Pleural Abnormalities Research Articles

164: Characterization of Point-of-Care Lung Ultrasound in Young Children with Viral-Induced Wheeze in a Pediatric Emergency Department

Young children with viral-induced wheeze pose a diagnostic challenge as there are no diagnostic tests available to differentiate bronchiolitis from reactive airway disease. Point-of-care ultrasound is an increasingly available tool for emergency physicians and may serve a role in discriminating different lung pathologies. To describe lung ultrasound findings in young children with viral upper respiratory tract infections and wheeze presenting to a pediatric emergency department. A cross-sectional study was conducted in children <2 years of age presenting with URTI symptoms and wheeze to a pediatric emergency department from October 2013 to July 2014. Prior to management, one investigator (TV) performed all point-of-care lung ultrasounds and saved 5-second video clips in each of the six lung zones. A physician (ASD) blinded to all clinical and ultrasound information reviewed the latter and provided the final interpretations used for the main outcome measure. Abnormal lung ultrasound was defined as the presence of any of the following findings: multiple B-lines, consolidations, pleural abnormalities, or absent lung slide. The treating physician remained blinded to the findings and prospectively documented discharge diagnoses. Proportion of children with abnormal lung ultrasounds were characterized and categorized abnormalities by discharge diagnoses (reactive airway disease versus other respiratory diagnoses). 96 patients were enrolled (median age 11.1 months (IQR 6.7–16.1), 65% male). Ultrasound revealed an abnormality in 40/96 (41.7%) patients: multiple B-lines 32/40 (80%), consolidation 25/40 (62.5%; larger than >1 cm in 4/40 [10%]), and pleural abnormalities 8/40 (20%). When categorized per diagnosis, an abnormal lung ultrasound was found in 0/16 (0%) with reactive airway disease, which was significantly less compared to all other respiratory diagnoses: bronchiolitis 20/43 (46.5%, P=0.001), viral respiratory illness 13/29 (44.8%, P=0.001), and pneumonia 7/8 (87.5%, P<0.0001). Excellent agreement was found between raters for an abnormal lung ultrasound (kappa ± SE: 0.89±0.04). Over a third of young children with undifferentiated wheeze had an abnormal point-of-care lung ultrasound. Given that all children with a discharge diagnosis of reactive airway disease (compared to other respiratory diagnoses) had a normal ultrasound, the next step would be to prospectively determine if lung ultrasound might help guide clinicians with the management of children with undifferentiated viral-induced wheeze.

Use of Lung Ultrasound in Detection of Complications of Respiratory Distress Syndrome

Repeated chest radiography is required for the diagnosis and follow-up of neonates with respiratory distress syndrome (RDS) and carries the risk of radiation hazards. Lung ultrasound (LUS) is a non-invasive bedside diagnostic tool that has proven to be effective in the diagnosis of RDS. Our aim was to assess the role of LUS with respect to the standard chest X-ray (CXR) in the detection of complications of RDS in neonates. Ninety premature newborns of both genders with RDS (mean gestational age = 29.91 ± 1.33 wk) and 40 premature babies as a control group were involved in this study. All patients underwent initial clinical assessment as well as CXR and LUS. Those who presented with respiratory distress and/or exhibited deterioration of oxygenation parameters were followed by CXR and, within 4 h, by LUS. Alveolo-interstitial syndrome and pleural line abnormalities were detected in all cases (100%) in the initial assessment, patchy consolidation was detected in 34 cases and white lung was detected in 80 cases. Alveolo-interstitial syndrome was detected in 19 controls. In follow-up of the patients, LUS was superior to CXR in detection of consolidation and sub-pleural atelectasis, but not in detection of pneumothorax. We concluded that bedside LUS is a good non-hazardous alternative tool in the early detection and follow-up of RDS in the neonatal intensive care unit; it could be of value in reducing exposure to unnecessary radiation.

