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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]

BackgroundUltrasound has demonstrated its interest in the analysis of diaphragm function in patients with respiratory failure. The criteria used to diagnose hemidiaphragm paralysis are not well defined.MethodsThe aim of this observational retrospective study was to describe the ultrasound findings in 103 patients with diaphragm paralysis, previously diagnosed by conventional methods after various circumstances such as trauma or surgery. The ultrasound study included the recording of excursions of both diaphragmatic domes and the measurement of inspiratory thickening.ResultsOn paralyzed hemidiaphragm, thickening was less than 20% in all patients during deep inspiration. Thinning was recorded in 53% of cases. In some cases, the recording of the thickening could be difficult. The study of motion during voluntary sniffing reported a paradoxical excursion in all but one patient. During quiet breathing, an absence of movement or a paradoxical displacement was observed. During deep inspiration, a paradoxical motion at the beginning of inspiration followed by a reestablishment of movement in the cranio-caudal direction was seen in 82% of cases. In some patients, there was a lack of movement followed, after an average delay of 0.4 s, by a cranio-caudal excursion. Finally, in 4 patients no displacement was recorded. Evidence of hyperactivity (increased inspiratory thickening and excursion) of contralateral non-paralyzed hemidiaphragm was observed.ConclusionTo accurately detect hemidiaphragm paralysis, it would be interesting to combine the ultrasound study of diaphragm excursion and thickening. The different profiles reported by our study must be known to avoid misinterpretation.

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]

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.

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 ± 768.27 s). 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.

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]

Abstract Background Despite advances in antimicrobial therapy and a range of drainage techniques for the infected pleural area, thoracic empyema continues to be a serious reason behind morbidity and mortality. Although chest ultrasonography has been found to be an efficient diagnostic tool for pleural effusion features, it is rarely utilized to predict the outcomes of pleural illnesses. Aim of the work To determine the impact of sonographic patterns in predicting the outcomes of thoracic empyema patients. Patients and methods In this retrospective study, patients were divided into four groups based on their sonographic patterns: (I) complex non-septated effusions (plankton sign), (II) complex fixed septated effusions, (III) complex mobile septated effusions, and (IV) homogenously echogenic effusions (hematocrit sign). These sonographic patterns were compared to the patients’ co-morbidities, length of stay in the hospital, chest tube drainage, and medicinal or surgical therapy effectiveness. Results In comparison with other sonographic pattern groups, patients in group I (70.6%) and group IV (45.5%) had effective thoracic tube drainage with a very high statistically significant difference (P value < 0.001). For patients in group II (75%) (P value < 0.001), open thoracotomy was a very highly significant effective therapy (P value 0.001). Conclusion The sonographic pattern of thoracic empyema is a useful tool for guiding treatment decisions in these patients.

BackgroundAlthough previous studies have determined limit values of normality for diaphragm excursion and thickening, it would be beneficial to determine the normal diaphragm motion-to-inspired volume ratio that integrates the activity of the diaphragm and the quality of the respiratory system.MethodsTo determine the normal values of selected ultrasound diaphragm motion-volume indices, subjects with normal pulmonary function testing were recruited. Ultrasound examination recorded diaphragm excursion on both sides during quiet breathing and deep inspiration. Diaphragm thickness was also measured. The inspired volumes of the corresponding cycles were systematically recorded using a spirometer. The indices were calculated using the ratio excursion, or percentage of thickening, divided by the corresponding breathing volume. From this corhort, normal values and limit values for normality were determined. These measurements were compared to those performed on the healthy side in patients with hemidiaphragm paralysis because an increase in hemidiaphragm activity has been previously demonstated in such circumstances.ResultsA total of 122 subjects (51 women, 71 men) with normal pulmonary function were included in the study. Statistical analysis revealed that the ratio of excursion, or percentage of thickening, to inspired volume ratio significantly differed between males and females. When the above-mentioned indices using excursion were normalized by body weight, no gender differences were found. The indices differed between normal respiratory function subjects and patients with hemidiaphragm paralysis (27 women, 41 men). On the paralyzed side, the average ratio of the excursion divided by the inspired volume was zero. On the healthy side, the indices using the excursion and the percentage of thickening during quiet breathing or deep inspiration were significantly increased comparedto patients with normal lung function. According to the logistic regression analysis, the most relevant indice appeared to be the ratio of the excursion measured during quiet breathing to the inspired volume.ConclusionThe normal values of the diaphragm motion-volume indices could be useful to estimate the performance of the respiratory system. Proposed indices appear suitable in a context of hyperactivity.

