Radiographic lung congestion scores in dogs with acute congestive heart failure caused by myxomatous mitral valve disease.

BACKGROUND: In humans, lung congestion scores are predictive of recurrence of acute congestive heart failure (CHF) and are superior to cardiac biomarkers in predicting survival. OBJECTIVES: The primary aim of this retrospective study was to determine if a modified lung congestion score (LCS) in dogs diagnosed with acute CHF because of myxomatous mitral valve disease was associated with time until recurrence or death. ANIMALS: Complete medical records were available for a total of 94 dogs between 2010 and 2019, but only 35 dogs fulfilled the criteria for inclusion. METHODS: This retrospective study used descriptive statistics to describe the cumulative and corrected LCS. Correlations were used to examine the association of the corrected LCS and time until recurrence or death, selected echocardiographic variables, and timing of furosemide administration. RESULTS: The mean LCS was 8.4 (SD 3.3) and corrected LCS was 0.48 (SD 0.19). The pattern was predominantly symmetric (40% of dogs) and focal (caudal) but more commonly right-sided when asymmetric (40% vs 20%). The median number of days after initial diagnosis of acute CHF to readmission and death was 150 days (range 4-572), and 266 days (range 5-965), respectively. No significant association between the dog's corrected LCS and number of days until readmission (r = .173, P = .42) nor survival (r = .109, P = .56) was found. There was a negative significant correlation (r = -.71, P < .001) between the time interval of furosemide administration and corrected LCS.

Optimizing Lung Ultrasound: The Effect of Depth, Gain and Focal Position on Sonographic B-Lines.

Ultrasonographic B-lines are artifacts present in alveolar-interstitial syndromes. We prospectively investigated optimal depth, gain, focal position and transducer type for B-line visualization and image quality. B-Lines were assessed at a single rib interspace with curvilinear and linear transducers. Video clips were acquired by changing parameters: depth (6, 12, 18 and 24 cm for curvilinear transducer, 4 and 8 cm for linear transducer), gain (10%, 50% and 90%) and focal position (at the pleural line or half the scanning depth). Clips were scored for B-lines and image quality. Five hundred sixteen clips were obtained and analyzed. The curvilinear transducer improved B-line visualization (63% vs. 37%, p < 0.0001), with higher image quality (3.52 ± 0.71 vs. 3.31 ± 0.86, p = 0.0047) compared with the linear transducer. B-Lines were better visualized at higher gains (curvilinear: gain of 50% vs. 10%, odds ratio = 7.04, 95% confidence interval: 4.03-12.3; gain of 90% vs. 10%, odds ratio = 9.48, 95% confidence interval: 5.28-17.0) and with the focal point at the pleural line (odds ratio = 1.64, 95% confidence interval: 1.02-2.63). Image quality was highest at 50% gain (p = 0.02) but decreased at 90% gain (p < 0.0001) and with the focal point at the pleural line (p < 0.0001). Image quality was highest at depths of 12-18 cm. B-Lines are best visualized using a curvilinear transducer with at least 50% gain and focal position at the pleural line. Gain less than 90% and image depth between 12 and 18 cm improve image quality.

Lung Ultrasound for Pulmonary Contusions.

Lung ultrasound (LUS) has high sensitivity for the rapid and reliable diagnosis of pulmonary contusions (PC) in patients who have sustained trauma. LUS diagnosis of PC exceeds that of thoracic radiographs in multiple animal and human studies. The sonographer should understand potential caveats and confounding variables for proper diagnosis of PC with LUS. LUS does not replace conventional radiography or computed tomography, especially in the polytrauma patient. LUS should be used concurrently with other point-of-care ultrasound trauma protocols to rapidly optimize patient assessment before movement to the radiology suite.

Bedside sonography assessment of extravascular lung water increase after major pulmonary resection in non-small cell lung cancer patients.

