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AIUM Official Statement: Statement and Recommendations for Safety Assurance in Lung Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:E63-E67. [PMID: 37668294 DOI: 10.1002/jum.16314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 09/06/2023]
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Wolfram F, Miller D, Demi L, Verma P, Moran CM, Walther M, Mathis G, Prosch H, Kollmann C, Jenderka KV. Best Practice Recommendations for the Safe use of Lung Ultrasound. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:516-519. [PMID: 36377189 DOI: 10.1055/a-1978-5575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Frank Wolfram
- Clinic of Thoracic and Vascular Surgery, SRH Wald-Clinic Gera, Germany
| | - Douglas Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor, United States
| | - Libertario Demi
- Department of Information Engineering and Computer Science, University of Trento Department of Information Engineering and Computer Science, Povo, Italy
| | - Prashant Verma
- Department of Medical Physics, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Carmel M Moran
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Marcel Walther
- Mindray Medical Imaging, MINDRAY Medical Germany GmbH, Darmstadt, Germany
| | - Gebhard Mathis
- Gastroenterologie, Internistische Praxis, Rankweil, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image guided Therapy, Medical University of Vienna, Austria
| | - Christian Kollmann
- Center for Medical Physics & Biomedical Engineering, Medical University Vienna, Austria
| | - Klaus-Vitold Jenderka
- Department of Engineering and Natural Sciences, University of Applied Sciences Merseburg, Germany
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Miller DL, Dou C, Dong Z. Frame Rate Exposimetry for Pulmonary Capillary Hemorrhage During Lung Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1689-1698. [PMID: 36723246 PMCID: PMC10363177 DOI: 10.1002/jum.16186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/13/2022] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Chunyan Dou
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Zhihong Dong
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Demi L, Wolfram F, Klersy C, De Silvestri A, Ferretti VV, Muller M, Miller D, Feletti F, Wełnicki M, Buda N, Skoczylas A, Pomiecko A, Damjanovic D, Olszewski R, Kirkpatrick AW, Breitkreutz R, Mathis G, Soldati G, Smargiassi A, Inchingolo R, Perrone T. New International Guidelines and Consensus on the Use of Lung Ultrasound. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:309-344. [PMID: 35993596 PMCID: PMC10086956 DOI: 10.1002/jum.16088] [Citation(s) in RCA: 77] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/28/2022] [Accepted: 07/31/2022] [Indexed: 05/02/2023]
Abstract
Following the innovations and new discoveries of the last 10 years in the field of lung ultrasound (LUS), a multidisciplinary panel of international LUS experts from six countries and from different fields (clinical and technical) reviewed and updated the original international consensus for point-of-care LUS, dated 2012. As a result, a total of 20 statements have been produced. Each statement is complemented by guidelines and future developments proposals. The statements are furthermore classified based on their nature as technical (5), clinical (11), educational (3), and safety (1) statements.
