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Malignant pleural effusion (MPE) is a manifestation of advanced cancer that requires a prompt and accurate diagnosis. Ultrasonography (US) and computed tomography (CT) are valuable imaging techniques for evaluating pleural effusions; however, their relative predictive ability for a malignant origin remains debatable. This prospective study aimed to compare chest US with CT findings as predictors of malignancy in patients with undiagnosed exudative pleural effusion. Fifty-four adults with undiagnosed exudative pleural effusions underwent comprehensive clinical evaluation including chest US, CT, and histopathologic biopsy. Blinded radiologists evaluated the US and CT images for features suggestive of malignancy, based on predefined criteria. Diagnostic performance measures were calculated using histopathology as a reference standard. Of the 54 patients, 33 (61.1%) had MPEs confirmed on biopsy. No significant differences between US and CT were found in detecting parietal pleural abnormalities, lung lesions, chest wall invasion, or liver metastasis. US outperformed CT in identifying diaphragmatic pleural thickening ≥10 mm (33.3% vs. 6.1%, p < 0.001) and nodularity (45.5% vs. 3%, p < 0.001), whereas CT was superior for mediastinal thickening (48.5% vs. 15.2%, p = 0.002). For diagnosing MPE, diaphragmatic nodularity detected by US had 45.5% sensitivity and 100% specificity, whereas CT mediastinal thickening had 48.5% sensitivity and 90.5% specificity. Both US and CT demonstrate reasonable diagnostic performance for detecting MPE, with particular imaging findings favoring a malignant origin. US may be advantageous for evaluating diaphragmatic pleural involvement, whereas CT is more sensitive to mediastinal abnormalities. [ABSTRACT FROM AUTHOR]

Background: The impact of serial imaging on the outcome of ICU patients has not been studied specifically in patients with high illness severity. Methods: The authors sought a relationship between the numbers of antero-posterior supine chest X-rays (CXR), computed tomography (CT) examinations, and outcome in a cohort of 292 patients with severe COVID-19 ARDS collected over 24 months in a high-volume ECMO center with established ultrasound and echocardiographic diagnostics. Of the patients, 172 (59%) were obese or morbidly obese, and 119 (41%) were treated with ECMO. Results: The median number of CXRs was eight per 14 days of the length of stay in the ICU. The CXR rate was not related to ICU survival (p = 0.37). Patients required CT scanning in 26.5% of cases, with no relationship to the outcome except for the better ICU survival of the ECMO patients without a need for a CT scan (p = 0.01). The odds ratio for survival associated with ordering a CT scan in an ECMO patient was 0.48, p = 0.01. The calculated savings for not routinely requesting a whole-body CT scan in every patient were 98.685 EUR/24 months. Conclusions: Serial imaging does not impact the survival rates of patients with severe ARDS. Extracorporeal membrane oxygenation patients who did not need CT scanning had significantly better ICU outcomes. [ABSTRACT FROM AUTHOR]

Introduction Endotracheal intubation is an important technique in airway management. Although, little experience is present in the use of ultrasound in endotracheal intubation, studies suggest that it is reliable and fast as other usual methods and is a simple, feasible, portable, and noninvasive tool. Aim To assess the usefulness of ultrasonography compared with capnography and chest radiography in confirmation of correct endotracheal tube position in ICU patients. Patients and methods Fifty patients in need for intubation were included in this study. All patients were subjected immediately after intubation to the following to confirm correct endotracheal intubation: clinical evaluation, neck ultrasound, chest ultrasound, and chest radiographs. All methods were compared with capnography, the gold standard method for confirmation. Results Successful endotracheal intubation was confirmed by the presence of three successive waves in the capnography. This was achieved in 48 (96%) of cases (endotracheal tube), and in two (4%) cases, the tube was falsely placed in the esophagus. Direct localization of intubation by neck ultrasound had 97.7% sensitivity and 100% specificity to confirm correct intubation. On the contrary, indirect localization of the tube by chest ultrasound had 93.7% sensitivity and 100% specificity. Although localization of the tube by chest radiography has 97.8% sensitivity, it took longer time to be done in such critical casas (29236.44±768.27s). Clinical evidence of intubation had 95.8% sensitivity and 100% specificity. Conclusion Ultrasonography is a feasible, fast, and cost-effective method for the confirmation of the correct endotracheal tube placement. [ABSTRACT FROM AUTHOR]

Imaging methods available at the bedside have become an indispensable part of the diagnostic process of COVID-19 in the intensive care setting. Chest ultrasound has been established as an exquisite bedside imaging tool to assess and diagnose a myriad of lung pathologies, assess the pleural space and diaphragm, and ultimately gauge therapeutic interventions. Furthermore, vital information can be attained on the haemodynamic status of a patient when chest ultrasound is combined with echocardiography and Doppler vascular assessment. Bedside chest x-ray has its technical limitations, is not sensitive in early stages of the disease, and exposes patients to radiation. Computed tomography has great spatial resolution and all the structures in the chest can be assessed, but on the other hand, it requires patient transport and exposes them to radiation and the potential side effects of contrast administration. Recently, chest ultrasound has proved to be extremely useful during the COVID-19 pandemic in assessing COVID-19 pneumonia and its complications with a resultant reduction in potential infectious cross-contamination of staff and patients due to transport to and from the radiology department. In this review, the authors compare the three most frequent modalities of chest imaging in the diagnosis of COVID-19 in critical care, with a focus on the benefits of chest ultrasound. [ABSTRACT FROM AUTHOR]

