None. No funding was received for this project.

These studies were approved by the George Washington University Institutional Review Board (IRB # NCR203147). The study subject for all procedures described below (and pictured in figures) was a 32-year-old male who gave full informed consent to the study and publication of de-identified images. Inclusion criteria include any patient undergoing airway management or anesthetic care (especially those who have characteristics of a difficult airway) and exclusion criteria would include any patient who does not consent to this procedure.
1. Differentiating esophageal from endotracheal intubation
<ol>
	<li>Prior to the induction of general anesthesia, prepare a high frequency, linear ultrasound probe (see Table of Materials) by placing a single layer of ultrasound gel (see Table of Materials) to the probe transducer. Select the linear probe from the transducer menu on the touchscreen and specify MSK (musculoskeletal) from the dropdown menu. Place the ultrasound in scanning mode by pushing the 2D button on the bottom left corner of the touchscreen. Induce general anesthesia as recommended by the attending anesthesiologist.</li>
	<li>Following the induction of general anesthesia,place the probe in the transverse position on the midline of the patient&#39;s anterior neck just cephalad to the suprasternal notch (Figure 1A). Ensure the probe marker is on the left of the screen on the ultrasound instrument (see Table of Materials).</li>
	<li>Identify the trachea midline and note the constricted esophagus just lateral to the trachea (Figure 1B). For further anatomic confirmation, scan laterally to identify the carotid artery and internal jugular vein if necessary.</li>
	<li>Check for obvious tracheal and surrounding tissue movement associated with intubation as the endotracheal tube moves into the trachea. In the event that tracheal movement is not observed, slightly twist the endotracheal tube to attempt to generate movement on the ultrasound image.
	<ol>
		<li>Additionally, check that the hyperechoic, posterior aspect of the trachea disappears due to the endotracheal tube, leaving a characteristic acoustic shadowing that is bullet shaped (this is called the &#34;bullet sign&#34;, shown in Figure 2). If, instead, there is an esophageal intubation, there will be obvious tissue movement to the left of the trachea, and there will now be two lumens. This is called &#34;double track sign,&#34; and there will be two air/mucosal interfaces (Figure 3). 
		NOTE: Use this ultrasound technique in real-time intubations to obtain immediate feedback as to whether the tube is being placed in the trachea or the esophagus. In addition, consider using this technique during emergency airway management, where end tidal carbon dioxide confirmation may not be reliable due to poor pulmonary blood flow17.</li>
	</ol>
	</li>
</ol>
2. Identifying the cricothyroid membrane in preparation for a cricothyrotomy
NOTE: For emergency airway management, a cricothyrotomy might be a necessary step if the provider encounters a &#34;cannot intubate, cannot oxygenate&#34; scenario. In the event a difficult airway situation is suspected, the provider may opt to identify the CTM prior to the induction of anesthesia, in case it might be required to perform a cricothyrotomy.
<ol>
	<li>Perform CTM identification with the patient lying in the supine position and the neck extended. Prepare the ultrasound probe as described in step 1.1. As the CTM is shallow in the neck, place the probe to a depth of approximately 1.5-2 cm based on an average-sized patient. 
	NOTE: There are two methods for utilizing ultrasound to locate the CTM.</li>
	<li>Perform the first method to locate the CTM as described below.
	<ol>
		<li>Place a linear, high frequency probe in the sagittal plane of the patient&#39;s neck just caudal to the thyroid cartilage (Figure 4A). The thyroid cartilage appears as the superficial, hypoechoic structure at the cranial side of the scan and casts an acoustic shadow (Figure 4B).</li>
		<li>Next, locate the cricoid cartilage, which is in a caudal location and appears hypoechoic. Identify the CTM lying between these two structures using the underlying air-mucosal interface, which appears as a hyperechoic line that runs the length of the trachea.</li>
		<li>For further confirmation, scan caudal to locate the tracheal rings, which will appear as a hyperechoic &#34;string of beads&#34;18. 