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Affiliation(s)
- Libertario Demi
- Department of Information Engineering and Computer ScienceUniversity of TrentoTrentoItaly
| | - Frank Wolfram
- Department of Thoracic and Vascular SurgerySRH Wald‐Klinikum GeraGeraGermany
| | - Catherine Klersy
- Unit of Clinical Epidemiology and BiostatisticsFondazione IRCCS Policlinico S. MatteoPaviaItaly
| | - Annalisa De Silvestri
- Unit of Clinical Epidemiology and BiostatisticsFondazione IRCCS Policlinico S. MatteoPaviaItaly
| | | | - Marie Muller
- Department of Mechanical and Aerospace EngineeringNorth Carolina State UniversityRaleighNorth CarolinaUSA
| | - Douglas Miller
- Department of RadiologyMichigan MedicineAnn ArborMichiganUSA
| | - Francesco Feletti
- Department of Diagnostic ImagingUnit of Radiology of the Hospital of Ravenna, Ausl RomagnaRavennaItaly
- Department of Translational Medicine and for RomagnaUniversità Degli Studi di FerraraFerraraItaly
| | - Marcin Wełnicki
- 3rd Department of Internal Medicine and CardiologyMedical University of WarsawWarsawPoland
| | - Natalia Buda
- Department of Internal Medicine, Connective Tissue Disease and GeriatricsMedical University of GdanskGdanskPoland
| | - Agnieszka Skoczylas
- Geriatrics DepartmentNational Institute of Geriatrics, Rheumatology and RehabilitationWarsawPoland
| | - Andrzej Pomiecko
- Clinic of Pediatrics, Hematology and OncologyUniversity Clinical CenterGdańskPoland
| | - Domagoj Damjanovic
- Heart Center Freiburg University, Department of Cardiovascular Surgery, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Robert Olszewski
- Department of Gerontology, Public Health and DidacticsNational Institute of Geriatrics, Rheumatology and RehabilitationWarsawPoland
| | - Andrew W. Kirkpatrick
- Departments of Critical Care Medicine and SurgeryUniversity of Calgary and the TeleMentored Ultrasound Supported Medical Interventions Research GroupCalgaryCanada
| | - Raoul Breitkreutz
- FOM Hochschule für Oekonomie & Management gGmbHDepartment of Health and SocialEssenGermany
| | - Gebhart Mathis
- Emergency UltrasoundAustrian Society for Ultrasound in Medicine and BiologyViennaAustria
| | - Gino Soldati
- Diagnostic and Interventional Ultrasound UnitValledel Serchio General HospitalLuccaItaly
| | - Andrea Smargiassi
- Pulmonary Medicine Unit, Department of Medical and Surgical SciencesFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Internal Medicine, IRCCS San Matteo Hospital FoundationUniversity of PaviaPaviaItaly
| | - Riccardo Inchingolo
- Pulmonary Medicine Unit, Department of Medical and Surgical SciencesFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Internal Medicine, IRCCS San Matteo Hospital FoundationUniversity of PaviaPaviaItaly
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Miller DL, Dou C, Dong Z. Lung Ultrasound Induction of Pulmonary Capillary Hemorrhage in Neonatal Swine. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:2276-2291. [PMID: 36030131 PMCID: PMC9942946 DOI: 10.1016/j.ultrasmedbio.2022.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 05/05/2023]
Abstract
This study investigated induction of pulmonary capillary hemorrhage (PCH) in neonatal pigs (piglets) using three different machines: a GE Venue R1 point-of-care system with C1-5 and L4-12t probes, a GE Vivid 7 Dimension with a 7L probe and a SuperSonic Imagine machine with an SL15-4 probe and shear wave elastography (SWE). Female piglets were anesthetized, and each was mounted vertically in a warm bath for scanning at two or three intercostal spaces. After aiming at an innocuous output, the power was raised for a test exposure. Hydrophone measurements were used to calculate in situ values of mechanical index (MIIS). Inflated lungs were removed and scored for PCH area. For the C1-5 probe at 50% and 100% acoustical output (AO), a PCH threshold of 0.53 MIIS was obtained by linear regression (r2 = 0.42). The L4-12t probe did not induce PCH, but the 7L probe induced zones of PCH in the scan planes. The Venue R1 automated B-line tool applied with the C1-5 probe did not detect PCH induced by the C1-5 probe as B-line counts. However, when PCH induced by C1-5 and 7L exposures were subsequently scanned with the L4-12t probe using the automated tool, B-lines were counted in association with the PCH. The SWE induced PCH at push-pulse positions for 3, 30 and 300 s of SWE with PCH accumulating at 0.33 mm2/s and an exponential rise to a maximum of 18.4 mm2 (r2 = 0.61). This study demonstrated the induction of PCH by LUS of piglets, and supports the safety recommendation for use of MIs <0.4 in neonatal LUS.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Chunyan Dou
- Department of Radiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Zhihong Dong
- Department of Radiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Miller DL, Dou C, Raghavendran K, Dong Z. The Influence of Xylazine and Clonidine on Lung Ultrasound-Induced Pulmonary Capillary Hemorrhage in Spontaneously Hypertensive Rats. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2331-2338. [PMID: 33972153 PMCID: PMC8243848 DOI: 10.1016/j.ultrasmedbio.2021.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 05/21/2023]
Abstract
Induction of pulmonary capillary hemorrhage (PCH) by lung ultrasound (LUS) depends not only on physical exposure parameters but also on physiologic conditions and drug treatment. We studied the influence of xylazine and clonidine on LUS-induced PCH in spontaneously hypertensive and normotensive rats using diagnostic B-mode ultrasound at 7.3 MHz. Using ketamine anesthesia, rats receiving saline, xylazine, or clonidine treatment were tested with different pulse peak rarefactional pressure amplitudes in 5 min exposures. Results with xylazine or clonidine in spontaneously hypertensive rats were not significantly different at the three exposure pulse peak rarefactional pressure amplitudes, and thresholds were lower (2.2 MPa) than with saline (2.6 MPa). Variations in LUS PCH were not correlated with mean systemic blood pressure. Similar to previous findings for dexmedetomidine, the clinical drug clonidine tended to increase susceptibility to LUS PCH.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA.
