Lung ultrasound in the critically ill

Point-of-care ultrasonography in nephrology: Growing applications, misconceptions and future outlook

Ultrasound has long been an essential tool in nephrology, traditionally used for procedures like vascular access and kidney biopsies. Point-of-care ultrasonography (POCUS), a rapidly evolving bedside technology, is now gaining momentum in nephrology by providing real-time imaging to enhance physical examination findings. Unlike comprehensive radiology-performed ultrasound, POCUS focuses on specific clinical questions, providing immediate and actionable insights. This narrative review examines the philosophy behind POCUS, its expanding applications in nephrology, and its impact on patient care, including its role in diagnosing obstructive uropathy, guiding fluid management, and evaluating hemodynamics in cardiorenal syndrome. Additionally, the review addresses barriers to widespread adoption, such as the need for structured training, competency validation, and interdisciplinary cooperation. By integrating POCUS into routine practice, nephrologists can refine diagnostic accuracy, improve patient outcomes, and strengthen the role of bedside medicine.

Interrater Agreement of Physicians Identifying Lung Sliding Artifact on B-Mode And M-Mode Point of Care Ultrasound (POCUS)

Background

Chest point of care ultrasound (POCUS) is a first-line diagnostic test to identify lung sliding, an important artifact to diagnose or rule out pneumothorax. Despite enthusiastic adoption of this modality, the interrater reliability for physicians to identify lung sliding is unknown. Additionally, the relative diagnostic performance of physicians interpreting B-mode and M-mode ultrasound is unclear. We sought to determine the interrater reliability of physicians to detect lung sliding on B-mode and M-mode POCUS.

Methods

We performed a cross-sectional interrater agreement study surveying acute care physicians on their interpretation of 20 B-mode and M-mode POCUS clips. Two experienced clinicians determined the reference standard diagnosis. Respondents reported their interpretation of each POCUS B-mode clip or M-mode image. The primary outcome was the interrater agreement, determined by an intra-class correlation coefficient (ICC).

Results

From September to November 2023, there were 20 survey respondents. Fourteen (70%) respondents were resident physicians. Respondents were confident or very confident in their skill performing chest POCUS in 14 (70%) cases, with 19 (90%) performing chest POCUS every week or more frequently. The ICC on B-mode was 0.44 and for M-mode was 0.43, indicating moderate agreement. There were no significant differences in interrater reliability between subgroups of confidence or experience.

Conclusion

There is only moderate interrater reliability between clinicians to diagnose lung sliding. Clinicians have superior accuracy on B-mode compared to M-mode clips.

Prognostication and integration of bedside lung ultrasound and computed tomography imaging findings with clinical features to Predict COVID-19 In-hospital mortality and ICU admission

INTRODUCTION

Bedside lung ultrasound (LUS) and computed tomography (CT) imaging are valuable modalities in screening and diagnosis of pulmonary diseases. This study aims to investigate the prognostic value of integrating LUS and CT imaging findings with clinical features to predict poor outcomes upon ER admission in COVID-19.

METHODS

Patients visiting the study center with clinical presentation and laboratory findings compatible with COVID-19 between April 2020 to January 2022 were considered for this study. Several imaging findings (ground glass opacity, consolidation, atelectatic bands, mosaic attenuation, ARDS pattern, crazy paving, pleural thickening in CT and A-line, comet-tail artifact, confluent B-Line in BLUS, pleural thickening and Consolidation in both modalities) were evaluated, alongside clinical assessments upon admission, to assess their prognostic value. The top radiological, LUS findings, and clinical signs were integrated in a nomogram for predicting mortality.

RESULTS

A total of 1230 patients were included in the analyses. Among the findings, consolidation in BLUS and CT imaging, and absence of A-lines were associated with mortality. In addition to these findings, ground-glass opacities, atelectatic band, mosaic attenuation, crazy paving, and confluent B-line were also associated with ICU hospitalization. Although, the prognostic value of individual markers was poor and comparable (AUC < 0.65), the combined use of top clinical and imaging findings in the associated nomogram led to a high accuracy in predicting mortality (Area under curve: 87.3%).

CONCLUSIONS

BLUS and CT imaging findings alone provide limited utility in stratifying patients for higher mortality and ICU admission risk and should not be used for risk stratification alone outside the context of each patient and their clinical presentations in suspected COVID-19 patients.

Lung Ultrasound in Critical Care: A Narrative Review

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

Lung Ultrasound as a Tool for Analysis of Ventilation in Children With Respiratory Failure

OBJECTIVE

To describe lung ultrasound findings in children with respiratory failure on invasive mechanical ventilation (MV).

METHOD

This is a longitudinal, observational, quantitative study conducted in the pediatric intensive care unit. Children with respiratory distress syndrome, aged between 6 months and 7 years, on invasive MV were included in the study. Lung ultrasound was performed using the BLUE protocol in the first 48 h of hospitalization and during ventilatory weaning.

RESULTS

Seventeen patients who presented a significant reduction in A lines were included in the study. B lines showed worsening, indicating possible pulmonary complications. The decrease in pleural sliding from 14 to 3 (p = 0.04) and in the bat sign from 10 to 5 (p = 0.002) was statistically significant. The stratospheric sign showed a favorable trend (reduction from 3 to 0), but the p value of 0.08 was not significant. There was a moderate negative correlation between MV time and A lines, while a moderate positive correlation was observed between MV time and A lines. Furthermore, a moderate negative correlation between MV time and bat sign was also significant.

CONCLUSION

It is indicated that bedside lung ultrasound is a valuable tool for monitoring and management of children on invasive MV, allowing the follow-up of critical pediatric patients during the hospitalization period.

Lung Ultrasound for the Assessment of Patients With Acute Respiratory Failure

ABSTRACT

Lung ultrasound has become a standard practice in acute care as an adjunct to the physical exam, providing valuable insights to guide clinical decision making at the point of care. Lung ultrasound can rapidly uncover anatomic detail, help resolve undifferentiated respiratory failure, and delineate equivocal findings on standard plain film without the need for transport to access additional diagnostic imaging. In the following review, basic concepts of lung ultrasound are reviewed including its role in detecting and assessing a variety of common problems.

Transfer of POCUS Skills of Anesthesia Trainees from the Simulation Laboratory to Clinical Practice: A Follow-Up Pilot Evaluation After ABC US Protocol Training

Background/objectives: Point-of-care ultrasound (POCUS) in the intensive care unit (ICU) has gained much attention in the last few years as an alternative to the classic ways of assessing and diagnosing life-threatening conditions in critical patients. During the COVID-19 pandemic, we proposed a POCUS protocol based on the airway, breathing, and circulation (ABC) approach to quickly evaluate and diagnose life-threatening diseases in critical patients with acute respiratory failure and shock, and later, we used it as a curriculum to teach POCUS to anesthesia and intensive care trainees. Methods: We developed an evaluation protocol where evaluators with experience in POCUS in critically ill patients had to assess the trainee's ultrasound scan; this was based on the ABC protocol taught in the simulation laboratory and applied in a clinical setting at the bedside. Results: Statistically significant differences were observed in some categories evaluated regarding independence and diagnosis. Conclusion: Initial POCUS simulation-based training using an ABC POCUS protocol (that demonstrated good results in the simulation laboratory) is useful when transferring US skills to the bedside and is applicable in daily clinical practice with good results in terms of operator independence.

