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Luks AM, Beidleman BA, Freer L, Grissom CK, Keyes LE, McIntosh SE, Rodway GW, Schoene RB, Zafren K, Hackett PH. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med 2024; 35:2S-19S. [PMID: 37833187 DOI: 10.1016/j.wem.2023.05.013] [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: 12/27/2022] [Revised: 04/14/2023] [Accepted: 05/17/2023] [Indexed: 10/15/2023]
Abstract
To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for prevention, diagnosis, and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches for managing each form of acute altitude illness that incorporate these recommendations as well as recommendations on how to approach high altitude travel following COVID-19 infection. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in Wilderness & Environmental Medicine in 2010 and the subsequently updated WMS Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness published in 2014 and 2019.
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Affiliation(s)
- Andrew M Luks
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Beth A Beidleman
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, MA
| | - Luanne Freer
- Everest ER, Himalayan Rescue Association, Kathmandu, Nepal
| | - Colin K Grissom
- Pulmonary and Critical Care Medicine, Intermountain Healthcare and the University of Utah, Salt Lake City, UT
| | - Linda E Keyes
- Department of Emergency Medicine, Section of Wilderness Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - George W Rodway
- Department of Family Medicine-Sports Medicine, University of Nevada, Reno School of Medicine, Reno, NV
| | - Robert B Schoene
- Division of Pulmonary and Critical Care Medicine, Sound Physicians, St. Mary's Medical Center and Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, San Francisco, CA
| | - Ken Zafren
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
- Himalayan Rescue Association, Kathmandu, Nepal
| | - Peter H Hackett
- Altitude Research Center, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Lahham S, Moeller J, Choi H, Fischetti C, Myatt T, Bove N, Saadat S, Mazumder P, Algaze Gonzalez I, Kurzweil A, Fox J. Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines. West J Emerg Med 2023; 24:359-362. [PMID: 36976605 PMCID: PMC10047746 DOI: 10.5811/westjem.2022.11.54300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/04/2022] [Indexed: 03/22/2023] Open
Abstract
Introduction: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days.
Methods: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days.
Results: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4 (P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004).
Conclusion: By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.
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Affiliation(s)
- Shadi Lahham
- Kaiser Permanente Orange County, Department of Emergency Medicine, Anaheim, California
| | - John Moeller
- Dartmouth-Hitchcock Medical Center, Department of Emergency Medicine, Lebanon, New Hampshire
| | - Heesun Choi
- Kingman Regional Medical Center, Department of Emergency Medicine, Kingman, Arizona; Midwestern University AZCOM, Department of Emergency Medicine, Glendale, Arizona; Touro University Nevada College of Osteopathic Medicine, Clark County, Nevada; University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Chanel Fischetti
- Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts; Harvard Medical School, Lecturer in Emergency Medicine, Boston, Massachusetts
| | - Toby Myatt
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Nicholas Bove
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Soheil Saadat
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Proma Mazumder
- Touro University Nevada College of Osteopathic Medicine, Clark County, Nevada
| | | | - Ami Kurzweil
- Eisenhower Health, Department of Emergency Medicine, Rancho Mirage, California
| | - John Fox
- University of California, Irvine, Department of Emergency Medicine, Orange, California
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Lo CH, Kao WF, How CK, Li LH, Chien DK, Chiu YH. Chest pain in six Taiwanese teenagers at high altitudes. J Travel Med 2022; 29:6571353. [PMID: 35442441 DOI: 10.1093/jtm/taac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 11/12/2022]
Abstract
There is scant literature to date about the application of point-of-care devices for diagnosis of high-altitude pulmonary edema and clinical management in symptomatic teenagers. Hence, we characterized the early changes in point-of-care assessments to gain a deeper insight into the physiological responses in teenagers during a 3-day trek.
