Update on the use of ultrasound in the diagnosis and monitoring of the critical patient | Revista Española de Anestesiología y Reanimación (English Edition)

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B) Pulmonary atelectasis. C) Subpleural consolidation. D) Mitral inflow. Grade I diastolic dysfunction (impaired relaxation). E/A < 1." ] ] ] "textoCompleto" => "IntroductionThe differential diagnosis and early treatment of cardiorespiratory complications is a key element in critical care units (CCU).Over the past 10 years, ultrasound (US) has become a fundamental tool in critical patient monitoring<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. It is now an integral part of the physical examination, to the extent that it has even been called the “21st century stethoscope”<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. US is a reproducible, reliable, point-of-care examination technique that has become increasingly popular in many medical and surgical fields. In the context of critical care, where immediate decision-making can save lives, these advantages are particularly important and have led to the rapid introduction of US in CCUs worldwide.Various US echocardiography and pulmonary protocols based on the pathophysiological interaction of the heart and the lung have been developed for the differential diagnosis of hypotension and/or respiratory failure in CCUs. The most important of these are the Bedside Lung Ultrasound in Emergency<a class="elsevierStyleCrossRef" href="#bib0015">3</a> (BLUE) protocol, which was developed as a diagnostic guide for acute respiratory failure, and the Fluid Administration Limited by Lung Sonography<a class="elsevierStyleCrossRef" href="#bib0020">4</a> (FALLS) protocol, which assesses the haemodynamic status and fluid requirements of critically ill patients. Aside from these standard protocols, US is now of major interest in the assessment of venous congestion and its impact on the liver and kidneys, and in evaluating diaphragmatic function<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>. This approach (heart-lung, visceral venous territory, diaphragm) highlights the importance of a broader algorithm for comprehensive patient management (fluid therapy, use of vasoactive drugs, diuretics, weaning from mechanical ventilation).We performed a narrative review of scientific articles on US in critically ill patients. We searched PubMed, ScienceDirect and Google Scholar for studies published between 2010 and 2020. In this review, we also mention some other studies published prior to 2010, for comparative purposes. The keywords used in the search were “lung ultrasound”, “echocardiography”, “critical care”, “response to fluids”, “abdominal ultrasound”, “diaphragmatic function”, “mechanical ventilation weaning”.Ultrasound as a diagnostic-therapeutic tool in critically ill patientsHaemodynamic management of the critically ill patient with arterial hypotension and hypoperfusionThe administration of fluids to treat hypotension in critically ill and/or perioperative patients is one of the most common strategies; however, it is seldom based on standardised, objective criteria. Hypotension and tissue hypoperfusion must be treated on the basis of aetiology, and although fluids may sometime be needed, they are not always the primary treatment. Not only is it important to know when fluids, vasoconstrictors, or inotropes should be administered, it is also essential to correctly titrate the dose, monitor treatment response, and determine the optimal duration of treatment in order to avoid side effects (from both catecholamines and fluids). Below, we propose a protocol for systematic and comprehensive US exploration (cardiac, pulmonary, abdominal) in patients with shock with arterial hypotension.Determination of cardiac output and ventricular functionShock refers to circulatory failure with insufficient tissue perfusion that leads to generalized cellular hypoxia. Shock can have different aetiologies and can be treated in different ways<a class="elsevierStyleCrossRef" href="#bib0035">7</a>. Remember that blood pressure (BP) = cardiac output (CO) x systemic vascular resistance (SVR); therefore, it is essential to measure CO in order to determine the aetiology of hypotension.Pulsed spectral Doppler US is a non-invasive method of quantifying cardiac output and an excellent haemodynamic monitor<a class="elsevierStyleCrossRef" href="#bib0040">8</a>. Assuming that the left ventricular outflow tract (LVOT) is cylindrical, blood flow through its cross-section (stroke volume, SV) can be calculated by multiplying the area of this cross section by the velocity-time integral (VTI), which represents the height of the column of blood that passes through the LVOT at each heartbeat. Thus, SV = LVOT area × VTI. The LVOT area is obtained in the parasternal long axis view, 0.3–1 cm below the valve orifice<a class="elsevierStyleCrossRef" href="#bib0045">9</a>. Thus, by obtaining the diameter of the LVOT, we obtain its area (Area = π *radius²). Pulsed Doppler determines blood flow at a specific point on the basis of VTI and the time it takes the blood to pass through point. In echocardiography, the VTI of the LVOT is measured 1 cm below the aortic valve in an apical five-chamber view. As the population mean of the LVOT is 2 cm (therefore, radius of 1 cm), calculation of the area in all individuals is simplified to same value, and therefore the SV can generally be inferred from the VTI. A VTI value of 17 cm indicates a normal stroke volume (approximately 55 ml/beat)<a class="elsevierStyleCrossRef" href="#bib0050">10</a>. This technique should not be used to estimate SV in moderate-to-severe aortic insufficiency, septal hypertrophy, or in patients with dynamic LV outflow tract obstruction<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>.Pulsed Doppler, therefore, can differentiate between normal/high or low stroke (S) volume (and thus normal/high or low CO). Bearing in mind the BP = CO × SVR formula, vasoconstrictors would normalize SVR, and therefore, BP in patients with hypotension and high stroke volume. However, in the case of low stroke volume, it is essential to estimate ventricular function in order to start inotropic support. An operator with basic echocardiography skills can quantify right or left ventricular function and exclude various causes of flow obstruction (such as pericardial effusion that causes cardiac tamponade, tension pneumothorax, or pulmonary thromboembolism, see the section on respiratory failure)<a class="elsevierStyleCrossRef" href="#bib0065">13</a>. Once vasoconstrictors or inotropes have been started, ultrasound can also be used to titrate the dose on the basis of the response, and to subsequently stop treatment by monitoring the SV, thus minimizing the side effects associated with these drugs<a class="elsevierStyleCrossRef" href="#bib0070">14</a>.Biventricular function can be evaluated qualitatively after a relatively short learning curve by visually examining the size of the chamber and assessing myocardial thickening and shortening. These factors allow the operator to distinguish between normal ventricular function and significant dysfunction<a class="elsevierStyleCrossRef" href="#bib0075">15</a>.Blood volume and dynamic response to fluidsIrrespective of the presence of ventricular dysfunction, assessing blood volume and response to fluids is one of the most important, though difficult, techniques in routine clinical practice.Echocardiography can identify ventricular dysfunction and the causes of left ventricular filling obstruction as a cause of low cardiac output. Once these entities have been excluded, hypovolaemia (absolute or relative) is a common cause of low cardiac output with low stroke volume. Static parameters, such as central venous pressure (CVP), the diameter of the inferior vena cava (IVC) or pulmonary capillary pressure (PCP), have now been replaced by dynamic parameters in the diagnosis of hypovolaemia. These parameters can predict whether CO will improve if preload is increased<a class="elsevierStyleCrossRef" href="#bib0080">16</a>.A patient is a volume responder if increasing the LV end-diastolic volume after volume replacement increases the stroke volume. This will indicate that stroke volume is on the ascending portion of the Frank Starling curve. Volume responsiveness is defined as ≥12% increase in CO/SV after administration of fluids or after performing the passive leg raising test<a class="elsevierStyleCrossRef" href="#bib0085">17</a>. Respiratory stroke volume variation (SVV) of ≥12% in the LVOT VTI in a mechanically ventilated patient (tidal volume 8 ml/kg, sinus rhythm, no severe RV dysfunction, and normal intrathoracic pressures) predicts a positive response to fluid. If stroke volume does not vary, the administration of fluids will have no haemodynamic benefit. SVV ≥ 12% only indicates that fluid administration will increase stroke volume, but administration should not be inferred directly or solely from this parameter, and the pulmonary and venous territories must be evaluated before administering fluids in order to avoid or reduce the adverse effects of excessive fluid replacement<a class="elsevierStyleCrossRefs" href="#bib0090">18–20</a>.Lung ultrasoundRecent studies have provided compelling evidence on the adverse effects of liberal fluid therapy, particularly in critically ill patients, where less than 5% of infused fluid may remain in the vasculature after 1 h of administration<a class="elsevierStyleCrossRef" href="#bib0105">21</a>. In patients with sepsis, a decrease in oncotic blood pressure together increased permeability of the alveolar-capillary barrier will make the lung more susceptible to fluid accumulation in the interstitium and alveolar compartment. This greatly reduces the volume replacement safety margin, and fluids must be titrated by identifying the risk of third spacing<a class="elsevierStyleCrossRef" href="#bib0110">22</a>.Extravascular lung water (EVLW) has been shown to increase in patients with sepsis<a class="elsevierStyleCrossRef" href="#bib0115">23</a> and this increase has been correlated with mortality<a class="elsevierStyleCrossRef" href="#bib0120">24</a>. EVLW, therefore, is a clinically relevant parameter that can be used to guide fluid therapy in critically ill patients. Transpulmonary thermodilution is currently the gold standard for measuring EVLW, but requires specialized equipment. Chest x-ray is the standard method of quantifying EVLW, but the images correlate poorly with lung water<a class="elsevierStyleCrossRef" href="#bib0125">25</a>. Lung ultrasound has proven to be an excellent tool for detecting pulmonary oedema. The presence of US B lines correlate well with parameters such as PCP and EVLW<a class="elsevierStyleCrossRef" href="#bib0090">18</a>. A