Precision medicine: "Point of Care Ultrasound" (PoCUS) in the diagnostic approach to the patient with hyponatremia.

Hyponatremia is a multifactorial disorder defined as a decrease in plasma sodium concentration. Its differential diagnosis requires an adequate evaluation of the extracellular volume (ECV). However, ECV determination, simply based on the clinical history, vital signs, physical examination, and laboratory findings can leads to misdiagnosis and inappropriate treatment. The use of Point-of-Care Ultrasound (POCUS), through the combination of Lung Ultrasound (LUS), Venous Excess UltraSound (VExUS) and Focused Cardiac Ultrasound (FoCUS), allows a much more accurate holistic assessment of the patient's ECV status in combination with the other parameters.

Medicina de precisión: «Point of Care Ultrasound» (PoCUS) en el abordaje diagnóstico del paciente con hiponatremia / Precision medicine: “Point of Care Ultrasound” (PoCUS) in the diagnostic approach to the patient with hyponatremia

La hiponatremia es un trastorno multifactorial definido como una disminución en la concentración plasmática de sodio. Su diagnóstico diferencial requiere una evaluación adecuada del volumen extracelular. Sin embargo, la determinación del volumen extracelular, simplemente basada en la historia clínica, las constantes vitales, el examen físico y los hallazgos de laboratorio, conducen en ocasiones a un diagnóstico erróneo por lo que el enfoque terapéutico puede ser equivocado. El empleo de ecografía a pie de cama (Point-of-Care Ultrasound [PoCUS]), mediante la combinación de ecografía pulmonar (Lung Ultrasound [LUS]), Venous Excess UltraSound (VExUS) y la ecocardioscopia (Focused Cardiac Ultrasound [FoCUS]) permiten, en combinación con el resto de los parámetros, una valoración holística mucho más precisa del estado del volumen extracelular del paciente.(AU)

Hyponatremia is a multifactorial disorder defined as a decrease in plasma sodium concentration. Its differential diagnosis requires an adequate evaluation of the extracellular volume. However, extracellular volume determination, simply based on the clinical history, vital signs, physical examination, and laboratory findings can leads to misdiagnosis and inappropriate treatment. The use of Point-of-Care Ultrasound (PoCUS), through the combination of Lung Ultrasound (LUS), Venous Excess UltraSound (VExUS) and Focused Cardiac Ultrasound (FoCUS), allows a much more accurate holistic assessment of the patient's extracellular volume status in combination with the other parameters.(AU)

Ultrasound multifrequency strategy to estimate the lung surface roughness, in silico and in vitro results.

Lung ultrasound (LUS) is an important imaging modality to assess the state of the lung surface. Nevertheless, LUS is limited to the visual evaluation of imaging artifacts, especially the vertical ones. These artifacts are observed in pathologies characterized by a reduction of dimensions of air-spaces (alveoli). In contrast, there exist pathologies, such as chronic obstructive pulmonary disease (COPD), in which an enlargement of air-spaces can occur, which causes the lung surface to behave essentially as a perfect reflector, thus not allowing ultrasound penetration. This characteristic high reflectivity could be exploited to characterize the lung surface. Specifically, air-spaces of different sizes could cause the lung surface to have a different roughness, whose estimation could provide a way to assess the state of the lung surface. In this study, we present a quantitative multifrequency approach aiming at estimating the lung surface's roughness by measuring image intensity variations along the lung surface as a function of frequency. This approach was tested both in silico and in vitro, and it showed promising results. For the in vitro experiments, radiofrequency (RF) data were acquired from a novel experimental model. The results showed consistency between in silico and in vitro experiments.

