Thoracic ultrasound may improve paramedic diagnostic and management accuracy in undifferentiated respiratory distress

Objectives

Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) exacerbations present with similar history and physical examination findings. This complicates both the diagnostic process and the creation of appropriate treatment plans for patients presenting in respiratory distress, particularly in the prehospital setting. Thoracic point-of-care-ultrasound (POCUS) may increase diagnostic accuracy; however, its potential to improve patient management by emergency medical services clinicians is unknown. We aimed to determine whether a brief thoracic POCUS educational intervention would improve prehospital diagnostic accuracy and treatment plans for patients with COPD and CHF exacerbations.

Methods

In this prospective pre-/post-study, paramedics completed a thoracic POCUS training program. The pre-test presented history and physical examination data for 10 patients and asked paramedics to diagnose each patient with COPD or CHF exacerbation and to select the appropriate treatment(s). The post-test asked paramedics to interpret ultrasound images in addition to selecting diagnosis and treatment(s). Pre-post differences in average cumulative diagnostic and management accuracy were analyzed using paired two-tailed t-tests.

Results

Thirty-three paramedics participated in the study. At baseline, paramedics selected the accurate patient diagnosis and treatment(s) 73% and 60% of the time, respectively. On the post-test, diagnostic accuracy improved by 17% (95% confidence interval [CI]: 11-24, p < 0.001) and appropriate treatment selection improved by 23% (95% CI: 16-28, p < 0.001). Paramedics correctly interpreted ultrasound images 90% of the time.

Conclusion

Effective training of paramedics to recognize the clinical scenario of undifferentiated respiratory distress and their associated thoracic ultrasound images may lead to improved treatment plans.

Thoracic Ultrasound Utility in Pulmonary Pathologies Following Blunt Chest Trauma: A Cross-Sectional Study From Barcelona, Venezuela

Background The thoracic ultrasound (TUS) is a monitoring tool that has gained worldwide popularity in various scenarios, offering the opportunity for dynamic, bedside evaluations. Recent studies indicate that the use of TUS enables the diagnosis of pathologies resulting from blunt chest trauma (BCT), yielding favorable outcomes. This study aimed to compare the utility of TUS versus chest radiography (CXR) in diagnosing pulmonary pathologies resulting from closed-chest traumas. Methodology A prospective cross-sectional study was conducted with a sample of 58 patients diagnosed with BCT who sought emergency care at the "Dr. Luis Razetti" University Hospital in Barcelona, Venezuela, from November 2023 to January 2024. Results Of the patients, 75.9% (n = 44) were male, with an average age of 37.8 years (standard deviation = 18.4 years). Injuries were reported in 8.6% (n = 5) of the patients, including 60% (n = 3) pneumothorax and 40% (n = 2) hemothorax. Ultrasound results coincided with CXR in 94.8% (n = 55) of the cases, with a Cohen's kappa coefficient of 0.9 (95% confidence interval (CI) = 0.642-1.0). TUS demonstrated higher sensitivity than CXR (100% vs. 60%) for detecting hemothorax and pneumothorax in patients with BCT, with an area under the receiver operating characteristic curve of 0.991 (95% CI = 0.968-1.013). Conclusions BCT predominantly occurred in young males, resulting primarily in pneumothorax and hemothorax lesions, detectable with higher sensitivity through TUS compared to CXR. The use of TUS should be considered an essential component of the initial assessment for individuals with BCT.

Accuracy and inter-rater agreement among practitioners using quick thoracic ultrasonography to diagnose calf pneumonia

BACKGROUND

Thoracic ultrasonography (TUS) is a commonly used tool for on-farm detection of pneumonia in calves. Different scanning methods have been described, but the performance of novice practitioners after training has not been documented.

METHODS

In this study, 38 practitioners performed quick TUS (qTUS) on 18-23 calves each. Pneumonia was defined as lung consolidation 1 cm or more in depth. Diagnostic parameters (accuracy [Acc], sensitivity [Se] and specificity [Sp]) were compared to those of an experienced operator. Cohen's kappa and Krippendorff's alpha (Kalpha) were determined. The potential effects of training and exam sessions on performance were evaluated.

RESULTS

The average relative Se and Sp were 0.66 (standard deviation [SD] = 0.26; minimum [Min.]-Maximum [Max.] = 0-1) and 0.71 (SD = 0.19; Min.-Max. = 0.25-1), respectively. The average relative Acc was 0.73 (SD = 0.11; Min.-Max. = 0.52-0.96). Over all sessions, Cohen's kappa averaged 0.40 (SD = 0.24; Min.-Max. = 0.014-0.90) and Kalpha was 0.24 (95% confidence interval [CI]: 0.20-0.27), indicating 'fair' agreement. Calf age and housing influenced Se and Sp. Supervised practical training improved Se by 17.5% (95% CI: 0.01-0.34).

LIMITATIONS

The separate effects of calf age and housing could not be determined.

CONCLUSION

This study showed that qTUS, like any other clinical skill, has a learning curve, and variability in performance can be substantial. Adequate training and certification of one's skill are recommended to assure good diagnostic accuracy.

Physician-led thoracic ultrasound-guided biopsy; a district general hospital perspective

BACKGROUND

Physician-led thoracic ultrasound (TUS)-guided biopsies provide a prompt route to tissue diagnosis in pleural and peripheral lung malignancies. This retrospective study reviews the diagnostic performance and safety of this approach in a UK District General Hospital.

METHODS

Time to biopsy, diagnostic yield and complication rate were analysed in a cohort of 49 patients undergoing ultrasound-guided tissue sampling between September 2019 and December 2022.

RESULTS

Fifty-one TUS-guided biopsies were attempted. Mean time from decision to biopsy was 5 days. The overall diagnostic yield was 82%. Complication rate was low; 3 minor adverse effects were reported which led to no change in routine care.

CONCLUSION

This single centre retrospective study shows that physician-led TUS-guided biopsy provides a safe and timely method of obtaining a tissue diagnosis in thoracic malignancy. It offers an alternative to computer tomography (CT)-guided or thoracoscopic biopsies and should be considered in selected patients where local procedural expertise exists.

Stratifying Disease Severity in Pediatric COVID-19: A Correlative Study of Serum Biomarkers and Lung Ultrasound-A Retrospective Observational Dual-Center Study

The COVID-19 pandemic, caused by SARS-CoV-2, has manifested distinct impacts on infants and children. This study delves into the intricate connection between lung ultrasound (LUS) findings and serum biomarkers in neonates and infants with COVID-19. Exploring factors contributing to the mild symptoms in this demographic, including immune responses and pre-existing immunity, the study spans 3 years and 9 months, involving 42 patients. Respiratory and gastrointestinal symptoms predominate, and LUS emerges as a vital, non-irradiating tool for evaluating pulmonary abnormalities. Serum biomarkers like CRP, procalcitonin, and cytokines provide key insights into the pathophysiology. Correlations reveal nuanced links between LUS score and clinical parameters, unveiling associations with hospitalization duration (rho = 0.49), oxygen saturation (rho = -0.88), and inflammatory markers, like ferritin (rho = 0.62), LDH (rho = 0.73), and D-dimer (rho = 0.73) with significance level (p < 0.05). The absence of large consolidations in LUS suggests unique pulmonary characteristics. The novelty of these findings lies in the comprehensive integration of LUS with serum biomarkers to assess and monitor the severity of lung involvement in neonates and infants affected by SARS-CoV-2. This approach offers valuable insights into disease severity, biomarker levels, the duration of hospitalization, and oxygen saturation, providing a multifaceted understanding of COVID-19's impact on this vulnerable population.

