Tag Archives: Lung ultrasound

Join the POCUS Revolution: Unlock the Power of Point-of-Care Ultrasound

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A Hand-held ultrasound device scanning a patient

If you’re a fan of the AIUM (American Institute of Ultrasound in Medicine), then you already understand the importance of ultrasound technology in revolutionizing patient care. However, the emergence of Point-of-Care Ultrasound (POCUS) has taken this technology to new heights. POCUS is transforming the medical landscape, offering a sleek, affordable, and user-friendly solution that brings ultrasound imaging directly to the bedside. In this blog post, we’ll explore the advantages of POCUS over other imaging fields, share statistical data, discuss key POCUS techniques, and invite you to join us at the AIUM’s POCUS Course in Portland, Oregon, sponsored by AIUM and OHSU (Oregon Health & Science University), where you’ll discover the top 5 reasons to attend.

POCUS: Your Trusty Sidekick
POCUS is designed to be there for you when you need it the most, acting as a trusty sidekick to clinicians. With its ability to be performed at the bedside, POCUS delivers real-time answers, confirming diagnoses and guiding procedures without the need for additional appointments or waiting for results.

The Power of POCUS 

Let’s explore some statistical data that demonstrates the effectiveness and widespread adoption of POCUS:

  • Improved Diagnosis Accuracy
    According to a study published in a Royal College of Physicians journal, POCUS improved the accuracy of initial diagnoses compared to physical examination alone in various medical specialties, including emergency medicine, critical care, and primary care.
    Reduced Supplemental Exams
    A research article published in the Journal of Ultrasound in Medicine found that POCUS reduced the need for additional imaging studies and can reduce length of stay and imaging costs in various cases leading to significant cost savings and streamlined patient care pathways.
    Enhanced Patient Outcomes
    A systematic review and meta-analysis published in the Ultrasound Journal demonstrated that POCUS-guided interventions in cardiac patients resulted in improved outcomes, including reduced mortality rates and shorter hospital stays.

Key POCUS Techniques

POCUS encompasses various techniques that aid in diagnosing and guiding procedures. Some of the key techniques include:

  • Focused Cardiac Ultrasound (FOCUS)
    FOCUS allows clinicians to rapidly assess cardiac function, detect pericardial effusions, and evaluate for cardiac abnormalities such as wall motion abnormalities or valvular dysfunction.
  • Lung Ultrasound (LUS)
    LUS is valuable in the assessment of pulmonary conditions, including pneumothorax, pleural effusions, and pulmonary edema. It provides real-time visualization of lung sliding, B-lines, and consolidations.
  • Abdominal Ultrasound
    Abdominal POCUS aids in the evaluation of acute abdominal pain, gallbladder disease, kidney stones, and abdominal aortic aneurysms, among other conditions. It enables quick assessment and intervention in critical situations.
  • Musculoskeletal Ultrasound
    Musculoskeletal POCUS allows for an accurate evaluation of joint effusions, tendon injuries, muscle tears, and other soft tissue abnormalities. It assists in guiding interventions such as joint aspirations and injections.

POCUS is a game-changer, offering real-time answers that confirm diagnoses and guide procedures at the bedside. The statistical data highlights its effectiveness in improving diagnosis accuracy, reducing the need for supplemental exams, and enhancing patient outcomes. Don’t miss your chance to join the POCUS revolution and become a superhero in your own right. Register today for the AIUM’s POCUS Course in Portland, Oregon, and unlock the power of Point-of-Care Ultrasound. It’s time to level up your medical game and make a lasting impact on patient care. Sign up today!

Sources
Smallwood N, Dachsel M. Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine? Clin Med (Lond) 2018; 18(3):219–224. doi: 10.7861/clinmedicine.18-3-219. PMID: 29858431; PMCID: PMC6334078.

Amina Jaji, Rohit S. Loomba. Hocus POCUS! Parental quantification of left-ventricular ejection fraction using point of care ultrasound: Fiction or reality? [published online ahead of print December 30, 2022] Pediatr Cardiol. doi:10.1007/s00246-022-03090-w.

