Inspiratory-expiratory variation of pleural line thickness in neonates with and without acute respiratory failure.

BACKGROUND: There are relatively few data about the ultrasound evaluation of pleural line in patients with respiratory failure. We measured the pleural line thickness during different phases of the respiratory cycle in neonates with and without acute respiratory failure as we hypothesized that this can significantly change. METHODS: Prospective, observational, cohort study performed in an academic tertiary neonatal intensive care unit recruiting neonates with transient tachypnoea of the neonate (TTN), respiratory distress syndrome (RDS) or neonatal acute respiratory distress syndrome (NARDS). Neonates with no lung disease (NLD) were also recruited as controls. Pleural line thickness was measured with high-frequency ultrasound at end-inspiration and end-expiration by two different raters. RESULTS: Pleural line thickness was slightly but significantly higher at end-expiration (0.53 [0.43-0.63] mm) than at end-inspiration (0.5 [0.4-0.6] mm; p = 0.001) for the whole population. End-inspiratory (NLD: 0.45 [0.38-0.53], TTN: 0.49 [0.43-0.59], RDS: 0.53 [0.41-0.62], NARDS: 0.6 [0.5-0.7] mm) and -expiratory (NLD: 0.47 [0.42-0.56], TTN: 0.48 [0.43-0.61], RDS: 0.53 [0.46-0.65], NARDS: 0.61 [0.54-0.72] mm) thickness were significantly different (overall p = 0.021 for both), between the groups although the absolute differences were small. The inter-rater agreement was optimal (ICC: 0.95 (0.94-0.96)). Coefficient of variation was 2.8% and 2.5% for end-inspiratory and end-expiratory measurements, respectively. These findings provide normative data of pleural line thickness for the most common forms of neonatal acute respiratory failure and are useful to design future studies to investigate possible clinical applications.

Setting positive end-expiratory pressure: lung and diaphragm ultrasound.

PURPOSE OF REVIEW: The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed. RECENT FINDINGS: Lung ultrasound can accurately diagnose the cause of acute respiratory failure, including acute respiratory distress syndrome and can identify focal and nonfocal lung morphology in these patients. This is essential in determining optimal ventilator strategy and PEEP level. Assessment of the effect of PEEP on lung recruitment using lung ultrasound is promising, especially in the perioperative setting. Diaphragm ultrasound can monitor the effects of PEEP on the diaphragm, but this needs further validation. In patients with an acute exacerbation of chronic obstructive pulmonary disease, diaphragm ultrasound can be used to predict noninvasive ventilation failure. Lung and diaphragm ultrasound can be used to predict weaning outcome and accurately diagnose the cause of weaning failure. SUMMARY: Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.

Electrical Impedance Tomography to Monitor Hypoxemic Respiratory Failure.

Hypoxemic respiratory failure is one of the leading causes of mortality in intensive care. Frequent assessment of individual physiological characteristics and delivery of personalized mechanical ventilation (MV) settings is a constant challenge for clinicians caring for these patients. Electrical impedance tomography (EIT) is a radiation-free bedside monitoring device that is able to assess regional lung ventilation and changes in aeration. With real-time tomographic functional images of the lungs obtained through a thoracic belt, clinicians can visualize and estimate the distribution of ventilation at different ventilation settings or following procedures such as prone positioning. Several studies have evaluated the performance of EIT to monitor the effects of different MV settings in patients with acute respiratory distress syndrome, allowing more personalized MV. For instance, EIT could help clinicians find the positive end-expiratory pressure that represents a compromise between recruitment and overdistension and assess the effect of prone positioning on ventilation distribution. The clinical impact of the personalization of MV remains to be explored. Despite inherent limitations such as limited spatial resolution, EIT also offers a unique noninvasive bedside assessment of regional ventilation changes in the ICU. This technology offers the possibility of a continuous, operator-free diagnosis and real-time detection of common problems during MV. This review provides an overview of the functioning of EIT, its main indices, and its performance in monitoring patients with acute respiratory failure. Future perspectives for use in intensive care are also addressed.

