The diagnostic accuracy of lung ultrasound to determine PiCCO-derived extravascular lung water in invasively ventilated patients with COVID-19 ARDS

Background: Lung ultrasound (LUS) can detect pulmonary edema and it is under consideration to be added to updated acute respiratory distress syndrome (ARDS) criteria. However, it remains uncertain whether different LUS scores can be used to quantify pulmonary edema in patient with ARDS. Objectives: This study examined the diagnostic accuracy of four LUS scores with the extravascular lung water index (EVLWi) assessed by transpulmonary thermodilution in patients with moderate-to-severe COVID-19 ARDS. Methods: In this predefined secondary analysis of a multicenter randomized-controlled trial (InventCOVID), patients were enrolled within 48 hours after intubation and underwent LUS and EVLWi measurement on the first and fourth day after enrolment. EVLWi and ∆EVLWi were used as reference standards. Two 12-region scores (global LUS and LUS–ARDS), an 8-region anterior–lateral score and a 4-region B-line score were used as index tests. Pearson correlation was performed and the area under the receiver operating characteristics curve (AUROCC) for severe pulmonary edema (EVLWi &gt; 15 mL/kg) was calculated. Results: 26 out of 30 patients (87%) had complete LUS and EVLWi measurements at time point 1 and 24 out of 29 patients (83%) at time point 2. The global LUS (r = 0.54), LUS–ARDS (r = 0.58) and anterior–lateral score (r = 0.54) correlated significantly with EVLWi, while the B-line score did not (r = 0.32). ∆global LUS (r = 0.49) and ∆anterior–lateral LUS (r = 0.52) correlated significantly with ∆EVLWi. AUROCC for EVLWi &gt; 15 ml/kg was 0.73 for the global LUS, 0.79 for the anterior–lateral and 0.85 for the LUS–ARDS score. Conclusions: Overall, LUS demonstrated an acceptable diagnostic accuracy for detection of pulmonary edema in moderate–to–severe COVID-19 ARDS when compared with PICCO. For identifying patients at risk of severe pulmonary edema, an extended score considering pleural morphology may be of added value. Trial registration: ClinicalTrials.gov identifier NCT04794088, registered on 11 March 2021. European Clinical Trials Database number 2020–005447-23.</p

Waterstof in de gebouwde omgeving:Synthese Thematiek WaterstofLab

Er ligt een gemeenschappelijke uitdaging om de warmtevoorziening van de gebouwde omgeving CO2-neutraal te maken. In de meeste huishoudens is aardgas nu nog een vanzelfsprekende keuze voor verwarmen en koken. Daar komt de komende 30 jaar verandering in. Niet in één keer, maar geleidelijk en gefaseerd. In het Klimaatakkoord is afgesproken dat iedere gemeente voor eind 2021 een transitievisie warmte heeft. Waterstof kan hier als klimaatneutraal gas mogelijk een rol in spelen, maar er zijn ook nog veel vragen. Het WaterstofLab, gestart in 2020, beoogt door het organiseren van dialoog tussen een breed scala aan betrokkenen en belanghebbenden op zoek te gaan naar een meer eenduidig beeld omtrent de rol die waterstof kan spelen als onderdeel van de oplossing voor een CO2-neutrale gebouwde omgeving, de huidige stand van zaken rond waterstof, en de termijn waarop een bijdrage verwacht zou kunnen worden. Dit document is het resultaat van de voorbeschouwing. Het geeft weer waar de regiegroep van het WaterstofLab het in grote lijnen over eens is en waar nog de grote vraagtekens zitten. Dit is nadrukkelijk geen eindconclusie, maar een tussenstand op basis van huidige inzichten in de groep. Het is bedoeld als start van een bredere dialoog

Nursing workload measurement instrument : Validity, Reliability and Applicability

The management of the thorax centre of the UMCG needs a good insight in personnel, equipment and materials needed to provide the necessary quality of care. It is hard to determine the number of nurses that are needed in future time periods. The management decided to develop a workload measurement instrument, in which every action a nurse performs on a specific patient is documented, aiming to get more insight in the personnel needed. After two years of using the instrument a group of students from the University of Groningen were asked to evaluate the instrument. They suggested that the validity and the reliability of the measurement instrument are questionable. This led to the following research question: What are the validity, reliability and the applicability of the measurement instrument used by the thorax centre of the UMCG? In order to answer this question different research methods were applied. Firstly, a literature review was performed leading to the requirements which an applicable measurement instrument needs to meet. The nursing workload measurement instrument of the UMCG is in this thesis tested against each of these requirements. After the literature review the data needed to answer these sub questions was obtained using observations, interviews and the historic data of the measurement instrument. Six of the nurses of the thorax centre were observed during a dayshift and interviewed after that dayshift. During these observations every activity of the nurse was documented and timed. The gathered data was later compared to the historical data collected with the current nursing workload measurement instrument. Analysis of the collected data leads to the conclusion that the nursing workload measurement instrument is not reaching its full potential. The activities listed in the measurement instrument are not fully covering the definition of nursing work and the operation time of each of these items are not matching the actual times needed by the nurses. Therefore, the current measurement instrument is not supporting the decision making process of the management. However, the measurement instrument has potential. When the measurement instrument is improved the management will have a useful tool to support their budget requests and get insight in the nursing work on their wards.

