Aims
Pulmonary congestion is an important finding in patients with heart failure (HF) that can be quantified by lung ultrasound (LUS). We conducted a systematic review to describe dynamic changes in ...LUS findings of pulmonary congestion (B‐lines) in HF and to examine the prognostic utility of B‐lines in HF.
Methods and results
We searched online databases for studies conducted in patients with chronic or acute HF that used LUS to assess dynamic changes or the prognostic value of pulmonary congestion. We included studies in adult populations, published in English, and conducted in ≥25 patients. Of 1327 identified studies, 13 (25–290 patients) met the inclusion criteria: six reported on dynamic changes in LUS findings (438 patients) and seven on the prognostic value of B‐lines in HF (953 patients). In acute HF, B‐line number changed within as few as 3 h of HF treatment. In acute HF, ≥15 B‐lines on 28‐zone LUS at discharge identified patients at a more than five‐fold risk for HF readmission or death. Similarly, in ambulatory patients with chronic HF, ≥3 B‐lines on five‐ or eight‐zone LUS marked those at a nearly four‐fold risk for 6‐month HF hospitalization or death.
Conclusions
Lung ultrasound findings change rapidly in response to HF therapy. This technique may represent a useful and non‐invasive method to track dynamic changes in pulmonary congestion. Furthermore, residual congestion at the time of discharge in acute HF or in ambulatory patients with chronic HF may identify those at high risk for adverse events.
Pulmonary congestion is a common and important finding in heart failure (HF). While clinical examination and chest radiography are insensitive, lung ultrasound (LUS) is a novel technique that may ...detect and quantify subclinical pulmonary congestion. We sought to independently relate LUS and clinical findings to 6-month HF hospitalizations and all-cause mortality (composite primary outcome).
We used LUS to examine 195 NYHA class II-IV HF patients (median age 66, 61% men, 74% white, ejection fraction 34%) during routine cardiology outpatient visits. Lung ultrasound was performed in eight chest zones with a pocket ultrasound device (median exam duration 2 min) and analysed offline.
In 185 patients with adequate LUS images in all zones, the sum of B-lines (vertical lines on LUS) ranged from 0 to 13. B-lines, analysed by tertiles, were associated with clinical and laboratory markers of congestion. Thirty-two per cent of patients demonstrated ≥3 B-lines on LUS, yet 81% of these patients had no findings on auscultation. During the follow-up period, 50 patients (27%) were hospitalized for HF or died. Patients in the third tertile (≥3 B-lines) had a four-fold higher risk of the primary outcome (adjusted HR 4.08, 95% confidence interval, CI 1.95, 8.54; P < 0.001) compared with those in the first tertile and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P < 0.001).
Pulmonary congestion assessed by ultrasound is prevalent in ambulatory patients with chronic HF, is associated with other features of clinical congestion, and identifies those who have worse prognosis.
Organ injury and impairment are commonly observed in patients with acute heart failure (AHF), and congestion is an essential pathophysiological mechanism of impaired organ function. Congestion is the ...predominant clinical profile in most patients with AHF; a smaller proportion presents with peripheral hypoperfusion or cardiogenic shock. Hypoperfusion further deteriorates organ function. The injury and dysfunction of target organs (i.e. heart, lungs, kidneys, liver, intestine, brain) in the setting of AHF are associated with increased risk for mortality. Improvement in organ function after decongestive therapies has been associated with a lower risk for post‐discharge mortality. Thus, the prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials. Treatment strategies that specifically prevent, reduce or reverse organ dysfunction remain to be identified and evaluated to determine if such interventions impact mortality, morbidity and patient‐centred outcomes. This paper reflects current understanding among experts of the presentation and management of organ impairment in AHF and suggests priorities for future research to advance the field.
Background:
Lung ultrasound is a useful tool in the assessment of pulmonary congestion in heart failure that is typically performed and interpreted by physicians at the point-of-care.
Aims:
To ...investigate the ability of nurses, students, and paramedics to accurately identify B-lines and pleural effusions for the detection of pulmonary congestion in heart failure and to examine the training necessary.
Methods and results:
We conducted a systematic review and searched online databases for studies that investigated the ability of nurses, students, and paramedics to perform lung ultrasound and detect B-lines and pleural effusions. Of 979 studies identified, 14 met our inclusion criteria: five in nurses, eight in students, and one in paramedics. After 0–12 h of didactic training and 58–62 practice lung ultrasound examinations, nurses were able to identify B-lines and pleural effusions with a sensitivity of 79–98% and a specificity of 70–99%. In image adequacy studies, medical students with 2–9 h of training were able to acquire adequate images for B-lines and pleural effusions in 50–100%. Only one eligible study investigated paramedic-performed lung ultrasound which did not support the ability of paramedics to adequately acquire and interpret lung ultrasound images after 2 h of training.