The utility of diaphragm ultrasound thickening indices for assessing respiratory decompensation in amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Amyotrophic lateral sclerosis (ALS) leads to diaphragmatic weakness at some point during its course, which is a major cause of respiratory insufficiency. The aim of this study was to evaluate ultrasound-based measures for assessing the diaphragmatic competency and the need for ventilatory support. METHODS: Twenty-six subjects with ALS and 12 healthy controls were enrolled. All participants underwent B-mode diaphragm ultrasound (DUS). Diaphragm thickness and thickening indices were recorded. In the subjects with ALS, further assessments included functional scales and spirometry. We investigated the diagnostic accuracy of DUS thickening indices in predicting diaphragmatic dysfunction and the correlation between clinical, spirometric, and DUS data. RESULTS: Significant relationships were found between forced vital capacity and all diaphragmatic thickening indices. Similarly, all diaphragmatic thickening indices correlated with both Milano Torino staging and disease progression rate. Only thickening fraction (TFdi) correlated with score on the revised ALS Functional Rating Scale (r = 0.459, P = .024). TFdi had better accuracy in predicting diaphragmatic dysfunction (area under the curve [AUC] = 0.839, 95% confidence interval [CI] 0.643 to 0.953) and the need for initiation of noninvasive ventilation (NIV) (AUC = 0.989, 95% CI 0.847 to 1.000) compared with the other indices. A TFdi cut-off point of 0.50 was a sensitive threshold to consider NIV. DISCUSSION: DUS successfully identifies diaphragmatic dysfunction in ALS, being a valuable accessory modality for investigating respiratory symptoms. TFdi was found to be the most useful DUS index, which encourages further investigation.

Ecografía pleuropulmonar y diafragmática en medicina intensiva / Pleuropulmonary and diaphragmatic ultrasound in intensive care medicine

La utilidad de la ultrasonografía para la exploración del tórax fue descrita en 1968. No es hasta la década de los 90 cuando se generaliza su uso en las unidades de cuidados intensivos como una herramienta diagnóstica, de seguimiento y guía en procedimientos invasivos. Que sea una herramienta no invasiva, accesible a pie de cama, con una sensibilidad y especificidad cercanas a la tomografía computarizada (TC) y con una curva de aprendizaje corta, la ha convertido en una técnica de uso obligado en el manejo del paciente crítico. Es fundamental conocer que la distinta relación aire/fluido que generan las distintas patologías pulmonares da lugar a distintos patrones ecográficos. La identificación de estos patrones junto con la información clínica nos permitirá hacer un diagnóstico acertado en la mayor parte de causas de insuficiencia respiratoria. Asimismo, no debemos olvidar la importancia de la evaluación de la función diafragmática mediante ecografía durante la desconexión de la ventilación mecánica. (AU)

The usefulness of ultrasound for chest exploration was described in 1968. It was not until the 1990s, when its use became widespread in Intensive Care Units as a diagnostic, monitoring and procedural guide tool. The fact that it is a non-invasive tool, accessible at the bedside, with a sensitivity and specificity close to computerized tomography (CT) and with a short learning curve, have made it a mandatory technique in the management of critically ill patients. It is essential to know that there are different air/fluid ratio generated by different pathologies that gives rise to one echographic pattern or another. The identification of these patterns together with the clinical information will allow to make an accurate diagnosis in most settings of respiratory failure. Likewise, we must not forget the importance of evaluating diaphragmatic function by ultrasound during weaning from mechanical ventilation. (AU)

Comparison of chest radiograph and lung ultrasound in children with acute respiratory failure.

