ESICM—ESPNIC international expert consensus on quantitative lung ultrasound in intensive care
Intensive Care Med. 2025 May 12.
https://pubmed.ncbi.nlm.nih.gov/40353867/
ESICM: the European Society of Intensive Care (ESICM)
ESPNIC: the European Society of Paediatric and Neonatal Intensive Care
Question 1: In ICU-admitted patients, how should we name the LUS score?
STATEMENT 1.1: The term “lung ultrasound” should be preferred to “thoracic ultrasound” in defining the score.
STATEMENT 1.2: The calculation of a LUS score is a quantitative approach. “Quantitative lung ultrasound” (quantitative LUS) is a general term indicating multiple different visual/automated approaches using lung ultrasound in a quantitative manner.
STATEMENT 1.3: The term “lung ultrasound aeration score” (abbreviated “LUS Aeration Score”) should be used when referring to the scoring system applied to quantify lung aeration.
這個臨床問題主要在確認定義和名詞，
lung US指掃描的是肺實質，thoracic US可能還會包含diaphragm，
因此在評估肺部病灶時，Lung US這個名詞合適些。
即然已經針對掃描區域和病變形式給予計分，
LUS score的計分被認定為可量化計分系統。
計分系統目前有許多的名詞，為求統一，
Lung ultrasound aeration score (LUS aeration score)被共識為建議的名詞。
Question 2: in ICU-admitted patients, how many regions should be examined to compute the score and how should they be identified?
STATEMENT 2.1: In ICU-admitted adults, adolescents and in children aged more than one year, the LUS aeration score should be computed in six regions per hemithorax; anterior, lateral, and posterior fields are identified by sternum, anterior, and posterior axillary lines; each field is divided into superior and inferior regions.
STATEMENT 2.2: In neonates and infants below one year of age the score can be computed in two ways: A) simplified, to be used in the first 24-48 h of life (one lateral and two anterior regions with no posterior regions, i.e., three regions per hemithorax); B) extended, to be used after the first 24-48 h (as in adults but with one single lateral region, i.e., five regions per hemithorax).
STATEMENT 2.3: Some applications of LUS aeration score can be performed with a simplified approach (i.e., in a limited number of regions) in patients of any age.
STATEMENT 2.4: Any effort should be done to obtain a complete examination; in adult patients where this is unfeasible, a score indexed on the accessible number of regions has been proposed; however, in non-homogeneous diseases and when multiple regions are missing, this approach can be at risk of misleading conclusions.
STATEMENT 2.5: The regions are named according to their location with an acronym including side, field, upper/lower (e.g. Left Upper Anterior – LUA) or side and a numerical order (Right R1-6, Left L1-6).
在加護病房的患者，要掃描多少的區域來進行計分呢 ?
不同年紀有不一樣的建議，
成入和大於一歲的小孩，
一般建議前/中/後三個部分，進一步均分為上/下，
因此雙側共計12個區域。
小於一歲和剛出生，
可以用簡化版較少的區域來計分，如下圖所示。
如果因為不可抗拒的原因無法進行完整的掃描，
也可採用簡化版的掃描來計分，
區域的命名以左/右 (R/L) – 上/下 (U/L) – 前/中/後(A/L/P)的順序來定義:
右上前胸部: RUA – right upper anterior
左下後胸部: LLP – left lower posterior
Question 3. In ICU-admitted patients, which machine setting should be preferred?
STATEMENT 3.1: In adults, a standard examination should start with a linear probe in anterior fields and switch to a low-frequency probe in posterior fields. In children, neonates and infants, a high-frequency linear probe should be preferred.
STATEMENT 3.2: A transversal approach, aligned with the intercostal space, has advantages once the pleura is correctly identified in a longitudinal scan. No clear preferences on marker’s position are available.
STATEMENT 3.3: The following settings are advised: 1) turning off tissue harmonics, 2) turning off postprocessing/artifact removal/auto-optimization features, 3) field-depth at least twice the pleural depth. Building a customized “lung pre-set” may be helpful.
STATEMENT 3.4: Hand-held devices are probably reliable for the quantification of aeration loss in adults. Their use in ICU-admitted children and neonates is possible but not validated.
