Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment

Association of point-of-care lung ultrasound findings with 30-day pulmonary complications after cardiac surgery: A prospective cohort study

Background

Several studies have shown that bedside lung ultrasound findings in postanaesthesia care units (PACUs) and intensive care units (ICUs) correlate with postoperative pulmonary complications(PPCs) after noncardiac major surgery. However, it remains unclear whether lung ultrasound findings can be used as early predictors of PPCs in patients undergoing cardiac surgery. The main aim of our study was to evaluate the relationship between early postoperative point-of-care lung ultrasound findings and PPCs after cardiac surgery.

Methods

Two board-certified physicians performed a point-of-care pulmonary ultrasound on cardiac surgery patients approximately 2 h after the patient was admitted to the ICU. Pulmonary complications occurring within 30 days postoperatively were recorded. Logistic regression modeling was used to analyze the relationship between lung ultrasound findings and PPCs.

Results

PPCs occurred in 61 (30.9 %) of the 197 patients. Lung ultrasound scores(LUS), number of lung consolidation(NLC), and depth of pleural effusion(DPE) were more significant in patients who developed PPCs (P < 0.001). According to the multivariate analysis, NLC≥3(aOR 2.71,95%CI 1.14-6.44; p = 0.024)and DPE >0.95(aOR 3.79,95%CI 1.60-8.99; p = 0.002) were found to be independently associated with PPCs during this study.

Conclusions

Our study demonstrated that DPE >0.95 and NLC ≥3 were associated with PPCs after cardiac surgery based on bedside lung ultrasound findings in the ICU. When these signs manifest perioperatively, the surgeon should be alerted and the necessary steps should be taken, especially if they present simultaneously.

Ultrasound-Assisted and Ultrasound-Guided Thoracentesis: An Educational Review

Thoracentesis is one of the most important invasive procedures in the clinical setting. Particularly, thoracentesis can be relevant in the evaluation of a new diagnosed pleural effusion, thus allowing for the collection of pleural fluid so that laboratory tests essential to establish a diagnosis can be performed. Furthermore, thoracentesis is a maneuver that can have therapeutic and palliative purposes. Historically, the procedure was performed based on a physical examination. In recent years, the role of ultrasound has been established as a valuable tool for assistance and guidance in the thoracentesis procedure. The use of ultrasound increases success rates and significantly reduces complications. The aim of this educational review is to provide a detailed and sequential examination of the procedure, focusing on the two main modalities, the ultrasound-assisted and ultrasound-guided form.

Comparative Evaluation of Chest Ultrasonography and Computed Tomography as Predictors of Malignant Pleural Effusion: A Prospective Study

Malignant pleural effusion (MPE) is a manifestation of advanced cancer that requires a prompt and accurate diagnosis. Ultrasonography (US) and computed tomography (CT) are valuable imaging techniques for evaluating pleural effusions; however, their relative predictive ability for a malignant origin remains debatable. This prospective study aimed to compare chest US with CT findings as predictors of malignancy in patients with undiagnosed exudative pleural effusion. Fifty-four adults with undiagnosed exudative pleural effusions underwent comprehensive clinical evaluation including chest US, CT, and histopathologic biopsy. Blinded radiologists evaluated the US and CT images for features suggestive of malignancy, based on predefined criteria. Diagnostic performance measures were calculated using histopathology as a reference standard. Of the 54 patients, 33 (61.1%) had MPEs confirmed on biopsy. No significant differences between US and CT were found in detecting parietal pleural abnormalities, lung lesions, chest wall invasion, or liver metastasis. US outperformed CT in identifying diaphragmatic pleural thickening ≥10 mm (33.3% vs. 6.1%, p < 0.001) and nodularity (45.5% vs. 3%, p < 0.001), whereas CT was superior for mediastinal thickening (48.5% vs. 15.2%, p = 0.002). For diagnosing MPE, diaphragmatic nodularity detected by US had 45.5% sensitivity and 100% specificity, whereas CT mediastinal thickening had 48.5% sensitivity and 90.5% specificity. Both US and CT demonstrate reasonable diagnostic performance for detecting MPE, with particular imaging findings favoring a malignant origin. US may be advantageous for evaluating diaphragmatic pleural involvement, whereas CT is more sensitive to mediastinal abnormalities.

Lung Ultrasound Signs: The Beginning. Part 3-An Accademia di Ecografia Toracica Comprehensive Review on Ultrasonographic Signs and Real Needs

Over the last 20 years, scientific literature and interest on chest/lung ultrasound (LUS) have exponentially increased. Interpreting mixed-anatomical and artifactual-pictures determined the need of a proposal of a new nomenclature of artifacts and signs to simplify learning, spread, and implementation of this technique. The aim of this review is to collect and analyze different signs and artifacts reported in the history of chest ultrasound regarding normal lung, pleural pathologies, and lung consolidations. By reviewing the possible physical and anatomical interpretation of these artifacts and signs reported in the literature, this work aims to present the AdET (Accademia di Ecografia Toracica) proposal of nomenclature and to bring order between published studies.

Point-of-care ultrasound for non-vascular invasive procedures in critically ill neonates and children: current status and future perspectives

Point-of-care ultrasound (POCUS) has been established as an essential bedside tool for real-time image guidance of invasive procedures in critically ill neonates and children. While procedural guidance using POCUS has become the standard of care across many adult medicine subspecialties, its use has more recently gained popularity in neonatal and pediatric medicine due in part to improvement in technology and integration of POCUS into physician training programs. With increasing use, emerging data have supported its adoption and shown improvement in pediatric outcomes. Procedures that have traditionally relied on physical landmarks, such as thoracentesis and lumbar puncture, can now be performed under direct visualization using POCUS, increasing success, and reducing complications in our most vulnerable patients. In this review, we describe a global and comprehensive use of POCUS to assist all steps of different non-vascular invasive procedures and the evidence base to support such approach.

CONCLUSION

There has been a recent growth of supportive evidence for using point-of-care ultrasound to guide neonatal and pediatric percutaneous procedural interventions. A global and comprehensive approach for the use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures.

WHAT IS KNOWN

• Point-of-care ultrasound has been established as a powerful tool providing for real-time image guidance of invasive procedures in critically ill neonates and children and allowing to increase both safety and success.

