Diagnostic thoracic ultrasound imaging - An exploration of respiratory physiotherapists' interest and use in clinical practice: A national survey

The use of diaphragm and lung ultrasound in acute respiratory physiotherapy practice and the impact on clinical decision-making: A systematic review and meta-analysis

OBJECTIVES

Diaphragm and lung ultrasound (DLUS) is emerging as an important point-of-care respiratory assessment tool and is being used in clinical care by trained respiratory physiotherapists, both in Australia and internationally. However, the impact of DLUS on physiotherapists' clinical decision-making remains largely unknown. This systematic review aims to review the evidence for implementing DLUS in acute respiratory physiotherapy management.

REVIEW METHOD USED

We conducted a systematic review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, CENTRAL, and Scopus from inception to 18th April 2023 for all original clinical studies reporting on the physiotherapy clinical decision-making, following a DLUS examination and/or where DLUS was used to evaluate the effect of respiratory physiotherapy, in adults over 18 years of age.

REVIEW METHODS

Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the Newcastle-Ottawa Scale, and certainty in outcomes was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework.

RESULTS

A total of seven observational studies (n = 299) were included, all of which were in the intensive care setting. DLUS changed physiotherapy diagnosis, management, and treatment in 63.9% (50-64%), 16.8% (15-50%), and 48.4% (25-50%) of patients, respectively. There was a significant improvement in the lung ultrasound score post respiratory physiotherapy treatment (mean difference -2.31, 95% Confidence Interval (95% CI) -4.42 to -0.21; very low certainty) compared to before respiratory physiotherapy treatment. Moderate risk of bias was present in six studies, and there was variance in the DLUS methodology across included studies.

CONCLUSIONS

The findings of this review suggest DLUS influences physiotherapy clinical decision-making and can be used to evaluate the effects of acute respiratory physiotherapy treatment. However, the available data is limited, and further high-quality studies are needed.

TRIAL REGISTRATION

This study is registered with the International Prospective Register of Systematic Reviews; CRD42023418312.

Scoping Review of Curricula and Pedagogical Approaches for Physiotherapist Performed Point of Care Ultrasonography

Purpose

This study collates and maps physiotherapy pre- and post-licensure curricula and pedagogical approaches for point of care ultrasonography (POCUS).

Method

We used a standardized scoping review methodology and reporting framework. A total of 18,217 titles and abstracts, and 1,372 full text citations were screened, with 209 studies classified as physiotherapist performed POCUS.

Results

Of the 209 studies, 15 evaluated pre- and post-licensure curricula and pedagogical approaches. Seventy-two to 98% of pre-licensure programs reported including theoretical knowledge of POCUS and 44-45% reported practical teaching or competency assessment. In post-licensure studies of POCUS, 0-61% of physiotherapists reported training for POCUS. All studies of post-licensure pedagogical approaches included an assessment of theoretical knowledge of POCUS, but only one study included a practical assessment of competency. There was considerable variability in POCUS methods and duration of pedagogical approaches. Except for one study, all pedagogical approaches reported improvement in theoretical knowledge.

Conclusion

Progress in physiotherapy-specific, standardized, competency-based curricula and pedagogical approaches in POCUS has been limited, with minimal research available, and considerable variability both pre- and post-licensure. These findings could be used to advocate for the inclusion of POCUS in pre- and post-licensure physiotherapy curriculum, and suggest a need for clear guidelines from regulatory colleges and licensing bodies, and a common terminology for physiotherapist performed POCUS. Future directions for research include a systematic review of the psychometric properties of physiotherapist performed POCUS within and across anatomical areas, an assessment of value of different forms of training, and an evaluation of the impact of physiotherapist performed POCUS on patient outcomes.

An international survey exploring the adoption and utility of diagnostic lung ultrasound by physiotherapists and respiratory therapists in intensive care

Introduction

Lung ultrasound (LUS) is an emerging assessment tool for intensive care unit (ICU) therapists (physiotherapists, physical therapists and respiratory therapists) to aid pathology identification, intervention selection, clinical reasoning and as an outcome measure to assess intervention efficacy. However, the extent of LUS adoption and use by ICU therapists internationally has not been described in the literature.

Objectives

This survey explored the interest in LUS amongst ICU therapists internationally. In addition, LUS training, use in clinical practice and barriers to implementation were also explored. The survey findings were used to facilitate recommendations for future adoption.

Methods

International ICU therapists were invited to answer a 37 question cross-sectional open e-survey, distributed using the online survey tool REDCap®. The exact sample size of eligible ICU therapists from around the world is unknown, therefore the participant responses received were a representative convenience sample of the international ICU therapist population. Survey links were posted on the relevant web pages and social media forums utilised by various ICU therapist associations and professional organisations worldwide. A snowballing technique was used to encourage survey participants to forward the survey link within their professional networks. The survey was open on REDCap® for an 8-week period between March and May 2021.

