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Howroyd F, Chacko C, MacDuff A, Gautam N, Pouchet B, Tunnicliffe B, Weblin J, Gao-Smith F, Ahmed Z, Duggal NA, Veenith T. Ventilator-associated pneumonia: pathobiological heterogeneity and diagnostic challenges. Nat Commun 2024; 15:6447. [PMID: 39085269 PMCID: PMC11291905 DOI: 10.1038/s41467-024-50805-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024] Open
Abstract
Ventilator-associated pneumonia (VAP) affects up to 20% of critically ill patients and induces significant antibiotic prescription pressure, accounting for half of all antibiotic use in the ICU. VAP significantly increases hospital length of stay and healthcare costs yet is also associated with long-term morbidity and mortality. The diagnosis of VAP continues to present challenges and pitfalls for the currently available clinical, radiological and microbiological diagnostic armamentarium. Biomarkers and artificial intelligence offer an innovative potential direction for ongoing future research. In this Review, we summarise the pathobiological heterogeneity and diagnostic challenges associated with VAP.
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Affiliation(s)
- Fiona Howroyd
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK.
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK.
| | - Cyril Chacko
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Institute of Acute Care, Royal Wolverhampton Hospital and University of Wolverhampton, Wolverhampton, UK
| | - Andrew MacDuff
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
- Institute of Acute Care, Royal Wolverhampton Hospital and University of Wolverhampton, Wolverhampton, UK
| | - Nandan Gautam
- Critical Care Department, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Brian Pouchet
- Critical Care Department, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Bill Tunnicliffe
- Critical Care Department, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Jonathan Weblin
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, UK
| | - Fang Gao-Smith
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK.
| | - Niharika A Duggal
- Institute of Inflammation and Ageing, The University of Birmingham, Edgbaston, Birmingham, UK.
| | - Tonny Veenith
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Trust, Wolverhampton, UK.
- Institute of Acute Care, Royal Wolverhampton Hospital and University of Wolverhampton, Wolverhampton, UK.
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Smit MR, Mayo PH, Mongodi S. Lung ultrasound for diagnosis and management of ARDS. Intensive Care Med 2024; 50:1143-1145. [PMID: 38656359 DOI: 10.1007/s00134-024-07422-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/29/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Marry R Smit
- Department of Intensive Care, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, The Netherlands.
| | - Paul H Mayo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health LIJ/NSUH Medical Center, Hempstead, NY, USA
| | - Silvia Mongodi
- Anaesthesia and Intensive Care, San Matteo Hospital, Pavia, Italy
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Quarton S, Livesey A, Pittaway H, Adiga A, Grudzinska F, McNally A, Dosanjh D, Sapey E, Parekh D. Clinical challenge of diagnosing non-ventilator hospital-acquired pneumonia and identifying causative pathogens: a narrative review. J Hosp Infect 2024; 149:189-200. [PMID: 38621512 DOI: 10.1016/j.jhin.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Non-ventilated hospital-acquired pneumonia (NV-HAP) is associated with a significant healthcare burden, arising from high incidence and associated morbidity and mortality. However, accurate identification of cases remains challenging. At present, there is no gold-standard test for the diagnosis of NV-HAP, requiring instead the blending of non-specific signs and investigations. Causative organisms are only identified in a minority of cases. This has significant implications for surveillance, patient outcomes and antimicrobial stewardship. Much of the existing research in HAP has been conducted among ventilated patients. The paucity of dedicated NV-HAP research means that conclusions regarding diagnostic methods, pathology and interventions must largely be extrapolated from work in other settings. Progress is also limited by the lack of a widely agreed definition for NV-HAP. The diagnosis of NV-HAP has large scope for improvement. Consensus regarding a case definition will allow meaningful research to improve understanding of its aetiology and the heterogeneity of outcomes experienced by patients. There is potential to optimize the role of imaging and to incorporate novel techniques to identify likely causative pathogens. This would facilitate both antimicrobial stewardship and surveillance of an important healthcare-associated infection. This narrative review considers the utility of existing methods to diagnose NV-HAP, with a focus on the significance and challenge of identifying pathogens. It discusses the limitations in current techniques, and explores the potential of emergent molecular techniques to improve microbiological diagnosis and outcomes for patients.