PURPOSE: Chest x-ray (CXR) is the standard imaging used to evaluate children in acute respiratory distress and failure. Our objective was to compare the lung-imaging techniques of CXR and lung ultrasound (LUS) in the evaluation of children with acute respiratory failure (ARF) to quantify agreement and to determine which technique identified a higher frequency of pulmonary abnormalities. METHODS: This was a secondary analysis of a prospective observational study evaluating the sensitivity and specificity of LUS in children with ARF from 12/2018 to 02/2020 completed at the University of Wisconsin-Madison (USA). Children > 37.0 weeks corrected gestational age and ≤ 18 years of age admitted to the PICU with ARF were evaluated with LUS. We compared CXR and LUS completed within 6 h of each other. Kappa statistics (k) adjusted for maximum attainable agreement (k/kmax) were used to quantify agreement between imaging techniques and descriptive statistics were used to describe the frequency of abnormalities. RESULTS: Eighty-eight children had LUS completed, 32 with concomitant imaging completed within 6 h are included. There was fair agreement between LUS and CXR derived diagnoses with 58% agreement (k/kmax = 0.36). Evaluation of imaging patterns included: normal, 57% agreement (k = 0.032); interstitial pattern, 47% agreement (k = 0.003); and consolidation, 65% agreement (k = 0.29). CXR identified more imaging abnormalities than LUS. CONCLUSIONS: There is fair agreement between CXR and LUS-derived diagnoses in children with ARF. Given this, clinicians should consider the benefits and limitations of specific imaging modalities when evaluating children with ARF. Additional studies are necessary to further define the role of LUS in pediatric ARF given the small sample size of our study.

Role of ultrasound in acute respiratory failure and in the weaning of mechanical ventilation.

Comprehensive ultrasound assessment has become an essential tool to facilitate the diagnosis and therapeutic management of critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia and acute pulmonary thromboembolism, and in patients with COVID-19. In addition, in recent years, the use of ultrasound to evaluate responses to treatment in critically ill patients with ARF has been developed, providing a noninvasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone position, as well as for facilitating weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.

Point-of-care lung ultrasound score for predicting escalated care in children with respiratory distress.

PURPOSE: Respiratory distress due to lower respiratory illnesses is a leading cause of death in children. Early recognition of high-risk populations is critical for the allocation of adequate resources. Our goal was to assess whether the lung ultrasound (US) score obtained at admission in children with respiratory distress predicts the need for escalated care. METHODS: This prospective study included 0-18-year-old patients with respiratory distress admitted to three emergency departments in the state of Sao Paulo, Brazil, between July 2019 and September 2021. The enrolled patients underwent lung US performed by a pediatric emergency physician within two hours of arrival. Lung ultrasound scores ranging from 0 to 36 were computed. The primary outcome was the need for high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), or mechanical ventilation within 24 h. RESULTS: A total of 103 patients were included. The diagnoses included wheezing (33%), bronchiolitis (27%), pneumonia (16%), asthma (9%), and miscellaneous (16%). Thirty-five patients (34%) required escalated care and had a higher lung ultrasound score: median 13 (0-34) vs 2 (0-21), p < 0.0001; area under the curve (AUC): 0.81 (95% confidence interval [CI]: 0.71-0.90). The best cut-off score derived from Youden's index was seven (sensitivity: 71.4%; specificity: 79.4%; odds ratio (OR): 9.6 [95% CI: 3.8-24.7]). A lung US score above 12 was highly specific and had a positive likelihood ratio of 8.74 (95% CI:3.21-23.86). CONCLUSION: An elevated lung US score measured in the first assessment of children with any type of respiratory distress was predictive of severity as defined by the need for escalated care with HFNC, NIV, or mechanical ventilation.

Cardiopulmonary Ultrasound-Guided Treatment of Premature Infants with Respiratory Failure and Patent Ductus Arteriosus: A Randomized, Controlled Trial.

