Mauro F. Frascisco

Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure.

PURPOSES Multiple artifacts B lines (B+) at transthoracic lung ultrasound have been proposed as a sonographic sign of pulmonary congestion. Our aim is to assess B+ clearance after medical treatment in acute decompensated heart failure (ADHF) and to compare the usefulness of sonography with other traditional tools in monitoring resolution of pulmonary congestion. METHODS Eighty-one patients with a diagnosis of ADHF were submitted to lung ultrasound and chest radiography at admission, and 70 of them underwent the same procedures as control group after 4.2 +/- 1.7 days of medical treatment. The ultrasound examination was performed with 11 scans on as many anterolateral thoracic areas (6 on the right side and 5 on the left side). Then, we calculated a sonographic score counting the B+ scans and compared it with radiologic score for extravascular lung water, clinical, and plasma brain natriuretic peptide improvement. MAIN RESULTS All patients showed B+ pattern at admission and significant clearing after treatment, with median number of 8 positive scans (range, 3-9 scans) vs 0 (range, 0-7 scans) (P < .05). Our sonographic score showed positive linear correlation with radiologic score (r = 0.62; P < .05), clinical score (r = 0.87; P < .01), and brain natriuretic peptide levels (r = 0.44; P < .05). Delta Sonographic score correlated with Delta clinical (r = 0.55; P < .05) and radiologic (r = 0.28; P < .05) scores. CONCLUSIONS B line pattern mostly clears after adequate medical treatment of ADHF and represents an easy-to-use alternative bedside diagnostic tool for clinically monitoring pulmonary congestion in patients with ADHF.

Lung Ultrasound Predicts Well Extravascular Lung Water but Is of Limited Usefulness in the Prediction of Wedge Pressure

Background:Pulmonary congestion is indicated at lung ultrasound by detection of B-lines, but correlation of these ultrasound signs with pulmonary artery occlusion pressure (PAOP) and extravascular lung water (EVLW) still remains to be further explored. The aim of the study was to assess whether B-lines, and eventually a combination with left ventricular ejection fraction (LVEF) assessment, are useful to differentiate low/high PAOP and EVLW in critically ill patients. Methods:The authors enrolled 73 patients requiring invasive monitoring from the intensive care unit of four university-affiliated hospitals. Forty-one patients underwent PAOP measurement by pulmonary artery catheterization and 32 patients had EVLW measured by transpulmonary thermodilution method. Lung and cardiac ultrasound examinations focused to the evaluation of B-lines and gross estimation of LVEF were performed. The absence of diffuse B-lines (A-pattern) versus the pattern showing prevalent B-lines (B-pattern) and the combination with normal or impaired LVEF were correlated with cutoff levels of PAOP and EVLW. Results:PAOP of 18 mmHg or less was predicted by the A-pattern with 85.7% sensitivity (95% CI, 70.5 to 94.1%) and 40.0% specificity (CI, 25.4 to 56.4%), whereas EVLW 10 ml/kg or less with 81.0% sensitivity (CI, 62.6 to 91.9%) and 90.9% specificity (CI, 74.2 to 97.7%). The combination of A-pattern with normal LVEF increased sensitivity to 100% (CI, 84.5 to 100%) and specificity to 72.7% (CI, 52.0 to 87.2%) for the prediction of PAOP 18 mmHg or less. Conclusions:B-lines allow good prediction of pulmonary congestion indicated by EVLW, whereas are of limited usefulness for the prediction of hemodynamic congestion indicated by PAOP. Combining B-lines with estimation of LVEF at transthoracic ultrasound may improve the prediction of PAOP.

