Feasibility of a new ultrasound guided procedure to ensure the correct position of the central venous catheter tip.

BACKGROUND: Safety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. METHODS: We investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. RESULTS: The procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. CONCLUSIONS: This study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

Effects of seasonality in emergency admissions for mental disorders: two years of clinical experience.

OBJECTIVES: This retrospective study, conducted in Turin, Italy, between January 2021 and February 2023, investigates the impact of seasonal heatwaves on emergency department (ED) admissions for mental disorders. METHODS: Through the analysis of data from 2,854 patients, this research found a significant link between the occurrence of heatwaves, especially from June to August, and an elevated rate of ED admissions for psychiatric conditions. RESULTS: The data indicate a clear seasonal pattern, with admissions peaking during the hot months and diminishing in the colder months. Particularly, the study delineates an enhanced correlation between heatwaves and admissions for severe psychiatric disorders, such as bipolar disorder, major depression, personality disorders, and schizophrenia, accounting for 1,868 of the cases examined. This correlation was most pronounced among individuals aged 50-59 years. CONCLUSIONS: The results of this study highlight a critical association between the incidence of seasonal heatwaves and an uptick in ED visits for psychiatric disorders, with a distinct impact on severe cases. It underscores the urgency for healthcare systems to anticipate seasonal fluctuations in psychiatric ED admissions and to allocate resources effectively to support patients during peak periods.

Retrospective analysis of the application of CT scan in the emergency department to screen clinically asymptomatic COVID-19 before hospital admission.

BACKGROUND: The necessity to identify and isolate COVID-19 patients to avoid intrahospital cross infections is particularly felt as a challenge. Clinically occult SARS-CoV-2 infection among patients admitted to the hospital is always considered a risk during the pandemic. The aim of our study is to describe the application of CT scan to reveal unexpected COVID-19 in patients needing hospital admission. METHOD: In our emergency department, we prospectively enrolled adult patients needing hospital admission, without symptoms suspected of COVID-19, and showing negative reverse transcriptase-polymerase chain reaction (RT-PCR) swab test. CT scan was performed to diagnose clinically occult COVID-19 pneumonia. All the exams were read and discussed retrospectively by two expert radiologists and assigned to one of 4 exclusive diagnoses: typical (typCT), indeterminate (indCT), atypical (atyCT), negative (negCT). The clinical characteristics and final diagnoses were described and compared with the results of CT scans. RESULTS: From May 25 to August 18, 2020, we prospectively enrolled 197 patients. They showed 122 negCT, 52 atyCT, 22 indCT, and 1 typCT. Based on the CT imaging, the prevalence of suspected clinically occult COVID-19 pneumonia was 11.6% (23 patients). None had confirmation of SARS-CoV-2 infection after the hospital stay. Nineteen patients had negative serial RT-PCR while in 4 cases, the infection was excluded by clinical follow-up or appearance of positivity of RT-PCR after months. CONCLUSION: Our descriptive analysis confirms that CT scan cannot be considered a valid tool to screen clinically occult COVID-19, when the asymptomatic patients need hospitalization for other conditions. Application of personnel protections and distancing among patients remains the best strategies to limit the possibility of intrahospital cross-infections.

European Respiratory Society statement on thoracic ultrasound.

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Quantitative Lung Ultrasound: Technical Aspects and Clinical Applications.

Lung ultrasound is increasingly used in emergency departments, medical wards, and critical care units-adult, pediatric, and neonatal. In vitro and in vivo studies show that the number and type of artifacts visualized change with lung density. This has led to the idea of a quantitative lung ultrasound approach, opening up new prospects for use not only as a diagnostic but also as a monitoring tool. Consequently, the multiple scoring systems proposed in the last few years have different technical approaches and specific clinical indications, adaptable for more or less time-dependent patients. However, multiple scoring systems may generate confusion among physicians aiming at introducing lung ultrasound in their clinical practice. This review describes the various lung ultrasound scoring systems and aims to clarify their use in different settings, focusing on technical aspects, validation with reference techniques, and clinical applications.

Lung Ultrasound for Heart Failure Diagnosis in Primary Care.

