Rosangela Giannuzzi

Ultrasound M-mode assessment of diaphragmatic kinetics by anterior transverse scanning in healthy subjects.

The purpose of this study was to set an effective standardized method to assess diaphragmatic kinetics by ultrasound. Forty healthy volunteers were submitted to a B- and M-mode ultrasound study using a convex transducer positioned in the subcostal anterior area for transverse scanning. Ultrasound examination was completed in 38/40 cases (95%), spending on average <10 min for examination. The resting and forced diaphragmatic excursions were 18.4 ± 7.6 and 78.8 ± 13.3 mm, respectively, unrelated to demographic or anthropometric parameters: intraobserver variability on three successive measurements resulted in 6.0% and in 3.9%, respectively. An inexperienced sonographer completed the ultrasound examination in 37/40 cases, spending on average >15 min, with significant, although marginal, interobserver variability (31.9% and 14.7% for resting and forced diaphragmatic excursion, respectively). Bedside ultrasonography by an anterior subcostal transverse scanning on semi-recumbent patient proves to be a safe, feasible, reliable, fast, relatively easy and reproducible way to assess diaphragm movement.

The role of chest ultrasonography in the management of respiratory diseases: document II

Chest ultrasonography can be a useful diagnostic tool for respiratory physicians. It can be used to complete and widen the general objective examination also in emergency situations, at the patient’s bedside. The aim of this document is to promote better knowledge and more widespread use of thoracic ultrasound among respiratory physicians in Italy.This document II is focused on advanced approaches to chest ultrasonography especially in diagnosing sonographic interstitial syndrome with physical hypotheses about the genesis of vertical artifacts, differential diagnosis of cardiogenic pulmonary edema and non-cardiogenic pulmonary edema, raising diagnostic suspicion of pulmonary embolism, ultrasound characterization of lung consolidations and the use of ultrasonography to guide procedural interventions in pulmonology.Finally, document II focuses on chest ultrasonography as useful diagnostic tool in neonatal and pediatric care.

Early recognition of the 2009 pandemic influenza A (H1N1) pneumonia by chest ultrasound

IntroductionThe clinical picture of the pandemic influenza A (H1N1)v ranges from a self-limiting afebrile infection to a rapidly progressive pneumonia. Prompt diagnosis and well-timed treatment are recommended. Chest radiography (CRx) often fails to detect the early interstitial stage. The aim of this study was to evaluate the role of bedside chest ultrasonography (US) in the early management of the 2009 influenza A (H1N1)v infection.Methods98 patients who arrived in the Emergency Department complaining of influenza-like symptoms were enrolled in the study. Patients not displaying symptoms of acute respiratory distress were discharged without further investigations. Among patients with clinical suggestion of a community-acquired pneumonia, cases encountering other diagnoses or comorbidities were excluded from the study. Clinical history, laboratory tests, CRx, and computed tomography (CT) scan, if indicated, contributed to define the diagnosis of pneumonia in the remaining patients. Chest US was performed by an emergency physician, looking for presence of interstitial syndrome, alveolar consolidation, pleural line abnormalities, and pleural effusion, in 34 patients with a final diagnosis of pneumonia, in 16 having normal initial CRx, and in 33 without pneumonia, as controls.ResultsChest US was carried out without discomfort in all subjects, requiring a relatively short time (9 minutes; range, 7 to 13 minutes). An abnormal US pattern was detected in 32 of 34 patients with pneumonia (94.1%). A prevalent US pattern of interstitial syndrome was depicted in 15 of 16 patients with normal initial CRx, of whom 10 (62.5%) had a final diagnosis of viral (H1N1) pneumonia. Patients with pneumonia and abnormal initial CRx, of whom only four had a final diagnosis of viral (H1N1) pneumonia (22.2%; P < 0.05), mainly displayed an US pattern of alveolar consolidation. Finally, a positive US pattern of interstitial syndrome was found in five of 33 controls (15.1%). False negatives were found in two (5.9%) of 34 cases, and false positives, in five (15.1%) of 33 cases, with sensitivity of 94.1%, specificity of 84.8%, positive predictive value of 86.5%, and negative predictive value of 93.3%.ConclusionsBedside chest US represents an effective tool for diagnosing pneumonia in the Emergency Department. It can accurately provide early-stage detection of patients with (H1N1)v pneumonia having an initial normal CRx. Its routine integration into their clinical management is proposed.