Kasmire KE and Davis J. Emergency department point-of-care ultrasonography can reduce length of stay in pediatric appendicitis: A retrospective review. J Ultrasound Med 2021; 40:2745–2750. https://doi.org/10.1002/jum.15675

Ávila-Reyes D, Acevedo-Cardona AO, Gómez-González JF, Echeverry-Piedrahita DR, Aguirre-Flórez M, Giraldo-Diaconeasa A. Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article. Ultrasound J 2021; 13(1):46. doi: 10.1186/s13089-021-00248-0. PMID: 34855015; PMCID: PMC8639882.

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

POCUS in COVID-19—Clutch or Not So Much?

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Health care workers see patients with undifferentiated symptoms day and night in emergency departments, hospitals, and outpatient clinics, so we are hard-pressed to identify symptoms that are NOT part of the constellation of symptoms seen with COVID-19. Practically speaking, any patient we encounter is likely to have one or more of the symptoms, which include incredibly common findings such as fever, chills, cough, shortness of breath, chest pain, headache, myalgias, nausea, vomiting, diarrhea, abdominal pain, and rash!

A Critical Question Exists: How Might Point-of-Care Ultrasound (POCUS) Be Best Utilized in This Pandemic?

While data is still being collected and definite answers may not be attainable, we seek to outline a few scenarios where POCUS may greatly aid every-day patient care.

No Test or Slow Test Scenario

While COVID-19 testing is more available than early in the pandemic, there are still communities in the U.S. and worldwide that lack access to testing or expeditious results. A prior post on AIUM’s The Scan, “My Sonography Experience With COVID-19”, (https://aiumthescan.blog/2020/04/21/my-sonography-experience-with-covid-19/) by Yale Tung Chen, MD, PhD, details common POCUS findings that may aid in diagnosing COVID-19 when tests or test results are not available.1

POCUS offers greater sensitivity for COVID-19 pneumonia than CXR and is safer (no ionizing radiation) and more cost-effective in comparison to CT imaging of the chest.2

Is This Patient’s Shortness of Breath Due to COVID-19 Pneumonia?

The differential diagnosis of a patient with undifferentiated shortness of breath can be broad. It includes not just COVID-19 pneumonia, but also pulmonary embolism, heart failure, pericarditis, pericardial effusion/tamponade, pneumothorax, and many more.

POCUS can reliably exclude decreased left ventricular ejection fraction, pericardial effusion, and pneumothorax, often rapidly shortening the differential. And POCUS findings of right heart strain may help direct clinicians toward further testing for pulmonary embolism (PE) or the use of thrombolytics in patients in extremis. Detection of a deep venous thrombosis (DVT) may serve as a proxy for diagnosing PE in a patient with shortness of breath or chest pain with a high probability of PE.

As has long been recognized but is reinforced in the COVID-19 pandemic, the ability to detect these pathologies at the bedside makes POCUS an invaluable tool for patients who are too critically ill to be transported for further diagnostic studies.

POCUS Takes One for the Team, Limiting Healthcare Worker Exposure

Limiting the number of people involved in the hands-on care of a patient with COVID-19 is an important principle in reducing healthcare worker (HCW) exposure.

In another previous post on The Scan, “How the COVID-19 Pandemic Has Changed Your Practice”, Margarita V. Revzin, MD, MS, detailed the time-intensive protocols that are in place to protect both the patients receiving and the HCWs performing ultrasound exams in the radiology department (https://aiumthescan.blog/2020/12/15/how-the-covid-19-pandemic-has-changed-your-practice/).

The ability of POCUS to answer binary clinical questions may help limit the exposure of HCWs who are not part of the primary team for the infected patients. In POCUS, the ultrasound exam is performed by a provider responsible for the comprehensive care of the patient—in essence, one of the HCWs who is primarily caring for the patient. When POCUS is able to definitively answer the clinical question at the bedside, additional imaging studies may be unnecessary, thus reducing the number of consulting providers exposed to a patient with COVID-19.

POCUS as the Great Prognosticator

The lung ultrasound findings of COVID-19 pneumonia precede findings on physical exam and x-ray imaging. Therefore, ultrasound could be used as a screening tool and additional data point in triaging patients and determining if they can be treated as an outpatient or admitted to the hospital.