Ultrasonographic view of fluid bronchogram secondary to endobronchial obstruction: A case report

Background

Ultrasound has become an important aspect of emergency medicine due to its wide availability and portability for bedside investigations. Understanding some important ultrasound findings can aid in diagnosis and management.

Key findings

We present a case of a 65-year-old smoker who presented with shortness of breath and hemoptysis and was in respiratory failure upon arrival in the emergency department. Bedside ultrasound demonstrated a fluid bronchogram, aiding the diagnosis of lung collapse secondary to endobronchial obstruction.

Discussion

Fluid bronchograms are seen on CT chest and ultrasonography as linear images corresponding to dilated bronchus, filled with mucus, distal to an endobronchial obstruction. They are characterised by anechoic, tubular structures, suggestive of fluid filled bronchi, over the hypoechogenic pulmonary parenchyma, and can be differentiated from blood vessels by the lack of Doppler signal. Ultrasonographic image of fluid bronchogram is very unique and can help to detect collapse secondary to endobronchial obstruction using point-of-care ultrasonography in emergency.

Effects of Hook Maneuver on Oxygen Saturation Recovery After -40 m Apnea Dive-A Randomized Crossover Trial

To reduce the risk of syncope, trained breath-hold divers (BHDs) use a specialized breathing technique after surfacing called "hook breathing" (HB). It consists of a full inspiration followed by a Valsalva-like maneuver and with subsequent exhalation performed against resistance to generate continuous positive airway pressure during exhalation. This study analyzed the influence of HB on oxygen saturation recovery after a -40 m depth apnea dive in trained BHDs. Thirteen BHDs performed two dives to -40 m at different days, one followed by HB after a dive and the other using usual breathing (UB). To detect signs of lung edema, ultrasound B-line measurements were conducted before, 10 min after the dive, and within 1 h after the dive. To detect oxygen saturation recovery, pulse oximetry was recorded before and immediately after surfacing. Both groups exhibited significant increases in SpO2 over time (UB: F (2.25, 24.7) = 22.1, p < 0.001, ηg2 = 0.612; HB: F (2.11, 23.2) = 29.0, p < 0.001, ηg2 = 0.688). Significant differences in SpO2 were observed between the HB and UB groups at 30-45 s post-apnea, with higher SpO2 values in the HB group; between 1.64 and 5.08% of SpO2 in favor of the HB intervention. Four participants showed ultrasound B-lines within ten minutes post-dive. After a 40 m apnea dive, the results revealed significant SpO2 recovery from 30 s to 45 s, with the HB recovering more rapidly. No differences were found at earlier (10-25 s) or later time points (50-60 s).

Inter-rater agreement and characterization of pleural line and subpleural fields in canine lung ultrasound: a comparative pilot study between high-frequency linear and curvilinear transducers using B- and M-mode ultrasonographic profiles

BACKGROUND

Lung ultrasound (LUS) is increasingly utilized in veterinary medicine to assess pulmonary conditions. However, the characterization of pleural line and subpleural fields using different ultrasound transducers, specifically high-frequency linear ultrasound transducers (HFLUT) and curvilinear transducers (CUT), remains underexplored in canine patients. This study aimed to evaluate inter-rater agreement in the characterization of pleural line and subpleural fields using B- and M-mode ultrasonography in dogs with and without respiratory distress.

RESULTS

Eighty-eight ultrasound clips from nine dogs were analyzed. HFLUT demonstrated strong inter-rater agreement in B-mode (κ = 0.89) and near-perfect agreement in M-mode (κ = 1.00) for pleural line homogeneity. In contrast, CUT showed minimal agreement in both B-mode (κ = 0.34) and M-mode (κ = 0.37). Homogeneous pleural lines were predominantly observed in control dogs or those with cardiogenic pulmonary edema (CPE), while non-homogeneous pleural lines were more common in dogs with non-cardiogenic alveolar-interstitial syndrome (NCAIS). Vertical subpleural fields identified in M-mode were associated with both CPE and NCAIS, whereas horizontal fields were more often observed in control dogs.

CONCLUSIONS

HFLUT offers superior inter-rater reliability for characterizing pleural and subpleural features in canine LUS compared to CUT, particularly in M-mode. These findings suggest HFLUT may enhance diagnostic accuracy for pulmonary conditions in dogs. Further studies are needed to explore the diagnostic potential of LUS in differentiating vertical artifact (e.g., B-lines) etiologies in veterinary patients.

Point-of-Care Lung Ultrasound in Small Animal Emergency and Critical Care Medicine: A Clinical Review

Thoracic point-of-care ultrasound (T-POCUS) has grown in popularity and usage in small animal emergencies and critical care settings due to its non-invasive nature, mobility, and ability to acquire images in real time. This review summarizes current understanding about T-POCUS in dogs and cats with respiratory illnesses, including normal thoracic ultrasonography appearance and numerous pathological situations. The basics of T-POCUS are covered, including equipment, scanning procedures, and picture settings. Practical applications in patients with respiratory distress are discussed, with an emphasis on pleural space abnormalities and lung diseases. Ultrasound results define pulmonary disorders such as pneumonia, atelectasis, cardiogenic and non-cardiogenic pulmonary edema, lung lobe torsion, pulmonary fibrosis, pulmonary thromboembolism, pulmonary neoplasms, and pulmonary bleeding. The evaluation focuses on T-POCUS diagnostic skills in a variety of clinical settings. Limitations and the need for more study to standardize techniques, establish agreed terminology, and create specialized educational routes are highlighted.