OBJECTIVES: To evaluate the role of cardiopulmonary ultrasonography in the treatment of preterm infants with respiratory failure combined with patent ductus arteriosus (PDA). METHODS: A single-center, prospective, randomized, controlled trial of premature infants born in the authors' hospital with a birth weight ≤ 1500 g and respiratory failure combined with PDA was conducted from January 2020 to December 2021. The included infants were randomly assigned to the cardiopulmonary ultrasound-guided therapy group or the traditional therapy group. The primary outcome of this study was data on respiratory support and PDA. RESULTS: A total of 76 premature infants were included in the study. There were 39 patients in the cardiopulmonary ultrasound-guided therapy group and 37 patients in the traditional therapy group. There was no difference in the baseline data, and the cardiopulmonary ultrasound-guided therapy group had a higher initial positive end-expiratory pressure [difference in median = -1.5 cm H2O, 95% confidence interval (CI): -2.0 to -1.0, p < 0.0001], earlier use of ibuprofen to close the PDA (difference in median = 2.5 d, 95% CI: 1.0-4.0, p = 0.004), fewer patients requiring invasive respiratory support [risk ratio (RR) = 0.63, 95% CI: 0.41-0.99, p = 0.04], and a lower incidence of moderate to severe bronchopulmonary dysplasia (RR = 0.44, 95% CI: 0.44-0.96, p = 0.04). There was no difference in the incidence of adverse events. CONCLUSIONS: For premature infants with respiratory failure combined with PDA, cardiopulmonary ultrasonography can better guide respiratory support. The timely administration of drugs helps treat PDA, thereby decreasing the risk of intubation and BPD. TRIAL REGISTRATION: https://www.trialos.com/index/ , TRN: 20220420024607012, date of registration: 2022/03/28, retrospectively registered.

Association of subpleural ground-glass opacities with respiratory failure and RNAemia in COVID-19.

OBJECTIVES: To examine the radiological patterns specifically associated with hypoxemic respiratory failure in patients with coronavirus disease (COVID-19). METHODS: We enrolled patients with COVID-19 confirmed by qPCR in this prospective observational cohort study. We explored the association of clinical, radiological, and microbiological data with the development of hypoxemic respiratory failure after COVID-19 onset. Semi-quantitative CT scores and dominant CT patterns were retrospectively determined for each patient. The microbiological evaluation included checking the SARS-CoV-2 viral load by qPCR using nasal swab and serum specimens. RESULTS: Of the 214 eligible patients, 75 developed hypoxemic respiratory failure and 139 did not. The CT score was significantly higher in patients who developed hypoxemic respiratory failure than in those did not (median [interquartile range]: 9 [6-14] vs 0 [0-3]; p < 0.001). The dominant CT patterns were subpleural ground-glass opacities (GGOs) extending beyond the segmental area (n = 44); defined as "extended GGOs." Multivariable analysis showed that hypoxemic respiratory failure was significantly associated with extended GGOs (odds ratio [OR] 29.6; 95% confidence interval [CI], 9.3-120; p < 0.001), and a CT score > 4 (OR 12.7; 95% CI, 5.3-33; p < 0.001). The incidence of RNAemia was significantly higher in patients with extended GGOs (58.3%) than in those without any pulmonary lesion (14.7%; p < 0.001). CONCLUSIONS: Extended GGOs along the subpleural area were strongly associated with hypoxemia and viremia in patients with COVID-19. KEY POINTS: • Extended ground-glass opacities (GGOs) along the subpleural area and a CT score > 4, in the early phase of COVID-19, were independently associated with the development of hypoxemic respiratory failure. • The absence of pulmonary lesions on CT in the early phase of COVID-19 was associated with a lower risk of developing hypoxemic respiratory failure. • Compared to patients with other CT findings, the extended GGOs and a higher CT score were also associated with a higher incidence of RNAemia.

