scholarly journals Quantitative Lung Ultrasonography for the Nephrologist: Applications in Dialysis and Heart Failure

Kidney360 ◽  
2021 ◽  
pp. 10.34067/KID.0003972021
Author(s):  
Nathaniel Reisinger ◽  
Abhilash Koratala
Keyword(s):  
Heart Failure ◽  
Acute Care ◽  
Extravascular Lung Water ◽  
Lung Ultrasound ◽  
Volume Overload ◽  
Care Utilization ◽  
Lung Ultrasonography ◽  
Lung Water ◽  
Acute Care Utilization ◽  
B Lines

Volume overload and its attendant increase in acute care utilization and cardiovascular morbidity and mortality represents a critical challenge for the practicing nephrologist. This is particularly true among patients with ESKD on HD where pre-dialysis volume overload and intradialytic and postdialytic hypovolemia account for almost a third of all cost for the Medicare dialysis benefit. Quantitative lung ultrasound is a tool for assessing the extent of extravascular lung water which outperforms physical exam and plain chest radiography. B-lines are vertical hyperechoic artifacts present in patients with increased extravascular lung water. B-lines have been shown to decrease dynamically during the hemodialysis treatment in proportion to ultrafiltration volume. Among patients with chronic heart failure, titration of diuretics based on the extent of pulmonary congestion noted on lung ultrasonography has been shown to decrease recurrent acute care utilization. Early data from randomized-controlled trials of lung ultrasound-guided ultrafiltration therapy among patients with ESKD on HD have shown promise for potential reduction in recurrent episodes of decompensated heart failure and cardiovascular events. Ultimately lung ultrasound may predict those who are ultrafiltration tolerant and could be used to decreased acute care utilization and thus cost in this population.

scholarly journals The Association Between Patient-reported Clinical Factors and 30-day Acute Care Utilization in Chronic Heart Failure

Medical Care ◽  
2020 ◽  
Vol 58 (4) ◽  
pp. 336-343 ◽  
Author(s):  
Jinying Chen ◽  
Rajani Sadasivam ◽  
Amanda C. Blok ◽  
Christine S. Ritchie ◽  
Catherine Nagawa ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Acute Care ◽  
Care Utilization ◽  
Clinical Factors ◽  
Patient Reported ◽  
Acute Care Utilization

scholarly journals Post-discharge Acute Care and Outcomes in the Era of Readmission Reduction

2019 ◽  
Author(s):  
Rohan Khera ◽  
Yongfei Wang ◽  
Susannah M. Bernheim ◽  
Zhenqiu Lin ◽  
Harlan M. Krumholz
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Acute Care ◽  
Care Utilization ◽  
Post Discharge ◽  
Readmission Rates ◽  
Risk Of Death ◽  
Observation Units ◽  
Acute Care Utilization ◽  
Significant Change

ABSTRACTBackgroundWith incentives to reduce readmission rates, there are concerns that patients who need hospitalization after a recent hospital discharge may be denied access, which would increase their risk of mortality.ObjectiveWe determined whether patients with hospitalizations for conditions covered by national readmission programs who received care in emergency department (ED) or observation units but were not hospitalized within 30 days had an increased risk of death. We also evaluated temporal trends in post-discharge acute care utilization in inpatient units, emergency department (ED) and observation units for these patients.Design, Setting, and ParticipantsIn this observational study, national Medicare claims data for 2008-2016, we identified patients ≥65 years hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia, conditions included in the HRRP.Main Outcomes and MeasuresPost-discharge 30-day mortality according to patients’ 30-day acute care utilization. Acute care utilization in inpatient and observation units, and the ED during the 30-day and 31-90-day post-discharge period.ResultsThere were 3,772,924 hospitalizations for HF, 1,570,113 for AMI, and 3,131,162 for pneumonia. The overall post-discharge 30-day mortality was 8.7% for HF, 7.3% for AMI, and 8.4% for pneumonia. Post-discharge mortality increased annually by 0.16% (95% CI, 0.11%, 0.22%) for HF, decreased by 0.15% (95% CI, -0.18%, -0.12%) for AMI, and did not significantly change for pneumonia. Specifically, mortality only increased for HF patients who did not utilize any post-discharge acute care, increasing at a rate of 0.16% per year (95% CI, 0.11%, 0.22%), accounting for 99% of the increase in post-discharge mortality in heart failure. Concurrent with a reduction in 30-day readmission rates, 30-day observation stays and visits to the ED increased across all 3 conditions during and beyond the post-discharge 30-day period. There was no significant change in overall 30-day post-acute care utilization (P-trend >0.05 for all).Conclusions and RelevanceThe only condition with an increasing mortality through the study period was HF; the increase preceded the policy and was not present among those received ED or observation unit care without hospitalization. Overall, during this period, there was not a significant change in the overall 30-day post-discharge acute care utilization.

