Pleural ultrasound compared with chest radiographic detection of pneumothorax resolution after drainage

The Impact of Respiratory Therapist Performed Point-of-Care Lung Ultrasound on the Respiratory Care in Neonates, Manitoba Experience, Canada

OBJECTIVE

We aimed to evaluate the impact of the registered respiratory therapist (RRT) performed point-of-care lung ultrasound (POC-LUS) on patient management in the neonatal intensive care unit (NICU).

STUDY DESIGN

This is a retrospective cohort study of neonates who had RRT performed POC-LUS in two level III NICUs in Winnipeg, Manitoba, Canada. The analysis aims mainly to describe the implementation process of the POC-LUS program. The primary outcome was the prediction of the change in clinical management.

RESULTS

A total of 136 neonates underwent 171 POC-LUS studies during the study period. POC-LUS resulted in a change in clinical management following 113 POC-LUS studies (66%), while it supported continuing the same management in 58 studies (34%). The lung ultrasound severity score (LUSsc) was significantly higher in the group with worsening hypoxemic respiratory failure and on respiratory support than infants on respiratory support and stable or not on respiratory support, p < 0.0001. LUSsc was significantly higher in infants on either noninvasive or invasive than those not on respiratory support, p-value <0.0001.

CONCLUSION

RRT performed POC-LUS service utilization in Manitoba improved and guided the clinical management of a significant proportion of patients who received the service.

Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study

BACKGROUND

There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications.

OBJECTIVES

To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber.

DESIGN AND SETTING

A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil.

METHODS

Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups.

RESULTS

Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively.

CONCLUSIONS

Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe.

REGISTRATION

RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Pneumothorax detection with thoracic ultrasound as the method of choice in interventional pulmonology - A retrospective single-center analysis and experience

BACKGROUND

Recent studies have shown that thoracic ultrasound (TUS) is not inferior to chest radiography (CR) in detecting pneumothorax (PTX). It is unclear if adopting TUS can reduce the number of CR in the daily clinical routine. This retrospective study investigates the utilization of post-interventional CR and TUS for PTX detection after the introduction of TUS as the method of choice in an interventional pulmonology unit.

METHODS

All interventions with CR or TUS for ruling out PTX performed in the Pneumology Department of the University Hospital Halle (Germany) 2014 to 2020 were included. The documented TUS and CR performed before (period A) and after the introduction of TUS as the method of choice (period B), as well as the number of diagnosed and missed PTX were recorded.

RESULTS

The study included 754 interventions (110 in period A and 644 in period B). The proportion of CR decreased from 98.2% (n = 108) to 25.8% (n = 166) (p < 0.001). During period B, a total of 29 (4.5%) PTX were diagnosed. Of these, 28 (96.6%) were detected on initial imaging (14 by CR, 14 by TUS ). One PTX (0.2%) was initially missed by TUS, none by CR. Confirmatory investigations were ordered more frequently after TUS (21 of 478, 4.4%) than after CR (3 of 166, 1.8%).

CONCLUSION

The use of TUS in interventional pulmonology can effectively reduce the number of CR and thus save resources. However, CR may still be favored in specific circumstances or if pre-existing conditions limit sonographic findings.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

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.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

Point of care lung ultrasound service in neonatal intensive care: Five years of experience in Manitoba, Canada

OBJECTIVE

To evaluate the utility of a point of care lung ultrasound (POC-LUS) on patient management in the Neonatal Intensive Care Unit (NICU).

STUDY DESIGN

A retrospective cohort study of neonates who had POC-LUS from 2016 to 2020 in two-level III NICUs in Winnipeg, Manitoba, Canada. The primary outcome was the change in clinical management. The analysis aims mainly to describe the implementation process of the POC-LUS program.

RESULTS

A total of 956 neonates underwent 4076 POC-LUS studies during the study period. The number of POC-LUS studies increased significantly every year, from 316 (in 2016) to 1257 (in 2020) (p < 0.001). POC-LUS resulted in a change in clinical management following 2528 POC-LUS studies (62%), while it supported continuing the same management in 1548 studies (38%).