Lung ultrasound in diagnosing and monitoring pulmonary interstitial fluid

Chronic heart failure is a complex clinical syndrome often characterised by recurrent episodes of acute decompensation. This is acknowledged as a major public health problem, leading to a steadily increasing number of hospitalisations in developed countries. In decompensated heart failure, the redistribution of fluids into the pulmonary vascular bed leads to respiratory failure, a common cause of presentation to the emergency department. The ability to diagnose, quantify and monitor pulmonary congestion is particularly important in managing the disease. Lung ultrasound (US) is a relatively new method that has gained a growing acceptance as a bedside diagnostic tool to assess pulmonary interstitial fluid and alveolar oedema. The latest developments in lung US are not because of technological advance but are based on new applications and discovering the meanings of specific sonographic artefacts designated as B-lines. Real-time sonography of the lung targeted to detection of B-lines allows bedside diagnosis of respiratory failure due to impairment of cardiac function, as well as quantification and monitoring of pulmonary interstitial fluid. Lung US saves time and cost, provides immediate information to the clinician and relies on very easy-toacquire and highly reproducible data.RiassuntoL’insufficienza cardiaca cronica è una complessa sindrome clinica caratterizzata spesso da episodi ricorrenti di scompenso acuto. Tale condizione rappresenta uno dei maggiori problemi di salute pubblica, che porta ad un numero sempre crescente di ospedalizzazione nei paesi più sviluppati. Nella insufficienza cardiaca scompensata, la redistribuzione dei fluidi nel letto vascolare polmonare comporta l’insufficienza respiratoria, una causa comune di presentazione nel Dipartimento di Emergenza. La capacità di diagnosticare, quantificare e monitorare la congestione polmonare è di particolare importanza nel trattamento di questa malattia. L’ecografia polmonare è un metodo relativamente nuovo, oramai sempre più diffusamente riconosciuto come mezzo diagnostico utile per la valutazione dell’edema interstiziale ed alveolare al letto del paziente. Il recente sviluppo dell’ecografia polmonare non è legato allo sviluppo tecnologico, ma è basato sulle nuove applicazioni e sulla scoperta del significato di specifici artefatti ecografici chiamati linee B. L’ecografia polmonare mirata alla identificazione delle linee B permette la diagnosi al letto del paziente in tempo reale dell’insufficienza respiratoria dovuta a scompenso cardiaco, cosÌ come la quantificazione ed il monitoraggio della congestione polmonare. La tecnica ecografica polmonare riduce i tempi ed i costi diagnostici, e si basa su segni semplici da identificare ed altamente riproducibili che forniscono immediate informazioni nella gestione del paziente.

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED.

PURPOSES Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR). METHODS Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS. RESULTS In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis. CONCLUSIONS Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.

Sonographic detection of radio-occult interstitial lung involvement in measles pneumonitis.

We present the cases of 23- and 38-year-old healthy patients with clinical diagnosis of acute measles who experienced shortness of breath on exertion with nonproductive cough and showed signs of mild respiratory failure at presentation in the emergency department (ED) but with normal chest radiograph and auscultation. In both cases, bedside ultrasound of the lung showed the appearance of signs of interstitial diffuse involvement with vertical B lines spread all over the lateral and posterior chest wall. This sonographic pattern is typical of the interstitial involvement during acute viral pneumonitis that can be missed by physical examination and chest radiography. Even without radiologic infiltrates and pulmonary sounds, based on sonographic and arterial gas signs, a diagnosis of measles pneumonitis was done and patients admitted to the ward for close follow-up and supportive care. We hypothesize a new diagnostic role of bedside lung sonography in screening patients presenting to the ED with initial lung involvement in measles who warrant close follow-up and hospital admission.

The clinical spectrum of acute 'uncomplicated' pyelonephritis from an emergency medicine perspective

Acute uncomplicated pyelonephritis (APN) is a complex clinical entity, which is defined differently based on clinical or imaging criteria. The aim of this study was to describe the clinical and radiological presentation of APN-upper urinary tract infection (UTI) cases observed between May 2005 and June 2006 and hospitalised in the Emergency Medicine ward of San Luigi Hospital, Orbassano, Turin, Italy. All patients underwent imaging scans and were differentiated on the basis of parenchymal involvement. Of around 45000 patient visits to the emergency room between May 2005 and June 2006, 23 patients were diagnosed as having uncomplicated upper UTI (all female, age 15-57 years). Renal parenchymal involvement was confirmed by imaging in 16 cases (69.6%). The imaging spectrum ranged from a small single lesion to large multiple defects; on admission, 2 cases had no pain and 2 had no fever; lower urinary tract symptoms were present in only 13 patients (7 with parenchymal involvement). All patients with parenchymal involvement had at least one sign of systemic inflammation-infection. Most patients (15) had taken antibiotics before hospitalisation; consequently, urine cultures were negative in 21 cases (14 cases with positive imaging (87.5%)). The data from patients with and without parenchymal involvement overlapped, the only difference being a higher prevalence of high CRP levels in cases with parenchymal involvement.