BACKGROUND: Lung ultrasound (LUS) is useful for diagnosing pulmonary congestion, but its value in primary care remains unclear. We investigated whether LUS improved diagnostic accuracy in outpatients with heart failure (HF) suspicion. METHODS AND RESULTS: LUS was performed on 2 anterior (A), 2 lateral (L), and 2 posterior (P) areas per hemithorax. An area was positive when ≥3 B-lines were observed. Two diagnostic criteria were used: for LUS-C1, 2 positive areas of 4 (A-L) on each hemithorax; and for LUS-C2, 2 positive areas of 6 (A-L-P) on each hemithorax. A cardiologist blinded to LUS validated HF diagnosis. 162 patients were included (age 75.6 ± 9.4 years, 70.4% women). Both LUS criteria, alone and combined with other HF diagnostic criteria, were accurate for identifying HF. LUS-C2 outperformed LUS-C1, showing remarkable specificity (0.99) and positive predictive value (0.92). LUS-C2, together with Framingham criteria, N-terminal pro-B-type natriuretic peptide, and electrocardiogram, added diagnostic value (area under the receiver operating characteristic curves 0.90 with LUS-C2 vs 0.84 without; P = .006). In the absence of N-terminal pro-B-type natriuretic peptide, LUS-C2 significantly reclassified one-third of patients above Framingham criteria and electrocardiogram (net reclassification improvement 0.65, 95% confidence interval 0.04-1.1). CONCLUSIONS: LUS was accurate enough to rule-in HF in a primary care setting. The accuracy of diagnostic workup for HF in primary care is enhanced by incorporating LUS, irrespective NT-proBNP availability.

Recommendations for core critical care ultrasound competencies as a part of specialist training in multidisciplinary intensive care: a framework proposed by the European Society of Intensive Care Medicine (ESICM).

Critical care ultrasound (CCUS) is an essential component of intensive care practice. Although existing international guidelines have focused on training principles and determining competency in CCUS, few countries have managed to operationalize this guidance into an accessible, well-structured programme for clinicians training in multidisciplinary intensive care. We seek to update and reaffirm appropriate CCUS scope so that it may be integrated into the international Competency-based Training in Intensive Care Medicine. The resulting recommendations offer the most contemporary and evolved set of core CCUS competencies for an intensive care clinician yet described. Importantly, we discuss the rationale for inclusion but also exclusion of competencies listed. BACKGROUND/AIM: Critical care ultrasound (CCUS) is an essential component of intensive care practice. The purpose of this consensus document is to determine those CCUS competencies that should be a mandatory part of training in multidisciplinary intensive care. METHODS: A three-round Delphi method followed by face-to-face meeting among 32 CCUS experts nominated by the European Society of Intensive Care Medicine. Agreement of at least 90% of experts was needed in order to enlist a competency as mandatory. RESULTS: The final list of competencies includes 15 echocardiographic, 5 thoracic, 4 abdominal, deep vein thrombosis diagnosis and central venous access aid. CONCLUSION: The resulting recommendations offer the most contemporary and evolved set of core CCUS competencies for an intensive care clinician yet described.

Essential Image Acquisition Protocols for Thoracic Ultrasonography.

Image acquisition is the technique of correct placement, holding, and manipulation of the ultrasound probe in an ultrasound examination for the purpose of answering a specific clinical question. We review the literature and discuss the image acquisition protocols used for thoracic ultrasound, explaining, where possible, the associated advantages, disadvantages, and alternatives. A better understanding of how to fine-tune image acquisition specifically for thoracic ultrasound will help physicians on all levels to standardise their practice and improve networking and collaboration. It will also lead to better-quality investigations and, potentially, new applications.

The Potential for Remotely Mentored Patient-Performed Home Self-Monitoring for New Onset Alveolar-Interstitial Lung Disease.

Purpose: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is an acute respiratory illness. Although most infected persons are asymptomatic or have only mild symptoms, some patients progress to devastating disease; such progression is difficult to predict or identify in a timely manner. COVID-19 patients who do not require hospitalization can self-isolate at home. Calls from one disease epicenter identify the need for homebased isolation with telemedicine surveillance to monitor for impending deterioration. Methodology: Although the dominant approach for these asymptomatic/paucisymptomatic patients is to monitor oxygen saturation, we suggest additionally considering the potential merits and utility of home-based imaging. Chest computed tomography is clearly impractical, but ultrasound has shown comparable sensitivity for lung involvement, with major advantages of short and simple procedures, low cost, and excellent repeatability. Thoracic ultrasound may thus allow remotely identifying the development of pneumonitis at an early stage of illness and potentially averting the risk of insidious deterioration to severe pneumonia and critical illness while in home isolation. Conclusions: Lung sonography can be easily performed by motivated nonmedical caregivers when directed and supervised in real time by experts. Remote mentors could thus efficiently monitor, counsel, and triage multiple home-based patients from their "control center." Authors believe that this approach deserves further attention and study to reduce delays and failures in timely hospitalization of home-isolated patients.