CONCLUSION

POC-LUS in Manitoba increased since its inception and led to an alteration in the clinical management in a significant proportion of patients who received the service.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

ABSTRACT

This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

LEVEL OF EVIDENCE

Consensus algorithm from the Western Trauma Association, Level V.

Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care expert consensus statement on the use of lung ultrasound in critically ill patients with coronavirus disease 2019 (ITACO)

Background

To produce statements based on the available evidence and an expert consensus (as members of the Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care, SIAARTI) on the use of lung ultrasound for the management of patients with COVID-19 admitted to the intensive care unit.

Methods

A modified Delphi method was applied by a panel of anesthesiologists and intensive care physicians expert in the use of lung ultrasound in COVID-19 intensive critically ill patients to reach a consensus on ten clinical questions concerning the role of lung ultrasound in the following: COVID-19 diagnosis and monitoring (with and without invasive mechanical ventilation), positive end expiratory pressure titration, the use of prone position, the early diagnosis of pneumothorax- or ventilator-associated pneumonia, the process of weaning from invasive mechanical ventilation, and the need for radiologic chest imaging.

Results

A total of 20 statements were produced by the panel. Agreement was reached on 18 out of 20 statements (scoring 7–9; “appropriate”) in the first round of voting, while 2 statements required a second round for agreement to be reached. At the end of the two Delphi rounds, the median score for the 20 statements was 8.5 [IQR 8.9], and the agreement percentage was 100%.

Conclusion

The Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care produced 20 consensus statements on the use of lung ultrasound in COVID-19 patients admitted to the ICU. This expert consensus strongly suggests integrating lung ultrasound findings in the clinical management of critically ill COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44158-021-00015-6.

European Respiratory Society statement on thoracic ultrasound

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Pipeline for Advanced Contrast Enhancement (PACE) of Chest X-ray in Evaluating COVID-19 Patients by Combining Bidimensional Empirical Mode Decomposition and Contrast Limited Adaptive Histogram Equalization (CLAHE)

COVID-19 is a new pulmonary disease which is driving stress to the hospitals due to the large number of cases worldwide. Imaging of lungs can play a key role in the monitoring of health status. Non-contrast chest computed tomography (CT) has been used for this purpose, mainly in China, with significant success. However, this approach cannot be massively used, mainly for both high risk and cost, also in some countries, this tool is not extensively available. Alternatively, chest X-ray, although less sensitive than CT-scan, can provide important information about the evolution of pulmonary involvement during the disease; this aspect is very important to verify the response of a patient to treatments. Here, we show how to improve the sensitivity of chest X-ray via a nonlinear post-processing tool, named PACE (Pipeline for Advanced Contrast Enhancement), combining properly Fast and Adaptive Bidimensional Empirical Mode Decomposition (FABEMD) and Contrast Limited Adaptive Histogram Equalization (CLAHE). The results show an enhancement of the image contrast as confirmed by three widely used metrics: (i) contrast improvement index, (ii) entropy, and (iii) measure of enhancement. This improvement gives rise to a detectability of more lung lesions as identified by two radiologists, who evaluated the images separately, and confirmed by CT-scans. The results show this method is a flexible and an effective approach for medical image enhancement and can be used as a post-processing tool for medical image understanding and analysis.

Feasibility and efficacy of lung ultrasound to investigate pulmonary complications in patients who developed postoperative Hypoxaemia-a prospective study

Background

Postoperative pulmonary complications (PPCs) and hypoxaemia are associated with morbidity and mortality. We aimed to evaluate the feasibility and efficacy of lung ultrasound (LUS) to diagnose PPCs in patients suffering from hypoxaemia after general anaesthesia and compare the results to those of thoracic computed tomography (CT).

Methods

Adult patients who received general anaesthesia and suffered from hypoxaemia in the postanaesthesia care unit (PACU) were analysed. Hypoxaemia was defined as an oxygen saturation measured by pulse oximetry (SPO₂) less than 92% for more than 30 s under ambient air conditions. LUS was performed by two trained anaesthesiologists once hypoxaemia occurred. After LUS examination, each patient was transported to the radiology department for thoracic CT scan within 1 h before returning to the ward.

