Ultrasonographic quantification of pleural effusion: comparison of four formulae

Pleural effusions identified by thoracic ultrasound predict poor quality of life in patients with acute decompensated heart failure

INTRODUCTION

Pleural effusion (PE) is a common manifestation of acute decompensated heart failure (ADHF); however, its influence on the quality of life (QoL) is unknown.

OBJECTIVES

To identify whether PE detected using thoracic ultrasound (TUS) is associated with poorer QoL in patients with ADHF and a reduced ejection fraction (≤40 %).

METHODS

We conducted a prospective, longitudinal, descriptive, observational, single-center study at a university hospital in Mexico. We included participants with a reduced left ventricular ejection fraction who were admitted for ADHF. We performed TUS and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) within the first 48 h of hospitalization.

RESULTS

Forty patients with ADHF (30 males and 10 females; mean age, 51.24 ± 16.942 years) were included in this study. The participants were categorized into two groups: those with (n = 25, 62.5 %) or without (n = 15, 37.5 %) PE on TUS. We found a statistically significant association between the presence of PEs and a worse perception of QoL. The mean MLHFQ score in the group of patients with PEs was 40 points, compared to 12 points in the group without PEs (p < 0.001). Poorer QoL was associated with a higher quantity of pleural fluid, as evidenced by the greater number of intercostal spaces occupied by the PE (p < 0.001).

CONCLUSIONS

Patients with ADHF and a reduced ejection fraction who present with PE have a worse perception of QoL than patients without PE.

Ultrasound quantification of pleural effusion volume in supine position: comparison of three model formulae

BACKGROUND

To investigate the accuracy of three model formulae for ultrasound quantification of pleural effusion (PE) volume in patients in supine position.

METHODS

A prospective study including 100 patients with thoracentesis and drainage of PE was conducted. Three model formulae (single section model, two section model and multi-section model) were used to calculate the PE volume. The correlation and consistency analyses between calculated volumes derived from three models and actual PE volume were performed.

RESULTS

PE volumes calculated by three models all showed significant linear correlations with actual PE volume in supine position (all p < 0.001). The reliability of multi-section model in predicting PE volume was significantly higher than that of single section model and slightly higher than that of two section model. When compared with actual drainage volume, the intra-class correlation coefficients (ICCs) of single section model, two section model and multi-section model were 0.72, 0.97 and 0.99, respectively. Significant consistency between calculated PE volumes by using two section model and multi-section model existed for full PE volume range (ICC 0.98).

CONCLUSION

Based on the convenience and accuracy of ultrasound quantification of PE volume, two section model is recommended for pleural effusion assessment in routine clinic, though different model formulae can be selected according to clinical needs.

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

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

MUltiparametric Score for Ventilation Discontinuation in Intensive Care Patients: A Protocol for an Observational Study

BACKGROUND

Mechanical ventilation significantly improves patient survival but is associated with complications, increasing healthcare costs and morbidity. Identifying optimal weaning times is paramount to minimize these risks, yet current methods rely heavily on clinical judgment, lacking specificity.

METHODS

This study introduces a novel multiparametric predictive score, the MUSVIP (MUltiparametric Score for Ventilation discontinuation in Intensive care Patients), aimed at accurately predicting successful extubation. Conducted at Santo Stefano Hospital's ICU, this single-center, observational, prospective cohort study will span over 12 months, enrolling adult patients undergoing invasive mechanical ventilation. The MUSVIP integrates variables measured before and during a spontaneous breathing trial (SBT) to formulate a predictive score.

RESULTS

Preliminary analyses suggest an Area Under the Curve (AUC) of 0.815 for the MUSVIP, indicating high predictive capacity. By systematically applying this score, we anticipate identifying patients likely to succeed in weaning earlier, potentially reducing ICU length of stay and associated healthcare costs.

CONCLUSION

This study's findings could significantly influence clinical practices, offering a robust, easy-to-use tool for optimizing weaning processes in ICUs.

