Lung Ultrasound Signs: The Beginning. Part 3-An Accademia di Ecografia Toracica Comprehensive Review on Ultrasonographic Signs and Real Needs.

Over the last 20 years, scientific literature and interest on chest/lung ultrasound (LUS) have exponentially increased. Interpreting mixed-anatomical and artifactual-pictures determined the need of a proposal of a new nomenclature of artifacts and signs to simplify learning, spread, and implementation of this technique. The aim of this review is to collect and analyze different signs and artifacts reported in the history of chest ultrasound regarding normal lung, pleural pathologies, and lung consolidations. By reviewing the possible physical and anatomical interpretation of these artifacts and signs reported in the literature, this work aims to present the AdET (Accademia di Ecografia Toracica) proposal of nomenclature and to bring order between published studies.

Management of malignant pleural effusion in Italian clinical practice: a nationwide survey.

BACKGROUND: Pleural disease (PD), particularly malignant pleural effusion (MPE), is a common cause of hospital admission and its prevalence is rising worldwide. Recent advances in diagnostic and therapeutic options, such as Indwelling Pleural Catheters (IPCs), have simplified PD treatment, allowing an effective outpatients management. Therefore, dedicated pleural services can improve PD care, guaranteeing specialized management and optimizing time and cost. We aimed to provide an overview on MPE management in Italy, mainly focused on distribution and characteristics of pleural services and IPCs use. METHODS: A nationwide survey, endorsed by the Italian Thoracic Society, was distributed by email to members of selected subgroups in 2021. RESULTS: Ninety (23%) members replied, most of whom being pulmonologists (91%). MPE resulted the most common cause of pleural effusion and was managed with heterogenous approaches, including talc pleurodesis via slurry (43%), talc poudrage (31%), repeated thoracentesis (22%) and IPCs insertion (2%). The setting of IPC insertion was inpatient care in 48% of cases, with a predominance of draining frequency every other day. IPC management mainly relied on caregivers (42%). The presence of a pleural service was reported by 37% of respondents. CONCLUSIONS: The present study provides an extensive overview of MPE management in Italy, showing a highly heterogeneous approach, a scarce prevalence of out-patient pleural services, and a still limited adoption of IPCs, mainly due to lack of dedicated community care systems. This survey emphasizes the need of promoting a higher spreading of pleural services and an innovative healthcare delivery with more favourable cost-benefit ratio.

Spontaneous synchronous bilateral hemothorax as the only finding in primary pleural angiosarcoma: a case report and a literature review.

Angiosarcoma is a rare malignancy of vascular origin, mostly originating from skin, soft tissues, and breast, but rarely also from the pleura. We present the case of a 55-year-old man who referred to our hospital for a spontaneous bilateral hemothorax. The CT angiography did not show any source of active bleeding; plus, no pleural or lung masses were observable. Cytological and microbiological analyses made on a sample of pleural fluid resulted negative. Despite numerous blood transfusions and thoracenteses, the patient deceased from hemorrhagic shock ten days later and the diagnosis of primary pleural epithelioid angiosarcoma was obtained only by autopsy. Additionally, we present a review of the literature about primary pleural angiosarcomas.

Research data communication strategy at the time of pandemics: a retrospective analysis of the Italian experience.

Coronavirus pandemic has radically changed the scientific world. During these difficult times, standard peer-review processes could be too long for the continuously evolving knowledge about this disease. We wanted to assess whether the use of other types of network could be a faster way to disseminate the knowledge about Coronavirus disease. We retrospectively analyzed the data flow among three distinct groups of networks during the first three months of the pandemic: PubMed, preprint repositories (biorXiv and arXiv) and social media in Italy (Facebook and Twitter). The results show a significant difference in the number of original research articles published by PubMed and preprint repositories. On social media, we observed an incredible number of physicians participating to the discussion, both on three distinct Italian-speaking Facebook groups and on Twitter. The standard scientific process of publishing articles (i.e., the peer-review process) remains the best way to get access to high-quality research. Nonetheless, this process may be too long during an emergency like a pandemic. The thoughtful use of other types of network, such as preprint repositories and social media, could be taken into consideration in order to improve the clinical management of COVID-19 patients.

Clinical Use and Barriers of Thoracic Ultrasound: A Survey of Italian Pulmonologists.