The role of emergency ultrasound in the diagnosis of acute non-traumatic epigastric pain

The epigastrium is the site where pain coming from both abdominal and extraabdominal organs is frequently referred. Although acute or chronic diseases of the stomach, duodenum, liver, pancreas and biliary tree are the most common causes of acute epigastric pain, several other entities, potentially more severe, should also be suspected and investigated. Clinical bedside ultrasonography (US) is actually the first-line imaging in acute epigastric pain patients presenting to the hospital Emergency Department (ED) because it is rapid, noninvasive, relatively inexpensive and focused, repeatable and reliable. Moreover, the systematic use of emergency US as a complement to routine management might save economic resources by avoiding further costs for complications and substantially reducing the time for making an accurate diagnosis. The purpose of this paper is to review the US spectrum of the most common diseases responsible for acute epigastric pain onset. We also propose a focused, well codified US protocol, that we call the “

The ‘Dark Side' of Chronic Obstructive Pulmonary Disease

approach”, based on our clinical experience and the current literature for acute non-traumatic epigastric pain evaluation in an emergency setting. Its systematic application by the emergency physician may reduce the wait for diagnosis and the over-usage of second-line radiological techniques, including computed tomography, as well as to increase the diagnostic accuracy with potential benefits for patient (safety), physician (efficacy) and the institution (efficiency).

Septic shock recognition by bedside chest ultrasonography in the emergency department

contraction, either thickness or flattening or motion, could provide relevant information on respiratory mechanics and functional capacity to improve diagnosis formulation and evaluate the progression of COPD. Traditional respiratory functional tests mainly assess downstream airflow limitations in COPD patients. By contrast, the diaphragm represents the less explored ‘side’ of the COPD, being affected by the upstream effects of airway obstruction (local overload), other than systemic imbalance. In this issue of Respiration , Smargiassi et al. [3] propose ultrasonography (US) in detecting diaphragm thickness and thickening at different lung volumes in a consecutive series of patients with COPD. The relationship between US measurements and parameters of respiratory function and body composition is computed. All diaphragm thickness measures are found positively related to fat-free mass. As regards lung volumes, diaphragm thickness at total lung capacity is found to be closely related to the inspiratory capacity. Moreover, there is a significant negative association between the values for diaphragm thickening and the air trapping indices. The authors propose that the assessment of the diaphragm is a useful tool to study the progression of the disease in COPD patients in terms of lung hyperinflation and loss of fat-free mass. The utility of US in the evaluation of diaphragm function in COPD has previously been established, and it will Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide, accounting for a major healthcare problem. It is characterized by incompletely reversible airway obstruction with airway inflammation and remodeling as initial pathological lesions. Accordingly, functional and anatomical changes in different compartments of the lungs occur, leading to air trapping and pulmonary hyperinflation and imposing an excessive load on the respiratory muscles. Other than these complex mechanical lung changes, increasing evidence indicates that COPD results in important systemic manifestations due to inflammation, gas exchange abnormalities, nutritional imbalance, comorbidity and chronic steroid administration, which might affect skeletal muscle performance, including diaphragm function [1] . Spirometry has universally been recognized as the gold standard for the diagnosis of COPD. However, it is accepted that a single measurement of FEV 1 incompletely represents the complex clinical picture of COPD. Therefore, the evaluation of additional parameters is recommended in order to assess the respiratory and systemic consequences of COPD [2] . The diaphragm is the principal generator of tidal volume in normal subjects at rest. A reduction in diaphragm mobility has been identified in patients with COPD and has been associated with a decline in pulmonary function parameters. Therefore, the assessment of diaphragmatic Published online: April 11, 2014

Economic analysis of bedside ultrasonography (US) implementation in an Internal Medicine department

The case of a young man who presented in the emergency department complaining of sudden onset of cough, fever and haemoptysis is described. Chest ultrasonography rapidly diagnosed an acute respiratory distress syndrome picture, which was confirmed on computed tomography. This allowed prompt management of the patient. Blood cultures yielded Streptococcus pyogenes and pharyngeal exudates were positive for influenza B virus.