Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill

BACKGROUND: In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. METHODS: This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. RESULTS: The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients. CONCLUSION: The agreement between lung ultrasound and auscultation is poor

Hemodynamic and ventilatory complications of mechanical ventilation with high intrinsic positive end-expiratory pressure

In three mechanically ventilated patients ventilatory and circulatory complications resulted from high levels of intrinsic positive end-expiratory pressure (PEEPi): progressive pulmonary hyperinflation due to impairment of the expiration. PEEPi was initially not considered as the cause of shock and low tidal volumes and/or high inflation pressures. In a 74-year-old man the circulation deteriorated further when hand bagging was started in an attempt to improve his ventilatory condition; after reduction of the respiration rate, he recovered well. In a 40-year-old woman with relapsing polychondritis sedation helped to reduce the respiratory rate so as to restore sufficient expiratory time. A 59-year-old woman developed acute exacerbation of severe chronic obstructive pulmonary disease, and went into shock during interhospital ambulance transport; she was stabilized after recognition of PEEPi and adjustment of the setting of the ventilator. Detection of PEEPi (e.g. by the finding of a deep inflation level on physical examination) is more important than exact measurement of PEEPi. If PEEPi is detected, the ventilator should be set at PEEP at 80-90% of PEEPi, low frequency (e.g. 8/min) and a long expiratory time, and high inspiratory flow.</p