scholarly journals Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: A two-centre cohort study

2016 ◽  
Vol 6 (1) ◽  
Author(s):  
Stefano Coiro ◽  
Guillaume Porot ◽  
Patrick Rossignol ◽  
Giuseppe Ambrosio ◽  
Erberto Carluccio ◽  
...  
Keyword(s):  
Heart Failure ◽  
Poor Prognosis ◽  
Prognostic Value ◽  
Lung Ultrasound ◽  
Systolic Arterial Pressure ◽  
Lung Ultrasonography ◽  
Pulmonary Congestion ◽  
Prognostic Role ◽  
Heart Failure Hospitalisation ◽  
B Lines

Abstract Pulmonary congestion assessed at discharge by lung ultrasonography predicts poor prognosis in heart failure (HF) patients. We investigated the association of B-lines with indices of hemodynamic congestion [BNP, E/e’, pulmonary systolic arterial pressure (PAPs)] in HF patients, and their prognostic value overall and according to concomitant atrial fibrillation (AF), reduced (≤40%) ejection fraction (EF), and timing of quantification during hospitalisation for heart failure (HHF). In 110 HHF patients, B-lines were highly discriminative of BNP >400 pg/ml (AUC ≥ 0.80 for all), and moderately discriminative of PAPs >50 mmHg (AUC = 0.68, 0.56 to 0.80); conversely, B-lines poorly discriminated average E/e’ ≥ 15, except at discharge. B-line count significantly predicted mid-term recurrent HHF or death (overall and in subgroups), regardless of AF status, EF, and timing of quantification during HHF (all p for interaction >0.10). regardless, B-lines ≥30 at discharge were most predictive of outcome (HR = 7.11, 2.06–24.48; p = 0.002) while B-lines ≥45 early during HHF were most predictive of outcome (HR = 9.20, 1.82–46.61; p = 0.007). Lung ultrasound was able to identify patients with high BNP levels, but not with increased E/e’, also showing a prognostic role regardless of AF status, EF or timing of quantification; best B-line cut-off appears to vary according to the timing of quantification during hospitalization.

Lung Ultrasound Predicts Well Extravascular Lung Water but Is of Limited Usefulness in the Prediction of Wedge Pressure

2014 ◽  
Vol 121 (2) ◽  
pp. 320-327 ◽  
Author(s):  
Giovanni Volpicelli ◽  
Stefano Skurzak ◽  
Enrico Boero ◽  
Giuseppe Carpinteri ◽  
Marco Tengattini ◽  
...  
Keyword(s):  
Pulmonary Artery ◽  
Extravascular Lung Water ◽  
Lung Ultrasound ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Pulmonary Congestion ◽  
Lung Water ◽  
Ventricular Ejection Fraction ◽  
B Lines ◽  
Limited Usefulness