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Affiliation(s)
- S Quarton
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK.
| | - A Livesey
- National Institute for Health Research/Wellcome Trust Clinical Research Facility, University Hospitals Birmingham, Birmingham, UK
| | - H Pittaway
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Birmingham, UK
| | - A Adiga
- Warwick Hospital, South Warwickshire University NHS Foundation Trust, Warwick, UK
| | - F Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - A McNally
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - D Dosanjh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - E Sapey
- National Institute for Health Research Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK; National Institute for Health Research Midlands Applied Research Collaborative, University of Birmingham, Birmingham, UK
| | - D Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Cammarota G, Vetrugno L, Longhini F. Lung ultrasound monitoring: impact on economics and outcomes. Curr Opin Anaesthesiol 2023; 36:234-239. [PMID: 36728722 DOI: 10.1097/aco.0000000000001231] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Gianmaria Cammarota
- Anesthesia and Intensive Care Unit 2, Department of Medicine and Surgery, University of Perugia
| | - Luigi Vetrugno
- Anesthesiology, Critical Care Medicine, and Emergency, 'S.S. Annunziata' Hospital, Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Gabriele d'Annunzio University of Chieti and Pescara
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, 'Mater Domini' University Hospital, Magna Graecia University, Catanzaro, Italy
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Nosokomiale Pneumonie und beatmungsassoziierte Krankenhauserreger. ANÄSTHESIE NACHRICHTEN 2022. [PMCID: PMC9411841 DOI: 10.1007/s44179-022-00078-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kalkanis A, Schepers C, Louvaris Z, Godinas L, Wauters E, Testelmans D, Lorent N, Van Mol P, Wauters J, De Wever W, Dooms C. Lung Aeration in COVID-19 Pneumonia by Ultrasonography and Computed Tomography. J Clin Med 2022; 11:jcm11102718. [PMID: 35628846 PMCID: PMC9144288 DOI: 10.3390/jcm11102718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 11/16/2022] Open
Abstract
We conducted a prospective single-center observational study to determine lung ultrasound reliability in assessing global lung aeration in 38 hospitalized patients with non-critical COVID-19. On admission, fixed chest CT scans using visual (CTv) and software-based (CTs) analyses along with lung ultrasound imaging protocols and scoring systems were applied. The primary endpoint was the correlation between global chest CTs score and global lung ultrasound score. The secondary endpoint was the association between radiographic features and clinical disease classification or laboratory indices of inflammation. Bland−Altman analysis between chest CT scores obtained visually (CTv) or using software (CTs) indicated that only 1 of the 38 paired measures was outside the 95% limits of agreement (−4 to +4 score). Global lung ultrasound score was highly and positively correlated with global software-based CTs score (r = 0.74, CI = 0.55−0.86; p < 0.0001). Significantly higher median CTs score (p = 0.01) and lung ultrasound score (p = 0.02) were found in severe compared to moderate COVID-19. Furthermore, we identified significantly lower (p < 0.05) lung ultrasound and CTs scores in those patients with a more severe clinical condition manifested by SpO2 < 92% and C-reactive protein > 58 mg/L. We concluded that lung ultrasound is a reliable bedside clinical tool to assess global lung aeration in hospitalized non-critical care patients with COVID-19 pneumonia.
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Affiliation(s)
- Alexandros Kalkanis
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
- Correspondence: ; Tel.: +32-16-346801
| | - Christophe Schepers
- Department of Radiology, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (C.S.); (W.D.W.)
| | - Zafeiris Louvaris
- Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
| | - Laurent Godinas
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
| | - Els Wauters
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
| | - Dries Testelmans
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
| | - Natalie Lorent
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
| | - Pierre Van Mol
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
- Laboratory of Translational Genetics, VIB—KU Leuven Center for Cancer Biology, 3000 Leuven, Belgium
| | - Joost Wauters
- Department of Internal Medicine, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
| | - Walter De Wever
- Department of Radiology, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (C.S.); (W.D.W.)
| | - Christophe Dooms
- Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit Leuven, 3000 Leuven, Belgium; (L.G.); (E.W.); (D.T.); (N.L.); (P.V.M.); (C.D.)
