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Browsing by Author "Gargani, Luna"
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Item Design and rationale of the B-lines lung ultrasound guided emergency department management of acute heart failure (BLUSHED-AHF) pilot trial(Elsevier, 2018) Russell, Frances M.; Ehrman, Robert R.; Ferre, Robinson; Gargani, Luna; Noble, Vicki; Rupp, Jordan; Collins, Sean P.; Hunter, Benton; Lane, Kathleen A.; Levy, Phillip; Li, Xiaochun; O'Connor, Christopher; Pang, Peter S.; Emergency Medicine, School of MedicineBackground Medical treatment for acute heart failure (AHF) has not changed substantially over the last four decades. Emergency department (ED)-based evidence for treatment is limited. Outcomes remain poor, with a 25% mortality or re-admission rate within 30 days post discharge. Targeting pulmonary congestion, which can be objectively assessed using lung ultrasound (LUS), may be associated with improved outcomes. Methods BLUSHED-AHF is a multicenter, randomized, pilot trial designed to test whether a strategy of care that utilizes a LUS-driven treatment protocol outperforms usual care for reducing pulmonary congestion in the ED. We will randomize 130 ED patients with AHF across five sites to, a) a structured treatment strategy guided by LUS vs. b) a structured treatment strategy guided by usual care. LUS-guided care will continue until there are ≤15 B-lines on LUS or 6h post enrollment. The primary outcome is the proportion of patients with B-lines ≤ 15 at the conclusion of 6 h of management. Patients will continue to undergo serial LUS exams during hospitalization, to better understand the time course of pulmonary congestion. Follow up will occur through 90 days, exploring days-alive-and-out-of-hospital between the two arms. The study is registered on ClinicalTrials.gov (NCT03136198). Conclusion If successful, this pilot study will inform future, larger trial design on LUS driven therapy aimed at guiding treatment and improving outcomes in patients with AHF.Item Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study(Springer Nature, 2021) Volpicelli, Giovanni; Gargani, Luna; Perlini, Stefano; Spinelli, Stefano; Barbieri, Greta; Lanotte, Antonella; Casasola, Gonzalo García; Nogué-Bou, Ramon; Lamorte, Alessandro; Agricola, Eustachio; Villén, Tomas; Deol, Paramjeet Singh; Nazerian, Peiman; Corradi, Francesco; Stefanone, Valerio; Fraga, Denise Nicole; Navalesi, Paolo; Ferre, Robinson; Boero, Enrico; Martinelli, Giampaolo; Cristoni, Lorenzo; Perani, Cristiano; Vetrugno, Luigi; McDermott, Cian; Miralles-Aguiar, Francisco; Secco, Gianmarco; Zattera, Caterina; Salinaro, Francesco; Grignaschi, Alice; Boccatonda, Andrea; Giostra, Fabrizio; Infante, Marta Nogué; Covella, Michele; Ingallina, Giacomo; Burkert, Julia; Frumento, Paolo; Forfori, Francesco; Ghiadoni, Lorenzo; International Multicenter Study Group on LUS in COVID-19; Emergency Medicine, School of MedicinePurpose: To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient's symptoms and clinical history. Methods: This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed. Results: We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23-91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients with objective respiratory failure (99.3%). The HighLUS showed a specificity of 88.8% (CI 85.55-91.65%) that was higher in the mild phenotype (94.4%; CI 90.0-97.0%). At multivariate analysis, the HighLUS was a strong independent predictor of RT-PCR positivity (odds ratio 4.2, confidence interval 2.6-6.7, p < 0.0001). Conclusion: Combining LUS patterns of probability with clinical phenotypes at presentation can rapidly identify those patients with or without COVID-19 pneumonia at bedside. This approach could support and expedite patients' management during a pandemic surge.Item Lung Ultrasound Guided Emergency Department Management of Acute Heart Failure (BLUSHED-AHF): A Randomized, Controlled Pilot Trial(Elsevier, 2021) Pang, Peter S.; Russell, Frances M.; Ehrman, Robert; Ferre, Rob; Gargani, Luna; Levy, Phillip D.; Noble, Vicki; Lane, Kathleen A.; Li, Xiaochun; Collins, Sean P.; Emergency Medicine, School of MedicineObjectives: The goal of this study was to determine whether a 6-hour lung ultrasound (LUS)-guided strategy-of-care improves pulmonary congestion over usual management in the emergency department (ED) setting. A secondary goal was to explore whether early targeted intervention leads to improved outcomes. Background: Targeting pulmonary congestion in acute heart failure remains a key goal of care. LUS B-lines are a semi-quantitative assessment of pulmonary congestion. Whether B-lines decrease in patients with acute heart failure by targeting therapy is not well known. Methods: A multicenter, single-blind, ED-based, pilot trial randomized 130 patients to receive a 6-hour LUS-guided treatment strategy versus structured usual care. Patients were followed up throughout hospitalization and 90 days' postdischarge. B-lines ≤15 at 6 h was the primary outcome, and days alive and out of hospital (DAOOH) at 30 days was the main exploratory outcome. Results: No significant difference in the proportion of patients with B-lines ≤15 at 6 hours (25.0% LUS vs 27.5% usual care; P = 0.83) or the number of B-lines at 6 hours (35.4 ± 26.8 LUS vs 34.3 ± 26.2 usual care; P = 0.82) was observed between groups. There were also no differences in DAOOH (21.3 ± 6.6 LUS vs 21.3 ± 7.1 usual care; P = 0.99). However, a significantly greater reduction in the number of B-lines was observed in LUS-guided patients compared with those receiving usual structured care during the first 48 hours (P = 0.04). Conclusions: In this pilot trial, ED use of LUS to target pulmonary congestion conferred no benefit compared with usual care in reducing the number of B-lines at 6 hours or in 30 days DAOOH. However, LUS-guided patients