Studies have suggested that infero-posterior lung POCUS findings are most sensitive for the diagnosis of COVID-19 pneumonia but that anterior lung findings best predict the need for non-invasive ventilation support while hospitalized.3

In addition, calculation of a lung ultrasound score (LUS) may help quantify severity of disease, with higher LUS predicting invasive ventilatory support need, ARDS, and death.4

The Future

POCUS is unique. It is the imaging modality that most easily incorporates into telehealth via remote guidance. As the role of POCUS in diagnosis, monitoring, and prognostication in pulmonary disease is better defined, it may play a role in determining care plans for patients seeking care via telehealth while minimizing COVID-19 exposure for both HCWs and patients.5,6

Furthermore, combining handheld ultrasound devices with novel artificial intelligence algorithms may allow for the automation of diagnosis and monitoring as described in a prior blog post by Alper Yilmaz, PhD, “Using AI and Ultrasound to Diagnose COVID-19 Faster” (https://aiumthescan.blog/2020/08/11/using-ai-and-ultrasound-to-diagnose-covid-19-faster/).

References

  1. Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standardization of the use of lung ultrasound for patients with COVID-19: a simple, quantitative, reproducible method. J Ultrasound Med. 2020 Jul;39(7):1413-1419. doi: 10.1002/jum.15285. Epub 2020 Apr 13. PMID: 32227492; PMCID: PMC7228287.
  2. Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020 May;46(5):849-850. doi: 10.1007/s00134-020-05996-6. Epub 2020 Mar 12. PMID: 32166346; PMCID: PMC7080149.
  3. Castelao J, Graziani D, Soriano JB, Izquierdo JL. Findings and prognostic value of lung ultrasound in COVID-19 pneumonia. J Ultrasound Med. 2020 Sep 16. doi: 10.1002/jum.15508. Epub ahead of print. PMID: 32936491.
  4. Ji L, Cao C, Gao Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care. 2020 Dec 22;24(1):700. doi: 10.1186/s13054-020-03416-1. PMID: 33353548; PMCID: PMC7754180.
  5. Kirkpatrick AW, McKee JL, Volpicelli G, Ma IWY. The potential for remotely mentored patient-performed home self-monitoring for new onset alveolar-interstitial lung disease. Telemed J E Health. 2020 Oct;26(10):1304-1307. doi: 10.1089/tmj.2020.0078. Epub 2020 Jul 10. PMID: 32654656.
  6. Kirkpatrick AW, McKee JL. Re: “Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID-19: A Simple, Quantitative, Reproducible Method”-Could Telementoring of Lung Ultrasound Reduce Health Care Provider Risks, Especially for Paucisymptomatic Home-Isolating Patients? J Ultrasound Med. 2021 Jan;40(1):211-212. doi: 10.1002/jum.15390. Epub 2020 Jul 8. PMID: 32639037; PMCID: PMC7362148.

Jennifer Carnell, Tobias Kummer, and Arun Nagdev are the leaders (2020–2022) of the AIUM Point-of-Care Ultrasound Community. Jennifer Carnell is the Secretary, Tobias Kummer is the Vice-Chair, and Arun Nagdev Arun is the Chair.

Interested in learning more about POCUS? Check out the following posts from the Scan:

How the COVID-19 Pandemic Has Changed Your Practice

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Coronavirus disease 2019 (COVID-19, also known as SARS-CoV-2) was declared an official pandemic by the World Health Organization (WHO) on March 11, 2020, with infections reported in all countries around the world. As of today, November 12, 2020, there have been almost 53 million cases of COVID-19 reported worldwide, with over 1.3 million COVID-19-associated deaths.

This pandemic is severe, and the mortality and morbidity associated with this disease cannot be overstated. Although most infected patients are either asymptomatic or experience mild symptoms, a significant number end up in serious or critical condition. This is the patient population that develops a number of complications that affect all body systems, and this group of patients should be very closely monitored in the hospital setting.

Radiology professionals play a significant role in the diagnosis of infected individuals, identification of complications that are not apparent on physical exam or laboratory analysis, and the follow-up imaging assessment of known COVID-related complications. Given that this virus is highly contagious, it became very apparent that safe methods for patient assessment had to be designed and implemented. Ultrasound serves as a first-line imaging modality for evaluation of a number of COVID-19 pathologies and related complications, including evaluation of pulmonary, hepatobiliary, renal, gastrointestinal, and cardiac manifestations. It is the modality of choice in the pediatric population and in pregnant patients. Moreover, ultrasound plays a critical role in the evaluation of patency of peripheral and central vascular systems, including both the arterial and venous circulation as well as solid organ perfusion.

