Good morning, everybody. My name is Jeff Darna. I am part of the Professional Development Committee for the American Association of Nurse Anesthesiology. And I want to welcome you here to day four in our presentation day, Point of Care Ultrasound, an option for the early assessment and management of pulmonary edema. Before we begin, I have a few reminders that you've heard from other PDC members. But we'll try to move through these quickly so we can get to our presenter. So for everybody here in the room, please do make sure you download the app and use the app to claim your CEs. We recommend you claiming your CEs and completing those evaluations immediately after the presentation. Very important, all attendees will have until Monday, September 9th at 12 noon Pacific time to submit all individual session evaluations as well as the overall conference evaluation. So please make sure you get that completed by then. It will not be available to you after that date. And you will not be able to claim the CE credits for the annual Congress. You can submit questions to the speaker via the questions icon that's located within this session. I'm going to monitor those questions throughout the presentation. And if time permits, your question will be asked and answered live by our speaker. If you would like to come up and ask a question, you may come up to one of the mics, which I hope are, I can't see out there, but are hopefully are strategically placed for your availability. If they aren't, we will get you a mic if you would like to ask a question. Lastly, and also, well, lastly, mark your calendars. We're looking for some speakers for the 2025 annual Congress in Nashville, Tennessee. If you'd like to speak, if you'd like to share your expertise, the call for abstracts opens on August 14th. So that is next week. More information about the submission guidelines as well as reviewing the video help to help optimize your abstract for review, please visit aana.com. Now it's my absolute pleasure to introduce our speaker, Dr. Shane Holguin. Dr. Holguin is an associate professor of clinical, professor of clinical, clinical in the School of Nursing and Health Science at the University of Miami, as well as our newly announced chief science and practice officer for the ANA. So please join me in welcoming Dr. Holguin as he presents Point of Care Ultrasound, an option for early assessment and management of pulmonary edema, Shane. Can you guys hear me back there okay? Yeah, I think that's loud enough, right? First of all, I can't do this without acknowledging my students that got up really early to come to this. So thank you, thank you, thank you. You know, College Bowl was yesterday, so I'm a little shocked that they made it, to be honest. I don't know how much they'll be paying attention. So it is, like everybody says, it's pretty bright up here. It's an honor to be here, you guys. It always is an honor to be here. And I know there's a call for abstracts. I really, really encourage everybody to think about that. We need more, right? We need to hear from questions. We need to hear from people. We need these opportunities for you guys to speak. And doing this over the years, it's a wonderful experience and a way to be able to disseminate your information, your expertise, okay? And I think that's really important. I almost feel like I'm sitting down here, but, you know, bring up, and you don't want me to be drawing, so that's not going to happen. But point-of-care ultrasound, you guys. I know it's becoming more prevalent. First of all, how many people are using point-of-care ultrasound? So we got one hand, two hands. We have a couple, couple hands, three hands that are up there, okay? It's not new, right? But it's kind of newer to our profession. We're kind of lagging behind a little bit for some of our peers. ER physicians are well ahead of us. So to me, what the exciting point of using ultrasound is not so much on procedural performance. It's great for that. That's well established. But to me, it's the frontier of what I would like to call visual medicine, is being able to see, you know, it's so much more impactful to be able to see what's happening underneath the skin. Traditionally, in the past, we couldn't look at that. We couldn't see that. And I like to look at this as kind of my research hat and look at it as another data point. It gives us more information to help us make a clinical decision and allows us to be able to do that the bedside. It's readily available, and it's rapid assessments. Not only that, is there's a lot of evidence to show that it's better than our traditional ones that we currently use. So that being said, again, no conflict of interest for this discussion. Learn your outcomes. I always like to go over the current evidence. So start with that and kind of take a dive into that and to highlight why we use it. Then looking and kind of going over some of the sonographic findings of kind of some key things to look at, and then kind of summarizing some of those, okay? I have a case study at the end that really I wanted to bring in to kind of highlight. And it's a real case study to highlight the use of point-of-care ultrasound for this specific of looking for pulmonary edema. So here's kind of the overview. What I'll do is look at the introduction, current evidence. I don't want to drown you in the evidence, so we'll go over that. But again, just to highlight some of the key things we show to really impact to you guys the importance of it, of not only using this