Superthreshold behavior and threshold estimation of ultrasound-induced lung hemorrhage in pigs: role of age dependency

Lung Ultrasound Induction of Pulmonary Capillary Hemorrhage in Rats With Consideration of Exposimetric Relationships to Previous Similar Observations in Neonatal Swine

OBJECTIVE

Lung ultrasound (LUS) has become an essential clinical tool for pulmonary evaluation. LUS has been found to induce pulmonary capillary hemorrhage (PCH) in animal models, posing a safety issue. The induction of PCH was investigated in rats, and exposimetry parameters were compared with those of a previous neonatal swine study.

METHODS

Female rats were anesthetized and scanned in a warmed water bath with the 3Sc, C1-5 and L4-12t probes from a GE Venue R1 point-of-care ultrasound machine. Acoustic outputs (AOs) of sham, 10%, 25%, 50% or 100% were applied for 5-min exposures with the scan plane aligned with an intercostal space. Hydrophone measurements were used to estimate the in situ mechanical index (MIIS) at the lung surface. Lung samples were scored for PCH area, and PCH volumes were estimated.

RESULTS

At 100% AO, the PCH areas were 73 ± 19 mm2 for the 3.3 MHz 3Sc probe (4 cm lung depth), 49 ± 20 mm2 (3.5 cm lung depth) or 96 ± 14 mm2 (2 cm lung depth) for the 3.0 MHz C1-5 probe and 7.8 ± 2.9 mm2 for the 7 MHz L4-12t (1.2 cm lung depth). Estimated volumes ranged from 378 ± 97 mm3 for the C1-5 at 2 cm to 1.3 ± 1.5 mm3 for the L4-12t. MIIS thresholds for PCH were 0.62, 0.56 and 0.48 for the 3Sc, C1-5 and L4-12t, respectively.

CONCLUSION

Comparison between this study and previous similar research in neonatal swine revealed the importance of chest wall attenuation. Neonatal patients may be most susceptible to LUS PCH because of thin chest walls.

Lung Ultrasound Induction of Pulmonary Capillary Hemorrhage in Neonatal Swine

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.

The Impact of Hemorrhagic Shock on Lung Ultrasound-Induced Pulmonary Capillary Hemorrhage

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.

Variation of Diagnostic Ultrasound-Induced Pulmonary Capillary Hemorrhage with Fraction of Inspired Oxygen

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.

Diagnostic Ultrasound Safety Review for Point-of-Care Ultrasound Practitioners

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.

Ultrasound-based triggered drug delivery to tumors

Over the past few decades, applications of ultrasound (US) in drug delivery have been documented widely for local and site-specific release of bioactives in a controlled manner, after acceptable use in mild physical therapy for tendinitis and bursitis, and for high-energy applications in fibroid ablation, cataract removal, bone fracture healing, etc. US is a non-invasive, efficient, targetable and controllable technique. Drug delivery can be enhanced by applying directed US in terms of targeting and intracellular uptake. US cannot only provide local hyperthermia but can also enhance local extravasations and permeability of the cell membrane for delivery of cell-impermeable and poorly permeable drugs. It is also found to increase the anticancer efficacy of drug against solid tumors by facilitating uniform drug delivery throughout the tumor mass. This review summarizes the mechanism of US; various drug delivery systems like microbubbles, liposomes, and micelles; and biological manifestations employed for improving treatment of cancer, i.e., hyperthermia and enhanced extravasation. Safety issues are also discussed for better therapeutic outcomes of US-assisted drug delivery to tumors. This review can be a beneficial asset to the scientists looking at non-invasive techniques (externally guided) for improving the anticancer potential of drug delivery systems.

Pulmonary Capillary Hemorrhage Induced by Different Imaging Modes of Diagnostic Ultrasound

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.

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Mechanisms for Induction of Pulmonary Capillary Hemorrhage by Diagnostic Ultrasound: Review and Consideration of Acoustical Radiation Surface Pressure

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.

Influence of Scan Duration on Pulmonary Capillary Hemorrhage Induced by Diagnostic Ultrasound

Diagnostic ultrasound can induce pulmonary capillary hemorrhage (PCH) in rats and display this as "comet tail" artifacts (CTAs) after a time delay. To test the hypothesis that no PCH occurs for brief scans, anesthetized rats were scanned using a 6-MHz linear array for different durations. PCH was characterized by ultrasound CTAs, micro-computed tomography (μCT), and measurements of fixed lung tissue. The μCT images revealed regions of PCH, sometimes penetrating the entire depth of a lobe, which were reflected in the fixed tissue measurements. At -3 dB of power, PCH was substantial for 300-s scans, but not significant for 25-s scans. At 0 dB, PCH was not strongly dependent on scan durations of 300 to 10 s. Contrary to the hypothesis, CTAs were not evident during most 10-s scans (p > 0.05), but PCH was significant (p = 0.02), indicating that PCH could occur without evidence of the injury in the images.

