Point-of-care lung ultrasound for the detection of pulmonary manifestations of malaria and sepsis: An observational study

Stije J Leopold, Aniruddha Ghose, Katherine A Plewes, Subash Mazumder, Luigi Pisani, Hugh W F Kingston, Sujat Paul, Anupam Barua, M Abdus Sattar, Michaëla A M Huson, Andrew P Walden, Patricia C Henwood, Elisabeth D Riviello, Marcus J Schultz, Nicholas P J Day, Asok Kumar Dutta, Nicholas J White, Arjen M Dondorp, Stije J Leopold, Aniruddha Ghose, Katherine A Plewes, Subash Mazumder, Luigi Pisani, Hugh W F Kingston, Sujat Paul, Anupam Barua, M Abdus Sattar, Michaëla A M Huson, Andrew P Walden, Patricia C Henwood, Elisabeth D Riviello, Marcus J Schultz, Nicholas P J Day, Asok Kumar Dutta, Nicholas J White, Arjen M Dondorp

Abstract

Introduction: Patients with severe malaria or sepsis are at risk of developing life-threatening acute respiratory distress syndrome (ARDS). The objective of this study was to evaluate point-of-care lung ultrasound as a novel tool to determine the prevalence and early signs of ARDS in a resource-limited setting among patients with severe malaria or sepsis.

Materials and methods: Serial point-of-care lung ultrasound studies were performed on four consecutive days in a planned sub study of an observational cohort of patients with malaria or sepsis in Bangladesh. We quantified aeration patterns across 12 lung regions. ARDS was defined according to the Kigali Modification of the Berlin Definition.

Results: Of 102 patients enrolled, 71 had sepsis and 31 had malaria. Normal lung ultrasound findings were observed in 44 patients on enrolment and associated with 7% case fatality. ARDS was detected in 10 patients on enrolment and associated with 90% case fatality. All patients with ARDS had sepsis, 4 had underlying pneumonia. Two patients developing ARDS during hospitalisation already had reduced aeration patterns on enrolment. The SpO2/FiO2 ratio combined with the number of regions with reduced aeration was a strong prognosticator for mortality in patients with sepsis (AUROC 91.5% (95% Confidence Interval: 84.6%-98.4%)).

Conclusions: This study demonstrates the potential usefulness of point-of-care lung ultrasound to detect lung abnormalities in patients with malaria or sepsis in a resource-constrained hospital setting. LUS was highly feasible and allowed to accurately identify patients at risk of death in a resource limited setting.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Common lung ultrasound patterns.
Fig 1. Common lung ultrasound patterns.
(A) ‘A-lines’ are reverberation artefacts of the pleura line present in normally aerated lung tissue; they are indicated by the arrows. (B) ‘B-patterns’ are pathological signs of extravascular lung water. Here, multiple coalescent B-lines are shown between the indicator arrows, extending to the lower end of the screen. (C) ‘C-patterns’ are characteristic for pulmonary consolidation suggesting pneumonia. Here, an interruption of the normal pleural line is shown, with multiple echogenic punctiform laesions (as indicated by the arrows) and an underlying air bronchogram.
Fig 2. STROBE flow diagram.
Fig 2. STROBE flow diagram.
*Complications can overlap in the same patient.
Fig 3. Lung ultrasound observations and associated…
Fig 3. Lung ultrasound observations and associated case fatality rates in patients with sepsis and severe malaria (n = 102) in Bangladesh.
Fig 4. AUROCC of LUS findings, SF…
Fig 4. AUROCC of LUS findings, SF ratios, and their combined ability to predict fatal outcome in patients with sepsis (n = 71) in Bangladesh.
Area Under the Receiver Operating Characteristics Curve (AUROCC) of 1) Lung ultrasound (LUS) quantification of the number of lung regions (0 to 12) with a B-pattern (B1 or B2); 2) SpO2/FiO2 ratios (SF); and 3) SF and LUS combined.

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