Background Coronavirus disease 2019 (COVID-19) virus infection is an ongoing, catastrophic, worldwide pandemic with significant morbidity and mortality. Large numbers of people who are getting COVID-19 virus infection are at high risk of developing COVID-19 pneumonia; early diagnosis of COVID-19 pneumonia, patient care, and isolation using simple, less expensive images are required. High-resolution computed tomography chest (HRCT chest) is the reference standard method for the diagnosis of COVID-19 pneumonia; however, it is expensive with increasing the exposure risk; chest ultrasonography (CUS) may be an alternative method. Patients and methods CUS is performed on patients accepting to participate in the study at presentation of COVID-19 suspicious cases. HRCT chest to confirm COVID-19 pneumonia were done within 24 h of CUS examination. Two chest consultants who are experts in CUS at Assiut University Hospital performed CUS. The CUS is done using a convex probe of 3.5 MHz. The CUS was considered positive for pneumonia if the examiners find the presence of abnormal multiple vertical B lines with or without the presence of consolidation dots unilateral or bilateral with good cardiac function; HRCT chest results are recorded. Results In all, 197 patients were included in the study (102 males, mean age 48 ± 16.2 years). Regarding comorbidity: 10% had diabetes mellitus and 9% had hypertension. Ten (5%) patients needed hospitalization with a mean oxygen saturation of 95 ± 5%. One hundred fifty-two patients confirmed COVID-19 pneumonia with HRCT chest, while 45 patients had normal HRCT chest. CUS showed positive pneumonic finding in 128 patients and normal picture in 69 patients. There was good association (r=0.690, P<0.001) between both diagnostic modalities in COVID-19 pneumonia diagnosis. Sensitivity and specificity and accuracy of CUS in the diagnosis of COVID-19 pneumonia were 84.56, 95.83, and 87.31%, respectively, when compared with HRCT chest. One hundred and two patients were successfully followed; all of them showing clinical and ultrasonographic improvement. [ABSTRACT FROM AUTHOR]

Objective Plain chest radiography is the commonest ordered investigation in chest outpatient clinic; however, it is time consuming and may be expensive in some settings. With the availability of chest ultrasonography (CUS) at bedside, CUS might be used instead of plain chest radiography in outpatient settings. Still there is controversy regarding CUS as the primary investigation in outpatient chest clinics. Patients and methods Consecutive patients referred to the outpatient chest clinic of Assiut University between March 2018 till June 2020 who were proposed to have computed tomography (CT) chest after plain chest radiography were asked to participate in the study. The included patients had CUS with a pulmonologist who was blind to the chest radiography and chest CT results. CUS was done using a convex probe of ultrasonography in all chest anatomical planes for any finding that may help in the diagnosis. The plain chest radiography results also were recorded. Both results were compared with chest CT results as the gold standard investigation. Result A total of 101 patients were included in the study. There were 18% female patients, with mean age of 49.4±17.9 years. The final diagnosis was lung malignancy, pneumonia, bronchiectasis, chronic obstructive lung diseases, pulmonary embolism, pleural effusion, interstitial lung disease, and other miscellaneous causes. CUS were normal in 14 cases, with a sensitivity of 89.5% and a specificity of 80%, whereas chest radiography was normal in 20 cases, with a positive finding in 81 cases, with a sensitivity of 83.3% and a specificity of 80%, in comparison with chest CT. Conclusion CUS may be the primary investigation in chest outpatient clinic with good accuracy and rapid patient diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative pulmonary complications are among the most frequent problems in perioperative care. The risk of their development depends not only on the parameters associated with the patient's initial clinical condition, but also on the employed anesthesia technique, the method of mechanical ventilation, and the type and technique of the surgical procedure. Atelectasis is the most common complication, affecting nearly 90% of the patients undergoing general anesthesia. Aim: The aim of this study was to determine whether it was possible to positively impact the postoperative period and reduce the frequency of postoperative pulmonary complications via patient-based intraoperative ultrasound-guided recruitment maneuvers. Methodology: The course of the postoperative period was analyzed in two groups of patients. One of them comprised 100 patients in whom no recruitment maneuvers were performed during general anesthesia. The other group (100 patients) consisted of patients in whom patientbased ultrasound-guided pulmonary recruitment maneuvers were performed. Results: In the recruitment group, the postoperative hospitalization was statistically significantly shorter (p = 0.003) and the risk of intensive care treatment significantly lower. Additionally, the need for prolonged postoperative mechanical ventilation was reduced, as was the risk of respiratory tract infections. Conclusions: Intraoperative ultrasound-guided recruitment maneuvers reduce the frequency of postoperative pulmonary complications. [ABSTRACT FROM AUTHOR]

