Evolution of Lung Abnormalities on Lung Ultrasound in Recovery From COVID-19 Disease-A Prospective, Longitudinal Observational Cohort Study.

OBJECTIVES: SARS-CoV-2 can cause respiratory diseases with various manifestations. However, little is known about its potential for lung recovery. Lung ultrasound has shown characteristic changes during COVID-19 and has proven to be useful for triage, diagnosis, and therapy. This study investigated how the recovery process from COVID-19 respiratory disease can be monitored using 12-zone lung ultrasound. METHODS: This prospective observational cohort study was conducted in a busy urban emergency department in London, United Kingdom, over a 20-week period between April and October 2020. We followed 24 patients recovering from COVID-19 with varying disease severity using 12-zone lung ultrasound at 2-week intervals and monitored the changes in the prevalence of lung abnormalities previously described in COVID-19 infection (irregular pleura, subpleural consolidation, B-lines, and small localized effusions). RESULTS: Lung ultrasound showed that the lung recovers significantly over 20 weeks postdisease. Individual lung abnormalities also resolved at different rates. The entire rib space occupied by confluent B-lines wane after the acute phase, whereas irregular pleura and subpleural consolidations resolved more gradually. Separate wide B-lines moving with the pleura during respiration may represent more stable features, indicating residual fibrotic changes. Small, localized effusions appear transiently after the initial acute phase of the disease, peaking at approximately 10 weeks after infection. The measured lung abnormalities were strong predictors of perceived shortness of breath during ambulation. CONCLUSION: Lung ultrasound can be a useful tool for long-term monitoring of COVID-19 lung disease, avoiding repeated exposure to ionizing radiation, and may distinguish between acute and past infections.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) SHORT VERSION.

OBJECTIVE: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendations were produced, including assigning levels of evidence (LoE) and grading of recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement of the summary and recommendation for each question (using a 5-point Likert scale), which was approved in the case of a level of agreement of greater than 75 %. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1), the remaining 9 questions achieved broad agreement with an assigned LoE of 4 and a weak GRADE recommendation (question 2), three achieved an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8) and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION.

AIMS: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

Diagnostic accuracy of point-of-care lung ultrasound for COVID-19: a systematic review and meta-analysis.

BACKGROUND: Point-of-care (POC) lung ultrasound (LUS) is widely used in the emergency setting and there is an established evidence base across a range of respiratory diseases, including previous viral epidemics. The necessity for rapid testing combined with the limitations of other diagnostic tests has led to the proposal of various potential roles for LUS during the COVID-19 pandemic. This systematic review and meta-analysis focused specifically on the diagnostic accuracy of LUS in adult patients presenting with suspected COVID-19 infection. METHODS: Traditional and grey-literature searches were performed on 1 June 2021. Two authors independently carried out the searches, selected studies and completed the Quality Assessment Tool for Diagnostic Test Accuracy Studies (QUADAS-2). Meta-analysis was carried out using established open-source packages in R. We report overall sensitivity, specificity, positive and negative predictive values, and the hierarchical summary receiver operating characteristic curve for LUS. Heterogeneity was determined using the I2 statistic. RESULTS: Twenty studies were included, published between October 2020 and April 2021, providing data from a total of 4314 patients. The prevalence and admission rates were generally high across all studies. Overall, LUS was found to be 87.2% sensitive (95% CI 83.6 to 90.2) and 69.5% specific (95% CI 62.2 to 72.5) and demonstrated overall positive and negative likelihood ratios of 3.0 (95% CI 2.3 to 4.1) and 0.16 (95% CI 0.12 to 0.22), respectively. Separate analyses for each reference standard revealed similar sensitivities and specificities for LUS. Heterogeneity was found to be high across the studies. Overall, the quality of studies was low with a high risk of selection bias due to convenience sampling. There were also applicability concerns because all studies were undertaken during a period of high prevalence. CONCLUSION: During a period of high prevalence, LUS had a sensitivity of 87% for the diagnosis of COVID-19 infection. However, more research is required to confirm these results in more generalisable populations, including those less likely to be admitted to hospital. PROSPERO REGISTRATION NUMBER: CRD42021250464.

Diagnostic accuracy of point-of-care ultrasound (PoCUS) for shoulder dislocations and reductions in the emergency department: a diagnostic randomised control trial (RCT).