Sonographic diagnosis of pulmonary embolism with cardiac arrest without major dilation of the right ventricle or direct sign of lower limb venous thrombosis

Bedside focused echocardiography diagnosis of massive pulmonary embolism during cardiac arrest is mainly based on the detection of a dilated right ventricle, while the lack of compressibility of a deep vein of the lower limbs confirms diagnosis in doubtful cases. We describe a case of unusual sonographic signs in a young woman with cardiac arrest due to massive pulmonary embolism showing spontaneous blood echogenicity in the inferior vena cava (“sludge sign”) and nonmodulated (“flat”) Doppler waveform in the left lower limb veins, suggesting isolated iliac vein thrombosis.

A case of unilateral re-expansion pulmonary oedema successfully treated with non-invasive continuous positive airway pressure.

Unilateral re-expansion pulmonary oedema is a rare threatening complication of the treatment of lung atelectasis, pleural effusion or pneumothorax, the pathogenesis of which is not completely known. The clinical picture varies considerably from asymptomatic radiological findings to dramatic respiratory failure with circulatory shock. There are few literature reports of the treatment of re-expansion pulmonary oedema with non-invasive continuous positive airway pressure. We present the case of a 75-year-old man who presented in our emergency room with a large left-sided spontaneous pneumothorax and developed severe respiratory failure and circulatory collapse after drainage via a chest tube. The diagnosis of unilateral re-expansion pulmonary oedema was made and he was successfully treated with non-invasive continuous positive airway pressure. Literature data about the aetiological and pathogenetic factors of the condition are also considered.

Young Man With Left Thoracic Pain

A 19-year-old man presented to the emergency department, complaining of left thoracic pain and dyspnea on exertion for 2 days. He had a history of 3 recurrences of primary spontaneous left pneumothoraces. The third recurrence was treated by abrasion pleurodesis 7 months before. Bedside lung ultrasonography in the supine position showed an unusual pattern in the anterior left chest: absent lung sliding but alternating small areas without sonographic B lines and small areas with B lines and sonographic lung pulse (Figure 1; Video 1). A “lung point” was detected by ultrasonography at the lateral chest seventh intercostal space (Figure 2; Video 2). Figure 1. Lung ultrasonography of the anterior chest, showing alternation of B lines and lung pulse (white stars) with areas of motionless lung (white double-headed arrow). The lung pulse, which is a vertical movement of the lung synchronous with heartbeats, is not evident on a still image (but can be seen on Video 1). B lines are vertical echogenic artifacts that may or may not be evident in normal lung. Lung pulse and B lines are strongly predictive of the absence of a pneumothorax. Figure 2. Lung ultrasonography of the lateral chest, showing alternation between lung sliding (no-PNX side) and absence of lung sliding (PNX side). This is the lung point. Lung sliding, which is indicative of the absence of a pneumothorax, is the horizontal movement of the lung synchronous with respiration and not evident on a still image (but can be seen on Video 2). The alternation of sliding and nonsliding patterns is highly predictive of pneumothorax and indicates the point on the chest at which the visceral and parietal pleura are touching again, ie, the edge of the pneumothorax. White arrow pleural interface. PNX, Pneumothorax.

A case of severe hypercalcemia with acute renal failure in sarcoidosis: a diagnostic challenge for the emergency department.

We present and discuss the case of a man admitted to our emergency room because of severe hypercalcemia and renal failure with maintained diuresis. We diagnosed a relapse of sarcoidosis, manifesting as hypercalcemia and renal failure, based on a history of lung sarcoidosis. This is a rare complication of sarcoidosis, due to granulomatous production of vitamin D. This mechanism may have been exacerbated by exposure of sunlight. The initial treatment of the patient was directed towards lowering the circulating calcium level through hyperhydration and forced diuresis, with secondary control of granulomatous activity using corticosteroid therapy. The patient was discharged after 7 days with normal levels of serum calcium, urinary calcium excretion and serum creatinine. Recognition of this rare cause of hypercalcemia is a challenge for the emergency physician.