The Diagnosis of Neonatal Pulmonary Atelectasis Using Lung Ultrasonography

BACKGROUND: Ultrasonography has been used for the diagnosis of many kinds of lung conditions, but few studies have investigated ultrasound for the diagnosis of neonatal pulmonary atelectasis (NAP). In this study, we evaluated the usefulness of lung ultrasonography for the diagnosis of NPA.METHODS: From May 2012 to December 2013, 80 neonates with NPA and 50 neonates without lung disease were enrolled in this study. Each lung of every infant was divided into the anterior, lateral, and posterior regions by the anterior and posterior axillary lines. Each region was scanned carefully with the probe perpendicular or parallel to the ribs. The ultrasound findings were confirmed by chest radiograph (CXR) or CT scan.RESULTS: Sixty of the 80 patients with signs of NPA on lung ultrasound also had signs of NPA on CXR (termed focal-type atelectasis), and the other 20 patients had signs of NPA on chest CT scan while there were no abnormal findings on CXR (termed occult lung atelectasis). In patients with NPA, the main ultrasound findings were large areas of lung consolidation with clearly demarcated borders, air bronchograms, pleural line abnormalities, and absence of A-lines, as well as the presence of lung pulse and absence of lung sliding on real-time ultrasound. The sensitivity of lung ultrasonography for the diagnosis of NPA was 100%, whereas the sensitivity of CXR was 75%. Large areas of lung consolidation with clearly demarcated borders were only observed in patients with NPA.CONCLUSIONS: Lung ultrasonography is an accurate and reliable method for diagnosing NPA; most importantly, it can find those occult lung atelectasis that could not be detected on CXR. Routine lung ultrasonography is a useful method of diagnosing or excluding NPA in neonates.

The Role of Lung Ultrasound in Diagnosis of Respiratory Distress Syndrome in Newborn Infants.

Background:Respiratory distress syndrome (RDS) is one of the most common causes of neonatal respiratory failure and mortality. The risk of developing RDS decreases with both increasing gestational age and birth weight.Objectives:The aim of this study was to evaluate the value of lung ultrasound in the diagnosis of respiratory distress syndrome (RDS) in newborn infants.Materials and Methods:From March 2012 to May 2013, 100 newborn infants were divided into two groups: RDS group (50 cases) and control group (50 cases). According to the findings of chest x-ray, there were 10 cases of grade II RDS, 15 grade III cases, and 25 grade IV cases in RDS group. Lung ultrasound was performed at bedside by a single expert. The ultrasound indexes observed in this study included pleural line, A-line, B-line, lung consolidation, air bronchograms, bilateral white lung, interstitial syndrome, lung sliding, lung pulse etc.Results:In all of the infants with RDS, lung ultrasound consistently showed generalized consolidation with air bronchograms, bilateral white lung or alveolar-interstitial syndrome, pleural line abnormalities, A-line disappearance, pleural effusion, lung pulse, etc. The simultaneous demonstration of lung consolidation, pleural line abnormalities and bilateral white lung, or lung consolidation, pleural line abnormalities and A-line disappearance co-exists with a sensitivity and specificity of 100%. Besides, the sensitivity was 80% and specificity 100% of lung pulse for the diagnosis of neonatal RDS.Conclusions:This study indicates that using an ultrasound to diagnose neonatal RDS is accurate and reliable too. A lung ultrasound has many advantages over other techniques. Ultrasound is non-ionizing, low-cost, easy to operate, and can be performed at bedside, making this technique ideal for use in NICU.

Lung ultrasound in heart failure: Lessons from re-analysis of Lung Ultrasound 2011 database.

Introduction: In the setting of patients presenting with shortness of breath to an Emergency Department a simple lung ultrasound protocol aimed at detecting pulmonary oedema has been shown to have diagnostic accuracy of 85%. This article reviews data from the original study, in an attempt to determine whether adjusting the protocol and/or interpretive criteria would improve results. Method: A large lung ultrasound project provided the dataset. Inter‐rater and intertest discrepancies were reviewed. Then original stored images and comments were retrospectively analysed using alternate interpretive criteria. Specific variations included changing the number of B‐lines required to define ‘wet lung’ and assessing other pleural line abnormalities. Where they had been acquired cardiac loops were reviewed in addition to the lung images. Results: The 204 original studies available were reviewed. Some disagreement could be attributed to inexperience and unclear definitions. Adjusting the number of B‐lines did not improve diagnostic accuracy. All positive scans, with numerous B‐lines were reviewed using more advanced diagnostic criteria (pleural line abnormalities) and the number of false positives was decreased. In cases where cardiac views were available, their inclusion was beneficial. Conclusion: A simple lung ultrasound protocol to assess for ‘wet lung’ in patients presenting to Emergency Departments provides diagnostic accuracy of around 85% in the hands of relative novices. More advanced interpretation of the same_ultrasound images, and the addition of cardiac views, is likely to further improve diagnostic accuracy.