Ultrasound Lung Aeration Map via Physics-Aware Neural Operators

Lung ultrasound is a growing modality in clinics for diagnosing and monitoring acute and chronic lung diseases due to its low cost and accessibility. Lung ultrasound works by emitting diagnostic pulses, receiving pressure waves and converting them into radio frequency (RF) data, which are then processed into B-mode images with beamformers for radiologists to interpret. However, unlike conventional ultrasound for soft tissue anatomical imaging, lung ultrasound interpretation is complicated by complex reverberations from the pleural interface caused by the inability of ultrasound to penetrate air. The indirect B-mode images make interpretation highly dependent on reader expertise, requiring years of training, which limits its widespread use despite its potential for high accuracy in skilled hands. To address these challenges and democratize ultrasound lung imaging as a reliable diagnostic tool, we propose Luna (the Lung Ultrasound Neural operator for Aeration), an AI model that directly reconstructs lung aeration maps from RF data, bypassing the need for traditional beamformers and indirect interpretation of B-mode images. Luna uses a Fourier neural operator, which processes RF data efficiently in Fourier space, enabling accurate reconstruction of lung aeration maps. From reconstructed aeration maps, we calculate lung percent aeration, a key clinical metric, offering a quantitative, reader-independent alternative to traditional semi-quantitative lung ultrasound scoring methods. The development of Luna involves synthetic and real data: We simulate synthetic data with an experimentally validated approach and scan ex vivo swine lungs as real data. Trained on abundant simulated data and fine-tuned with a small amount of real-world data, Luna achieves robust performance, demonstrated by an aeration estimation error of 9% in ex-vivo swine lung scans. We demonstrate the potential of directly reconstructing lung aeration maps from RF data, providing a foundation for improving lung ultrasound interpretability, reproducibility and diagnostic utility.

The Role of Ultrasound in Bedside Procedures

Ultrasound guidance for bedside procedures improves rates of success while reducing complications. It is the standard of care for most bedside procedures and has ever-increasing utility for peri-procedural assessment. Herein, we provide a concise description with associated images and videos detailing the proper technique for ultrasound image acquisition and interpretation, along with common pitfalls to be avoided.

Deep phenotyping of pulmonary edema and pulmonary vascular permeability in COVID-19 ARDS

Clinical monitoring of pulmonary edema due to vascular hyperpermeability in acute respiratory distress syndrome (ARDS) poses significant clinical challenges. Presently, no biological or radiological markers are available for quantifying pulmonary edema. Our aim was to phenotype pulmonary edema and pulmonary vascular permeability in patients with coronavirus disease 2019 (COVID-19) ARDS. Transpulmonary thermodilution measurements were conducted in 65 patients with COVID-19 ARDS on the day of intubation to determine the extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPi). In parallel, ventilatory parameters, clinical outcomes, the volume of lung opacity measured by chest computed tomography (CT), radiographic assessment of lung edema (RALE) score by chest radiography, and plasma proteomics (358 unique proteins) were compared between tertiles based on the EVLWi and PVPi. Regression models were used to associate EVLWi and PVPi with plasma, radiological, and clinical parameters. Computational pathway analysis was performed on significant plasma proteins in the regression models. Patients with the highest EVLWi values at intubation exhibited poorer oxygenation parameters and more days on the ventilator. Extravascular lung water strongly correlated with the total volume of opacity observed on CT (r = 0.72, P < 0.001), whereas the PVPi had weaker associations with clinical and radiological parameters. Extravascular lung water did not correlate with the RALE score (r = 0.15, P = 0.33). Plasma protein concentrations demonstrated a stronger correlation with PVPi than with EVLWi. The highest tertile of PVPi was associated with proteins linked to the acute phase response (cytokine and chemokine signaling) and extracellular matrix turnover. In the clinical setting of COVID-19 ARDS, pulmonary edema (EVLWi) can be accurately quantified through chest CT and parallels deterioration in ventilatory parameters and clinical outcomes. Vascular permeability (PVPi) is strongly reflected by inflammatory plasma proteins.NEW & NOTEWORTHY This study is unique in that it phenotypes pulmonary edema in COVID-19 ARDS using various clinical parameters and biomarkers. First, there is a noteworthy tipping point in the amount of pulmonary edema at which ventilatory and clinical parameters deteriorate. Second, chest CT gives a good approximation of the amount of pulmonary edema. Finally, pulmonary vascular permeability is strongly reflected by inflammatory plasma proteins.

Ultrasound for body composition assessment: a narrative review

Ultrasound has become an increasingly valuable tool for the assessment of body composition, offering several applications and indications in clinical practice. Ultrasound allows bedside evaluation of muscle mass, fat compartments, and extravascular water, providing a cost-effective, portable, and accessible alternative to traditional methods, such as Dual-energy X-ray Absorptiometry (DEXA), Bioelectrical Impedance Analysis (BIA), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). It is particularly useful in evaluating conditions, such as malnutrition, sarcopenia, and sarcopenic obesity, which require poor muscle mass to establish a diagnosis. The potential uses of ultrasound in body composition assessment include measurement of muscle thickness, cross-sectional area, pennation angle, and echo-intensity, which are indicative of muscle health. Additionally, ultrasound can be used to evaluate various fat compartments, including visceral, subcutaneous, and ectopic fat, which are important for understanding metabolic health and cardiovascular risk. However, the widespread adoption of ultrasound is challenged by the lack of standardized measurements and the absence of ultrasound measures in the validated diagnostic criteria. This article reviews the current applications of ultrasound in body composition assessment, highlighting the recent advancements and the correlation between ultrasound parameters and clinical outcomes. It discusses the advantages of ultrasound while also addressing its limitations, such as the need for standardized protocols and cut-off points. By providing a comprehensive update based on recent publications, this article aims to enhance the clinical utility of ultrasound in assessing and monitoring body composition and pave the way for future research in this field.

Thoracic ultrasound for diagnosing pneumopathies in neotropical primates

Lung ultrasound can be useful for the early diagnosis and treatment of respiratory complications. The combination of air and soft tissue confirms imaging artefacts that can contribute to differentiation between healthy and deteriorated lung tissue. Although non-human primates are often chosen as research models due to their anatomical and physiological similarity to humans, there is a lack of data on the use of lung ultrasound in these individuals. The aim of this study was to evaluate the contribution of ultrasound examinations of the thoracic region of Callithrix sp. for diagnosing pneumopathy. Parameters were obtained from 166 new world non-human primates of both sexes, aged between 1 and 15 years and weighing between 128 g and 680 g kept under human care at the Mucky Project in Itu, São Paulo. Thoracic ultrasound examinations were carried out using a LOGIQe-R7 device (GE, United States), with a 10-22 MHz linear transducer, at four points on the left and right antimeres. Among these 166 individuals, 72 had some kind of pulmonary alteration. Forty-one of the animals with pulmonary alterations diagnosed on ultrasound died and underwent necropsy. Histopathological examination showed that in half of the samples the lung tissue was compatible with some form of pneumopathy. Considering these cases, the pulmonary alterations diagnosed through thoracic ultrasound examination in Callithrix sp. can be correlated with the occurrence of pneumopathy, which is often asymptomatic. Lung ultrasound is an important tool for use in clinics to detect and monitor respiratory diseases and can save lives by enabling early treatment.

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

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

Automatic B-lines: a tool for minimizing time to diuretic administration in pulmonary edema patients in the emergency department of a developing country

BACKGROUND

Effective management of pulmonary edema in the emergency department (ED) is crucial given its significant global impact on health. This study aimed to investigate the hypothesis: "Does the utilization of Automatic B-lines via ultrasonography in patients with pulmonary edema facilitate faster diuretic administration in a developing country?"

