval [CI], 0-13.7). Pulmonary interstitial syndrome was found in 2 of 25 (8%, 95% CI, 1-26) women undergoing an uCD (P = .490 for VD versus uCD and P = .490 for eCD versus uCD). In 1 woman, this correlated clinically with the development of pulmonary edema. One or more positive lung regions were present in 5 of 25 (20%), 6 of 25 (24%), and 11 of 25 (44%) parturients following VD, eCD, and uCD, respectively (P = .136). Positive lung regions were predominantly found in lateral lung regions. The number of positive lung regions showed a weak correlation with patient age (r = 0.25, 95% CI, 0.05-0.47; P = .033). No significant association was found between LUS pattern and parity, duration of labor, labor augmentation, labor induction, estimated total intravenous fluid intake, or net intravenous fluid intake.

CONCLUSIONS

Although many focal areas of increased extravascular lung water (20%-44% prevalence) can be identified on LUS, the overall prevalence of pulmonary interstitial syndrome was 2.7% (2 of 75; 95% CI, 0.3-9.3) among healthy term parturients soon after delivery. Focal areas of positive lung water regions were weakly correlated with maternal age.

Response to a massive SARS-CoV-2 infection in a nursing home transformed into a caring center

BACKGROUND

The best policy to follow when nursing homes are massively hit by SARS-CoV2 is unclear.

AIM

To describe COVID-19 containment in a nursing home transformed into a caring center.

METHODS

Physicians and nurses were recruited. The facility was reorganized and connected with the laboratory of the reference hospital. Ultrasound was used to diagnose pneumonia. Patients needing intensive care were transferred to the reference hospital. Hydroxychloroquine/azithromycin/enoxaparin were used initially, while amiodarone/enoxaparin were used at a later phase. Under both regimens, methylprednisolone was added for severe cases. Prophylaxis was done with hydroxychloroquine initially and then with amiodarone.

PERIOD COVERED

March 22-July 31, 2020.

RESULTS

The facility was reorganized in two days. Ninety-two guests of the 121 (76%) and 25 personnel of 118 (21.1%) became swab test positive. Seven swab test negative patients who developed symptoms were considered to have COVID-19. Twenty-seven patients died, 23 swab test positive, 5 of whom after full recovery. Four patients needing intensive care were transferred (3 died). Mortality, peaking in April 2020, was correlated with symptoms, comorbidities, dyspnea, fatigue, stupor/coma, high neutrophil to lymphocyte ratio, C-reactive protein, interleukin-6, pro-calcitonin, and high oxygen need (p ≤ 0.001 for all). Among swab-positive staff, 3 had pneumonia and recovered. Although no comparison could be made between different treatment and prophylaxis strategies, potentially useful suggestions emerged. Mortality compared well with that of nursing homes of the same area not transformed into care centers.

CONCLUSION

Nursing homes massively hit by SARS-CoV-2 can become caring centers for patients not needing intensive care.

Pneumonia Lung Ultrasound Score (PLUS): A New Tool for Detecting Pneumonia in the Oldest Patients

OBJECTIVES

To compare the diagnostic accuracy of lung ultrasound (LUS) and standard chest X-ray (CXR) in older patients admitted to an acute-care geriatric ward for suspected acute pneumonia, and to develop an easy-to-use diagnostic tool, now called Pneumonia Lung Ultrasound Score (PLUS), for early risk stratification.

DESIGN

Prospective, single-center, cohort study.

SETTING

Acute-care geriatric ward of tertiary care center.

PARTICIPANTS

Individuals, aged 65 years and older, with suspected acute pneumonia.

MEASUREMENTS

Participants were stratified according to the Multidimensional Prognostic Index. All the patients underwent CXR and LUS, whereas chest computed tomography was performed in case of mismatch between LUS and CXR. Using logistic multivariate regression, we assessed the influence of age, sex, multimorbidity, cognitive impairment, and clinical biomarkers in the misdiagnosis of acute pneumonia. Finally, an easy-to-perform diagnostic tool based on the combination of biomarkers (brain natriuretic peptide, high-sensitivity C-reactive protein, and partial pressure arterial oxygen/fraction of inspired oxygen ratio) and LUS was realized. A receiver operating characteristic curve was used to verify the predictive accuracy of PLUS, CXR, and LUS in pneumonia diagnosis.

RESULTS

A total of 132 subjects (69% women; mean age = 85.3 ± 6.9 years) were enrolled in the study. Acute pneumonia was diagnosed in 94 of 132 cases. LUS showed higher diagnostic accuracy compared with CXR (0.91 (95% confidence interval (CI) = 0.85-0.93) vs 0.67 (95% CI = 0.58-0.75)) in detecting pneumonic consolidations. A higher degree of cognitive impairment was associated with both LUS and CXR pneumonia misdiagnosis (odds ratio = 1.30 (95% CI = 1.04-1.65)). PLUS showed higher predictive accuracy in the diagnosis of acute pneumonia compared with LUS (AUC = 0.92 (95% CI = 0.87-0.98) vs 0.86 (95% CI = 0.80-0.96); P = .029).

