Lung ultrasound training: how short is too short? observational study on the effects of a focused theoretical training for novice learners.

BACKGROUND: Lung ultrasound has been increasingly used in the last years for the assessment of patients with respiratory diseases; it is considered a simple technique, now spreading from physicians to other healthcare professionals as nurses and physiotherapists, as well as to medical students. These providers may require a different training to acquire lung ultrasound skills, since they are expected to have no previous experience with ultrasound. The aim of the study was to assess the impact of a short theoretical training focused on lung ultrasound pattern recognition in a population of novice nurse learners with no previous experience with ultrasound. METHODS: We included the nurses attending a critical care advanced course for nurses performed at the University of Pavia. Images' interpretation skills were tested on two slide sets (a 25-clip set focused on B-pattern recognition and a 25-clip set focused on identification of pleural movement as lung sliding, lung pulse, lung point, no movement) before and after three 30-minute teaching modules dedicated to general ultrasound principles, B-lines assessment and lung sliding assessment. A cut off of 80% was considered acceptable for correctly interpreted images after this basic course. RESULTS: 22 nurses were enrolled (age 26.0 [24.0-28.0] years; men 4 (18%)); one nurse had previous experience with other ultrasound techniques, none of them had previous experience with lung ultrasound. After the training, the number of correctly interpreted clips improved from 3.5 [0.0-13.0] to 22.0 [19.0-23.0] (p < 0.0001) for B-pattern and from 0.5 [0.0-2.0] to 8.5 [6.0-12.0] (p < 0.0001) for lung sliding assessment. The number of correct answers for B-pattern recognition was significantly higher than for lung sliding assessment, both before (3.5 [0.0-13.0] vs. 0.5 [0.0-2.0]; p = 0.0036) and after (22.0 [19.0-23.0] vs. 8.5 [6.0-12.0]; p < 0.0001) the training. After the training, nurses were able to correctly recognize the presence or the absence of a B-pattern in 84.2 ± 10.3% of cases; lung sliding was correctly assessed in 37.1 ± 15.3% of cases. CONCLUSIONS: Lung ultrasound is considered a simple technique; while a short, focused training significantly improves B-pattern recognition, lung sliding assessment may require a longer training for novice learners. TRIAL REGISTRATION: Not applicable.

The mental health toll of COVID-19: significant increase in admissions to ICU for voluntary self-inflicted injuries after the beginning of the pandemic.

BACKGROUND: COVID-19 outbreak deeply impacted on mental health, with high rate of psychological distress in healthcare professionals, patients and general population. Current literature on trauma showed no increase in ICU admissions for deliberate self-inflicted injuries in the first weeks after the beginning of COVID-19. OBJECTIVES: We tested the hypothesis that self-inflicted injuries/harms of any method requiring ICU admission increased in the year following COVID-19 outbreak. METHODS: Retrospective cohort single-center study comparing admissions to ICU the year before and the year after the pandemic start. All patients admitted to polyvalent ICUs-Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy from February 21st, 2019 to February 21st, 2020 (pre-COVID) and from February 22nd, 2020 to February 22nd, 2021 (post-COVID) were enrolled. RESULTS: We enrolled 1038 pre-COVID and 854 post-COVID patients. In post-COVID, the incidence of self-inflicted injuries was 32/854 (3.8% [2.5-5.1]), higher than in pre-COVID (23/1038, 2.2%-p = 0.0014-relative increase 72.7%). The increase was more relevant when excluding COVID-19 patients (suicide attempts 32/697 (4.6% [3.0-6.2])-relative increase 109.1%; p < 0.0001). Both in pre-COVID and post-COVID, the most frequent harm mean was poisoning [15 (65.2%) vs. 25 (78.1%), p = 0.182] and the analysed population was younger than general ICU population (p = 0.0015 and < 0.0001, respectively). The distribution of admissions for self-inflicted injuries was homogeneous in pre-COVID along the year. In post-COVID, no admissions were registered during the lockdown; an increase was observed in summer with pandemic curve at minimal levels. CONCLUSIONS: An increase in ICU admissions for self-inflicted injuries/harms was observed in the year following COVID-19 outbreak.

Tidal lung hysteresis to interpret PEEP-induced changes in compliance in ARDS patients.

