Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures, and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training, and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multi-centre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

BackgroundClinical lung ultrasound examinations are widely used in the primary assessment or monitoring of patients with dyspnoea or respiratory failure. Despite being increasingly implemented, there is no international consensus on education, assessment of competencies, and certification. Today, training is usually based on the concept of mastery learning, but is often unstructured and limited by bustle in a clinical daily life. The aim of the systematic review is to provide an overview of published learning studies in clinical lung ultrasound, and to collect evidence for future recommendations in lung ultrasound education and certification.MethodsAccording to PRISMA guidelines, three databases (PubMed, Embase, Cochrane Library) were searched, and two reviewers examined the results for eligibility. Included publications were described and assessed for level of evidence and risk of bias according to guidelines from Oxford Centre for Evidence-Based Medicine and Cochrane Collaboration Tool for Risk of Bias assessment.ResultsOf 7796 studies screened, 16 studies were included. Twelve pre- and post-test studies, three descriptive studies and one randomized controlled trial were identified. Seven studies included web-based or online modalities, while remaining used didactic or classroom-based lectures. Twelve (75%) studies provided hands-on sessions, and of these, 11 assessed participants’ hands-on skills. None of the studies used validated neither written nor practical assessment. The highest level of evidence score was 2 (n = 1), remaining scored 4 (n = 15). Risk of bias was assessed high in 11 of 16 studies (68.75%).ConclusionAll educational methods proved increased theoretical and practical knowledge obtained at the ultrasound courses, but the included studies were substantial heterogeneous in setup, learning-, and assessment methods, and outcome measures. On behalf of current published studies, it was not possible to construct clear guidelines for the future education and certification in clinical lung ultrasound, but the use of different hands-on training facilities tends to contribute to different aspects of the learning process. This systematic review proves a lack of learning studies within this content, and research with validated theoretical and practical tests for assessment is desired.

Background: The use of simulators in a training programme for technically challenging procedures has the advantages of lowering the risk of patient complications while helping the trainees with the initial part of their learning curve. Objectives: The aim of this study was to perform a systematic review of simulation-based training in flexible bronchoscopy and endobronchial ultrasound (EBUS). Methods: We identified 1,006 publications in the PubMed database and included publications on flexible bronchoscopy below the carina and EBUS involving hands-on simulation-based training. Publications were excluded if they were written in languages other than English, if paediatric airways were involved or if they were not journal articles. The screening process was performed by 2 individuals, and a third reviewer made the final decision in case of disagreement. Results: We included 30 publications. The studies included participants of varying experience and most commonly used a virtual reality simulator as a training modality. Assessment of the participants' skills was based on simulator metrics or on an assessment tool. Some studies included performance on patients for assessment of the operator after training on a simulator. Conclusions: Simulation-based training was demonstrated to be more efficient than the traditional apprenticeship model. Physical models and virtual reality simulators complement each other. Simulation-based education should be based on a mastery learning approach and structured as directed self-regulated learning in a distributed training programme.

Introduction Crowding of the emergency departments is an increasing problem. Many patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are often treated in the emergency departments for a very short period before discharged to their homes. It is possible that this treatment could take place in the patients’ homes with sufficient diagnostics supporting the treatment. In an effort to keep the diagnostics and treatment of some of these patients in their homes and thus to reduce the patient load at the emergency departments, we implemented a prehospital treat-and-release strategy based on ultrasonography and blood testing performed by emergency medical technicians (EMT) or paramedics (PM) in patients with acute exacerbation of COPD. Method EMTs and PMs were enrolled in a six-hour educational program covering ultrasonography of the lungs and point of care blood tests. During the seasonal peak of COPD exacerbations (October 2018 – May 2019) all patients who were treated by the ambulance crews for respiratory insufficiency were screened in the ambulances. If the patient had uncomplicated COPD not requiring immediate transport to the hospital, ultrasonographic examination of the lungs, measurements of C-reactive protein and venous blood gases analyses were performed. The response to the initial treatment and the results obtained were discussed via telemedical consultation with a prehospital anaesthesiologist who then decided to either release the patient at the scene or to have the patient transported to the hospital. The primary outcome was strategy feasibility. Results We included 100 EMTs and PMs in the study. During the study period, 771 patients with respiratory insufficiency were screened. Uncomplicated COPD was rare as only 41patients were treated according to the treat-and-release strategy. Twenty of these patients (49%) were released at the scene. In further ten patients, technical problems were encountered hindering release at the scene. Conclusion In a few selected patients with suspected acute exacerbations of COPD, it was technically and organisationally feasible for EMTs and PMs to perform prehospital POCT-ultrasound and laboratory testing and release the patients following treatment. None of the patients released at the scene requested a secondary ambulance within the first 48 h following the intervention.