Abstract Background: Pulmonary congestion is indicated at lung ultrasound by detection of B-lines, but correlation of these ultrasound signs with pulmonary artery occlusion pressure (PAOP) and extravascular lung water (EVLW) still remains to be further explored. The aim of the study was to assess whether B-lines, and eventually a combination with left ventricular ejection fraction (LVEF) assessment, are useful to differentiate low/high PAOP and EVLW in critically ill patients. Methods: The authors enrolled 73 patients requiring invasive monitoring from the intensive care unit of four university-affiliated hospitals. Forty-one patients underwent PAOP measurement by pulmonary artery catheterization and 32 patients had EVLW measured by transpulmonary thermodilution method. Lung and cardiac ultrasound examinations focused to the evaluation of B-lines and gross estimation of LVEF were performed. The absence of diffuse B-lines (A-pattern) versus the pattern showing prevalent B-lines (B-pattern) and the combination with normal or impaired LVEF were correlated with cutoff levels of PAOP and EVLW. Results: PAOP of 18 mmHg or less was predicted by the A-pattern with 85.7% sensitivity (95% CI, 70.5 to 94.1%) and 40.0% specificity (CI, 25.4 to 56.4%), whereas EVLW 10 ml/kg or less with 81.0% sensitivity (CI, 62.6 to 91.9%) and 90.9% specificity (CI, 74.2 to 97.7%). The combination of A-pattern with normal LVEF increased sensitivity to 100% (CI, 84.5 to 100%) and specificity to 72.7% (CI, 52.0 to 87.2%) for the prediction of PAOP 18 mmHg or less. Conclusions: B-lines allow good prediction of pulmonary congestion indicated by EVLW, whereas are of limited usefulness for the prediction of hemodynamic congestion indicated by PAOP. Combining B-lines with estimation of LVEF at transthoracic ultrasound may improve the prediction of PAOP.

scholarly journals Lung Ultrasound to Quantitatively Evaluate Extravascular Lung Water Content and its Clinical Significance

2020 ◽  
Author(s):  
Guo Guo ◽  
Xue-Feng Zhang ◽  
Jing Liu ◽  
Hai-Feng Zong
Keyword(s):  
Extravascular Lung Water ◽  
Lung Ultrasound ◽  
Rabbit Model ◽  
Dry Weight ◽  
Type I ◽  
Lung Water ◽  
Arterial Blood Gas ◽  
Injection Volume ◽  
Arterial Blood ◽  
B Lines

Abstract Background:B-line assessment with lung ultrasound (LUS) has recently been proposed as a reliable, noninvasive semiquantitative tool for evaluating extravascular lung water (EVLW). Currently, there has been no easy quantitative method to evaluate EVLW by LUS. To establish a simple, accurate and clinically operable method for quantitative assessment of EVLW using LUS. Methods:Forty-five New Zealand rabbits were randomized into 9 groups (n=5). After anesthesia, each group of rabbits was injected with different amounts of warm sterile NS (0 ml/kg, 2 ml/kg, 4 ml/kg, 6 ml/kg, 8 ml/kg, 10 ml/kg, 15 ml/kg, 20 ml/kg, 30 ml/kg) via the endotracheal tube. Each rabbit was examined by LUS before and after NS injection. At the same time, the spontaneous respiratory rate (RR, breaths per minute), heart rate (HR, bpm) and arterial blood gas (ABG) of the rabbits were recorded. Then, both lungs were dissected to obtain the wet and dry weight and conduct a complete histological examination.Results:Injecting NS into the lungs through a tracheal tube can successfully establish a rabbit model with increased EVLW. When theNS injection volume is 2~6 ml/kg, comet-tail artifacts and B-lines are the main patterns found on LUS; as additional NS is injected into the lungs, the rabbits' RR gradually increases, while their HR gradually decreases. Confluent B-lines grow gradually but significantly, reaching a dominant position when the NS injection volume reaches 6~8 ml/kg and predominating almost entirely when the NS injection volume is 8~15 ml/kg; at that time, rabbits' RRs and HRs decrease sharply, and the ABG indicated type I respiratory failure (RF). Compact B-lines occur and predominate almost entirely when the NS injection volume reaches 10 ml/kg and 15~20 ml/kg, respectively. At that time, rabbits begin to enter cardiac and respiratory arrest, and ABG shows type II RF and metabolic acidosis (MA).Conclusion: LUS can estimate EVLW content based on the type of B-line.We can give clinical treatment depending on the type of LUS B-line.

Application of lung ultrasound surface wave elastography for assessment of extravascular lung water in patients hospitalized with congestive heart failure

2019 ◽  
Vol 145 (3) ◽  
pp. 1673-1674
Author(s):  
Brandon M. Wiley ◽  
Boran Zhou ◽  
Govind Pandompatam ◽  
Jinling Zhou ◽  
Hilal Olgun Kucuk ◽  
...  
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Surface Wave ◽  
Extravascular Lung Water ◽  
Lung Ultrasound ◽  
Lung Water

scholarly journals Cost-Effective Reduction of Acute Care Utilization using Home-Based Heart Failure Program.