Differential Chest Computed Tomography Findings of Pulmonary Parasite Infestation Between the Paragonimiasis and Nonparagonimiatic Parasite Infestation

The aims of this study were to evaluate the chest computed tomography findings of parasite infestation regardless of pathogen and to compare the differential findings between paragonimiasis and nonparagonimiatic parasite infestation (NPPI). Between January 2008 and November 2011, 75 patients (46 men; 52.9 ± 14.1 years) with serologically proven parasite infestation and available chest computed tomography images were evaluated. Computed tomography images of 40 patients with paragonimiasis and 35 patients with NPPI (13 with sparganosis, 12 with toxocariasis, 8 with cysticercosis, and 2 with clonorchiasis) were assessed for the presence or absence of pleural abnormalities, consolidation, cavitary lesions, aggregated cysts, worm-migration tracts, and pure ground-glass opacity. Findings associated with consolidation were further assessed for characteristics including size, perilesional ground-glass opacity, presence of perilesional centrilobular nodules, and internal low attenuation, and multisegmentality and bilaterality were assessed for all patients. In both groups, the most common pleural abnormality was pleural effusion (42.5% in paragonimiasis vs 22.9% in NPPI, P = 0.09), and the most common pulmonary abnormality was consolidation (82.5% vs 80.0%, P = 1.00). Multisegmentality (35% vs 42.9%, P = 0.64) and bilaterality (55.0% vs 60%, P = 0.82) of pleuropulmonary lesions were often observed in both groups. Internal low attenuation, perilesional centrilobular nodules, cavitary lesions, and worm-migration tracts were more frequently found in the paragonimiasis group (P ≤ 0.05). The presence of internal low attenuation and perilesional centrilobular nodules associated with pulmonary consolidative lesions, along with cavitary lesions and worm-migration tracts, is more frequent in patients with paragonimiasis than in patients with NPPI.

Fatal Scopulariopsis Infection in a Lung Transplant Recipient: Lessons of Organ Procurement

Seventeen days after double lung transplantation, a 56-year-old patient with idiopathic pulmonary fibrosis developed respiratory distress. Imaging revealed bilateral pulmonary infiltrates with pleural effusions and physical examination demonstrated sternal instability. Broad-spectrum antibacterial and antifungal therapy was initiated and bilateral thoracotomy tubes were placed. Both right and left pleural cultures grew a mold subsequently identified as Scopulariopsis brumptii. The patient underwent pleural irrigation and sternal debridement three times but pleural and wound cultures continued to grow S. brumptii. Despite treatment with five antifungal agents, the patient succumbed to his illness 67 days after transplantation. Autopsy confirmed the presence of markedly invasive fungal disease and pleural rind formation. The patient's organ donor had received bilateral thoracostomy tubes during resuscitation in a wilderness location. There were no visible pleural abnormalities at the time of transplantation. However, the patient's clinical course and the location of the infection, in addition to the lack of similar infection in other organ recipients, strongly suggest that Scopulariopsis was introduced into the pleural space during prehospital placement of thoracostomy tubes. This case of lethal infection transmitted through transplantation highlights the unique risk of using organs from donors who are resuscitated in an outdoor location.

Inter-reader agreement in HRCT detection of pleural plaques and asbestosis in participants with previous occupational exposure to asbestos

ObjectivesTo investigate inter-reader agreement for the detection of pleural and parenchymal abnormalities using CT in a large cross-sectional study comprising information on individual cumulative exposure to asbestos.MethodsThe project was approved...

