Sonographic chest B-lines anticipate elevated B-type natriuretic peptide level, irrespective of ejection fraction

To B or not to B. The rationale for quantifying B-lines in pediatric lung diseases

Lung ultrasound (LUS) is emerging as adjunct tool to be used during clinical assessment. Among the different hallmarks of LUS, B-lines are well known artifacts, which are not correlated with identifiable structures, but which can be used for pathological classification. The presence of multiple B-lines is a sonographic sign of lung interstitial syndrome. It has been demonstrated in adults that there is a direct correlation between the number of B-lines and the severity of the interstitial involvement of lung disease. Counting B-lines is an attempt to enrich the clinical assessment and clinical information, beyond obtaining a simple dichotomous answer. Semiquantitative or quantitative B-line assessment has been shown to correlate with fluid overload and demonstrated prognostic implications in specific neonatal and pediatric conditions. LUS with quantitative B-lines assessment is promising. Current evidence allows for quantification of B-lines in a limited number of neonatal and pediatric diseases.

[Prognostic value of the absolute decrease of the N-terminal portion of B-type natriuretic propeptide in decompensated heart failure: secondary analysis of the CLUSTER-HF study]

Objective

The purpose of this study is to determine the prognostic value of the absolute decrease in the N-terminal portion of pro-B-type natriuretic peptide (NT-proBNP) to prevent fewer clinical events, in the population of CLUSTER-HF (efficacy of ultrasound lung to guide therapy and prevent readmissions in heart failure).

Materials and methods

This study was conducted in a subgroup of ninety-four patients with available NT-proBNP information at hospital discharge and prior to randomization in the CLUSTER-HF study. The primary objective of the study was to determine the prognostic value of absolute NT-proBNP decline below which fewer events of all-cause death, emergency room visits, and rehospitalization for heart failure at 180 days.

Results

The absolute decrease in NT-proBNP below 3,350 pg/mL has a moderate discriminative capacity with AUC= 0.602, with a prognostic value in the combined event at 180 days (log-rank test, p=0.01). Also, according to the multivariable analysis, it is an independent marker of clinical events at 180 days OR 0.319 (0.102-0.995, p=0.04) above other clinical variables.

Conclusions

An absolute decrease to 3,350 pg/mL of NT-proBNP or less at discharge from the hospitalization due to heart failure, was associated with fewer clinical events at 180 days.

An Interpretable Object Detection-Based Model For The Diagnosis Of Neonatal Lung Diseases Using Ultrasound Images

Over the last few decades, Lung Ultrasound (LUS) has been increasingly used to diagnose and monitor different lung diseases in neonates. It is a noninvasive tool that allows a fast bedside examination while minimally handling the neonate. Acquiring a LUS scan is easy, but understanding the artifacts concerned with each respiratory disease is challenging. Mixed artifact patterns found in different respiratory diseases may limit LUS readability by the operator. While machine learning (ML), especially deep learning can assist in automated analysis, simply feeding the ultrasound images to an ML model for diagnosis is not enough to earn the trust of medical professionals. The algorithm should output LUS features that are familiar to the operator instead. Therefore, in this paper we present a unique approach for extracting seven meaningful LUS features that can be easily associated with a specific pathological lung condition: Normal pleura, irregular pleura, thick pleura, A- lines, Coalescent B-lines, Separate B-lines and Consolidations. These artifacts can lead to early prediction of infants developing later respiratory distress symptoms. A single multi-class region proposal-based object detection model faster-RCNN (fRCNN) was trained on lower posterior lung ultrasound videos to detect these LUS features which are further linked to four common neonatal diseases. Our results show that fRCNN surpasses single stage models such as RetinaNet and can successfully detect the aforementioned LUS features with a mean average precision of 86.4%. Instead of a fully automatic diagnosis from images without any interpretability, detection of such LUS features leave the ultimate control of diagnosis to the clinician, which can result in a more trustworthy intelligent system.

Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians

BACKGROUND

Dyspnea is a common and often debilitating symptom with a complex diagnostic work-up.

PURPOSE

To evaluate the benefits, harms, and diagnostic test accuracy of point-of-care ultrasonography (POCUS) in patients with acute dyspnea. (PROSPERO: CRD42019126419).

DATA SOURCES

Searches of multiple electronic databases without language limitations (January 2004 to August 2020) and reference lists of pertinent articles and reviews.

STUDY SELECTION

Five randomized controlled trials (RCTs) and 44 prospective cohort-type studies in patients with acute dyspnea evaluated POCUS as a diagnostic tool to determine the underlying cause of dyspnea. Two investigators independently screened the literature for inclusion.

DATA EXTRACTION

Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias and determined certainty of evidence.

DATA SYNTHESIS

Point-of-care ultrasonography, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses in patients with dyspnea than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests. Finally, POCUS consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax; specificities increased in most but not all studies.

LIMITATIONS

Most studies assessed diagnostic test accuracy, which has limited utility for clinical decision making. Studies rarely reported on the proportion of indeterminate sonography results, and no evidence is available on adverse health outcomes of false-positive or false-negative POCUS results.

CONCLUSION

Point-of-care ultrasonography can improve the correctness of diagnosis in patients with acute dyspnea.

PRIMARY FUNDING SOURCE

American College of Physicians.

Assessment and Management of Volume Overload Among Patients on Chronic Dialysis

Volume overload is the most common complication in end-stage renal disease (ESRD) patients, being directly related to numerous complications including resistant hypertension, cardiac hypertrophy, congestive heart failure or arterial stiffness, among others. Therefore, volume overload is now considered an important risk factor for hard outcomes, like all-cause or cardiovascular mortality. Relying solely on clinical examination for assessing volume overload in ESRD patients lacks sensitivity and specificity. Numerous efforts have been made to identify new methods that could objectively assess volume status; however, each of them has important limitations. This review aims to discuss the most frequently used methods (biomarkers, inferior vena cava assessment, lung ultrasonography, bioimpedance analysis and blood volume monitoring) and to compare the advantage of each method vs. the overall/ clinical strategy.

Modified BLUE protocol ultrasonography can diagnose thrombotic complications of COVID-19 with normal lung ultrasound

The BLUE protocol provides an excellent step-by-step approach for diagnosis of acute dyspnea. Adding FECHO (Focused Echocardiography) to the BLUE protocol completes the picture and helps make solid diagnoses, especially in submassive and massive PE (Pulmonary embolism). COVID-19 infection can present with thrombotic manifestations like DVT (Deep vein thrombosis) and PE with no ultrasonographic evidence of lung parenchymal affection.

Lung Ultrasound Eight-Point Method in Diagnosing Acute Heart Failure in Emergency Patients with Acute Dyspnea: Diagnostic Accuracy and 72 h Monitoring

Background and Objectives: Acute dyspnea is a common chief complaint in the emergency department (ED), with acute heart failure (AHF) as a frequent underlying disease. Early diagnosis and rapid therapy are highly recommended by international guidelines. This study evaluates the accuracy of point-of-care B-line lung ultrasound in diagnosing AHF and monitoring the therapeutic success of heart failure patients. Materials and Methods: This is a prospective mono-center study in adult patients presenting with undifferentiated acute dyspnea to a German ED. An eight-zone pulmonary ultrasound was performed by experienced sonographers in the ED and 24 and 72 h after. Along with the lung ultrasound evaluation patients were asked to assess the severity of shortness of breath on a numeric rating scale. The treating ED physicians were asked to assess the probability of AHF as the underlying cause. Final diagnosis was adjudicated by two independent experts. Follow-up was done after 30 and 180 days. Results: In total, 102 patients were enrolled. Of them, 89 patients received lung ultrasound evaluation in the ED. The sensitivity of lung ultrasound evaluation in ED in diagnosing AHF was 54.2%, specificity 97.6%. As much as 96.3% of patients with a positive LUS test result for AHF in ED actually suffered from AHF. Excluding diuretically pretreated patients, sensitivity of LUS increased to 75% in ED. Differences in the sum of B-lines between admission time point, 24 and 72 h were not statistically significant. There were no statistically significant differences in the subjectively assessed severity of dyspnea between AHF patients and those with other causes of dyspnea. Of the 89 patients, 48 patients received the final adjudicated diagnosis of AHF. ED physicians assessed the probability of AHF in patients with a final diagnosis of AHF as 70%. Roughly a quarter (23.9%) of the overall cohort patients were rehospitalized within 30 days after admission, 38.6% within 180 days of follow-up. Conclusion: In conclusion, point-of-care lung ultrasound is a helpful tool for the early rule-in of acute heart failure in ED but only partially suitable for exclusion. Of note, the present study shows no significant changes in the number of B-lines after 24 and 72 h.

