Giorgio Garofalo

Usefulness of lung ultrasound in the bedside distinction between pulmonary edema and exacerbation of COPD

This review discusses the usefulness of bedside lung ultrasound in the diagnostic distinction between different causes of acute dyspnea in the emergency setting, particularly focusing on differential diagnosis of pulmonary edema and exacerbation of chronic obstructive pulmonary disease (COPD). This is possible using a simple unit and easy-to-acquire technique performed by radiologists and clinicians. Major advantages include bedside availability, absence of radiation, high feasibility and reproducibility, and cost efficiency. The technique is based on analysis of sonographic artifacts instead of direct visualization of pulmonary structures. Artifacts are because of interactions between water-rich structures and air and are called “comet tails” or B lines. When such artifacts are widely detected on anterolateral transthoracic lung scans, we diagnose diffuse alveolar-interstitial syndrome, which is often a sign of acute pulmonary edema. This condition rules out exacerbation of COPD as the main cause of an acute dyspnea.

CT-guided percutaneous transthoracic biopsy in the diagnosis of mediastinal masses: evaluation of 73 procedures

PurposeThis study was performed to evaluate the factors affecting the diagnostic accuracy and rate of complications of CT-guided percutaneous transthoracic needle biopsy of mediastinal masses.Materials and methodsWe reviewed 73 consecutive mediastinal biopsies in 70 patients. Final diagnoses were based on a retrospective analysis of surgical outcomes, results of repeat biopsies or findings of imaging and clinical follow-up lasting at least 4 months. Benign and malignant biopsy findings were compared with the final outcomes to determine the diagnostic accuracy of the method. Finally, we analysed the complications.ResultsCT-guided percutaneous transthoracic needle biopsy provided adequate samples in 61/73 cases, with a total sample rate of 83.6%. Of these 61 biopsies, 51 yielded a correct diagnosis with specific histological typing, mainly in the case of thymoma and metastasis. Lymphomas were less reliably diagnosed. The overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy values were 83.6%, 100%, 100%, 35.3% and 83.6%, respectively. Pneumothorax was the most common complication (5.5%).ConclusionsCT-guided percutaneous transthoracic needle biopsy is an easy, reliable and safe procedure that obviates the need for exploratory surgery in medically treatable or unresectable cases. It should be the first invasive procedure in the diagnostic workup of mediastinal masses.RiassuntoObiettivoValutare i fattori che influenzano l’accuratezza diagnostica ed il tasso di complicanze dell’agobiopsia transtoracica percutanea TC-guidata di lesioni espansive mediastiniche.Materiali e metodiSono state considerate 73 procedure bioptiche mediastiniche consecutive su 70 pazienti. La diagnosi finale deriva dall’analisi dei risultati della chirurgia, di un’eventuale successiva agobiopsia transtoracica o dall’esito del follow-up clinico/radiologico pari ad un periodo non inferiore a 4 mesi. I riscontri bioptici con esito benigno e maligno sono stati confrontati con la diagnosi finale, ricavando l’accuratezza diagnostica della metodica. È stata quindi condotta un’analisi delle complicanze.RisultatiL’agobiopsia percutanea trastoracica sotto guida TC ha fornito materiale adeguato in 61/73 casi, offrendo un tasso di campionamento complessivo del 83,6%. Di queste 61 procedure, 51 hanno stabilito la diagnosi corretta con specificità di istotipo, principalmente nei casi di timoma e di lesioni metastatiche. Il gruppo dei linfomi ha riscontro diagnostico meno affidabile. I valori globali di sensibilità, specificità, valore predittivo positivo, valore predittivo negativo e accuratezza diagnostica sono risultati pari a 83,6%, 100%, 100%, 35,3%, e 83,6% rispettivamente. Lo pneumotorace ha rappresentato la complicanza più comune (5,5%).ConclusioniL’agobiopsia percutanea trastoracica sotto guida TC rappresenta procedura semplice, affidabile e sicura, evitando il ricorso ad un accertamento esplorativo chirurgico nei casi passibili di trattamento medico o non resecabili. Dovrebbe costituire il primo accertamento invasivo nella gestione diagnostica di una formazione espansiva mediastinica.

Ultrasound diagnosis of pneumothorax

Purpose.The purpose of this study was to show the effectiveness of ultrasound (US) in the evaluation of pneumothorax by comparison with X–rays and computed tomography (CT).Materials and methods.A series of 184 patients (130 men and 54 women), aged 26 to 82 years, underwent chest US after percutaneous needle biopsy. US findings were compared with CT postbiopsy selective slices and to X–rays.Results.Pneumothorax was identified in 46 patients (25%) by CT, in 44 by US, with no false positives, and in 19 by X–rays. US sensitivity was 95.65%, specificity 100% and diagnostic effectiveness 98.91%.Conclusions.Chest US was found to be a valuable diagnostic tool in pneumothorax diagnosis, with diagnostic effectiveness well beyond X–rays and similar to CT.