INTRODUCTION: Thoracic ultrasound is accurate in the diagnosis of a wide range of respiratory diseases. Yet the extent of its use is unknown. Through a national survey, we aimed to explore the clinical use of thoracic ultrasound and the barriers to the diffusion of the technique in Italy. METHODS: Accademia di Ecografia Toracica (AdET) developed a self-administered survey which was sent by email to Italian pulmonologists via national scientific societies and networks. RESULTS: Of the 2010 physicians invited, 514 completed the survey (26% response rate). According to 99% of responders, thoracic ultrasound had a relevant clinical role. Seventy-nine percent of the responders used thoracic ultrasound at least once a month. The main settings were: 53% pulmonology ward, 15% outpatient clinic, 15% interventional pulmonology room, 10% internal medicine ward, 4% respiratory intensive care units, and 9% other. Thoracic ultrasound was primarily used: (1) with both diagnostic and interventional aims (72%), (2) as diagnostic imaging (17%), and (3) as guidance for interventional procedures (11%). The main clinical applications were: (1) diagnosis and management of pleural effusion, (2) pneumothorax, (3) pneumonia, (4) cardiac failure, and (5) acute dyspnea. Twenty-one percent of the responders do not use thoracic ultrasound. The main reported bar-riers were: (1) availability of an ultrasound system (52%), (2) lack of protected time and training (22%), and (3) use of the technique by other specialists (15%). CONCLUSION: Thoracic ultrasound is widely used by Italian pulmonologists and considered a clinically relevant tool. The availability of dedicated ultrasound systems seems to be a major limit of the use of the technique.

Immune reconstitution inflammatory syndrome in tuberculous pleurisy and ulcerative colitis: a case report.

We present the case of a 46-year-old Caucasian male, affected by ulcerative colitis, who developed tuberculous pleurisy during immunosuppressive therapy; despite proper therapy, worsening of the radiological findings was observed. The case was discussed among an online group of Italian physicians and diagnosis of immune reconstitution inflammatory syndrome (IRIS) tuberculosis was established. Therapy was continued and full recovery was obtained. IRIS is a syndrome initially described during opportunistic infections in HIV infected after being placed in anti-retroviral therapy. It reveals itself through a wide variety of manifestations, including fever, lymphadenopathies, worsening of lung infiltrates, pleural or pericardial effusion, central nervous system involvement. Few data are available regarding the best therapeutic options. IRIS is an insidious and potentially serious complication of opportunistic infections in immunocompromised patients. The always wider diffusion of immunosuppressive therapies increases the number of patients at risk, therefore physicians need to be aware of the issue.

Pneumomediastinum in COVID-19: Risk factors and outcomes from a multicentre case-control study.

BACKGROUND: An increased incidence of pneumomediastinum has been observed among patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. The study aimed to identify risk factors for COVID-19-associated pneumomediastinum and investigate the impact of pneumomediastinum on clinical outcomes. METHODS: In this multicentre retrospective case-control study, we included consecutive patients with COVID-19 pneumonia and pneumomediastinum hospitalized from March 2020 to July 2020 at ten centres; then, we identified a similarly sized control group of consecutive patients hospitalized with COVID-19 pneumonia and respiratory failure who did not develop pneumomediastinum during the same period. Clinical, laboratory, and radiological characteristics, as well as respiratory support and outcomes, were collected and compared between the two groups. Risk factors of pneumomediastinum were assessed by multivariable logistic analysis. RESULTS: Overall 139 patients with pneumomediastinum and 153 without pneumomediastinum were analysed. Lung involvement ≥75 %, consolidations, body mass index (BMI) < 22 kg/m2, C-reactive protein (CRP) > 150 mg/L, D-dimer >3000 ng/mL FEUs, and smoking exposure >20 pack-year were all independently correlated with the occurrence of pneumomediastinum. Patients with pneumomediastinum had a longer hospital stay (mean ± SD 31.2 ± 20.2 days vs 19.6 ± 14.2, p < 0.001), higher intubation rate (73/139, 52.5 % vs 27/153, 17.6 %, p < 0.001), and in-hospital mortality (68/139, 48.9 % vs 36/153, 23.5 %, p < 0.001) compared to controls. CONCLUSIONS: Extensive lung parenchyma involvement, consolidations, low BMI, high inflammatory markers, and tobacco exposure are associated with a greater risk of pneumomediastinum in COVID-19 pneumonia. This complication significantly worsens the outcomes.

Pleural Mesothelioma: Advances in Blood and Pleural Biomarkers.

