Lung Ultrasound B-lines Research Articles

Prognostic value of the early lung ultrasound B-line score for postoperative pulmonary insufficiency in patients undergoing thoracic surgery: an observational study

BackgroundPostoperative pulmonary insufficiency (PPI) is an important contributor to morbidity and mortality after thoracic surgery. Lung ultrasound is a reliable tool for assessing respiratory function. We sought to determine the clinical value of the early lung ultrasound B-line score for predicting changes in pulmonary function after thoracic surgery.MethodsEighty-nine patients undergoing elective lung surgery were included in this study. The B-line score was determined 30 min after removal of the endotracheal tube, and the PaO2/FiO2 ratio was recorded 30 min after extubation and on the third postoperative day. Patients were divided into normal (PaO2/FiO2 ≥ 300) and PPI (PaO2/FiO2 < 300) groups according to their PaO2/FiO2 ratios. A multivariate logistic regression model was used to identify independent predictors of postoperative pulmonary insufficiency. Receiver operating characteristic (ROC) analysis was performed for significantly correlated variables.ResultsEighty-nine patients undergoing elective lung surgery were included in this study. We evaluated 69 patients in the normal group and 20 in the PPI group. Patients conforming to NYHA class 3 at administration were significantly more represented in the PPI group (5.8 and 55%; p < 0.001). B-line scores were significantly higher in the PPI group than in the normal group (16; IQR 13–21 vs. 7; IQR 5–10; p < 0.001). The B-line score was an independent risk factor (OR = 1.349 95% CI 1.154–1.578; p < 0.001), and its best cutoff value for predicting PPI was 12 (sensitivity: 77.5%; specificity: 66.7%).ConclusionsLung ultrasound B-line scores 30 min after extubation are effective in predicting early PPI in patients undergoing thoracic surgery.Trial registration This study was registered with the Chinese Clinical Trials Registry (ChiCTR2000040374).

Automated lung ultrasound image assessment using artificial intelligence to identify fluid overload in dialysis patients

BackgroundFluid assessment is challenging, and fluid overload poses a significant problem among dialysis patients, with pulmonary oedema being the most serious consequence. Our study aims to develop a simple objective fluid assessment strategy using lung ultrasound (LUS) and artificial intelligence (AI) to assess the fluid status of dialysis patients.MethodsThis was a single-centre study of 76 hemodialysis and peritoneal dialysis patients carried out between July 2020 to May 2022. The fluid status of dialysis patients was assessed via a simplified 8-point LUS method using a portable handheld ultrasound device (HHUSD), clinical examination and bioimpedance analysis (BIA).The primary outcome was the performance of 8-point LUS using a portable HHUSD in diagnosing fluid overload compared to physical examination and BIA. The secondary outcome was to develop and validate a novel AI software program to quantify B-line count and assess the fluid status of dialysis patients.ResultsOur study showed a moderate correlation between LUS B-line count and fluid overload assessed by clinical examination (r = 0.475, p < 0.001) and BIA (r = 0.356. p < 0.001). The use of AI to detect B-lines on LUS in our study for dialysis patients was shown to have good agreement with LUS B lines observed by physicians; (r = 0.825, p < 0.001) for the training dataset and (r = 0.844, p < 0.001) for the validation dataset.ConclusionOur study confirms that 8-point LUS using HHUSD, with AI-based detection of B lines, can provide clinically useful information on the assessment of hydration status and diagnosis of fluid overload for dialysis patients in a user-friendly and time-efficient way.

Serum B-cell activating factor and lung ultrasound B-lines in connective tissue disease related interstitial lung disease.

