Lung ultrasound to quantitatively evaluate extravascular lung water content and its clinical significance.

BACKGROUND: As we all know, pulmonary edema can be diagnosed by lung ultrasound (LUS), but how to accurately and quantitatively evaluate lung water content by ultrasound is a difficult problem that needs to be solved urgently. B-line assessment with LUS has recently been proposed as a reliable, noninvasive semiquantitative tool for evaluating extravascular lung water (EVLW). To date, however, there has been no easy quantitative method to evaluate EVLW by LUS. OBJECTIVE: (1) To explore the feasibility of establishing a rabbit model with increased EVLW by injecting warm normal saline (NS) into the lungs via the endotracheal tube. (2) To establish a simple, accurate and clinically operable method for quantitative assessment of EVLW using LUS. (3) To develop LUS into a resource for guiding the clinical treatment of patients with increased EVLW. METHODS: Forty-five New Zealand rabbits were randomized into nine groups (n = 5). After anesthesia, each group of rabbits was injected with different amounts of warm sterile NS (0 ml/kg, 2 ml/kg, 4 ml/kg, 6 ml/kg, 8 ml/kg, 10 ml/kg, 15 ml/kg, 20 ml/kg, 30 ml/kg) via the endotracheal tube. Each rabbit was examined by LUS before and after NS injection. At the same time, the spontaneous respiratory rate (RR, breaths per minute), heart rate (HR, bpm) and arterial blood gas (ABG) of the rabbits were recorded. Then, both lungs were dissected to obtain the wet and dry weight and conduct a complete histological examination. RESULTS: Injecting NS into the lungs through a tracheal tube can successfully establish a rabbit model with increased EVLW. The extent of EVLW increase is related to the volume of NS injected into the lungs. As the EVLW increases, three different types of B-lines can be seen in the LUS. When the NS injection volume is 2-6 ml/kg, comet-tail artifacts and B-lines are the main patterns found on LUS; as additional NS is injected into the lungs, the rabbits' RR gradually increases, while their HR gradually decreases, ABG remains normal or shows mild metabolic acidosis (MA). Confluent B-lines grow gradually but significantly, reaching a dominant position when the NS injection volume reaches 6-8 ml/kg and predominating almost entirely when the NS injection volume is 8-15 ml/kg; at that time, rabbits' RRs and HRs decrease sharply, and the ABG indicated type I respiratory failure (RF).Compact B-lines occur and predominate almost entirely when the NS injection volume reaches 10 ml/kg and 15-20 ml/kg, respectively. At that time, rabbits begin to enter cardiac and respiratory arrest, and ABG shows type II RF and MA. CONCLUSION: In this study, the establishment of an animal model with increased EVLW confirmed that different lung water content had corresponding manifestations in ultrasound and was associated with different degrees of clinical symptoms, and the study results can be used to guide clinical practice.

Influence of Alveolar Fluid on Aquaporins and Na+/K+-ATPase and Its Possible Theoretical or Clinical Significance.

OBJECTIVE: Pulmonary edema is the most common pathophysiological change in pulmonary disease. Aquaporins (AQPs) and Na+/K+-ATPase play pivotal roles in alveolar fluid clearance. This study aimed to explore the influence of increased alveolar fluid on the absorption of lung fluid. STUDY DESIGN: Eighty New Zealand rabbits were randomly divided into eight groups (n = 10 in each group), and models of different alveolar fluid contents were established by the infusion of different volumes of normal saline (NS) via the endotracheal tube. Five animals in each group were sacrificed immediately after infusion to determine the wet/dry ratio, while the remaining animals in each group were killed 4 hours later to determine the wet/dry ratio at 4 hours. Additionally, lung specimens were collected from each group, and quantitative real-time PCR (qRT-PCR), western blot, and immunohistochemical (IHC) analyses of AQPs and Na+/K+-ATPase were performed. RESULTS: The qRT-PCR analysis and western blot studies showed markedly decreased mRNA and protein levels of AQP1 and Na+/K+-ATPase when the alveolar fluid volume was ≥6 mL/kg, and the mRNA level of AQP5 was significantly reduced when the alveolar fluid volume was ≥4 mL/kg. In addition, IHC analysis showed the same results. At 4 hours, the lung wet/dry ratio was significantly increased when the alveolar fluid volume was ≥6 mL/kg; however, compared with 0 hours after NS infusion, there was still a significant absorption of alveolar fluid for a period of 4 hours. CONCLUSION: The results of this study suggest that increased alveolar fluid may induce the downregulation of the mRNA and protein expression of AQPs and Na+/K+-ATPase, which appear to affect alveolar fluid clearance in rabbit lungs. Early intervention is required to avoid excessive alveolar fluid accumulation. KEY POINTS: · The expression levels of AQPs and Na+/K+--ATPase were significantly decreased as alveolar fluid increased.. · At 4 hours, wet/dry ratio was significantly increased when infusion volume was ≥ 6 mL/kg.. · Early intervention is required to avoid excessive alveolar fluid accumulation..

Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination.

Lung ultrasound (LUS) is now widely used in the diagnosis and monitor of neonatal lung diseases. Nevertheless, in the published literatures, the LUS images may display a significant variation in technical execution, while scanning parameters may influence diagnostic accuracy. The inter- and intra-observer reliabilities of ultrasound exam have been extensively studied in general and in LUS. As expected, the reliability declines in the hands of novices when they perform the point-of-care ultrasound (POC US). Consequently, having appropriate guidelines regarding to technical aspects of neonatal LUS exam is very important especially because diagnosis is mainly based on interpretation of artifacts produced by the pleural line and the lungs. The present work aimed to create an instrument operation specification and parameter setting guidelines for neonatal LUS. Technical aspects and scanning parameter settings that allow for standardization in obtaining LUS images include (1) select a high-end equipment with high-frequency linear array transducer (12-14 MHz). (2) Choose preset suitable for lung examination or small organs. (3) Keep the probe perpendicular to the ribs or parallel to the intercostal space. (4) Set the scanning depth at 4-5 cm. (5) Set 1-2 focal zones and adjust them close to the pleural line. (6) Use fundamental frequency with speckle reduction 2-3 or similar techniques. (7) Turn off spatial compounding imaging. (8) Adjust the time-gain compensation to get uniform image from the near-to far-field.

Wet lung leading to RDS: the lung ultrasound findings and possible mechanisms - a pilot study from an animal mode.

BACKGROUND: Clinically, the lung ultrasound (LUS) showed wet lung could cause respiratory distress syndrome (RDS) in newborns. This work aimed to investigate LUS changes over time and its potential mechanism as alveolar fluid increase in a rabbit model. METHODS: A total of 35 New Zealand Rabbits were randomly assigned to seven groups. Models of various alveolar fluid levels were induced by infusion of different volumes of normal saline (NS) via the endotracheal tube. LUS was performed before NS infusion, immediately after NS infusion and 4 h after NS infusion. To appraise LUS changes and its potential mechanism as alveolar fluid increase, histopathological examination, the mRNA and protein expression of surfactant protein (SP), and immunohistochemistry (IHC) were performed. The expression levels of SP-B and SP-C proteins were detected using western blotting, and the relative expression levels of SP-B and SP-C mRNA were detected using qRT-PCR. RESULTS: The results showed that LUS changed from B-line to lung consolidations accompanied by air-bronchograms in some locations of lungs at 4 h when the injection volume ≥ 6 ml/kg. Histopathological examination showed alveoli collapse, inflammatory cell infiltration and alveolar wall thickened. SP-B and SP-C mRNA and protein expression were statistically significantly reduced when the injection volume ≥6 ml/kg (p < .05). IHC staining displayed the same findings. CONCLUSIONS: As alveolar fluid increase, LUS changed from wet lung to RDS after 4 h. The possible mechanism was that the SP protein expression was significantly reduced. LUS can be used to guide the administration of exogenous surfactant in this situation.

Using lung ultrasound to quantitatively evaluate pulmonary water content.

BACKGROUND: Increases in extravascular lung water (EVLW) can lead to respiratory failure. This study aimed to investigate whether the B-line score (BLS) was correlated with the EVLW content determined by the lung wet/dry ratio in a rabbit model. METHODS: A total of 45 New Zealand rabbits were randomly assigned to nine groups. Among the animals, models of various lung water content levels were induced by the infusion of different volumes of warm sterile normal saline (NS) via the endotracheal tube. The arterial blood gas, spontaneous respiratory rate, and PaO2 /FiO2 ratio were detected before and after infusion. In addition, the B-lines were determined before and immediately after infusion in each group. Finally, both lungs were resected to determine the wet/dry ratio. In addition, all lung specimens were analyzed histologically, and EVLW was quantified using the BLS based on the number and confluence of B-lines in the intercostal space. RESULTS: The BLS increased with increasing infusion volume. The BLS was statistically correlated with the wet/dry ratio (r2 = .946) and with the PaO2 /FiO2 ratio (r2 = .916). Furthermore, a repeatability study was performed for the lung ultrasound (LUS) technology (Bland-Altman plots), and the results suggest that LUS had favorable intraobserver and interobserver reproducibility. CONCLUSIONS: This study is the first to suggest that the BLS can serve as a sensitive, quantitative, noninvasive, and real-time indicator of EVLW in a rabbit model of lung water accumulation. Notably, the BLS displayed an obvious correlation with the experimental gravimetry results and could also be used to predict the pulmonary oxygenation status.