METHODS

This retrospective observational study was conducted at a tertiary academic center in Thailand. Patients with pulmonary edema admitted to the ED between January 2023 and June 2024 were enrolled. Ultrasound documentation and electronic ED medical records were compared to assess the time of diuretic administration between patients who had lung ultrasounds utilizing automatic B-lines and those who had manual B-lines counted by physician eye inspection. Multivariate logistic regression was employed to examine the relationship between the use of automatic B-lines and early diuretic administration.

RESULTS

The study included 134 patients with pulmonary edema. The time to diuretic administration was significantly shorter in the automatic B-lines group (median time [Q1-Q3], 55 min; range, 35-110 min) compared to the non-automatic B-lines group (median time, 100 min; range, 75-145 min). In the multivariable logistic regression analysis, early diuretic administration within 60 min of triage was significantly more likely in the automatic B-lines group (adjusted odds ratio, 1.45; 95% confidence interval, 1.10-2.45) than in the non-automatic B-lines group.

CONCLUSIONS

In a developing country, patients with pulmonary edema who had lung ultrasound evaluation with automated B lines experienced a fastest diuresis compared to those who utilized ultrasonography without automatic B lines. Implementing automatic B-lines as an early screening protocol could enhance clinical practice in the ED.

Imaging in acute percutaneous mechanical circulatory support in adults: a clinical consensus statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC and the European branch of the Extracorporeal Life Support Organization (EuroELSO)

The use of temporary mechanical circulatory support (tMCS) in cardiogenic shock patients has increased during the last decades with most management strategies relying on observational studies and expert opinion, including hemodynamic monitoring, device selection, and timing of support institution/duration. In this context, imaging has a pivotal role throughout the patient pathway, from identification to initiation, monitoring, and weaning. This manuscript summarizes the consensus of an expert panel from the European Society of Cardiology Association for Acute CardioVascular Care, the European Association of CardioVascular Imaging, and the European Extracorporeal Life Support Organization, providing the rationale for and practical guidance of imaging to tMCS based on existing evidence and consensus on best current practice.

A nursing-led sepsis response team guiding resuscitation with point-of-care ultrasound: A review and model for improving bundle compliance while individualizing sepsis care

A dysregulated host response to infection resulting in life-threatening organ dysfunction defines the onset of sepsis. Unfortunately, sepsis is common, costly, and deadly. The Surviving Sepsis Campaign publishes regularly updated, evidence-informed, detection, and treatment guidelines culminating in time-sensitive care "bundles." The goal of these bundles is to expedite sepsis recognition because it is widely held that early treatment is life-saving. Hospitals are mandated to publicly report their bundle compliance, and this will soon be tied to hospital reimbursement. For these reasons, hospitals are creating sepsis emergency response teams which are a form of a rapid response team consisting of dedicated medical professionals who evaluate patients with suspected sepsis and initiate therapy when appropriate. Evidence to date support sepsis emergency response teams as a mechanism to improve bundle compliance, and potentially, patient outcome. Nevertheless, some elements of bundled sepsis care are controversial (e.g., intravenous fluid administration) as some argue that mandated treatment precludes personalized care. Herein, we briefly describe general sepsis emergency response team structure, review evidence supporting sepsis emergency response teams to improve bundle compliance and patient outcome and report our unique experience incorporating point of care ultrasound-to guide intravenous fluid-into a nursing-led sepsis team. We propose that our sepsis emergency response team approach allays concern that sepsis care is either bundled or personalized. Instead, incorporating point of care ultrasound into a nursing-led sepsis emergency response team increases bundle compliance and individualizes care.

Malignant Pleural Effusion: Diagnosis and Treatment-Up-to-Date Perspective

Malignant pleural effusion is the presence of malignant cells within the pleural fluid, representing the second most common cause of pleural exudate. Although diagnostic methods and management techniques for malignant pleural effusion have dramatically improved over the decades, the current treatment is still palliative, aiming to remove pleural fluid, possibly prevent its recurrence, and alleviate symptoms through a wide range of available procedures. Treatment should be tailored to the individual patient, considering comorbidities, size of the effusion, rate of fluid accumulation, underlying cardiac or respiratory conditions, rate of recurrence, presence of loculations or trapped lung, tumor characteristics, cancer type, and patient preferences. This manuscript aims to review the available literature and to present the latest evidence on malignant pleural effusion management in order to provide an updated perspective on its diagnosis and treatment.

Airway and Thoracic Ultrasound

Airway and thoracic ultrasound applications can provide critical information to improve patient safety for procedures and management of pulmonary conditions. Emergency physicians should utilize airway ultrasound in the preparation for an anatomically and/or physiologically difficult airway, which may include site demarcation for surgical airway planning. Thoracic ultrasound is useful in the prompt evaluation of a dyspneic patient. This article underscores the crucial role of airway and thoracic ultrasound in emergency medicine, emphasizing its utility for assessing difficult airways, planning surgical airways, and promptly evaluating dyspneic patients.

Managing Multiorgan Failure in Acute on Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is defined as a clinical syndrome that develops in patients with chronic liver disease characterized by the presence of organ failure and high short-term mortality, although there is still no worldwide consensus on diagnostic criteria. Management of ACLF is mainly based on treatment of "precipitating factors" (the most common are infections, alcohol-associated hepatitis, hepatitis B flare, and bleeding) and support of organ failure, which often requires admission to the intensive care unit. Liver transplantation should be considered in patients with ACLF grades 2 to 3 as a potentially life-saving treatment. When a transplant is not indicated, palliative care should be considered after 3 to 7 days of full organ support in patients with at least four organ failures or a CLIF-C ACLF score of >70. This review summarizes the current knowledge on the management of organ failure in patients with ACLF, focusing on recent advances.

Lower limit of normal of cross-sectional area of peripheral muscles and diaphragm measurements performed with ultrasound in full-term and preterm infants

To stratify groups of infants by gestational age and identify the lower limit of normal (LLN) of the cross-sectional area of peripheral muscles as well as diaphragmatic excursion and thickness and parasternal activation during spontaneous respiration in full-term and preterm newborns. A cross-sectional study was conducted at a neonatal unit. Preterm newborns (PTNBs) with gestational age of 28 to 366/7 weeks and full-term newborns (NBs) with gestational age of 37 to 416/7 weeks, clinically and hemodynamically stable, breathing ambient air with no signs of respiratory distress were included. NBs on oxygen therapy, those with known genetic syndromes, malformations of the nervous system and those having undergone surgery were excluded. Ultrasound was performed over the rectus femoris, tibialis anterior, and biceps brachii muscles (cross-sectional area) and diaphragm (thickness and excursion). One hundred twenty NBs were stratified based on gestational age (< 30 weeks [n = 25]; 31 to 35 weeks [n = 51]; 37 to 41 6/7 weeks [n = 44]). Significant differences were found in the cross-sectional area of the rectus femoris muscles and thigh circumference of NBs > 37 weeks compared to the other 2 groups (p < 0.05). Differences were found in diaphragm thickness and excursion between the groups with gestational age > 37 weeks and < 30 weeks. Greater activation of the parasternal muscles was found in the PTNBs. With regard to LLN, significant differences were found between the groups with gestational age > 37 weeks and < 30 weeks for all variables analyzed and between the group with gestational age > 37 weeks and other 2 groups for the cross-sectional area of the rectus femoris, diaphragmatic excursion, and diaphragm contraction velocity. Differences were found among the groups in the size of peripheral muscles as well as diaphragm thickness and excursion. Moreover, greater activation of the parasternal muscle was found in NBs with gestational age < 30 weeks. This study establishes normal values of ultrasound measures for full-term and preterm newborns.