Neutrophil-mediated Inflammatory Plasminogen Degradation, Rather Than High Plasminogen-Activator Inhibitor-1, May Underly Failures and Inefficiencies of Intrapleural Fibrinolysis

BACKGROUND

Complex pleural space infections often require treatment with multiple doses of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease, with treatment failure frequently necessitating surgery. Pleural infections are rich in neutrophils, and neutrophil elastase degrades plasminogen, the target substrate of tPA, that is required to generate fibrinolysis. We hypothesized that pleural fluid from patients with pleural space infection would show high elastase activity, evidence of inflammatory plasminogen degradation, and low fibrinolytic potential in response to tPA that could be rescued with plasminogen supplementation.

RESEARCH QUESTION

Does neutrophil elastase degradation of plasminogen contribute to intrapleural fibrinolytic failure?

STUDY DESIGN AND METHODS

We obtained infected pleural fluid and circulating plasma from hospitalized adults (n = 10) with institutional review board approval from a randomized trial evaluating intrapleural fibrinolytics vs surgery for initial management of pleural space infection. Samples were collected before the intervention and on days 1, 2, and 3 after the intervention. Activity assays, enzyme-linked immunosorbent assays, and Western blot analysis were performed, and turbidimetric measurements of fibrinolysis were obtained from pleural fluid with and without exogenous plasminogen supplementation. Results are reported as median (interquartile range) or number (percentage) as appropriate, with an α value of .05.

RESULTS

Pleural fluid elastase activity was more than fourfold higher (P = .02) and plasminogen antigen levels were more than threefold lower (P = .04) than their corresponding plasma values. Pleural fluid Western blot analysis demonstrated abundant plasminogen degradation fragments consistent with elastase degradation patterns. We found that plasminogen activator inhibitor 1 (PAI-1), the native tPA inhibitor, showed high antigen levels before the intervention, but the overwhelming majority of this PAI-1 (82%) was not active (P = .003), and all PAI-1 activity was lost by day 2 after the intervention in patients receiving intrapleural tPA and deoxyribonuclease. Finally, using turbidity clot lysis assays, we found that the pleural fluid of 9 of 10 patients was unable to generate a significant fibrinolytic response when challenged with tPA and that plasminogen supplementation rescued fibrinolysis in all patients.

INTERPRETATION

Our findings suggest that inflammatory plasminogen deficiency, not high PAI-1 activity, is a significant contributor to intrapleural fibrinolytic failure.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03583931; URL: www.

CLINICALTRIALS

gov.

Pleural effusion guidelines from ICS and NCCP Section 1: Basic principles, laboratory tests and pleural procedures

Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions.

Establishment and validation of a predictive nomogram for severe pleural effusion in liver cancer patients after hepatectomy

This study aims to develop and validate a predictive nomogram for severe postoperative pleural effusion (SPOPE) in patients undergoing hepatectomy for liver cancer. A total of 536 liver cancer patients who underwent hepatectomy at the Department of Hepatobiliary Surgery I of the Affiliated Hospital of North Sichuan Medical College from January 1, 2018, to December 31, 2022, were enrolled in a retrospective observational study and comprised the training dataset. Lasso regression and logistic regression analyses were employed to construct a predictive nomogram. The nomogram was internally validated using Bootstrapping and externally validated with a dataset of 203 patients who underwent liver cancer resection at the Department of General Surgery III of the same hospital from January 1, 2020, to December 31, 2022. We evaluated the nomogram using the receiver operating characteristic curve, calibration curve, and decision curve analysis. Variables such as drinking history, postoperative serum albumin, postoperative total bilirubin, right hepatectomy, diaphragm incision, and intraoperative blood loss were observed to be associated with SPOPE. These factors were integrated into our nomogram. The C-index of the nomogram was 0.736 (95% CI: 0.692-0.781) in the training set and 0.916 (95% CI: 0.872-0.961) in the validation set. The nomogram was then evaluated using sensitivity, specificity, positive predictive value, negative predictive value, calibration curve, and decision curve analysis. The nomogram demonstrates good discriminative ability, calibration, and clinical utility.