BACKGROUND: In ARDS, the PEEP level associated with the best respiratory system compliance is often selected; however, intra-tidal recruitment can increase compliance, falsely suggesting improvement in baseline mechanics. Tidal lung hysteresis increases with intra-tidal recruitment and can help interpreting changes in compliance. This study aims to assess tidal recruitment in ARDS patients and to test a combined approach, based on tidal hysteresis and compliance, to interpret decremental PEEP trials. METHODS: A decremental PEEP trial was performed in 38 COVID-19 moderate to severe ARDS patients. At each step, we performed a low-flow inflation-deflation manoeuvre between PEEP and a constant plateau pressure, to measure tidal hysteresis and compliance. RESULTS: According to changes of tidal hysteresis, three typical patterns were observed: 10 (26%) patients showed consistently high tidal-recruitment, 12 (32%) consistently low tidal-recruitment and 16 (42%) displayed a biphasic pattern moving from low to high tidal-recruitment below a certain PEEP. Compliance increased after 82% of PEEP step decreases and this was associated to a large increase of tidal hysteresis in 44% of cases. Agreement between best compliance and combined approaches was accordingly poor (K = 0.024). The combined approach suggested to increase PEEP in high tidal-recruiters, mainly to keep PEEP constant in biphasic pattern and to decrease PEEP in low tidal-recruiters. PEEP based on the combined approach was associated with lower tidal hysteresis (92.7 ± 20.9 vs. 204.7 ± 110.0 mL; p < 0.001) and lower dissipated energy per breath (0.1 ± 0.1 vs. 0.4 ± 0.2 J; p < 0.001) compared to the best compliance approach. Tidal hysteresis ≥ 100 mL was highly predictive of tidal recruitment at next PEEP step reduction (AUC 0.97; p < 0.001). CONCLUSIONS: Assessment of tidal hysteresis improves the interpretation of decremental PEEP trials and may help limiting tidal recruitment and energy dissipated into the respiratory system during mechanical ventilation of ARDS patients.

Thoracic UltrasONOgraphy Reporting: The TUONO Consensus.

The widespread use of the lung ultrasound (LUS) has not been followed by the development of a comprehensive standardized tool for its reporting in the intensive care unit (ICU) which could be useful to promote consistency and reproducibility during clinical examination. This work aims to define the essential features to be included in a standardized reporting tool and provides a structured model form to fully express the diagnostic potential of LUS and facilitate intensivists in the use of a LUS in everyday clinical ICU examination. We conducted a modified Delphi process to build consensus on the items to be integrated in a standardized report form and on its structure. A committee of 19 critical care physicians from 19 participating ICUs in Italy was formed, including intensivists experienced in ultrasound from both teaching hospitals and referral hospitals, and internationally renowned experts on the LUS. The consensus for 31 statements out of 33 was reached at the third Delphi round. A structured model form was developed based on the approved statements. The development of a standardized model as a backbone to report a LUS may facilitate the guidelines' application in clinical practice and increase inter-operator agreement. Further studies are needed to evaluate the effects of standardized reports in critically ill patients.

Lung Ultrasound in Critical Care and Emergency Medicine: Clinical Review.

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.

Impact of SARS-CoV-2 Omicron and Delta variants in patients requiring intensive care unit (ICU) admission for COVID-19, Northern Italy, December 2021 to January 2022.

This multicenter observational study included 171 COVID-19 adult patients hospitalized in the ICUs of nine hospitals in Lombardy (Northern Italy) from December, 1st 2021, to February, 9th 2022. During the study period, the Delta/Omicron variant ratio of cases decreased with a delay of two weeks in ICU patients compared to that in the community; a higher proportion of COVID-19 unvaccinated patients was infected by Delta than by Omicron whereas a higher rate of COVID-19 boosted patients was Omicron-infected. A higher number of comorbidities and a higher comorbidity score in ICU critically COVID-19 inpatients was positively associated with the Omicron infection as well in vaccinated individuals. Although people infected by Omicron have a lower risk of severe disease than those infected by Delta variant, the outcome, including the risk of ICU admission and the need for mechanical ventilation due to infection by Omicron versus Delta, remains uncertain. The continuous monitoring of the circulating SARS-CoV-2 variants remains a milestone to counteract this pandemic.

Quality of Life in COVID-Related ARDS Patients One Year after Intensive Care Discharge (Odissea Study): A Multicenter Observational Study.

