Point-of-Care Lung Ultrasound in Critically ill Patients

Establishment of seven lung ultrasound phenotypes: a retrospective observational study of an LUS registry

BACKGROUND

Lung phenotypes have been extensively utilized to assess lung injury and guide precise treatment. However, current phenotypic evaluation methods rely on CT scans and other techniques. Although lung ultrasound (LUS) is widely employed in critically ill patients, there is a lack of comprehensive and systematic identification of LUS phenotypes based on clinical data and assessment of their clinical value.

METHODS

Our study was based on a retrospective database. A total of 821 patients were included from September 2019 to October 2020. 1902 LUS examinations were performed in this period. Using a dataset of 55 LUS examinations focused on lung injuries, a group of experts developed an algorithm for classifying LUS phenotypes based on clinical practice, expert experience, and lecture review. This algorithm underwent validation and refinement with an additional 140 LUS images, leading to five iterative revisions and the generation of 1902 distinct LUS phenotypes. Subsequently, a validated machine learning algorithm was applied to these phenotypes. To assess the algorithm's effectiveness, experts manually verified 30% of the phenotypes, confirming its efficacy. Using K-means cluster analysis and expert image selection from the 1902 LUS examinations, we established seven distinct LUS phenotypes. To further explore the diagnostic value of these phenotypes for clinical diagnosis, we investigated their auxiliary diagnostic capabilities.

RESULTS

A total of 1902 LUS phenotypes were tested by randomly selecting 30% to verify the phenotypic accuracy. With the 1902 LUS phenotypes, seven lung ultrasound phenotypes were established through statistical K-means cluster analysis and expert screening. The acute respiratory distress syndrome (ARDS) exhibited gravity-dependent phenotypes, while the cardiogenic pulmonary edema exhibited nongravity phenotypes. The baseline characteristics of the 821 patients included age (66.14 ± 11.76), sex (560/321), heart rate (96.99 ± 23.75), mean arterial pressure (86.5 ± 13.57), Acute Physiology and Chronic Health Evaluation II (APACHE II)score (20.49 ± 8.60), and duration of ICU stay (24.50 ± 26.22); among the 821 patients, 78.8% were cured. In severe pneumonia patients, the gravity-dependent phenotype accounted for 42% of the cases, whereas the nongravity-dependent phenotype constituted 58%. These findings highlight the value of applying different LUS phenotypes in various diagnoses.

CONCLUSIONS

Seven sets of LUS phenotypes were established through machine learning analysis of retrospective data; these phenotypes could represent the typical characteristics of patients with different types of critical illness.

Implementation of an International Severe Infection Point-of-Care Ultrasound Research Network

INTRODUCTION

Point-of-care ultrasound (POCUS) is a rapid, readily available, and cost-effective diagnostic and prognostic modality in a range of clinical settings. However, data to support its clinical application are limited. This project's main goal was to assess the effectiveness of standardizing lung ultrasound (LUS) training for sonographers to determine if universal LUS adoption is justified.

MATERIALS AND METHODS

We describe the effectiveness of an implementation of a LUS research training program across eight international study sites in Asia, Africa, and North America as part of prospective Coronavirus Disease of 2019 (COVID-19) and sepsis study cohorts (Rapid Assessment of Infection with SONography research network). Within our network, point-of-care LUS was used to longitudinally evaluate radiographic markers of lung injury. POCUS operators were personnel from a variety of backgrounds ranging from research coordinators with no medical background to experienced clinicians.

RESULTS

Following a standardized protocol, 49 study sonographers were trained and LUS images from 486 study participants were collected. After training was completed, we compared before and after image qualities for interpretation. The proportion of acceptable images improved at each site between the first 25 scans and the second 25 scans, resulting in 80% or greater acceptance at each study site.

CONCLUSIONS

POCUS training and implementation proved feasible in diverse research settings among a range of providers. Standardization across ongoing cohort protocols affords opportunities for increased statistical power and generalizability of results. These results potentially support care delivery by enabling military medics to provide care at the point of injury, as well as aiding frontline clinicians in both austere and highly resourced critical care settings.