Pleural mesothelioma (PM) is a type of cancer that is highly related to exposure to asbestos fibers. It shows aggressive behavior, and the current therapeutic approaches are usually insufficient to change the poor prognosis. Moreover, apart from staging and histological classification, there are no validated predictors of its response to treatment or its long-term outcomes. Numerous studies have investigated minimally invasive biomarkers in pleural fluid or blood to aid in earlier diagnosis and prognostic assessment of PM. The most studied marker in pleural effusion is mesothelin, which exhibits good specificity but low sensitivity, especially for non-epithelioid PM. Other biomarkers found in pleural fluid include fibulin-3, hyaluronan, microRNAs, and CYFRA-21.1, which have lower diagnostic capabilities but provide prognostic information and have potential roles as therapeutic targets. Serum is the most investigated matrix for biomarkers of PM. Several serum biomarkers in PM have been studied, with mesothelin, osteopontin, and fibulin-3 being the most often tested. A soluble mesothelin-related peptide (SMRP) is the only FDA-approved biomarker in patients with suspected mesothelioma. With different serum and pleural fluid cut-offs, it provides useful information on the diagnosis, prognosis, follow-up, and response to therapy in epithelioid PM. Panels combining different markers and proteomics technologies show promise in terms of improving clinical performance in the diagnosis and monitoring of mesothelioma patients. However, there is still no evidence that early detection can improve the treatment outcomes of PM patients.

Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery.

Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined "complicated" since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.

Possible Role of Chest Ultrasound in the Assessment of Costo-Phrenic Angle Lesions Prior to Medical Thoracoscopy: A Retrospective Pilot Case Series.

Background: Pleural malignancy (PM) and malignant pleural effusion (MPE) represent an increasing burden of diseases. Costo-phrenic angle (CPA) could be involved by malignant small nodularities or thickenings in the case of MPE. The aim of this study was to evaluate whether lung ultrasound (LUS), performed prior to medical thoracoscopy (MT), could detect pleural abnormalities in CPA not easily detectable by chest computed tomography scan (CCT). Methods: Patients suspected for PM and MPE were retrospectively recruited. Patients underwent both LUS examination with a linear array and CCT prior to diagnostic medical thoracoscopy. LUS pathological findings in CPA were compared with pathological findings detected by CCT. Findings were confirmed by subsequent MT, the gold standard for PMs. Results: Twenty-eight patients were recruited. LUS detected 23 cases of pleural abnormalities in CPA. CCT was detected 12 pleural abnormalities. Inter-rater agreement between the two techniques was minimal (Cohen's Kappa: 0.28). MT detected PMs in CPA in 22 patients. LUS had a sensitivity of 100% and specificity of 83%. CCT had a sensitivity of 54% and specificity of 100%. A better sensitivity for CCT was reached analysing only all abnormalities > 5 mm (64.3%). Conclusions: LUS examination, in the case of PMs, could change and speed up diagnostic workup.

Predictors of Worse Prognosis in Young and Middle-Aged Adults Hospitalized with COVID-19 Pneumonia: A Multi-Center Italian Study (COVID-UNDER50).

Obesity as well as metabolic and cardiovascular comorbidities are established, significant predictors of worse prognosis in the overall COVID-19 population, but limited information is available on their roles in young and middle-aged adults (aged ≤ 50 years). The main objectives of the present Italian multi-center study were to describe clinical characteristics and role of selected prognostic predictors in a large cohort of young and middle-aged hospitalized patients. Nine pulmonology units, across north and center of Italy, were involved in this retrospective study. Comorbidities were classified according to their known or potential association with COVID-19. A total of 263 subjects were included. The prevalence of obesity was 25.9%, mechanical ventilation (MV) was needed in 27.7%, and 28 in-hospital deaths occurred (10.6%). Obesity and older age were the only independent, significant predictors for MV. Comorbidities, such as hypertension, diabetes, asthma, and increased D-dimer levels were significantly associated with higher mortality risk, regardless of age, body mass index, and MV. Obesity in young and middle-aged adults is a strong predictor of a more complicated COVID-19, without, however, evidence of a significant effect on in-hospital mortality. Selected comorbidities, including hypertension, diabetes and asthma, significantly impact survival even in a younger population, suggesting the need for prompt recognition of these conditions.

Ultrasound Evaluation of Hemidiaphragm Function Following Thoracentesis: A Study on Mechanisms of Dyspnea Related to Pleural Effusion.