high-frequency linear transducer (6–13 Mhz) should be used to explore more superficial structures (chest wall and pleura). The ribs are visible as curvilinear structures with acoustic shadowing in the anterior and lateral areas of the thorax. The pleural line is visualised as a horizontal echogenic line from which bright, well-defined hyperechoic lines emerge and extend vertically to the far field of the US without disappearing; these are the B lines. B lines are caused by the presence of extravascular water thickening the interlobular septa or by the accumulation of fluid in the pulmonary interstitium or in alveoli. The authors of a recently study<a class="elsevierStyleCrossRef" href="#bib0130">26</a> reported that the presence of 3 positive chest quadrants (“positive” defined as 3 or more B lines within the quadrant) has a sensitivity and specificity of 100% and 70%, respectively, for the detection of EVLW > 10 ml/kg (value associated with pulmonary oedema). Taken together, the foregoing shows the usefulness of lung ultrasound to detect EVLW and restrict fluid administration.Abdominal ultrasound: venous congestionFluid administration can cause venous congestion due to increased pressures in the right heart chambers, leading to generalised interstitial oedema, visceral oedema, and secondary renal dysfunction. All these in turn contribute to intravascular and extravascular volume accumulation<a class="elsevierStyleCrossRef" href="#bib0135">27</a>. Venous congestion must be evaluated on the basis of haemodynamics, bearing in mind that it can be severely altered for causes other than hypervolaemia, such as pulmonary hypertension and RV dysfunction, and for this reason not only diuretics but also pulmonary vasodilators or inotropes may be the treatment of choice.Various ultrasound markers of this congestive process and of the consequences of increased venous congestion have been suggested. Beaubien-Souligny et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> developed a prototypical Venous Excess Ultrasound (VExUS) system for grading the severity of venous congestion, and validated its potential clinical utility in predicting the occurrence of acute kidney injury (AKI). In their study, congestion was classified as mild, moderate, or severe based on a combination of the following parameters: the diameter of the inferior vena cava (IVC) and the Doppler waveform of the suprahepatic veins, portal vein and renal interlobular veins. Hepatic Doppler was considered mildly abnormal when the S phase was of less amplitude than the diastolic (D) phase, and severely abnormal when the S phase was reversed (toward the heart). For portal Doppler, a pulsatility fraction of 30%–49% was considered mild, while a pulsatility fraction of <50% was considered severe. For the intra-renal venous Doppler, a discontinuous pattern with a systolic and a diastolic phase was considered mild while a discontinuous pattern with only a diastolic phase was considered severe. They observed that the presence of at least 2 severe alterations of hepatic vein, portal vein, or intra-renal venous flow on pulse-wave Doppler ultrasound with an IVC of ≥2 cm in diameter at ICU admission after cardiac surgery indicated a high risk of post-operative AKI.<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, Image A, section C shows the flow pattern of the portal vein. It is recommended to use the low frequency convex transducer placed on the anterior axillary line between the 9th and 11th intercostal space (ICS). The vein is characterized by its hyperechoic border and hepatoportal flow towards the transducer (red in our image). On pulsed Doppler, the image shows moderate venous congestion. Image B shows the venous pattern of the suprahepatic veins, which are visualised by placing the ultrasound transducer on the midaxillary line perpendicular to the patient's ribs or in the subcostal plane. On US, these veins appear as anechoic structures without the hyperechoic rim that characterizes the portal vein. Although there are episodes of retrograde flow, most of the venous flow is antegrade, that is, from the liver to the heart. This flow moves away from the transducer, so it will appear blue on colour Doppler and below the baseline on pulsed Doppler. The image shows the pulsed Doppler pattern of the vein in a patient with severe congestion, with an inverted S wave. Image C shows the pattern of the kidney veins. To obtain the image, the transducer is placed on the mid-axillary line and the patient is asked to take a deep breath. The transducer is moved until the kidney is visualised (below the liver). Once identified, colour Doppler is used to identify the kidney vessels at the corticomedullary junction. The Doppler waveform above baseline shows the renal artery flow, while the venous flow is seen below the baseline. The image shows a pattern consistent with moderate venous congestion.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Although these parameters have not been validated in other clinical contexts, when interpreted rationally on the basis of the patient’s pathophysiology they can be used to extend the haemodynamic assessment to include an evaluation of venous congestion, and thus adjust real fluid requirements by assessing their potential adverse effects. Despite recent interest in venous congestion and the publication of several studies supporting its clinical utility<a class="elsevierStyleCrossRef" href="#bib0030">6</a>, the VExUS system still needs to be validated in different clinical contexts. This will confirm the optimal evaluation criteria, and show whether it can be used to individualize haemodynamic management in venous congestion, and consequently, organ perfusion.Differential diagnosis and therapeutic management of acute respiratory failureAnother common scenario encountered in the CCU is acute respiratory failure, a situation in which ultrasound also plays a key role. To help integrate the data obtained from pulmonary ultrasound images into clinical diagnosis, in 2008 Lichtenstein published a paper in which he organized ultrasound patterns into different profiles and developed an algorithm that, though not diagnostic in itself, can help guide diagnosis with a specificity of more than 90%<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. These patterns are based on combining venous analysis with the presence or absence of the following signs: lung sliding, A or B lines, and effusion or consolidation. The differential diagnosis includes the most common entities (97.5% of all cases), which are asthma or exacerbation of chronic obstructive pulmonary disease, pulmonary oedema, pneumothorax, pneumonia, and pulmonary thromboembolism.PneumothoraxOne of the first pathologies to be ruled out in patients with acute respiratory failure is pneumothorax (PTX), a condition that is often associated with haemodynamic instability. Air usually accumulates in the least dependent position, so it is best to examine the patient in a supine or sitting position, and place the transducer as high as possible on the anterior chest wall, at the level of the second or third ICS on the midclavicular or axillary line. A linear transducer should preferably be used for this examination. Several spaces should be examined in quick succession by moving the transducer over the intercostal spaces. The presence of lung sliding will exclude PTX with a sensitivity of 95.3%, a specificity of 91.1%, and a negative predictive value of 100%<a class="elsevierStyleCrossRef" href="#bib0145">29</a>. Visualization of B lines also excludes PTX, since their presence indicates that the lung is fully expanded at the transducer site, because the presence of any amount of air between the pleura would block the US beam. However, the lung point has a specificity of 100% for the diagnosis of PTX<a class="elsevierStyleCrossRef" href="#bib0150">30</a>. Lung point is observed at the margin between the PTX (where there is no contact between the two pleurae; there is no lung sliding) and the partially aerated lung (there is still contact between the pleural surfaces; there is lung sliding).Interstitial pattern: B linesOnce PTX has been ruled out, the US operator must evaluate the alveolar-interstitial pattern, which is characterized by the presence of B lines. The critically ill patient is particularly susceptible to developing interstitial and/or alveolar oedema, given their stress, their baseline pathology, the possibility of developing systolic and diastolic ventricular dysfunction, and the need for fluid replacement, as discussed above. Pulmonary ultrasound has a sensitivity and specificity of 98% and 88%, respectively, for the diagnosis of acute pulmonary oedema, and it is superior to chest X-ray in the diagnosis of interstitial syndromes<a class="elsevierStyleCrossRef" href="#bib0155">31</a>. B lines appear in 2 common clinical syndromes in the CCU: acute pulmonary oedema (APO) and acute respiratory distress syndrome (ARDS). In APO, B lines are homogeneously distributed in the anterior and posterior lung fields, that is, with no interposed areas of normal aeration (A lines). In ARDS, bilateral B lines are non-homogeneously distributed in non-dependent lung fields, so while some areas contain numerous B lines, in others they are coalescent and normal lung (A lines) are observed between these areas. B lines can also appear in lobar pneumonia, but only in the affected region and usually accompanied by pleural changes with subpleural consolidations.Pleural effusionSwitching to a convex transducer placed on the posterior axillary line allows the US operator to evaluate the presence of pleural effusion. Pleural effusion is a common occurrence in critically ill patients, and can cause respiratory failure and even cardiac tamponade if it is located in the right hemithorax, compressing the right heart chambers. A finding of opaque hemithorax on US can be used for differential diagnosis (effusion-atelectasis) and can guide treatment.Between 150 and 200 ml of fluid must have accumulated in the costophrenic sinus before it can be detected by a postero-anterior radiograph, whereas US is capable of detecting as little as 50 ml of fluid. In a study published in 2011<a class="elsevierStyleCrossRef" href="#bib0160">32</a>, chest radiography had a sensitivity of 65%, specificity of 81%, and diagnostic accuracy of 69% for the detection of pleural fluid, while US had a sensitivity, specificity and diagnostic accuracy of 100%.<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, image A shows a pleural effusion obtained with a 3–5 Mhz convex transducer placed on the posterior axillary line (PLAPS-point: posterolateral alveolar and/or pleural syndrome) in the subdiaphragmatic area. With the transducer placed horizontal to the ribs, the pleural effusion is visualised as anechoic material surrounding the hyperechoic lung, which has collapsed as a result of the effusion.