		NOTE: The second technique for identifying the CTM (step 2.5 to step 2.8) involves using a transverse scanning orientation on the anterior neck. This technique is sometimes referred to as the thyroid-airline-cricoid-airline (TACA) approach19.</li>
	</ol>
	</li>
	<li>Perform the second technique to locate the CTM as described below.
	<ol>
		<li>Begin by placing a linear high frequency probe in the transverse plane at the level of the thyroid cartilage, which appears as hyperechoic and casts an acoustic shadow-a black triangle with the tip being most superficial (Figure 5).</li>
		<li>Scan in a caudal direction until the black triangle disappears as the thyroid cartilage ends and the CTM begins. Identify this as the air-mucosal interface that appears as a bright white line with reverberation effects (Figure 5).</li>
		<li>Continue scanning in a caudal direction until the CTM ends and the cricoid cartilage appears. The cricoid cartilage will appear as a hypoechoic band surrounding the trachea (Figure 5). Once the cricoid is identified, the sonographer will have located the inferior border of the CTM.</li>
		<li>To ensure that the proper anatomy has been identified, reverse these steps and scan in a cephalad direction, again identifying the CTM and the thyroid cartilage. Once these landmarks have been identified, mark the CTM location on the patient. Once the CTM has been marked, proceed to the induction of anesthesia and airway management as planned, knowing the CTM is properly identified in the rare event a surgical airway is required.</li>
	</ol>
	</li>
</ol>
3. Acquisition of parameters for the prediction of difficult airway management
NOTE: For the prediction of difficult airway management, the skin to epiglottis distance and LPWT are measured. These steps should be performed prior to the induction of anesthesia.
<ol>
	<li>To measure the skin to epiglottis distance, place the patient in the supine position with the neck in a neutral position and prepare the probe and ultrasound as described in step 1.1.
	<ol>
		<li>Place a high frequency, linear probe in the transverse position on the anterior neck at the level of the thyrohyoid membrane (Figure 6A).</li>
		<li>Identify the epiglottis, which appears as the hypoechoic structure midway between the hyoid bone and thyroid cartilage (Figure 6B). The laryngeal surface of the epiglottis forms a hyperechoic line, which represents the air-mucosal interface. Tilt the probe in either direction if the anterior border of the epiglottis is not clearly defined.</li>
		<li>Note an echogenic (fat-filled) pre-epiglottic space20.</li>
		<li>To measure the skin to epiglottis distance, freeze the image by touching the large Freeze button at the bottom of the touchscreen. Next, select the blue Distance button on the right side of the screen. Use a finger to drag one cursor to the superficial surface of the epiglottis, and move the other cursor to the anterior surface of the neck (skin). The skin to epiglottis distance will be displayed in the gray box on the upper left side of the screen. 
		NOTE: Based on this measurement, it is possible to predict difficult intubation. A skin to epiglottis distance greater than 2.7 cm indicates that a Cormacke-Lehane score of 3 or 4 may be encountered on direct laryngoscopy21.</li>
	</ol>
	</li>
	<li>To measure the LPWT, place the patient in the supine position with the neck in neutral orientation.
	<ol>
		<li>Place a curvilinear, low-frequency probe in the coronal orientation below the mastoid process and in-line with the carotid artery (Figure 7A).</li>
		<li>Use doppler flow to identify the carotid artery. To accomplish this, press the C button on the bottom left of the screen. Using a finger on the touch screen, move the yellow box over the carotid vasculature. Identify the carotid artery by noting the pulsatile vascular flow.</li>
		<li>To measure the LPWT, freeze the image (Figure 7B) by pushing the Freeze button on the bottom of the screen. Then press the blue Distance button on the right side of the screen. Place one cursor on the inferior border of the carotid artery and the second cursor on the anterior aspect of the airway. The LPWT will then be displayed in the gray box on the upper left side of the screen. 
		NOTE: In the event of an emergency airway scenario requiring rapid sequence induction, step 3.2 may be skipped, as mask ventilation is not likely to be necessary, and in the interest of time.</li>
	</ol>
	</li>
</ol>