as a tool to help us make a decision, but using a powerful tool that's better than other tools to make this decision. And then the sonographic, you know, some of those, and then findings and kind of a conclusion for that stuff. So if we think about introduction to POCUS of the lung, traditionally in the past, we didn't think we could do POCUS for the lung, ultrasound in the lung, because it's all aerated. Now, if you guys know, sound doesn't travel through air. That's why we put ultrasound gel on there to create a medium for it to pass through. So traditionally, we didn't think that we could see anything, because the air, it doesn't allow us to see stuff. And what we use is we basically use artifact. And then you'll get changes in the artifact to give us clinical impressions, to give us pathology. And that's what we're looking for. So it's first of all, it's really important to understand what we normally see. And then what are the changes to what we normally see? And that's where we can get into then the pathology is of those changes from normal artifacts that you're getting into. And that's what we'll kind of talk about a little bit of the normal ones, and then getting into the artifacts and changes of artifacts. Easiest thing to think about, you guys, is if you think of lungs being aerated, you look at it, it doesn't matter if it's a chest X-ray, whatever radiological tool you're using, is it's changing in tissue density. That's really what's happening. So you have to think of the parenchyma, the lung pleura. There's changes to those tissue density that is changing then the image that we're seeing on the screen. And that's what's causing a change in those artifacts that we're seeing. So in other words, discriminating between cardiac and non-cardiac. Now one thing I also want to really stress to you guys is the importance of the history. The history and physical of the individual is about 85% of the diagnosis, right? We're not just doing a point-of-care ultrasound on just everybody or without knowing that information. There's a clinical reason why we're using this to help us make that decision, to help us manage. So we have to look at important information about that to determine and then think. So if it's cardiac in origin, there's going to be some cardiac history to that stuff versus non-cardiac, for example, negative pulmonary edema. Two different patient categories. We're still suspicious of it, but we're suspicious for different reasons. So in other words, if it's non-cardiac, you're not necessarily going to see a decrease in EF and things like that. Or if it's cardiac, you're going to see those manifestations of low EFs and stuff. So if we look at current evidence, interestingly, if you look, and I've talked about this year after year of a number of different topics from a gastric ultrasound, airway, cricothyroidomy, pneumothorax. How many people, for instance, because pneumothorax is a really good example of this, how many people do POCUS to diagnose a pneumothorax versus a chest X-ray? Pretty few hands, right? How many people see clinically POCUS used to diagnose a pneumothorax? How many people see a chest X-ray used to diagnose a pneumothorax? Well, the evidence shows that a chest X-ray is at its best, is ultrasound at its worst. That's how impactful it is, is we are using a substandard tool to help us diagnose somebody. Ultrasound in a supine individual is much more sensitive, right? It's almost double the sensitivity of that. Chest X-ray is a very poor tool for looking at a supine individual for a pneumothorax. And to be honest, most of our, all of our patients are going to be supine when we're looking at this stuff. So clinically, we're not there yet, even though there's tons of evidence to show that point-of-care ultrasound is superior. So here's the same thing for, well, and the other is, is after a central line. It should be the gold standard is we use ultrasound to do the insertion of the central line. Slide the probe down and look for lung sliding. Slide the probe down and look for the presence or non-presence of pneumothorax. We have the same probe we're using for the central line. It takes us 30 seconds to slide it down and add that data point in there, to add that assessment in there to give us really important information, right? So we have a lot of, still a lot of places to go. And that's where, again, we're kind of adopting this and we're learning this. And to me, that's what's exciting about using ultrasound is it can be so impactful. And it's information that we get at the bedside that does not take long to do. What we need to do is we need to understand how to do it. Now, my students over here, now some of them and some of them didn't, what we integrate is we have a advanced diagnostic course where they go through week after week and they do gastrointestinal ultrasound. They'll have this whole lab, like three, four-hour session just scanning each other, different IPO statuses. Then they get the diagnosis or they get the course and talking about that. And we go through each system to do that. This is the second semester in their program. This is students with very little anesthesia knowledge or the very little anesthesia understanding. And it's impactful to see the change that happens from the beginning with them not even knowing what probe, how to turn the machine on, not even knowing how to interpret anything on the pixels on there, to afterwards being able to go through and do an assessment, a lung assessment, a gastrointestinal