Results

From January 2019 to May 2019, 113 patients (61 men) undergoing abdominal surgery (45 patients, 39.8%), video-assisted thoracic surgery (31 patients, 27.4%), major orthopaedic surgery (17 patients, 15.0%), neurosurgery (10 patients, 8.8%) or other surgery (10 patients, 8.8%) were included. CT diagnosed 327 of 1356 lung zones as atelectasis, while LUS revealed atelectasis in 311 of the CT-confirmed zones. Pneumothorax was detected by CT scan in 75 quadrants, 72 of which were detected by LUS. Pleural effusion was diagnosed in 144 zones on CT scan, and LUS detected 131 of these zones. LUS was reliable in diagnosing atelectasis (sensitivity 98.0%, specificity 96.7% and diagnostic accuracy 97.2%), pneumothorax (sensitivity 90.0%, specificity 98.9% and diagnostic accuracy 96.7%) and pleural effusion (sensitivity 92.9%, specificity 96.0% and diagnostic accuracy 95.1%).

Conclusions

Lung ultrasound is feasible, efficient and accurate in diagnosing different aetiologies of postoperative hypoxia in healthy-weight patients in the PACU.

Trial registration

Current Controlled Trials NCT03802175, 2018/12/05, www.ClinicalTrials.gov

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.

Lung Ultrasound in Emergency and Critically Ill Patients

Background

Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence.

Methods

This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees’ ability to adequately classify lung regions with normal aeration, interstitial–alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert.

Results

Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days.

Conclusions

A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial–alveolar syndrome, and consolidation in emergency and critically ill patients.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Accuracy of Resident-Performed Point-of-Care Lung Ultrasound Examinations Versus Chest Radiography in Pneumothorax Follow-up After Tube Thoracostomy in Rwanda

OBJECTIVES

The aim of this study was to evaluate the accuracy and timeliness of resident-performed point-of-care lung ultrasound (LUS) examinations for the follow-up of pneumothorax (PTX) after tube thoracostomy.

METHODS

After brief training, Rwandan surgical residents blinded to chest radiography (CXR) performed and interpreted LUS examinations for PTX in participants undergoing CXR for PTX follow-up. Treating clinicians interpreted CXR for the presence of PTX for therapeutic decisions. Lung ultrasound was later reviewed by ultrasound experts, and CXR was reviewed by a radiologist. We defined expert LUS interpretation as the reference standard. The sensitivity and specificity of resident-performed LUS examinations for diagnosing PTX were calculated. We assessed agreement between trained resident versus expert LUS and clinician versus radiology CXR using the Cohen κ coefficient. We compared the time to results between LUS and CXR.

RESULTS

Over an 8-month period, 51 participants were enrolled. Compared to expert LUS interpretation, the sensitivity and specificity (95% confidence intervals) of resident LUS were 100% (85%-100%) and 96% (82%-100%), respectively, whereas the sensitivity and specificity of clinician-interpreted CXR were 48% (27%-69%) and 100% (88%-100%). The agreement between resident and expert LUS was excellent (κ = 0.96), whereas the agreement between clinician and radiologist CXR was only moderate (κ = 0.60). The time to results was significantly longer for CXR than LUS (mean, 1335 versus 396 minutes; P = .0001).

CONCLUSIONS

A resident-performed LUS examination was a quicker imaging modality with superior sensitivity compared to clinician-interpreted CXR for PTX follow-up after tube thoracostomy in this Rwandan study. Lung ultrasound can be a valuable imaging tool for PTX follow-up, especially in resource-limited settings.

Thoracic ultrasonography: a narrative review

This narrative review focuses on thoracic ultrasonography (lung and pleural) with the aim of outlining its utility for the critical care clinician. The article summarizes the applications of thoracic ultrasonography for the evaluation and management of pneumothorax, pleural effusion, acute dyspnea, pulmonary edema, pulmonary embolism, pneumonia, interstitial processes, and the patient on mechanical ventilatory support. Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the management of a wide variety of disease processes that are common features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonography the "go to" modality for imaging the lung and pleura in an efficient, cost effective, and safe manner, such that it can largely replace chest imaging in critical care practice. It is best used in conjunction with other components of critical care ultrasonography to yield a comprehensive evaluation of the critically ill patient at point of care.