Lung Ultrasonography for the Diagnosis of Severe Neonatal Pneumonia

Lung ultrasonography is useful for the diagnosis of pneumonia in children and adults. This study investigated the lung ultrasound findings in severe neonatal pneumonia. From September 2012 to October 2013, 80 neonates admitted to Bayi Children's Hospital, affiliated with the Beijing Military General Hospital, were divided into two groups: 40 neonates with severe pneumonia according to their medical history, clinical manifestations, and chest radiograph findings and 40 neonates with no lung disease (control group). All subjects underwent bedside lung ultrasound examination in a quiet state. A single expert physician performed all ultrasound examinations. Findings of pleural line abnormalities, B lines, lung consolidation, air bronchograms, bilateral white lung, interstitial syndrome, lung sliding, and lung pulse were compared between the groups. The lung ultrasound findings associated with infectious pneumonia included large areas of lung consolidation with irregular margins and air bronchograms, pleural line abnormalities, and interstitial syndrome. A large area of lung consolidation with irregular margins had 100% sensitivity and 100% specificity for the diagnosis of neonatal pneumonia. Lung ultrasonography is a reliable tool for diagnosing neonatal pneumonia. It is suitable for routine use in the neonatal ICU and may eventually replace chest radiography and CT scanning.

Chest HRCT signs predict deaths in long-term follow-up among asbestos exposed workers

ObjectivesTo study associations between chest HRCT signs and subsequent deaths in long-term follow-up. MethodsLung and pleural signs of 633 asbestos exposed workers (age 45–86, mean 65) screened with HRCT were recorded by using the International Classification of Occupational and Environmental Respiratory Diseases (ICOERD) system, which contains detailed instructions for use and reference images. Subsequent mortality was checked from the national register. Cox regression adjusted for covariates (age, sex, BMI, asbestos exposure, pack-years) was used to explore the relations between HRCT signs and all-cause deaths, cardiovascular and benign respiratory deaths, and deaths from neoplasms – all according to the ICD-10 diagnostic system. ResultsThe follow-up totalled 5271.9 person-years (mean 8.3y/person, range .04–10.3). 119 deaths were reported. Irregular/linear opacities, honeycombing, emphysema, large opacities, visceral pleural abnormalities and bronchial wall thickening were all significantly related to all-cause deaths. Most of these signs were associated also with deaths from neoplasms and benign respiratory disease. Deaths from cardiovascular disease were predicted by emphysema and visceral pleural abnormalities. ConclusionsSeveral HRCT signs predicted deaths. Careful attention should be paid on subjects with radiological signs predictive of deaths and new secondary preventive strategies developed. This calls for further focused studies among different populations.

0330 A Study of Radiographic Abnormalities in Minnesota Taconite Workers

ObjectivesA limited number of studies have been conducted in the taconite industry, typically without detailed exe posure information. We assessed occupational exposure to elongate mineral particles (EMP) in association with...

0043 Benign pleural abnormalities and mesothelioma among asbestosis workers in Hong Kong

ObjectivesTo evaluate whether the presence of pleural abnormalities was a reasonable marker to predict mesothelioma among workers with asbestosis in Hong Kong.MethodThis is a historical cohort study comprised of 99...

0423 Development of a disease surveillance system for Silicosis and respiratory disorders in stone carving workers in Thailand

ObjectivesTo (a) develop a surveillance system for silicosis (b)estimate prevalence of silicosis and respiratory disorders among stone carversand (c) develop a guideline for screening for silicosis.MethodThis was a cross-sectional, descriptive...

Chest computed tomography in children undergoing extra-corporeal membrane oxygenation: a 9-year single-centre experience.

We retrospectively reviewed the imaging findings, indications, technique and clinical impact in children who had undergone chest CT while undergoing extra-corporeal membrane oxygenation (ECMO). Radiology and ECMO databases were searched to identify all 19 children who had undergone chest CT (20 scans in total) while on ECMO at our institution between May 2003 and May 2012. We reviewed all CT scans for imaging findings. Chest CT is performed in a minority of children on ECMO (4.5% in our series). Timing of chest CT following commencement of ECMO varied among patient groups but generally it was performed earlier in the neonatal group. Clinically significant imaging findings were found in the majority of chest CT scans. Many scans contained several findings, with most cases demonstrating parenchymal or pleural abnormalities. Case examples illustrate the spectrum of imaging findings, including underlying pathology such as necrotising pneumonia and severe barotrauma, and ECMO-related complications such as tension haemothoraces and cannula migration. The results of chest CT led to a change in patient management in 16 of 19 children (84%). There were no adverse events related to patient transfer. An understanding of scan technique and awareness of potential findings is important for the radiologist to provide prompt and optimal image acquisition and interpretation in appropriate patients.