• B-lines, fragmented pleural line, consolidations frequently coexist in Covid pneumonia. • B-lines, often multifocal, are early detectable; consolidations are usually late findings. • LUS shows a high diagnostic accuracy, to be interpreted considering pre-test probability. • LUS score seems to predict adverse outcome and to add information for a safe discharge. • Execution and scoring protocols vary widely, evidencing a need for standardization. [ABSTRACT FROM AUTHOR]

Summary: Background: M‐mode ultrasonography might be useful for detecting hemidiaphragm paralysis. The objective of the present study was to describe the motion recorded by M‐mode ultrasonography of both diaphragmatic leaves in patients with a pre‐established diagnosis of hemidiaphragm paralysis. Methods: A study was conducted in 26 patients (18 men, 8 women) with unilateral diaphragmatic paralysis. They were referred to two different rehabilitation centres after thoracic surgery in 23 cases and cardiac interventional procedures in three cases. The pulmonary function tests and the study of the diaphragmatic motion using M‐mode ultrasonography were recorded. Results: The pulmonary function tests showed a restrictive pattern. The M‐mode ultrasonography reported either the absence of motion or a weak paradoxical (cranial) displacement (less than 0·5 cm) of the paralysed hemidiaphragm during quiet breathing. A paradoxical motion was recorded in all patients during voluntary sniffing, reaching around −1 cm. During deep breathing, a paradoxical motion at the beginning of the inspiration was observed. Thereafter, a re‐establishment of the motion in the craniocaudal direction was recorded. The excursions measured on the healthy side, during quiet breathing and voluntary sniffing, were increased in patients suffering from contralateral hemidiaphragm paralysis, when compared with 170 healthy volunteers. Conclusions: To detect diaphragmatic dysfunction in patients at risk, it would be useful to study diaphragmatic motion by M‐mode ultrasonography during quiet breathing, voluntary sniffing and deep breathing. [ABSTRACT FROM AUTHOR]

Background: Lung ultrasound examination is becoming an even more important part of pulmonologists' clinical routine. As indicated in the literature, the coordinates of any findings on lung parenchyma are based on surface landmarks or conventional quadrants. In our experience we have noticed that lung fissures are clearly detectable as interruptions of the pleural line, but this has never been investigated previously. The aim of this study was to evaluate whether lung fissures are detectable under normal conditions in routine clinical practice.Methods: Ten operators were enrolled from Pleural-Hub, a scientific discussion group. After compiling a prestudy survey to investigate whether they had observed fissures previously, they were asked to note if the following fissures were detectable: posterior right (PR) and left (PL), lateral right (LR) and left (LL), anterior right (AR), and anterolateral left (AL). Enrollment was competitive, aiming to reach 100 case subjects.Results: We found that general fissure detection was 61.3%, in particular: PR, 59%; LR, 75%; AR, 69%; PL, 45%; LL, 64%; AL, 56%. Single operators yielded different detection rates ranging from 90% to 25%, showing strong operator dependency. Before being made aware of general results operators indicated operator's skill and rib shadow artifacts as the principal factors affecting fissure detection.Conclusions: Lung fissures may be detected with ultrasound once adequate training is provided. This may allow the clinician a more precise anatomical delineation of pathology identified by lung ultrasound. [ABSTRACT FROM AUTHOR]

Echocardiography at its basic level has become a compulsory component of the educational curriculum in intensive care and an ultrasound device should become standard equipment in the intensive care unit. The issue of quality and standardization of education in echocardiography is addressed by available accreditations, which should provide a growing number of supervisors for the basic level, and stimulate the spread of echocardiographic applications and research in the field of non-invasive haemodynamics. Since 2016, an opportunity exists in the EU to gain the accreditation in critical care echocardiography in the form of the European Diploma in Echocardiography (EDEC), which is unique in combining transthoracic (TTE) and transesophageal (TEE) echocardiography. To obtain the accreditation, the Czech intensivist is expected to register with his/her supervisor at the EDEC Board. A supervisor might be someone in possession of a renowned accreditation or a board certified cardiologist. The accreditation is granted after 40 hours of certified courses, completion and logging of 100 TTEs plus 35 TEEs into a structured logbook, passing of the MCQ test, a video case-reporting test and a practical TEE exam on an electronic trainer (http://www.esicm.org/education/edec). [ABSTRACT FROM AUTHOR]