Use of thoracic ultrasound in acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a significant cause of morbidity and mortality in critically ill patients, yet it is often underrecognized. Current imaging techniques, such as CT scan and X-ray, have several limitations, including inter-observer reliability, limited accessibility, radiation and the need for transportation. Ultrasound has become an essential bedside tool in the critical care setting and the emergency room, offering several advantages over traditional imaging techniques. It is nowadays widely used for diagnosis and early management of acute respiratory and circulatory failure. Lung ultrasound (LUS) provides non-invasively valuable information regarding lung aeration, ventilation distribution and respiratory complications in ARDS patients at the bedside. Moreover, a holistic ultrasound approach, combining LUS, echocardiography, and diaphragm ultrasound offers physiological information that could help the clinician to personalize ventilator settings and guide fluid resuscitation in these patients. Ultrasound techniques could also inform about possible causes of weaning failure in difficult-to-wean patients. However, it is uncertain whether clinical decisions based on ultrasound assessment can improve outcomes in ARDS patients and this clinical approach requires further investigation. In this article, we review the use of thoracic ultrasound, including lung and diaphragm examination, for the clinical assessment of patients with ARDS, and discuss its limitations and future perspectives.

Can Dialysis Patients Identify and Diagnose Pulmonary Congestion Using Self-Lung Ultrasound?

BACKGROUND: With the recent developments in automated tools, smaller and cheaper machines for lung ultrasound (LUS) are leading us toward the potential to conduct POCUS tele-guidance for the early detection of pulmonary congestion. This study aims to evaluate the feasibility and accuracy of a self-lung ultrasound study conducted by hemodialysis (HD) patients to detect pulmonary congestion, with and without artificial intelligence (AI)-based automatic tools. METHODS: This prospective pilot study was conducted between November 2020 and September 2021. Nineteen chronic HD patients were enrolled in the Soroka University Medical Center (SUMC) Dialysis Clinic. First, we examined the patient's ability to obtain a self-lung US. Then, we used interrater reliability (IRR) to compare the self-detection results reported by the patients to the observation of POCUS experts and an ultrasound (US) machine with an AI-based automatic B-line counting tool. All the videos were reviewed by a specialist blinded to the performer. We examined their agreement degree using the weighted Cohen's kappa (Kw) index. RESULTS: A total of 19 patients were included in our analysis. We found moderate to substantial agreement between the POCUS expert review and the automatic counting both when the patient performed the LUS (Kw = 0.49 [95% CI: 0.05-0.93]) and when the researcher performed it (Kw = 0.67 [95% CI: 0.67-0.67]). Patients were able to place the probe in the correct position and present a lung image well even weeks from the teaching session, but did not show good abilities in correctly saving or counting B-lines compared to an expert or an automatic counting tool. CONCLUSIONS: Our results suggest that LUS self-monitoring for pulmonary congestion can be a reliable option if the patient's count is combined with an AI application for the B-line count. This study provides insight into the possibility of utilizing home US devices to detect pulmonary congestion, enabling patients to have a more active role in their health care.

Assessing lung aeration using ultrasound after birth in near-term lambs at risk of respiratory distress.

Background: Optimizing respiratory support after birth requires real-time feedback on lung aeration. We hypothesized that lung ultrasound (LUS) can accurately monitor the extent and progression of lung aeration after birth and is closely associated with oxygenation. Methods: Near-term (140 days gestation, term ∼147 days), spontaneously breathing lambs with normal (controls; n = 10) or elevated lung liquid levels (EL; n= 9) were delivered by Caesarean section and monitored for four hours after birth. LUS (Phillips CX50, L3-12 transducer) images and arterial blood gases were taken every 5-20 min. LUS images were analyzed both qualitatively (grading) and quantitatively (using the coefficient of variation of pixel intensity (CoV) to estimate the degree of lung aeration), which was correlated with the oxygen exchange capacity of the lungs (Alveolar-arterial difference in oxygen; AaDO2). Results: Lung aeration, measured using LUS, and the AaDO2 improved over the first 4 h after birth. The increase in lung aeration measured using CoV of pixel intensity, but not LUS grade, was significantly reduced in EL lambs compared to controls (p = 0.02). The gradual decrease in AaDO2 after birth was significantly correlated with increased lung aeration in both control (grade, r2 = 0.60, p < 0.0001; CoV, r2 = 0.54, p < 0.0001) and EL lambs (grade, r2 = 0.51, p < 0.0001; CoV, r2 = 0.44, p < 0.0001). Conclusions: LUS can monitor lung aeration and liquid clearance after birth in spontaneously breathing near-term lambs. Image analysis techniques (CoV) may be able detect small to moderate differences in lung aeration in conditions with lung liquid retention which are not readily identified using qualitative LUS grading.