Although during the last few years the lung ultrasound (LUS) technique has progressed substantially, several artifacts, which are currently observed in clinical practice, still need a solid explanation of the physical phenomena involved in their origin. This is particularly true for vertical artifacts, conventionally known as B‐lines, and for their use in clinical practice. A wider consensus and a deeper understanding of the nature of these artifactual phenomena will lead to a better classification and a shared nomenclature, and, ultimately, result in a more objective correlation between anatomo‐pathological data and clinical scenarios. The objective of this review is to collect and document the different signs and artifacts described in the history of chest ultrasound, with a particular focus on vertical artifacts (B‐lines) and sonographic interstitial syndrome (SIS). By reviewing the possible physical and anatomical interpretation of the signs and artifacts proposed in the literature, this work also aims to bring order to the available studies and to present the AdET (Accademia di Ecografia Toracica) viewpoint in terms of nomenclature and clinical approach to the SIS. [ABSTRACT FROM AUTHOR]

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.

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.

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

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]

BackgroundSARS-CoV-2 infection can impair diaphragm function at the acute phase but the frequency of diaphragm dysfunction after recovery from COVID-19 remains unknown.Materials and methodsThis study was carried out on patients reporting persistent respiratory symptoms 3–4 months after severe COVID-19 pneumonia. The included patients were selected from a medical consultation designed to screen for recovery after acute infection. Respiratory function was assessed by a pulmonary function test, and diaphragm function was studied by ultrasonography.ResultsIn total, 132 patients (85M, 47W) were recruited from the medical consultation. During the acute phase of the infection, the severity of the clinical status led to ICU admission for 58 patients (44%). Diaphragm dysfunction (DD) was detected by ultrasonography in 13 patients, two of whom suffered from hemidiaphragm paralysis. Patients with DD had more frequently muscle pain complaints and had a higher frequency of prior cardiothoracic or upper abdominal surgery than patients with normal diaphragm function. Pulmonary function testing revealed a significant decrease in lung volumes and DLCO and the dyspnea scores (mMRC and Borg10 scores) were significantly increased in patients with DD. Improvement in respiratory function was recorded in seven out of nine patients assessed 6 months after the first ultrasound examination.ConclusionAssessment of diaphragm function by ultrasonography after severe COVID-19 pneumonia revealed signs of dysfunction in 10% of our population. In some cases, ultrasound examination probably discovered an un-recognized pre-existing DD. COVID-19 nonetheless contributed to impairment of diaphragm function. Prolonged respiratory physiotherapy led to improvement in respiratory function in most patients.Clinical trial registration[www.cnil.fr], identifier [#PADS20-207].

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]

Background: Children with acute febrile respiratory illnesses are commonly seen in the emergency department. Apart from the initial stabilization, they need to be assessed for the underlying cause, and clinicians should formulate differential diagnoses to start treatment. Radiological investigations including x-ray and ultrasonography are often used to narrow down the initial possibilities based on history and examination. A child presenting with an opaque hemithorax is one such scenario. Clinical Description: A 3-year-old boy presented with a short duration of fever, cough and respiratory distress. Examination showed rightward mediastinal shift with dull percussion note and reduced breath sounds over the left hemithorax, along with congested neck veins, stridor and left sided wheeze. Chest x-ray showed an opacified left hemithorax and ultrasonography suggested moderate pleural effusion. Management: Complicated pneumonia with parapneumonic effusion (or empyema) was considered, but a diagnostic pleural tap was dry. The possibilities were revised to include cystic space occupying lesions with mediastinal compression. Computed tomography of the chest confirmed a mass lesion with predominantly cystic components. The patient underwent surgical excision, and histopathology showed pleuropulmonary blastoma. Conclusion: Although respiratory infections are common in childhood, clinical evaluation and judicious use of imaging modalities can uncover less common conditions. Although bedside ultrasonography is a handy tool in the emergency department, it is not infallible.

