Lung lesions induced by continuous- and pulsed-wave (diagnostic) ultrasound in mice, rabbits, and pigs

State of the Art in Lung Ultrasound, Shifting from Qualitative to Quantitative Analyses

Lung ultrasound (LUS) has been increasingly expanding since the 1990s, when the clinical relevance of vertical artifacts was first reported. However, the massive spread of LUS is only recent and is associated with the coronavirus disease 2019 (COVID-19) pandemic, during which semi-quantitative computer-aided techniques were proposed to automatically classify LUS data. In this review, we discuss the state of the art in LUS, from semi-quantitative image analysis approaches to quantitative techniques involving the analysis of radiofrequency data. We also discuss recent in vitro and in silico studies, as well as research on LUS safety. Finally, conclusions are drawn highlighting the potential future of LUS.

How safe is it to use ultrasound in prenatal medicine? Facts and contradictions - Part 2 - Laboratory experiments regarding non-thermal effects and epidemiological studies

The first part of this CME article (issue 5/20) provided a detailed examination of the biophysical effects of ultrasound waves, the exposure values, and in particular the thermal effect. In vivo and in vitro measurements have shown that the temperature increase in tissue associated with B-mode ultrasound is far too low to pose a potential risk. Even experiments with exposure values in the range of pulsed Doppler have shown that temperature increases of over 1.5 °C can only occur in areas in direct contact with the probe, thus making a limited exposure time particularly in the case of transvaginal application advisable. The second part of this CME article describes various laboratory and animal experiments for evaluating non-thermal effects and also presents the most important epidemiological studies in the last 30 years in the form of an overview and review. In addition to direct insonation of isolated cells to examine possible mutagenic effects, the blood of patients exposed in vivo to ultrasound was also analyzed in multiple experiments. Reproducible chromosome aberrations could not be found in any of the studies. In contrast, many experiments on pregnant rodents showed some significant complications, such as abortion, deformities, and behavioral disorders. As in the case of thermal effects, the results of these experiments indicate the presence of an intensity- or pressure-dependent effect threshold. Numerous epidemiological studies examining possible short-term and long-term consequences after intrauterine ultrasound exposure are available with the most important studies being discussed in the following. In contrast to information presented incorrectly in the secondary literature and in the lay press, health problems could not be seen in the children observed in the postpartum period in any of these studies.

How Safe Is the Use of Ultrasound in Prenatal Medicine? Facts and Contradictions. Part 1 - Ultrasound-Induced Bioeffects

The "Ordinance on Protection Against the Harmful Effects of Non-Ionizing Radiation in Human Applications" will go into effect at the beginning of 2021 1. § 10 of this ordinance prohibits non-medical fetal ultrasound exposure thereby resulting in uncertainty, particularly among affected patients, with respect to the generally accepted theory regarding the lack of ultrasound side effects. Although not a single study has shown a detrimental effect on fetal or child development following exposure to ultrasound, the Federal Ministry for the Environment, Nature Conservation and Nuclear Safety has justified the ban with the purely hypothetical possibility of an unidentified side effect. The first part of the following study shows which ultrasound-induced biophysical effects are known and which dose-dependent threshold values must be taken into consideration. In particular, the study focuses on the well-researched heat effect with some in vivo measurements in humans showing that the actual temperature increase is less than the theoretically calculated values. The planned second part of this study will discuss the non-thermal effects and present the most important epidemiological studies.

Effects of Therapeutic Ultrasound Applied to the Lumbar Region on Renal Function: A Randomized Controlled Prospective Trial

OBJECTIVES

Therapeutic ultrasound (TUS) is one of the most commonly used modalities in low back pain treatment. The objective of this study was to determine whether TUS applied to the low back region in patients with chronic low back pain had any effect on renal function.

METHODS

Forty patients with chronic low back pain were randomized to 2 groups by a block randomization method. Thirty-seven patients completed the final evaluation. All patients were treated for 5 sessions per week for 3 weeks with the same physiotherapy modalities (superficial heating and transcutaneous electrical nerve stimulation) and exercise therapy; in addition to these treatments, the second group was treated with TUS for 10 minutes (frequency, 1 MHz; intensity, 1.5 W/cm² ; and effective irradiation area of the transducer head, 5 cm² ). The serum creatinine, serum cystatin C, 24-hour urine creatinine, creatinine clearance, 24-hour urine microalbumin and microprotein, urine volume, and glomerular filtration rate were measured. The patients were evaluated at baseline (day 0) and the end of the treatment (day 21).

RESULTS

The serum cystatin C levels were increased in both groups, but this increase was not significant (P > .05). There was no difference between the groups in the percent change in all outcome measures (P > .05).

CONCLUSIONS

This showed that TUS applied to the low back region does not affect renal function.

Acoustic Fountains and Atomization at Liquid Surfaces Excited by Diagnostic Ultrasound

Pulmonary capillary hemorrhage (PCH) has been found in mammalian lungs exposed to diagnostic ultrasound (DUS), although the mechanism is poorly understood. This work investigates acoustic atomization and fountains at liquid-air interfaces subjected to DUS, which has been suggested as a possible PCH damage mechanism. Primarily using a SuperSonic Imagine Aixplorer DUS machine (SuperSonic Imagine, Aix-en-Provence, France), blood and water surfaces were excited in vitro by DUS and recorded with a high-speed camera. The surface was driven by B-mode, color Doppler, pulsed Doppler, and shear wave elastography imaging modes with center frequencies from 5.0-7.2 MHz and mechanical indexes (MI) up to 1.7. Fountains and atomization were only observed for SWE, for MI as low as 1.0. A comparison of the SWE waveforms with the surface dynamics suggests that fountains and atomization were driven by push-pulses and depended on pulse duration and intensity. However, we conclude that atomization and fountaining are unlikely primary mechanisms behind all DUS-induced PCH because neither phenomenon occurred for traditional diagnostic imaging modes.