Lung ultrasound protocol decreases radiation in newborn population without side effects: A quality improvement project / La implementación de un protocolo de ecografía pulmonar disminuye la radiación sin efectos secundarios: proyecto de mejora cualitativa

Objective To reduce radiation exposure in newborns admitted due respiratory distress based on the implementation of lung ultrasound (LUS). Design Quality improvement (QI), prospective, before-after, pilot study. Setting Third level neonatal intensive care unit (NICU) level with 25-bed and 1800 deliveries/year. Patients Inclusion criteria were neonates admitted with respiratory distress. Interventions After a theoretical and practical LUS training a new protocol was approved and introduced to the unit were LUS was the first-line image. To study the effect of the intervention we compare two 6-month periods: group 1, with the previous chest X-ray (CXR)-protocol (CXR as the first diagnostic technique) vs. group 2, once LUS-protocol had been implemented. Main variables of interest The main QI measures were the total exposure to radiation. Secondary QI were to evaluate if the LUS protocol modified the clinical evolution as well as the frequency of complications. Results 122 patients were included. The number of CXR was inferior in group 2 (group 1: 2 CXR (IQR 1–3) vs. Group 2: 0 (IQR 0–1), p<0.001), as well as had lower median radiation per baby which received at least one CXR: 56 iGy (IQR 32–90) vs. 30 iGy (IQR 30–32), p<0.001. Respiratory support was similar in both groups, with lower duration of non-invasive mechanical ventilation and oxygen duration the second group (p<0.05). No differences regarding respiratory development complications, length of stay and mortality were found. Conclusions The introduction of LUS protocol in unit decreases the exposure radiation in infants without side effects (AU)

Objetivo Reducir la exposición a la radiación en neonatos ingresados por distrés respiratorio mediante implementación de la ecografía pulmonar (EP). Diseño Estudio piloto, prospectivo, anterior-posterior, mejoría de la calidad. Ámbito Unidad de cuidados intensivos neonatal (UCIN) de tercer nivel con 25 camas y 1800 partos/anuales. Pacientes Criterio de inclusión neonatos con distrés respiratorio. Intervenciones Después de una formación teórico-práctica en EP un nuevo protocolo fue implementado y aprobado siendo la EP la primera técnica de imagen. Para estudiar el efecto de la intervención comparamos dos períodos de 6 meses: grupo 1, con el protocolo de radiografía de tórax (RTX) (RTX primera técnica diagnóstica) vs. grupo 2, una vez implementado el protocolo de EP. Variables de interés La principal variable de interés fue la exposición total a la radiación. Las secundarias fueron la evolución clínica y la frecuencia de complicaciones. Resultados Se incluyeron 122 pacientes. El número de RTX fue inferior en el grupo 2 (grupo 1: 2 RTX [RIQ 1-3] vs. grupo 2: 0 [RIQ 0-1], p<0,001), con una menor dosis de radiación media por cada paciente que recibió al menos una RTX: 56 iGy (RIQ 32-90) vs. 30 iGy (RIQ 30-32), p<0,001. El soporte respiratorio fue similar en ambos grupos, con menor duración de la ventilación no invasiva y oxigenoterapia en el segundo grupo (p< 0,05). No hubo diferencias en el desarrollo de complicaciones respiratorias, días de ingreso o mortalidad. Conclusiones La introducción de un protocolo de EP en una unidad disminuye la exposición a la radiación sin efectos secundarios (AU)

Diaphragmatic Ultrasound Predictors of High-Flow Nasal Cannula Therapeutic Failure in Critically Ill Patients With SARS-CoV-2 Pneumonia.

OBJECTIVES: High flow nasal cannula (HFNC) is frequently used in patients with acute respiratory failure, but there is limited evidence regarding predictors of therapeutic failure. The objective of this study was to assess diaphragmatic ultrasound criteria as predictors of failure to HFNC, defined as the need for orotracheal intubation or death. METHODS: Prospective cohort study including adult patients consecutively admitted to the critical care unit, from July 24 to October 20, 2020, with respiratory failure secondary to SARS-CoV-2 pneumonia who required HFNC. After 12 hours of HFNC initiation we measured ROX index (ratio of SpO2 /FiO2 to respiratory rate), excursion and diaphragmatic contraction speed (diaphragmatic excursion/inspiratory time) by ultrasound, both in supine and prone position. RESULTS: In total, 41 patients were analyzed, 25 succeeded and 16 failed HFNC therapy. At 12 hours, patients who succeeded HFNC therapy presented higher ROX index in supine position (9.8 [9.1-15.6] versus 5.4 [3.9-6.8], P < .01), and higher PaO2 /FiO2 ratio (186 [135-236] versus 117 [103-162] mmHg, P = .03). To predict therapeutic failure, the supine diaphragmatic contraction speed presented sensitivity of 89% and a specificity of 57%, while the ROX index presented a sensitivity of 92.8% and a specificity of 75%. CONCLUSIONS: Diaphragmatic contraction speed by ultrasound emerges as a diagnostic complement to clinical tools to predict HFNC success. Future studies should confirm these results.