BACKGROUND: Investigating the health-related quality of life (HRQoL) after intensive care unit (ICU) discharge is necessary to identify possible modifiable risk factors. The primary aim of this study was to investigate the HRQoL in COVID-19 critically ill patients one year after ICU discharge. METHODS: In this multicenter prospective observational study, COVID-19 patients admitted to nine ICUs from 1 March 2020 to 28 February 2021 in Italy were enrolled. One year after ICU discharge, patients were required to fill in short-form health survey 36 (SF-36) and impact of event-revised (IES-R) questionnaire. A multivariate linear or logistic regression analysis to search for factors associated with a lower HRQoL and post-traumatic stress disorded (PTSD) were carried out, respectively. RESULTS: Among 1003 patients screened, 343 (median age 63 years [57-70]) were enrolled. Mechanical ventilation lasted for a median of 10 days [2-20]. Physical functioning (PF 85 [60-95]), physical role (PR 75 [0-100]), emotional role (RE 100 [33-100]), bodily pain (BP 77.5 [45-100]), social functioning (SF 75 [50-100]), general health (GH 55 [35-72]), vitality (VT 55 [40-70]), mental health (MH 68 [52-84]) and health change (HC 50 [25-75]) describe the SF-36 items. A median physical component summary (PCS) and mental component summary (MCS) scores were 45.9 (36.5-53.5) and 51.7 (48.8-54.3), respectively, considering 50 as the normal value of the healthy general population. In all, 109 patients (31.8%) tested positive for post-traumatic stress disorder, also reporting a significantly worse HRQoL in all SF-36 domains. The female gender, history of cardiovascular disease, liver disease and length of hospital stay negatively affected the HRQoL. Weight at follow-up was a risk factor for PTSD (OR 1.02, p = 0.03). CONCLUSIONS: The HRQoL in COVID-19 ARDS (C-ARDS) patients was reduced regarding the PCS, while the median MCS value was slightly above normal. Some risk factors for a lower HRQoL have been identified, the presence of PTSD is one of them. Further research is warranted to better identify the possible factors affecting the HRQoL in C-ARDS.

Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study).

BACKGROUND: The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication. METHODS: This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death. RESULTS: We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001). CONCLUSIONS: C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality. TRIAL REGISTRATION: this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).

Thoracic UltrasONOgraphy Reporting: The TUONO Study.

Lung ultrasound (LUS) is a validated technique for the prompt diagnosis and bedside monitoring of critically ill patients due to its availability, safety profile, and cost-effectiveness. The aim of this work is to detect similarities and differences among LUS reports performed in ICUs and to provide a common ground for an integrated report form. We collected all LUS reports during an index week in 21 ICUs from the GiViTI network. First, we considered signs, chest areas, and terminology reported. Then, we compared different report structures and categorized them as structured reports (SRs), provided with a predefined model form, and free unstructured text reports (FTRs) that had no predetermined structure. We analyzed 171 reports from 21 ICUs, and 59 reports from 5 ICUs were structured. All the reports presented a qualitative description that mainly focused on the presence of B-lines, consolidations, and pleural effusion. Zones were defined in 66 reports (39%). In SRs, a complete examination of all the regions was more frequently achieved (96% vs. 74%), and a higher impact on therapeutic strategies was observed (17% vs. 6%). LUS reports vary significantly among different centers. Adopting an integrated SR seems to promote a systematic approach in scanning and reporting, with a potential impact on LUS clinical applications.

Association of COVID-19 Vaccinations With Intensive Care Unit Admissions and Outcome of Critically Ill Patients With COVID-19 Pneumonia in Lombardy, Italy.