The Incremental Role of Multiorgan Point-of-Care Ultrasounds in the Emergency Setting.

Point-of-care ultrasonography (POCUS) represents a goal-directed ultrasound examination performed by clinicians directly involved in patient healthcare. POCUS has been widely used in emergency departments, where US exams allow physicians to make quick diagnoses and to recognize early life-threatening conditions which require prompt interventions. Although initially meant for the real-time evaluation of cardiovascular and respiratory pathologies, its use has been extended to a wide range of clinical applications, such as screening for deep-vein thrombosis and trauma, abdominal ultrasonography of the right upper quadrant and appendix, and guidance for invasive procedures. Moreover, recently, bedside ultrasounds have been used to evaluate the fluid balance and to guide decongestive therapy in acutely decompensated heart failure. The aim of the present review was to discuss the most common applications of POCUS in the emergency setting.

Lung Ultrasound in the Evaluation of Neonatal Respiratory Distress Syndrome.

OBJECTIVE: The purpose of this study is to examine the impact of bedside lung ultrasound (LUS) and LUS scores in the evaluating and grading of neonatal respiratory distress syndrome (NRDS). METHODS: We performed a prospective study on 80 children with suspected NRDS. Infants with a PaO2 -to-FiO2 ratio of <200, 200-300, and >300 mmHg were categorized as the "severe-NRDS group," "mild-NRDS group," and "non-NRDS group," respectively. Left and right lungs were divided into six areas, respectively. For each lung area, a 0- to 3-point score was given. RESULTS: The most common ultrasonic signs of NRDS include bilateral coalescent B-lines, thickened pleural line, and white lung without spared areas. Moreover, different LUS scores among non-NRDS, mild-NRDS, and severe-NRDS groups were identified (6.00 ± 4.033, 25.82 ± 3.778 and 27.90 ± 4.071, respectively; P < .05). When the cutoff value of LUS score was selected as 13 for the differentiation of non-NRDS from NRDS, the sensitivity and specificity were 96.9% and 93.3%, respectively, and the area under the curve (AUC) of receiver operating characteristics (ROC) was 0.938 (95% confidence interval [CI], 0.84-1.00). With a cutoff value of 26.5 for the differentiation between mild- and severe-ARDS, the AUC of ROC curve of the LUS score was 0.707 (95% CI, 0.58-0.83). Similar results were revealed as those with chest X-ray. CONCLUSION: This study showed that LUS and LUS scores complement each other, and are highly reliable and efficient in bedside radiological diagnostic investigations in newborns with NRDS.

Feasibility of Very Early Identification of Cardiogenic Shock by Semi-automated Ultrasound Exam in the Emergency Department.

Background Cardiogenic shock (CS) is critical end-organ hypoperfusion due to reduced cardiac output. Early therapy, such as vasoactive agents or the initiation of mechanical circulatory support (MCS), requires early diagnosis and is associated with better outcomes. A novel ultrasound platform (GE Healthcare, Milwaukee, WI) has semi-automated imaging software (SAIS), which could simplify the point-of-care ultrasound (POCUS) diagnosis of CS. We assessed the feasibility of using POCUS with SAIS in patients in shock, determined the ability of SAIS to identify the subset of patients with CS, and described the process and outcome of care of patients with vs. without CS after presenting to Emergency Department (ED) with hypotension. Methods This prospective case-control study was conducted at an urban ED. Physicians with prior POCUS education received one hour of training with the study device. The qualitative ejection fraction was determined by visual assessment. SAIS measurements of hemodynamics were made with the study device and included left ventricle outflow tract velocity time integral (LVOT VTI), inferior vena cava collapsibility or distensibility indices, and pulmonary B-line assessment. ED patients with a systolic blood pressure ≤ 90 mmHg or need for a vasopressor initiation in the ED were enrolled. The diagnosis of CS was determined by a medical record review. All data were summarized descriptively. Results Twenty-nine cases underwent POCUS, and 87 controls did not. Baseline characteristics, process, and outcome of care were similar between groups. Seventy-nine percent (79%) of cases had a complete POCUS with SAIS. Of these, 55% had reduced LVOT VTI, 38% had IVC collapsibility <50%, and 48% of cases had a B-line pattern consistent with pulmonary edema. The mean LVOT VTI for cases with CS was 9.4± 5.4 cm; the mean LVOT VTI for cases without CS was 15.2 ± 6.0 cm. Among patients who did not undergo POCUS, 31 (36%) had a formal echocardiogram, and eight (9%) had a final diagnosis of cardiogenic shock during hospitalization. Conclusion Physicians with one hour of platform-specific training were able to implement POCUS with SAIS among patients who present with shock. POCUS with SAIS may aid in the early recognition of CS.