The sound of air: point-of-care lung ultrasound in perioperative medicine.

PURPOSE: Lung ultrasound (LUS) has emerged as an effective and accurate goal-directed diagnostic tool that can be applied in real time for the bedside assessment of patients with respiratory symptoms and signs. Lung ultrasound has definite and easily recognized findings and has been shown to outperform physical examination and chest radiography for the diagnosis and monitoring of many pulmonary and pleural conditions. In this article, we review the principles of LUS image acquisition and interpretation, summarizing key terms and sonographic findings. PRINCIPAL FINDINGS: Although LUS is easy to learn, adequate training and performance in an organized fashion are crucial to its clinical effectiveness and to prevent harm. Therefore, we review normal LUS findings and propose step-wise approaches to the most common LUS diagnoses, such as pneumothorax, pleural effusion, interstitial syndrome, and lung consolidation. We highlight potential pitfalls to avoid and review a recently published practical algorithm for LUS use in clinical practice. CONCLUSIONS: Because of the unique physical properties of the lungs, only a careful and systematic analysis of both artifacts and anatomical images allows accurate interpretation of sonographic findings. Future studies exploring the use of software for automatic interpretation, quantitative methods for the assessment of interstitial syndrome, and continuous monitoring devices may further simplify and expand the use of this technique at the bedside in acute medicine and the perioperative setting.

Lung recruitment prevents collapse during laparoscopy in children: A randomised controlled trial.

BACKGROUND: Capnoperitoneum and anaesthesia impair lung aeration during laparoscopy in children. These changes can be detected and monitored at the bedside by lung ultrasound (LUS). OBJECTIVE: The aim of our study was to assess the impact of general anaesthesia and capnoperitoneum on lung collapse and the potential preventive effect of lung recruitment manoeuvres, using LUS in children undergoing laparoscopy. DESIGN: Randomised controlled study. SETTING: Single-institution study, community hospital, Mar del Plata, Argentina. PATIENTS: Forty-two children American Society of Anesthesiologists I-II aged 6 months to 7 years undergoing laparoscopy. INTERVENTIONS: All patients were studied using LUS before, during and after capnoperitoneum. Children were allocated to a control group (C-group, n=21) receiving standard protective ventilation, or to a lung recruitment manoeuvre group (RM-group) (n=21), in which lung recruitment manoeuvres were performed after recording baseline LUS images before capnoperitoneum. Loss of aeration was scored by summing a progressive grading from 0 to 3 assigned to each of 12 lung areas, based on the detection of four main ultrasound patterns: normal aeration = 0, partial loss-mild = 1, partial loss-severe = 2, total loss-consolidation = 3. MAIN OUTCOME MEASURES: Lung aeration score and atelectasis assessed by ultrasound. RESULTS: Before capnoperitoneum and recruitment manoeuvres in the treated group the two groups presented similar ultrasound scores (5.95 ±â€Š4.13 vs. 5.19 ±â€Š3.33, P = 0.5). In the RM-group, lung aeration significantly improved both during (2.71 ±â€Š2.47) and after capnoperitoneum (2.52 ±â€Š2.86), compared with the C-group (6.71 ±â€Š3.54, P < 0.001, and 8.48 ±â€Š3.22, P < 0.001, respectively). There was no statistically significant difference in the percentage of atelectasis before capnoperitoneum and recruitment manoeuvres in the RM-group (62%) and in the C-group (47%, P = 0.750). However, during capnoperitoneum, only 19% of the RM-group had atelectasis compared with 80% in the C-group (P < 0.001). CONCLUSION: The majority of children undergoing laparoscopy have anaesthesia-induced atelectasis. In most cases, lung collapse due to capnoperitoneum could have been prevented by recruitment manoeuvres followed by positive-end expiratory pressure. TRIAL REGISTRY NUMBER: NCT02824146.

Could the use of bedside lung ultrasound reduce the number of chest x-rays in the intensive care unit?

