Abstract
Purpose
To assess the impact of lung ultrasound (LU) on clinical decision making in mechanically ventilated critically ill patients.
Methods
One hundred and eighty-nine patients took part in this prospective study. The patients were enrolled in the study when LU was requested by the primary physician for (1) unexplained deterioration of arterial blood gases and (2) a suspected pathologic entity [pneumothorax, significant pleural effusion (including parapneumonic effusion, empyema, or hemothorax), unilateral atelectasis (lobar or total), pneumonia and diffuse interstitial syndrome (pulmonary edema)].
Results
Two hundred and fifty-three LU examinations were performed; 108 studies (42.7 %) were performed for unexplained deterioration of arterial blood gases, and 145 (57.3 %) for a suspected pathologic entity (60 for pneumothorax, 34 for significant pleural effusion, 22 for diffuse interstitial syndrome, 15 for unilateral lobar or total lung atelectasis, and 14 for pneumonia). The net reclassification index was 85.6 %, indicating that LU significantly influenced the decision-making process. The management was changed directly as a result of information provided by the LU in 119 out of 253 cases (47 %). In 81 cases, the change in patient management involved invasive interventions (chest tube, bronchoscopy, diagnostic thoracentesis/fluid drainage, continuous venous–venous hemofiltration, abdominal decompression, tracheotomy), and in 38 cases, non-invasive (PEEP change/titration, recruitment maneuver, diuretics, physiotherapy, change in bed position, antibiotics initiation/change). In 53 out of 253 cases (21 %), LU revealed findings which supported diagnoses not suspected by the primary physician (7 cases of pneumothorax, 9 of significant pleural effusion, 9 of pneumonia, 16 of unilateral atelectasis, and 12 of diffuse interstitial syndrome).
Conclusion
Our study shows that LU has a significant impact on decision making and therapeutic management.
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References
Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ (2004) Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 100:9–15
Xirouchaki N, Magkanas E, Vaporidi K, Kondili E, Plataki M, Patrianakos A, Akoumianaki E, Georgopoulos D (2011) Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med 37:1488–1493
Lichtenstein DA, Meziere GA (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134:117–125
Bouhemad B, Liu ZH, Arbelot C, Zhang M, Ferarri F, Le-Guen M, Girard M, Lu Q, Rouby JJ (2010) Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med 38:84–92
Blaivas M (2012) Lung ultrasound in evaluation of pneumonia. J Ultrasound Med 31:823–826
Lichtenstein DA (2009) Ultrasound examination of the lungs in the intensive care unit. Pediatr Crit Care Med 10:693–698
Bouhemad B, Zhang M, Lu Q, Rouby JJ (2007) Clinical review: bedside lung ultrasound in critical care practice. Crit Care 11:205
Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38:577–591
Lichtenstein DA, Meziere G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M (2005) Ultrasound diagnosis of occult pneumothorax. Crit Care Med 33:1231–1238
Volpicelli G (2011) Sonographic diagnosis of pneumothorax. Intensive Care Med 37(2):224–232
Lichtenstein D, Meziere G, Biderman P, Gepner A (2000) The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med 26:1434–1440
Maslove DM, Chen BT, Wang H, Kuschner WG (2012) The diagnosis and management of pleural effusions in the ICU. J Intensive Care Med 28:24–36
Lichtenstein DA, Lascols N, Meziere G, Gepner A (2004) Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med 30:276–281
Lichtenstein D (2005) Ultrasound diagnosis of atelectasis. Int J Intensive Care 12:88–93
Lichtenstein DA, Lascols N, Prin S, Meziere G (2003) The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Med 29:2187–2192
Lichtenstein D, Meziere G, Seitz J (2009) The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 135:1421–1425
Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O (1997) The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 156:1640–1646
Mallamaci F, Benedetto FA, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C (2010) Detection of pulmonary congestion by chest ultrasound in dialysis patients. JACC Cardiovasc Imaging 3:586–594
Lichtenstein D (2012) Fluid administration limited by lung sonography: the place of lung ultrasound in assessment of acute circulatory failure (the FALLS-protocol). Expert Rev Respir Med 6:155–162
Pencina MJ, D’Agostino RB, Vasan RS (2010) Statistical methods for assessment of added usefulness of new biomarkers. Clin Chem Lab Med 48:1703–1711
Steyerberg EW, Vickers AJ, Cook NR, Gerds T, Gonen M, Obuchowski N, Pencina MJ, Kattan MW (2010) Assessing the performance of prediction models: a framework for traditional and novel measures. Epidemiology 21:128–138
Yu CJ, Yang PC, Chang DB, Luh KT (1992) Diagnostic and therapeutic use of chest sonography: value in critically ill patients. AJR Am J Roentgenol 159:695–701
Acknowledgments
The authors would like to acknowledge G. Chlouverakis, Associate Professor of Biostatistics, for his contribution to the statistical analysis.
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Take-home message: In mechanically ventilated critically ill patients lung ultrasound has a significant impact on clinical decision making and therapeutic management.
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Xirouchaki, N., Kondili, E., Prinianakis, G. et al. Impact of lung ultrasound on clinical decision making in critically ill patients. Intensive Care Med 40, 57–65 (2014). https://doi.org/10.1007/s00134-013-3133-3
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DOI: https://doi.org/10.1007/s00134-013-3133-3