Background: Inspiratory loading is experienced by military divers when they use rebreather device. Our objective was to assess the changes in diaphragm function induced by an increase in inspiratory load at values similar to those experienced by divers in real life. Methods : We recorded the excursion and the thickness of the right hemidiaphragm in 22 healthy male volunteers under inspiratory load conditions, using ultrasound in B- and M-mode. The measurements were performed at tidal volume and during breathing at 50% of inspiratory capacity. The breathing rate was regulated and similar in the various sessions with and without load. Results: The rebreather device used by French military divers leads to an increase in inspiratory load of close to 30 cmH2O. Consequently, the session under load was performed using a device set to this threshold. Significant increases in the excursion and the thickening fraction of the diaphragm were observed between the sessions at tidal volume and at high volume. With addition of the inspiratory load, the excursion of the right hemidiaphragm increased significantly from 2.3 to 3.4cm at tidal volume and from 3.9 to 4.7cm at high volume. The thickening fraction increased significantly from 30.4 to 76.6% at tidal volume and from 70 to 123% at high volume. The statistical analysis demonstrated that assessment of the changes of the thickening fraction during breathing at tidal volume was the most relevant marker to assess the impact of the inspiratory load on the diaphragm. Conclusion: Diaphragm ultrasound can be used to assess the changes in the diaphragm contraction pattern secondary to an increase in the respiratory load that can be generated by use a diving apparatus. The recording of the changes of the motion, and more importantly of the thickness of the diaphragm, during the breathing cycle is able to provide relevant information regarding the inspiratory load. [ABSTRACT FROM AUTHOR]

Background: Inspiratory loading is experienced by military divers when they use rebreather device. Our objective was to assess the changes in diaphragm function induced by an increase in inspiratory load at values similar to those experienced by divers in real life.Methods: We recorded the excursion and the thickness of the right hemidiaphragm in 22 healthy male volunteers under inspiratory load conditions, using ultrasound in B- and M-mode. The measurements were performed at tidal volume and during breathing at 50% of inspiratory capacity. The breathing rate was regulated and similar in the various sessions with and without load.Results: The rebreather device used by French military divers leads to an increase in inspiratory load of close to 30 cmH2O. Consequently, the session under load was performed using a device set to this threshold. Significant increases in the excursion and the thickening fraction of the diaphragm were observed between the sessions at tidal volume and at high volume. With addition of the inspiratory load, the excursion of the right hemidiaphragm increased significantly from 2.3 to 3.4cm at tidal volume and from 3.9 to 4.7cm at high volume. The thickening fraction increased significantly from 30.4 to 76.6% at tidal volume and from 70 to 123% at high volume. The statistical analysis demonstrated that assessment of the changes of the thickening fraction during breathing at tidal volume was the most relevant marker to assess the impact of the inspiratory load on the diaphragm.Conclusion: Diaphragm ultrasound can be used to assess the changes in the diaphragm contraction pattern secondary to an increase in the respiratory load that can be generated by use a diving apparatus. The recording of the changes of the motion, and more importantly of the thickness of the diaphragm, during the breathing cycle is able to provide relevant information regarding the inspiratory load.