Application of analyzer based X-ray imaging technique for detection of ultrasound induced cavitation bubbles from a physical therapy unit

BACKGROUND

The observation of ultrasound generated cavitation bubbles deep in tissue is very difficult. The development of an imaging method capable of investigating cavitation bubbles in tissue would improve the efficiency and application of ultrasound in the clinic. Among the previous imaging modalities capable of detecting cavitation bubbles in vivo, the acoustic detection technique has the positive aspect of in vivo application. However the size of the initial cavitation bubble and the amplitude of the ultrasound that produced the cavitation bubbles, affect the timing and amplitude of the cavitation bubbles' emissions.

METHODS

The spatial distribution of cavitation bubbles, driven by 0.8835 MHz therapeutic ultrasound system at output power of 14 Watt, was studied in water using a synchrotron X-ray imaging technique, Analyzer Based Imaging (ABI). The cavitation bubble distribution was investigated by repeated application of the ultrasound and imaging the water tank. The spatial frequency of the cavitation bubble pattern was evaluated by Fourier analysis. Acoustic cavitation was imaged at four different locations through the acoustic beam in water at a fixed power level. The pattern of cavitation bubbles in water was detected by synchrotron X-ray ABI.

RESULTS

The spatial distribution of cavitation bubbles driven by the therapeutic ultrasound system was observed using ABI X-ray imaging technique. It was observed that the cavitation bubbles appeared in a periodic pattern. The calculated distance between intervals revealed that the distance of frequent cavitation lines (intervals) is one-half of the acoustic wave length consistent with standing waves.

CONCLUSION

This set of experiments demonstrates the utility of synchrotron ABI for visualizing cavitation bubbles formed in water by clinical ultrasound systems working at high frequency and output powers as low as a therapeutic system.

Pulmonary Capillary Hemorrhage Induced by Fixed-Beam Pulsed Ultrasound

The induction of pulmonary capillary hemorrhage (PCH) by pulsed ultrasound was discovered 25 y ago, but early research used fixed-beam systems rather than actual diagnostic ultrasound machines. In this study, results of exposure of rats to fixed-beam focused ultrasound for 5 min at 1.5 and 7.5 MHz were compared with recent research on diagnostic ultrasound. One exposure condition at each frequency used 10-μs pulses delivered at 25-ms intervals. Three conditions involved Gaussian modulation of the pulse amplitudes at 25-ms intervals to simulate diagnostic scanning: 7.5 MHz with 0.3- and 1.5-μs pulses at 100- and 500-μs pulse repetition periods, respectively, and 1.5 MHz with 1.7-μs pulses at 500-μs repetition periods. Four groups were tested for each condition to assess PCH areas at different exposure levels and to determine occurrence thresholds. The conditions with identical pulse timing resulted in smaller PCH areas for the smaller 7.5-MHz beam, but both had thresholds of 0.69-0.75 MPa in situ peak rarefactional pressure amplitude. The Gaussian modulation conditions for both 7.5 MHz with 0.3-μs pulses and 1.5 MHz with 1.7-μs pulses had thresholds of 1.12-1.20 MPa peak rarefactional pressure amplitude, although the relatively long 1.5-μs pulses at 7.5 MHz yielded a threshold of 0.75 MPa. The fixed-beam pulsed ultrasound exposures produced lower thresholds than diagnostic ultrasound. There was no clear tendency for thresholds to increase with increasing ultrasonic frequency when pulse timing conditions were similar.

Anesthetic techniques influence the induction of pulmonary capillary hemorrhage during diagnostic ultrasound scanning in rats

OBJECTIVES

Pulmonary capillary hemorrhage can be induced by diagnostic ultrasound (US) during direct pulmonary US scanning in rats. The influence of specific anesthetic techniques on this bioeffect was examined.

METHODS

Ketamine plus xylazine has been used previously. In this study, the influence of intraperitoneal injections of ketamine and pentobarbital, inhalational isoflurane, and the supplemental use of xylazine with ketamine and isoflurane was tested. A diagnostic US machine with a 7.6-MHz linear array was used to image the right lung of anesthetized rats in a warmed water bath at different mechanical index (MI) settings. Pulmonary capillary hemorrhage was assessed by measuring comet tail artifacts in the image and by morphometry of the hemorrhagic areas on excised lungs.

