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Ultrasound CornerUltrasound Corner: Announcing a New Video-Based Ultrasound Series FREE TO VIEW

Seth J. Koenig, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University.

Correspondence to: Seth J. Koenig, MD, FCCP, Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University, 410 Lakeville Rd, Ste 107, New Hyde Park, NY 11040; e-mail: Skoenig@nshs.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(1):4-5. doi:10.1378/chest.12-2520
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Published online

Consider this scenario. A young patient presents with acute respiratory failure and shock requiring mechanical ventilatory support. She has a nondiagnostic supine chest radiograph and a history of a cardiomyopathy. Physical examination fails to reveal a definite diagnosis. Chest CT scans with contrast, echocardiogram, and lower extremity ultrasound duplex study are ordered. While waiting for these results, the care team starts the patient on heparin, inotropes, and vasopressors and begins antibiotics.

Now imagine an alternative. The frontline intensivist immediately performs a goal-directed, point-of-care ultrasound examination which reveals an alveolar consolidation of the left lower lobe with a small pleural effusion, hyperdynamic left ventricular function with normal right ventricular size and function, a 0.5-cm inferior vena cava, bilateral A-line pattern on anterior lung exam, and a negative lower extremity ultrasound compression study. The intensivist concludes that the patient has pneumonia with septic shock and is preload sensitive. There is no evidence of pulmonary embolism or cardiomyopathy, and volume resuscitation is safe, as there is no cardiogenic pulmonary edema.1,2 This young patient is not subjected to a CT scan with contrast, thereby avoiding a large unnecessary radiation dose and contrast exposure. Inotropes and heparin are never initiated. The ultrasound examination is performed in <10 min.

There is a quiet revolution stirring in many ICUs. Critical care specialists are performing and interpreting their own ultrasound exams and developing diagnostic and therapeutic plans without the clinical and time dissociation inherent in standard radiologic and echocardiographic imaging. To grow, this revolution will require a breakdown of current dogma and a paradigm shift in patient management.

This issue of CHEST (see page e1 online at: http://dx.doi.org/10.1378/chest.12-2878)3 features the inaugural appearance of a new video-based case series called “Ultrasound Corner” with the intent of bringing to the reader important aspects of critical care ultrasonography. Through real cases generated by the readership, this section will present key concepts of general critical care ultrasonography. By correlating patient ultrasound studies with standard radiographic imaging, the reader will be challenged to interpret the images and to integrate the results into a patient management plan.

Current dogma compartmentalizes patient management into diagnostic imaging (such as echocardiography and radiology) and patient care based upon history, physical examination, and review of the diagnostic imaging performed by other services. This model does not always work well for critically ill patients.

The paradigm shift involves using the ultrasound machine as an extension of the physical examination. When faced with a patient who has severe cardiopulmonary failure, the intensivist proceeds as usual with the history and the standard physical exam; but now, this individual has the ability to see into the body. This breaks down the compartmentalized approach to patient care by allowing the intensivist to provide primary imaging to obtain rapid diagnostic information that is accurate, repeatable, and portable with no exposure to ionizing radiation.

Training in critical care ultrasonography requires the intensivist to be able to acquire and interpret ultrasound images and use this information to guide clinical management. A competency statement, written in collaboration with the American College of Chest Physicians (ACCP) in partnership with La Société de Réanimation de Langue Française (SRLF), lays out specific requirements in each area of critical care ultrasonography that all intensivists interested in the field should learn.4 The ACCP has developed innovative courses that provide training to the intensive care community in critical care ultrasonography. More than 1,800 critical care specialists have completed the courses. In the coming year, the ultrasound working group at the ACCP will offer a roster of courses including, for the first time, a 3-day program on advanced critical care echocardiography, unique in the United States.

The ACCP has also developed a Certification of Completion training sequence for critical care ultrasonography which includes 50 h of coursework combining hands-on training, a 20-h Internet-based tutorial, a mandatory image portfolio refereed by course faculty, and a challenging video-based, hands-on examination. The ACCP commitment to faculty development aims to train trainers who in turn can bring their skills to the local fellowship program level. With this experiential trickle-down model, ultrasonography will become like bronchoscopy, airway management, mechanical ventilation, vascular access, and pleural procedures: an integral part of pulmonary/critical care medical practice. The Accreditation Council for Graduate Medical Education has taken an important step in this direction by mandating that ultrasound guidance of thoracentesis and vascular access be included as part of fellowship training.

The new “Ultrasound Corner” section, a positive development, calls attention to the use of ultrasonography in critical care medicine. The new section will enhance CHEST’s strong reputation of publishing advances in critical care ultrasonography and serve to continue this tradition.

We encourage readers to submit their ultrasound case reports for this series. Please see the first offering3 as an example of what we seek; if you would like to contribute, follow the detailed instructions at http://journal.publications.chestnet.org/ss/forauthors.aspx for specific information on how to prepare a submission. In this way, we can all learn from each other and establish a worldwide community of critical care ultrasonographers to advance the field.

References

Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142(4):1042-1048. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Koenig SJ, Narasimhan M, Mayo P. Shock: a case of mistaken identity. Chest. 2013;143(1):e1-e3.
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. [CrossRef] [PubMed]
 

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References

Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142(4):1042-1048. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125. [CrossRef] [PubMed]
 
Koenig SJ, Narasimhan M, Mayo P. Shock: a case of mistaken identity. Chest. 2013;143(1):e1-e3.
 
Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest. 2009;135(4):1050-1060. [CrossRef] [PubMed]
 
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