BACKGROUND: Lung ultrasound can be used as an alternative to chest radiography (CXR) for the diagnosis and follow-up of various lung diseases in the intensive care unit (ICU). Our aim was to evaluate the influence that introducing a routine daily use of lung ultrasound in critically ill patients may have on the number of CXRs and as a consequence, on medical costs and radiation exposure. METHODS: Data were collected by conducting a retrospective evaluation of the medical records of adult patients who needed thoracic imaging and were admitted to our academic polyvalent ICU. We compared the number of CXRs and relative costs before and after the introduction of lung ultrasound in our ICU. RESULTS: A total of 4134 medical records were collected from January 2010 to December 2014. We divided our population into two groups, before (Group A, 1869 patients) and after (Group B, 2265 patients) the introduction of a routine use of LUS in July 2012. Group A performed a higher number of CXRs compared to Group B (1810 vs 961, P = 0.012), at an average of 0.97 vs 0.42 exams per patient. The estimated reduction of costs between Groups A and B obtained after the introduction of LUS, was 57%. No statistically significant difference between the outcome parameters of the two groups was observed. CONCLUSIONS: Lung ultrasound was effective in reducing the number of CXRs and relative medical costs and radiation exposure in ICU, without affecting patient outcome.

Point-of-Care Lung Sonography: An Audit of 1150 Examinations.

OBJECTIVES: Point-of-care lung sonography has theoretical usefulness in numerous diseases; however clinical indications and the impact of this technique have not been fully investigated. We aimed to describe the current use of point-of-care lung sonography. METHODS: A 2-year prospective observational study was performed by pulmonologists in an Italian university hospital. Techniques, indications, consequences of lung sonography, and barriers to the examination were analyzed. RESULTS: A total of 1150 lung sonographic examinations were performed on 951 patients. The most common indications were diagnosis and follow-up of pleural effusion in 361 cases (31%), evaluation of lung consolidation (322 [28%]), acute heart failure (195 [17%]), guide to pleural procedures (117 [10%]), pneumothorax (54 [5%]) and acute exacerbations of chronic obstructive pulmonary disease (30 [3%]). The mean duration of the examination ± SD was 6 ± 4 minutes. The transducers most frequently used were convex (746 [65%]) and linear (161 [14%]), whereas in 205 examinations (18%), both transducers were used. According to the judgment of the caring clinician, 51% of the examinations were clinically relevant. CONCLUSIONS: Point-of-care lung sonography performed by pulmonologists is quick and feasible and could be widely used for different clinical indications with a potentially high clinical impact. The widespread use of this technique may have a relevant clinical impact in several indications.

Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography.

OBJECTIVES: Despite emerging evidences on the clinical usefulness of lung ultrasound (LUS), international guidelines still do not recommend the use of sonography for the diagnosis of pneumonia. Our study assesses the accuracy of LUS for the diagnosis of lung consolidations when compared to chest computed tomography (CT). METHODS: This was a prospective study on an emergency department population complaining of respiratory symptoms of unexplained origin. All patients who had a chest CT scan performed for clinical reasons were consecutively recruited. LUS was targeted to evaluate lung consolidations with the morphologic characteristics of pneumonia, and then compared to CT. RESULTS: We analyzed 285 patients. CT was positive for at least one consolidation in 87 patients. LUS was feasible in all patients and in 81 showed at least one consolidation, with a good inter-observer agreement (k = 0.83), sensitivity 82.8% (95% CI 73.2%-90%) and specificity 95.5% (95% CI 91.5%-97.9%). Sensitivity raised to 91.7% (95% CI 61.5%-98.6%) and specificity to 97.4% (95% CI 86.5%-99.6%) in patients complaining of pleuritic chest pain. In a subgroup of 190 patients who underwent also chest radiography (CXR), the sensitivity of LUS (81.4%, 95% CI 70.7%-89.7%) was significantly superior to CXR (64.3%, 95% CI 51.9%-75.4%) (P<.05), whereas specificity remained similar (94.2%, 95% CI 88.4%-97.6% vs. 90%, 95% CI 83.2%-94.7%). CONCLUSIONS: LUS represents a reliable diagnostic tool, alternative to CXR, for the bedside diagnosis of lung consolidations in patients with respiratory complains.

The imaging spectrum of pulmonary tuberculosis.

Tuberculosis has still an important impact on public health because it is an important cause of death, particularly in developing countries. On the other hand recent studies have shown that tuberculosis is again becoming concentrated in big cities of Western Europe, especially among immigrants, drug addicts, poor people, and the homeless, despite progress in reducing national rates of the disease. Diagnostic imaging is challenging for radiologists because signs of tuberculosis may easily mimic other diseases such as neoplasms or sarcoidosis. Clinical signs and symptoms in affected adults can be non-specific and a high level of pre-test clinical suspicion based on history is fundamental in the diagnostic work-up. Impact of tuberculosis in the world is extremely important considering the high incidence estimated during 2011 that was 8.7 million cases. This article gives a review of imaging patterns of chest tuberculosis as may be detected on conventional radiography and computerized tomography (CT). The main aim is to improve radiologist's familiarity with the spectrum of imaging features of this disease and facilitate timely diagnosis. Furthermore, we consider the emerging role of alternative methods of imaging, such as magnetic resonance imaging (MRI), that can be helpful and highly accurate for a better definition of some signs of tuberculosis.

