We decided to have this platform mandatory and not optional as in the step-1 for RWMA, since in case of B-lines the technique is relatively young and recent advances in acquisition with 4-site scan mode and reporting were adopted in the SE platform [ 16 ]. Sixty readers from 52 different centers initially asked to enter the SE study, had passed the RWMA test for quality control and therefore were allowed to enter the step-2 of SE The Stress-LUS general protocol.
The adopted protocol is the 4-site simplified scan. The screenshot of the test-match step during B-lines quality control. There are 5 still frames or videos with B-lines and the trainee has to choose among 5 possible answers, ranging from 0 left lower panel to 9 upper middle panel. An expert trainer QC or MCS remained available to all readers for e-mail or phone contact to provide assistance with any issue concerning the training.
At all times there was the possibility of face-to-face discussion via Skype to address issues requiring special clarification with the principal investigator. After completing the web-based module the reader could take the test maximum three attempts. After each attempt, the sequence of videos was mixed. We selected 20 cases of 10 patients with rest and stress images in which the presence and number of B-lines was documented by unanimous decision of 2 experienced observers EP and QC. The privacy of patients during acquisition, storage, and transmission of the SE study was protected.
Quality control of B-lines analysis in stress Echo 2020
All images were anonymized, and the identity of patients or the study condition rest or stress was not disclosed at any time to the readers. Each test clip was scored from 0 black lung, A-lines, no B-lines to 10 white lung with coalescing B-lines. The diagnostic gold standard was the reading of Pisa lab. The LUS images were selected to represent the garden variety of stress testing modes, responses, results and image quality. The stress employed was exercise in 17 subjects, high dose accelerated dipyridamole 0. The projection selected was the third intercostal space between left mid-axillary and anterior axillary lines in 4; third intercostal space between right mid-axillary and anterior axillary lines in 4; third intercostal space between right anterior-axillary and mid-clavicular lines in 4; third intercostal space between left anterior-axillary and mid-clavicular lines in 8.
With pass, the reader received a certificate of accreditation and could start recruiting with a written informed consent signed by each patient and after clearance by the local ethical committee. The intra-class correlation coefficient was calculated, for each reader, in the whole series of 20 paired measurements made by the peripheral reader and the reference reader.
A user-friendly web-based learning is highly effective for training B-lines also for echocardiographers without previous exposure to B-lines. After a limited learning effort, the accuracy of B-lines reading is comparable between very experienced and freshly trained readers. B-lines with 4-site simplified scan of the lung has a very high success rate in acquisition and analysis. It has been embedded as an integral part of dual imaging SE adopted as the core protocol in SE for all forms of physical and pharmacological stress for all patients, from coronary artery disease to heart failure.
The American College of Chest Physicians has defined the knowledge and technical elements required for competence in lung ultrasound [ 18 ]. There have been a number of prior lung ultrasound education papers, showing that a limited training of a few hours can improve the capability of execution and interpretation of LUS even in medical students without previous exposure to ultrasound [ 19 , 20 ]. In the present study we are dealing with a specific and limited aspect of LUS of special interest for cardiologists, i. There is a lack of a specific training and certification pathway in cardiology, and as a result training and performance of LUS varies widely among different institutions.
An approach similar to the one adopted in the present study was developed in Pisa for centers recruiting in the LUST study [ 21 ]. However, this study differs from the previous one under some aspects: first, it was focused on LUS-SE, not on resting LUS; the adopted scan scheme was the simplified 4-site scan, easier to do, to teach and to learn than the previously adopted site scan; and the quality control procedures required some prior reading and slide presentation to facilitate a standardized learning [ 9 ].
Our findings are consistent with a large body of literature showing that stable web applications are increasingly used for improving medical image interpretation skills regardless of time and space and without the need for expensive imaging equipment or a patient to scan [ 22 ]. With the adopted web-based approach, the educational path is standardized, shared, and - after validation and refinement - prospectively available in open source, and exploitable for scientific purposes and clinical education.
The use of enabling technologies makes the accreditation process faster, smoother and cheaper, and coupled with the open-source platform grants an unprecedented opportunity for continuing education, also fostered by endorsement and governance by the scientific society supporting the study. We focused on the assessment of B-lines, which is a particularly simple aspect of LUS diagnosis [ 10 , 11 ].
Similar harmonization and accreditation issues are present for other aspects of SE diagnosis. The lack of a universally acceptable gold standard makes the assessment of reading performance difficult. From the library of images arriving from all the world and stored in our data bank, we selected cases meeting the conditions of unanimous reading of the two most experienced readers from the reference lab.
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This is a far from perfect gold standard, yet a reasonable, and perhaps the only possible, one. We restricted our validation phase to participants in the SE study, who had a substantial reading experience and certification in RWMA as a prerequisite. This reader pool may have been especially knowledgeable and motivated, thereby justifying the excellent learning results. However, 53 of them were B-lines naive, and therefore probably the selection criteria of our readers did not affect the generalizability of results.
