New International Guidelines and Consensus on the Use of Lung Ultrasound

Ultrasound in the Study of Thoracic Diseases: Innovative Aspects

Thoracic ultrasound (TU) has rapidly gained popularity over the past 10 years. This is in part because ultrasound equipment is available in many settings, more training programmes are educating trainees in this technique, and ultrasound can be done rapidly without exposure to radiation. The aim of this review is to present the most interesting and innovative aspects of the use of TU in the study of thoracic diseases. In pleural diseases, TU has been a real revolution. It helps to differentiate between different types of pleural effusions, guides the performance of pleural biopsies when necessary and is more cost-effective under these conditions, and assists in the decision to remove thoracic drainage after talc pleurodesis. With the advent of COVID19, the use of TU has increased for the study of lung involvement. Nowadays it helps in the diagnosis of pneumonias, tumours and interstitial diseases, and its use is becoming more and more widespread in the Pneumology ward. In recent years, TU guided biopsies have been shown to be highly cost-effective, with other advantages such as the absence of radiation and the possibility of being performed at bedside. The use of contrast in ultrasound to increase the cost-effectiveness of these biopsies is very promising. In the study of the mediastinum and peripheral pulmonary nodules, the introduction of echobronchoscopy has brought about a radical change. It is a fully established technique in the study of lung cancer patients. The introduction of elastography may help to further improve its cost-effectiveness. In critically-ill patients, diaphragmatic ultrasound helps in the assessment of withdrawal of mechanical ventilation, and is now an indispensable tool in the management of these patients. In neuromuscular patients, ultrasound is a good predictor of impaired lung function. Currently, in Neuromuscular Disease Units, TU is an indispensable tool. Ultrasound study of the intercostal musculature is also effective in the study of respiratory function, and is widely used in Respiratory Rehabilitation. In Intermediate Care Units, thoracic ultrasound is indispensable for patient management. In these units there are ultrasound protocols for the management of patients with acute dyspnoea that have proven to be very effective.

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.

COVID-19 on Oral Health: A New Bilateral Connection for the Pandemic

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and transmission are generally known to be produced by respiratory droplets and aerosols from the oral cavity (O.C.) of infected subjects, as stated by the World Health Organization. Saliva also retains the viral particles and aids in the spread of COVID-19. Angiotensin-converting enzyme Type 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2) are two of the numerous factors that promote SARS-CoV-2 infection, expressed by O.C. structures, various mucosa types, and the epithelia of salivary glands. A systemic SARS-CoV-2 infection might result from viral replication in O.C. cells. On the other hand, cellular damage of different subtypes in the O.C. might be associated with various clinical signs and symptoms. Factors interfering with SARS-CoV-2 infection potential might represent fertile ground for possible local pharmacotherapeutic interventions, which may confine SARS-CoV-2 virus entry and transmission in the O.C., finally representing a way to reduce COVID-19 incidence and severity.

Point-of-Care Ultrasound-History, Current and Evolving Clinical Concepts in Emergency Medicine

Point-of-care ultrasound (PoCUS) has become an indispensable standard in emergency medicine. Emergency medicine ultrasound (EMUS) is the application of bedside PoCUS by the attending emergency physician to assist in the diagnosis and management of many time-sensitive health emergencies. In many ways, using PoCUS is not only the mere application of technology, but also a fusion of already existing examiner skills and technology in the context of a patient encounter. EMUS practice can be defined using distinct anatomy-based applications. The type of applications and their complexity usually depend on local needs and resources, and practice patterns can vary significantly among regions, countries, or even continents. A different approach suggests defining EMUS in categories such as resuscitative, diagnostic, procedural guidance, symptom- or sign-based, and therapeutic. Because EMUS is practiced in a constantly evolving emergency medical setting where no two patient encounters are identical, the concept of EMUS should also be practiced in a fluid, constantly adapting manner driven by the physician treating the patient. Many recent advances in ultrasound technology have received little or no attention from the EMUS community, and several important technical advances and research findings have not been translated into routine clinical practice. The authors believe that four main areas have great potential for the future growth and development of EMUS and are worth integrating: 1. In recent years, many articles have been published on novel ultrasound applications. Only a small percentage has found its way into routine use. We will discuss two important examples: trauma ultrasound that goes beyond e-FAST and EMUS lung ultrasound for suspected pulmonary embolism. 2. The more ultrasound equipment becomes financially affordable; the more ultrasound should be incorporated into the physical examination. This merging and possibly even replacement of aspects of the classical physical exam by technology will likely outperform the isolated use of stethoscope, percussion, and auscultation. 3. The knowledge of pathophysiological processes in acute illness and ultrasound findings should be merged in clinical practice. The translation of this knowledge into practical concepts will allow us to better manage many presentations, such as hypotension or the dyspnea of unclear etiology. 4. Technical innovations such as elastography; CEUS; highly sensitive color Doppler such as M-flow, vector flow, or other novel technology; artificial intelligence; cloud-based POCUS functions; and augmented reality devices such as smart glasses should become standard in emergencies over time.

