Comete polmonari, un segno ecografico di acqua extravascolare polmonare: confronto con i peptidi natriuretici cardiaci nella diagnosi differenziale di dispnea.

Le comete ultrasonografiche polmonari sono un segno ecografico di ispessimento dei setti interlobulari sottopleurici; rappresentano quindi un segno indiretto di edema interstiziale polmonare. La loro valutazione è molto semplice e veloce da eseguire, ha una curva di apprendimento di pochi esami e può essere effettuta con qualsiasi ecografo, anche portatile. Abbiamo confrontato l’accuratezza delle comete rispetto ai valori di NT-proBNP (il frammento aminoterminale del peptide natriuretico di tipo B) nella diagnosi differenziale di dispnea cardiogena o non cardiogena, in pazienti ammessi in ospedale con dispnea in classe New York Heart Association II, III o IV. L’origine della dispnea è stata valutata analizzando l’intera documentazione del paziente: anamnesi, esame obiettivo, diario clinico, esami di laboratorio e strumentali e lettera di dimissione. Il numero di comete, se confrontato con i valori di NT-proBNP considerati come gold-standard di riferimento, mostra una buona accuratezza nel predire l’origine cardiogena della dispnea. Le comete polmonari sono quindi un metodo molto semplice che può aiutare il medico nella diagnosi differenziale di dispnea: il loro impiego può eventualmente sostituire quello dei peptidi natriuretici cardiaci, nei casi in cui il loro dosaggio non sia disponibile, mantenendo una buona accuratezza diagnostica

Effective and timely evaluation of pulmonary congestion: Qualitative comparison between lung ultrasound and thoracic bioelectrical impedance in maintenance hemodialysis patients

The assessment of pulmonary congestion in maintenance hemodialysis (MHD) patients is challenging. Bioelectrical impedance analysis (BIA) can estimate body water compartments. Natriuretic peptides are markers of hemodynamic stress, neurohormonal activation and extracellular volume overload. Lung ultrasound (LUS) has been proposed for the non-invasive estimation of extravascular lung water through B-lines assessment. Up to now, no study evaluated the correlation between B-lines, segmental thoracic BIA, and natriuretic peptides in MHD patients. The aims of this study were: (1) To validate LUS as a tool for an effective and timely evaluation of pulmonary congestion in MHD patients, in comparison with segmental thoracic BIA, and with natriuretic peptides; (2) To compare a comprehensive whole chest ultrasound scanning with a simplified and timely scanning scheme limited to the lateral chest regions.Thirty-one MHD adult patients were examined. LUS, total body and thoracic BIA, and natriuretic peptides were performed immediately before and after a mid-week dialysis session. The number of B-lines assessed by LUS was compared with total body and thoracic impedance data and with natriuretic peptides.Pre-HD B-lines ranged 0-147 (mean 31) and decreased significantly post-HD (mean 16, P < 0.001). A significant correlation was found between the number of B-lines and extra-cellular water index (ECWI, r = 0.45, P < 0.001), with thoracic impedance (r = 0.30, P < 0.05), and with BNP (r = 0.57, P < 0.01). The dynamic changes in B-lines correlated better with thoracic impedance than with total body impedance, and correlated with extra-cellular but not with intra-cellular water index. The correlation between B-lines and ECWI was similar when LUS was limited to the lateral chest regions or performed on the whole chest. Multivariate analysis showed that only segmental thoracic impedance was an independent predictor of residual pulmonary congestion.The dynamic changes in B-lines after hemodialysis are correlated to the changes in total body and extra-cellular water, and particularly to lung fluids removal. B-line assessment in MHD patients is highly feasible with a simplified and timely scanning scheme limited to the lateral chest regions. These premises make B-lines a promising biomarker for a bedside assessment of pulmonary congestion in MHD patients

Ultrasound Lung Comets versus cardiac natriuretic peptides in patients with acute dyspnoea

