The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings. A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus. Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear. This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

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International evidence-based recommendations for point-of-care lung ultrasound.

Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol.

Compact ultrasound technology has facilitated growth in point-of-care uses in many specialties. This review includes videos demonstrating the use of ultrasonography to guide central venous access, detect pneumothorax, detect evidence of hemorrhage after trauma, and screen for abdominal aortic aneurysm.

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Point-of-Care Ultrasonography

BackgroundLung auscultation and bedside chest radiography are routinely used to assess the respiratory condition of ventilated patients with acute respiratory distress syndrome (ARDS). Clinical experience suggests that the diagnostic accuracy of these procedures is poor.MethodsThis prospective study

Comparative Diagnostic Performances of Auscultation, Chest Radiography, and Lung Ultrasonography in Acute Respiratory Distress Syndrome

Background: Thoracic ultrasound (EFAST) has shown promise in inferring the presence of post-traumatic pneumothoraces (PTXs) and may have a particular value in identifying occult pneumothoraces (OPTXs) missed by the AP supine chest radiograph (CXR). However, the diagnostic utility of hand-held US has not been previously evaluated in this role. Methods: Thoracic US examinations were performed during the initial resuscitation of injured patients at a provincial trauma referral center. A high frequency linear transducer and a 2.4 kg US attached to a video-recorder were used. Real-time EFAST examinations for PTXs were blindly compared with the subsequent results of CXRs, a composite standard (CXR, chest and abdominal CT scans, clinical course, and invasive interventions), and a CT gold standard (CT only). Charts were reviewed for in-hospital outcomes and follow-up. Results: There were 225 eligible patients (207 blunt, 18 penetrating); 17 were excluded from the US examination because of battery failure or a lost probe. Sixty-five (65) PTXs were detected in 52 patients (22% of patients), 41 (63%) being occult to CXR in 33 patients (14.2% whole population, 24.6% of those with a CT). The US and CXR agreed in 186 (89.4%) of patients, EFAST was better in 16 (7.7%), and CXR better in 6 (2.9%). Compared with the composite standard, the sensitivity of EFAST was 58.9% with a likelihood ratio of a positive test (LR) of 69.7 and a specificity of 99.1%. Comparing EFAST directly to CXR, by looking at each of 266 lung fields with the benefit of the CT gold standard, the EFAST showed higher sensitivity over CXR (48.8% versus 20.9%). Both exams had a very high specificity (99.6% and 98.7%), and very predictive LR (46.7 and 36.3). Conclusion: EFAST has comparable specificity to CXR but is more sensitive for the detection of OPTXs after trauma. Positive EFAST findings should be addressed either clinically or with CT depending on hemodynamic stability. CT should be used if detection of all PTXs is desired.

Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST).

Can ultrasound be of any help in the diagnosis of alveolar-interstitial syndrome? In a prospective study, we examined 250 consecutive patients in a medical intensive care unit: 121 patients with radiologic alveolar-interstitial syndrome (disseminated to the whole lung, n = 92; localized, n = 29) and 129 patients without radiologic evidence of alveolar-interstitial syndrome. The antero-lateral chest wall was examined using ultrasound. The ultrasonic feature of multiple comet-tail artifacts fanning out from the lung surface was investigated. This pattern was present all over the lung surface in 86 of 92 patients with diffuse alveolar-interstitial syndrome (sensitivity of 93.4%). It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specificity of 93.0%). Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact. In conclusion, presence of the comet-tail artifact allowed diagnosis of alveolar-interstitial syndrome.

The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome.

Objective: We studied an ultrasound sign, the fleeting appearance of a lung pattern (lung sliding or pathologic comet-tail artifacts) replacing a pneumothorax pattern (absent lung sliding plus exclusive horizontal lines) in a particular location of the chest wall This sign was called the "lung point" Design: Prospective study Setting: The medical ICU of a university-affiliated teaching hospital Patients: The "lung point" was sought in 66 consecutive cases of proven pneumothorax analyzable using ultrasound – including 8 radio-occult cases diagnosed by means of CT – and in 233 consecutive hemithoraces studied by CT and free of pneumothorax – including 17 cases where pneumothorax was suspected Results: The "lung point" was observed in 44 of 66 cases of pneumothorax (including 6 of 8 radio-occult cases) and in no case in the control group The location of this sign roughly correlated with the radiological size of the pneumothorax The "lung point" therefore had an overall sensitivity of 66% (75% in the case of radio-occult pneumothorax alone) and a specificity of 100% Conclusion: The presence of a "lung point" allows positive diagnosis of pneumothorax at the bedside using ultrasound

The "lung point": an ultrasound sign specific to pneumothorax.

Objectives:Pneumothorax can be missed by bedside radiography, and computed tomography is the current alternative. We asked whether lung ultrasound could be of any help in this situation.Design:Retrospective study.Setting:The medical intensive care unit of a university-affiliated teaching hospital.Pa

http://www.ultrasoundleadershipacademy.com/wp-content/uploads/2014/01/Crit_Care_Med_2005_Lichtenstein.pdf

Ultrasound diagnosis of occult pneumothorax.

Objective
Alveolar consolidation is a basic concern in critically ill patients. Radiography is not a precise tool, and referral to CT raises problems (transport, irradiation). The aim of this study was to assess the utility of ultrasound in the diagnosis of alveolar consolidation.

Ultrasound diagnosis of alveolar consolidation in the critically ill.

Objective: Ultrasound artifacts arising from the lung–wall interface are either vertical (comet-tail artifacts) or horizontal. The significance of these artifacts for the diagnosis of pneumothorax was assessed. Design: Prospective clinical study. Setting: The medical ICU of a university-affiliated teaching hospital. Patients: We compared 41 complete pneumothoraces with 146 hemithoraces in 73 critically ill patients in which computed tomography showed absence of pneumothorax. Measurements: The anterior chest wall was investigated in supine patients using a portable device. The test was defined as positive for complete pneumothorax when only horizontal artifacts were visible, and negative when artifacts arising from the pleural line and spreading up to the edge of the screen (referred to as “comet-tail artifacts”) were present. Results: The feasibility was 98 %. Ultrasound showed exclusive horizontal artifacts in all 41 analyzable cases of complete pneumothorax. In the pneumothorax-free group, “comet-tail artifacts” were present in 87 cases and exclusive horizontal artifacts in 56. Ultrasound as well as computed tomography showed anterior consolidation or anterior pleural effusion in three cases. Horizontal artifacts had a sensitivity and a negative predictive value of 100 % and a specificity of 60 % for the diagnosis of pneumothorax. Horizontal artifacts and absent lung sliding, when combined, had a sensitivity and a negative predictive value of 100 % and a specificity of 96.5 %. Conclusions: Ultrasound detection of the “comet-tail artifact” at the anterior chest wall allows complete pneumothorax to be discounted.

A Gepner

Papers

The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome.

The "lung point": an ultrasound sign specific to pneumothorax.

Ultrasound diagnosis of occult pneumothorax.

Ultrasound diagnosis of alveolar consolidation in the critically ill.

The comet-tail artifact: an ultrasound sign ruling out pneumothorax.