To investigate the role of serum B-cell activating factor (BAFF) and lung ultrasound (LUS) B-lines in connective tissue disease related interstitial lung disease (CTD-ILD), and their association with different ILD patterns on high resolution computed tomography (HRCT) of chest. We measured the levels of BAFF and KL-6 by ELISA in the sera of 63 CTD-ILD patients [26 with fibrotic ILD (F-ILD), 37 with non-fibrotic ILD (NF-ILD)], 30 CTD patients without ILD, and 26 healthy controls. All patients underwent chest HRCT and LUS examination. Serum BAFF levels were significantly higher in CTD patients compared to healthy subjects (617.6 ± 288.1 pg/ml vs. 269.0 ± 60.4 pg/ml, p < 0.01). BAFF concentrations were significantly different between ILD group and non-ILD group (698.3 ± 627.4 pg/ml vs. 448.3 ± 188.6 pg/ml, p < 0.01). In patients with ILD, BAFF concentrations were significantly correlated with B-lines number (r = 0.37, 95% CI 0.13-0.56, p < 0.01), KL-6 level (r = 0.26, 95% CI 0.01-0.48, p < 0.05), and Warrick score (r = 0.33, 95% CI 0.09-0.53, p < 0.01), although all correlations were only low to moderate. B-lines number correlated with Warrick score (r = 0.65, 95% CI 0.48-0.78, p < 0.01), and KL-6 levels (r = 0.43, 95% CI 0.21-0.61, p < 0.01). Patients with F-ILD had higher serum BAFF concentrations (957.5 ± 811.0 pg/ml vs. 516.1 ± 357.5 pg/ml, p < 0.05), KL-6 levels (750.7 ± 759.0 U/ml vs. 432.5 ± 277.5 U/ml, p < 0.05), B-lines numbers (174.1 ± 82 vs. 52.3 ± 57.5, p < 0.01), and Warrick score (19.9 ± 4.6 vs. 13.6 ± 3.4, p < 0.01) vs. NF-ILD patients. The best cut-off values to separate F-ILD from NF-ILD using ROC curves were 408 pg/ml for BAFF (AUC = 0.73, p < 0.01), 367 U/ml for KL-6 (AUC = 0.72, p < 0.05), 122 for B-lines number (AUC = 0.89, p < 0.01), and 14 for Warrick score (AUC = 0.87, p < 0.01) respectively. Serum BAFF levels and LUS B-lines number could be useful supportive biomarkers for detecting and evaluating the severity and/or subsets of CTD-ILD. If corroborated, combining imaging, serological, and sonographic biomarkers might be beneficial and comprehensive in management of CTD-ILD.

197 Deep Learning-Based Scoring of Pulmonary Congestion for BLUSHED AHF Trial

Point-of-care ultrasound (POCUS) offers real-time data to guide clinical decision- making and patient care. Despite having advantages over alternative imaging studies such as computed tomography or magnetic resonance imaging, performing POCUS requires technical expertise for image acquisition and interpretation, thereby limiting its use for many clinicians. Deep learning technologies can provide automated interpretation of POCUS images thus making POCUS accessible to even novice users. The goal of this study was to determine the ability of a deep learning algorithm to grade the severity of lung ultrasound (LUS) B-lines in patients with acute heart failure (AHF) when compared to expert reviewers.

Lung Ultrasound B-Lines in the Evaluation of the Extent of Interstitial Lung Disease in Systemic Sclerosis.

Background: Chest computed tomography (CT) is the gold standard for the evaluation of systemic sclerosis-related interstitial lung disease (SSc-ILD). Lung ultrasound (LUS) is a radiation-free tool that identifies the B-lines as a main feature of ILD. We aimed to investigate the role of LUS in the evaluation of the extent of SSc-ILD. Methods: Adult SSc patients underwent pulmonary function tests (PFTs), LUS and CT. The CT images were qualitatively, semi-quantitatively (the Wells score on five levels and the categorical Goh et al. staging) and quantitatively (histogram-based densitometry) analysed for ILD. LUS quantified B-lines in 21 intercostal spaces on both the anterior and posterior chest wall. Results: Out of the 77 SSc patients eligible for the study, 35 presented with ILD on CT (21 limited, 14 extensive). Total B-lines significantly differentiated ILD vs. no ILD (median 24 vs. 8, p < 0.001). Posterior and total B-lines significantly differentiated limited from absent ILD, while anterior B-lines distinguished extensive from limited ILD. Total B-lines correlated with the Wells score (r = 0.446, p < 0.001) and MLA (r = −0.571, p < 0.001); similar results were confirmed when anterior and posterior B-lines were analysed separately. Conclusions: LUS is a useful tool to identify SSc-ILD and to correlate with different evaluations of ILD extent and severity.

Simplified Lung Ultrasound Examination and Telehealth Feasibility in Early SARS-CoV-2 Infection

BackgroundIn COVID-19, inpatient studies have demonstrated that lung ultrasound B-lines relate to disease severity and mortality and can occur in apical regions that can be imaged by patients themselves. However, as illness begins in an ambulatory setting, the aim of this study was to determine the prevalence of apical B-lines in early outpatient infection and then test the accuracy of their detection using telehealth and automated methods.MethodsConsecutive adult patients (N = 201) with positive results for SARS-CoV-2, at least one clinical risk factor, and mild to moderate disease were prospectively enrolled at a monoclonal antibody infusion clinic. Physician imaging of the lung apices for three B-lines (ultrasound lung comet [ULC]) using 3-MHz ultrasound was performed on all patients for prevalence data and served as the standard for a nested subset (n = 50) to test the accuracy of telehealth methods, including patient self-imaging and automated B-line detection. Patient characteristics, vaccination data, and hospitalizations were analyzed for associations with the presence of ULC.ResultsPatients’ mean age was 54 ± 15 years, and all lacked hypoxemia or fever. ULC was present in 55 of 201 patients (27%) at a median of 7 symptomatic days (interquartile range, 5-8 days) and in four of five patients who were later hospitalized (P = .03). Presence of ULC was associated with unvaccinated status (odds ratio [OR], 4.11; 95% CI, 1.85-9.33; P = .001), diabetes (OR, 2.56; 95% CI, 1.08-6.05; P = .03), male sex (OR, 2.14; 95% CI, 1.07-4.37; P = .03), and hypertension or cardiovascular disease (OR, 2.06; 95% CI, 1.02-4.23; P = .04), while adjusting for body mass index > 25 kg/m2. Telehealth and automated B-line detection had 84% and 82% accuracy, respectively.ConclusionsIn high-risk outpatients, B-lines in the upper lungs were common in early SARS-CoV-2 infection, were related to subsequent hospitalization, and could be detected by telehealth and automated methods.

