Imaging of the ADRS patient: Risk of transportation and alternative to repetitive radiation exposure Jean-Jacques Rouby Pitié-Salpêtrière Hospital The Intensive Care Unit The Intensive Care Unit Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine,University School of Medicine Pierre and Marie Curie (UPMC) - Paris 6 - http://www.reapitie-univparis6.aphp.fr 25 05 2012
Lung Computed Tomography in the Critically ill Risk of transportation http://www.reapitie-univparis6.aphp.fr 25 05 2012
Risks of transportation outside the ICU Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Beckmann U et al. Intensive Care Medicine 30: 1579-1585 2004 93 ICUs 176 patients undergoing intra-hospital transportation (operating theatre and department of Radiology), 191 incidents http://www.reapitie-univparis6.aphp.fr 25 05 2012
Risks of transportation outside the ICU Monitors Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Beckmann U et al. Intensive Care Medicine 30: 1579-1585 2004 Battery supply problem 8 Not available 2 Faulty monitors 2 Airway equipment Problem with intubation/airway equipment 7 Transport ventilator malfunction 4 Problems with oxygen supply 3 Drugs 93 ICUs 176 patients undergoing intra-hospital transportation (operating theatre and department of Radiology), 191 incidents http://www.reapitie-univparis6.aphp.fr Delayed administration/failure to deliver drug 14 Infusion interruption 4 Emergency drugs unavailable 2 Infusion pumps Battery supply problem 6 Not available 1 Other Emergency elevator access 18 Bed-related problems 4 25 05 2012
Risks of transportation outside the ICU Staff management Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Beckmann U et al. Intensive Care Medicine 30: 1579-1585 2004 Communication/liaison problems 18 Inappropriate staff escort 4 Lack of staff 6 Inadequate notification of arrival 5 Airway/ventilation management Malposition of artificial airway 10 Inadequate securing of airway 6 Unplanned reintubation 4 Accidental extubation 3 Portable ventilator incorrectly set-up 2 Failure to check oxygen supply 2 Vascular line management 93 ICUs 176 patients undergoing intra-hospital transportation (operating theatre and department of Radiology), 191 incidents http://www.reapitie-univparis6.aphp.fr Other Incorrect moving of patient 10 Incorrect stabilization of injured site 4 Staff back-lifting injury 4 Other 3 Accidental dislodgment 9 Disconnection/loose connection 3 Inadequate securing 7 Monitor use Inadequate monitoring 11 Alarm parameters not used/inadequate 3 Incorrect set-up 2 25 05 2012
Lung CT in the critically ill patient Risk resulting from radiation exposure Brenner DJ et al. NEJM 2007 357: 2277-84 http://www.reapitie-univparis6.aphp.fr 25 05 2012
Radiation exposure: respective role of different radiologic tests Number of CT per habitant continuously increases TDM Lung CT 49% % Radiology Radiologie Mammographie Mammography 11% Interventional Radiologie interventionnelle Radiology 14% % Médecine Nuclear nucléaire Medicine 26% % Hricak et al. Radiology 2011 258: 889-905 Hall et al. Br J Radiol 2008 81: 362-78 http://www.reapitie-univparis6.aphp.fr 25 05 2012
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Lung CT : irradiation exposure Smith-Bindman R et al. Arch Intern Med 2009;169:2078 86
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Lung CT: Irradiation-induced carcinologic risk Hall EJ and Brenner DJ. Cancer risks from diagnostic radiology Br J Radiol 2008 81: 362-78 1 No epidemiologic study is avaailable (5 are on the way in Europe and United state) 2 Risk is assessed by analogy with the risk measured in survivors from Nagasaki and d Hiroshima, present 3 kms away from the impact and exposed to low irradiations, ranging between 50 and 100 msv). 3 Validity of this method has been partially validated by epidemiologic studies performed in workers exposed to low irradiations in nuclear industry.
