Best Practice Recommendations for the Safe use of Lung Ultrasound

Abstract

The safety of ultrasound is of particular importance when examining the lungs, due to specific bioeffects occurring at the alveolar air-tissue interface. Lung is significantly more sensitive than solid tissue to mechanical stress. The causal biological effects due to the total reflection of sound waves have also not been investigated comprehensively.

On the other hand, the clinical benefit of lung ultrasound is outstanding. It has gained considerable importance during the pandemic, showing comparable diagnostic value with other radiological imaging modalities.

Therefore, based on currently available literature, this work aims to determine possible effects caused by ultrasound on the lung parenchyma and evaluate existing recommendations for acoustic output power limits when performing lung sonography.

This work recommends a stepwise approach to obtain clinically relevant images while ensuring lung ultrasound safety. A special focus was set on the safety of new ultrasound modalities, which had not yet been introduced at the time of previous recommendations.

Finally, necessary research and training steps are recommended in order to close knowledge gaps in the field of lung ultrasound safety in the future.

These recommendations for practice were prepared by ECMUS, the safety committee of the EFSUMB, with participation of international experts in the field of lung sonography and ultrasound bioeffects.

Zusammenfassung

Die Sicherheit des Ultraschalls ist bei der Untersuchung der Lunge von besonderer Bedeutung, da spezifische Wechselwirkungsmechanismen an der alveolaren Luft-Gewebe-Grenze auftreten. Lungengewebe ist dabei deutlich empfindlicher gegenüber mechanischen Kräften als solides Gewebe. Die ursächlichen biologischen Effekte, basierend auf Totalreflektion von Schallwellen, sind zudem nur unzureichend untersucht.

Andererseits ist der klinische Nutzen des Lungenultraschalls beträchtlich und hat aufgrund der Pandemiesituation einen erheblichen Stellenwert dazugewonnen. Dabei erweist sich dieser bisweilen dem anderer radiologischer Bildgebungsverfahren als ebenbürtig.

Deshalb widmet sich diese Arbeit, basierend auf derzeit verfügbaren Literaturquellen, dem Einfluss von Schalleffekten auf das Lungenparenchym und evaluiert bestehende Empfehlungen zur Schalldruckreduzierung bei der Durchführung der Lungensonografie.

Es wird ein Vorgehen empfohlen, um klinisch relevante Bilder zu erhalten und gleichzeitig die Ultraschallsicherheit zu gewährleisten. Ein besonderes Augenmerk liegt auf der Sicherheit neuer Ultraschall-Modalitäten, welche zum Zeitpunkt früherer Empfehlungen noch nicht berücksichtigt waren.

Abschließend werden notwendige Forschungs- und Ausbildungsschritte empfohlen, um Wissenslücken auf dem Gebiet des Lungenultraschalls in Zukunft schließen zu können.

Diese Empfehlungen für die Praxis wurden von ECMUS, dem Sicherheitskomitee der EFSUMB, unter Mitwirkung von internationalen Experten auf dem Gebiet der Lungensonografie und biologischer Ultraschallwechselwirkung, erstellt.