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.

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.

Adjustment of ultrasound exposure duration to microbubble sonodestruction kinetics for optimal cell sonoporation in vitro

Cell sonoporation enables the delivery of various exogenous molecules into the cells. To maximize the percentage of reversibly sonoporated cells and to increase cell viability we propose a model for implicit dosimetry for adjustment of ultrasound (US) exposure duration. The Chinese hamster ovary cell suspension was supplemented with microbubbles (MB) and exposed to US, operating at the frequency of 880kHz, with a 100% duty cycle and with an output peak negative pressure (PNP) of 500kPa for durations ranging from 0.5 to 30s. Using diagnostic B-scan imaging we showed that the majority of the MB at 500kPa US peak negative pressure undergo sonodestruction in less than a second. During this time maximal number of reversibly sonoporated cells was achieved. Increase of US exposure duration did not increase sonoporated cell number, however it induced additional cell viability decrease. Therefore aiming to achieve the highest level of reversibly sonoporated cells and also to preserve the highest level of cell viability, the duration of US exposure should not exceed the duration needed for complete MB sonodestruction.

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.

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.

Fetal ultrasound: mechanical effects

In this discussion, any biological effect of ultrasound that is accompanied by temperature increments less than 1 degrees C above normal physiologic levels is called a mechanical effect. However, one should keep in mind that the term mechanical effect also includes processes that are not of a mechanical nature but arise secondary to mechanical interaction between ultrasound and tissues, such as chemical reactions initiated by free oxygen species generated during cavitation and sonoluminescence. Investigations with laboratory animals have documented that pulsed ultrasound can produce damage to biological tissues in vivo through nonthermal mechanisms. The acoustic output used to induce these adverse bio-effects is considerably greater than the output of diagnostic devices when gas bodies are not present. However, low-intensity pulsed ultrasound is used clinically to accelerate the bone fracture repair process and induce healing of nonunions in humans. Low-intensity pulsed ultrasound also has been shown to enhance repair of soft tissue damage and accelerate nerve regeneration in animal models. Although such exposures to low intensity do not appear to cause damage to exposed tissues, they do raise questions about the acoustic threshold that might induce potentially adverse developmental effects in the fetus. To date, bioeffects studies in humans do not substantiate a causal relationship between diagnostic ultrasound exposure during pregnancy and adverse biological effects to the fetus. However, the epidemiologic studies were conducted with commercially available devices predating 1992, having outputs not exceeding a derated spatial-peak temporal-average intensity (ISPTA.3) of 94 mW/cm2. Current limits in the United States allow an ISPTA.3 of 720 mW/cm2 for obstetric modes. At the time of this report, available evidence, experimental or epidemiologic, is insufficient to conclude that there is a causal relationship between obstetric diagnostic ultrasound exposure and adverse nonthermal effects to the fetus. However, low-intensity pulsed ultrasound effects reported in humans and animal models indicate a need for further investigation of potentially adverse developmental effects.

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.

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.

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.

Forced linear oscillations of microbubbles in blood capillaries

A theoretical investigation of the forced linear oscillations of a gas microbubble in a blood capillary, whose radius is comparable in size to the bubble radius is presented. The natural frequency of oscillation, the thermal and viscous damping coefficients, the amplitude resonance, the energy resonance, as well as the average energy absorbed by the system, bubble plus vessel, have been computed for different kinds of gas microbubbles, containing air, octafluropropane, and perflurobutane as a function of the bubble radius and applied frequency. It has been found that the bubble behavior is isothermal at low frequencies and for small bubbles and between isothermal and adiabatic for larger bubbles and higher frequencies, with the viscous damping dominating over the thermal damping. Furthermore, the width of the energy resonance is strongly dependent on the bubble size and the natural frequency of oscillation is affected by the presence of the vessel wall and position of the bubble in the vessel. Therefore, the presence of the blood vessel affects the way in which the bubble absorbs energy from the ultrasonic field. The motivation of this study lies in the possibility of using gas microbubbles as an aid to therapeutic focused ultrasound treatments.

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.

Impedance measurements of ex vivo rat lung at different volumes of inflation

A previous study [J. Acoust. Soc. Am. 111, 1102-1109 (2002)] showed that the occurrence of ultrasonically induced lung hemorrhage in rats was directly correlated to the level of lung inflation. In that study, it was hypothesized that the lung could be modeled as two components consisting of air and parenchyma (contiguous tissue [pleura and septa]). The speed of sound and lung impedance would then depend on the fractional volume of air in the lung. According to that model, an inflated lung should act like a pressure-release surface for sound incident from tissue onto a tissue-lung boundary. A deflated lung containing less air should allow more acoustic energy into the lung tissue because the impedance was more closely matched to the contiguous tissues. In the study reported herein, a measurement technique was devised to calculate the impedance of seven rat lungs, ex vivo, under deflation (atmospheric pressure) and three volumes of inflation pressure (7-cm H2O, 10-cm H2O, and 15-cm H2O). Lungs were dissected from rats and immediately scanned in a tank of degassed 37 degrees C water. The frequency-dependent acoustic pressure reflection coefficient was measured over a frequency range of 3.5 to 10 MHz. From the reflection coefficient, the frequency-dependent lung impedance was calculated with values ranging from an average of 1 Mrayls in deflated lungs to 0.2 Mrayls for fully inflated lungs. Lung impedance calculations showed that deflated lungs had an impedance closer to water (1.52 Mrayls) than inflated lungs. At all volumes of inflation, the lungs acted as pressure-release surfaces relative to the water. The average of the four lung impedance values (deflated, 7-cm H2O, 10-cm H2O, and 15-cm H2O) at each level of inflation was statistically different (p<0.0001).