WHAT IS NEW

• A global and comprehensive use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures: from diagnosis to semi-quantitative assessment, and from real-time puncture to follow-up.

Lung ultrasound and supine chest X-ray use in modern adult intensive care: mapping 30 years of advancement (1993-2023)

In critically ill patients with acute respiratory failure, thoracic images are essential for evaluating the nature, extent and progression of the disease, and for clinical management decisions. For this purpose, computed tomography (CT) is the gold standard. However, transporting patients to the radiology suite and exposure to ionized radiation limit its use. Furthermore, a CT scan is a static diagnostic exam for the thorax, not allowing, for example, appreciation of "lung sliding". Its use is also unsuitable when it is necessary to adapt or decide to modify mechanical ventilation parameters at the bedside in real-time. Therefore, chest X-ray and lung ultrasound are today's contenders for shared second place on the podium to acquire a thoracic image, with their specific strengths and limitations. Finally, electrical impedance tomography (EIT) could soon have a role, however, its assessment is outside the scope of this review. Thus, we aim to carry out the following points: (1) analyze the advancement in knowledge of lung ultrasound use and the related main protocols adopted in intensive care units (ICUs) over the latest 30 years, reporting the principal publications along the way, (2) discuss how and when lung ultrasound should be used in a modern ICU and (3) illustrate the possible future development of LUS.

Point-of-Care Lung Ultrasound in the Intensive Care Unit-The Dark Side of Radiology: Where Do We Stand?

Patients in intensive care units (ICUs) are critically ill and require constant monitoring of clinical conditions. Due to the severity of the underlying disease and the need to monitor devices, imaging plays a crucial role in critically ill patients' care. Given the clinical complexity of these patients, who typically need respiratory assistance as well as continuous monitoring of vital functions and equipment, computed tomography (CT) can be regarded as the diagnostic gold standard, although it is not a bedside diagnostic technique. Despite its limitations, portable chest X-ray (CXR) is still today an essential diagnostic tool used in the ICU. Being a widely accessible imaging technique, which can be performed at the patient's bedside and at a low healthcare cost, it provides additional diagnostic support to the patient's clinical management. In recent years, the use of point-of-care lung ultrasound (LUS) in ICUs for procedure guidance, diagnosis, and screening has proliferated, and it is usually performed at the patient's bedside. This review illustrates the role of point-of-care LUS in ICUs from a purely radiological point of view as an advanced method in ICU CXR reports to improve the interpretation and monitoring of lung CXR findings.

The diagnostic value of interleukin-36 cytokines in pleural effusions of varying etiologies

BACKGROUND

The clinical management of pleural effusion (PE) poses challenges due to its diverse etiologies. The objective of this research was to investigate the concentrations of interleukin-36 (IL-36) cytokines in pleural fluid (PF) from different etiologies and assess their diagnostic efficacy in distinguishing the causes of PE.

METHODS

This study enrolled 89 patients with confirmed PE, comprising 11 cases classified as transudate, 24 cases as malignant pleural effusion (MPE), 24 cases as tuberculous pleural effusion (TPE), and 30 cases as parapneumonic pleural effusion (PPE). The PPE group was further subdivided into 20 cases of uncomplicated parapneumonic effusion (UPPE) and 10 cases of complicated parapneumonic effusion (CPPE)/empyema. The concentrations of IL-36 cytokines in the PF of all 89 patients were quantified by the enzyme-linked immunosorbent assay (ELISA).

RESULTS

IL-36α exhibited excellent diagnostic accuracy in TPE, achieving a sensitivity of 91.7 % and specificity of 83.1 %, along with a cut-off value of 435.3 pg/ml. IL-36Ra also demonstrated relatively favorable diagnostic performance in PPE, with a sensitivity of 80.0 % and specificity of 76.3 %, along with a cut-off value of 390.8 pg/ml. Multivariable logistic regression models were successfully developed for both TPE and PPE, confirming their diagnostic utility. Furthermore, the levels of IL-36Ra were notably elevated in CPPE/empyema in comparison to UPPE. Moreover, in PF, IL-36γ exhibited positive associations with both IL-36α and IL-36Ra.

CONCLUSION

IL-36α and IL-36Ra may serve as novel biomarkers for diagnosing TPE and PPE, respectively. The multivariate models established significantly enhance the diagnostic efficacy of both TPE and PPE. Furthermore, IL-36Ra can function as an indicator for assessing the extent of pleural inflammation. Additionally, the interaction among IL-36 cytokines in PF may contribute to their expression modulation.

Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department

Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.

Point-of-Care Thoracic Ultrasound in Children: New Advances in Pediatric Emergency Setting

Point-of-care thoracic ultrasound at the patient's bedside has increased significantly recently, especially in pediatric settings. Its low cost, rapidity, simplicity, and repeatability make it a practical examination to guide diagnosis and treatment choices, especially in pediatric emergency departments. The fields of application of this innovative imaging method are many and include primarily the study of lungs but also that of the heart, diaphragm, and vessels. This manuscript aims to describe the most important evidence for using thoracic ultrasound in the pediatric emergency setting.

The assessment in patients with acute fatty liver of pregnancy (AFLP) treated with plasma exchange: a cohort study of 298 patients

BACKGROUND

To assess the prevalence, risk factors, clinical characteristics of Acute fatty liver of pregnancy (AFLP) patients, and outcomes of AFLP patients treated with plasma exchange (PE).

METHODS

We retrospectively reviewed the AFLP patients admitted to the First Affiliated Hospital of Xi'an Jiaotong University and Xijing Hospital of Air Force Medical University from January 2012 to May 2022. Final prediction model for death among AFLP by means of stepwise backward elimination with p value < 0.05. Patients treated with and without PE were compared by propensity-matched cohort study.

RESULTS

Two hundred ninety eight patients with the diagnosis of AFLP, and finally 290 patients were enrolled in the cohort study, 50 of whom (17.2%) were dead. Compared with AFLP patients alive, the dead of patients were more likely to be combined encephalopathy (p < 0.01), postpartum hemorrhage (p < 0.01), and found significantly higher frequency of fetal distress (p = 0.04), fetal death (p < 0.01). we developed a predicted probability value and with an area under the receiver operating characteristics (ROC) curve of 0.94 (95%CI 0.87 to 1.00), indicating AFLP patients' death. The patients treated with PE had a significantly lower 60-day mortality rate (OR 0.42, 95% CI 0.29 to 2.64, p = 0.04), and significantly shorter duration of hospital-free days at day 28 (p = 0.01).

