Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound

Department of Emergency Medicine, San Luigi Gonzaga University Hospital, 10043 Orbassano, Torino, Italy.
Intensive Care Medicine (Impact Factor: 7.21). 03/2012; 38(4):577-91. DOI: 10.1007/s00134-012-2513-4
Source: PubMed


The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings.
A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus.
Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear.
This document reflects the overall results of the first consensus conference on "point-of-care" lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

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    • "Initially, B-lines are present in the lung base, but extend with increasing capillary venous pressure to the superior lung. In cardiac edema, interstitial syndrome is usually bilateral and symmetric, with only a few pleural abnormalities, whereas acute respiratory distress syndrome presents with subpleural consolidations, ''spared areas'' of normal parenchyma, pleural line abnormalities and a non-homogeneous distribution of B-lines (Volpicelli et al. 2012). A diffuse and non-homogeneous distribution of B-lines, in conjunction with fragmentation and thickening of the pleural line, is also characteristic of pulmonary fibrosis (Copetti et al. 2008; Kreuter and Mathis 2014; Volpicelli et al. 2006). "
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    ABSTRACT: The value of ultrasound techniques in examination of the pleurae and lungs has been underestimated over recent decades. One explanation for this is the assumption that the ventilated lungs and the bones of the rib cage constitute impermeable obstacles to ultrasound. However, a variety of pathologies of the chest wall, pleurae and lungs result in altered tissue composition, providing substantially increased access and visibility for ultrasound examination. It is a great benefit that the pleurae and lungs can be non-invasively imaged repeatedly without discomfort or radiation exposure for the patient. Ultrasound is thus particularly valuable in follow-up of disease, differential diagnosis and detection of complications. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can tolerably be performed under real-time ultrasound guidance. In this article, an updated overview is given presenting not only the benefits and indications, but also the limitations of pleural and pulmonary ultrasound.
    Full-text · Article · Feb 2015 · Ultrasound in Medicine & Biology
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    • "But CT is not always easily available in all emergency departments and is limited by exposure risks and costs [11] [12]. Lung ultrasonography (LUS) has also been proposed for detection of pneumonia [13] [14] [15] [16] [17], but it is still not widely accepted in clinical practice [18] [19]. This is because LUS has been generally validated by comparison with CXR, which is recognized to have low specificity, whereas CT was only sporadically used as comparator. "
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    ABSTRACT: Background and Objective. Chest X-ray is recommended for routine use in patients with suspected pneumonia, but its use in emergency settings is limited. In this study, the diagnostic performance of a new method for quantitative analysis of lung ultrasonography was compared with bedside chest X-ray and visual lung ultrasonography for detection of community-acquired pneumonia, using thoracic computed tomography as a gold standard. Methods. Thirty-two spontaneously breathing patients with suspected community-acquired pneumonia, undergoing computed tomography examination, were consecutively enrolled. Each hemithorax was evaluated for the presence or absence of abnormalities by chest X-ray and quantitative or visual ultrasonography. Results. Quantitative ultrasonography showed higher sensitivity (93%), specificity (95%), and diagnostic accuracy (94%) than chest X-ray (64%, 80%, and 69%, resp.), visual ultrasonography (68%, 95%, and 77%, resp.), or their combination (77%, 75%, and 77%, resp.). Conclusions. Quantitative lung ultrasonography was considerably more accurate than either chest X-ray or visual ultrasonography in the diagnosis of community-acquired pneumonia and it may represent a useful first-line approach for confirmation of clinical diagnosis in emergency settings.
    Full-text · Article · Feb 2015 · BioMed Research International
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    • "Larger footprint lower frequency curvilinear (up to 60 mm in length) or microconvex probes can be used to rapidly assess the extent of lung pathology, especially in patients with impending respiratory failure [5,15]. Interstitial syndrome on ultrasound is visualized as numerous B-lines (at least 3 per field of view) [8,11,12]. Acute respiratory distress syndrome (ARDS) is seen as the predominant presence of confluent B lines ( at least >3 B lines per field) or white lung associated with pleural line abnormalities described as thickening (>2 mm) or coarsening, with few spared areas (observation of A lines) [10]. Bacterial (consolidated) pneumonia is distinguished from viral (interstitial) pneumonia by ultrasonography visualized as lung consolidations with sonographic air bronchograms, typically larger than 0.5 cm in depth [4,5,7,16,17]. "
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    ABSTRACT: Background Lung ultrasound has been shown to identify in real-time, various pathologies of the lung such as pneumonia, viral pneumonia, and acute respiratory distress syndrome (ARDS). Lung ultrasound maybe a first-line alternative to chest X-ray and CT scan in critically ill patients with respiratory failure. We describe the use of lung ultrasound imaging and findings in two cases of severe respiratory failure from avian influenza A (H7N9) infection. Methods Serial lung ultrasound images and video from two cases of H7N9 respiratory failure requiring mechanical ventilation and extracorporeal membrane oxygenation in a tertiary care intensive care unit were analyzed for characteristic lung ultrasound findings described previously for respiratory failure and infection. These findings were followed serially, correlated with clinical course and chest X-ray. Results In both patients, characteristic lung ultrasound findings have been observed as previously described in viral pulmonary infections: subpleural consolidations associated or not with local pleural effusion. In addition, numerous, confluent, or coalescing B-lines leading to ‘white lung’ with corresponding pleural line thickening are associated with ARDS. Extension or reduction of lesions observed with ultrasound was also correlated respectively with clinical worsening or improvement. Coexisting consolidated pneumonia with sonographic air bronchograms was noted in one patient who did not survive. Conclusions Clinicians with access to point-of-care ultrasonography may use these findings as an alternative to chest X-ray or CT scan. Lung ultrasound imaging may assist in the efficient allocation of intensive care for patients with respiratory failure from viral pulmonary infections, especially in resource scarce settings or situations such as future respiratory virus outbreaks or pandemics.
    Full-text · Article · May 2014 · Critical ultrasound journal
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