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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Limitations+of+difficult+airway+prediction+in+patients+intubated+in+the+emergency+department.">Limitations of difficult airway prediction in patients intubated in the emergency department.</a> Annals of Emergency Medicine. 44 (4), 307-313 (2004).</li><li>Sotoodehnia, M., Rafiemanesh, H., Mirfazaelian, H., Safaie, A., Baratloo, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonography+indicators+for+predicting+difficult+intubation:+a+systematic+review+and+meta-analysis.">Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis.</a> BMC Emergency Medicine. 21 (1), 76 (2021).</li><li>Liu, K. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+measurement+of+lateral+parapharyngeal+wall+thickness+in+patients+with+obstructive+sleep+apnea.">Sonographic measurement of lateral parapharyngeal wall thickness in patients with obstructive sleep apnea.</a> Sleep. 30 (11), 1503-1508 (2022).</li><li>Moln&#225;r, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+prognostic+role+of+ultrasound+and+magnetic+resonance+imaging+in+obstructive+sleep+apnoea+based+on+lateral+oropharyngeal+wall+obstruction.">The prognostic role of ultrasound and magnetic resonance imaging in obstructive sleep apnoea based on lateral oropharyngeal wall obstruction.</a> Sleep Breath. , (2022).</li></ol>

None of the authors have any conflicts of interest to disclose.

In 2018, a call to action was made by the leadership of the Society of Cardiovascular Anesthesiologists for "Perioperative ultrasound training in anesthesiology"23. Notably, these leaders highlighted that POCUS education should become an essential component of anesthesiology training programs. More recently, experts in anesthesiology further explained the utility and necessity of POCUS in all aspects of perioperative patient care, including airway management24. Experts emph...

Portable ultrasonography has evident utility in the perioperative care of patients. Its accessibility and lack of invasiveness are benefits that have led to the rapid incorporation of point of care ultrasound (POCUS) to the clinical care of surgical patients1,2. As POCUS continues to find new indications in the perioperative arena, there are several established indications that have clear benefits over traditional clinical exams. In this methods paper, we review the recent findings and demonstrate how to integrate POCUS into clinical practice or airway management.
Undetected esophageal intubation results in significant morbidity and mortality; therefore, it is critical to identify esophageal intubation immediately and place the tube in an endotracheal location to avoid disastrous respiratory compromise. Traditional confirmation of endotracheal intubation relies on clinical examinations such as auscultation for bilateral breath sounds and chest rise3,4. Even after the American Society of Anesthesiologists (ASA) instituted end-tidal CO2 as a required monitor for identifying endotracheal intubation, there still remained cases of undetected esophageal intubation leading to significant morbidity and mortality5. One main benefit of incorporating tracheal ultrasonography into the intubation procedure is that esophageal intubation can be recognized immediately, and real-time, direct visualization of the tube can be confirmed in the trachea. In a recent meta-analysis, the pooled sensitivity and specificity of endotracheal confirmation were 98% and 94%, respectively, illustrating the superior diagnostic accuracy of this technique6. In this methods paper, a video example will be shown of the tube being placed in the esophagus erroneously, immediate recognition of this complication, and proper placement of the tube in the trachea. This highlights the real-time visual benefits that POCUS allows during an intubation procedure.
Despite advances in supraglottic airways and video laryngoscopy, surgical airway may remain a life-saving necessity in a &#34;cannot intubate, cannot oxygenate&#34; scenario. The updated ASA Difficult Airway Guidelines highlight that in the event of a life-saving invasive airway being required, the procedure must be performed as quickly as possible and by a trained specialist7. In the event a cricothyrotomy is required, the identification of proper anatomy is required to prevent further complications. Utilization of ultrasonography to visualize the anatomy of the cricothyroid membrane (CTM) is a quick and effective technique that is now being suggested preoperatively if there is any concern of a difficult airway8. This technique can be taught in a relatively quick manner, with learners gaining almost complete competency after a brief 2 hour tutorial and 20 expert guided scans9. In this methods paper, two techniques to identify the CTM with POCUS will be demonstrated in the hopes of further educating any healthcare providers who routinely perform airway management.
Preoperative assessment of the patient&#39;s airway involves traditional bedside clinical exams (e.g., Mallampati score, mouth opening, cervical range of motion, etc.). There are several problems with these assessments. The first and probably most salient is that they are not very accurate at predicting a difficult airway situation10. In addition, these tests require patient participation, which is not possible in all clinical scenarios (such as in cases of trauma or altered mental status).
Preoperative airway ultrasound measurements have shown improved accuracy in predicting difficult endotracheal tube placement11,12. Anterior neck soft tissue thickness at varying levels has been measured and analyzed as a prediction of difficult intubation. The ultrasonographic measurement of the distance between the skin to epiglottis appears to have the best diagnostic accuracy identified to date13. This measurement has also been shown to improve predictive capability considerably when added to the traditional bedside examinations14. This paper explains how to use POCUS to measure the skin-to-epiglottis distance and incorporate it into the preoperative airway examination, in order to help healthcare providers better predict a difficult airway situation.
In addition, investigators have begun to identify anatomical structures that indicate difficult mask ventilation. One such anatomical structure is the lateral pharyngeal wall, whose thickness (LPWT) has been shown to correspond to the severity of obstructive sleep apnea (OSA) and apnea-hypopnea index15. Preliminary data also suggest that measurement of the LPWT preoperatively provides evidence for the difficulty of mask ventilation16. This methods paper and the associated video will demonstrate how to acquire the LPWT with portable ultrasonography to assess the severity of OSA in a patient and potential for difficulty in mask ventilation.

