Look at the lung: can chest ultrasonography be useful in pregnancy?

Recent ultrasound advancements for the manipulation of nanobiomaterials and nanoformulations for drug delivery

Recent advances in ultrasound (US) have shown its great potential in biomedical applications as diagnostic and therapeutic tools. The coupling of US-assisted drug delivery systems with nanobiomaterials possessing tailor-made functions has been shown to remove the limitations of conventional drug delivery systems. The low-frequency US has significantly enhanced the targeted drug delivery effect and efficacy, reducing limitations posed by conventional treatments such as a limited therapeutic window. The acoustic cavitation effect induced by the US-mediated microbubbles (MBs) has been reported to replace drugs in certain acute diseases such as ischemic stroke. This review briefly discusses the US principles, with particular attention to the recent advancements in drug delivery applications. Furthermore, US-assisted drug delivery coupled with nanobiomaterials to treat different diseases (cancer, neurodegenerative disease, diabetes, thrombosis, and COVID-19) are discussed in detail. Finally, this review covers the future perspectives and challenges on the applications of US-mediated nanobiomaterials.

Implementation of lung ultrasound in the triage of pregnant women during the SARS-CoV-2 pandemics

Lung ultrasound (US) has been shown that it is able to detect interstitial lung disease, subpleural consolidations and acute respiratory distress syndrome in clinical and physical studies that assess its role in upper respiratory infections. It is used worldwide in the coronavirus disease 2019 (COVID-19) outbreak and the effectiveness has been assessed in several studies. Fast diagnosis of COVID-19 is essential in deciding for patient isolation, clinical care and reducing transmission. Imaging the lung and pleura by ultrasound is efficient, cost-effective, and safe and it is recognized as rapid, repeatable, and reliable. Obstetricians are already using the US and are quite proficient in doing so. During the pandemic, performing lung US (LUS) right after the fetal assessment until reverse transcription polymerase chain reaction results are obtained, particularly in settings that have a centralized testing center, was found feasible for the prediction of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The use of LUS is efficient in the triage and monitoring of pregnant women. Clinicians dealing with pregnant women should consider LUS as the first-line diagnostic tool in pregnant women during the SARS-CoV-2 pandemic.

Point-of-care lung ultrasound patterns in late third-trimester gravidas with and without preeclampsia

BACKGROUND

Transthoracic point-of-care ultrasonography of the lungs has become a standard technique in critical care medicine for the evaluation of patients with respiratory signs or symptoms but has not been well studied in pregnancy.

OBJECTIVE

To compare lung ultrasound patterns in third-trimester gravidas with and without preeclampsia and assess interobserver agreement between 3 obstetrical providers and a physician expert in critical care lung ultrasound.

STUDY DESIGN

This is a prospective observational study of 262 women with singleton pregnancies between 32 0/7 and 41 6/7 weeks' gestation. Lung ultrasound examinations were performed and interpreted by a team of obstetrical care providers and then interpreted by an expert in point-of-care lung ultrasound. The number of B-lines in each of the 4 lung fields, indicating the accumulation of fluid in the interstitial space and the alveoli, was evaluated. The primary outcome was a positive study for pulmonary interstitial edema, defined as an ultrasound study with 3 or more B-lines in 2 or more bilateral lung fields. The secondary outcome was a lung ultrasound study with 1 or 2 B-lines in 1 or more lung fields or 3 B-lines in 1 lung field. Interobserver agreement in lung ultrasound interpretation between obstetrical care providers and an expert in critical care point-of-care ultrasonography of the lung was assessed.

RESULTS

Among healthy gravidas, no subject had a lung ultrasound examination positive for pulmonary interstitial edema. Notably, 2 patients with preeclampsia had positive lung ultrasound studies, and both had respiratory symptoms or signs of pulmonary edema. One or 2 B-lines or 3 B-lines in 1 lung field were identified in 11.4% of healthy gravidas and 18.6% of patients with preeclampsia. There was no difference in lung ultrasound patterns between healthy gravidas and those with preeclampsia. The obstetrical care providers and the lung ultrasound expert had a high proportion of agreement regarding the interpretation of negative lung ultrasound examinations. The 2 patients with clinical signs of pulmonary edema were judged to have positive studies by both the obstetrical team and the expert; however, the obstetrical team classified more studies as positive.