BACKGROUND: Early detection and treatment of pneumothorax is critically important. It often remains undiagnosed after trauma and may rapidly lead to tension pneumothorax and subsequently to cardiac arrest. A quick bedside chest ultrasound may expedite the diagnosis, treatment and resuscitation of patient. It is an easy and simple technique which does not require higher expertise. OBJECTIVE: To determine diagnostic accuracy of chest ultrasound in the detection of pneumothorax taking chest CT scan as gold standard. METHODOLOGY: The ultrasound chest performed on patient lying supine, scanning both lung fields. With use of high frequency linear probe one can clarl distinguish the visceral and parietal pleura, lung sliding and comet tail artifact representing normal lung. Absence of lung sliding and comettail artifact representing pneumothorax. The results then compared with gold standard multislice (64) CT scan of chest. RESULTS: In our study, out of 275 cases, 65.82% (n=181) were between 18-40 years of age while 34.18% (n=94) were between 41-60 years of age, mean ± sd was calculated as 35.31 ± 8.96 years, 58.91% (n=162) were male and 41.09% (n=113) were females, frequency of pneumothorax on CT was recorded as 8.36% (n=23), the diagnostic accuracy of chest ultrasound to detect pneumothorax taking chest CT scan as gold standard shows sensitivity, specificity, positive predictive value, negative predictive value and accurate as 78.26%, 96.83%, 69.23%, 97.99% and 95.27% respectively. CONCLUSION: Chest ultrasound is a useful, radiation free, easy and rapid technique in the detection of pneumothorax as a bedside procedure in emergency trauma cases. [ABSTRACT FROM AUTHOR]

Background: lung ultrasound is a part of the diagnostic armamentarium in Resuscitation and Recovery Units with an enormous potential due to its advantages capacity to diagnose more precisely than conventional radiology, earlier diagnosis, convenience due to being able to perform at the bedside, possibility of being performed by one person, absence of ionizing radiation and due to its dynamic character. Aim of the Work: this study aimed to assess the impact of chest ultrasonography in detecting, differentiation and management of the different pleural diseases. Patients and Methods: this prospective study included 50 patients who were presented with suspected clinical and/or radiological evidence of pleural disease in the Chest Department of Demerdash Hospital, during the period between November 2014 and June 2017. Patients with pleural diseases with lung involvement were excluded. Results: US was more statistically significantly sensitive and specific in the detection of pleural effusion compared to chest radiography. A sensitivity of 0.92 for US examination against 0.74 for chest radiography in detection of pleural thickening was noted. There were no statistically significant differences between the sensitivity and specificity of chest US and chest CT in detection of different pleural pathologies. Conclusion: US is an efficient and suitable method for the evaluation of different pleural diseases in critically ill patients in the RICU. US is mostly sensitive and specific in diagnosing pleural effusions. US-guided diagnostic and therapeutic pleural interventions are successful in achieving their goal with favorable outcomes and minimal complications. Recommendations: US accessibility was difficult for some patients because of tissue edema, subcutaneous emphysema and obesity. Thus further studies are needed in order to generalize these results. [ABSTRACT FROM AUTHOR]

High resolution computed tomography, (HRCT), is currently considered the diagnostic gold standard to diagnose early stage malignant pleural mesothelioma and other non-malignant pleural conditions, but it is expensive and exposes the patient to radiation dose. In a screening and population medicine perspective, Thoracic Ultrasounds may become a valuable alternative because it can detect minimal changes in pleural surface, is widely available and safe. On these bases, we therefore validated thoracic US in subjects with history of exposure to asbestos, having HRCT as the reference standard. One hundred-fifty subjects were screened and 117 were recruited. Pleural abnormalities at US and/or HRCT were detected in 66 out of 117 subjects (prevalence = 57%), and their prevalence was unrelated to both mansion and smoking habit, while mean age and mean length of exposure were higher in those having pleural abnormalities (age = 47 ± 5 vs 44 ± 6 years, p < 0.05; years of exposure = 20 ± 7 vs 17 ± 5, p < 0.05). Thirteen out of 19 subjects with pleural abnormalities at HRCT were also identified by thoracic US, whereas 47 participants had lesions seen at US, but not at the HRCT scan. Positive and negative percent agreement were 66.6% and 51.8%, respectively; the McNemar’s test for equality showed a p -value <0.001. In conclusion, chest US might complement HRCT in the health surveillance of asbestos exposed population to detect earlier lesions or to follow up US approachable lesions. Further research is needed to clarify whether this approach may enhance early recognition of pleural mesothelioma and ameliorate prognosis. [ABSTRACT FROM AUTHOR]

Medical approach to patients is a fundamental step to get the correct diagnosis. The aim of this paper is to analyze some aspects of the reasoning process inherent in medical diagnosis in our era. Pathologic signs (anamnestic data, symptoms, semiotics, laboratory and strumental findings) represent informative phenomena to be integrated for inferring a diagnosis. Thus, diagnosis begins with "signs" and finishes in a probability of disease. The abductive reasoning process is the generation of a hypothesis to explain one or more observations (signs) in order to decide between alternative explanations searching the best one. This process is iterative during the diagnostic activity while collecting further observations and it could be creative generating new knowledge about what has not been experienced before. In the clinical setting the abductive process is not only theoretical, conversely the physical exploitation of the patient (palpation, percussion, auscultation) is always crucial. Through this manipulative abduction, new and still unexpressed information is discovered and evaluated and physicians are able "to think through doing" to get the correct diagnosis. Abductive inferential path originates with an emotional reaction (discovery of the signs), step by step explanations are formed and it ends with another emotional reaction (diagnosis). Few bedside instruments are allowed to physicians to amplify their ability to search for signs. Stethoscope is an example. Similarities between ultrasound exploration and percussion can be found. Bedside ultrasonography can be considered an external amplifier of signs, a particular kind of percussion and represents a valid example of abductive manipulation. In this searching for signs doctors act like detectives and sometimes the discovering of a strategic, unsuspected sign during abductive manipulation could represent the key point for the correct diagnosis. This condition is called serendipity. Ultrasound is a powerful tool for detecting soft, hidden, unexpected and strategic signs. [ABSTRACT FROM AUTHOR]

