The effect of focused lung ultrasonography on antibiotic prescribing in patients with acute lower respiratory tract infections in Danish general practice: study protocol for a pragmatic randomized controlled trial (PLUS-FLUS).

BACKGROUND: The use of antibiotics is a key driver of antimicrobial resistance and is considered a major threat to global health. In Denmark, approximately 75% of antibiotic prescriptions are issued in general practice, with acute lower respiratory tract infections (LRTIs) being one of the most common indications. Adults who present to general practice with symptoms of acute LRTI often suffer from self-limiting viral infections. However, some patients have bacterial community-acquired pneumonia (CAP), a potential life-threatening infection, that requires immediate antibiotic treatment. Importantly, no single symptom or specific point-of-care test can be used to discriminate the various diagnoses, and diagnostic uncertainty often leads to (over)use of antibiotics. At present, general practitioners (GPs) lack tools to better identify those patients who will benefit from antibiotic treatment. The primary aim of the PLUS-FLUS trial is to determine whether adults who present with symptoms of an acute LRTI in general practice and who have FLUS performed in addition to usual care are treated less frequently with antibiotics than those who only receive usual care. METHODS: Adults (≥ 18 years) presenting to general practice with acute cough (< 21 days) and at least one other symptom of acute LRTI, where the GP suspects a bacterial CAP, will be invited to participate in this pragmatic randomized controlled trial. All participants will receive usual care. Subsequently, participants will be randomized to either the control group (usual care) or to an additional focused lung ultrasonography performed by the GP (+ FLUS). The primary outcome is the proportion of participants with antibiotics prescribed at the index consultation (day 0). Secondary outcomes include comparisons of the clinical course for participants in groups. DISCUSSION: We will examine whether adults who present with symptoms of acute LRTI in general practice, who have FLUS performed in addition to usual care, have antibiotics prescribed less frequently than those given usual care alone. It is highly important that a possible reduction in antibiotic prescriptions does not compromise patients' recovery or clinical course, which we will assess closely. TRIAL REGISTRATION: ClinicalTrials.gov NCT06210282. Registered on January 17, 2024.

Ultrasound in predicting improvement in dyspnoea after therapeutic thoracentesis in patients with recurrent unilateral pleural effusion.

Background: In patients with recurrent pleural effusion, therapeutic thoracentesis is one way of relief. Correct prediction of which patients will experience relief following drainage may support the management of these patients. This study aimed to assess the association between ultrasound (US) characteristics and a relevant improvement in dyspnoea immediately following drainage. Methods: In a prospective, observational study, patients with recurrent unilateral pleural effusion underwent US evaluation of effusion characteristics and diaphragm movement measured by M-mode and the Area method before and right after drainage. The level of dyspnoea was assessed using the modified Borg scale (MBS). A minimal important improvement in dyspnoea was defined as delta MBS ≥ 1. Results: In the 104 patients included, 53% had a minimal important improvement in dyspnoea following thoracentesis. We found no association between US-characteristics, including diaphragm shape or movement (M-mode or the Area method), and a decrease in dyspnoea following drainage. Baseline MBS score ≥ 4 and a fully drained effusion were significant correlated with a minimal important improvement in dyspnoea (OR 3.86 (1.42-10.50), p = 0.01 and 2.86 (1.03-7.93), p = 0.04, respectively). Conclusions: In our study population, US-characteristics including assessment of diaphragm movement or shape was not associated with a minimal important improvement in dyspnoea immediately following thoracentesis.

Detection of Interstitial Lung Disease in Rheumatoid Arthritis by Thoracic Ultrasound. A Diagnostic Test Accuracy study.

OBJECTIVE: The Objective was to determine the diagnostic accuracy of thoracic ultrasound (TUS) for detecting (ILD) in rheumatoid arthritis (RA) with respiratory symptoms. METHODS: Individuals with RA visiting Rheumatological outpatient clinics in the Region of Southern Denmark were systematically screened for dyspnoea, cough, recurrent pneumonia, prior severe pneumonia or a chest X-ray indicating interstitial abnormalities. Eighty participants with a positive screening were consecutively included. Individuals were not eligible if they had a chest high-resolution CT (HRCT) <12 months or were already diagnosed with ILD. A blinded TUS expert evaluated TUS, and TUS was registered as positive for ILD if ≥10 B-lines or bilateral thickened and fragmented pleura were present. The primary outcomes were TUS's sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV). An ILD-specialised thoracic radiologist assessed HRCT, followed by a multi-disciplinary team discussion, which was the reference standard. The accepted window of HRCT was <30 days after TUS was performed. RESULTS: 77 participants received HRCT <30 days after TUS, and 23 (30%) were diagnosed with ILD. TUS had a sensitivity of 82.6% (95% CI: 61.2% to 95.0%) and a specificity of 51.9% (95% CI: 37.8% to 65.7%), corresponding to a PPV of 42.2% (95%CI 27.7% to 57.8%) and an NPV of 87.5% (95% CI 71.0% to 96.5%). CONCLUSION: To our knowledge, this prospective study is the first to use respiratory symptoms in RA as inclusion criteria. Systematic screening for respiratory symptoms combined with TUS can reduce the diagnostic delay of ILD in RA.

