What are the minimum requirements to establish proficiency in lung ultrasound training for quantifying B‐lines?

Abstract

Aims The goal of this study was to determine the number of scans needed for novice learners to attain proficiency in B-line quantification compared with expert interpretation. Methods and results This was a prospective, multicentre observational study of novice learners, physicians and non-physicians from three academic institutions. Learners received a 2 h lung ultrasound (LUS) training session on B-line assessment, including lecture, video review to practice counting and hands-on patient scanning. Learners quantified B-lines using an eight-zone scanning protocol in patients with suspected acute heart failure. Ultrasound (US) machine settings were standardized to a depth of 18 cm and clip length of 6 s, and tissue harmonics and multibeam former were deactivated. For quantification, the intercostal space with the greatest number of B-lines within each zone was used for scoring. Each zone was given a score of 0-20 based on the maximum number of B-lines counted during one respiratory cycle. The B-line score was determined by multiplying the percentage of the intercostal space filled with B-lines by 20. We compared learner B-line counts with a blinded expert reviewer (five US fellowship-trained faculty with > 5 years of clinical experience) for each lung zone scanned; proficiency was defined as an intraclass correlation of > 0.7. Learning curves for each learner were constructed using cumulative sum method for statistical analysis. The Wilcoxon rank-sum test was used to compare the number of scans required to reach proficiency between different learner types. Twenty-nine learners (21 research associates, 5 residents and 3 non-US-trained emergency medicine faculty) scanned 2629 lung zones with acute pulmonary oedema. After a mean of 10.8 (standard deviation 14.0) LUS zones scanned, learners reached the predefined proficiency standard. The number of scanned zones required to reach proficiency was not significantly different between physicians and non-physicians (P = 0.26), learners with no prior US experience vs. > 25 prior patient scans (P = 0.64) and no prior vs. some prior LUS experience (P = 0.59). The overall intraclass correlation for agreement between learners and experts was 0.74 and 0.80 between experts. Conclusions Our results show that after a short, structured training, novice learners are able to achieve proficiency for quantifying B-lines on LUS after scanning 11 zones. These findings support the use of LUS for B-line quantification by non-physicians in clinical and research applications.

B-line quantification: comparing learners novice to lung ultrasound assisted by machine artificial intelligence technology to expert review

“…This data suggests that further AI technology development is necessary to improve the algorithm to achieve good correlation. If successful, this has great implications clinically as a clinician or even a non-clinician could track treatment progress in patients with AHF to determine response to treatment, guide additional therapy, and determine when a patient is decongested and ready for hospital discharge [ 2 ].…”

“…Lung ultrasound (LUS) for the evaluation of pulmonary edema in acute heart failure (AHF) has become standard care in many emergency departments (ED) and intensive care settings [ 1 ]. Ultrasound can be used by practitioners across a broad range of expertise to evaluate the lungs for the presence of B-lines, indicating pulmonary edema or loss of lung aeration [ 2 ]. Presence of B-lines is highly specific for the presence of interstitial and alveolar fluid.…”

Lung ultrasound training and evaluation for proficiency among physicians in a low-resource setting

“…Cumulative sum (Cusum) statistical methodology was used to evaluate the number of LUS scans required to reach an adequate level of training [ 19 , 20 ]. As described in more detail by Russell et al, Cusum analysis uses pre-defined acceptable and unacceptable failure rates and evaluates sequential data to determine when a learner has reached proficiency with a skill [ 12 , 19 , 20 ]. This statistical method assesses procedural competence for learners over time.…”

“…Only a handful of prior studies have evaluated LUS proficiency in learners [10][11][12][13][14][15]. Several of these studies primarily focused on learners in the intensive care unit (ICU) with varied supervision and assessments of proficiency [10,14,15].…”

“…While Arbelot et al included ED residents, the study was performed in the ICU setting [ 15 ]. Other studies primarily focused on particular disease processes, such as pneumothoraces [ 13 ] or patients with cardiogenic pulmonary edema [ 12 ]. There remains a lack of evidence regarding the amount of training and the number of LUS examinations needed to attain proficiency for evaluating the undifferentiated dyspneic patient presenting to the ED.…”