The impact of lung ultrasound on clinical-decision making across departments: a systematic review

Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies

Point of Care ultrasound (POCUS) of the lungs, also known as lung ultrasound (LUS), has emerged as a technique that allows for the diagnosis of many respiratory pathologies with greater accuracy and speed compared to conventional techniques such as chest x-ray and auscultation. The goal of this narrative review is to provide a simple and practical approach to LUS for critical care, pulmonary, and anesthesia providers, as well as respiratory therapists and other health care providers to be able to implement this technique into their clinical practice. In this review, we will discuss the basic physics of LUS, provide a hands-on scanning technique, describe LUS findings seen in normal and pathological conditions (such as mainstem intubation, pneumothorax, atelectasis, pneumonia, aspiration, COPD exacerbation, cardiogenic pulmonary edema, ARDS, and pleural effusion) and also review the training necessary to achieve competence in LUS.

The Influence of Thoracic Ultrasound on the Clinical Practice of Pulmonologists in Portugal

BACKGROUND

Thoracic ultrasound (TUS) has garnered increased recognition, both in aiding pleural procedures and as a complement to physical examination. Operator ability is essential to obtain reliable findings. This study aimed to inquire pulmonology specialists and residents about their confidence with the technique and to determine future needs.

METHODS

A self-administered online survey, including a total of 24 questions, was sent to pulmonology specialists and residents registered as members of the Portuguese Pulmonology Society. Participation was pseudoanonymized and voluntary.

RESULTS

One hundred fourteen valid answers were obtained. Most responders had prior TUS training. The primary method for knowledge consolidation was unsupervised practice. The majority had an ultrasound machine available in their daily practice; only 17% performed TUS more than 3 times per week. Overall confidence in TUS usage for diagnostic purposes (median: 7/10), disease monitoring (median: 7/10), and invasive procedures (median: 8/10) were high. There was a significant relation between higher levels of confidence and regularly attending TUS courses and performing TUS more than 3 times per week. The main reasons cited as preventing regular use of TUS were the availability/cost of courses and the availability/cost of equipment.

CONCLUSION

Regular TUS training and utilization are essential to boost user's confidence degree. Its use is already a regular feature in the daily practice of pulmonologists in Portugal, but further and better structured training is required to meet the needs of clinicians. The inclusion of mandatory TUS training in residency programs should be considered in the future.

Integration of Diagnostic Lung Ultrasound Into Clinical Practice by Hospitalists in an Academic Medical Center: A Retrospective Chart Review

Background Point-of-care lung ultrasound (LUS) is a guideline-recommended imaging modality that has been shown to be more accurate than chest radiography for multiple causes of dyspnea. This study was conducted to understand the impact of LUS on real-world clinical decision-making among hospitalists. Methods  A retrospective chart review was conducted of patients who received a LUS while hospitalized at a quaternary care academic medical center between July 2020 and June 2022. Data was extracted from the electronic health record (EHR) into a standardized REDCap form. Cases were defined as patients who had received a LUS that (1) had images archived and accessible to viewing through the EHR and (2) had an imaging report documented in the EHR. Results Of the 820 LUSs reviewed, 297 (36.2%) were performed to evaluate for appropriateness of thoracentesis, 205 (25%) for diagnosing or monitoring of pneumonia related to COVID-19, 169 (20.6%) for volume status assessment, 136 (16.6%) for worsening respiratory status, 114 (13.9%) for monitoring pleural effusions, 64 (7.8%) for diagnosing or monitoring of pneumonia not related to COVID-19, and 12 (1.5%) for monitoring of diuresis. Documentation was sufficient to determine clinical decision-making in 730 (89%) of LUSs reviewed, 739 (90.1%) were considered to be diagnostically useful, and 327 (39.9%) changed management. Conclusions These findings suggest LUS was diagnostically useful and routinely changed management in hospitalist practice. Further, documentation in the EHR was sufficient to allow for the evaluation of real-world clinical decision-making using LUS, which is an important gap in both the education and health services research literature.

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.

American Society of Echocardiography COVID-19 Statement Update: Lessons Learned and Preparation for Future Pandemics

The COVID-19 pandemic has evolved since the publication of the initial American Society of Echocardiography (ASE) statements providing guidance to echocardiography laboratories. In light of new developments, the ASE convened a diverse, expert writing group to address the current state of the COVID-19 pandemic and to apply lessons learned to echocardiography laboratory operations in future pandemics. This statement addresses important areas specifically impacted by the current and future pandemics: (1) indications for echocardiography, (2) application of echocardiographic services in a pandemic, (3) infection/transmission mitigation strategies, (4) role of cardiac point-of-care ultrasound/critical care echocardiography, and (5) training in echocardiography.