A lung disease diagnosis algorithm based on 2D spectral features of ultrasound RF signals

Lung diseases are commonly diagnosed based on clinical pathological indications criteria and radiological imaging tools (e.g., X-rays and CT). During a pandemic like COVID-19, the use of ultrasound imaging devices has broadened for emergency examinations by taking their unique advantages such as portability, real-time detection, easy operation and no radiation. This provides a rapid, safe, and cost-effective imaging modality for screening lung diseases. However, the current pulmonary ultrasound diagnosis mainly relies on the subjective assessments of sonographers, which has high requirements for the operator's professional ability and clinical experience. In this study, we proposed an objective and quantifiable algorithm for the diagnosis of lung diseases that utilizes two-dimensional (2D) spectral features of ultrasound radiofrequency (RF) signals. The ultrasound data samples consisted of a set of RF signal frames, which were collected by professional sonographers. In each case, a region of interest of uniform size was delineated along the pleural line. The standard deviation curve of the 2D spatial spectrum was calculated and smoothed. A linear fit was applied to the high-frequency segment of the processed data curve, and the slope of the fitted line was defined as the frequency spectrum standard deviation slope (FSSDS). Based on the current data, the method exhibited a superior diagnostic sensitivity of 98% and an accuracy of 91% for the identification of lung diseases. The area under the curve obtained by the current method exceeded the results obtained that interpreted by professional sonographers, which indicated that the current method could provide strong support for the clinical ultrasound diagnosis of lung diseases.

Thoracic Ultrasound Utility in Pulmonary Pathologies Following Blunt Chest Trauma: A Cross-Sectional Study From Barcelona, Venezuela

Background The thoracic ultrasound (TUS) is a monitoring tool that has gained worldwide popularity in various scenarios, offering the opportunity for dynamic, bedside evaluations. Recent studies indicate that the use of TUS enables the diagnosis of pathologies resulting from blunt chest trauma (BCT), yielding favorable outcomes. This study aimed to compare the utility of TUS versus chest radiography (CXR) in diagnosing pulmonary pathologies resulting from closed-chest traumas. Methodology A prospective cross-sectional study was conducted with a sample of 58 patients diagnosed with BCT who sought emergency care at the "Dr. Luis Razetti" University Hospital in Barcelona, Venezuela, from November 2023 to January 2024. Results Of the patients, 75.9% (n = 44) were male, with an average age of 37.8 years (standard deviation = 18.4 years). Injuries were reported in 8.6% (n = 5) of the patients, including 60% (n = 3) pneumothorax and 40% (n = 2) hemothorax. Ultrasound results coincided with CXR in 94.8% (n = 55) of the cases, with a Cohen's kappa coefficient of 0.9 (95% confidence interval (CI) = 0.642-1.0). TUS demonstrated higher sensitivity than CXR (100% vs. 60%) for detecting hemothorax and pneumothorax in patients with BCT, with an area under the receiver operating characteristic curve of 0.991 (95% CI = 0.968-1.013). Conclusions BCT predominantly occurred in young males, resulting primarily in pneumothorax and hemothorax lesions, detectable with higher sensitivity through TUS compared to CXR. The use of TUS should be considered an essential component of the initial assessment for individuals with BCT.

Use of thoracic fluid content for prediction of fluid balance and postoperative pulmonary complications after major abdominal surgery: an observational study

BACKGROUND AND OBJECTIVES

The harmful effects of excess fluids frequently manifest in the lungs. Thoracic fluid content (TFC) is a variable provided by the STARLINGTM bioreactance monitor, which represents the total volume of fluid in the chest. The objective is to analyse the association between the variation in TFC values (TFCd0%) at 24 h postoperatively, postoperative fluid balance, and postoperative pulmonary complications.

