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Ultrasound Lung Comets: A Simple and Effective Tool for Imaging Extravascular Lung Water

This article explores the use of ultrasound lung comets (ULC) as a practical and valuable method for imaging extravascular lung water. It discusses the shape, clinical value, limitations, and guidelines for ULC, as well as its potential future applications in various medical conditions. The article also highlights the simplified scan technique for stress imaging, which can save time and improve diagnostic accuracy.

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Ultrasound Lung Comets: A Simple and Effective Tool for Imaging Extravascular Lung Water

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  1. SE2020, February 9, 2017 Ultrasound lung comets in the heart failure sky Eugenio Picano Institute of Clinical Physiology, CNR Pisa, Italy

  2. ULC or ultrasound B-lines “Ultrasound Lung Comets represent a useful, practical, appealingly simple way to image directly extravascular lung water” J Am SocEchocardiogr 2006;19:356

  3. COMPREHENSIVE SCAN (n=28 sites) left side right side 17 8 21 25 15 EKG leads 14 V5 V4 V6 IS = Inter-costal space PS = Para-sternal MA = Mid-axillary MC = Mid-clavicular AA = Anterior-axillary

  4. ULC: the shape of the water • The sign • The clinical value • Limitations • Guidelines and recommendations • What’s next

  5. Normal Pulmonary edema Air Histology Schematic US rendering Water In vivo US A-lines 2-3 B-lines 4-5 B-lines 7-8 B-lines 9-10 B-lines Picano E, Pellikka P, Eur Heart j 2016

  6. B-lines: quantitative assessment of Extra-Vascular Lung Water (pigs) (humans) (Picano E, Pellikka P, Eur Heart J, 20016 – redrawn from original data of Jambrik, Picano et al, Ultr Med Biol 2010, e Enghard et al Crit care 2015)

  7. Training-time stress echo university secondary school color/Doppler echo 2D echo elementary school kindergarten lung ultrasound

  8. B-lines made simple Absent Mild Moderate Severe “Black lung” “Black and white lung” “White lung” Method movie: Youtube: the incredible ULC http://www.youtube.com/watch?v=amsULLws8GI

  9. ULC: the shape of the water • The sign • The clinical value • Limitations • Guidelines and recommendations • What’s next

  10. Point‐of‐care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta‐analysis 94 % sensitivity and 92 % specificity of B- lines for identification of acute cardiogenic dyspnea N= 7 studies totalling 1,075 patients Academic Emergency MedicineVolume 21, Issue 8, pages 843-852, 30 AUG 2014 DOI: 10.1111/acem.12435http://onlinelibrary.wiley.com/doi/10.1111/acem.12435/full#acem12435-fig-0003 (Al-Deeb et al, 2014)

  11. 100 90 80 No ULCs (70%) 70 Moderate ULCs (63%) 60 Mild ULCs (58%) Spontaneous event-free survival (%) 50 40 30 Severe ULCs (20%) 20 Log rank 15.65, P=0.0013 10 0 0 10 20 30 40 Time (months) 138 47 41 28 9 Subjects at risk 53 15 14 10 4 33 13 11 8 4 No ULCs 2 69 13 10 6 Mild ULCs Moderate ULCs Severe ULCs Results Event free-survival (n=64): 41 deaths Frassi F et al. J Card Failure 2007

  12. Lung ultrasound in heart failure outpatients (Platz et al, Eur Heart J, 2016)

  13. ULC: the shape of the water • The sign • Prognostic value • Limitations • Guidelines and recommendations • What’s next

  14. Lung ultrasound for the screening of interstitial lung disease in very early systemic sclerosis. Barskova T, Gargani L, et al. Ann Rheumat Dis 2012

  15. ULC: the shape of the water • The sign • Prognostic value • Limitations • Guidelines and recommendations • What’s next

  16. What guidelines say • ESC recommendations 2015 (Acute heart failure): may be useful (Class II b,class C ) for signs of interstitial edema, if expertise is available (Mebazaa et al, EJ Heart Fail 2015) • ESC guidelines 2016 (Heart Failure): IIb, class C (Ponikowski P et al, Eur Heart J 2016) • EACVI-ASE recommendations 2016 (SE beyond CAD): The demonstration of B-lines during exercise seems a feasible way for demonstrating that exertional dyspnea is related to pulmonary congestion (Lancellotti P et al, E H J CV Img 2016)

  17. ULC: the shape of the water • The sign • The clinical value • Limitations • Guidelines and recommendations • What’s next

  18. LUST Trial (Prof. Carmine Zoccali from Reggio Calabria, Italy)

  19. A-lines REST POST- EXERCISE 1 2 3 B- lines (Agricola E, Picano E et al, JASE 2005)

  20. p<0.0001 Stress B- lines in Heart Failure : increase during exercise B-lines Scali MC, Marzilli M, Picano E et al, EJHF 2017

  21. Scali MC, Marzilli M, Picano E et al, EJHF 2017

  22. (Scali MC, Marzilli M, Picano E et al, EJHF 2017)

  23. Stress B- lines in Heart Failure : Correlation with spiroergometry (Scali MC, Marzilli M, Picano E et al, EJHF 2017)

  24. Stress B- lines in Heart Failure : Prognostic value (Scali MC, Marzilli M, Picano E et al, EJHF 2017)

  25. B- lines can be evaluated anywhere, anytime, by anyone, at baseline and during stress. Cardiologists can achieve much diagnostic gain with little investment of technology, training, and time. B-lines represent the “shape of lung water”. They allow non-invasive detection,in real time, of even sub-clinical forms of pulmonary edema with a low cost, radiation-free approach But 28-sites scan too time consuming: need to simplify scan for stress success From 28- to 4- regions scan (from 3 min to 20 seconds)

  26. (Scali MC,Zagatina A, Simova I,Picano E in preparation 2017)

  27. SIMPLIFIED SCAN (n= 4 sites) for STRESS right side left side ACCEPTABLE FOR REST-STRESS

  28. SOFTWARE PROGRAM FOR SIMPLIFIED SCAN for STRESS

  29. Naked eye (low tech) comet spotting for HFrEF,HFpEF, ischemia, HAPE, LVOTG, MR, … (Distracted astronomer, Unknown, French?,19th century) (Distracted cardiologist, Picano, Italy, 21st century)

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