Lung Ultrasound versus Pulmonary Auscultation in Detecting Pulmonary Congestion in the Critically Ill

BACKGROUND: In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound (LUS) as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. AIM: The aim of this study was to compare LUS versus pulmonary auscultation for detecting pulmonary edema in critically ill patients. PATIENTS AND METHODS: Sixty-one patients were included in this study, all included patients underwent clinical examination, chest auscultation of anterior and lateral (axillary) chest wall and back in each hemithorax in supine position was done, followed by LUS using Bedside LUS in Emergency (BLUE) protocol. LUS score was recorded; abnormal auscultation was defined as the presence of rales or wheezes. Laboratory tests were done on admission such as pro-BNP, renal function, and blood gases. Pro-BNP was used as diagnostic tool for volume overload and was correlated with LUS and stethoscope for detecting pulmonary edema. Pneumonia was excluded with normal total leukocyte counts, C-reactive protein, and absence of fever. RESULTS: This study included 61 patients with diagnosis of pulmonary edema, all data were recorded on admission and showed that there was statistically significant good positive correlation between LUS and Pro-BNP (p < 0.05), and Pearson correlation between LUS and Pro-BNP among the studied patients is statistically significant at the 0.01 level (two-tailed). Furthermore, we found that both LUS and Pro-BNP were statistically significant higher among patients with rales (p < 0.05) only 36 (59%) patients were positive as pulmonary edema with pulmonary auscultation (presence of rales) and 25 (41%) patients were negative for pulmonary edema (NO RALES) while they were positive for pulmonary edema with LUS (high LUS score)and pro-BNP. CONCLUSION: Pulmonary auscultation has poor sensitivity for pulmonary congestion while LUS had statistically significant higher sensitivity for pulmonary edema.

Dengue and scrub typhus co-infection causing septic shock

ABSTRACT A 33-year-old female presented with a history of high-grade fever, cough, dyspnea, joint pain and myalgia. On examination, the patient was febrile with tachycardia, hypotension and decreased oxygen saturation. Chest auscultation revealed bilateral decreased air entry with crepitation supported by bilateral pulmonary infiltrates on chest X-ray. The laboratory investigations showed leukocytosis, thrombocytopenia, transaminitis and renal impairment. The patient was treated with intravenous fluids, ceftriaxone and levofloxacin; however, there was no clinical improvement till 48 h. She was then diagnosed with scrub typhus and dengue co-infection via serologies. Doxycycline was started following which the patient improved in 24 h. Scrub typhus can present with septic shock but does not respond to the usual antibiotics and the addition of doxycycline will result in rapid clinical improvement. Co-infection with other tropical diseases such as dengue is also common, hence it is important to test based on local endemicity.

Haemoptysis in breath-hold divers; where does it come from?

Introduction: The aim of reporting these two cases is to present visual evidence by bronchoscopy of the origin of haemoptysis in two elite breath-hold divers. Case reports: Two male elite breath-hold divers of similar physical characteristics presented to our clinic after performing dives of up to 75 and 59 meters of seawater depth for 2:30 and 2:35 (minutes:seconds) respectively. Both patients presented with haemoptysis. Lung ultrasound was performed. The first patient had crackles on chest auscultation, overt pulmonary oedema clinically and 90 ultrasound lung comets. The second patient had no oedema or crackles, but presented with 20 ultrasound lung comets. Video bronchoscopy was performed which showed traces of blood coming from all three segments of the right upper lobe in both patients. The rest of the airways and lungs were intact. Conclusions: These finding suggest that the apical parts of the lungs are the most prone to deep-dive induced damage. The precise mechanism of lung barotrauma and haemoptysis in breath-hold divers remains to be elucidated. These findings may be of importance for a better understanding of the underlying pathology of haemoptysis.

Fine crackles on chest auscultation in the early diagnosis of idiopathic pulmonary fibrosis: a prospective cohort study

IntroductionIdiopathic pulmonary fibrosis (IPF) is an interstitial lung disease (ILD) with a poor prognosis. Early diagnosis and treatment of IPF may increase lifespan and preserve quality of life. Chest CT is the best test to diagnose IPF, but it is expensive and impractical as a screening test. Fine crackles on chest auscultation may be the only best to screen for IPF.MethodsWe prospectively assessed the presence and type of crackles on chest auscultation in all patients referred to the ILD Clinic at the Kingston Health Sciences Center in Ontario, Canada. Clinicians with varying levels of experience recorded the presence of fine crackles, coarse crackles or both independently and unaware of the final diagnosis. We applied multinomial logistic regression to adjust for ILD severity and factors that could affect the identification of crackles.ResultsWe evaluated 290 patients referred to the ILD Clinic. On initial presentation, 93% of patients with IPF and 73% of patients with non-IPF ILD had fine crackles on auscultation. In patients with IPF, fine crackles were more common than cough (86%), dyspnoea (80%), low diffusing capacity (87%), total lung capacity (57%) and forced vital capacity (50%). There was 90% observer agreement in identifying fine crackles at a subsequent visit. In multiple regression analysis, the identification of fine crackles was unaffected by lung function, symptoms, emphysema, chronic obstructive pulmonary disease, obesity or clinician experience (p>0.05).ConclusionsFine crackles on chest auscultation are a sensitive and robust screening tool that can lead to early diagnosis and treatment of patients with IPF.

