Lung ultrasound in a COVID pandemic - Choosing wisely.

This is an opinion piece on the role of POCUS in COVID-19, with a focus on lung ultrasound. It is not an instructional essay. Crisis management in medicine has often been likened to crisis management in the aviation industry. The important difference between pilots and clinicians is that the clinician's life was not in imminent danger, should one fail. The clinician did not have the same emotional urgency as the pilot. The COVID-19 pandemic has changed this, and clinicians are now faced with the need to make urgent decisions whilst exposed to some personal risk. Whether to embrace POCUS and lung ultrasound during this pandemic is an important decision. Whilst there are clear advantages, poorly considered overzealous uptake is not without hazard, opportunity cost and potential risk to patient and clinician.

The Zentensivist Manifesto. Defining the Art of Critical Care.

Evidence-based medicine asks us to integrate the best available evidence with clinical experience and patient values. In the modern intensive care unit, the primary focus is on complex technology and electronic health records, often away from the bedside. Excess interventionism is the norm. The term "intensivist" itself implies an intensive management strategy, which can lead us away from a patient-centered practice and toward iatrogenic harm. Under the hashtag #zentensivist, an international, multiprofessional group of clinicians has begun to discuss via Twitter how to apply key principles of history taking, physical examination, physiology, pharmacology, and clinical research in a competent, compassionate, and minimalist fashion. The term "zentensivist" intentionally combines concepts seemingly at odds-Zen philosophy and intensive care-to describe a holistic approach to the art of caring for the critically ill. We describe the key tenets of zentensivist practice and how we may inspire these actions in those we lead and educate.

Implementation study reporting diagnostic accuracy, outcomes and costs in a multicentre randomised controlled trial of non-expert lung ultrasound to detect pulmonary oedema.

BACKGROUND: Lung ultrasound experts claim that 'B line' artefacts herald pulmonary oedema, but links between early recognition and improved outcome are unconfirmed, particularly for non-expert clinicians. OBJECTIVE: Assess individual and system impacts of early, non-expert lung ultrasound (LUS) in breathless older patients. METHODS: Prospective single-blinded randomised controlled trial of point of care LUS by non-expert clinicians, augmenting ED assessment of patients over 60 years, presenting with dyspnoea. After brief training, clinicians at three hospitals used computer-generated block randomisation envelopes to allocate a convenience sample of consenting presenters to conventional or LUS-augmented management. ED provisional diagnosis was compared to a post-discharge chart audit diagnosis, blinded to ultrasound findings. Secondary outcomes were the length of stay in ED and hospital, costs and discharge destinations. RESULTS: From three sites, 224 controls were compared with 218 interventions. LUS improved diagnostic accuracy, with a small effect size in favour of LUS (risk difference: 6.5%, 95% CI 0.9-12) and a number needed to scan of 16 (95% CI 8-107). With LUS, ED and hospital stay increased non-significantly, while discharge destination trends improved. No harm ensued. CONCLUSIONS: Non-expert LUS augmenting dyspnoea workup may improve diagnostic accuracy, but did not significantly alter costs or outcomes in the ED or the hospital. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry (ACTRN12613001023741).

The prevalence of lung surface abnormalities in a healthy population as detected by a screening lung ultrasound protocol: Comparison between young and older volunteers.

