Patients and Methods

Patients and Methods

Study design:
This study was carried on 158 patients with acute respiratory failure
who were collected from those admitted at chest department and respiratory
critical care unit, Assuit university hospital and those admitted at chest
department, Minia university hospital during the period from October
2011to May 2014.

Acute respiratory failure(ARF) was defined based on the clinical and

gasometric evaluation.Clinically it involved manifestations of hypoxemia
(cyanosis, tachypnea, tachycardia, altered mental status ), hypercapnia
(restlessness, lethargy, tremor, asterixis , headache), or both (Chakrabarti
and Calverley. 2006).Gasometrically ARF was defined as arterial oxygen
tension (Pa,O2) of <8.0 kPa (60 mmHg), with or without increase in arterial
carbon dioxide tension (Pa,CO2) of>6.0 kPa (45 mmHg) (Epstein.,2013).
 Inclusion criteria:

 Any patients with acute and or acute on top of chronic

respiratory failure with a proven diagnosis of the underlying
diseases that cause ARF.

 Exclusion criteria:
 Patients with no final diagnosis (unknown final diagnosis or
died before final diagnosis could be identified).

 Emergency trauma patients

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 Non respiratory (extra-pulmonary) causes of acute respiratory

failure as neurological causes (drug toxicity, brain stem
lesions) and cardiogenic pulmonary oedema.

The final etiological diagnosis of acute respiratory failure was

established by RICU and inpatient resident staff according to history,
clinical examination, investigations (not including chest ultrasound).This
study was approved by the hospital’s research ethics board of Minia
University and informed consents were obtained from either patients
themselves or their relatives.
Methods:
All patients were subjected to the followings:
1-History taking (from patients or their relatives)
2-General and local chest examination
3- Chest radiography
4-Thoracic computed tomography

Thoracic computed tomography (CT) scan was done (when

needed)using "Aquilion 64, Toshiba, Otawara, Japan helical scanner" in
Assuit university hospital and 'light speed 64, GE, multislice scanner" in
Minia university hospital.

5- Other diagnostic tools were done according to the case:-

A-Spirometry:

It was done in both obstructive airway disease groups and interstitial

lung disease group, at the time or some days after admission using a
spirometer (Zan 300, Germany).

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B-Echocardiography and duplex lower limb

Echocardiographic examination was performed by an independent
cardiologist immediately or within 3 days using (GE , Vivid S3, sector
probe ) to assess right ventricular function in suspected cases of pulmonary
embolism. Lower limb venous duplex was done using (GE logic P5) for
patients with unilateral lower limb swelling and in suspected cases with
pulmonary embolism using linear probe .Visualization of anatomic echoic
intraluminal thrombosis or absence of compressibility was considered as a
positive finding of DVT(Lichtenstein(2).,2010).
C-Pleural fluid analysis
Chemical (glucose, protein), bacteriological (gram staining and Zeil
nelsen) and cytological examination of the pleural fluid were done in
patients had pleural effusion.

D-Complete blood count (CBC)

6-Transthoracic ultrasonography (TUS)

TUS was performed to all patients on the same day of admission
without interrupting and participating in their management using either
(ALOKA, prosound SSD-3500 SV model IPG -1530 apparatus,JAPAN)
for those admitted at chest department Assuit university hospital,(Samsung
Medison, SonoAce R3 Portable Ultrasound System) for patients admitted
to RICU, chest department, Assuit University Hospital and either
(Sonoscape portable ultrasound diagnostic system A5
model,sonomed)or(Philips ClearVue 350 ultrasound,USA)was used for
those admitted at chest department, Minia University Hospital.TUS was
done using both (2.5-5MHz) convex probe and (7.5-10 MHz) linear probe
for lung and pleura examination.TUS was done blindly with no data on the
clinical or radiological findings.

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Figure (115) Aloka ultrasound

Figure(116)Sonoscape A5

Figure (117) Philips ClearVue 350 ultrasound

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 Patients and Methods

Each patient underwent a comprehensive TUS assessment within 10

minutes including anterior, lateral and posterior aspects of the chest
wall.Patients were investigated in supine if intubated, or in a sitting position
with raising their arms above head to widen the intercostal space for inward
patients. For the critically ill patient , the posterior field scanning was
accomplished either in the supine position by pushing the transducer
posteriorly and angulating the transducer toward the center of the body or
by placing the patient in the lateral decubitus or semi sitting position with
the ipsilateral arm pulled across the body in order to expose part of the
posterior hemithorax.Lung ultrasonography was performed in a series of
scan lines along the chest wall with the transducer orientated either
perpendicular or transverse to the chest wall.

Examination of anterior lung field examination of the posterior field in supine

Figure(118 ) Scanning areas in critically ill patient.

