The "Survived Lung:" An Ultrasound Sign of "Bubbly Consolidation" Pulmonary Infarction

The Diagnostic Role of Lung Ultrasound and Contrast-Enhanced Ultrasound in Pulmonary Embolism

The diagnosis of pulmonary embolism (PE) relies essentially on a probabilistic approach that requires careful clinical assessments, targeted laboratory tests, and the use of appropriate imaging tools. Nowadays, the diagnostic gold standard is computed tomographic pulmonary angiography. Lung ultrasound (LUS) can play a role in the diagnosis of PE mainly by allowing the visualization of peripheral lung infarctions. Hypoechoic, pleural-based parenchymal consolidation is the most typical and common finding of pulmonary infarction. More than 85% of infarct lesions are wedge-shaped, extending to the pleural surface and are localized to where the patient complains of pleuritic chest pain. Contrast-enhanced ultrasound can be performed in addition to basic ultrasound examination to ascertain nonvascularization of the consolidation, thus confirming that the lesion is an infarct. The aim of this narrative review is to summarize the latest evidence on the application of LUS to the diagnosis of PE, focusing purely on thoracic/lung signs.

Role of ultrasound in acute respiratory failure and in the weaning of mechanical ventilation

Comprehensive ultrasound assessment has become an essential tool to facilitate the diagnosis and therapeutic management of critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia and acute pulmonary thromboembolism, and in patients with COVID-19. In addition, in recent years, the use of ultrasound to evaluate responses to treatment in critically ill patients with ARF has been developed, providing a noninvasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone position, as well as for facilitating weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.

Pulmonary Embolism Presenting with Pulmonary Infarction: Update and Practical Review of Literature Data

Pulmonary infarction (PI) is a possible consequence of pulmonary embolism (PE). The real incidence of PI could be underestimated considering only non-fatal PE presentation. However, following postmortem examination, the prevalence of PI is considerably higher. This evidence suggests the necessity of proper diagnostic protocol for identifying PI. Unfortunately, PI diagnosis can sometimes be challenging, due to the overlapping of symptoms with other diseases. Nowadays, the diagnosis is mainly based on radiological evaluation, although the combination with emerging imaging techniques such as ultrasound and nuclear scanning might improve the diagnostic algorithm for PI. This review aims to summarize the available data on the prevalence of PI, the main predisposing factors for the development of PI among patients with PE, to resume the possible diagnostic tools, and finally the clinical and prognostic implications.

Lung Ultrasound Patterns in Multisystem Inflammatory Syndrome in Children (MIS-C)-Characteristics and Prognostic Value

Objective and design: Following COVID-19 infection, children can develop an hyperinflammatory state termed Multisystem Inflammatory Syndrome in Children (MIS-C). Lung Ultrasound (LUS) features of COVID-19 in children have been described, but data describing the LUS findings of MIS-C are limited. The aim of this retrospective observational study conducted between 1 March and 31 December 2020, at a tertiary pediatric hospital in Milano, is to describe LUS patterns in patients with MIS-C and to verify correlation with illness severity. The secondary objective is to evaluate concordance of LUS with Chest X-ray (CXR). Methodology: Clinical and laboratory data were collected for all patients (age 0−18 years) admitted with MIS-C, as well as LUS and CXR patterns at admission. PICU admission, needed for respiratory support and inotrope administration, hospital, and PICU length of stay, were considered as outcomes and evaluated in the different LUS patterns. An agreement between LUS and CXR evaluation was assessed with Cohen’ k. Results: 24 children, who had a LUS examination upon admission, were enrolled. LUS pattern of subpleural consolidations < or > 1 cm with or without pleural effusion were associated with worse Left Ventricular Ejection Fraction at admission and need for inotropes. Subpleural consolidations < 1 cm were also associated with PICU length of stay. Agreement of CXR with LUS for consolidations and effusion was slight. Conclusion: LUS pattern of subpleural consolidations and consolidations with or without pleural effusion are predictors of disease severity; under this aspect, LUS can be used at admission to stratify risk of severe disease.

The wedge sign: A possible lung ultrasound sign for pulmonary thromboembolism

OBJECTIVE

To describe the finding of the lung ultrasound (LUS) "wedge sign" in dogs with presumptive pulmonary thromboembolism (PTE).