Inflammatory and transudative B-line patterns on lung ultrasound: a brief communication

Lung ultrasonic B-lines have high accuracy in diagnosing extravascular lung water (ELW) but have not been systematically subcategorized to differentiate the varied etiologies of ELW. This brief communication describes subcategories of B-lines into "inflammatory" and "transudative" patterns, based on their location, pleural morphology and associated subpleural pathologies. This subcategorization was derived using information from trainees undergoing lung ultrasound training in the Learning Ultrasound in Critical Care program, pathophysiological principles and their corresponding ultrasound correlates. This subcategorization helped trainees differentiate inflammatory pathologies of ELW (e.g. pneumonia, acute respiratory distress syndrome) from transudative (congestive) pathologies (e.g. fluid overload, cardiac failure).

Acute Respiratory Failure in Children: A Clinical Update on Diagnosis

Acute respiratory failure (ARF) is a sudden failure of the respiratory system to ensure adequate gas exchanges. Numerous clinical conditions may cause ARF, including pneumonia, obstructive lung diseases (e.g., asthma), restrictive diseases such as neuromuscular diseases (e.g., spinal muscular atrophy and muscular dystrophy), and albeit rarely, interstitial lung diseases. Children, especially infants, may be more vulnerable to ARF than adults due to anatomical and physiological features of the respiratory system. Assessing respiratory impairment in the pediatric population is particularly challenging as children frequently present difficulties in reporting symptoms and due to compliance and cooperation in diagnostic tests. The evaluation of clinical and anamnestic aspects represents the cornerstone of ARF diagnosis: first level exams (e.g., arterial blood gas analysis) confirm and evaluate the severity of the ARF and second level exams help to uncover the underlying cause. Prompt management is critical, with supplemental oxygen, mechanical ventilation, and the treatment of the underlying problem. The aim of this review is to provide a comprehensive summary of the current state of the art in diagnosing pediatric ARF, with a focus on pathophysiology, novel imaging applications, and new perspectives, such as biomarkers and artificial intelligence.

BILL Strategy: Points to Consider During the Performance and Interpretation of Critical Care Echocardiography

The growing utilization of critical care echocardiography (CCE) by clinicians necessitates a meticulous review of clinical conditions in critically ill patients, both before and during the examination. The reviewing process of clinical conditions minimizes the risk of overlooking or misinterpreting crucial findings. This article proposes a comprehensive strategy, namely BILL strategy, to integrate into the CCE protocol, where "B" represents baseline respiratory and hemodynamic support, "I" signifies information gleaned from invasive monitoring, including central venous pressure and thermodilution-derived cardiac output, the first "L" denotes laboratory results such as central venous oxygen saturation, troponin, and brain natriuretic peptide, and the second "L" refers to lung ultrasound data. Combining the BILL strategy with CCE can enhance comprehensive understanding of critical conditions, potentially leading to improved diagnostic accuracy and patient outcomes.

Antibiotic De-escalation Patterns and Outcomes in Critically Ill Patients with Suspected Pneumonia as Informed by Bronchoalveolar Lavage Results

Background

Antibiotic stewardship in critically ill pneumonia patients is crucial yet challenging, partly due to the limited diagnostic yield of noninvasive infectious tests. In this study, we report an antibiotic prescription pattern informed by bronchoalveolar lavage (BAL) results, where clinicians de-escalate antibiotics based on the combination of quantitative cultures and multiplex PCR rapid diagnostic tests.

Methods

We analyzed data from SCRIPT, a single-center prospective cohort study of mechanically ventilated patients who underwent a BAL for suspected pneumonia. We used the novel Narrow Antibiotic Therapy (NAT) score to quantify day-by-day antibiotic prescription pattern for each suspected pneumonia episode etiology (bacterial, viral, mixed bacterial/viral, microbiology-negative, and non-pneumonia control). We also analyzed and compared clinical outcomes for each pneumonia etiology, including unfavorable outcomes (a composite of in-hospital mortality, discharge to hospice, or requiring lung transplantation during hospitalization), duration of ICU stay, and duration of intubation. Clinical outcomes were compared with the Mann-Whitney U test and Fisher's exact test.

Results

We included 686 patients with 927 pneumonia episodes. NAT score analysis indicated that an antibiotic de-escalation pattern was evident in all pneumonia etiologies except resistant bacterial pneumonia. Microbiology-negative pneumonia was treated similarly to susceptible bacterial pneumonia in terms of antibiotic spectrum. Over a quarter of the time in viral pneumonia episodes, antibiotics were completely discontinued. Unfavorable outcomes were comparable across all pneumonia etiologies. Patients with viral and mixed bacterial/viral pneumonia had longer durations of ICU stay and intubation.

Conclusions

BAL quantitative cultures and multiplex PCR rapid diagnostic tests resulted in prompt antibiotic de-escalation in critically ill pneumonia patients. There was no evidence of increased incidence of unfavorable outcomes.

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

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

Point-of-Care Ultrasound: A Vital Tool for Anesthesiologists in the Perioperative and Critical Care Settings

Point-of-care ultrasound (POCUS) is an essential skill in various specialties like anesthesiology, critical care, and emergency medicine. Anesthesiologists utilize POCUS for quick diagnosis and procedural guidance in perioperative and critical care settings. Key applications include vascular ultrasound for challenging venous and arterial catheter placements, gastric ultrasound for aspiration risk assessment, airway ultrasound, diaphragm ultrasound, and lung ultrasound for respiratory assessment. Additional utilities of POCUS can include multi-organ POCUS evaluation for undifferentiated shock or cardiac arrest, ultrasound-guided central neuraxial and peripheral nerve blocks, focused cardiac ultrasound, and novel applications such as venous excess ultrasound. This review highlights these POCUS applications in perioperative and intensive care and summarizes the latest evidence of their accuracy and limitations.

