Assessment of Lung Parenchyma Recovery after Antibiotic Administration using Lung Ultrasound in Critically Ill Patients with Pneumonia
Keywords:Pneumonia, Lung ultrasound, Thoracic computed tomography
Background: Pneumonia is a common cause of Intensive care unit (ICU) admission, requiring frequent imaging for following up parenchymal lung involvement and antibiotic response. Being bedside and non-invasive technique; lung ultrasound (US) is increasingly used in ICU.
Objectives: Assessing accuracy of lung ultrasound in detecting parenchymal lung recovery following antibiotic administration in critically ill patients with pneumonia.
Methods: Fifty patients with pneumonia were included in the study with time-dependent analysis for APACHEII, CURB-65 and modified CPIS. Lung US at day 0 described basal lung condition then according to changes in lung parenchyma, US score could be first calculated at day 3. At day 5 US score was calculated again and changes in score (delta score) was calculated to asses ability of US to predict early good antibiotic response and finally lung US was repeated at day 7, score calculated to detect lung parenchyma recovery and compared with follow up CT for accuracy and agreement. Air bronchogram was reported whenever seen, described as static or dynamic and assessed in follow up examinations to be compared with CT follow up.
Results: Lung US score ranged from -2 to 17 with mean value of 8.75 ± 3.88 for improving patients, while worsening patients showed lung US score of -11 to -20 with mean value of -10.08 ± 6.95 with high statistical significance (p<0.001).The best cutoff value of lung US score changes for detecting good response to antibiotic was 2.5, detected using area under the curve (AUC) (p<0.001). Ultrasound score on day seven showed excellent sensitivity and specificity of 91.89% and 92.31% respectively when compared to CT with PPV of 97.14% and NPV 80% and accuracy 92% with strong statistical significance (p<0.001). Air bronchogram showed sensitivity of 61.5% and specificity of 89.1% and with PPV of 66.67% and NPV of 86.84% and accuracy of 82% and moderate agreement (0.52) with CT while B-lines were significant for assessing lung reaeration with sensitivity of 69.2% and specificity of 67.5% and accuracy of 68% but with fair (0.31) agreement with CT (p<0.027) in detecting parenchymal lung recovery.
Conclusion: Lung US is a reasonable bedside method for quantifying parenchymal lung recovery in patients with pneumonia who are successfully treated with antibiotics.
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Lichtenstein DA. Ultrasound in the management of thoracic disease. Crit Care Med. 2007;35(Suppl):S250-61.
Reissig A, Kroegel C. Sonographic diagnosis and follow-up of pneumonia: A prospective study. Respiration. 2007;74(5):537-47. https://doi.org/10.1159/000100427 PMid:17337882
Govindan S, Hyzy RC (2016) The 2016 guidelines for hospital-acquired and ventilator-associated pneumonia. A selection correction? Am J Respir Crit Care Med 194:658–660. https://doi.org/10.1164/rccm.201607-1447ED
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2(Suppl 2):S27-72. https://doi.org/10.1086/511159. PMID: 17278083;
Zilberberg MD, Shorr AF. Ventilator-associated pneumonia: the clinical pulmonary infection score as a surrogate for diagnostics and outcome. Clin Infect Dis. 2010;51(Suppl 1):S131-5. https://doi.org/10.1086/653062 PMid:20597663
Rubinowitz AN, Siegel MD, Tocino I. Thoracic imaging in the ICU. Crit Care Clin. 2007;23(3):539-73. https://doi.org/10.1016/j.ccc.2007.06.001 PMid:17900484
Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M. Accuracy and efficacy of chest radiography in the intensive care unit. Radiol Clin North Am. 1996;34(1):21-31. PMid:8539351
Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: Bedside lung ultrasound in critical care practice. Crit Care. 2007;11(1):205. https://doi.org/10.1186/cc5668 PMid:17316468
Bouhemad B, Liu ZH, Arbelot C, Zhang M, Ferarri F, Le-Guen M, et al. Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Crit Care Med. 2009;38(1):84-92. https://doi.org/10.1097/ccm.0b013e3181b08cdb PMid:19633538
Raman K, Nailor MD, Nicolau DP, Aslanzadeh J, Nadeau M, Kuti JL. Early antibiotic discontinuation in patients with clinically suspected ventilator-associated pneumonia and negative quantitative bronchoscopy cultures. Crit Care Med. 2013;41(7):1656-63. https://doi.org/10.1097/ccm.0b013e318287f713 PMid:23528805
Lu Q, Malbouisson M, Mourgeon E, Goldstein I, Coriat P, Rouby JJ. Assessment of PEEP-induced reopening of collapsed lung regions in acute lung injury: Are one or three CT sections representative of the entire lung? Intensive Care Med. 2001;27(9):1504-10. https://doi.org/10.1007/s001340101049 PMid:11685344
Puybasset L, Cluzel P, Gusman P, Grenier P, Preteux F, Rouby JJ. Regional distribution of gas and tissue in acute respiratory distress syndrome, I: Consequences for lung morphology. CT Scan ARDS Study Group. Intensive Care Med. 2000;26(7):857-69. https://doi.org/10.1007/s001340051274 PMid:10990099
Malbouisson LM, Preteux F, Puybasset L, Grenier P, Coriat P, Rouby JJ. Validation of a software designed for computed tomographic (CT) measurement of lung water. Intensive Care Med. 2001;27:602-8. https://doi.org/10.1007/s001340100860
Peris A, Tutino L, Zagli G, Batacchi S, Cianchi G, Spina R, et al. The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients. Anesth Analg. 2010;111(3):687-92. https://doi.org/10.1213/ane.0b013e3181e7cc42 PMid:20733164
Vitturi N, Dugo M, Soattin M, Simoni F, Maresca L, Zagatti R, et al. Lung ultrasound during hemodialysis: The role in the assessment of volume status. Int Urol Nephrol. 2014;46(1):169-74. https://doi.org/10.1007/s11255-013-0500-5 PMid:23884727
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: The BLUE protocol. Chest. 2008;134(1):117-25. https://doi.org/10.1378/chest.07-2800 PMid:18403664
El-Moursia AA, Besheya BN. Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. Res Opin Anesth Intens Care. 2017;4:7-16. https://doi.org/10.4103/2356-9115.202699
Cortellaro F, Colombo S, Coen D, Duca PG. Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. Emerg Med J. 2012;29(1):19-23. https://doi.org/10.1136/emj.2010.101584 PMid:21030550
Beckh S, Bölcskei PL, Lessnau KD. Real-time chest ultrasonography: A comprehensive review for the pulmonologist. Chest. 2002;122(5):1759-73. https://doi.org/10.1378/chest.122.5.1759 PMid:12426282
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