among lung compartments, it was expected that they correlate closely. EFFi is easier to study, as it is noninvasive and may be continuously monitored. The study is limited to small groups. However, at health, the results show a low degree of variation, as expected from absence of variability caused by disease. The total separation between health and ARDS indicates that, in mechanically ventilated patients, EFFi may be useful for monitoring of ARDS evolution. This aspect is strengthened by the fact that EFFi may automatically, continuously, and noninvasively be monitored in the individual patient, who then serves as his own standard of reference. EFFi merits further studies in broad materials covering ARDS and other diseases, performed with modern capnographic equipment. n Author disclosures are available with the text of this letter at www.atsjournals.org.

Background Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence. Methods This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees’ ability to adequately classify lung regions with normal aeration, interstitial–alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert. Results Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days. Conclusions A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial–alveolar syndrome, and consolidation in emergency and critically ill patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

PurposeEarly discharge from the intensive care unit (ICU) may constitute a strategy of resource consumption optimization; however, unplanned readmission of hospitalized patients to an ICU is associated with a worse outcome. We aimed to compare the effectiveness of the Stability and Workload Index for Transfer score (SWIFT), Sequential Organ Failure Assessment score (SOFA) and simplified Therapeutic Intervention Scoring System (TISS-28) in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU.MethodsWe conducted a prospective cohort study in a single tertiary hospital in southern Brazil. All adult patients admitted to the ICU for more than 24 hours from January 2008 to December 2009 were evaluated. SWIFT, SOFA and TISS-28 scores were calculated on the day of discharge from the ICU. A stepwise logistic regression was conducted to evaluate the effectiveness of these scores in predicting unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU. Moreover, we conducted a direct accuracy comparison among SWIFT, SOFA and TISS-28 scores.ResultsA total of 1,277 patients were discharged from the ICU during the study period. The rate of unplanned ICU readmission or unexpected death in the first 48 hours after discharge from the ICU was 15% (192 patients). In the multivariate analysis, age (P = 0.001), length of ICU stay (P = 0.01), cirrhosis (P = 0.03), SWIFT (P = 0.001), SOFA (P = 0.01) and TISS-28 (P<0.001) constituted predictors of unplanned ICU readmission or unexpected death. The SWIFT, SOFA and TISS-28 scores showed similar predictive accuracy (AUC values were 0.66, 0.65 and 0.74, respectively; P = 0.58).ConclusionsSWIFT, SOFA and TISS-28 on the day of discharge from the ICU have only moderate accuracy in predicting ICU readmission or death. The present study did not find any differences in accuracy among the three scores.

Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.