掃描重點在表淺部的肋膜和B lines的話，以線形探頭為主，
深部和實質病變或較大的身形，以腹部探頭為主，
如果切換探頭很容易進行，建議以線形掃前側部位，腹部掃後背的區域，
實務上大部份情境用腹部弧形探頭進行12個區域的掃描就可以符合需求，
新生兒和身形較小的孩童可以線形探頭為主。
建議以縱向掃描開始，找到Bat sign，以便定位肋膜的位置，
之後轉為平行肋間，避開肋骨的干擾，以便觀察更多部位的肋膜。
深度至少要是皮膚到肋膜的兩倍，以便清楚觀察A line。
如果設備有tissue harmonics或影像優化的功能，
最好要關掉以免無法觀察到lung artifacts，
畢竟lung US主要是分析不同artifacts的影像工具。
手持的超音波設備也可用來掃描和計算Lung US aeration score。
Question 4: In ICU-admitted patients, how should the progressive steps of loss of aeration be defined and the score computed?
STATEMENT 4.1: The progressive loss of lung aeration in critical patients of any age should be defined in four steps (0–1-2–3, from the most to the least aerated); this approach has been validated with quantitative CT and extravascular lung water (EVLW) in adults, and with EVLW, oxygenation, lung mechanics and biological assays in neonates.
STATEMENT 4.2: To distinguish between score 1 and 2 (i.e., mild vs. moderate loss of aeration) of the 0–3 scale, two approaches have been proposed: coalescence-based and quantitative-based. In adults, the quantitative-based approach outperforms the coalescence-based in terms of assessment of aeration, correlation with CT/EVLW and interobserver agreement.
STATEMENT 4.3: The score 3 (severe loss of aeration) is attributed when a large consolidation is detected. To this aim, consolidation size can be quantified by measuring the distance from the pleural line to its deepest edge (> 2–2.5 cm in adults; > 1 cm or > 0.5 cm/kg in neonates).
LUS aeration score每個區域的計分由0-3，所有12個區域總分由0 ~ 36。
Score 0 = normal aeration
Score 1 = mild loss of aeration
Score 2 = moderate loss of aeration
Score 3 = severe loss of aeration
每個區域中觀察到最嚴重的超音波影像用來計分，
０～３分的對應影像如下列的兩個圖形（成人/兒童)所示。
Score 0 A lines + sliding (最多可以看到2個B lines)
Score 1 > 3 B lines or subpleural consolidation佔觀察肋膜50%以下
Score 2 > 3 B lines or subpleural consolidation佔觀察肋膜50%以上
Score3 consolidation的深度 > 2cm (成人) > 1cm (孩童) > 0.5cm/kg (新生兒)
兒童和新生兒Lung US的計分和相對應的超音波影像
QUESTION 5: In ICU-admitted patients, is the automated/assisted score calculation reliable and useful ?
STATEMENT 5.1: Automated/assisted quantitative lung ultrasound has the potential to reduce inter- and intra-observer variability and create a unique quantification system.
對初學者而言，利用機器具備的自動化或輔助系統來計分已是可行的應用。
目前有許多廠商正在發展這一塊，希望不久的將來在掃描完成的同時，
能夠直接進行判讀和給予計分。
Question 6: for ICU clinicians, which is the minimum required training to correctly compute the lus aeration score?
STATEMENT 6.1: Theoretical-practical training in LUS varies widely but enhances participants’ knowledge regardless of patients’ age.
STATEMENT 6.2: In adults, the minimum practical training required to accurately compute the LUS aeration score is 25 supervised examinations. In paediatrics, less precise data are available; from 2 weeks to 3 months of supervised practice seems to be a reasonable training timeframe.
STATEMENT 6.3: The interobserver agreement between experts in LUS aeration score computation is near perfect irrespective of patients’ age.
ICU的醫師要接受多少Lung US aeration score的訓練才足夠呢 ?
至少要完成25例檢查 (大多POCUS檢查的魔術數字)
資源和師資足夠的話，實地臨床掃描最合適，
可以搭配不同的訓練模組和進行方式來補強。
Question 7: in patients admitted to ICU for respiratory failure, is LUS aeration score reliable, safe and suitable to assess and monitor lung aeration and the severity of the disease compared to other imaging (e.g., CT, CXR, electrical impedance tomography – EIT) and non-imaging (e.g., EVLW assessment) techniques?
STATEMENT 7.1: Quantitative LUS can reliably assess and monitor lung aeration and severity of the disease in critically ill adults, children and neonates.
STATEMENT 7.2: Evidence about quantitative LUS safety in terms of nosocomial infections and side effects is limited.
STATEMENT 7.3: Quantitative LUS is suitable and little time-consuming to assess and monitor lung aeration in adults, children and neonates.