Background: Acute shortness of breath as a presenting symptom is a frequent challenge for physicians. The main differential diagnosis is between cardiac and non-cardiac origin of dyspnoea. Natriuretic peptides levels have been used to successfully aid in the diagnosis of congestive heart failure (CHF) in patients presenting with dyspnoea. Ultrasound lung comets (ULCs) are a useful chest sonography sign of increased extravascular lung water. Aim: To assess the concordance rate between ULCs and cardiac natriuretic peptides. Methods: 275 patients (87 females; age 70?14 yrs) admitted with dyspnoea (NYHA class II, III or IV) to a Cardiology-Pneumology or Emergency Department were evaluated. Cardiac peptides assessment and chest sonography, scanning along the intercostal spaces, were performed in all (within 3 hours) and independently analyzed. NT-proBNP values &#8805;157 ng/l, BNP &#8805;100 ng/l and ULCs &#8805;5 were considered abnormal, according to pre-determined cut-offs. Results: Abnormal values of natriuretic peptides were found in 251 patients, while ULCs were present in 220 patients. The total number of discordant cases was 36 (13%), with a concordance rate of 87%. The dominant source of discordance was due to abnormal natriuretic peptides and absence of ULCs (34 patients, see figure): in these patients the mean hospitalization time was significantly lower than in patients with abnormal cardiac peptides and presence of ULCs (7.8?3.7 vs 10.9?6 days, p<.001). Conclusions: ULCs findings are in broad concordance with natriuretic peptides values. Being natriuretic peptides analysis not always available, especially in peripheral Emergency Departments, ULCs assessment could be a plausible alternative to identify CHF in patients with acute dyspnoea

The prognostic value of ultrasound lung comets in patients with pulmonary hypertension

Background: Ultrasound Lung Comets (ULCs) consist of multiple comet tails originating from thickened interlobular septa, due to water or connective tissue accumulation. Therefore they are detectable in patients with several lung diseases. Aim: To assess the prognostic value of ULCs in patients with pulmonary hypertension. Materials and methods: 33 in-hospital patients (age 67?13 years, 16 females) admitted to the Pneumology Division of Clinical Physiology in Pisa with diagnosis of idiopathic or secondary pulmonary hypertension were evaluated upon admission with a comprehensive 2D and Doppler echocardiography, and chest sonography with ULCs assessment. A patient ULC score was obtained by summing the number of comets from each of the scanning spaces in the anterior right and left hemithorax, from second to fifth intercostal spaces. By echocardiography, we measured Tricuspid Annular Plane Systolic Excursion (TAPSE) as an index of right ventricular function, and Pulmonary Artery Systolic Pressure (PASP) from tricuspid regurgitant jet velocity. Results: During the follow-up, 16 events occurred: 4 deaths, 12 new admission for the worsening of symptoms or respiratory function. A ROC analysis identified 14 ULCs as the best diagnostic cut-off to predict events with 94 % sensitivity and 71 % specificity. The 9-months event-free survival was higher in patients with no ULCs and lower in patients with ULCs (see Figure). There was a weak significant correlation between ULCs and PAPs (r=.541, p<.001) and no correlation between ULCs and TAPSE (r=.088, p=ns). Conclusion: ULCs are a simple, user-friendly, radiation-free bedside sign of thickened lung interlobular septa, adding a useful information for straightforward prognostic stratification of patients with pulmonary hypertension

Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study

BACKGROUND: B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF). METHODS: A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 ± 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge. RESULTS: Mean B-lines at admission was 48 ± 48 with a statistically significant reduction before discharge (20 ± 23, p 15) (log rank χ(2) 20.5, p 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30-106.16) was an independent predictor of events at 6 months. CONCLUSIONS: Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation

Ultrasound lung comets for serial assessment of pulmonary congestion in heart failure