BACKGROUND: Extra vascular lung water (EVLW) following pulmonary resection increases due to fluid infusion and rises in capillary surface and permeability of the alveolar capillary membranes. EVLW increase clinically correlates to pulmonary oedema and it may generate impairments of gas exchanges and acute lung injury. An early and reliable assessment of postoperative EVLW, especially following major pulmonary resection, is useful in terms of reducing the risk of postoperative complications. The currently used methods, though satisfying these criteria, tend to be invasive and cumbersome and these factors might limit its use. The presence and burden of EVLW has been reported to correlate with sonographic B-line artefacts (BLA) assessed by lung ultrasound (LUS). This observational study investigated if bedside LUS could detect EVLW increases after major pulmonary resection. Due to the clinical association between EVLW increase and impairment of gas exchange, secondary aims of the study included investigating for associations between any observed EVLW increases and both respiratory ratio (PaO2/FiO2) and fluid retention, measured by brain natriuretic peptide (BNP). METHODS: Overall, 74 major pulmonary resection patients underwent bedside LUS before surgery and at postoperative days 1 and 4, in the inviolate hemithorax which were divided into four quadrants. BLA were counted with a four-level method. The respiratory ratio PaO2/FiO2 and fluid retention were both assessed. RESULTS: BLA resulted being increased at postoperative day 1 (OR 9.25; 95% CI, 5.28-16.20; P<0.0001 vs. baseline), and decreased at day 4 (OR 0.50; 95% CI, 0.31-0.80; P=0.004 vs. day 1). Moreover, the BLA increase was associated with both increased BNP (OR 1.005; 95% CI, 1.003-1.008; P<0.0001) and body weight (OR 1.040; 95% CI, 1.008-1.073; P=0.015). Significant inverse correlations were observed between the BLA values and the PaO2/FiO2 respiratory ratios. CONCLUSIONS: Our results suggest that LUS, due to its non-invasiveness, affordability and capacity to detect increases in EVLW, might be useful in better managing postoperative patients.

Lung ultrasound in early diagnosis of neonatal transient tachypnea and its differentiation from other causes of neonatal respiratory distress.

BACKGROUND: Transient tachypnea of the newborn (TTN) is one of the most common causes of neonatal respiratory distress (RD). However, distinguishing TTN from other causes of RD may be difficult during the first 12:24 h after birth. Lung ultrasonography (LUS) has been successfully utilized in the diagnosis and differential diagnosis of neonatal RD. This study aimed to investigate the diagnostic value of LUS for early diagnosis of TTN as well as differentiate it from other causes of neonatal RD in near and full term Egyptian neonates. METHODS: LUS was performed in 65 near and full term neonates presented with RD within the first 12:24 hours of admission in NICU of Suez Canal University, Ismailia, Egypt. RESULTS: Among the 65 neonates included in the study, 73.8% were diagnosed to have TTN, 18.5% were diagnosed to have pneumonia, 4.6% had meconium aspiration syndrome (MAS) and 3.1% had respiratory distress syndrome (RDS). The Double lung point has 69.6% sensitivity, 100% specificity, 100% PPV and 39.1% NPV for detecting TTN. We have novel data showing a positive correlation between the degree of alveolar-interstitial syndrome (AIS) and the type of oxygen support offered to neonates diagnosed with TTN. CONCLUSION: We found LUS to be a reliable and non-invasive tool for the early diagnosis of TTN and its differentiation from other causes of neonatal RD in near and full term Egyptian neonates.

Intraoperative lung ultrasound: A clinicodynamic perspective.

In the era of evidence-based medicine, ultrasonography has emerged as an important and indispensable tool in clinical practice in various specialties including critical care. Lung ultrasound (LUS) has a wide potential in various surgical and clinical situations for timely and easy detection of an impending crisis such as pulmonary edema, endobronchial tube migration, pneumothorax, atelectasis, pleural effusion, and various other causes of desaturation before it clinically ensues to critical level. Although ultrasonography is frequently used in nerve blocks, airway handling, and vascular access, LUS for routine intraoperative monitoring and in crisis management still necessitates recognition. After reviewing the various articles regarding the use of LUS in critical care, we found, that LUS can be used in various intraoperative circumstances similar to Intensive Care Unit with some limitations. Except for few attempts in the intraoperative detection of pneumothorax, LUS is hardly used but has wider perspective for routine and crisis management in real-time. If anesthesiologists add LUS in their routine monitoring armamentarium, it can assist to move a step ahead in the dynamic management of critically ill and high-risk patients.

Interobserver agreement in the evaluation of B-lines using bedside ultrasound.