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Ultrasound has proven useful in reducing the rate of complications associated percutaneous techniques, such as thoracocentesis, pericardiocentesis or evacuation of abscesses/haematomas<a class="elsevierStyleCrossRefs" href="#bib0165">33,34</a>. The British Society for Thoracic Surgery recommends performing thoracocentesis at a site with a depth of pleural fluid of at least 10 mm, as this will ensure sufficient separation of the lung from the parietal pleura<a class="elsevierStyleCrossRef" href="#bib0175">35</a>. Lung motion over an entire respiratory cycle should be observed, as the lung may move in the path of the needle. The position of the diaphragm must also be determined to avoid accidental perforation. Pleural effusion with septa or loculations may be more difficult to evacuate. Pleural effusion can be approximately quantified using the following formula: interpleural distance (in mm) × 20 = ml of effusion<a class="elsevierStyleCrossRef" href="#bib0180">36</a>. Static US can be used to mark the puncture site, and dynamic US (covered with a sterile cover) can be used during the procedure to confirm the position of the drainage tube<a class="elsevierStyleCrossRef" href="#bib0185">37</a>. Given the capacity of colour Doppler to identify blood flow, some experts propose using this technique to reduce the risk of vascular injury during thoracentesis<a class="elsevierStyleCrossRef" href="#bib0190">38</a>.AtelectasisSignificant effusion may be accompanied by passive atelectasis. The collapsed or consolidated lung has the appearance of poorly defined, wedge-shaped hyperechoic tissue. Because of its resemblance to liver tissue, it is referred to as pulmonary hepatization. This total loss of air occurs in both pneumonia and atelectasis, and the pattern is also observed in some cases of pulmonary contusion, tumours, and pulmonary infarction. Atelectasis is differentiated from pneumonia on the basis of the patient’s clinical history and laboratory tests. One recent study found that lung ultrasound had a sensitivity of 93.4% and a specificity of 97.7% for pneumonia compared with chest radiography<a class="elsevierStyleCrossRef" href="#bib0195">39</a>.<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, image B shows lung base atelectasis obtained with a convex transducer placed on the PLAPS-point.Despite major advances in regional anaesthesia techniques, general anaesthesia is still unavoidable in some surgical procedures. Approximately 90% of surgical patients develop aeration alterations as a result of positive pressure mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0200">40</a>. Atelectasis can cause intraoperative and/or postoperative complications (mainly hypoxaemia), and can trigger a local inflammatory response that leads to ventilation-induced lung injury<a class="elsevierStyleCrossRef" href="#bib0205">41</a>. The imaging technique of choice for atelectasis is CT; however, it is not a point-of-care technique, and produces ionizing radiation.Alveolar recruitment manoeuvres performed to reduce aeration alterations are associated with some complications (barotrauma, volutrauma, haemodynamic instability, etc.). The authors of a recent study<a class="elsevierStyleCrossRef" href="#bib0210">42</a> detected atelectasis, initially appearing as subpleural consolidations, in up to 14% of patients after 10 min of general anaesthesia. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, image C shows subpleural consolidations obtained with a convex transducer, visualized as hyperechoic pinpoints in contact with the visceral pleura. In the same study, the authors performed alveolar recruitment manoeuvres and repeated the lung ultrasound evaluation after each incremental increase in positive end-expiratory pressure (PEEP) until they found the peak pressure and PEEP that achieved optimal aeration. This study shows that ultrasound-guided recruitment manoeuvres allow clinicians to individualise alveolar recruitment and reduce the pressure needed to aerate areas of intraoperative atelectasis, thus reducing the risk of recruitment-related complications. In another study published in 2021<a class="elsevierStyleCrossRef" href="#bib0215">43</a>, the authors reported that 100% of patients aged over 60 years of age undergoing laparoscopic surgery for colorectal carcinoma developed pulmonary atelectasis. After performing US-guided intraoperative alveolar recruitment manoeuvres, this incidence decreased by 50%.US, therefore, can identify areas of atelectasis and show their response to alveolar recruitment manoeuvres in real time. This, together with the determination of pulmonary compliance, can identify the optimal PEEP needed to prevent the reappearance of consolidations, making US a valuable point-of-care monitoring tool to prevent respiratory complications<a class="elsevierStyleCrossRefs" href="#bib0220">44,45</a>.Weaning failure from mechanical ventilationWeaning failure occurs in between 26% to 42% of patient<a class="elsevierStyleCrossRef" href="#bib0230">46</a>, and is often due to a combination of factors involving a complex interaction between cardiac, diaphragmatic, and pulmonary dysfunction.Ultrasound can help optimise the patient's cardiac and respiratory function prior to extubation, and can even indicate the need to place patients at risk of weaning failure on non-invasive ventilation before discontinuing ventilatory support<a class="elsevierStyleCrossRef" href="#bib0235">47</a>.Evaluation of the weaning process can be divided into 3 categories:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Cardiac function.</li><li class="elsevierStyleListItem" id="lsti0010">•Diaphragmatic function.</li><li class="elsevierStyleListItem" id="lsti0015">•Lung function.</li></ul>Cardiac functionCardiac dysfunction appears to play a key role, and may underly most cases of weaning failure from mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0240">48</a>.The change from positive to negative intrathoracic pressure after switching to spontaneous ventilation can disrupt preload conditions, resulting in a sudden increase in left ventricular (LV) filling pressures if ventricular compliance is reduced. This is why weaning-induced pulmonary oedema is a leading cause of weaning failure, particularly in high-risk patients with underlying heart disease, chronic obstructive pulmonary disease (COPD), or obesity<a class="elsevierStyleCrossRef" href="#bib0245">49</a>.Echocardiography is useful for evaluating LV systolic and diastolic function, with diastolic dysfunction being the predominant factor in weaning failure. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, image D shows mitral filling visualised in a 4-chamber US plane. During diastole, LV filling is studied using pulsed Doppler, placing the cursor at the level of the free edges of the mitral leaflets. Two wave forms are observed in patient in sinus rhythm: wave E, early diastolic rapid filling, and wave A, atrial contraction. The image shows a restrictive transmitral flow pattern, with an increase in the speed of the A wave (therefore, E/A ratio <1). This is one of the measurements used to establish grade I diastolic dysfunction.Tissue Doppler must also be performed at the level of the mitral annulus during assessment of diastolic function and LV filling pressures. This will give the E wave (pulsed Doppler) - Em wave (tissue Doppler) ratio. There is evidence that a high E/Em ratio and decreased Em is an indicator of weaning failure<a class="elsevierStyleCrossRef" href="#bib0240">48</a>.In 2011, Papanikolaou et al.<a class="elsevierStyleCrossRef" href="#bib0250">50</a> observed that weaning failure occurred in 35% of patients with normal diastolic function, in 57% of patients with grade 1 (mild) diastolic dysfunction, and in 80% of patients with grade 2 (moderate) or 3 (serious) diastolic dysfunction.Recently, Goudelin et al.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> observed that patients who developed pulmonary oedema when switching to spontaneous ventilation exhibited significantly higher E wave velocity and E/A ratio, shorter E-wave deceleration time, lower left ventricular ejection fraction (LVEF), and higher tricuspid regurgitation peak velocity compared to those in whom weaning was successful. This could show the inability of the cardiovascular system to withstand the increased preload.Diaphragmatic functionDiaphragmatic atrophy and dysfunction are common in mechanically ventilated patients, and are associated with difficult and prolonged weaning, reintubation, tracheostomy, and increased mortality<a class="elsevierStyleCrossRef" href="#bib0260">52</a>.In recent years, several researchers have investigated the underlying mechanisms of respiratory muscle and diaphragm dysfunction and atrophy in critically ill patients. Techniques such as chest radiography for assessing diaphragmatic function have low sensitivity and specificity. Others, such as magnetic phrenic nerve stimulation and transdiaphragmatic pressure measurement using oesophageal or gastric sensors are difficult to use in CCUs. Ultrasound has emerged as a non-invasive technique that can be used to evaluate diaphragm structure and function<a class="elsevierStyleCrossRef" href="#bib0265">53</a>. US can be used to observe diaphragmatic motion in a variety of normal and pathological conditions. Evaluating the characteristics of diaphragmatic motion (amplitude, force, speed, thickness) can provide CCU clinicians with data that can be used in the evaluation and follow-up of patients with respiratory failure or difficult weaning from mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0025">5</a>.Diaphragm function can be explored in 2 acoustic windows:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">•In the zone of apposition, between the 8th and 10th intercostal space, in the midaxillary or anterior axillary line, 0.5–2 cm below the costophrenic sinus. A high-frequency linear transducer is required for proper visualisation of diaphragmatic thickness. Two parallel echogenic layers (parietal pleura and peritoneum) are easily identified, and the diaphragm is the hypoechoic structure that lies between these 2 lines. Normal diaphragmatic thickness is 2–2.8 mm in expiration and 4 mm at maximal inspiration; <2 mm is considered diaphragmatic atrophy. M mode will show diaphragm thickening on inspiration and quantify it using fractional shortening (FS) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>, image A).<elsevierMultimedia ident="fig0015"></elsevierMultimedia></li></ul>FS = [thickness at end of inspiration – thickness at end of expiration]/thickness at end of expiration × 100. Cut-off values to predict successful weaning range from 25% to 35%<a class="elsevierStyleCrossRefs" href="#bib0270">54,55</a>.