ultrasound assessment. So the point is, is we all can do it, right? It's just having those opportunities to be able to understand what we're looking at and how to do it. That's it. Once we get that, it's hard to undo it, hard to not see it. So these are examples of kind of pathology that are improved if we think of pneumothorax, pleural fusions, pneumonia, and pulmonary edema, right? These are instances where POCUS is better, where we should be looking at that. The other is, is we have to think about serial assessment of people. It's not a just static assessment where you just do one assessment. Say you have a patient that comes in and has a EF of 20%. You read an echo report. Well, when was the echo report done? They have a history of CHF. All right. At the time when you did the radiological testing, they were clear. That's not their functional status, though, when they're presenting to you to the OR. We can scan them preoperatively. We can see what their baseline is. So then we can do serial ones intraoperatively if we have any issues. Postoperatively, in a PACU, if we have any issues, we scan them and see where they are. Now say they're having symptoms. We scan them, and we decide to give them LASIKs. Well, now we do serial ones as of how the LASIKs is working. And in fact, ultrasound will pick up that changes before you will see symptoms. So it's not just helping diagnosis, but it's also helping manage it, right? And because it's no harm to the patient, we can do it over and over and over and over again and keep assessing them. It's like somebody told me a story that the stethoscope, when it first came out, cardiologists didn't think nurses could use it because it was too deep of understanding to use this advanced tool, right? It's the same thing. This is going to be your stethoscope of the future. Everyone's going to have a pocket ultrasound probe that are already available, that are only getting better and better and better. And we will be using this for so many things. All right. So if we look at some of the evidence, again, if you look at heart failure, this was comparing if you look at ultrasound diagnosis, ED diagnosis, and final diagnosis. And then over there, you can see concordance, so how well they match. And you can see that number, again, closer to one there with heart failure, 0.8. Now, interestingly, if you look here, laser's not showing up on there. But the pneumothorax is 0.9. So those are strong, powerful tools that are showing, again, better or similar results for them. If we look at diagnostic accuracy, again, you look at heart failure. I tried to highlight those ones in blue there to kind of give you an area of focus a little bit to kind of exclude those items. But if you look at the top on there, heart failure, you can see the sensitivity of that. Again, 88%, right? If you look at the specificity, 96. Predictive value of 85.8. Very strong predictive values, right? Positive likelihood ratios, negative likelihood. So what it's showing is, again, the statistical power of these tools. We're not using this as something that's subpar. We're using something that really has strong evidence supporting its use. And that's really what all of this is just to highlight to you guys, is not for us to get lost in the numbers, but for us to really look and say, yes, this is important for us to understand. This is an important tool that we need to adopt, that we need to start to, because the evidence shows that it really provides that really superiority of us to be able to help us manage patients. That's really what it is, is how is it gives us information. Now here, all of you looking at here, this is just looking, you can see some forest plots on there. You can see I tried to put it at 0.9, the red line through there, so you can see some of the differences. The top one is looking at ultrasound, the bottom one is comparing that to chest X-ray. Now you can see, over on the sensitivity versus specificity, you can see the differences when we're looking at that. Again, just more evidence to highlight to you guys how impactful. And that's what all of this evidence is just showing. It's not that one is saying strong evidence, one is saying really low evidence. They're all consistently showing how well and how good of a tool it is. Here we look at ultrasound, again, on the top of the highlighted and the one in the bottom is chest X-ray. And you can see, again, how sensitive, specific, but if you look at the accuracy, again, the difference. Now this is across providers too. If you look at EM, emergency medicine, internal medicine, look at radiology as well. Even improvements in radiology. Now obviously the improvements aren't as much because they're experts in that. But even being experts in that, you can still, it's still statistically significant. Not as significant in the other ones, but again, we wouldn't compare ourselves to radiologists. We're going to compare ourselves to the other providers on there. So you can see, again, that big difference that you see from, again, looking at a number of different providers on there. Here, novice reads. So now looking at novices and looking at that, again, EM, emergency medicine, right? If you look into internal medicine, you look at radiologists, similar results that you can see, significant results for that. More evidence showing that, and again, I'm going to get through this. I'm not going to spend a lot of time on these slides. It's just, again, trying to give you facts just to, right, because to me, facts