The Outcome- or Cost-Effectiveness Analysis of LUS-Based Care or CXR-Based Care of Neonatal Lung Diseases: The Clinical Practice Evidence from a Level â ¢ NICU in China.

OBJECTIVE: To compare the effect of managing neonatal lung disease with lung ultrasound (LUS) or chest X-ray (CXR) monitoring on health outcomes and cost-effectiveness. METHODS: The data obtained from the NICU of the Beijing Chaoyang District Maternal and Child Healthcare Hospital were used as the study group, as LUS has completely replaced CXR in managing newborn lung disease in the hospital for the past 5 years. The primary outcomes of this study were the misdiagnosis rate of respiratory distress syndrome (RDS), the using status of mechanical ventilation, the incidence rate of bronchopulmonary dysplasia (BPD) and the survival rate in hospitalized infants. The secondary outcomes included the use pulmonary surfactant (PS), and the mortality rate of severe diseases (such as pneumothorax, pulmonary hemorrhage and RDS, etc.). RESULTS: Managing neonatal lung disease with LUS monitoring may enable the following effects: The frequency of ventilator use reducing by 40.2%; the duration of mechanical ventilation reducing by 67.5%; and the frequency of ventilator weaning failure being totally avoided. A misdiagnosis rate of 30% for RDS was also avoided. The dosage of PS was significantly reduced by 50% to 75%. No BPD occurred in the LUS-based care group for 5 years. The fatality rates of RDS, pneumothorax and pulmonary hemorrhage decreased by 100%. The poor prognosis rate of VLBW infants decreased by 85%, and the total mortality rate of hospitalized infants decreased by 90%. Therefore, the cost of LUS-based care was inevitably saved. CONCLUSIONS: Diagnosing and managing neonatal lung diseases with LUS monitoring have significant benefits, and this technology should be widely promoted and applied around the world.

Point-of-care Lung Ultrasound, Lung CT and NEWS to Predict Adverse Outcomes and Mortality in COVID-19 Associated Pneumonia.

Introduction: The appraisal of disease severity and prediction of adverse outcomes using risk stratification tools at early disease stages is crucial to diminish mortality from coronavirus disease 2019 (COVID-19). While lung ultrasound (LUS) as an imaging technique for the diagnosis of lung diseases has recently gained a leading position, data demonstrating that it can predict adverse outcomes related to COVID-19 is scarce. The main aim of this study is therefore to assess the clinical significance of bedside LUS in COVID-19 patients who presented to the emergency department (ED). Methods: Patients with a confirmed diagnosis of SARS-CoV-2 pneumonia admitted to the ED of our hospital between March 2021 and May 2021 and who underwent a 12-zone LUS and a lung computed tomography scan were included prospectively. Logistic regression and Cox proportional hazard models were used to predict adverse events, which was our primary outcome. The secondary outcome was to discover the association of LUS score and computed tomography severity score (CT-SS) with the composite endpoints. Results: We assessed 234 patients [median age 59.0 (46.8-68.0) years; 59.4% M), including 38 (16.2%) in-hospital deaths for any cause related to COVID-19. Higher LUS score and CT-SS was found to be associated with ICU admission, intubation, and mortality. The LUS score predicted mortality risk within each stratum of NEWS. Pairwise analysis demonstrated that after adjusting a base prediction model with LUS score, significantly higher accuracy was observed in predicting both ICU admission (DBA -0.067, P = .011) and in-hospital mortality (DBA -0.086, P = .017). Conclusion: Lung ultrasound can be a practical prediction tool during the course of COVID-19 and can quantify pulmonary involvement in ED settings. It is a powerful predictor of ICU admission, intubation, and mortality and can be used as an alternative for chest computed tomography while monitoring COVID-19-related adverse outcomes.