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.

Effect of pulse polarity and energy on ultrasound-induced lung hemorrhage in adult rats

The objective of this study was to further assess the role of inertial cavitation in ultrasound-induced lung hemorrhage by examining the effect of pulse polarity at a common in situ (at the lung surface) peak rarefactional pressure [pr(in situ)] and at a common in situ pulse intensity integral (PII(in situ)). A total of 60 rats was divided into three experimental groups of 20 animals per group and randomly exposed to pulsed ultrasound. The groups were exposed as follows: Group 1 to 0 degree polarity pulses (compression followed by rarefraction) at a pr(in situ) of 3.48 MPa and a PII(in situ) of 4.78 Ws/m2, group 2 to 180 degree polarity pulses (rarefraction followed by compression) at a pr(in situ) of 3.72 MPa and a PII(in situ) of 2.55 Ws/m2, and group 3 to 180 degree polarity pulses at a pr(in situ) of 4.97 MPa and a PII(in situ) of 4.79 Ws/m2. For all experimental groups, the frequency was 2.46 MHz, the exposure duration was 240 s, the pulse repetition frequency was 2.5 kHz, and the pulse duration was 0.42 micros. Six sham animals were also randomly distributed among the experimental animals. The lesion surface area and depth were determined for each rat as well as lesion occurrence (percentage of rats with lesions) per group. It was found that lesion occurrence and size correlated better with PII(in situ) than with pr(in situ), suggesting that a mechanism other than inertial cavitation was responsible for the damage.

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

Age-dependent threshold and superthreshold behavior of ultrasound-induced lung hemorrhage were investigated with 116 2.1 +/- 0.3-kg neonate crossbred pigs (4.9 +/- 1.6 days old), 103 10 +/- 1.1-kg crossbred pigs (39 +/-5 days old), and 104 20+/-1.2-kg crossbred pigs (58 +/- 5 days old). Exposure conditions were: 3.1 MHz, 10-s exposure duration, 1-kHz pulse repetition frequency (PRF), and 1.2-micros pulse duration. The in situ (at the pleural surface) peak rarefactional pressure ranged between 2.2 and 10.4 MPa with either eight or nine acoustic pressure groups for each of the three pig ages (12 pigs/exposure group) plus sham exposed pigs. There were no lesions in the shams. Pigs were exposed bilaterally with the order of exposure (left then right lung, or right then left lung) and acoustic pressure both randomized. Pig age was not randomized. Individuals involved in animal handling, exposure, and lesion scoring were blinded to the exposure condition. Logistic regression analysis was used to examine the dependence of the lesion incidence rates on in situ peak rarefactional pressure, left versus right lung exposure, order of exposure (first versus second), and age in three age groups. Likewise, lesion depth and lesion root surface area were analyzed using Gaussian tobit regression analysis. A significant threshold effect on lesion occurrence was observed as a function of age; younger pigs were less susceptible to lung damage given equivalent in situ exposure. Overall, the oldest pigs had a significantly lower threshold (2.87 +/- 0.29 MPa) than middle-aged pigs (5.83 +/- 0.52 MPa). The oldest pigs also had a lower threshold than neonate pigs (3.60 +/- 0.44 MPa). Also, an unexpected result was observed. The ultrasound exposures were bilateral, and the threshold results reported above were based on the lung that was first exposed. After the first lung was exposed, the pig was turned over and the other lung was exposed to the same acoustic pressure. There was a significant decrease (greater than the confidence limits) in occurrence thresholds: 3.60 to 2.68, 5.83 to 2.97, and 2.87 to 1.16 MPa for neonates, middle-aged, and oldest pigs, respectively, in the second lung exposed. Thus, a subtle effect in lung physiology resulted in a major effect on lesion thresholds.

High-frequency sound transmissions under water and risk of decompression sickness

We tested the possible occurrence of a neurological insult secondary to high-frequency sound exposure. Immersed, anesthetized rats were subjected to a simulated diving profile designed to induce decompression sickness, while exposed to the transmission of an acoustic beacon. Intermittent sound at a pressure level of 184.5 dB re 1 microPa at 1 m (1.7 kPa), a frequency of 37 kHz, and with a duration of 4 ms, was transmitted in a duty cycle of 0.26%. Four groups, each containing nine animals, were included in the study as follows: group 1, immersion only, no sound exposure; group 2, immersion with sound exposure; group 3, diving simulation when immersed, no sound exposure; group 4, diving simulation when immersed, with sound exposure. Somatosensory evoked potentials (SSEPs) were recorded the day before the study, and a second recording was made 30 min after immersion. Some of the SSEP components disappeared after the dive in 3 rats from group 3 and 2 rats from group 4. SSEP components could not be identified in a significantly larger number of animals from groups 3 and 4, compared with groups 1 and 2. No differences were found in wave latency, amplitude or conduction time. Our data show that the high-frequency sound exposure employed did not contribute to the development of the neurological insult.