<table><tbody><tr><td>High Frequency Ultrasound Probe (HFL38xp)</td><td>SonoSite (FujiFilm)</td><td>P16038</td><td></td></tr><tr><td>Low Frequency Ultrasound Probe (C35xp)</td><td>SonoSite (FujiFilm)</td><td>P19617</td><td></td></tr><tr><td>SonoSite X-porte Ultrasound</td><td>SonoSite (FujiFilm)</td><td>P19220</td><td></td></tr><tr><td>Ultrasound Gel</td><td>AquaSonic</td><td>PLI 01-08</td><td></td></tr></tbody></table>

image acquisition using portable sonography for emergency airway management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

By utilizing real-time ultrasound probe visualization of the trachea, the directions in step 1 of the protocol enable the airway manager to secure the airway expeditiously and safely. The endotracheal tube is quickly recognized and removed from the esophagus by following the steps for placement in the proper endotracheal position under ultrasound visualization (Figure 1, Figure 2, and Figure 3). The advantage of thi...

Watch this Scientific Journal Video about Image Acquisition using Portable Sonography for Emergency Airway Management at JoVE.com

Image Acquisition using Portable Sonography for Emergency Airway Management

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

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2.3K Views.  George Washington University School of Medicine and Health Sciences. Het gebruik van luchtweg POCUS heeft verschillende indicaties in noodgevallen of moeilijk luchtwegbeheer. In deze video zullen we enkele van deze indicaties bespreken en hoe u de echografiebeelden kunt verkrijgen die nodig zijn om effectief te zijn. Het belangrijkste voordeel van het gebruik van luchtweg POCUS is dat het een snelle, gemakkelijk toegankelijke en niet-invasieve beeldvormingsmodaliteit is die kan worden gebruikt in klinische situaties met een hoge scherpte.Hoewel deze pro...

Video: Image Acquisition using Portable Sonography for Emergency Airway Management

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

Hand-held Clinical Photoacoustic Imaging System for Real-time Non-invasive Small Animal Imaging

Translation of photoacoustic imaging into the clinic is a major challenge. Handheld real-time clinical photoacoustic imaging systems are very rare. Here, we report a combined photoacoustic and clinical ultrasound imaging system by integrating an ultrasound probe with light delivery for small animal imaging. We demonstrate this by showing sentinel lymph node imaging in small animals along with minimally invasive real-time needle guidance. A clinical ultrasound platform with access to raw channel data allows the integration of photoacoustic imaging leading to a handheld real-time clinical photoacoustic imaging system. Methylene blue was used for sentinel lymph node imaging at 675 nm wavelength. Additionally, needle guidance with dual modal ultrasound and photoacoustic imaging was shown using the imaging system. Depth imaging of up to 1.5 cm was demonstrated with a 10 Hz laser at a photoacoustic imaging frame rate of 5 frames per second.

A clinical handheld photoacoustic imaging system will be demonstrated for real-time non-invasive small animal imaging.

Translation of photoacoustic imaging into the clinic is a major challenge. Handheld real-time clinical photoacoustic imaging systems are very rare. Here, ...

Bioengineering

Bedside Ultrasound for Guiding Fluid Removal in Patients with Pulmonary Edema: The Reverse-FALLS Protocol

Fluid retention is the most common risk factor for mortality and cardiovascular complications in patients with volume-overloaded disease states. The extent of diuresis or fluid removal is frequently determined by physical examination which is subject to inaccuracies.
Bedside ultrasound (US) is a portable tool that brings real-time diagnostic imaging to the patient's bedside. This versatile modality makes it possible for the clinician to investigate patients' extravascular and intravascular volume states. The extravascular volume, particularly in the case of pulmonary edema, can be quantitatively assessed by US of the anterior chest. Intravascular volume is estimated by visualizing the inferior vena cava (IVC) caliber. Taken together, the degree of extravascular lung water and the IVC caliber provide objective data that can guide the clinician to determine the level of diuresis needed to effectively yet safely treat pulmonary edema. 
The objective of this article is threefold: 1) to summarize the findings of previous studies on the efficacy of portable US to guide fluid management, 2) to describe a proposed ultrasound protocol to help guide fluid management, and 3) to elucidate techniques that address the measurement of intravascular and extravascular volumes using portable US.

We describe an imaging protocol that enables the clinician to visualize, in real-time, the patient&#39;s intravascular and extravascular space volumes and set diuresis and fluid removal parameters accordingly for the safe and efficient treatment of pulmonary edema.

Fluid retention is the most common risk factor for mortality and cardiovascular complications in patients with volume-overloaded disease states. The ...

Ultrasonographic Assessment During Cardiopulmonary Resuscitation

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, airway, and breathing status of a patient during cardiopulmonary resuscitation (CPR) in an advanced life support-compliant manner. US-C provides a subxiphoid view of the heart, to look for potentially reversible causes of disease, such as pericardial effusion, pulmonary embolism, hypovolemia, and acute coronary thrombosis. Sonographic cardiac activity during CPR not only helps differentiate pseudo-pulseless electrical activity (PEA) from true PEA but also represents a higher chance of the return of spontaneous circulation (ROSC) and survival. Evaluation of the inferior vena cava (IVC) shows the fluid status of the patient and indicates the best methods to use for fluid resuscitation. If aortic dissection is suspected, a subxiphoid view of the aorta is suggested for identifying an intimal flap. Once intubation is done, tracheal ultrasound (US-A) at the suprasternal notch helps differentiate endotracheal intubation (one air-mucosal interface with one comet-tail) from esophageal intubation (double tract sign). Immediately following US-A, bilateral lung US (US-B) should be done to confirm proper bilateral ventilation using the lung sliding sign. In addition, US-C can be serially followed to see the dynamic changes in the cardiac chambers and IVC, or any cardiac contraction suggestive of ROSC. US-B can also detect coexisting lung or pleural pathologies without interfering with the performance of CPR. The main concern when implementing this method is maintaining high-quality CPR without delays in chest compressions when performing US-CAB. Rigorous training and continued practice are key to minimize any interruptions during resuscitation.