Lung ultrasound to guide the administration of exogenous pulmonary surfactant in respiratory distress syndrome of newborn infants: A retrospective investigation study.

Background: Respiratory distress syndrome (RDS) is a common disease that seriously endangers the life and safety of newborns, especially premature infants. Exogenous pulmonary surfactant (PS) is the specific agent for the treatment of neonatal RDS. Lung ultrasound (LUS) has been successfully used in the diagnosis of RDS, but its value in guiding the application of PS is still unclear. This paper explored whether the application of PS under LUS monitoring has some advantages, including (1) decreasing the misdiagnosis rate of RDS and decreasing probability of using PS, and (2) reducing the dose of PS without reducing the therapeutic effect. Methods: This study included two parts. Part 1: To decide whether the LUS is good to differentiate RDS from other lung diseases in the premature infants. All patients who were diagnosed with RDS and required PS treatment based on conventional criteria were routinely examined by LUS. Then, according to LUS findings, we decided whether they needed to receive PS treatment. Part 2: To see the dose reduction of surfactant is applicable. In RDS patients diagnosed based on LUS presentation and treated with Curosurf (Chiesi Pharmaceutical, Parma, Italy), the dose of Curosurf was compared with that recommended by the European RDS management guidelines. Results: (1) Since March 2017, 385 newborn infants admitted to our neonatal intensive care unit met the traditional diagnostic criteria of RDS. Of these, only 269 cases were diagnosed with RDS and needed PS treatment according to LUS manifestations. The other 116 infants who did not meet the criteria for ultrasound diagnosis of RDS did not receive PS supplementation but obtained good outcomes, that is LUS findings decreased a misdiagnosis rate of RDS by 30.1% and subsequently resulted in a 30.1% reduction in PS use. (2) Among the 269 RDS patients diagnosed based on LUS findings, 148 were treated with Curosurf (another 121 RDS infants who received domestic PS treatment were not included in the study group), and the average dose was 105.4 ± 24.3 mg/kg per time, which is significantly lower than the dose of 200 mg/kg per time recommended by the European RDS guidelines. (3) The mortality rate of RDS patients was 0%, and no patients had ventilator-associated pneumonia or bronchopulmonary dysplasia in this study. Conclusion: LUS can decrease the misdiagnosis rate of RDS, thereby decreasing the probability of using PS and decreasing the dose of PS, and can help RDS infants to achieve better outcomes.

Utility and Limits of Lung Ultrasound in Childhood Pulmonary Tuberculosis: Lessons from a Case Series and Literature Review.

Childhood pulmonary tuberculosis (PTB) diagnosis is often a challenge that requires a combination of history, clinical, radiological, immunological and microbiological findings. Radiological diagnosis is based today on the use of chest X-ray and chest CT that, in addition to being radio-invasive tools for children, are often not available in countries with low-resources. A non-invasive, easily usable and reproducible, low-cost diagnostic tool as LUS would therefore be useful to use to support the diagnosis of childhood PTB. Data on the use of LUS for the diagnosis and follow-up of childhood PTB are limited and in some respects contradictory. To help better define the potential role of LUS we have described the pros and cons of lung ultrasound method through a brief review of the studies in the literature and reporting some case series in which we describe clinical, laboratory, radiological results as well as detailed lung ultrasound findings of four children/adolescents with PTB.