Due to the highly contagious nature of COVID-19, our routine ultrasound radiology practice had to undergo dramatic changes in order to ensure proper infection prevention. We accomplished this through the establishment of control measures and good hygiene practices that were shown to limit spread of COVID‐19 and protect patients, sonographers, and physicians. In addition to following specific guidelines (established at the beginning of the pandemic by the ACR and the SRU) for cleaning and disinfection of ultrasound equipment and use of personal protective equipment (PPE), we also incorporated our own changes that we found to be beneficial in preventing spread of the infection and limiting staff exposure. 

At our institution, all patients are considered to be SARS-CoV-2 persons under investigation (PUI), including those without respiratory or digestive symptoms, and appropriate safeguards are taken while performing examinations.

Given the fact that transmission of SARS-CoV-2 occurs primarily through respiratory droplets, fomites, and possibly aerosols, we emphasize the use of portable ultrasound imaging at the patient’s bedside whenever feasible, with the radiology staff wearing appropriate PPE, including an N95 mask, gloves, protective eyewear or an overlying face shield, and a disposable gown.We request that all patients wear surgical masks during the examination.    

Equipment must be disinfected after every exposure to COVID-19 positive or suspected positive patients. According to the Centers for Disease Control and Prevention (CDC), surfaces need to be either washed with soap and water or decontaminated using a low-level or intermediate-level disinfectant such as iodophor germicidal detergent solution, ethyl alcohol, or isopropyl alcohol. Vendors should be contacted to determine the safest disinfectant for each piece of equipment. Radiology technologists should perform sanitizing procedures while remaining in full PPE.    

It is uncertain how long the air within an examination room remains infectious. Contributing factors likely include the size of the room, the number of air exchanges per hour, the length of time the patient was in the room, type of filters installed in the room, and whether an aerosol-generating procedure was performed. Use of air exchange measures vary depending on the availability of equipment. At our institutions, a 20-minute downtime is mandated for disinfection of the air in an examination room.

The keyboard and monitor of the ultrasound equipment are covered with a plastic drape or cover, and only the required probes are utilized during specific examinations. External transducers require low-level disinfection between procedures, while internal transducers require a single-use transducer cover and high-level disinfection between patients. It should be noted that products that are alcohol-based should be avoided when cleaning keyboards and track balls. If possible, a dedicated machine should be utilized for COVID-positive or suspected-positive patients. The machine should be cleaned with an EPA-approved disinfectant for viral pathogens, by a technologist in full PPE.

One of the primary changes that we implemented within our ultrasound division is the utilization of abbreviated protocols while imaging COVID-19 patients. We found that abbreviated protocols are useful and sufficient for the diagnosis of most COVID-19-related pathologies and complications, and are usually able to provide answers to the questions posed by referring clinicians. We strongly believe that abbreviated protocols have allowed us to decrease technologists’ exposure to the infection and the amount of time spent during imaging exams. When performing ultrasound examinations, we focus only on the area of interest and acquire cine clips rather than still images during the exam. It has also been shown that post processing of images, including image labeling and parameter optimization, significantly decrease the amount of time spent on scanning.

Lastly, it is important to recognize that not every patient benefits from imaging. We carefully review requests for imaging studies with the patient providers and try to weigh the benefits of imaging against the risk of exposure. The guiding principle to keep in mind is that studies don’t need to be performed unless patient management is going to be affected by the imaging findings. 

The ultrasound workforce provides a valuable clinical service but is particularly vulnerable because of the prolonged close physical contact between staff and patients. Hopefully, this blog post will serve as a resource to help practitioners improve safety and minimize exposure risk during the performance of ultrasound examinations.

From top left: Basilic vein thrombosis, chest wall hematoma, gallbladder sludge, internal jugular vein occlusion, lung consolidation with air bronchograms, lung interstitial edema with B lines, popliteal artery occlusion, and urinary bladder clot.
Lung US annotated B lines and pleural thickening.