Acute respiratory failure, a condition frequently fraught with haemodynamic instability, is one of the most frequent reasons for admission to the intensive care ward. Obligatory questions in every patient concern the left ventricular function and assessment of the left atrial and left ventricular filling pressures. The prognosis and management of respiratory failure also depend on assessment of the right ventricular function and pulmonary circulation. A complex echo protocol is warranted to judiciously decide on the treatment strategy including optimization of the patient's preload, contractility, heart rate and afterload. This allows for effective treatment of respiratory disequilibrium, which can continue to be monitored by means of ultrasound. Monitoring of the lung parenchyma and pleural space enables the physician to obtain additional data supporting the echocardiography findings, assisting the decision making on the ventilation strategy, the need for bronchoscopy, pleural drainage and to determine optimal patient position including prone postitioning. The appropriateness of prescribed therapy for the acute respiratory failure management can then be monitored by bedside echocardiography and lung ultrasonography in the attempt to optimize pulmonary gas exchange without haemodynamic alteration, and also to improve the patient's haemodynamic status without adding an unnecessary burden to the respiratory system. As the respiratory failure responds to treatment, echocardiography can then assist with weaning and termination of ventilatory support. Where the respiratory failure is critical, rapid assessment with echocardiography and chest ultrasound helps in the decision-making as to whether to proceed to extracorporeal lung assist (ECLS) support and if adopted, its optimal configuration. ECLS requires ultrasound modalities for correct indication, management and weaning of this mode of support. Echocardiographic monitoring of patients in acute respiratory failure is indispensable and an ultrasonic device should be considered essential equipment for every intensive care unit. [ABSTRACT FROM AUTHOR]

Background: Lung ultrasonography (LUS) has been used for noninvasive detection of pulmonary edema. Semiquantitative LUS visual scores (visual LUS [V-LUS]) based on B lines are moderately correlated with pulmonary capillary wedge pressure (PCWP) and extravascular lung water (EVLW). A new computer-aided quantitative LUS (Q-LUS) analysis has been recently proposed. This study investigated whether Q-LUS better correlates with PCWP and EVLW than V-LUS and to what extent positive end-expiratory pressure (PEEP) affects the assessment of pulmonary edema by Q-LUS or V-LUS.Methods: Forty-eight mechanically ventilated patients with PEEP of 5 or 10 cm H2O and monitored by PCWP (n = 28) or EVLW (n = 20) were studied.Results: PCWP was significantly and strongly correlated with Q-LUS gray (Gy) unit value (r(2) = 0.70) but weakly correlated with V-LUS B-line score (r(2) = 0.20). EVLW was significantly and more strongly correlated with Q-LUS Gy unit mean value (r(2) = 0.68) than with V-LUS B-line score (r(2) = 0.34). Q-LUS showed a better diagnostic accuracy than V-LUS for the detection of PCWP >18 mm Hg or EVLW ≥ 10 mL/kg. With 5-cm H2O PEEP, the correlations with PCWP or EVLW were stronger for Q-LUS than V-LUS. With 10-cm H2O PEEP, the correlations with PCWP or EVLW were still significant for Q-LUS but insignificant for V-LUS. Interobserver reproducibility was better for Q-LUS than V-LUS.Conclusions: Both V-LUS and Q-LUS are acceptable indicators of pulmonary edema in mechanically ventilated patients. However, at high PEEP only Q-LUS provides data that are significantly correlated with PCWP and EVLW. Computer-aided Q-LUS has the advantages of being not only independent of operator perception but also of PEEP. [ABSTRACT FROM AUTHOR]

Pleural effusion (fluidothorax) is characterized by the presence of excessive amount of fluid in the pleural space caused by various pathological clinical conditions. Pleural effusion leads to increased morbidity and adversely affects the prognosis and clinical outcome of critically ill patients in the intensive care setting. Early recognition of pleural effusion and diagnosis of the causal factors belong to the standard components of its management in intensive care. Diagnosis is usually made by chest X-ray and computer tomography followed by pleural aspiration. Nowadays, chest ultrasonography has become an invaluable diagnostic tool. Moreover, it also plays an important role as a guide for invasive pleural procedures. Therapeutic management of pleural effusion is based on treatment of causal factors whenever possible, or on symptomatic approaches. [ABSTRACT FROM AUTHOR]