Prognostic Value of Admission-to-Discharge Change in Integral Congestion Assessment for Predicting Adverse Outcomes in Patients with Decompensated Heart Failure.

This study was performed to evaluate the prognostic value of relative changes from admission to discharge (Δ%) of integrated congestion assessment to predict adverse outcomes in patients with irreversible heart failure (HF) during a one-year follow-up. The study included 122 patients (60% males, median age of 69 years) with decompensated HF. Most of the patients (92%) had a history of arterial hypertension, 53.3% had coronary heart disease, and 40.2% had type 2 diabetes mellitus. All patients underwent assessments, including NT-proBNP, lung ultrasound (LUS) B-line score, liver stiffness by transient elastography, and resistance and reactance by bioimpedance vector analysis (BIVA). The assessments were performed at admission and discharge, and a relative change from admission (delta percentage, Δ%) was calculated. Long-term clinical outcomes were assessed by a structured interview conducted 1, 3, 6, and 12 months after discharge. The cut-offs for the occurrence of the endpoint events were Δ% NT-proBNP of ≥ -25, Δ% liver stiffness of ≥ -44, Δ% B-line score on lung ultrasound of ≥ -73, Δ% BIVA resistance of ≤ 18, and Δ% BIVA reactance of ≤ 40. It was revealed that 55% of endpoint events, including 22 (18%) deaths and 33 (27%) readmissions, occurred within a median of 74 days (interquartile range: 33-147). Patients with an endpoint event had significantly worse values of all studied parameters in contrast to patients without it. There was a significant direct association between Δ% NT-proBNP and Δ% B-lines (r=0.18; P=0.04), and a highly reliable inverse association was observed between Δ% liver stiffness and Δ% BIVA reactance (r=-0.4; P<0.001). No significant associations were found between the other parameters. Univariate Cox regression analysis demonstrated the independent prognostic value of all congestion markers under study (NT-proBNP, LUS B-lines, liver stiffness, and BIVA reactance) for predicting the combined endpoint. Multivariate Cox regression analysis confirmed the independent prognostic value in predicting the risk of endpoint event for the following parameters: NT-proBNP (hazard rate [HR] 2.5, P=0.001), liver stiffness (HR 2.3, P=0.012), LUS B-line score (HR 2.2, P=0.008). However, it did not find any significant prognostic value for BIVA resistance and reactance. The relative admission-to-discharge change in the integral assessment of congestion had a prognostic value for predicting the risk of adverse outcomes (all-cause mortality and readmission rate) in patients with decompensated HF during a one-year follow-up.

Impact of B-lines-guided intensive heart failure management on outcome of discharged heart failure patients with residual B-lines.

AimsPulmonary congestion (PC) expressed by residual lung ultrasound B‐lines (LUS‐BL) could exist in some discharged heart failure (HF) patients, which is a known determinant of poor outcomes. Detection efficacy for PC is suboptimal with widely used imaging modalities, like X‐ray or echocardiography, while lung ultrasound (LUS) can sufficiently detect PC by visualizing LUS‐BL. In this trial, we sought to evaluate the impact LUS‐BL‐guided intensive HF management post‐discharge on outcome of HF patients discharged with residual LUS‐BL up to 1 year after discharge. IMP‐OUTCOME is a prospective, single‐centre, single‐blinded, randomized cohort study, which is designed to investigate if LUS‐BL‐guided intensive HF management post‐discharge in patients with residual LUS‐BL could improve the clinical outcome up to 1 year after discharge or not.Methods and resultsAfter receiving the standardized treatment of HF according to current guidelines, 318 patients with ≥3 LUS‐BL assessed by LUS within 48 h before discharge will be randomly divided into the conventional HF management group and the LUS‐BL‐guided intensive HF management group at 1:1 ratio. Patient‐related basic clinical data including sex, age, blood chemistry, imaging examination, and drug utilization will be obtained and analysed. LUS‐BL will be assessed at 2 month interval post‐discharge in both groups, but LUS‐BL results will be enveloped in the conventional HF management group, and diuretics will be adjusted based on symptom and physical examination results with or without knowing the LUS‐BL results. Echocardiography examination will be performed for all patients at 12 month post‐discharge. The primary endpoint is consisted of the composite of readmission for worsening HF and all‐cause death during follow up as indicated. The secondary endpoints consisted of the change in the New York Heart Association classification, Duke Activity Status Index, N terminal pro brain natriuretic peptide value, malignant arrhythmia event and 6 min walk distance at each designed follow up, echocardiography‐derived left ventricular ejection fraction, and number of LUS‐BL at 12 month post‐discharge. Safety profile will be recorded and managed accordingly for all patients.ConclusionsThis trial will explore the impact of LUS‐BL‐guided intensive HF management on the outcome of discharged HF patients with residual LUS‐BL up to 1 year after discharge in the era of sodium‐glucose cotransporter‐2 inhibitors and angiotensin receptor blocker‐neprilysin inhibitor.Trial Registration: ClinicalTrials.gov: NCT05035459

