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The safety of ultrasound is of particular importance when examining the lungs, due to specific bioeffects occurring at the alveolar air-tissue interface. Lung is significantly more sensitive than solid tissue to mechanical stress. The causal biological effects due to the total reflection of sound waves have also not been investigated comprehensively.On the other hand, the clinical benefit of lung ultrasound is outstanding. It has gained considerable importance during the pandemic, showing comparable diagnostic value with other radiological imaging modalities.Therefore, based on currently available literature, this work aims to determine possible effects caused by ultrasound on the lung parenchyma and evaluate existing recommendations for acoustic output power limits when performing lung sonography.This work recommends a stepwise approach to obtain clinically relevant images while ensuring lung ultrasound safety. A special focus was set on the safety of new ultrasound modalities, which had not yet been introduced at the time of previous recommendations.Finally, necessary research and training steps are recommended in order to close knowledge gaps in the field of lung ultrasound safety in the future.These recommendations for practice were prepared by ECMUS, the safety committee of the EFSUMB, with participation of international experts in the field of lung sonography and ultrasound bioeffects., Competing Interests: Prof. Demi is cofounder of UltraAI (Trento, IT); received funding from the European Institute for Innovation and Technology, Fondazione Valorizzazione Ricerca Trentina, the National Research Council (CNR), and Esaote(IT).Dr Wolfram receives Funding from the Federal Ministry of Education and Research (BMBF, Germany)., (Thieme. All rights reserved.)

(1) Background: Millions of people worldwide were infected with COVID-19. After the acute phase of the disease, many suffer from prolonged symptoms, the post-COVID syndrome, especially the phenotype with lung residuals. Many open questions regarding lung ultrasound (LUS) have to be answered. One essential question is the means for optimal following-up of patients with post-COVID-19 residuals with LUS; (2) Methods: A retrospective data analysis of patients after acute COVID-19 infection diagnosed with post-COVID syndrome in the state hospital of Steyr and the rehabilitation center of Hochegg was performed. LUS examinations following a 12-zone scanning protocol were performed, and the LUS score quantified comet tail artifacts. A total of 16 patients were evaluated twice with LUS from May 2020 until June 2021. (3) Results: All patients’ reverberation artifacts were reduced over time. The initial LUS score of 17.75 (SD 4.84) points was decreased over the duration of the second rehabilitation to 8,2 (SD 5.94). The difference in the Wilcoxon test was significant (p < 0.001); (4) Conclusions: Lung ultrasound was a valuable tool in the follow-up of post-COVID-syndrome with lung residuals in the first wave of COVID-19. A reduction in reverberation artifacts was demonstrated. Further studies about the clinical significance have to follow.

Strong Increase in Lung Ultrasound Due to COVID-19 Abstract. Due to the COVID-19 pandemic, lung ultrasound is experiencing a tremendous upswing and rapid diffusion. This affects both publications and clinical use. The typical changes are described here, also for lung consolidations of other genesis and in interstitial lung diseases. Comparisons with other imaging techniques and indications of the accuracy of lung ultrasound are also presented hereafter.

POCUS - Thoracic Sonography in Times of Corona: What Sonographing Family Physicians Should Examine Abstract. When performing chest sonography of patients with symptoms such as respiratory infection, dyspnea and chest pain, the primary goal is to find or exclude significant diagnoses such as pneumothorax, pleural effusion, pulmonary edema, tumors, pulmonary emboli, etc. as the cause of the symptoms. If infection with SARS-CoV-2 is present, COVID-19 pneumonia can be confirmed or excluded as the cause of the symptoms with a high degree of probability based on the sonographic signs. COVID-19 pneumonia shows typical changes in the lungs, which are easily accessible to ultrasound due to their usually peripheral location. These are ubiquitous signs, such as a thickened, fragmented pleura with subpleural consolidations, multiple comet tail artifacts of varying size and thickness, some of which are coascent, broad bright light beams, and possibly small encapsulated pleural effusions. The more of these sonographic signs are present and the more pronounced they are, the sooner the patient must be hospitalized and possibly intubated. Ultrasound is also useful as a follow-up tool, together with clinical and laboratory findings.

The analysis of vertical reverberation artefacts is an essential component of the differential diagnosis in pulmonary ultra-sound. Traditionally, they are often, but not exclusively, called B-line artefacts (BLA) and/or comet tail artefacts (CTA), but this view is misleading. In this position paper we clarify the terminology and relation of the two lung reverberation artefacts BLA and CTA to spe-cific clinical scenarios. BLA are defined by a normal pleura line and are a typical hallmark of cardiogenic pulmonary edema after exclusion of certain pathologies including pneumonia or lung contusion, whereas CTAs show an irregular pleura line representing a variety of parenchymal lung diseases. The dual approach using low frequency transducers to determine BLA and high frequency transducer to determine the pleural surface is recommended.