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Affiliation(s)
- Chih-Hung Lo
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Wei-Fong Kao
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Emergency and Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chorng-Kuang How
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Kinmen Hospital, Ministry of Health and Welfare, Kinmen, Taiwan
| | - Li-Hua Li
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Program of Medical Biotechnology, Taipei Medical University, Taipei, Taiwan
| | - Ding-Kuo Chien
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Yu-Hui Chiu
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Nowadly CD, Kelley KM, Crane DH, Rose JS. Evaluation of High Altitude Interstitial Pulmonary Edema in Healthy Participants Using Rapid 4-View Lung Ultrasound Protocol During Staged Ascent to Everest Base Camp. Wilderness Environ Med 2021; 32:278-283. [PMID: 34175211 DOI: 10.1016/j.wem.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 12/29/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Prior research identified possible interstitial pulmonary fluid, concerning for early high altitude pulmonary edema (HAPE), in a large percentage of trekkers above 3000 m using a comprehensive 28-view pulmonary ultrasound protocol. These trekkers had no clinical symptoms of HAPE despite these ultrasound findings. The more common 4-view lung ultrasound protocol (LUP) is accurate in rapidly detecting interstitial edema during resource-rich care. The objective of this study was to evaluate whether the 4-view LUP detects interstitial fluid in trekkers ascending to Everest Base Camp. METHODS Serial 4-view LUP was performed on 15 healthy trekkers during a 9-d ascent from Kathmandu to Everest Base Camp. Ascent protocols complied with Wilderness Medical Society guidelines for staged ascent. A 4-view LUP was performed in accordance with the published 2012 international consensus protocols on lung ultrasound. Symptom assessment and 4-view LUP were obtained at 6 waypoints along the staged ascent. A 4-view LUP was positive for interstitial edema if ≥3 B-lines were detected in 2 ultrasound windows. RESULTS A single participant had evidence of interstitial lung fluid at 5380 m as defined by the 4-view LUP. There was no evidence of interstitial fluid in any participant below 5380 m. One participant was evacuated for acute altitude sickness at 4000 m but showed no preceding sonographic evidence of interstitial fluid. CONCLUSIONS In this small study, sonographic detection of interstitial fluid, suggestive of early HAPE, was not identified by the 4-view LUP protocol.
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Affiliation(s)
- Craig D Nowadly
- Department of Emergency Medicine, University of California at Davis, Sacramento, California.
| | - Kenneth M Kelley
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - Desiree H Crane
- Steele Memorial Medical Center, Salmon, Idaho; University of California, San Francisco (Fresno), Fresno, California
| | - John S Rose
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
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Lichtblau M, Bader PR, Carta AF, Furian M, Muralt L, Saxer S, Hartmann SE, Rawling JM, Poulin MJ, Bloch KE, Ulrich S. Extravascular lung water and cardiac function assessed by echocardiography in healthy lowlanders during repeated very high-altitude exposure. Int J Cardiol 2021; 332:166-174. [PMID: 33775791 DOI: 10.1016/j.ijcard.2021.03.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/05/2021] [Accepted: 03/22/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND High-altitude pulmonary edema is associated with elevated systolic pulmonary artery pressure (sPAP) and increased extravascular lung water (EVLW). We investigated sPAP and EVLW during repeated exposures to high altitude (HA). METHODS Healthy lowlanders underwent two identical 7-day HA-cycles, where subjects slept at 2900 m and spent 4-8 h daily at 5050 m, separated by a weeklong break at low altitude (LA). Echocardiography and EVLW by B-lines were measured at 520 m (baseline, LA1), on day one, two and six at 5050 m (HA1-3) and after descent (LA2). RESULTS We included 21 subjects (median 25 years, body mass index 22 kg/m2, SpO2 98%). SPAP rose from 21 mmHg at LA1 to 38 mmHg at HA1, decreased to 30 mmHg at HA3 (both p < 0.05 vs LA1) and normalized at 20 mmHg at LA2 (p = ns vs LA1). B-lines increased from 0 at LA1 to 6 at HA2 and 7 at HA3 (both p < 0.05 vs LA1) and receded to 1 at LA2 (p = ns vs LA1). Overall, in cycle two, sPAP did not differ (mean difference (95% confidence interval) -0.2(-2.3 to 1.9) mmHg, p = 0.864) but B-lines were more prevalent (+2.3 (1.4-3.1), p < 0.001) compared to cycle 1. Right ventricular systolic function decreased significantly but minimally at 5050 m. CONCLUSIONS Exposure to 5050 m induced a rapid increase in sPAP. B-lines rose during prolonged exposures to 5050 m, despite gradual decrease in sPAP, indicating excessive hydrostatic pressure might not be solely responsible for EVLW-development. Repeated HA-exposure had no acclimatization effect on EVLW. This may affect workers needing repetitive ascents to altitude and could indicate greater B-line development upon repeated exposure.