Key words

lung ultrasound - bio effects - pulmonary hemorrhage - safety - chest

Publication History

Received: 21 July 2022

Accepted: 14 November 2022

Accepted Manuscript online:
14 November 2022

Article published online:
03 March 2023

• References

• 1 Mathis G. Pneumonia: Does Ultrasound Replace Chest X-Ray?. Praxis 1994; 107 (23) 1283-1287
• 2 Soldatia G, Demi M, Smargiassic A. et al. The role of ultrasound lung artefacts in the diagnosis of respiratory diseases. Exp Rev Resp Med 2019; 13 (02) 163-172
• 3 Soldati G, Demi M. The use of lung ultrasound images for the differential diagnosis of pulmonary and cardiac interstitial pathology. J Ultrasound 2017; 20 (02) 91-96
• 4 Gutsche H, Lesser T, Wolfram F. et al. Significance of Lung Ultrasound in Patients with Suspected COVID-19 Infection at Hospital Admission. Diagnostics 2021; 11 (06) 921
• 5 Demi L, Wolfram F, Klersy C. et al. New International Guidelines and Consensus on the Use of Lung Ultrasound. J Ultrasound Med 2022;
• 6 Rott H. Lung hemorrhage caused by diagnostic ultrasound. Review of the literature. Ultraschall in Med 1997; 18 (05) 226-228
• 7 Jagła M, Krzeczek O, Buczyńska A. et al. The safety of pulmonary ultrasonography in the neonatal intensive care unit. Dev Period Med 2018; 22 (01) 75-80
• 8 Meltzer R, Adsumelli R, Risher W. et al. Lack of Lung Hemorrhage in Humans After Intraoperative Transesophageal Echocardiography with Ultrasound Exposure Conditions Similar to Those Causing Lung Hemorrhage in Laboratory Animals. J Am Echocardiography 1998; 11 (01) 57-60
• 9 Miller D, Dong Z, Dou C. et al. Pulmonary capillary hemorrhage induced by diagnostic ultrasound in ventilated rats. Ultrasound Med Biol 2017; 44 (08) 1810-1817
• 10 Miller D, Dong Z, Dou C. et al. Pulmonary Capillary Hemorrhage Induced by Different Imaging Modes of Diagnostic Ultrasound. Ultrasound Med Biol 2018; 44 (05) 1012-1021
• 11 Miller D, Dong Z, Dou C. et al. Pulmonary Capillary Hemorrhage Induced by Super Sonic Shear Wave Elastography in Rats. Ultrasound Med Biol 2019; 45 (11) 2993-3004
• 12 Takayama N, Ishiguro Y, Taniguchi N. et al. The effect of ultrasound with acoustic radiation force on rabbit lung tissue: a preliminary study. J Med Ultrason 2001; 43 (04) 481-485
• 13 Miller D, Dong Z, Dou C. et al. Influence of scan duration on pulmonary capillary hemorrhage induced by diagnostic ultrasound. Ultrasound in Med. & Biol 2016; 42 (08) 1942-1950
• 14 Abramowicz J, Bagley J, Church C. et al. Medical Ultrasound Safety/Fourth Edition. Part Three: Implementing ALARA. 2020
• 15 Patterson B, Miller D. Experimental measurements of ultrasound attenuation in human chest wall and assessment of the mechanical index for lung ultrasound. Ultrasound Med Biol 2020; 46 (06) 1442-1454
• 16 British Medical Ultrasound Society. BMUS. [Online]. 2009 [cited 2021. Available from: https://www.bmus.org/policies-statements-guidelines/safety-statements/
• 17 American Institute of Ultrasound in Medicine A. Official Statements. [Online]. 2015 [cited 2021. Available from: https://www.aium.org/officialStatements/67
• 18 Miller D. Mechanism for induction of pulmonary capillary hemorrhage by diagnostic ultrasound : Review and consideration of acoustical pleural surface pressure. Ultrasound Med Biol 2016; 42 (12) 2743-2757
• 19 Miller D, Suresh M, Dou C. et al. Characterization of ultrasound-induced pulmonary capillary hemorrhage in rats. Microvasc Res 2014; 93: 42-45
• 20 Tsang S, Wing MaK, Hoi SheW. et al. High-intensity focused ultrasound ablation of liver tumors in difficult locations. Int J Hyperthermia 2021; 38 (02) 56-64
• 21 Knott E, Longo K, Swietlik J. et al. Hepatic Ablation with Robotically Assisted Sonic Therapy (RAST) Through Full Rib Coverage in a Porcine Model. In ITSU EUFUS. Barcelona: International Society for Therapeutic Ultrasound; 2019
• 22 Jang K, Tu T, Nagle M. et al. Molecular and histological effects of MR-guided pulsed focused ultrasound to the rat heart. J Transl Med 2017; 15 (01) 252
• 23 Gargani L, Volpicelli G. How I do it: lung ultrasound. Cardiovasc Ultrasound 2014; 12 (25)
• 24 Liu J, Guo G, Kurepa D. et al. Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination. J Matern Fetal Neonatal Med 2021; 35 (05) 1003-1016
• 25 OʼBrien W, Frizzell L, Weigel R. et al. Ultrasound-induced lung hemorrhage is not caused by inertial cavitation. J Acoust Soc Am 2000; 108 (03) 1290-1297
• 26 Church C, OʼBrien W. Evaluation of the Threshold for Lung Hemorrhage by Diagnostic Ultrasound and a Proposed New Safety Index. Ultrasound Med Biol 2007; 33 (05) 810-818