<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025">•In the subcostal region, between the anterior axillary line and the midclavicular line. A cardiac or convex (low frequency) transducer should be used. Using the liver or spleen as acoustic windows, the diaphragm is seen as a hyperechoic line that is displaced towards the transducer during inspiration. As before, M-mode is used to observe diaphragmatic excursion in inspiration. Normal diaphragmatic movement during inspiration is caudal, as the diaphragm migrates towards the transducer during inspiration and away from the transducer during expiration. Normal diaphragmatic excursion values range from 15 to 21 mm in men and 13 to 19 mm in women<a class="elsevierStyleCrossRef" href="#bib0060">12</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> image B). Several studies have associated higher diaphragmatic excursion values with successful weaning from mechanical ventilation<a class="elsevierStyleCrossRefs" href="#bib0280">56–58</a>.</li></ul>Lung functionAccumulation of pleural fluid causes the adjacent lung to collapse due to the hydrostatic pressure generated by the effusion, resulting in a loss of alveolar volume available for gas exchange. Furthermore, as elastic chest wall recoil is no longer opposed by outward lung recoil, the configuration of the chest wall changes in the area of the effusion and reduces the efficiency of the longitudinal tension of the intercostal muscles. As a result, the diaphragm detaches from the surface of the visceral pleural and attenuates lung inflation. In large effusions, pleural pressure may be high enough to reverse the curvature of the ipsilateral diaphragm (the preloading function of the diaphragm is optimal only with normal concavity).Evidence of the association between pleural effusion and difficulties in weaning from mechanical ventilation is inconclusive<a class="elsevierStyleCrossRef" href="#bib0295">59</a>. In some studies<a class="elsevierStyleCrossRef" href="#bib0300">60</a>, effusion is associated with weaning failure; however, more studies are required to confirm whether effusion drainage or aggressive management with diuretic therapy has the potential to reduce the duration of mechanical ventilation in these patients.US can also predict weaning failure with some accuracy by identifying global and regional alveolar derecruitment. The “lung ultrasound score” (LUS) has been used to provide comparable quantifiable measurement of progressive changes in aeration.The LUS assigns numerical values ranging from 0 to 3 to lung ultrasound patterns in each particular chest region, depending on the degree of aeration loss (12 regions, anterior, lateral, and posterior). The score is follows:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0030">•0 points: A Lines, normal aeration.</li><li class="elsevierStyleListItem" id="lsti0035">•1 point: Multiple B lines, moderate aeration loss.</li><li class="elsevierStyleListItem" id="lsti0040">•2 points: Coalescing B lines, severe aeration loss.</li><li class="elsevierStyleListItem" id="lsti0045">•3 points: Consolidation pattern, complete loss of aeration.</li></ul>Thus, an LUS of <13 is predictive of extubation success; a score of between 13–17 predicts indeterminate success, and >17 predicts a high probability of extubation failure<a class="elsevierStyleCrossRef" href="#bib0305">61</a>.LimitationsUS is hampered by specific patient-related factors, such as obesity, massive oedema, developed musculature, chest wall dressings, and the inability to change the position of critically ill patients. All this can substantially detract from the quality of the image.Like other techniques, ultrasound is operator-dependent and requires training to correctly acquire and interpret images. The Spanish Society of Anaesthesiology and Resuscitation (SEDAR), the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Emergency Medicine (SEMES) recently published a consensus document containing a series of recommendations for training and acquisition of minimum skills in the use of ultrasound in Intensive Care, Anaesthesia and Emergency Medicine<a class="elsevierStyleCrossRef" href="#bib0310">62</a>.ConclusionUltrasound is a useful tool for the multimodal assessment of critically ill patients. Echocardiography, pulmonary ultrasound, and Doppler venous flow analysis can be used in the CCU to obtain an overall assessment: haemodynamic monitoring, diagnosis of acute respiratory failure, assessment of pulmonary fluid overload and venous congestion. US can also help clinicians detect mechanical ventilation weaning difficulties, assess response to established treatment (including alveolar recruitment manoeuvres), and reduce the risk of complications derived from percutaneous techniques. Real-time image capture, a short learning curve, and absence of ionizing radiation has made US an essential and mandatory instrument in the evaluation of critical patients.Conflict of interestsThe authors have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1796059" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1572069" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1796060" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1572068" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Ultrasound as a diagnostic-therapeutic tool in critically ill patients" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Haemodynamic management of the critically ill patient with arterial hypotension and hypoperfusion" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Determination of cardiac output and ventricular function" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Blood volume and dynamic response to fluids" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Lung ultrasound" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Abdominal ultrasound: venous congestion" ] ] ] 1 => array:3 [ "identificador" => "sec0040" "titulo" => "Differential diagnosis and therapeutic management of acute respiratory failure" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Pneumothorax" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Interstitial pattern: B lines" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Pleural effusion" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Atelectasis" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Weaning failure from mechanical ventilation" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Cardiac function" ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Diaphragmatic function" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Lung function" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0085" "titulo" => "Limitations" ] 7 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-06-22" "fechaAceptado" => "2022-01-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1572069" "palabras" => array:3 [ 0 => "Multimodal ultrasound" 1 => "Critical care" 2 => "Review article" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1572068" "palabras" => array:3 [ 0 => "Ecografía multimodal" 1 => "Cuidados críticos" 2 => "Revisión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Hemodynamic and respiratory complications are the main causes of morbidity and mortality in in critical care units (CCU). Imaging techniques are a key tool in differential diagnosis and treatment.In the last decade, ultrasound has shown great potential for bedside diagnosis of respiratory disease, as well as for the hemodynamic assessment of critically ill patients.Ultrasound has proven to be a useful guide for identifying the type of shock, estimating cardiac output, guiding fluid therapy and vasoactive drugs, providing security in the performance of percutaneous techniques (thoracentesis, pericardiocentesis, evacuation of abscesses/hematomas), detecting dynamically in real time pulmonary atelectasis and its response to alveolar recruitment maneuvers, and predicting weaning failure from mechanical ventilation.Due to its dynamic nature, simple learning curve and absence of ionizing radiation, it has been incorporated as an essential tool in daily clinical practice in CCUs.The objective of this review is to offer a global vision of the role of ultrasound and its applications in the critically ill patient." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las complicaciones cardiorrespiratorias son las principales causas de morbimortalidad en las unidades de cuidados críticos (UCC). Las técnicas de imagen son una pieza fundamental tanto en el diagnóstico diferencial como en el tratamiento.En la última década la ecografía ha demostrado gran potencial para el diagnóstico a pie de cama de patología respiratoria, así como para la valoración hemodinámica de los pacientes críticos. La ecografía ha demostrado ser una guía útil para la identificación del tipo de shock, la estimación del gasto cardíaco, guiar la fluidoterapia y los fármacos vasoactivos, aportar seguridad en la realización de las técnicas percutáneas (toracocentesis, pericardiocentesis, evacuación de abscesos/hematomas), objetivar de forma dinámica y en tiempo real la atelectasia pulmonar y su respuesta a las maniobras de reclutamiento alveolar, y predecir el fracaso en el destete de la ventilación mecánica.Por su carácter dinámico, sencilla curva de aprendizaje y ausencia de radiación ionizante, se ha incorporado como una herramienta imprescindible en la práctica clínica diaria en las UCC.El objetivo de la presente revisión es ofrecer una visión global del papel de la ecografía y sus aplicaciones en el paciente crítico." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1859 "Ancho" => 2925 "Tamanyo" => 365290 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Protocol for systematic, comprehensive US exploration (cardiac, pulmonary, abdominal) in patients in shock with arterial hypotension." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2080 "Ancho" => 2516 "Tamanyo" => 491964 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Pleural effusion associated with pulmonary atelectasis. B) Pulmonary atelectasis. C) Subpleural consolidation. D) Mitral inflow. Grade I diastolic dysfunction (impaired relaxation). E/A < 1." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 848 "Ancho" => 2515 "Tamanyo" => 264069 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Diaphragmatic thickness in inspiration and expiration. 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Update on the use of ultrasound in the diagnosis and monitoring of the critical patient

Actualización sobre el uso de la ecografía en el diagnóstico y monitorización del paciente crítico

M.Á. Ródenas Monteagudo

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miguelangelrodenasmonteagudo@gmail.com

Corresponding author.

