International evidence-based recommendations for point-of-care lung ultrasound

Abstract

Background: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings. Methods: A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus. Results: Seventythree proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/ conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear. Conclusions: This document reflects the overall results of the first consensus conference on ''point-of-care'' lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

Diagnostic accuracy of basic lung ultrasound in breathless patients over 60 years of age; stressing the protocol

“…Since our research, international consensus guidelines have been released recommending that a positive field be considered as three or more B‐lines, shown between two ribs in a longitudinal plane, yet references the tangential studies 1 . We have presented data that supports, quantifies and yet modifies the evidence upon which these guidelines are based 4 …”

“…The intention of this study was to investigate a practical, auditable beginner's protocol, hence the choice of dichotomous decision, limited views and still image storage. The storage of still images compels compliance with the international recommendations 1 (three separate B lines) but led to some disagreements between blinded reviewer and bedside sonologists who were inexperienced with the cine‐loop function 17 . Further analysis of the false negative and false positive subgroups of scans will be performed.…”

“…This research was instigated to see how an internationally recognised lung ultrasound protocol 1 (LUS) performs in the differentiation of pulmonary oedema from other causes of breathlessness in elderly patients presenting to the emergency department. This protocol has been tested in exclusive groups with high rates of pulmonary oedema 2 – 7 but has yet to be challenged by a widened spectrum of disease.…”

“…It is predicted that the sensitivity of the recommended protocol 1 will fall as the inclusion criterion widens. Specificity is likely to reduce when the target condition changes from radiographically defined ‘interstitial syndrome’ to the more clinically relevant ‘pulmonary oedema.’ 2 , 4 – 7 , 15 This study challenges the protocol and generates robust test characteristics by using practitioners with varying skill, asking the most relevant question of an inclusive population.…”

Comparison of a basic lung scanning protocol against formally reported chest x‐ray in the diagnosis of pulmonary oedema

“…We used a modification of the Volpicelli, et al 21 scanning protocol, since ratified by the international consensus group 28 . This requires 4 pictures each side, one anterosuperior then one anteroinferior in the mid clavicular line (sagittal plane), one anterior axillary (oblique) and one laterobasal (coronal) view (Figure 1).…”