Carcinologic effects of exposure to low dose radiation in survivors of Nagasaki and Hiroshima More than 30 000 survivors (adults and children), exposed to radiation ranging between 5 and 500 MsV (corresponding to one or several CTs) had a 60-year follow-up for mortality and cancer Hall et al. Br J Radiol 2008 81: 362-78 1 gray (Gy) = 1 Sivert (sv) Brenner DJ et al. NEJM 2007 357: 2277-84 http://www.reapitie-univparis6.aphp.fr 25 05 2012
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Carcinologic effects of exposure to low dose radiation in survivors of Nagasaki and Hiroshima Increased risk of cancer is expressed as the number of additional cancers for 100 000 inhabitants exposed to 100 msv (= 3 CTs) Shuryak I et al. J Natl Cancer Inst 2010;102:1628 1636
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Lung CT: How to decrease irradiation? 1 Reduce the number of useless tests (20 à 30 %...) 2 Automatic modulation of radiation dose
http://www.reapitie-univparis6.aphp.fr 25 05 2012 For reducing irradiation exposure, «new generation» scanners automatically adapt irradiation dose to the density of each organ Irradiation dose can be reduced by 20-50% whereas preserving image quality Hricak et al. Radiology 2011 258: 889-905
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Lung CT: How to decrease irradiation? 1 Reduce the number of useless tests (20 à 30 %...) 2 Automatic modulation of radiation dose 3 Introduce alternative and non invasive techniques Bedside lung ultrasound
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Lung diseases where Lung Ultrasound = Lung CT Alveolar-interstitial syndrome Lichtenstein et al. Anesthesiology 2004 100: 9-15 Lung consolidation Lichtenstein et al. Anesthesiology 2004 100: 9-15 Ventilator-associated pneumonia Bouhemad et al. Critical Care Medicine 2010 38: 84-92 Lung abscess Lichtenstein et al. Intensive Care Medicine 2006 32:334-335 Pulmonary embolism Mathis et al. Chest 2005 128:1531-1538 Pneumothorax Zhang et al. Critical Care 2006 10; R112 Pleural effusion Remérand et al. Intensive Care Medicine 2010 36: 656-664
Multiple B-lines - «comet-tails» - interstitial edema (B 1 ) 7 mm apart «B lines» thickened interlobular septa http://www.reapitie-univparis6.aphp.fr http://www.reapitie-univparis6.aphp.fr JJR 25 05 2012 D Lichtenstein et al AJRCCM 156 : 1640-1646, 1997 25 05 2012
Coalescent B lines - «comet-tails» - alveolar edema 3 mm apart «B lines» ground-glass areas http://www.reapitie-univparis6.aphp.fr 30 11 2011 25 05 2012 D Lichtenstein et al AJRCCM 156 : 1640-1646, 1997
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Coalescent B lines issued from juxtapleural consolidations confluent bronchopneumonia B Bouhemad, JJ Rouby Critical Care Medicine 2009 A Reissig et al Respiration 74 : 537, 2007
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Pulmonary consolidations: ultrasound characteristics Presence of punctiform or tubular images resulting from static or dynamic aeric bronchogram Pleural effusion Lower lobe
http://www.reapitie-univparis6.aphp.fr 25 05 2012 Pulmonary consolidations: ultrasound characteristics Presence of punctiform or tubular images resulting from static or dynamic aeric bronchogram
Inflammatory or infectious consolidations are characterized by persistent regional blood flow http://www.reapitie-univparis6.aphp.fr http://www.reapitie-univparis6.aphp.fr/ 25 05 2012
Multiple abscesses of the left lower lobe http://www.reapitie-univparis6.aphp.fr 25 05 2012
Multiple abscesses of the right lower lobe http://www.reapitie-univparis6.aphp.fr 25 05 2012
Multiple lung abscesses are not detected by lung ultrasound when located centrally within aerated lung regions. http://www.reapitie-univparis6.aphp.fr 25 05 2012
Quantification of pleural effusion which volume is 500 ml Interpleural distance at the lung base (PLD base ) Between 3 et 5 cms, inconclusive limits Roch A et al Chest 2005; 127:224 232 http://www.reapitie-univparis6.aphp.fr 26 11 2011 25 05 2012
http://www.reapitie-univparis6.aphp.fr 25 05 2012 2010 36: 656 PE volume US = PE area midlength x PE axial length
Quantification of small and large pleural effusions: The multiplane ultrasound approach Rémérand F et al Intensive Care Medicine 2010, 36: 999-1007 http://www.reapitie-univparis6.aphp.fr 26 11 2011 25 05 2012
Prospective evaluation of pulmonary auscultation, bedside chest radiography and lung ultrasound for the diagnosis of pleural effusion, alveolar-interstitial syndrome and lung consolidation in 31 patients with early ARDS The same day : Auscultation 6 quadrants in the anterior, lateral and posterior planes Bedside chest radiography 4 quadrants in the anterior and lateral planes and the «silhouette sign» for diagnosing posterior opacities Ultrasound 6 quadrants in the anterior, lateral and posterior planes Gold standard : CT of the whole lung http://www.reapitie-univparis6.aphp.fr 25 05 2012 D Lichtentsein and JJ Rouby., Annesthesiology 2004, 100 : 9-15
Diagnostic accuracy of Chest Radiography vs Lung Ultrasound in 32 patients with ARDS Pleural Effusion Alveolar-interstitial Consolidation syndrome sensitivity specificity Diagnostic accuracy http://www.reapitie-univparis6.aphp.fr 25 05 2012 D Lichtentsein and JJ Rouby, Annesthesiology 2004, 100 : 9-15
http://www.reapitie-univparis6.aphp.fr 25 05 2012 CONCLUSIONS The routine use of lung ultrasound in critically ill patients drastically reduces the indications of bedside chest radiography and thoracic CT. Simultaneously, radiation exposure and ICU costs should decrease whereas, at the same time, very accurate information on the lung status of patients with ARDS should become available at the bedside.