Lung Ultrasound B-lines Occurrence in Relation to Left Ventricular Function and Hydration Status in Hemodialysis Patients

Background and objective: Reliable assessment of the fluid status in hemodialysis (HD) patients is often difficult. A lung ultrasound with an assessment of the B-lines (“lung comets” (LCs)) number is a novel hydration status measure. However, the occurrence of left ventricular dysfunction may have a significant effect on pulmonary congestion and further modulate the LC number. The aim of this study was to analyze to what extent left ventricular dysfunction, pulmonary hypertension, and hypervolemia affect the occurrence of LC in a cohort of prevalent HD patients. Material and methods: This cross-sectional study included 108 assessments performed in 54 patients who attended thrice weekly outpatient HD. Each patient’s fluid status was evaluated twice, prior to HD sessions, using echocardiography, LC number assessment, measurement of inferior vena cava (IVC) diameters, and bioelectric impedance analysis (BIA). Patients were stratified into three subgroups according to their LC number. Results: There were 76 separate assessments with mild (<14), 16 with moderate (14–30), and 16 with severe (>30) LC occurrence. There was a negative correlation between the LC number and left ventricular ejection fraction (LVEF), and positive correlations between the LC number and mitral gradient, and the left and right atrium area and volume, but not with the BIA-derived relative fluid overload. Multivariate linear regression analysis revealed that the LC number was proportionally related to the mitral gradient (β = 0.407 (0.247–0.567), p < 0.001) and IVC max diameter (β = 0.219 (0.060–0.378), p < 0.01), and was inversely related to LVEF (β = −0.431 (−0.580 to −0.282), p < 0.001). Conclusions: The number of LCs appears to reflect both overhydration and left ventricular dysfunction in our HD patients cohort. Therefore, heart failure must be considered as an important factor limiting the usefulness of LCs number assessment in this population.

A Simplified Ultrasound Comet Tail Grading Scoring to Assess Pulmonary Congestion in Patients with Heart Failure

Ultrasound lung comets (ULCs) are a nonionizing bedside approach to assess extravascular lung water. We evaluated a protocol for grading ULC score to estimate pulmonary congestion in heart failure patients and investigated clinical and echocardiographic correlates of the ULC score. Ninety-three patients with congestive heart failure, admitted to the emergency department, underwent pulmonary ultrasound and echocardiography. A ULC score was obtained by summing the ULC scores of 7 zones of anterolateral chest scans. The results of ULC score were compared with echocardiographic results, the New York Heart Association (NYHA) functional classification, radiologic score, and N-terminal pro-b-type natriuretic peptide (NT-proBNP). Positive linear correlations were found between the 7-zone ULC score and the following: E/e′, systolic pulmonary artery pressure, severity of mitral regurgitation, left ventricular global longitudinal strain, NYHA functional classification, radiologic score, and NT-proBNP. However, there was no significant correlation between ULC score and left ventricular ejection fraction, left ventricle diameter, left ventricular volume, or left atrial volume. A multivariate analysis identified the E/e′, systolic pulmonary artery pressure, and radiologic score as the only independent variables associated with ULC score increase. The simplified 7-zone ULC score is a rapid and noninvasive method to assess lung congestion. Diastolic rather than systolic performance may be the most important determinant of the degree of lung congestion in patients with heart failure.