RESULTS

Pulmonary capillary hemorrhage was greatest for pentobarbital, lower for inhalational isoflurane, and lowest for ketamine anesthesia, with occurrence thresholds at MIs of about 0.44, 0.8, and 0.8, respectively. Addition of xylazine produced a substantial increase in hemorrhage and a significant proportion of hemorrhage occurrence for ketamine at an MI of 0.7 (P < .01) and for isoflurane at an MI of 0.52 (P < .01).

CONCLUSIONS

Ketamine plus xylazine and pentobarbital yield lower thresholds than ketamine or isoflurane alone by nearly a factor of 2 in MI. These results suggest that the choice of the anesthetic agent substantially modifies the relative risks of pulmonary capillary hemorrhage from pulmonary US.

Contrast ultrasound imaging of the aorta alters vascular morphology and circulating von Willebrand factor in hypercholesterolemic rabbits

OBJECTIVES

Ultrasound contrast agents (UCAs) are intravenously infused microbubbles that add definition to ultrasonic images. Ultrasound contrast agents continue to show clinical promise in cardiovascular imaging, but their biological effects are not known with confidence. We used a cholesterol-fed rabbit model to evaluate these effects when used in conjunction with ultrasound (US) to image the descending aorta.

METHODS

Male New Zealand White rabbits (n = 41) were weaned onto an atherogenic diet containing 1% cholesterol, 10% fat, and 0.11% magnesium. At 21 days, rabbits were exposed to contrast US at 1 of 4 pressure levels using either the UCA Definity (Lantheus Medical Imaging, Inc, North Billerica, MA) or a saline control (n = 5 per group). Blood samples were collected and analyzed for lipids and von Willebrand factor (vWF), a marker of endothelial function. Animals were euthanized at 42 days, and tissues were collected for histologic analysis.

RESULTS

After adjustment for pre-exposure vWF, high-level US (in situ [at the aorta] peak rarefactional pressure of 1.4 or 2.1 MPa) resulted in significantly lower vWF 1 hour post exposure (P = .0127; P(adj) < .0762). This difference disappeared within 24 hours. Atheroma thickness in the descending aorta was lower in animals receiving the UCA compared to animals receiving saline.

CONCLUSIONS

Contrast US affected the descending aorta, as evidenced by two separate outcome measures. These results may be a first step in elucidating a previously unknown biological effect of UCAs. Further research is warranted to characterize the effects of this procedure.

Ultrasonic imaging: safety considerations

Modern ultrasound imaging for diagnostic purposes has a wide range of applications. It is used in obstetrics to monitor the progress of pregnancy, in oncology to visualize tumours and their response to treatment, and, in cardiology, contrast-enhanced studies are used to investigate heart function and physiology. An increasing use of diagnostic ultrasound is to provide the first photograph for baby's album-in the form of a souvenir or keepsake scan that might be taken as part of a routine investigation, or during a visit to an independent high-street 'boutique'. It is therefore important to ensure that any benefit accrued from these applications outweighs any accompanying risk, and to evaluate the existing ultrasound bio-effect and epidemiology literature with this in mind. This review considers the existing laboratory and epidemiological evidence about the safety of diagnostic ultrasound and puts it in the context of current clinical usage.

Threshold estimation and superthreshold behavior of ultrasound-induced lung hemorrhage in rats: role of age dependency

Age-dependent threshold and superthreshold behaviors of ultrasound-induced lung hemorrhage were investigated with one hundred ten 12.6 +/- 0.8-d-old rats, one hundred ten 22.9 +/- 0.8-d-old rats, and one hundred 57.7 +/- 3.9-d-old rats. Exposure conditions were: 2.8 MHz, 10-s exposure duration, 1-kHz pulse repetition frequency and 1.3-mus pulse duration. The in situ (at the pleural surface) peak rarefactional pressure (p(r(in situ))) ranged between 1.4 and 10.8 MPa for which there were either 9 or 10 acoustic pressure groups for each of the three rat ages (10 rats/exposure group). For each of the three rat ages there were also shams; there were no lesions in the shams. The p(r(in situ)) levels were randomized within each age group; rat age was not randomized. Individuals involved in animal handling, exposure and lesion scoring were blinded to the exposure condition. In addition, one hundred fifty-six 72-d-old rats were included from three completed studies (same experimental conditions) to provide a fourth age group for the analysis. Probit regression analysis was used to examine the dependence of the occurrence of lesions on p(r(in situ)) in the four age groups. Likewise, lesion depth and lesion root surface area were analyzed using Gaussian tobit regression analysis. Although p(r(in situ)) was a significant variable, no significant age dependence of the p(r(in situ)) effect was found. Furthermore, age had no significant effect on either the rate of occurrence or the depth of lesions. Given the occurrence of a lesion, a weak age dependence was found for the median surface area of the induced lesion (p-value = 0.037).

