Evolution of point of care ultrasound (POCUS) education: cardiovascular, pulmonary, and beyond
A recent CHEST Physician article noted the ubiquity of POCUS employment but lamented inconsistencies and possible inadequacies of POCUS education amongst ACGME specialty fellowships (Satterwhite L. An update on the current standard for ultrasound education in fellowship. CHEST Physician. 2019 Dec. 9). POCUS education/training is no longer limited to physician fellowships but has percolated into the undergraduate medical education curricula of first-year medical students and physician assistant (PA) programs (Hoppmann RA, et al. Crit Ultrasound J. 2011;[3]:1; Rizzolo D, et al. J Physician Assist Educ. 2019;30[2]:103). Some PA residencies have long-incorporated POCUS training to varying degrees, providing emergency/critical care/cardiovascular ultrasound training comparable to that of physician residencies (Daymude ML, et al. J Physician Assist Educ. 2007;18[1]:29). A 12-month POCUS fellowship, which mirrors physician POCUS fellowship curricula, is also available for PAs at Madigan and Brooke Army Medical Centers and allows graduates the opportunity to earn RDMS/RDCS credentials (Monti J. J Physician Assist Educ. 2017;28[1]:27). POCUS employment is not limited to physicians and PAs, however. Respiratory therapists and other allied health professionals are also exploring the value of pulmonary, cardiovascular, and other critical care POCUS applications in their respective practices (Karthika M, et al. Respir Care. 2019;64[2]:217). Meanwhile, POCUS devices continue to evolve toward inexpensive handheld machines that incorporate machine learning/artificial intelligence, further mitigating barriers to integration of POCUS into routine clinical practice (Tsay D, et al. Circulation. 2018;138[22]:2569). With the expansion of POCUS across the full spectrum of health care, leadership from multiprofessional organizations, such as CHEST and the Society of Point-of-Care Ultrasound (SPOCUS), are well-positioned to leverage their diverse leadership to govern the training and safe employment of POCUS.
Dr. Robert Baeten II
Robert Baeten II, DmSc, FCCP Steering Committee Member
Chest infections
New laboratory testing guidelines for diagnosing fungal infections
Secondary to a growing number of immunosuppressed individuals, the incidence of invasive fungal infections (IFI) is increasing. IFIs can be difficult to treat and are associated with a high mortality rate. Effective treatment is predicated on early recognition and accurate diagnosis (Limper AH, et al. Am J Respir Crit Care Med. 2011;183[1]:96). Therefore, the American Thoracic Society created a clinical practice guideline on laboratory diagnosis of the most common fungal infections (Hage CA, et al. Am J Respir Crit Care Med. 2019;200[5]:535). The most important diagnostic considerations for clinicians are summarized below:
1. Serum galactomannan and serum aspergillus PCR are recommended in severely immunocompromised patients suspected of having invasive pulmonary aspergillosis (IPA).
2. Galactomannan and aspergillus PCR in bronchoalveolar lavage (BAL) are recommended for patients who are strongly suspected of having IPA, especially if serum is negative. In less severe immunocompromised patients, the BAL sensitivity of galactomannan is better compared with serum, without reducing specificity.
3. Due to low specificity/high false-positive rate, 1,3-B-D-glucan should not be used in isolation to diagnose invasive candidiasis.
4. No single best test exists for the diagnosis of blastomycosis or coccidioidomycosis; rather, more than one diagnostic test including fungal smear, culture, serum antibody, and antigen testing should be used for suspected blastomycosis or coccidioidomycosis.
5. Urine or serum antigen testing is recommended for patients with suspected disseminated or acute histoplasmosis. For immunocompetent patients suspected of pulmonary histoplasmosis, serologic testing is recommended; antigen testing may increase the diagnostic yield.
Dr. Eva M. Carmona
While these recommendations provide a basis for laboratory testing for the most common IFIs, they must be integrated into the clinical context to ensure accurate diagnosis.
Kelly Pennington, MD, Steering Committee MemberEva M. Carmona, MD, PhD, NetWork Member