Here, we present a US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol for use during cardiopulmonary resuscitation (CPR). US-C evaluates the subxiphoid view of the heart and inferior vena cava. After intubation, tracheal US (US-A) and lung US (US-B) help confirm endotracheal intubation and proper ventilation.

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, ...

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally prevents direct visualization of the lung parenchyma. When showing the lung parenchyma, ultrasound typically generates a number of non-anatomic artifacts. However, over the past several decades, these artifacts have been studied by diagnostic point-of-care ultrasound (POCUS) practitioners, who have identified findings that have value in narrowing the differential diagnoses of cardiopulmonary dysfunction. For instance, in patients presenting with dyspnea, lung POCUS is superior to chest radiography (CXR) for the diagnosis of pneumothorax, pulmonary edema, lung consolidations, and pleural effusions. Despite its known diagnostic value, the utilization of lung POCUS in clinical medicine remains variable, in part because training in this modality across hospitals remains inconsistent. To address this educational gap, this narrative review describes lung POCUS image acquisition in adults, including patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

Point-of-care ultrasound (POCUS) of the lungs provides quick answers in rapidly changing clinical scenarios. We present an efficient and informative protocol for image acquisition for use in acute care settings.

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally ...

Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON method, which looks for and evaluates the Mallampati classification, signs of obstruction, and neck mobility. Clinical findings help predict a higher likelihood of difficult tracheal intubation, but no clinical result reliably excludes difficult intubation. Ultrasound as an adjunct to clinical examination can provide the clinician with a dynamic anatomical airway assessment, which is impossible with clinical examination alone. In the hands of anesthesiologists, ultrasound is becoming more popular in the perioperative period. This method is particularly applicable for identifying proper endotracheal tube positioning in specific patient populations, such as those who are morbidly obese and patients with head and neck cancer or trauma. The focus is on identifying the normal anatomy, correctly positioning the endotracheal tube, and refining the parameters that predict difficult intubation. Several ultrasound measurements are clinical indicators of difficult direct laryngoscopy in the literature. A meta-analysis revealed that the distance from the skin to the epiglottis (DSE) is most associated with a difficult laryngoscopy. An ultrasound of the airway could be applied in routine practice as an adjunct to the clinical examination. A full stomach, rapid sequence intubation, gross visual anatomical abnormalities, and restricted neck flexibility prevent using ultrasound to assess the airway. The airway evaluation is performed with a linear array transducer of 12-4 MHz, with the patient in the supine position, with no pillow, and with the head and neck in a neutral position. The central axis of the neck is where the ultrasound parameters are measured. These image acquisitions guide the standard ultrasound examination of the airway.

A point-of-care ultrasound (POCUS) is a simple, non-invasive, and portable tool that enables dynamic airway assessment. Several studies have attempted to determine the role of ultrasound parameters as an adjunct to clinical examination in predicting difficult laryngoscopies.

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON ...

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. 
This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h ...

Imaging the Abdominal Aorta with Point-of-Care Ultrasound

An Approach to Point-Of-Care Ultrasound Evaluation of the Abdominal Aorta

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography (CT) is the current gold standard to image the abdominal aorta, the process of obtaining a CT may be time-consuming, requires the use of intravenous contrast dye, and involves exposure to ionizing radiation. Point-of-care Ultrasound (POCUS) can be performed at the bedside and has excellent sensitivity and specificity for the diagnosis of abdominal aortic aneurysm and excellent specificity for the diagnosis of abdominal aortic dissection. Additionally, POCUS is non-invasive, cost-effective, lacks ionizing radiation, requires no intravenous contrast dye, and can be performed without taking the patient from a critical care area. Screening for abdominal aortic aneurysm (AAA) can be done in primary care settings as well. 
This article will review the approach to POCUS of the abdominal aorta to evaluate such critical pathology. In this paper, we will review the sonographic anatomy of the abdominal aorta as well as the choice of the ultrasound probe, description of POCUS image acquisition, and some pearls and pitfalls of using POCUS to aid in the diagnosis of potentially life-threatening abdominal aortic pathology.