Observations of MI Values During Neonatal Cardiac Ultrasound Scanning

Aim: The on-screen Mechanical Index (MI), was recorded from eight diagnostic ultrasound machines used for cardiac scanning of neonates. The objective of the study was to compare values of MI used in neonatal cardiac scanning with those recommended by the British Medical Ultrasound Society safety guidelines.

Methods: The eight scanners were based at Sheffield Teaching Hospitals NHS Trust (STH), Sheffield Children's Hospitals NHS Trust (SCH) and Leeds Teaching Hospitals NHS Trust (LTH). Two methods of recording the MI value were used. At the Sheffield sites the on-screen safety index was obtained from archived patient studies saved on the Trust PACS. At the Leeds site the on-screen safety index was recorded from the scanner when it was switched on to its default neonatal or paediatric pre-sets with the appropriate transducer connected.

Results: Data from clinical examinations at the Sheffield sites show that on average the MI values, for cardiac scanning, in B-mode and colour/pulsed wave Doppler mode were 1·1±0·3 and 1·3±0·3 respectively. The maximum values of MI recorded during clinical cardiac examinations were 1·6 for B-mode and 1·7 for colour/pulsed wave Doppler mode. Data from the Leeds site recorded default MI values, using appropriate transducers with neonatal and paediatric presets. One scanner from the Leeds site defaulted to an MI value of 1·9 in colour/pulsed Doppler mode with a neonatal preset. All the MI values are well above BMUS guideline recommendations for neonates when lung tissue is present within the ultrasound beam.

Conclusions: The implication of these results is that neonates undergoing cardiac ultrasound examinations, were regularly exposed to MI values at least four to six times that recommended by BMUS guidelines (MI<0·3).

Estimation of the acoustic impedance of lung versus level of inflation for different species and ages of animals

In a previous study, it was hypothesized that ultrasound-induced lung damage was related to the transfer of ultrasonic energy into the lungs (W. D. O'Brien et al. 2002, "Ultrasound-induced lung hemorrhage: Role of acoustic boundary conditions at the pleural surface," J. Acoust. Soc. Am. 111, 1102-1109). From this study a technique was developed to: 1) estimate the impedance (Mrayl) of fresh, excised, ex vivo rat lung versus its level of inflation (cm H(2)O) and 2) predict the fraction of ultrasonic energy transmitted into the lung (M. Oelze et al. 2003, "Impedance measurements of ex vivo rat lung at different volumes of inflation." J. Acoust. Soc. Am. 114, 3384-3393). In the current study, the same technique was used to estimate the frequency-dependent impedance of lungs from rats, rabbits, and pigs of various ages. Impedance values were estimated from lungs under deflation (atmospheric pressure, 0 cm H(2)O) and three volumes of inflation pressure [7 cm H(2)O (5 cm H(2)O for pigs), 10 cm H(2)O, and 15 cm H(2)O]. Lungs were scanned in a tank of degassed 37 degrees C water. The frequency-dependent acoustic pressure reflection coefficient was determined over a frequency range of 3.5-10 MHz. From the reflection coefficient, the frequency-dependent lung impedance was calculated with values ranging from an average of 1.4 Mrayl in deflated lungs (atmospheric pressure) to 0.1 Mrayl for fully inflated lungs (15 cm H(2)O). Across all species, deflated lung (i.e., approximately 7% of the total lung capacity) had impedance values closer to tissue values, suggesting that more acoustic energy was transmitted into the lung under deflated conditions. Finally, the impedance values of deflated lungs from different species at different ages were compared with the thresholds for ultrasound-induced lung damage. The comparison revealed that increases in ultrasonic energy transmission corresponded to lower injury threshold values.