Case report: Application of color Doppler sonography for the assessment of pulmonary consolidations in a dog

A 1,5-year-old male Maltipoo was presented to the emergency service for dyspnea, weakness, and cough. An echocardiographic examination showed evidence of pulmonary hypertension with a McConnell sign. Lung ultrasound, including color Doppler, was performed and identified two distinct populations of lung consolidation. Color Doppler analysis of the first type of consolidation showed the absence of blood flow within regions of the consolidation and flow amputation. These findings were consistent with the "vascular sign" reported in human medicine and prompted consideration of pulmonary thromboembolism as a differential diagnosis. In the second type of consolidation, color Doppler identified blood flow within the pulmonary vessels of the consolidated lung, forming a "branching tree-like" pattern that followed the anatomical course of the pulmonary vasculature. These findings suggested that blood flow was preserved within the pulmonary vasculature of the consolidated lung and prompted consideration of inflammatory causes of pulmonary pathology. On recheck 6 days later, recanalization of the first type of consolidation was identified with color Doppler. The case was followed serially once a month for 5 months with LUS, which showed continued improvement. Based on a positive fecal Baermann test, a final diagnosis of Angiostrongylus vasorum was made. New or Unique information Provided-this is the first report of color Doppler LUS being used to characterize and help differentiate the cause of lung consolidation in dogs.

Can Artificial Intelligence Aid Diagnosis by Teleguided Point-of-Care Ultrasound? A Pilot Study for Evaluating a Novel Computer Algorithm for COVID-19 Diagnosis Using Lung Ultrasound

With the 2019 coronavirus disease (COVID-19) pandemic, there is an increasing demand for remote monitoring technologies to reduce patient and provider exposure. One field that has an increasing potential is teleguided ultrasound, where telemedicine and point-of-care ultrasound (POCUS) merge to create this new scope. Teleguided POCUS can minimize staff exposure while preserving patient safety and oversight during bedside procedures. In this paper, we propose the use of teleguided POCUS supported by AI technologies for the remote monitoring of COVID-19 patients by non-experienced personnel including self-monitoring by the patients themselves. Our hypothesis is that AI technologies can facilitate the remote monitoring of COVID-19 patients through the utilization of POCUS devices, even when operated by individuals without formal medical training. In pursuit of this goal, we performed a pilot analysis to evaluate the performance of users with different clinical backgrounds using a computer-based system for COVID-19 detection using lung ultrasound. The purpose of the analysis was to emphasize the potential of the proposed AI technology for improving diagnostic performance, especially for users with less experience.

Advancing healthcare through thoracic ultrasound research in older patients

This paper reports the proceedings of a meeting convened by the Research Group on Thoracic Ultrasound in Older People of the Italian Society of Gerontology and Geriatrics, to discuss the current state-of-the-art of clinical research in the field of geriatric thoracic ultrasound and identify unmet research needs and potential areas of development. In the last decade, point-of-care thoracic ultrasound has entered clinical practice for diagnosis and management of several respiratory illnesses, such as bacterial and viral pneumonia, pleural effusion, acute heart failure, and pneumothorax, especially in the emergency-urgency setting. Very few studies, however, have been specifically focused on older patients with frailty and multi-morbidity, who frequently exhibit complex clinical pictures needing multidimensional evaluation. At the present state of knowledge, there is still uncertainty on the best requirements of ultrasound equipment, methodology of examination, and reporting needed to optimize the advantages of thoracic ultrasound implementation in the care of geriatric patients. Other issues regard differential diagnosis between bacterial and aspiration pneumonia, objective grading of interstitial syndrome severity, quantification and monitoring of pleural effusions and solid pleural lesions, significance of ultrasonographic assessment of post-COVID-19 sequelae, and prognostic value of assessment of diaphragmatic thickness and motility. Finally, application of remote ultrasound diagnostics in the community and nursing home setting is still poorly investigated by the current literature. Overall, the presence of several open questions on geriatric applications of thoracic ultrasound represents a strong call to implement clinical research in this field.