For additional reference:

  1. Revzin MV, Raza S, Warshawsky R, D’Agostino C, Srivastava NC, Bader AS, Malhotra A, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 1: Viral Pathogenesis and Pulmonary and Vascular System Complications”. RadioGraphics 2020 Oct;40(6):1574–1599. doi: 10.1148/rg.2020200149 Monograph Issue.
  2. Revzin MV, Raza S, Srivastava NC, Warshawsky R, D’Agostino C, Malhotra A, Bader AS, Patel RD, Chen K, Kyriakakos C, Pellerito JS. “Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations.” Radiographics 2020 Nov–Dec;40(7):1866–1892. doi: 10.1148/rg.2020200195.

Margarita V. Revzin, MD, MS, FSRU, FAIUM, is an Associate Professor of Diagnostic Radiology in the Department of Radiology and Biomedical Imaging at Yale University School of Medicine, in New Haven, Connecticut.

Interested in learning more about ultrasound and COVID-19? Check out the following posts from the Scan:

My Sonography Experience With COVID-19

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It is been almost 5 weeks since I got infected with SARS-CoV-2 (also known as COVID-19), my life-changing experience.1

The day all started, during my night shift, I started with low-grade fever, chills, and myalgia; I did not doubt for a second that I had to have the test for SARS-CoV-2. That same day, most of my mild COVID-19 patients had these same cold-like symptoms, but some of them did not have a known epidemiological contact. Without time to have any other tests done, laboratory or X-ray, I self-quarantined at home waiting for the result. And finally, it came in the midst of the night; I received the “positive”.

In the morning, as more symptoms started to appear, headache, diarrhea, anosmia, ageusia and dry cough, it was a relief to have my hand-held ultrasound device at home. With the rush, I even left my oximeter, which measures heart rate and blood oxygen levels, in my hospital locker.

There is now growing evidence regarding the imaging findings of COVID-19, but at that time, the only studies were performed via CT scan and X-ray. With my ultrasound probe, I scanned following 8 zones (2 anterior, 2 lateral of both hemithorax) plus posterior lobes. I felt relieved (didn’t last long) to see there was a normal A-line pattern. More relief came when at some point I had a dull but constant right lower abdominal pain with normal appendix and no hydronephrosis on ultrasound.

 

What impresses most about this disease is its dynamic pattern, with sudden changes during the evolution. As my symptoms waxed and waned, so did my lung ultrasound, probably in a different manner than I would have expected. As the disease progressed, I saw all the possible lung findings, from the initial posterobasal scattered B-lines, to small pleural effusions, irregular pleural line, coalescent B-lines, and finally subpleural consolidations, especially in posterior and lateral areas. My personal impression was that I wasn’t feeling worse when I had more B-lines, but when the subpleural consolidations started to appear and spread. Each time I had new subpleural consolidations, there was a worsening in my symptoms coming: more myasthenia, cough, and diarrhea. After the second week, the subpleural consolidations were replaced by coalescent and scattered B-lines. Following that, the irregular pleural line persisted longer.

March 22 still

 

Surprisingly, during the third week, things started to worsen again, and on ultrasound there was a big consolidation appearing in one lobe, that was my sign for a therapy shift towards antibiotics.

My personal feeling is that consolidations are more reliable than just the number of B-lines, and correlated better with my symptoms. Actually, after 3 weeks from the symptom onset, after recovering and testing negative for SARS-CoV-2, I still had several areas with scattered and coalescent B-lines, as well as thickening of the pleural line. We have to be more flexible and take into account other parameters (i.e. oximetry), rather than rely solely on the number of affected areas on ultrasound, to compose the clinical picture, and influence the management.

As I remarked before, what impresses me most about this disease is the ultrasound dynamism. After having recovered, I still had new areas of thickening of pleural line that appeared in the back (asymptomatic) for the following week (4th), and almost 5 weeks after, I still had one plaque. And after 5 weeks, I am still surprised to have unnoticed findings, such as an asymptomatic pericardial effusion.

As a firm sonobeliever, I found it extremely useful to monitor my disease for sonographic progression and or resolution, and quickly detect complications. After this experience and having returned to work, I would have no excuse to irradiate my patients before scanning them, in the same way I went through.

Definitely, this experience was the best lesson I could have before returning to the trenches.

 

Yale Tung Chen, MD, PhD, is an associate professor at Universidad Alfonso X El Sabio, in Madrid, Spain. He was diagnosed with COVID-19 and shared his symptoms and ultrasound images each day on Twitter @yaletung. Follow his thread at #mycoviddiary.

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan: