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Evolution of point of care ultrasound (POCUS) education: cardiovascular, pulmonary, and beyond
A recent CHEST Physician article noted the ubiquity of POCUS employment but lamented inconsistencies and possible inadequacies of POCUS education amongst ACGME specialty fellowships (Satterwhite L. An update on the current standard for ultrasound education in fellowship. CHEST Physician. 2019 Dec. 9). POCUS education/training is no longer limited to physician fellowships but has percolated into the undergraduate medical education curricula of first-year medical students and physician assistant (PA) programs (Hoppmann RA, et al. Crit Ultrasound J. 2011;[3]:1; Rizzolo D, et al. J Physician Assist Educ. 2019;30[2]:103). Some PA residencies have long-incorporated POCUS training to varying degrees, providing emergency/critical care/cardiovascular ultrasound training comparable to that of physician residencies (Daymude ML, et al. J Physician Assist Educ. 2007;18[1]:29). A 12-month POCUS fellowship, which mirrors physician POCUS fellowship curricula, is also available for PAs at Madigan and Brooke Army Medical Centers and allows graduates the opportunity to earn RDMS/RDCS credentials (Monti J. J Physician Assist Educ. 2017;28[1]:27). POCUS employment is not limited to physicians and PAs, however. Respiratory therapists and other allied health professionals are also exploring the value of pulmonary, cardiovascular, and other critical care POCUS applications in their respective practices (Karthika M, et al. Respir Care. 2019;64[2]:217). Meanwhile, POCUS devices continue to evolve toward inexpensive handheld machines that incorporate machine learning/artificial intelligence, further mitigating barriers to integration of POCUS into routine clinical practice (Tsay D, et al. Circulation. 2018;138[22]:2569). With the expansion of POCUS across the full spectrum of health care, leadership from multiprofessional organizations, such as CHEST and the Society of Point-of-Care Ultrasound (SPOCUS), are well-positioned to leverage their diverse leadership to govern the training and safe employment of POCUS.
Robert Baeten II, DmSc, FCCP Steering Committee Member
Chest infections
New laboratory testing guidelines for diagnosing fungal infections
Secondary to a growing number of immunosuppressed individuals, the incidence of invasive fungal infections (IFI) is increasing. IFIs can be difficult to treat and are associated with a high mortality rate. Effective treatment is predicated on early recognition and accurate diagnosis (Limper AH, et al. Am J Respir Crit Care Med. 2011;183[1]:96). Therefore, the American Thoracic Society created a clinical practice guideline on laboratory diagnosis of the most common fungal infections (Hage CA, et al. Am J Respir Crit Care Med. 2019;200[5]:535). The most important diagnostic considerations for clinicians are summarized below:
1. Serum galactomannan and serum aspergillus PCR are recommended in severely immunocompromised patients suspected of having invasive pulmonary aspergillosis (IPA).
2. Galactomannan and aspergillus PCR in bronchoalveolar lavage (BAL) are recommended for patients who are strongly suspected of having IPA, especially if serum is negative. In less severe immunocompromised patients, the BAL sensitivity of galactomannan is better compared with serum, without reducing specificity.
3. Due to low specificity/high false-positive rate, 1,3-B-D-glucan should not be used in isolation to diagnose invasive candidiasis.
4. No single best test exists for the diagnosis of blastomycosis or coccidioidomycosis; rather, more than one diagnostic test including fungal smear, culture, serum antibody, and antigen testing should be used for suspected blastomycosis or coccidioidomycosis.
5. Urine or serum antigen testing is recommended for patients with suspected disseminated or acute histoplasmosis. For immunocompetent patients suspected of pulmonary histoplasmosis, serologic testing is recommended; antigen testing may increase the diagnostic yield.
While these recommendations provide a basis for laboratory testing for the most common IFIs, they must be integrated into the clinical context to ensure accurate diagnosis.
Kelly Pennington, MD, Steering Committee MemberEva M. Carmona, MD, PhD, NetWork Member
Clinical pulmonary medicine
Definitive pleural interventions in malignant pleural effusions
Malignant pleural effusions (MPEs) contribute significantly to symptom burden, and an emphasis on patient-centered outcomes prioritizes palliation of symptoms and definitive management with pleurodesis. Clinical guidelines (Feller-Kopman DJ, et al. Am J Respir Crit Care Med. 2018;198[7]:839) for MPE recommend an indwelling pleural catheter (IPC) or chemical pleurodesis as first-line definitive pleural intervention. In a recent prospective study, Bhatnagar and colleagues (Bhatnagar R, et al. JAMA. 2019 Dec 5. doi: 10.1001/jama.2019.19997) evaluated the effectiveness of thoracoscopy with talc poudrage compared with chest tube placement with talc slurry. The authors randomized 330 patients with MPE and expandable lung, and the primary outcome was pleurodesis failure at 90 days after randomization. There was no significant difference in primary outcome, and pleurodesis failure at 90 days was 22% with talc poudrage and 24% with talc slurry. Similar results for pleurodesis failure at 30 and 180 days were noted.