Background: Diagnosing diaphragm dysfunction in the absence of complete paralysis remains difficult. The aim of the present study was to assess the normal values of the thickness and the inspiratory thickening of both hemidiaphragms as measured by ultrasonography in healthy volunteers while in a seated position.Methods: Healthy volunteers with a normal pulmonary function test were recruited. The diaphragmatic thickness was measured on both sides at the zone of apposition of the diaphragm to the rib cage during quiet breathing at end-expiration, end-inspiration, and after maximal inspiration. The thickening ratio, the thickening fraction, and the thickness at end-inspiration divided by the thickness at deep breathing were determined. The mean values and the lower and upper limits of normal were determined for men and women.Results: 200 healthy volunteers (100 men and 100 women) were included in the study. The statistical analysis revealed that women had a thinner hemidiaphragm than men on both sides and at the various breathing times studied. The lower limit of normality of the diaphragm thickness measured at end-expiration was estimated to be 1.3 mm in men and 1.1 mm in women, on both sides. The thickening fraction did not differ significantly between men and women. In men, it ranged from 60 to 260% on the left side and from 57 to 200% on the right side. In women, it ranged from 58 to 264% on the left side and from 60 to 229% on the right side. The lower limits of normality of the thickening fraction were determined to be 40 and 39% in men and 39 and 48% in women for the right and left hemidiaphragms, respectively. The upper limit for normal of the mean of both sides of the ratio thickness at end-inspiration divided by the thickness at deep breathing was determined to be 0.78 in women and 0.79 in men.Conclusion: The normal values of thickness and the indexes of diaphragmatic function should help clinicians with detecting diaphragm atrophy and dysfunction.

• 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]

Abstract Introduction The ultrasound (US) of the chest is useful in the diagnosis of different parenchymal, pleural, and chest wall diseases. The US is preferred because no radiation is used (safe during pregnancy), is not expensive, is easy portability, provides real-time imaging, and has the ability to make a dynamic imaging. Aim This study aimed for the correlation between B-lines and spirometry, arterial blood gases, 6-minute walk test (6MWT), and pulmonary artery systolic pressure (PASP) in patients with diffuse parenchymal lung disease (DPLD). Design A prospective study was conducted. Setting The study was conducted at Fayoum University Hospital in Egypt between January 2017 and June 2017. Patients and methods This study was done on 60 patients with DPLD. They were subjected to a full medical history, a detailed clinical examination, high-resolution computed tomography, echocardiography, arterial blood gases analysis, spirometry, 6MWT, and chest US. Results The studied group showed female predominance, with 54 (90%) patients. They had a wide range of age from 20 to 75 years, and their mean age was 47.5±13.6 years. Most of them were involved in breeding birds, exposed to biomass, and nonsmokers. The studied patients had bilateral B-lines. The number of B-lines was positively correlated with PaO2, 6MWT, forced vital capacity, and PASP and negatively correlated with high-resolution computed tomography affection, whereas the distance between B-lines was inversely correlated with each of PaO2, numbers of B-line, 6MWT, forced vital capacity, and PASP. Most of patients had irregular and thickened pleura (71.6%), and abolished lung sliding was seen in 51.6%. Conclusion Chest US may be used in the evaluation of DPLD. Multiple B-lines with thickened and irregular pleural line are suggestive of DPLD.

Abstract Objective Chest ultrasound has many uses, both diagnostic and interventional. It may be used for the diagnosis of multiple pleural diseases (pleural effusion, pleural masses, and pneumothorax). It is also used in the diagnosis of diseases caused by lung parenchymal lesions, such as neoplasms, pulmonary embolism, pneumonia, and lung abscesses. Aim This study aimed to evaluate the sonographic features of diffuse parenchymal lung disease (DPLD). Design This was a prospective study. Setting The study was carried out at Fayoum University Hospital in Egypt during the period spanning from January 2017 to June 2017. Patients and methods This study included 120 participants. Sixty of them were diagnosed as having DPLD. For the diagnosis of these cases, we need a full medical history, a detailed clinical examination, spirometry, 6 min walk test, arterial blood gases’ analysis, high-resolution computed tomography, and chest ultrasound. The other 60 were studied as controls. Statistical analysis The data were collected and coded to facilitate data manipulation, and they were double entered into Microsoft Access; the data analysis was performed by using SPSS software, version 18 in Windows 7. The simple descriptive analysis was carried out in the form of numbers and percentages for qualitative data and arithmetic means as central tendency measurement, SDs as measure of dispersion for the quantitative parametric data and the inferential statistic test. Results There was a female predominance with a wide range of age. Most of the cases were nonsmokers, breeding birds, and exposed to biomass. All cases had diffuse bilateral B-lines. There was a negative relation between the Warrick score on the one hand and the B-line number, PaO2, 6 min walk test, and forced vital capacity on the other hand. In contrast, a positive relation was demonstrated between the Warrick score and B-line distance and pleural thickness. Most of the studied patients (71.6%) had irregular and thickened pleura and (51.6%) had an abolished lung sliding. Conclusion Chest ultrasound has a significant role in the diagnosis of DPLD and also in estimating the severity of the disease according to the number and the distance between B-lines. Multiple B-lines in the combination of thickened and irregular pleural line are highly suggestive of DPLD.

