A fluid challenge can generate an infraclinical interstitial syndrome that may be detected by the appearance of B-lines by lung ultrasound. Our objective was to evaluate the appearance of B-lines as a diagnostic marker of preload unresponsiveness and postoperative complications in the operating theater. We conducted a prospective, bicentric, observational study. Adult patients undergoing abdominal surgery were included. Stroke volume (SV) was determined before and after a fluid challenge with 250 mL crystalloids (Delta-SV) using esophageal Doppler monitoring. Responders were defined by an increase of Delta-SV > 10% after fluid challenge. B-lines were collected at four bilateral predefined zones (right and left anterior and lateral). Delta-B-line was defined as the number of newly appearing B-lines after a fluid challenge. Postoperative pulmonary complications were prospectively recorded according to European guidelines. In total, 197 patients were analyzed. After a first fluid challenge, 67% of patients were responders and 33% were non-responders. Delta-B-line was significantly higher in non-responders than responders [4 (2–7) vs 1 (0–3), p < 0.0001]. Delta-B-line was able to diagnose fluid non-responders with an area under the curve of 0.74 (95% CI 0.67–0.80, p < 0.0001). The best threshold was two B-lines with a sensitivity of 80% and a specificity of 57%. The final Delta-B-line could predict postoperative pulmonary complications with an area under the curve of 0.74 (95% CI 0.67–0.80, p = 0.0004). Delta-B-line of two or more detected in four lung ultrasound zones can be considered to be a marker of preload unresponsiveness after a fluid challenge in abdominal surgery. The objectives and procedures of the study were registered at Clinicaltrials.gov (NCT03502460; Principal investigator: Stéphane BAR, date of registration: April 18, 2018).

Critical care ultrasound (CCUS) is an essential component of intensive care practice. Although existing international guidelines have focused on training principles and determining competency in CCUS, few countries have managed to operationalize this guidance into an accessible, well-structured programme for clinicians training in multidisciplinary intensive care. We seek to update and reaffirm appropriate CCUS scope so that it may be integrated into the international Competency-based Training in Intensive Care Medicine. The resulting recommendations offer the most contemporary and evolved set of core CCUS competencies for an intensive care clinician yet described. Importantly, we discuss the rationale for inclusion but also exclusion of competencies listed.BACKGROUND/AIM:Critical care ultrasound (CCUS) is an essential component of intensive care practice. The purpose of this consensus document is to determine those CCUS competencies that should be a mandatory part of training in multidisciplinary intensive care.METHODS:A three-round Delphi method followed by face-to-face meeting among 32 CCUS experts nominated by the European Society of Intensive Care Medicine. Agreement of at least 90% of experts was needed in order to enlist a competency as mandatory.RESULTS:The final list of competencies includes 15 echocardiographic, 5 thoracic, 4 abdominal, deep vein thrombosis diagnosis and central venous access aid.CONCLUSION:The resulting recommendations offer the most contemporary and evolved set of core CCUS competencies for an intensive care clinician yet described.

OBJECTIVES Lung ultrasound has shown increasing diagnostic value in many lung diseases and has become an efficient tool in the management of dyspnea. In the present case report, we describe a new ultrasound feature of potential interest. DATA SOURCES Clinical observation of a patient. STUDY SELECTION Case report. DATA EXTRACTION Data were extracted from medical records, after obtaining consent from the patient's family. Illustrations were extracted from the imaging software and a video device. DATA SYNTHESIS A 56-year-old man was admitted with pneumonia of adverse outcome. Lung ultrasound, a method increasingly considered as a bedside gold standard in critically ill patients due to its overwhelming advantages, was the only tool able to specify the lung injuries. We describe herein a distinctive sign unequivocally evoking a destructive process suggestive of pulmonary gangrene, a variant of the fractal sign combining a lung consolidation with an underlying heterogeneous free fluid. CONCLUSIONS Lung ultrasound may help highlight pulmonary gangrene, a poorly-known disease, with this new ultrasonographic description. The next step will be to ascertain the relation between this new ultrasound feature and pulmonary gangrene and to assess how this bedside diagnosis could impact the prognosis of the disease.

Point-of-care ultrasound is increasingly used at the bedside to integrate the clinical assessment of the critically ill; in particular, lung ultrasound has greatly developed in the last decade. This review describes basic lung ultrasound signs and focuses on their applications in critical care. Lung semiotics are composed of artifacts (derived by air/tissue interface) and real images (i.e., effusions and consolidations), both providing significant information to identify the main acute respiratory disorders. Lung ultrasound signs, either alone or combined with other point-of-care ultrasound techniques, are helpful in the diagnostic approach to patients with acute respiratory failure, circulatory shock, or cardiac arrest. Moreover, a semiquantification of lung aeration can be performed at the bedside and used in mechanically ventilated patients to guide positive end-expiratory pressure setting, assess the efficacy of treatments, monitor the evolution of the respiratory disorder, and help the weaning process. Finally, lung ultrasound can be used for early detection and management of respiratory complications under mechanical ventilation, such as pneumothorax, ventilator-associated pneumonia, atelectasis, and pleural effusions. Lung ultrasound is a useful diagnostic and monitoring tool that might in the near future become part of the basic knowledge of physicians caring for the critically ill patient.

Detecting weaning-induced pulmonary oedema (WIPO) is important because its treatment might prompt extubation. For this purpose, lung ultrasound might be an attractive tool, since it demonstrates pulmonary oedema through the appearance of B-lines.

It is good to see the growing success of lung ultrasound in the critically ill (LUCI) and the literal explosion of the number of publications.1 In the approach published in 1991 on whole body ultrasound used by the critical care physician, a dominant position was given to the lung.2 Today, an increasing number of specialties (pulmonologists, pediatricians, etc) use LUCI. This commentary is devoted to experts who have the responsibility of widespread LUCI. It aims at encouraging them to do even better.

Critical lung ultrasound was originated from in France,as we know,professor Daniel A.Lichtenstein who was regarded as the father of critical lung ultrasound in the world,pushed the great development of critical lung ultrasound,concluded twelve signs of lung ultrasound,created the BLUE-protocol which allows fast causal diagnosis of acute respiratory failure,the FALLS-protocol used in acute circulatory failure without obvious causes and the SESAME-protocol used during cardiac arrest.Critical lung ultrasound as a new interdisciplinary subject,will provide more new ideas and solutions for diagnosis and treatments in critically ill patients.

For a cardiologist, lung ultrasound is an add-on to transthoracic echocardiography, just as lung auscultation is part of a cardiac physical examination. A cardiac 3.5- to 5.0-MHz transducer is generally suitable because the small footprint makes it ideal for scanning intercostal spaces. The image quality is often adequate, and the lung acoustic window is always patent. The cumulative increase in imaging time is <1 min for the 2 main applications targeted on pleural water (pleural effusion) and lung water (pulmonary congestion as multiple B-lines). In these settings, lung ultrasound outperforms the diagnostic accuracy of the chest radiograph, with a low-cost, portable, real-time, radiation-free method. A “wet lung” detected by lung ultrasound predicts impending acute heart failure decompensation and may trigger lung decongestion therapy. The doctors of tomorrow may still listen with a stethoscope to their patient’s lung, but they will certainly be seeing it with ultrasound.

The BLUE-protocol is a fast protocol allowing the diagnosis of an acute respiratory failure. It considers the main causes seen in 97% of adults admitted to the ICU. It uses the 10 main signs of lung ultrasound in the critically ill and a venous approach. A decision tree considers first anterior lung sliding. Present with multiple B-lines (the B-profile), it suggests hemodynamic pulmonary edema (sensitivity 97%, specificity 95%). Present without B-lines (A-profile), it is associated with pulmonary embolism if venous thrombosis detected (sensitivity 81%, specificity 99%). Absent with exclusive A-lines (A'-profile), it suggests pneumothorax (when lung point associated, sensitivity 88%, specificity 100%). Absent with multiple B-lines (B'-profile), it is linked with pneumonia (specificity 100%). COPD or asthma generate a nude profile. Pneumonia generates 3 other profiles (space constraints prevent their description). A simple unit with a unique microconvex probe is suitable. Answers to many questions are detailed in our textbook.

Over the past decades, ultrasound (US) has gained its place in the armamentarium of monitoring tools in the intensive care unit (ICU). Critical care ultrasonography (CCUS) is the combination of general CCUS (lung and pleural, abdominal, vascular) and CC echocardiography, allowing prompt assessment and diagnosis in combination with vascular access and therapeutic intervention. This review summarises the findings, challenges lessons from the 3rd Course on Acute Care Ultrasound (CACU) held in November 2015, Antwerp, Belgium. It covers the different modalities of CCUS; touching on the various aspects of training, clinical benefits and potential benefits. Despite the benefits of CCUS, numerous challenges remain, including the delivery of CCUS training to future intensivists. Some of these are discussed along with potential solutions from a number of national European professional societies. There is a need for an international agreed consensus on what modalities are necessary and how best to deliver training in CCUS.

FALLS-protocol combines simple echocardiography and lung ultrasound, using our universal microconvex probe and simple material for sequentially assessing causes of circulatory failure, following Weil’s terminology. The cardiac sonography excludes pericardial tamponade, right heart dilatation of pulmonary embolism, BLUE-protocol excludes a tension pneumothorax (A’-profile): obstructive shock is discounted. Then a negative search of a B-profile (usually pulmonary edema) allows to discount left cardiogenic shocks. The remaining causes are hypovolemic and distributive shocks. These patients (FALLS-responders) have the A-profile, schematically, indicating clearance for fluid therapy. Patient's improvement suggests hypovolemic shock. No improvement under fluid therapy results in a interstitial edema, a direct marker of clinical volemia at an early, infra-cinical stage: a B-profile appears (FALLS-endpoint). Hypovolemic shock is discounted. The only remaining mechanism is distributive shock, mainly septic shock. FALLS-protocol is open to any criticism. Answers to many questions are detailed in our textbook. FALLS-protocol can be associated with any usual tool.