| | - Chunyan Dou
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Krishnan Raghavendran
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Zhihong Dong
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Miller DL, Dou C, Raghavendran K, Dong Z. The Impact of Hemorrhagic Shock on Lung Ultrasound-Induced Pulmonary Capillary Hemorrhage. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:787-794. [PMID: 32856724 PMCID: PMC7914277 DOI: 10.1002/jum.15463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/09/2020] [Accepted: 07/16/2020] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Lung ultrasound (LUS) exposure can induce pulmonary capillary hemorrhage (PCH), depending on biological and physical exposure parameters. This study was designed to investigate the variation in the LUS induction of PCH due to hemorrhagic shock, which itself can engender pulmonary injury. METHODS Male rats were anesthetized with isoflurane in air. Shock was induced by withdrawal of 40% of the blood volume and assessed by the blood pressure detected by a femoral artery catheter and by blood glucose tests. B-mode ultrasound was delivered at 7.3 MHz with a low output (-20 dB) for aiming and with the maximal output (0 dB) for exposure. Pulmonary capillary hemorrhage was quantified by an assessment of comet tail artifacts in the LUS images and by measurement of PCH areas on the surface of fresh lung samples. RESULTS Tests without shock or catheterization surgery gave results for PCH similar to those of previous studies using different methods. Exposure before hemorrhagic shock gave a mean PCH area ± SE of 24.8 ± 9.2 mm2 on the ultrasound scan plane, whereas exposure after shock gave 0 PCH (P < .001; n = 7). CONCLUSIONS The presence of hemorrhagic shock significantly reduces the occurrence of LUS-induced PCH.
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Affiliation(s)
- Douglas L. Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor MI 48109
| | - Chunyan Dou
- Department of Radiology, University of Michigan Health System, Ann Arbor MI 48109
| | | | - Zhihong Dong
- Department of Radiology, University of Michigan Health System, Ann Arbor MI 48109
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Miller DL, Dou C, Raghavendran K, Dong Z. Variation of Diagnostic Ultrasound-Induced Pulmonary Capillary Hemorrhage with Fraction of Inspired Oxygen. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:1978-1985. [PMID: 32423571 PMCID: PMC7329604 DOI: 10.1016/j.ultrasmedbio.2020.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/25/2020] [Accepted: 04/02/2020] [Indexed: 05/08/2023]
Abstract
Pulmonary capillary hemorrhage induction by diagnostic ultrasound (DUS-PCH) was investigated with respect to the influence of the fraction of inspired oxygen (FiO2). Sprague-Dawley rats were anesthetized with Telazol only (TO) or Telazol plus xylazine (TX), which can enhance DUS-PCH. A linear array probe (10 L, GE Vivid 7 Dimension) was used in B-mode at 7.5 MHz to expose the right lung. FiO2 at 10%, 20%, 60% and 100% was delivered through a nose cone. On the ultrasound images, the PCH effect was observed as growing comet tail (B-line) artifacts and as subpleural consolidated segments at higher FiO2. PCH for TO with 20% and 60% FiO2 were significantly greater (p < 0.05) than for the 10% FiO2. PCHs with TX at 10% and 20% FiO2 were significantly greater (p < 0.02) than those for TO anesthesia. Added xylazine and high percentages of FiO2 reduced PCH thresholds, but xylazine and high percentages of FiO2 together did not lower the PCH threshold further. The lowest threshold observed, 1.4 MPa, corresponded to an in situ mechanical index of 0.5.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA.