Secondary outcomes for all-cause mortality, quality of life measures, symptom (chest pain, dyspnea) scores, hospital days, and radiographic opacification also showed no difference. This supports an earlier study by Dresler and associates (Dresler CM, et al. Chest. 2005 Mar;127[3]:909) that reported similar efficacy of talc poudrage and talc slurry. Interestingly, Bhatnagar’s group (Bhatnagar R, et al. N Engl J Med. 2018 Apr 5;378[14]:1313) previously demonstrated administration of talc slurry via IPC was safe and effective in the outpatient setting, but no direct comparison of IPC combined with talc poudrage or talc slurry is available.
These studies provide support for flexibility in MPE management, and selection of definitive pleural intervention can be tailored for each individual patient.
Saadia Faiz, MD, FCCP, Steering Committee Member
Mark Warner, MD, FCCP, NetWork Member
Interprofessional team
Interprofessional team and noninvasive ventilation in COPD exacerbation
Noninvasive ventilation (NIV) is a standard of care for treatment of COPD exacerbations, resulting in reduced need for mechanical ventilation, length of hospital stay, and mortality. Patient selection is as important to success as is choice of an appropriate interface, maintenance of synchrony, and a dedicated interprofessional team. Prior studies have identified that necessary factors for successful implementation of NIV in exacerbations of severe COPD include adequate equipment, sufficient numbers of qualified respiratory therapists, flexibility in staffing, provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education (Fisher et al. Ann Am Thorac Soc. 2017;14[11]:1674). These studies also suggest that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. The authors further point out that although NIV is a cornerstone of treatment for patients with severe exacerbations of COPD with proven reduced need for intubation, hospital length of stay, and mortality and despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals.
Since interdisciplinary teamwork, respiratory therapy autonomy, and staff education have been identified as important factors in appropriate implementation of NIV, investigators are currently studying the effectiveness, acceptability, and feasibility of interprofessional education for physicians, respiratory therapists, and nurses vs online education for increasing the delivery of NIV in patients hospitalized with COPD exacerbation (R01 HL 146615 – 01 Implementation of interprofessional training to improve uptake of noninvasive ventilation in patients hospitalized with severe COPD exacerbation).
More importantly, this work will further elucidate the interdisciplinary nature of NIV therapy and the benefit of an interprofessional approach to team education.
Mary Jo Farmer, MD, PhD, FCCP, Steering Committee Member Munish Luthra, MD, FCCP, Steering Committee Member
Evolution of point of care ultrasound (POCUS) education: cardiovascular, pulmonary, and beyond
A recent CHEST Physician article noted the ubiquity of POCUS employment but lamented inconsistencies and possible inadequacies of POCUS education amongst ACGME specialty fellowships (Satterwhite L. An update on the current standard for ultrasound education in fellowship. CHEST Physician. 2019 Dec. 9). POCUS education/training is no longer limited to physician fellowships but has percolated into the undergraduate medical education curricula of first-year medical students and physician assistant (PA) programs (Hoppmann RA, et al. Crit Ultrasound J. 2011;[3]:1; Rizzolo D, et al. J Physician Assist Educ. 2019;30[2]:103). Some PA residencies have long-incorporated POCUS training to varying degrees, providing emergency/critical care/cardiovascular ultrasound training comparable to that of physician residencies (Daymude ML, et al. J Physician Assist Educ. 2007;18[1]:29). A 12-month POCUS fellowship, which mirrors physician POCUS fellowship curricula, is also available for PAs at Madigan and Brooke Army Medical Centers and allows graduates the opportunity to earn RDMS/RDCS credentials (Monti J. J Physician Assist Educ. 2017;28[1]:27). POCUS employment is not limited to physicians and PAs, however. Respiratory therapists and other allied health professionals are also exploring the value of pulmonary, cardiovascular, and other critical care POCUS applications in their respective practices (Karthika M, et al. Respir Care. 2019;64[2]:217). Meanwhile, POCUS devices continue to evolve toward inexpensive handheld machines that incorporate machine learning/artificial intelligence, further mitigating barriers to integration of POCUS into routine clinical practice (Tsay D, et al. Circulation. 2018;138[22]:2569). With the expansion of POCUS across the full spectrum of health care, leadership from multiprofessional organizations, such as CHEST and the Society of Point-of-Care Ultrasound (SPOCUS), are well-positioned to leverage their diverse leadership to govern the training and safe employment of POCUS.