MATERIAL AND METHODS

Prospective and analytical observational study. Patients scheduled for major abdominal surgery at a tertiary teaching hospital were included. They were monitored during the intervention and the first 24 postoperative hours with the monitor. STARLINGTM, measuring TFC and its variation in different stages of the perioperative period. Serial lung ultrasounds were performed and postoperative pulmonary complications were recorded. Logistic regression was performed to predict the occurrence of atelectasis and pulmonary congestion. The Pearson correlation coefficient was calculated to verify the association between TFC and fluid balance.

RESULTS

50 patients were analyzed. TFCd0% measured on the morning of the first postoperative day increased by a median of 27.1% [IQR: 20.3-37.5] and was correlated at r = 0.44 with the postoperative balance of 677 ml [IQR: 125.5-1,412]. Increased TFC was related to a higher risk of atelectasis (OR = 1.24) and pulmonary congestion (OR = 1.3).

CONCLUSIONS

TFCd0% measured 24 h after surgery presents a moderate correlation with postoperative fluid balance. Its increase is a risk factor for the appearance of postoperative pulmonary complications.

Lung Ultrasonography Does Not Distinguish between Interstitial and Alveolar Pulmonary Edema

For a long time, lung diseases have been considered the "forbidden zone" for ultrasound diagnosis because the lung is filled with gas, and the ultrasound waves are totally reflected when they encounter gas [...].

Lung ultrasound for the early diagnosis of acute lung injury: A case report

BACKGROUND

The extensive availability of ultrasound (US) technology has increased its use for point-of-care applications in many health care settings. During anaesthesia and surgery, acute respiratory failure or pulmonary oedema are common life-threatening events that, if not recognized and treated appropriately, result in a high mortality rate.

CASE SUMMARY

We report a patient under anaesthesia whose lung US examination showed multiple vertical artefacts (B-lines) in the lung tissue, indicating pulmonary oedema. The respiratory state improved with the resolution of the pulmonary oedema after our treatment.

CONCLUSION

We believe that US of the lungs may be a useful tool for dynamic respiratory monitoring at the bedside during anaesthesia.

Clinical benefit of AI-assisted lung ultrasound in a resource-limited intensive care unit

BACKGROUND

Interpreting point-of-care lung ultrasound (LUS) images from intensive care unit (ICU) patients can be challenging, especially in low- and middle- income countries (LMICs) where there is limited training available. Despite recent advances in the use of Artificial Intelligence (AI) to automate many ultrasound imaging analysis tasks, no AI-enabled LUS solutions have been proven to be clinically useful in ICUs, and specifically in LMICs. Therefore, we developed an AI solution that assists LUS practitioners and assessed its usefulness in  a low resource ICU.

METHODS

This was a three-phase prospective study. In the first phase, the performance of four different clinical user groups in interpreting LUS clips was assessed. In the second phase, the performance of 57 non-expert clinicians with and without the aid of a bespoke AI tool for LUS interpretation was assessed in retrospective offline clips. In the third phase, we conducted a prospective study in the ICU where 14 clinicians were asked to carry out LUS examinations in 7 patients with and without our AI tool and we interviewed the clinicians regarding the usability of the AI tool.

RESULTS

The average accuracy of beginners' LUS interpretation was 68.7% [95% CI 66.8-70.7%] compared to 72.2% [95% CI 70.0-75.6%] in intermediate, and 73.4% [95% CI 62.2-87.8%] in advanced users. Experts had an average accuracy of 95.0% [95% CI 88.2-100.0%], which was significantly better than beginners, intermediate and advanced users (p < 0.001). When supported by our AI tool for interpreting retrospectively acquired clips, the non-expert clinicians improved their performance from an average of 68.9% [95% CI 65.6-73.9%] to 82.9% [95% CI 79.1-86.7%], (p < 0.001). In prospective real-time testing, non-expert clinicians improved their baseline performance from 68.1% [95% CI 57.9-78.2%] to 93.4% [95% CI 89.0-97.8%], (p < 0.001) when using our AI tool. The time-to-interpret clips improved from a median of 12.1 s (IQR 8.5-20.6) to 5.0 s (IQR 3.5-8.8), (p < 0.001) and clinicians' median confidence level improved from 3 out of 4 to 4 out of 4 when using our AI tool.