MO648: Evaluation of Fluid Status with Lung Ultrasound and Continuous Blood Volume Monitoring in Chronic Haemodialysis Patients

Abstract BACKGROUND AND AIMS Continuous blood volume (BV) monitoring with Haemoscan monitor is a noninvasive photometric method that measures BV% change according to the changes in haematocrit during haemodialysis (HD) session (haemoconcentration depending on HD ultrafiltration rate and interstitial refilling rate). Lung ultrasound (LUS) has recently been shown to be a useful, noninvasive technique for the assessment of extravascular lung water and pulmonary congestion. Interstitial lung water is detected as LUS B-lines and the sum of B lines in 28 measurements sites gives the lung score (LS, 0–280). The aim of the present study was to evaluate the hydration status and its changes during the HD session, both by LUS and by BV monitoring and to identify any correlations between the two methods in chronic HD patients. METHOD All patients transferred to our new dialysis unit were examined clinically and with pre- and post-dialysis LUS, as part of routine assessment. Haemoscan BV monitoring during HD sessions is a feature of the dialysis machine. Changes between pre- and post-dialysis measurements (Delta, Δ) of different clinical and imaging parameters were recorded and evaluated. RESULTS A total of 24 patients, 19 men and 5 women, 65.5 ± 13.7 years old, on dialysis for 73 (7–201) months, with all usual causes of end-stage renal disease (ESRD) and 27 HD sessions of 3–4 h were included. Median pre-dialysis LS was 4 (0–116) and post-dialysis 1 (0–28), Δ LS: 3 (−1 to 102). The final BV change detected by Haemoscan was −8.8 ± 3.6% (−1.7 to −18.4%) and the final fluid loss was 2.43 ± 0.8 L (32.3 ± 8.3 ml/kg BW or 8.8 ± 2.2 mL/kg BW/h). Pre-dialysis systolic blood pressure (SBP)/diastolic blood pressure (DBP) was 159 ± 21/86 ± 17 mmHg and post-dialysis 138 ± 18/78 ± 14 mmHg (Δ SBP 22 ± 24 mmHg and Δ DBP: 8 ± 14 mmHg). Statistically significant correlations were found between BV change and fluid loss (rho = −0.535, P = .004) (the higher the fluid loss during HD, the higher the haemoconcentration) and between Δ LS and Δ SBP (rho = 0.550, P = .003) and Δ DBP (rho = 0.544, P = .003). No correlation was found between BV% change and Δ LS. However, most of the patients had few or no pre-dialysis B lines and a minimal Δ LS, rendering impossible the finding of any correlation. But if we consider the only 7 sessions with ≥10 pre-dialysis B lines (indicating some pulmonary congestion), a strong negative correlation was found between BV% change and Δ LS (rho = −0.786, P = .036), (the higher the hemoconcentration, the higher the pulmonary decongestion). Nevertheless, even in patients without pulmonary congestion (B-lines &amp;lt;5), a significant haemoconcentration during HD session was observed: BV change = −9.8 ± 3.7% (−3.9 to −18.4%) with final fluid loss of 2.5 ± 0.7 L (32 ± 8 mL/kg BW or 8.7 ± 2.3 mL/kg BW/h). CONCLUSION Fluid loss during HD correlates to haemoconcentration (BV % change), but not to Δ LS, even in patients with some pulmonary congestion (pre-dialysis LS ≥10). It seems that inter-dialysis fluid accumulation can be less apparent in the lungs and even patients without clinical signs of fluid overload (dyspnoea, oedema) and no pulmonary congestion (minimal B lines) can lose substantial fluid amounts during HD sessions with significant haemoconcentration. Indeed, in our study, no difference in fluid loss and BV% change was found between patients with high and low pre-dialysis LS. Thus, a high pre-dialysis LS score may indicate fluid overload and pulmonary congestion, but the opposite (low pre-dialysis LS) cannot indicate that the patient is dehydrated. This also may explain why we found a strong correlation of Δ LS and BV% change in those with high pre-dialysis LS, but not in all the patients. Lung ultrasound is a useful tool for fluid overload detection and can be used complementary to BV monitoring: redefining dry weight in those with high pre-dialysis LS and lung congestion and avoiding very high BV% changes which indicate reduced refilling rate and risk of hypotensive consequences.