Do We Need Postoperative Chest Radiographs After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

STUDY DESIGN

The question was addressed in three ways: (1) a query of Kids' Inpatient Database (KID) to obtain nationally representative data; (2) retrospective review of cases at a single institution; (3) survey of Scoliosis Research Society (SRS) spine surgeons.

OBJECTIVES

Evaluate the rate of immediate postoperative pulmonary complications, risk factors, and relevant surgeon practice patterns, to determine the usefulness of routine postoperative chest radiographs after posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Routine postoperative chest radiography after PSIF for AIS is performed in many institutions to evaluate for acute pulmonary complications, particularly pneumothorax (PTX). The incidence of pneumothorax and its effect on management is unknown.

METHODS

The frequency of PTX and surgical intervention were recorded. We evaluated associations between PTX and patient demographics or comorbidities, as well as survey respondent demographics and their practice patterns.

RESULTS

In the KID data sets, the risk of PTX after PSIF for AIS patients was 0.3% (30/9,036), with intervention required in 13.3% (4/30) of PTX-positive patients (0.04% of all cases). Review of cases at our institution revealed a PTX rate of 3.3% (8/244) by radiology report. No surgical intervention was required. Patients with PTX had, on average, an increased number of vertebrae fused (p = .012), a proximal thoracic scoliosis curve location (p = .009), and/or an intraoperative blood transfusion (p = .002). SRS respondents reported a PTX risk of 0.8% (87/11,318), and 32.2% (89/276) of respondents indicated routine use of postoperative chest radiographs. Of those, 46.1% (41/89) specified willingness to change practice patterns if provided evidence of low PTX rates.

CONCLUSIONS

Pneumothorax is uncommon after PSIF for AIS. The need for intervention is even less common. Routine postoperative chest radiographs are of questionable value after PSIF for AIS.

LEVEL OF EVIDENCE

Level III.

Use of Ultrasonography for Lung Transplant Recipients on Postoperative Care

The authors report their findings regarding lung ultrasound profiles in a population of transplant recipients. Twenty-two patients were studied once each in multiple different ultrasound windows focusing on pleural, lung, and diaphragmatic signatures. All studies were performed in presumably otherwise healthy recipients at an outpatient follow-up visit at least 3 months after transplantation. Those with recent pulmonary infections or decline in lung function were excluded from enrollment. The majority of scans revealed otherwise normal lungs with lung sliding, but there were more abnormalities than one would expect in a healthy control group. Lung ultrasonography will likely never replace other cross-sectional imaging given its inherent visual limitations but adds another modality to interrogate the lung/pleural interface and diaphragmatic function.

Contralateral Traumatic Hemopneumothorax

Pneumothorax is the entry of air into the virtual space between the visceral and the parietal pleurae, which can occur spontaneously or to a greater extent in a traumatic way. In daily clinical practice it is frequent to find injuries that generate traumatic pneumothorax that is ipsilateral to the lesion. However, there are case reports of contralateral pneumothorax that occurred in procedures such as insertion of pacemakers, or in cases of pneumonectomy. The following is the case report of a 37-year-old man who was admitted with a sharp wound to the right paravertebral region who developed a left haemopneumothorax due to a tangential course of the injuring agent. Adequate clinical judgment was followed, and several imaging studies were carried out, leading to the diagnosis of traumatic pneumothorax that was contralateral to the described injury.

Diagnostic chest ultrasound for acute respiratory failure

Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying aetiologies. Diagnostic chest ultrasound provides accurate diagnosis of conditions that commonly cause ARF, and may improve overall diagnostic accuracy in critical care settings as compared to standard diagnostic approaches. Respiratory physicians are becoming increasingly familiar with ultrasound as a part of routine clinical practice, although the majority of data to date has focused on the emergency and intensive care settings. This review will examine the evidence for the use of diagnostic chest ultrasound, focusing on different levels of imaging efficacy; specifically ultrasound test attributes, impacts on clinician behaviour and impact on health outcomes. The evidence behind use of multi-modality ultrasound examinations in ARF will be reviewed. It is hoped that readers will become familiar with the advantages and potential issues with chest ultrasound, as well as evidence gaps in the field.