Ultrasound multifrequency strategy to estimate the lung surface roughness, in silico and in vitro results

Lung ultrasound (LUS) is an important imaging modality to assess the state of the lung surface. Nevertheless, LUS is limited to the visual evaluation of imaging artifacts, especially the vertical ones. These artifacts are observed in pathologies characterized by a reduction of dimensions of air-spaces (alveoli). In contrast, there exist pathologies, such as chronic obstructive pulmonary disease (COPD), in which an enlargement of air-spaces can occur, which causes the lung surface to behave essentially as a perfect reflector, thus not allowing ultrasound penetration. This characteristic high reflectivity could be exploited to characterize the lung surface. Specifically, air-spaces of different sizes could cause the lung surface to have a different roughness, whose estimation could provide a way to assess the state of the lung surface. In this study, we present a quantitative multifrequency approach aiming at estimating the lung surface's roughness by measuring image intensity variations along the lung surface as a function of frequency. This approach was tested both in silico and in vitro, and it showed promising results. For the in vitro experiments, radiofrequency (RF) data were acquired from a novel experimental model. The results showed consistency between in silico and in vitro experiments.

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.

Best Practice Recommendations for the Safe use of Lung Ultrasound

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

Ultrasound imaging of lung disease and its relationship to histopathology: An experimentally validated simulation approach

Lung ultrasound (LUS) is a widely used technique in clinical lung assessment, yet the relationship between LUS images and the underlying disease remains poorly understood due in part to the complexity of the wave propagation physics in complex tissue/air structures. Establishing a clear link between visual patterns in ultrasound images and underlying lung anatomy could improve the diagnostic accuracy and clinical deployment of LUS. Reverberation that occurs at the lung interface is complex, resulting in images that require interpretation of the artifacts deep in the lungs. These images are not accurate spatial representations of the anatomy due to the almost total reflectivity and high impedance mismatch between aerated lung and chest wall. Here, we develop an approach based on the first principles of wave propagation physics in highly realistic maps of the human chest wall and lung to unveil a relationship between lung disease, tissue structure, and its resulting effects on ultrasound images. It is shown that Fullwave numerical simulations of ultrasound propagation and histology-derived acoustical maps model the multiple scattering physics at the lung interface and reproduce LUS B-mode images that are comparable to clinical images. However, unlike clinical imaging, the underlying tissue structure model is known and controllable. The amount of fluid and connective tissue components in the lung were gradually modified to model disease progression, and the resulting changes in B-mode images and non-imaging reverberation measures were analyzed to explain the relationship between pathological modifications of lung tissue and observed LUS.

Lung ultrasound in the COVID-19 era: a lesson to be learned for the future

Lung Ultrasound (LUS) is a reliable, radiation free and bedside imaging technique to assess several pulmonary diseases. Although the diagnosis of COVID-19 is made with the nasopharyngeal swab, detection of pulmonary involvement is key for a safe patient management. LUS is a valid alternative to explore, in paucisymptomatic self-presenting patients, the presence and extension of pneumonia compared to High Resolution Computed Tomography (HRCT) that represent the gold standard. This is a single-centre prospective study with 131 patients enrolled. Twelve lung areas were explored reporting a semiquantitative assessment to obtain the LUS score. Each patient performed reverse-transcription polymerase chain reaction test (rRT-PCR), hemogasanalysis and HRCT. We observed an inverse correlation between LUSs and pO2, P/F, SpO2, AaDO2 (p value < 0.01), a direct correlation with LUSs and AaDO2 (p value < 0.01). Compared with HRCT, LUS showed sensitivity and specificity of 81.8% and 55.4%, respectively, and VPN 75%, VPP 65%. Therefore, LUS can represent an effective alternative tool to detect pulmonary involvement in COVID-19 compared to HRCT.

COVID-19 in Infants and Children under 2 Years-Could Lung Ultrasound Score Be Correlated with Biomarkers and Symptoms?

INTRODUCTION

It is already well known that infants and children infected with COVID-19 develop mild to moderate forms of the disease, with fever and oropharyngeal congestion being the most common symptoms. However, there are instances when patients claim to be experiencing respiratory symptoms. Because of the repeated lung examinations required in these situations, non-irradiating imaging techniques are preferred. This study's objective is to ascertain the value of lung ultrasonography (LUS) in the medical management of these specific cases.

METHODS

Infants and children under two years old with SARS-CoV-2 infection were evaluated using LUS. Patients with other respiratory pathologies were excluded by using specific tests. The LUS score (LUSS) was correlated with biomarkers and clinical findings using the Mann-Whitney U test and Spearman's rank correlation rho.

