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Lung ultrasound (LUS) is an accurate tool for the diagnosis and follow-up of pneumonia in adults as well as in children. LUS is at least as accurate as chest radiography in diagnosing pneumonia. The most important parenchymal criterion is the positive air bronchogram within an echopoor area. Among pleural criteria, basal effusion was most often detected. The presence of multiple diffuse bilateral B-lines on lung examination indicates the interstitial syndrome (IS). For further differential diagnosis, an integrated consideration of history, clinical examination, LUS and echocardiography should be performed. LUS is an excellent tool for IS screening. Repeated LUS control examinations may reflect the dynamics of IS under therapy and so LUS may serve as a therapy guide. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The aim of this secondary analysis was to evaluate current microbiological approaches, microbiology, and antibiotic therapy in patients with community-acquired pneumonia (CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in clinical practice and to compare them with current international guidelines. Methods: A total of 362 patients with suspected CAP were enrolled in 14 European centers in a prospective multicenter study. Results: A total of 279 inpatients (CAP, n = 222; AECOPD, n = 57) were evaluated. A total of 83 (37 %) CAP patients and 25 (44 %) AECOPD patients did not undergo any microbiological tests. In patients with CAP/AECOPD, blood culture was performed in 109 (49 %)/16 (28.1 %), urinary antigen tests for Legionella pneumophila in 67 (30 %)/9 (16 %), and sputum investigation in 55 (25 %)/17 (30 %), respectively. The most frequent pathogens in CAP were Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, L. pneumophila, Staphylococcus aureus, and Enterobacter cloacae; in AECOPD they were Escherichia coli, Haemophilus haemolyticus, Haemophilus influenzae, and Moraxella catarrhalis. All CAP patients (mean = 11.1 days) and 35 (61.4 %) of AECOPD patients (mean = 8.9 days) received antibiotics. CAP patients were given mostly aminopenicillin with β-lactamase inhibitors and AECOPD patients were given mostly cephalosporins. Conclusions: Pathogens isolated in CAP and AECOPD and the antibiotic therapy used are in good accordance with the guidelines. Blood culture, recommended for all CAP patients, was performed in only 50 % of the cases and antibiotic therapy lasted longer than the suggested 5-7 days. Therefore, international guidelines regarding performance of blood culture and duration of antibiotic therapy should be adopted more often. This duration was independent of the number of isolated pathogens and number of symptoms on admission. Therefore, the question arises as to whether microbiological data are necessary only for patients who are resistant to initial therapy. [ABSTRACT FROM AUTHOR]

The article investigates the accuracy of lung ultrasound (LUS) in diagnosing community-acquired pneumonia (CAP). Results of the study reveal that 229 patients out of 362 were confirmed to have CAP. LUS reveals a sensitivity rating of 93.4 percent, while specificity was at 97.7 percent. The authors claim that LUS is a nonivasive tool for high-accuracy diagnosis of CAP, particularly if radiography is unavailable. They add that around eight percent of pneumonic lesions are not detectable by LUS.

Abstract: CAP may be diagnosed and followed up by lung sonography (LUS), a technique that shows excellent sensitivity and specificity that is at least comparable with that of chest X-ray in two planes. LUS may be performed with any abdomen-sonography device. Therefore, LUS is a readily available diagnostic tool that does not involve radiation exposure and has wide applications especially in situations where X-ray is not available and/or not applicable. An X-ray or CT of the chest should be performed in cases of negative lung sonography and if other differential diagnoses or complications are suspected. [Copyright &y& Elsevier]

The article discusses the role of emergency chest sonography. Emergency ultrasound of the chest is a non-invasive and portable diagnostic technique which can be performed any time, anywhere. Chest sonography allows immediate diagnosis of diseases and injuries such as pulmonary embolism, pneumonia, rib fracture and pneumothorax.

The aim of the study was to compare transthoracic sonography (TS) with multislice computed tomography (MSCT) in the detection of peripheral pulmonary embolism (PE). In addition, the study verified peripheral parenchymal findings visualized by TS and MSCT. A total of 33 patients (16 females, 17 males; mean age = 65.4 years) with symptoms of suspected PE were enrolled in the study. TS and MSCT were undertaken within 24 h of the beginning of clinical PE signs. Ten patients suffered from PE as visualized by MSCT. The sensitivity of TS for detecting PE was 70.0% and the specificity was 69.6%. Preferentially, PE and peripheral parenchymal findings were situated in the lower lobes. Oligemia was the main parenchymal alteration detected by MSCT. TS demonstrated that wedge-shaped consolidations were frequently associated with PE. In addition, localized pleural effusion was a typical finding in the presence of PE for both TS and MSCT. TS had moderate sensitivity and specificity compared with MSCT. Furthermore, the study revealed that PE is often associated with peripheral parenchymal changes, both of which are detectable by TS and MSCT. In case of contraindication with MSCT, TS is a potential technique for diagnosing PE-related parenchymal findings and can serve as an alternative method in the diagnosis of PE. However, a negative result with TS does not rule out a PE. [ABSTRACT FROM AUTHOR]