BACKGROUND: Following blunt trauma, diagnosis of shoulder dislocation based on physical examination alone is difficult due to possible concurrent proximal humeral fractures. X-rays are therefore used to confirm diagnosis. Results from recent observational studies comparing diagnostic accuracy of point-of-care ultrasound (PoCUS) with X-rays for shoulder dislocation have been encouraging. The aim of this study was to determine whether PoCUS improves diagnostic accuracy when used with physical examination for the diagnosis of shoulder dislocation, proximal humeral fracture and ascertaining successful reduction in the ED. METHODS: A prospective, single-centre, open, parallel randomised control study over a 6-month period was used to answer the research question and test the null hypothesis. Consecutive eligible adult patients attending the ED of Mater Dei Hospital in Malta were randomised to either the control (C) (physical examination only) or experimental group (E) (physical examination and a two-point PoCUS scan). The study objectives were to measure diagnostic accuracy for both examinations for detecting shoulder dislocation, any associated proximal humeral fractures and confirming reduction. X-rays were used as reference standard for both groups. RESULTS: 1206 patients were enrolled in this study (C n=600, E n=606). 290 dislocations (C n=132 and E n=158), 332 proximal humeral fractures (C n=154 and E n=178) and 278 reductions (C n=130 and E n=148) were analysed. A statistically significant difference (p<0.001) was found between the two groups for diagnostic accuracy in shoulder dislocation (C=65%, likelihood ratio (LR)+=2.03 and LR-=0.35 and E=100%, LR+=∞ and LR-=0), proximal humeral fractures (C=45.7%, LR+=1.23 and LR-=0.52 and E=98.3%, LR+=103.9 and LR-=0.03) and reduction (C=68.7%, E=100%). The null hypothesis for this study was thus rejected. CONCLUSIONS: The addition of PoCUS to a physical examination significantly improves diagnostic accuracy for dislocations, proximal humeral fractures and reduction confirmation. TRIAL REGISTRATION NUMBER: International Standard Randomised Controlled Trials Number Registry (ISRCTN17048126).

Normology: Is it Time to Rethink Point-of-Care Ultrasound Training?

Point-of-care ultrasound (PoCUS) is increasingly being adopted by clinicians to augment their clinical examination and aid procedures. Evidence-based clinical practice guidelines now support many aspects of PoCUS practice. As a result, more and more medical schools are integrating PoCUS into their curricula, creating a significant demand for training resources. All training must ensure that trainees have the appropriate knowledge, skills and behaviour to enable the clinical integration of PoCUS. The transition from supervised to unsupervised practice is an important step in PoCUS, but should not be confused with expertise. At the start of clinical practice, confirming that something is not normal is probably enough, and trainees can subsequently improve their PoCUS diagnostic accuracy at the bedside during clinical rotations. Our hypothesis is that competency can be achieved without the need to scan patients suspected or suffering from the target pathology. This would enable most of the training to be carried out outside the clinical environment, using volunteers in planned sessions. These planned sessions will be able to accommodate a larger number of trainees and may facilitate collaboration between specialties. When patients are scanned in the clinical environment, trainees should have acquired a good level of competence beforehand. In summary, normology principles could help PoCUS trainees, at the start of their training, to acquire the knowledge, skills and behaviour necessary to achieve a level of competency allowing them to proceed to unsupervised practice. Initially confirming whether something is normal or not is enough. Nevertheless, further research should be conducted to support this concept, and its impact on PoCUS teaching in clinical practice.

Can absence of cardiac activity on point-of-care echocardiography predict death in out-of-hospital cardiac arrest? A systematic review and meta-analysis.

AIM: The purpose of this systematic review and meta-analysis was to evaluate the accuracy of the absence of cardiac motion on point-of-care echocardiography (PCE) in predicting termination of resuscitation (TOR), short-term death (STD), and long-term death (LTD), in adult patients with cardiac arrest of all etiologies in out-of-hospital and emergency department setting. METHODS: A systematic review and meta-analysis was conducted based on PRISMA guidelines. A literature search in Medline, EMBASE, Cochrane, WHO registry, and ClinicalTrials.gov was performed from inspection to August 2022. Risk of bias was evaluated using QUADAS-2 tool. Meta-analysis was divided into medical cardiac arrest (MCA) and traumatic cardiac arrest (TCA). Sensitivity and specificity were calculated using bivariate random-effects, and heterogeneity was analyzed using I2 statistic. RESULTS: A total of 27 studies (3657 patients) were included in systematic review. There was a substantial variation in methodologies across the studies, with notable difference in inclusion criteria, PCE timing, and cardiac activity definition. In MCA (15 studies, 2239 patients), the absence of cardiac activity on PCE had a sensitivity of 72% [95% CI 62-80%] and specificity of 80% [95% CI 58-92%] to predict LTD. Although the low numbers of studies in TCA preluded meta-analysis, all patients who lacked cardiac activity on PCE eventually died. CONCLUSIONS: The absence of cardiac motion on PCE for MCA predicts higher likelihood of death but does not have sufficient accuracy to be used as a stand-alone tool to terminate resuscitation. In TCA, the absence of cardiac activity is associated with 100% mortality rate, but low number of patients requires further studies to validate this finding. Future work would benefit from a standardized protocol for PCE timing and agreement on cardiac activity definition.

Is gallbladder PoCUS diagnostic accuracy accessible to medical students after PoCUS training exclusively on healthy volunteers? A pilot randomized control trial.