CASE SERIES SUMMARY

This case series describes 2 dogs with predisposing risk factors of (1) right transvenous pacemaker terminating in its right ventricle, severe protein-losing nephropathy, and glucocorticoid therapy, and (2) caval syndrome, each having the LUS "wedge sign" in upper lung regions, a sign consistent with pulmonary infarction and peripheral PTE.

NEW OR UNIQUE INFORMATION PROVIDED

Historically, the diagnosis of canine PTE has been made through supportive findings because the gold standard test, computed tomography pulmonary angiography (CTPA), poses limitations. The use of LUS has shown promise in people for detecting PTE, with the advantages of availability, being radiation- and contrast medium-sparing, rapid (<90 s), point-of-care, real-time information. Our cases suggest a possible new first-line approach for suspecting canine PTE by using LUS and the finding of the "wedge sign" in nongravity-dependent caudodorsal and perihilar lung regions.

Role of Lung Ultrasound in the Management of Patients with Suspected SARS-CoV-2 Infection in the Emergency Department

Background: The lung ultrasound (LUS) score has been proposed as an optimal scheme for the ultrasound study of patients with suspected/confirmed COVID-19 pneumonia. The aims of our study were to evaluate the use of lung ultrasound as a diagnostic tool for diagnosing SARS-CoV-2 pneumonia, to examine the validity of the LUS score for the diagnosis of COVID-19 pneumonia, and to correlate this score with hospitalization rate and 30-day mortality. Materials and Methods: A retrospective analysis was performed on 1460 patients who were referred to the General Emergency Department of the S. Orsola-Malpighi Hospital from April 2020 to May 2020 for symptoms suspected to indicate SARS-CoV-2 infection. The ultrasound examination was based on a common execution scheme called the LUS score, as previously described. Results and Conclusions: The LUS score was found to correlate with the degree of clinical severity and respiratory failure (paO2/FiO2 ratio and the alveolar−arterial gradient increase than expected for age). It was shown that COVID-19 patients with an LUS score of >7 require the use of oxygen support, and a value of >10 is associated with an increased risk of oro-tracheal intubation. The LUS score was found to present higher values in hospitalized patients, increasing according to the degree of care intensity. Patients who died from COVID-19 were characterized by a mean LUS score of 11 at presentation to the emergency department. An LUS score of >7.5 was found to indicate a sensitivity of 83% and a specificity of 89% for 30-day mortality in COVID-19 patients. The use of LUS seems to be an optimal first level method for pneumonia detection and risk stratification in patients with suspected SARS-CoV-2 infection.

Lung Ultrasound Fundamentals, "Wet Versus Dry" Lung, Signs of Consolidation in Dogs and Cats

Vet BLUE, a standardized and validated rapid lung ultrasound examination, includes 9 acoustic windows: 4 transthoracic bilaterally applied named Caudodorsal, Perihilar, Middle, and Cranial Lung Regions plus the Diaphragmatico-Hepatic view of AFAST/TFAST. Moreover, Vet BLUE has a B-line scoring system (weak positives-1, 2, and 3 and strong positives->3 and infinite) that semiquantitate degree of alveolar-interstitial syndrome and a visual lung language for signs of consolidation (Shred Sign [air bronchogram], Tissue Sign [hepatization], Nodule Sign, and Wedge Sign [pulmonary infarction]). Using its regional, pattern-based approach, a respiratory working diagnosis may be rapidly developed point-of-care and followed serially.

One year of SARS-CoV-2 and lung ultrasound: what has been learned and future perspectives

A first screening by ultrasound can be relevant to set a specific diagnostic and therapeutic route for a patient with a COVID-19 infection. The finding of bilateral B-lines and white lung areas with patchy peripheral distribution and sparing areas is the most suggestive ultrasound picture of COVID-19 pneumonia. Failure to detect bilateral interstitial syndrome (A pattern) on ultrasound excludes COVID-19 pneumonia with good diagnostic accuracy, but does not exclude current infection. The use of shared semiotic and reporting schemes allows the comparison and monitoring of the COVID-19 pulmonary involvement over time. This review aims to summarise the main data on pulmonary ultrasound and COVID-19 to provide accurate and relevant information for clinical practice.