Background: Although transthoracic ultrasound offers several important advantages as diagnostic imaging technique in pleural and pulmonary conditions, its significance for the diagnosis and monitoring of pneumonia has yet to be established. Objectives: To identify sonographic features associated with pneumonia at admission and during the course of the disease under treatment. Methods: Thirty patients (12 females, 18 males; median age 65.5 years) with X-ray-proven pneumonia underwent transthoracic sonography (TS) on day 0, between days 1 and 3, 4 and 7, 8 and 14, 15 and 21, and after day 21. TS was assessed according to: number, location, shape, echogenicity, echotexture, echostructure, breath-depending movement, size of pneumonic lesions, bronchoaerogram, fluid bronchogram, superficial fluid alveologram, necrotic areas, vascularity and incidence of local and/or basal pleural effusion. Results:Thirty-three pneumonic infiltrates were eligible for analysis in 30 patients. In 57% (17/30), the likely pathogenic microorganism was identified. Pneumonia was recognized as a hypoechoic area of varying size (mean size between 33.7 × 9.38 and 91.2 × 45.3 mm) and shape, with irregular and blurred margins along with a nonhomogeneous echotexture. The most characteristic feature was a positive bronchoaerogram (32/33). Sixty-one percent (20/33) revealed basal and 9% (3/33) local effusion. During follow-up, lesions decreased in size or disappeared (30/33) or decreased in number (4/9). The bronchoaerogram became less pronounced (13/32), basal pleural effusion either diminished (7/20) or dissipated (7/20), as did localized effusion (3/3). In 30 cases, the course of pneumonia was comparable using X-ray and TS. Conclusions: TS is a noninvasive technique for the diagnosis and follow-up of patients with pneumonia. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective: Transthoracic sonography (TS) has evolved as an important imaging technique for diagnosing pleural and pulmonary conditions. However, the value of TS in either excluding or diagnosing pneumothorax is still under debate. This study was conducted to examine whether TS could replace chest radiography for the diagnosis of post-interventional pneumothorax and hydropneumothorax.Methods: 53 patients (21 females, 32 males; median age 64 years, range 37–94 years), 35 of whom underwent transbronchial biopsy (TBB) and 18 patients who had an ultrasound-guided chest tube placement (U-GCTP) were enrolled in the study. TS was performed three hours after either TBB or removal of a chest tube, followed by postero-anterior chest radiograph (CRX). If any discrepancy between TS, the clinical presentation and the CRX became apparent, either a lateral CRX or a computed tomography (CT) of the thorax was performed. TS was assessed according to the presence of the following criteria: (1) “gliding sign” of the pleural line, (2) comet tail artifacts, (3) reverberation artifacts, (4) air/fluid mirror, (5) hyperechoic reflectors within the pleural effusion and (6) “lung point”.Results: In four out of the 53 patients (7.5%) a post-interventional pneumothorax or hydropneumothorax occurred. One out of the 35 patients (2.9%) developed a pneumothorax after TBB, requiring chest tube placement. Three patients (16.7%) developed a hydropneumothorax due to U-GCTP which was detected by sonography but was missed by postero-anterior CRX in one patient. The sensitivity, specificity and accuracy of TS were 100% in excluding post-interventional pneumothorax/hydropneumothorax.Conclusion: TS is a cost-effective and safe bed-side-method, allowing for an immediate exclusion or diagnosis of post-interventional pneumothorax/hydropneumothorax in patients who have undergone TBB or U-GCTP. Thus, these preliminary results suggest that CXR may only be required in patients with pneumothorax diagnosed by TS in order to assess its extension or to exclude any discrepancy between the TS-result and the clinical presentation. [Copyright &y& Elsevier]

Discusses the issues on the application of computed tomography imaging as diagnostic tool in pulmonary embolism (PE). Prevalence of PE; Demand for other diagnostic techniques such as angiography; Discussion on the cost-effectiveness of spiral computed tomography; Benefits of the introduction of spiral computed tomography to the improvement in the diagnostic rate for PE.