We adopted a simplified 4-site scan for acquisition of B-lines at rest and during stress. This approach introduces a substantial abbreviation compared to other protocols such as the region scan originally adopted in the Pisa laboratory in the first application of LUS in heart failure patients [ 23 ] and also recommended by an international consensus in [ 24 ]. Over the years, simplified 8-zone and 4-zone lung imaging protocols were proposed [ 25 , 26 ], with comparable information between the 2 protocols as shown by Platz et al. Scali et al.
There is a linear, close correlation between the site and the 4-site B-lines score [ 16 ]. Therefore, there is no significant loss of information when going from to 4-site scan, but a substantial simplification and time saving, vital for SE imaging, when there are so many things to see and so little time available. B-lines are a useful adjunct to mainstream SE based on RWMA [ 27 , 28 ], but its impact may be limited by the relatively few centers currently using it in their routine SE practice, and the lack of standardization in acquisition, scoring and reporting [ 29 ].
After a web-based module and certification, the approach is better harmonized and the accumulation of clinical practice also allows the rapid growth of scientifically unique data. To achieve this goal, simplification is essential, and the 4-site simplified scan is ideal for LUS rest and stress testing. However, the SE technique does not tolerate improvisation, and an accurate standardization of terminology, standards of execution, and interpretation criteria is required before a center is allowed to enter its experience in the common data bank.
Similarly to what has been said for meta-analysis [ 30 ], multicenter SE studies are like a bouillabaisse: no matter how much seafood or recruiting centers is added, one tainted fish an unreliable center generating inconsistent reading will spoil the pot. Web-based learning is highly effective for teaching and harmonizing B-lines reading, with an enormous saving of time and resources versus the conventional hands-on approach of teaching and learning ultrasound techniques.
Coronary artery disease. Lung Ultrasound. Regional wall motion abnormalities. Stress echocardiography. Transthoracic echocardiography. The study was partially funded with the project Aging of the National Research Council. Miglioranza 24 , Marco A. Data sharing not applicable to this article as no data-sets were generated or analyzed during the current study.
EP is the study chairman, designed the protocol, organized the content of web-based training and drafted the manuscript; QC is the principal investigator of SE, helped to organize the structure of training, contributed to developing the web-based training, critically revised the manuscript for an intellectually important contribution and approved the submitted version; McS is the project leader of B-lines subproject in SE; MdN is the computer scientist who developed the website SE and the web-based training material; MP is the computer scientist who organized and governed the quality control access, results, and data analysis; all other authors contributed to study design, undertook the quality control up to certification, are active members of SE consortium and critically revised the manuscript for an intellectually important contribution and approved the submitted version.
The study protocol was reviewed and approved by the institutional ethics committee as a part of the SE study CE Lazio-1, July 20, All the authors have read and approved the manuscript and accorded the consent for pubblication. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Quality control of B-lines analysis in stress Echo Cardiovascular Ultrasound 16 Purpose To provide web-based upstream quality control and harmonization of B-lines reading criteria.
Conclusions Web-based learning is highly effective for teaching and harmonizing B-lines reading. Certification Lung comets Quality control Stress echocardiography Wall motion. The Pisa lab coordinated the quality control assessment for B-lines of all investigators who expressed their intention to participate in the study Fig. The complete list of participants in the SE consortium as per January 20th, is reported in the Appendix.
The study was funded with institutional funding of the Italian National Research Council and with travel grants of the Italian Society of Echocardiography and Cardiovascular Imaging with dedicated sessions during national meetings. No fort from industry was asked for or received. The depth was adjusted according to the body habitus of the patient, with thin patients requiring less depth and obese patients needing greater depth to visualize the pleural line.
A B-line was defined with 4 constant criteria: vertical, laser-like, hyperechoic reverberation; arises from the pleural line extending to the bottom of the screen without fading; moves synchronously with lung sliding; and erases the A-lines, which are a part of the normal lung pattern as a horizontal, multiple reverberation artefact, equidistant from one another below the pleura, at exact multiples of the transducer-pleural line distance [ 17 ]. Detailed description of the scanning procedure and scanning sites is also available in a 2-min movie from our laboratory on YouTube The incredible ULCs — ultrasound lung comets.
Accessed: July 10, LUS scanning was performed with the cardiac probe in the supine position at rest and soon after stress with the patient again resuming the supine position. The 4-site simplified scan of the lung was used [ 16 ]. We analyzed the anterior and lateral hemithoraces, scanning along the anterior axillary AA and midaxillary MA lines on the third intercostal space Fig. Of the initial 60 readers who started, 53 were B-lines naive without previous exposure to B-lines.
All 60 readers were successfully accredited Fig. Comparison with previous studies The American College of Chest Physicians has defined the knowledge and technical elements required for competence in lung ultrasound [ 18 ]. Fortunately, to help you avoid missing out on Lightning Deals that you are interested in you can 'watch' upcoming deals.
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Quality control of B-lines analysis in stress Echo | Cardiovascular Ultrasound | Full Text
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Adult Transthoracic Echocardiography (TTE) Certification
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