BACKGROUND: Point-of-care ultrasound (PoCUS) is increasingly used in clinical practice and is now included in many undergraduate curricula. Here, we aimed to determine whether medical students who participated in a PoCUS teaching program with several practical training sessions involving healthy volunteers could achieve a good level of diagnostic accuracy in identifying gallbladder pathologies. The intervention group (IG) was trained exclusively on volunteers with a healthy gallbladder, whereas the control group (CG) had access to volunteers with a pathological gallbladder as recommended in most PoCUS curricula. MATERIALS AND METHODS: Twenty medical students were randomly assigned to the IG and CG. After completing the training program over 2 months, students were evaluated by three independent examiners. Students and examiners were blind to group allocation and study outcome. Sensitivity and specificity of students' PoCUS gallstone diagnosis were assessed. Secondary outcomes were students' confidence, image quality, acquisition time, and PoCUS skills. RESULTS: Sensitivity and specificity for gallstone diagnosis were, respectively, 0.85 and 0.97 in the IG and 0.80 and 0.83 in the CG. Areas under the curve (AUC) based on the receiver operating characteristic curve analysis were 0.91 and 0.82 in the IG and CG, respectively, with no significant difference (p = 0.271) and an AUC difference of -0.092. No significant between-group difference was found for the secondary outcomes. CONCLUSIONS: Our pilot study showed that medical students can develop PoCUS diagnostic accuracy after training on healthy volunteers. If these findings are confirmed in a larger sample, this could favor the delivery of large practical teaching sessions without the need to include patients with pathology, thus facilitating PoCUS training for students.

Assessing left ventricular systolic function by emergency physician using point of care echocardiography compared to expert: systematic review and meta-analysis.

Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced, in patients presenting to ED.

Transoesophageal echocardiography in cardiac arrest: A systematic review.

AIMS: To identify, appraise and synthesize all available clinical evidence to evaluate the diagnostic role of transoesophageal echocardiography (TEE) during resuscitation of in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) in the identification of reversible causes of cardiac arrest and cardiac contractility. METHODS: We conducted a systematic review following PRISMA guidelines. Medline, EMBASE, Web of Science Core Collection, Proquest Dissertations, Open Grey, CDSR, Cochrane Central, Cochrane Clinical Answers, and the clinicaltrials.gov registry were searched for eligible studies. Studies involving adult patients, with non-traumatic cardiac arrest in whom TEE was used for intra-arrest evaluation, were included. Case studies and case series, animal studies, reviews, guidelines and editorials were excluded. The QUADAS-2 tool was used for quality assessment of all studies. RESULTS: Eleven studies with a total of 358 patients were included. Four studies involved perioperative IHCA, three involved OHCA, and four were mixed population settings. Overall, the risk of bias in the selected studies was either high or unclear due to evidence or lack of information. In all 11 studies, TEE allowed the identification of reversible causes of arrest. We found significant heterogeneity in the criteria used to interpret findings, TEE protocol used, and timing of TEE. CONCLUSION: Due to heterogeneity of studies, small sample size and inconsistent reference standard, the evidence for TEE in cardiac arrest resuscitation is of low certainty and is affected by a high risk of bias. Further studies are needed to better understand the true diagnostic accuracy of TEE in identifying reversible causes of arrest and cardiac contractility.

The utility of lung ultrasound in COVID-19: A systematic scoping review.

Introduction: Lung ultrasound (LUS) has an established evidence base and has proven useful in previous viral epidemics. An understanding of the utility of LUS in COVID-19 is crucial to determine its most suitable role based on local circumstances. Method: Online databases, specialist websites and social media platforms were searched to identify studies that explore the utility of LUS in COVID-19. Case reports and recommendations were excluded. Findings: In total, 33 studies were identified which represent a rapidly expanding evidence base for LUS in COVID-19. The quality of the included studies was relatively low; however, LUS certainly appears to be a highly sensitive and fairly specific test for COVID-19 in all ages and in pregnancy. Discussion: There may be LUS findings and patterns that are relatively specific to COVID-19; however, specificity may also be influenced by factors such as disease severity, pre-existing lung disease, operator experience, disease prevalence and the reference standard. Conclusion: LUS is almost certainly more sensitive than chest radiograph for COVID-19 and has several advantages over computed tomography and real-time polymerase chain reaction. High-quality research is needed into various aspects of LUS including: diagnostic accuracy in undifferentiated patients; triage and prognostication; monitoring progression and guiding interventions; the persistence of residual LUS findings; inter-observer agreement and the role of contrast-enhanced LUS.

My patient is injured: identifying foreign bodies with ultrasound.

Patients commonly present to the emergency department with a suspected retained foreign body, following penetrating injury. While plain radiography is often the first line in identifying radio-opaque foreign bodies, radiolucent foreign bodies such as wood and plastic can easily be missed. Furthermore, real-time visualization of such a foreign body can assist in its removal. This article evaluates the use of point-of-care ultrasound by emergency physicians in the identification and removal of soft-tissue foreign bodies along with describing the appropriate technique and highlighting the potential pitfalls. An illustrated case example is presented that highlights the benefits of point-of-care ultrasound foreign body detection and guided removal.