The risk of exposure to diagnostic ultrasound in postnatal subjects: nonthermal mechanisms

This review examines the nonthermal physical mechanisms by which ultrasound can harm tissue in postnatal patients. First the physical nature of the more significant interactions between ultrasound and tissue is described, followed by an examination of the existing literature with particular emphasis on the pressure thresholds for potential adverse effects. The interaction of ultrasonic fields with tissue depends in a fundamental way on whether the tissue naturally contains undissolved gas under normal physiologic conditions. Examples of gas-containing tissues are lung and intestine. Considerable effort has been devoted to investigating the acoustic parameters relevant to the threshold and extent of lung hemorrhage. Thresholds as low as 0.4 MPa at 1 MHz have been reported. The situation for intestinal damage is similar, although the threshold appears to be somewhat higher. For other tissues, auditory stimulation or tactile perception may occur, if rarely, during exposure to diagnostic ultrasound; ultrasound at similar or lower intensities is used therapeutically to accelerate the healing of bone fractures. At the exposure levels used in diagnostic ultrasound, there is no consistent evidence for adverse effects in tissues that are not known to contain stabilized gas bodies. Although modest tissue damage may occur in certain identifiable applications, the risk for induction of an adverse biological effect by a nonthermal mechanism due to exposure to diagnostic ultrasound is extremely small.

Evaluation of the threshold for lung hemorrhage by diagnostic ultrasound and a proposed new safety index

In a recent report (O'Brien et al. (2006b), it was suggested that the current expression for the mechanical index (MI) was not well suited to its function of quantifying the likelihood of an adverse biological effect after exposure of the gas-filled lung to diagnostic ultrasound. The purpose of this study was to analyze the relatively large database of experimental thresholds for the induction of lung hemorrhage to: (i) determine which variable(s) best describe the data and (ii) use the resulting equation to obtain a new formulation for the MI for lung exposures. Data from 14 studies of lung hemorrhage in four common laboratory animals (mouse, rat, rabbit and pig) were tabulated with regard to five common acoustic variables: center frequency (f(c)), pulse repetition frequency (PRF), pulse duration (PD), exposure duration (ED) and the threshold in situ peak rarefactional pressure (p(r)). The 34 threshold data points were fit by linear regression to: (i) a multiplicative model of the other variables, p(r) = Af(c)(B)PRF(C)PD(D)ED(E), where A is a constant; (ii) 14 "reduced" models in which one or more variables were not included in the analysis; (iii) four models in which a multiplicative combination of variables has a common name e.g., duty factor; and (iv) the general form of the current expression for the MI. The MI was shown to provide a poor fit to the threshold data (r(2) = 0.382), as were three of the four named models. The best fits were found for the complete model and for three reduced models, all of which contain the exposure duration. Because the implementation of a time-dependent safety parameter would present significant practical difficulties, a different model, p(r) = Af(c)(B)PRF(C)PD(D), was chosen as the basis for the new MI. Thus, the expression for the lung-specific mechanical index, MI(Lung), includes several, rather than only one, of the relevant acoustic variables. This is the first potential safety index developed as a direct result of experimental measurements rather than theoretical analysis.

Ultrasound-biophysics mechanisms

Ultrasonic biophysics is the study of mechanisms responsible for how ultrasound and biological materials interact. Ultrasound-induced bioeffect or risk studies focus on issues related to the effects of ultrasound on biological materials. On the other hand, when biological materials affect the ultrasonic wave, this can be viewed as the basis for diagnostic ultrasound. Thus, an understanding of the interaction of ultrasound with tissue provides the scientific basis for image production and risk assessment. Relative to the bioeffect or risk studies, that is, the biophysical mechanisms by which ultrasound affects biological materials, ultrasound-induced bioeffects are generally separated into thermal and non-thermal mechanisms. Ultrasonic dosimetry is concerned with the quantitative determination of ultrasonic energy interaction with biological materials. Whenever ultrasonic energy is propagated into an attenuating material such as tissue, the amplitude of the wave decreases with distance. This attenuation is due to either absorption or scattering. Absorption is a mechanism that represents that portion of ultrasonic wave that is converted into heat, and scattering can be thought of as that portion of the wave, which changes direction. Because the medium can absorb energy to produce heat, a temperature rise may occur as long as the rate of heat production is greater than the rate of heat removal. Current interest with thermally mediated ultrasound-induced bioeffects has focused on the thermal isoeffect concept. The non-thermal mechanism that has received the most attention is acoustically generated cavitation wherein ultrasonic energy by cavitation bubbles is concentrated. Acoustic cavitation, in a broad sense, refers to ultrasonically induced bubble activity occurring in a biological material that contains pre-existing gaseous inclusions. Cavitation-related mechanisms include radiation force, microstreaming, shock waves, free radicals, microjets and strain. It is more challenging to deduce the causes of mechanical effects in tissues that do not contain gas bodies. These ultrasonic biophysics mechanisms will be discussed in the context of diagnostic ultrasound exposure risk concerns.

