![Patient demographics N=102 [n (%)]](https://www.researchgate.net/profile/Mohammed-El-Bagalaty/publication/327444512/figure/tbl3/AS:726245587316738@1550161849845/Patient-demographics-N102-n_Q320.jpg)
Content uploaded by Mohammed Fathi El Bagalaty
Author content
All content in this area was uploaded by Mohammed Fathi El Bagalaty on Feb 14, 2019
Content may be subject to copyright.
Impact of integrated use of diagnostic ultrasound examinations
in respiratory intensive care units
Taher A. Al Najjar
a
, Ashraf M. Madkour
a
, Nehad M. Osman
a
,
Ashraf A. Gomaa
a
, Ahmed M. Osman
b
, Mohammed F. El Bagalaty
a
,
Khaled A. Abd EL Kader
c
Background Implementing point-of-care multiorgan
ultrasound (POCUS) to the initial assessment of ICU patients
allows intensivists to immediately integrate ultrasound
findings with the patient history, physical, and laboratory
results, yielding a powerful clinical synergy, improving
diagnostic accuracy, and ameliorating further management
plans. The aim of this work was to assess the diagnostic
performance and therapeutic effect of POCUS in patients
admitted to respiratory ICU (RICU).
Patients and methods A prospective study was carried out
on patients admitted to the RICU. POCUS examination was
performed to the patients within 12 h of admission that
included echocardiography, lung ultrasound, abdominal
ultrasound including inferior vena cava assessment and lower
limb venous duplex.
Results A total of 102 patients were included. The total
number of sonographic findings was 320, of which 94 (29.3%)
were new findings. This resulted in confirmation of the
admitting diagnosis, modification of the admitting diagnosis,
prompted further testing, change in medical therapy
prescribed, and prompted invasive procedures in 35, 51, 11,
41, and 14% of patients, respectively. However, it was
ineffective in confirming or modifying diagnosis, provided
wrong diagnosis, and missed a diagnosis in 29.4, 2, and
11.7% of patients, respectively.
Conclusion Integrating POCUS in the initial assessment of
critically ill RICU patients together with standard diagnostic
tests lead to diagnostic and therapeutic changes in most of
patients which affected the management of these patients.
Thus, it seems reasonable to consider the routine use of
POCUS as a new respiratory examination option in the
armamentarium of the intensivists.
Egypt J Bronchol 2018 12:448–460
©2018 Egyptian Journal of Bronchology
Egyptian Journal of Bronchology 2018 12:448–460
Keywords: bedside ultrasound; echocardiography; point of care; respiratory
intensive care
a
Department of Chest Diseases,
b
Department of Radiology,
c
Department of
Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Correspondence to Mohammed Fathi El Bagalaty, MSc Chest Diseases,
Assistant Lecturer of Pulmonary Medicine and Critical Care Faculty of
Medicine, Ain Shams University, 12 Soliman al Tamawy st, Sheraton
Buildings, Cairo, Egypt. Tel: +20 100 70 88 660;
e-mail: Mohammedfathi87@gmail.com
Received 29 July 2018 Accepted 12 August 2018
Introduction
The inaccuracy of physical examination at admission
to the ICU has been extensively reported, and life-
threatening conditions could be missed at the
primary assessment, especially in patients presented
with acute respiratory symptoms [1–3]. Thus,
intensivists need to make rapid, accurate, and
appropriate decisions in situations where there is a
high degree of stress and uncertainty and when
patients possess little physiologic reserve [4].
Implementing point-of-care multiorgan ultrasound
(POCUS) allows the intensivists to personally
perform and interpret the ultrasound (US)
examination results at the bedside and immediately
integrate ultrasound findings with the patient history,
physical, and laboratory results, hence yielding a
powerful clinical synergy, improving diagnostic
accuracy and ameliorating further management plans
[5–8].
Results of several studies have shown that application
of POCUS in patients admitted with acute
respiratory symptoms to emergency department or
ICU was superior to standard diagnostic tests alone
for establishing an accurate diagnosis, leading to
changes in medical therapy and prompting
further invasive procedures [3,5,8]. Therefore,
now it seems crucial to use POCUS as part of the
standard diagnostic tests in critically ill patients.
Lung US has been recently introduced in our
respiratory ICU (RICU). Its effect on diagnosis and
management has been established in several studies
[9,10]. Combing lung US examination with other
organ US examinations, such as heart, inferior vena
cava (IVC), abdomen, and deep venous system,
using POCUS concept into standard diagnostic
assessment of critical ICU patients, remains scarcely
applied on the international level and has never
been applied in our RICU [11,12]. The actual
levels of POCUS implementation and contribution
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new
creations are licensed under the identical terms.
Original article 448
©2018 Egyptian Journal of Bronchology | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejb.ejb_56_18
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
to ICU patient management need further studies
[11,13].
The aim of our study was to assess the diagnostic
performance and therapeutic effect of POCUS in
patients admitted to RICU.
Patients and methods
Setting and study population
This prospective study was carried out on patients
admitted to the RICU of Ain Shams University
hospitals, Egypt, in the period from October 2016 to
July 2017. The study design has been approved by the
research ethics committee of our institution, and a
written informed consent was obtained from the
patients or their relatives.
Inclusion and exclusion criteria
All adult patient admitted to the RICU were included
when the sonographic examinations could be
performed within 12 h after the primary assessment.
Exclusion criteria were age younger than 18 years,
discharge form RICU within 24 h, and the
presence of patient-related conditions that strongly
hamper ultrasound examination such as morbid
obesity, the presence of subcutaneous emphysema
and severe edema, and the presence of environment-
related limitations that hamper proper examination
such as patient isolation for fear of infection.