CONCLUSIONS

In conclusion, our study indicated that liver function were risk factors for maternal mortality, and PE was a protective factor for maternal 60-day mortality and hospital-free days at day 28 in AFLP patients.

Pleural effusion in critically ill patients and intensive care setting

Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses. Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients, with a wide range of variable prevalence rates of up to 50%-60% in some studies. This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit (ICU). The original disease that caused pleural effusion can be the exact cause of ICU admission. There is an impairment in the pleural fluid turnover and cycling in critically ill and mechanically ventilated patients. There are also many difficulties in diagnosing pleural effusion in the ICU, including clinical, radiological, and even laboratory difficulties. These difficulties are due to unusual presentation, inability to undergo some diagnostic procedures, and heterogenous results of some of the performed tests. Pleural effusion can affect the patient’s outcome and prognosis due to the hemodynamics and lung mechanics changes in these patients, who usually have frequent comorbidities. Similarly, pleural effusion drainage can modify the ICU-admitted patient’s outcome. Finally, pleural effusion analysis can change the original diagnosis in some cases and redirect the management toward a different way.

Ultrasound in Sepsis and Septic Shock-From Diagnosis to Treatment

Sepsis and septic shock are among the leading causes of in-hospital mortality worldwide, causing a considerable burden for healthcare. The early identification of sepsis as well as the individuation of the septic focus is pivotal, followed by the prompt initiation of antibiotic therapy, appropriate source control as well as adequate hemodynamic resuscitation. For years now, both emergency department (ED) doctors and intensivists have used ultrasound as an adjunctive tool for the correct diagnosis and treatment of these patients. Our aim was to better understand the state-of-the art role of ultrasound in the diagnosis and treatment of sepsis and septic shock.

METHODS

We conducted an extensive literature search about the topic and reported on the data from the most significant papers over the last 20 years.

RESULTS

We divided each article by topic and exposed the results accordingly, identifying four main aspects: sepsis diagnosis, source control and procedure, fluid resuscitation and hemodynamic optimization, and echocardiography in septic cardiomyopathy.

CONCLUSION

The use of ultrasound throughout the process of the diagnosis and treatment of sepsis and septic shock provides the clinician with an adjunctive tool to better characterize patients and ensure early, aggressive, as well as individualized therapy, when needed. More data are needed to conclude that the use of ultrasound might improve survival in this subset of patients.

Low-Cost Pseudo-Anthropomorphic PVA-C and Cellulose Lung Phantom for Ultrasound-Guided Interventions

A low-cost custom-made pseudo-anthropomorphic lung phantom, offering a model for ultrasound-guided interventions, is presented. The phantom is a rectangular solidstructure fabricated with polyvinyl alcohol cryogel (PVA-C) and cellulose to mimic the healthy parenchyma. The pathologies of interest were embedded as inclusions containing gaseous, liquid, or solid materials. The ribs were 3D-printed using polyethylene terephthalate, and the pleura was made of a bidimensional reticle based on PVA-C. The healthy and pathological tissues were mimicked to display acoustic and echoic properties similar to that of soft tissues. Theflexible fabrication process facilitated the modification of the physical and acoustic properties of the phantom. The phantom's manufacture offers flexibility regarding the number, shape, location, and composition of the inclusions and the insertion of ribs and pleura. In-plane and out-of-plane needle insertions, fine needle aspiration, and core needle biopsy were performed under ultrasound image guidance. The mimicked tissues displayed a resistance and recoil effect typically encountered in a real scenario for a pneumothorax, abscesses, and neoplasms. The presented phantom accurately replicated thoracic tissues (lung, ribs, and pleura) and associated pathologies providing a useful tool for training ultrasound-guided procedures.

Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions

Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.

Cardiopulmonary ultrasound correlates of pleural effusions in patients with congestive heart failure

Background

Pleural effusions are common in patients with congestive heart failure. However, there is a need to assess systematically the correlation between effusion volume, extravascular lung water and echocardiographic parameters. We used combined cardiopulmonary ultrasound to evaluate the relationship between effusion volume, extravascular lung water, and echocardiographic parameters in patients with congestive heart failure.

Methods

Patients who were hospitalized for congestive heart failure underwent combined cardiopulmonary ultrasound. A semiquantitative score of pleural effusions was derived by pulmonary ultrasound and extravascular lung water was estimated by ultrasound lung comets. The measurements were compared with echocardiographic and clinical results.

Results

Among 168 patients (median age 66 years, 69.6% men), 102 (60.7%) had pleural effusions, 84.3% bilateral, 10.8% right-sided, and 4.9% left-sided. High pleural effusion scores were associated with high ultrasound lung comet scores (P < 0.0001). Compared with patients without pleural effusions, patients with pleural effusions were significantly older and had higher systolic pulmonary artery pressure (SPAP), NT-proBNP, New York Heart Association scale, larger left atrium, larger right ventricle, more severe mitral regurgitation, and worse left and right heart function. Adjusted for age, multiple logistic regression analysis showed that SPAP (OR 5.688, P = 0.006) and E/A (OR 3.941, P = 0.043) were the significant variables and risk factors associated with pleural effusions in heart failure.

Conclusion

For patients with left heart failure, the degree of pleural effusions was associated with pulmonary congestion. Elevated SPAP and E/A were the main risk factors for the formation of pleural effusions in patients with congestive heart failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02638-1.