Advancements in Interventional Pulmonology: Harnessing Ultrasound Techniques for Precision Diagnosis and Treatment

Medical ultrasound has emerged as an indispensable tool within interventional pulmonology, revolutionizing diagnostic and procedural practices through its non-invasive nature and real-time visualization capabilities. By harnessing the principles of sound waves and employing a variety of transducer types, ultrasound facilitates enhanced accuracy and safety in procedures such as transthoracic needle aspiration and pleural effusion drainage, consequently leading to improved patient outcomes. Understanding the fundamentals of ultrasound physics is paramount for clinicians, as it forms the basis for interpreting imaging results and optimizing interventions. Thoracic ultrasound plays a pivotal role in diagnosing conditions like pleural effusions and pneumothorax, while also optimizing procedures such as thoracentesis and biopsy by providing precise guidance. Advanced ultrasound techniques, including endobronchial ultrasound, has transformed the evaluation and biopsy of lymph nodes, bolstered by innovative features like elastography, which contribute to increased procedural efficacy and patient safety. Peripheral ultrasound techniques, notably radial endobronchial ultrasound (rEBUS), have become essential for assessing pulmonary nodules and evaluating airway structures, offering clinicians valuable insights into disease localization and severity. Neck ultrasound serves as a crucial tool in guiding supraclavicular lymph node biopsy and percutaneous dilatational tracheostomy procedures, ensuring safe placement and minimizing associated complications. Ultrasound technology is suited for further advancement through the integration of artificial intelligence, miniaturization, and the development of portable devices. These advancements hold the promise of not only improving diagnostic accuracy but also enhancing the accessibility of ultrasound imaging in diverse healthcare settings, ultimately expanding its utility and impact on patient care. Additionally, the integration of enhanced techniques such as contrast-enhanced ultrasound and 3D imaging is anticipated to revolutionize personalized medicine by providing clinicians with a more comprehensive understanding of anatomical structures and pathological processes. The transformative potential of medical ultrasound in interventional pulmonology extends beyond mere technological advancements; it represents a paradigm shift in healthcare delivery, empowering clinicians with unprecedented capabilities to diagnose and treat pulmonary conditions with precision and efficacy. By leveraging the latest innovations in ultrasound technology, clinicians can navigate complex anatomical structures with confidence, leading to more informed decision-making and ultimately improving patient outcomes. Moreover, the portability and versatility of modern ultrasound devices enable their deployment in various clinical settings, from traditional hospital environments to remote or resource-limited areas, thereby bridging gaps in healthcare access and equity.

Setting the Standards: Neonatal Lung Ultrasound in Clinical Practice

The use of lung ultrasonography in neonates is increasing at a very fast rate. Evidence-based guidelines on the use of lung ultrasound (LU) in neonates and children have been published and well received across the world. However, there remains a lack of standardized curriculum for lung ultrasound training and standards for its application at the bedside. This article focuses on providing a standardized approach to the application of lung ultrasonography in neonates for the common neonatal conditions and how it can be integrated into bedside clinical decision-making.

Diagnostic Potentials of Lung Ultrasound In Neonatal Care: An Updated Overview

Recent technological strides, including high-frequency probes and lung ultrasound, have become a crucial non-invasive diagnostic tool in neonatal care, revolutionizing how respiratory conditions are assessed in the neonatal intensive care unit (NICU). High-frequency probes and portable devices significantly enhance the effectiveness of lung ultrasound in identifying respiratory distress syndrome (RDS), pneumonia, and pneumothorax, and underscore its growing significance. This comprehensive review explores the historical journey of lung ultrasonography, technological advancements, contemporary applications in neonatal care, emerging trends, and collaborative initiatives, and foresees a future where personalized healthcare optimizes outcomes for neonates.

Hydrochloric Acid-Induced Acute Lung Injury Models: Dynamic Change and Quantitative Analysis of Modified Lung Ultrasound Scoring System and High-Resolution Computed Tomography

OBJECTIVE

Acute lung injury (ALI) has become a research hotspot due to its significant public health impact. To explore the value of the use of modified lung ultrasound (MLUS) scoring system for evaluating ALI using a rabbit model of ALI induced by hydrochloric acid (HCl) and investigate its correlation with high-resolution computed tomography (HRCT) and histopathological scores.

METHODS

Twenty New Zealand laboratory rabbits were randomly assigned to control group (N = 5) and 3 experimental groups (N = 5 each). The control group received instillation of physiological saline, while the 3 experimental groups received 2 mL/kg of different doses of HCl instillation (mild group: pH 1.5, moderate group: pH 1.2, and severe group: pH 1.0) through the trachea under ultrasound guidance. Pulmonary ultrasound (using Mindray Reason9 linear array probes with frequency of 6-15 mHz) and HRCT examinations were performed before modeling (0H) and at 1H, 2H, 4H, 8H, 12H after modeling. The experimental rabbits were sacrificed at 12H for examination of gross lung morphology and hematoxylin-eosin-stained histopathological sections. The correlation of MLUS scores with HRCT/histopathological scores was assessed.

RESULTS

All rabbits in the experimental groups showed oxygenation index PaO₂/FiO₂<300. Successful establishment of ALI model was proven by autopsy (successful modeling rate: 100%). The pathological damage increased with increase in HCl dosage. MLUS scores showed a positive correlation with HRCT scores/pathological severity. There was a strong positive correlation between MLUS scores and histopathological scores (r = 0.963, p < 0.05) as well as between HRCT scores and histopathological scores (r = 0.932, p < 0.05).

CONCLUSION

Transtracheal injection of different dosages of HCl under ultrasound guidance induced different degrees of ALI. The MLUS scoring system can be used for semiquantitative evaluation of ALI, and is suitable as a screening tool.

Diagnostic role of thoracic ultrasound in patients with acute respiratory failure at emergency service

BACKGROUND AND AIM

This study aimed to elucidate the effectiveness of bedside thoracic ultrasound according to BLUE protocol and to investigate its superiority over other imaging methods in the emergency service.

METHODS

A total of 120 patients admitted to our institution's emergency care department due to respiratory distress have been enrolled in this prospective research. Thorax USG has been performed in the right and left hemithorax at the points specified in the BLUE protocol for each patient. Pleural sliding motion, A-lines, B-lines, consolidation, effusion, and the presence of barcode signs were evaluated individually. Age, sex, comorbid diseases, other radiological examination findings, laboratory findings, final clinical diagnosis, and hospitalization-discharge status of the patients were recorded.

RESULTS

When a correct diagnosis of pneumonia has been analyzed for imaging techniques, the diagnostic rate of chest radiography was 83.3%, CT was 100.0%, and USG was 66.6%. The correct diagnostic rate of chest radiography was 94.5%; CT and USG were 100.0%. The correct diagnosis of pulmonary edema on chest radiography was 94.5%; CT and USG were 100.0%. While the correct diagnosis of pleural effusion on chest radiography and CT was 100.0%, it was 92.3% in USG imaging. Finally, CT and USG imaging performed better than chest radiography in patients with pneumothorax (chest radiography 80.0%, CT and USG 100%).