Quoted from (Bolliger et al., 2009)

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Ultrasonographic chest examination was done using real time(B)

mode, motion mode(M) , color coded Doppler mode to trace the prescence
of pleural effusion and to evaluate vascular distribuation in consolidation ,
infarction and lung mass. Pulsed wave Doppler and Power Doppler were
performed in certain cases with suspected masses.
The following were assessed on chest ultrasonography

1-Lung sliding; in case of absent lung sliding, M-mode was used to

assess presence or absence of seashore sign and lung point.

2-Artifacts types and lung profiles were detected using BLUE protocol
algorithm as a rapid bedside tool for evaluation of chest diseases causing
acute respiratory failure (Lichtenstein andMezière., 2008). In the
BLUE-protocol, three standardized points were located on the chest
wall, the upper BLUE-point, lower BLUE-point and PLAPS-point. Two
hands (without the thumbs) are applied together as in fig ( 119).The
upper hand is applied with the little finger against the lower border of
the clavicle (in its long axis)and the finger tips touch the midline. The
lower hand is applied below the first one with the thumbs do not count.
The upper BLUE point is at the root of the middle and ring fingers of the
upper hand (upper cross) while the lower BLUE point is in the middle
of the palm of the lower hand (lower cross) and the lower edge of the
lower hand roughly indicates the phrenic line which representing the
end of the lung (arrow). The PLAPS-point is defined by the intersection
of a horizontal line at the level of the lower BLUE-point with a vertical
line at the posterior axillary line.

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Figure (119) showing the BLUE points on the left panel , PLAP point on the right
panel (black arrow ) and phrenic point (cross mark) (Lichtenstein(3)., 2010)

Lung profiles were detected anteriorly and described based on BLUE

protocol as A, A′, B, B′, AB and C profile in the presence or absence of
PLAPs (Lichtenstein andMezière., 2008):
 A- profile = anterior predominant bilateral A lines associated with lung
sliding. The number of A- lines were recorded in the scanning area as
zero (absence of A line), three lines or more and five lines or more.

 A′- profile = A profile with abolished lung sliding and without lung
point.

 B - profile= anterior predominant bilateral B lines associated with lung

sliding. Alveolo-interstial syndrome , constitutes a group of diseases that
is caused by an increase in lung fluid and/or reduction in its air content.
It is a sonograhic term that means the presence of three or more B-lines
in a longitudinal plane between two ribs in two or more regions
bilaterally (Volpicelli et al.,2012). Interstitial syndrome occur in the
following conditions: Pulmonary oedema of various causes, interstitial
pneumonia or pneumonitis and diffuse parenchymal lung disease
(pulmonary fibrosis). B line distance was evaluated and recorded as

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B+3(lung rockets with an approximate distance of 3 mm between each

line measured close to the pleural line, B+5 (approximate distance 5
mm) and B+7 (approximate distance between two B line nearly 7mm).
 B′- profile = B profile with abolished lung sliding.

 A/B - profile = anterior predominant B+ lines at one side, predominant

A lines at the other.

 C- profile = anterior alveolar consolidation(s)

 O- profile(non-A, non-B) defined as absence of any artifact, either

horizontal or vertical, arising from the pleural line.
 PLAPS = posterior-lateral alveolar consolidation and/or pleural
effusion syndrome

3-lung point

4-Abnormal sonographic finding as consolidation ,pleural effusion ,

mass and presence of pneumothorax were also evaluated.Patients were
considered to have pulmonary embolism if they had either A profile
with positive DVT or triangular pleural based hypoechoic lesion with
no or little perfusion (absent or trace color flow signal).

5-Follow up lung sonographic examination was done at the 10th day in

cases of ARF due to pneumonia.

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(120) A-lines

(121)B-lines
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Figure (122) C-lines

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Statistical analysis:

Data entry and data analysis were done using SPSS version 19
(Statistical Package for Social Science), and Medcalc version 13.3. Data
were presented as number, percentage, mean, standard deviation. Chi-square
test was used to compare between qualitative variables. Spearman
correlation was done to measure correlation between quantitative variables.
ROC curve analysis was used for calculation of sensitivity, specificity,
positive predictive value, negative predictive value and accuracy .P-value
considered statistically significant when P < 0.05.

Sensitivity =[TP/(TP+FN)] x 100 where, TP= true positive, FN = false negative

 It represents the ability of the test to identify correctly those
individual who truly have the disease.
 Specificity=[TN/(TN+ FP)] x 100where, TN = true negative, FP =false
positive

 It represents the ability of the test to identify correctly those

individual who truly do not have the disease.
 Positive predictive value (PPV)=[TP/(TP+FP)] x 100
 Negative predictive value (NPV)= [TN/(TN+FN)] x100
 Diagnostic accuracy (DA)=[(TP+TN)/(TP+ TN+FP+ FN)] x100

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