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Review
. 2023 Oct 26;13(11):1541.
doi: 10.3390/jpm13111541.

Point-of-Care Lung Ultrasound in the Intensive Care Unit-The Dark Side of Radiology: Where Do We Stand?

Affiliations
Review

Point-of-Care Lung Ultrasound in the Intensive Care Unit-The Dark Side of Radiology: Where Do We Stand?

Marco Di Serafino et al. J Pers Med. .

Abstract

Patients in intensive care units (ICUs) are critically ill and require constant monitoring of clinical conditions. Due to the severity of the underlying disease and the need to monitor devices, imaging plays a crucial role in critically ill patients' care. Given the clinical complexity of these patients, who typically need respiratory assistance as well as continuous monitoring of vital functions and equipment, computed tomography (CT) can be regarded as the diagnostic gold standard, although it is not a bedside diagnostic technique. Despite its limitations, portable chest X-ray (CXR) is still today an essential diagnostic tool used in the ICU. Being a widely accessible imaging technique, which can be performed at the patient's bedside and at a low healthcare cost, it provides additional diagnostic support to the patient's clinical management. In recent years, the use of point-of-care lung ultrasound (LUS) in ICUs for procedure guidance, diagnosis, and screening has proliferated, and it is usually performed at the patient's bedside. This review illustrates the role of point-of-care LUS in ICUs from a purely radiological point of view as an advanced method in ICU CXR reports to improve the interpretation and monitoring of lung CXR findings.