Point of care thoracic ultrasound versus chest computed tomography in the approach of febrile neutropenia patients: A diagnostic accuracy cohort study

Single-center prospective cohort diagnostic accuracy study. Our study aimed to evaluate the accuracy and reproducibility of Thoracic Ultrasound (TUS) in detecting pulmonary pathology in immunosuppressed patients. We conducted a single-center prospective study. Consecutive patients with febrile neutropenia who underwent CT (Computerized Tomography) underwent TUS evaluation within 24h of CT. Both studies were performed by an expert who was blinded to the clinical information and results of the alternative imaging modalities. 34 patients met the inclusion criteria. The median age was 39.9 years (±17 standard deviation). TUS as a diagnostic test had a sensitivity of 92.9% and specificity of 83.3%, negative predictive value of 71.4%, and positive predictive value of 96.3%. Substantial between-method agreement was demonstrated with a kappa of 0.71 (P = .001) between the TUS and chest CT findings. We obtained a kappa of 1 (P = .001) for the final diagnosis of Pleural Effusion (PE). We concluded that TUS is a promising screening test for immunocompromised individuals. The results showed good diagnostic performance of TUS compared to CT for the detection of pulmonary findings highly suggestive of pathology with high accuracy and reproducibility.

Ultrasound in the Diagnosis of Non-Expandable Lung: A Prospective Observational Study of M-Mode, B-Mode, and 2D-Shear Wave Elastography

BACKGROUND

Non-expandable lung (NEL) has severe implications for patient symptoms and impaired lung function, as well as crucial implications for the management of malignant pleural effusion (MPE). Indwelling pleural catheters have shown good symptom relief for patients with NEL; hence, identifying patients early in their disease is vital. With the inability of the lung to achieve pleural apposition following thoracentesis and the formation of a hydropneumothorax, traditionally, chest X-ray and clinical symptoms have been used to make the diagnosis following thoracentesis. It is our aim to investigate whether ultrasound measurement of lung movement during respiration can predict NEL before thoracentesis, thereby aiding clinicians in their planning for the optimal treatment of affected patients.

METHODS

A total of 49 patients were consecutively included in a single-centre trial performed at a pleural clinic. Patients underwent protocolled ultrasound assessment pre-thoracentesis with measurements of lung and diaphragm movement and shear wave elastography measurements of the pleura and pleural effusion at the planned site of thoracentesis.

RESULTS

M-mode measurements of lung movement provided the best diagnostic ROC-curve results, with an AUC of 0.81. Internal validity showed good results utilising the calibration belt test and Brier test.

CONCLUSION

M-mode measurement of lung movement shows promise in diagnosing NEL before thoracentesis in patients with known or suspected MPE. A validation cohort is needed to confirm the results.

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.

Chest X-rays and Lung Ultrasound Are Not Interchangeable in Intensive Care Practice

PURPOSE

Data comparing lung ultrasound (LUS) and chest X-rays (CXRs) have increased over the past years. However, there still is a lack of knowledge as to how these modalities compare with one another in the critical care setting, and several factors, including artificial study conditions, limit the generalizability of most published studies. Our study aimed to analyze the performance of LUS in comparison with CXRs in real-world critical care practice.

MATERIALS AND METHODS

This study presents new data from the prospective FASP-ICU trial. A total of 209 corresponding datasets of LUS and CXR results from 111 consecutive surgical ICU patients were subanalyzed, and categorial findings were compared. Statistical analysis was performed on the rates of agreement between the different imaging modalities.

RESULTS

A total of 1162 lung abnormalities were detected by LUS in ICU patients compared with 1228 detected by CXR, a non-significant difference (p = 0.276; 95% CI -0.886 to 0.254). However, the agreement rates varied between the observed abnormalities: the rate of agreement for the presence of interstitial syndrome ranged from 0 to 15%, consolidation from 0 to 56%, basal atelectasis from 33.9 to 49.34%, pleural effusion from 40.65 to 50%, and compression atelectasis from 14.29 to 19.3%. The rate of agreement was 0% for pneumothorax and 20.95% for hypervolemia.

CONCLUSIONS

LUS does not detect more lung abnormalities in real-world critical care practice than CXRs, although a higher sensitivity of LUS has been reported in previous studies. Overall, low agreement rates between LUS and CXRs suggest that these diagnostic techniques are not equivalent but instead are complementary and should be used alongside each other.

Effect of on-arrival bovine respiratory disease vaccination on ultrasound-confirmed pneumonia and production parameters in male dairy calves: A randomized clinical trial

The high degree of commingling and accumulation of stressors during and after transport makes prevention of bovine respiratory disease (BRD) extremely challenging in the veal and dairy beef industry. Upon arrival, vaccination for agents involved in BRD is practically most achievable, but its efficacy under such conditions in dairy veal calves is unknown. Given the high prevalence of subclinical pneumonia in these settings, the primary objective of the present study was to determine the effect of 2 vaccination protocols administered upon arrival against bovine respiratory syncytial virus (BRSV), bovine parainfluenza type 3 virus (BPI-3), and Mannheimia haemolytica on clinical BRD and lung ultrasonographic findings in dairy veal calves. In addition, the effects of vaccination on average daily live weight gain and cold carcass weight were determined. In this randomized clinical trial, 443 male dairy calves were assigned to one of 3 groups: a negative, placebo-controlled group (n = 151), a vaccination group with 2 subcutaneous injections 4 wk apart with an inactivated vaccine containing BRSV, BPI-3, and M. haemolytica (parenteral [PE] group; n = 149) and a second vaccination group receiving an intranasal live-attenuated vaccine containing BRSV and BPI-3 and 2 subcutaneous vaccinations with the same inactivated vaccine as the PE vaccination group (intranasal-parenteral [IN-PE] group; n = 143). Clinical scoring and quick thoracic ultrasonography (qTUS) were performed on all calves on arrival (wk 0), at the peak of respiratory disease (outbreak; wk 1), at the end of the first antimicrobial group treatment (wk 3), and at a long-term evaluation point (wk 10). Culture and nanopore sequencing on nonendoscopic bronchoalveolar lavage (nBAL) samples were used to identify pathogens involved in the outbreak. Upon arrival, 15.1% of the calves had lung consolidation ≥1cm and incidence quickly rose to 42.8% during the outbreak. In both the PE and IN-PE group, the odds of pneumonia in wk 10 were reduced by 62% (odds ratio [OR] = 0.38; 95% confidence interval [CI] = 0.23-0.64) and 41% (OR = 0.59; 95% CI = 0.37-0.96), respectively. Short-term cure rate (50.3%), as determined immediately after the first group antimicrobial treatment, was not influenced by vaccination. In contrast, long-term cure rate, determined at wk 10, was affected by vaccination with higher cure in the PE group compared with the control group (69.4% vs. 51.2%; OR = 2.2; 95% CI = 1.1-5.0). Average daily gain in the first 10 wk of production was not affected by vaccination. Vaccination resulted in an increase in cold carcass weight of 3.5 and 4.3 kg in the PE (95% CI = -0.9-7.9) and IN-PE group (95% CI = -0.17-8.7), respectively. In conclusion, under the conditions of the present study, vaccination upon arrival resulted in a reduced prevalence of pneumonia at wk 10 of production, likely caused both by an improved cure rate of secondary infections and a reduced incidence of new cases between outbreak and long-term evaluation. The present protocol, using qTUS for pneumonia detection and nBAL diagnostics for pathogen identification adds a new dimension to randomized clinical trials on respiratory disease in calves.

Ultrasound on the Frontlines: Empowering Paramedics with Lung Ultrasound for Dyspnea Diagnosis in Adults-A Pilot Study

Lung transthoracic ultrasound (LUS) is an accessible and widely applicable method of rapidly imaging certain pathologies in the thorax. LUS proves to be an optimal tool in respiratory emergency medicine, applicable in various clinical settings. However, despite the rapid development of bedside ultrasonography, or point-of-care (POCUS) ultrasound, there remains a scarcity of knowledge about the use of LUS in pre-hospital settings. Therefore, our aim was to assess the usefulness of LUS as an additional tool in diagnosing dyspnea when performed by experienced paramedics in real-life, pre-hospital settings. Participants were recruited consecutively among patients who called for an emergency due to dyspnea in the Warsaw region of Poland. All the enrolled patients were admitted to the Emergency Department (ED). In the prehospital setting, a paramedic experienced in LUS conducted an ultrasonographic examination of the thorax, including Bedside Lung Ultrasound in Emergency (BLUE) and extended Focused Assessment with Sonography for Trauma (eFAST) protocols. The paramedic's diagnosis was compared to the ED diagnosis, and if available, to the final diagnosis established on the day of discharge from the hospital. We enrolled 44 patients in the study, comprising 22 (50%) men and (50%) women with a median age of 76 (IQR: 69.75-84.5) years. The LUS performed by paramedic was concordant with the discharge diagnosis in 90.91% of cases, where the final diagnosis was established on the day of discharge from the hospital. In cases where the patient was treated only in the ED, the pre-hospital LUS was concordant with the ED diagnosis in 88.64% of cases. The mean time of the LUS examination was 63.66 s (SD: 19.22). The inter-rater agreement between the pre-hospital diagnosis and ER diagnosis based on pre-hospital LUS and complete ER evaluation was estimated at k = 0.822 (SE: 0.07; 95%CI: 0.68, 0.96), indicating strong agreement, and between the pre-hospital diagnosis based on LUS and final discharge diagnosis, it was estimated at k = 0.934 (SE: 0.03; 95%CI: 0.88, 0.99), indicating almost perfect agreement. In conclusion, paramedic-acquired LUS seems to be a useful tool in the pre-hospital differential diagnosis of dyspnea in adults.