Threshold estimation of ultrasound-induced lung hemorrhage in adult rabbits and comparison of thresholds in mice, rats, rabbits and pigs

The objective of this study was to assess the threshold and superthreshold behavior of ultrasound (US)-induced lung hemorrhage in adult rabbits to gain greater understanding about species dependency. A total of 99 76 +/- 7.6-d-old 2.4 +/- 0.14-kg New Zealand White rabbits were used. Exposure conditions were 5.6-MHz, 10-s exposure duration, 1-kHz PRF and 1.1-micros pulse duration. The in situ (at the pleural surface) peak rarefactional pressure, p(r(in situ)), ranged between 1.5 and 8.4 MPa, with nine acoustic US exposure groups plus a sham exposure group. Rabbits were assigned randomly to the 10 groups, each with 10 rabbits, except for one group that had nine rabbits. Rabbits were exposed bilaterally with the order of exposure (left then right lung, or right then left lung) and acoustic pressure both randomized. Individuals involved in animal handling, exposure and lesion scoring were blinded to the exposure condition. Probit regression analysis was used to examine the dependence of the lesion occurrence on in situ peak rarefactional pressure and order of exposure (first vs. second). Likewise, lesion depth and lesion root surface area were analyzed using Gaussian tobit regression analysis. Neither probability of a lesion nor lesion size measurements was found to be statistically dependent on the order of exposure after the effect of p(r(in situ)) was considered. Also, a significant correlation was not detected between the two exposed lung sides on the same rabbit in either lesion occurrence or size measures. The p(r(in situ)) threshold estimates (in MPa) were similar to each other across occurrence (3.54 +/- 0.78), depth (3.36 +/- 0.73) and surface area (3.43 +/- 0.77) of lesions. Using the same experimental techniques and statistical approach, great consistency of thresholds was demonstrated across three species (mouse, rat and rabbit). Further, there were no differences in the biologic mechanism of injury induced by US and US-induced lesions were similar in morphology in all species and age groups studied. The extent of US-induced lung damage and the ability of the lung to heal led to the conclusion that, although US can produce lung damage at clinical levels, the degree of damage does not appear to be a significant medical problem.

Superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse repetition frequency and pulse duration

OBJECTIVE

The purpose of this study was to enhance the findings of an earlier ultrasound-induced lung hemorrhage study (Ultrasound Med Biol 2003; 29:1625-1634) that estimated pressure thresholds as a function of pulse duration (PD: 1.3, 4.4, 8.2, and 11.6 micros; 2.8 MHz; 10-s exposure duration [ED]; 1-kHz pulse repetition frequency [PRF]). In this study, the roles of PRF and PD were evaluated at 5.9 MPa, the peak rarefactional pressure threshold near that of the ED50 estimate previously determined.

METHODS

A 4 x 4 factorial design study (PRF: 50, 170, 500, and 1700 Hz; PD: 1.3, 4.4, 8.2, and 11.6 mus) was conducted (2.8 MHz; 10-s ED). Sprague Dawley rats (n = 175) were divided into 16 exposure groups (10 rats per group) and 1 sham group (15 rats); no lesions were produced in the sham group. Logistic regression analysis evaluated significance of effects for lesion occurrence, and Gaussian tobit analysis evaluated significance for lesion depth and surface area.

RESULTS

For lesion occurrence and sizes, the main effect of PRF was not significant. The interaction term, PRF x PD, was highly significant, indicating a strong positive dependence of lesion occurrence on the duty factor. The main effect of PD was almost significant (P = .052) and thus was included in the analysis model for a better fit.

CONCLUSIONS

Compared with the findings from a PRF x ED factorial study (J Ultrasound Med 2005; 24:339-348), a function that considers PRF, PD, and ED might yield a sensitive indicator for consideration of a modified mechanical index, at least for the lung.

Can pulsed ultrasound increase tissue damage during ischemia? A study of the effects of ultrasound on infarcted and non-infarcted myocardium in anesthetized pigs

BACKGROUND

The same mechanisms by which ultrasound enhances thrombolysis are described in connection with non-beneficial effects of ultrasound. The present safety study was therefore designed to explore effects of beneficial ultrasound characteristics on the infarcted and non-infarcted myocardium.