LUS aeration score計分的嚴重度和CT上的嚴重度有高度相關，
用來評估和監測lung aeration的程度和變化是方便且較為快速的。
雖然在院內感染性的肺炎沒有好的証據，但應該還是可以適用的，
不過要小心探頭和設備的本身成為院內感染的媒介物，
必要的清潔、消毒和防護是不可少的。
QUESTION 8: In patients admitted to ICU for respiratory failure, is a quantitative approach reliable and suitable to define ARDS and its phenotype (focal/non-focal)?
STATEMENT 8.1: LUS associated with clinical parameters is reliable and suitable to define ARDS in adults, children and neonates when both LUS aeration score and pleural abnormalities are considered.
STATEMENT 8.2: Quantitative LUS may be reliable and suitable for the ARDS phenotyping and the classification of lung morphology in adult patients.
下表為ARDS的參考定義,
lung US也被納入影像診斷的依據之一，
如果加上肋膜的病變會更準確些。
Question 9: In patients admitted to ICU for respiratory failure, is lus aeration score reliable and suitable to indicate and interpret specific diagnostic and/or therapeutic procedures?
STATEMENT 9.1: LUS aeration score is reliable and suitable to indicate surfactant replacement in neonates with RDS, ensuring its timely administration, and to monitor its effectiveness.
STATEMENT 9.2: Quantitative LUS is reliable and suitable to assess EVLW and guide fluid therapies in adults, children and neonates.
STATEMENT 9.3: There is no evidence supporting quantitative LUS to indicate and monitor bronchodilators.
STATEMENT 9.4: In adults and children beyond the neonatal age, LUS aeration score may be reliable and suitable tool to prescribe, monitor and tailor respiratory physiotherapy.
STATEMENT 9.5: LUS aeration score is reliable and suitable to assess PEEP-induced recruitment in adults; limited evidence is available in children and neonates.
STATEMENT 9.6: LUS aeration score is reliable and suitable to monitor the effects of prone positioning, in patients of any age.
STATEMENT 9.7: To date, there is no evidence to support quantitative LUS for assessment and monitoring of lung hyperinflation; a reduced sliding in the anterior fields may suggest hyperinflation, but limited data are available.
LUS aeration score可用來決定是否在新生兒使用surfactant，
Cut-off score: 8
治療後氧合的改善和LUS aeration score的進步，
代表LUS可用來評估surfactant治療的成效。
LUS aeration score主要是評估air/fluid ratio的比例，
因此也可以用來評估EVLW (extravascular lung water)，
用來評估患者的輸液耐受程度，
也可用來評估體液移除治療(如利尿劑或透析治療)的成效。
目前並無証據可以用Lung aeration score來評估氣管擴張劑的成效。
LUS aeration score可能可以用來協助呼吸物理治療的進行。
LUS aeration score可以用來評估PEEP-induced recruitment的成效。
LUS aeration score可以用來評估prone positioning的成效。
目前沒有足夠証據可以用來評估lung hyperinflation。
QUESTION 10: In patients admitted to ICU for respiratory failure, is quantitative LUS reliable and suitable to predict weaning failure and other clinical outcomes?
STATEMENT 10.1: LUS aeration score combined to clinical parameters is reliable and suitable to predict weaning and extubation failure in adults, children and neonates.
STATEMENT 10.2: LUS aeration score is reliable and suitable for early prediction of BPD in preterm infants.
STATEMENT 10.3: LUS aeration score seems reliable and suitable to predict the need, monitor the efficacy and predict the failure of non-invasive respiratory supports in children and neonates; scarce data are available in adults.
STATEMENT 10.4: LUS aeration score may be associated with ICU mortality in adult COVID-19 patients and probably in non-COVID-19 acute respiratory failure; inconclusive data are available for length of mechanical ventilation, ICU and hospital stay.
STATEMENT 10.5: Quantitative LUS is reliable and suitable to predict post-operative complications in adults and children.
LUS aeration score配合其他臨床參數時，
可以用來預測是否可以成功拔管，
LUS aeration score > 17有很高的風險會拔管失敗。
如果只掃描anterior or antero-lateral regions，>5也代表高風險。
如果患者因為呼吸道控制或力量不足所致的呼吸衰竭，
除了LUS aeration score外，
可能還要搭配diaphragm US和cardiac US以便更準確的預測。
LUS aeration score可以用來早期預測BPD (Bronchopulmonary Dysplasia)
LUS aeration score可以用來評估兒科患者使用非侵入性呼吸支持治療的成效。
ICU患者的LUS aeration score愈高，死亡率也會愈高。
術後併發症也可藉由LUS aeration score來預測。
QUESTION 11: In NICU-admitted patients is lus aeration score reliable and suitable to diagnose lung/thoracic malformations or to confirm the prenatal diagnosis of lung/thoracic malformations
STATEMENT 11.1: Qualitative LUS is suitable to diagnose/confirm the diagnosis of malformations, but its reliability and the role of quantitative LUS are unknown.