CONCLUSIONS

AI-assisted LUS can help non-expert clinicians in an LMIC ICU improve their performance in interpreting LUS features more accurately, more quickly and more confidently.

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED) using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans 83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion  This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

Diagnostic accuracy of lung ultrasound for transient tachypnea: a meta-analysis

OBJECTIVE

The objective of this meta-analysis was to study the diagnostic value of lung ultrasound (LUS) for transient tachypnea of the newborn (TTN).

METHODS

Embase, Cochrane Library, PubMed, Web of Science, and Google Scholar were searched, and the last search date was October 31, 2020. Studies on the diagnostic accuracy of pulmonary ultrasound for transient tachypnea were included. The quality assessment of the included study was assessed using the Diagnostic Accuracy Studies-2 tool. A meta-analysis was performed using Meta-Disc 1.4. A random-effects model was used and subgroup analysis was carried out to identify possible sources of heterogeneity.

RESULTS

A total of 378 articles were retrieved and nine studies with 3239 patients were included in the present meta-analysis. The overall quality of the included studies was moderate to high. The result of threshold analysis shows that there was no threshold effect. However, there was a significant heterogeneity caused by non-threshold effects in the included studies. A random-effects model was used. The pooled sensitivity, specificity, PLR and NLR were 0.55 (95% CI: 0.51-0.58), 0.98 (95% CI: 0.98-0.99), 58.30 (95% CI: 14.05-241.88) and 0.28 (95% CI: 0.18-0.43). The pooled DOR and AUC were 689.12 (95% CI: 68.71 to 6911.79) and 0.994. The results of subgroup analysis showed that the LUS diagnostic criteria and gold standard might be responsible for heterogeneity. Choosing "DLP combined with B line" as the diagnostic standard of LUS and choosing CXR as the gold standard could significantly improve the diagnostic performance of LUS.

CONCLUSION

LUS is a promising method to diagnose TTN. Only DLP is not enough to diagnose TTN, while DLP combined with B-line has good diagnostic performance.

COVID-19 triajında CLUE protokolünün etkinliği

Purpose: The purpose of this study was to evaluate the effectiveness of the CLUE protocol in COVID-19 triage. Materials and Methods: Patients who presented to the emergency department due to dyspnea with oxygen saturation below 95 % and were diagnosed with COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) tests were included in this prospective, observational study. Patients included in the study underwent lung ultrasound (LUS) in the light of the CLUE protocol, and were accordingly given LUS scores of between 0 and 36, also within the scope of the protocol. Patients were placed under observation, and clinical outcomes of discharge from the emergency department, admission to the ward, and admission to intensive care or discharge were recorded. ROC analysis was applied in the calculation of threshold values for LUS scores predicting discharge, admission to intensive care, and mortality. Results: Forty-five patients with a mean age of 63 ± 18 years were included in the study. Fifteen patients (33 %) were treated on an outpatient basis and discharged, while 12 (27 %) were admitted to the ward and 18 (40 %) to the intensive care unit. Mortality occurred in 15 (33 %) patients. An LUS score lower than 3 was 97 % sensitive and 80 % specific for discharge, a score greater than 10 was 94 % sensitive and 78 % specific for admission to the intensive care unit, and a score higher than 11 was 93 % sensitive and 87 % specific for mortality. Based on regression analysis, an LUS score higher than 10 emerged as an independent risk factor for intensive care requirement, a score lower than 3 for discharge, and a score over 11 for mortality. Conclusion: The CLUE protocol may be a useful bedside test in COVID-19 triage, and one that does not involve radiation or require laboratory tests.

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.