Contrast–enhanced ultrasonography in Crohn’s disease

Purpose.The purpose of this study was to demonstrate the diagnostic efficacy of contrast–enhanced power Doppler (CEPD) after ultrasound (US) with colour power Doppler (CPD) in defining disease activity in patients with ileal Crohn’s disease in the acute phase and during treatment follow–up.Materials and methods.The study included 15 patients with ileal Crohn’s disease, 12 of whom were examined in the acute phase of their illness and then 30–60 days after treatment. Three patients were studied during clinical quiescence. All patients were examined prior to treatment with US–CPD study and then with contrast–enhanced power Doppler (CEPD) examination (CEPD) with the use of US contrast agent (SonoVue, Bracco), together with clinical assessment and laboratory tests. Disease activity was defined by the Crohn’s Disease Activity Index (CDAI) and some of the most sensitive biohumoural markers. After initial US, CPD and CEPD were performed to assess enhancement of the thickened bowel wall with the use of a reference box and a semiquantitative scoring system.Results.The CEPD study is more reliable then US–CPD in the diagnosis of Crohn’s disease and statistically agrees significantly with clinical and laboratory indices for disease activity.Conclusions.This study demonstrates the importance of US–CPD in the follow–up of patients with Crohn’s disease and suggests systematic use of the US contrast agent, which can improve diagnostic performance of abdominal US study. It also provides more information about patients both in the acute phase and during follow–up, thus improving treatment planning and better monitoring of treatment efficacy.

Follow-up of mediastinal lymphoma: role of ultrasonography

Purpose.Patients with lymphoma are often young and require long and intensive treatment, the toxic effects of which compound the impact of frequent radiological examinations. Computed tomography (CT) is of great value in the evaluation of the mediastinum, which is frequently involved by the disease, but carries a high radiation load. Ultrasonography (US) has therefore been proposed as an alternative procedure to evaluate response to treatment. Major advantages include good compliance, absence of patient risks, low cost, easy reproducibility, dynamic images enabling multiplanar evaluation and qualitative and quantitative criteria. The purpose of this study was to investigate the role of US in evaluating response to treatment in patients with mediastinal lymphomas using CT as the gold standard.Materials and methods.In 2005, 12 patients were evaluated by chest X-ray, mediastinal sonography and contrast-enhanced CT (gold standard). Each mediastinal region was accurately assessed for adenopathies. Lymph nodes were studied by evaluating their structure and morphology, measuring their size and classifying them according to location.Results.US proved to be more sensitive and accurate (93%) than X-ray [66% sensitivity and 68% diagnostic accuracy (DA)]. In particular, the best sensitivity values were observed in the supraaortic (97% vs. 55%), prevascular (97% vs. 39%) and paratracheal (87% vs. 77%) regions and in the aortopulmonary window (80% vs. 0%). Deeper mediastinal compartments (subcarinal region and posterior mediastinum) could not be assessed. X-ray proved to be superior in hilar adenopathies only. US provides qualitative information (hypoechoic or hyperechoic tissues) in addition to quantitative data (maximum diameter of each lymph node) it shares with CT.Discussion.Compared with X-ray, US allows for a better evaluation of the anterior mediastinal regions, showing small, central adenopathies that do not alter the mediastinal lines on X-ray. It is, however, of very limited value in the evaluation of posterior compartments because of their deep location. US adds qualitative criteria to the quantitative criteria typical of CT. Limitations of mediastinal US include site of adenopathies, dependence on the patient’s characteristics (body habit, concurrent diseases and chest anatomy) and dependence on the operator.Conclusions.US may have a specific role in monitoring patients with mediastinal adenopathies, providing early indications on possible response to treatment and allowing the frequency of CT follow-up scans to be reduced. In conclusion, US may be used to complement, but not replace CT, which remains the gold standard.

C2-02: Factors effecting risk of pneumothorax (PNX) in CT-guided transthoracic needle biopsy of lung lesions: results of 708 consecutive procedures

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Pulmonary scan in evaluating alveolar-interstitial syndrome in ER

Diffuse comet-tail artifacts at lung ultrasound are due to thickened interlobular septa and extravascular lung water. This condition is typical of the alveolar-interstitial syndrome due to pulmonary edema, diffuse parenchymal lung disease or ARDS. Aim of our study is to assess the potential of bedside lung ultrasound to diagnose the alveolar-interstitial syndrome in patients admitted to our emergency medicine unit. The ultrasonic feature of multiple and diffuse comet-tail artifacts was investigated during 5 months, in 121 consecutive patients admitted to our unit. Each patient was studied bedside in a supine position, by 8 antero-lateral pulmonary intercostal scans. Ultrasonic results were compared with chest radiograph and clinical outcome. Lung ultrasound showed a sensitivity of 84% and a specificity of 98% in diagnosing the radiologic alveolar-interstitial syndrome. Corresponding figures in the identification of a disease involving lung interstitium were 83% and 96%. These preliminary data show that the study of comet-tail artifacts at lung ultrasound is a method reasonably accurate for diagnosing the alveolar-interstitial syndrome at bedside. This conclusion opens the hypothesis of the usefullness of bedside lung ultrasound in the evaluation of dyspnoeic patients in the emergency setting.