Chest ultrasonography has become an indispensable tool for pulmonary specialists in human medicine, but its current use in dogs and cats is primarily for emergency. The diagnostic performances of various ultrasonographic features other than comet-tail artifacts are of limited information in veterinary literatures. Therefore, the aims of this retrospective study were to investigate ultrasonographic findings in feline and canine respiratory patients with lung parenchymal and pleural space diseases, and to assess how ultrasonographic features correspond to specific diagnoses. Sixty-five non-emergency cases with radiographically identified lung parenchymal and pleural space abnormalities were included. Medical records and ultrasound video clips were reviewed, and additional follow-up information was subsequently collected. Common findings such as comet-tail artifacts (87.7% of cases), consolidation (84.6%), and thickened/irregular pleura (69.2%) were not distinguishable for a specific diagnosis. The presence of nodular/mass-like lesion (OR = 212, p < 0.001) and consolidated lesion with heteroechogenicity (OR = 240, p < 0.001) was significantly associated with and strongly predictive of neoplasia after age, body weight and other sonographic findings were adjusted. The finding of nodular/mass-like lesion has the best diagnostic performance (AUC = 0.93) for neoplasia, with sensitivity of 91.7% and specificity of 93.6%. For predicting a diagnosis of pneumonia, although several sonographic features were found to be statistically associated with pneumonia, only a negative finding of nodular/mass-like lesion showed good diagnostic performance (AUC = 0.83, sensitivity 95.7%, specificity 71%). These findings demonstrate the value of chest ultrasonography in predicting diagnosis in non-emergency cases. The application of thoracic ultrasound in small animal respiratory patients as part of non-invasive assessment warrants further investigation.

Background: Ultrasound has demonstrated its interest in the analysis of diaphragm function in patients with respiratory failure. The criteria used to diagnose hemidiaphragm paralysis are not well defined., Methods: The aim of this observational retrospective study was to describe the ultrasound findings in 103 patients with diaphragm paralysis, previously diagnosed by conventional methods after various circumstances such as trauma or surgery. The ultrasound study included the recording of excursions of both diaphragmatic domes and the measurement of inspiratory thickening., Results: On paralyzed hemidiaphragm, thickening was less than 20% in all patients during deep inspiration. Thinning was recorded in 53% of cases. In some cases, the recording of the thickening could be difficult. The study of motion during voluntary sniffing reported a paradoxical excursion in all but one patient. During quiet breathing, an absence of movement or a paradoxical displacement was observed. During deep inspiration, a paradoxical motion at the beginning of inspiration followed by a reestablishment of movement in the cranio-caudal direction was seen in 82% of cases. In some patients, there was a lack of movement followed, after an average delay of 0.4 s, by a cranio-caudal excursion. Finally, in 4 patients no displacement was recorded. Evidence of hyperactivity (increased inspiratory thickening and excursion) of contralateral non-paralyzed hemidiaphragm was observed., Conclusion: To accurately detect hemidiaphragm paralysis, it would be interesting to combine the ultrasound study of diaphragm excursion and thickening. The different profiles reported by our study must be known to avoid misinterpretation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Boussuges, Fourdrain, Leone, Brioude, Menard, Zieleskiewicz, Delliaux, Gouitaa, Dutau and Brégeon.)

