ERS statement on chest imaging in acute respiratory failure

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Abstract

Chest imaging in patients with acute respiratory failure plays an important role in diagnosing, monitoring and assessing the underlying disease. The available modalities range from plain chest X-ray to computed tomography, lung ultrasound, electrical impedance tomography and positron emission tomography. Surprisingly, there are presently no clear-cut recommendations for critical care physicians regarding indications for and limitations of these different techniques.

The purpose of the present European Respiratory Society (ERS) statement is to provide physicians with a comprehensive clinical review of chest imaging techniques for the assessment of patients with acute respiratory failure, based on the scientific evidence as identified by systematic searches. For each of these imaging techniques, the panel evaluated the following items: possible indications, technical aspects, qualitative and quantitative analysis of lung morphology and the potential interplay with mechanical ventilation. A systematic search of the literature was performed from inception to September 2018. A first search provided 1833 references. After evaluating the full text and discussion among the committee, 135 references were used to prepare the current statement.

These chest imaging techniques allow a better assessment and understanding of the pathogenesis and pathophysiology of patients with acute respiratory failure, but have different indications and can provide additional information to each other.

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Most cited references 120

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The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome.

DANIEL LICHTENSTEIN, GILBERT MÉZIÈRE, PHILIPPE BIDERMAN … (1997)

Can ultrasound be of any help in the diagnosis of alveolar-interstitial syndrome? In a prospective study, we examined 250 consecutive patients in a medical intensive care unit: 121 patients with radiologic alveolar-interstitial syndrome (disseminated to the whole lung, n = 92; localized, n = 29) and 129 patients without radiologic evidence of alveolar-interstitial syndrome. The antero-lateral chest wall was examined using ultrasound. The ultrasonic feature of multiple comet-tail artifacts fanning out from the lung surface was investigated. This pattern was present all over the lung surface in 86 of 92 patients with diffuse alveolar-interstitial syndrome (sensitivity of 93.4%). It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specificity of 93.0%). Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact. In conclusion, presence of the comet-tail artifact allowed diagnosis of alveolar-interstitial syndrome.

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Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment.

Belaïd Bouhemad, Hélène Brisson, Morgan Le-Guen … (2011)

In the critically ill patients, lung ultrasound (LUS) is increasingly being used at the bedside for assessing alveolar-interstitial syndrome, lung consolidation, pneumonia, pneumothorax, and pleural effusion. It could be an easily repeatable noninvasive tool for assessing lung recruitment. Our goal was to compare the pressure-volume (PV) curve method with LUS for assessing positive end-expiratory pressure (PEEP)-induced lung recruitment in patients with acute respiratory distress syndrome/acute lung injury (ARDS/ALI). Thirty patients with ARDS and 10 patients with ALI were prospectively studied. PV curves and LUS were performed in PEEP 0 and PEEP 15 cm H₂O₂. PEEP-induced lung recruitment was measured using the PV curve method. Four LUS entities were defined: consolidation; multiple, irregularly spaced B lines; multiple coalescent B lines; and normal aeration. For each of the 12 lung regions examined, PEEP-induced ultrasound changes were measured, and an ultrasound reaeration score was calculated. A highly significant correlation was found between PEEP-induced lung recruitment measured by PV curves and ultrasound reaeration score (Rho = 0.88; P < 0.0001). An ultrasound reaeration score of +8 or higher was associated with a PEEP-induced lung recruitment greater than 600 ml. An ultrasound lung reaeration score of +4 or less was associated with a PEEP-induced lung recruitment ranging from 75 to 450 ml. A statistically significant correlation was found between LUS reaeration score and PEEP-induced increase in Pa(O₂) (Rho = 0.63; P < 0.05). PEEP-induced lung recruitment can be adequately estimated with bedside LUS. Because LUS cannot assess PEEP-induced lung hyperinflation, it should not be the sole method for PEEP titration.