Primary assessment
On admission, the diagnosis was made by the
attending resident and senior registrar in charge,
who had at least 3 years of experience in RICU,
dependingonhistorytakenintheemergency
department or referring ward, clinical examination,
laboratory findings, and imaging findings without
beside ultrasonographic evaluation. The severity of
the patient’s condition on admission was graded
using the new Simplified Acute Physiology Score
(SAPS II) [14]
Sonographic examination
Within 12 h of RICU admission, POCUS of the heart,
lungs, deep veins, and abdomen was performed by a
single physician (M.F.) who received a 2-month
comprehensive training in bedside ultrasonography
and echocardiography under supervision of an
expert radiologist and an expert cardiologist. This
was followed by a 2-month period of directly
supervised practice after which he started to work
independently.
The operator was aware of the patient’s clinical picture
but was blinded from the provisional diagnosis and any
initial radiological assessment.
Ultrasound machine used was MINDRAY M7
Ultrasound machine (Mindray Bio-Medical
Electronics Co., Shenzhen, China), equipped with a
linear probe (5–10 MHz), a sector probe (2–4 MHz),
and a convex probe (2–5 MHz). No particular order
was recommended for the examination.
The examinations included
Lung ultrasound
‘Six’ultrasound areas were examined on each side: the
anterior, lateral, and posterolateral views in the upper
and lower thoracic regions [2]. Interpretation was done
following the principles described by Lichtenstein [15].
The low-frequency curvilinear probe was used to
examine the lung parenchyma at a depth of 10 cm
and the high-frequency linear probe for examination
of pleural sliding on 2D and M-mode.
Focused echocardiography
A goal-directed transthoracic echocardiography was
done using the basic views, including parasternal
short axis and long axis views, apical views (four-
chamber, five-chamber, and two-chamber), and
subcostal views [2].
Pelvi-abdominal ultrasound
Pelvi-abdominal ultrasound was done according to ‘the
focused assessment with sonography for trauma’
examination [16].
Assessment of the inferior vena cava
The subcostal view was used to measure maximum
diameter, estimate the percent of respiratory
collapsibility (Caval index) [17], and visualize the
intraluminal thrombosis. The curvilinear 2–5-MHz
probe was used. Measurements were made at a
distance not less than 2 cm caudal from the junction
of the right atrium [18].
Venous system
Mild compression maneuver was used to assess the
lower limb (right and left femoral and popliteal veins)
and neck vessels (right and left jugular veins). Doppler
study was used when needed.
The following specific diagnostic points (Table 1) were
prospectively defined as previously described by others
[2,3].
Diagnostic ultrasound in respiratory ICU Al Najjar et al. 449
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
We used the criteria previously described by Manno
et al. [2] to define ultrasound-induced modification,
confirmation, wrong evaluation, and lack of
confirmation of admitting diagnosis (Table 2).
Ultrasound findings not previously known to the
attending resident and the senior registrar in charge,
which was unrevealed by ultrasonographic
examination, will be defined as a ‘new’finding.
Changing the admitting diagnosis or medical
therapy or to perform invasive procedures was
decided by the senior physician and the RICU
consultant.
Statistical analysis
Data were collected, revised, coded, and entered to the
Statistical Package for Social Science (IBM SPSS)
version 20.0. (SPSS Inc., Chicago, Illinois, USA).
Descriptive statistics were performed, including
demographic characteristics, medical history, and
symptoms, at admission. The effect of point of care
ultrasonography on the diagnosis and treatment was
calculated. Percentages were computed for the
categorical variables. Data analysis was conducted
using SPSS software, version 20.0 (SPSS Inc.,
Chicago, Illinois, USA).
Results
Baseline patient characteristics
A total of 102 patients were enrolled in our study.
Patient characteristics, presenting symptoms, and
Table 1 Prospective definition of specific diagnostic points
Clinical diagnosis Thoracic examination
Pneumothorax Absence of ‘lung sliding’,
absence of B-lines, and
detection of the ‘lung point’
Pneumonia One of the 4 profiles: C profile,
B’Profile, A/B profile, and A-no-
v-PLAPS profile
Cardiogenic pulmonary edema
(increased PV hydrostatic
pressure)
More than 3 B-lines/examined
area; extended from the lung
bases to the medium and
superior fields, bilaterally,
symmetrically, without pleural
line abnormalities
ARDS/ALI Nonhomogeneous B-line
distribution (more than 3 B-lines/
examined area); presence of
spared areas and pleural line
abnormalities; and subpleural
consolidations
Chronic Interstitial lung
disease
Heterogenous B-line distribution
usually more at bases (more
than 3 B-lines/examined area);
presence of pleural line
irregularity and may show
subpleural alteration
Pleural effusion Echogenic or echo-free space
between the visceral and
parietal pleura, which may be:
Anechoic effusion, Complex
nonseptated, Complex septated
pattern with fibrin strands and
septations within or the
homogenously echogenic
pattern
Asthma/COPD/normal lung
aeration
Nude profile (Bilateral A lines
with lung sliding and no DVT
and no PLAPS)
Clinical diagnosis Cardiac examination
Valvular disease Moderate/severe valvular
insufficiency/stenosis
Systolic heart failure EF less than 45%
LV, LA dilatation LA more than 5 cm, LV more
than 6 cm
Pulmonary hypertension Peak systolic pressure greater
than 30 mmHg