Importance: Data on the association of COVID-19 vaccination with intensive care unit (ICU) admission and outcomes of patients with SARS-CoV-2-related pneumonia are scarce. Objective: To evaluate whether COVID-19 vaccination is associated with preventing ICU admission for COVID-19 pneumonia and to compare baseline characteristics and outcomes of vaccinated and unvaccinated patients admitted to an ICU. Design, Setting, and Participants: This retrospective cohort study on regional data sets reports: (1) daily number of administered vaccines and (2) data of all consecutive patients admitted to an ICU in Lombardy, Italy, from August 1 to December 15, 2021 (Delta variant predominant). Vaccinated patients received either mRNA vaccines (BNT162b2 or mRNA-1273) or adenoviral vector vaccines (ChAdOx1-S or Ad26.COV2). Incident rate ratios (IRRs) were computed from August 1, 2021, to January 31, 2022; ICU and baseline characteristics and outcomes of vaccinated and unvaccinated patients admitted to an ICU were analyzed from August 1 to December 15, 2021. Exposures: COVID-19 vaccination status (no vaccination, mRNA vaccine, adenoviral vector vaccine). Main Outcomes and Measures: The incidence IRR of ICU admission was evaluated, comparing vaccinated people with unvaccinated, adjusted for age and sex. The baseline characteristics at ICU admission of vaccinated and unvaccinated patients were investigated. The association between vaccination status at ICU admission and mortality at ICU and hospital discharge were also studied, adjusting for possible confounders. Results: Among the 10 107 674 inhabitants of Lombardy, Italy, at the time of this study, the median [IQR] age was 48 [28-64] years and 5 154 914 (51.0%) were female. Of the 7 863 417 individuals who were vaccinated (median [IQR] age: 53 [33-68] years; 4 010 343 [51.4%] female), 6 251 417 (79.5%) received an mRNA vaccine, 550 439 (7.0%) received an adenoviral vector vaccine, and 1 061 561 (13.5%) received a mix of vaccines and 4 497 875 (57.2%) were boosted. Compared with unvaccinated people, IRR of individuals who received an mRNA vaccine within 120 days from the last dose was 0.03 (95% CI, 0.03-0.04; P < .001), whereas IRR of individuals who received an adenoviral vector vaccine after 120 days was 0.21 (95% CI, 0.19-0.24; P < .001). There were 553 patients admitted to an ICU for COVID-19 pneumonia during the study period: 139 patients (25.1%) were vaccinated and 414 (74.9%) were unvaccinated. Compared with unvaccinated patients, vaccinated patients were older (median [IQR]: 72 [66-76] vs 60 [51-69] years; P < .001), primarily male individuals (110 patients [79.1%] vs 252 patients [60.9%]; P < .001), with more comorbidities (median [IQR]: 2 [1-3] vs 0 [0-1] comorbidities; P < .001) and had higher ratio of arterial partial pressure of oxygen (Pao2) and fraction of inspiratory oxygen (FiO2) at ICU admission (median [IQR]: 138 [100-180] vs 120 [90-158] mm Hg; P = .007). Factors associated with ICU and hospital mortality were higher age, premorbid heart disease, lower Pao2/FiO2 at ICU admission, and female sex (this factor only for ICU mortality). ICU and hospital mortality were similar between vaccinated and unvaccinated patients. Conclusions and Relevance: In this cohort study, mRNA and adenoviral vector vaccines were associated with significantly lower risk of ICU admission for COVID-19 pneumonia. ICU and hospital mortality were not associated with vaccinated status. These findings suggest a substantial reduction of the risk of developing COVID-19-related severe acute respiratory failure requiring ICU admission among vaccinated people.

Waveforms-guided cycling-off during pressure support ventilation improves both inspiratory and expiratory patient-ventilator synchronisation.

OBJECTIVE: To test the performance of a software able to control mechanical ventilator cycling-off by means of automatic, real-time analysis of ventilator waveforms during pressure support ventilation. DESIGN: Prospective randomised crossover study. SETTING: University Intensive Care Unit. PATIENTS: Fifteen difficult-to-wean patients under pressure support ventilation. INTERVENTIONS: Patients were ventilated using a G5 ventilator (Hamilton Medical, Bonaduz, Switzerland) with three different cycling-off settings: standard (expiratory trigger sensitivity set at 25% of peak inspiratory flow), optimised by an expert clinician and automated; the last two settings were tested at baseline pressure support and after a 50% increase in pressure support. MEASUREMENTS AND MAIN RESULTS: Ventilator waveforms were recorded and analysed by four physicians experts in waveforms analysis. Major and minor asynchronies were detected and total asynchrony time computed. Automation compared to standard setting reduced cycling delay from 407 ms [257-567] to 59 ms [22-111] and ineffective efforts from 12.5% [3.4-46.4] to 2.8% [1.9-4.6]) at baseline support (p < 0.001); expert optimisation performed similarly. At high support both cycling delay and ineffective efforts increased, mainly in the case of expert setting, with the need of reoptimisation of expiratory trigger sensitivity. At baseline support, asynchrony time decreased from 39.9% [27.4-58.7] with standard setting to 32% [22.3-39.4] with expert optimisation (p < 0.01) and to 24.4% [19.6-32.5] with automation (p < 0.001). Both at baseline and at high support, asynchrony time was lower with automation than with expert setting. CONCLUSIONS: Cycling-off guided by automated real-time waveforms analysis seems a reliable solution to improve synchronisation in difficult-to-wean patients under pressure support ventilation.

