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Anaesthesia and Intensive Care Management of Face Transplantation

COMMENT Thoracic imaging is commonly performed in critically ill patients and usually comprises portable CXRs or departmental CT. Both of these imaging modalities are associated with a time and resource burden as well as the unfavorable exposure of patients to ionizing radiation. Point-of care US offers a potentially faster, safer, and more cost-effective thoracic imaging alternative because it obviates the need to transfer patients, avoids radiation, and can be performed immediately at the bed side. This review evaluates the diagnostic performance of thoracic US in the critical care setting to help determine whether it can eventually replace conventional imaging. To this end, a comprehensive literature search was performed to identify relevant studies assessing the ability of CCUS to diagnose pleural effusions, consolidation, pulmonary edema/EVLW, and pneumothorax compared with standard CXR. Computed tomography was used as the reference test in most of these studies. The most compelling evidence favoring CCUS came in the identification of pleural effusions, where CCUS had comparable DA to CT and was more sensitive and specific compared with CXR. The diagnostic advantage of US over radiography was also seen when identifying consolidation with the additional benefit of possible determination of the etiology. The differentiation of an inflammatory versus hydrostatic cause of increased EVLW is well described on CT. Because air-filled tissue such as the lung is a poor medium for the transmission of US, the usefulness of thoracic US has historically been undervalued. Interestingly, however, interpretation of certain reverberation artifact can be used to help identify pathology such as pulmonary edema and pneumothorax. Using A-lines and B-lines on lung CCUS, studies have attempted to demonstrate a link with surrogate markers of pulmonary edema with relatively low specificity. Presence of A-lines and absence of B-lines and lung sliding on CCUS define pneumothorax. Despite limited data, CCUS is at least as effective as CXR in identifying pneumothorax. This review suggest that US shows promise as a potentially viable alternative to conventional thoracic imaging in identifying pleural effusions, consolidation, and pneumothorax in the critical care setting, but sensibly acknowledges the limitations of the evidence. There were no randomized controlled trials in the final analysis, and the majority of studies used were observational only. Furthermore, single centers dominated the evidence pool in certain fields (eg, 4 of the total of 5 studies assessing the diagnostic performance of US in identifying consolidation were from the same research group). Sonographer operator skill was also not constant. In summary, US scanning is a safe and versatile imaging modality whose role in medicine will no doubt expand in the future. It has already evolved to become an established abdominal screening tool in the trauma setting, and it is frequently used to aid vascular access and perform regional blockade, not to mention bedside echocardiography. This review tentatively suggests that the role of US can potentially be expanded further still to include basic thoracic imaging in the critical care setting. Numerous expert groups including The Royal College of Radiologists have produced training standards for CCUS.