Cor pulmonale Altered structure and/or
impaired function of the right
ventricle that results from
pulmonary hypertension
associated with diseases of the
lung, upper airway, or chest wall
Pericardial effusion Moderate/severe pericardial
effusion more than 2 cm
Valve vegetation Mobile hypoechoic soft tissue
lesion resting on the valve
Clinical diagnosis Abnormal abdomen examination
Peritoneal ascites An echoic or echogenic with
floating particles
Cholecystitis Gallbladder distension,
pericholecystic fluid, gallbladder
wall more than 3.5 mm, and
ultrasound Murphy’s sign
Hydronephrosis Dilated pelvis and collecting
system, hypoechoic area in the
kidney hilum
(Continued )
Table 1 (Continued)
Clinical diagnosis Thoracic examination
Parenchymal abnormalities
(spleen, liver, kidney, and
bladder)
Parenchymal abnormalities such
as liver cirrhosis, focal lesions,
and nephropathy, and bladder
assessment for retention
Abnormal venous system
examination
DVT positive vein
compression test
Distended non-compressible
vein, filled with echogenic
material (thrombus)
Inferior vena cava (IVC)
assessment
CVP >10 mmHg diameter >2 cm and absent or
reduced (<50%) collapsibility
CVP <5 mmHg diameter <2 cm and total or
enhanced collapsibility (>50%)
Sign of acute overload visualization of spontaneous
echo contrast (sludge) or solid
echogenic thrombi
ALI, acute lung injury; ARDS, adult respiratory distress syndrome;
COPD, chronic obstructive pulmonary disease; CVP, central
venous pressure hypertrophy; DVT, deep vein thrombosis; EF,
ejection fraction; LA, left atrium; LV, left ventricle; RA, right atrium;
RV, right ventricle.
450 Egyptian Journal of Bronchology, Vol. 12 No. 4, October-December 2018
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
medical history are presented in Table 3. Overall, 18
(17.6%) patients required invasive mechanical
ventilation and nine patients needed noninvasive
positive pressure ventilation.
The admitting and final diagnosis among studied
patients are reported in Table 4; Acute exacerbation
of chronic obstructive pulmonary disease was the most
common diagnosis among our patients.
Different sonographic findings are shown in Table 5.
The total number of sonographic findings was 320, of
which 94 (29.3%) were new ultrasound findings
(Figs 1–3). The number of new finding per patient
ranged from 0 to 4 with a median of one finding per
patient.
Regarding the IVC assessment, 35 (34.3%) patients
had plethoric IVC, another two (2%) patients showed
signs of acute overload (sludge), 20 (19.6%)
patients had IVC with signs of intravascular volume
depletion, and IVC could not be assessed in seven
(6.8%) patients.
Diagnostic effect
The effect of ultrasound examination among studied
patients is detailed in Table 6. Ultrasound examination
modified the admitting diagnosis in 52/102 cases
(50.9%) (Figs 1 and 5). In 14 (13.7%) cases, more
than one modality was used. Ultrasound also confirmed
the diagnosis (Figs 2 and 3) in 36/102 (35.2%) cases,
was ineffective in confirming or modifying in 30
(29.4%) of 102 cases, had a wrong diagnosis (Fig. 4)
in 2 (2%) of 102, and missed a diagnosis in 12 (11.7%)
of 102 cases.
The ultrasonographic findings prompted further
testing (Fig. 5) in 11/102 (10.8%) patients, changes
in medical therapy in 42/102 (41.2%) patients, and led
to invasive procedures (Fig. 6) in 14/102 (13.7%)
patients.
Sonographic examination
The time required to complete the examination ranged
from 15 to 45 min, being least in the last 20 patients,
with a mean of 38.4 min.
Outcome
Regarding patient outcome, 79/102 (77.5%) of the
patients improved and were discharged, 18/102
(17.6%) died, and 5/102 (4.9%) were transferred to
other hospitals.
Discussion
Adding POCUS of the heart, lungs, abdomen, IVC,
and deep veins to the standard initial diagnostic tests
within 12 h of RICU admission resulted in
confirmation of the admitting diagnosis,
modification of the admitting diagnosis, prompted
further testing, change in medical therapy
prescribed, and prompted invasive procedures in 35,
Table 3 Patient demographics
N=102 [n(%)]
Age (years)
Mean±SD 53.59±16.61
Range 19–90
Median 57
Sex
Male 69 (67.6)
Female 33 (32.4)
Mechanical ventilation
No MV 75 (73.5)
Invasive MV 18 (17.6)
Noninvasive MV 9 (8.8)
Relevant history
Intravenous drug addict 5
Pregnancy 3
Presenting symptoms
Dyspnea 91
Orthopnea 8
Wheeze 9
Cough and expectoration 43
Dry cough 13
Hemoptysis 18
Fever/toxic symptoms 20
Chest pain 8
Disturbed conscious level 7
Generalized edema 6
Cyanosis 3
MV, mechanical ventilation.
Table 2 Criteria to define ultrasound-induced modification,
confirmation, wrong evaluation, and lack of confirmation of
admitting diagnosis
Ultrasound-induced
modification of admitting
diagnosis
(a) Ultrasound evidence of an
etiological diagnosis (unknown)
upon a generic organ failure. (b)
Ultrasound allows a different
etiological diagnosis in
comparison with the etiological
admitting diagnosis
Ultrasound-induced
confirmation of admitting
diagnosis
Ultrasound confirms the etiological
admitting diagnosis
Ultrasound-induced wrong
evaluation of diagnosis
(a) Ultrasound-based etiological
diagnosis was not confirmed by
gold standard. (b) Ultrasound
missed etiological diagnosis
evidenced by gold standard
Lack of confirmation of
diagnosis by ultrasound
Ultrasound was not effective in
confirming or modifying etiological
diagnosis
Diagnostic ultrasound in respiratory ICU Al Najjar et al. 451
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
51, 11, 41, and 14% of patients, respectively. However,
it was ineffective in confirming or modifying
diagnosis, provided wrong diagnosis, and missed a
diagnosis in 29.4, 2, and 11.7% of patients,
respectively.
