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Expert Consensus on Advanced Critical Care EchocardiographyAdvanced Critical Care Echocardiography: Opportunity to Do It Right FREE TO VIEW

Gregory A. Schmidt, MD, FCCP
Author and Funding Information

From the Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa.

Correspondence to: Gregory A. Schmidt, MD, FCCP, Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242; e-mail: Gregory-a-schmidt@uiowa.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. 2014;145(6):1188-1189. doi:10.1378/chest.14-0502
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Published online

These are exciting times for echocardiography in the ICU. Several factors, including the following, have combined to produce a boom: high-quality ultrasound devices are commonplace in the ICU, increasing numbers of intensivists and fellows have sought out specialized training in critical care ultrasonography and echocardiography, echocardiography regularly reveals findings that complement more traditional measures of hemodynamic status, and intensivists have learned that personally integrating echocardiography into clinical assessment and treatment improves the traditional cardiologist-consultant model of formal echocardiography.1 Basic critical care echocardiography (BCCE) is goal oriented, seeks to answer a limited number of clinical questions, uses five basic views (parasternal long- and short-axis, apical four-chamber, subxiphoid, and inferior vena caval), and should be required training for all intensivists.2 On the other hand, advanced critical care echocardiography (ACCE) requires a comprehensive evaluation of cardiac anatomy and physiology, includes additional views and techniques (including transesophageal echocardiography [TEE] and Doppler), and, because it requires substantial additional training, is optional for the intensivist.2 ACCE addresses a broader range of clinical questions than does BCCE, such as those surrounding regional ventricular function, valvular assessment, measurement of pressures and flows, diastolic function, tamponade, aortic dissection, and many others.

Will intensivists embrace ACCE? Like cardiac anesthesiologists in the operating room, intensivists are uniquely qualified to apply ACCE because of the nature of their work. Take, for example, management of the patient with severe ARDS. Good evidence shows that clinically significant right ventricular dysfunction is common and that echocardiography (both via transthoracic and TEE approaches), yields images that show whether right ventricular dysfunction is present, how severe it is, and how it responds to interventions in real time.3-5 Moreover, modest changes in ventilator settings, blood gas values, vasoactive medications, fluid infusions, or even body positioning can provoke hemodynamic deterioration in ways that would be difficult to judge, monitor, or respond to without ACCE. One can readily imagine that intensivist-conducted echocardiography, especially when this includes advanced capabilities, will alter management and improve outcomes at modest cost and little risk. It seems self-evident that the future is bright.

But perhaps this is a good time to recall the history of the adoption of the pulmonary artery catheter (PAC) by intensivists. Pressure tracings of the right side of the heart, insight into left-sided heart function through the pulmonary artery occlusion pressure, accurate estimates of cardiac output, and chamber-specific oxyhemoglobin saturation values promised to guide management of the critically ill and save patients with shock, ARDS, and failing hearts. But it did not work out that way. In the ensuing decades, we learned that obtaining valid data was not simple,6 physicians could not agree on how to translate the data into a plan,7 and accurate data and explicit protocols simply failed to lead to the expected benefits.8 No doubt some of this can be blamed on intensivists’ woeful lack of knowledge regarding the PAC.9 Haphazard training may have played a role. There were wide variations in what was taught, how much experience was expected before independent practice, and how competency was judged (if at all). If we could start all over again, we would surely begin with a curriculum, incorporate rigorous methodology into the training of fellows and practicing physicians, document competence rigorously, and then conduct clinical trials.

This editorial coincides with the publication of an International Expert Consensus Statement on ACCE.10 Professional societies from Europe, Asia, Australia, and North America, including the American College of Chest Physicians, contributed to and have endorsed the statement. The document builds on the foundation of two prior consensus publications regarding the competencies2 and training standards11 for critical care ultrasound and BCCE. Like them, the new statement describes, in rich detail, what is expected of physicians wishing to incorporate advanced echocardiographic techniques, including TEE, into ICU practice. Comprehensive tables list the views, qualitative and quantitative assessments, clinical questions, and requirements for faculty teaching ACCE. A detailed scoring system to judge competency is proposed. A particular strength of the statement is its emphasis on judging formal competence, including a specific instrument for testing. The authors conclude that, unlike for general critical care ultrasonography and BCCE, national-level certification should be awarded to those completing formal training and demonstrating competence in advanced ACCE.