Background and purpose: This case report describes the physiotherapy assessments and interventions provided to a 56-year-old male in an Australian intensive care unit. The non-intubated patient suffered from respiratory deterioration, secretion retention, complete opacification of the left hemithorax on chest X-ray (CXR) and widespread coarse crackles on lung auscultation. The addition of lung ultrasound (LUS) facilitated more accurate diagnosis than what was formed on the basis of CXR and lung auscultation resulting in more effective treatment. Methods: The method used is a case report. Written consent was obtained from the patient for these data to be published. Summary: Secretion retention was initially suspected (based on clinical examination and CXR) and treated with airway clearance techniques, patient positioning and nasopharyngeal suction. Even though this assisted with secretion removal, the patient continued to have a high perceived work of breathing and increasing oxygen requirements. Physiotherapist performed LUS, under supervision, and revealed a large pleural effusion (1500 mL), which was then drained by the medical team. Discussion: The addition of LUS to the critical care physiotherapist's assessment skills may provide clinical benefit. The increased diagnostic accuracy of LUS compared with other routine assessments warrants further investigation. [ABSTRACT FROM AUTHOR]

Background In critical care, part of the physiotherapist's respiratory assessment aims to identify parenchymal pulmonary pathology, which may be amenable to respiratory physiotherapy. In addition to clinical assessment, the tools that are most readily available to the respiratory physiotherapist to distinguish between acute pulmonary pathologies include auscultation and chest Xray. The limited diagnostic accuracy of these tools may not allow for the accurate differentiation between conditions such as lung collapse, consolidation and pleural effusion. Although computed tomography allows for this differentiation, it requires patient transport and exposes the patient to increased risk and high levels of radiation. Diagnostic lung ultrasound (LUS) has emerged as a highly sensitive bedside diagnostic tool with high level evidence to support its use for the differentiation of various common acute pulmonary pathologies. In this review, the diagnostic performances of auscultation, chest Xray and LUS are reviewed, and the usefulness of LUS as an adjunct to respiratory physiotherapy assessment is discussed. The issues surrounding training physiotherapists and the implementation of LUS are also explored. Methods The method used is a narrative review of the literature. Conclusion To our knowledge, LUS is not routinely utilized by critical care physiotherapists. However, its superior sensitivity and specificity would enable the physiotherapist to make an accurate, timely and point of care diagnosis of lung pathology and determine whether the pathology is amenable to respiratory physiotherapy. Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Purpose: Chest ultrasonography is currently a required element to achieve competence in general critical care ultrasound (GCCUS) which should be part of the training of every intensivist. We sought to assess the ability of resident novices in ultrasonography to identify and quantify unloculated pleural effusions in ICU patients after a limited training program. Methods: A total of 147 patients (mean age, 62 ± 17 years; simplified acute physiology score II, 35 ± 15; 78 % ventilated) with a suspected pleural effusion underwent a thoracic ultrasonography performed successively by a recently trained resident novice in ultrasound and by an experienced intensivist with expertise in GCCUS, considered as reference. Ultrasonographic examinations were performed randomly and independently. In the presence of a pleural effusion, the maximal interpleural distance was measured at the thoracic base. Results: Residents performed a mean of 15 ± 9 examinations. Agreement between residents and experienced intensivists for the diagnosis of left- and right-sided pleural effusions was good to excellent [kappa 0.74 (95 % CI 0.63-0.85) and 0.86 (95 % CI 0.78-0.94), respectively)]. Agreement for the measurement of left and right maximal interpleural distance was excellent (intraclass concordance coefficient, 0.86 [95 % CI 0.77-0.91] and 0.85 [95 % CI 0.75-0.90], respectively). Mean bias for left and right interpleural distance was −0.3 mm (95 % CI −2.4, 1.8 mm) and −1.2 mm (95 % CI −3.4, 1.1 mm), respectively. Conclusions: After a focused training program, resident novices in ultrasound identify and quantify unloculated pleural effusions in ICU patients using chest ultrasonography with a good agreement with experts. [ABSTRACT FROM AUTHOR]

The case of a young man who presented in the emergency department complaining of sudden onset of cough, fever and haemoptysis is described. Chest ultrasonography rapidly diagnosed an acute respiratory distress syndrome picture, which was confirmed on computed tomography. This allowed prompt management of the patient. Blood cultures yielded Streptococcus pyogenes and pharyngeal exudates were positive for influenza B virus. [ABSTRACT FROM AUTHOR]

This study was conducted to evaluate the chest and abdominal ultrasonography findings in patients with dengue viral infection in dr. Soetomo General Hospital. This study is a descriptive, cross-sectional study with consecutive sampling. It done from February to April 2012. Samples were 33 pediatric patients and 25 adult patients diagnosed as dengue fever and dengue hemorrhargic fever according to WHO 1997 criteria underwent chest and abdominal ultrasonography on the first day of admission. The sonographic findings in pediatric patients including hepatomegaly (39,4%), splenomegaly (6,1%), thickened gallblaDFer wall (51,5%), ascites (27,3%), perinephric fluid (15,2%) right and bilateral pleural effusion (15,2% and 21,2%). The sonographic findings in adult patients including hepatomegaly (24%), splenomegaly (12%), thickened gallblaDFer wall (32%), ascites (24%), perinephric fluid (12%), right and bilateral pleural effusion (8% and 12%). There is significant correlation between the number of findings and the severity of disease in pediatric patients (p < 0.05). Several pediatric patients clinically diagnosed as dengue fever had ultrasonographic findings of plasma leakage. Ultrasonography shows hepatomegaly, splenomegaly, thickened gallblaDFer wall, ascites, perinephric fluid and pleural effusion in patients with dengue viral infection. Ultrasonography examination can be used as imaging modality in evaluating patients with dengue viral infection for better monitoring and treatment [ABSTRACT FROM AUTHOR]

