Bedside Ultrasound for the diagnosis of ALI ARDS

1. Bedside Ultrasound for the diagnosis of ALI ARDS Chief of Medicine Conference 10/29/2013 Cameron Bass, MD

2. Disclosures • Mobisante ™ provided me with one of their smartphone based ultrasound devices for use in the study • The UWMC pays my salary, so I suppose I’m less likely to say bad things about them publically • I haven’t brushed my hair in almost a full year

3. Outline • Background on Cameron • Critical Illness in the resource limited setting • ARDS review • Ultrasound • Basic review • Pulmonary ultrasound • Pulse oximetry • Bedside Ultrasound for the diagnosis of ARDS • Methods • Challenges • Future directions • Brilliant and incisive Q&A

4. A Brief Introduction to Cameron • Engineering • Rwanda

5. Critical Illness in the Resource Limited Setting • Resource allocation • Cost of Critical Care • Faith in the system1 • A lack of knowledge2

6. Critical Illness in the Resource Limited Setting • Appropriate use of technology • Ventilators • Ultrasound3

7. Critical Illness in the Resource Limited Setting • Developing vs third world vs resource limited

8. Brief Introduction to ARDS • Initial description in 1967 by Ashbaugh4 • New definition in 1994 by AECCC5 • P:F ratio • Bilateral infiltrates on CXR (“A pulmonary Edema pattern”) • PCWP < 18mm Hg • Berlin definition in 20126 • Risk factors • Timing

9. Prevalence of ARDS • In the united states • >150,000 cases per year7 • In the resource limited setting • Challenges to diagnosis • Differences in etiology

10. How ultrasound works cartoon • 1540 m/s • You know what happens when you make an assumption? (Samuel L Jackson) • Reverberation artifact • Comet tail artifact

11. Pulmonary Ultrasound • Lung Sliding Videos courtesy http://sonocloud.org

12. Pulmonary Ultrasound • A lack of Lung Sliding Videos courtesy http://sonocloud.org

13. Pulmonary Ultrasound • A lines8 Videos courtesy http://sonocloud.org

14. Pulmonary Ultrasound • B lines8 Videos courtesy http://sonocloud.org

15. Thoracic Ultrasound • Ease of teaching9

16. Thoracic Ultrasound • Lichtenstein and the Blue protocol8

17. BLUE protocol8

18. Thoracic Ultrasound • Specific studies for ARDS • BLUE protocol8 • FALLS protocol • ARDS vs Acute Pulmonary Edema10

19. Arterial Blood Gasses • Cost of performing • Estimated at $110 cost to patient • SpO2 to ABG • In adults11 • S/F = 64 + 0.84 x (P/F) [p < 0.0001; r = 0.89) • S/F of 235 ≈ P/F of 200 • S/F of 315 ≈ P/F of 300 • In pediatrics12 • S/F = 76 + 0.62 x PF (p < 0.0001, R2 = 0.61) • S/F 201 ≈ P/F of 200 • S/F 263 ≈ P/F of 300

20. Bedside Ultrasound for the diagnosis of ARDS Study Design

21. Bedside Ultrasound for the diagnosis of ARDS • Scanning • Technique • Mobisante

22. Bedside Ultrasound for the diagnosis of ARDS • Reviewing Data • Chest Radiographs • Ultrasound scans

23. Bedside Ultrasound for the diagnosis of ARDS • Statistical Analysis • Lack of a Gold Standard • PPA • NPA • Kappa

24. Challenges • Identifying Patients • Prevalence • Positioning • SpO2 measurements • IRB/HIPAA

25. Future Directions • Cambodia/Rwanda

26. Citations • Neill KJ Adhikari, Robert A Fowler, SatishBhagwanjee, Gordon D Rubenfeld, Critical care and the global burden of critical illness in adults, The Lancet, Volume 376, Issue 9749, 16–22 October 2010, Pages 1339-1346 • Dünser MW, Baelani I, Ganbold L. “A review and analysis of intensive care medicine in the least developed countries.“Crit Care Med. 2006 Apr;34(4):1234-42. • Sippel S, Muruganandan K, Levine A, Shah S. “Review article: Use of ultrasound in the developing world.” Int J Emerg Med. 2011 Dec 7;4:72. doi: 10.1186/1865-1380-4-72. • Ashbaugh D, Bigelow D, Petty T, Levine B (1967). "Acute respiratory distress in adults". Lancet 2 (7511): 319–23. • Bernard G, Artigas A, Brigham K, Carlet J, Falke K, Hudson L, Lamy M, Legall J, Morris A, Spragg R (1994). "The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial • CV. Marco Ranieri, MD (2012). "The ARDS Definition Task Force*. Acute Respiratory Distress Syndrome: The Berlin Definition". JAMA 307 (23): 2526–2533 • Gordon D. Rubenfeld, MD, MSc; Margaret S. Herridge, MD, MPH, FCCP. “Epidemiology and Outcomes of Acute Lung Injury” Chest. 2007;131(2):554-562. doi:10.1378/chest.06-1976 • Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure. The BLUE-protocol. Chest 2008;134:117-125  • G Bedetti 1 , L Gargani 2 , A Corbisiero 3 , F Frassi 2 , E Poggianti 2 and G Mottola*“Evaluation of ultrasound lung comets by hand-held echocardiography“ Cardiovascular Ultrasound • Roberto Copetti* 1 , Gino Soldati 2 and Paolo Copetti . Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovascular Medicine . 29 April 2008 • Rice, Wheeler, bernard et al. ARDSNET “Comparison of the Sp O 2 /F IO 2 Ratio and the Pa O 2 /F IO 2 Ratio in Patients With Acute Lung Injury or ARDS” CHEST 2007; 132:410–417 • Robinder G. Khemani, MD, MSCI; Neal R. Patel, MD, MPH; Robert D. Bart, III, MD; and Christopher J. L. Newth, MD “Comparison of the Pulse Oximetric Saturation/Fraction of Inspired Oxygen Ratio and the Pa O 2 /Fraction of Inspired Oxygen Ratio in Children* CHEST 2009; 135:662-668