OUTLINE: Lung ultrasound can detect B-lines in both disease states and normal patients. B-lines are sensitive indicators for interstitial oedema, but research is limited in terms of what is a 'normal' amount in healthy adults. Current belief is that 3 B-lines in laterobasal areas can be normal. We aimed to determine what is normal in healthy patients of different ages. We hypothesised that older patients and patients with the previous history of lung disease or smoking would have more B-lines. METHODS: We performed a cross-sectional study on a convenience sample of 200 volunteers: 100 aged 18-49 (median age 33.5) and 100 aged 50-91 (median age 70.5). Volunteers were recruited in 2017 from two participating sites. All participants were scanned by a single researcher using a standardised lung protocol. Multivariate regression was conducted to determine independent predictors of B-line presence. RESULTS: B-lines were found in 12.5% (95%CI: 8.4-17.6) of all volunteers (n = 25/200), with 20% (95%CI: 13.3-28.9) prevalence in the younger group and 5% (95%CI: 1.9-10.7) in the older group (P < 0.0001). A total of 84% (95%CI: 65.3-93.6) had only 1 B-line (n = 21/25). 31.3% (95%CI: 20.0-45.6) of young females had B-lines. Only one volunteer had ≥3 B-lines in one scanned area. Participants with chronic lung disease had more B-lines (P = 0.03). Smokers (n = 13) also had more B-lines (31% vs. 11% of non-smokers). Smoking and younger age were independent predictors of B-line presence multivariate logistic regression models, but only for females. CONCLUSION: ≥2 B-lines are uncommon in healthy, ambulatory adults. Further research is needed to investigate the higher prevalence found in young females.

Point-of-Care Lung Ultrasound in Critically ill Patients.

BACKGROUND: Lung ultrasound is increasingly being used by the bedside physicians to complement the findings of physical examination. Lung ultrasound is non-invasive, devoid of radiation exposure and can be performed rapidly and repeatedly as needed at bedside. This review aims to elucidate the evidence base and the future directions for bedside point-of-care lung ultrasound in critically ill patients. METHODS: Research articles, review papers and online contents related to point-of-care ultrasound in critically ill patients were reviewed. RESULTS: The diagnostic accuracy of lung ultrasound for common conditions like pleural effusion, pneumothorax, pulmonary edema and pneumonia is superior to chest radiograph and is comparable to chest CT scan. Lung ultrasound is helpful to evaluate the progress of lung pathology and response to treatment, over time. Ultrasound guidance for thoracocentesis decreases the complication rates. CONCLUSION: Bedside lung ultrasound in critically ill patients can serve as a tool to diagnose common lung pathologies, monitor its course and guide clinical management.

Correction: RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates.

[This corrects the article DOI: 10.1371/journal.pone.0166483.].

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates.

INTRODUCTION: Overuse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4-10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America. AIMS: To describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation. METHODS: A retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation. RESULTS: Fourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8-15.4%; range 9.3-25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1-58.2%) and SSPE 8.8% (CI: 7.1-10.5%) of positive scans. CTPA usage (0.2-1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions. DISCUSSION/ CONCLUSIONS: We found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5-3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

Lung ultrasound in heart failure: Lessons from re-analysis of Lung Ultrasound 2011 database.

Introduction: In the setting of patients presenting with shortness of breath to an Emergency Department a simple lung ultrasound protocol aimed at detecting pulmonary oedema has been shown to have diagnostic accuracy of 85%. This article reviews data from the original study, in an attempt to determine whether adjusting the protocol and/or interpretive criteria would improve results. Method: A large lung ultrasound project provided the dataset. Inter-rater and intertest discrepancies were reviewed. Then original stored images and comments were retrospectively analysed using alternate interpretive criteria. Specific variations included changing the number of B-lines required to define 'wet lung' and assessing other pleural line abnormalities. Where they had been acquired cardiac loops were reviewed in addition to the lung images. Results: The 204 original studies available were reviewed. Some disagreement could be attributed to inexperience and unclear definitions. Adjusting the number of B-lines did not improve diagnostic accuracy. All positive scans, with numerous B-lines were reviewed using more advanced diagnostic criteria (pleural line abnormalities) and the number of false positives was decreased. In cases where cardiac views were available, their inclusion was beneficial. Conclusion: A simple lung ultrasound protocol to assess for 'wet lung' in patients presenting to Emergency Departments provides diagnostic accuracy of around 85% in the hands of relative novices. More advanced interpretation of the same_ultrasound images, and the addition of cardiac views, is likely to further improve diagnostic accuracy.

Sensitivity, specificity and diagnostic accuracy of novices integrating lung ultrasound into the care of breathless older patients.

Background: Lung ultrasound is frequently used to identify pulmonary oedema, using the 'B line' artefact. A small study in 2011 suggested that novice sonologists had a potential diagnostic accuracy of 85%, when performing the test without reference to other patient information. Aim: We aimed to test the overall diagnostic accuracy of novice clinician sonologists incorporating the 2011 protocol into routine assessment of the patient. Method: A prospective convenience sample of breathless older patients presenting to ED received an 8-view lung scan early in management. Initial ED diagnoses, utilising all information including ultrasound result, were compared against the opinion of a medical expert auditing the patient records after discharge from hospital. Results: The cohort of five novices scanned 63 cases, from which eleven were excluded. Novices using ultrasound differentiated between pulmonary oedema and other causes of breathlessness with a sensitivity of 71% (95%CI 44 to 87), Specificity of 91% (76 to 98), a diagnostic accuracy of 85% (72 to 92), a positive LR of 8.2 (2.7 to 25) and a negative LR of 0.32 (0.15 to 0.68). Discussion: The diagnostic accuracy of emergency department clinicians incorporating novice lung ultrasound into the investigation of breathlessness is consistent with the diagnostic accuracy of scanning performed in parallel to patient care, and is likely to be an improvement on current estimates of conventional ED diagnostic strategies. Clinicians should not be afraid that their learning curve would disadvantage the patient.

Limited lung ultrasound protocol in elderly patients with breathlessness; agreement between bedside interpretation and stored images as acquired by experienced and inexperienced sonologists.

Introduction: Bedside lung ultrasound is increasingly performed in the Emergency Department to assess dyspnoeic patients. Quantifying the number of B-lines (a vertical short path reverberation artefact caused by the presence of interstitial fluid) can help clinicians differentiate 'wet lung' - pulmonary oedema, from 'dry lung' - not pulmonary oedema. The aim of this study was to determine inter-rater agreement for this simple bedside investigation, comparing relative ultrasound novices with more experienced personnel. After completing an introductory ultrasound course the novices had only had four hours of specific lung ultrasound education, followed by 10 proctored scans. Method: A prospective convenience sample of 217 patients over the age of 60 and presenting with dyspnoea were recruited. Patients were either scanned by an experienced emergency physician sonologist or by relative ultrasound novices. The scans were saved and still images then interpreted by a blinded radiology registrar with sonography training, and agreement calculated using weighted kappa scores. Results: The experienced physician scanned 155 patients, and the 11 novices 62 between them. Agreement between the experienced sonologist and the blinded expert was excellent (kappa = 0.82, 95% CI 0.72 to 0.92); between novice group and sonographer, agreement was good (kappa = 0.70, 95% CI 0.45 to 0.95). Conclusion: This study demonstrates reasonable inter-rater agreement firstly between experts, and secondly between novices and experts.

Diagnostic accuracy of basic lung ultrasound in breathless patients over 60 years of age; stressing the protocol.

Introduction: Emergency department differentiation of pulmonary oedema from chronic obstructive airways disease causing acute breathlessness is inaccurate 25% of the time despite clinical acumen, clinician-reported chest x-ray and ECG. This research investigates whether a basic lung ultrasound protocol (LUS) could improve identification of pulmonary oedema in breathless elderly patients. Method: Researchers prospectively sampled patients over 60 years, describing any breathlessness on presentation to a suburban emergency department. LUS studies were acquired by experienced or novice sonologists, interpreted by a blinded reviewer and compared with cardiologist chart audit for diagnosis at admission (gold standard). The admitting doctor's diagnosis, blinded to LUS, was compared with the chart audit result. Results: 204 LUS were collected, 145 by experienced sonologist and 59 by inexperienced. Diagnostic accuracy compared to cardiologist audit was 86.2% (95% CI 80.9 to 90.3), significantly higher than 70.2%, diagnostic accuracy for admission diagnosis, difference in proportion of 16% (95%CI 7.7 to 24.4%). Conclusion: A simple lung scanning protocol can help exclude pulmonary oedema in any breathless elderly patient.