Lung ultrasound predicts well extravascular lung water but is of limited usefulness in the prediction of wedge pressure.

BACKGROUND: Pulmonary congestion is indicated at lung ultrasound by detection of B-lines, but correlation of these ultrasound signs with pulmonary artery occlusion pressure (PAOP) and extravascular lung water (EVLW) still remains to be further explored. The aim of the study was to assess whether B-lines, and eventually a combination with left ventricular ejection fraction (LVEF) assessment, are useful to differentiate low/high PAOP and EVLW in critically ill patients. METHODS: The authors enrolled 73 patients requiring invasive monitoring from the intensive care unit of four university-affiliated hospitals. Forty-one patients underwent PAOP measurement by pulmonary artery catheterization and 32 patients had EVLW measured by transpulmonary thermodilution method. Lung and cardiac ultrasound examinations focused to the evaluation of B-lines and gross estimation of LVEF were performed. The absence of diffuse B-lines (A-pattern) versus the pattern showing prevalent B-lines (B-pattern) and the combination with normal or impaired LVEF were correlated with cutoff levels of PAOP and EVLW. RESULTS: PAOP of 18 mmHg or less was predicted by the A-pattern with 85.7% sensitivity (95% CI, 70.5 to 94.1%) and 40.0% specificity (CI, 25.4 to 56.4%), whereas EVLW 10 ml/kg or less with 81.0% sensitivity (CI, 62.6 to 91.9%) and 90.9% specificity (CI, 74.2 to 97.7%). The combination of A-pattern with normal LVEF increased sensitivity to 100% (CI, 84.5 to 100%) and specificity to 72.7% (CI, 52.0 to 87.2%) for the prediction of PAOP 18 mmHg or less. CONCLUSIONS: B-lines allow good prediction of pulmonary congestion indicated by EVLW, whereas are of limited usefulness for the prediction of hemodynamic congestion indicated by PAOP. Combining B-lines with estimation of LVEF at transthoracic ultrasound may improve the prediction of PAOP.

How I do it: lung ultrasound.

In the last 15 years, a new imaging application of sonography has emerged in the clinical arena: lung ultrasound (LUS). From its traditional assessment of pleural effusions and masses, LUS has moved towards the revolutionary approach of imaging the pulmonary parenchyma, mainly as a point-of-care technique. Although limited by the presence of air, LUS has proved to be useful in the evaluation of many different acute and chronic conditions, from cardiogenic pulmonary edema to acute lung injury, from pneumothorax to pneumonia, from interstitial lung disease to pulmonary infarctions and contusions. It is especially valuable since it is a relatively easy-to-learn application of ultrasound, less technically demanding than other sonographic examinations. It is quick to perform, portable, repeatable, non-ionizing, independent from specific acoustic windows, and therefore suitable for a meaningful evaluation in many different settings, both inpatient and outpatient, in both acute and chronic conditions.In the next few years, point-of-care LUS is likely to become increasingly important in many different clinical settings, from the emergency department to the intensive care unit, from cardiology to pulmonology and nephrology wards.

Clinical research on point-of-care lung ultrasound: misconceptions and limitations.

Over the last 20 years, advances in point-of-care lung ultrasound (PoCLUS) have been consistent. The clinical application of PoCLUS has drastically changed the diagnosis of some respiratory conditions mainly in the acute setting. Despite these improvements, misconceptions regarding the current scientific evidence and errors in the direction given to the latest research are delaying the implementation of PoCLUS in the clinical field. The diagnostic power of PoCLUS is still under-evaluated in many settings and there is a generalized yet unjustified feeling that further evidence is needed before introducing PoCLUS as a standard of care. In the effort to build up further evidence by new studies, the role of randomized clinical trials is over-emphasized and gold standards used to investigate diagnostic accuracy of PoCLUS are sometimes not appropriate. Moreover, the sonographic patterns and techniques used to confirm the diagnoses not always are adapted to the patients' clinical condition, which limit the scientific value of those clinical studies. Finally, there is a recurrent confusion in the role of PoCLUS scoring techniques, which should be only applied to quantify and monitor injury severity and not to diagnose lung diseases. Awareness of these misconceptions and errors could help the researchers when approaching new study projects on PoCLUS.