| | - Chunyan Dou
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Krishnan Raghavendran
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Zhihong Dong
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Miller DL, Abo A, Abramowicz JS, Bigelow TA, Dalecki D, Dickman E, Donlon J, Harris G, Nomura J. Diagnostic Ultrasound Safety Review for Point-of-Care Ultrasound Practitioners. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1069-1084. [PMID: 31868252 DOI: 10.1002/jum.15202] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 11/14/2019] [Accepted: 11/29/2019] [Indexed: 06/10/2023]
Abstract
Potential ultrasound exposure safety issues are reviewed, with guidance for prudent use of point-of-care ultrasound (POCUS). Safety assurance begins with the training of POCUS practitioners in the generation and interpretation of diagnostically valid and clinically relevant images. Sonographers themselves should minimize patient exposure in accordance with the as-low-as-reasonably-achievable principle, particularly for the safety of the eye, lung, and fetus. This practice entails the reduction of output indices or the exposure duration, consistent with the acquisition of diagnostically definitive images. Informed adoption of POCUS worldwide promises a reduction of ionizing radiation risks, enhanced cost-effectiveness, and prompt diagnoses for optimal patient care.
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Affiliation(s)
| | - Alyssa Abo
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Jacques S Abramowicz
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
| | - Timothy A Bigelow
- Center for Nondestructive Evaluation, Iowa State University, Ames, Iowa, USA
| | - Diane Dalecki
- Department of Biomedical Engineering, University of Rochester, Rochester, New York, USA
| | - Eitan Dickman
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, USA
| | - John Donlon
- Acoustic Measurements, Philips Healthcare, Bothell, Washington, USA
| | - Gerald Harris
- Center for Devices and Radiological Health, United States Food and Drug Administration (retired), Silver Spring, Maryland, USA
| | - Jason Nomura
- Department of Emergency Medicine, Christiana Hospital, Newark, Delaware, USA
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Miller DL, Dong Z, Dou C, Patterson B, Raghavendran K. Pulmonary Capillary Hemorrhage Induced by Super Sonic Shear Wave Elastography in Rats. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2993-3004. [PMID: 31412979 PMCID: PMC6768750 DOI: 10.1016/j.ultrasmedbio.2019.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/20/2019] [Accepted: 07/06/2019] [Indexed: 05/05/2023]
Abstract
The occurrence of the pulmonary capillary hemorrhage (PCH) bioeffect of diagnostic ultrasound in rats was investigated for a SuperSonic Imagine shear wave elastography system (Aixplorer, Supersonic Imagine, Aix-en-Provence, France). The elastography imaging repeated at 1 Hz and consisted of widely spaced B-mode image pulses, supersonic push (SSP) pulses and shear wave imaging (SWI) pulses. Groups of rats anesthetized with ketamine and xylazine, or with ketamine only, were imaged on their right side in a warm water bath for one frame, 30 s and 300 s. The image focus and region of interest were adjusted to give exposure only with the background B-mode imaging, or primarily with the SSP and SWI pulses. A sham group had only low power aiming scans. The lungs were removed 5 min after exposure and evaluated for PCH area and volume. The B mode was notably ineffective and produced significant PCH only at the maximum 0 dB output. The SSP pulses together with the SWI pulses produced significant PCH for 300 s, 30 s and even single image exposures. Peak rarefactional pressure amplitude PCH thresholds for 300 s exposure were the same with or without the B-mode pulses at 1.5 MPa (in situ mechanical index, MIIS = 0.67). A 30 s duration resulted in a slightly increased threshold of 1.7 MPa (MIIS = 0.76). The omission of xylazine from the anesthetic, which reduces the sensitivity of rat lung to PCH occurrence, resulted in an increased threshold of 2.1 MPa (MIIS = 0.94). The unique SSP pulses were much more effective than the B mode, but thresholds were comparable to previous results with other diagnostic ultrasound modes on other systems.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.