Validating a Simplified Lung Ultrasound Protocol for Detection and Quantification of Pulmonary Edema in Patients With Chronic Kidney Disease Receiving Maintenance Hemodialysis

OBJECTIVES

Pulmonary edema is a common clinical problem and lung ultrasound (LUS) presents an efficient method for evaluating this pathology. This study aims to investigate if a clinically efficient LUS protocol can quantify the level of extravascular lung fluid in patients receiving hemodialysis, and to develop a simplified B-line scoring system based on this protocol.

METHODS

A simple 8-area LUS approach was used for the assessment of the extravascular fluid status in patients before, during, and after receiving hemodialysis. The LUS assessments were compared to the amount of removed fluid over time. To determine the best B-line score system, different scorings for each zone were tested in a linear mixed model with pseudo R-square model fit against removed fluid. The B-line score was further validated through correlations with changes in oxygen saturation, grade of dyspnea, and body weight over time.

RESULTS

A total of 53 patients were included and examined on 108 hemodialysis occasions. Median fluid removal was 2.3 L. The B-line score model with best fit was a score of 0 points in a zone with 0 or 1 B-lines, 1 point with 2 or 3 B-lines, 2 points with 3 or more B-lines, and 3 points with any interstitial confluence. Using this B-line score, we found a significant association with amount of removed fluid, oxygen saturation, grade of dyspnea, and change in body weight.

CONCLUSION

A straightforward protocol for LUS and B-line score system was shown valid for quantification of pulmonary edema and fluid removal in hemodialysis patients. The scoring system developed here can be useful also in other patient groups, but this requires further validation.

Lung Ultrasound in Critical Care and Emergency Medicine: Clinical Review

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.

B-mode ultrasound and contrast-enhanced ultrasound for evaluation of pneumonia: A pictorial essay

Due to their often peripheral pleural-based location, pneumonias can be visualised by B-mode ultrasound. Therefore, sonography can be used as an alternative imaging modality to chest X-ray in suspected cases of pneumonia. Depending on the clinical background of the patient, and various underlying pathological mechanisms, a heterogeneous pattern of pneumonia is seen in both B-mode lung ultrasound and contrast-enhanced ultrasound. Here, we describe the spectrum of sonographic manifestations of pneumonic/inflammatory consolidation on B-mode lung ultrasound and contrast-enhanced ultrasound.

Effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients (CONFIDENCE): protocol for a multicentre randomised controlled trial

BACKGROUND

Fluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28.

METHODS

The "effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients" (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician's discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1-7 after randomisation and on days 1-7 after start of LUS examination; mean serum lactate on days 1-7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28.

DISCUSSION

The CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05188092. Registered since January 12, 2022.

The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study

OBJECTIVES

To investigate the impact of thoracic ultrasound (TUS) examinations on clinical management in adult ICU patients.

DESIGN

A prospective international observational study.

SETTING

Four centers in The Netherlands and Italy.

PATIENTS

Adult ICU patients (> 18 yr) that received a clinically indicated lung ultrasound examination.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinicians performing TUS completed a pre- and post-examination case report form. Patient characteristics, TUS, and resulting clinical effects were recorded. First, change of management, defined as a TUS-induced change in clinical impression leading to a change in treatment plan, was reported. Second, execution of intended management changes within 8 hours was verified. Third, change in fluid balance after 8 hours was calculated. A total of 725 TUS performed by 111 operators across 534 patients (mean age 63 ± 15.0, 70% male) were included. Almost half of TUS caused a change in clinical impression, which resulted in change of management in 39% of cases. The remainder of TUS confirmed the clinical impression, while a minority (4%) did not contribute. Eighty-nine percent of management changes indicated by TUS were executed within 8 hours. TUS examinations that led to a change in fluid management also led to distinct and appropriate changes in patient's fluid balance.

CONCLUSIONS

In this international observational study in adult ICU patients, use of TUS had a major impact on clinical management. These results provide grounds for future randomized controlled trials to determine if TUS-induced changes in decision-making also lead to improved health outcomes.