Diagnostic and Prognostic Value of Clinical Scoring and Lung Ultrasonography to Assess Pulmonary Lesions in Veal Calves

This study on veal calf respiratory disease assessed the association between an on-farm clinical scoring system and lung ultrasonography with the postmortem inspection of the lungs. The comparisons allowed the calculation of predictive values of the diagnostic methods. In total, 600 calves on an Austrian veal calf farm were examined at the beginning and the end of the fattening period. Overall, the area under the curve (AUC) for ultrasonographic scores was 0.90 (rsp = 0.78) with a sensitivity (Se) of 0.86. The specificity (Sp) was 0.78, and the positive predictive value (PPV) was 0.74. The AUC for the physical examination was 0.76 (rsp = 0.55) with a Se of 0.64, an Sp of 0.81, and a PPV of 0.69. For the combination of ultrasonography and physical examination, an AUC curve of 0.85 (rsp = 0.69) was calculated. A Se of 0.65 and a Sp of 0.88 with a PPV of 0.73 was calculated. This study concluded that both physical and ultrasonographic examination scoring are reliable examination methods for the detection of lung diseases in veal calves.

Oral meloxicam given as an ancillary treatment at respiratory disease diagnosis was not associated with growth, clinical scores, or ultrasound scores in preweaned dairy calves

Objective

To assess the efficacy of a single dose of oral meloxicam as an ancillary therapy to an antibiotic given at the time of respiratory disease identification on average daily gain (ADG), behavioral attitude, clinical respiratory, and lung ultrasound scores in preweaned dairy calves.

Animals

215 male and female Holstein, Jersey, and crossbred preweaned calves enrolled between 1 and 14 days of age at study enrollment on a single commercial dairy in the western US.

Methods

The study took place from March 4, 2021, to November 21, 2021. In this double-blind placebo-controlled study, calves were given an antibiotic (1.1 mL of tulathromycin/kg, SC, once) and either a placebo (1 mg of lactose monohydrate/kg, in a gelatin capsule) or oral meloxicam (1 mg/kg) at the time of respiratory disease identification. Behavioral attitude, clinical respiratory, and lung ultrasound scores and ADG were assessed in preweaned dairy calves at different time points including the next health examination, 1 week later, or at weaning.

Results

There was no association between treatment (placebo vs meloxicam) on ADG or respiratory disease status at weaning (P > .05). There was no effect of treatment on behavioral attitude, clinical respiratory, or lung ultrasound scores at the next health examination or 1 week later (P > .05).

Clinical Relevance

The present study did not provide evidence that oral meloxicam given once is beneficial for growth, behavioral attitude, or clinical or lung ultrasound scores.

Pleural clinic: where thoracic ultrasound meets respiratory medicine

Thoracic ultrasound (TUS) has become an essential procedure in respiratory medicine. Due to its intrinsic safety and versatility, it has been applied in patients affected by several respiratory diseases both in intensive care and outpatient settings. TUS can complement and often exceed stethoscope and radiological findings, especially in managing pleural diseases. We hereby aimed to describe the establishment, development, and optimization in a large, tertiary care hospital of a pleural clinic, which is dedicated to the evaluation and monitoring of patients with pleural diseases, including, among others, pleural effusion and/or thickening, pneumothorax and subpleural consolidation. The clinic was initially meant to follow outpatients undergoing medical thoracoscopy. In this scenario, TUS allowed rapid and regular assessment of these patients, promptly diagnosing recurrence of pleural effusion and other complications that could be appropriately managed. Over time, our clinic has rapidly expanded its initial indications thus becoming the place to handle more complex respiratory patients in collaboration with, among others, thoracic surgeons and oncologists. In this article, we critically describe the strengths and pitfalls of our "pleural clinic" and propose an organizational model that results from a synergy between respiratory physicians and other professionals. This model can inspire other healthcare professionals to develop a similar organization based on their local setting.

Thoracic ultrasonographic and clinical findings at 12-month follow-up of patients admitted with COVID-19

Introduction

Thoracic ultrasound (TUS) has proven useful in the diagnosis, risk stratification and monitoring of disease progression in patients with coronavirus disease 2019 (COVID-19). However, utility in follow-up is poorly described. To elucidate this area, we performed TUS as part of a 12-month clinical follow-up in patients previously admitted with COVID-19 and correlated findings with clinical assessment and pulmonary function tests.

Methods

Adult patients discharged from our hospital following admission with COVID-19 during March to May 2020 were invited to a 12-month follow-up. Enrolled patients were interviewed regarding persisting or newly developed symptoms in addition to TUS, spirometry and a 6-min walk test. Patients were referred to high-resolution computed tomography (HRCT) of the lungs if suspicion of pulmonary fibrosis was raised.

Results

Forty patients were enrolled in the study of whom had 13 developed acute respiratory distress syndrome (ARDS) during admission. Patients with ARDS were more prone to experience neurological symptoms at follow-up (p = 0.03) and showed more B-lines on TUS (p = 0.008) but did not otherwise differ significantly in terms of pulmonary function tests. Four patients had pathological findings on TUS where subsequent diagnostics revealed that two had interstitial lung abnormalities and two had heart failure. These four patients presented with a significantly lower diffusing capacity of lung for carbon monoxide (p=0.03) and 6-min walking distance (p=0.006) compared to the remaining 36 patients without ultrasound pathology. No significant difference was observed in spirometry values of % of predicted FEV1 (p=0.49) or FVC (p=0.07). No persisting cardiovascular pathology was observed in patients without ultrasonographic pathology.

Conclusion

At 12-month after admission with COVID-19, a follow-up combining TUS, clinical assessment, and pulmonary function tests may improve the selection of patients requiring further diagnostic investigations such as HRCT or echocardiography.

Ultrasonic Elastography-guided Pleural Biopsy for the Diagnosis of Pleural Effusion: A Multicenter Prospective Study of Diagnostic Test Performance

Rationale: The diagnostic yield of traditional ultrasound-guided pleural biopsy remains unsatisfactory, particularly when the pleural thickness is ⩽5 mm and/or no pleural nodules are detected. Pleural ultrasound elastography (UE) has a better diagnostic yield than traditional ultrasound for malignant pleural effusion (MPE). However, studies on UE-guided pleural biopsies are lacking. Objectives: To evaluate the feasibility and safety of UE-guided pleural biopsy. Methods: In this multicenter prospective single-arm trial, patients with pleural effusion whose pleural thickness was ⩽5 mm with no pleural nodules were enrolled between July 2019 and August 2021. The diagnostic yield of UE-guided pleural biopsy for pleural effusion and its sensitivity for detecting MPE were evaluated. Results: Ninety-eight patients (mean age, 62.4 ± 13.2 yr; 65 men) were prospectively enrolled. The diagnostic yield of UE-guided pleural biopsy for making any diagnosis was 92.9% (91/98), and its sensitivity for MPE was 88.7% (55/62). In addition, its sensitivity for pleural tuberculosis was 69.6% (16/23). The rate of postoperative chest pain was acceptable, and there was no pneumothorax. Conclusions: UE-guided pleural biopsy is a novel technique for diagnosing MPE with good diagnostic yield and sensitivity. Clinical trial registered with https://www.chictr.org.cn (ChiCTR2000033572).