Quantifying lung aeration in neonatal lambs at birth using lung ultrasound.

Background: Lung ultrasound (LUS) is a safe and non-invasive tool that can potentially assess regional lung aeration in newborn infants and reduce the need for X-ray imaging. LUS produces images with characteristic artifacts caused by the presence of air in the lung, but it is unknown if LUS can accurately detect changes in lung air volumes after birth. This study compared LUS images with lung volume measurements from high-resolution computed tomography (CT) scans to determine if LUS can accurately provide relative measures of lung aeration. Methods: Deceased near-term newborn lambs (139 days gestation, term ∼148 days) were intubated and the chest imaged using LUS (bilaterally) and phase contrast x-ray CT scans at increasing static airway pressures (0-50 cmH2O). CT scans were analyzed to calculate regional air volumes and correlated with measures from LUS images. These measures included (i) LUS grade; (ii) brightness (mean and coefficient of variation); and (iii) area under the Fourier power spectra within defined frequency ranges. Results: All LUS image analysis techniques correlated strongly with air volumes measured by CT (p < 0.01). When imaging statistics were combined in a multivariate linear regression model, LUS predicted the proportion of air in the underlying lung with moderate accuracy (95% prediction interval ± 22.15%, r 2 = 0.71). Conclusion: LUS can provide relative measures of lung aeration after birth in neonatal lambs. Future studies are needed to determine if LUS can also provide a simple means to assess air volumes and individualize aeration strategies for critically ill newborns in real time.

Ecografía multiórgano en infección por SARS-COV-2 / Multi-organ ultrasound for SARS-COV-2 disease

Aim: There is growing evidence regarding the imaging ultrasound findings of coronavirus disease 2019 COVID-19. Multi-organ ultrasoundhas played a significant role in the diagnosis and follow-up of thesepatients. The aim of this study was to describe the ultrasound findingsat pulmonary, cardiac and deep venous system of the lower extremities in patients with SARS-COV-2 infection.Material and method: Prospective, cross-sectional, observationalstudy was conducted in patients with confirmed COVID-19 who underwent a multi-organ point-of-care ultrasound (POCUS) examinationduring hospitalization.Results: A total of 107 patients were enrolled. Lung involvement waspresent in 100% of the patients, 93.4% bilaterally involvement. Themost affected lung area was the posteroinferior (94.39%) followed bythe lateral (89.72%). Subpleural consolidations were present in 71%of patients and consolidations larger than 1 cm in 25%. More echographic lung involvement is relational with the degree of respiratoryinsufficiency. Only two patients had proximal deep vein thrombosisin the lower extremities, 27 angiography tomography scan were performed and pulmonary thromboembolism was confirmed in 14 patients. The most frequent echocardiographic findings were impairedleft ventricular relaxation and left ventricular hypertrophy. All patientswith thromboembolic disease had severe or critical echocardiographicpulmonary involvement.Conclusions: Multi-organ POCUS ultrasound may be useful for themanifestations of COVID-19. The degree of lung ultrasound involvement was related to the degree of respiratory failure and to the presence of VTED. The relationship between DVT and PTE was lower thanexpected. Cardiac involvement has little relevance in our series. (AU)