Chest ultrasound in the evaluation of complicated pneumonia in the ICU patients: Can be viable alternative to CT?

ObjectiveTo compare ultrasound (US) and computed tomography (CT) for evaluating patients with complicated pneumonia admitted to the intensive care unit (ICU) to assess if US can be an alternative to CT. Subjects and methodsWe prospectively compared US and CT findings in 48 patients admitted to the ICU with complicated pneumonia with their final diagnosis at discharge. Images were evaluated for parenchymal findings (consolidation, necrosis, and abscess) and pleural findings (effusion, loculation or fibrin strands in the pleural fluid). ResultsUS was similar to CT in the evaluation of parenchymal and pleural abnormalities except for two patients with consolidation and effusion, three patients with loculated effusion, one patient with pulmonary necrosis and another patient with lung abscess. US was superior to CT in detection of fibrin strands within pleural effusion. ConclusionChest US provides an accurate evaluation of the pleural and parenchymal abnormalities associated with complicated pneumonia in the ICU patients. Considering that chest US is a bedside and avoids transportation of the patient outside ICU, free of radiation exposure and easily repeatable, chest US appears to be an attractive alternative to CT.

International Perspectives: Point-of-Care Chest Ultrasound in the Neonatal Intensive Care Unit: An Italian Perspective

Lung ultrasound outperforms conventional radiology in the emergency diagnosis of pneumothorax and pleural effusions. Neonatologists and pediatricians are now adapting lung ultrasound to their specific clinical issues. The normal image is relatively unchanged throughout the age span, whereas progressively fading B-lines (comet-tail artifacts) describe the fluid-to-air transition of the neonatal lung. Also, an homogeneous white (hyperechogenic) lung with pleural image abnormalities and absence of spared areas is accurate in diagnosing respiratory distress syndrome. The evidence of bilateral confluent B-lines in the dependent areas of the lung (‘‘white lung’’) and normal or near-normal appearance of the lung in the superior fields is highly sensitive and specific for transient tachypnea of the newborn. Infantile pneumonia has recently been proved to be accurately diagnosed by ultrasound after a short training period. In summary, chest ultrasonography is not yet ready to replace conventional chest radiology. However, when appropriately applied, a lung ultrasound scan can save time and radiation exposure to achieve a critical diagnosis.

Talcosis in soapstone artisans: High-resolution CT findings in 12 patients

To describe the high-resolution computed tomography (HRCT) features of pneumoconiosis observed in soapstone artisans. The present study included 12 soapstone artisans with chest radiography abnormalities consistent with the diagnosis of pneumoconiosis, in accordance with the International Labour Office classification. All patients had undergone HRCT, and the images were retrospectively analysed by two chest radiologists, who reached decisions in consensus. All patients presented with interlobular septal thickening. Small centrilobular nodules (75%) and ground-glass opacities (67%) were also common findings. The distributions of abnormalities were predominantly diffuse. No pleural abnormality was found. The HRCT abnormalities observed in this group of soapstone artisans are similar to those of pure talc pneumoconiosis.

Domestic asbestos exposure: a review of epidemiologic and exposure data.