Integral assessment of congestion in patients with acute decompensated heart failure

Aim. To assess the prognostic value of the integral assessment using various modern methods for diagnosing congestion in patients hospitalized with acute decompensated heart failure (ADHF).Material and methods. This single-center prospective study included 165 patients with ADHF. All patients underwent a standard clinical and paraclinical examination, including assessing NT-proBNP levels, lung ultrasound B-lines, liver transient elastography, bioelectrical impedance vector analysis (BIVA) at admission and discharge. To assess clinical congestion, the Heart Failure Association consensus document scale was used. Long-term clinical outcomes were assessed by telephone survey 1, 3, 6, 12 months after discharge. As an end point, the allcause mortality and readmissions were estimated.Results. In patients hospitalized with ADHF, at discharge, differences were found in the incidence of residual congestion according to certain paraclinical methods — from 22 to 38%, subclinical — from 14,5 to 27%. When using the integral assessment of stagnation, the incidence of residual and subclinical congestion was 53,6% and 35%, respectively. Patients with residual congestion had more severe symptoms of congestion, compared with those with subclinical congestion. Patients in whom congestion was detected by 4 methods, in contrast to those by 1, 2, and 3 methods, had worse clinical and paraclinical parameters. There was a significant increase in the risk of all-cause mortality and readmission in the presence of congestion, identified by 3 (hazard ratio, 9,4 (2,2-40,6); p&lt;0,001) and 4 methods (hazard ratio, 15,2 (3,3-68,1); p&lt;0,001).Conclusion. For patients hospitalized with ADHF, integral assessment of residual and subclinical congestion at should be performed at discharge. The introduction of an integral assessment of congestion into routine practice will allow to identify a group of patients with more unfavorable prognostic characteristics in relation to the risk of death and readmissions, as well as to intensify drug therapy and followup at the outpatient stage.

Lung Congestion Severity in Kidney Transplant Recipients Is Not Affected by Arteriovenous Fistula Function.

Lung ultrasound is a bedside technique for the assessment of pulmonary congestion. The study aims to assess the severity of lung congestion in kidney transplant recipients (KTR) in relation to arteriovenous fistula (AVF) patency. One hundred fifty-seven patients at least 12 months after kidney transplantation were recruited to participate in a cross-sectional study. Apart from routine visits, lung ultrasound at 28 typical points was performed. The patients were assigned to either AVF+ or AVF− groups. The mean number of lung ultrasound B-lines (USBLs) was 5.14 ± 4.96 with no differences between groups: 5.5 ± 5.0 in AVF+ and 4.8 ± 4.9 in AVF−, p = 0.35. The number and proportion of patients with no congestion (0–5 USBLs), mild congestion (6–15 USBLs), and moderate congestion (16–30 USBLs) were as follows: 101 (64.7%), 49 (31.4%), and 6 (3.8%), respectively. In multivariate analysis, only symptoms (OR 5.90; CI 2.43,14.3; p = 0.0001), body mass index (BMI) (OR 1.09; CI 1.03,1.17; p = 0.0046), and serum cholesterol level (OR 0.994; CI 0.998,1.000; p = 0.0452) contributed significantly to the severity of lung congestion. Lung ultrasound is a valuable tool for the evaluation of KTR. Functioning AVF in KTR is not the major factor affecting the severity of pulmonary congestion.

Lung Ultrasound B-lines as a Surrogate Marker for High Left Ventricular Diastolic Pressures; a bed-side Diagnostic tool

Background: We studied the diagnostic accuracy of B-lines (comet-tail sign) on bedside lung US, NT-proBNP, E/e` on ECHO in differentiation of the causes of acute dyspnea in the emergency setting. Major advantages include bedside availability, no radiation, high feasibility and reproducibility, and cost efficiency. Methods: Our prospective study was performed at the alazhar university hospital, Cairo, Egypt, between July 2019 and March 2020. All patients underwent lung ultrasound examinations, along with TTE, laboratory testing, including rapid NT-proBNP testing. Results: The median E/e’ levels in patients with B-profile were 18, compared with a median of 7.4 in the subjects with A-profile (P =&lt; 0.0001 CI = -9.649 to -7.044). It was found that the sensitivity and the specificity of detecting B-profile on ultrasound is high when E/e’ &gt; 15.5 (95.0% and 83.0% consecutively), which concluded the high correlation between finding B profile on U/S chest and elevated left ventricle filling pressure in a patient presenting with picture of suggestive of heart failure Conclusion: Chest ultrasound can be used as screening test for the evaluation of patients with suspicion of heart failure with excellent sensitivity and good specificity.