Lung ultrasound B-lines in exacerbations of chronic obstructive pulmonary disease

We report on preliminary observations on performing lung ultrasound (LUS) in patients admitted to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD). We found that LUS had high specificity and moderate sensitivity in identifying patients with elevated B-type natriuretic peptide. Thus, we hypothesise that LUS may have utility in screening COPD patients with an exacerbation to identify the sub-group with elevated natriuretic peptides and are at risk of increased cardiovascular mortality. The use of LUS in patients with acute and chronic respiratory disorders is increasing and its role in COPD patients is an interesting subject for future research.

Diagnostic value of brain natriuretic peptide and β-endorphin plasma concentration changes in patients with acute left heart failure and atrial fibrillation

RATIONALE

This study aims to evaluate the diagnostic value of beta-endorphin (β-EP) and brain natriuretic peptid (BNP) plasma concentrations for the early diagnosis of acute left heart failure and atrial fibrillation.

PATIENT CONCERNS

A total of 45 patients were included. These patients comprised 23 male and 22 female patients,and 20 healthy subjects who underwent physical examinations in the Outpatient Department during the same periodwere included and assigned to the control group.

DIAGNOSES

The diagnos stand was that of the Chinese guidelines for the diagnosis and treatment of heart failure.

INTERVENTIONS

Enzyme-linked immunosorbent assay was performed to detect the plasma concentration of β-EP and BNP in the treatment and control groups, and electrocardiogram targeting was performed to determine the left ventricular ejection fraction (LVEF).

OUTCOMES

BNP, β-EP, and LVEF levels were higher in the treatment group (688.01 ± 305.78 ng/L, 394.06 ± 180.97 ng/L, and 70.48 ± 16.62%) compared with the control group (33.90 ± 8.50 ng/L, 76.87 ± 57.21 ng/L, and 32.11 ± 5.25%). The P-values were .015, .019, and .026, respectively, which were <.05. The difference was statistically significant. The BNP and β-EP's 4 correlations (r = 0.895, P <.001), BNP, β-EP, and the combination of BNP and β-EP for acute left heart failure diagnosis in maximizing Youden index sensitivity, specific degree, area under the ROC curve (AUC), and 95% confidence interval (CI) were respectively 93.5%, 81.3%, 0.921, 0.841, 0.921; 80.5%, 78.6%, 0.697, 0.505, 0.697; 94.1%, 83.5%, 0.604 to 0.979, and 0.604. Acute left heart failure in patients with LVEF acuity plasma BNP and β-EP 50% group was obviously lower than that in the LVEF <50% group (P <.01). BNP, β-EP, and LVEF were negatively correlated (r = -0.741, -0.635, P = .013, .018).

LESSONS

β-EP and BNP have high specificity and sensitivity for detecting early acute left heart failure and atrial fibrillation in patients, which is convenient, easy to perform, and suitable for clinical applications.

Accuracy of Point-of-Care B-Line Lung Ultrasound in Comparison to NT-ProBNP for Screening Acute Heart Failure

AIM

The objective of this pilot study was to determine the accuracy of point-of-care B-line lung ultrasound in comparison to NT Pro-BNP for screening acute heart failure.

MATERIALS AND METHODS

An 8-zone lung ultrasound was performed by experienced sonographers in patients presenting with acute dyspnea in the ED. AHF was determined as the final diagnosis by 2 independent reviewers.

RESULTS

Contrary to prior studies, B-line ultrasound in our study was highly specific, but moderately sensitive for identifying patients with AHF. There was a strong association between elevated NT-proBNP levels and an increased number of B-lines.

CONCLUSION

In conclusion, point-of-care lung ultrasound is a helpful tool for ruling in or ruling out important differential diagnoses in ED patients with acute dyspnea.