The Utility of Teleultrasound to Guide Acute Patient Management

Ultrasound has evolved into a core bedside tool for diagnostic and management purposes for all subsets of adult and pediatric critically-ill patients. Teleintensive care unit coverage has undergone a similar rapid expansion period throughout the United States. Round-the-clock access to ultrasound equipment is very common in today's intensive care unit, but 24/7 coverage with staff trained to acquire and interpret point-of-care ultrasound in real time is lagging behind equipment availability. Medical trainees and physician extenders require attending level supervision to ensure consistent image acquisition and accurate interpretation. Teleintensivists can extend the utility of ultrasound by supervising and guiding providers without or with only partial training in ultrasound, and also by extending direct trainee ultrasound supervision to time periods when no direct bedside attending supervisor is available, and when treatment decisions otherwise would have been made without supervision and feedback on image acquisition and interpretation. Nursing staff without ultrasound training can also be directed to perform basic ultrasound exams, which may have immediate diagnostic and/or treatment consequences, thereby overcoming access barriers in the absence of physicians or physician extenders. We discuss 4 real-life clinical scenarios in which teleintensivist supervision extended and standardized bedside ultrasound exams to guide management decisions which significantly impacted patient outcomes.

State of the art thoracic ultrasound: intervention and therapeutics

The use of thoracic ultrasound outside the radiology department and in everyday clinical practice is becoming increasingly common, having been incorporated into standards of care for many specialties. For the majority of practitioners, their experience of, and exposure to, thoracic ultrasound will be in its use as an adjunct to pleural and thoracic interventions, owing to the widely recognised benefits for patient safety and risk reduction. However, as clinicians become increasingly familiar with the capabilities of thoracic ultrasound, new directions for its use are being sought which might enhance practice and patient care. This article reviews the ways in which the advent of thoracic ultrasound is changing the approach to the investigation and treatment of respiratory disease from an interventional perspective. This will include the impact of thoracic ultrasound on areas including patient safety, diagnostic and therapeutic procedures, and outcome prediction; and will also consider potential future research and clinical directions.

Lung ultrasound: a useful tool in the assessment of the dyspnoeic patient in the emergency department. Fact or fiction?

Patients with respiratory distress present a frequent and challenging dilemma for emergency physicians (EPs). The accurate diagnosis and treatment of the underlying pathology is vitally important in these sick patients to ensure the best outcome and minimise harm from unnecessary treatments. Within the last decade, studies have shown lung ultrasonography (LU) to be valuable in the accurate diagnosis of a variety of lung pathologies, including cardiogenic pulmonary oedema, pleural effusion, pneumothorax, haemothorax and pneumonia. However, despite advances in techniques and the evidence for the use of LU in the diagnosis of respiratory pathology, it remains poorly understood and rarely used by EPs. This clinical review article provides an overview of LU and its relevance as a diagnostic aid to the detection of respiratory pathology in the Emergency Department (ED).

State-of-the-art: Radiological investigation of pleural disease

Pleural disease is common. Radiological investigation of pleural effusion, thickening, masses, and pneumothorax is key in diagnosing and determining management. Conventional chest radiograph (CXR) remains as the initial investigation of choice for patients with suspected pleural disease. When abnormalities are detected, thoracic ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) can each play important roles in further investigation, but appropriate modality selection is critical. US adds significant value in the identification of pleural fluid and pleural nodularity, guiding pleural procedures and, increasingly, as "point of care" assessment for pneumothorax, but is highly operator dependent. CT scan is the modality of choice for further assessment of pleural disease: Characterising pleural thickening, some pleural effusions and demonstration of homogeneity of pleural masses and areas of fatty attenuation or calcification. MRI has specific utility for soft tissue abnormalities and may have a role for younger patients requiring follow-up serial imaging. MRI and PET/CT may provide additional information in malignant pleural disease regarding prognosis and response to therapy. This article summarises existing techniques, highlighting the benefits and applications of these different imaging modalities and provides an up to date review of the evidence.