CONCLUSION

USG imaging could be preferred in the diagnosis of pneumonia, pulmonary edema, pleural effusion, pneumothorax, pulmonary embolism, and differential diagnosis at the emergency service.

Lung Ultrasound Signs: The Beginning. Part 3-An Accademia di Ecografia Toracica Comprehensive Review on Ultrasonographic Signs and Real Needs

Over the last 20 years, scientific literature and interest on chest/lung ultrasound (LUS) have exponentially increased. Interpreting mixed-anatomical and artifactual-pictures determined the need of a proposal of a new nomenclature of artifacts and signs to simplify learning, spread, and implementation of this technique. The aim of this review is to collect and analyze different signs and artifacts reported in the history of chest ultrasound regarding normal lung, pleural pathologies, and lung consolidations. By reviewing the possible physical and anatomical interpretation of these artifacts and signs reported in the literature, this work aims to present the AdET (Accademia di Ecografia Toracica) proposal of nomenclature and to bring order between published studies.

Dynamic Air Bronchogram Ultrasound Sign in a Noninvasive Ventilated Patient

Acute dyspnea is one of the most common complaints in any emergency department. Physical examination and chest radiography have been insufficient to diagnose these patients accurately and quickly. We present a clinical case of a dyspneic patient presenting to the emergency department, who was promptly diagnosed with lobar pneumonia by point-of-care pulmonary ultrasonography. This permitted the rapid onset of adequate treatment. Furthermore, we describe a dynamic air bronchogram sign in a noninvasive ventilated patient. Chest computed tomography scan was performed confirming consolidation of the middle lobe. The advent of handheld point-of-care ultrasonography is revolutionizing practical care enabling physicians with a high-accuracy, low-cost, fast, safe, and repeatable diagnostic tool.

Detection of COVID-19 features in lung ultrasound images using deep neural networks

BACKGROUND

Deep neural networks (DNNs) to detect COVID-19 features in lung ultrasound B-mode images have primarily relied on either in vivo or simulated images as training data. However, in vivo images suffer from limited access to required manual labeling of thousands of training image examples, and simulated images can suffer from poor generalizability to in vivo images due to domain differences. We address these limitations and identify the best training strategy.

METHODS

We investigated in vivo COVID-19 feature detection with DNNs trained on our carefully simulated datasets (40,000 images), publicly available in vivo datasets (174 images), in vivo datasets curated by our team (958 images), and a combination of simulated and internal or external in vivo datasets. Seven DNN training strategies were tested on in vivo B-mode images from COVID-19 patients.

RESULTS

Here, we show that Dice similarity coefficients (DSCs) between ground truth and DNN predictions are maximized when simulated data are mixed with external in vivo data and tested on internal in vivo data (i.e., 0.482 ± 0.211), compared with using only simulated B-mode image training data (i.e., 0.464 ± 0.230) or only external in vivo B-mode training data (i.e., 0.407 ± 0.177). Additional maximization is achieved when a separate subset of the internal in vivo B-mode images are included in the training dataset, with the greatest maximization of DSC (and minimization of required training time, or epochs) obtained after mixing simulated data with internal and external in vivo data during training, then testing on the held-out subset of the internal in vivo dataset (i.e., 0.735 ± 0.187).

CONCLUSIONS

DNNs trained with simulated and in vivo data are promising alternatives to training with only real or only simulated data when segmenting in vivo COVID-19 lung ultrasound features.

Development of an Automated Ultrasound Signal Indicator of Lung Interstitial Syndrome

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Thoracic ultrasound use in hospitalized and ambulatory adult patients: a quantitative picture

INTRODUCTION AND OBJECTIVES

Thoracic ultrasound (TUS) has been established as a powerful diagnostic and monitoring tool in the Intensive Care Unit (ICU). However, studies outside the critical care setting are scarce. The aim of this study was to investigate the value of TUS for hospitalized or ambulatory community patients.

MATERIALS AND METHODS

This was a retrospective study conducted from 2016 to 2020 in the TUS clinic at Heraklion University Hospital. TUS examination was performed using a standard ultrasound machine (EUB HITACHI 8500), and a high-frequency microconvex probe (5-8 MHz). Patients had been referred by their primary physician to address a range of different questions. The various respiratory system entities were characterised according to internationally established criteria.

RESULTS

762 TUS studies were performed on 526 patients due to underlying malignancy (n = 376), unexplained symptoms/signs (n = 53), pregnancy related issues (n = 42), evaluation of abnormal findings in X-ray (n = 165), recent surgery/trauma (n = 23), recent onset respiratory failure (n = 12), acute respiratory infection (n = 66) and underlying non-malignant disease (n = 25). Pleural effusion was the commonest pathologic entity (n = 610), followed by consolidation (n = 269), diaphragmatic dysfunction/paradox (n = 174) and interstitial syndrome (n = 53). Discrepancies between chest X-ray and ultrasonographic findings were demonstrated in 96 cases. The TUS findings guided invasive therapeutic management in 448 cases and non-invasive management in 43 cases, while follow-up monitoring was decided in 271 cases.

CONCLUSIONS

This study showed that TUS can identify the most common respiratory pathologic entities encountered in hospitalized and community ambulatory patients, and is especially useful in guiding the decision making process in a diverse group of patients.

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

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

Use of a Handheld Ultrasonographic Device to Identify Heart Failure and Pulmonary Disease in Rural Africa

Importance

Agreement in lung ultrasonography findings between clinicians using a handheld ultrasonographic device and expert sonographers using a high-end ultrasonographic machine has not been studied in sub-Saharan Africa.

Objective

To determine the agreement in ultrasonographic findings and diagnoses between primary care clinicians trained in lung ultrasonography, board-certified expert sonographers, and senior physicians.

Design, Setting, and Participants

This cross-sectional single-center study was conducted from February 1, 2022, to April 30, 2023 at a referral center in rural Tanzania. Individuals 5 years or older with respiratory symptoms and at least 2 distinct respiratory signs or symptoms were eligible. A total of 459 individuals were screened.

Exposures

Participants provided their medical history and underwent a clinical examination and lung ultrasonography performed by a clinician, followed by a lung ultrasonography performed by an expert sonographer, and finally chest radiography and a final evaluation performed by a senior physician. Other tests, such as echocardiography and Mycobacterium tuberculosis testing, were conducted on the decision of the physician. Clinicians received 2 hours of instruction and three 2-hour sessions of clinical training in the use of a handheld lung ultrasonographic device; expert sonographers were board-certified.

Main Outcomes and Measures

Percentage agreement and Cohen κ coefficient for sonographic findings and diagnoses compared between clinicians and expert sonographers, and between clinicians and senior physicians.