Comparison of a basic lung scanning protocol against formally reported chest x-ray in the diagnosis of pulmonary oedema.

Introduction: Brief lung scan protocols have been recommended as a useful adjunct to identify pulmonary oedema in the breathless elderly patient. Some papers quote diagnostic accuracies above that of chest x-ray. Method: We recruited a prospective convenience sample of patients over sixty years of age reporting any breathlessness on presentation to the emergency department. Those who received both bedside lung scan and chest x-ray later had their case notes audited by an expert cardiologist for the cause of their breathlessness at presentation. Admission diagnosis was also extracted. Results: 204 comparative data sets were collected. Compared with cardiologist chart review, delayed expert radiology report had a diagnostic accuracy of 92.2% (95%CI 87.6 to 95.1). Bedside interpretation of lung scan protocol had a diagnostic accuracy of 85.3% (95%CI 79.8 to 89.5). The difference of 6.9% between the two accuracy measures was significant (95%CI 0.69 to 13.1). Admission diagnosis accuracy, which encompasses inexpert x-ray interpretation was 70.2%(95%CI 62.9 to 76.6), significantly less than either lung scan or expert chest x-ray report. Conclusion: For identifying heart failure in breathless patients, urgent chest x-ray with delayed formal report has not been shown to be redundant. Basic lung scan protocols should not yet replace chest x-ray, but may be more reliable in the interim than inexpert clinician interpretation of chest x-rays.

Effecting change using careplans: experience from two fractured neck of femur pathways.

OBJECTIVE: To use a qualitative track of the effects of two fractured neck of femur careplans (1 & 2) implemented at the Ipswich Emergency Department in 2002 and 2003 in order to comment on the reasons for comparative successes and failures as instruments for change in clinical practice. Careplan 1 was initiated by local clinicians in 2002, rescinded in 2003 to make way for the system wide careplan 2, then informally restituted in 2004 after careplan 2 was withdrawn. Careplan 2 did not articulate specific ED management plans. METHOD: Biennial retrospective chart audits of two newly introduced evidence-based clinical practices over time was used to track changes from careplan 1. These were the use of regional anaesthesia by medical staff, and the compliance with indwelling urinary catheter insertion by nursing staff. RESULTS: Elements of careplan 1 continued despite lack of promotion. There has been significant increase in nerve block (2.8% to 27%) and indwelling catheter insertion (26% to 75%) from 2000 to 2009. Formal use of careplan 1 has declined to 13-20% in 2009. Careplan 2 was withdrawn for review in 2004. CONCLUSIONS: Careplans are one way to effect lasting changes in clinical behaviours which may persist beyond their implementation and promotion phases. For acceptance, corporate plans should incorporate local practices. For longevity, local plans should comply with the corporate vision of continuity of care, but local investment in the plan will facilitate uptake.

Retrospective case note review of patients brought to Ipswich emergency department under mental health emergency examination orders: does intoxication alter outcome?

OBJECTIVE: To alter staff perceptions, and to examine alternative management processes for intoxicated patients brought to Ipswich ED under mental health emergency examination orders by comparing disposition outcomes with non-intoxicated patients. METHODS: Consultation-Liaison mental health nursing staff completed surveys on all patients assessed under emergency examination orders over a 6 month period in 2008. Patients were classified as intoxicated if they recorded alcometer readings of greater than 0.05%, or self-reported drug use during the events leading to their transport to the ED. Outcomes were retrospectively collated with entries in Clinical Liaison nursing logbooks. Outcome measures recorded were rates of admission, outpatient referrals to the Integrated Mental Health Service, follow up by other community services or no follow up. Differences in outcomes for intoxicated and non-intoxicated patient groups were tested for significance using χ(2) or Fisher's exact test. RESULTS: One hundred and sixty-eight cases were included in the audit. No cases were excluded. Sixty patients were identified as intoxicated. The age and sex distributions were similar between intoxicated and non-intoxicated patients. There were no significant differences in admission or referral rates. The average length of assessment time in the ED was longer in the intoxicated group. DISCUSSION: This audit showed similar outcomes for both patient groups contrary to the perceptions expressed by ED staff in informal surveys. The admission and referral rate for both groups indicate they are an at-risk population. The admission rate of 16% has led to this department negotiating alternative accommodation for patients while they sober up.