| | - Zhihong Dong
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Chunyan Dou
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Brandon Patterson
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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Miller DL, Dong Z, Dou C, Patterson B, Raghavendran K. Pulmonary Capillary Hemorrhage Induced by Acoustic Radiation Force Impulse Shear Wave Elastography in Ventilated Rats. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2575-2587. [PMID: 30702763 PMCID: PMC6771037 DOI: 10.1002/jum.14950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/13/2018] [Accepted: 01/06/2019] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Diagnostic ultrasound (DUS) imaging can induce pulmonary capillary hemorrhage (PCH), possibly related to the ultrasonic radiation surface pressure arising from reflection at the lung blood-air interfaces. Acoustic radiation force impulse (ARFI) elastography is a relatively new DUS mode with high-energy "push pulses" used to move tissue and generate shear waves. The objective of this study was to characterize PCH induced by the ARFI elastographic mode for comparison with other previously tested DUS modes. METHODS Pulmonary capillary hemorrhage induction was examined for ARFI elastographic frames with 5.7-MHz push pulses (Acuson S3000; Siemens Medical Solutions, Mountain View, CA), which had a derated PRPA of 2.6 MPa. Groups of rats with tracheal tube placement had no ventilation (spontaneous breathing), intermittent positive pressure ventilation (IPPV), or IPPV plus 8 cm H2 O of positive end-expiratory pressure (PEEP). Exposure was to 1 or 20 manually triggered image frame acquisitions. The PCH area was measured on the lung surface. RESULTS All 20-frame exposure groups, and even the single-frame group, had significant PCH relative to shams. Single-frame exposures produced significantly less PCH (P = .002) than 20-frame exposures in rats with a tracheal tube only (spontaneous breathing). The PEEP inhibited the PCH and produced about half of the PCH area induced for IPPV without PEEP (P = .014). CONCLUSIONS The PCH results were comparable with those from a previous study using B-mode or color Doppler exposure for 5 minutes; however, these modes delivered many more pulses for continuous imaging frames, suggesting that the ARFI elastographic frames were individually much more effective.
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Affiliation(s)
- Douglas L. Miller
- Department of Radiology, University of Michigan, Ann Arbor, MI. 48109
| | - Zhihong Dong
- Department of Radiology, University of Michigan, Ann Arbor, MI. 48109
| | - Chunyan Dou
- Department of Radiology, University of Michigan, Ann Arbor, MI. 48109
| | - Brandon Patterson
- Department of Radiology, University of Michigan, Ann Arbor, MI. 48109
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Miller DL, Dong Z, Dou C, Raghavendran K. Pulmonary Capillary Hemorrhage Induced by Different Imaging Modes of Diagnostic Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1012-1021. [PMID: 29428168 PMCID: PMC5869104 DOI: 10.1016/j.ultrasmedbio.2017.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/03/2017] [Accepted: 11/13/2017] [Indexed: 05/16/2023]
Abstract
The induction of pulmonary capillary hemorrhage (PCH) is a well-established non-thermal biological effect of pulsed ultrasound in animal models. Typically, research has been done using laboratory pulsed ultrasound systems with a fixed beam and, recently, by B-mode diagnostic ultrasound. In this study, a GE Vivid 7 Dimension ultrasound machine with 10 L linear array probe was used at 6.6 MHz to explore the relative PCH efficacy of B-mode imaging, M-mode (fixed beam), color angio mode Doppler imaging and pulsed Doppler mode (fixed beam). Anesthetized rats were scanned in a warmed water bath, and thresholds were determined by scanning at different power steps, 2 dB apart, in different groups of six rats. Exposures were performed for 5 min, except for a 15-s M-mode group. Peak rarefactional pressure amplitude thresholds were 1.5 MPa for B-mode and 1.1 MPa for angio Doppler mode. For the non-scanned modes, thresholds were 1.1 MPa for M-mode and 0.6 MPa for pulsed Doppler mode with its relatively high duty cycle (7.7 × 10-3 vs. 0.27 × 10-3 for M-mode). Reducing the duration of M-mode to 15 s (from 300 s) did not significantly reduce PCH (area, volume or depth) for some power settings, but the threshold was increased to 1.4 MPa. Pulmonary sonographers should be aware of this unique adverse bio-effect of diagnostic ultrasound and should consider reduced on-screen mechanical index settings for potentially vulnerable patients.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA.