The evaluation of the intracavitary effusions by a beside ultrasound examination

OBJECTIVE: This study aims to evaluate the bedside use of the pocket-sized ultrasound (US) device for the detection of the intracavitary effusions. METHODS: We randomly enrolled 40 patients admitted to S. Andrea Hospital of Rome. Every patient received a clinical and biochemical evaluation and a bedside US examination to detect and estimate the intracavitary (pleural, pericardial and intra-abdominal) effusions; the US measurements have been compared to the computed tomography (CT) scans (as gold standard). RESULTS: The patients presented a high prevalence of effusions: right pleural 16/40 = 40% (esteemed volume 236.3±500.7 ml, mean±standard deviation m±SD), left pleural 8/40 = 20% (127.0±377.4 ml), pericardial 12/40 = 30% (47.5±72.8 ml) and intra-abdominal effusions 5/40 = 12.5% of cases (110.9±600.6 ml). Linear regression analysis showed a significant correlation between US and CT measurements: pleural r = 0.973 p <  1×10–38, pericardial r = 0.927 p <  1×10–39, intra-abdominal space r = 0.921 p <  1×10–59. The accuracy of the bedside US at the pleural, pericardial and abdominal level was respectively 98%, 93% and 96% (Cohen’s kappa coefficient 0.966, 0.841 and 0.833). CONCLUSIONS: The present study showed a high prevalence of the intracavitary effusions and a high accuracy of the bedside US. The bedside US by a pocket-sized device is promising tool for its advantages of reproducibility and non-invasiveness of the device.

Quantitative Lung Ultrasonography for the Nephrologist: Applications in Dialysis and Heart Failure

Volume overload, and its attendant increase in acute care utilization and cardiovascular morbidity and mortality, represents a critical challenge for the practicing nephrologist. This is particularly true among patients with ESKD on HD, where predialysis volume overload and intradialytic and postdialytic hypovolemia account for almost a third of all cost for the Medicare dialysis benefit. Quantitative lung ultrasound is a tool for assessing the extent of extravascular lung water that outperforms physical exam and plain chest radiography. B-lines are vertical hyperechoic artifacts present in patients with increased extravascular lung water. B-lines have been shown to decrease dynamically during the hemodialysis treatment in proportion to ultrafiltration volume. Among patients with chronic heart failure, titration of diuretics on the basis of the extent of pulmonary congestion noted on lung ultrasonography has been shown to decrease recurrent acute care utilization. Early data from randomized controlled trials of lung ultrasound-guided ultrafiltration therapy among patients with ESKD on HD have shown promise for potential reduction in recurrent episodes of decompensated heart failure and cardiovascular events. Ultimately, lung ultrasound may predict those who are ultrafiltration tolerant and could be used to decrease acute care utilization and, thus, cost in this population.

Case Report: Lung Ultrasound in Critically Ill Neonates With Lung Diseases: Experience From Several Typical Cases

Lung ultrasound (LUS) can be used to diagnose various neonatal lung diseases. It more sensitively diagnoses pulmonary edema, pneumothorax, pulmonary consolidation, and atelectasis than traditional X-ray and quickly determines the cause of dyspnea. As a component of severe ultrasound, LUS enables rapid bedside visualization of lung diseases and plays a major role in guiding the differential diagnosis of disease, ventilator treatment, and lung recruitment. This study introduced the application of LUS in the diagnosis and treatment of critically ill neonates with lung diseases.

A training plan to implement lung ultrasound for diagnosing pneumonia in children

BACKGROUND

Lung ultrasound (LUS) for critical patients requires trained operators to perform them, though little information exists on the level of training required for independent practice. The aims were to implement a training plan for diagnosing pneumonia using LUS and to analyze the inter-observer agreement between senior radiologists (SRs) and pediatric intensive care physicians (PICPs).

METHODS

Prospective longitudinal and interventional study conducted in the Pediatric Intensive Care Unit of a tertiary hospital. Following a theoretical and practical training plan regarding diagnosing pneumonia using LUS, the concordance between SRs and the PICPs on their LUS reports was analyzed.

RESULTS

Nine PICPs were trained and tested on both theoretical and practical LUS knowledge. The mean exam mark was 13.5/15. To evaluate inter-observer agreement, a total of 483 LUS were performed. For interstitial syndrome, the global Kappa coefficient (K) was 0.51 (95% CI 0.43-0.58). Regarding the presence of consolidation, K was 0.67 (95% CI 0.53-0.78), and for the consolidation pattern, K was 0.82 (95% CI 0.79-0.85), showing almost perfect agreement.

CONCLUSIONS

Our training plan allowed PICPs to independently perform LUS and might improve pneumonia diagnosis. We found a high inter-observer agreement between PICPs and SRs in detecting the presence and type of consolidation on LUS.

IMPACT

Lung ultrasound (LUS) has been proposed as an alternative to diagnose pneumonia in children. However, the adoption of LUS in clinical practice has been slow, and it is not yet included in general clinical guidelines. The results of this study show that the implementation of a LUS training program may improve pneumonia diagnosis in critically ill patients. The training program's design, implementation, and evaluation are described. The high inter-observer agreement between LUS reports from the physicians trained and expert radiologists encourage the use of LUS not only for pneumonia diagnosis, but also for discerning bacterial and viral patterns.

Manual zur Indikation und Durchführung spezieller echokardiographischer Anwendungen

Das zweite Manual zur Indikation und Durchführung der Echokardiographie bezieht sich auf spezifische Anwendungen der Echokardiographie und besondere Fragestellungen bei speziellen Patientengruppen. Dabei stehen v. a. praktische Aspekte im Vordergrund. Methodisch etabliert sind die transösophageale Echokardiographie, die Stressechokardiographie und die Kontrastechokardiographie. Bei nahezu allen echokardiographischen Untersuchungen spielen aktuell 3‑D-Echokardiographie und Deformationsbildgebung eine Rolle. Das gesamte Spektrum der echokardiographischen Möglichkeiten wird derzeit in Notfall- und Intensivmedizin, bei der Überwachung und Führung von Katheterinterventionen, bei strukturellen Herzerkrankungen, bei herzchirurgischen Operationen, bei der Nachsorge von kardialen Unterstützungssystemen, bei kongenitalen Vitien im Erwachsenenalter und bei der Versorgung von hochinfektiösen Patienten in Pandemiezeiten angewandt. Die diagnostischen Fortschritte der konventionellen und modernen echokardiographischen Anwendungen stehen im Fokus dieses Manuals. Die 3‑D-Echokardiographie zur Charakterisierung der kardialen Morphologie und die Deformationsbildgebung zur Objektivierung der kardialen Funktion sind bei vielen Indikationen im klinischen Alltag etabliert. Die Stressechokardiographie zur Ischämie‑, Vitalitäts- und Vitiendiagnostik, die Bestimmung der koronaren Flussreserve und die Kontrastechokardiographie bei der linksventrikulären Wandbewegungsanalyse und kardialen Tumordetektion finden zunehmend klinische Anwendung. Wie für die konventionelle Echokardiographie im ersten Manual der Echokardiographie 2009 beschrieben, erfordert der Einsatz moderner echokardiographischer Verfahren die standardisierte Dokumentation und Akquisition bestimmter Bildsequenzen bei optimierter Geräteeinstellung, da korrekte und reproduzierbare Auswertungen nur bei guter Bildqualität möglich sind.