Attenuation coefficient and propagation speed estimates of rat and pig intercostal tissue as a function of temperature

Attenuation coefficient and propagation speed of intercostal tissues were estimated as functions of temperature (22, 30, and 37 degrees C) from fresh chest walls from eight 10- to 11-week-old female Sprague-Dawley (SD) rats, eight 21- to 24-week-old female Long-Evans (LE) rats, and ten 6- to 10-week-old mixed sex Yorkshire (York) pigs. The primary purpose of the study was to estimate the temperature dependence of the intercostal tissue's attenuation coefficient so that accurate estimates of the in situ (at the pleural surface) acoustic pressure levels could be made for our ultrasound-induced lung hemorrhage studies. The attenuation coefficient of intercostal tissue for both species was independent of the temperature at the discrete frequencies of 3.1 MHz (-0.0076, 0.0065, and 0.016 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively) and 6.2 MHz (-0.015, 0.014, and 0.014 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively). However, the temperature-dependent regressions yielded a significant temperature dependency of the intercostal tissue attenuation coefficients in SD and LE rats (over the 3.1 to 9.6 MHz frequency range); there was no temperature dependency in York pigs (over the 3.1 to 8.6 MHz frequency range). There was no significant temperature dependency of the intercostal tissue propagation speed in SD rats; there was a temperature dependency in LE rats and York pigs (-0.59, -1.6, and -2.9 m/s/degrees C for SD rats, LE rats, and York pigs, respectively). Even though the attenuation coefficient's temperature dependency was significant from the linear regression functions, the differences were not very great (-0.040 to -0.13, 0.011 to 0.18, and 0.055 to 0.10 dB/cm/degrees C for SD rats, LE rats, and York pigs, respectively, over the data frequency range). These findings suggest that it is not necessary to determine the attenuation coefficient of intercostal tissue at body temperature (37 degrees C), but rather it is sufficient to determine the attenuation coefficient at room temperature (22 degrees C), a much easier experimental procedure.

Attenuation coefficient and propagation speed estimates of intercostal tissue as a function of pig age

Attention coefficient and propagation speed of intercostal tissues were estimated from chest walls removed postmortem (pm) from 15 5.3+/-2.3-day-old, 19 31+/-6-day-old, and 15 61+/-3-day-old crossbred pigs. These ultrasonic propagation properties were determined from measurements through the intercostal tissues, from the surface of the skin to the parietal pleura. The chest walls were placed in a 0.9% sodium chloride solution, sealed in freezer bags, and stored at -15 degrees C prior to measurements. When evaluated, chest-wall storage time ranged between 1 and 477 days pm. All chest walls were allowed to equilibrate to 22 degrees C in a water bath prior to evaluation. There was an age dependency of the intercostal tissue propagation speed, with the speed increasing with increasing age. The attenuation coefficient of intercostal tissue was shown to be independent of the age of the pig at the discrete frequencies of 3.1 and 6.2 MHz. For pig intercostal tissues, the estimated attenuation coefficient over the 3.1-9.2 MHz frequency range was A = 1.94f(0.90) where A is in decibels per centimeter (dB/cm) and f is the ultrasonic frequency in megahertz. In order to determine if there was an effect of storage time pm on estimates of attenuation coefficient, a second experiment was conducted. Five of the youngest pig chest walls measured on day 1 pm in the first experiment were stored at 4 degrees C prior to the first evaluation then stored at -15 degrees C before being measured again at 108 days pm. There was no difference in the estimated intercostal tissue attenuation coefficient as a function of storage time pm.

High-frequency sound field and bubble formation in a rat decompression model

High-frequency sound might cause bubble enlargement by rectified diffusion. The purpose of the present study was to investigate gas bubble formation in the immersed diving animal during exposure to high-frequency sound. Anaesthetised rats were subjected to a simulated diving profile while immersed inside a hyperbaric chamber. An acoustic beacon (pinger) was placed ventral to the animal's abdomen, transmitting at an intensity of 208.9 dB re 1 micro Pa and a frequency of 37 kHz. Six groups of eight animals were included in the study as in Table 1, breathing air (n = 4) or Nitrox 72/28 (n = 2), at a depth of 0 m, 30 m or 40 m. Immediately after decompression, the intestinal mesenterium was imaged, and frames were acquired digitally. The number of bubbles and their radii were analysed and compared among the groups. The mean bubble density for group 1 was 1.35 +/- 0.18 bubbles/mm(2), significantly higher when compared with the other groups (p < 0.0001). The average bubble radius for groups 1 and 2 was similar (12.57 +/- 4.1 and 10.63 +/- 1.8 microm, respectively), but significantly larger than in the other groups (p < 0.0002). The percentage of bubbles with a radius greater than 50 microm was significantly higher in group 1 (p < 0.0001). The results suggest that commercially available underwater pingers might enhance bubble growth during deep air diving.