OBJECTIVES: The diagnosis of pulmonary embolism (PE) is still a problem especially at emergency units. The purpose of study was to determine the diagnostic accuracy of thoracic ultrasonography (TUS) in patients with PE. METHODS: In this prospective study, 50 patients with suspected PE were evaluated in Department of Pulmonary Diseases of a Training and Research Hospital between January 2010 and July 2011. At the begining, TUS was performed by a chest physician, subsequently for definitive diagnosis computed tomography pulmonary angiography were performed in all cases as a reference method. Other diagnostic procedures were examination of serum d-dimer levels, echocardiography, and venous doppler ultrasonography of the legs. Both chest physician and radiologist were blinded to the results of other diagnostic method. Diagnosis of PE was suggested if at least one typical pleural-based/subpleural wedge-shaped or round hypoechoic lesion with or without pleural effusion was reported by TUS. Presence of pure pleural effusion or normal sonographic findings were accepted as negative TUS for PE. RESULTS: PE was diagnosed in 30 patients. It was shown that TUS was true positive in 27 patients and false positive in eight and true negative in 12 and false negative in three. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of TUS in diagnosis of PE for clinically suspected patients were 90%, 60%, 77.1%, 80%, and 78%, respectively. CONCLUSIONS: TUS with a high sensitivity and diagnostic accuracy, is a noninvasive, widely available, cost-effective method which can be rapidly performed. A negative TUS study cannot rule out PE with certainty, but positive TUS findings with moderate/high suspicion for PE may prove a valuable tool in diagnosis of PE at bedside especially at emergency setting, for critically ill and immobile patients, facilitating immediate treatment decision. [ABSTRACT FROM AUTHOR]

Whole lung lavage (WLL) pathophysiologically represents a human model of controlled lung de-aeration, resembling various pathological conditions encountered in the critically ill. Through one-lung ventilation and progressive alveolar flooding, it mimics, respectively, re-absorption atelectasis formation and lung consolidation. With re-ventilation of the treated lung, PEEP application and diuretics administration, it then creates a model of pulmonary edema and its progressive resolution. No studies have so far described lung aeration changes during WLL with ultrasound: objectives of the study were to describe ultrasound findings during WLL with validated semiotics in the critically ill and to investigate their relation with the lung’s state of relative aeration. In seven patients, 12 lung areas/patient were prospectively studied with ultrasound during six procedural steps of WLL. A three-tiered pattern classification was assigned (1, normal/nearly normal; 2, alveolar-interstitial syndrome; 3, alveolar consolidation) consistently with their previously described meaning in terms of relative air content. The distribution was compared throughout different WLL maneuvers as it was for arterial oxygen measurement distribution. During one-lung ventilation and saline flooding, ultrasound findings shifted from artifact patterns (normal/nearly normal and alveolar-interstitial syndrome) to alveolar consolidation. Saline removal, re-ventilation and negative water balance were associated with a gradual return to alveolar-interstitial syndrome, then to a normal/nearly normal pattern. Arterial oxygen tension variations were not always consistent with these changes. In a controlled human model of lung air content variation, the different states of aeration determined by WLL procedure were reliably described with lung ultrasound. [ABSTRACT FROM AUTHOR]

The assessment of patients with pulmonary focal abnormalities continues to represent an important problem in pulmonary diagnosis. A large number of lung nodules remains undetermined after bronchoscopy, radiological and CT imaging analysis. Ultrasound can contribute to the determination of the nature of peripheral lung tumors, serving as an important aid in decision-making. It helps the investigator to decide the appropriate subsequent step in order to establish the etiologic diagnosis: another imagistic investigation, ultrasonographic guided transthoracic needle biopsy or surgery. This pictorial essay summarizes the main sonographic signs of subpleural lung tumors and the differentiation of benign and malignant lesions. [ABSTRACT FROM AUTHOR]

The article presents the results of a study on the characteristics of the resolution of sonographic B-lines used to assess the presence of extravascular lung water in hemodialysis patients. According to the authors, 34 out of 40 patients had remarkable reductions in the number of B-lines from predialysis to the midpoint scan and from predialysis to postdialysis. They mention the absence of link between subjective dyspnea scores and number of B-lines removed. They indicate the occurrence of B-line resolution in real time as fluid is removed from the body.