Lung ultrasound and the role of lung aeration score in patients with acute respiratory distress syndrome on extracorporeal membrane oxygenation

OBJECTIVE

This was a pilot study to determine the utility of daily lung ultrasound (LUS) in patients requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO) for acute respiratory distress syndrome (ARDS).

DESIGN

This was a prospective, observational study.

SETTING

The study took place in the intensive care unit at Royal Papworth Hospital in Cambridge, UK.

PARTICIPANTS

We recruited adult patients receiving VV-ECMO for ARDS.

INTERVENTIONS

All patients received a lung computed tomography (CT) scan and LUS on admission. Bedside chest radiography (CXR) and LUS were done on a daily basis until patients were decannulated.

MEASUREMENTS AND MAIN RESULTS

Daily LUS aeration scores were calculated according to the appearance of four defined patterns. An independent radiologist calculated corresponding scores for CT and CXR, retrospectively. These were checked for correlation with LUS aeration scores. There were statistically significant correlations between LUS versus CT (r = 0.868, p = 0.002) and LUS versus CXR (r = 0.498, p = 0.018) with good agreement and no evidence of proportional bias. LUS was able to detect 13.5% of pleural effusions and 54.2% of pneumothorax that were not picked up on CXR.In most of the patients who were weaned off VV-ECMO, a progressive reduction of LUS aeration scores corresponding to lung re-aeration was observed.

CONCLUSIONS

LUS correlated with findings on CT and CXR for quantifying lung aeration and the clinical presentation of patients. LUS also picked up more pleural effusions and pneumothorax than CXR. Together with traditional imaging techniques, the routine use of LUS should be considered for this patient group.

Interpretation of Thoracic Radiography Shows Large Discrepancies Depending on the Qualification of the Physician-Quantitative Evaluation of Interobserver Agreement in a Representative Emergency Department Scenario

(1) Background: Chest radiography (CXR) is still a key diagnostic component in the emergency department (ED). Correct interpretation is essential since some pathologies require urgent treatment. This study quantifies potential discrepancies in CXR analysis between radiologists and non-radiology physicians in training with ED experience. (2) Methods: Nine differently qualified physicians (three board-certified radiologists [BCR], three radiology residents [RR], and three non-radiology residents involved in ED [NRR]) evaluated a series of 563 posterior-anterior CXR images by quantifying suspicion for four relevant pathologies: pleural effusion, pneumothorax, pneumonia, and pulmonary nodules. Reading results were noted separately for each hemithorax on a Likert scale (0–4; 0: no suspicion of pathology, 4: safe existence of pathology) adding up to a total of 40,536 reported pathology suspicions. Interrater reliability/correlation and Kruskal–Wallis tests were performed for statistical analysis. (3) Results: While interrater reliability was good among radiologists, major discrepancies between radiologists’ and non-radiologists’ reading results could be observed in all pathologies. Highest overall interrater agreement was found for pneumothorax detection and lowest agreement in raising suspicion for malignancy suspicious nodules. Pleural effusion and pneumonia were often suspected with indifferent choices (1–3). In terms of pneumothorax detection, all readers mainly decided for a clear option (0 or 4). Interrater reliability was usually higher when evaluating the right hemithorax (all pathologies except pneumothorax). (4) Conclusions: Quantified CXR interrater reliability analysis displays a general uncertainty and strongly depends on medical training. NRR can benefit from radiology reporting in terms of time efficiency and diagnostic accuracy. CXR evaluation of long-time trained ED specialists has not been tested.

The Role of Lung Ultrasound Before and During the COVID-19 Pandemic: A review article

Lung ultrasound [LUS] has evolved considerably over the last years. The aim of the current review is to conduct a systematic review reported from a number of studies to show the usefulness of [LUS] and point of care ultrasound for diagnosing COVID-19. A systematic search of electronic data was conducted including the national library of medicine, and the national institute of medicine, PubMed Central [PMC] to identify the articles depended on [LUS] to monitor COVID-19. This review highlights the ultrasound findings reported in articles before the pandemic [11], clinical articles before COVID-19 [14], review studies during the pandemic [27], clinical cases during the pandemic [5] and other varying aims articles. The reviewed studies revealed that ultrasound findings can be used to help in the detection and staging of the disease. The common patterns observed included irregular and thickened A-lines, multiple B-lines ranging from focal to diffuse interstitial consolidation, and pleural effusion. Sub-plural consolidation is found to be associated with the progression of the disease and its complications. Pneumothorax was not recorded for COVID-19 patients. Further improvement in the diagnostic performance of [LUS] for COVID-19 patients can be achieved by using elastography, contrast-enhanced ultrasound, and power Doppler imaging.

Ultrasound use in the ICU for interventional pulmonology procedures

Critical care ultrasound has shifted the paradigm of thoracic imaging by enabling the treating physician to acquire and interpret images essential for clinical decision-making, at the bedside, in real-time. Once considered impossible, lung ultrasound based on interpretation of artifacts along with true images, has gained momentum during the last decade, as an integral part of rapid evaluation algorithms for acute respiratory failure, shock and cardiac arrest. Procedural ultrasound image guidance is a standard of care for both common bedside procedures, and advanced procedures within interventional pulmonologist’s (IP’s) scope of practice. From IP’s perspective, the lung, pleural, and chest wall ultrasound expertise is a prerequisite for mastery in pleural drainage techniques and transthoracic biopsies. Another ultrasound application of interest to the IP in the intensive care unit (ICU) setting is during percutaneous dilatational tracheostomy (PDT). As ICU demographics shift towards older and sicker patients, the indications for closed pleural drainage procedures, bedside transthoracic biopsies, and percutaneous dilatational tracheostomies have dramatically increased. Although ultrasound expertise is considered an essential IP operator skill there is no validated curriculum developed to address this component. Further, there is a need for developing an educational tool that matches up with the curriculum and could be integrated real-time with ultrasound-guided procedures.