Pleural disease.

The incidence of pleural disease is increasing and the mortality and morbidity is high. Many recent RCTs have resulted in evidence-based guidelines published in 2023, pointing towards a more individualized and specialized management. Most patients with pleural disease are admitted at the A and E but can be managed in outpatient clinics. Thus, there is a need to establish specialized, multidisciplinary pleural clinics to ensure optimal, individualized and evidence-based management of the increasing number of patients with pleural disease in Denmark, as argued in this review.

Improving diagnostics using extended point-of-care testing during in-home assessments of older adults with signs of emerging acute disease: a prospective observational non-randomised pilot and feasibility study.

BACKGROUND: Delayed recognition of acute disease among older adults hinders timely management and increases the risk of hospital admission. Point-of-Care testing, including Focused Lung Ultrasound (FLUS) and in-home analysis of biological material, may support clinical decision-making in suspected acute respiratory disease. The aim of this study was to pilot test the study design for a planned randomised trial, investigate whether in-home extended use of point-of-care testing is feasible, and explore its' potential clinical impact. METHODS: A non-randomised pilot and feasibility study was conducted during September-November 2021 in Kolding Municipality, Denmark. A FLUS-trained physician accompanied an acute community nurse on home-visits to citizens aged 65 + y with signs of acute respiratory disease. The acute community nurses did a clinical assessment (vital signs, capillary C-reactive protein and haemoglobin) and gave a presumptive diagnosis. Subsequently, the physician performed FLUS, venipuncture with bedside analysis (electrolytes, creatinine, white blood cell differential count), nasopharyngeal swab (PCR for upper respiratory pathogens), and urine samples (flow-cytometry). Primary outcomes were feasibility of study design and extended point-of-care testing; secondary outcome was the potential clinical impact of extended point-of-care testing. RESULTS: One hundred consecutive individuals were included. Average age was 81.6 (SD ± 8.4). Feasibility of study design was acceptable, FLUS 100%, blood-analyses 81%, PCR for upper respiratory pathogens 79%, and urine flow-cytometry 4%. In addition to the acute community nurse's presumptive diagnosis, extended point-of-care testing identified 34 individuals with a condition in need of further evaluation by a physician. CONCLUSION: Overall, in-home assessments with extended point-of-care testing are feasible and may aid to identify and handle acute diseases in older adults.

Lung Ultrasound Reproducibly Outperforms Computed Tomography in the Detection of Extravascular Lung Water in Patients Undergoing Haemodialysis.

BACKGROUND: Lung ultrasound (LUS) is increasingly used as an extension of physical examination, informing clinical diagnosis, and decision making. There is particular interest in the assessment of patients with pulmonary congestion and extravascular lung water, although gaps remain in the evidence base underpinning this practice as a result of the limited evaluation of its inter-rater reliability and comparison with more established radiologic tests. METHODS: 30 patients undergoing haemodialysis were prospectively recruited to an observational cohort study (NCT01949402). Patients underwent standardised LUS assessment before, during and after haemodialysis; their total LUS B-line score was generated, alongside a binary label of whether appearances were consistent with an interstitial syndrome. LUS video clips were recorded and independently scored by two blinded expert clinician sonographers. Low-dose non-contrast thoracic CT, pre- and post dialysis, was used as a "gold standard" radiologic comparison. RESULTS: LUS detected a progressive reduction in B-line scores in almost all patients undergoing haemodialysis, correlating with the volume of fluid removed once individuals with no or minimal B-lines upon pre-dialysis examination were discounted. When comparing CT scans pre- and post dialysis, radiologic evidence of the change in fluid status was only identified in a single patient. CONCLUSIONS: This is the first study to demonstrate that LUS detects changes in extravascular lung water caused by changing fluid status during haemodialysis using a blinded outcome assessment and that LUS appears to be more sensitive than CT for this purpose. Further research is needed to better understand the role of LUS in this and similar patient populations, with the aim of improving clinical care and outcomes.

Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol.

BACKGROUND: Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions. METHOD: We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat. DISCUSSION: To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions. TRIAL REGISTRATION: www. CLINICALTRIALS: org NCT05546073 (Date of registration: September 19th, 2022).

National survey on management of spontaneous pneumothorax from emergency department to specialised treatment: room for improvement.

Introduction: Spontaneous pneumothorax (SP) affects both young, otherwise healthy individuals and older persons with known underlying pulmonary disease. Initial management possibilities are evolving and range from observation to chest tube insertion. SP guidelines suggest an individualized approach based on multiple factors such as symptoms, size of pneumothorax, comorbidity and patient preference. Aim: With this Danish national survey we aimed to map organization of care including involved specialties, treatment choice, training, and follow-up plans to identify aspects, and optimization of spontaneous pneumothorax management. Method: A survey developed by the national interest group for pleural medicine was sent to all departments of emergency medicine, thoracic surgery, respiratory medicine, and to relevant departments of abdominal or orthopaedic surgery. Results: The response rate was 75 % (47 of 65). Overall, 21% of responding departments had no guideline for SP management, which was provided by multiple specialties with marked heterogeneity in choice of treatment including tube size, management during admission, and referral procedure to follow-up. Few departments required procedure training, and nearly all of the responders called for improvements in management of pneumothorax. Conclusion: This survey suggests that SP management and care is delivered heterogeneously across Danish hospitals with marked difference between respiratory physicians, emergency physicians, general surgeons and thoracic surgeons. It is therefore likely that management is sub-optimal. There is a need for a common Danish SP guideline to ensure optimal treatment across involved specialties.

Thrombelastography and Conventional Coagulation Markers in Chronic Obstructive Pulmonary Disease: A Prospective Paired-Measurements Study Comparing Exacerbation and Stable Phases.

Chronic Obstructive Pulmonary Disease (COPD) exacerbation is known for its substantial impact on morbidity and mortality among affected patients, creating a significant healthcare burden worldwide. Coagulation abnormalities have emerged as potential contributors to exacerbation pathogenesis, raising concerns about increased thrombotic events during exacerbation. The aim of this study was to explore the differences in thrombelastography (TEG) parameters and coagulation markers in COPD patients during admission with exacerbation and at a follow-up after discharge. This was a multi-center cohort study. COPD patients were enrolled within 72 h of hospitalization. The baseline assessments were Kaolin-TEG and blood samples. Statistical analysis involved using descriptive statistics; the main analysis was a paired t-test comparing coagulation parameters between exacerbation and follow-up. One hundred patients participated, 66% of whom were female, with a median age of 78.5 years and comorbidities including atrial fibrillation (18%) and essential arterial hypertension (45%), and sixty-five individuals completed a follow-up after discharge. No significant variations were observed in Kaolin-TEG or conventional coagulation markers between exacerbation and follow-up. The Activated Partial Thromboplastin Clotting Time (APTT) results were near-significant, with p = 0.08. In conclusion, TEG parameters displayed no significant alterations between exacerbation and follow-up.

Assessment of Basic Thoracic Ultrasound Skills in Immersive Virtual Reality: Gathering Validity Evidence.

OBJECTIVE: Operator skills are essential for thoracic ultrasound (TUS) to ensure diagnostic accuracy. Immersive virtual reality (IVR) has shown potential within medical education but never for assessment of TUS skills. This study was aimed at developing an IVR test for assessing TUS skills, gathering validity evidence and establishing a pass/fail score. METHODS: An expert panel developed a test based on the TUS protocol by the European Respiratory Society (ERS), including a tutorial and two clinical cases (pleural effusion and interstitial syndrome), using an IVR platform (VitaSim, Odense, Denmark). Four anterior, four lateral and six posterior zones were available for examination and decision of diagnosis. Each correct examination equaled one point. The contrasting groups' method was used to set a pass/fail score. RESULTS: Data were collected during the 2022 ERS Congress. We included 13 novices (N, experience: 0 TUS), 22 intermediates (I, 1-50 TUS) and 11 experienced clinicians (E, >50 TUS). Cronbach's α was 0.86. The total mean point scores in case 1 (C1) were (N) 5.0 ± 2.7, (I) 7.3 ± 2.4 and (E) 8.7 ± 1.3, and the scores in case 2 (C2) were (N) 4.5 ± 1.8, (I) 6.7 ± 2.3 and (E) 8.5 ± 2.1. Significant differences were found between N and I for C1 (p = 0.007) and C2 (p = 0.02), I and E for C1 (p = 0.04) and C2 (p = 0.019) and N and E for C1 (p < 0.001) and C2 (p < 0.001). The pass/fail score was 7 points in each case. CONCLUSION: We established an IVR test that can distinguish between operators with different TUS skills. This enables a standardized, objective and evidence-based approach to assessment of TUS skills.