Point-of-care ultrasound training for residents in anaesthesia and critical care: results of a national survey comparing residents and training program directors' perspectives.

BACKGROUND: Point-of-care ultrasound (POCUS) has become an essential tool for anaesthesia and critical care physicians and dedicated training is mandatory. This survey describes the current state of Italian residency training programs through the comparison of residents' and directors' perspective. METHODS: Observational prospective cross-sectional study: 12-question national e-survey sent to Italian directors of anaesthesia and critical care residency programs (N = 40) and residents (N = 3000). Questions focused on POCUS teaching (vascular access, transthoracic echocardiography, focused assessment for trauma, transcranial Doppler, regional anaesthesia, lung and diaphragm ultrasound), organization (dedicated hours, teaching tools, mentors), perceived adequacy/importance of the training and limiting factors. RESULTS: Five hundred seventy-one residents and 22 directors completed the survey. Bedside teaching (59.4-93.2%) and classroom lessons (29.7-54.4%) were the most frequent teaching tools. Directors reported higher participation in research projects (p < 0.05 for all techniques but focused assessment for trauma) and simulation (p < 0.05 for all techniques but transthoracic echocardiography). Use of online teaching was limited (< 10%); however, 87.4% of residents used additional web-based tools. Consultants were the most frequent mentors, with different perspectives between residents (72.0%) and directors (95.5%; p = 0.013). Residents reported self-training more frequently (48.5 vs. 9.1%; p < 0.001). Evaluation was mainly performed at the bedside; a certification was not available in most cases (< 10%). Most residents perceived POCUS techniques as extremely important. Residents underestimated the relevance given by directors to ultrasound skills in their evaluation and the minimal number of exams required to achieve basic competency. Overall, the training was considered adequate for vascular access only (62.2%). Directors mainly agreed on the need of ultrasound teaching improvement in all fields. Main limitations were the absence of a standardized curriculum for residents and limited mentors' time/expertise for directors. CONCLUSION: POCUS education is present in Italian anaesthesia and critical care residency programs, although with potential for improvement. Significant discrepancies between residents' and directors' perspectives were identified.

The Role of Lung Ultrasound Monitoring in Early Detection of Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Observational Study.

Specific lung ultrasound signs combined with clinical parameters allow for early diagnosis of ventilator-associated pneumonia in the general ICU population. This retrospective cohort study aimed to determine the accuracy of lung ultrasound monitoring for ventilator-associated pneumonia diagnosis in COVID-19 patients. Clinical (i.e., clinical pulmonary infection score) and ultrasound (i.e., presence of consolidation and a dynamic linear−arborescent air bronchogram, lung ultrasound score, ventilator-associated lung ultrasound score) data were collected on the day of the microbiological sample (pneumonia-day) and 48 h before (baseline) on 55 bronchoalveolar lavages of 33 mechanically-ventilated COVID-19 patients who were monitored daily with lung ultrasounds. A total of 26 samples in 23 patients were positive for ventilator-associated pneumonia (pneumonia cases). The onset of a dynamic linear−arborescent air bronchogram was 100% specific for ventilator-associated pneumonia. The ventilator-associated lung ultrasound score was higher in pneumonia-cases (2.5 (IQR 1.0 to 4.0) vs. 1.0 (IQR 1.0 to 1.0); p < 0.001); the lung ultrasound score increased from baseline in pneumonia-cases only (3.5 (IQR 2.0 to 6.0) vs. −1.0 (IQR −2.0 to 1.0); p = 0.0001). The area under the curve for clinical parameters, ventilator-associated pneumonia lung ultrasound score, and lung ultrasound score variations were 0.472, 0.716, and 0.800, respectively. A newly appeared dynamic linear−arborescent air bronchogram is highly specific for ventilator-associated pneumonia in COVID-19 patients. A high ventilator-associated pneumonia lung ultrasound score (or an increase in the lung ultrasound score) orients to ventilator-associated pneumonia.

The weaning from mechanical ventilation: a comprehensive ultrasound approach.