Robert Baeten II, DmSc, FCCP Steering Committee Member
Chest infections
New laboratory testing guidelines for diagnosing fungal infections
Secondary to a growing number of immunosuppressed individuals, the incidence of invasive fungal infections (IFI) is increasing. IFIs can be difficult to treat and are associated with a high mortality rate. Effective treatment is predicated on early recognition and accurate diagnosis (Limper AH, et al. Am J Respir Crit Care Med. 2011;183[1]:96). Therefore, the American Thoracic Society created a clinical practice guideline on laboratory diagnosis of the most common fungal infections (Hage CA, et al. Am J Respir Crit Care Med. 2019;200[5]:535). The most important diagnostic considerations for clinicians are summarized below:
1. Serum galactomannan and serum aspergillus PCR are recommended in severely immunocompromised patients suspected of having invasive pulmonary aspergillosis (IPA).
2. Galactomannan and aspergillus PCR in bronchoalveolar lavage (BAL) are recommended for patients who are strongly suspected of having IPA, especially if serum is negative. In less severe immunocompromised patients, the BAL sensitivity of galactomannan is better compared with serum, without reducing specificity.
3. Due to low specificity/high false-positive rate, 1,3-B-D-glucan should not be used in isolation to diagnose invasive candidiasis.
4. No single best test exists for the diagnosis of blastomycosis or coccidioidomycosis; rather, more than one diagnostic test including fungal smear, culture, serum antibody, and antigen testing should be used for suspected blastomycosis or coccidioidomycosis.
5. Urine or serum antigen testing is recommended for patients with suspected disseminated or acute histoplasmosis. For immunocompetent patients suspected of pulmonary histoplasmosis, serologic testing is recommended; antigen testing may increase the diagnostic yield.
While these recommendations provide a basis for laboratory testing for the most common IFIs, they must be integrated into the clinical context to ensure accurate diagnosis.
Kelly Pennington, MD, Steering Committee MemberEva M. Carmona, MD, PhD, NetWork Member
Clinical pulmonary medicine
Definitive pleural interventions in malignant pleural effusions
Malignant pleural effusions (MPEs) contribute significantly to symptom burden, and an emphasis on patient-centered outcomes prioritizes palliation of symptoms and definitive management with pleurodesis. Clinical guidelines (Feller-Kopman DJ, et al. Am J Respir Crit Care Med. 2018;198[7]:839) for MPE recommend an indwelling pleural catheter (IPC) or chemical pleurodesis as first-line definitive pleural intervention. In a recent prospective study, Bhatnagar and colleagues (Bhatnagar R, et al. JAMA. 2019 Dec 5. doi: 10.1001/jama.2019.19997) evaluated the effectiveness of thoracoscopy with talc poudrage compared with chest tube placement with talc slurry. The authors randomized 330 patients with MPE and expandable lung, and the primary outcome was pleurodesis failure at 90 days after randomization. There was no significant difference in primary outcome, and pleurodesis failure at 90 days was 22% with talc poudrage and 24% with talc slurry. Similar results for pleurodesis failure at 30 and 180 days were noted.
Secondary outcomes for all-cause mortality, quality of life measures, symptom (chest pain, dyspnea) scores, hospital days, and radiographic opacification also showed no difference. This supports an earlier study by Dresler and associates (Dresler CM, et al. Chest. 2005 Mar;127[3]:909) that reported similar efficacy of talc poudrage and talc slurry. Interestingly, Bhatnagar’s group (Bhatnagar R, et al. N Engl J Med. 2018 Apr 5;378[14]:1313) previously demonstrated administration of talc slurry via IPC was safe and effective in the outpatient setting, but no direct comparison of IPC combined with talc poudrage or talc slurry is available.
These studies provide support for flexibility in MPE management, and selection of definitive pleural intervention can be tailored for each individual patient.