Kidney-lung connections in acute and chronic diseases: current perspectives

Lung and kidney functions are intimately related in both health and disease. The regulation of acid-base equilibrium, modification of partial pressure of carbon dioxide and bicarbonate concentration, and the control of blood pressure and fluid homeostasis all closely depend on renal and pulmonary activities. These interactions begin in fetal age and are often responsible for the genesis and progression of diseases. In gestational age, urine is a fundamental component of the amniotic fluid, acting on pulmonary maturation and growth. Moreover, in the first trimester of pregnancy, kidney is the main source of proline, contributing to collagen synthesis and lung parenchyma maturation. Pathologically speaking, the kidneys could become damaged by mediators of inflammation or immuno-mediated factors related to a primary lung pathology or, on the contrary, it could be the renal disease that determines a consecutive pulmonary damage. Furthermore, non immunological mechanisms are frequently involved in renal and pulmonary diseases, as observed in chronic pathologies such as sleep apnea syndrome, pulmonary hypertension, progressive renal disease and hemodialysis. Kidney damage has also been related to mechanical ventilation. The aim of this review is to describe pulmonary-renal interactions and their related pathologies, underscoring the need for a close collaboration between intensivists, pneumologists and nephrologists.

Thoracic ultrasound: Potential new tool for physiotherapists in respiratory management. A narrative review

The use of diagnostic ultrasound by physiotherapists is not a new concept; it is frequently performed in musculoskeletal physiotherapy. Physiotherapists currently lack accurate, reliable, sensitive, and valid measurements for the assessment of the indications and effectiveness of chest physiotherapy. Thoracic ultrasound may be a promising tool for the physiotherapist and could be routinely performed at patients' bedsides to provide real-time and accurate information on the status of pleura, lungs, and diaphragm; this would allow for assessment of lung aeration from interstitial syndrome to lung consolidation with much better accuracy than chest x-rays or auscultation. Diaphragm excursion and contractility may also be assessed by ultrasound. This narrative review refers to lung and diaphragm ultrasound semiology and describes how physiotherapists could use this tool in their clinical decision-making processes in various cases of respiratory disorders. The use of thoracic ultrasound semiology alongside typical examinations may allow for the guiding, monitoring, and evaluating of chest physiotherapy treatments. Thoracic ultrasound is a potential new tool for physiotherapists.

Ultrasonographic Evaluation of the Pleura

Pleural ultrasonography is useful to diagnose, monitor, and guide management of pleural disease. This article reviews the applications of ultrasonography to pleural disease.

Application of Lung Ultrasonography in the Diagnosis of Childhood Lung Diseases

In this paper, we focus on the characteristics of LUS in diagnosing childhood pulmonary disease. LUS is convenient, noninvasive, and free of radiation. It helps in the differentiation of lung diseases. Therefore, LUS has the potential to become a reference instrument for bedside dynamic respiratory monitoring. We hope that this review will help clinicians become acquainted with LUS and will accelerate the extensive application of LUS in children.

Role of ultrasonography in the diagnosis and management of pneumothorax following transbronchial lung biopsy

BACKGROUND

Pneumothorax (PTX) following flexible bronchoscopy (FB) and transbronchial lung biopsy (TBLB) occurs in 1% to 6% of cases. Chest radiography (CXR) is therefore routinely requested to detect PTX following TBLB. The objective of this study was to prospectively evaluate the accuracy of ultrasound (US) in the detection of post-TBLB PTX.

METHODS

Consecutive patients undergoing elective FB at a tertiary care hospital were included in the study. A real-time US was used to rule out PTX immediately after FB. PTX was defined by the absence of lung sliding and the presence of "lung point" and "stratosphere" sign. In cases of PTX, US was repeated at 2-hour intervals, and the resolution or progression of PTX was assessed based on dynamic shifts of the "lung points."