PURPOSE OF REVIEW: Due to heart, lung and diaphragm interactions during weaning from mechanical ventilation, an ultrasound integrated approach may be useful in the detection of dysfunctions potentially leading to weaning failure. In this review, we will summarize the most recent advances concerning the ultrasound applications relevant to the weaning from mechanical ventilation. RECENT FINDINGS: The role of ultrasonographic examination of heart, lung and diaphragm has been deeply investigated over the years. Most recent findings concern the ability of lung ultrasound in detecting weaning induced pulmonary edema during spontaneous breathing trial. Furthermore, in patients at high risk of cardiac impairments, global and anterolateral lung ultrasound scores have been correlated with weaning and extubation failure, whereas echocardiographic indexes were not. For diaphragmatic ultrasound evaluation, new indexes have been proposed for the evaluation of diaphragm performance during weaning, but further studies are needed to validate these results. SUMMARY: The present review summarizes the potential role of ultrasonography in the weaning process. A multimodal integrated approach allows the clinician to comprehend the pathophysiological processes of weaning failure.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography.

BACKGROUND: To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard. METHODS: A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients. RESULTS: As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view. CONCLUSIONS: The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Respiratory failure due to concomitant interstitial lung disease and diaphragmatic involvement in a patient with anti-MDA5 dermatomyositis: a case report.

Diaphragm myositis is a rare manifestation of idiopathic inflammatory myopathies, barely portrayed in literature despite its potential severity. We describe a 57-year-old Caucasian male with anti-MDA5 positive dermatomyositis, that had a 4-month history of progressive dyspnoea requiring oxygen-therapy, scarcely responsive to prednisolone. Chest high resolution computed tomography (HRCT) showed mild interstitial lung disease (ILD), whereas pulmonary function tests evidenced severe restrictive syndrome with high lung ultrasound score. Diaphragm ultrasound revealed a marked diaphragm dysmotility, confirmed by electromyography (EMG). The patient was treated with intravenous immunoglobulins and mofetil mycophenolate with progressive improvement of dyspnoea, lung volumes and ILD at CT scan. Ultrasound examination also revealed marked improvement of the diaphragmatic disfunction and a reduction of lung ultrasound score. The use of ultrasound may provide a valuable tool in the diagnosis of diaphragm myositis, which may play a major role in the respiratory impairment of these patients. A combined lung and diaphragm examination allowed bedside monitoring of the improvements in both lung aeration and diaphragm contractility.

Extracorporeal membrane oxygenation for COVID-19 and influenza H1N1 associated acute respiratory distress syndrome: a multicenter retrospective cohort study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has become an established rescue therapy for severe acute respiratory distress syndrome (ARDS) in several etiologies including influenza A H1N1 pneumonia. The benefit of receiving ECMO in coronavirus disease 2019 (COVID-19) is still uncertain. The aim of this analysis was to compare the outcome of patients who received veno-venous ECMO for COVID-19 and Influenza A H1N1 associated ARDS. METHODS: This was a multicenter retrospective cohort study including adults with ARDS, receiving ECMO for COVID-19 and influenza A H1N1 pneumonia between 2009 and 2021 in seven Italian ICU. The primary outcome was any-cause mortality at 60 days after ECMO initiation. We used a multivariable Cox model to estimate the difference in mortality accounting for patients' characteristics and treatment factors before ECMO was started. Secondary outcomes were mortality at 90 days, ICU and hospital length of stay and ECMO associated complications. RESULTS: Data from 308 patients with COVID-19 (N = 146) and H1N1 (N = 162) associated ARDS who had received ECMO support were included. The estimated cumulative mortality at 60 days after initiating ECMO was higher in COVID-19 (46%) than H1N1 (27%) patients (hazard ratio 1.76, 95% CI 1.17-2.46). When adjusting for confounders, specifically age and hospital length of stay before ECMO support, the hazard ratio decreased to 1.39, 95% CI 0.78-2.47. ICU and hospital length of stay, duration of ECMO and invasive mechanical ventilation and ECMO-associated hemorrhagic complications were higher in COVID-19 than H1N1 patients. CONCLUSION: In patients with ARDS who received ECMO, the observed unadjusted 60-day mortality was higher in cases of COVID-19 than H1N1 pneumonia. This difference in mortality was not significant after multivariable adjustment; older age and longer hospital length of stay before ECMO emerged as important covariates that could explain the observed difference. TRIAL REGISTRATION NUMBER: NCT05080933 , retrospectively registered.