CONCLUSION

Lung ultrasound patterns in women with preeclampsia without respiratory symptoms or clinical signs of pulmonary edema are similar to the lung ultrasound patterns of healthy gravidas. Point-of-care lung ultrasound can be used to evaluate third-trimester gravidas with preeclampsia and respiratory complaints or signs concerning for pulmonary edema. Formal training is important before the widespread adoption of point-of-care lung ultrasound by obstetrical healthcare providers.

Lung Ultrasound Can Influence the Clinical Treatment of Pregnant Women With COVID-19

Lung ultrasound (LUS) is an effective tool to detect and monitor patients infected with 2019 coronavirus disease (COVID-19). The use of LUS on pregnant women is an emerging trend, considering its effectiveness during the outbreak. Eight pregnant women with a diagnosis of COVID-19 confirmed by nasal/throat real-time reverse transcription polymerase chain reaction testing who underwent point-of-care LUS examinations after routine obstetric ultrasound are described. A routinely performed LUS examination revealed serious lung involvement in 7 cases: 2 were initially asymptomatic; 3 have chest computed tomography; 1 had initial negative real-time reverse transcription polymerase chain reaction results; and 1 had initial negative computed tomographic findings. Treatment for COVID-19 was either commenced or changed in 87.5% of the patients (n = 7 of 8) on LUS findings. Among patients with abnormal LUS findings, treatment was commenced in 5 patients (71.5%) and changed in 2 patients (28.5%). One normal and 7 abnormal LUS cases indicate the impact of routine LUS on the clinical outcome and treatment of pregnant women.

Lung Sonography in Obstetrics during COVID-19

In the current coronavirus SARS-CoV-2 pandemic, certain patients are becoming seriously ill. Lung pathologies are common, and some patients even go on to develop acute respiratory distress syndrome (ARDS), which requires intubation and artificial respiration of the critically ill patient. Imaging of the lung is absolutely necessary to obtain a diagnosis, assess the course of disease and for treatment. Particularly in gynecology and obstetrics (OBGYN), ultrasound scans of the lung can be a useful additional tool when caring for pregnant patients in the delivery room. As obstetricians use ultrasound imaging a lot in routine clinical practice, in the current pandemic setting, routine prenatal imaging screening could be expanded by the addition of ultrasound scans of the lung. Lung sonography can offer important additional information, particularly in obstetrics where the indications for radiation-emitting imaging are particularly restrictive. If there is a sonographic suspicion of lung involvement, then, depending on the symptoms and the morphological extent of the ultrasound findings, it may be necessary to consider admitting the patient to hospital for close fetal and maternal monitoring.

The diagnosis of pneumonia in a pregnant woman with coronavirus disease 2019 using maternal lung ultrasound

Lung ultrasound examination has been demonstrated to be an accurate imaging method to detect pulmonary and pleural conditions. During pregnancy, there is a need for rapid assessment of the maternal lung in patients with suspected coronavirus disease 2019. We report our experience on lung ultrasound examination in the diagnosis of coronavirus disease 2019 pneumonia in a pregnant woman. Typical ultrasound features of this pulmonary pathology, including diffuse hyperechoic vertical artifacts with thickened pleural line and “white lung” with patchy distribution, were observed. We suggest point-of-care lung ultrasound examination as a diagnostic imaging tool in pregnant women with suspected coronavirus disease 2019.

Lung ultrasonography in pregnant women during the COVID-19 pandemic: an interobserver agreement study among obstetricians

Purpose

This study investigated interobserver agreement in lung ultrasonography (LUS) in pregnant women performed by obstetricians with different levels of expertise, with confirmation by an expert radiologist.

Methods

This prospective study was conducted at a tertiary "Coronavirus Pandemic Hospital" in April 2020. Pregnant women suspected to have coronavirus disease 2019 (COVID-19) were included. Two blinded experienced obstetricians performed LUS on pregnant women separately and noted their scores for 14 lung zones. Following a theoretical and hands-on practical course, one experienced obstetrician, two novice obstetric residents, and an experienced radiologist blindly evaluated anonymized and randomized still images and videoclips retrospectively. Weighted Cohen's kappa and Krippendorff’s alpha tests were used to assess the interobserver agreement.

Results

Fifty-two pregnant women were included, with confirmed COVID-19 diagnosis rate of 82.7%. In total, 336 eligible still images and 115 videoclips were included in the final analysis. The overall weighted Cohen’s kappa values ranged from 0.706 to 0.912 for the 14 lung zones. There were only seven instances of major disagreement (>1 point) in the evaluation of 14 lung zones of 52 patients (n=728). The overall agreement between the radiologist and obstetricians for the still images (Krippendorff's α=0.856, 95% confidence interval [CI], 0.797 to 0.915) and videoclips (Krippendorff's α=0.785; 95% CI, 0.709 to 0.861) was good.

