Extended Lung Ultrasound to Differentiate Between Pneumonia and Atelectasis in Critically Ill Patients: A Diagnostic Accuracy Study.

OBJECTIVES: To determine the diagnostic accuracy of extended lung ultrasonographic assessment, including evaluation of dynamic air bronchograms and color Doppler imaging to differentiate pneumonia and atelectasis in patients with consolidation on chest radiograph. Compare this approach to the Simplified Clinical Pulmonary Infection Score, Lung Ultrasound Clinical Pulmonary Infection Score, and the Bedside Lung Ultrasound in Emergency protocol. DESIGN: Prospective diagnostic accuracy study. SETTING: Adult ICU applying selective digestive decontamination. PATIENTS: Adult patients that underwent a chest radiograph for any indication at any time during admission. Patients with acute respiratory distress syndrome, coronavirus disease 2019, severe thoracic trauma, and infectious isolation measures were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Lung ultrasound was performed within 24 hours of chest radiograph. Consolidated tissue was assessed for presence of dynamic air bronchograms and with color Doppler imaging for presence of flow. Clinical data were recorded after ultrasonographic assessment. The primary outcome was diagnostic accuracy of dynamic air bronchogram and color Doppler imaging alone and within a decision tree to differentiate pneumonia from atelectasis. Of 120 patients included, 51 (42.5%) were diagnosed with pneumonia. The dynamic air bronchogram had a 45% (95% CI, 31-60%) sensitivity and 99% (95% CI, 92-100%) specificity. Color Doppler imaging had a 90% (95% CI, 79-97%) sensitivity and 68% (95% CI, 56-79%) specificity. The combined decision tree had an 86% (95% CI, 74-94%) sensitivity and an 86% (95% CI, 75-93%) specificity. The Bedside Lung Ultrasound in Emergency protocol had a 100% (95% CI, 93-100%) sensitivity and 0% (95% CI, 0-5%) specificity, while the Simplified Clinical Pulmonary Infection Score and Lung Ultrasound Clinical Pulmonary Infection Score had a 41% (95% CI, 28-56%) sensitivity, 84% (95% CI, 73-92%) specificity and 68% (95% CI, 54-81%) sensitivity, 81% (95% CI, 70-90%) specificity, respectively. CONCLUSIONS: In critically ill patients with pulmonary consolidation on chest radiograph, an extended lung ultrasound protocol is an accurate and directly bedside available tool to differentiate pneumonia from atelectasis. It outperforms standard lung ultrasound and clinical scores.

Holistic Ultrasound to Predict Extubation Failure in Clinical Practice.

BACKGROUND: A weaning trial can be considered a stress test of the cardiorespiratory system; it increases oxygen demand and thus warrants a higher cardiac index and elevated breathing effort. We hypothesized that the combination of easily performed ultrasound measurements of heart, lungs, and diaphragm would yield good diagnostic accuracy to predict extubation failure. METHODS: Adult subjects ventilated for > 72 h with a successful spontaneous breathing trial were included. Ultrasound measurements of heart (left ventricular function), lungs (number of B-lines), and diaphragm thickening fraction were performed during a spontaneous breathing trial. The primary outcomes were sensitivity, specificity, and area under the receiver operating characteristic curve of a holistic ultrasound approach for extubation failure. Re-intubation within 48 h was considered extubation failure. RESULTS: Eighty-three subjects were included, of whom 15 (18%) were re-intubated within 48 h. The sensitivity and specificity of a holistic approach were 100% (78.2-100%) and 7.7% (2.5-17.1%), respectively, with an area under the receiver operating characteristic curve of 0.54. The sensitivity and specificity of diaphragm thickening fraction, using a cutoff value of < 30% for extubation failure were 86.7% (59.5-98.3%) and 25.4% (15.5-37.5%), respectively, with an area under the receiver operating characteristic curve of 0.61. CONCLUSIONS: In subjects ventilated for > 72 h who had a successful spontaneous breathing trial, holistic ultrasound was a weak predictor for extubation failure. (ClinicalTrials.gov registration NCT04196361).

Lung ultrasound findings in patients with novel SARS-CoV-2.

BACKGROUND: Over 2 million people worldwide have been infected with severe acute respiratory distress syndrome-coronavirus-2 (SARS CoV-2). Lung ultrasound has been proposed to diagnose and monitor it, despite the fact that little is known about the ultrasound appearance due to the novelty of the illness. The aim of this manuscript is to characterise the lung ultrasonographic appearance of critically ill patients with SARS-CoV-2 pneumonia, with particular emphasis on its relationship with the time course of the illness and clinical parameters. METHODS: Adult patients from the intensive care unit of two academic hospitals who tested positive for SARS-CoV-2 were included. Images were analysed using internationally recognised techniques which included assessment of the pleura, number of B-lines, pathology in the PLAPS (posterolateral alveolar and/or pleural syndrome) point, bedside lung ultrasound in emergency profiles, and the lung ultrasound score. The primary outcomes were frequencies, percentages and differences in lung ultrasound findings overall and between short (≤14 days) and long (>14 days) durations of symptoms and their correlation with clinical parameters. RESULTS: In this pilot observational study, 61 patients were included with 76 examinations available for analysis. 26% of patients had no anterior lung abnormalities, while the most prevalent pathological ultrasound findings were thickening of the pleura (42%), ≥3 B-lines per view (38%) and presence of PLAPS (74%). Patients with "long" duration of symptoms presented more frequently with a thickened and irregular pleura (32 (21%) versus 11 (9%)), C-profile (18 (47%) versus 8 (25%)) and pleural effusion (14 (19%) versus 3 (5%)), compared to patients with short duration of symptoms. Lung ultrasound findings did not correlate with arterial oxygen tension/inspiratory oxygen fraction ratio, fluid balance or dynamic compliance. CONCLUSION: SARS-CoV-2 results in significant, but not specific, ultrasound changes, with decreased lung sliding, thickening of the pleura and a B-profile being the most commonly observed. With time, a thickened and irregular pleura, C-profile and pleural effusion become more common findings. When screening patients, a comprehensive ultrasound protocol might be necessary.

Two sides of the same coin: Monetary incentives concurrently improve and bias confidence judgments.

Decisions are accompanied by a feeling of confidence, that is, a belief about the decision being correct. Confidence accuracy is critical, notably in high-stakes situations such as medical or financial decision-making. We investigated how incentive motivation influences confidence accuracy by combining a perceptual task with a confidence incentivization mechanism. By varying the magnitude and valence (gains or losses) of monetary incentives, we orthogonalized their motivational and affective components. Corroborating theories of rational decision-making and motivation, our results first reveal that the motivational value of incentives improves aspects of confidence accuracy. However, in line with a value-confidence interaction hypothesis, we further show that the affective value of incentives concurrently biases confidence reports, thus degrading confidence accuracy. Finally, we demonstrate that the motivational and affective effects of incentives differentially affect how confidence builds on perceptual evidence. Together, these findings may provide new hints about confidence miscalibration in healthy or pathological contexts.