Background In a prehospital setting, the severity of respiratory symptoms in patients calling for an ambulance differ. The initial evaluation, diagnosing, and thereby management can be challenging because respiratory symptoms can be caused by disease in many organs. Ultrasound examinations can contribute with important information and support the clinical decision-making. However, ultrasound is user-dependent and requires sufficient knowledge and training. The aim of this study was to explore the quality of thoracic ultrasound examinations performed on patients by emergency medical technicians and paramedics in a prehospital, clinical setting. Methods From November 2018 – April 2020, Danish emergency medical technicians and paramedics (n = 100) performed thoracic ultrasound examinations on patients with respiratory symptoms using a portable ultrasound device. The ultrasound examinations were stored and retrospectively assessed by a reviewer blinded to the patients’ symptoms and history, as well as the emergency medical technicians’ and paramedics’ findings. The image quality was scored from 1 to 5. The findings determined by the reviewer was then correlated with a questionnaire filled out by the emergency medical technicians and paramedics regarding ultrasonic findings and potential change in treatment or management of the patient. The agreement in percentage and as Cohen’s kappa was explored. Results A total of 590 ultrasound examinations were assessed, resulting in a median image quality score of 3 (IQ1 = 4, IQ3 = 3). The overall agreement in percentage between the emergency medical technicians and paramedics and reviewer was high (87.7% for a normal scan, 89.9% for interstitial syndrome, 97.3% for possible pneumothorax, and 96.3% for pleural effusion). Cohen’s kappa varied from 0.01 for possible pneumothorax to 0.69 for pleural effusion. Based on the questionnaires (n = 406), the ultrasound examination entailed a change in treatment or visitation in 48 cases (11.7%) which in this study population encompasses a number-needed-to-scan of 8.5. Conclusion Emergency medical technicians and paramedics perform focused thoracic ultrasound examinations with adequate image quality sufficient to determine if pathology is present or not. The emergency medical technicians’ and paramedics’ assessment correlates to some extent with an experienced reviewer and their findings are most reliable for the inclusion of a normal scan or inclusion of pleural effusion. Implementation could possibly impact the number of patients receiving correct prehospital treatment and optimal choice of receiving facility.

Background: Thoracic ultrasound (TUS) has a high diagnostic accuracy for many common pulmonary diseases, but theoretic knowledge in sonographic physics, thoracic anatomy and physiology, and sonopathologic patterns is required to develop competence. Objectives: The aims of the study were to develop and gather validity evidence for a theoretical test in TUS and to establish a pass/fail standard. Methods: Content was provided based on expert interviews, leading to creation of 113 initial multiple-choice (MCQ) items. Consensus was reached on 92 proceeding items through a Delphiprocess, and items were presented to physicians with different knowledge and experience in TUS. Answers were used for item statistics in order to select the items with the most optimal item discrimination and difficulty (i.e. Level 1 items) to be included in the final test. Mean scores of the novice-, intermediate-and experienced group were compared, and a pass/fail score was established using the contrasting groups' standard setting method. Results: Item statistic revealed 38 Level 1 items, of which 30 were selected to be included in the final test. The internal consistency was high (Cronbach's alpha =0.88). Differences in mean scores were 8.6 points (p<0.001), 6.3 points (p=0.01), and 14.0 points (p<0.001) between novices and intermediates, intermediates and experienced, and novices and experienced, respectively. A pass/fail standard of 20 points was established. Conclusion: The established MCQ-test can distinguish between physicians with different level of competence in TUS, and enables an objective, evidence-based approach for assessing the theoretical knowledge for trainees undergoing an educational program in TUS.

Background: Clinical lung ultrasound (LUS) is a fast bedside diagnostic tool which can assist clinicians in decisions regarding the treatment and monitoring of patients with respiratory symptoms. LUS training and education differ widely, and is often done in a clinical setting, with potential risks for patients if decisions are made based on the wrong interpretations. No clear guidelines or recommendations for objective and standardized assessment of LUS skills exist, and those that do are often based on a fixed time-frame or an arbitrary number of examinations performed; this does not ensure adequate competencies. Objectives: The study aimed to develop and gather validity evidence for a practical, simulation-based test in LUS. Methods: Nine cases were developed in collaboration with 3D Systems Healthcare, Littleton, CO, USA, representing the most common diagnosis and sonographic findings in patients with respiratory symptoms. Thirty-six participants with different levels of competence in LUS, completed the test. The participants were divided into groups, i.e., novices, intermediates, and experienced, according to their experience with LUS, the number of examinations they had performed, and any research they had conducted. Their answers were used for item analyses. Results: The intraclass correlation coefficient, Cronbachs’ α, was 0.69 summarized, and there was a statistically significant difference (p < 0.001) between the novices and the trained participants (intermediates and experienced). A pass/fail score of 16 points was calculated according to the contrasting-groups method. Conclusion: We developed a test for the assessment of clinical competencies in LUS. The test proved solid validity evidence, and a pass/fail standard without any false-negatives, and only 2 explained false-positives.

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