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

Imaging of Acute Complications of Community-Acquired Pneumonia in the Paediatric Population-From Chest Radiography to MRI

The most common acute infection and leading cause of death in children worldwide is pneumonia. Clinical and laboratory tests essentially diagnose community-acquired pneumonia (CAP). CAP can be caused by bacteria, viruses, or atypical microorganisms. Imaging is usually reserved for children who do not respond to treatment, need hospitalisation, or have hospital-acquired pneumonia. This review discusses the imaging findings for acute CAP complications and the diagnostic role of each imaging modality. Pleural effusion, empyema, necrotizing pneumonia, abscess, pneumatocele, pleural fistulas, and paediatric acute respiratory distress syndrome (PARDS) are acute CAP complications. When evaluating complicated CAP patients, chest radiography, lung ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) can be used, with each having their own pros and cons. Imaging is usually not needed for CAP diagnosis, but it is essential for complicated cases and follow-ups. Lung ultrasound can supplement chest radiography (CR), which starts the diagnostic algorithm. Contrast-enhanced computed tomography (CECT) is used for complex cases. Advances in MRI protocols make it a viable alternative for diagnosing CAP and its complications.

Advancing healthcare through thoracic ultrasound research in older patients

This paper reports the proceedings of a meeting convened by the Research Group on Thoracic Ultrasound in Older People of the Italian Society of Gerontology and Geriatrics, to discuss the current state-of-the-art of clinical research in the field of geriatric thoracic ultrasound and identify unmet research needs and potential areas of development. In the last decade, point-of-care thoracic ultrasound has entered clinical practice for diagnosis and management of several respiratory illnesses, such as bacterial and viral pneumonia, pleural effusion, acute heart failure, and pneumothorax, especially in the emergency-urgency setting. Very few studies, however, have been specifically focused on older patients with frailty and multi-morbidity, who frequently exhibit complex clinical pictures needing multidimensional evaluation. At the present state of knowledge, there is still uncertainty on the best requirements of ultrasound equipment, methodology of examination, and reporting needed to optimize the advantages of thoracic ultrasound implementation in the care of geriatric patients. Other issues regard differential diagnosis between bacterial and aspiration pneumonia, objective grading of interstitial syndrome severity, quantification and monitoring of pleural effusions and solid pleural lesions, significance of ultrasonographic assessment of post-COVID-19 sequelae, and prognostic value of assessment of diaphragmatic thickness and motility. Finally, application of remote ultrasound diagnostics in the community and nursing home setting is still poorly investigated by the current literature. Overall, the presence of several open questions on geriatric applications of thoracic ultrasound represents a strong call to implement clinical research in this field.

Pleural clinic: where thoracic ultrasound meets respiratory medicine

Thoracic ultrasound (TUS) has become an essential procedure in respiratory medicine. Due to its intrinsic safety and versatility, it has been applied in patients affected by several respiratory diseases both in intensive care and outpatient settings. TUS can complement and often exceed stethoscope and radiological findings, especially in managing pleural diseases. We hereby aimed to describe the establishment, development, and optimization in a large, tertiary care hospital of a pleural clinic, which is dedicated to the evaluation and monitoring of patients with pleural diseases, including, among others, pleural effusion and/or thickening, pneumothorax and subpleural consolidation. The clinic was initially meant to follow outpatients undergoing medical thoracoscopy. In this scenario, TUS allowed rapid and regular assessment of these patients, promptly diagnosing recurrence of pleural effusion and other complications that could be appropriately managed. Over time, our clinic has rapidly expanded its initial indications thus becoming the place to handle more complex respiratory patients in collaboration with, among others, thoracic surgeons and oncologists. In this article, we critically describe the strengths and pitfalls of our "pleural clinic" and propose an organizational model that results from a synergy between respiratory physicians and other professionals. This model can inspire other healthcare professionals to develop a similar organization based on their local setting.

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.

Pleural effusion and thoracentesis in ICU patients: A longitudinal observational cross-sectional study

BACKGROUND

Pleural effusion is common among patients in the intensive care unit (ICU) but reported prevalence varies. Thoracentesis may improve respiratory status, however, indications for this are unclear. We aimed to explore prevalence, development, and progression of pleural effusion, and the incidence and effects of thoracentesis in adult ICU patients.

METHODS

This is a prospective observational study utilizing repeated daily ultrasonographic assessments of pleurae bilaterally, conducted in all adult patients admitted to the four ICUs of a Danish university hospital throughout a 14-day period. The primary outcome was the proportion of patients with ultrasonographically significant pleural effusion (separation between parietal and visceral pleurae >20 mm) in either pleural cavity on any ICU day. Secondary outcomes included the proportion of patients with ultrasonographically significant pleural effusion receiving thoracentesis in ICU, and the progression of pleural effusion without drainage, among others. The protocol was published before study initiation.