Ultrasound-induced lung hemorrhage: role of acoustic boundary conditions at the pleural surface

In a previous study [J. Acoust. Soc. Am. 108, 1290 (2000)] the acoustic impedance difference between intercostal tissue and lung was evaluated as a possible explanation for the enhanced lung damage with increased hydrostatic pressure, but the hydrostatic-pressure-dependent impedance difference alone could not explain the enhanced occurrence of hemorrhage. In that study, it was hypothesized that the animal's breathing pattern might be altered as a function of hydrostatic pressure, which in turn might affect the volume of air inspired and expired. The acoustic impedance difference between intercostal tissue and lung would be affected with altered lung inflation, thus altering the acoustic boundary conditions. In this study, 12 rats were exposed to 3 volumes of lung inflation (inflated: approximately tidal volume; half-deflated: half-tidal volume; deflated: lung volume at functional residual capacity), 6 rats at 8.6-MPa in situ peak rarefactional pressure (MI of 3.1) and 6 rats at 16-MPa in situ peak rarefactional pressure (MI of 5.8). Respiration was chemically inhibited and a ventilator was used to control lung volume and respiratory frequency. Superthreshold ultrasound exposures of the lungs were used (3.1-MHz, 1000-Hz PRF, 1.3-micros pulse duration, 10-s exposure duration) to produce lesions. Deflated lungs were more easily damaged than half-deflated lungs, and half-deflated lungs were more easily damaged than inflated lungs. In fact, there were no lesions observed in inflated lungs in any of the rats. The acoustic impedance difference between intercostal tissue and lung is much less for the deflated lung condition, suggesting that the extent of lung damage is related to the amount of acoustic energy that is propagated across the pleural surface boundary.

Superthreshold behavior and threshold estimates of ultrasound-induced lung hemorrhage in adult rats: role of beamwidth

It is well documented that ultrasound-induced lung hemorrhage can occur in mice, rats, rabbits, pigs, and monkeys. The objective of this study was to assess the role of the ultrasound beamwidth (beam diameter incident on the lung surface) on lesion threshold and size. A total of 144 rats were randomly exposed to pulsed ultrasound at three exposure levels and four beamwidths (12 rats per group). The three in situ peak rarefactional pressures were about 5, 7.5, and 10 MPa. The four 19-mm-diameter focused transducers had measured pulse-echo -6-dB focal beamwidths of 470 microm (2.8 MHz; f/1), 930 microm (2.8 MHz; f/2), 310 microm (5.6 MHz; f/1), and 510 microm (5.6 MHz; f/2). Exposure durations were 10 s, pulse repetition frequencies were 1 kHz, and pulse durations were 1.3 micros (2.8 MHz; f/1), 1.2 micros (2.8 MHz; f/2), 0.8 micros (5.6 MHz; f/1) and 1.1 micros (5.6 MHz; f/2). The lesion surface area and depth were measured for each rat as well as the percentage of rats with lesions per group. Logistic regression analysis and Gaussian-Tobit analysis methods were used to analyze the data. The effects of in situ peak rarefactional pressure and beamwidth were highly significant, but ultrasonic frequency was not significant. In addition, the estimated interaction between in situ peak rarefactional pressure and beamwidth was positive and highly significant. The ultrasound beamwidth incident on the lung surface was shown to strongly affect the percentage and size of ultrasound-induced lung hemorrhage lesions. Even though ultrasonic frequency was an experimental variable, it was not shown to affect the lesion percentage or size.

Temporal and spatial evaluation of lesion reparative responses following superthreshold exposure of rat lung to pulsed ultrasound

This study characterized the reparative responses in rat lung. Forty-five adult female rats were exposed at two sites over the left lung to 3.1-MHz superthreshold pulsed ultrasound. The repair of lung lesions was evaluated from 0 through 44 days postexposure. Macroscopic lesions at 0 days postexposure were large bright red ellipses of hemorrhage. By 1 and 3 days postexposure, lesions were the same size and dark red to red-black, but, by 3 days postexposure, lesions had a raised surface appearance. From 5 to 10 days postexposure, lesions grew smaller in size, progressed from red-gray to yellow-brown, and retained a raised surface appearance. From 13 through 44 days postexposure, lesions gradually decreased in size, had a faint yellow-brown discoloration, and gradually lost the raised surface appearance. By 37 and 44 days postexposure, lung returned to near normal morphology, but had small areas of light yellow-brown discoloration in the areas where lung was exposed. Microscopic lesions at 0 and 1 days postexposure were areas of acute alveolar hemorrhage. By 3 days postexposure, lesions had loss of alveolar erythrocytes and the formation of hemoglobin crystals. From 5 through 44 days postexposure, iron in degraded erythrocytes was processed to hemosiderin and was negligible in quantity at 44 days postexposure. The proliferation of resident cells (likely alveolar epithelial cells, fibroblasts and endothelial cells) and the infiltration of inflammatory cells in lesions declined in intensity as the lesions aged and was minimal by 44 days postexposure. Under the superthreshold exposure conditions described, lesions induced by ultrasound do not seem to have long-term residual effects in lung.

Attenuation coefficient estimates of mouse and rat chest wall

Attenuation coefficients of intercostal tissues were estimated from chest walls removed postmortem (pm) from 41 6-to-7-week-old female ICR mice and 27 10-to-11-week-old female Sprague-Dawley rats. These values were determined from measurements through the intercostal tissues, from the surface of the skin to the parietal pleura. Mouse chest walls were sealed in plastic wrap and stored at 4 degrees C until evaluated, and rat chest walls were sealed in Glad-Lock Zipper sandwich bags, and stored at -15 degrees C. When evaluated, chest wall storage time ranged between 1 and 2 days pm for mice and between 41 and 110 days pm for rats. All chest walls were allowed to equilibrate to 22 degrees C in a water bath prior to evaluation. For both mouse and rat intercostal tissues, the estimated frequency normalized attenuation coefficient was 1.1 dB/cm-MHz. In order to determine if there was an effect of storage time on estimates of attenuation coefficient, an independent experiment was conducted. The intercostal tissues from six mouse chest walls were evaluated at three time points (1, 22, and 144 days pm), and from six rat chest walls were evaluated at four time points (1, 22, 50, and 125 days pm). There was no difference in the estimated intercostal tissue attenuation coefficient as a function of time postmortem.