The determination of pleurodesis using sonography after surgical pleurectomy for pneumothorax: a pilot study

The aim of this study is to evaluate feasibility of monitoring the process of pleurodesis after surgical pleurectomy with thoracic ultrasound. Repetitive measurements with thoracic ultrasound after surgical pleurectomy could provide information on the extent and development speed of pleurodesis. We conducted a prospective single-center cohort study. Adult patients who required surgical pleurectomy after pneumothorax were eligible. Participants had daily thoracic ultrasound examination until discharge to determine lung sliding [present (0 point), questionable (1 point), or absent (2 points)], and pleural thickening [normal (0 point), questionable (1 point), or present (2 points)]. Thoracic ultrasound was performed in six regions, the sum of all scores was divided by the number of regions. Fourteen patients were enrolled. Thoracic ultrasound on day 1-4 was 0.25±0.26, 0.39±0.48, 0.84±0.49, 1.12±0.56 for mean lung sliding, and 1.0±0.56, 1.17±0.48, 1.44±0.44, 1.54±0.34 for mean pleural thickening. Lung sliding and pleural thickening increased significantly between day 1 and day 4 (P=0.002 and P=0.023, respectively). One (7%) and 3 (21%) patients reached the maximum achievable grade for lung sliding and pleural thickening, respectively. Thoracic ultrasound grades tended to be lower in three patients with recurrent pneumothorax, although this was not statistically significant. This study shows a significant increase in thoracic ultrasound grading for pleurodesis lung sliding and pleural thickening during the first postoperative days after surgical pleurectomy, probably attributable to progressing pleurodesis. Only a minority of patients reached complete pleurodesis before discharge despite complete surgical pleurodesis (SP). The results of this study may guide future research regarding optimal timing of chest tube removal.

Point-of-care echocardiography and thoracic ultrasound in the management of critically ill patients with COVID-19 infection: Experience in three regional UK intensive care units

INTRODUCTION

Point-of-care ultrasound (POCUS) has an established role in the management of the critically ill. Information and experience of its use in those with COVID-19 disease is still evolving. We undertook a review of cardiac and thoracic ultrasound examinations in patients with COVID-19 on the intensive care unit (ICU). Our aim was to report key findings and their impact on patient management.

METHODS

A retrospective evaluation of critically ill patients with COVID-19 was undertaken in three adult ICUs, who received point-of-care cardiac and/or thoracic ultrasound during the 2019-2020 COVID-19 pandemic. We recorded baseline demographic data, principal findings, change in clinical management and outcome data.

RESULTS

A total of 55 transthoracic echocardiographic examinations scans were performed on 35 patients. 35/55 (64%) echocardiograms identified an abnormality, most commonly a dilated or impaired right ventricle (RV) and 39/55 (70%) scans resulted in a change in management. Nine patients (26%) were found to have pulmonary arterial thrombosis on CTPA or post-mortem. More than 50% of these patients showed evidence of right ventricular dilatation or impairment. Of the patients who were known to have pulmonary arterial thrombosis and died, 83% had evidence of right ventricular dilatation or impairment. 32 thoracic ultrasound scans were performed on 23 patients. Lung sliding and pleural thickening were present bilaterally in all studies. Multiple B-lines were present in all studies, and sub-pleural consolidation was present bilaterally in 72%.

CONCLUSION

POCUS is able to provide useful and clinically relevant information in those critically ill with COVID-19 infection, resulting in change in management in a high proportion of patients. Common findings in this group are RV dysfunction, multiple B-lines and sub-pleural consolidation.

Bochdalek hernia masquerading as pleural effusion in a young adult

Bochdalek hernia (BH) is a congenital diaphragmatic hernia which rarely presents in adulthood. We report on a 25-year-old man admitted with 3-year recurrent and self-limiting abdominal pain and vomiting. Chest radiograph showed left pleural opacity which shifted position in the decubitus film suggesting pleural effusion. Before attempting drainage, point-of-care (POC) thoracic ultrasound (TUS) demonstrated features of intrathoracic gastrointestinal content above the left hemi-diaphragm. Computed tomography of the thorax confirmed a large left BH. Acute recurrent symptoms 3 months post-discharge was associated with BH enlargement and early bowel ischemia, which was successfully managed by emergency surgery. This case illustrates the importance of pre-procedural imaging with POC-TUS before pleural procedures in all cases of suspected or apparent pleural effusion, and of prompt surgical treatment of symptomatic BH despite clinical stabilization.

Lung Ultrasonographic Signs in Pulmonary Disease - A Video Review

Lung ultrasound (US) is a well-established imaging tool in the inpatient and critical care setting. It has proven its worth in the rapid bedside diagnosis of a variety of conditions pertaining to the lungs and the thorax. Lung US was initially introduced as a bedside imaging tool to evaluate the size and characteristics of pleural effusion. Over the years, the field of lung ultrasonography has rapidly expanded introducing nuances in image interpretation. Numerous primary and secondary signs have been described in the literature to identify both normal and abnormal findings. The primary signs can help narrow the list of differential diagnoses, whereas the addition of secondary signs help create an imaging pattern facilitating the confirmation of diagnosis or recognition of the underlying disease process. These wide variety of signs and patterns can present a challenge to the learning of lung ultrasonography, particularly to a novice user. We sought to compile a comprehensive list of these findings to serve as a useful resource to aid effortless adoption of lung ultrasonography in clinical practice. In this review, we narrate the evolution of lung US, describe common protocols applied in performance of the lung US, and illustrate a comprehensive list of common lung US signs and patterns along with their differential diagnosis and clinical utility.

Concise, Practical Review on Transthoracic Lung Ultrasound in Prehospital Diagnosis of Dyspnea in Adults

Ultrasonography is a relatively young but widely recognized method of imaging parenchymal organs, including the lungs. Our concise, practical review on transthoracic lung ultrasound (LUS) in the prehospital diagnosis of dyspnea in adults attempts to summarize current knowledge in the field. Furthermore, we discussed POCUS protocols in the analyzed context, discussing their usefulness. We concluded that bedside ultrasonography, or point of care (POCUS), is developing rapidly; however, the knowledge about the use of LUS in a pre-hospital setting is scarce, highlighting the need for further research in this field. Additionally, despite the possibility of using various ultrasound protocols in diagnosing a patient with dyspnea, there is no comprehensive and, at the same time, highly sensitive and specific protocol covering a satisfactory saccade of differential diagnosis of this symptom. It seems reasonable to conduct further targeted research to create such a dedicated solution.

Thoracic point-of-care ultrasound is an accurate diagnostic modality for clinically significant traumatic pneumothorax

OBJECTIVE

There are conflicting data regarding the accuracy of thoracic point-of-care ultrasound (POCUS) in detecting traumatic pneumothorax (PTX). The purpose of our study was to determine the accuracy of thoracic POCUS performed by emergency physicians for the detection of clinically significant PTX in blunt and penetrating trauma patients.

METHODS

We conducted a retrospective institutional review board-approved study of trauma patients 15 years or older presenting to our urban Level I academic trauma center from December 2021 to June 2022. All study patients were imaged with single-view chest radiography (CXR) and thoracic POCUS. The presence or absence of PTX was determined by multidetector computed tomography (CT) or CXR and ultrasound (US) with tube thoracostomy placement.

RESULTS

A total of 846 patients were included, with 803 (95%) sustaining blunt trauma. POCUS identified 13/15 clinically significant PTXs (defined as ≥35 mm of pleural separation on a blinded overread or placement of a tube thoracostomy prior to CT) with a sensitivity of 87% (95% confidence interval [CI] 58-97), specificity of 100% (95% CI 99-100), positive predictive value of 81% (95% CI 54%-95%), and negative predictive value of 100% (95% CI 99%-100%). The positive likelihood ratio was 484 and the negative likelihood ratio was 0.1. CXR identified eight (53%) clinically significant PTXs, with a sensitivity of 53% (95% CI 27%-78%) and a specificity of 100%, when correlated with the CT. The most common reason for a missed PTX identified on expert-blinded overread was failure to recognize a lung point sign that was present on US.