2019 ◽  
Author(s):  
Victoria Thomas ◽  
Roopa Rao ◽  
Cathy Schubert ◽  
Andrew Nagel ◽  
Rebecca Kafer
Keyword(s):  
Heart Failure ◽  
Acute Care ◽  
Cost Effective ◽  
Care Utilization ◽  
Home Based ◽  
Effective Reduction ◽  
Acute Care Utilization

scholarly journals Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States

BMJ ◽  
2020 ◽  
pp. l6831 ◽  
Author(s):  
Rohan Khera ◽  
Yongfei Wang ◽  
Susannah M Bernheim ◽  
Zhenqiu Lin ◽  
Harlan M Krumholz
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Acute Care ◽  
The United States ◽  
Care Utilization ◽  
Post Discharge ◽  
Observation Units ◽  
Acute Care Utilization

Abstract Objectives To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. Design Retrospective cohort study. Setting Medicare claims data for 2008-16 in the United States. Participants Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia—conditions included in the US Hospital Readmissions Reduction Program. Main outcome measures Post-discharge 30 day mortality according to patients’ 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. Results 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (−0.09% to −0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. Conclusions The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.

scholarly journals B-Lines Scores Derived From Lung Ultrasound Provide Accurate Prediction of Extravascular Lung Water Index: An Observational Study in Critically Ill Patients

2020 ◽  
pp. 088506662096765 ◽  
Author(s):  
Ulrich Mayr ◽  
Marina Lukas ◽  
Livia Habenicht ◽  
Johannes Wiessner ◽  
Markus Heilmaier ◽  
...  
Keyword(s):  
Pulmonary Edema ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Extravascular Lung Water ◽  
Lung Ultrasound ◽  
Lung Water ◽  
Extravascular Lung Water Index ◽  
Water Index ◽  
Non Invasive ◽  
B Lines

Introduction: Visualization of B-lines via lung ultrasound provides a non-invasive estimation of pulmonary hydration. Extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) assessed by transpulmonary thermodilution (TPTD) represent the most validated parameters of lung water and alveolocapillary permeability, but measurement is invasive and expensive. This study aimed to compare the correlations of B-lines scores from extensive 28-sector and simplified 4-sector chest scan with EVLWI and PVPI derived from TPTD in the setting of intensive care unit (primary endpoint). Methods: We performed scoring of 28-sector and 4-sector B-Lines in 50 critically ill patients. TPTD was carried out with the PiCCO-2-device (Pulsion Medical Systems SE, Maquet Getinge Group). Median time exposure for ultrasound procedure was 12 minutes for 28-sector and 4 minutes for 4-sector scan. Results: Primarily, we found close correlations of 28-sector as well as 4-sector B-Lines scores with EVLWI (R2 = 0.895 vs. R2 = 0.880) and PVPI (R2 = 0.760 vs. R2 = 0.742). Both B-lines scores showed high accuracy to identify patients with specific levels of EVLWI and PVPI. The extensive 28-sector B-lines score revealed a moderate advantage compared to simplified 4-sector scan in detecting a normal EVLWI ≤ 7 (28-sector scan: sensitivity = 81.8%, specificity = 94.9%, AUC = 0.939 versus 4-sector scan: sensitivity = 81.8%, specificity = 82.1%, AUC = 0.902). Both protocols were approximately equivalent in prediction of lung edema with EVLWI ≥ 10 (28-sector scan: sensitivity = 88.9%, specificity = 95.7%, AUC = 0.977 versus 4-sector scan: sensitivity = 81.5%, specificity = 91.3%, AUC = 0.958) or severe pulmonary edema with EVLWI ≥ 15 (28-sector scan: sensitivity = 91.7%, specificity = 97.4%, AUC = 0.995 versus 4-sector scan: sensitivity = 91.7%, specificity = 92.1%, AUC = 0.978). As secondary endpoints, our evaluations resulted in significant associations of 28-sector as well as simplified 4-sector B-Lines score with parameters of respiratory function. Conclusion: Both B-line protocols provide accurate non-invasive evaluation of lung water in critically ill patients. The 28-sector scan offers a marginal advantage in prediction of pulmonary edema, but needs substantially more time than 4-sector scan.

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