Author Spotlight: Using Point-of-Care Ultrasound for Comprehensive Evaluation of the Abdominal Aorta

This protocol reviews the steps to image the abdominal aorta with point-of-care ultrasound. We discuss image acquisition, troubleshooting imaging pitfalls and artifacts, and the recognition of life-threatening abdominal aortic pathology.

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography ...

Focused Assessment with Sonography for Trauma (FAST) Exam: Image Acquisition

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a combination of trauma (blunt or penetrating) and hypotension. In these hemodynamically unstable trauma patients, the FAST exam permits rapid and noninvasive screening for free pericardial or peritoneal fluid, the latter of which implicates intra-abdominal injury as a likely contributor to the hypotension and justifies emergent abdominal surgical exploration. Further, the abdominal portion of the FAST exam can also be used outside of the trauma setting to screen for free peritoneal fluid in patients who become hemodynamically unstable in any context, including after procedures that may inadvertently injure abdominal organs. These "non-trauma" situations of hemodynamic instability are often triaged by providers from specialties other than emergency medicine or trauma surgery who are not familiar with the FAST exam. Therefore, there is a need to promulgate knowledge about the FAST exam to all clinicians caring for critically ill patients. Toward this end, this article describes FAST exam image acquisition: patient positioning, transducer selection, image optimization, and exam limitations. Since the free fluid is likely to be found in specific anatomic locations that are unique for each canonical FAST exam view, this work centers on the unique image acquisition considerations for each window: subcostal, right upper quadrant, left upper quadrant, and pelvis.

Focused Assessment with Sonography for Trauma FAST Exam: Image Acquisition

The Focused Assessment with Sonography for Trauma (FAST) exam is a diagnostic point-of-care ultrasound examination used to screen for the presence of free fluid in the pericardium and peritoneum. Indications, techniques, and pitfalls of the procedure are discussed in this article.

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a ...

Echocardiographic Assessment Using Subxiphoid-Only Examination for Hypotensive Patients

Point-of-care ultrasound, or POCUS, has gathered significant interest as a tool to augment clinical decision-making in the care of acutely ill patients. Patients with hemodynamic instability, in particular, require immediate intervention and are at high risk for further cardiovascular and/or respiratory decompensation. POCUS examination of these patients, therefore, requires a protocol that is sufficient to answer clinicians' questions while still retaining adequate brevity to be feasible in a short period of time at the bedside. Here, we demonstrate a protocol for obtaining such information by the Echocardiographic Assessment using Subxiphoid-Only - Mean Arterial Pressure, or EASy MAP exam, a focused ultrasonographic assessment of the cardiovascular and respiratory systems. The cardiovascular portion of the examination utilizes the subcostal window to obtain views of the heart and inferior vena cava (IVC); this is then supplemented by anterior upper lung and posterolateral diaphragmatic pleural views for the respiratory portion. All six views (cardiac, IVC, left and right anterior upper lung, and left and right posterolateral pleural) are obtained using a low-frequency phased array transducer. We discuss some of the common pitfalls encountered in obtaining these images and the basics of interpreting the most common findings; also described is a 12-point scale for rating the quality of the images obtained from the cardiac view and a small number of supplementary views that may be considered when clinically relevant.

The protocol here provides a rapid, phenotype-based approach for focused ultrasound evaluation of the hypotensive patient, using subcostal images of the inferior vena cava and heart, with additional views of the upper lungs and pleural spaces.

Point-of-care ultrasound, or POCUS, has gathered significant interest as a tool to augment clinical decision-making in the care of acutely ill patients. ...

Image Acquisition using Portable Sonography for Emergency Airway Management

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