Results

The median (IQR) age of 438 included participants was 54 (38-66) years, and 225 (51%) were male. The median (range) percentage agreement of ultrasonographic findings between clinicians and expert sonographers was 93% (71%-99%), with κ ranging from -0.003 to 0.83. Median (range) agreement of diagnoses between clinicians and expert sonographers was 90% (50%-99%), with κ ranging from -0.002 to 0.76. Between clinicians and senior physicians, median (range) agreement of diagnoses was 89% (55%-90%), with κ ranging from -0.008 to 0.76. Between clinicians and senior physicians, diagnosis agreements were 85% (κ, 0.69) for heart failure, 78% (κ, 0.57) for definite or probable tuberculosis, 50% (κ, 0.002) for viral pneumonia, and 56% (κ, 0.06) for bacterial pneumonia.

Conclusions and Relevance

In this cross-sectional study, the agreement of ultrasonographic findings between clinicians and sonographers was mostly substantial. Between clinicians and senior physicians, agreement was substantial in the diagnosis of heart failure, moderate in the diagnosis of tuberculosis, but slight in the diagnosis of pneumonia. These findings suggest that handheld ultrasonographic devices used in addition to clinical examination may support clinicians in diagnosing cardiac and pulmonary diseases in rural sub-Saharan Africa.

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

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

Ultrasound Evaluation of Interstitial Lung Disease in Rheumatoid Arthritis and Autoimmune Diseases

The interpretation of lung ultrasound is the result of the analysis of artifacts rather than exact representations of anatomical structures, which appear when changes in the physical properties of the lung occur. Its application to the study of interstitial lung disease (ILD) associated with autoimmune diseases has aroused great interest in the last 10 years, as evidenced by a growing number of publications studying its usefulness in the diagnostic process, as a prognostic marker and as an aid in monitoring of patients. The main elements in lung ultrasound interpretation in ILD are the B lines and the changes in the pleural line. B lines are vertical artifacts that are generated when there is a partial decrease in the air content of the lung parenchyma and/or the volume of the interstitial area expands. Pleural line alterations that can be seen are irregularities, thickening, fragmentation, or subpleural nodules. Both the B lines and the changes in the pleural line have shown a significant positive correlation with the evidence on chest computed tomography [high resolution computed tomography (HRCT)] of ILD associated with autoimmune diseases, with sensitivity and negative predictive values of up to 100%. These results, together with the safety, accessibility, and low cost of lung ultrasound, support this imaging technique as a promising screening method for optimizing the indication for HRCT. The role of lung ultrasound regarding sensitivity to change needs further investigation with multicenter prospective studies.

Lung Ultrasound and Pleural Artifacts: A Pictorial Review

Lung ultrasound is a well-established diagnostic approach used in detecting pathological changes near the pleura of the lung. At the acoustic boundary of the lung surface, it is necessary to differentiate between the primary visualization of pleural parenchymal pathologies and the appearance of secondary artifacts when sound waves enter the lung or are reflected at the visceral pleura. The aims of this pictorial essay are to demonstrate the sonographic patterns of various pleural interface artifacts and to illustrate the limitations and pitfalls of the use of ultrasound findings in diagnosing any underlying pathology.

Efficiency of Simulation-Based Learning Using an ABC POCUS Protocol on a High-Fidelity Simulator

Critically ill patients with rapidly deteriorating clinical status secondary to respiratory and cardio-vascular compromise are at risk for immediate collapse if the underlying pathology is not recognized and treated. Rapid diagnosis is of utmost importance regardless of the setting. Although there are data to support the use of point-of-care ultrasound in critical patients, there is no consensus about the best educational strategy to implement. We designed a curriculum based on the ABC (Airway, Breathing, Circulation) protocol that covers essential airway, lung, and cardiac ultrasound skills needed for fast diagnosis in critical patients and applied it in high-fidelity simulation-based medical education sessions for anesthesia and intensive care residents year one and two. After theoretical and practical assessments, our results show statistical differences in the theoretical knowledge and above-average results in practical assessment. Our proposed curriculum based on a simple ABC POCUS protocol, with an Airway, Breathing, and Circulation approach, is useful in teaching ultrasound basics regarding airway, lung, and cardiac examination using high-fidelity simulation training to anesthesia and intensive care residents, but further research is needed to establish the utility of Simulation-Based Medical Education in Point of Care Ultrasound in the critical patient.

Lung ultrasound score in dogs and cats: A reliability study

BACKGROUND

Lung ultrasound (LUS) is a noninvasive tool for examining respiratory distress patients. The lung ultrasound score (LUSS) can be used to quantify and monitor lung aeration loss with good reliability.

HYPOTHESIS/OBJECTIVES

Assess the reliability of a new LUSS among raters with different levels of experience and determine how well the same raters agree on identifying patterns of LUS abnormalities.

ANIMALS

Forty LUS examinations of dogs and cats and 320 videos were reviewed from a digital database.

METHODS

Retrospective reliability study with post hoc analysis. Protocolized LUS were randomly selected; intrarater and interrater reliability of the LUSS and pattern recognition agreement among 4 raters with different levels of experience in LUS were tested.

RESULTS

The intrarater intraclass correlation coefficient (ICC) single measurement, absolute agreement, and 2-way mixed effects model was 0.967 for the high-experience rater (H-Exp), 0.963 and 0.952 for the medium-experience raters (M-Exp-1; M-Exp-2), and 0.950 for the low-experience rater (L-Exp). The interrater ICC average measurement, absolute agreement, and 2-way random effects model among the observers was 0.980. The Fleiss' kappa (k) values showed almost perfect agreement (k = 1) among raters in identifying pleural effusion and translobar tissue-like pattern, strong agreement for A-lines (k = 0.881) and B-lines (k = 0.806), moderate agreement (k = 0.693) for subpleural loss of aeration, and weak agreement (k = 0.474) for irregularities of the pleural line.

CONCLUSIONS AND CLINICAL IMPORTANCE

Our results indicate excellent intra- and interrater reliability for LUS scoring and pattern identification, providing a foundation for the use of the LUSS in emergency medicine and intensive care.

Radiological imaging and interventional procedures of the thorax in children

The thoracic region in pediatric patients poses unique diagnostic and interventional challenges, necessitating specialized approaches in radiological imaging and procedures. This review provides an overview of the key considerations, techniques, and clinical significance in the field of pediatric thoracic radiology and interventions. We discuss the importance of age-appropriate imaging modalities and the application of advanced technologies in assessing a wide range of thoracic conditions in children, including congenital anomalies, infections, neoplasms, and trauma. Furthermore, we highlight the evolving role of minimally invasive interventional procedures in the management of pediatric thoracic disorders. As the understanding of pediatric thoracic pathology continues to expand, this review aims to guide healthcare professionals, radiologists, and pediatricians in delivering optimal care to children with thoracic concerns.