The Prognostic Value of Lung Ultrasound in Patients With Newly Diagnosed Heart Failure With Preserved Ejection Fraction in the Ambulatory Setting.

Background: Heart failure with preserved ejection fraction (HFpEF) is a growing healthcare burden, and its prevalence is steadily increasing. Lung ultrasound (LUS) is a promising screening and prognostic tool in the heart failure population. However, more information on its value in predicting outcome is needed.Aims: The aim of our study was to assess the prognostic performance of LUS B-lines compared to traditional and novel clinical and echocardiographic parameters and natriuretic peptide levels in patients with newly diagnosed HFpEF in an ambulatory setting.Methods: In our prospective cohort study, all ambulatory patients with clinical suspicion of HFpEF underwent comprehensive echocardiography, lung ultrasound and NT-proBNP measurement during their first appointment at our cardiology outpatient clinic. Our endpoint was a composite of worsening heart failure symptoms requiring hospitalization or loop diuretic dose escalation and death.Results: We prospectively enrolled 75 consecutive patients with HFpEF who matched our inclusion and exclusion criteria. We detected 11 events on a 26 ± 10-months follow-up. We found that the predictive value of B-lines is similar to the predictive value of NT-proBNP (AUC 0.863 vs. 0.859), with the best cut-off at >15 B-lines. Having more B-lines than 15 significantly increased the likelihood of adverse events with a hazard ratio of 20.956 (p = 0.004). The number of B-lines remained an independent predictor of events at multivariate modeling. Having more than 15 B-lines lines was associated with a significantly worse event-free survival (Log-rank: 16.804, p < 0.001).Conclusion: The number of B-lines seems to be an independent prognostic factor for adverse outcomes in HFpEF. Since it is an easy-to-learn, feasible and radiation-free method, it may add substantial value to the commonly used diagnostic and risk stratification models.

Utility of Lung Ultrasound in the Estimation of Extravascular Lung Water in a Pediatric Population—A Prospective Observational Study

Lung ultrasound (LUS) is a promising bedside modality for the estimation of extravascular lung water index (EVLWI), but has not been validated against objective measures in children. This study aimed to investigate the correlation of LUS B-line scoring with EVLWI, thresholds indicating elevated EVLWI, and its outcome following pediatric cardiac surgery. Prospective observational study. Cardiothoracic surgical intensive care unit in a tertiary care teaching hospital. Children younger than 12 years undergoing elective complete surgical correction of cyanotic or acyanotic congenital heart disease (Aristotle score ≤9), excluding neonates, those weighing <3.5 kg, and those with thoracic deformities, pulmonary pathology, and hemodynamic instability. Extravascular lung water index measurement by transpulmonary thermodilution, along with concurrent LUS B-line and Chest-X ray (CXR) scoring. LUS B-line score had a moderate correlation with EVLWI (Pearson's correlation coefficient 0.57; 95% CI 0.44-0.69). LUS B-line scores showed acceptable discrimination only for higher thresholds of EVLWI (sensitivity 82% and 79%, respectively, for EVLWI >20 mL/kg v sensitivity and specificity 57% and 80% for EVLWI >10 mL/kg). Age, body surface area, vasoactive-inotropic score (VIS), chest X-ray score, and EVLWI but not LUS B-line score were significant predictors for duration of mechanical ventilation in this cohort. LUS B-line scoring has limited utility in semiquantitative estimation of EVLWI at lower thresholds of EVLWI in pediatric cardiac surgical patients. It may have better discrimination and acceptable sensitivity and specificity at higher thresholds of EVLWI. Contrasting with multiple reports of clinical utility, these results call for wider evaluation of LUS and its clinical modifiers like age, pathology, and pretest probability in estimation of EVLWI.

Lung ultrasound B-lines in systemic sclerosis: cut-off values and methodological indications for interstitial lung disease screening.

Lung ultrasound (LUS), through assessment of B-lines and pleural line alterations, is able to evaluate interstitial lung disease (ILD), a frequent complication of SSc. Different scanning schemes and counting methods have been proposed but no clear cut-off values have been indicated for screening. We aimed to evaluate the accuracy of different LUS methodological approaches to detect ILD compared with high-resolution CT (HRCT) as the gold standard. Sixty-nine SSc patients underwent LUS and chest HRCT on the same day. Both exams were scored by expert readers. The accuracy of different scanning schemes and counting methods was assessed and clinical and functional data were compared with imaging findings. B-lines were more numerous in patients with the diffuse skin subset and Scl70 autoantibody positivity. The number of B-lines correlated with the Scleroderma Lung Study (SLS) I HRCT score (R = 0.754, P < 0.0001). A total of >10 B-lines on the whole chest or >1 B-line on the postero-basal chest showed 97% sensitivity for detecting even very early ILD signs (corresponding to an SLS I score of 1). Sensitivity increased to 100% when pleural line alterations were included in the analysis. LUS has a very high sensitivity in detecting SSc-related ILD. A cut-off value of >10 B-lines on the whole chest or >1 B-line on the postero-basal chest can be used for the screening of SSc-ILD. Assessing only the postero-basal chest seems to be mostly effective, combining high sensitivity with a less time-consuming approach.