, I. Albero Roselló, Á. del Mazo Carrasco, P. Carmona García, I. Zarragoikoetxea Jauregui

Hospital Universitari I Politècnic La Fe, Valencia, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The differential diagnosis and early treatment of cardiorespiratory complications is a key element in critical care units &#40;CCU&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Over the past 10 years&#44; ultrasound &#40;US&#41; has become a fundamental tool in critical patient monitoring<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; It is now an integral part of the physical examination&#44; to the extent that it has even been called the &#8220;21st century stethoscope&#8221;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; US is a reproducible&#44; reliable&#44; point-of-care examination technique that has become increasingly popular in many medical and surgical fields&#46; In the context of critical care&#44; where immediate decision-making can save lives&#44; these advantages are particularly important and have led to the rapid introduction of US in CCUs worldwide&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Various US echocardiography and pulmonary protocols based on the pathophysiological interaction of the heart and the lung have been developed for the differential diagnosis of hypotension and&#47;or respiratory failure in CCUs&#46; The most important of these are the Bedside Lung Ultrasound in Emergency<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;BLUE&#41; protocol&#44; which was developed as a diagnostic guide for acute respiratory failure&#44; and the Fluid Administration Limited by Lung Sonography<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> &#40;FALLS&#41; protocol&#44; which assesses the haemodynamic status and fluid requirements of critically ill patients&#46; Aside from these standard protocols&#44; US is now of major interest in the assessment of venous congestion and its impact on the liver and kidneys&#44; and in evaluating diaphragmatic function<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; This approach &#40;heart-lung&#44; visceral venous territory&#44; diaphragm&#41; highlights the importance of a broader algorithm for comprehensive patient management &#40;fluid therapy&#44; use of vasoactive drugs&#44; diuretics&#44; weaning from mechanical ventilation&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a narrative review of scientific articles on US in critically ill patients&#46; We searched PubMed&#44; ScienceDirect and Google Scholar for studies published between 2010 and 2020&#46; In this review&#44; we also mention some other studies published prior to 2010&#44; for comparative purposes&#46; The keywords used in the search were &#8220;lung ultrasound&#8221;&#44; &#8220;echocardiography&#8221;&#44; &#8220;critical care&#8221;&#44; &#8220;response to fluids&#8221;&#44; &#8220;abdominal ultrasound&#8221;&#44; &#8220;diaphragmatic function&#8221;&#44; &#8220;mechanical ventilation weaning&#8221;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ultrasound as a diagnostic-therapeutic tool in critically ill patients</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Haemodynamic management of the critically ill patient with arterial hypotension and hypoperfusion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The administration of fluids to treat hypotension in critically ill and&#47;or perioperative patients is one of the most common strategies&#59; however&#44; it is seldom based on standardised&#44; objective criteria&#46; Hypotension and tissue hypoperfusion must be treated on the basis of aetiology&#44; and although fluids may sometime be needed&#44; they are not always the primary treatment&#46; Not only is it important to know when fluids&#44; vasoconstrictors&#44; or inotropes should be administered&#44; it is also essential to correctly titrate the dose&#44; monitor treatment response&#44; and determine the optimal duration of treatment in order to avoid side effects &#40;from both catecholamines and fluids&#41;&#46; Below&#44; we propose a protocol for systematic and comprehensive US exploration &#40;cardiac&#44; pulmonary&#44; abdominal&#41; in patients with shock with arterial hypotension&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Determination of cardiac output and ventricular function</span><p id="par0030" class="elsevierStylePara elsevierViewall">Shock refers to circulatory failure with insufficient tissue perfusion that leads to generalized cellular hypoxia&#46; Shock can have different aetiologies and can be treated in different ways<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Remember that blood pressure &#40;BP&#41;&#8239;&#61;&#8239;cardiac output &#40;CO&#41; x systemic vascular resistance &#40;SVR&#41;&#59; therefore&#44; it is essential to measure CO in order to determine the aetiology of hypotension&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Pulsed spectral Doppler US is a non-invasive method of quantifying cardiac output and an excellent haemodynamic monitor<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Assuming that the left ventricular outflow tract &#40;LVOT&#41; is cylindrical&#44; blood flow through its cross-section &#40;stroke volume&#44; SV&#41; can be calculated by multiplying the area of this cross section by the velocity-time integral &#40;VTI&#41;&#44; which represents the height of the column of blood that passes through the LVOT at each heartbeat&#46; Thus&#44; SV&#8239;&#61;&#8239;LVOT area&#8239;&#215;&#8239;VTI&#46; The LVOT area is obtained in the parasternal long axis view&#44; 0&#46;3&#8211;1&#8239;cm below the valve orifice<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Thus&#44; by obtaining the diameter of the LVOT&#44; we obtain its area &#40;Area&#8239;&#61;&#8239;<span class="elsevierStyleItalic">&#960;</span> &#42;radius&#178;&#41;&#46; Pulsed Doppler determines blood flow at a specific point on the basis of VTI and the time it takes the blood to pass through point&#46; In echocardiography&#44; the VTI of the LVOT is measured 1&#8239;cm below the aortic valve in an apical five-chamber view&#46; As the population mean of the LVOT is 2&#8239;cm &#40;therefore&#44; radius of 1&#8239;cm&#41;&#44; calculation of the area in all individuals is simplified to same value&#44; and therefore the SV can generally be inferred from the VTI&#46; A VTI value of 17&#8239;cm indicates a normal stroke volume &#40;approximately 55&#8239;ml&#47;beat&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; This technique should not be used to estimate SV in moderate-to-severe aortic insufficiency&#44; septal hypertrophy&#44; or in patients with dynamic LV outflow tract obstruction<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Pulsed Doppler&#44; therefore&#44; can differentiate between normal&#47;high or low stroke &#40;S&#41; volume &#40;and thus normal&#47;high or low CO&#41;&#46; Bearing in mind the BP&#8239;&#61;&#8239;CO&#8239;&#215;&#8239;SVR formula&#44; vasoconstrictors would normalize SVR&#44; and therefore&#44; BP in patients with hypotension and high stroke volume&#46; However&#44; in the case of low stroke volume&#44; it is essential to estimate ventricular function in order to start inotropic support&#46; An operator with basic echocardiography skills can quantify right or left ventricular function and exclude various causes of flow obstruction &#40;such as pericardial effusion that causes cardiac tamponade&#44; tension pneumothorax&#44; or pulmonary thromboembolism&#44; see the section on respiratory failure&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#46; Once vasoconstrictors or inotropes have been started&#44; ultrasound can also be used to titrate the dose on the basis of the response&#44; and to subsequently stop treatment by monitoring the SV&#44; thus minimizing the side effects associated with these drugs<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Biventricular function can be evaluated qualitatively after a relatively short learning curve by visually examining the size of the chamber and assessing myocardial thickening and shortening&#46; These factors allow the operator to distinguish between normal ventricular function and significant dysfunction<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Blood volume and dynamic response to fluids</span><p id="par0050" class="elsevierStylePara elsevierViewall">Irrespective of the presence of ventricular dysfunction&#44; assessing blood volume and response to fluids is one of the most important&#44; though difficult&#44; techniques in routine clinical practice&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Echocardiography can identify ventricular dysfunction and the causes of left ventricular filling obstruction as a cause of low cardiac output&#46; Once these entities have been excluded&#44; hypovolaemia &#40;absolute or relative&#41; is a common cause of low cardiac output with low stroke volume&#46; Static parameters&#44; such as central venous pressure &#40;CVP&#41;&#44; the diameter of the inferior vena cava &#40;<span class="elsevierStyleSmallCaps">IVC</span>&#41; or pulmonary capillary pressure &#40;PCP&#41;&#44; have now been replaced by dynamic parameters in the diagnosis of hypovolaemia&#46; These parameters can predict whether CO will improve if preload is increased<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A patient is a volume responder if increasing the LV end-diastolic volume after volume replacement increases the stroke volume&#46; This will indicate that stroke volume is on the ascending portion of the Frank Starling curve&#46; Volume responsiveness is defined as &#8805;12&#37; increase in CO&#47;SV after administration of fluids or after performing the passive leg raising test<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Respiratory stroke volume variation &#40;SVV&#41; of &#8805;12&#37; in the LVOT VTI in a mechanically ventilated patient &#40;tidal volume 8&#8239;ml&#47;kg&#44; sinus rhythm&#44; no severe RV dysfunction&#44; and normal intrathoracic pressures&#41; predicts a positive response to fluid&#46; If stroke volume does not vary&#44; the administration of fluids will have no haemodynamic benefit&#46; SVV&#8239;&#8805;&#8239;12&#37; only indicates that fluid administration will increase stroke volume&#44; but administration should not be inferred directly or solely from this parameter&#44; and the pulmonary and venous territories must be evaluated before administering fluids in order to avoid or reduce the adverse effects of excessive fluid replacement<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Lung ultrasound</span><p id="par0065" class="elsevierStylePara elsevierViewall">Recent studies have provided compelling evidence on the adverse effects of liberal fluid therapy&#44; particularly in critically ill patients&#44; where less than 5&#37; of infused fluid may remain in the vasculature after 1&#8239;h of administration<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#46; In patients with sepsis&#44; a decrease in oncotic blood pressure together increased permeability of the alveolar-capillary barrier will make the lung more susceptible to fluid accumulation in the interstitium and alveolar compartment&#46; This greatly reduces the volume replacement safety margin&#44; and fluids must be titrated by identifying the risk of third spacing<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Extravascular lung water &#40;EVLW&#41; has been shown to increase in patients with sepsis<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> and this increase has been correlated with