RESULTS

The LUSS for each patient varied from 1 to 8 points out of a maximum of 36 points. The arithmetic mean was 4.47 ± 2.36 (S.D), while the 95% CI for the arithmetic mean was 3.33 to 5.61. Sparse B-lines were present in all enrolled infants and children (100%), while only 36.84% developed alveolar syndrome (confluent B-lines). The lung changes were correlated with their biomarkers, specifically inflammatory markers. The correlation between LUSS and LDH, D-dimers, and IL-6 was a strongly positive one with rho = 0.55 (p = 0.001, 95% CI 0.13 to 0.80) between the LUSS and D-dimer levels and rho = 0.60 (p = 0.03, 95% CI 0.04 to 0.87) between LUSS and D-dimer levels at symptomatic infants and children (with respiratory involvement).

CONCLUSIONS

Infants and children under the age of two are prone to develop mild forms of COVID-19 disease with a B-line pattern on LUS, although inflammatory markers have elevated blood levels. Despite the small sample, D-dimer levels and O2 saturation were correlated with LUSS in patients with respiratory involvement, while similar results were also found in the entire lot.

Spinal cord perfusion pressure correlates with breathing function in patients with acute, cervical traumatic spinal cord injuries: an observational study

OBJECTIVE

This study aims to determine the relationship between spinal cord perfusion pressure (SCPP) and breathing function in patients with acute cervical traumatic spinal cord injuries.

METHODS

We included 8 participants without cervical TSCI plus 13 patients with cervical traumatic spinal cord injuries, American Spinal Injury Association Impairment Scale grades A-C. In the TSCI patients, we monitored intraspinal pressure from the injury site for up to a week and computed the SCPP as mean arterial pressure minus intraspinal pressure. Breathing function was quantified by diaphragmatic electromyography using an EDI (electrical activity of the diaphragm) nasogastric tube as well as by ultrasound of the diaphragm and the intercostal muscles performed when sitting at 20°-30°.

RESULTS

We analysed 106 ultrasound examinations (total 1370 images/videos) and 198 EDI recordings in the patients with cervical traumatic spinal cord injuries. During quiet breathing, low SCPP (< 60 mmHg) was associated with reduced EDI-peak (measure of inspiratory effort) and EDI-min (measure of the tonic activity of the diaphragm), which increased and then plateaued at SCPP 60-100 mmHg. During quiet and deep breathing, the diaphragmatic thickening fraction (force of diaphragmatic contraction) plotted versus SCPP had an inverted-U relationship, with a peak at SCPP 80-90 mmHg. Diaphragmatic excursion (up and down movement of the diaphragm) during quiet breathing did not correlate with SCPP, but diaphragmatic excursion during deep breathing plotted versus SCPP had an inverse-U relationship with a peak at SCPP 80-90 mmHg. The thickening fraction of the intercostal muscles plotted versus SCPP also had inverted-U relationship, with normal intercostal function at SCPP 80-100 mmHg, but failure of the upper and middle intercostals to contract during inspiration (i.e. abdominal breathing) at SCPP < 80 or > 100 mmHg.

CONCLUSIONS

After acute, cervical traumatic spinal cord injuries, breathing function depends on the SCPP. SCPP 80-90 mmHg correlates with optimum diaphragmatic and intercostal muscle function. Our findings raise the possibility that intervention to maintain SCPP in this range may accelerate ventilator liberation which may reduce stay in the neuro-intensive care unit.

Lung Ultrasound Reduces Chest X-rays in Postoperative Care after Thoracic Surgery: Is There a Role for Artificial Intelligence?-Systematic Review

BACKGROUND

Chest X-ray (CXR) remains the standard imaging modality in postoperative care after non-cardiac thoracic surgery. Lung ultrasound (LUS) showed promising results in CXR reduction. The aim of this review was to identify areas where the evaluation of LUS videos by artificial intelligence could improve the implementation of LUS in thoracic surgery.

METHODS

A literature review of the replacement of the CXR by LUS after thoracic surgery and the evaluation of LUS videos by artificial intelligence after thoracic surgery was conducted in Medline.

RESULTS

Here, eight out of 10 reviewed studies evaluating LUS in CXR reduction showed that LUS can reduce CXR without a negative impact on patient outcome after thoracic surgery. No studies on the evaluation of LUS signs by artificial intelligence after thoracic surgery were found.

CONCLUSION

LUS can reduce CXR after thoracic surgery. We presume that artificial intelligence could help increase the LUS accuracy, objectify the LUS findings, shorten the learning curve, and decrease the number of inconclusive results. To confirm this assumption, clinical trials are necessary. This research is funded by the Slovak Research and Development Agency, grant number APVV 20-0232.