Lung Ultrasound in Patients With SARS-COV-2 Pneumonia: Correlations With Chest Computed Tomography, Respiratory Impairment, and Inflammatory Cascade.

ObjectivesLung ultrasound (LUS) might be comparable to chest computed tomography (CT) in detecting parenchymal and pleural pathology, and in monitoring interstitial lung disease. We aimed to describe LUS characteristics of patients during the hospitalization for COVID‐19 pneumonia, and to compare the extent of lung involvement at LUS and chest‐CT with inflammatory response and the severity of respiration impairment.MethodsDuring a 2‐week period, we performed LUS and chest CT in hospitalized patients affected by COVID‐19 pneumonia. Dosages of high sensitivity C‐reactive protein (HS‐CRP), d‐dimer, and interleukin‐6 (IL‐6) were also obtained. The index of lung function (P/F ratio) was calculated from the blood gas test. LUS and CT scoring were assessed using previously validated scores.ResultsTwenty‐six consecutive patients (3 women) underwent LUS 34 ± 14 days from the early symptoms. Among them, 21 underwent CT on the same day of LUS. A fair association was found between LUS and CT scores (R = 0.45, P = .049), which became stronger if the B‐lines score on LUS was not considered (R = 0.57, P = .024). LUS B‐lines score correlated with IL‐6 levels (R = 0.75, P = .011), and the number of involved lung segments detected by LUS correlated with the P/F ratio (R = 0.60, P = .019) but not with HS‐CRP and d‐Dimer levels. No correlations were found between CT scores and inflammations markers or P/F.ConclusionIn patients with COVID‐19 pneumonia, LUS was correlated with both the extent of the inflammatory response and the P/F ratio.

Outcomes of Simplified Lung Ultrasound Exam in COVID-19: Implications for Self-Imaging.

ObjectivesLung ultrasound B‐lines represent interstitial thickening or edema and relate to mortality in COVID‐19. As B‐lines can be detected with minimal training using point‐of‐care ultrasound (POCUS), we examined the frequency, clinical associations, and outcomes of B‐lines when found using a simplified POCUS method in acutely ill patients with COVID‐19.MethodsIn this retrospective cohort study, hospital data from COVID‐19 patients who had undergone lung imaging during standard echocardiography or POCUS were reviewed for an ultrasound lung comet (ULC) sign, defined as the presence of ≥3 B‐lines from images of only the antero‐apex of either lung (ULC+). Clinical risk factors, oximetry and radiographic results, and disease severity were analyzed for associations with ULC+. Clinical risk factors and ULC+ were analyzed for associations with hospital mortality or the need for intensive care in multivariable models.ResultsOf N = 160 patients, age (mean ± standard deviation) was 64.8 ± 15.5 years, and 46 (29%) died. ULC+ was present in 100/160 (62%) of patients overall, in 81/103 (79%) of severe‐or‐greater disease versus 19/57 (33%) of moderate‐or‐less disease (P < .0001) and was associated with mortality (odds ratio [OR] = 2.4 [95% confidence interval [CI]: 1.1–5.4], P = .02) and the need for intensive care (OR = 5.23 [95% CI: 2.42–12.40], P < .0001). In the multivariable models, symptom duration and severe‐or‐greater disease were associated with ULC+, and ULC+, diabetes, and symptom duration were associated with the need for intensive care.ConclusionsB‐lines in the upper chest were common and related to disease severity, intensive care, and hospital mortality in COVID‐19. Validation of a simplified lung POCUS exam could provide the evidence basis for a self‐imaging application during the pandemic.

Diagnostic and Prognostic Value of Lung Ultrasound B-Lines in Acute Heart Failure With Concomitant Pneumonia.

