Physician who are novices in ultrasound can reliably acquire and interpret bedside lung ultrasound scans after a few hours of training. Non-physician novices can reliably acquire and interpret lung POCUS scans after a few hours of training in clinical settings.

Overview

In emergency departments, training in eight-zone ultrasound scan protocols in limited time frames show potential for novice use of bedside ultrasound to triage and guide management especially in situations of limited access to radiography or longer wait for radiography.

A four hour training session for novice sonographers who were experienced medical officers in the emergency department showed good agreement (kappa = .70) with sonography experts for scan interpretation as wet, dry or indeterminate. Emergency resident physicians, novices in sonography, were able to identify B-lines with similar accuracy to expert sonographers after a 30-minute tutorial on the Volpicelli method.

Even with limited training, nurses and medical students can learn to scan and interpret B-lines and pleural effusions. Evidence from POCUS can provide support in patient assessment, especially in clinical contexts.

After POCUS education comprising 0–12 h of didactic training and 58–62 practice examinations or approximately 2–9 h of hands-on training, nurses demonstrated a sensitivity of 79% to 100% and specificity of 70% to 100% and medical students showed sensitivity of 91% and specificity of 95% for detection of B-lines and pleural effusion in inpatients and outpatients. Medical students also showed a 96% agreement rate with experts for lung ultrasound interpretation in the emergency department on scans acquired by the students using pocket-sized ultrasound.

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Training Novices in POCUS

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Publication

Limited lung ultrasound protocol in elderly patients with breathlessness; agreement between bedside interpretation and stored images as acquired by experienced and inexperienced sonologists.

‍Key Findings

• Agreement between experienced sonologist and blinded expert was excellent (kappa = 0.82, 95% CI 0.72 to 0.92) in eight-lateral-views scans on interpreting acquired scan as "wet," "dry," or "indeterminate"
• Agreement between novice group and blinded expert was good (kappa = 0.70, 95% CI 0.45 to 0.95) in eight-lateral-views scans on interpreting acquired scan as "wet," "dry," or "indeterminate"
• Note: Novice group had worked in emergency department between 7 to 25 years, but without ultrasound experience

‍Paper Implications

• Emergency practitioners with good knowledge of pathophysiology can be taught a very basic bedside lung ultrasound protocol in four hours with good reproducibility
• Can be helpful for determining priority for radiography or inform management until arrival of radiographer
  

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Publication

Comparison of expert and novice sonographers' performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome.

Key Findings

• Using expert interpretation as standard, B-line detection by novice group had sensitivity of 85%, specificity of 84%, positive likelihood ratio (+LR) of 5.2, negative likelihood ratio (−LR) of 0.2, positive predictive value (PPV) of 64%, and negative predictive value (NPV) of 94%
• Note: Novice group comprised emergency resident physicians with limited prior ultrasound training. Experience was limited to intern year 2-week rotation and several residency conference lectures and workshops. No ultrasound training featured thoracic B-line assessment.
• Lung ultrasound training in the study was a 30-minute lecture on the Volpicelli method using eight lung zones.
• Using expert interpretation as standard, diagnosis of acute heart failure syndrome by novice group when one lung zone was positive was sensitivity 87%, specificity 49%, +LR 1.7, −LR 0.3, PPV 50%, and NPV 88%
• Using expert interpretation as standard, diagnosis of acute heart failure syndrome by novice group when all eight lung zones were positive was sensitivity 19%, specificity 97%, +LR 5.7, −LR 0.8, PPV 76%, and NPV 68%
• Areas under the curve were 0.77 (95% CI = 0.72 to 0.82) for novice and 0.76 (95% CI = 0.71 to 0.82) for expert

‍Paper Implications

• Novices were able to identify B-lines with similar accuracy to expert sonographers after a 30-minute tutorial.
• For both expert and novice sonographers, eight-zone lung ultrasound has "fair predictive value" for determining pulmonary edema originating from acute heart failure syndrome

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Publication‍

Ability of non-physicians to perform and interpret lung ultrasound: A systematic review.

Key Findings

• For nurses, detection of B-lines originating from pleural effusion in 6 or 8 scan zones ranged from sensitivity of 79% to 100% and specificity of 70% to 100% after didactic training ranging from 0 to 12 hours and hands-on training ranging from 58 to 62 scans.
• For ultrasound-inexperienced medical students in their first to fifth year, didactic training ranging from 1 to 8 hours and 1 to 2 hours of hands-on training resulted in image acquisition adequacy rates from 87% to 100% in ultrasound studies comprising 2 to 6 scan zones. One study showed sensitivity and specificity of 91% and 95%, respectively, for detection of B-lines and pleural effusion in inpatients and outpatients, and another showed a 96% physician agreement rate in emergency department.
• For paramedics scanning patients during urban transport, a 30-min lecture and 1.5h of hands-on training resulted in paramedic impressions of dry or wet lung compared to final emergency department diagnosis matching well (kappa = 0.74), but the rate of interpretable images obtained was less than 80%.
• Note: Participants have little to no ultrasound training prior to studies.

Paper Implications

• Nurses and medical students can perform bedside lung ultrasound and interpret B-lines and pleural effusions with limited training
• Longer hands-on training tends to result in better sensitivity