Objetivo: Existe una creciente evidencia con respecto a los hallazgosecográficos y la COVID-19, destacando la ecografía multiórgano parael diagnóstico y el seguimiento de estos pacientes. El objetivo fuedescribir los hallazgos ecográficos a nivel pulmonar, cardiaco y delsistema venoso profundo de extremidades inferiores en pacientes coninfección por SARS-COV-2.Material y Métodos: Estudio prospectivo, transversal y observacionalrealizado en pacientes con COVID-19 confirmado a los que se lesrealizó una ecografía multiórgano en el punto de atención durante lahospitalización.Resultados: Un total de 107 pacientes se inscribieron. El 100% delos pacientes tenían afectación pulmonar (93,4% bilateral). Las zonaspulmonares más afectadas fueron la posteroinferior (94,39%) y la lateral (89,72%). Se observó consolidaciones subpleurales en el 71%de los pacientes y consolidaciones mayores de 1 cm en el 25%. Amayor afectación pulmonar ecográfica, mayor grado de insuficienciarespiratoria. 2 pacientes presentaron TVP proximal en extremidadesinferiores. Se realizaron 27 Angiotomografía computarizada confirmándose tromboembolismo pulmonar en 14 pacientes. Los hallazgosecocardiográficos más frecuentes fueron: alteración de la relajacióndel ventrículo izquierdo e hipertrofia ventricular izquierda. Todos lospacientes con enfermedad tromboembólica tenían una afectación pulmonar ecográfica grave o crítica.Conclusión: la ecografia multiórgano puede ser útil para lasmanifestaciones de la COVID-19. El grado de afectación ecográficapulmonar se relacionó con el grado de insuficiencia respiratoria y conla presencia de ETEV. La relación entre TVP y TEP fue más baja de loesperado. La afectación cardiaca fue poco relevante en nuestra serie. (AU)

Instant Heart Failure Diagnosis Using Point-of-Care Ultrasound (POCUS) in a Patient Incorrectly Diagnosed With Asthma.

Congestive heart failure is one of the most common causes of hospitalization in the United States, yet it often goes undetected due to the poor sensitivity of chest X-rays for detecting pulmonary edema. In this case, a patient presented with one year of shortness of breath and a diagnosis of asthma; however, a three-minute point-of-care ultrasound (POCUS) exam revealed that the correct diagnosis was in fact congestive heart failure. This highlights the importance of incorporating POCUS into the physical exam of any patient presenting with cardiopulmonary symptoms.

Lung ultrasound in young children with neurological impairment: A proposed integrative clinical tool for deaeration-detection related to feeding.

Infants and children with neurological impairment, such as cerebral palsy (CP), often experience abnormal ingestion functions, including oropharyngeal dysphagia and gastroesophageal reflux disease, which led to aspiration-related respiratory complications, morbidity, hospitalization, or death. There is a lack of evidence-based, repeatable, infant-friendly instrumental procedures to assess aspiration-risk in infants with CP or other neurological disorders, with also a lack of clinical assessment measures to support the use of more invasive diagnostic techniques. To this purpose, in the current study we explore the feasibility of lung ultrasound (LUS), to assess lung deaeration possibly related to aspiration during meal, in a cohort of 35 subjects affected by CP or other encephalopathies, and 10 controls in the same age-range. We coupled LUS procedure with meal caregiver administration for each child. Our results support the feasibility of this innovative approach in the clinical setting. Exploratory findings revealed a number of lung abnormalities likely related to abnormal ingestion function in subjects. Subgroup analyses revealed possible differences in LUS abnormalities between CP and other encephalopathies, possibly related to different mechanism of disease or dysfunction. Also, some evidences arose about the possible relationship between such LUS abnormalities and feeding and swallowing abilities in CP or other encephalopathies. LUS showed preliminarily feasibility and effectiveness in detecting meal-related LUS abnormalities in a dynamic manner in the clinical setting. This approach demonstrated usefulness as a potential tool for improving assessment and management in complex care of infants and young children with severe neurological disorders.

Diagnosis of a Ruptured Pulmonary Hydatid Cyst in a 26-Week Pregnant Female With Bedside Lung Ultrasound in Emergency (BLUE) Protocol: A Case Report.