Influence of Ultrasound Settings on Laboratory Vertical Artifacts

OBJECTIVE

The aim of the work described here was to analyze the relationship between the change in ultrasound (US) settings and the vertical artifacts' number, visual rating and signal intensity METHODS: An in vitro phantom consisting of a damp sponge and gelatin mix was created to simulate vertical artifacts. Furthermore, several US parameters were changed sequentially (i.e., frequency, dynamic range, line density, gain, power and image enhancement) and after image acquisition. Five US experts rated the artifacts for number and quality. In addition, a vertical artifact visual score was created to determine the higher artifact rating ("optimal") and the lower artifact rating ("suboptimal"). Comparisons were made between the tested US parameters and baseline recordings.

RESULTS

The expert intraclass correlation coefficient for the number of vertical artifacts was 0.694. The parameters had little effect on the "optimal" vertical artifacts but changed their number. Dynamic range increased the number of discernible vertical artifacts to 3 from 36 to 102 dB.

CONCLUSION

The intensity did not correlate with the visual rating score. Most of the available US parameters did not influence vertical artifacts.

Acute dyspnea in the emergency department: a clinical review

Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.

Frame Rate Exposimetry for Pulmonary Capillary Hemorrhage During Lung Ultrasound

OBJECTIVES

Lung ultrasound (LUS) is a powerful and accessible clinical tool for pulmonary diagnosis, but risk of pulmonary capillary hemorrhage (PCH) presents a safety issue. The dependence of PCH in a rat model of LUS was evaluated for image frames-per-second (fps) and associated on-screen Mechanical Index (MIOS ) and Thermal Index (TI).

METHODS

A Philips iE33 machine with L15-7io probe was used to scan anesthetized rats in a warmed water bath. B mode was applied at 9 MHz with settings of 34, 61 and 118 fps. After 2 minutes of exposure at an MIOS setting, samples were obtained for assessment of PCH areas on the lung surface. Ultrasound parameters were measured to determine the in situ MIIS at the lung surface.

RESULTS

The PCH trend counter-intuitively decreased with increasing fps, with areas of 19.5 mm2 for 34 fps (MIOS  = 1.0, TI = 0.8, 4080 images), 9.6 mm2 at 61 fps (MIOS  = 1.0, TI = 0.5, 7320 images) and 7.5 mm2 at 118 fps (MIOS  = 1.1, TI = 0.4, 14,160 images). The PCH was not significantly different for 34 fps (TI = 0.5, MIOS  = 0.8) (10.7 mm2 ), compared to 61 and 118 fps, above, indicating some value for the TI as a predictive indicator of PCH. MIIS thresholds were 0.42, 0.46, and 0.49 for 34, 61 and 118 fps, respectively.

CONCLUSIONS

The increase in PCH at low fps was associated with delivering more relatively high amplitude grazing pulse exposures during slower image scans. No significant PCH was found for the MIOS setting of 0.5, corresponding to in MIIS values of 0.35-0.39.

Lung Ultrasonography Is an Acceptable Imaging Modality to Diagnose COVID-19 and Effectively Correlates with HRCT Chest-A Prospective Study

It has been validated beyond doubt that High-Resolution Computed Tomography (HRCT) chest and to some extent chest radiographs have a role in corona virus disease-19 (COVID-19). Much less is known about the role of lung ultrasonography (LUS) in COVID-19. In this paper, our main purpose was to gauge the relationship between LUS and chest HRCT in reverse transcriptase polymerase chain reaction (RT-PCR) documented cases of COVID-19, as well as in those with high suspicion of COVID-19 with negative RT-PCR. It was a prospective study carried out at our tertiary care hospital, namely, SKIMS Soura. The total number of patients in this study were 152 (200 patients were selected out of which only 152 had undergone both LUS and chest HRCT). The patients were subjected to both LUS and chest HRCT. The radiologist who performed LUS was blinded to clinical findings and HRCT was evaluated by a radiologist with about a decade of experience. The LUS findings compatible with the disease were subpleural consolidations, B-lines and irregular pleural lines. Findings that were compatible with COVID-19 on chest HRCT were bibasilar, subpleural predominant ground glass opacities, crazy paving and consolidations. COVID-19-positive patients were taken up for chest HRCT for disease severity stratification and were also subjected to LUS. On HRCT chest, the imaging abnormalities compatible with COVID-19 were evident in 110 individuals (72.37%), and on Lung Ultrasound they were observed in 120 individuals (78.95%). Imaging of COVID-19 patients assessed by both LUS and HRCT chest,, showed a positive correlation (p < 0.0001). The study revealed a sensitivity of 88%, a specificity of 76.62%, a positive predictive value of 78.57% and a negative predictive value of 86.76%. None of the individuals with a diagnosis of COVID-19 on HRCT were missed on LUS. An excellent correlation was derived between the LUS score and CT total severity score (p < 0.0001 with a kappa of 0.431). Similar precision compared with chest HRCT in the detection of chest flaws in COVID-19 patients was obtained on LUS.