Conclusions:
Our findings suggest that nurses and students can accurately acquire and interpret lung ultrasound images after a brief training period in a majority of cases. The examination of heart failure patients with lung ultrasound by non-clinicians appears feasible and warrants further investigation.
Abstract Background Mortality following cardiac arrest remains high, and point-of-care ultrasound has been suggested to improve outcomes from advanced cardiac life support (ACLS), but no large ...studies have explored how point-of-care ultrasound should be incorporated into ACLS. Our aim was to determine whether detection of cardiac activity by ultrasound during ACLS is associated with improved survival. Methods We conducted a non-randomized, prospective, protocol-driven observational study. It was a 20 site, multi-center study of emergency departments (EDs) across United States and Canada. Patients presenting with out-of-hospital cardiac arrest or in-ED arrest with pulseless electrical activity or asystole were included. An initial ultrasound was performed at the beginning and end of ACLS. The primary outcome was percentage of patients that survive to hospital admission. Subgroups for additional analysis were identified through univariate and multivariate analysis. Secondary outcomes included survival to hospital discharge and return of spontaneous circulation. Findings 953 patients presenting May 2011 to November 2014 were enrolled with 793 included in the analysis. Overall 208 patients (26.2%) survived the initial resuscitation, 114 (14.4%) survived to hospital admission, and 13 (1.6%) surviving to hospital discharge. Cardiac activity on initial US was the variable most associated with survival at all time points. On multivariate regression modeling, cardiac activity was associated with a greater incidence of survival to hospital admission (OR 3.6, 2.2 to 5.9) and hospital discharge (OR 5.7, 1.5 to 21.9). The lack of cardiac activity on initial US was strongly associated with non-survival, but 0.6% (95% CI − 0.3 to 2.3) of patients with no cardiac activity survived to discharge. Ultrasound identified findings during the resuscitation that responded to interventions outside of standard ACLS interventions. Patients with pericardial effusion who underwent pericardiocentesis demonstrated higher survival rates (15.4%) compared to all others (1.3%). Conclusion The presence of cardiac activity at the initiation of ACLS in the ED was the variable most associated with survival following cardiac arrest. Point-of-care ultrasound during cardiac arrest can identify patients with higher likelihood of survival to hospital discharge, and can identify interventions outside of the standard ACLS algorithm. Point-of-care ultrasound should be integrated into ACLS algorithms.
Abstract
In acute heart failure (AHF) syndromes significant respiratory failure (RF) is essentially seen in patients with acute cardiogenic pulmonary oedema (ACPE) or cardiogenic shock (CS). ...Non-invasive ventilation (NIV), the application of positive intrathoracic pressure through an interface, has shown to be useful in the treatment of moderate to severe RF in several scenarios. There are two main modalities of NIV: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV) with positive end expiratory pressure. Appropriate equipment and experience is needed for NIPSV, whereas CPAP may be administered without a ventilator, not requiring special training. Both modalities have shown to be effective in ACPE, by a reduction of respiratory distress and the endotracheal intubation rate compared to conventional oxygen therapy, but the impact on mortality is less conclusive. Non-invasive ventilation is also indicated in patients with AHF associated to pulmonary disease and may be considered, after haemodynamic stabilization, in some patients with CS. There are no differences in the outcomes in the studies comparing both techniques, but CPAP is a simpler technique that may be preferred in low-equipped areas like the pre-hospital setting, while NIPSV may be preferable in patients with significant hypercapnia. The new modality ‘high-flow nasal cannula’ seems promising in cases of AHF with less severe RF. The correct selection of patients and interfaces, early application of the technique, the achievement of a good synchrony between patients and the ventilator avoiding excessive leakage, close monitoring, proactive management, and in some cases mild sedation, may warrant the success of the technique.
Epinephrine injection represents the standard of care for anaphylaxis treatment. It is most effective if delivered intramuscularly, whereas inadvertent intraosseous injection may be harmful. The ...needle length in current pediatric epinephrine autoinjectors (EAIs) is 12.7 mm; however, the ideal needle length for infants and toddlers weighing less than 15 kg is unknown.
To determine the skin-to-bone distance (STBD) and skin-to-muscle distance (STMD) at baseline and after simulated EAI application in infants and toddlers (weighing 7.5–15 kg).
Study participants recruited from 2 North American allergy clinics underwent baseline and compression (10-lb pressure) ultrasonography of the anterolateral thigh with a modified ultrasound transducer mimicking the footprint and maximum pressure application of an EAI device. Ultrasound images, with clinical data masked, were analyzed offline for STBD and STMD in short-axis approach.