The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias

INTRODUCTION

Traditional evaluation for suspicion of gallstone or gallbladder-related disease includes evaluation with a formal technician-performed ultrasound. However, the use of point-of-care bedside ultrasounds (Bedside US) has been shown to be a viable alternative for the diagnosis of gallstones and gallbladder-related diseases. Purpose Statement: The purpose of this study was to evaluate the impact of Bedside US use in gallbladder evaluation on key patient care outcomes within our community-based emergency department setting.

METHODS

This retrospective study compared the use of no ultrasound (No US), a formal technician performed ultrasound (Tech US) and Bedside US for gallstone and gallbladder related diseases within a community hospital emergency department between January 1, 2015 and January 1, 2018. Initial vitals, lab work, patient socio-demographics, medical history, emergency department length of stay in hours and disposition were reviewed.

RESULTS

Of a total N = 449 patients included, patients who received a Bedside US had the fewest computerized tomography scans (No US 62% vs. Tech US 29% vs. Bedside US 16%; p < 0.0001), the shortest median emergency department length of stay (No US 4.5 days vs. Tech US 5.0 days vs. Bedside US 3.0 days; p < 0.0001), and were more likely to be discharged home (No US 41% vs. Tech US 55% vs. Bedside US 81%; p = 0.0006) compared to those that received no ultrasound or a formal ultrasound. Patients who received a Bedside US also had the statistically significant highest incidence of prior cholelithiasis (No US 29.4% vs Tech US 14.3% vs. Bedside US 31.3%; p = 0.001) and lowest total median bilirubin levels (No US 0.5 vs. Tech US 0.5 vs. Bedside US 0.3; p = 0.016) when compared to the other two groups.

CONCLUSIONS

Although there was a confirmation bias, these study results indicate that point-of-care bedside ultrasound could be a viable alternative for gallstones and gallbladder-related diseases with benefits of use in a community hospital setting.

Dynamic assessment of lung injury by ultrasound in patients with acute paraquat poisoning

Objective

To investigate the value of ultrasound in the dynamic assessment of lung injury after acute paraquat poisoning.

Methods

A prospective observational study was performed on patients with paraquat poisoning from admission to day 28 or discharge. Ultrasound assessment of the lungs was performtyed every 48 hours. The correlation of the lung ultrasound score (LUS) with other indicators was analyzed.

Results

Twenty-six patients were enrolled, with an average age of 46 ± 16 years. The average toxic dose was 95 ± 51 mL. The intensive care unit (ICU) stay averaged 9 ± 8 days, and the 28-day mortality was 88.5%. There was a significant negative correlation between LUS and oxygenation index (rho = −0.896) and a significant positive correlation between LUS and carbon dioxide concentration (rho = 0.567). Lung ultrasound and computed tomography imaging correlated closely.

Conclusion

Lung ultrasound can reflect changes in lung status in patients with paraquat poisoning and can be used to evaluate lung injury in these patients.

Trial registration: ChiCTR, ChiCTR-DDD-16010211. Registered 21 December 2016, http://www.chictr.org.cn/listbycreater.aspx.

Pilot Study of Robot-Assisted Teleultrasound Based on 5G Network: A New Feasible Strategy for Early Imaging Assessment During COVID-19 Pandemic