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Affiliation(s)
- Mona Lichtblau
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Patrick R Bader
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Arcangelo F Carta
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Michael Furian
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Lara Muralt
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Sara E Hartmann
- Department of Physiology and Pharmacology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Jean M Rawling
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Marc J Poulin
- Department of Physiology and Pharmacology and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Konrad E Bloch
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Silvia Ulrich
- Department of Respiratory Medicine, University Hospital Zurich, Zurich, Switzerland.
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Xian J, Pei X, Lu W, Zhong H, Lin Y, Jin H, Su Z. The clinical value of bedside ultrasound in predicting the severity of coronavirus disease-19 (COVID-19). ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:336. [PMID: 33708963 PMCID: PMC7944274 DOI: 10.21037/atm-20-7944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background To summarise the ultrasound manifestations of coronavirus disease-19 (COVID-19) patients with lung lesions and explore the clinical value of bedside ultrasound in the identification of patients at risk of progression to severe disease. Methods This retrospective study enrolled 31 patients with COVID-19 who were admitted to our hospital from January 18 to February 5, 2020. Lung ultrasounds were performed in all cases to evaluate the ultrasound manifestations of the patient’s lung lesions and to determine the lung ultrasound scores (LUS). The Cox proportional hazards regression model was used for the multifactor analysis of 7 candidate parameters, including the LUS and the oxygenation index (PaO2/FiO2). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of the LUS. Results Lung ultrasound images of COVID-19 patients mainly reflected the presence of interstitial pulmonary lesions (90.3%, 28/31). The lung lesions were primarily distributed in the subpleural and peripheral pulmonary zones. Multivariate analyses identified the oxygenation index, the LUS, and the lymphocyte count as factors related to the progression to severe-critical disease in COVID-19 patients (P<0.05). With a cut-off value of 9.5, the area under the ROC curve was 0.910. The LUS showed a sensitivity and specificity of 81.3% and 93.0%, respectively (P≤0.001), with an overall accuracy of 75%. Conclusions The lung ultrasound findings in COVID-19 patients were mainly and specifically manifested as interstitial lesions involving the peripheral zones of the lung. In addition, ultrasound imaging could predict the likelihood of COVID-19 patients progressing to severe disease, thereby allowing for early intervention. Thus, lung ultrasounds have great clinical value in monitoring and evaluating COVID-19 patients.
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Affiliation(s)
- Jianzhong Xian
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China.,Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Xiaofeng Pei
- Department of Thoracic Oncology, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Wuzhu Lu
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Haihong Zhong
- Department of Radiology, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Yuhong Lin
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Hongjun Jin
- Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Zhongzhen Su
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China.,Guangdong Provincial Key Laboratory of Biomedical Imaging and Guangdong Provincial Engineering Research Center of Molecular Imaging, Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
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Yanamandra U, Vardhan V, Saxena P, Singh P, Gupta A, Mulajkar D, Grewal R, Nair V. Radiographical Spectrum of High-altitude Pulmonary Edema: A Pictorial Essay. Indian J Crit Care Med 2021; 25:668-674. [PMID: 34316147 PMCID: PMC8286401 DOI: 10.5005/jp-journals-10071-23827] [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] [Indexed: 11/23/2022] Open
Abstract
Background High-altitude pulmonary edema (HAPE) is a common cause of hospitalization in high altitude areas with significant morbidity. The clinical presentation of HAPE can overlap with a broad spectrum of cardiopulmonary diseases. Also, it is associated with varied radiological manifestations mimicking other conditions and often leading to unnecessary and inappropriate treatment. Patients and methods The primary aim of the study was to study the various radiological manifestations of HAPE through real-world chest radiographs. We present six different chest X-ray patterns of HAPE as a pictorial assay, at initial presentation, and after the resolution of symptoms with supplemental oxygen therapy and bed rest alone. Results HAPE can present as bilateral symmetrical perihilar opacities, bilateral symmetrical diffuse opacities, unilateral diffuse opacities, bilateral asymmetrical focal opacities, and even lobar consolidation with lower zone or less commonly upper zonal predilection. These presentations can mimic many common conditions like heart failure, acute respiratory distress syndrome, pulmonary embolism, aspiration pneumonitis, pneumonia, malignancy, and tuberculosis. Conclusion A holistic clinical–radiological correlation coupled with analysis of the temporal course can help high-altitude physicians in differentiating true HAPE from its mimics. How to cite this article Yanamandra U, Vardhan V, Saxena P, Singh P, Gupta A, Mulajkar D, et al. Radiographical Spectrum of High-altitude Pulmonary Edema: A Pictorial Essay. Indian J Crit Care Med 2021;25(6):668–674.