Inhalation of asbestos resulting from living with and handling the clothing of workers directly exposed to asbestos has been established as a possible contributor to disease. This review evaluates epidemiologic studies of asbestos-related disease or conditions (mesothelioma, lung cancer, and pleural and interstitial abnormalities) among domestically exposed individuals and exposure studies that provide either direct exposure measurements or surrogate measures of asbestos exposure. A meta-analysis of studies providing relative risk estimates (n = 12) of mesothelioma was performed, resulting in a summary relative risk estimate (SRRE) of 5.02 (95% confidence interval [CI]: 2.48–10.13). This SRRE pertains to persons domestically exposed via workers involved in occupations with a traditionally high risk of disease from exposure to asbestos (i.e., asbestos product manufacturing workers, insulators, shipyard workers, and asbestos miners). The epidemiologic studies also show an elevated risk of interstitial, but more likely pleural, abnormalities (n = 6), though only half accounted for confounding exposures. The studies are limited with regard to lung cancer (n = 2). Several exposure-related studies describe results from airborne samples collected within the home (n = 3), during laundering of contaminated clothing (n = 1) or in controlled exposure simulations (n = 5) of domestic exposures, the latter of which were generally associated with low-level chrysotile-exposed workers. Lung burden studies (n = 6) were also evaluated as a surrogate of exposure. In general, available results for domestic exposures are lower than the workers’ exposures. Recent simulations of low-level chrysotile-exposed workers indicate asbestos levels commensurate with background concentrations in those exposed domestically.

X ray screening at entry and systematic screening for the control of tuberculosis in a highly endemic prison.

BackgroundTuberculosis (TB) is a major issue in prisons of low and middle income countries where TB incidence rates are much higher in prison populations as compared with the general population. In the Rio de Janeiro (RJ) State prison system, the TB control program is limited to passive case-finding and supervised short duration treatment. The aim of this study was to measure the impact of X-ray screening at entry associated with systematic screening on the prevalence and incidence of active TB.MethodsWe followed up for 2 years a RJ State prison for adult males (1429 inmates at the beginning of the study) and performed, in addition to passive case-finding, 1) two “cross-sectional” X-ray systematic screenings: the first at the beginning of the study period and the second 13 months later; 2) X-ray screening of inmates entering the prison during the 2 year study period. Bacteriological examinations were performed in inmates presenting any pulmonary, pleural or mediastinal X-ray abnormality or spontaneously attending the prison clinic for symptoms suggestive of TB.ResultsOverall, 4326 X-rays were performed and 246 TB cases were identified. Prevalence among entering inmates remained similar during 1st and the 2nd year of the study: 2.8% (21/754) and 2.9% (28/954) respectively, whereas prevalence decreased from 6.0% (83/1374) to 2.8% (35/1244) between 1st and 2nd systematic screenings (p < 0.0001). Incidence rates of cases identified by passive case-finding decreased from 42 to 19 per 1000 person-years between the 1st and the 2nd year (p < 0.0001). Cases identified by screenings were less likely to be bacteriologically confirmed as compared with cases identified by passive-case finding.ConclusionsThe strategy investigated, which seems highly effective, should be considered in highly endemic confined settings such as prisons.

Lung ultrasound for diagnosis of neonatal atelectasis

The diagnosis of neonatal atelectasis (NA) is usually based on clinical manifestations and chest X-rays, lung ultrasounds are not included in the diagnostic work-up of NA.Recently, ultrasounds have been used extensively and successfully in the diagnosis of many kinds of lung diseases, but few studies have addressed NA. The aim of this study was to evaluate the ultrasound imaging features of NA-and to evaluate the value of lung ultrasound in diagnosing NA. From May, 2012 to June, 2013, 40 newborn infants with NA and another 40 neonates without lung disease were enrolled into this study.Lung ultrasound was performed at the bedside by a single expert physician.In a quiet state, the infants were positioned in supine, side or prone postures. The lung field was divided into three areas by the anterior auxilary and posterior auxilary line. The regions of the bilateral lungs were scanned by the probe which was vertical or parallel with the ribs, then compared the results with conventional chest X-ray findings. (1) The main ultrasound imaging features of neonatal NA include lung consolidation with air bronchograms, pleural line abnormalities and A-line disappearance. Besides, lung pulse and lung sliding disappearance could be seen by real-time ultrasound. (2) The sensitivity of lung ultrasound for diagnosis of NA was 100%, while it was only 70% for conventional chest X-rays. Use of ultrasound to diagnose NA is accurate and reliable, the sensitivity was superior to that of conventional chest X-ray examination, which also has many other advantages including easy-operating, non-ionizing, can be performed at the bedside, therefore, ultrasonic can provide important value for clinicians.