Superthreshold behavior and threshold estimation of ultrasound-induced lung hemorrhage in adult mice and rats

Threshold estimates and superthreshold behaviors for ultrasound-induced lung hemorrhage were investigated as a function of species (adult mice and rats) and ultrasound frequency (2.8 and 5.6 MHz). A total of 151 6-to-7-week-old female ICR mice and 160 10-to-11-week-old female Sprague-Dawley rats were randomly divided into two ultrasonic frequency groups, and further randomly divided into seven or eight ultrasonic peak rarefactional pressure groups. Each group consisted of about 10 animals. Animals were exposed to pulsed ultrasound at either 2.8-MHz center frequency (1-kHz PRF, 1.42-microsecond pulse duration) or 5.6-MHz center frequency (1-kHz PRF, 1.17-microsecond pulse duration) for a duration of 10 seconds. The in situ (at the pleural surface) peak rarefactional pressure levels ranged between 2.5 and 10.5 MPa for mice and between 2.3 and 11.3 MPa for rats. The mechanical index (MI) ranged between 1.4 and 6.3 at 2.8 MHz for mice and between 1.1 and 3.1 at 5.6 MHz for rats. The lesion surface area and depth were measured for each animal as well as the percentage of animals with lesions per group. The characteristics of the lesions produced in mice and rats were similar to those described in previous studies by our research group and others, suggesting a common pathogenesis in the initiation and propagation of the lesions at the gross and microscopic levels. The percentage of animals with lesions showed no statistical differences between species or between ultrasound frequencies. These findings suggest that mice and rats are similar in sensitivity to ultrasound-induced lung damage and that the occurrence of lung damage is independent of frequency. Lesion depth and surface area also showed no statistically significant differences between ultrasound frequencies for mice and rats. However, there was a significant difference between species for lesion area and a suggestive difference between species for lesion depth. The superthreshold behavior of lesion area and depth showed that rat lung had more damage than mouse lung, and the threshold estimates showed a weak, or lack of, frequency dependency, suggesting that the MI is not consistent with the observed findings.

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

Superthreshold behavior for ultrasound-induced lung hemorrhage was investigated in adult mice and rats at an ultrasound center frequency of 2.8 MHz to assess the role of pulse repetition frequency and exposure duration. One hundred fifty, 6-7-week-old female ICR mice and 150 10-11-week-old female Sprague-Dawley rats were each divided into 15 exposure groups (10 animals per group) for a 3 x 5 factorial design (3 exposure durations of 5, 10, and 20 s and 5 pulse repetition frequencies of 25, 50, 100, 250, and 500 Hz). The in situ (at the pleural surface) peak rarefactional pressure of 12.3 MPa and the pulse duration of 1.42 micros were the same for all ultrasonically-exposed animals. In addition, 15 sham exposed mice and 15 sham exposed rats were included into both studies. In each study of 165 animals, the exposure conditions were randomized. The lesion depth and surface area were measured for each animal, as well as the percentage of animals with lesions per group. The characteristics of the lesions produced in mice and rats were similar to those described in studies by our research group and others, suggesting a common pathogenesis for the initiation and propagation of the lesions at the gross and microscopic levels. The proportion of lesions in both species was related statistically to pulse repetition frequency (PRF) and exposure duration (ED), with the exception that PRF in rats was not quite significant; the PRF x ED interaction (number of pulses) for lesion production was not significant for either species. The PRF, but not ED, significantly affected lesion depth in both species; the PRF x ED interaction for depth was not significant for either species. Both PRF and ED significantly affected lesion surface area in mice, while neither affected area in rats; the PRF x ED interaction for surface area was not significant for either species.

Ultrasound-induced lung hemorrhage is not caused by inertial cavitation

In animal experiments, the pathogenesis of lung hemorrhage due to exposure to clinical diagnostic levels of ultrasound has been attributed to an inertial cavitation mechanism. The purpose of this article is to report the results of two experiments that directly contradict the hypothesis that ultrasound-induced lung hemorrhage is caused by inertial cavitation. Elevated hydrostatic pressure was used to suppress the involvement of inertial cavitation. In experiment one, 160 adult mice were equally divided into two hydrostatic pressure groups (0.1 or 1.1 MPa), and were randomly exposed to pulsed ultrasound (2.8-MHz center frequency, 1-kHz PRF, 1.42-micros pulse duration, 10-s exposure duration). For the two hydrostatic pressure groups (80 mice each), 8 in situ peak rarefactional pressure levels were used that ranged between 2.82 and 11.8 MPa (10 mice/group). No effect of hydrostatic pressure on the probability of hemorrhage was observed. These data lead to the conclusion that lung hemorrhage is not caused by inertial cavitation. Also, the higher hydrostatic pressure enhanced rather than inhibited the impact of ultrasonic pressure on the severity (hemorrhage area, depth, and volume) of lesions. These counterintuitive findings were confirmed in a second experiment using a 2 x 5 factorial design that consisted of two ultrasonic pressure levels and five hydrostatic pressure levels (100 mice, 10 mice/group). If inertial cavitation were the mechanism responsible for lung hemorrhage, then elevated hydrostatic pressures should have resulted in less rather than more tissue damage at each ultrasonic pressure level. This further supports the conclusion that the pathogenesis of ultrasound-induced lung hemorrhage is not caused by inertial cavitation.