Influence of language skills on the choice of terms used to describe lung sounds in a language other than English: a cross-sectional survey of staff physicians, residents and medical students

IntroductionThe value of chest auscultation would be enhanced by the use of a standardised terminology. To that end, the recommended English terminology must be transferred to a language other than English (LOTE) without distortion.ObjectiveTo examine the transfer to Hebrew—taken as a model of LOTE—of the recommended terminology in English.Design/settingCross-sectional study; university-based hospital.Participants143 caregivers, including 31 staff physicians, 65 residents and 47 medical students.MethodsObservers provided uninstructed descriptions in Hebrew and English of audio recordings of five common sounds, namely, normal breath sound (NBS), wheezes, crackles, stridor and pleural friction rub (PFR).Outcomes(a) Rates of correct/incorrect classification; (b) correspondence between Hebrew and recommended English terms; c) language and auscultation skills, assessed by crossing the responses in the two languages with each other and with the classification of the audio recordings validated by computer analysis.ResultsRange (%) of correct rating was as follows: NBS=11.3–20, wheezes=79.7–87.2, crackles=58.6–69.8, stridor=67.4–96.3 and PFR=2.7–28.6. Of 60 Hebrew terms, 11 were correct, and 5 matched the recommended English terms. Many Hebrew terms were adaptations or transliterations of inadequate English terms. Of 687 evaluations, good dual-language and single-language skills were found in 586 (85.3%) and 41 (6%), respectively. However, in 325 (47.3%) evaluations, good language skills were associated with poor auscultation skills.ConclusionPoor auscultation skills surpassed poor language skills as a factor hampering the transfer to Hebrew (LOTE) of the recommended English terminology. Improved education in auscultation emerged as the main factor to promote the use of standardised lung sound terminology. Using our data, a strategy was devised to encourage the use of standardised terminology in non-native English-speaking countries.

Clinical impact of respiratory syncytial virus infection on children hospitalized for pertussis

Background Although Respiratory syncytial virus (RSV) is one of the common pathogens in children with pertussis and viral coinfection, the clinical impact of RSV infection on pertussis remains unclear. We compared clinical characteristics and sought differences between infants with single Bordetella pertussis (B. pertussis) infection and those with RSV coinfection. Methods We enrolled 80 patients with pertussis who were hospitalized in Shenzhen Children’s Hospital from January 2017 to December 2019. Respiratory tract samples were tested for B. pertussis with real-time polymerase chain reaction and respiratory viruses with immunofluorescence assay. Clinical data were obtained from hospital records and collected using a structured questionnaire. Results Thirty-seven of 80 patients had B. pertussis infection alone (pertussis group) and 43 had RSV-pertussis coinfection (coinfection group). No significant differences were found with regard to sex, body weight, preterm birth history, pertussis vaccination, symptoms, presence of pneumonia, or lymphocyte count between the 2 groups. Univariate analysis showed patients with RSV coinfection were older (median, 4.57 months vs 4.03 months, p = 0.048); more commonly treated with β-lactam antibiotics (21% vs 5%, p = 0.044); had higher rates of wheezes (40% vs 14%, p = 0.009) and rales (35% vs 14%, p = 0.028) on chest auscultation, a higher rate of readmission (40% vs 11%, p = 0.004), and a longer hospital stay (median, 10 days vs 7 days, p = 0.002). In the further binary logistic regression analysis, patients with RSV coinfection had higher rates of wheezes (OR = 3.802; 95% CI: 1.106 to 13.072; p = 0.034) and readmission (OR = 5.835; 95% CI: 1.280 to 26.610; p = 0.023). Conclusions RSV coinfection increases readmission rate in children hospitalized for pertussis. RSV infection should be suspected when wheezes are present on auscultation of the chest in these patients. Early detection of RSV may avoid unnecessary antibiotic use.