COVID-19 Lung Ultrasound Scores and Lessons from the Pandemic: A Narrative Review

The WHO recently declared that COVID-19 no longer constitutes a public health emergency of international concern; however, lessons learned through the pandemic should not be left behind. Lung ultrasound was largely utilized as a diagnostic tool thanks to its feasibility, easy application, and the possibility to reduce the source of infection for health personnel. Lung ultrasound scores consist of grading systems used to guide diagnosis and medical decisions, owning a good prognostic value. In the emergency context of the pandemic, several lung ultrasound scores emerged either as new scores or as modifications of pre-existing ones. Our aim is to clarify the key aspects of lung ultrasound and lung ultrasound scores to standardize their clinical use in a non-pandemic context. The authors searched on PubMed for articles related to "COVID-19", "ultrasound", and "Score" until 5 May 2023; other keywords were "thoracic", "lung", "echography", and "diaphragm". A narrative summary of the results was made. Lung ultrasound scores are demonstrated to be an important tool for triage, prediction of severity, and aid in medical decisions. Ultimately, the existence of numerous scores leads to a lack of clarity, confusion, and an absence of standardization.

Can Dialysis Patients Identify and Diagnose Pulmonary Congestion Using Self-Lung Ultrasound?

BACKGROUND

With the recent developments in automated tools, smaller and cheaper machines for lung ultrasound (LUS) are leading us toward the potential to conduct POCUS tele-guidance for the early detection of pulmonary congestion. This study aims to evaluate the feasibility and accuracy of a self-lung ultrasound study conducted by hemodialysis (HD) patients to detect pulmonary congestion, with and without artificial intelligence (AI)-based automatic tools.

METHODS

This prospective pilot study was conducted between November 2020 and September 2021. Nineteen chronic HD patients were enrolled in the Soroka University Medical Center (SUMC) Dialysis Clinic. First, we examined the patient's ability to obtain a self-lung US. Then, we used interrater reliability (IRR) to compare the self-detection results reported by the patients to the observation of POCUS experts and an ultrasound (US) machine with an AI-based automatic B-line counting tool. All the videos were reviewed by a specialist blinded to the performer. We examined their agreement degree using the weighted Cohen's kappa (Kw) index.

RESULTS

A total of 19 patients were included in our analysis. We found moderate to substantial agreement between the POCUS expert review and the automatic counting both when the patient performed the LUS (Kw = 0.49 [95% CI: 0.05-0.93]) and when the researcher performed it (Kw = 0.67 [95% CI: 0.67-0.67]). Patients were able to place the probe in the correct position and present a lung image well even weeks from the teaching session, but did not show good abilities in correctly saving or counting B-lines compared to an expert or an automatic counting tool.

CONCLUSIONS

Our results suggest that LUS self-monitoring for pulmonary congestion can be a reliable option if the patient's count is combined with an AI application for the B-line count. This study provides insight into the possibility of utilizing home US devices to detect pulmonary congestion, enabling patients to have a more active role in their health care.

Thoracic UltrasONOgraphy Reporting: The TUONO Consensus

The widespread use of the lung ultrasound (LUS) has not been followed by the development of a comprehensive standardized tool for its reporting in the intensive care unit (ICU) which could be useful to promote consistency and reproducibility during clinical examination. This work aims to define the essential features to be included in a standardized reporting tool and provides a structured model form to fully express the diagnostic potential of LUS and facilitate intensivists in the use of a LUS in everyday clinical ICU examination. We conducted a modified Delphi process to build consensus on the items to be integrated in a standardized report form and on its structure. A committee of 19 critical care physicians from 19 participating ICUs in Italy was formed, including intensivists experienced in ultrasound from both teaching hospitals and referral hospitals, and internationally renowned experts on the LUS. The consensus for 31 statements out of 33 was reached at the third Delphi round. A structured model form was developed based on the approved statements. The development of a standardized model as a backbone to report a LUS may facilitate the guidelines' application in clinical practice and increase inter-operator agreement. Further studies are needed to evaluate the effects of standardized reports in critically ill patients.