mortality<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46; EVLW&#44; therefore&#44; is a clinically relevant parameter that can be used to guide fluid therapy in critically ill patients&#46; Transpulmonary thermodilution is currently the gold standard for measuring EVLW&#44; but requires specialized equipment&#46; Chest x-ray is the standard method of quantifying EVLW&#44; but the images correlate poorly with lung water<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#46; Lung ultrasound has proven to be an excellent tool for detecting pulmonary oedema&#46; The presence of US B lines correlate well with parameters such as PCP and EVLW<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; A high-frequency linear transducer &#40;6&#8211;13&#8239;Mhz&#41; should be used to explore more superficial structures &#40;chest wall and pleura&#41;&#46; The ribs are visible as curvilinear structures with acoustic shadowing in the anterior and lateral areas of the thorax&#46; The pleural line is visualised as a horizontal echogenic line from which bright&#44; well-defined hyperechoic lines emerge and extend vertically to the far field of the US without disappearing&#59; these are the B lines&#46; B lines are caused by the presence of extravascular water thickening the interlobular septa or by the accumulation of fluid in the pulmonary interstitium or in alveoli&#46; The authors of a recently study<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> reported that the presence of 3 positive chest quadrants &#40;&#8220;positive&#8221; defined as 3 or more B lines within the quadrant&#41; has a sensitivity and specificity of 100&#37; and 70&#37;&#44; respectively&#44; for the detection of EVLW&#8239;&#62;&#8239;10&#8239;ml&#47;kg &#40;value associated with pulmonary oedema&#41;&#46; Taken together&#44; the foregoing shows the usefulness of lung ultrasound to detect EVLW and restrict fluid administration&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Abdominal ultrasound&#58; venous congestion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Fluid administration can cause venous congestion due to increased pressures in the right heart chambers&#44; leading to generalised interstitial oedema&#44; visceral oedema&#44; and secondary renal dysfunction&#46; All these in turn contribute to intravascular and extravascular volume accumulation<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&#46; Venous congestion must be evaluated on the basis of haemodynamics&#44; bearing in mind that it can be severely altered for causes other than hypervolaemia&#44; such as pulmonary hypertension and RV dysfunction&#44; and for this reason not only diuretics but also pulmonary vasodilators or inotropes may be the treatment of choice&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Various ultrasound markers of this congestive process and of the consequences of increased venous congestion have been suggested&#46; Beaubien-Souligny et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> developed a prototypical Venous Excess Ultrasound &#40;VExUS&#41; system for grading the severity of venous congestion&#44; and validated its potential clinical utility in predicting the occurrence of acute kidney injury &#40;AKI&#41;&#46; In their study&#44; congestion was classified as mild&#44; moderate&#44; or severe based on a combination of the following parameters&#58; the diameter of the inferior vena cava &#40;IVC&#41; and the Doppler waveform of the suprahepatic veins&#44; portal vein and renal interlobular veins&#46; Hepatic Doppler was considered mildly abnormal when the S phase was of less amplitude than the diastolic &#40;D&#41; phase&#44; and severely abnormal when the S phase was reversed &#40;toward the heart&#41;&#46; For portal Doppler&#44; a pulsatility fraction of 30&#37;&#8211;49&#37; was considered mild&#44; while a pulsatility fraction of &#60;50&#37; was considered severe&#46; For the intra-renal venous Doppler&#44; a discontinuous pattern with a systolic and a diastolic phase was considered mild while a discontinuous pattern with only a diastolic phase was considered severe&#46; They observed that the presence of at least 2 severe alterations of hepatic vein&#44; portal vein&#44; or intra-renal venous flow on pulse-wave Doppler ultrasound with an IVC of &#8805;2&#8239;cm in diameter at ICU admission after cardiac surgery indicated a high risk of post-operative AKI&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; Image A&#44; section C shows the flow pattern of the portal vein&#46; It is recommended to use the low frequency convex transducer placed on the anterior axillary line between the 9th and 11th intercostal space &#40;ICS&#41;&#46; The vein is characterized by its hyperechoic border and hepatoportal flow towards the transducer &#40;red in our image&#41;&#46; On pulsed Doppler&#44; the image shows moderate venous congestion&#46; Image B shows the venous pattern of the suprahepatic veins&#44; which are visualised by placing the ultrasound transducer on the midaxillary line perpendicular to the patient&#39;s ribs or in the subcostal plane&#46; On US&#44; these veins appear as anechoic structures without the hyperechoic rim that characterizes the portal vein&#46; Although there are episodes of retrograde flow&#44; most of the venous flow is antegrade&#44; that is&#44; from the liver to the heart&#46; This flow moves away from the transducer&#44; so it will appear blue on colour Doppler and below the baseline on pulsed Doppler&#46; The image shows the pulsed Doppler pattern of the vein in a patient with severe congestion&#44; with an inverted S wave&#46; Image C shows the pattern of the kidney veins&#46; To obtain the image&#44; the transducer is placed on the mid-axillary line and the patient is asked to take a deep breath&#46; The transducer is moved until the kidney is visualised &#40;below the liver&#41;&#46; Once identified&#44; colour Doppler is used to identify the kidney vessels at the corticomedullary junction&#46; The Doppler waveform above baseline shows the renal artery flow&#44; while the venous flow is seen below the baseline&#46; The image shows a pattern consistent with moderate venous congestion&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Although these parameters have not been validated in other clinical contexts&#44; when interpreted rationally on the basis of the patient&#8217;s pathophysiology they can be used to extend the haemodynamic assessment to include an evaluation of venous congestion&#44; and thus adjust real fluid requirements by assessing their potential adverse effects&#46; Despite recent interest in venous congestion and the publication of several studies supporting its clinical utility<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; the VExUS system still needs to be validated in different clinical contexts&#46; This will confirm the optimal evaluation criteria&#44; and show whether it can be used to individualize haemodynamic management in venous congestion&#44; and consequently&#44; organ perfusion&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Differential diagnosis and therapeutic management of acute respiratory failure</span><p id="par0095" class="elsevierStylePara elsevierViewall">Another common scenario encountered in the CCU is acute respiratory failure&#44; a situation in which ultrasound also plays a key role&#46; To help integrate the data obtained from pulmonary ultrasound images into clinical diagnosis&#44; in 2008 Lichtenstein published a paper in which he organized ultrasound patterns into different profiles and developed an algorithm that&#44; though not diagnostic in itself&#44; can help guide diagnosis with a specificity of more than 90&#37;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; These patterns are based on combining venous analysis with the presence or absence of the following signs&#58; lung sliding&#44; A or B lines&#44; and effusion or consolidation&#46; The differential diagnosis includes the most common entities &#40;97&#46;5&#37; of all cases&#41;&#44; which are asthma or exacerbation of chronic obstructive pulmonary disease&#44; pulmonary oedema&#44; pneumothorax&#44; pneumonia&#44; and pulmonary thromboembolism&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pneumothorax</span><p id="par0100" class="elsevierStylePara elsevierViewall">One of the first pathologies to be ruled out in patients with acute respiratory failure is pneumothorax &#40;PTX&#41;&#44; a condition that is often associated with haemodynamic instability&#46; Air usually accumulates in the least dependent position&#44; so it is best to examine the patient in a supine or sitting position&#44; and place the transducer as high as possible on the anterior chest wall&#44; at the level of the second or third ICS on the midclavicular or axillary line&#46; A linear transducer should preferably be used for this examination&#46; Several spaces should be examined in quick succession by moving the transducer over the intercostal spaces&#46; The presence of lung sliding will exclude PTX with a sensitivity of 95&#46;3&#37;&#44; a specificity of 91&#46;1&#37;&#44; and a negative predictive value of 100&#37;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&#46; Visualization of B lines also excludes PTX&#44; since their presence indicates that the lung is fully expanded at the transducer site&#44; because the presence of any amount of air between the pleura would block the US beam&#46; However&#44; the lung point has a specificity of 100&#37; for the diagnosis of PTX<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46; Lung point is observed at the margin between the PTX &#40;where there is no contact between the two pleurae&#59; there is no lung sliding&#41; and the partially aerated lung &#40;there is still contact between the pleural surfaces&#59; there is lung sliding&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Interstitial pattern&#58; B lines</span><p id="par0105" class="elsevierStylePara elsevierViewall">Once PTX has been ruled out&#44; the US operator must evaluate the alveolar-interstitial pattern&#44; which is characterized by the presence of B lines&#46; The critically ill patient is particularly susceptible to developing interstitial and&#47;or alveolar oedema&#44; given their stress&#44; their baseline pathology&#44; the possibility of developing systolic and diastolic ventricular dysfunction&#44; and the need for fluid replacement&#44; as discussed above&#46; Pulmonary ultrasound has a sensitivity and specificity of 98&#37; and 88&#37;&#44; respectively&#44; for the diagnosis of acute pulmonary oedema&#44; and it is superior to chest X-ray in the diagnosis of interstitial syndromes<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46; B lines appear in 2 common clinical syndromes in the CCU&#58; acute pulmonary oedema &#40;APO&#41; and acute respiratory distress syndrome &#40;ARDS&#41;&#46; In APO&#44; B lines are homogeneously distributed in the anterior and posterior lung fields&#44; that is&#44; with no interposed areas of normal aeration &#40;A lines&#41;&#46; In ARDS&#44; bilateral B lines are non-homogeneously distributed in non-dependent lung fields&#44; so while some areas contain numerous B lines&#44; in others they are coalescent and normal lung &#40;A lines&#41; are observed between these areas&#46; B lines can also appear in lobar pneumonia&#44; but only in the affected region and usually accompanied by pleural changes with subpleural consolidations&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pleural effusion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Switching to a convex transducer placed on the posterior axillary line allows the US operator to