| | - Zhihong Dong
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Chunyan Dou
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Krishnan Raghavendran
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
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Correlation of B-Lines on Ultrasonography With Interstitial Lung Disease on Chest Radiography and CT Imaging. Chest 2017; 152:990-998. [PMID: 28522112 DOI: 10.1016/j.chest.2017.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/06/2017] [Accepted: 05/01/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We prospectively identified B-lines in patients undergoing ultrasonographic (US) examinations following liver transplantation who also had chest radiography (CXR) or chest CT imaging, or both, on the same day to determine if an association between the presence of B-lines from the thorax on US images correlates with the presence of lung abnormalities on CXR. METHODS Following institutional review board (IRB) approval, patients who received liver transplants and underwent routine US examinations and chest radiography or CT imaging, or both, on the same day between January 1, 2015 through July 1, 2016 were prospectively identified. Two readers who were blinded to chest films and CT images and reports independently reviewed the US interreader agreement for the presence or absence of B-lines and performed an evaluation for the presence or absence of diffuse parenchymal lung disease (DPLD) on chest films and CT images as well as from clinical evaluation. Receiver operating characteristic (ROC) curves were constructed. RESULTS There was good agreement between the two readers on the presence of absence of B-lines (kappa = 0.94). The area under the ROC curve for discriminating between positive DPLD and negative DPLD for both readers was 0.79 (95% CI, 0.71-0.87). CONCLUSIONS There is an association between the presence of extensive B-lines to the point of confluence and "dirty shadowing" on US examinations of the chest and associated findings on chest radiographs and CT scans of DPLD. Conversely, isolated B-lines do not always correlate with abnormalities on chest films and in fact sometimes appear to be a normal variant.
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Miller DL. Mechanisms for Induction of Pulmonary Capillary Hemorrhage by Diagnostic Ultrasound: Review and Consideration of Acoustical Radiation Surface Pressure. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2743-2757. [PMID: 27649878 PMCID: PMC5116429 DOI: 10.1016/j.ultrasmedbio.2016.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 05/03/2023]
Abstract
Diagnostic ultrasound can induce pulmonary capillary hemorrhage (PCH) in rats and other mammals. This phenomenon represents the only clearly demonstrated biological effect of (non-contrast enhanced) diagnostic ultrasound and thus presents a uniquely important safety issue. However, the physical mechanism responsible for PCH remains uncertain more than 25 y after its discovery. Experimental research has indicated that neither heating nor acoustic cavitation, the predominant mechanisms for bioeffects of ultrasound, is responsible for PCH. Furthermore, proposed theoretical mechanisms based on gas-body activation, on alveolar resonance and on impulsive generation of liquid droplets all appear unlikely to be responsible for PCH, owing to unrealistic model assumptions. Here, a simple model based on the acoustical radiation surface pressure (ARSP) at a tissue-air interface is hypothesized as the mechanism for PCH. The ARSP model seems to explain some features of PCH, including the approximate frequency independence of PCH thresholds and the dependence of thresholds on biological factors. However, ARSP evaluated for experimental threshold conditions appear to be too weak to fully account for stress failure of pulmonary capillaries, gauging by known stresses for injurious physiologic conditions. Furthermore, consideration of bulk properties of lung tissue suggests substantial transmission of ultrasound through the pleura, with reduced ARSP and potential involvement of additional mechanisms within the pulmonary interior. Although these recent findings advance our knowledge, only a full understanding of PCH mechanisms will allow development of science-based safety assurance for pulmonary ultrasound.
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Affiliation(s)
- Douglas L Miller
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.
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