RESULTS

In total, 81 patients were included of which 25 (31%) had or developed ultrasonographically significant pleural effusion. Thoracentesis was performed in 10 of these 25 patients (40%). Patients with ultrasonographically significant pleural effusion, which was not drained, had an overall decrease in estimated pleural effusion volume on subsequent days.

CONCLUSION

Pleural effusion was common in the ICU, but less than half of all patients with ultrasonographically significant pleural effusion underwent thoracentesis. Progression of pleural effusion without thoracentesis showed reduced volumes on subsequent days.

Main applications of point-of care ultrasound in palliative care

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

Quantification of pleural effusions by two-dimensional transthoracic echocardiography

PURPOSE

There is lack of validated methods for quantifying the size of pleural effusion from standard transthoracic (TTE) windows. The purpose of this study is to determine whether pleural effusion (Peff) measured from routine two-dimensional (2D) TTE views correlate with chest radiograph (CXR).

MATERIALS AND METHODS

We retrospectively identified all inpatients who underwent a TTE and CXR within 2 days in a large tertiary care center. Peff was measured on TTE from parasternal long axis (PLAX), apical four-chamber (A4C), and subcostal views and on CXR. Logistic regression models were used determine optimal cut points to predict moderate or greater Peff.

RESULTS

In 200 patients (mean age 69.3 ± 14.3 years, 49.5% female), we found statistically significant associations between Peff size assessed by all TTE views and CXR, with weak to moderate correlation (PLAX length: 0.21 (95% CI [0.05, 0.35]); PLAX depth: 0.21 (95% CI [0.05, 0.35]); A4C left: 0.31 (95% CI [0.13, 0.46]); A4C right: 0.39 (95% CI [0.17, 0.57]); subcostal: 0.38 (95% CI [0.07, 0.61]). The best TTE thresholds for predicting moderate or greater left-sided Peff on CXR was PLAX length left >  = 8.6 cm (sensitivity 78%, specificity 54%, PPV 26%, and NPV 92%). The best TTE thresholds for predicting moderate or greater right-sided Peff on CXR was A4C right >  = 2.6 cm (sensitivity 87%, specificity 60%, PPV 37%, and NPV 94%).

CONCLUSIONS

We identified statistically significant associations with Peff size measured on TTE and CXR. The predictive ability of TTE to identify moderate or large pleural effusion is limited.

Management of complicated parapneumonic effusions

PURPOSE OF REVIEW

Approximately 36-57% of cases of pneumonia are associated with a parapneumonic effusion (PPE). It begins as sterile effusion, which can quickly evolve to a fibrinopurulent stage with evidence of infection called complicated parapneumonic effusions (CPPE). Marked fibrinous organization then follows. This study focuses on literature synthesis on management of CPPE.

RECENT FINDINGS

Ultrasound has become an indispensable tool in the identification and treatment of CPPE. Prompt antibiotic administration remains the universal standard of care. Decision to drain the fluid is based on fluid staging, characterization and assessment of risk of poor outcomes vs. risk of complications. There is growing evidence to support use of intrapleural fibrinolytic therapy (IPFT) in case of loculated effusions. Newer areas of research include antibodies against plasminogen activator inhibitors and stratification scores that can identify patients at an increased risk. Lastly, timing of surgical referral is an important area under study.

SUMMARY

Evolution of medical therapy over recent years has increased treatment success rates. Use of IPFT in conjunction to thoracostomy is now the standard of care for loculated effusions. Understanding available therapeutic options, both medical and interventional, can ensure evidence-based practice and improve patient-centred outcomes.

Precision of pleural puncture sites using thoracic ultrasound

INTRODUCTION

Lung ultrasound (LUS) has been recommended by the British Thoracic Society as a standard of care before performing pleural procedures since 2010. Indeed, the choice of the puncture site based only on physical examination and chest x-ray can lead to complications. The aim of this study was to compare the accuracy of pleural puncture sites using LUS as opposed to clinical examination.

METHODS

An evaluative prospective study including 43 patients hospitalized in the pneumology department at the Military Hospital of Tunis was conducted between January and November 2021.Pleural puncture sites were proposed by two groups involving 'senior' and 'junior' physicians, classified according to their experience and grades, based on the clinical examination and the chest x-ray findings. The accuracy of the proposed sites was then verified by an ultrasound-qualified "expert" using LUS.