Lung ultrasound: a narrative review and proposed protocol for patients admitted to Cardiac Rehabilitation Unit

Lung ultrasonography (LUS) has become in the last 10 years a technique that has reduced the need of second level diagnostic methods such as chest X-ray (CXR) and computerize tomography (CT) for the diagnostic imaging of lung and pleural space, throughout its diagnostic accuracy, radiation free, low cost, real time and bedside approach. The common use of LUS has been recently extend to cardiac and pulmonary disease even in context of Cardiac Rehabilitation Unit and it could be an additional tool for physiotherapist for the management of patients during Rehabilitation course. The authors performed a literature review in PubMed and suggested a new standardize protocol for LUS, based on guidelines and expert consensus document, for patients admitted to Cardiac Rehabilitation Unit. In this protocol, LUS should be performed in six scan each hemithorax, covering twelve imagine regions. For each scan will be noted a specific physiologic or pathological patterns. Furthermore, we suggest for each patient, the use of the Lung Ultrasound Score (LUS score) to obtain a global view of lung aeration and to monitor any changes during the hospitalization. An increase in score range indicates a more severe condition. This Lung Ultrasonography Protocol should be performed in all patients at the time of admission to Cardiac Rehabilitation Unit to monitoring the aeration of the lungs and the possible lung and/or pleura complications after a cardiac disease avoiding the use of second level surveys.

Ultrasound for Pleural Disease. Beyond a Pocket of Pleural Fluid

The evolution of pleural disease imaging modalities through the years has helped the scientific community understand and treat various disease states. Ultrasound (US) has been an image modality that has reigned superior to those used in the past such as chest X-ray and computed tomographic scan in terms of cost effectiveness, portability, and reduction in unwarranted radiation exposure to patients. Here we provide a succinct review of US use in pleural disease including imaging techniques, identifying safe pleural space for access, and predicting pleural fluid volume and etiology along with specificities regarding trapped lung identification and pleural mass biopsy. We believe bedside chest US is an adjunct to the physical exam adding superior diagnostic abilities. Further research is warranted in more specific aspects of sonographic use such as in fibrinolytic therapy management, evaluation for trapped lung, and the utility of specific modes like the color flow Doppler.

Ultrasound in central venous access for hemodialysis

Central venous cannulation is a frequent need for urgent or scheduled hemodialysis. Many studies confirmed the pivotal role of ultrasound in this procedure. Vascular access guidelines strongly recommend ultrasound guidance. Its usefulness has been demonstrated not only in reducing complications of venipuncture but more recently for the evaluation of central venous catheter (CVC) placement and real-time check for possible complications. The use of ultrasound requires a precise technique for the correct handling of the probe and the needle movement. Different approaches as the out-of-plane, in-plane, and oblique methods are available, enabling the most appropriate for the individual case. Although the learning curve for CVC ultrasound placement is usually fast, formal training and certification for beginners are strongly recommended.

Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP)

BACKGROUND

Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of "indirect" and "direct" cardiac and pulmonary lung ultrasound signs.

METHODS

LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged  >  65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns-each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5.

CONCLUSIONS

Lung ultrasound (LU), as a tool within the anesthesiologist's armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019.

Point-of-Care Thoracic Ultrasonography in Patients With Cirrhosis and Liver Failure

Point-of-care ultrasonography (POCUS) helps determine liver-related pathologies like an abscess, portal vein or hepatic vein thromboses, presence of ascites, site for pleural or ascitic paracentesis, and guiding biopsies. POCUS is revolutionizing the management of critically ill patients presenting with pneumonia, acute respiratory distress syndrome, acute-on-chronic liver failure, and in the emergency. The objectives of thoracic ultrasonography (TUS) are to aid the clinician in differentiating between pneumonia, effusions, interstitial edema and collections, and in estimating the volume status of patients with liver disease using inferior vena cava dynamic indices. The use of POCUS in patients with cirrhosis has since evolved. It is now widely used to help diagnose volume status, left ventricular diastolic dysfunction, myocardial infarction, and right ventricular dilation due to pulmonary embolism and to determine the causes for weaning failures such as effusions, lung collapse, and pneumothorax. During the Coronavirus Disease 2019 (COVID-19) pandemic, moving patients for computed tomography can be difficult. Therefore, TUS is now essential in liver transplantation and intensive care practice to assess ventilatory pressures, cardiac function, and fluid management. This review indicates the current and optimized use of TUS, offers a practical guide on TUS in the liver intensive care unit (ICU), and presents a diagnostic pathway for determining lung and pleural pathology, resolution of respiratory failure, and aid weaning from mechanical ventilation.

ACR Appropriateness Criteria® Intensive Care Unit Patients

Chest radiography is the most frequent and primary imaging modality in the intensive care unit (ICU), given its portability, rapid image acquisition, and availability of immediate information on the bedside preview. Due to the severity of underlying disease and frequent need of placement of monitoring devices, ICU patients are very likely to develop complications related to underlying disease process and interventions. Portable chest radiography in the ICU is an essential tool to monitor the disease process and the complications from interventions; however, it is subject to overuse especially in stable patients. Restricting the use of chest radiographs in the ICU to only when indicated has not been shown to cause harm. The emerging role of bedside point-of-care lung ultrasound performed by the clinicians is noted in the recent literature. The bedside lung ultrasound appears promising but needs cautious evaluation in the future to determine its role in ICU patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Efficacy of Ultrasonography in the Diagnosis of Transudative Pleural Fluids

AIMS

We aimed to evaluate the efficacy of thoracic ultrasonography (USG) in diagnosis of pleural exudates and transudates using pleural thickness (PT) measurement.

PATIENTS AND METHODS

Patients who underwent investigations for pleural fluid between January 2018 and May 2018 were included in this prospective study. The patients were evaluated using radiologic imaging modalities to detect pleural fluid, and PT was measured using thoracic USG. The patients were then divided into 2 groups according to Light's criteria as transudative pleural fluid (TPF) and exudative pleural fluid (EPF), and the results were compared between the groups.