This consensus should prove highly valuable, especially when considered along with the two previous expert consensus statements. Programs can now develop training content, expecting that a similar syllabus will be taught to intensivists in other programs and even in other countries. In addition, training faculty know what competencies they must develop so that they can teach, supervise, and evaluate trainees. One can imagine that the core curriculum encouraged by this statement may facilitate the development of standardized software for displaying, comparing, and reporting ACCE studies. Importantly, the statement describes the expectations for training in ACCE in sufficient detail to act as a blueprint for the future. If only we had implemented PAC training with similar forethought!

It remains to be seen how many intensivists will embrace ACCE, given the extra training and testing required for full competence and certification. No doubt many will be satisfied with BCCE. Others will learn and practice certain components of ACCE that complement their patient population, without seeking broader competence or formal certification. But for those who recognize the value to patient care added by the ACCE-capable intensivist, a structured framework for training will be a huge asset. More importantly, clear guidelines on content and competence may help us avoid the missteps that dogged the PAC.

References

Schmidt GA. ICU ultrasound. The coming boom. Chest. 2009;135(6):1407-1408. [CrossRef]
 
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]
 
Vieillard-Baron A, Schmitt J-M, Augarde R, et al. Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Crit Care Med. 2001;29(8):1551-1555. [CrossRef]
 
Mekontso Dessap A, Charron C, Devaquet J, et al. Impact of acute hypercapnia and augmented positive end-expiratory pressure on right ventricle function in severe acute respiratory distress syndrome. Intensive Care Med. 2009;35(11):1850-1858. [CrossRef]
 
Jozwiak M, Teboul J-L, Anguel N, et al. Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2013;188(12):1428-1433. [CrossRef]
 
Al-Kharrat T, Zarich S, Amoateng-Adjepong Y, Manthous CA. Analysis of observer variability in measurement of pulmonary artery occlusion pressures. Am J Respir Crit Care Med. 1999;160(2):415-420. [CrossRef]
 
Jain M, Canham M, Upadhyay D, Corbridge T. Variability in interventions with pulmonary artery catheter data. Intensive Care Med. 2003;29(11):2059-2062. [CrossRef]
 
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;Wheeler AP, Bernard GR, Thompson BT, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006;354(21):2213-2224. [CrossRef]
 
Iberti TJ, Fischer EP, Leibowitz AB, Panacek EA, Silverstein JH, Albertson TE; Pulmonary Artery Catheter Study Group. A multicenter study of physicians’ knowledge of the pulmonary artery catheter. JAMA. 1990;264(22):2928-2932. [CrossRef]
 
Vieillard-Baron A, Mayo PH, Vignon P, et al. International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med. 2014;40(5):654-666. [CrossRef]
 
Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011;37(7):1077-1083. [CrossRef]
 

Figures

Tables

References

Schmidt GA. ICU ultrasound. The coming boom. Chest. 2009;135(6):1407-1408. [CrossRef]
 
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]
 
Vieillard-Baron A, Schmitt J-M, Augarde R, et al. Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Crit Care Med. 2001;29(8):1551-1555. [CrossRef]
 
Mekontso Dessap A, Charron C, Devaquet J, et al. Impact of acute hypercapnia and augmented positive end-expiratory pressure on right ventricle function in severe acute respiratory distress syndrome. Intensive Care Med. 2009;35(11):1850-1858. [CrossRef]
 
Jozwiak M, Teboul J-L, Anguel N, et al. Beneficial hemodynamic effects of prone positioning in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2013;188(12):1428-1433. [CrossRef]
 
Al-Kharrat T, Zarich S, Amoateng-Adjepong Y, Manthous CA. Analysis of observer variability in measurement of pulmonary artery occlusion pressures. Am J Respir Crit Care Med. 1999;160(2):415-420. [CrossRef]
 
Jain M, Canham M, Upadhyay D, Corbridge T. Variability in interventions with pulmonary artery catheter data. Intensive Care Med. 2003;29(11):2059-2062. [CrossRef]
 
National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network;Wheeler AP, Bernard GR, Thompson BT, et al. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med. 2006;354(21):2213-2224. [CrossRef]
 
Iberti TJ, Fischer EP, Leibowitz AB, Panacek EA, Silverstein JH, Albertson TE; Pulmonary Artery Catheter Study Group. A multicenter study of physicians’ knowledge of the pulmonary artery catheter. JAMA. 1990;264(22):2928-2932. [CrossRef]
 
Vieillard-Baron A, Mayo PH, Vignon P, et al. International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med. 2014;40(5):654-666. [CrossRef]
 
Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultrasonography. Intensive Care Med. 2011;37(7):1077-1083. [CrossRef]
 
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