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Wang R, Qi B, Zhang X, Meng L, Wu X. Prophetic values of lung ultrasound score on post-extubation distress in patients with acute respiratory distress syndrome. Eur J Med Res 2022; 27:27. [PMID: 35193686 PMCID: PMC8864851 DOI: 10.1186/s40001-022-00652-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 02/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) has been a prevalent disease in ICU with mortality of up to 27–45%. A considerable proportion of extubated ARDS patients passing spontaneous breathing trial (SBT) still requires reintubation. Methods Lung ultrasonography (LUS) was used to predict the success rate of extubation. Ninety-two patients passing the 60-min SBT were included in this prospective research. Their clinical characters including LUS, APACHE II, SOFA, CPIS, EVLWI and PaO2/FiO2 were collected before the SBT. Another two LUS assessments were performed at the end of and 4 h after SBT. LUS results were evaluated and scored by two independent experts, and the correlations of LUS scores, APACHE-II scores, SOFA scores, CPIS and EVLWI with the success rate of extubation and rate of reintubation were analyzed. Results Failed weaning and reintubation of ARDS patients were correlated with higher LUS scores both before and after SBT. Post-extubation distress was correlated with higher APACHE-II scores, SOFA scores, CPIS and EVLWI before SBT. There were positive correlations between the LUS score and APACHE-II score, SOFA score, CPIS and EVLWI before SBT, respectively. Conclusion LUS score measured at the end of 60-min SBT could be used to predict post-extubation distress in ARDS patients.
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Affiliation(s)
- Ran Wang
- Department of Emergency Internal Medicine, The First Affiliated Hospital of Bengbu Medical College, No. 287 Changhuai Road, Bengbu, 233004, Anhui, China
| | - Benquan Qi
- Department of Emergency Internal Medicine, The First Affiliated Hospital of Bengbu Medical College, No. 287 Changhuai Road, Bengbu, 233004, Anhui, China
| | - Xiaohua Zhang
- Department of Emergency Internal Medicine, The First Affiliated Hospital of Bengbu Medical College, No. 287 Changhuai Road, Bengbu, 233004, Anhui, China
| | - Liang Meng
- Department of Emergency Internal Medicine, The First Affiliated Hospital of Bengbu Medical College, No. 287 Changhuai Road, Bengbu, 233004, Anhui, China
| | - Xiaofei Wu
- Department of Emergency Internal Medicine, The First Affiliated Hospital of Bengbu Medical College, No. 287 Changhuai Road, Bengbu, 233004, Anhui, China.
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Wicky PH, Martin-Loeches I, Timsit JF. "HAP and VAP after Guidelines". Semin Respir Crit Care Med 2022; 43:248-254. [PMID: 35042265 DOI: 10.1055/s-0041-1740246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.
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Affiliation(s)
- Paul-Henri Wicky
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
| | - Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland.,Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France.,UMR 1137, IAME, Université Paris Diderot, Paris, France
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Vetrugno L, Mojoli F, Cortegiani A, Bignami EG, Ippolito M, Orso D, Corradi F, Cammarota G, Mongodi S, Boero E, Iacovazzo C, Vargas M, Poole D, Biasucci DG, Persona P, Bove T, Ball L, Chiumello D, Forfori F, de Robertis E, Pelosi P, Navalesi P, Giarratano A, Petrini F. Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care expert consensus statement on the use of lung ultrasound in critically ill patients with coronavirus disease 2019 (ITACO). JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2021. [PMCID: PMC8611396 DOI: 10.1186/s44158-021-00015-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background To produce statements based on the available evidence and an expert consensus (as members of the Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care, SIAARTI) on the use of lung ultrasound for the management of patients with COVID-19 admitted to the intensive care unit. Methods A modified Delphi method was applied by a panel of anesthesiologists and intensive care physicians expert in the use of lung ultrasound in COVID-19 intensive critically ill patients to reach a consensus on ten clinical questions concerning the role of lung ultrasound in the following: COVID-19 diagnosis and monitoring (with and without invasive mechanical ventilation), positive end expiratory pressure titration, the use of prone position, the early diagnosis of pneumothorax- or ventilator-associated pneumonia, the process of weaning from invasive mechanical ventilation, and the need for radiologic chest imaging. Results A total of 20 statements were produced by the panel. Agreement was reached on 18 out of 20 statements (scoring 7–9; “appropriate”) in the first round of voting, while 2 statements required a second round for agreement to be reached. At the end of the two Delphi rounds, the median score for the 20 statements was 8.5 [IQR 8.9], and the agreement percentage was 100%. Conclusion The Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care produced 20 consensus statements on the use of lung ultrasound in COVID-19 patients admitted to the ICU. This expert consensus strongly suggests integrating lung ultrasound findings in the clinical management of critically ill COVID-19 patients. Supplementary Information The online version contains supplementary material available at 10.1186/s44158-021-00015-6.