RESULTS

The mean age was 60 ± 17 years. LUS revealed the presence of pleural effusion in 88% of the cases (n=38). Differential diagnosis was therefore excluded in 12% of the cases (n=5), including pleural thickening (5%, n=2) and atelectasis (7%, n=3). Compared to LUS, clinical examination and chest x-ray had lower sensitivities, estimated at 74% and 83%, respectively. The clinical identification error rate was significantly higher in junior (77%) compared to senior physicians (49%) (p<0.05). LUS prevented possible accidental organ puncture in 36% of the cases (n=31). The risk factors associated with inaccurate clinical site selection included right-sided effusion and minimal pleural effusion on chest radiography, with an estimated relative risk (RR) of 1.44 [CI95%:0.56-3.72] and 1.82 [CI95%:0.52-6.40], respectively. The experience of the senior physicians influenced the choice of the clinical sites with moderate agreement (Kappa index: 0.4-0.6).

CONCLUSION

Compared to the ACPA- group, the ACPA+ one had more lung-hyperinflation and OVI, and comparative percentages of RVI, MVI, and NSVI.

CONCLUSION

LUS significantly improves the accuracy of pleural puncture sites, thus minimizing the risk of complications regardless of the operator's level of clinical experience.

Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have?

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

A phase II study of bevacizumab in non-squamous, non-small-cell lung cancer patients with malignant pleural effusion

Aim: To investigate the efficacy, safety and optimal dosage of bevacizumab in non-squamous, non-small-cell lung cancer (NSCLC) patients with malignant pleural effusion (MPE). Methods: 20 patients were enrolled and received intrapleural injection of bevacizumab (group A: 2.5 mg/kg d1, d8; group B: 5 mg/kg d1, d8; group C: 7.5 mg/kg d1, d8). Results: The objective control rate (ORR) of MPE was 50%. The median progression-free survival (PFS) of MPE was 7.0 months (95% CI 4.9-9.2). The ORR and PFS of MPE from group B were better than those of group A and group C. The most common adverse events (AEs) were hypertension (15%) and anemia (15%). Conclusion: Bevacizumab has certain efficacy in non-squamous NSCLC patients with MPE. Clinical Trial Registration: NCT02942043 (ClinicalTrials.gov).

Challenges in Image-Guided Drainage of Infected Pleural Collections: A Review

Infected pleural fluid collections (IPFCs) commonly occur as a part of bacterial, fungal, or tubercular pneumonia or due to involvement of pleura through hematogenous route. Management requires early initiation of therapeutic drugs, as well as complete drainage of the fluid, to relieve patients’ symptoms and prevent pleural fibrosis. Image-guided drainage plays an important role in achieving these goals and improving outcomes. Intrapleural fibrinolytic therapy (IPFT) is also a vital component of the management. The concepts of image-guided drainage procedures, IPFT, and nonexpanding lung are discussed in this review.

Contrast-Enhanced Ultrasound of the Pleural Cavity: A Method to Locate Pleural Catheters and Identify Fibrous Septa

We aimed to explore the value of contrast-enhanced ultrasound (CEUS) of the pleural cavity in locating catheters and identifying fibrous septa and to compare CEUS with multiple existing methods. We included 304 participants whose pleural effusion could not continue to be drained and compared the catheter-localization capabilities of empirical diagnosis, B-mode ultrasound with normal saline and CEUS, with computed tomography as the reference standard. CEUS performed the best (accuracy, 100%; sensitivity, 100%; specificity, 100%), followed by B-mode ultrasound with normal saline (accuracy, 77.78%; sensitivity, 62.5%; specificity, 100%), and finally empirical diagnosis (accuracy, 54.17%; sensitivity, 66.67%; specificity, 33.33%). The capabilities of CEUS and computed tomography to identify fibrous septa were evaluated, with B-mode ultrasound as the reference, and CEUS (accuracy, 100%; sensitivity, 100%; specificity, 100%) was superior to computed tomography (accuracy, 82.41%; sensitivity, 26.09%; specificity, 97.65%). Overall, CEUS can accurately locate catheters and identify fibrous septa, with performance superior to existing methods.