Background: Serial chest radiographs are too insensitive and therefore NOT recommended for monitoring pulmonary congestion in heart failure patients (AHA/ACC guidelines 2006). Ultrasound lung comets (ULCs) are a simple, quantitative chest sonography sign of pulmonary congestion, originating from water-thickened interlobular septa, and might represent a convenient alternative to chest x-ray in this clinical setting. Aim: To assess whether dynamic changes in ULCs could mirror variations in clinical status and natriuretic peptides. Methods: 104 patients (28 females; age 70?11 years) admitted with dyspnoea (NYHA class &#8805;II) to a Cardiology or Emergency Department were evaluated. NT-proBNP assessment and ULC were independently performed at admission and again before discharge. A patient ULC score was obtained by summing the number of comets from each of the scanning spaces from second to fifth intercostal spaces on anterior chest. Patients were considered "responders" to therapy when NYHA class decreased &#8805;1 grade at discharge. Results: Responders (group I, n=90) and non-responders (group II, n=14) had similar NT-proBNP (I=5560?6643 vs II=5470?4047 ng/l, p=.313), and ULCs number (I=27?34 vs II=34?24, p=.133) at admission. At discharge, responders had lower NT-proBNP (I=3633?5194 vs II=4654?3366 ng/l, p<.05) and ULCs (I=11?12 vs II=28?32, p<.01, see figure) when compared to non-responders. Variation in NT-proBNP somewhat mirrored variations in ULCs (r=.322, p<0.0001). Conclusions: ULC variations mirror changes in clinical functional class and natriuretic peptides in patients hospitalized with acute dyspnoea. ULCs represent an objective parameter of clinical improvement, useful for serial assessment of extra-vascular lung water in patients admitted with acute dyspnoea

Pulmonary arterial hypertension and interstitial lung fibrosis in systemic sclerosis: One-stop shop assessment with cardiac and chest ultrasound

Background: Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are common complications of systemic sclerosis (SSc). Echocardiography evaluates PAH, and chest sonography detects even mild ILC as ultrasound lung comets (ULC), i.e. multiple comet-tails fanning out from the lung surface and originating from subpleural interlobular septa thickened by fibrosis. Aim: to assess ILD and PAH by integrated cardiac and chest ultrasound in SSc. Materials and methods: We enrolled 30 consecutive SSc patients (age=54?13 years, 23 females) in the Rheumatology Clinic of Pisa University. In all, we assessed Systolic Pulmonary Arterial Pressure (SPAP), from maximal velocity of tricuspid regurgitation flow, and ULC score with chest sonography (summing the number of ULC from each scanning space of anterior and posterior right and left chest, from second to fifth intercostal space). All patients underwent plasma assay for anti-topoisomerase antibodies (anti-Scl70), associated with development of pulmonary fibrosis. Twenty-eight patients also underwent High Resolution Computed Tomography, HRCT (from 0=no fibrosis to 3=honey combing). Results: ULC number - but not SPAP - was correlated to HRCT fibrosis and presence SSc-70 antibodies (see figure). ULC number was similar in localized or diffuse forms (16?20 vs. 21?19, p=ns) and was unrelated to SPAP (r=0.216, p=ns). Conclusions: Cardiac and chest sonography assessment of SPAP and ULC allow a complete, simple, radiation-free characterization of vascular and interstitial lung involvement in SSc - all in one setting and with the same instrument, same transducer and the same sonographer. In particular, ULC number, but not SPAP, is associated with HRCT evidence of lung fibrosis and presence of Scl-70 antibodies

Lung ultrasound in young children with neurological impairment: A proposed integrative clinical tool for deaeration-detection related to feeding

Infants and children with neurological impairment, such as cerebral palsy (CP), often experience abnormal ingestion functions, including oropharyngeal dysphagia and gastroesophageal reflux disease, which led to aspiration-related respiratory complications, morbidity, hospitalization, or death. There is a lack of evidence-based, repeatable, infant-friendly instrumental procedures to assess aspiration-risk in infants with CP or other neurological disorders, with also a lack of clinical assessment measures to support the use of more invasive diagnostic techniques. To this purpose, in the current study we explore the feasibility of lung ultrasound (LUS), to assess lung deaeration possibly related to aspiration during meal, in a cohort of 35 subjects affected by CP or other encephalopathies, and 10 controls in the same age-range. We coupled LUS procedure with meal caregiver administration for each child. Our results support the feasibility of this innovative approach in the clinical setting. Exploratory findings revealed a number of lung abnormalities likely related to abnormal ingestion function in subjects. Subgroup analyses revealed possible differences in LUS abnormalities between CP and other encephalopathies, possibly related to different mechanism of disease or dysfunction. Also, some evidences arose about the possible relationship between such LUS abnormalities and feeding and swallowing abilities in CP or other encephalopathies. LUS showed preliminarily feasibility and effectiveness in detecting meal-related LUS abnormalities in a dynamic manner in the clinical setting. This approach demonstrated usefulness as a potential tool for improving assessment and management in complex care of infants and young children with severe neurological disorders