RESULTS

A total of 73 patients were included in the study. The mean age was 62±15.1 years. Forty-eight patients (65.8%) had EPF and 25 (34.2%) had TPF. Thoracic USG revealed a mean PT of 0.3±0.1 cm in the TPF group and 0.6±0.3 cm in the EPF group (P<0.001). The optimal cut-off value for PT was 0.2 cm in the TPF group. The sensitivity and specificity of thoracic USG were calculated as 87.5% and 56%, respectively.

CONCLUSION

The measurement of PT using thoracic USG in this study has a high sensitivity but low specificity for identifying transudates from exudates. This approach may be useful in patients who refuse thoracentesis or have a contraindication for the procedure, and in emergency and intensive care unit settings. We recommend further studies to determine the efficacy of thoracic USG studies in patients with pleural fluids.

Lung Ultrasound: The Essentials

Although US of the lungs is increasingly used clinically, diagnostic radiologists are not routinely trained in its use and interpretation. Lung US is a highly sensitive and specific modality that aids in the evaluation of the lungs for many different abnormalities, including pneumonia, pleural effusion, pulmonary edema, and pneumothorax. This review provides an overview of lung US to equip the diagnostic radiologist with knowledge needed to interpret this increasingly used modality. Supplemental material is available for this article. © RSNA, 2021.

[Perioperative Anesthesiologic Management: Risk Assessment and Preoperative Improvement of Patient Conditions]

With patient safety being anesthesiologists' top priority, the focus of preoperative assessment must be to reduce perioperative morbidity and mortality of each patient entrusted to us. Perioperative risk is multifactorial and depends on the extent of surgery and the preoperative condition of the patient.The three main causes of unexpected perioperative death are cardiac arrest, hypoxemia and acute bleeding. Therefore, cardiac and pulmonary risk assessment should cover pre-existing conditions, patient's functional capacity and risk factors associated with the surgical procedure. Specific assessment tools have been developed, are easily accessible and have proven effective in every day clinical practice. Regarding the risk of bleeding, taking a detailed patients' history (including medication) seems to be more suitable to detect mild bleeding disorders than laboratory screening.Functional capacity, defined as the patient's ability to cope with everyday life, gains importance in preoperative risk assessment, as do further factors like deficiencies in nutrition, anaemia, physical capacity, the metabolic status or frailty in the elderly. Prehabilitation strategies reduce perioperative mortality and morbidity by improving functional capacity. These include preoperative nutrition supplementation, physical exercise, correction of iron deficiency and optimized treatment of hyperglycemia.A combination of thorough risk stratification and prehabilitation strategies can improve preoperative conditions and reduce complications in the postoperative period.

Point-of-Care Ultrasound: Applications in Low- and Middle-Income Countries

Purpose of Review

This review highlights the applications of point-of-care ultrasound in low- and middle-income countries and shows the diversity of ultrasound in the diagnosis and management of patients.

Recent Findings

There is a paucity of data on point-of-care ultrasound in anesthesiology in low- and middle-income countries. However, research has shown that point-of-care ultrasound can effectively help manage infectious diseases, as well as abdominal and pulmonary pathologies.

Summary

Point-of-care ultrasound is a low-cost imaging modality that can be used for the diagnosis and management of diseases that affect low- and middle-income countries. There is limited data on the use of ultrasound in anesthesiology, which provides clinicians and researchers opportunity to study its use during the perioperative period.

The new application of point-of-care lung ultrasound in guiding or assisting neonatal severe lung disease treatment based on a case series

Objective: Lung ultrasound (LUS) has been successfully used for neonatal lung disease diagnosis, as a non-invasive, free of radiation tool, the application of point-of-care LUS (POC-LUS) to diagnose lung disease has become a new trend worldwide. This paper was to introduce the new application of LUS to guide or assist the neonatal lung diseases treatment.Methods: Based on case series of our daily routine clinical work, in combining with the latest literatures, we introducing the new using field of POC-LUS in guiding the treatment of uninflated lung disease by bronchoalveolar lavage (BAL), guiding the treatment of severe pleural effusion and pneumothorax, guide the use of and weaning from mechanical ventilation, and in assessing the efficacy of exogenous pulmonary surfactant (PS) therapy.Results: The results of this study showed that the using rate of invasive ventilation and PS were decreased significantly, the duration of invasive ventilation was shortened significantly, the recovery of pleural effusion and pneumothorax were more quickly and safety, and finally a significantly shortened length of hospitalizations was obtained.Conclusions: LUS monitoring had significant effects in guiding the management of neonatal severe lung diseases, which with the worthy of extensive clinical application.

Clinical application of ultrasound-guided mediastinal lymph node biopsy through cervical mediastinoscopy

BACKGROUND

Cervical mediastinoscopy is useful for diagnosing lung and mediastinal disease. Ultrasound is a safe real-time diagnostic tool widely employed in many surgical fields. Ultrasound was used in cervical mediastinoscopy in our cohort with satisfactory results. This study investigated the safety, feasibility, and availability of video-assisted mediastinoscopy (VAM) combined with ultrasound for mediastinal lymph node biopsy.

METHODS

A total of 87 cases involving cervical mediastinal lymph node biopsy performed from November 2015 to May 2020, with complete clinical and pathological information, were retrospectively analyzed in the Department of Thoracic Surgery at Beijing Chaoyang Hospital. The cohort was divided into two groups: ultrasound-guided biopsy under video-assisted mediastinoscopy (UVAM) (44 cases) and routine VAM (43 cases). Operation time, biopsy number and nodal stations, postoperative complications, pathological conditions, and surgical difficulty were compared between the two nodal stations.

RESULTS

UVAM was significantly shorter and more lymph node specimens were obtained than with VAM. There was one case of fatal bleeding and two cases of right recurrent laryngeal nerve injury in the VAM group, and no postoperative complications in the UVAM group.

CONCLUSIONS

When used with cervical VAM, ultrasound guidance assists physicians assess the space between lymph nodes, surrounding tissues, and large vessels systematically, making biopsy safer and easier, improving lymph node sampling, and decreasing postoperative complications. Furthermore, surgeons can easily learn and master this method.