Several previous studies evaluated POCUS in
patients presented with respiratory symptoms to the
emergency room (ER) or general ICUs, but up
to our knowledge, none of them assessed it
specifically in RICU [2,3,5,8,12,13]. RICU patients
are a heterogeneous group presenting with either
primary respiratory disease or secondary
respiratory disease to other illness. They are
characterized by respiratory failure, need for
mechanical ventilation, severe illness, multiple
system dysfunction, and multiple coexisting
comorbidities [19].
In a prospective multicentric study in 142 ICUs in
France, Belgium, and Switzerland by Zieleskiewicz
et al. [13] to describe the diagnostic and therapeutic
effects of POCUS performed during a 24-h
period, the use of POCUS changed the diagnosis
in 21% of cases, led to confirmation of a suspected
diagnosis in 63% of cases, and was associated with
interventions including treatment, imagery ordering,
and patient triage in 69% of cases [13].
Table 4 Admitting and final diagnosis among studied patients
Admitting diagnosis Final diagnosis
AECOPD 28 AECOPD 23
AECOPD+lung cancer 2
AECOPD+bronchiectasis 1
Cardiogenic pulmonary edema 2
Acute severe asthma 3 Acute severe asthma 3
Bronchiectasis acute exacerbation 5 Bronchiectasis acute exacerbation 5
Diffuse parenchymal lung disease with respiratory
failure
8 Diffuse parenchymal lung disease with respiratory failure 8
Acute cardiogenic pulmonary edema 2 Acute cardiogenic pulmonary edema 2
ARDS 2 ARDS 2
Lower respiratory tract infection 16 Pneumonia 10
Postobstructive pneumonia secondary to endobronchial carcinoid
tumor
1
Cardiogenic Pulmonary edema 2
Lung cancer 1
Pulmonary embolism 1
IEC 1
Suspected pulmonary embolism 9 Pulmonary embolism 6
Pulmonary TB 1
Lung cancer 1
Cardiogenic pulmonary edema 1
Primary pulmonary hypertension 1 Primary pulmonary hypertension 1
Empyema 3 Empyema 3
Abscess 3 Abscess 2
IEC+abscess 1
Lung cancer 8 Lung cancer 7
Lung cancer+tamponading malignant pericardial effusion 1
Pleural mesothelioma 2 Mesothelioma 2
OHVS/OSA 4 OHVS/OSA 3
Cardiogenic pulmonary edema 1
Shock 2 Cardiogenic shock 1
Hypovolemic shock 1
Hemoptysis 4 Tight MS 1
Pulmonary TB 1
Pneumonia 2
Undiagnosed pleural effusion with respiratory failure 2 Lung cancer 1
Tamponading malignant pericardial effusion 1
Total 102 Total 102
AECOPD, acute exacerbation of COPD; ARDS, acute respiratory distress syndrome; IEC, infective endocarditis; MS, mitral stenosis;
OHVS, obesity hypoventilation syndrome; OSA, obstructive sleep apnea; PPHTN, primary pulmonary hypertension; PVC, pulmonary
venous congestion; TB, tuberculosis.
452 Egyptian Journal of Bronchology, Vol. 12 No. 4, October-December 2018
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
Manno et al. [2] also investigated the use of POCUS in
ICU patients, and it was found that ultrasound
examination confirmed the admitting diagnosis in
58.4% of cases, modified it in 25.6% of cases, was
ineffective in confirming or modifying it in 13.6% of
cases, and missed it in 2.4% of cases. The
Table 5 Distribution of findings on ultrasound examination
All findings (N=320) [n(%)] New (N=94) [n(%)]
Lung ultrasound 130 (40.6) 12 (12.8)
Asthma/COPD/normal lung aeration
Nude profile (A-profile with no DVT and no PLAPS) 26 (8.1)
Pulmonary embolism
A-DVT-profile 3 (0.9)
Alveolar interstitial syndrome (B profile)
Cardiogenic pulmonary edema 13 (4.1) 6 (6.4)
ARDS/ALI 3 (0.9)
Interstitial syndrome 7 (2.2) 2 (2.1)
Bronchiectasis 4 (1.3) 1 (1.1)
Pneumonia
C profile 16 (5.0)
B’-profile 10 (3.1)
A/B 1 (0.3)
A-noV-PLAPS-profile 3 (0.9)
Pleural abnormalities
Simple unilateral pleural effusion 16 (5.0) 1 (1.1)
Simple bilateral pleural effusion 7 (2.2)
Complex pleural effusion 7 (2.2)
Complex septated effusion 2 (0.6) 2 (2.1)
Pleural thickening 1 (0.3)
Pneumothorax (A’profile) 1 (0.3)
Focal lesions
Infarction/wedges 5 (1.6)
Lung mass 4 (1.3)
Abscess 1 (0.3)
Echocardiography 150 (46.9) 62 (66.0)
Valvular heart disease 15 (4.7) 7 (7.4)
PHTN 52 (16.3) 14 (14.9)
Dilated RV/RA with preserved RV function 21 (6.6) 5 (5.3)
Impaired RV systolic function 15 (4.7) 7 (7.4)
EF 45% or less 19 (5.9) 13 (13.8)
LV/LA dilatation 14 (4.4) 6 (6.4)
Pericardial effusion 11 (3.4) 7 (7.4)
Valve vegetations 2 (0.6) 2 (2.1)
Atrial Invasion 1 (0.3) 1 (1.1)
Pelviabdominal ultrasound 31 (9.7) 14 (14.9)
Organomegally 6 (1.9) 2 (2.1)
Ascites 9 (2.8) 4 (4.3)
Bladder mass 1 (0.3) 1 (1.1)
Cholecystitis 1 (0.3) 1 (1.1)
Nephropathy 2 (0.6)
Hydronephrosis 1 (0.3) 1 (1.1)
Cystic kidney 4 (1.3) 1 (1.1)
Hepatic focal lesion 5 (1.6) 3 (3.2)
Chronic liver disease 1 (0.3)
Cystic liver 1 (0.3) 1 (1.1)
Duplex 9 (2.8) 6 (6.4)
Lower limb DVT 4 (1.3) 4 (4.3)
IJV thrombosis 5 (1.6) 2 (2.1)
ALI, acute lung injury; ARDS, adult respiratory distress syndrome; DVT, deep venous thrombosis; EF, ejection fraction; IJV, internal
jugular vein; LA, left atrium; LV, left ventricle; M/AVD, mitral/aortic valve disease; PHTN, pulmonary hypertension; RA, right atrium; RV,
right ventricle; TR, tricuspid regurgitation.