CONCLUSIONS

Thoracic POCUS accurately identifies the majority of clinically significant PTXs in both blunt and penetrating trauma patients. Common themes for false-negative thoracic US in the expert-blinded overread process identified key gaps in training to inspire US education and medical education research.

Prevalence of respiratory disease in Irish preweaned dairy calves using hierarchical Bayesian latent class analysis

Introduction

Bovine respiratory disease (BRD) has a significant impact on the health and welfare of dairy calves. It can result in increased antimicrobial usage, decreased growth rate and reduced future productivity. There is no gold standard antemortem diagnostic test for BRD in calves and no estimates of the prevalence of respiratory disease in seasonal calving dairy herds.

Methods

To estimate BRD prevalence in seasonal calving dairy herds in Ireland, 40 dairy farms were recruited and each farm was visited once during one of two calving seasons (spring 2020 & spring 2021). At that visit the prevalence of BRD in 20 calves between 4 and 6 weeks of age was determined using thoracic ultrasound score (≥3) and the Wisconsin respiratory scoring system (≥5). Hierarchical Bayesian latent class analysis was used to estimate the calf-level true prevalence of BRD, and the within-herd prevalence distribution, accounting for the imperfect nature of both diagnostic tests.

Results

In total, 787 calves were examined, of which 58 (7.4%) had BRD as defined by a Wisconsin respiratory score ≥5 only, 37 (4.7%) had BRD as defined by a thoracic ultrasound score of ≥3 only and 14 (1.8%) calves had BRD based on both thoracic ultrasound and clinical scoring. The primary model assumed both tests were independent and used informed priors for test characteristics. Using this model the true prevalence of BRD was estimated as 4%, 95% Bayesian credible interval (BCI) (1%, 8%). This prevalence estimate is lower or similar to those found in other dairy production systems. Median within herd prevalence varied from 0 to 22%. The prevalence estimate was not sensitive to whether the model was constructed with the tests considered conditionally dependent or independent. When the case definition for thoracic ultrasound was changed to a score ≥2, the prevalence estimate increased to 15% (95% BCI: 6%, 27%).

Discussion

The prevalence of calf respiratory disease, however defined, was low, but highly variable, in these seasonal calving dairy herds.

Thoracic ultrasound alone or in combination with tracheal amylase as a tool predictor of ventilator-associated pneumonia in neurocritical patients

In this study, we aim to evaluate whether thoracic ultrasound (TUS) and tracheal amylase (TA) alone or in combination can predict the development of ventilator-associated pneumonia (VAP) in neurocritical patients. Consecutive adult patients with neurocritical disease with normal chest radiographs who required intensive care unit admission and mechanical ventilation between March 2015 and July 2018 were included. TUS and Amylase levels were measured during the first 24 hours and repeated 48 hours after orotracheal intubation. Forty-three patients with a median age of 34 years (17-82) were included. TUS had a sensitivity of 100% and specificity of 96.3% as a predictor of VAP within the first 48 hours when nonpattern A was observed. TA levels > 200 UI/L in the first 48 hours had a sensitivity of 87.5%, and specificity of 63% as a predictor of VAP. Moreover, no benefit of TUS plus TA compared to TUS alone as a predictor of VAP was found. The identification of abnormal TUS patterns in the first 48 hours of orotracheal intubation is a significant predictor of VAP in neurocritical patients.

Diagnosis of malignant pleural disease: Ultrasound as "a detective probe"

BACKGROUND

Malignant pleural mesothelioma (MPM) is an invasive, aggressive pleural tumor with a predominantly local spread. The objective of this study was to assess thoracic ultrasound (TUS) as an imaging modality with high sensitivity for the identification of malignant pleural involvement and in order to guide pleural biopsies.

METHODS

In this retrospective single-center study between January 2018 and June 2022, 51 consecutive patients with impassable circumferential pleural thickening underwent TUS at the Thoracic Surgery Unit of the Vanvitelli University of Naples. Pleural biopsies were performed, and then large and multiple samples were sent to the pathological anatomy for histological examination.

RESULTS

In all patients who underwent ultrasound examination, we chose the optimal point of entry to perform pleural biopsies and selected the areas of greater thickening without pleural effusion. No patient had any complications. No drainage tubes were placed after the pleural biopsies and no pneumothorax was present during the following days of hospitalization. The patients were discharged on the second postoperative day.

CONCLUSION

With TUS the precise pleural thickening localization, local infiltration, mass extent, its nature (solid, cystic or complex) and ultrasound features can be easily defined. Furthermore, ultrasound is more economical than computed tomography and avoids the risks associated with radiation. Thoracic ultrasound is an important component of the diagnostic procedure in detecting a safe entry site for biopsies of MPMs.

Thoracic ultrasound competence for ultrasound guided pleural procedures: The creation and validation of an assessment tool for use in the certification of basic thoracic ultrasound competence

OBJECTIVES

Focused thoracic ultrasound (TUS) provides an increased safety profile when undertaking invasive pleural procedures. This has led to the requirement for defined curricula, high quality teaching and robust, validated assessment tools among physicians to ensure patient safety and clinical excellence. Current UK practice is based almost exclusively on expert consensus, but assessment methods employed have been shown to have low reliability and validity and are potentially open to bias. As a result, several assessment tools have been developed, although each has its own limitations.

METHODS

This study aimed to develop and validate an assessment tool corresponding to those skills associated with the most basic level of practice, defined recently as an emergency level operator in the British Thoracic Society Training Standards for Thoracic Ultrasound.

RESULTS

A total of 27 candidates were enrolled by two examiners based in Belfast and Oxford over a 10-month period between February and November 2019. Mean score of the inexperienced group was 44.3 (95% CI 39.2-49.4, range 28-54) compared with 74.9 (95% CI 72.8-77, range 64-80) in the experienced group providing an estimated mean difference of 30.7 between the two groups (95% CI 24.7-36.7; p < .001).

CONCLUSIONS

This tool appears to discriminate between trainees with limited experience of TUS performance and those with no experience. It has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond, alongside well established assessment tools in postgraduate training.

Use of Point-of-Care Ultrasound by Non-Physicians to Assess Respiratory Distress in the Out-of-Hospital Environment: A Scoping Review

Background:

The use of ultrasound in the out-of-hospital environment is increasingly feasible. The potential uses for point-of-care ultrasound (POCUS) by paramedics are many, but have historically been limited to traumatic indications. This study utilized a scoping review methodology to map the evidence for the use of POCUS by paramedics to assess respiratory distress and to gain a broader understanding of the topic.

Methods:

Databases Ovid MEDLINE, EMBASE, CINAHL Plus, and PUBMED were searched from January 1, 1990 through April 14, 2021. Google Scholar was searched, and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital POCUS performed by non-physicians for non-traumatic respiratory distress.

Results:

A total of 591 unique articles were identified, of which seven articles met the inclusion criteria. The articles reported various different scan protocols and, with one exception, suffered from low enrolments and low participation. Most articles reported that non-physician-performed ultrasound was feasible. Articles reported moderate to high levels of agreement between paramedics and expert reviewers for scan interpretation in most studies.

Conclusion:

Paramedics and emergency medical technicians (EMTs) have demonstrated the feasibility of lung ultrasound in the out-of-hospital environment. Further research should investigate the utility of standardized education and scanning protocols in paramedic-performed lung ultrasound for the differentiation of respiratory distress and the implications for patient outcomes.

Randomized field trial comparing the efficacy of florfenicol and oxytetracycline in a natural outbreak of calf pneumonia using lung reaeration as a cure criterion

Background

Respiratory infections are the main indication for antimicrobial use in calves. Optimal treatment duration currently is unknown, but shorter duration would likely decrease selection for antimicrobial resistance.

Hypothesis/Objectives

Determine differences in cure rate and healing time between animals treated with florfenicol and oxytetracycline in a natural outbreak of respiratory disease using reaeration observed on thoracic ultrasound examination as healing criterion.

Animals

Commercial farm housing 130, 3 to 9 month old Belgian blue beef calves.