CONCLUSIONS

This study confirms the higher diagnostic accuracy of LUS compared with CXR for acute pneumonia in older adults. Nonetheless, the accuracy of PLUS, an easy-to-use, biomarker-derived diagnostic tool, was superior to LUS regardless of patients' degree of frailty.

The chest CT features of coronavirus disease 2019 (COVID-19) in China: a meta-analysis of 19 retrospective studies

OBJECTIVE

Aimed to summarize the characteristics of chest CT imaging in Chinese hospitalized patients with Coronavirus Disease 2019 (COVID-19) to provide reliable evidence for further guiding clinical routine.

METHODS

PubMed, Embase and Web of Science databases were searched to identify relevant articles involving the features of chest CT imaging in Chinese patients with COVID-19. All data were analyzed utilizing R i386 4.0.0 software. Random-effects models were employed to calculate pooled mean differences.

RESULTS

19 retrospective studies (1332 cases) were included. The results demonstrated that the combined proportion of ground-glass opacities (GGO) was 0.79 (95% CI 0.68, 0.89), consolidation was 0.34 (95% CI 0.23, 0.47); mixed GGO and consolidation was 0.46 (95% CI 0.37; 0.56); air bronchogram sign was 0.41 (95% CI 0.26; 0.55); crazy paving pattern was 0.32 (95% CI 0.17, 0.47); interlobular septal thickening was 0.55 (95% CI 0.42, 0.67); reticulation was 0.30 (95% CI 0.12, 0.48); bronchial wall thickening was 0.24 (95% CI 0.11, 0.40); vascular enlargement was 0.74 (95% CI 0.64, 0.86); subpleural linear opacity was 0.28 (95% CI 0.12, 0.48); intrathoracic lymph node enlargement was 0.03 (95% CI 0.00, 0.07); pleural effusions was 0.03 (95% CI 0.02, 0.06). The distribution in lung: the combined proportion of central was 0.05 (95% CI 0.01, 0.11); peripheral was 0.74 (95% CI 0.62, 0.84); peripheral involving central was 0.38 (95% CI 0.19, 0.75); diffuse was 0.19 (95% CI 0.06, 0.32); unifocal involvement was 0.09 (95% CI 0.05, 0.14); multifocal involvement was 0.57 (95% CI 0.48, 0.68); unilateral was 0.16 (95% CI 0.10, 0.23); bilateral was 0.83 (95% CI 0.78, 0.89); The combined proportion of lobes involved (> 2) was 0.70 (95% CI 0.61, 0.78); lobes involved (≦ 2) was 0.35 (95% CI 0.26, 0.44).

CONCLUSION

GGO, vascular enlargement, interlobular septal thickening more frequently occurred in patients with COVID-19, which distribution features were peripheral, bilateral, involved lobes > 2. Therefore, based on chest CT features of COVID-19 mentioned, it might be a promising means for identifying COVID-19.

Is bronchiectasis really a disease?

The definition of a disease requires that distinguishing signs and symptoms are present that are common, and that the constellation of signs and symptoms differentiate the condition from other causes. In bronchiectasis, anatomical changes, airways inflammation and airway infection are the distinguishing features that are common to this disease. However, bronchiectasis is a heterogenous disease: signs and symptoms are shared with other airway diseases, there are multiple aetiologies and certain phenotypes of bronchiectasis have distinct clinical and laboratory features that are not common to all people with bronchiectasis. Furthermore, response to therapeutic interventions in clinical trials is not uniform. The concept of bronchiectasis as a treatable trait has been suggested, but this may be too restrictive in view of the heterogeneity of bronchiectasis. It is our opinion that bronchiectasis should be defined as a disease in its own right, but one that shares several pathophysiological features and "treatable traits" with other airway diseases. These traits define the large heterogeneity in the pathogenesis and clinical features and suggest a more targeted approach to therapy.

Use of ultrasonography for differentiation between bullae and pneumothorax

PURPOSE

Modern lung ultrasound (US) is mainly applied not only in critical care, emergency medicine, and trauma surgery, but also in pulmonary and internal medicine. In some cases, pneumothorax (PTX) distinguishes with bullous diseases. In this study, we aimed to discuss the success of US on detecting PTX versus bullae.