National Emergency Department Overcrowding Study tool is not useful in an Australian emergency department.

OBJECTIVE: To determine the accuracy and usefulness of the National Emergency Department Overcrowding Study (NEDOCS) tool in an urban hospital ED in Australia by direct comparison with subjective assessment by senior ED staff. METHOD: A sample of simultaneous subjective and objective data pairs were collected six times a day for a period of 3 weeks. All senior medical staff in the ED answered a brief questionnaire along with the senior charge nurse for the ED. Simultaneously, the senior charge nurse also documented the total number of patients in the ED, the number of patients awaiting admission, the number of patients on ventilators, the longest time waited by an ED patient for ward bed, and the waiting time for the last patient from the Waiting Room placed on a trolley. The objective indicators were entered into a Web-based NEDOCS tool and transformed scores were compared with the averaged and transformed subjective scores for each sample time. Bland-Altmann and Kappa statistics were used to test the agreement between the objective and subjective measuring methods. RESULTS: The mean difference between the subjective and objective methods was small (3.5 [95% confidence interval -0.875-7.878] ); however, the 95% limits of agreement was wide (-46.52-53.43). The Kappa statistic used to assess the extent of reproducibility between categorical variables was 0.31 (95% confidence interval 0.17-0.45). CONCLUSION: The present study suggests that NEDOCS method of processing the objective overcrowding data does not accurately reflect the subjective assessment of the senior staff working at that time in the ED. This might be because the assumptions of the original NEDOCS study are flawed.

Chronic pain syndromes in the emergency department: identifying guidelines for management.

OBJECTIVES: To explore current literature on chronic pain syndromes and develop ED recommendations for the management and minimalization of chronic non-cancer pain. METHODS: A focused literature review. RESULTS: Chronic pain is a common presentation to the ED but is poorly understood and managed. Research into the psychophysiology of chronic pain shows that there are definite changes in the receptive and processing pathways in patients suffering chronic pain syndromes. Evidence shows the effectiveness of early recognition with multimodal treatment, however high level evidence is lacking. All experts recommend balanced drug therapy, cognitive and behavioural interventions. Certain interventions are appropriate to the ED setting. CONCLUSIONS: Emergency Medicine lacks a cohesive, informed strategy for management of chronic pain. The proposed guidelines represent the first step toward establishing consistency in the management of patients with chronic pain syndromes. Further work needs to be undertaken at a national level in developing evidence based guidelines.

Recent advances in the neurophysiology of chronic pain.

UNLABELLED: The chronic pain syndrome patient has become the 'leper' of emergency medicine. There are no emergency medicine guidelines and minimal research into managing this challenging group of patients. OBJECTIVE: To summarize the recent advances in laboratory research into the development of chronic pain that have relevance to emergency management. When the level of supporting evidence is low, it is imperative that emergency physicians understand the physiology that underpins those expert opinions upon which they base their treatment strategies. METHODS: Literature was searched via Medline, Cochrane, Cinahl, and PsycINFO from 1996 to 2004, under 'chronic pain and emergency management'. Medline from 1996 was searched for 'chronic pain and prevention', 'chronic pain and emergency' and 'chronic pain'. Bibliographies were manually searched for older keynote articles. RESULTS: Advances in understanding the biochemical changes of chronic pain are paralleled by lesser known advances in delineation of the corticol processing. CONCLUSIONS: Drug manipulation causes complex action and reaction in chronic pain. Emergency physicians must also optimize cognitive and behavioural aspects of treatment to successfully manage this systemic disease.