The Role of Echocardiography in Extracorporeal Membrane Oxygenation.

PURPOSE OF REVIEW: Extracorporeal membrane oxygenation (ECMO) is increasingly used to temporarily support patients in severe circulatory and/or respiratory failure. Echocardiography is a core component of successful ECMO deployment. Herein, we review the role of echocardiography at different phases on extracorporeal support including candidate identification, cannulation, maintenance, complication vigilance, and decannulation. RECENT FINDINGS: During cannulation, ultrasound is used to confirm intended vascular access and appropriate inflow cannula positioning. While on ECMO, echocardiographic evaluation of ventricular loading conditions and hemodynamics, cannula positioning, and surveillance for intracardiac or aortic thrombi is needed for complication mitigation. Echocardiography is crucial during all phases of ECMO use. Specific echocardiographic queries depend on the ECMO type, V-V, or V-A, and the specific cannula configuration strategy employed.

Ultrasound-assessed lung aeration correlates with respiratory system compliance in adults and neonates with acute hypoxemic restrictive respiratory failure: an observational prospective study.

BACKGROUND: Lung ultrasound allows lung aeration to be assessed through dedicated lung ultrasound scores (LUS). Despite LUS have been validated using several techniques, scanty data exist about the relationships between LUS and compliance of the respiratory system (Crs) in restrictive respiratory failure. Aim of this study was to investigate the relationship between LUS and Crs in neonates and adults affected by acute hypoxemic restrictive respiratory failure, as well as the effect of patients' age on this relationship. METHODS: Observational, cross-sectional, international, patho-physiology, bi-center study recruiting invasively ventilated, adults and neonates with acute respiratory distress syndrome (ARDS), neonatal ARDS (NARDS) or respiratory distress syndrome (RDS) due to primary surfactant deficiency. Subjects without lung disease (NLD) and ventilated for extra-pulmonary conditions were recruited as controls. LUS, Crs and resistances (Rrs) of the respiratory system were measured within 1 h from each other. RESULTS: Forty adults and fifty-six neonates were recruited. LUS was higher in ARDS, NARDS and RDS and lower in control subjects (overall p < 0.001), while Crs was lower in ARDS, NARDS and RDS and higher in control subjects (overall p < 0.001), without differences between adults and neonates. LUS and Crs were correlated in adults [r = - 0.86 (95% CI - 0.93; - 0.76), p < 0.001] and neonates [r = - 0.76 (95% CI - 0.85; - 0.62), p < 0.001]. Correlations remained significant among subgroups with different causes of respiratory failure; LUS and Rrs were not correlated. Multivariate analyses confirmed the association between LUS and Crs both in adults [B = - 2.8 (95% CI - 4.9; - 0.6), p = 0.012] and neonates [B = - 0.045 (95% CI - 0.07; - 0.02), p = 0.001]. CONCLUSIONS: Lung aeration and compliance of the respiratory system are significantly and inversely correlated irrespective of patients' age. A restrictive respiratory failure has the same ultrasound appearance and mechanical characteristics in adults and neonates.

[Predictive value of combined assessment of diaphragmatic and pulmonary ultrasound for weaning outcomes in mechanical ventilated patients with acute respiratory failure].