Methods

Randomized clinical trial during an outbreak of respiratory disease. Metaphylactic treatment was initiated, randomly treating animals with either florfenicol or oxytetracycline. Ultrasonographic follow‐up was done the first day and every other day for a 14‐day period. At the individual animal level, treatment was discontinued when reaeration of the lungs occurred. Differences in cure rate and healing time were determined.

Results

Of the 130 animals studied, 67.7% developed a lung consolidation ≥0.5 cm. The mean ultrasonographic healing time was 2.5 days in the florfenicol group compared to 3.1 days in the oxytetracycline group (P = .04). After single treatment, 80.6% and 60.3% had no consolidations in the florfenicol and oxytetracycline groups, respectively (P = .01). A Mycoplasma bovis strain was genetically and phenotypically determined to be susceptible to both antimicrobials.

Conclusions and Clinical Importance

Ultrasonographic lung reaeration shows potential as a cure criterion to rationalize antimicrobial use for outbreaks of pneumonia. In our study, florfenicol resulted in a faster cure and higher reduction in antimicrobial usage than did oxytetracycline.

Saline lavage for the management of severe pleural empyema: A cohort study

BACKGROUND

Despite advances in the treatment of pleural infection, up to 20% of patients die. So far, studies assessing the role of intrapleural saline lavage for the management of all stage pleural infections are very scarce, usually excluding patients with cancer.

METHODS

The method used was a retrospective cohort study including pleural empyema managed with a pleural lavage of saline solution through a small-bore chest tube. The primary outcome was the rate of failure at 3 months (surgical referral or additional pleural manoeuver due to recurrent infection or all-cause mortality). Secondary outcomes were hospital stay, the change of the chest radiograph and inflammatory biomarkers, and complications.

RESULTS

Thirty patients with pleural empyema were included, 11 (36.7%) with an active cancer. The overall rate of failure at 3 months was 13.3% (surgical referral = 0; additional pleural manoeuver = 3; mortality = 1). Median length of pleural lavage and hospital stay were, respectively, 14 days (7-28) and 17 days (11-42). Inflammatory markers and size of the effusion on chest radiograph significantly decreased for Day 0 to Day 14. No chest tube blockade was reported, but seven (23.3%) accidentally withdrew. No other side effects were reported.

CONCLUSIONS

Intrapleural saline lavage is efficient and safe for the management of pleural empyema, even in severe status patients with cancer, at the cost of a prolonged hospitalization.

Diagnostic imaging in acute interstitial pneumonia in foals: High variability of interpretation of chest radiographs and good conformity between ultrasonographic and post-mortem findings

Acute interstitial pneumonia (AIP) in foals is a rare but challenging syndrome. Diagnostic imaging is crucial for its diagnosis. While there are some reports on radiographic findings, ultrasound is sparsely described. Variability in the evaluation of radiographs in AIP has been well described in human literature. Part one of this study is a prospective, observational, observer agreement study investigating inter- and intraobserver agreement in the assessment of thoracic radiographs. Part two is a prospective, controlled, descriptive study on thoracic ultrasonography in foals with AIP. Eighteen foals with AIP were examined daily by thoracic ultrasound. Thoracic radiographs were taken on three successive occasions. Blinded radiographs were assessed by three observers based on two semi-quantitative scores (pattern recognition, subjective evaluation). Foals that died underwent postmortem examination (n = 9); postmortem findings were compared to ultrasound findings on the day of death. Ultrasonographic findings were consistent with postmortem findings. Comet tail scores in foals with AIP were significantly higher (p < 0.0001) than in control foals. Interrater agreement for the assessment of radiographs was none to moderate (κ = 0.07-0.65) for pattern recognition and weak to moderate (κ = 0.58-0.62) for subjective scoring. Intrarater agreement varied from minimal to strong (κ = 0.30-0.80) for pattern recognition but was strong (κ = 0.83) for subjective scoring. In conclusion, the diagnostic value of thoracic ultrasound in foals with AIP is high due to good conformity with postmortem findings. The evaluation of thoracic radiographs showed high variability in inter- and intra-agreement.

Diagnostics in Pleural Disease

Pleural disease diagnostics represent a sprawling topic that has enjoyed a renaissance in recent years from humble beginnings. Whilst pleural patients are heterogeneous as a population and in the aetiology of the disease with which they present, we provide an overview of the typical diagnostic approach. Pleural fluid analysis is the cornerstone of the diagnostic pathway; however, it has many shortcomings. Strong cases have been made for more invasive upfront investigations, including image-guided biopsies or local anaesthetic thoracoscopy, in selected populations. Imaging can guide the diagnostic process as well as act as a vehicle to facilitate therapies, and this is never truer than with the recent advances in thoracic ultrasound.

Utility of Different Lung Ultrasound Simulation Modalities Used by Paramedics during Varied Ambulance Driving Conditions

INTRODUCTION

Prehospital use of lung ultrasound (LUS) by paramedics to guide the diagnoses and treatment of patients has expanded over the past several years. However, almost all of this education has occurred in a classroom or hospital setting. No published prehospital use of LUS simulation software within an ambulance currently exists.

STUDY OBJECTIVE

The objective of this study was to determine if various ambulance driving conditions (stationary, constant acceleration, serpentine, and start-stop) would impact paramedics' abilities to perform LUS on a standardized patient (SP) using breath-holding to simulate lung pathology, or to perform LUS using ultrasound (US) simulation software. Primary endpoints included the participating paramedics': (1) time to acquiring a satisfactory simulated LUS image; and (2) accuracy of image recognition and interpretation. Secondary endpoints for the breath-holding portion included: (1) the agreement between image interpretation by paramedic versus blinded expert reviewers; and (2) the quality of captured LUS image as determined by two blinded expert reviewers. Finally, a paramedic LUS training session was evaluated by comparing pre-test to post-test scores on a 25-item assessment requiring the recognition of a clinical interpretation of prerecorded LUS images.

METHODS

Seventeen paramedics received a 45-minute LUS lecture. They then performed 25 LUS exams on both SPs and using simulation software, in each case looking for lung sliding, A and B lines, and seashore or barcode signs. Pre- and post-training, they completed a 25-question test consisting of still images and videos requiring pathology recognition and formulation of a clinical diagnosis. Sixteen paramedics performed the same exams in an ambulance during different driving conditions (stationary, constant acceleration, serpentines, and abrupt start-stops). Lung pathology was block randomized based on driving condition.

RESULTS

Paramedics demonstrated improved post-test scores compared to pre-test scores (P <.001). No significant difference existed across driving conditions for: time needed to obtain a simulated image; clinical interpretation of simulated LUS images; quality of saved images; or agreement of image interpretation between paramedics and blinded emergency physicians (EPs). Image acquisition time while parked was significantly greater than while the ambulance was driving in serpentines (Z = -2.898; P = .008). Technical challenges for both simulation techniques were noted.

CONCLUSION

Paramedics can correctly acquire and interpret simulated LUS images during different ambulance driving conditions. However, simulation techniques better adapted to this unique work environment are needed.

Lung Ultrasound Eight-Point Method in Diagnosing Acute Heart Failure in Emergency Patients with Acute Dyspnea: Diagnostic Accuracy and 72 h Monitoring

Background and Objectives: Acute dyspnea is a common chief complaint in the emergency department (ED), with acute heart failure (AHF) as a frequent underlying disease. Early diagnosis and rapid therapy are highly recommended by international guidelines. This study evaluates the accuracy of point-of-care B-line lung ultrasound in diagnosing AHF and monitoring the therapeutic success of heart failure patients. Materials and Methods: This is a prospective mono-center study in adult patients presenting with undifferentiated acute dyspnea to a German ED. An eight-zone pulmonary ultrasound was performed by experienced sonographers in the ED and 24 and 72 h after. Along with the lung ultrasound evaluation patients were asked to assess the severity of shortness of breath on a numeric rating scale. The treating ED physicians were asked to assess the probability of AHF as the underlying cause. Final diagnosis was adjudicated by two independent experts. Follow-up was done after 30 and 180 days. Results: In total, 102 patients were enrolled. Of them, 89 patients received lung ultrasound evaluation in the ED. The sensitivity of lung ultrasound evaluation in ED in diagnosing AHF was 54.2%, specificity 97.6%. As much as 96.3% of patients with a positive LUS test result for AHF in ED actually suffered from AHF. Excluding diuretically pretreated patients, sensitivity of LUS increased to 75% in ED. Differences in the sum of B-lines between admission time point, 24 and 72 h were not statistically significant. There were no statistically significant differences in the subjectively assessed severity of dyspnea between AHF patients and those with other causes of dyspnea. Of the 89 patients, 48 patients received the final adjudicated diagnosis of AHF. ED physicians assessed the probability of AHF in patients with a final diagnosis of AHF as 70%. Roughly a quarter (23.9%) of the overall cohort patients were rehospitalized within 30 days after admission, 38.6% within 180 days of follow-up. Conclusion: In conclusion, point-of-care lung ultrasound is a helpful tool for the early rule-in of acute heart failure in ED but only partially suitable for exclusion. Of note, the present study shows no significant changes in the number of B-lines after 24 and 72 h.