Lung Ultrasound in the Evaluation of Lung Disease Severity in Children with Clinically Stable Cystic Fibrosis: A Prospective Cross-Sectional Study

With the increasing longevity of cystic fibrosis (CF), there is a growing need to minimise exposure to ionising radiation in patients who undergo regular imaging tests while monitoring the course of the lung disease. This study aimed to define the role of lung ultrasounds (LUS) in the evaluation of lung disease severity in children with clinically stable CF. LUS was performed on 131 patients aged 5 weeks to 18 years (study group) and in 32 healthy children of an equivalent age range (control group). Additionally, an interobserver study was performed on 38 patients from the study group. In CF patients, the following ultrasound signs were identified: I-lines; Z-lines; single, numerous and confluent B-lines; Am-lines; small and major consolidations; pleural line abnormalities and small amounts of pleural fluid. The obtained results were evaluated against an original ultrasound score. LUS results were correlated with the results of chest X-ray (CXR) [very high], pulmonary function tests (PFTs) [high] and microbiological status [significant]. The interobserver study showed very good agreement between investigators. We conclude that LUS is a useful test in the evaluation of CF lung disease severity compared to routinely used methods. With appropriate standardisation, LUS is highly reproducible.

Lung ultrasound monitoring: impact on economics and outcomes

PURPOSE OF REVIEW

This review aims to summarize the impact of lung ultrasonography (LUS) on economics and possible impact on patients' outcomes, proven its diagnostic accuracy in patients with acute respiratory failure.

RECENT FINDINGS

Despite some previous ethical concerns on LUS examination, today this technique has showed several advantages. First, it is now clear that the daily use of LUS can provide a relevant cost reduction in healthcare of patients with acute respiratory failure, while reducing the risk of transport of patients to radiological departments for chest CT scan. In addition, LUS reduces the exposition to x-rays since can replace the bedside chest X-ray examination in many cases. Indeed, LUS is characterized by a diagnostic accuracy that is even superior to portable chest X-ray when performed by well trained personnel. Finally, LUS examination is a useful tool to predict the course of patients with pneumonia, including the need for hospitalization and ICU admission, noninvasive ventilation failure and orotracheal intubation, weaning success, and mortality.

SUMMARY

LUS should be implemented not only in Intensive Care Units, but also in other setting like emergency departments. Since most data comes from the recent coronavirus disease 2019 pandemic, further investigations are required in Acute Respiratory Failure of different etiologies.

Use of Cardio-Pulmonary Ultrasound in the Neonatal Intensive Care Unit

Cardiopulmonary ultrasound (CPUS), the combination of lung ultrasound (LUS) and targeted neonatal echocardiography (TnECHO)AA, may offer a more appropriate approach to the challenging neonatal cardiovascular and respiratory disorders. This paper reviews the possible use of CPUS in the neonatal intensive care unit (NICU).

Vertical Artifacts as Lung Ultrasound Signs: Trick or Trap? Part 2- An Accademia di Ecografia Toracica Position Paper on B-Lines and Sonographic Interstitial Syndrome

Although during the last few years the lung ultrasound (LUS) technique has progressed substantially, several artifacts, which are currently observed in clinical practice, still need a solid explanation of the physical phenomena involved in their origin. This is particularly true for vertical artifacts, conventionally known as B-lines, and for their use in clinical practice. A wider consensus and a deeper understanding of the nature of these artifactual phenomena will lead to a better classification and a shared nomenclature, and, ultimately, result in a more objective correlation between anatomo-pathological data and clinical scenarios. The objective of this review is to collect and document the different signs and artifacts described in the history of chest ultrasound, with a particular focus on vertical artifacts (B-lines) and sonographic interstitial syndrome (SIS). By reviewing the possible physical and anatomical interpretation of the signs and artifacts proposed in the literature, this work also aims to bring order to the available studies and to present the AdET (Accademia di Ecografia Toracica) viewpoint in terms of nomenclature and clinical approach to the SIS.

The Incremental Role of Multiorgan Point-of-Care Ultrasounds in the Emergency Setting

Point-of-care ultrasonography (POCUS) represents a goal-directed ultrasound examination performed by clinicians directly involved in patient healthcare. POCUS has been widely used in emergency departments, where US exams allow physicians to make quick diagnoses and to recognize early life-threatening conditions which require prompt interventions. Although initially meant for the real-time evaluation of cardiovascular and respiratory pathologies, its use has been extended to a wide range of clinical applications, such as screening for deep-vein thrombosis and trauma, abdominal ultrasonography of the right upper quadrant and appendix, and guidance for invasive procedures. Moreover, recently, bedside ultrasounds have been used to evaluate the fluid balance and to guide decongestive therapy in acutely decompensated heart failure. The aim of the present review was to discuss the most common applications of POCUS in the emergency setting.