Diagnostic ultrasound in respiratory ICU Al Najjar et al. 453
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
ultrasonographic findings prompted further testing in
18.4% of patients, led to changes in medical therapy in
17.6% of patients, and led to invasive procedures in
21.6% patients [2].
Echocardiography
Transthoracic echocardiography in critically ill has
been associated with an improvement in the
diagnosis of patients with acute respiratory failure
and/or shock [20,21]. It also increased treating
physicians ability to pick up subtle acute
decompensated heart failure cases initially
misdiagnosed as COPD or other diagnoses [8].
Similarly, in our study, echocardiography had the
greatest effect on diagnosis in 41% (42/102) of
patients, of whom 13 patients had ejection fraction
less than or equal to 45%.
Tricuspid gradient measurement for estimation of right
ventricular systolic pressure is a useful and practical
method for noninvasive prediction of pulmonary artery
pressure and correlates strongly with invasive
pulmonary artery systolic pressure assessment
[22,23]. A clinical diagnosis of pulmonary
hypertension (PHTN) was made if the peak systolic
pressure was greater than 30 mmHg.
Secondary PHTN is a common complication of
chronic lung disease, which is always associated with
poor prognosis and usually progresses to right heart
Figure 1
(a) Color Doppler showing severe mitral regurge (arrow) in patient having rheumatic heart disease with pulmonary venous congestion. (b)
Continuous-wave Doppler showing severe mitral stenosis [mean pressure gradient (MPG) 17 mmHg and mitral valve area (MVA) 0.8 cm
2
by
pulmonary hypertension (PHT)] in a patient with systemic lupus presented with hemoptysis. (c) Internal jugular vein thrombosis (star) in a male
patient with lung cancer presented with shock. (d) In a 68-year-old male patient with chronic obstructive pulmonary disease presented with acute
exacerbation and dysuria, pelviabdominal ultrasound showed a bladder mass (open arrow), which proved to be bladder carcinoma.
454 Egyptian Journal of Bronchology, Vol. 12 No. 4, October-December 2018
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
Figure 2
A known breast cancer female patient with severe dyspnea, and chest radiograph showed massive effusion confirmed by lung ultrasound (a).
Echocardiography (b) showed pericardial effusion (star) with signs of tamponade adding a new etiological diagnosis for her dyspnea.
Figure 3
A 35-year-old IV addict male patient presented with toxic symptoms and respiratory failure, and chest radiograph and computed tomography
showed septic emboli (a). Lung ultrasound (b) revealed confirmed pleural-based hypoechoic lesions (arrow); echo showed vegetation over
tricuspid valve (star) and rim of pericardial effusion (arrow), leading to modification of diagnosis and medical treatment.
Diagnostic ultrasound in respiratory ICU Al Najjar et al. 455
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
failure [24]. However, diagnosis may be delayed in
many cases as the dyspnea is usually attributed to the
primary lung disease [24]. This was clearly obvious in
our study, as 14 (74%) of 19 patients were newly
diagnosed as having PHTN and/or right-sided heart
dysfunction, and PHTN was secondary to their
primary lung disease (nine patients with COPD,
four patients with bronchiectasis, one patient with
interstitial lung disease). This finding greatly
influenced the workup of the patients and had a
direct effect on the therapeutic plan.
Noncardiologists who learn focused critical care
echocardiography can adequately interpret basic
information and successfully incorporate it into
advanced cardiopulmonary life support [25]. On the
contrary, noncardiologists with minimal training
failed to identify important cardiac abnormalities
such as valvular heart diseases, regional wall
abnormalities, and acute cor pulmonale [26,27].
This obstacle was surmounted in our study by the
comprehensive training given to our sonographer,
where severe mitral stenosis as a cause of massive
hemoptysis was diagnosed in a patient with known
systemic lupus erythematosus and severe mitral
regurgitation causing pulmonary venous congestion
in another patient, in addition to the previously stated
patients with PHTN (Fig. 1).
