Education  |   April 2020
Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence
Author Notes
  • From the Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine (C.A., H.B., R.D., A.M., J.-M.C., J.-J.R.) and the Department of Parasitology-Mycology (F.G.), La Pitié-Salpêtrière Hospital, Public Assistance of Paris Hospitals (AP HP), Sorbonne University of Paris, Paris, France; Intensive Care Unit, Federal University of Rio Grande do Sul, Ernesto Dornelles Hospital, Moinhos de Vento Hospital, Postgraduate Program for Pulmonology Science, Porto Alegre, Brazil (F.L.D.N.); the Department of Emergency Medicine, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Institute of Emergency Medicine, Hangzhou, China (Y.G., M.Z.); the Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China (W.C., D.B.); the Department of Critical Care Medicine, Peking University People’s Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China (J.L., Y.A.); the Multidisciplinary Intensive Care Unit, Hospital Albert Einstein, São Paulo, Brazil (C.S.V.B.); the Department of Perioperative Medicine, Centre Hospitalo–Universitaire Clermont-Ferrand, University Clermont Auvergne, National Institute for Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Clermont-Ferrand, France (S.P.); University of São Paulo, Surgical and Trauma Intensive Care Unit, Hospital Das Clinicas, São Paulo, Brazil (F.P.C., L.M.); the Multidisciplinary Intensive Care Unit, Hospital da Bahia, Salvador and Santa Helena Hospital, Salvador, Brazil (E.J.S.L., J.N.); La Republica University, Intensive Care Unit, Hospital de Clínicas Dr. Manuel Qintela, University School of Medicine, Montevideo, Uruguay (A.C.); and the Multidisciplinary Intensive Care Unit, Hospital Copa D’Or, Rio de Janeiro, Brazil (J.S.).
  • *Members of the APECHO Study Group are listed in the Appendix.
    Members of the APECHO Study Group are listed in the Appendix.×
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication December 19, 2018. Accepted for publication November 25, 2019. Published online first on January 6, 2020. Corrected on July 22, 2020.
    Submitted for publication December 19, 2018. Accepted for publication November 25, 2019. Published online first on January 6, 2020. Corrected on July 22, 2020.×
  • Address correspondence to Dr. Rouby: Multidisciplinary Intensive Care Unit, La Pitié–Salpêtrière Hospital, School of Medicine Sorbonne University of Paris, 47-83 Boulevard de l’Hôpital 75013, Paris, France. jjrouby@invivo.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Critical Care / Radiological and Other Imaging / Respiratory System
Education   |   April 2020
Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence
Anesthesiology 4 2020, Vol.132, 899-907. doi:https://doi.org/10.1097/ALN.0000000000003096
Anesthesiology 4 2020, Vol.132, 899-907. doi:https://doi.org/10.1097/ALN.0000000000003096
Abstract

Background: Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence.

Methods: This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees’ ability to adequately classify lung regions with normal aeration, interstitial–alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert.

Results: Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days.

Conclusions: A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial–alveolar syndrome, and consolidation in emergency and critically ill patients.

Editor’s Perspective:

What We Already Know about This Topic:

  • Transthoracic ultrasound may be clinically useful, but training is not standardized, and it remains unclear when naïve trainees have sufficient competency to perform exams unsupervised

What This Article Tells Us That Is New:

  • A multicenter, international study was conducted in 10 intensive care units among residents and staff in anesthesiology, critical care, emergency medicine, and internal medicine who underwent supervised training to determine the number of exams required to achieve basic competence

  • After 25 supervised examinations, 80% of lung regions were adequately classified by trainees

  • Ultrasound exam average duration was 8 to 10 min in experts and decreased from 19 (after 5 exams) to 12 min (after 25 exams) in trainees