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Affiliation(s)
- Uday Yanamandra
- Department of Hematology & Stem Cell Transplant, Army Hospital (R&R), New Delhi, India
| | - Vasu Vardhan
- Department of Pulmonology, Base Hospital, New Delhi, India
| | - Puneet Saxena
- Department of Pulmonology, Army Hospital (R&R), New Delhi, India
| | - Priyanka Singh
- Department of Pulmonology, Army Hospital (R&R), New Delhi, India
| | - Amul Gupta
- Department of Radiology, Base Hospital, New Delhi, India
| | - Deepak Mulajkar
- Department of Oncology, Army Hospital (R&R), New Delhi, India
| | - Rajan Grewal
- Ex Director General, Medical Services (Army), Currently, Vice Chancellor, Sikkim Manipal University, Sikkim, Gangtok, India
| | - Velu Nair
- Department of Haemato-Oncology and Bone Marrow Transplant, Apollo CBCC Cancer Care, Ahmedabad, Gujarat, India
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Holthof N, Wipplinger F, Lienert J, Budowski A, Brodmann Maeder M, Moens D. Point-of-Care Ultrasound Diagnosis of Community-Acquired Pneumonia in a High-Altitude, Resource-Poor Setting. PREHOSP EMERG CARE 2020; 25:839-843. [DOI: 10.1080/10903127.2020.1852352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Niels Holthof
- Department of Anesthesiology and Pain Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Flavia Wipplinger
- Department of Anesthesiology and Pain Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Jasmin Lienert
- Department of Emergency Medicine, Hôpital du Valais, Sion, Switzerland
| | | | - Monika Brodmann Maeder
- Department of Emergency Medicine, Inselspital Bern University Hospital, Bern, Switzerland
- Institute for Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Didier Moens
- Department of Emergency Medicine, Liège University Hospital, Liège, Belgium
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Hahn M, Ray J, Hall MM, Coe I, Situ-LaCasse E, Waterbrook AL. Ultrasound in Trauma and Other Acute Conditions in Sports, Part I. Curr Sports Med Rep 2020; 19:486-494. [DOI: 10.1249/jsr.0000000000000774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Swimming-Induced Pulmonary Edema. Chest 2020; 158:1586-1595. [DOI: 10.1016/j.chest.2020.04.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 12/24/2022] Open
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Cox EGM, Koster G, Baron A, Kaufmann T, Eck RJ, Veenstra TC, Hiemstra B, Wong A, Kwee TC, Tulleken JE, Keus F, Wiersema R, van der Horst ICC. Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill. Crit Care 2020; 24:14. [PMID: 31931844 PMCID: PMC6958607 DOI: 10.1186/s13054-019-2719-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Methods This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. Results The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients. Conclusion The agreement between lung ultrasound and auscultation is poor. Trial registration NCT02912624. Registered on September 23, 2016.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Geert Koster
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Aidan Baron
- Emergency, Cardiovascular, and Critical Care Research Group, Centre for Health and Social Care Research, Kingston University and St George's University, London, UK
| | - Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T Corien Veenstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adrian Wong
- Department of Anaesthesiology and Intensive Care, Royal Surrey County Hospital, Guildford, UK
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
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