METHODS

In an open chest porcine model (n = 17), myocardial infarction was induced by ligating a coronary diagonal branch. Pulsed ultrasound of frequency 1 MHz and intensity 0.1 W/cm2 (ISATA) was applied during one hour to both infarcted and non-infarcted myocardial tissue. These ultrasound characteristics are similar to those used in studies of ultrasound enhanced thrombolysis. Using blinded assessment technique, myocardial damage was rated according to histopathological criteria.

RESULTS

Infarcted myocardium exhibited a significant increase in damage score compared to non-infarcted myocardium: 6.2 +/- 2.0 vs. 4.3 +/- 1.5 (mean +/- standard deviation), (p = 0.004). In the infarcted myocardium, ultrasound exposure yielded a further significant increase of damage scores: 8.1 +/- 1.7 vs. 6.2 +/- 2.0 (p = 0.027).

CONCLUSION

Our results suggest an instantaneous additive effect on the ischemic damage in myocardial tissue when exposed to ultrasound of stated characteristics. The ultimate damage degree remains to be clarified.

Superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse repetition frequency and exposure duration revisited

OBJECTIVE

The purpose of this study was to augment and reevaluate the ultrasound-induced lung hemorrhage findings of a previous 5 x 3 factorial design study (Ultrasound Med Biol 2001; 27:267-277) that evaluated the role of pulse repetition frequency (PRF: 25, 50, 100, 250, and 500 Hz) and exposure duration (ED; 5, 10, and 20 s) on ultrasound-induced lung hemorrhage at an in situ (at the pleural surface) peak rarefactional pressure [pr(in situ)] of 12.3 MPa; only PRF was found to be significant. However, saturation (response plateau) due to the high pr(in situ) might have skewed the results. In this follow-up 3 x 3 factorial design study, a wider range of PRFs and EDs were used at a lower pr(in situ).

METHODS

Sprague Dawley rats (n=198) were divided into 18 ultrasonically exposed groups (10 rats per group) and 6 sham groups (3 per group). The 3 x 3 factorial design study (PRF: 17, 170, and 1700 Hz; ED: 5, 31.6, and 200 s) was conducted at 2 frequencies (2.8 and 5.6 MHz). The p(r(in situ)) was 6.1 MPa. Logistic regression analysis evaluated lesion occurrence, and Gaussian tobit analysis evaluated lesion depth and surface area.

RESULTS

Frequency did not have a significant effect, so the analysis combined results for the 2 frequencies. For lesion occurrence and sizes, the main effects for PRF and ED were not significant. The interaction term was highly significant, indicating a strong dependence of lesion occurrence and size on the total number of pulses (PRF x ED).

CONCLUSIONS

The results of both studies are consistent with the hypothesis that the total number of pulses is an important factor in the genesis of ultrasound-induced lung hemorrhage.

Excess risk thresholds in ultrasound safety studies: statistical methods for data on occurrence and size of lesions

Concerns about the safe use of clinical ultrasound (US) at diagnostic pressure levels (below a mechanical index, or MI, = 1.9) have stimulated considerable research in US risk assessment. The objective of the present study was to develop probability-based risk thresholds for US safety studies, to present statistical methods for estimating the thresholds and their standard errors and to compare these methods with the analysis based on a piecewise linear ("hockey stick") model. The excess risk at exposure level x > 0 was defined as the relative increase in the probability of a lesion at that level compared with the background probability of a lesion at exposure x = 0. The risk threshold was then defined as the exposure level at which the excess risk exceeded a specified level (e.g. 5% or 50%). Thus, given pressure-dependent estimates of the excess risk, the thresholds were estimated by solving the risk equation to obtain the pressure at which the target level of excess risk occurs. Threshold estimates of this type have been developed extensively in the literature for incidence (presence or absence) data. Only recently, however, have excess risk threshold estimates been derived for data in which lesion size (depth, surface area) is measured if present and a zero is recorded if the lesion is absent. Tobit regression was used to estimate pressure-dependent percentiles of the size distribution, and the excess risks were estimated from the tobit probability of a positive-valued response. The tobit model provides a well-established approach to modeling data constrained to be nonnegative. Solving the risk equation for the tobit model leads to risk threshold estimates that incorporate the information on size of observed lesions. Results using these probability-based risk estimates were compared with results for a piecewise linear ("hockey stick") model, which has also been used in the US safety literature, although it does not explicitly address the nonnegativity constraint in the sampling model. The comparisons were carried out for data from two previously published studies, from different laboratories, on US-induced lung hemorrhage. The thresholds derived from logistic regression of lesion occurrence and tobit regression of lesion size were quite consistent with each other and within sampling error. The hockey stick thresholds, defined as the exposure level at which the piecewise linear model for the probability of the expected size of a lesion bends upward, corresponded to quite different excess risk values for incidence (lesion occurrence) compared with size (lesion surface area or depth), although these methods have been developed previously for both types of data. The use of probability-based excess risk thresholds is recommended to obtain consistent incidence vs. size thresholds and to ensure that the thresholds are well-defined and interpretable independent of the details of the statistical model.