Introduction/objective: The aim of the study was to compare findings of transthoracic sonography (TS) and of spiral computed tomography (sCT) in patients with suspected pulmonary embolism (PE). Methods and patients: Peripheral parenchymal and pleural findings of TS and sCT were compared in 62 patients (25 females, 37 males; mean age 62.2 years) with suspected PE. Results: In 39 patients PE was established, of whose pleura-based lesions could be detected by TS in 30 patients and by sCT in 31 patients. Whilst in three of the patients parenchymal lesions were exclusively detected by sonography, no peripheral abnormalities could be discovered with either technique in five patients. Among the nine patients lacking peripheral abnormalities on sonography, four revealed peripheral lesions in sCT. In 23 patients without PE, peripheral consolidations at CT were detected in six patients whereas two showed lesions on TS. With respect to the appearance, pleura-based wedge-shaped consolidations were the main parenchymal alterations (82.4% at TS, 66.1% at sCT) as compared with non-wedge-shaped consolidations (17.6% at TS, 33.9% at sCT). Peripheral lesions were located preferentially within the lower lobes. In addition, both localised and basal pleural effusion associated with PE could be demonstrated in 58.9% at TS and in 23.1% by sCT. Discussions and conclusion: The study shows that in PE parenchymal and pleural changes are detectable by TS and sCT. If parenchymal findings are present at sCT, peripheral PE should be considered, even in the absence of directly visible emboli. [Copyright &y& Elsevier]

The diagnosis of pulmonary embolism (PE) presents a considerable challenge and requires a high index of clinical suspicion from the attending physician. In addition, diagnosing PE may require the use of one or more direct and indirect diagnostic methods. Here, transthoracic sonography (TS) provides an alternative and attractive bedside approach which is based on (1) detecting alterations in the lung parenchyma, (2) involvement of the pleura and (3) peripheral perfusion characteristics associated with thromboembolism. Using a 5 MHz or 3.5 MHz convex scanner, occasionally supplemented by a 7.5 MHz linear scanner or colour-flow Doppler mode, the intercostal areas are systematically examined by TS. Most of the PE-related lesions are localised in the lower lobes of the lung and are often associated with an area of pleuritic chest pain. The characteristic sonographic findings of TS in PE are multiple, hypoechoic, pleural-based parenchymal lesions which adopt a wedge-shape. In addition, a central echo may occasionally be detectable within the lesion. Another regular sonographic feature is the involvement of the pleura manifesting as either localised effusion, basal effusion or both. However, several differential diagnoses such as pneumonia, bronchogenic carcinoma, metastases of extra-pulmonary malignancies, and simple pleurisy need to be excluded. Since localisation of PE-associated lesions may occasionally escape sonographic detection, an inconspicuous sonographic result does not fully exclude PE. As detection of PE-associated lesions using chest ultrasonography has a high specificity and sensitivity, can be rapidly performed, is widely available, non-invasive, cost-effective, and avoids transport of critically ill patients to the investigation site, the technique may prove a valuable tool in the diagnosis of PE at bedside facilitating immediate treatment decision. Further, because the method focuses on detection of peripheral lesions it complements other diagnostic techniques employed when PE is suspected. [ABSTRACT FROM AUTHOR]

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are distinct but related aspects of the same dynamic disease process known as venous thromboembolism (VTE). An estimated 200,000 new cases occur in the United States every year, including 94,000 with PE, resulting in an incidence of 23 per 100,000 patients per year-cases. Without treatment, pulmonary embolism is associated with a mortality rate of approximately 30%, causing nearly 50,000 deaths per year. Moreover, based on post-mortem studies, two-thirds of the patients with pulmonary emboli remain undiagnosed. Clinically, PE may present as (1) isolated dyspnea, (2) pleuritic pain and/or hemoptysis, and (3) circulatory collapse. However, clinical history and examination can be notoriously misleading in reaching a diagnosis. A number of acquired etiologic risk factors (predispositions) are associated with a tendency to develop VTE. These include increasing age, immobilization, surgery, trauma, hospital or nursing home confinement, malignancy, neurologic disease with extremity paresis, as well as certain types of oral contraception and hormone replacement therapy. In addition, a variety of genetic risk factors, such as factor V Leiden, protein S or C deficiency have also been identified. However, in at least half of the instances, no predisposing factors can be identified (idiopathic PE). In the majority of cases thromboemboli originate in the deep veins of the calf or pelvis. The pathogenic conditions for VTE comprise a triad of factors and include (1) venous stasis, (2) hypercoagulable states, and (3) vascular endothelium injury. Occlusion of pulmonary arteries has variable and transient clinical and pathophysiologic consequences, involving both mechanical and reflex effects of vascular occlusion with a consecutive perfusion defect as well as the release of vasoactive and other inflammatory mediators. The objectives of this article are to present an overview of the etiologic and pathogenic factors promoting VTE as well as the pathophysiologic and inflammatory processes following PE. [ABSTRACT FROM AUTHOR]