KEY POINTS

Significant findings of the study: Ultrasound was used in combination with cervical mediastinoscopy and the results showed that ultrasound guidance makes biopsy in patients safer and easier, improves lymph node sampling, and decreases postoperative complications.

WHAT THIS STUDY ADDS

Surgeons can easily learn and master this method.

Point of care and intensive care lung ultrasound: A reference guide for practitioners during COVID-19

Objectives

Current events with the recent COVID-19 outbreak are necessitating steep learning curves for the NHS workforce. Ultrasound, although not used in the diagnosis of COVID-19 may be utilised by practitioners at the point of care (POC) or on the intensive care units (ITUs) where rapid assessment of the lung condition may be required. The aim of this article was to review current literature surrounding the use of lung ultrasound in relation to COVID-19 and provide Sonographers with a quick and digestible reference guide for lung pathologies.

Key findings

Ultrasound is being used in Italy and China to help review lung condition during the COVID-19 outbreak however not strictly as a diagnostic tool as Computed Tomography (CT) of the chest and chest radiographs are currently gold standard. Ultrasound is highly sensitive in the detection of multiple lung pathologies which can be demonstrated in conjunction with COVID-19 however to date there are no specific, nor pathognomonic findings which relate to COVID-19 on ultrasound.

Conclusion

Lung ultrasound is highly sensitive and can quickly and accurately review lung condition creating potential to assess for changes or resolution over time, especially in the ITU and POC setting. However it should not be used as a diagnostic tool for COVID-19 due to low specificity in relation to the virus.

Implications for practice

The adoption of lung ultrasound to monitor lung condition during the COVID-19 outbreak may reduce the need for serial exposure to ionising radiation on the wards and in turn reduce the number of radiographers required to attend infected wards and bays, protecting both patients and the workforce.

Lung Ultrasound in Children with Respiratory Tract Infections: Viral, Bacterial or COVID-19? A Narrative Review

Respiratory tract infections (RTIs) are common complaints among patients presenting to the pediatric emergency department. In the diagnostic assessment of children with RTIs, many patients ultimately undergo imaging studies for further evaluation. Point-of-care lung ultrasound (LUS) can be used safely and with a high degree of accuracy in differentiating etiologies of RTIs in pediatric patients. Ultrasonographical features such as an irregular pleural line, subpleural consolidations, focal and lobar consolidation and signs of interstitial involvement can be used to distinguish between several pathologies. This work offers a comprehensive overview of pediatric LUS in cases of the most common pediatric RTIs including bacterial and viral pneumonia, bronchiolitis, and COVID-19.

Procalcitonin and lung ultrasound algorithm to diagnose severe pneumonia in critical paediatric patients (PROLUSP study). A randomised clinical trial

Background

Lung ultrasound (LUS) in combination with a biomarker has not yet been studied. We propose a clinical trial where the primary aims are: 1. To assess whether an algorithm with LUS and procalcitonin (PCT) may be useful for diagnosing bacterial pneumonia; 2. To analyse the sensitivity and specificity of LUS vs chest X-ray (CXR).

Methods/design

A 3-year clinical trial. Inclusion criteria: children younger than 18 years old with suspected pneumonia in a Paediatric Intensive Care Unit. Patients will be randomised into two groups: Experimental Group: LUS will be performed as first lung image. Control Group: CXR will be performed as first pulmonary image. Patients will be classified according to the image and the PCT: a) PCT < 1 ng/mL and LUS/CXR are not suggestive of bacterial pneumonia (BN), no antibiotic will be prescribed; b) LUS/CXR are suggestive of BN, regardless of the PCT, antibiotic therapy is recommended; c) LUS/CXR is not suggestive of BN and PCT > 1 ng/mL, antibiotic therapy is recommended.

Conclusion

This algorithm will help us to diagnose bacterial pneumonia and to prescribe the correct antibiotic treatment. A reduction of antibiotics per patient, of the treatment length, and of the exposure to ionizing radiation and in costs is expected.

Trial registration

NCT04217980.

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.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

The "pandemic" increase in lung ultrasound use in response to Covid-19: can we complement computed tomography findings? A narrative review

Coronavirus disease of 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has rapidly spread to a global pandemic in March 2020. This emergency condition has been putting a severe strain on healthcare systems worldwide, and a prompt, dynamic response is instrumental in its management. While a definite diagnosis is based on microbiological evidence, the relationship between lung ultrasound (LU) and high-resolution computed tomography (HRCT) in the diagnosis and management of COVID-19 is less clear. Lung ultrasound is a point-of-care imaging tool that proved to be useful in the identification and severity assessment of different pulmonary conditions, particularly in the setting of emergency and critical care patients in intensive care units; HRCT of the thorax is regarded as the mainstay of imaging evaluation of lung disorders, enabling characterization and quantification of pulmonary involvement. Aims of this review are to describe LU and chest HRCT main imaging features of COVID-19 pneumonia, and to provide state-of-the-art insights regarding the integrated role of these techniques in the clinical decision-making process of patients affected by this infectious disease.

Recommendations for Lung Ultrasound in Internal Medicine

A growing amount of evidence prompts us to update the first version of recommendations for lung ultrasound in internal medicine (POLLUS-IM) that was published in 2018. The recommendations were established in several stages, consisting of: literature review, assessment of literature data quality (with the application of QUADAS, QUADAS-2 and GRADE criteria) and expert evaluation carried out consistently with the modified Delphi method (three rounds of on-line discussions, followed by a secret ballot by the panel of experts after each completed discussion). Publications to be analyzed were selected from the following databases: Pubmed, Medline, OVID, and Embase. New reports published as of October 2019 were added to the existing POLLUS-IM database used for the original publication of 2018. Altogether, 528 publications were systematically reviewed, including 253 new reports published between September 2017 and October 2019. The new recommendations concern the following conditions and issues: pneumonia, heart failure, monitoring dialyzed patients' hydration status, assessment of pleural effusion, pulmonary embolism and diaphragm function assessment. POLLUS-IM 2020 recommendations were established primarily for clinicians who utilize lung ultrasound in their everyday clinical work.