evaluate the presence of pleural effusion&#46; Pleural effusion is a common occurrence in critically ill patients&#44; and can cause respiratory failure and even cardiac tamponade if it is located in the right hemithorax&#44; compressing the right heart chambers&#46; A finding of opaque hemithorax on US can be used for differential diagnosis &#40;effusion-atelectasis&#41; and can guide treatment&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Between 150 and 200&#8239;ml of fluid must have accumulated in the costophrenic sinus before it can be detected by a postero-anterior radiograph&#44; whereas US is capable of detecting as little as 50&#8239;ml of fluid&#46; In a study published in 2011<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#44; chest radiography had a sensitivity of 65&#37;&#44; specificity of 81&#37;&#44; and diagnostic accuracy of 69&#37; for the detection of pleural fluid&#44; while US had a sensitivity&#44; specificity and diagnostic accuracy of 100&#37;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; image A shows a pleural effusion obtained with a 3&#8211;5&#8239;Mhz convex transducer placed on the posterior axillary line &#40;PLAPS-point&#58; posterolateral alveolar and&#47;or pleural syndrome&#41; in the subdiaphragmatic area&#46; With the transducer placed horizontal to the ribs&#44; the pleural effusion is visualised as anechoic material surrounding the hyperechoic lung&#44; which has collapsed as a result of the effusion&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Ultrasound has proven useful in reducing the rate of complications associated percutaneous techniques&#44; such as thoracocentesis&#44; pericardiocentesis or evacuation of abscesses&#47;haematomas<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#44;34</span></a>&#46; The British Society for Thoracic Surgery recommends performing thoracocentesis at a site with a depth of pleural fluid of at least 10&#8239;mm&#44; as this will ensure sufficient separation of the lung from the parietal pleura<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46; Lung motion over an entire respiratory cycle should be observed&#44; as the lung may move in the path of the needle&#46; The position of the diaphragm must also be determined to avoid accidental perforation&#46; Pleural effusion with septa or loculations may be more difficult to evacuate&#46; Pleural effusion can be approximately quantified using the following formula&#58; interpleural distance &#40;in mm&#41;&#8239;&#215;&#8239;20&#8239;&#61;&#8239;ml of effusion<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#46; Static US can be used to mark the puncture site&#44; and dynamic US &#40;covered with a sterile cover&#41; can be used during the procedure to confirm the position of the drainage tube<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46; Given the capacity of colour Doppler to identify blood flow&#44; some experts propose using this technique to reduce the risk of vascular injury during thoracentesis<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Atelectasis</span><p id="par0130" class="elsevierStylePara elsevierViewall">Significant effusion may be accompanied by passive atelectasis&#46; The collapsed or consolidated lung has the appearance of poorly defined&#44; wedge-shaped hyperechoic tissue&#46; Because of its resemblance to liver tissue&#44; it is referred to as pulmonary hepatization&#46; This total loss of air occurs in both pneumonia and atelectasis&#44; and the pattern is also observed in some cases of pulmonary contusion&#44; tumours&#44; and pulmonary infarction&#46; Atelectasis is differentiated from pneumonia on the basis of the patient&#8217;s clinical history and laboratory tests&#46; One recent study found that lung ultrasound had a sensitivity of 93&#46;4&#37; and a specificity of 97&#46;7&#37; for pneumonia compared with chest radiography<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; image B shows lung base atelectasis obtained with a convex transducer placed on the PLAPS-point&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Despite major advances in regional anaesthesia techniques&#44; general anaesthesia is still unavoidable in some surgical procedures&#46; Approximately 90&#37; of surgical patients develop aeration alterations as a result of positive pressure mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>&#46; Atelectasis can cause intraoperative and&#47;or postoperative complications &#40;mainly hypoxaemia&#41;&#44; and can trigger a local inflammatory response that leads to ventilation-induced lung injury<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46; The imaging technique of choice for atelectasis is CT&#59; however&#44; it is not a point-of-care technique&#44; and produces ionizing radiation&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Alveolar recruitment manoeuvres performed to reduce aeration alterations are associated with some complications &#40;barotrauma&#44; volutrauma&#44; haemodynamic instability&#44; etc&#46;&#41;&#46; The authors of a recent study<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> detected atelectasis&#44; initially appearing as subpleural consolidations&#44; in up to 14&#37; of patients after 10&#8239;min of general anaesthesia&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; image C shows subpleural consolidations obtained with a convex transducer&#44; visualized as hyperechoic pinpoints in contact with the visceral pleura&#46; In the same study&#44; the authors performed alveolar recruitment manoeuvres and repeated the lung ultrasound evaluation after each incremental increase in positive end-expiratory pressure &#40;PEEP&#41; until they found the peak pressure and PEEP that achieved optimal aeration&#46; This study shows that ultrasound-guided recruitment manoeuvres allow clinicians to individualise alveolar recruitment and reduce the pressure needed to aerate areas of intraoperative atelectasis&#44; thus reducing the risk of recruitment-related complications&#46; In another study published in 2021<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#44; the authors reported that 100&#37; of patients aged over 60 years of age undergoing laparoscopic surgery for colorectal carcinoma developed pulmonary atelectasis&#46; After performing US-guided intraoperative alveolar recruitment manoeuvres&#44; this incidence decreased by 50&#37;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">US&#44; therefore&#44; can identify areas of atelectasis and show their response to alveolar recruitment manoeuvres in real time&#46; This&#44; together with the determination of pulmonary compliance&#44; can identify the optimal PEEP needed to prevent the reappearance of consolidations&#44; making US a valuable point-of-care monitoring tool to prevent respiratory complications<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">44&#44;45</span></a>&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Weaning failure from mechanical ventilation</span><p id="par0155" class="elsevierStylePara elsevierViewall">Weaning failure occurs in between 26&#37; to 42&#37; of patient<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>&#44; and is often due to a combination of factors involving a complex interaction between cardiac&#44; diaphragmatic&#44; and pulmonary dysfunction&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Ultrasound can help optimise the patient&#39;s cardiac and respiratory function prior to extubation&#44; and can even indicate the need to place patients at risk of weaning failure on non-invasive ventilation before discontinuing ventilatory support<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Evaluation of the weaning process can be divided into 3 categories&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Cardiac function&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Diaphragmatic function&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Lung function&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cardiac function</span><p id="par0185" class="elsevierStylePara elsevierViewall">Cardiac dysfunction appears to play a key role&#44; and may underly most cases of weaning failure from mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The change from positive to negative intrathoracic pressure after switching to spontaneous ventilation can disrupt preload conditions&#44; resulting in a sudden increase in left ventricular &#40;LV&#41; filling pressures if ventricular compliance is reduced&#46; This is why weaning-induced pulmonary oedema is a leading cause of weaning failure&#44; particularly in high-risk patients with underlying heart disease&#44; chronic obstructive pulmonary disease &#40;COPD&#41;&#44; or obesity<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a>&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Echocardiography is useful for evaluating LV systolic and diastolic function&#44; with diastolic dysfunction being the predominant factor in weaning failure&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#44; image D shows mitral filling visualised in a 4-chamber US plane&#46; During diastole&#44; LV filling is studied using pulsed Doppler&#44; placing the cursor at the level of the free edges of the mitral leaflets&#46; Two wave forms are observed in patient in sinus rhythm&#58; wave E&#44; early diastolic rapid filling&#44; and wave A&#44; atrial contraction&#46; The image shows a restrictive transmitral flow pattern&#44; with an increase in the speed of the A wave &#40;therefore&#44; E&#47;A ratio &#60;1&#41;&#46; This is one of the measurements used to establish grade I diastolic dysfunction&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Tissue Doppler must also be performed at the level of the mitral annulus during assessment of diastolic function and LV filling pressures&#46; This will give the E wave &#40;pulsed Doppler&#41; - Em wave &#40;tissue Doppler&#41; ratio&#46; There is evidence that a high E&#47;Em ratio and decreased Em is an indicator of weaning failure<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In 2011&#44; Papanikolaou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> observed that weaning failure occurred in 35&#37; of patients with normal diastolic function&#44; in 57&#37; of patients with grade 1 &#40;mild&#41; diastolic dysfunction&#44; and in 80&#37; of patients with grade 2 &#40;moderate&#41; or 3 &#40;serious&#41; diastolic dysfunction&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Recently&#44; Goudelin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> observed that patients who developed pulmonary oedema when switching to spontaneous ventilation exhibited significantly higher E wave velocity and E&#47;A ratio&#44; shorter E-wave deceleration time&#44; lower left ventricular ejection fraction &#40;LVEF&#41;&#44; and higher tricuspid regurgitation peak velocity compared to those in whom weaning was successful&#46; This could show the inability of the cardiovascular system to withstand the increased preload&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Diaphragmatic function</span><p id="par0215" class="elsevierStylePara elsevierViewall">Diaphragmatic atrophy and dysfunction are common in mechanically ventilated patients&#44; and are associated with difficult and prolonged weaning&#44; reintubation&#44; tracheostomy&#44; and increased mortality<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">In recent years&#44; several researchers have investigated the underlying mechanisms of respiratory muscle and diaphragm dysfunction and atrophy in critically ill patients&#46; Techniques such as chest radiography for assessing