Of 53 infants (mean age, 18.9 months; 54.7% male; 81.1% white; mean weight, 11.0 kg), 51 had adequate images for short-axis STBD measurements. In these infants, the mean (SD) baseline STBD was 22.4 (3.8 mm), and the mean (SD) STMD was 7.9 (1.7) mm. With 10-lb compression, the mean (SD) STBD was 13.3 (2.1) mm, and the mean (SD) STMD was 6.3 (1.2) mm. An EAI with a needle length of 12.7 mm applying 10-lb pressure could strike the bone in 43.1% of infants and toddlers in this cohort.
Our data suggest that the optimal EAI needle length for infants and toddlers weighing 7.5 to 15 kg should be shorter than the needle length in currently available pediatric EAIs to avoid accidental intraosseous injections.
Aims
Pulmonary oedema is a common and important finding in acute heart failure (AHF). We conducted a systematic review to describe the methods used to assess pulmonary oedema in recent randomized AHF ...trials and report its prevalence in these trials.
Methods and results
Of 23 AHF trials published between 2002 and 2013, six were excluded because they were very small or not randomized, or missing full‐length publications. Of the remaining 17 (n = 200–7141) trials, six enrolled patients with HF and reduced ejection fraction (HF‐REF) and 11, patients with both HF‐REF and HF with preserved ejection fraction (HF‐PEF). Pulmonary oedema was an essential inclusion criterion, in most trials, based upon findings on physical examination (‘rales’), radiographic criteria (‘signs of congestion’), or both. The prevalence of pulmonary oedema in HF‐REF trials ranged from 75% to 83% and in combined HF‐REF and HF‐PEF trials from 51% to 100%. Five trials did not report the prevalence or extent of pulmonary oedema assessed by either clinical examination or chest x‐ray. Improvement of pulmonary congestion with treatment was inconsistently reported and commonly grouped with other signs of congestion into a score. One trial suggested that patients with rales over >2/3 of the lung fields on admission were at higher risk of adverse outcomes than those without.
Conclusion
Although pulmonary oedema is a common finding in AHF, represents a therapeutic target, and may be of prognostic importance, recent trials used inconsistent criteria to define it, and did not consistently report its severity at baseline or its response to treatment. Consistent and ideally quantitative, methods for the assessment of pulmonary oedema in AHF trials are needed.
Wall Motion Score Index (WMSI) is a simple method to quantify global and regional systolic function on echocardiography. We sought to investigate the prognostic importance of global and regional WMSI ...for the development of incident heart failure (HF) in the general population.
We included adults without HF or ischemic heart disease from the 4th Copenhagen City Heart Study (2001–2003). At baseline, participants underwent an echocardiography and physical examination and completed a self-administered health questionnaire. WMSI was assessed by conventional echocardiography using a 16-segment model obtaining WMSI assessments for the anterior, lateral, inferior, septal, and posterior left ventricular (LV) walls and calculating a global WMSI. The primary endpoint was incident HF.
Among 3415 participants (mean age 58 years, 42% male, 45% with hypertension), 83 (2.4%) had hypo-, a-, or dyskinesia of at least one LV wall segment at baseline. During a median follow-up of 15.4 years, 297 (8.7%) participants developed HF. After adjusting for important clinical variables, LV ejection fraction and E/A, hypo-, a- or dyskinesia of at least one segment in any of the LV regional walls was associated with a higher risk of incident HF (HR 3.63, 95% CI 2.15–6.12, p < 0.001). Similarly, global WMSI was independently associated with a higher risk of HF (HR 1.38 per 0.1 increase, 95%CI 1.22–1.56, p < 0.001).
Wall motion abnormalities in any regional LV wall and global WMSI were associated with incident HF in this general population cohort independent of various baseline clinical data, LV ejection fraction and E/A.
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•3,415 participants from the general population without heart failure or ischemic heart disease were included.•Wall motion score index was assessed by echocardiography at baseline using a 16 segment model.•83 participants (2.4%) had hypo-, a-, or dyskinesia of at least one left ventricular segment at baseline.•During a median follow-up of 15.4 years (IQR 11.9-16.0), 297 participants (8.7%) developed incident heart failure.•Hypo-, a-, or dyskinesia of ≥1 segment in any left ventricular wall was associated with a higher risk of incident heart failure.
Abstract Acute heart failure (AHF) is a multi-organ dysfunction syndrome. In addition to known cardiac dysfunction, non-cardiac comorbidity, frailty and disability are independent risk factors of ...mortality, morbidity, cognitive and functional decline, and risk of institutionalization. Frailty, a treatable and potential reversible syndrome very common in older patients with AHF, increases the risk of disability and other adverse health outcomes. This position paper highlights the need to identify frailty in order to improve prognosis, the risk–benefits of invasive diagnostic and therapeutic procedures, and the definition of older-person-centred and integrated care plans.
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