Early diagnosis is critical for the prevention and control of the coronavirus disease 2019 (COVID-19). We attempted to apply a protocol using teleultrasound, which is supported by the 5G network, to explore the feasibility of solving the problem of early imaging assessment of COVID-19. Four male patients with confirmed or suspected COVID-19 were hospitalized in isolation wards in two different cities. Ultrasound specialists, located in two other different cities, carried out the robot-assisted teleultrasound and remote consultation in order to settle the problem of early cardiopulmonary evaluation. Lung ultrasound, brief echocardiography, and blood volume assessment were performed. Whenever difficulties of remote manipulation and diagnosis occurred, the alternative examination was repeated by a specialist from another city, and in sequence, remote consultation was conducted immediately to meet the consensus. The ultrasound specialists successfully completed the telerobotic ultrasound. Lung ultrasound indicated signs of pneumonia with varying degrees in all cases and mild pleural effusion in one case. No abnormalities of cardiac structure and function and blood volume were detected. Remote consultation on the issue of manipulation practice, and the diagnosis in one case was conducted. The cardiopulmonary information was delivered to the frontline clinicians immediately for further treatment. The practice of teleultrasound protocol makes early diagnosis and repeated assessment available in the isolation ward. Ultrasound specialists can be protected from infection, and personal protective equipment can be spared. Quality control can be ensured by remote consultations among doctors. This protocol is worth consideration as a feasible strategy for early imaging assessment in the COVID-19 pandemic.

Pneumoperitoneum-induced pneumothorax during laparoscopic living donor hepatectomy: a case report

Background

We present a living donor case with an unexpected large-volume pneumothorax diagnosed using lung ultrasound during a laparoscopic hepatectomy for liver transplantation (LT).

Case presentation

A 38-year-old healthy female living donor underwent elective laparoscopic right hepatectomy. The preoperative chest radiography (CXR) and computed tomography images were normal. The surgery was uneventfully performed with tolerable CO₂ insufflation and the head-up position. SpO₂ decreased and airway peak pressure increased abruptly after beginning the surgery. There were no improvements in the SpO₂ or airway pressure despite adjusting the endotracheal tube. Eventually, lung ultrasound was performed to rule out a pneumothorax, and we verified the stratosphere sign as a marker for the pneumothorax. The surgeon was asked to temporarily hold the surgery and cease with the pneumoperitoneum. Portable CXR verified a large right pneumothorax with a small degree of left lung collapse; thus, a chest tube was inserted on the right side. The hemodynamic parameters fully recovered and were stable, and the surgery continued laparoscopically. The surgeon explored the diaphragm and surrounding structures to detect any defects or injuries, but there were no abnormal findings. The postoperative course was uneventful, and a follow-up CXR revealed complete resolution of the two-sided pneumothorax.

Conclusion

This living donor case suggests that a pneumothorax can occur during laparoscopic hepatectomy due to the escape of intraperitoneal CO₂ gas into the pleural cavity. Because missing the chance to identify a pneumothorax early significantly decreases the safety for living donors, point-of-care lung ultrasound may help attending physicians reach the final diagnosis of an intraoperative pneumothorax more rapidly and to plan the treatment more effectively.

Preparedness Tested: Severe Cerebral Malaria Presenting as a High-Risk Person Under Investigation for Ebola Virus Disease at a US Hospital

In 2019, a 42-year-old African man who works as an Ebola virus disease (EVD) researcher traveled from the Democratic Republic of Congo (DRC), near an ongoing EVD epidemic, to Philadelphia and presented to the Hospital of the University of Pennsylvania Emergency Department with altered mental status, vomiting, diarrhea, and fever. He was classified as a "wet" person under investigation for EVD, and his arrival activated our hospital emergency management command center and bioresponse teams. He was found to be in septic shock with multisystem organ dysfunction, including circulatory dysfunction, encephalopathy, metabolic lactic acidosis, acute kidney injury, acute liver injury, and diffuse intravascular coagulation. Critical care was delivered within high-risk pathogen isolation in the ED and in our Special Treatment Unit until a diagnosis of severe cerebral malaria was confirmed and EVD was definitively excluded.This report discusses our experience activating a longitudinal preparedness program designed for rare, resource-intensive events at hospitals physically remote from any active epidemic but serving a high-volume international air travel port-of-entry.

Point-of-care ultrasound in the preoperative setting

Point-of-care ultrasound (POCUS) is a widely used diagnostic tool, especially in emergency and critical care medicine, and it is increasingly being used in the perioperative setting. Its specific role in preoperative assessment of patients, however, has not yet been defined. While some data show innovative use of the technique in the preoperative setting, higher-level evidence to underscore potential advantages is still limited. We review and discuss a range of POCUS examinations which can potentially help anaesthesiologists in the preoperative clinic decide whether to perform additional testing, can assist in selecting the best anaesthetic approach, and can support perioperative and postoperative monitoring.