Point-of-Care Ultrasound in the Evaluation of COVID-19

BACKGROUND

The novel coronavirus SARS-CoV-2 has caused a pandemic, overwhelming health care systems around the world. Hospitals around the world, including the United States, have been struggling to adapt to the influx of patients with COVID-19, the illness caused by SARS-CoV2, given limited resources and high demand for medical care.

OBJECTIVES

This article seeks to provide emergency physicians with a guide to sonographic findings in COVID-19 and an algorithm by which point-of-care lung ultrasound may assist emergency physicians caring for these patients during the SARS-CoV-2 pandemic.

DISCUSSION

The studies currently being published have established a typical set of ultrasound findings in COVID-19. Point-of-care lung ultrasound is rapid and accessible in most emergency departments in the United States, and even in many resource-poor settings.

CONCLUSION

Point-of-care ultrasound provides numerous benefits to emergency providers caring for patients with COVID-19, including decreasing resource utilization, assisting in diagnosis, guiding management of the critically ill patient, and aiding in rapid triage of patients under investigations for COVID-19.

Diagnostic thoracic ultrasound imaging - An exploration of respiratory physiotherapists' interest and use in clinical practice: A national survey

INTRODUCTION

Physiotherapists are learning to perform diagnostic thoracic ultrasound but it is currently unknown how they are learning, how they are using thoracic ultrasound in their practice, or any factors affecting the implementation of thoracic ultrasound into practice. The aim of this survey was to explore the use of thoracic ultrasound by physiotherapists. This information could be used to aid training and implementation strategies to assist physiotherapists to integrate thoracic ultrasound safely into their practice.

METHODS

A questionnaire comprising of open/closed questions was distributed to respiratory physiotherapist. Distribution was at three national study days and via a specialist newsletter containing a link to a SurveyMonkey™ questionnaire.

RESULTS

A total of 133 questionnaires were returned with 31 reported that they used thoracic ultrasound imaging and 101 reporting they did not. The most common roles of thoracic ultrasound in practice were to: enhance the ability to differentially diagnose respiratory pathologies, aid respiratory assessment and support clinical reasoning. Of the 133 respondents, 58 reported that they had undertaken training in thoracic ultrasound imaging and 75 had not. The most common factors identified regarding thoracic ultrasound implementation were team support, ultrasound machine availability/cost, time pressures and mentor availability.

DISCUSSION

This survey has provided an understanding of thoracic ultrasound practice amongst respiratory physiotherapists in the UK. The survey results demonstrated the barriers that inhibit current practice and highlighted the importance of mentor support. There was a good understanding by all respondents regarding the clinical application of thoracic ultrasound. These findings are being used to develop professional guidance and ensure safe practice of thoracic ultrasound.

Outcomes of an initiative to improve inpatient safety of small bore thoracostomy tube insertion

Background

Intercostal chest catheter (ICC) insertion is a common hospital procedure with attendant risks including life‐threatening complications such as pneumothorax and visceral damage.

Aim

To investigate the effect of a quality improvement (QI) initiative on complications associated with inpatient thoracostomy tube insertion.

Methods

Following an audit of ICC complications in inpatients over a 2‐year period we implemented a comprehensive QI programme. This involved formal training in and mandatory use of thoracic ultrasound, standardisation of the procedure and documentation, a dedicated procedure room with nurses trained in assisting ICC insertion and senior supervision for medical staff. An audit over 2 years post‐implementation of the QI protocol was compared with pre‐implementation results.

Results

A total of 103 cases were reviewed pre‐implementation and 105 cases were reviewed post‐implementation of the QI programme. All procedures following the QI initiative were image guided compared to 23.3% of cases pre‐implementation. The rate of developing a pneumothorax requiring intervention post‐implementation was less than pre‐implementation (1.9% vs 5.8% (P = 0.023). Post‐implementation, there were no instances of dry taps, viscera perforation, clinically significant bleeding or wrong side ICC insertion and documentation improved.

Conclusion

QI initiative applied to thoracostomy tube insertion in hospital inpatients can reduce complications and improve procedure documentation.

Clinically Significant Pleural Effusion in Intensive Care: A Prospective Multicenter Cohort Study

OBJECTIVES

The prevalence and optimal management of clinically significant pleural effusion, confirmed by thoracic ultrasound, in the critically ill is unknown. This study aimed to determine: 1) the prevalence, characteristics, and outcomes of patients treated in intensive care with clinically significant effusion and 2) the comparative efficacy and safety of pleural drainage or expectant medical management.

DESIGN

A prospective multicenter cohort study.

SETTING

ICUs in four teaching hospitals in Western Australia.

PATIENTS

Consecutive patients with clinically significant pleural effusions (depth ≥ 2 cm on thoracic ultrasound with clinician-determined adverse effects on patient progress).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was the change in Pao2:Fio2 (mm Hg) ratio from baseline to 24 hours. Changes in diagnosis and treatment based on pleural fluid analysis and pleural effusion related serious adverse events between those who underwent either drainage within 24 hours or expectant management were compared. Of the 7,342 patients screened, 226 patients (3.1%) with 300 pleural effusions were enrolled. Early drainage of pleural effusion occurred in 76 patients (34%) and significantly improved oxygenation (Pao2:Fio2 ratio 203 at baseline vs 263 at 24 hr, +29.6% increment; p < 0.01). This was not observed in the other 150 patients who had expectant management (Pao2:Fio2 ratio 250 at baseline vs 268 at 24 hr, +7.2% increment; p = 0.44). The improvement in oxygenation after early drainage remained unchanged after adjustment for a propensity score on the decision to initiate early drainage. Pleural effusion related serious adverse events were not different between the two groups (early drainage 10.5% vs no early drainage 16.0%; p = 0.32). Improvements in diagnosis were noted in 91 initial (nonrepetitive) drainages (76.5% out of 119); treatment strategy was optimized after 80 drainage episodes (59.7% out of 134).

CONCLUSIONS

Early drainage of clinically significant pleural effusion was associated with improved oxygenation and diagnostic accuracy without increased complications.

Lung Ultrasound for the Cardiologist

For a cardiologist, lung ultrasound is an add-on to transthoracic echocardiography, just as lung auscultation is part of a cardiac physical examination. A cardiac 3.5- to 5.0-MHz transducer is generally suitable because the small footprint makes it ideal for scanning intercostal spaces. The image quality is often adequate, and the lung acoustic window is always patent. The cumulative increase in imaging time is <1 min for the 2 main applications targeted on pleural water (pleural effusion) and lung water (pulmonary congestion as multiple B-lines). In these settings, lung ultrasound outperforms the diagnostic accuracy of the chest radiograph, with a low-cost, portable, real-time, radiation-free method. A "wet lung" detected by lung ultrasound predicts impending acute heart failure decompensation and may trigger lung decongestion therapy. The doctors of tomorrow may still listen with a stethoscope to their patient's lung, but they will certainly be seeing it with ultrasound.