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Kalkanis A, Wauters E, Testelmans D, Yserbyt J, Lorent N, Louvaris Z, Godinas L, Van Mol P, Wauters J, Eleftheriou M, Dooms C. Early lung ultrasound assessment for the prognosis of patients hospitalized for COVID-19 pneumonia. A pilot study. Respir Med Res 2021; 80:100832. [PMID: 34130209 PMCID: PMC8177497 DOI: 10.1016/j.resmer.2021.100832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/14/2021] [Accepted: 05/26/2021] [Indexed: 01/19/2023]
Abstract
Objective SARS CoV-2 is an epidemic viral infection that can cause mild to severe lung involvement. Newly apprehended knowledge on thoracic imaging abnormalities and the growing clinical experience on the evolution of this disease make the radiographic follow-up of hospitalized patients relevant. The value of consecutive bedside lung ultrasonography in the follow-up of hospitalized patients with SARS CoV-2 pneumonia and its correlation with other clinical and laboratory markers needs to be evaluated. Methods We assessed 39 patients [age: 64 y(60.1–68.7)] with confirmed SARS CoV-2 pneumonia. A total of 24 patients were hospitalized until the follow-up test, 9 were discharged early and 6 required a transfer to critical care unit. Two ultrasound scans of the lung were performed on day 1 and 4 of patients’ hospitalization. Primary endpoint was the magnitude of association between a global lung ultrasound score (LUS) and clinical and laboratory markers. Secondary endpoint was the association between the evolution of LUS with the corresponded changes in clinical and laboratory outcomes during hospitalization period. Results LUS score on admission was higher among the deteriorating patients and significantly (P = 0.038–0.0001) correlated (Spearman's rho) with the levels of C-reactive protein (0.58), lymphocytes (−0.33), SpO2 (−0.48) and oxygen supplementation (0.48) upon admission. The increase in LUS score between the two scans was significantly correlated (0.544, P = 0.006) with longer hospital stay. Conclusion Lung ultrasound assessment can be a useful as an imaging modality for SARS CoV-2 patients. Larger studies are needed to further investigate the predictive role of LUS in the duration and the outcome of the hospitalization of these patients.
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Affiliation(s)
- A Kalkanis
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - E Wauters
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - D Testelmans
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - J Yserbyt
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - N Lorent
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Z Louvaris
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - L Godinas
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - P Van Mol
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Laboratory of Translational Genetics, VIB - KU Leuven Center for Cancer Biology, Herestraat 49 b912, 3000 Leuven, Belgium
| | - J Wauters
- Department of Internal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - M Eleftheriou
- Aristotle University of Thessaloniki, Department of Mathematics, Thessaloniki, Greece
| | - C Dooms
- Department of Respiratory Diseases, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Prager R, Wu K, Bachar R, Unni RR, Bowdridge J, McGrath TA, Thavanathan R, Woo MY, McInnes MDF. Blinding practices during acute point-of-care ultrasound research: the BLIND-US meta-research study. BMJ Evid Based Med 2021; 26:110-111. [PMID: 33177166 DOI: 10.1136/bmjebm-2020-111577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) diagnostic accuracy research has significant variation in blinding practices. This study characterises the blinding practices during acute POCUS research to determine whether research methodology adequately reflects POCUS use in routine clinical practice. DESIGN, SETTINGS AND PARTICIPANTS A search for POCUS diagnostic accuracy studies published in Emergency Medicine, Anaesthesia and Critical Care journals from January 2016 to January 2020 was performed. Studies were included if they were primary diagnostic accuracy studies. The study year, journal impact factor, population, hospital area, body region, study design, blinding of the POCUS interpreter to clinical information, whether the person performing the POCUS scan was the same person interpreting the scan, and whether the study reported incremental diagnostic yield were extracted in duplicate by two authors. Descriptive statistics were provided and prespecified subgroup analysis was performed. MAIN OUTCOME MEASURES The primary outcome was the number of studies that blinded the POCUS interpreter to at least some part of the clinical information. Secondary outcomes included whether the person performing the POCUS scan was the same person interpreting it and whether the study reported incremental diagnostic yield. RESULTS 520 abstracts were screened with 97 studies included. The POCUS interpreter was blinded to clinical information in 37 studies (38.1%), not blinded in 34 studies (35.1%) and not reported in 26 studies (26.8%). The POCUS interpreter was the same person obtaining the images in 72 studies (74.2%), different in 14 studies (14.4%) and not reported in 11 studies (11.3%). Only four studies (4.1%) reported incremental diagnostic yield for POCUS. Inter-rater reliability was moderate (k=0.64). Subgroup analysis based on impact factor, body region, hospital area, patient population and study design did not show significant differences after completing pairwise comparisons. CONCLUSIONS Although blinding the POCUS interpreter to clinical information may be done in a perceived attempt to limit bias, this may result in accuracy estimates that do not reflect routine clinical practice. Similarly, having a different clinician perform and interpret the POCUS scan significantly limits generalisability to practice as it does not truly reflect 'point-of-care' ultrasound at all. Reporting incremental diagnostic yield from implementing POCUS into a diagnostic pathway better reflects the value of POCUS; however, this methodology was infrequently used. TRIAL REGISTRATION NUMBER The study protocol was registered on Open Science Framework (https://osf.io/h5fe7/).
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Affiliation(s)
- Ross Prager
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kay Wu
- Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Rudy R Unni
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Bowdridge
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Trevor A McGrath
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Rajiv Thavanathan
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Y Woo
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew D F McInnes
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
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Lung ultrasound score as a tool to monitor disease progression and detect ventilator-associated pneumonia during COVID-19-associated ARDS. Heart Lung 2021; 50:700-705. [PMID: 34107394 PMCID: PMC8165084 DOI: 10.1016/j.hrtlng.2021.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 05/04/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Lung ultrasound can accurately detect pandemic coronavirus disease (COVID-19) pulmonary lesions. A lung ultrasound score (LUS) was developed to improve reproducibility of the technique. OBJECTIVES To evaluate the clinical value of LUS monitoring to guide COVID-19-associated acute respiratory distress syndrome (ARDS) management. METHODS We conducted a single center, prospective observational study, including all patients admitted with COVID-19-associated ARDS between March and April 2020. A systematic daily LUS evaluation was performed. RESULTS Thirty-three consecutive patients were included. LUS was significantly and negatively correlated to PaO2/FIO2. LUS increased significantly over time in non-survivors compared to survivors. LUS increased in 83% of ventilatory associated pneumonia (VAP) episodes, when compared to the previous LUS evaluation. LUS was not significantly higher in patients presenting post-extubation respiratory failure. CONCLUSIONS In conclusion, our study demonstrates that LUS variations are correlated to disease severity and progression, and LUS monitoring could contribute to the early diagnosis of VAPs.
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Gaudet A, Devos M, Keignart S, Pouly O, Lecailtel S, Wallet F, Nseir S. Usefulness of Sepsis-3 in diagnosing and predicting mortality of ventilator-associated lower respiratory tract infections. PLoS One 2021; 16:e0245552. [PMID: 33444395 PMCID: PMC7808583 DOI: 10.1371/journal.pone.0245552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/30/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Early distinguishing ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) remains difficult in the daily practice. However, this question appears clinically relevant, as treatments of VAT and VAP currently differ. In this study, we assessed the accuracy of sepsis criteria according to the Sepsis-3 definition in the early distinction between VAT and VAP. METHODS Retrospective single-center cohort, including all consecutive patients with a diagnosis of VAT (n = 70) or VAP (n = 136), during a 2-year period. Accuracy of sepsis criteria according to Sepsis-3, total SOFA and respiratory SOFA, calculated at time of microbiological sampling were assessed in differentiating VAT from VAP, and in predicting mortality on ICU discharge. RESULTS Sensitivity and specificity of sepsis criteria were found respectively at 0.4 and 0.91 to distinguish VAT from VAP, and at 0.38 and 0.75 for the prediction of mortality in VA-LRTI. A total SOFA ≥ 6 and a respiratory SOFA ≥ 3 were identified as the best cut-offs for these criteria in differentiating VAT from VAP, with sensitivity and specificity respectively found at 0.63 and 0.69 for total SOFA, and at 0.49 and 0.7 for respiratory SOFA. Additionally, for prediction of mortality, a total SOFA ≥ 7 and a respiratory SOFA = 4 were identified as the best-cut-offs, respectively yielding sensitivity and specificity at 0.56 and 0.61 for total SOFA, and at 0.22 and 0.95 for respiratory SOFA. CONCLUSIONS Sepsis criteria according to the Sepsis-3 definition show a high specificity but a low sensitivity for the diagnosis of VAP. Our results do not support the use of these criteria for the early diagnosis of VAP in patients with VA-LRTI.