Ultrasonido pulmonar en Medicina, su utilidad en la práctica clínica

Lung ultrasound has become increasingly important in the evaluation of the thorax and its pathologies. It has proved to be very useful in the evaluation of hospitalized patients, allowing doctors to evaluate and make quick decisions, as well as providing guidance for diagnostic and therapeutic procedures. Ultrasound has many advantages over other studies since it can avoid transferring patients, and it is harmless, accessible and fast. In this article we will review basic concepts of lung ultrasound and its use in the diagnosis of pathologies. Key words: Pulmonary ultrasound; pleura; pneumothorax; pleural effusion.

Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill

Background

In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients.

Methods

This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated.

Results

The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients.

Conclusion

The agreement between lung ultrasound and auscultation is poor.

Trial registration

NCT02912624. Registered on September 23, 2016.

Neonatal lung ultrasonography score after surfactant in preterm infants: A prospective observational study

OBJECTIVE

To assess changes in neonatal lung ultrasonography score (nLUS) after surfactant administration in preterm infants with respiratory distress syndrome (RDS).

WORKING HYPOTHESIS

The reduction of nLUS score before (nLUSpre), 2 hours (nLUS2h), and 12 hours (nLUS12h) after surfactant administration to identify patients who will not need a second treatment.

STUDY DESIGN AND SETTING

Prospective observational study in the tertiary neonatal intensive care unit.

PATIENTS SELECTION

Forty-six preterm neonates with RDS of 32 weeks median gestational age (IQR 30-33) and mean birth weight of 1650 ± 715 g.

METHODOLOGY

Lung ultrasonography was performed before, 2 hours, and 12 hours after surfactant administration in preterm infants with RDS needing surfactant treatment. Resulting nLUS was analyzed.

RESULTS

The Wilcoxon signed-rank test demonstrated an nLUS lowering after 2 hours (P < .001) and 12 hours (P < .001) from surfactant administration. Sixteen newborns required surfactant retreatment with median gestational age of 32 weeks (IQR 29-33) and mean birth weight of 1519 ± 506 g.The receiver operating characteristic analysis for the nLUS2h yielded an area under the curve of 0.80 (95% confidence interval, 0.76-0.85; P < .001). A nLUS2h ≥7 showed a sensitivity of 94% and a specificity of 60% for needing a second treatment with surfactant.

CONCLUSIONS

In preterm infants with RDS requiring surfactant treatment, nLUS evaluated 2 hours after surfactant administration can be used to identify patients who will not need a second treatment.

Correlation between Transthoracic Lung Ultrasound Score and HRCT Features in Patients with Interstitial Lung Diseases

Chest high-resolution computed tomography (HRCT) is considered the “gold” standard radiological method in interstitial lung disease (ILD) patients. The objectives of our study were to evaluate the correlation between two transthoracic lung ultrasound (LUS) scores (total number of B-lines score = the total sum of B-lines in 10 predefined scanning sites and total number of positive chest areas score = intercostal spaces with ≥3 B-lines) and the features in HRCT simplified scores, in different interstitial disorders, between LUS scores and symptoms, as well as between LUS scores and pulmonary function impairment. We have evaluated 58 consecutive patients diagnosed with ILD. We demonstrated that there was a good correlation between the total number of B-lines score and the HRCT simplified score (r = 0.784, p < 0.001), and also a good correlation between the total number of positive chest areas score and the HRCT score (r = 0.805, p < 0.005). The results confirmed the value of using LUS as a diagnostic tool for the assessment of ILD compared to HRCT. The use of LUS in ILD patients can be a useful, cheap, accessible and radiation-free investigation and can play a complementary role in the diagnosis and monitoring of these patients.