Purpose: To evaluate the potential confounding effect of concomitant pneumonia (PNM) on lung ultrasound (LUS) B-lines in acute heart failure (AHF).Methods: We enrolled 86 AHF patients with (31 pts, AHF/PNM) and without (55 pts, AHF) concomitant PNM. LUS B-lines were evaluated using a combined antero-lateral (AL) and posterior (POST) approach at admission (T0), after 24 h from T0 (T1), after 48 h from T0 (T2) and before discharge (T3). B-lines score was calculated at each time point on AL and POST chest, dividing the number of B-lines by the number of explorable scanning sites. The decongestion rate (DR) was calculated as the difference between the absolute B-lines number at discharge and admission, divided by the number of days of hospitalization. Patients were followed-up and hospital readmission for AHF was considered as adverse outcome.Results: At admission, AHF/PNM patients showed no difference in AL B-lines score compared with AHF patients [AHF/PNM: 2.00 (IQR: 1.44–2.94) vs. AHF: 1.65 (IQR: 0.50–2.66), p = 0.072], whereas POST B-lines score was higher [AHF/PNM: 3.76 (IQR: 2.70–4.77) vs. AHF = 2.44 (IQR: 1.20–3.60), p < 0.0001]. At discharge, AL B-lines score [HR: 1.907 (1.097–3.313), p = 0.022] and not POST B-lines score was found to predict adverse events (AHF rehospitalization) after a median follow-up of 96 days (IQR: 30–265) in the overall population.Conclusions: Assessing AL B-lines alone is adequate for diagnosis, pulmonary congestion (PC) monitoring and prognostic stratification in AHF patients, despite concomitant PNM.

Association Between Arterial Oxygen Saturation and Lung Ultrasound B-Lines After Competitive Deep Breath-Hold Diving.

Breath-hold diving (freediving) is an underwater sport that is associated with elevated hydrostatic pressure, which has a compressive effect on the lungs that can lead to the development of pulmonary edema. Pulmonary edema reduces oxygen uptake and thereby the recovery from the hypoxia developed during freediving, and increases the risk of hypoxic syncope. We aimed to examine the efficacy of SpO2, via pulse-oximetry, as a tool to detect pulmonary edema by comparing it to lung ultrasound B-line measurements after deep diving. SpO2 and B-lines were collected in 40 freedivers participating in an international deep freediving competition. SpO2 was measured within 17 ± 6 min and lung B-lines using ultrasound within 44 ± 15 min after surfacing. A specific symptoms questionnaire was used during SpO2 measurements. We found a negative correlation between B-line score and minimum SpO2 (rs = −0.491; p = 0.002) and mean SpO2 (rs = −0.335; p = 0.046). B-line scores were positively correlated with depth (rs = 0.408; p = 0.013), confirming that extra-vascular lung water is increased with deeper dives. Compared to dives that were asymptomatic, symptomatic dives had a 27% greater B-line score, and both a lower mean and minimum SpO2 (all p < 0.05). Indeed, a minimum SpO2 ≤ 95% after a deep dive has a positive predictive value of 29% and a negative predictive value of 100% regarding symptoms. We concluded that elevated B-line scores are associated with reduced SpO2 after dives, suggesting that SpO2 via pulse oximetry could be a useful screening tool to detect increased extra-vascular lung water. The practical application is not to diagnose pulmonary edema based on SpO2 – as pulse oximetry is inexact – rather, to utilize it as a tool to determine which divers require further evaluation before returning to deep freediving.

Lung Ultrasound–Guided Emergency Department Management of Acute Heart Failure (BLUSHED-AHF): A Randomized Controlled Pilot Trial

ObjectivesThe goal of this study was to determine whether a 6-hour lung ultrasound (LUS)-guided strategy-of-care improves pulmonary congestion over usual management in the emergency department (ED) setting. A secondary goal was to explore whether early targeted intervention leads to improved outcomes. BackgroundTargeting pulmonary congestion in acute heart failure remains a key goal of care. LUS B-lines are a semi-quantitative assessment of pulmonary congestion. Whether B-lines decrease in patients with acute heart failure by targeting therapy is not well known. MethodsA multicenter, single-blind, ED-based, pilot trial randomized 130 patients to receive a 6-hour LUS-guided treatment strategy versus structured usual care. Patients were followed up throughout hospitalization and 90 days’ postdischarge. B-lines ≤15 at 6 h was the primary outcome, and days alive and out of hospital (DAOOH) at 30 days was the main exploratory outcome. ResultsNo significant difference in the proportion of patients with B-lines ≤15 at 6 hours (25.0% LUS vs 27.5% usual care; P = 0.83) or the number of B-lines at 6 hours (35.4 ± 26.8 LUS vs 34.3 ± 26.2 usual care; P = 0.82) was observed between groups. There were also no differences in DAOOH (21.3 ± 6.6 LUS vs 21.3 ± 7.1 usual care; P = 0.99). However, a significantly greater reduction in the number of B-lines was observed in LUS-guided patients compared with those receiving usual structured care during the first 48 hours (P = 0.04). ConclusionsIn this pilot trial, ED use of LUS to target pulmonary congestion conferred no benefit compared with usual care in reducing the number of B-lines at 6 hours or in 30 days DAOOH. However, LUS-guided patients had faster resolution of congestion during the initial 48 hours. (B-lines Lung Ultrasound–Guided ED Management of Acute Heart Failure Pilot Trial; NCT03136198)