METHODS

We performed a prospective blinded study. Patients underwent thorax computed tomography (CT) if bullae or pneumothorax could not be differentiated from the chest radiography. An emergency medicine specialist trained in lung US and unaware of x-ray and CT findings performed US. All patients US performed from anterior and lateral wall.

RESULTS

Final study population included 81 patients. The sensitivity of the presence of pleural sliding in the diagnosis of bullae was 97.50% (86.84-99.94%), and specificity was 100.0% (91.4-100.0%).

CONCLUSION

In conclusion, direct visualisation of ultrasonographic pleural sliding can be a good tool for differentiating bullae and pneumothorax.

Accuracy of Lung Ultrasound in Patients with Acute Dyspnea: The Influence of Age, Multimorbidity and Cognitive and Motor Impairment

Discriminating between causes of dyspnea may be difficult, particularly in the elderly. The aim of this retrospective study of 83 inpatients with acute dyspnea was to assess the influence of age, multimorbidity and cognitive or motor impairment on the diagnostic accuracy of lung ultrasound (LUS) in discriminating acute heart failure (AHF) from noncardiogenic dyspnea (NCD). Univariate analysis indicates that LUS misdiagnosis was associated with the following parameters: history of stroke (p = 0.037), lower activity of daily living (p = 0.039), higher modified-Rankin scale (mRS) (p = 0.027) and need of two operators to complete LUS because of reduced patient compliance (p = 0.030). Regression analysis identified only history of stroke (p = 0.048) as an independent predictor of LUS misdiagnosis. This study supports LUS usefulness to differentiate AHF from NCD. Our data suggest that diagnostic accuracy of LUS is affected by history of stroke as a proxy for severe motor impairment but not by age, cognitive impairment and multimorbidity.

Thoracic ultrasound: A complementary diagnostic tool in cardiology

Clinical assessment and workup of patients referred to cardiologists may need an extension to chest disease. This requires more in-depth examination of respiratory co-morbidities due to uncertainty or severity of the clinical presentation. The filter and integration of ecg and echocardiographic information, addressing to the clues of right ventricular impairment, pulmonary embolism and pulmonary hypertension, and other less frequent conditions, such as congenital, inherited and systemic disease, usually allow more timely diagnosis and therapeutic choice. The concurrent use of thoracic ultrasound (TUS) is important, because, despite the evidence of the strict links between cardiac and respiratory medicine, heart and chest US imaging approaches are still separated. Actually, available expertise, knowledge, skills and training and equipment’s suitability are not equally fitting for heart or lung examination and not always already accessible in the same room or facility. Echocardiography is useful for study and monitoring of several respiratory conditions and even detection, so that this is nowadays an established functional complementary tool in pulmonary fibrosis and diffuse interstitial disease diagnosis and monitoring. Extending the approach of the cardiologist to lung and pleura will allow the achievement of information on pleural effusion, even minimal, lung consolidation and pneumothorax. Electrocardiography, pulse oximetry and US equipment are the friendly extension of the physical examination, if their use relies on adequate knowledge and training and on appropriate setting of efficient and working machines. Lacking these premises, overshadowing or misleading artefacts may impair the usefulness of TUS as an imaging procedure.

Thoracic ultrasound: An adjunctive and valuable imaging tool in emergency, resource-limited settings and for a sustainable monitoring of patients

Imaging workup of patients referred for elective assessment of chest disease requires an articulated approach: Imaging is asked for achieving timely diagnosis. The concurrent or subsequent use of thoracic ultrasound (TUS) with conventional (chest X-rays-) and more advanced imaging procedures (computed tomography and magnetic resonance imaging) implies advantages, limitations and actual problems. Indeed, despite TUS may provide useful imaging of pleura, lung and heart disease, emergency scenarios are currently the most warranted field of application of TUS: Pleural effusion, pneumothorax, lung consolidation. This stems from its role in limited resources subsets; actually, ultrasound is an excellent risk reducing tool, which acts by: (1) increasing diagnostic certainty; (2) shortening time to definitive therapy; and (3) decreasing problems from blind procedures that carry an inherent level of complications. In addition, paediatric and newborn disease are particularly suitable for TUS investigation, aimed at the detection of congenital or acquired chest disease avoiding, limiting or postponing radiological exposure. TUS improves the effectiveness of elective medical practice, in resource-limited settings, in small point of care facilities and particularly in poorer countries. Quality and information provided by the procedure are increased avoiding whenever possible artefacts that can prevent or mislead the achievement of the correct diagnosis. Reliable monitoring of patients is possible, taking into consideration that appropriate expertise, knowledge, skills, training, and even adequate equipment’s suitability are not always and everywhere affordable or accessible. TUS is complementary imaging procedure for the radiologist and an excellent basic diagnostic tool suitable to be shared with pneumologists, cardiologists and emergency physicians.