1. Bedside Ultrasound for the diagnosis of ALI ARDS Chief of Medicine Conference 10/29/2013 Cameron Bass, MD

2. Disclosures Mobisante ™ provided me with one of their smartphone based ultrasound devices for use in the study The UWMC pays my salary, so I suppose I’m less likely to say bad things about them publically I haven’t brushed my hair in almost a full year

3. Outline Background on Cameron Critical Illness in the resource limited setting ARDS review Ultrasound – Basic review – Pulmonary ultrasound Pulse oximetry Bedside Ultrasound for the diagnosis of ARDS – Methods – Challenges – Future directions Brilliant and incisive Q&A

4. A Brief Introduction to Cameron Engineering Rwanda

5. Critical Illness in the Resource Limited Setting Resource allocation – Cost of Critical Care – Faith in the system 1 – A lack of knowledge 2

6. Critical Illness in the Resource Limited Setting Appropriate use of technology – Ventilators – Ultrasound 3

7. Critical Illness in the Resource Limited Setting Developing vs third world vs resource limited

8. Brief Introduction to ARDS Initial description in 1967 by Ashbaugh 4 New definition in 1994 by AECCC 5 – P:F ratio – Bilateral infiltrates on CXR (“A pulmonary Edema pattern”) – PCWP < 18mm Hg Berlin definition in 2012 6 – Risk factors – Timing

9. Prevalence of ARDS In the united states – >150,000 cases per year 7 In the resource limited setting – Challenges to diagnosis – Differences in etiology

10. 1540 m/s You know what happens when you make an assumption? (Samuel L Jackson) Reverberation artifact Comet tail artifact How ultrasound works cartoon

11. Pulmonary Ultrasound Lung Sliding Videos courtesy http://sonocloud.orghttp://sonocloud.org

12. Pulmonary Ultrasound A lack of Lung Sliding Videos courtesy http://sonocloud.orghttp://sonocloud.org

13. Pulmonary Ultrasound A lines 8 Videos courtesy http://sonocloud.orghttp://sonocloud.org

14. Pulmonary Ultrasound B lines 8 Videos courtesy http://sonocloud.orghttp://sonocloud.org

15. Thoracic Ultrasound Ease of teaching 9

16. Thoracic Ultrasound Lichtenstein and the Blue protocol 8

17. BLUE protocol 8

18. Thoracic Ultrasound Specific studies for ARDS – BLUE protocol 8 – FALLS protocol – ARDS vs Acute Pulmonary Edema 10

19. Arterial Blood Gasses Cost of performing – Estimated at $110 cost to patient SpO 2 to ABG – In adults 11 S/F = 64 + 0.84 x (P/F) [p < 0.0001; r = 0.89) S/F of 235 ≈ P/F of 200 S/F of 315 ≈ P/F of 300 – In pediatrics 12 S/F = 76 + 0.62 x PF (p < 0.0001, R 2 = 0.61) S/F 201 ≈ P/F of 200 S/F 263 ≈ P/F of 300

20. Bedside Ultrasound for the diagnosis of ARDS Study Design

21. Bedside Ultrasound for the diagnosis of ARDS Scanning – Technique – Mobisante

22. Bedside Ultrasound for the diagnosis of ARDS Reviewing Data – Chest Radiographs – Ultrasound scans

23. Bedside Ultrasound for the diagnosis of ARDS Statistical Analysis – Lack of a Gold Standard PPA NPA Kappa

24. Challenges Identifying Patients Prevalence Positioning SpO2 measurements IRB/HIPAA

25. Future Directions Cambodia/Rwanda

26. Citations 1.Neill KJ Adhikari, Robert A Fowler, Satish Bhagwanjee, Gordon D Rubenfeld, Critical care and the global burden of critical illness in adults, The Lancet, Volume 376, Issue 9749, 16–22 October 2010, Pages 1339-1346 2.Dünser MW, Baelani I, Ganbold L. “A review and analysis of intensive care medicine in the least developed countries.“Crit Care Med. 2006 Apr;34(4):1234-42. 3.Sippel S, Muruganandan K, Levine A, Shah S. “Review article: Use of ultrasound in the developing world.” Int J Emerg Med. 2011 Dec 7;4:72. doi: 10.1186/1865-1380-4-72. 4.Ashbaugh D, Bigelow D, Petty T, Levine B (1967). "Acute respiratory distress in adults". Lancet 2 (7511): 319–23. 5.Bernard G, Artigas A, Brigham K, Carlet J, Falke K, Hudson L, Lamy M, Legall J, Morris A, Spragg R (1994). "The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial 6.CV. Marco Ranieri, MD (2012). "The ARDS Definition Task Force*. Acute Respiratory Distress Syndrome: The Berlin Definition". JAMA 307 (23): 2526– 2533 7.Gordon D. Rubenfeld, MD, MSc; Margaret S. Herridge, MD, MPH, FCCP. “Epidemiology and Outcomes of Acute Lung Injury” Chest. 2007;131(2):554- 562. doi:10.1378/chest.06-1976 8.Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure. The BLUE-protocol. Chest 2008;134:117-125 9.G Bedetti 1, L Gargani 2, A Corbisiero 3, F Frassi 2, E Poggianti 2 and G Mottola*“Evaluation of ultrasound lung comets by hand-held echocardiography“ Cardiovascular Ultrasound 10.Roberto Copetti* 1, Gino Soldati 2 and Paolo Copetti. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovascular Medicine. 29 April 2008 11.Rice, Wheeler, bernard et al. ARDSNET “Comparison of the Sp O 2 /F IO 2 Ratio and the Pa O 2 /F IO 2 Ratio in Patients With Acute Lung Injury or ARDS” CHEST 2007; 132:410–417 12.Robinder G. Khemani, MD, MSCI; Neal R. Patel, MD, MPH; Robert D. Bart, III, MD; and Christopher J. L. Newth, MD “Comparison of the Pulse Oximetric Saturation/Fraction of Inspired Oxygen Ratio and the Pa O 2 /Fraction of Inspired Oxygen Ratio in Children* CHEST 2009; 135:662-668