Saadia Faiz, MD, FCCP, Steering Committee Member
Mark Warner, MD, FCCP, NetWork Member
Interprofessional team
Interprofessional team and noninvasive ventilation in COPD exacerbation
Noninvasive ventilation (NIV) is a standard of care for treatment of COPD exacerbations, resulting in reduced need for mechanical ventilation, length of hospital stay, and mortality. Patient selection is as important to success as is choice of an appropriate interface, maintenance of synchrony, and a dedicated interprofessional team. Prior studies have identified that necessary factors for successful implementation of NIV in exacerbations of severe COPD include adequate equipment, sufficient numbers of qualified respiratory therapists, flexibility in staffing, provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education (Fisher et al. Ann Am Thorac Soc. 2017;14[11]:1674). These studies also suggest that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. The authors further point out that although NIV is a cornerstone of treatment for patients with severe exacerbations of COPD with proven reduced need for intubation, hospital length of stay, and mortality and despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals.
Since interdisciplinary teamwork, respiratory therapy autonomy, and staff education have been identified as important factors in appropriate implementation of NIV, investigators are currently studying the effectiveness, acceptability, and feasibility of interprofessional education for physicians, respiratory therapists, and nurses vs online education for increasing the delivery of NIV in patients hospitalized with COPD exacerbation (R01 HL 146615 – 01 Implementation of interprofessional training to improve uptake of noninvasive ventilation in patients hospitalized with severe COPD exacerbation).
More importantly, this work will further elucidate the interdisciplinary nature of NIV therapy and the benefit of an interprofessional approach to team education.
Mary Jo Farmer, MD, PhD, FCCP, Steering Committee Member Munish Luthra, MD, FCCP, Steering Committee Member
Evolution of point of care ultrasound (POCUS) education: cardiovascular, pulmonary, and beyond
A recent CHEST Physician article noted the ubiquity of POCUS employment but lamented inconsistencies and possible inadequacies of POCUS education amongst ACGME specialty fellowships (Satterwhite L. An update on the current standard for ultrasound education in fellowship. CHEST Physician. 2019 Dec. 9). POCUS education/training is no longer limited to physician fellowships but has percolated into the undergraduate medical education curricula of first-year medical students and physician assistant (PA) programs (Hoppmann RA, et al. Crit Ultrasound J. 2011;[3]:1; Rizzolo D, et al. J Physician Assist Educ. 2019;30[2]:103). Some PA residencies have long-incorporated POCUS training to varying degrees, providing emergency/critical care/cardiovascular ultrasound training comparable to that of physician residencies (Daymude ML, et al. J Physician Assist Educ. 2007;18[1]:29). A 12-month POCUS fellowship, which mirrors physician POCUS fellowship curricula, is also available for PAs at Madigan and Brooke Army Medical Centers and allows graduates the opportunity to earn RDMS/RDCS credentials (Monti J. J Physician Assist Educ. 2017;28[1]:27). POCUS employment is not limited to physicians and PAs, however. Respiratory therapists and other allied health professionals are also exploring the value of pulmonary, cardiovascular, and other critical care POCUS applications in their respective practices (Karthika M, et al. Respir Care. 2019;64[2]:217). Meanwhile, POCUS devices continue to evolve toward inexpensive handheld machines that incorporate machine learning/artificial intelligence, further mitigating barriers to integration of POCUS into routine clinical practice (Tsay D, et al. Circulation. 2018;138[22]:2569). With the expansion of POCUS across the full spectrum of health care, leadership from multiprofessional organizations, such as CHEST and the Society of Point-of-Care Ultrasound (SPOCUS), are well-positioned to leverage their diverse leadership to govern the training and safe employment of POCUS.
Robert Baeten II, DmSc, FCCP Steering Committee Member
Chest infections
New laboratory testing guidelines for diagnosing fungal infections
Secondary to a growing number of immunosuppressed individuals, the incidence of invasive fungal infections (IFI) is increasing. IFIs can be difficult to treat and are associated with a high mortality rate. Effective treatment is predicated on early recognition and accurate diagnosis (Limper AH, et al. Am J Respir Crit Care Med. 2011;183[1]:96). Therefore, the American Thoracic Society created a clinical practice guideline on laboratory diagnosis of the most common fungal infections (Hage CA, et al. Am J Respir Crit Care Med. 2019;200[5]:535). The most important diagnostic considerations for clinicians are summarized below:
1. Serum galactomannan and serum aspergillus PCR are recommended in severely immunocompromised patients suspected of having invasive pulmonary aspergillosis (IPA).
2. Galactomannan and aspergillus PCR in bronchoalveolar lavage (BAL) are recommended for patients who are strongly suspected of having IPA, especially if serum is negative. In less severe immunocompromised patients, the BAL sensitivity of galactomannan is better compared with serum, without reducing specificity.