BACKGROUND: Dyspnea is the major symptom caused by pleural effusion. The pathophysiological pathways leading to dyspnea are poorly understood. Dysfunction of respiratory mechanics may be a factor. We aimed to study the change in diaphragmatic function following thoracentesis. METHODS: Patients undergoing thoracentesis at a highly specialized pleural center, underwent ultrasound evaluation of hemidiaphragm movement, before and after thoracentesis was performed. The change was compared to the reduction of dyspnea measured at the modified Borg scale. RESULTS: Thirty-two patients were included. Dyspnea was reduced from 5.01 [95% confidence interval (CI): 4.12-6.04] to 2.6 (95% CI: 1.87-3.4, P<0.0001). Low hemidiaphragmatic movement before thoracentesis on the side of pleural effusion was improved by 17.4 cm (95% CI: 13.04-21.08), equalizing movement to the side without pleural effusion. On average, 1283 mL (SD: 469) fluid was drained. Multiple linear regression analysis showed that prethoracentesis ultrasound evaluation of hemidiaphragmatic function was correlated with successful thoracentesis. CONCLUSION: Hemidiaphragm function is reduced on the side of pleural effusion, and thoracentesis restores function. Improvement in diaphragm movement is related to a reduction in dyspnea.

Competence in thoracic ultrasound.

Ultrasound examination is traditionally considered a safe and repeatable exam, but its use is highly operator-dependent. Because of this, lack of sufficient operator skills could lead to diagnostic errors and damage to patient safety related to unnecessary tests or interventional procedures. The indications for lung ultrasound include: diagnosis, quantification, and follow-up of different conditions for which acute respiratory failure or chest pain are the main clinical presentation. Clinicians should have theoretical and practical knowledge on: physics and technology of ultrasound, indications and methodology of ultrasound examination, normal thoracic anatomy identification by echography, and detection of signs of pleuro-pulmonary pathology. Consequently, according to international recommendations, core basic skills and minimum training recommendations for the practice of medical ultrasound and image acquisition are needed to ensure competence of clinicians using ultrasound.

Competence in pleural procedures.

Diseases of the pleura and pleural space are common and present a significant contribution to the workload of respiratory physicians, with most cases resulting from congestive heart failure, pneumonia, and cancer. Although the radiographic and ultrasonographic detection of pleural abnormalities may be obvious, the determination of a specific diagnosis can often represent a challenge. Invasive procedures such as pleural drainage, ultrasound/CT-guided pleural biopsy or medical thoracoscopy can be useful in determining specific diagnosis of pleural diseases. Management of primary and secondary spontaneous pneumothorax is mandatory in an interventional pulmonology training program, while the medical or surgical treatment of the recurrence is still a matter of discussion. Pleural drainage is a diagnostic and therapeutic procedure used in the treatment of pneumothorax and pleural effusions of different etiologies and even in palliation of symptomatic in malignant pleural effusion. Medical thoracoscopy (MT) is a minimally invasive procedure aimed at inspecting the pleural space. It could be a diagnostic procedure in pleural effusions (suspected malignant pleural effusion, infective pleural disease such as empyema or tuberculosis) or therapeutic procedure (chemical pleurodesis or opening of loculation in empyema). Diagnostic yield is 95% in patients with pleural malignancies and higher in pleural tuberculosis. In parapneumonic complex effusion, MT obviates the need for surgery in most cases. Thoracoscopy training should be considered being as important as bronchoscopy training for interventional pulmonology, although prior acquisition of ultrasonography and chest tube insertion skills is essential.

Endoscopic diagnosis and management of pleural effusion in malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is an asbestos-related aggressive tumor, that requires proper diagnosis and management. Symptoms are nonspecific and chest computed tomography (CT) and chest ultrasound (US) are important radiological tools in the initial workup to identify early pathological signs. Performing a medical thoracoscopy (MT) is essential for a definitive diagnosis of MPM. The procedure, integrated with a prior US, allows a global evaluation of the pleural cavity and the execution of multiple targeted biopsies, with low risk of complications. Some different endoscopic patterns are recognized. Thoracoscopic biopsies provide enough material to allow a thorough pathological and immunohistochemical characterization. The presence of extensive pleural adhesions and critical patient conditions are the only absolute contraindications. The clinical course of MPM is characterized by chronic symptoms such as chest pain and progressive dyspnea, the latter caused mainly by recurrent pleural effusion. Palliative interventions are required in order to relieve symptoms and improve the quality of life (QoL). These include thoracentesis, pleurodesis and the placement of an indwelling pleural catheter.

New insights in the use of pleural ultrasonography for diagnosis and treatment of pleural disease.