Knowledge and skills in chest auscultation among nurses

Introduction. Medical history and physical examination are basic elements allowing nurses to assess patients’ health. The ability to auscultate the chest in combination with anatomical and physiological knowledge constitute a quick and reliable method of differentiation and diagnosis of many diseases.Aim. The aim of the study was to assess knowledge and skills in the field of chest auscultation among nursing staff .Material and method. A prospective, pilot observational study was conducted on a group of 51 nurses. The level of knowledge and skills in the field of chest auscultation and independence in undertaking this activity in professional work were assessed. The knowledge test developed by the author, survey questionnaire and SimScope 360-3400 trainer were used. P<0.05 value was considered statistically significant.Results. Lack of chest auscultation skills was observed in 10% of the respondents, although none of them revealed lack of knowledge in this respect (p<0.001). Higher level of knowledge correlated with higher level of skills of the respondents, while a lower level of knowledge conditioned a lower level of skills (p=0.049). In the respondents’ opinion, auscultation of the lungs and heart are activities performed only by a doctor.Conclusions. Despite a moderate level of knowledge and skills in the field of chest auscultation, nursing staff do not use physical examination techniques in their daily work.

Air Quality in the Working Environment and Respiratory Health of Female Congolese Stone Quarry Workers

Background and Aim. Environmental and occupational exposure to high dust levels are known to be associated with lung function impairment. We assessed the ambient air quality in the working environment and the respiratory health of female stone quarry workers in Lubumbashi, Democratic Republic of Congo (DRC) in a context of severe economic, security, and health crises. Methods. This was a case-control study conducted in three stone quarry sites. Participants were 256 dust-exposed female stone quarry workers matched to 256 unexposed female office workers and market tax collectors (N = 512). They each answered a structured respiratory health questionnaire and underwent physical examination and a lung function test with the use of a spirometer and peak flow meter. Quality of ambient air in the working environment was assessed by means of a BRAMC air quality monitor (BR-AIR-329). Results. Results showed that exposed women did not use any personal protective equipment (PPE); in quarry sites, abnormally high levels of PM2.5 (205 ± 13.2 μg/m3 vs. 31.3 ± 10.3 μg/m3 in control sites; p < 0.001) and volatile organic compounds (VOC, 2.2 ± 0.2 μg/m3 vs. 0.5 ± 0.3 μg/m3, respectively; p < 0.01) were found. Furthermore, respiratory complaints were more common among exposed women (32.4% vs. 3.5% in controls; p < 0.01), who had abnormal chest auscultation and reduced lung capacity than controls (mean PEFR: 344.8 ± 2.26 and 405 ± 67.7 L/s, respectively; p < 0.001 Conclusion. Findings from this study show that in the midst of severe crises in the DRC, women stone quarry workers are exposed to abnormally high levels of respiratory hazards, which contribute to impaired lung function. There is a need to regulate quarry work and improve the working conditions in quarry sites in the DRC.

Clinical impact of respiratory syncytial virus infection on children hospitalized for pertussis

Background: Although Respiratory syncytial virus (RSV) is one of the common pathogens in children with pertussis and viral coinfection, the clinical impact of RSV infection on pertussis remains unclear. We compared clinical characteristics and sought differences between infants with single Bordetella pertussis (B. pertussis) infection and those with RSV coinfection.Methods: We enrolled 80 patients with pertussis who were hospitalized in Shenzhen Children’s Hospital from January 2017 to December 2019. Respiratory tract samples were tested for B. pertussis with real-time polymerase chain reaction and respiratory viruses with immunofluorescence assay. Clinical data were obtained from hospital records and collected using a structured questionnaire.Results: Thirty-seven of 80 patients had B. pertussis infection alone (pertussis group) and 43 had RSV-pertussis coinfection (coinfection group). No significant differences were found with regard to sex, body weight, preterm birth history, pertussis vaccination, symptoms, presence of pneumonia, or lymphocyte count between the 2 groups. Patients with RSV coinfection were older; received more β-lactam antibiotic treatment; had higher rates of wheezes and rales on chest auscultation, a higher rate of readmission, and a longer hospital stay.Conclusions: RSV coinfection increases β-lactam antibiotic use, readmission rate, and hospital stay in children hospitalized for pertussis. RSV infection should be suspected when wheezes or rales are present on auscultation of the chest in these patients. Early detection of RSV may avoid unnecessary antibiotic use.

A case of pediatric paraspinal arteriovenous fistula with multiple fistulas

Paraspinal arteriovenous fistula (AVF) is a rare vascular malformation. This is the first described case of a pediatric paraspinal AVF along nonvertebral segmental nerve with multiple fistulas. An 8 months-old girl was found to have a continuous murmur on the back on chest auscultation. Enhanced computed tomography revealed a segmental nerve AVF of the right thoracic spine. Selective angiography of the right T8 and T9 intercostal arteries demonstrated a high flow fistula at the level of the neural foramen, with drainage to the epidural and azygos veins. The fistulas point was visualized using Volume rendering(VR) and Minimum Intensity Projection(MIP) images. Endovascular treatment from the right T8 and T9 feeding arteries was provided using coils and n-butyl-2-cyanoacrylate(NBCA). Postembolization angiography demonstrated complete occlusion of the fistulas. The postoperative course was uneventful. We discuss the first case of a pediatric paraspinal AVF along nonvertebral segmental nerve with double holes of fistulas with literature review.