Endoscopic ultrasound-guided fine-needle aspiration using the bronchial ultrasound scope (EUS-B-FNA) for diagnosing pancreatic metastasis in a lung cancer patient case report.

Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) of the pancreas is performed routinely in many endoscopic centers as part of the diagnostic set-up for suspected pancreatic cancer. The use of transesophageal bronchoscopic ultrasound-guided fine needle aspiration (EUS-B-FNA) by pulmonologists has expanded significantly, since it enables effective diagnosis of lesions in the mediastinum and upper abdomen. The following case demonstrates the safety and feasibility of EUS-B-FNA in a patient with non-small cell lung cancer (NSCLC) cancer and a pancreatic mass of unknown origin. A patient who was previously diagnosed with NSCLC was referred to the Department of Respiratory Medicine, Odense University Hospital due to suspected recurrence of NSCLC. The patient underwent endobronchial ultrasound guided (EBUS)-FNA from several suspected mediastinal lymph nodes and combined EUS-B-FNA from a pancreatic mass during the same procedure. Pathology results from the pancreatic mass and from the mediastinal lymph nodes showed squamous-cell carcinoma, metastasis from the previous NSCLC. We here by demonstrated that EUS-B-FNA is a feasible and safe technique to obtain tissue samples from pancreatic lesions in patients under investigation for lung cancer.

Consequences of Losing Incidental Pulmonary Nodules to Follow-Up: Unmonitored Nodules Progressing to Stage IV Lung Cancer.

INTRODUCTION: Lung cancer is the leading cause of cancer-related death globally. Incidental pulmonary nodules represent a golden opportunity for early diagnosis, which is critical for improving survival rates. This study explores the impact of missed pulmonary nodules on the progression of lung cancer. METHODS: A total of 4,066 stage IV lung cancer cases from 2019 to 2021 in Danish hospitals were investigated to determine whether a chest computed tomography (CT) had been performed within 2 years before diagnosis. CT reports and images were reviewed to identify nodules that had been missed by radiologists or were not appropriately monitored, despite being mentioned by the radiologist, and to assess whether these nodules had progressed to stage IV lung cancer. RESULTS: Among stage IV lung cancer patients, 13.6% had undergone a chest CT scan before their diagnosis; of these, 44.4% had nodules mentioned. Radiologists missed a nodule in 7.6% of cases. In total, 45.3% of nodules were not appropriately monitored. An estimated 2.5% of stage IV cases could have been detected earlier with proper surveillance. CONCLUSION: This study underlines the significance of monitoring pulmonary nodules and proposes strategies for enhancing detection and surveillance. These strategies include centralized monitoring and the implementation of automated registries to prevent gaps in follow-up.

Lung Ultrasound and Pleural Artifacts: A Pictorial Review.

Lung ultrasound is a well-established diagnostic approach used in detecting pathological changes near the pleura of the lung. At the acoustic boundary of the lung surface, it is necessary to differentiate between the primary visualization of pleural parenchymal pathologies and the appearance of secondary artifacts when sound waves enter the lung or are reflected at the visceral pleura. The aims of this pictorial essay are to demonstrate the sonographic patterns of various pleural interface artifacts and to illustrate the limitations and pitfalls of the use of ultrasound findings in diagnosing any underlying pathology.

Ultrasound in the Diagnosis of Non-Expandable Lung: A Prospective Observational Study of M-Mode, B-Mode, and 2D-Shear Wave Elastography.

BACKGROUND: Non-expandable lung (NEL) has severe implications for patient symptoms and impaired lung function, as well as crucial implications for the management of malignant pleural effusion (MPE). Indwelling pleural catheters have shown good symptom relief for patients with NEL; hence, identifying patients early in their disease is vital. With the inability of the lung to achieve pleural apposition following thoracentesis and the formation of a hydropneumothorax, traditionally, chest X-ray and clinical symptoms have been used to make the diagnosis following thoracentesis. It is our aim to investigate whether ultrasound measurement of lung movement during respiration can predict NEL before thoracentesis, thereby aiding clinicians in their planning for the optimal treatment of affected patients. METHODS: A total of 49 patients were consecutively included in a single-centre trial performed at a pleural clinic. Patients underwent protocolled ultrasound assessment pre-thoracentesis with measurements of lung and diaphragm movement and shear wave elastography measurements of the pleura and pleural effusion at the planned site of thoracentesis. RESULTS: M-mode measurements of lung movement provided the best diagnostic ROC-curve results, with an AUC of 0.81. Internal validity showed good results utilising the calibration belt test and Brier test. CONCLUSION: M-mode measurement of lung movement shows promise in diagnosing NEL before thoracentesis in patients with known or suspected MPE. A validation cohort is needed to confirm the results.

Chronic Pulmonary Aspergillosis as a Considerable Complication in Post-Tuberculosis Lung Disease.

Post-tuberculosis lung disease (PTLD) has only recently been put in the spotlight as a medical entity. Recent data suggest that up to 50% of tuberculosis (TB) patients are left with PTLD-related impairment after completion of TB treatment. The presence of residual cavities in the lung is the largest risk factor for the development of chronic pulmonary aspergillosis (CPA) globally. Diagnosis of CPA is based on four criteria including a typical radiological pattern, evidence of Aspergillus species, exclusion of alternative diagnosis, and a chronic course of disease. In this manuscript, we provide a narrative review on CPA as a serious complication for patients with PTLD.

Education in Focused Assessment With Sonography for Trauma Using Immersive Virtual Reality: A Prospective, Interventional Cohort Study and Non-inferiority Analysis With a Historical Control.

OBJECTIVE: Focused assessment with sonography for trauma (FAST) is a valuable ultrasound procedure in emergency settings, and there is a need for evidence-based education in FAST to ensure competencies. Immersive virtual reality (IVR) is a progressive training modality gaining traction in the field of ultrasound training. IVR holds several economic and practical advantages to the common instructor-led FAST courses using screen-based simulation (SBS). METHODS: This prospective, interventional cohort study investigated whether training FAST using IVR unsupervised and out-of-hospital was non-inferior to a historical control group training at a 90 min SBS course in terms of developing FAST competencies in novices. Competencies were assessed in both groups using the same post-training simulation-based FAST test with validity evidence, and a non-inferiority margin of 2 points was chosen. RESULTS: A total of 27 medical students attended the IVR course, and 27 junior doctors attended the SBS course. The IVR group trained for a median time of 117 min and scored a mean 14.2 ± 2.0 points, compared with a mean 13.7 ± 2.5 points in the SBS group. As the lower bound of the 95% confidence interval at 13.6 was within the range of the non-inferiority margin (11.7-13.7 points), training FAST in IVR for a median of 117 min was found non-inferior to training at a 90 min SBS course. No significant correlation was found between time spent in IVR and test scores. CONCLUSION: Within the limitations of the use of a historical control group, the results suggest that IVR could be an alternative to SBS FAST training and suitable for unsupervised, out-of-hospital courses in basic FAST competencies.

Using the Endoscope for Endobronchial Ultrasound in the Esophagus.

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that pulmonologists can use to visualize and biopsy structures adjacent to the esophagus and stomach. EUS-B gives access to many structures of which some may also be reached by EBUS (mediastinal lymph nodes, lung or pleural tumors, pericardial fluid) while others cannot be reached such as retroperitoneal lymph nodes, ascites, and lesions in the liver, pancreas or left adrenal gland. The procedure is a pulmonologist- and patient- friendly version of the gastroenterologists' EUS using the thin EBUS endoscope that the pulmonologist already masters. Thus EUS-B training should be easy and a natural continuation of EBUS. With the patient under conscious sedation and in the supine position, the echoendoscope is introduced either through the nostril or mouth into the oropharynx. Then the patient is encouraged to swallow while the endoscope is slowly bent posteriorly and introduced into the esophagus and stomach. Using the ultrasonic image, the operator identifies the six landmarks by EUS-B and EUS: the left liver lobe, abdominal aorta (with the celiac trunk and superior mesenteric artery), left adrenal gland, and mediastinal lymph node stations 7, 4L, and 4R. Biopsies can be taken from suspected lesions under real-time ultrasonographic guidance- fine needle aspiration (EUS-B-FNA) using a technique similar to that used with EBUS-TBNA. The biopsy order is M1b-M1a-N3-N2-N1-T (M = metastasis, N = lymph node, T = tumor) to avoid iatrogenic upstaging. Pre- and post-procedural observation is similar to that of bronchoscopy. EUS-B is safe and feasible in the hands of experienced interventional pulmonologists and provides a significant expansion of the diagnostic possibilities in providing safe, fast, and thorough diagnosis and staging of lung cancer.