A variety of complications attributed to septic
pulmonary emboli have been described in right-sided
endocarditis [28]. This makes transthoracic
echocardiography an important initial investigation
Table 6 The impact of ultrasound examination among studied
patients
N=102 [n
(%)]
Ultrasound modification of admitting diagnosis 52 (51)
Echocardiography 42 (41.2)
Pulmonary hypertension +/−RV dysfunction 19 (18.6)
Systolic heart failure 13 (12.7)
Atrial invasion by mediastinal mass 1 (1.0)
Severe mitral stenosis 1 (1.0)
Rheumatic heart 1 (1.0)
Severe mitral regurgitation 1 (1.0)
Valve vegetations 2 (2.0)
Moderate pericardial effusion 2 (2.0)
Tamponading pericardial effusion 2 (2.0)
Lung ultrasound 12 (11.7)
Undetected complex effusion 1 (1.0)
Complex septated effusion 2 (2.0)
Cardiogenic pulmonary edema pattern 6 (5.9)
Interstitial lung disease pattern 2 (2.0)
Focal bronchiectasis 1 (1.0)
Pelviabdominal ultrasound 7 (6.9)
Bilateral hydronephrosis 1 (1.0)
Bladder mass 1 (1.0)
Hepatic focal lesion(s) 2 (2.0)
Tense ascites 2 (2.0)
Chronic calculous cholecystitis 1 (1.0)
Duplex 5 (4.9)
Lower limb DVT 3 (2.9)
IJV thrombosis 2 (2.0)
More than one examination 14 (13.7)
Ultrasound confirmed primary diagnosis 36 (35.3)
Ultrasound wrong diagnosis 2 (2.0)
Full stomach as abdominal collection 1 (1.0)
Suspected PE 1 (1.0)
Ultrasound missed a diagnosis 12 (11.7)
Missed hilar LN 2 (2.0)
Missed hilar MASS 2 (2.0)
Missed mediastinal mass 1 (1.0)
Missed endobronchial mass 1 (1.0)
Early ILD 1 (1.0)
Early apical pneumonia-hemoptysis 1 (1.0)
Missed small hepatic focal lesions 1 (1.0)
Missed contralateral pulmonary embolism 1 (1.0)
Fungal ball 1 (1.0)
Miliary nodules 1 (1.0)
Ultrasound not effective in confirming or
modifying
30 (29.4)
Lead to changes in medical therapy 42 (41.2)
Intravenous fluids 10 (9.8)
Diuretics 12 (11.7)
Diuretics+inotropes 1 (1.0)
Inotropes 1 (1.0)
Antiheart failure medications 5 (4.9)
Anticardiac ischemic 5 (4.9)
Thrombolytic therapy 2 (2.0)
Anticoagulation 4 (3.9)
Antibiotics for infective endocarditis 1 (2.0)
Promote further investigation 11 (10.8)
(Continued )
Table 6 (Continued)
N=102 [n
(%)]
CT pulmonary angiography 2 (2.0)
Triphasic computed tomography abdomen
scan
3 (2.9)
Coronary angiography 2 (2.0)
Transesophageal echocardiography 2 (2.0)
High resolution CT chest 1 (2.0)
Further invasive procedure 14 (13.7)
Percutaneous coronary intervention 2 (2.0)
Pleural biopsy/thoracoscopy 1 (1.0)
Fiberoptic bronchoscopy 1 (1.0)
Ascites tapping 2 (2.0)
Thoracentesis 2 (2.0)
Pericardiocentesis 2 (2.0)
Transthoracic biopsy 1 (1.0)
Fine needle aspiration cytology 1 (1.0)
Intercostal tube insertion/VATS 2 (2.0)
DVT, deep venous thrombosis; IJV, internal jugular vein; PHTN,
pulmonary hypertension.
456 Egyptian Journal of Bronchology, Vol. 12 No. 4, October-December 2018
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
in these patients. POCUS enabled rapid, bedside,
noninvasive diagnosis of infective endocarditis in
two patients with history of intravenous drug abuse
who presented with septic embolic and empyema
(Fig. 3).
These data highlight the importance of transthoracic
point-of-care echocardiography by respiratory
intensivists, as performing an echocardiography and
getting immediate interpretation by a cardiologist is
not always available in the RICU [29].
Inferior vena cava ultrasound
Integrating the IVC analysis with a multiorgan
ultrasound approach, which includes evaluation of
the dimensions and function of the right and left
cardiac chambers, with basic evaluation of the
pulmonary congestion by assessing lung ultrasound
for B lines led to changes in the medical therapy in
10/102 (8%) of our patients. This is consistent with the
results of other studies that reported fluid status
adjustments to be a frequent therapeutic action
performed following a focused ultrasound
examination [12].
Lung ultrasound
In one study, focused LUS identified a missed
life-threatening conditionin23(17%)patients
presenting with acute respiratory symptoms [3]. In
another study, LUS pointed out 55 (40.3%) new
findings in patients admitted to medical ICU
enabling the differentiation of the etiologic
diagnosis in patients withanadmittingdiagnosis
of acute respiratory insufficiency [2].
In our study, LUS was able to assess the lungs in all
included patients. A total of 130 findings were seen, of
which 12 were identified as new findings; causing
modification of the admitting diagnosis in 12/102
(11.7%) patients. LUS also led to changes in
medical therapy in 23 (22.5%) patients, including
fluid management and diuretic therapy. We
attributed this small number of new finding to the
nature of our patients, as most of them have a
significant respiratory disorder that was usually
apparent in plain chest radiograph.