Study objectives: Despite the widespread use of lung scanning and angiography, pulmonary embolisms (PEs) remain undiagnosed in the majority of patients, suggesting the need for alternative diagnostic approaches. The present study investigates the clinical utility of transthoracic sonography (TS) for the diagnosis of PE and compares the data obtained with the technique to those obtained by spiral CT (sCT) scanning. Design: This prospective study was performed using 69 patients with suspected PEs. TS was performed in all patients. In addition, sCT scanning was carded out in 62 patients. Other diagnostic procedures included the estimation of d-dimers, echocardiography, venous duplex sonography of the legs, pulmonary angiography, and ventilation/perfusion scanning. The diagnosis of PE was accepted when there was a conclusive result of these investigations or when an embolus could be visualized on a CT scan. Setting: The Department of Pneumology in Friedrich-Schiller-University Hospital (Jena, Germany). Patients: Sixty-nine patients (27 women and 42 men) with suspected PEs. Results: A diagnosis of PE was established in 44 patients. Ninety-one peripheral parenchymal lesions (mean, 2.6 lesions per patient; range 1 to 9 lesions per patient) that are associated with PE were detected by TS in 35 patients (80%). Multiple, triangular, hypoechoic, and pleural-based parenchymal lesions with a localized and/or basal effusion were typical of the PEs as shown by TS. In nine patients with central PEs that had been diagnosed by CT scanning, no peripheral lesions could be detected by sonography. One patient with sonographic signs of PEs had a diffuse bronchogenic adenocarcinoma that was diagnosed at autopsy. In another patient with parenchymal lesions, pneumonia was diagnosed by CT scanning. The sensitivity of TS for detecting PEs was 80% (sensitivity of CT scanning, 82%), and the specificity of TS for detecting pulmonary lesions was 92% (specificity of CT scanning, 100%). The... [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Lung Ultrasound in the Diagnosis and Follow-Up of Community-Acquired Pneumonia: A Prospective, Multicenter, Diagnostic Accuracy Study" by A. Reissig and colleagues in the October 2012 issue.

A letter to the editor is presented in response to the article "Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure," by D. Lichtenstein and G. Mezière in the July 2008 issue.

Abstract: A rapid identification of the causes of hemodynamic instability or cardiac arrest is crucial for correct treatment. In a critical care setting, ultrasound seems to be an ideal tool for a rapid diagnosis. A multiple-goal problem-based approach represents the main peculiarity of emergency ultrasound and may be considered an extension of physical examination. The integration of data that can rapidly be obtained from the heart, lung, inferior vena cava, abdomen and leg vein examination are often essential for the diagnosis and treatment in critically ill patients. The role and potentiality of integrated ultrasound in cardiac arrest, shock/hypotension and severe dyspnea are considered in this article. [Copyright &y& Elsevier]

Introduction. The aim of this retrospective study was to examine effect of erlotinib in patients with advanced non-small cell lung cancer (NSCLC) in second-line and further therapy in daily clinical practice. Methods. Patients with histologically or cytologically proven NSCLC (n = 84) treated with erlotinib in second-line (n = 34), third-line (n = 36), and more-line therapy (n = 14) were examined for progression-free survival (PFS), overall survival (OS), disease control rate (DCR), duration of therapy, and adverse effects. Results. Median PFS of all lines was 83 days (CI 70.0-96.0), OS was 7months (CI 4.7-9.3), DCR was 66.2% (CI 55-77%), and 1-year survival rate was 33% (CI 22-43%), with no significant difference between therapy lines. Median duration of treatment was 76 days (IQR 39-139.5). Patients with epidermal growth factor receptor mutation (EGFR-M) reached the highest PFS (204 days), as did patients with good performance status (ECOG 0-1: 94 versus ECOG 2-3: 65 days, P = 0.035). Patients with EGFR-M also revealed a DCR of 100%. The most frequent side effects were rash (69%) and diarrhoea (41%), without any significant difference between therapy lines. In 24 patients, the treatment dose was reduced and in 18, the therapy was paused. Conclusion. Erlotinibworks in all therapy lines without any significant differences in efficacy and side effects. [ABSTRACT FROM AUTHOR]