Lung ultrasound compared to chest X-ray for the diagnosis of CAP in children

BACKGROUND

Community-acquired pneumonia (CAP) represents one of the most common infectious diseases among children. Diagnosis of CAP is mainly clinical. Chest X-ray (CXR) remains the gold standard for the diagnosis in severe or controversial conditions. Recently, some authors have focused on the application of ultrasound in lung diseases but the role of lung ultrasound (LUS) in the diagnosis of CAP is still debated. We aimed to study the concordance between LUS and CXR in evaluating specific signs of CAP. As a secondary aim, we sought to determine the sensitivity and specificity of LUS in CAP diagnosis compared with CXR. Finally, we evaluated the role of LUS during the follow up.

METHODS

We enrolled 68 children (<16 years old) hospitalized from October 2018 to September 2019 with a clinical and radiological diagnosis of CAP (cases: N = 41), or with no respiratory diseases (controls: N = 27), in whom a CXR was performed for clinical indications. All the children underwent LUS during hospitalization. The average time needed to perform LUS was 5-10 min for each child, and 19/41 cases were re-evaluated by LUS and CXR 30 days after discharge.

RESULTS

Lung ultrasound confirmed CAP diagnosis in 40/41 patients. Concordance between the two techniques was K = 0.88 for the right lung and K = 0.70 for the left lung. Lung ultrasound showed a sensitivity of 97% and a specificity of 96% compared with CXR. At the follow up, sensitivity increased to 100% while specificity was 94%.

CONCLUSIONS

Our study showed a potential benefit of LUS compared with CXR in the diagnosis and the follow up of CAP.

Respiratory and Hemodynamic Effects of Prophylactic Alveolar Recruitment During Liver Transplant: A Randomized Controlled Trial

OBJECTIVES

Prolonged surgical retraction may cause atelectasis. We aimed to recruit collapsed alveoli, stepwise, monitored by lung dynamic compliance and observe effects on arterial oxygenation and systemic and graft hemodynamics. Secondarily, we observed alveolar recruitment effects on postoperative mechanical ventilation, international normalized ratio, and pulmonary complications.

MATERIALS AND METHODS

For 58 recipients (1 excluded), randomized with optimal positive end-expiratory pressure (n = 28) versus control (fixed positive end-expiratory pressure, 5 cm H₂O; n = 29), alveolar recruitment was initiated (pressure-controlled ventilation guided by lung dynamic compliance) to identify optimal conditions. Ventilation shifted to volume-control mode with 0.4 fraction of inspired oxygen, 6 mL/kg tidal volume, and 1:2 inspiratory-to-expiratory ratio. Alveolar recruitment was repeated postretraction and at intensive care unit admission. Primary endpoints were changes in lung dynamic compliance, arterial oxygenation, and hemodynamics (cardiac output, invasive arterial and central venous pressures, graft portal and hepatic vein flows). Secondary endpoints were mechanical ventilation period and postoperative international normalized ratio, aspartate/alanine aminotransferases, lactate, and pulmonary complications.

RESULTS

Alveolar recruitment increased positive end-expiratory pressure, lung dynamic compliance, and arterial oxygenation (P < .01) and central venous pressure (P = .004), without effects on corrected flow time (P = .7). Cardiac output and invasive arterial pressure were stable with (P = .11) and without alveolar recruitment (P = .1), as were portal (P = .27) and hepatic vein flow (P = .30). Alveolar recruitment reduced postoperative pulmonary complications (n = 0/28 vs 8/29; P = .001), without reduction in postoperative mechanical ventilation period (P = .08). International normalization ratio, aspartate/alanine aminotransferases, and lactate were not different from control (P > .05).

CONCLUSIONS

Stepwise alveolar recruitment identified the optimal positive end-expiratory pressure to improve lung mechanics and oxygenation with minimal hemodynamic changes, without liver graft congestion/dysfunction, and was associated with significant reduction in postoperative pulmonary complications.