Advanced Point-of-care Bedside Monitoring for Acute Respiratory Failure

Advanced respiratory monitoring involves several mini- or noninvasive tools, applicable at bedside, focused on assessing lung aeration and morphology, lung recruitment and overdistention, ventilation-perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator asynchrony, in dealing with acute respiratory failure. Compared to a conventional approach, advanced respiratory monitoring has the potential to provide more insights into the pathologic modifications of lung aeration induced by the underlying disease, follow the response to therapies, and support clinicians in setting up a respiratory support strategy aimed at protecting the lung and respiratory muscles. Thus, in the clinical management of the acute respiratory failure, advanced respiratory monitoring could play a key role when a therapeutic strategy, relying on individualization of the treatments, is adopted.

A proposed framework for point of care lung ultrasound by respiratory physiotherapists: scope of practice, education and governance

Background

Point of care ultrasound (PoCUS) has the potential to provide a step change in the management of patients across a range of healthcare settings. Increasingly, healthcare practitioners who are not medical doctors are incorporating PoCUS into their clinical practice. However, the professional, educational and regulatory environment in which this occurs is poorly developed, leaving clinicians, managers and patients at risk.

Main body

Drawing upon existing medical and non-medical literature, the authors present a proposed framework for the use of PoCUS. Throughout, mechanisms for applying the principles to other professionals and healthcare settings are signposted. Application of the framework is illustrated via one such group of healthcare practitioners and in a particular healthcare setting: respiratory physiotherapists in the UK.

In defining the point of care LUS scope of practice we detail what structures are imaged, differentials reported upon and clinical decisions informed by their imaging. This is used to outline the educational and competency requirements for respiratory physiotherapists to safely and effectively use the modality. Together, these are aligned with the regulatory (professional, legal and insurance) arrangements for this professional group in the UK.

In so doing, a comprehensive approach for respiratory physiotherapists to consolidate and expand their use of point of care LUS is presented. This provides clarity for clinicians as to the boundaries of their practice and how to train in the modality; it supports educators with the design of courses and alignment of competency assessments; it supports managers with the staffing of existing and new care pathways. Ultimately it provides greater accessibility for patients to safe and effective point of care lung ultrasound.

For clinicians who are not respiratory physiotherapists and/or are not based in the UK, the framework can be adapted to other professional groups using point of care LUS as well as other point of care ultrasound (PoCUS) applications, thereby providing a comprehensive and sustainable foundation for PoCUS consolidation and expansion.

Conclusion

This paper presents a comprehensive framework to support the use of point of care LUS by respiratory physiotherapists in the UK. Mechanisms to adapt the model to support a wide range of other PoCUS users are outlined.

Routine Application of Lung Ultrasonography in Respiratory Care: Knowledge, Perceptions, and Barriers to Instigate

Background

Lung Ultrasound (LUS) had proved to be beneficial in detecting respiratory disorders at the bedside. Understanding the important role of Respiratory Therapists (RTs) in the critical care, we aimed to assess their knowledge, perceived relevance of LUS to clinical practice, current skill gaps, and barriers to practice.

Methods

A cross-sectional, nationwide survey conducted among the RTs working in the Kingdom of Saudi Arabia. The validated questionnaire included 4 sections; the demographics, knowledge and perceptions, applicability and self-reported proficiency, and barriers to the use of LUS by RTs.

Results

A total of 256 RTs across different regions of Saudi Arabia participated in this survey. 71.9% of them were males, and 46.1% of the participants were having <5 years of working experience. Only (18.1%) of the participants used LUS in their clinical practice, and (43%) of them had never received any training. 66% of the participants perceived LUS as an effective tool in the RT practice and immensely valuable in their daily practice (70%). A large proportion of RTs perceived LUS to be ineffective in calculating the lung score (50.4%), assessing the diaphragm (40.2%), and detecting pulmonary edema (38.3%). Calculating lung score has a lower mean score of 2.55 on both skills, and identifying its applicability to clinical practice with a mean score of 2.71 than other indications. Lack of training and curriculum (154/256; 60.2%) remains the top barrier that prevented RTs from using LUS in their clinical practice.

Conclusion

While many RTs in Saudi Arabia perceived LUS as an effective tool in the RT practice, considerable competence gap exist, indicating the need for LUS training. There is a need for incorporating LUS into the curriculum of RT schools and promoting competency-based training for the current RT workforce to help improve patient care.