had faster resolution of congestion during the initial 48 hours.Item Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study(Springer (Biomed Central Ltd.), 2015) Gargani, Luna; Pang, Peter S.; Frassi, F.; Miglioranza, M. H.; Dini, F. L.; Landi, P.; Picano, E.; Department of Emergency Medicine, IU School of MedicineBACKGROUND: B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF). METHODS: A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 ± 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge. RESULTS: Mean B-lines at admission was 48 ± 48 with a statistically significant reduction before discharge (20 ± 23, p < .0001). During follow-up, 14 patients were rehospitalized for decompensated HF. The 6-month event-free survival was highest in patients with less B-lines (≤ 15) and lowest in patients with more B-lines (> 15) (log rank χ(2) 20.5, p < .0001). On multivariable analysis, B-lines > 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30-106.16) was an independent predictor of events at 6 months. CONCLUSIONS: Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation.Item Prognostic value of lung ultrasound in patients hospitalized for heart disease irrespective of symptoms and ejection fraction(Wiley, 2021) Gargani, Luna; Pugliese, Nicola Riccardo; Frassi, Francesca; Frumento, Paolo; Poggianti, Elisa; Mazzola, Matteo; De Biase, Nicolò; Landi, Patrizia; Masi, Stefano; Taddei, Stefano; Pang, Peter S.; Sicari, Rosa; Emergency Medicine, School of MedicineAims: Lung ultrasound B-lines are the sonographic sign of pulmonary congestion and can be used in the differential diagnosis of dyspnoea to rule in or rule out acute heart failure (AHF). Our aim was to assess the prognostic value of B-lines, integrated with echocardiography, in patients admitted to a cardiology department, independently of the initial clinical presentation, thus in patients with and without AHF, and in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF). Methods and results: We enrolled consecutive patients admitted for various cardiac conditions. Patients were classified into three groups: (i) acute HFrEF; (ii) acute HFpEF; and (iii) non-AHF. All patients underwent an echocardiogram coupled with lung ultrasound at admission, according to standardized protocols. We followed up 1021 consecutive inpatients (69 ± 12 years) for a median of 14.4 months (interquartile range 4.6-24.3) for death and rehospitalization for AHF. During the follow-up, 126 events occurred. Admission B-lines > 30, ejection fraction < 50%, tricuspid regurgitation velocity > 2.8 m/s, and tricuspid annular plane systolic excursion < 17 mm were independent predictors at multivariable analysis. B-lines > 30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF. Conclusions: Ultrasound B-lines can detect subclinical pulmonary interstitial oedema in patients thought to be free of congestion and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is more robust in patients with HFpEF compared with HFrEF.Item What are the minimum requirements to establish proficiency in lung ultrasound training for quantifying B-lines?(Wiley, 2020-07-22) Russell, Frances M.; Ferre, Robinson; Ehrman, Robert R.; Noble, Vicki; Gargani, Luna; Collins, Sean P.; Levy, Phillip D.; Fabre, Katarina L.; Eckert, George J.; Pang, Peter S.; Emergency Medicine, School of MedicineAims The goal of this study was to determine the number of scans needed for novice learners to attain proficiency in B‐line quantification compared with expert interpretation. Methods and results This was a prospective, multicentre observational study of novice learners, physicians and non‐physicians from three academic institutions. Learners received a 2 h lung ultrasound (LUS) training session on B‐line assessment, including lecture, video review to practice counting and hands‐on patient scanning. Learners quantified B‐lines using an eight‐zone scanning protocol in patients with suspected acute heart failure. Ultrasound (US) machine settings were standardized to a depth of 18 cm and clip length of 6 s, and tissue harmonics and multibeam former were deactivated. For quantification, the intercostal space with the greatest number of B‐lines within each zone was used for scoring. Each zone was given a score of 0–20 based on the maximum number of B‐lines counted during one respiratory cycle. The B‐line score was determined by multiplying the percentage of the intercostal space filled with B‐lines by 20. We compared learner B‐line counts with a blinded expert reviewer (five US fellowship‐trained faculty with > 5 years of clinical experience) for each lung zone scanned; proficiency was defined as an intraclass correlation of > 0.7. Learning curves for each learner were constructed using cumulative sum method for statistical analysis. The Wilcoxon rank‐sum test was used to compare the number of scans required to reach proficiency between different learner types. Twenty‐nine learners (21 research associates, 5 residents and 3 non‐US‐trained emergency medicine faculty) scanned 2629 lung zones with acute pulmonary oedema. After a mean of 10.8 (standard deviation 14.0) LUS zones scanned, learners reached the predefined proficiency standard. The number of scanned zones required to reach proficiency was not significantly different between physicians and non‐physicians (P = 0.26), learners with no prior US experience vs. > 25 prior patient scans (P = 0.64) and no prior vs. some prior LUS experience (P = 0.59). The overall intraclass correlation for agreement between learners and experts was 0.74 and 0.80 between experts. Conclusions Our results show that after a short, structured training, novice learners are able to achieve proficiency for quantifying B‐lines on LUS after scanning 11 zones. These findings support the use of LUS for B‐line quantification by non‐physicians in clinical and research applications.