The article evaluates the ability of lung ultrasonography to detect acute respiratory failure. Ultrasonography was done on consecutive patients admitted to the intensive care unit with acute respiratory failure, comparing lung ultrasonography results on initial presentation. Results suggest that lung ultrasound can aid the clinician make a fast diagnosis in patients with acute respiratory failure.

Abstract: A series of 186 patients with blunt chest trauma was studied with transthoracic ultrasonography to diagnose pneumothorax and to evaluate its size and location. The results were compared with bedside chest radiography and spiral CT scan. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: “radiographic deep sulcus sign” was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of ±2.3 cm (range 1–5 cm) from the US study in evaluating size and location of pneumothorax. In conclusion, ultrasound study may detect occult pneumothorax undiagnosed by standard plain radiography. It reflects accurately the extent of pneumothorax if compared with CT scan, outlining the “ultrasonographic deep sulcus sign” on anterior chest wall. (E-mail: testaa@rm.unicatt.it) [Copyright &y& Elsevier]

The lung is a vital organ. Although often deemed of limited value at this area, ultrasound proves its ability in detecting the main disorders that affect the critically ill. Pleural effusion, alveolar consolidation, interstitial syndrome, pneumothorax and other are assessed. The clinical relevance of these findings, especially detecting interstitial syndrome in a dyspneic patient or the use of interventional ultrasound are then envisaged. Outcomes like the possibility of decreasing medical radiation doses or cost-savings are viewed. Used like a visual stethoscope, ultrasound highlights the lungs together with the heart, making the thorax a whole for the intensivist. [ABSTRACT FROM AUTHOR]

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.Design: Prospective clinical study.Setting: The medical ICU of a university-affiliated teaching hospital.Patients: A total of 65 cases of alveolar consolidation proven on CT were compared to 53 CT controls.Measurements: Alveolar consolidation was defined as a tissue-like pattern visible at the chest wall, arising from the pleural line and devoid of centrifugal inspiratory dynamics.Results: Feasibility was 99%. In 65 cases of alveolar consolidation, ultrasound was positive in 59 and negative in 6. In 52 analyzable controls, ultrasound was negative in 51 and positive in 1. Sensitivity of ultrasound was 90% and specificity 98%. A concordance test showed a Kappa coefficient of 0.89. Among 62 posterior locations on CT, ultrasound showed posterior consolidation patterns in 56 cases and was negative in 6. Ultrasound showed anterior involvement in all 3 cases of whole lung consolidation.Conclusions: Ultrasound provides a reliable non-invasive, bedside method for accurate detection and location of alveolar consolidation in critically ill patients. [ABSTRACT FROM AUTHOR]

Introduction: Postoperative respiratory failure is a serious problem in patients who undergo general anesthesia. Approximately 90% of mechanically ventilated patients during the surgery may develop atelectasis that leads to perioperative complications. Aim: The aim of this study is to determine whether it is possible to optimize recruitment maneuvers with the use of chest ultrasonography, thus limiting the risk of respiratory complications in patients who undergo general anesthesia. Methodology: The method of incremental increases in positive end-expiratory pressure (PEEP) values with simultaneous continuous ultrasound assessments was employed in mechanically ventilated patients. Results: The study group comprised 100 patients. The employed method allowed for atelectasis reduction in 91.9% of patients. The PEEP necessary to reverse areas of atelectasis averaged 17cmH2O, with an average peak pressure of 29cmH2O. The average PEEP that prevented repeat atelectasis was 9cmH2O. A significant improvement in lung compliance and saturation was obtained. Conclusions: Ultrasound-guided recruitment maneuvers facilitate the patient-based adjustment of the process. Consequently, the reduction in ventilation pressures necessary to aerate intraoperative atelectasis is possible, with the simultaneous reduction in the risk of procedure-related complications. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Thoracic echography easily detects the sign of ‘pleural sliding’, due to the movement of the visceral pleura on the parietal pleura. This sign is absent when pleurodesis is present. This study was designed to test thoracic echography in the assessment of difference in pleurodesis obtained after abrasion or pleurectomy performed for spontaneous pneumothorax, mainly based on the presence or absence of the ‘pleural sliding’ sign. Methods: The population was composed by 10 patients, 5 submitted to VATS complete pleurectomy and 5 to VATS pleural abrasion. Thoracic ultrasonography was performed 4–6 weeks after surgery by an anesthesist trained in thoracic echography blinded to the pleurodesis technique used. Pleurodesis was defined as excellent if pleural sliding was absent in all the 9 considered points, effective when it was present in less than 3 points, poor when it was present in 3 points or more. Results: Pleurodesis was excellent in all the pleurectomy patients and in 1 abrasion patient. In one case, pleural sliding was present at one single explored point and in the last 3 cases there were two contiguous points of pleural sliding. Interestingly, one of these patients developed partial recurrence of pneumothorax 3 weeks after echography exactly at the level of recorded pleural sliding. Conclusions: Thoracic echography for the postoperative evaluation of pleurodesis is feasible and simple. An ideal pleurodesis is more likely after pleurectomy than after pleural abrasion. Areas of persisting pleural sliding are probably at risk of recurrence. [Copyright &y& Elsevier]