We describe a pattern of bronchiectasis in LUS, in
the form of intersecting comet tail artifacts not erasing
A-lines with or without an irregular pleural line
detected by linear probe, a finding that was not
previously mentioned and needs further analysis
(VEDIO).
At bedside, initial chest ultrasound is more sensitive
than chest radiographies in the detection of small
pleural effusions that are misdiagnosed as
parenchymal opacities or are not seen [9,30]. A total
of 32 pleural effusions were detected in our study
(Fig. 2), and with the help of bedside LUS, the
nature of the fluid could be assessed and aided the
change in the management in three cases. Overall, LUS
had a greater effect on the therapeutic plan of our
patients rather than a diagnostic effect.
Pelviabdominal ultrasound
Abdominal ultrasound evidenced 14 new pathologic
findings and modified admitting diagnosis in 7/102
(6.8%) cases (Fig. 1). This nearly matched the results of
Manno et al. [2], where abdominal examination as a
part of the ICU ‘sound protocol’evidenced 20 new
pathologic findings and induced changes in therapy in
3/125 (2.4%) cases.
Duplex
Central line insertion is a daily practice in ICU.
Diagnosing IJV thrombosis in two patients using
ultrasonography helped in selecting the site of
Figure 4
A peripheral hypoechoic lesion (arrow), which was suspected to be a
pulmonary infarction in a patient with chronic obstructive pulmonary
disease, computed tomography pulmonary angiogram showed an
atelectatic band.
Diagnostic ultrasound in respiratory ICU Al Najjar et al. 457
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
Figure 6
A 30-year-old male presented with severe dyspnea, fever, and right sided D-shaped homogenous opacity (b). Lung ultrasound revealed complex
septated pleural effusion (a) managed by medical treatment followed by video-assisted thoracoscopy.
Figure 5
(a, b) Echocardiography showed a mediastinal mass (arrows) with atrial invasion in a patient presented with severe dyspnea, hemoptysis, and
wide mediastinum. Computed tomography with contrast (c) was done to identify boundaries of the lesion.
458 Egyptian Journal of Bronchology, Vol. 12 No. 4, October-December 2018
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
central line insertion in addition to initiation of
therapeutic anticoagulation (Fig. 1).
Among the three patients in which a new lower limb
DVT was diagnosed, two cases were diagnosed as
having pulmonary embolism. This is in accordance
with previous studies that combined
echocardiography and venous ultrasonography to
chest sonography as a reliable method for screening
patients with suspected pulmonary embolism at
bedside [31].
Wrong diagnosis
In two cases, ultrasonography provided a wrong
diagnosis; a full stomach appearing below the
diaphragm was misdiagnosed as a peritoneal fluid
collection, which is a common pitfall in point-of-
care ultrasound [32]. Another patient with systolic
heart failure, a pleural-based triangular wedge-
shaped opacity suggested the diagnosis of pulmonary
embolism (Fig. 4), but appeared to be an atelectatic
band in computed tomography pulmonary
angiography.
Missed diagnosis
Transthoracic ultrasound achieves only poor
visualization of the mediastinum as compared with
computed tomography scan [33]. Thus, it was
expected to miss central, mediastinal, or hilar lesions
in 5/102 (4.9%) of studied patients.
The limitation of our study was that the examiner has
not been blinded to the clinical picture of the patient,
which is difficult to eliminate in any ultrasound
examination. Being a single-center study, which
included only patients with respiratory diseases,
the results cannot necessarily be applied to other
ICUs.
In conclusion, integrating POCUS in the initial
assessment of critically ill RICU patients together
with standard diagnostic tests led to diagnostic and
therapeutic changes in most of patients, which affected
these patients’management. Thus, it seems reasonable
to consider routine use of POCUS as a new respiratory
examination option in the armamentarium of the
intensivists.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1Leuppi JD, Dieterle T, Koch G, Martina B, Tamm M, Perruchoud AP, et al.
Diagnostic value of lung auscultation in an emergency room setting. Swiss
Med Wkly 2005; 135:520–524.
2Manno E, Navarra M, Faccio L, Motevallian M, Bertolaccini L, Mfochivè A,
et al. Deep impact of ultrasound in the intensive care unit: the ‘iCU-sound’
protocol. Anesthesiology 2012; 117:801–809.
3Laursen CB, Sloth E, Lambrechtsen J, Lassen AT, Madsen PH, Henriksen
DP, et al. Focused sonography of the heart, lungs, and deep veins
identifies missed life-threatening conditions in admitted patients with
acute respiratory symptoms. Chest 2013; 144:1868–1875.
4Lighthall GK, Vazquez-Guillamet C. Understanding decision making in
critical care. Clin Med Res 2015; 13:156–168.
5Laursen CB, Sloth E, Lassen AT, Christensen R, Lambrechtsen J, Madsen
PH, et al. Point-of-care ultrasonography in patients admitted with
respiratory symptoms: a single-blind, randomised controlled trial.
Lancet Respir Med 2014; 2:638–646.
6Bhagra A, Tierney DM, Sekiguchi H, Soni NJ. Point-of-care
ultrasonography for primary care physicians and general internists.
Mayo Clin Proc 2016; 91:1811–1827.
7Narasimhan M, Koenig SJ, Mayo PH. A whole-body approach to point of
care ultrasound. Chest 2016; 150:772–776.
8Mantuani D, Frazee B, Fahimi J, Nagdev A. Point-of-care multi-organ
ultrasound improves diagnostic accuracy in adults presenting to the
emergency department with acute dyspnea. West J Emerg Med 2016;
17:46–53.