One-Year Follow-Up Lung Ultrasound of Post-COVID Syndrome-A Pilot Study

(1) Background: Millions of people worldwide were infected with COVID-19. After the acute phase of the disease, many suffer from prolonged symptoms, the post-COVID syndrome, especially the phenotype with lung residuals. Many open questions regarding lung ultrasound (LUS) have to be answered. One essential question is the means for optimal following-up of patients with post-COVID-19 residuals with LUS; (2) Methods: A retrospective data analysis of patients after acute COVID-19 infection diagnosed with post-COVID syndrome in the state hospital of Steyr and the rehabilitation center of Hochegg was performed. LUS examinations following a 12-zone scanning protocol were performed, and the LUS score quantified comet tail artifacts. A total of 16 patients were evaluated twice with LUS from May 2020 until June 2021. (3) Results: All patients’ reverberation artifacts were reduced over time. The initial LUS score of 17.75 (SD 4.84) points was decreased over the duration of the second rehabilitation to 8,2 (SD 5.94). The difference in the Wilcoxon test was significant (p < 0.001); (4) Conclusions: Lung ultrasound was a valuable tool in the follow-up of post-COVID-syndrome with lung residuals in the first wave of COVID-19. A reduction in reverberation artifacts was demonstrated. Further studies about the clinical significance have to follow.

Patient Self-Performed Point-of-Care Ultrasound: Using Communication Technologies to Empower Patient Self-Care

Point-of-Care ultrasound (POCUS) is an invaluable tool permitting the understanding of critical physiologic and anatomic details wherever and whenever a patient has a medical need. Thus the application of POCUS has dramatically expanded beyond hospitals to become a portable user-friendly technology in a variety of prehospital settings. Traditional thinking holds that a trained user is required to obtain images, greatly handicapping the scale of potential improvements in individual health assessments. However, as the interpretation of ultrasound images can be accomplished remotely by experts, the paradigm wherein experts guide novices to obtain meaningful images that facilitate remote care is being embraced worldwide. The ultimate extension of this concept is for experts to guide patients to image themselves, enabling secondary disease prevention, home-focused care, and self-empowerment of the individual to manage their own health. This paradigm of remotely telementored self-performed ultrasound (RTMSPUS) was first described for supporting health care on the International Space Station. The TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group has been investigating the utility of this paradigm for terrestrial use. The technique has particular attractiveness in enabling surveillance of lung health during pandemic scenarios. However, the paradigm has tremendous potential to empower and support nearly any medical question poised in a conscious individual with internet connectivity able to follow the directions of a remote expert. Further studies and development are recommended in all areas of acute and chronic health care.

B-Lines Lung Ultrasonography Simulation Using Finite Element Method

Introduction: Lung Ultrasonography (LUS) is a fast technique for the diagnosis of patients with respiratory syndromes. B-lines are seen in response to signal reverberations and amplifications into sites with peripheral lung fluid concentration or septal thickening. Mathematical models are commonly applied in biomedicine to predict biological responses to specific signal parameters. Objective: This study proposes a Finite-Element numerical model to simulate radio frequency ultrasonic lines propagated from normal and infiltrated lung structures. For tissue medium, a randomized inhomogeneous data method was used. The simulation implemented in COMSOL® used Acoustic Pressure and Time-Explicit models, which are based on the discontinuous Galerkin method (dG). Results: The RF signals, processed in MATLAB®, resulted in images of horizontal A-lines and vertical B-lines, which were reasonably similar to real images. Discussion: The use of inhomogeneous materials in the model was good enough to simulate the scattering response, similar to others in the literature. The model is useful to study the impact of the lung infiltration characteristics on the appearance of LUS images.

Possible Role of Chest Ultrasound in the Assessment of Costo-Phrenic Angle Lesions Prior to Medical Thoracoscopy: A Retrospective Pilot Case Series

Background: Pleural malignancy (PM) and malignant pleural effusion (MPE) represent an increasing burden of diseases. Costo-phrenic angle (CPA) could be involved by malignant small nodularities or thickenings in the case of MPE. The aim of this study was to evaluate whether lung ultrasound (LUS), performed prior to medical thoracoscopy (MT), could detect pleural abnormalities in CPA not easily detectable by chest computed tomography scan (CCT). Methods: Patients suspected for PM and MPE were retrospectively recruited. Patients underwent both LUS examination with a linear array and CCT prior to diagnostic medical thoracoscopy. LUS pathological findings in CPA were compared with pathological findings detected by CCT. Findings were confirmed by subsequent MT, the gold standard for PMs. Results: Twenty-eight patients were recruited. LUS detected 23 cases of pleural abnormalities in CPA. CCT was detected 12 pleural abnormalities. Inter-rater agreement between the two techniques was minimal (Cohen’s Kappa: 0.28). MT detected PMs in CPA in 22 patients. LUS had a sensitivity of 100% and specificity of 83%. CCT had a sensitivity of 54% and specificity of 100%. A better sensitivity for CCT was reached analysing only all abnormalities > 5 mm (64.3%). Conclusions: LUS examination, in the case of PMs, could change and speed up diagnostic workup.