Biological effects of ultrasound: development of safety guidelines. Part I: personal histories

After the end of World War II, advances in ultrasound (US) technology brought improved possibilities for medical applications. The first major efforts in this direction were in the use of US to treat diseases. Medical studies were accompanied by experiments with laboratory animals and other model systems to investigate basic biological questions and to obtain better understanding of mechanisms. Also, improvements were made in methods for measuring and controlling acoustical quantities such as power, intensity and pressure. When diagnostic US became widely used, the scope of biological and physical studies was expanded to include conditions for addressing relevant safety matters. In this historical review, a major part of the story is told by 21 investigators who took part in it. Each was invited to prepare a brief personal account of his/her area(s) of research, emphasizing the "early days," but including later work, showing how late and early work are related, if possible, and including anecdotal material about mentors, colleagues, etc.

The effect of low-frequency ultrasound on immersed pig lungs

Acoustic models suggest that high-intensity, low-frequency ultrasound (US) at 21-31 kHz, could cause damage to divers' lungs. The purpose of the study was to investigate lung tissue changes secondary to water-borne low-frequency US produced by commonly used underwater acoustic beacons (pingers). Explanted pig lungs were immersed and exposed to four different modes of low-frequency US pinger transmission. In each trial, 5 pairs of lungs were exposed to sound and 5 pairs served as controls. One central and one peripheral section were taken from each lung and evaluated microscopically for location and extent of damage. When present, microhaemorrhages were primarily found in a patchy alveolar distribution, as well as in the septal and subpleural regions. Only rare focal microhaemorrhages could be found in the Control Group. The results demonstrate a potential hazard to the immersed lungs of large mammals on exposure to prolonged transmission by commercially available underwater pingers. The relevance of these findings to human exposure should be further evaluated.

Lack of lung hemorrhage in humans after intraoperative transesophageal echocardiography with ultrasound exposure conditions similar to those causing lung hemorrhage in laboratory animals

This study investigated the phenomenon of ultrasonically induced lung hemorrhage in humans. Multiple experimental laboratories have shown that diagnostic ultrasound exposure can cause hemorrhage in the lungs of laboratory animals. The left lung of 50 patients (6 women, 44 men, mean age 61 years) was observed directly by the surgeon after routine intraoperative transesophageal echocardiography was performed. From manufacturer specifications the maximum derated intensity in the sound field of the system used was 186 W/cm2, the maximum derated rarefactional acoustic pressure was 2.4 MPa, and the maximum mechanical index was 1.3. The lowest frequency used was 3.5 MHz. This exposure exceeds the threshold found for surface lung hemorrhage seen on gross observation of laboratory animals. No hemorrhage was noted on any lung surface by the surgeon on gross observation. We conclude that clinical transesophageal echocardiography, even at field levels a little greater than the reported thresholds for lung hemorrhage in laboratory animals, did not cause surface lung hemorrhage apparent on gross observation. These negative results support the conclusion that the human lung is not markedly more sensitive to ultrasound exposure than that of other mammals.

Albunex Does Not Increase the Sensitivity of the Lung to Pulsed Ultrasound

If cavitation in the vasculature of the lung is the physical mechanism responsible for lung hemorrhage, then addition of cavitation nuclei to the blood should enhance the bioeffect. To test the cavitation hypothesis, the extent of lung hemorrhage in mice injected with the echocontrast agent, Albunex(R), was compared to lung hemorrhage in animals injected with saline. Animals were exposed for 5 minutes to 1.1-MHz pulsed ultrasound (10 µs pulse length, 100-Hz pulse repetition frequency) at a peak positive pressure at the surface of the animal of 2 MPa. This exposure is approximately twice the threshold pressure amplitude for lung hemorrhage. Lesion areas did not differ significantly in the two groups of animals and were approximately equal to the lesion area in uninjected mice from an earlier study where acoustic exposures were the same. Neither this study nor a related study of hemolysis in vivo suggests that use of Albunex in echocardiographic procedures increases the risk of bioeffects.

Lung damage assessment from exposure to pulsed-wave ultrasound in the rabbit, mouse, and pig

The principal motivation of the study was to assess experimentally the question: "Is the MI (Mechanical Index) an equivalent or better indicator of nonthermal bioeffect risk than I(SPPA.3) (derated spatial peak, pulse average intensity)?" To evaluate this question, the experimental design consisted of a reproducible biological effect in order to provide a quantitative assessment of the effect. The specific biological effect used was lung damage and the species chosen was the rabbit. This work was initiated, in part, by a study in which lung hemorrhage was observed in 7-week old C3H mice for diagnostic-type, pulsed-wave ultrasound exposures, and, therefore, 6- to 7-week old C3H mice were used in this study as positive controls. Forty-seven adult New Zealand White male rabbits were exposed to a wide range of ultrasound amplitude conditions at center frequencies of 3 and 6 MHz with all temporal exposure variables held constant. A calibrated, commercial diagnostic ultrasound system was used as the ultrasound source with output levels exceeding, in some cases, permissible FDA levels. The MI was shown to be at least an equivalent, and in some cases, a better indicator of rabbit lung damage than either the I(SPPA.3) or p(r.3) (derated peak rarefactional pressure), thus answering the posed question positively. Further, in situ exposure conditions were estimated at the lung pleural surface (PS); the estimated in situ I(SPPA.PS) and p(r.PS) exposure conditions tracked lung damage no better than I(SPPA.3) and p(r.3), respectively, whereas the estimated in situ MI(PS) exposure condition was a slightly poorer predictor of lung damage than MI. Finally, the lungs of six adult crossbred pigs were exposed at the highest amplitude exposure levels permitted by a diagnostic ultrasound system (to prevent probe damage) at both frequencies; no lung damage was observed which suggests the possibility of a species dependency biological effect.

