Lung Ultrasound: The Essentials

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.

Summary Diarrhoea and pneumonia are the leading infectious causes of childhood morbidity and mortality. We comprehensively reviewed the epidemiology of childhood diarrhoea and pneumonia in 2010–11 to inform the planning of integrated control programmes for both illnesses. We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years. We estimated that, in 2011, 700 000 episodes of diarrhoea and 1·3 million of pneumonia led to death. A high proportion of deaths occurs in the first 2 years of life in both diseases—72% for diarrhoea and 81% for pneumonia. The epidemiology of childhood diarrhoea and that of pneumonia overlap, which might be partly because of shared risk factors, such as undernutrition, suboptimum breastfeeding, and zinc deficiency. Rotavirus is the most common cause of vaccine-preventable severe diarrhoea (associated with 28% of cases), and Streptococcus pneumoniae (18·3%) of vaccine-preventable severe pneumonia. Morbidity and mortality from childhood pneumonia and diarrhoea are falling, but action is needed globally and at country level to accelerate the reduction.

Dear Editor, Up to 24 February 2020, there have been 77,269 officially reported confirmed cases of 2019 novel corona virus (SARS-CoV-2) infection in China. As lung abnormalities may develop before clinical manifestations and nucleic acid detection, experts have recommended early chest computerized tomography (CT) for screening suspected patients [1]. The high contagiousness of SARS-CoV-2 and the risk of transporting unstable patients with hypoxemia and hemodynamic failure make chest CT a limited option for the patient with suspected or established COVID-19. Lung ultrasonography gives the results that are similar to chest CT and superior to standard chest radiography for evaluation of pneumonia and/or adult respiratory distress syndrome (ARDS) with the added advantage of ease of use at point of care, repeatability, absence of radiation exposure, and low cost [2]. In this report, we summarize our early experience with lung ultrasonography for evaluation of SARS-CoV-2 infection in China with the intent of alerting frontline intensivists to the utility of lung ultrasonography for management of COVID-19. Ultrasonographic features of nCoV pneumonia We performed lung ultrasonography on 20 patients with COVID-19 using a 12-zone method [3]. Characteristic findings included the following: Thickening of the pleural line with pleural line irregularity; B lines in a variety of patterns including focal, multifocal, and confluent; Consolidations in a variety of patterns including multifocal small, non-translobar, and translobar with occasional mobile air bronchograms; Appearance of A lines during recovery phase; Pleural effusions are uncommon. The observed patterns occurred across a continuum from mild alveolar interstitial pattern, to severe bilateral interstitial pattern, to lung consolidation. Table 1 summarizes typical lung ultrasonography finds in patients with COVID-19 respiratory disease in comparison with chest CT findings. Typical lung ultrasonography images are shown in the supplementary material (Supplementary Fig. 1.) Table 1 CT and ultrasonographic features of COVID-19 pneumonia Lung CT Lung ultrasound Thickened pleura Thickened pleural line Ground glass shadow and effusion B lines (multifocal, discrete, or confluent) Pulmonary infiltrating shadow Confluent B lines Subpleural consolidation Small (centomeric) consolidations) Translobar consolidation Both non-translobar and translobar consolidation Pleural effusion is rare. Pleural effusion is rare More than two lobes affected Multilobar distribution of abnormalities Negative or atypical in lung CT images in the super-early stage, then diffuse scattered or ground glass shadow with the progress of the disease, further lung consolidation Focal B lines is the main feature in the early stage and in mild infection; alveolar interstitial syndrome is the main feature in the progressive stage and in critically ill patients; A lines can be found in the convalescence; pleural line thickening with uneven B lines can be seen in patients with pulmonary fibrosis The findings of lung ultrasonography features of SARS-CoV-2 pneumonia/ARDS are related to the stage of disease, the severity of lung injury, and comorbidities. The predominant pattern is of varying degrees of interstitial syndrome and alveolar consolidation, the degree of which is correlated with the severity of the lung injury. A recognized limitation of lung ultrasonography is that it cannot detect lesions that are deep within the lung, as aerated lung blocks transmission of ultrasonography, i.e., the abnormality must extend to the pleural surface to be visible with on ultrasonography examination. Chest CT is required to detect pneumonia that does not extend to the pleural surface. Based upon our experience, we consider that lung ultrasonography has major utility for management of COVID-19 with respiratory involvement due to its safety, repeatability, absence of radiation, low cost and point of care use; chest CT may be reserved for cases where lung ultrasonography is not sufficient to answer the clinical question. We find there is utility of lung ultrasonography for rapid assessment of the severity of SARS-CoV-2 pneumonia/ARDS at presentation, to track the evolution of disease, to monitor lung recruitment maneuvers, to guide response to prone position, the management of extracorporeal membrane therapy, and for making decisions related to weaning the patient form ventilatory support. Electronic supplementary material Supplementary Figure 1: Typical lung ultrasonography images of nCoV pneumonia. B lines; B. confluent B lines; C. small consolidations; D. translobar consolidation. Supplementary Figure 1 Typical lung ultrasonography images of nCoV pneumonia. A. B lines; B. confluent B lines; C. small consolidations; D. translobar consolidation. (TIFF 34299 kb)