Comparison of video assisted thoracoscopic surgery and thoracotomy for treatment of pleural infection stage II and III: a literature review.

Background and Objective: Pleural infection is associated with significant mortality and morbidity worldwide, with a steadily increasing incidence. We sought to investigate whether video-assisted thoracic surgery (VATS) or thoracotomy provides the best outcomes in the treatment of stage II and III pleural infection as indications remain controversial. Methods: Systematic review of relevant articles from the PubMed database. Key Content and Findings: Nine non-randomized retrospective studies published between 1996 and 2020 with a total of 2,121 patients were included. Results varied between studies, but overall shorter operative and recovery times and greater patient satisfaction were demonstrated using VATS compared with thoracotomy. Conclusions: Although VATS and thoracotomy are viable treatment options for stage II and III pleural infection, VATS has potential advantages in terms of decreased operation time, fewer days with tube drainage, shorter postoperative hospital stay, reduced postoperative pain, increased patient satisfaction with the procedure, and wound appearance. VATS has limitations in the treatment of patients with stage III pleural infection, where delayed surgical referral has been shown to increase the risk of intraoperative conversion to thoracotomy. The data to date implies that debridement by VATS should be proposed as soon as possible in stage II pleural infection and considered in cases of stage III pleural infection.

A Stepwise Approach for Performing Ultrasound Guided Transthoracic Lung Biopsy.

Diagnosing patients with radiological lung lesions, especially those suspected of having primary lung cancer, is a common and critical clinical scenario. When selecting the most suitable invasive procedure to establish a diagnosis in these cases, a delicate balance must be struck between achieving a high diagnostic yield, providing staging information, minimizing potential complications, enhancing the patient experience, and controlling costs. The integration of thoracic ultrasound as a routine clinical tool in respiratory medicine has led to increased awareness and utilization of ultrasound-guided invasive techniques in chest procedures, including transthoracic biopsies. By following a systematic and stepwise approach, transthoracic ultrasound-guided lung biopsy emerges as a safe, cost-effective procedure with a remarkable diagnostic accuracy. These attributes collectively position it as an ideal invasive technique when technically feasible. Consequently, in patients presenting subpleural lung lesions suspected of malignancy, transthoracic ultrasound-guided lung biopsy has become a standard procedure in the realm of modern invasive pulmonology.

Thoracic ultrasonographic and clinical findings at 12-month follow-up of patients admitted with COVID-19.

Introduction: Thoracic ultrasound (TUS) has proven useful in the diagnosis, risk stratification and monitoring of disease progression in patients with coronavirus disease 2019 (COVID-19). However, utility in follow-up is poorly described. To elucidate this area, we performed TUS as part of a 12-month clinical follow-up in patients previously admitted with COVID-19 and correlated findings with clinical assessment and pulmonary function tests. Methods: Adult patients discharged from our hospital following admission with COVID-19 during March to May 2020 were invited to a 12-month follow-up. Enrolled patients were interviewed regarding persisting or newly developed symptoms in addition to TUS, spirometry and a 6-min walk test. Patients were referred to high-resolution computed tomography (HRCT) of the lungs if suspicion of pulmonary fibrosis was raised. Results: Forty patients were enrolled in the study of whom had 13 developed acute respiratory distress syndrome (ARDS) during admission. Patients with ARDS were more prone to experience neurological symptoms at follow-up (p = 0.03) and showed more B-lines on TUS (p = 0.008) but did not otherwise differ significantly in terms of pulmonary function tests. Four patients had pathological findings on TUS where subsequent diagnostics revealed that two had interstitial lung abnormalities and two had heart failure. These four patients presented with a significantly lower diffusing capacity of lung for carbon monoxide (p=0.03) and 6-min walking distance (p=0.006) compared to the remaining 36 patients without ultrasound pathology. No significant difference was observed in spirometry values of % of predicted FEV1 (p=0.49) or FVC (p=0.07). No persisting cardiovascular pathology was observed in patients without ultrasonographic pathology. Conclusion: At 12-month after admission with COVID-19, a follow-up combining TUS, clinical assessment, and pulmonary function tests may improve the selection of patients requiring further diagnostic investigations such as HRCT or echocardiography.