新生兒加護病房內診斷胸腔和肺部的先天病變(malformation)角色仍未定。
QUESTION 12: In patients under mechanical ventilation, is quantitative LUS reliable and suitable to suspect and monitor ventilator-associated pneumonia (VAP)?
STATEMENT 12.1: In mechanically ventilated adults, an increase in LUS aeration score corresponding to a worsening of lung aeration is reliable and suitable to rise VAP suspicion when clinical criteria are met.
STATEMENT 12.2: Scoring systems including clinical, microbiological parameters and specific LUS patterns are reliable and suitable to rule in/out VAP in adults; the dynamic linear-arborescent air bronchogram is the sign with the highest specificity. Similar clinical ultrasound scores have been reported in paediatric and neonatal patients; however, scarce data preclude firm statements about their generalized use.
STATEMENT 12.3: Serial LUS aeration scores are suitable and reliable in the early detection of antibiotic-induced lung reaeration or extension of lung infection in case of antimicrobial success/failure in adults with VAP. Thus, the LUS aeration score may help in evaluating the duration of antibiotic therapy. This might also be possible in neonates, but scanty data are available.
使用呼吸器的患者，
LUS aeration score增加 代表肺部通氣功能變差，
配合臨床資訊，可用來做為早期診斷VAP的工具。
VAP不易由單一工具來診斷，
Lung US 中的subpleural consolidation或dynamic air-bronchogram都可用來作為輔助。
LUS aeration score跟procalcitonin相似，
可以用來評估抗生素治療的成效。
QUESTION 13: In hospitalized patients at risk of respiratory failure, is LUS aeration score reliable and suitable for an early detection and monitoring of respiratory deterioration
STATEMENT 13.1: Quantitative LUS is reliable and suitable for early detection and monitoring of respiratory deterioration and/or ARDS development in hospitalized adults, children and neonates with several conditions including respiratory disorders and renal failure.
住院患者中有呼吸衰竭風險的患者，
LUS aeration score可以用來早期辨認和監測呼吸狀況是否惡化 ?
QUESTION 14: Is quantitative LUS reliable and suitable in specific clinical conditions?
STATEMENT 14.1—QUANTITATIVE LUS AND COVID-19: In association with physical examination and clinical criteria, the LUS aeration score is reliable and suitable for COVID-19 triage and severity assessment in adult patients. In paediatric and neonatal patients with COVID-19, quantitative LUS is similarly suitable but its reliability for triage and severity assessment is uncertain.
STATEMENT 14.2—QUANTITATIVE LUS AND PREGNANT PATIENTS: Quantitative LUS is reliable and suitable in pregnant patients, allowing the detection of cardiogenic pulmonary oedema, pre-eclampsia-related pulmonary oedema, SARS-CoV-2 pneumonia and others pulmonary complications.
STATEMENT 14.3—QUANTITATIVE LUS AND CARDIOGENIC PULMONARY EDEMA (CPE): Quantitative LUS is reliable and suitable to detect CPE and indicate ICU admission in adults and probably in paediatric patients too.
STATEMENT 14.4—QUANTITATIVE LUS AND ECMO: LUS aeration score is suitable to monitor lung aeration changes in adult, paediatric and neonatal ARDS patients receiving ECMO; there are insufficient data for its reliability and prognostic value.
STATEMENT 14.5—QUANTITATIVE LUS IN LMIC: LUS aeration score is suitable in LMIC in critically ill adults, children and neonates but most of the available data are limited to non-ventilated patients.
在沒有插管的COVID-19患者，
LUS aeration score分數跟CT severity score和臨床預後有高度相關性，
因此可用來做為檢傷和嚴重度的評估工具。
在懷孕患者，
LUS aeration score可以用在pulmonary edema, pneumonia, atelectasis and ARDS等肺部急症。
Lung US在辨認cardiogenic pulmonary edema上遠比CXR準確，
配合心臟超音波的檢查更可確認是否為心因性所造成之肺水腫。
接受ECMO治療的ARDS患者，
LUS aeration score可以用來監測治療的成效。
在資源不足的地區 (LMIC: low- and middle-income countries)，
LUS aeration score可以用來評估肺部的通氣和許多肺部病變。