Mechanical Bioeffects of Ultrasound

Ultrasound is used widely in medicine as both a diagnostic and therapeutic tool. Through both thermal and nonthermal mechanisms, ultrasound can produce a variety of biological effects in tissues in vitro and in vivo. This chapter provides an overview of the fundamentals of key nonthermal mechanisms for the interaction of ultrasound with biological tissues. Several categories of mechanical bioeffects of ultrasound are then reviewed to provide insight on the range of ultrasound bioeffects in vivo, the relevance of these effects to diagnostic imaging, and the potential application of mechanical bioeffects to the design of new therapeutic applications of ultrasound in medicine.

An animal model for ultrasound lung imaging

In the past decade, a number of clinical investigators have used ultrasound (US) to image the lung during video-assisted thoracoscopic surgery (VATS). In contrast, animal studies have shown prohibitively high attenuation levels in the lung, incompatible with the ability to image the lung. We hypothesized that the use of anesthesia during VATS augments lung collapse upon exposure to atmospheric pressure; thus, making US lung imaging possible. To test this hypothesis, we compared the effect of two commonly used anesthetic protocols on our ability to image 200 microL of US gel injected in rabbit lungs using a pulse echo transducer at 13 MHz. The anesthetic protocol, using acepromazine, ketamine and isoflurane, allowed US lung imaging in rabbits. It is concluded that US at 13 MHz can detect 200 microL of US gel injected into the lung parenchyma in a rabbit model.

Threshold estimates and superthreshold behavior of ultrasound-induced lung hemorrhage in adult rats: role of pulse duration

The study objective was to estimate the pressure threshold (ED(05), effective dose, or in situ peak rarefactional pressure associated with 5% probability of lesions) of ultrasound (US)-induced lung hemorrhage as a function of pulse duration (PD) in adult rats. A total of 220 10- to 11-week-old 250-g female Sprague-Dawley rats (Harlan) were randomly divided into 20 ultrasonic exposure groups (10 rats/group) and one sham group (20 rats). The 20 ultrasonic exposure groups (2.8-MHz; 10-s exposure duration; 1-kHz PRF; -6-dB pulse-echo focal beam width of 470 microm) were divided into four PD groups (1.3, 4.4, 8.2 and 11.6 micros) and, for each PD group, there were five in situ peak rarefactional pressures (range between 4 and 9 MPa). Rats were weighed, anesthetized, depilated, exposed, and euthanized under anesthesia. The left lung was removed and scored for the occurrence of hemorrhage. If hemorrhage was present, the lesion surface area and depth were measured. Individuals involved in animal handling, exposure and lesion scoring were "blinded" to the exposure conditions. Logistic regression analysis was used to examine the dependence of the lesion occurrences, and Gaussian tobit regression analysis was used to examine the dependence of the lesion surface areas and depths on in situ peak rarefactional pressure and PD. Threshold results are reported in terms of ED(05). For PDs of 1.3, 4.4, 8.2 and 11.6 micros, respectively, lesion occurrence ED(05)s were 3.1, 2.8, 2.3 and 2.0 MPa with standard errors around 0.6 MPa. Lesion size ED(05)s showed similar values. A mechanical index (MI) of 1.9, the US Food and Drug Administration (FDA) regulatory limit of diagnostic US equipment, is equivalent to the adult rat's in situ peak rarefactional pressure of 4.0 MPa. PDs of 8.2 and 11.6 micros had ED(05)s more than 2 standard errors below 4.0 MPa, indicating that the ED(05)s of these two PDs are statistically significantly different from 4.0 MPa. The ED(05) threshold levels for a PD of 1.3 micros are consistent with previous US-induced lung hemorrhage studies. As the PD increases, the ED(05) levels decrease, suggesting greater likelihood of lung damage as the PD increases. All of the ED(05)s are less than the FDA limit.