3. Due to low specificity/high false-positive rate, 1,3-B-D-glucan should not be used in isolation to diagnose invasive candidiasis.
4. No single best test exists for the diagnosis of blastomycosis or coccidioidomycosis; rather, more than one diagnostic test including fungal smear, culture, serum antibody, and antigen testing should be used for suspected blastomycosis or coccidioidomycosis.
5. Urine or serum antigen testing is recommended for patients with suspected disseminated or acute histoplasmosis. For immunocompetent patients suspected of pulmonary histoplasmosis, serologic testing is recommended; antigen testing may increase the diagnostic yield.
While these recommendations provide a basis for laboratory testing for the most common IFIs, they must be integrated into the clinical context to ensure accurate diagnosis.
Kelly Pennington, MD, Steering Committee MemberEva M. Carmona, MD, PhD, NetWork Member
Clinical pulmonary medicine
Definitive pleural interventions in malignant pleural effusions
Malignant pleural effusions (MPEs) contribute significantly to symptom burden, and an emphasis on patient-centered outcomes prioritizes palliation of symptoms and definitive management with pleurodesis. Clinical guidelines (Feller-Kopman DJ, et al. Am J Respir Crit Care Med. 2018;198[7]:839) for MPE recommend an indwelling pleural catheter (IPC) or chemical pleurodesis as first-line definitive pleural intervention. In a recent prospective study, Bhatnagar and colleagues (Bhatnagar R, et al. JAMA. 2019 Dec 5. doi: 10.1001/jama.2019.19997) evaluated the effectiveness of thoracoscopy with talc poudrage compared with chest tube placement with talc slurry. The authors randomized 330 patients with MPE and expandable lung, and the primary outcome was pleurodesis failure at 90 days after randomization. There was no significant difference in primary outcome, and pleurodesis failure at 90 days was 22% with talc poudrage and 24% with talc slurry. Similar results for pleurodesis failure at 30 and 180 days were noted.
Secondary outcomes for all-cause mortality, quality of life measures, symptom (chest pain, dyspnea) scores, hospital days, and radiographic opacification also showed no difference. This supports an earlier study by Dresler and associates (Dresler CM, et al. Chest. 2005 Mar;127[3]:909) that reported similar efficacy of talc poudrage and talc slurry. Interestingly, Bhatnagar’s group (Bhatnagar R, et al. N Engl J Med. 2018 Apr 5;378[14]:1313) previously demonstrated administration of talc slurry via IPC was safe and effective in the outpatient setting, but no direct comparison of IPC combined with talc poudrage or talc slurry is available.
These studies provide support for flexibility in MPE management, and selection of definitive pleural intervention can be tailored for each individual patient.
Saadia Faiz, MD, FCCP, Steering Committee Member
Mark Warner, MD, FCCP, NetWork Member
Interprofessional team
Interprofessional team and noninvasive ventilation in COPD exacerbation
Noninvasive ventilation (NIV) is a standard of care for treatment of COPD exacerbations, resulting in reduced need for mechanical ventilation, length of hospital stay, and mortality. Patient selection is as important to success as is choice of an appropriate interface, maintenance of synchrony, and a dedicated interprofessional team. Prior studies have identified that necessary factors for successful implementation of NIV in exacerbations of severe COPD include adequate equipment, sufficient numbers of qualified respiratory therapists, flexibility in staffing, provider buy-in, respiratory therapist autonomy, interdisciplinary teamwork, and staff education (Fisher et al. Ann Am Thorac Soc. 2017;14[11]:1674). These studies also suggest that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. The authors further point out that although NIV is a cornerstone of treatment for patients with severe exacerbations of COPD with proven reduced need for intubation, hospital length of stay, and mortality and despite high-quality evidence and strong recommendations in clinical guidelines, use of NIV varies widely across hospitals.
Since interdisciplinary teamwork, respiratory therapy autonomy, and staff education have been identified as important factors in appropriate implementation of NIV, investigators are currently studying the effectiveness, acceptability, and feasibility of interprofessional education for physicians, respiratory therapists, and nurses vs online education for increasing the delivery of NIV in patients hospitalized with COPD exacerbation (R01 HL 146615 – 01 Implementation of interprofessional training to improve uptake of noninvasive ventilation in patients hospitalized with severe COPD exacerbation).
More importantly, this work will further elucidate the interdisciplinary nature of NIV therapy and the benefit of an interprofessional approach to team education.
Mary Jo Farmer, MD, PhD, FCCP, Steering Committee Member Munish Luthra, MD, FCCP, Steering Committee Member