Keywords: chest X-ray; intensive care unit; lung ultrasound; point-of-care ultrasound.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Utility of LUS in the ICU. Modified from [11].
Figure 2
Figure 2
Two examples of CXR and LUS diagnostic integration. Bedside CXR (a,d) and LUS diagnostic integration (b,c,e). In the first case (top line) the CXR showed small, blurred opacities in the left inferior pulmonary field (a, star); LUS of the left basis confirmed the consolidative area with hyperechogenic spots as signs of an air bronchogram (b, star). In the second case (below line), the CXR showed small, blurred opacities in the inferior pulmonary field bilaterally (d, arrowhead); LUS confirmed areas of lung consolidation with an air bronchogram in the lower right and left pulmonary fields without pleural effusion (c,e, arrowhead).
Figure 3
Figure 3
A 30-year-old male patient admitted to the ICU for motor vehicle crash polytrauma resulting in multiple costal fractures and coma status. Bedside CXR (a) and LUS (b,c). (a) The CXR showed a blurred opacity in the left inferior pulmonary field (star); the basal field of the right lung appeared normally expanded (arrowhead). (c,d) LUS diagnostic integration performed on the same day showed a fluid collection in the basal region of the right lung indicating the presence of a small pleural effusion (b, arrowhead) that was not clearly demonstrable in the bedside CXR and also an inhomogeneous hypo-echogenicity indicating a parenchymal consolidation in the basal region of the left lung without fluid collection (c, star).
Figure 4
Figure 4
A 27-year-old male patient admitted to the ICU for high-grade gunshot trauma with abdominal involvement and a clinically worsened condition after intubation. Bedside CXR (a,d) and LUS (b,c). (a) The admission CXR showed a good expansion of the lungs with just a subtle and blurred opacity in the left inferior field (arrow). (b,c) LUS follow-up was performed after 2 days with evidence of hypoechogenic consolidative change in the left parenchyma (b, star) and a compact disposition of the B-lines as a sign of interstitial involvement (c, arrowhead) suggestive of phlogistic parenchymal complication. (d) The CXR confirmed the LUS findings showing some ovular opacity with a confluence trend occupying the left superior, middle, and inferior pulmonary fields (d, arrows).
Figure 5
Figure 5
A 70-year-old male patient admitted to the ICU with acute respiratory failure from chronic obstructive pulmonary disease. Bedside CXR (a) LUS (b), CEUS (c), and CT scan (d). (a) The bedside CXR showed an area of pseudo-nodular consolidation (star) in the medium right pulmonary field. (b) LUS confirmed the parenchymal consolidation (star) that appears as a large heterogeneous hypoechoic area in the subpleural lung parenchyma. (c) CEUS examination with the administration of a sonographic contrast agent (Sonovue®, Bracco, Milan IT) showed no significative contrast enhancement in the pulmonary consolidation area (c, star) during the different phases of the study (c, arrowhead) concerning bronchial consolidation with the segmentary obstructive atelectatic area. (d) The CT scan highlighted areas of segmental parenchymal consolidation (d, star) caused by mucoid obstruction (d, arrow).
Figure 6
Figure 6
A 48-year-old male patient admitted to the ICU for post-traumatic subarachnoid hemorrhage and acute respiratory failure. Bedside CXR (a) and LUS (b). (a) The CXR showed an inhomogeneous opacity in the right inferior pulmonary field (arrowhead). (b) LUS confirmed a parenchymal consolidation area at the basis of the right lung (b, arrowhead) showing some hyperechogenic spots as signs of a static bronchogram (b, arrows) related to the diagnostic hypothesis of an atelectatic area.
Figure 7
Figure 7
A 36-year-old female patient admitted to the ICU for a comatose state related to cerebral hemorrhage with fever and dyspnea after endotracheal intubation. Bedside CXR (a) and LUS (b,c). (a) The CXR showed faint areas of decreased parenchymal transparency in the right and left inferior pulmonary field (a, arrowheads); (b). LUS confirmed the consolidative areas at the lung basis (b,c, arrowheads) with hyperechogenic spots as signs of an air bronchogram (b,c, arrows) that moved in line with the respiratory excursion. The clinical scenario and imaging findings were suggestive of phlogistic bronchopneumonia.
Figure 8
Figure 8
A 26-year-old male patient admitted to the ICU for a comatose state related to high-energy trauma due to a car accident. Bedside CXR (a,c) and LUS (b). (a) The CXR on the day of admission into the ICU showed normal lung expansion with no evidence of parenchymal change. (b) LSU was performed after 24 h endotracheal intubation with the onset of a respiratory worsening and showed an inhomogeneous area of mixed hypoechogenic change at the basis of the left lung (b, arrowhead) with some hyperechogenic spots suggestive of consolidation with an air bronchogram (b, arrow). (c) The CXR confirmed the LUS findings showing an area of reduced diaphony in the basal left field that was considered the manifestation of parenchymal consolidation (c, arrowhead). The clinical scenario and imaging findings were suggestive of phlogistic bronchopneumonia.
Figure 9
Figure 9
A 67-year-old male patient referred to the ICU after major trauma by a fall from a height. Bedside CXR (a) and LUS (b,c). (a) The CXR showed bilateral pulmonary opacities associated with pleural effusion (a, arrowheads). (b,c) Bilateral minimal pleural fluid was also confirmed by LUS (b,c, arrows) both on the right (b) and on the left (c) sides; lung consolidation was also visible (b,c, asterisks).
Figure 10
Figure 10
A 54-year-old male patient in respiratory failure. CT scan (a), CXR (b), and LUS (c). (a) The axial CT scan of the chest showed a parenchymal consolidation area with the air–fluid level in the basal segments of the right inferior pulmonary lobe suggestive of a pleural empyema (a, arrow). (b) The subsequent CXR control revealed a basal right-side decreased parenchymal transparency consistent with a persistent amount of the empyematous effusion (b, arrow). (c) LUS follow-up showed a better quantification of the residual fluid amount, with an inhomogeneous content of echogenic substance in suspension (c, arrow) and also confirmed the correct position of the surgical drainage tube (c, arrowhead).
Figure 11
Figure 11
A 79-year-old male patient suspected of having pulmonary edema. CXR (a) and LUS (b,c). (a) On the CXR opacity of the middle and inferior field was detected bilaterally (a, arrowheads) with right lung basis consolidation (a, arrow). (b,c) LUS integration showed on the right lung basis (b) a pleural anechoic effusion (b, arrow) associated with a consolidative area (b, star); the evaluation of the right and left lungs (c) showed a compact appearance of the B-lines on the explorable lung areas in the intercostal space (c, arrowheads). In this case LUS allowed us to better clarify the nature of the CXR lung opacities.
Figure 12
Figure 12
A 57-year-old female patient with acute respiratory failure during interstitial pneumonia not related to SARS-CoV2 infection. Bedside CXR (a,c) and LUS (b). (a) The CXR revealed on the right side multiple small opacities with signs of interstitial thickening suggestive of an interstitial and alveolar infective process (a, arrow). (b) The LUS examination performed after 5 days showed in the middle right pulmonary field and on the left side a compact appearance of B-lines (b, arrowheads) associated with some areas of parenchymal consolidation (b, star) with an irregular pleural line (b, arrow) that was suggestive of ARDS complication, according to the clinical worsening refractory to therapies. (c) The CXR confirmed massive involvement of the interstitial compartment and bilateral consolidation of the parenchyma with an internal air bronchogram suggestive of ARDS according to the clinical scenario (c, arrowheads).
Figure 13
Figure 13
A 33-year-old male patient referred to the ICU after major trauma by defenestration. Bedside CXR (a) and LUS (b,c). (a) The CXR revealed on the right side the presence of two thoracic tube drainages (a, arrows) after pneumothorax (not shown) with middle and lower right lung zones indicating several confluent opacities (a, arrowheads). (b,c) LUS revealed on the same side the presence of a thick pleural line (b,c, arrow) with multiple B-line artifacts (b, arrowheads) and hypoechoic alveolar consolidation (c, star) corresponding to lung contusion.
Figure 14
Figure 14
A 50-year-old male patient referred to the ICU after major trauma. Bedside CXR (a) and LUS (b). (a) The CXR showed the surgical drainage tube (arrowhead), with poor confidence on the entity of the residual pneumothorax. (b) LUS showed the presence of “lungs points” (arrow) confirming the residual pneumothorax that was not clearly demonstrable on the CXR.
Figure 15
Figure 15
Comparison between plain chest radiography and LUS in three different critical patients in the intensive care unit. (a,b) CXR and LUS surgical drainage tube evaluation (the same patient as in Figure 10) (a,b, arrow). (c,d) CXR and LUS nasogastric tube evaluation (c,d, star). (e,f) CXR and LUS endotracheal tube evaluation (e,f, arrowhead).
Figure 16
Figure 16
CVC thrombosis. Right supraclavicular ultrasound exploration highlights the presence of an isocogenic, non-compressible area attributable to thrombosis in the lumen of the subclavian vein (arrow); it also allows visualization of the course of the catheter, visible as a hyperechoic tubular structure (arrowheads).

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