RESULTS

A total of 379 FB procedures and 113 TBLB were performed during the study period. PTX occurred in 8 (2.1%) patients. US detected all cases of PTX, whereas CXR missed 1 PTX. The sensitivity, specificity, and overall accuracy for US were 100% as compared with sensitivity of 87.5% and accuracy of 99.6% for the CXR group. Shift of the "lung point" below the mid-thoracic line implied the progression of PTX and hence favored intervention (performed in 3 cases), whereas conservative management was done in cases where "lung point" shifted above mid-thoracic line.

CONCLUSIONS

This study demonstrates a good sensitivity of US in detecting PTX following TBBL. Bedside US may become the method of choice for diagnosing, monitoring, and managing PTX after TBLB.

[Diagnostic ultrasound in pneumothorax]

For a long time the lung has been regarded as inaccessible to ultrasound. However, recent clinical studies have shown that this organ can be examined by this technique, which appears, in some situations, to be superior to thoracic radiography. The examination does not require special equipment and is possible using a combination of simple qualitative signs: lung sliding, the presence of B lines and the demonstration of the lung point. The lung sliding corresponds to the artefact produced by the movement of the two pleural layers, one against the other. The B lines indicate the presence of an interstitial syndrome. The presence of lung sliding and/or B lines has a negative predictive value of 100% and formally excludes a pneumothorax in the area where the probe has been applied. The presence of the lung point is pathognomonic of pneumothorax but the sensitivity is no more than 60%. Ultrasound is therefore a rapid and simple means of excluding a pneumothorax (lung sliding or B lines) and of confirming a pneumothorax when the lung point is visible. The question that remains is whether ultrasound can totally replace radiography in the management of this disorder.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

Implementation of lung ultrasound in polyvalent intensive care unit: Impact on irradiation and medical cost

OBJECTIVE

To determine the effect of implementing a daily lung ultrasound round on the number of chest radiographs and chest computed tomography (CT) scans in a polyvalent intensive care unit (ICU).

STUDY DESIGN

Retrospective study comparing two consecutive periods.

PATIENTS

All patients hospitalized for longer than 48 hours in a polyvalent ICU.

METHODS

Implementation of a daily lung ultrasound round after a short educational program. The number of chest radiographs and chest CT scans and the patient outcome were measured before (group PRE) and after (group POST) the implementation of a daily lung ultrasound round.

RESULTS

No demographic difference was found between the two groups, with the exception of a higher severity score in the group POST. For each ICU stay, the number of chest radiographs was 10.3 ± 12.4 in the group PRE and 7.7 ± 10.3 in the group POST, respectively (P<0.005) The number of chest CT scans was not reduced in the group POST, as compared with the group PRE (0.5 ± 0.7 CT scan/patient/ICU stay versus 0.4 ± 0.6 CT scan/patient/ICU stay, P=0.01). The ICU mortality was similar in both groups (21% versus 22%, P=0.75) CONCLUSION: The implementation of a daily lung ultrasound round was associated with a reduction in radiation exposure and medical cost without altering patient outcome.

Overview of current lung imaging in acute respiratory distress syndrome

Imaging plays a key role in the diagnosis and follow-up of acute respiratory distress syndrome (ARDS). Chest radiography, bedside lung ultrasonography and computed tomography scans can provide useful information for the management of patients and detection of prognostic factors. However, imaging findings are not specific and several possible differential diagnoses should be taken into account. Herein we will review the role of radiological techniques in ARDS, highlight the plain radiological and computed tomography findings according to the pathological stage of the disease (exudative, inflammatory and fibroproliferative), and summarise the main points for the differential diagnosis with cardiogenic oedema, which is still challenging in the acute stage.

Bedside ultrasonography for the intensivist

Critical care ultrasonography is a bedside technique performed by the frontline clinician at the point of care. Point-of-care ultrasonography is conceptually related to physical examination. The intensivist uses visual assessment, auscultation, and palpation on an ongoing basis to monitor the patient. Ultrasonography adds to traditional physical examination by allowing the intensivist to visualize the anatomy and function of the body in real time. Initial, repeated, and goal-directed ultrasonography is an extension of the physical examination that allows the intensivist to establish a diagnosis and monitor the condition of the patient on a regular basis.