Point-of-care lung ultrasound in the assessment of patients with COVID-19: A tutorial

The adoption of point-of-care lung ultrasound for both suspected and confirmed COVID-19 patients highlights the issues of accessibility to ultrasound training and equipment. Lung ultrasound is more sensitive than chest radiography in detecting viral pneumonitis and preferred over computed tomography for reasons including its portability, reduced healthcare worker exposure and repeatability. The main lung ultrasound findings in COVID-19 patients are interstitial syndrome, irregular pleural line and subpleural consolidations. Consolidations are most likely found in critical patients in need of ventilatory support. Hence, lung ultrasound may be used to timely triage patients who may have evolving pneumonitis. Other respiratory pathology that may be detected by lung ultrasound includes pulmonary oedema, pneumothorax, consolidation and large effusion. A key barrier to incorporate lung ultrasound in the assessment of COVID-19 patients is adequate decontamination of ultrasound equipment to avoid viral spread. This tutorial provides a practical method to learn lung ultrasound and a cost-effective method of preventing contamination of ultrasound equipment and a practical method for performing and interpreting lung ultrasound.

Better With Ultrasound: Thoracic Ultrasound

Ultrasound examination of the thorax is superior to chest radiograph or physical examination for diagnosing common conditions such as pneumonia, pulmonary edema, pleural effusion, and pneumothorax. The basic skill set is straightforward to learn, quick to perform, repeatable, and does not involve patient transport, harmful ionizing radiation, or waiting time. This paper outlines the basic building blocks that makeup a thoracic ultrasound examination, regardless of which specific scanning protocol is performed. Narrative videos and illustrative figures demonstrating these techniques are included.

Methods of estimation of pleural effusion by ecography

Pleural effusion is a frequent pathology in intensive care units. The diagnosis has improved after the introduction of pulmonary ultrasound, an accessible method at the bedside, which allows not only the diagnosis but also the treatment of this entity. The aim of our study is to determine the accuracy of published mathematical equations to calculate the volume of pleural effusion from ultrasound measurements. After doing a systematic review, seven articles were selected that each proposed a mathematical equation. In all of them the results were statistically significant. However, there is no ideal formula among those studied.

Global Ultrasound Check for the Critically lll (GUCCI)-a new systematized protocol unifying point-of-care ultrasound in critically ill patients based on clinical presentation

Ultrasound technology is an essential tool in the management of critically ill patients. Point-of-care ultrasonography (POCUS) enables data collection from different anatomic areas to achieve the most probable diagnosis and administer the right therapy at the right time. Despite the increasing utilization of POCUS, there is still a lack of standards to establish how to use different bedside ultrasound protocols, and it is imperative to develop a unifying protocol. Thus, the aim of this paper is to establish a new systematized approach that can be adopted by all physicians to implement POCUS for critically ill patient management. To achieve this, we propose a new systematized approach—Global Ultrasound Check for the Critically Ill (GUCCI)—that integrates multiple protocols. This protocol is organized based on three syndromes (acute respiratory failure, shock, and cardiac arrest) and includes ultrasound-guided procedures.

[Usefulness and reliability of point of care ultrasound in Family Medicine: Focused cardiac and lung ultrasound]

The family doctor incorporates clinical ultrasound as an exploration and diagnosis technique in his care activity, the same way as the rest of the specialists. His generalist role makes him a potential user of all possible applications of this technique, which can provide a high impact on his ability to manage, focus and solve a large number of clinical situations. In this article we focus on assessing the usefulness and reliability of clinical ultrasound performed by the family doctor in their most novel aspects such as focused cardiac ultrasound and lung ultrasound.

Cancer antigen-125 levels correlate with pleural effusions and COPD-related complications in people living at high altitude

Chronic obstructive pulmonary disease (COPD) is the most frequently encountered progressive lung disease in clinical practice. This study sought to determine the predictive ability of the tumor biomarker cancer antigen-125 (CA-125) in the identification of COPD in a cohort of 284 patients with COPD living at high altitude (with an average elevation of over 2500 m).Patients were classified by pleural effusion volumes into 4 categories and serum CA-125 concentrations were measured in each category. The analyses revealed that CA-125 concentrations were positively and significantly correlated with pleural effusion volume. CA-125 concentrations were also positively correlated with pulmonary heart disease and acute exacerbations of COPD, and negatively correlated with pulmonary hypertension.The study evidence suggests that serum CA-125 concentrations are positively correlated with the risk of pleural effusions among patients with COPD living in high-altitude areas, and that CA-125 concentrations are also correlated with pulmonary heart disease, acute exacerbations, and pulmonary hypertension.