Abstract Background The risk factors of pulmonary edema induced by diving in healthy subjects are not well known. The aim of the present study was to assess the parameters contributing to the increase in extravascular lung water after diving. Methods This study was carried out in a professional diving institute. All divers participating in the teaching program from June 2012 to June 2014 were included in the study. Extravascular lung water was assessed using the detection of ultrasound lung comets (ULC) by chest ultrasonography. Clinical parameters and dive profiles were recorded using a questionnaire and a dive computer. Results One-hundred six divers were investigated after 263 dives. They used an open-circuit umbilical supplying compressed gas diving apparatus in 202 cases and a self-contained underwater breathing apparatus in 61 cases. A generalized linear mixed model analysis was performed which demonstrated that the dive induced a significant increase in ULC score (incidence rate ratio: 3.16). It also identified that the predictive variable of increased extravascular lung water after the dive was the exercise intensity at depth (z = 3.99, p

Abstract 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.

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]

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 Introduction Sometimes it is difficult to differentiate between acute cardiogenic pulmonary edema (APE) and acute respiratory distress syndrome (ARDS) on clinical basis only. Chest ultrasonography (CUS) may be helpful in providing ultrasonographic pleuropulmonary signs, which aids in such differentiation. Aim The aim of this study was to evaluate the role of CUS in differentiating between ARDS and APE through the characterization of comparative peculiar ultrasonographic pleuropulmonary signs. Patients and methods On admission, CUS was performed in Ain Shams University Hospital and Al-Abbassia Chest Hospital ICUs on 28 consecutive patients who presented with ARDS (15 cases) or APE (13 cases). CUS examination focused on the detection of the following pleuropulmonary signs in both ARDS and APE: alveolar–interstitial syndrome (AIS), pleural line abnormalities, absent or reduced lung sliding, consolidation, and pleural effusion. Results AIS was found in 100% of patients with ARDS and in 100% of patients with APE. Pleural line abnormalities were observed in 100% of patients with ARDS and in 0% of patients with APE (P=0.001). Absent or reduced lung sliding was observed in 100% of patients with ARDS and in 0% of patients with APE (P=0.001). Consolidations were present in 93.3% of patients with ARDS in 7.5% of patients with APE (P=0.001). Pleural effusion was present in 40% of patients with ARDS and in 76.9% of patients with APE (P=0.049). All pleuropulmonary signs, except the presence of AIS, presented a statistically significant difference in presentation between ARDS and APE, resulting peculiar ultrasonographic pleuropulmonary signs of ARDS. Conclusion CUS represents a useful tool for differentiating ARDS from APE in ICU patients. In fact, the presence of absent or reduced lung sliding, pleural line abnormalities, and lung consolidations on a background of AIS seems diagnostic of ARDS.

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]

Objectives: This study compares chest ultrasonography to current diagnostic tools for diagnosing the etiology of acute respiratory failure (ARF) in the ICU. Methods: The final etiology of ARF was diagnosed in 100 patients (excluding non-respiratory causes and multiple diagnoses) using conventional diagnostic tools (excluding ultrasound). They were pneumonia (49%), chronic obstructive pulmonary disease (COPD) (16%), acute respiratory distress syndrome (ARDS) (10%), pulmonary embolism (PE) (5%), empyema (5%), bronchial asthma (BA) (5%), pneumothorax (5%), idiopathic pulmonary fibrosis (IPF) (3%) and lung contusions (2%). Thoracic ultrasound was done on admission and the obtained profiles were compared to underling etiologies obtained by conventional methods. Characteristic ultrasound profiles that produced specificities >90% were considered diagnostic. Results: The main diagnostic profiles were: AB profile (asymmetric anterior interstitial syndrome) and C profile (anterior consolidation) indicated pneumonia. The B profile (diffuse anterior interstitial syndrome with lung sliding) indicated ARDS or IPF. Also the B + PLAPS profile (anterior interstitial syndrome with posterior and/or lateral alveolar and/or pleural syndrome) indicated ARDS. The A profile (normal) indicated COPD or bronchial asthma (21%). The A profile (normal) plus DVT indicated pulmonary embolism (5%). The lung point and loss of lung sliding (A′ profile) indicated pneumothorax (5%). Considering CT chest as the radiological gold standard, chest ultrasound produced 90% sensitivity and 100% specificity. Conclusions: Lung ultrasound provided an immediate diagnosis of the underlying etiology of acute respiratory failure in most cases; it can therefore be added to the armamentarium of ICU where urgent decisions are needed for rapid diagnosis and management of patients with ARF.