OBJECTIVE: To investigate the clinical predictive value of combined diaphragmatic and pulmonary ultrasound in acute respiratory failure patients with mechanical ventilation (MV). METHODS: From January 2020 to August 2022, patients with acute respiratory failure admitted to People's Hospital Affiliated to Ningbo University who underwent invasive MV and weaning were enrolled. After meeting the weaning standards, spontaneous breathing test (SBT) was performed using T-tube. Right diaphragm excursion (DE), diaphragm thickness and lung ultrasound score (LUS) were collected by bedside ultrasound at 30 minutes of SBT, and rapid shallow respiratory index (RSBI), diaphragmatic-shallow respiratory index (D-RSBI) and diaphragmatic thickening rate (DTF) were calculated. According to the weaning outcome, the patients were divided into successful weaning group and failed weaning group. The clinical data of all patients were collected, and the ultrasound parameters and clinical indicators were compared between the two groups. Receiver operator characteristic curve (ROC curve) was used to evaluate the predictive value of D-RSBI, RSBI, DE combined with LUS score and DTF combined with LUS score for weaning failure patients. RESULTS: A total of 77 patients were enrolled, including 54 cases in the successful weaning group and 23 cases in the failed weaning group. The right DE and DTF of patients in successful weaning group were significantly higher than those in failed weaning group [right DE (cm): 1.28±0.39 vs. 0.88±0.41, DTF: (32.64±18.27)% vs. (26.43±15.23)%, both P < 0.05], LUS score, RSBI and D-RSBI were significantly lower than those in failed weaning group [LUS score: 11.45±2.67 vs. 18.33±3.62, RSBI (times×min-1×L-1): 72.21±19.67 vs. 107.35±21.32, D-RSBI (times×min-1×mm-1): 0.97±0.19 vs. 1.78±0.59, all P < 0.05]. ROC curve analysis showed that when the cut-off value of D-RSBI and RSBI was 1.41 times×min-1×mm-1 and 56.46 times×min-1×L-1, the area under the ROC curve (AUC) for predicting weaning failure was 0.972 and 0.988; and the sensitivity was 95.7% and 87.0%, respectively; the specificity was 81.0% and 100.0%, respectively. The AUC of right DE combined with LUS score and DTF combined with LUS score in predicting weaning failure were 0.974 and 0.985, respectively, with a sensitivity of 91.3% and a specificity of 98.1%. CONCLUSIONS: Combined assessment of diaphragmatic and pulmonary ultrasound is a good parameter to effectively predict weaning failure in MV patients, which has high application value in guiding weaning in MV patients, and is worthy of clinical application.

Predicting Post-Extubation Respiratory Failure After Myocardial Infarction Using The Rapid Shallow Breathing Index And Lung Ultrasound Score.

BACKGROUND: The Rapid Shallow Breathing Index (RSBI) has been hypothesized to have discriminating power for categorizing patients at higher risk of post-extubation respiratory failure (RF). Hence aim of this study was to determine the predictive value of RSBI for post-extubation RF in patients after acute myocardial infarction (AMI). METHODS: Consecutive, intubated patients admitted post-revascularization were included. RSBI and lung ultrasound score (LUS) were measured and post-extubation RF within 48 hours was recorded. RESULTS: RF was observed in 36.3% (78/215) patients. For the prediction of RF, RSBI and LUS had area under the curve of 0.670 and 0.635, respectively. The sensitivity, specificity, negative predictive value, and positive predictive value of RSBI >50.5 were 75.6%, 54.7%, 79.8%, and 48.8% respectively, while, the accuracy measures for the combination of RSBI with LUS >1.5 were 44.9%, 84.7%, 73.0%, and 62.5% respectively. CONCLUSIONS: Combined RSBI and LUS measured during spontaneous breathing trial in patients after an AMI, have high predictive abilities for identifying post-extubation RF.

Breath-holding physiology, radiological severity and adverse outcomes in COVID-19 patients: A prospective validation study.