Semi-quantification of pneumothorax volume by lung ultrasound

BACKGROUND

Lung ultrasound (LUS) may accurately diagnose pneumothorax. However, there is uncertainty about its usefulness in the quantification of pneumothorax size. To determine the ability of LUS in the semi-quantification of pneumothorax volume, we compared the projection of the lung point (LP) with the pneumothorax volume measured by computerized tomography (CT) and the interpleural distance on chest radiography (CXR).

METHODS

We performed LUS in patients with pneumothorax and all the LP located on the chest wall were compared to CXR and CT studies. The primary outcome of the study was the ability of LP to grade pneumothorax volumes measured by CT. The secondary outcome was the accuracy of LP to predict small and large pneumothorax according to the societal guidelines based on CXR reading.

RESULTS

A total of 124 patients with pneumothorax were enrolled (76 spontaneous, 20 traumatic and 28 post-procedural). Ninety-four CXR and 58 CT were available for the analysis. An LP posterior to the mid axillary line corresponded to three different CXR criteria for large pneumothorax with sensitivity from 81.4 to 88.2 % and specificity from 64.7 to 72.6 %. The mid axillary line also represented the limit for predicting greater than 15 % of lung collapse when volume is measured at CT, with sensitivity 83.3 % and specificity 82.4 %.

CONCLUSIONS

LUS-targeted assessment of LP was a useful predictor of pneumothorax volume in this research study setting. LUS reliably classified pneumothorax size when compared to criteria based on CXR reading, particularly the small sized pneumothorax. However, LUS greatly outperformed conventional CXR reading for a graded quantification of the percentage of lung collapse.

Diagnosis and treatment of pneumothorax

Many diagnostic and therapeutic options exist for the evaluation and treatment of patients with pneumothorax. Guidelines from US and European professional societies and individual expert opinions differ in the approach to patient care. Advances in diagnostic techniques, such as real-time thoracic ultrasound, have added to the evaluation strategy. It is important for medical trainees and providers to become familiar with techniques utilized worldwide as they may be encountered in clinical practice. We review current evidence, expert recommendations, and compare professional society guidelines discussing the various diagnostic and management options for patients with pneumothorax to assist physicians and trainees involved in the care of hospitalized and outpatient adults who have primary, secondary, and traumatic iatrogenic pneumothorax. Management of traumatic non-iatrogenic pneumothorax is beyond the scope of this article, thus, not reviewed here.

Critical Asthma Syndrome in the ICU

Critical asthma syndrome represents the most severe subset of asthma exacerbations, and the critical asthma syndrome is an umbrella term for life-threatening asthma, status asthmaticus, and near-fatal asthma. According to the 2007 National Asthma Education and Prevention Program guidelines, a life-threatening asthma exacerbation is marked by an inability to speak, a reduced peak expiratory flow rate of <25 % of a patient's personal best, and a failed response to frequent bronchodilator administration and intravenous steroids. Almost all critical asthma syndrome cases require emergency care, and most cases require hospitalization, often in an intensive care unit. Among asthmatics, those with the critical asthma syndrome are difficult to manage and there is little room for error. Patients with the critical asthma syndrome are prone to complications, they utilize immense resources, and they incite anxiety in many care providers. Managing this syndrome is anything but routine, and it requires attention, alacrity, and accuracy. The specific management strategies of adults with the critical asthma syndrome in the hospital with a focus on intensive care are discussed. Topics include the initial assessment for critical illness, initial ventilation management, hemodynamic issues, novel diagnostic tools and interventions, and common pitfalls. We highlight the use of critical care ultrasound, and we provide practical guidelines on how to manage deteriorating patients such as those with pneumothoraces. When standard asthma management fails, we provide experience-driven recommendations coupled with available evidence to guide the care team through advanced treatment. Though we do not discuss medications in detail, we highlight recent advances.