The use of transthoracic ultrasound (US) has acquired a wide consensus among respiratory physicians during the last few years. The development of portable devices promotes patient's bedside evaluation providing rapid, real-time and low-cost diagnostic information. The different acoustic impedance between different tissues and organs produces artifacts known as A lines, B lines, sliding sign, lung point, etc. The identification of such artifacts is essential to discriminate normal pleural appearance from the presence of pleural effusion, pneumothorax, thickenings and tumors. Ultrasounds are also a valuable tool during interventional procedures, such as thoracentesis, chest tube insertion and transcutaneous biopsy. Its use is recommended before medical thoracoscopy in order to assess the best site of trocar insertion according to presence, quantity and characteristics of pleural effusion. The aim of this review is to provide practical tips on chest ultrasound in clinical and interventional respiratory practice.

Ultrasound Fissure Observation: Assessment of Lung by Pleural-Hub Affiliates.

BACKGROUND: Lung ultrasound examination is becoming an even more important part of pulmonologists' clinical routine. As indicated in the literature, the coordinates of any findings on lung parenchyma are based on surface landmarks or conventional quadrants. In our experience we have noticed that lung fissures are clearly detectable as interruptions of the pleural line, but this has never been investigated previously. The aim of this study was to evaluate whether lung fissures are detectable under normal conditions in routine clinical practice. METHODS: Ten operators were enrolled from Pleural-Hub, a scientific discussion group. After compiling a prestudy survey to investigate whether they had observed fissures previously, they were asked to note if the following fissures were detectable: posterior right (PR) and left (PL), lateral right (LR) and left (LL), anterior right (AR), and anterolateral left (AL). Enrollment was competitive, aiming to reach 100 case subjects. RESULTS: We found that general fissure detection was 61.3%, in particular: PR, 59%; LR, 75%; AR, 69%; PL, 45%; LL, 64%; AL, 56%. Single operators yielded different detection rates ranging from 90% to 25%, showing strong operator dependency. Before being made aware of general results operators indicated operator's skill and rib shadow artifacts as the principal factors affecting fissure detection. CONCLUSIONS: Lung fissures may be detected with ultrasound once adequate training is provided. This may allow the clinician a more precise anatomical delineation of pathology identified by lung ultrasound.

Medical thoracoscopy: Analysis on diagnostic yield through 30 years of experience.

BACKGROUND: Medical thoracoscopy (MT) or pleuroscopy is a procedure performed to diagnose and treat malignant and benign pleural diseases. Totally 2752 pleuroscopies executed in 1984-2013 in our center were considered in this study. METHODS: A retrospective observational study was performed. Observational time was divided into six series of 5 years. We calculated MT diagnostic yield and analyzed trends of main diseases diagnosed along the time. RESULTS: Along the 30 years population became progressively older. Number of pleuroscopies firstly increased, then stabilized and decreased in the last 5 years. The overall diagnostic yield of MT was 71%, increasing from 57% to 79%. The diagnostic yield was significantly higher in the presence of monolateral pleural effusion. Cancer represented more than half of diagnosis; tuberculosis was the most common nonneoplastic disease. The frequency of all cancers, mesothelioma, and lung cancer increased through the time; tuberculosis first decreased and then increased. All specimens resulted appropriate during the last 25 years. CONCLUSION: MT has a great diagnostic yield that can be improved by practice, permitting to achieve a specific histological diagnosis in about 80% of patients. Our experience demonstrates that the accurate selection of the patients undergoing to MT is very important to reach these results.

Medical thoracoscopy in MALT lymphoma causing pleural effusion: A case report.

Mucosa-associated lymphoid tissue (MALT) lymphoma is a form of low-grade malignant B-cell extranodal non-Hodgkin's lymphoma. It is classified as marginal-zone lymphoma and represents less than 1% of all lung cancer. We describe a case of MALT lymphoma limited exclusively to the lung that came to our attention with infective pleural effusion and concomitant lung consolidation of the left lower lobe. Our case demonstrates that MALT can begin with an acute clinical presentation. The clinical scenario, with fever, parietal chest pain, and leukocytosis, suggested an infective process. Radiological and sonographic examinations and the endoscopic aspect during medical thoracoscopy (MT) were typical of an infective etiology. The histological outcome of non-specific inflammatory pleuritis confirmed our suppositions. However, the missing resolution of lung consolidation after several weeks led us to an alternative diagnosis. Parenchymal biopsies obtained by bronchoscopy allowed us to reach the correct diagnosis: MALT lymphoma limited to the lung.