PURPOSE: We evaluated agreement among trained emergency physicians assessing the degree of B-line presence on bedside ultrasound in patients presenting to the emergency department (ED) with acute undifferentiated dyspnea. We also determined which thoracic zones offered the highest level of interobserver reliability for sonographic B-line assessment. MATERIALS AND METHODS: We evaluated a prospective convenience sample of adult patients presenting with dyspnea to an academic ED. Two consecutive bedside lung ultrasounds were performed on 91 patients by a pair of physician-sonographers. The lung ultrasounds were structured 10-zone thoracic sonograms, documented as videos. Sonographer pairs were expert/expert (>100 lung ultrasounds performed) or expert/novice pairs (novices performed 5 supervised examinations after structured training) and blinded to clinical data. Sonographers reported B-line concentration with 3 assessment methods: (1) normal (<3 B-lines) or abnormal (≥3 B-lines); (2) ordinal (normal, mild, moderate, or severe), and (3) counting B-lines (0-10; >10) in each zone. All statistical analyses were performed using SPSS version 18.0 (Chicago, IL) and Stata 12.1 (College Station, TX). We evaluated interrater and intrarater agreement using Intraclass correlation coefficients (ICCs). RESULTS: The right and left anterior/superior lung zones showed substantial agreement in all assessment methods and demonstrated best overall agreement (ICC for right: counting, ordinal, and normal/abnormal, 0.811 [0.714-0.875], 0.875 [0.810-0.917], and 0.729 [0.590-0.821], respectively). Furthermore, both expert/expert pairs and expert/novice pairs showed substantial agreement in the right and left anterior/superior thoracic zones (expert/expert, 0.904 and 0.777, respectively; expert/novice, 0.862, and 0.834, respectively). Second best agreement was found for the lateral/superior lung zones (right: counting, ordinal, and normal/abnormal, 0.744 [0.612-0.831], 0.686 [0.524-0.792], and 0.639 [0.453-0.761], respectively; and ICC left: counting, ordinal, and normal/abnormal, 0.671 [0.501-0.782], 0.615 [0.417-0.746], and 0.720 [0.577-0.815], respectively). When comparing agreement to distinguish "normal vs abnormal" B-line findings, our results showed significant agreement in all zones with the exception of the right and left inferior/lateral lung fields and left posterior lung. Reinterpretation by 2 experts of all their own randomized video clips at a later date showed agreement of 0.697 (n=733 zones) and 0.647 (n=266) zones for ordinal assessment of B-line concentration. CONCLUSION: Interrater agreement was best in the anterior/superior thoracic zones followed by the lateral/superior zones for both expert/expert and expert/novice pairs. Agreement in the lateral/inferior lung zones was overall inferior. Intrarater agreement was highest at extreme high or low numbers of B-lines.

Ultrasonido pulmonar en la unidad de terapia intensiva: fundamentos y aplicaciones clínicas / Pulmonary ultrasound in the intensive care unit

El ultrasonido pulmonar es una nueva herramienta para el diagnóstico de enfermedades pleuropulmonares en el enfermo grave. Las imágenes que se obtienen resultan de la interacción del haz ultrasónico con la pleura, el parénquima pulmonar y la interfase aire-líquido; se clasifican en horizontales y verticales. Para su correcta identificación e interpretación se requiere una curva de aprendizaje. El ultrasonido pulmonar se ha posicionado como una excelente alternativa para evaluar el estado pulmonar de los enfermos internados en la unidad de terapia intensiva. Tiene una elevada sensibilidad y especificidad para el diagnóstico de pneumotórax, síndrome alvéolo-intersticial y derrame pleural. Es uno de los procedimientos diagnósticos más promisorios en la medicina intensiva, por lo que seguramente se extenderá su práctica e indicaciones en los años venideros. El objetivo de este trabajo es dar a conocer a la comunidad médica los principios generales de este procedimiento y sus aplicaciones en el enfermo grave, conforme la experiencia en la Unidad de Terapia Intensiva de la Fundación Clínica Médica Sur.

Pulmonary ultrasonography (PUSG) is a new diagnostic tool for pleuropulmonary disease in the critically ill patient. Images obtained in this study result from the interaction between the ultrasound shaft with the pleura, the pulmonary parenchyma and the air/liquid interface. These images are classified as horizontal and vertical. Their correct identification and interpretation requires a learning curve. Currently, PUSG is an excellent alternative to evaluate pulmonary condition of hospitalized patients in the intensive care unit (ICU). Sensitivity and specificity are high for pneumothorax, alveolar-interstitial syndrome and pleural effusion diagnosis. PUSG practiced in the ICU is one of the most promising diagnostic procedures in intensive care medicine, and the practice and indications of this tool will surely extend in the coming years. The objective of this study is to make known the general principles of PUSG and their use in the critically ill patient, based on cases of hospitalized patients in the ICU of the Medica Sur Clinical Foundation that were studied with PUSG.