The combination of an ageing population with improving survival in malignant and non-malignant disease processes results in a growing cohort of patients with advanced or end-stage chronic diseases who require acute medical care. Emergency care has historically been stereotyped as the identification and treatment of acute life-threatening problems. Although palliative care may be considered to be new to the formal curriculum of emergency medicine, in many domains the ultrasound skillset of a physician in acute medical care can be efficaciously deployed the benefit of patients with both malignant and non-malignant disease processes that require palliative care in the full breadth of acute healthcare settings. In diagnostic domains (abdominal pain, urinary tract obstruction, dyspnoea, venous thromboembolism and musculoskeletal pain) and for specific intervention guidance (thoracentesis, paracentesis, venous access, regional anaesthesia and musculoskeletal interventions) we suggest that POCUS has the potential to streamline improve patient satisfaction, streamline diagnostic strategies, optimise patient length of stay, expedite timely symptomatic relief and reduce complications in this important patient population. POCUS is a mandatory competence in the European curriculum of internal medicine, and specific training programs which cover applications in the domains of palliative care in acute care settings are available. Supervision, quality assurance and appropriate documentation are required. We expect that as the availability of mobile units suitable for point of care applications increases, these applications should become standard of care in the acute management of patients who require palliative care., (Copyright © 2020. Published by Elsevier B.V.)

Lung Ultrasound in Differential Diagnosis of Dyspnea Abstract. Lung ultrasound offers an immediate diagnosis in accordance with the clinical examination in many causes of dyspnea: pleural effusion, pulmonary edema, pneumonia, pulmonary embolism and interstitial lung diseases. At first level exam, CXR, despite its intrinsic limitations and low accuracy, may still play a relevant role. CT scan remains the gold standard, but it requires patient transportation and use of radiation, which precludes an extensive use especially within the same patient. Lung ultrasound, after proper training of the physician, is able to provide greater accuracy than CXR and similar accuracy to the CT scan.

E-FAST (Extended-Focused Assessment with Sonography for Trauma) is now a widely utilized and internationally recognized standard exam in trauma care. It is highly accepted by emergency physicians and trauma surgeons alike. Thanks to the popularity of PoCUS (point-of-care ultrasound), it has continued to evolve over the last years and can now improve trauma diagnosis at all stages of the primary ABCDE. This review article summarizes key observations made over recent years and also highlights the extension of FAST into E-FAST in the context of PoCUS and CT developments for modern trauma management. Time has come to learn the lessons from 25 years of FAST and 15 years of E-FAST. We should redefine and position ultrasound in the primary ATLS survey (Advanced Trauma Life Support) on two levels: 1. Basic ATLS with new clinical questions, six additional abdominal image sections and one or more follow-up examinations depending on the clinical situation, and 2. Advanced ATLS with ultrasound applications for the entire trauma ABCDE., Competing Interests: The authors declare that they have no conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Bedside lung ultrasound (LUS) in emergency rooms and intensive care units can serve as a tool to diagnose common lung pathologies, monitor their course and guide clinical management. LUS requires only a few minutes and is a useful extension of the physical examination. Fractures of the ribs as well as the sternum are seen well on ultrasound. Minute pleural fluids (effusion, hemtothorax) are detectable. LUS is able to detect the sound of lung water and thus to differentiate a cardiogenic pulmonary edema from chronic obstructive lung disease. Inflammatory lung diseases such as pleuritis and pneumonia are better seen than on chest X‑ray. LUS should replace chest X‑ray in the diagnosis of ambulant acquired pneumonia. In ventilator-associated pneumonia and atelectasis, LUS measures the presence of lung consolidation as well as dynamic changes und reventilation. A heart-lung-vessel integrated triple ultrasonography according to clinical findings can help with the diagnosis of pulmonary embolism and should be a necessary weapon for the physicians, especially in emergency departments.

Pneumonia: Does Ultrasound Replace Chest X-Ray? Abstract. Pneumonic lung consolidations are characterized by typical changes in terms of sonomorphology: echopoor lesions with blurred margins, bronchoaerograms, regular vascularization, and parapneumonic effusions. Pneumonias may be first discovered at bedside. Reventilation is well correlated with clinical progression. Compared with CT in four metaanalyses, lung ultrasound shows accuracy with a sensitivity of 88-97 % and a specificity of 90-96 %. Chest x-ray on the other hand has a pooled sensitivity of 77 % and a specificity of 91 %. Thus, lung ultrasound should replace chest x-ray in the diagnosis of pneumonia aquired by out-patients.