Point of Care Ultrasound of the Respiratory System in the Critically Ill

Part I of this thesis revolved around various aspects of lung ultrasound in a critical care setting. Given the high prevalence of pulmonary pathology on the Intensive Care Unit (ICU), diagnostic tools to assess the lungs are of great importance. While tools such as chest X-ray, CT or indwelling catheters (pulmonary artery catheter and pulse contour cardiac output catheter) play an important role, they come with drawbacks of invasive- ness, high patient burden, risk of complications and necessity for patient transport. As POCUS (Point Of Care UltraSound) suffers significantly less from these limitations, it was quickly adopted on the ICU after it had been shown to be an accurate diagnostic tool on the emergency ward. While this seemed like an ideal continuation of its use in lung pathology, fundamental issues limited simple translation: epidemiological characteris- tics differ, normal pulmonary physiology is disturbed by positive pressure ventilation and location of pathology is influenced by gravity and differs between ambulatory and in-hospital patients. In Part II of this thesis, the focus shifted from the lung towards the diaphragm. Force generating capacity of the diaphragm was recognized to play a prominent role in lib- erating patients from mechanical ventilation. As such, tools to quantify function were deemed of importance. POCUS was being hypothesized to be a viable tool in this regard, but evidence was still scarce. As such, this part was started with a literature review of the available evidence in chapter 5. The result was a concise overview with recommen- dations for applications in clinical practice. Interestingly, important variability between study methodology was observed, ranging from choice and positioning of transducer, to caliper placement for thickness measurements. In essence, Part III was the synthesis of the knowledge acquired in the previous parts of this thesis. Integration of information about various components of the respiratory system, allows for a much more detailed and targeted response to questions of respira- tory pathology. Especially in a critical care setting, where clinical problems are rarely unifactorial, the diagnostic and therapeutic approach should match their multifaceted aspects. POCUS offers flexibility as required by the situation and the clinical context. The question whether a patient has pneumonia can be answered with a simple and swift examination of only a few pulmonary areas, while elucidating the causes of extubation failure can be done through focused assessment of various contributing components, including heart, lungs, diaphragm and abdominal processes

Ultrasound to assess diaphragmatic function in the critically ill-a critical perspective

Ultrasound of the diaphragm in critically ill patients has become a diagnostic technique of emerging interest among clinicians and scientists. The advantages include that it is widely available, non-invasive and examination can be performed after relatively short training and at low costs. It is used to estimate muscle mass by measurement of muscle thickness and diagnose weakness by the assessment of diaphragm movement during unassisted breathing. Thickening of the muscle during inspiration has been used to quantify force generation. The enthusiasm that surrounds this topic is shared by many clinicians and we agree that ultrasound is a valuable tool to screen for diaphragm dysfunction in intensive care unit (ICU) patients. However, in our opinion much more studies are required to validate ultrasound as a tool to quantify breathing effort. More sophisticated ultrasound techniques, such as speckle tracking imaging are promising techniques to evaluate respiratory muscle function in patients, including the critically ill

Weaning the patient: between protocols and physiology

PURPOSE OF REVIEW: Ventilator weaning forms an integral part in critical care medicine and strategies to shorten duration are rapidly evolving alongside our knowledge of the relevant physiological processes. The purpose of the current review is to discuss new physiological and clinical insights in ventilator weaning that help us to fasten liberation from mechanical ventilation. RECENT FINDINGS: Several new concepts have been introduced in the field of ventilator weaning in the past 2 years. Approaches to shorten the time until ventilator liberation include frequent spontaneous breathing trials, early noninvasive mechanical ventilation to shorten invasive ventilation time, novel ventilatory modes, such as neurally adjusted ventilatory assist and drugs to enhance the contractile efficiency of respiratory muscles. Equally important, ultrasound has been shown to be a versatile tool to monitor physiological changes of the cardiorespiratory system during weaning and steer targeted interventions to improve extubation outcome. SUMMARY: A thorough understanding of the physiological adaptations during withdrawal of positive pressure ventilation is extremely important for clinicians in the ICU. We summarize and discuss novel insights in this field

Pulmonary hemorrhage as a rare cause of lung ultrasound A/B-profile [version 1; peer review: 1 approved, 1 approved with reservations]

When using lung ultrasound to determine the cause of acute respiratory failure, the BLUE protocol is often used. In a 65-year old patient, an A/B-profile was found, suggesting pneumonia, following the flowchart of this protocol. In this case, however, pulmonary hemorrhage confirmed by bronchoscopy was the final diagnosis. This case report outlines the importance of understanding the limitations of the BLUE protocol and that lung ultrasound findings should always be used in the context of the patient’s history and physical exam. In addition, pulmonary hemorrhage should be considered in patients with no clinical signs of pneumonia and/or presence of risk factors for lung bleeding as a rare cause of lung ultrasound A/B-profile

Case report: Pulmonary hemorrhage as a rare cause of lung ultrasound A/B-profile [version 2; peer review: 2 approved]

When using lung ultrasound to determine the cause of acute respiratory failure, the BLUE protocol is often used. In a 65-year old patient, an A/B-profile was found, suggesting pneumonia, following the flowchart of this protocol. In this case, however, pulmonary hemorrhage confirmed by bronchoscopy was the final diagnosis. This case report outlines the importance of understanding the limitations of the BLUE protocol and that lung ultrasound findings should always be used in the context of the patient’s history and physical exam. In addition, pulmonary hemorrhage should be considered in patients with no clinical signs of pneumonia and/or presence of risk factors for lung bleeding as a rare cause of lung ultrasound A/B-profile