Gabriele Via

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS).

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described.Obtaining competence in ICU echocardiography may be achieved in different ways – either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level – obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countries needs.

Whole lung lavage: a unique model for ultrasound assessment of lung aeration changes

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

Ultrasound for “Lung Monitoring” of Ventilated Patients

LUS is normally performed in supine patients. Operator should firstly locate the diaphragm and the lungs. Lung consolidation or pleural effusion is found predominantly in dependent and dorsal lung regions and can be easily distinguished from liver or spleen once the diaphragm has been identified. By using the anterior and posterior axillary lines as anatomical landmarks, three areas per hemithorax (anterior, lateral, and posterior) can be iden-tified. Each area is divided in two, superior and inferior. In a given region of interest, lung surface of all adjacent inter-costal spaces must be explored by moving the probe trans-versally.

Peri-resuscitation echocardiography: Training the novice practitioner☆

AIMS Echocardiography performed in an ALS-compliant manner provides a tool whereby some of the potentially reversible causes of cardiac arrest can be diagnosed in real time by minimally trained practitioners. One of the major concerns this raises is how to deliver effective training to the required standard. The objective of this study was to determine the effectiveness of number of different educational methods used teach echocardiography to novices. This involved assessment of cognitive, psychomotor skills and affective aspects in five key areas. METHODS The study population was a convenience sample from participants attending standardised structured one-day training courses in peri-resuscitation echocardiography (n=204). Subjects were assessed for five learning outcomes including knowledge and image interpretation, practical performance of echocardiography including time taken to obtain a diagnostic view, integration into the ALS algorithm and overall compliance with established resuscitation guidelines. RESULTS There was a significant improvement in knowledge and interpretation of echocardiographic images before and after completion of the one-day course (pre 62%, post 78%, p<0.01). Skills acquisition resulted in 100% of participants being able to obtain a subcostal view of diagnostic quality by the end of the course, and 86% with a mean time to acquisition of <10s. On completion of the training programme, incorporation of echocardiography into current resuscitation practice did not compromise ALS-compliance. CONCLUSION Novice echocardiographers can obtain knowledge and skills relevant to ALS-compliant peri-resuscitation echocardiography using a range of educational techniques. In addition to the standard one-day training courses available, continued mentored practice and didactic adherence to ALS algorithms is required.

Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view.

Introduction Assessment of the size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for severe hypovolaemia [1], predict fluid responsiveness (FR) [2, 3] and assess potential intolerance to fluid loading. IVC size, collapsibility (IVCc) [2] and distensibility (IVCd) [3] have gained acceptance by emergency and intensive care unit (ICU) clinicians as FR predictors in patients with shock [4]. The ease of acquisition, reproducibility of measurements and increasing availability of ultrasound devices have supported the expansion of its use. Conflicting results have also been published [5, 6]. Injudicious application in clinical contexts where these indices have not been specifically tested may, however, mislead. On the basis of physiological principles and available, although limited, scientific evidence, it can be hypothesized that in a number of clinical conditions IVC size and/or respiratory variability may not depend on volume status and may not predict FR accurately. Although not specifically investigated yet, these conditions can be described and grouped on the basis of their main physiological determinant, as follows (Table 1) (pictorial samples are also presented as electronic supplementary material, ESM):

Ultrasound performs better than radiographs

We applaud the British Thoracic Society (BTS) for its efforts to improve patient care through scientific evidence. We thus recognise the recent guidelines on pleural procedures and thoracic ultrasound (TUS) as an important attempt to develop a rational approach to chest sonography.1 However, we are concerned that the BTS has reached conclusions based on a less complete review of TUS. The guidelines state that ‘the utility of thoracic ultrasound for diagnosing a pneumothorax is limited in hospital practice due to the ready availability of chest x-rays (CXR) and conflicting data from published reports’.1 This conclusion appears to be based on a small (but landmark) study of 11 patients from 1986 to 1989, two small studies with only four pneumothoraces in …

Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia

BACKGROUND Lung ultrasound (LUS) has been successfully applied for monitoring aeration in ventilator-associated pneumonia (VAP) and to diagnose and monitor community-acquired pneumonia. However, no scientific evidence is yet available on whether LUS reliably improves the diagnosis of VAP. METHODS In a multicenter prospective study of 99 patients with suspected VAP, we investigated the diagnostic performance of LUS findings of infection, subpleural consolidation, lobar consolidation, and dynamic arborescent/linear air bronchogram. We also evaluated the combination of LUS with direct microbiologic examination of endotracheal aspirates (EA). Scores for LUS findings and EA were analyzed in two ways. First, the clinical-LUS score (ventilator-associated pneumonia lung ultrasound score [VPLUS]) was calculated as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; and purulent EA, 1 point. Second, the VPLUS-direct gram stain examination (EAgram) was scored as follows: ≥ 2 areas with subpleural consolidations, 1 point; ≥ 1 area with dynamic arborescent/linear air bronchogram, 2 points; purulent EA, 1 point; and positive direct gram stain EA examination, 2 points. RESULTS For the diagnosis of VAP, subpleural consolidation and dynamic arborescent/linear air bronchogram had a positive predictive value of 86% with a positive likelihood ratio of 2.8. Two dynamic linear/arborescent air bronchograms produced a positive predictive value of 94% with a positive likelihood ratio of 7.1. The area under the curve for VPLUS-EAgram and VPLUS were 0.832 and 0.743, respectively. VPLUS-EAgram ≥ 3 had 77% (58-90) specificity and 78% (65-88) sensitivity; VPLUS ≥ 2 had 69% (50-84) specificity and 71% (58-81) sensitivity. CONCLUSIONS By detecting ultrasound features of infection, LUS was a reliable tool for early VAP diagnosis at the bedside. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02244723; URL: www.clinicaltrials.gov.

Assessment of a New E-Learning System on Thorax, Trachea, and Lung Ultrasound

Background. Lung ultrasound has become an emerging tool in acute and critical care medicine. Combined theoretical and hands-on training has been required to teach ultrasound diagnostics. Current computer technology allows for display, explanation, and animation of information in a remote-learning environment. Objective. Development and assessment of an e-learning program for lung ultrasound. Methods. An interactive online tutorial was created. A prospective learning success study was conducted with medical students using a multiple-choice test (Trial A). This e-learning program was used as preparation for a certified course followed by an evaluation of trained doctors (Trial B) by linear analogue scales. Pretests were compared with postcourse tests and sustainability tests as well as a posttest of a one-day custom classroom training. Results. In Trial A, during the learning success study (n = 29), the increase of correct answers was 11.7 to 17/20 in the post-test and to 16.6/20 in the sustainability test (relative change 45.1%, P < 0.0001). E-learning almost equalled scores of classroom-based training regarding gain and retention of factual knowledge. In Trial B, nineteen participating doctors found a 79.5% increase of knowledge (median, 95% CI: 69%; 88%). Conclusion. The basics of lung ultrasound can be taught in a highly effective manner using e-learning.

Usefulness of combined bedside lung ultrasound and echocardiography to assess weaning failure from mechanical ventilation: A suggestive case

Objective:Recognition of the cardiac origin of weaning failure is a crucial issue for successful discontinuation of mechanical ventilation. Bedside lung ultrasound and echocardiography have shown a potential in predicting weaning failure. Objective of this report was to describe the case of a patient repeatedly failing to wean from mechanical ventilation, where the combined use of lung ultrasound and echocardiography during a spontaneous breathing trial uncovered an unexpected cause of the failure. Design:Case report. Setting:General ICU of a university teaching hospital. Patients:Single case, abdominal surgery postoperative patient, not predicted to experience a difficult weaning. Interventions:Cardiovascular therapy adjustments consistent with lung ultrasound and echocardiography findings acquired during spontaneous breathing trials. Measurements and Main Results:All patient’s standard hemodynamic and respiratory parameters, datasets from comprehensive lung ultrasound and echocardiographic examinations, and pertinent data from biochemistry exams, were collected during two spontaneous breathing trials. Data from beginning and end of each of the two ultrasound monitored weaning trials, and from the end of the successful weaning trial following therapy and the previously failed one, were analyzed and qualitatively compared. Lung ultrasound performed at the end of the failed spontaneous breathing trial showed a pattern consistent with increased extravascular lung water (diffuse, bilateral, symmetrical, homogeneous sonographic interstitial syndrome). Concurrent echocardiography diagnosed left ventricular diastolic failure. Ultrasound findings at the end of the successful weaning trial showed normalization of the lung pattern and improvement of the echocardiographic one. The atient eventually returned to spontaneous respiration and was discharged from the ICU. Conclusions:The use of bedside lung ultrasound and echocardiography disclosed left ventricular diastolic dysfunction as unexpected cardiogenic cause of weaning failure and lead to subsequent correct patient management.