Complementary to part 1, this review summarizes indications, opportunities and applications of ultrasounds in palliative care medicine. In particular, the following topics are discussed: · Ultrasound as a non-invasive, low-threshold, bedside technique, which uniquely combines diagnostic efficacy and empathy.. · Sonographic surveillance of patients with malignant disease.. · Point-of-care application of ultrasound in palliative care services.. · Ultrasound-guided palliative interventions (drainage of effusions and other therapeutic procedures).., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The science of lung ultrasound has grown tremendously over the last two decades and lung ultrasound has not only entered the mainstream of point of care ultrasound but has become a dominant topic. Understanding lung ultrasound signs and artifacts is critical to being able to correlate findings with actual pathology and normal anatomy and physiology. Investigators have described multiple lung ultrasound artifacts and findings and it is important to understand both the physics and anatomic basis behind them. Additionally, ultrasound machine use and transducer selection can significantly affect results obtained on patient during an examination and the provider must carefully choose the correct settings. This manuscript describes the state of the art in ultrasound artifact recognition and correlation as well as management of ultrasound technology to optimize diagnostic success.

Background: The analysis of lung artefacts has gained increasing importance as markers of lung pathology. B-line artefact (BLA), caused by a reverberation phenomenon, is the most important lung artefact. In this review, we discuss the current role of BLA in pneumology and explore open questions of the published consensus., Methods: We summarized current literature about BLA. Also, we presented observations on healthy subjects and patients with interstitial syndrome (pulmonary fibrosis and edema), to investigate technical factors influencing BLA visualization., Results: BLA imaging is influenced by more factors than recently assumed. When multiple BLA is visualized in the lung, they represent a sign of increased density due to the loss of aeration in the lung periphery. This condition may indicate different diseases including cardiogenic pulmonary edema, diffuse or focal interstitial lung diseases (ILD), infections and acute respiratory distress syndrome (ARDS). Correct interpretation of BLA in lung ultrasound is strongly influenced by associated sonographic signs and careful integration of all relevant clinical information., Conclusions: BLA is useful to monitor clinical response, and may become crucial in directing the diagnostic process. Further research is warranted to clarify technical adjustments, different probe and machine factors that influence the visualization of BLA.

Imaging of pulmonary embolism (PTE) remains a great challange. Mortatity is even high. Possibilities of lung ultrasound, echocardiography, and compression leg vein sonography are discussed. Hemodynamic instable patients should achieve echocardiography at bed side with an accuracy of 90% and immeadiatly treated. In case of a suspected PTE, compression sonography of the leg veins is recommended. It can be performed within 2 min but, on average, yields a positive result in only one-half of the cases of PTE. During the last years, pulmonary sonography took root as a complementary method to MSCT either when the latter is not available or when it is contraindicated because of contrast agent allergy, renal insufficiency, or pregnancy. This method was able to provide evidence of subpleural pulmonary consolidations due to embolism in at least three-fourths of patients having a PTE. According to clinical presentation, combination of lung ultrasound, echocardiograpphy, and compression ultrasoud of the leg veins showed a sensitiviy of more than 90%.

The value of ultrasound techniques in examination of the pleurae and lungs has been underestimated over recent decades. One explanation for this is the assumption that the ventilated lungs and the bones of the rib cage constitute impermeable obstacles to ultrasound. However, a variety of pathologies of the chest wall, pleurae and lungs result in altered tissue composition, providing substantially increased access and visibility for ultrasound examination. It is a great benefit that the pleurae and lungs can be non-invasively imaged repeatedly without discomfort or radiation exposure for the patient. Ultrasound is thus particularly valuable in follow-up of disease, differential diagnosis and detection of complications. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can tolerably be performed under real-time ultrasound guidance. In this article, an updated overview is given presenting not only the benefits and indications, but also the limitations of pleural and pulmonary ultrasound., (Copyright © 2015 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Thoracic ultrasound is a noninvasive and portable diagnostic tool which is highly indicated for an initial workup of thoracic emergencies. The suspicion of a pneumothorax, pneumonia, pulmonary embolism or a lung contusion after trauma can be quickly assessed using ultrasound. Main advantages are its good availability and the steep learning curve. Another advantage of thoracic sonography is that this rapid, symptom-based examination has a high sensitivity and specificity. However, a disadvantage is that only pleura-affecting lesions or lesions visible through a sound window, e.g. an effusion or a subpleural consolidation, can be reached., (© 2014 S. Karger AG, Basel.)

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.

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.

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.