diaphragmatic function have low sensitivity and specificity&#46; Others&#44; such as magnetic phrenic nerve stimulation and transdiaphragmatic pressure measurement using oesophageal or gastric sensors are difficult to use in CCUs&#46; Ultrasound has emerged as a non-invasive technique that can be used to evaluate diaphragm structure and function<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>&#46; US can be used to observe diaphragmatic motion in a variety of normal and pathological conditions&#46; Evaluating the characteristics of diaphragmatic motion &#40;amplitude&#44; force&#44; speed&#44; thickness&#41; can provide CCU clinicians with data that can be used in the evaluation and follow-up of patients with respiratory failure or difficult weaning from mechanical ventilation<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Diaphragm function can be explored in 2 acoustic windows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">In the zone of apposition&#44; between the 8th and 10th intercostal space&#44; in the midaxillary or anterior axillary line&#44; 0&#46;5&#8211;2&#8239;cm below the costophrenic sinus&#46; A high-frequency linear transducer is required for proper visualisation of diaphragmatic thickness&#46; Two parallel echogenic layers &#40;parietal pleura and peritoneum&#41; are easily identified&#44; and the diaphragm is the hypoechoic structure that lies between these 2 lines&#46; Normal diaphragmatic thickness is 2&#8211;2&#46;8&#8239;mm in expiration and 4&#8239;mm at maximal inspiration&#59; &#60;2&#8239;mm is considered diaphragmatic atrophy&#46; M mode will show diaphragm thickening on inspiration and quantify it using fractional shortening &#40;FS&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; image A&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li></ul></p><p id="par0235" class="elsevierStylePara elsevierViewall">FS&#8239;&#61;&#8239;&#91;thickness at end of inspiration &#8211; thickness at end of expiration&#93;&#47;thickness at end of expiration&#8239;&#215;&#8239;100&#46; Cut-off values to predict successful weaning range from 25&#37; to 35&#37;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">54&#44;55</span></a>&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">In the subcostal region&#44; between the anterior axillary line and the midclavicular line&#46; A cardiac or convex &#40;low frequency&#41; transducer should be used&#46; Using the liver or spleen as acoustic windows&#44; the diaphragm is seen as a hyperechoic line that is displaced towards the transducer during inspiration&#46; As before&#44; M-mode is used to observe diaphragmatic excursion in inspiration&#46; Normal diaphragmatic movement during inspiration is caudal&#44; as the diaphragm migrates towards the transducer during inspiration and away from the transducer during expiration&#46; Normal diaphragmatic excursion values range from 15 to 21&#8239;mm in men and 13 to 19&#8239;mm in women<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> image B&#41;&#46; Several studies have associated higher diaphragmatic excursion values with successful weaning from mechanical ventilation<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56&#8211;58</span></a>&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Lung function</span><p id="par0245" class="elsevierStylePara elsevierViewall">Accumulation of pleural fluid causes the adjacent lung to collapse due to the hydrostatic pressure generated by the effusion&#44; resulting in a loss of alveolar volume available for gas exchange&#46; Furthermore&#44; as elastic chest wall recoil is no longer opposed by outward lung recoil&#44; the configuration of the chest wall changes in the area of the effusion and reduces the efficiency of the longitudinal tension of the intercostal muscles&#46; As a result&#44; the diaphragm detaches from the surface of the visceral pleural and attenuates lung inflation&#46; In large effusions&#44; pleural pressure may be high enough to reverse the curvature of the ipsilateral diaphragm &#40;the preloading function of the diaphragm is optimal only with normal concavity&#41;&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Evidence of the association between pleural effusion and difficulties in weaning from mechanical ventilation is inconclusive<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a>&#46; In some studies<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a>&#44; effusion is associated with weaning failure&#59; however&#44; more studies are required to confirm whether effusion drainage or aggressive management with diuretic therapy has the potential to reduce the duration of mechanical ventilation in these patients&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">US can also predict weaning failure with some accuracy by identifying global and regional alveolar derecruitment&#46; The &#8220;lung ultrasound score&#8221; &#40;LUS&#41; has been used to provide comparable quantifiable measurement of progressive changes in aeration&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The LUS assigns numerical values ranging from 0 to 3 to lung ultrasound patterns in each particular chest region&#44; depending on the degree of aeration loss &#40;12 regions&#44; anterior&#44; lateral&#44; and posterior&#41;&#46; The score is follows&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">0 points&#58; A Lines&#44; normal aeration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0270" class="elsevierStylePara elsevierViewall">1 point&#58; Multiple B lines&#44; moderate aeration loss&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0275" class="elsevierStylePara elsevierViewall">2 points&#58; Coalescing B lines&#44; severe aeration loss&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0280" class="elsevierStylePara elsevierViewall">3 points&#58; Consolidation pattern&#44; complete loss of aeration&#46;</p></li></ul></p><p id="par0285" class="elsevierStylePara elsevierViewall">Thus&#44; an LUS of &#60;13 is predictive of extubation success&#59; a score of between 13&#8211;17 predicts indeterminate success&#44; and &#62;17 predicts a high probability of extubation failure<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a>&#46;</p></span></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Limitations</span><p id="par0290" class="elsevierStylePara elsevierViewall">US is hampered by specific patient-related factors&#44; such as obesity&#44; massive oedema&#44; developed musculature&#44; chest wall dressings&#44; and the inability to change the position of critically ill patients&#46; All this can substantially detract from the quality of the image&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Like other techniques&#44; ultrasound is operator-dependent and requires training to correctly acquire and interpret images&#46; The Spanish Society of Anaesthesiology and Resuscitation &#40;SEDAR&#41;&#44; the Spanish Society of Internal Medicine &#40;SEMI&#41; and the Spanish Society of Emergency Medicine &#40;SEMES&#41; recently published a consensus document containing a series of recommendations for training and acquisition of minimum skills in the use of ultrasound in Intensive Care&#44; Anaesthesia and Emergency Medicine<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a>&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusion</span><p id="par0300" class="elsevierStylePara elsevierViewall">Ultrasound is a useful tool for the multimodal assessment of critically ill patients&#46; Echocardiography&#44; pulmonary ultrasound&#44; and Doppler venous flow analysis can be used in the CCU to obtain an overall assessment&#58; haemodynamic monitoring&#44; diagnosis of acute respiratory failure&#44; assessment of pulmonary fluid overload and venous congestion&#46; US can also help clinicians detect mechanical ventilation weaning difficulties&#44; assess response to established treatment &#40;including alveolar recruitment manoeuvres&#41;&#44; and reduce the risk of complications derived from percutaneous techniques&#46; Real-time image capture&#44; a short learning curve&#44; and absence of ionizing radiation has made US an essential and mandatory instrument in the evaluation of critical patients&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0305" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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                  "titulo" => "Determination of cardiac output and ventricular function"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hemodynamic and respiratory complications are the main causes of morbidity and mortality in in critical care units &#40;CCU&#41;&#46; Imaging techniques are a key tool in differential diagnosis and treatment&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In the last decade&#44; ultrasound has shown great potential for bedside diagnosis of respiratory disease&#44; as well as for the hemodynamic assessment of critically ill patients&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ultrasound has proven to be a useful guide for identifying the type of shock&#44; estimating cardiac output&#44; guiding fluid therapy and vasoactive drugs&#44; providing security in the performance of percutaneous techniques &#40;thoracentesis&#44; pericardiocentesis&#44; evacuation of abscesses&#47;hematomas&#41;&#44; detecting dynamically in real time pulmonary atelectasis and its response to alveolar recruitment maneuvers&#44; and predicting weaning failure from mechanical ventilation&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Due to its dynamic nature&#44; simple learning curve and absence of ionizing radiation&#44; it has been incorporated as an essential tool in daily clinical practice in CCUs&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The objective of this review is to offer a global vision of the role of ultrasound and its applications in the critically ill patient&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Las complicaciones cardiorrespiratorias son las principales causas de morbimortalidad en las unidades de cuidados cr&#237;ticos &#40;UCC&#41;&#46; Las t&#233;cnicas de imagen son una pieza fundamental tanto en el diagn&#243;stico diferencial como en el tratamiento&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En la &#250;ltima d&#233;cada la ecograf&#237;a ha demostrado gran potencial para el diagn&#243;stico a pie de cama de patolog&#237;a respiratoria&#44; as&#237; como para la valoraci&#243;n hemodin&#225;mica de los pacientes cr&#237;ticos&#46; La ecograf&#237;a ha demostrado ser una gu&#237;a &#250;til para la identificaci&#243;n del tipo de shock&#44; la estimaci&#243;n del gasto card&#237;aco&#44; guiar la fluidoterapia y los f&#225;rmacos vasoactivos&#44; aportar seguridad en la realizaci&#243;n de las t&#233;cnicas percut&#225;neas &#40;toracocentesis&#44; pericardiocentesis&#44; evacuaci&#243;n de abscesos&#47;hematomas&#41;&#44; objetivar de forma din&#225;mica y en tiempo real la atelectasia pulmonar y su respuesta a las maniobras de reclutamiento alveolar&#44; y predecir el fracaso en el destete de la ventilaci&#243;n mec&#225;nica&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Por su car&#225;cter din&#225;mico&#44; sencilla curva de aprendizaje y ausencia de radiaci&#243;n ionizante&#44; se ha incorporado como una herramienta imprescindible en la pr&#225;ctica cl&#237;nica diaria en las UCC&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">El objetivo de la presente revisi&#243;n es ofrecer una visi&#243;n global del papel de la ecograf&#237;a y sus aplicaciones en el paciente cr&#237;tico&#46;</p></span>"
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