Pulmonary hydatid cyst during pregnancy is extremely rare and life-threatening for the mother and fetus. Throughout pregnancy, hydatid cysts may enlarge due to the suppression of cellular immunity and steroids secreted from the placenta. In late pregnancy, the cysts can reach a huge volume with an increased risk for subsequent rupture due to the compression of the enlarging uterus and anaphylactic shock. Intrabronchial rupture is a rare and life-threatening complication of pulmonary hydatid cysts. It is vital to diagnose it as early as possible and manage patients with surgical intervention with aggressive medical treatment. Plain radiograph, computed tomography (CT) scan, and magnetic resonance imaging (MRI) can be used to identify pulmonary hydatid cysts. However, the diagnosis of hydatid cyst is quite challenging in pregnant patients due to concerns of radiation. Herein, we present a 26-week pregnant patient with acute respiratory failure. Bedside lung ultrasound was notable for thickened and severely broken pleural line with a large subpleural consolidation, and a giant fluid-filled cyst covered almost the entire left thorax, causing a mediastinal shift. In the present case, we highlighted that the bedside lung ultrasound in emergency (BLUE) protocol is an easy, safe, and fast way to identify pulmonary hydatid cyst. It should be the initial technique of choice for the diagnosis of pulmonary hydatid cysts in pregnant patients.

LUNCH-Lung Ultrasound for early detection of silent and apparent aspiratioN in infants and young CHildren with cerebral palsy and other developmental disabilities: study protocol of a randomized controlled trial.

BACKGROUND: Children with neurological impairment may have dysphagia and/or gastro-esophageal reflux disease (GERD), which predispose to complications affecting the airways, increasing risk for aspiration-induced acute and chronic lung disease, or secondarily malnutrition, further neurodevelopmental disturbances, stressful interactions with their caregivers and chronic pain. Only multidisciplinary clinical feeding evaluation and empirical trials are applied to provide support to the management of feeding difficulties related to dysphagia or GERD, but no standardized feeding or behavioral measure exists at any age to assess aspiration risk and support the indication to perform a videofluoroscopic swallowing study (VFSS) or a fibre-optic endoscopic examination of swallowing (FEES), in particular in newborns and infants with neurological impairments. Lung ultrasound (LUS) has been proposed as a non-invasive, radiation-free tool for the diagnosis of pulmonary conditions in infants, with high sensitivity and specificity. METHODS: A RCT will be conducted in infants aged between 0 and 6 years having, or being at risk for, cerebral palsy, or other neurodevelopmental disease that determines abnormal muscular tone or motor developmental delay assessed by a quantitative scale for infants or if there is the suspicion of GERD or dysphagia based on clinical symptoms. Infants will be allocated in one of 2 groups: 1) LUS-monitored management (LUS-m); 2) Standard care management (SC-m) and after baseline assessment (T0), both groups will undergo an experimental 6-months follow-up. In the first 3 months, infants will be evaluated a minimum of 1 time per month, in-hospital, for a total of 3 LUS-monitored meal evaluations. Primary and secondary endpoint measures will be collected at 3 and 6 months. DISCUSSION: This paper describes the study protocol consisting of a RCT with two main objectives: (1) to evaluate the benefits of the use of LUS for monitoring silent and apparent aspiration in the management of dysphagia and its impact on pulmonary illness and growth and (2) to investigate the impact of the LUS management on blood sample and bone metabolism, pain and interaction with caregivers. TRIAL REGISTRATION: Trial registration date 02/05/2020; ClinicalTrials.gov Identifier: NCT04253951 .

The Value of Lung Ultrasound Score in Neonatology.

Point-of-care lung ultrasound (LUS) is increasingly applied in the neonatal intensive care unit (NICU). Diagnostic applications for LUS in the NICU contain the diagnosis of many common neonatal pulmonary diseases (such as Respiratory distress syndrome, Transient tachypnea of the newborn, Meconium aspiration syndrome, Pneumonia, Pneumothorax, and Pleural effusion) which have been validated. In addition to being employed as a diagnostic tool in the classical sense of the term, recent studies have shown that the number and type of artifacts are associated with lung aeration. Based on this theory, over the last few years, LUS has also been used as a semi-quantitative method or as a "functional" tool. Scores have been proposed to monitor the progress of neonatal lung diseases and to decide whether or not to perform a specific treatment. The semi-quantitative LUS scores (LUSs) have been developed to predict the demand for surfactant therapy, the need of respiratory support and the progress of bronchopulmonary dysplasia. Given their ease of use, accuracy and lack of invasiveness, the use of LUSs is increasing in clinical practice. Therefore, this manuscript will review the application of LUSs in neonatal lung diseases.