Application of Lung Ultrasound in Critical Care Setting: A Review

This article reviews the use of thoracic ultrasound in the intensive care unit (ICU). The focus of this article is to review the basic terminology and clinical applications of thoracic ultrasound. The diagnostic approach to a breathless patient, the blue protocol, is presented in a simplified flow chart. The diagnostic application of thoracic ultrasound in lung parenchymal and pleural diseases, role in bedside procedures, diaphragmatic assessment, and lung recruitment are described. Recent updates discussed in this review help support its increasingly indispensable role in the emergent and critical care setting.

ESTABLISHING MARGINAL LYMPH NODE ULTRASONOGRAPHIC CHARACTERISTICS IN HEALTHY BOTTLENOSE DOLPHINS ( TURSIOPS TRUNCATUS)

Pulmonary disease has been well documented in wild and managed dolphin populations. The marginal lymph nodes of the dolphin thorax provide lymphatic drainage to the lungs and can indicate pulmonary disease. This study standardized a technique for rapid, efficient, and thorough ultrasonographic evaluation of the marginal lymph nodes in bottlenose dolphins ( Tursiops truncatus). Thoracic ultrasonography was performed on 29 clinically healthy adult bottlenose dolphins. Reference intervals for lymph node dimensions and ultrasonographic characteristics of marginal lymph nodes were determined from four transducer orientations: longitudinal, transverse, oblique, and an orientation optimized to the ultrasonographer's eye. The relationship between lymph node dimensions and dolphin age, sex, length, weight, origin, and management setting (pool versus ocean enclosure) were also evaluated. The mean marginal lymph nodes measured 5.26 cm in length (SD = 1.10 cm, minimum = 3.04 cm, maximum = 7.61 cm, reference interval [10th to 90th percentiles per node dimension] 3.78-6.55 cm) and 3.72 cm in depth (SD = 0.59 cm, minimum = 2.64, maximum = 5.38 cm, reference interval 2.98-4.50 cm). Sex, dolphin length, weight, and management setting had no effect on lymph node dimensions. Dolphins >30 yr of age had longer node lengths than dolphins 5-10 yr old. Node dimensions did differ between dolphins from various origins. Most commonly, the lymph node was found to be hyperechoic relative to surrounding soft tissues (98%) and to have irregular caudal borders (84%), ill-defined deep borders (83%), flat superficial border (67%), triangular or rounded triangle shape (59%), irregular cranial border (55%), and moderate heterogeneity (34%). The data reported in this study serve as a baseline reference that may contribute to earlier detection of pleural and pulmonary disease of managed and wild cetacean populations.

Approach to malignant pleural effusions: Role of pleural manometry exemplified by case scenarios

Issues related to the management of pleural effusion in India are unique. With high incidence of tuberculosis and malignancy, managing patients with pleural effusion may not be the same between patients. Decisions on intercostal chest drain insertion, volume of fluid to be removed during therapeutic thoracentesis, and further diagnostic imaging and investigations are often taken with difficulty in low-resource settings. Pleural manometry can help resolve these issues and help in the management of such patients. Pleural manometry has been advocated as a valuable tool to characterize underlying lung behavior during thoracentesis and has been proposed to be useful in diagnosing unexpandable lung, predicting the success of pleurodesis, and preventing the development of excessively negative pleural pressures which in turn may lead to the development of reexpansion pulmonary edema. There is very little literature on pleural manometry from India and other developing countries. In this article, the utility of pleural manometry in managing patients with malignant pleural effusion is discussed.

Field trial to evaluate the effect of an intranasal respiratory vaccine protocol on calf health, ultrasonographic lung consolidation, and growth in Holstein dairy calves

The objective of this field trial was to evaluate the effect of a vaccine protocol using a commercially available trivalent vaccine designed for intranasal use. Experimental challenge studies have demonstrated varying efficacies of vaccines administered via the intranasal route. A total of 468 calves from 3 herds were enrolled and randomized into 3 treatment groups (positive control, PC, n = 211; intranasal vaccine, IN, n = 215; negative control, NC, n = 42) and followed for 8 to 12 wk. The PC consisted of one dose of commercially available multivalent injectable vaccine against bovine respiratory syncytial virus, infectious bovine rhinotracheitis, parainfluenza 3, and bovine viral diarrhea administered subcutaneously at 6 wk of age. The IN was administered at enrollment and 6 wk of age, and contained antigen against bovine respiratory syncytial virus, infectious bovine rhinotracheitis, and parainfluenza 3. The NC was sterile saline administered intranasally and subcutaneously at enrollment and 6 wk of age. Clinical illness was assessed using systematic respiratory scoring, and thoracic ultrasonography was used to identify the lung consolidation associated with pneumonia. Rib fractures were identified in 6% of calves, and an association was observed between rib fractures and calving ease. Overall, 54% of the calves had at least one episode of an abnormal respiratory score (ILL). Vaccination protocol did not affect the occurrence of ILL. Similarly, 54% of the calves had at least one episode of lung consolidation ≥3 cm (CON). Vaccine protocol affected the odds of CON. The odds of CON in PC were 1.63 (95% confidence interval: 1.04-2.56) times the odds of CON in IN, and 0.38 (95% confidence interval: 0.16-0.93) times the odds of CON in NC. The odds of CON in IN were 0.23 (95% confidence interval: 0.09-0.59) times the odds of CON in NC. The outcomes ILL and CON were associated; however, the measure of agreement was only fair (kappa = 0.38). Multivariable linear regression revealed an interaction between vaccine protocol and herd on average daily gain (ADG); therefore, these data were stratified. In herd 1, IN (0.53 ± 0.03 kg/d) decreased ADG compared with PC (0.63 ± 0.03 kg/d). In herd 2, IN increased ADG (0.41 ± 0.03 kg/d) compared with PC (0.38 ± 0.03 kg/d). In contrast, none of the protocols affected ADG at herd 3. In conclusion, this commercially available trivalent IN vaccine protocol did not alter the incidence of ILL, reduced the risk of lung lesions associated with pneumonia, and improved the ADG of the calves in one of the commercial study herds.

Endoscopic diagnosis and management of pleural effusion in malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is an asbestos-related aggressive tumor, that requires proper diagnosis and management. Symptoms are nonspecific and chest computed tomography (CT) and chest ultrasound (US) are important radiological tools in the initial workup to identify early pathological signs. Performing a medical thoracoscopy (MT) is essential for a definitive diagnosis of MPM. The procedure, integrated with a prior US, allows a global evaluation of the pleural cavity and the execution of multiple targeted biopsies, with low risk of complications. Some different endoscopic patterns are recognized. Thoracoscopic biopsies provide enough material to allow a thorough pathological and immunohistochemical characterization. The presence of extensive pleural adhesions and critical patient conditions are the only absolute contraindications. The clinical course of MPM is characterized by chronic symptoms such as chest pain and progressive dyspnea, the latter caused mainly by recurrent pleural effusion. Palliative interventions are required in order to relieve symptoms and improve the quality of life (QoL). These include thoracentesis, pleurodesis and the placement of an indwelling pleural catheter.

Diagnostic approach to pleural diseases: new tricks for an old trade

The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering. Ignored for a long time as an epiphenomenon at the crossroad of many unrelated medical problems, pleural diseases are finally getting the attention they deserve and have spurred a vibrant and exciting field of research.

Pleural procedures in the management of malignant effusions

Malignant pleural effusion (MPE) is common in clinical practice, and despite the existence of studies to guide clinical decisions, it often poses diagnostic and therapeutic dilemmas. Once it is diagnosed, median survival does not usually exceed 6 months. The management of these patients focuses on symptom relief since no treatments have been shown to increase survival to date. Conversely, poor management can shorten survival. The approach must be multidisciplinary and allow for individualized care. Initial diagnostic procedures should be minimally invasive and, according to the results and other factors, procedures of increasing complexity will be selecting. Likewise, the treatment of MPEs should be individualized according to factors such as type of tumor, patient functional status, means available, benefits of each procedure, or life expectancy. Currently, treatment seems to tend toward less interventional approaches, in which patients can be managed on an outpatient basis, thus minimizing both the discomfort that more aggressive approaches involve and the costs of care associated with this disease. This article reviews the pleural procedures employed in the management of MPEs with special emphasis on the indication for each one, its usefulness, benefits, and complications.