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]

Background: The risk factors of pulmonary edema induced by diving in healthy subjects are not well known. The aim of the present study was to assess the parameters contributing to the increase in extravascular lung water after diving. Methods: This study was carried out in a professional diving institute. All divers participating in the teaching program from June 2012 to June 2014 were included in the study. Extravascular lung water was assessed using the detection of ultrasound lung comets (ULC) by chest ultrasonography. Clinical parameters and dive profiles were recorded using a questionnaire and a dive computer. Results: One-hundred six divers were investigated after 263 dives. They used an open-circuit umbilical supplying compressed gas diving apparatus in 202 cases and a self-contained underwater breathing apparatus in 61 cases. A generalized linear mixed model analysis was performed which demonstrated that the dive induced a significant increase in ULC score (incidence rate ratio: 3.16). It also identified that the predictive variable of increased extravascular lung water after the dive was the exercise intensity at depth ( z = 3.99, p < 0.0001). The other parameters studied such as the water temperature, dive profile, hyperoxic exposure, or anthropometric data were not associated with the increase in extravascular lung water after the dive. Conclusions: In this study, the exercise intensity was the main contributor to the increase in extravascular lung water in healthy divers. To improve the prevention of immersion pulmonary edema, the exercise intensity experienced during the dive should thus be adapted to the aerobic fitness level of the divers. [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]

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 Reasearch 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.

Background: Although previous studies have determined limit values of normality for diaphragm excursion and thickening, it would be beneficial to determine the normal diaphragm motion-to-inspired volume ratio that integrates the activity of the diaphragm and the quality of the respiratory system., Methods: To determine the normal values of selected ultrasound diaphragm motion-volume indices, subjects with normal pulmonary function testing were recruited. Ultrasound examination recorded diaphragm excursion on both sides during quiet breathing and deep inspiration. Diaphragm thickness was also measured. The inspired volumes of the corresponding cycles were systematically recorded using a spirometer. The indices were calculated using the ratio excursion, or percentage of thickening, divided by the corresponding breathing volume. From this corhort, normal values and limit values for normality were determined. These measurements were compared to those performed on the healthy side in patients with hemidiaphragm paralysis because an increase in hemidiaphragm activity has been previously demonstated in such circumstances., Results: A total of 122 subjects (51 women, 71 men) with normal pulmonary function were included in the study. Statistical analysis revealed that the ratio of excursion, or percentage of thickening, to inspired volume ratio significantly differed between males and females. When the above-mentioned indices using excursion were normalized by body weight, no gender differences were found. The indices differed between normal respiratory function subjects and patients with hemidiaphragm paralysis (27 women, 41 men). On the paralyzed side, the average ratio of the excursion divided by the inspired volume was zero. On the healthy side, the indices using the excursion and the percentage of thickening during quiet breathing or deep inspiration were significantly increased comparedto patients with normal lung function. According to the logistic regression analysis, the most relevant indice appeared to be the ratio of the excursion measured during quiet breathing to the inspired volume., Conclusion: The normal values of the diaphragm motion-volume indices could be useful to estimate the performance of the respiratory system. Proposed indices appear suitable in a context of hyperactivity., Competing Interests: GC was employed by AltraBio. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Boussuges, Chaumet, Boussuges, Menard, Delliaux and Brégeon.)