BACKGROUND AND OBJECTIVE: COVID-19 remains a major cause of respiratory failure, and means to identify future deterioration is needed. We recently developed a prediction score based on breath-holding manoeuvres (desaturation and maximal duration) to predict incident adverse COVID-19 outcomes. Here we prospectively validated our breath-holding prediction score in COVID-19 patients, and assessed associations with radiological scores of pulmonary involvement. METHODS: Hospitalized COVID-19 patients (N = 110, three recruitment centres) performed breath-holds at admission to provide a prediction score (Messineo et al.) based on mean desaturation (20-s breath-holds) and maximal breath-hold duration, plus baseline saturation, body mass index and cardiovascular disease. Odds ratios for incident adverse outcomes (composite of bi-level ventilatory support, ICU admission and death) were described for patients with versus without elevated scores (>0). Regression examined associations with chest x-ray (Brixia score) and computed tomography (CT; 3D-software quantification). Additional comparisons were made with the previously-validated '4C-score'. RESULTS: Elevated prediction score was associated with adverse COVID-19 outcomes (N = 12/110), OR[95%CI] = 4.54[1.17-17.83], p = 0.030 (positive predictive value = 9/48, negative predictive value = 59/62). Results were diminished with removal of mean desaturation from the prediction score (OR = 3.30[0.93-11.72]). The prediction score rose linearly with Brixia score (ß[95%CI] = 0.13[0.02-0.23], p = 0.026, N = 103) and CT-based quantification (ß = 1.02[0.39-1.65], p = 0.002, N = 45). Mean desaturation was also associated with both radiological assessment. Elevated 4C-scores (≥high-risk category) had a weaker association with adverse outcomes (OR = 2.44[0.62-9.56]). CONCLUSION: An elevated breath-holding prediction score is associated with almost five-fold increased adverse COVID-19 outcome risk, and with pulmonary deficits observed in chest imaging. Breath-holding may identify COVID-19 patients at risk of future respiratory failure.

Follow-up lung ultrasound to monitor lung failure in COVID-19 ICU patients.

OBJECTIVES: Point-of-care lung ultrasound (LU) is an established tool in the first assessment of patients with coronavirus disease (COVID-19). To assess the progression or regression of respiratory failure in critically ill patients with COVID-19 on Intensive Care Unit (ICU) by using LU. MATERIALS AND METHODS: We analyzed all patients admitted to Internal Intensive Care Unit, Ludwig-Maximilians-University (LMU) of Munich, from March 2020 to December 2020 suffering lung failure caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). LU was performed according to a standardized protocol at baseline and at follow up every other day for the first 15 days using a lung ultrasound score (LUSS). Ventilation data were collected simultaneously. RESULTS: Our study included 42 patients. At admission to ICU, 19 of them (45%) were mechanically ventilated. Of the non-invasive ventilated ones (n = 23, 55%), eleven patients required invasive ventilation over the course. While LUS did not differ at admission to ICU between the invasive ventilated ones (at baseline or during ICU stay) compared to the non-invasive ventilated ones (12±4 vs 11±2 points, p = 0.2497), LUS was significantly lower at d7 for those, who had no need for invasive ventilation over the course (13±5 vs 7±4 points, p = 0.0046). Median time of invasive ventilation counted 18 days; the 90-day mortality was 24% (n = 10) in our cohort. In case of increasing LUS between day 1 (d1) and day 7 (d7), 92% (n = 12/13) required invasive ventilation, while it was 57% (n = 10/17) in case of decreasing LUS. At d7 we found significant correlation between LU and FiO2 (Pearson 0.591; p = 0.033), p/F ratio (Pearson -0.723; p = 0.005), PEEP (Pearson 0.495; p = 0.043), pplat (Pearson 0.617; p = 0.008) and compliance (Pearson -0.572; p = 0.016). CONCLUSION: LUS can be a useful tool in monitoring of progression and regression of respiratory failure and in indicating intubation in patients with COVID-19 in the ICU.