Results

Three hundred twenty ICU therapists from 30 countries responded with most respondents coming from either the United Kingdom (n = 94) or Australia (n = 87). Eighty-nine of the ICU therapist respondents (30%) reported being users of LUS, however, 40 of those 89 respondents reported having no formal accreditation. The top clinical indications to perform a LUS scan were changes on chest radiograph, altered findings on auscultation and a low partial pressure of arterial oxygen/fraction of inspired oxygen ratio. The 71% of LUS users reported that their ICU does not have a local policy in place to guide ICU therapists' use of LUS. Most LUS users (82%) only document their LUS findings in the patient's medical notes and (73%) only store the LUS clips on the ICU's ultrasound machine. The 85% of respondents perceive LUS becoming an increasing part of their objective assessment in the future and 96% report that they have other ICU therapist colleagues interested in adopting LUS. Main reasons why respondents believe that ICU therapists are not adopting LUS in their ICU are a difficulty in access to appropriate training, mentorship, and a lack of local governance policy guiding their use of LUS.

Conclusions

To the authors' knowledge this is the first study to explore the international adoption and utility of LUS by ICU therapists. LUS is a growing technique with widespread interest from ICU therapists internationally with a desire to adopt LUS into their assessments and upskill their practice. ICU therapists' use of LUS could allow more targetted and appropriate treatment for patients on ICU. Barriers to LUS adoption could be mitigated by having access to quality training programmes and mentorship. Development of profession specific guidance and policies within local infrastructure should facilitate growth and ensure robust quality assurance and governance processes.

Implementation of physiotherapy-led lung ultrasound in the intensive care unit

The use of lung ultrasound (LUS) in clinical settings is emerging as an important tool in the assessment of lung pathology and/or function and has gained considerable acceptance. LUS is being integrated into clinical care by trained respiratory physiotherapists and has been shown to influence physiotherapists' clinical decision-making in the respiratory management of patients. Considering the use of LUS by physiotherapy is in its infancy and still evolving, there is likely variability in the ability and confidence of physiotherapists to use LUS in clinical practice, both in Australia and internationally. While the UK has had a rapid increase in the number of LUS-accredited physiotherapists (n  = 111), the number of LUS-accredited physiotherapists in Australia remains very low (n  = 4). There is a growing body of work in the UK on physiotherapy-led LUS in respiratory care, however, there is currently little work published on the practicalities of training and establishing physiotherapy-led LUS in Australia. This report describes the training and implementation of physiotherapy-led LUS in the intensive care unit from a regional hospital perspective.

Challenges and opportunities in point-of-care ultrasound: A qualitative exploration of respiratory physiotherapists' experiences of lung ultrasound training and its adoption in critical care

Introduction

Diagnostic lung ultrasound (LUS) is gaining popularity among respiratory physiotherapists as an imaging modality to aid pulmonary assessments, guide intervention selection, and monitor the efficacy of chosen interventions. The ability of respiratory physiotherapists to incorporate LUS into their clinical practice is influenced by multiple factors to adoption and implementation. The aim of this study was to explore the experiences of senior respiratory physiotherapists who have attempted to adopt and implement LUS into their clinical practice in critical care. It is hoped these experiences will inform the development of educational and adoption strategies for the future implementation of LUS.

Methods

Following a national call out, eight senior critical care respiratory physiotherapists were purposively selected to be interviewed using semi-structured questions exploring their varied experiences of LUS adoption into clinical practice in critical care. The transcribed data were thematically analysed.

Results

Five main themes emerged from the participants' responses: (i) support for physiotherapists using LUS, (ii) knowledge and understanding of LUS evidence, (iii) governance, (iv) physiotherapists' motivation to use LUS, and (v) resources. Quotes for each of the five themes are given as exemplars.

Conclusion

Participants reported a range of factors that influenced their ability to adopt and implement LUS into practice several were enabling, and others were barriers to progress. Online Appendix 1 contains recommendations from the authors to help guide managers and clinicians wishing to adopt LUS into respiratory physiotherapy services and patient pathways.

An Update on Cardiorespiratory Physiotherapy during Mechanical Ventilation

Physiotherapists are integral members of the multidisciplinary team managing critically ill adult patients. However, the scope and role of physiotherapists vary widely internationally, with physiotherapists in some countries moving away from providing early and proactive respiratory care in the intensive care unit (ICU) and focusing more on early mobilization and rehabilitation. This article provides an update of cardiorespiratory physiotherapy for patients receiving mechanical ventilation in ICU. Common and some more novel assessment tools and treatment options are described, along with the mechanisms of action of the treatment options and the evidence and physiology underpinning them. The aim is not only to summarize the current state of cardiorespiratory physiotherapy but also to provide information that will also hopefully help support clinicians to deliver personalized and optimal patient care, based on the patient's unique needs and guided by accurate interpretation of assessment findings and the current evidence. Cardiorespiratory physiotherapy plays an essential role in optimizing secretion clearance, gas exchange, lung recruitment, and aiding with weaning from mechanical ventilation in ICU. The physiotherapists' skill set and scope is likely to be further optimized and utilized in the future as the evidence base continues to grow and they get more and more integrated into the ICU multidisciplinary team, leading to improved short- and long-term patient outcomes.

Translating Ultrasound into Clinical Practice for the Assessment of Swallowing and Laryngeal Function: A Speech and Language Pathology-Led Consensus Study

Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1-13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field.