9Khalil MM, ELMaraghy AA, Yousef YR. Could chest ultrasonography
replace routine chest X-rays in mechanically ventilated patients? Egypt
J Chest Dis Tuberc 2015; 64:857–863.
10 Salah H. Diagnostic impact of integrating ultrasonography into routine
practice in respiratory intensive care units. Egypt J Bronchol 2014;
8:66.
11 Bobbia X, Hansel N, Muller L, Claret PG, Moreau A, Genre Grandpierre R,
et al. Availability and practice of bedside ultrasonography in emergency
rooms and prehospital setting: a French survey. Ann Fr Anesth Reanim
2014; 33:e29–e33.
12 Bernier-Jean A, Albert M, Shiloh AL, Eisen LA, Williamson D, Beaulieu Y.
The diagnostic and therapeutic impact of point-of-care ultrasonography in
the intensive care unit. J Intensive Care Med 2017; 32:197–203.
13 Zieleskiewicz L, Muller L, Lakhal K, Meresse Z, Arbelot C, Bertrand P-M ,
et al... Point-of-care ultrasound in intensive care units: assessment of 1073
procedures in a multicentric, prospective, observational study. Intensive
Care Med 2015; 41:1638–1647.
14 Gall JR, Lemeshow S, Saulnier F. A New Simplified Acute Physiology
Score (SAPS II) based on a European/North American multicenter study. J
Am Med Assoc 1993; 270:2957–2963.
15 Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of
lung ultrasound in the critically ill. Chest 2015; 147:1659–1670.
16 Bahner D, Blaivas M, Cohen HL, Fox JC, Hoffenberg S, Kendall J, et al.
AIUM practice guideline for the performance of the focused assessment
with sonography for trauma (FAST) examination. J Ultrasound Med 2014;
33:2047–2056.
17 Ilyas A, Ishtiaq W, Assad S, Ghazanfar H, Mansoor S, Haris M, et al.
Correlation of IVC diameter and collapsibility index with central venous
pressure in the assessment of intravascular volume in critically ill patients.
Cureus 2017; 9:e1025.
18 Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V,
et al. Point-of-care multiorgan ultrasonography for the evaluation of
undifferentiated hypotension in the emergency department. Intensive
Care Med 2013; 39:1290–1298.
19 Ghoneim AHA, Hussein RM, El-Ghamry R, Mahmoud LY. Patterns of
admitted cases to Respiratory Intensive Care Unit at Zagazig University
Hospitals, Egypt. Egypt J Chest Dis Tuberc 2013; 62:661–668.
20 Joseph MX, Disney PJS, Da Costa R, Hutchison SJ. Transthoracic
echocardiography to identify or exclude cardiac cause of shock. Chest
2004; 126:1592–1597.
21 Bataille B, Riu B, Ferre F, Moussot PE, Mari A, Brunel E, et al. Integrated
use of bedside lung ultrasound and echocardiography in acute respiratory
failure: a prospective observational stud y in ICU.Chest 2014 ; 146:1586–1593.
22 Forfia P, Roberts J. Diagnosis and assessment of pulmonary vascular
disease by Doppler echocardiography. Pulm Circ 2011; 1:160.
23 Chan KL, Currie PJ, Seward JB, Hagler DJ, Mair DD, Jamil Tajik A.
Comparison of three Doppler ultrasound methods in the prediction of
pulmonary artery pressure. J Am Coll Cardiol 1987; 9:549–554.
Diagnostic ultrasound in respiratory ICU Al Najjar et al. 459
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
24 Zangiabadi A, De Pasquale CG, Sajkov D. Pulmonary hypertension and right
heart dysfunction in chronic lung disease.Biomed Res Int 2014; 2014:739674.
25 Oren-Grinberg A, Talmor D, Brown SM. Focused critical care
echocardiography. Crit Care Med 2013; 41:2618–2626.
26 Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW.
Assessment of left ventricular function by intensivists using hand-held
echocardiography. Chest 2009; 135:1416–1420.
27 Labbé V, Ederhy S, Pasquet B, Miguel-Montanes R, Rafat C, Hajage D,
et al. Can we improve transthoracic echocardiography training in non-
cardiologist residents? Experience of two training programs in the
intensive care unit. Ann Intensive Care 2016; 6:44.
28 Moss R. Injection drug use and right sided endocarditis. Heart 2003;
89:577–581.
29 Casaroto E, Mohovic T, Pinto LM, de Lara TR. Bedside echocardiography
in critically ill patients. Einstein (São Paulo) 2015; 13:644–646.
30 Kitazono MT, Lau CT, Parada AN, Renjen P, Miller WT. Differentiation of
pleural effusions from parenchymal opacities: accuracy of bedside chest
radiography. Am J Roentgenol 2010; 194:407–412.
31 Mathis G, Blank W, Reißig A, Lechleitner P, ReußJ, Schuler A, et al.
Thoracic ultrasound for diagnosing pulmonary embolism: a prospective
multicenter study of 352 patients. Chest 2005; 128:1531–1538.
32 Blanco P, Volpicelli G. Common pitfalls in point-of-care ultrasound: a
practical guide for emergency and critical care physicians. Crit
Ultrasound J 2016; 8:15.
33 Herth FJF, Becker HD. Transthoracic ultrasound. Respiration 2003;
70:87–94.
460 Egyptian Journal of Bronchology, Vol. 12 No. 4, October-December 2018
[Downloaded free from http://www.ejbronchology.eg.net on Thursday, February 14, 2019, IP: 196.130.5.42]