Age dependence of ultrasonically induced lung hemorrhage in mice

Thresholds for ultrasonically induced lung hemorrhage were determined in neonatal mice (24-36 h old), juvenile mice (14 d old) and adult mice (8-10 weeks old) to assess whether or not the threshold for lung hemorrhage is dependent upon age. Ultrasonic exposures were at 1.15 MHz with a pulse length of 10 microseconds, pulse repetition frequency of 100 Hz and a total exposure duration of 3 min. The threshold for lung hemorrhage occurred at a peak positive acoustic pressure of approximately 1 MPa for mice in all three age groups. Although the thresholds were similar for neonatal, juvenile and adult mice, the sizes of the suprathreshold hemorrhages were significantly larger in adult mice than in neonatal or juvenile mice.

Ultrasonically induced lung hemorrhage in young swine

Ten-day old swine were used in the final step of a study of the age dependence of the threshold for lung hemorrhage resulting from exposure to diagnostically relevant levels of pulsed ultrasound. A 2.3-MHz focused transducer (pulse length of 10 microseconds, 100-Hz pulse repetition frequency) was incremented vertically at several sites for a distance of 2 or 2.5 cm over the chest of the subject for a total exposure period of 16 or 20 min. The procedure was repeated at a total of four sites per animal. Animals were euthanized and lungs were scored by visual inspection for numbers and areas of gross hemorrhages. The threshold level for hemorrhage was approximately 1.3-MPa peak positive pressure in water and the surface of the animal or, at the surface of the lung, 0.8-MPa peak positive pressure, 0.8-MPa fundamental pressure, 0.7-MPa maximum negative pressure and 20 Wcm-2 pulse average intensity. These values are essentially the same as those reported previously for neonatal swine, and neonatal, juvenile and adult mice.

Food and Drug Administration ultrasound device regulation: the output display standard, the "mechanical index," and ultrasound safety

The Food and Drug Administration has recently revised its guidelines regarding acoustic output on diagnostic ultrasound equipment to allow a new track for manufacturers to achieve approval to market diagnostic ultrasound equipment. It would move for the first time toward regulating instrumental output based on scientific bioeffect data. It would allow increased instrumental output in certain modes and at the same time mandate on-screen labeling of a "thermal index" or "mechanical index," coupled with a user education program on the significance of these indexes. The increased instrumental output allowed by these new guidelines may benefit adult echocardiography by allowing slightly more penetration and higher frequency/better resolution. However, a tradeoff is that echocardiographers need to understand more about how to perform an examination to decrease unnecessary patient exposure to ultrasound and more about ultrasound bioeffects, such as the theoretical potential for cavitation-related adverse effects in certain circumstances.

Rabbit and pig lung damage comparison from exposure to continuous wave 30-kHz ultrasound

Previous comparative studies of ultrasound-induced pulmonary hemorrhage in mice and rabbits suggested that sensitivity to damage was species dependent (O'Brien and Zachary 1994b). In order to understand better these differences in species more analogous to the human, 74 pigs and 75 rabbits were each exposed for 10 min at 1 of 6 acoustic pressure levels (0, 145, 290, 340 [rabbits only], 460 and 490 [pigs only] kPa) at an ultrasonic frequency of CW 30 kHz. Eighteen mice were used as positive controls (10-min duration at 145 kPa). Because pig lung has numerous physiological and anatomical similarities to human lung, it was selected as the appropriate animal model for these studies. Pig lung data were compared to rabbit lung data; rabbit lung data have already been compared with mouse lung data (O'Brien and Zachary 1994a). Comparative analyses and extrapolation of these experimental data are intended to provide a better scientific basis for understanding the potential biological effects of ultrasound on human lungs since such studies will probably never be conducted with humans. Under the same exposure conditions and lung assessment criteria, mouse lung was determined to be more sensitive to ultrasound-induced damage than that of the rabbit by a factor of 3.9, the rabbit lung was more sensitive to ultrasound-induced damage than that of the pig by a factor of 3.7, and the mouse lung was more sensitive to ultrasound-induced damage than that of the pig by a factor of 14.4.

In vitro measurements of inertial cavitation thresholds in human blood

Inertial cavitation thresholds were measured in human blood exposed to pulsed ultrasound. Freshly drawn blood, bank blood and aqueous dilutions of both were used in this experimental study. Micrometer-sized polystyrene particles were used as extra potential nuclei in some samples. Focused transducers with megahertz center frequencies (2.5 MHz, 4.3 MHz) were employed to generate pulsed ultrasound to induce cavitation. Specially designed cells for hosting the blood samples were made to adapt to the experimental environment. Cavitation threshold measurements were achieved by using an active cavitation detection scheme which utilizes a highly focused transducer with a much higher center frequency (30 MHz). In 50% diluted blood samples, when no polystyrene particles were added to the samples, the threshold for cavitation was about 4.1 MPa at 2.5 MHz, while no cavitation was detected at 4.3 MHz. Generally, the measured thresholds decrease in samples with lower volume concentration of red blood cells or when polystyrene particles were added to the samples. Results show that the measured thresholds in some circumstances are in the range of output pressure of diagnostic ultrasound instrumentation; but for whole, freshly drawn blood, our apparatus was unable to detect cavitation, even at 6.3 MPa.