Background: The aim of this prospective, multicenter study was to define the accuracy of lung ultrasound (LUS) in the diagnosis of community-acquired pneumonia (CAP).Methods: Three hundred sixty-two patients with suspected CAP were enrolled in 14 European centers. At baseline, history, clinical examination, laboratory testing, and LUS were performed as well as the reference test, which was a radiograph in two planes or a low-dose CT scan in case of inconclusive or negative radiographic but positive LUS findings. In patients with CAP, follow-up between days 5 and 8 and 13 and 16 was scheduled.Results: CAP was confirmed in 229 patients (63.3%). LUS revealed a sensitivity of 93.4% (95% CI, 89.2%-96.3%), specificity of 97.7% (95% CI, 93.4%-99.6%), and likelihood ratios (LRs) of 40.5 (95% CI, 13.2-123.9) for positive and 0.07 (95% CI, 0.04-0.11) for negative results. A combination of auscultation and LUS increased the positive LR to 42.9 (95% CI, 10.8-170.0) and decreased the negative LR to 0.04 (95% CI, 0.02-0.09). We found 97.6% (205 of 211) of patients with CAP showed breath-dependent motion of infiltrates, 86.7% (183 of 211) an air bronchogram, 76.5% (156 of 204) blurred margins, and 54.4% (105 of 193) a basal pleural effusion. During follow-up, median C-reactive protein levels decreased from 137 mg/dL to 6.3 mg/dL at days 13 to 16 as did signs of CAP; median area of lesions decreased from 15.3 cm2 to 0.2 cm2 and pleural effusion from 50 mL to 0 mL.Conclusions: LUS is a noninvasive, usually available tool used for high-accuracy diagnosis of CAP. This is especially important if radiography is not available or applicable. About 8% of pneumonic lesions are not detectable by LUS; therefore, an inconspicuous LUS does not exclude pneumonia. [ABSTRACT FROM AUTHOR]

Background: 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. Methods: 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. Results: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor of "CHEST" journal which commends a review on the potential therapeutic applications of interferon (IFN) in pulmonary diseases by K.M. Antoniou and associates and proposes to extend the conditions responsive to IFN treatment to include Churg-Strauss syndrome.

We report herein the therapeutic effect of interferon (IFN)-αcon in three patients with severe persistent asthma and long-term oral glucocorticoid treatment. IFN-αcon (9 μg) administered subcutaneously thrice a week over a period of more than 24 months led to a substantial clinical improvement with regard to the number of daily asthma attacks, nighttime disturbance, emergency visits and hospitalizations. In addition, lung function and exercise capacity improved. At the same time, treatment with IFN allowed discontinuation of the daily glucocorticoid dose in all patients for the first time in more than 8 years. Our findings suggest that IFN-αcon leads to a significant clinical improvement while at the same time allowing reduction and discontinuation of the glucocorticoid treatment in severe persistent glucocorticoid-dependent asthma. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Pulmonary embolism (PE) continues to be a major challenge in terms of diagnosis, as evidenced by the fact that many patients die undiagnosed and/or untreated. The aim of this multicenter study was to determine the accuracy of thorax ultrasound (TUS) in the diagnosis of PE (TUSPE). Methods: From January 2002 through September 2003, 352 patients with suspected PE were examined in seven clinics. The patients were investigated prospectively by TUS according to the following criteria: (1) PE confirmed: two or more typical triangular or rounded pleural-based lesions; (2) PE probable: one typical lesion with pleural effusion; (3) PE possible: small (< 5 mm) subpleural lesions or a single pleural effusion alone; or (4) normal TUS findings. In all cases, CT pulmonary angiography (CTPA) was used as the reference method. In the event of discrepant findings, a combination of duplex sonography of the leg veins, echocardiography, ventilation/perfusion scintigraphy, and a quantitative enzyme-linked immunosorbent assay or latex d-dimer, or a biopsy/autopsy was performed. Findings: PE was diagnosed in 194 patients. On TUS, 144 patients had a total of 333 subpleural lesions (mean, 2.3 lesions per patient) averaging 15.5 x 12.4 mm in size. Additionally, a narrow pleural effusion was found in 49% of the patients. TUS yielded the following results under application of the strict criteria 1 and 2: PE true-positive, n = 144; PE false-positive, n = 8; PE true-negative, n = 150; and PE false-negative, n = 50. The sensitivity was 74%, specificity was 95%, positive predictive value was 95%, negative predictive was value 75%, and accuracy was 84%, at a prevalence of 55%. The sensitivity in patients with criterion 1 was 43% and a specificity of 99%. Interpretation: TUS is a noninvasive method to diagnose peripheral PE. In the absence of CTPA, TUS is a suitable tool to demonstrate a PE at the bedside and in the emergency setting. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the comparison between the performance of thoracic ultrasound (TUS) and chest radiographs (CXR).