Conclusion

The interobserver agreement between obstetricians with different levels of experience on still images and videoclips of LUS was good. Following a brief theoretical course, obstetricians' performance of LUS in pregnant women and interpretation of pre-acquired LUS images can be considered consistent.

Chest Computed Tomography and Lung Ultrasound Findings in COVID-19 Pneumonia: A Pocket Review for Non-radiologists

COVID-19 is an infectious disease that has quickly spread worldwide, causing a pandemic. The main clinical manifestation is pneumonia. The most important test for the diagnosis is represented by RT-PCR, but, given the limited sensitivity, further radiological examinations are necessary. We reviewed the literature to highlight the typical manifestations and advantages of chest computed tomography and lung ultrasound in COVID-19 pneumonia in order to assist clinical researchers in the management of this disease.

How to perform lung ultrasound in pregnant women with suspected COVID-19

Under certain circumstances, such as during the current COVID-19 outbreak, pregnant women can be a target for respiratory infection, and lung examination may be required as part of their clinical evaluation, ideally while avoiding exposure to radiation. We propose a practical approach for obstetricians/gynecologists to perform lung ultrasound examination, discussing potential applications, semiology and practical aspects, which could be of particular importance in emergency situations, such as the current pandemic infection of COVID-19. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Abnormal lung ultrasound pattern during labor: A prospective cohort pilot study

PURPOSE

Lung ultrasound (LUS) examination is used to evaluate patients with acute respiratory failure. The physiological LUS pattern during labor in healthy parturients has not been well described. The aim of this study was to evaluate the LUS pattern in a cohort of healthy women during uncomplicated labor.

METHODS

We used the 8-point LUS assessment protocol and investigated lung sliding, A-lines, B-lines, interstitial syndrome, lung consolidation, and pleural effusion according to the International Consensus Document with two additional supradiaphragmatic projections. All patients were screened twice; once during the first stage of labor and again within 2 hours after delivery.

RESULTS

We included 24 patients in this study from February 2014 to August 2015. A total of 480 LUS records were retained for further analysis. Overall, 16 of 24 patients (67%) had at least one positive region (three or more B-lines) during the peridelivery LUS evaluation. Interstitial syndrome was detected in five patients (21%). There were no differences in A-line (P = 0.38) or B-line (P = 0.68) prevalence between LUS examinations before and after delivery.

CONCLUSIONS

Women in uncomplicated labor can present abnormal LUS findings, which may affect the interpretation of LUS results in patients with respiratory deterioration. Further studies should address this topic in larger cohort of patients.

Review article: Investigations and the pregnant woman in the emergency department - part 2: Point-of-care ultrasound, electrocardiography, respiratory function tests and radiology

Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound, electrocardiography and respiratory function tests. In addition, the emergency physician needs to be cognisant of disorders that are unique to or more common during pregnancy. Part 2 of this review addresses the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, changes in electrocardiography and respiratory function tests, and the safety of radiological procedures in the pregnant patient. Part 1 addressed potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy and the important causes of abnormal laboratory results in pregnancy.

Lung ultrasound for diagnosis of pneumonia in emergency department

Lung ultrasound (LUS) in the emergency department (ED) has shown a significant role in the diagnostic workup of pulmonary edema, pneumothorax and pleural effusions. The aim of this study is to assess the reliability of LUS for the diagnosis of acute pneumonia compared to chest X-ray (CXR) study. The study was conducted from September 2013 to March 2015. 107 patients were admitted to the ED with a clinical appearance of pneumonia. All the patients underwent a CXR study, read by a radiologist, and an LUS, performed by a trained ED physician on duty. Among the 105 patients, 68 were given a final diagnosis of pneumonia. We found a sensitivity of 0.985 and a specificity of 0.649 for LUS, and a sensitivity of 0.735 and specificity of 0.595 for CXR. The positive predictive value for LUS was 0.838 against 0.7 for CXR. The negative predictive value of LUS was 0.960 versus 0.550 for CXR. This study has shown sensitivity, positive predictive value and negative predictive value of LUS compared to the CXR study for the diagnosis of acute pneumonia. These results suggest the use of bedside thoracic US first-line diagnostic tool in patients with suspected pneumonia.