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Affiliation(s)
- Alexandre Gaudet
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
- Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, U1019-UMR9017-CIIL-Centre d’Infection et d’Immunité de Lille, Lille, France
| | - Matthieu Devos
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
| | - Sylvain Keignart
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
| | - Olivier Pouly
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
| | - Sylvain Lecailtel
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
| | | | - Saad Nseir
- Department of Intensive Care Medicine, Critical Care Center, CHU Lille, Lille, France
- Team Fungal Associated Invasive & Inflammatory Diseases, Lille Inflammation Research International Center, INSERM U995, Université de Lille, Lille, France
- * E-mail:
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Kameda T, Mizuma Y, Taniguchi H, Fujita M, Taniguchi N. Point-of-care lung ultrasound for the assessment of pneumonia: a narrative review in the COVID-19 era. J Med Ultrason (2001) 2021; 48:31-43. [PMID: 33438132 PMCID: PMC7803468 DOI: 10.1007/s10396-020-01074-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/15/2020] [Indexed: 12/12/2022]
Abstract
In the coronavirus disease-2019 (COVID-19) era, point-of-care lung ultrasound (LUS) has attracted increased attention. Prospective studies on LUS for the assessment of pneumonia in adult patients were extensively carried out for more than 10 years before this era. None of these prospective studies attempted to differentiate bacterial and viral pneumonia in adult patients using LUS. The majority of studies considered the LUS examination to be positive if sonographic consolidations or multiple B-lines were observed. Significant differences existed in the accuracy of these studies. Some studies revealed that LUS showed superior sensitivity to chest X-ray. These results indicate that point-of-care LUS has the potential to be an initial imaging modality for the diagnosis of pneumonia. The LUS diagnosis of ventilator-associated pneumonia in intensive care units is more challenging in comparison with the diagnosis of community-acquired pneumonia in emergency departments due to the limited access to the mechanically ventilated patients and the high prevalence of atelectasis. However, several studies have demonstrated that the combination of LUS findings with other clinical markers improved the diagnostic accuracy. In the COVID-19 era, many case reports and small observational studies on COVID-19 pneumonia have been published in a short period. Multiple B-lines were the most common and consistent finding in COVID-19 pneumonia. Serial LUS showed the deterioration of the disease. The knowledge and ideas on the application of LUS in the management of pneumonia that are expected to accumulate in the COVID-19 era may provide us with clues regarding more appropriate management.
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Affiliation(s)
- Toru Kameda
- Department of Clinical Laboratory Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan. .,Department of Emergency Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino-shi, Nagano, 399-8293, Japan.
| | - Yoshihiro Mizuma
- Department of Internal Medicine, Higashi Kobe Hospital, 1-24-13 Sumiyoshihonmachi, Higashinada-ku, Kobe-shi, Hyogo, 658-0051, Japan
| | - Hayato Taniguchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama-shi, Kanagawa, 232-0044, Japan
| | - Masato Fujita
- Department of Emergency Medicine, Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino-shi, Nagano, 399-8293, Japan
| | - Nobuyuki Taniguchi
- Department of Clinical Laboratory Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
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Lee J. Lung Ultrasound as a Monitoring Tool. Tuberc Respir Dis (Seoul) 2020; 83:S12-S16. [PMID: 33261244 PMCID: PMC7837375 DOI: 10.4046/trd.2020.0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 12/26/2022] Open
Abstract
Lung ultrasound has proven to be useful in detecting pneumothorax, interstitial syndrome, and lung consolidation. It is easily applied at the bedside, in real-time, and free of radiation hazards. Recently, the use of lung ultrasound has moved from a diagnostic tool to a monitoring tool for lung aeration quantification. This article reviewed the use of lung ultrasound in monitoring acute pulmonary edema, acute respiratory distress syndrome, and pneumonia, and how it could be used to monitor changes during the application of mechanical ventilation or other treatments for respiratory failure.
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Affiliation(s)
- Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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