speak volume. It's not my impression, it's the impression of what the evidence out there is showing you guys. And you can see here, again, how good of a tool that it is. And diagnostic accuracy, right? Suggests higher, right, diagnostic accuracy. You can see, again, B lines and A, and we'll get into B lines, we'll get into some of the specifics of that and some of the sonographic findings that we see with point-of-care ultrasound. Here's another one looking at some of those outcomes, and say that's pretty hard to see, but again, you can see with CHF, all it is is, again, showing you that superiority of that. Now, if we look at time, right, time is also a very impactful tool because not only is it giving us really great information, accurate information, but it's also doing it in a very timely manner. What would we rather have, if you look at here, the averages, again, about 20 minutes for chest x-ray versus 2.3 minutes for ultrasound? Very different when we are faced with somebody that is having a crisis that we need to intervene. We're waiting for a chest x-ray, we're already treating them before we get that out, get the chest x-ray back. We're doing that for to confirm, right? But we're not waiting 20 minutes to initiate care. We're going to initiate care based on the suspicion. Well, now, point-of-care ultrasound doesn't, it gives us that data point, it gives us that information at the bedside to help us, right? We're filtering through a lot of information quickly. And that's the struggle, and that's where some of the, again, students struggle with that is, is that you're going through A, B, C, D relatively quickly. Would this allow us to be able to help us be able to decide, do we go down A path, B path, C path, or D path? So here's another one, early assessment, and this looks in rabbits. Now, I know rabbits are not comparable to us, but the reason why I pulled this out and look at it is because I pulled some images from there that are very impactful to kind of highlight to us visually. So if we look here, if they look at number of B lines, now, B lines are vertical lines, and again, we'll get into it, but really what it is is it's changes in lung density. So you have fluid in there. So if you look at your alveolar, now, between you have fluid, so sound will travel through fluid. So now what we'll do is we'll get the sound to penetrate through, and we'll see an image. We'll see a change in the screen, how it looks. So you can see here is a correlation between the number of beelines, okay, the appearance of those beelines in minutes, and then what they were able to do is look at the score, and the worse the score, obviously, the worse the increased severity of the pulmonary edema. Now, obviously, beelines and rabbits are different beelines from us, so don't look at these numbers as being meaningful to translate to us. This is, again, just rabbits. Here's what I thought was a very impactful image, okay. If you look at the one at the top, you can see normal. Just visually look at the difference of that. It's pretty easy to be able to see the difference between the top one and the bottom one over here, sonographically how it looks. You see all that white shading that's coming down. Those are all beelines, okay. There's so many belines that we're really not even seeing some of that other normal findings like A-lines. So, the one in the top, all you're seeing is A-lines, but you're seeing lines going horizontal, okay, so it looks at the depth. It hits the pleura, sound bounces back, hits the pleura, bounces back. The machine thinks it's hitting that at a different time point, so it makes it deeper, right. It doesn't know. It's just looking at, I see this, and it took so much time for it to come back, so it's fooled. Those are the normal artifacts we see, but you can see as the progression of the severity goes on, you can see visually, very impactful, the difference that you're seeing on that screen and on that image. Now, translate that to us. Translate that to your patient. You're going to see the same thing. It's just the number of B-lines are going to be different, right. That's where it's, again, rabbits and us are a little different, but as far as your visual, it's going to be very similar findings of going from one to the other. It's pretty easy to see the severities, right, to look at good and ugly, and I think we have to start to think in looking at this and not be afraid as we want to make a decision. Good, bad, and ugly is how I look at it. I don't matter if you're doing transthoracic echoes is you don't need to figure out what an exact EF is. I just want something to give me clinical decisions to see is it good, is it bad, or is it ugly. That's it. To help us to make clinical decisions on how to manage that, right, that's the whole goal of this, and sometimes I think we get caught up in the specifics, right, but just be able to put a probe on it and see the difference from the top one to the bottom one. Now, remember, we also have other symptoms, right. This is one data point that's helping us confirm to narrow our focus into how to treat that patient. We're not just putting a probe on there and looking at this in isolation, right. We're looking at this with other symptoms that are on there, too. So also a very impactful image because now we see how the lung looks correlates to these sonographic findings here. So you can see A is the normal lung versus D, which is that one that had all that white vertical stuff coming down. That was the one that was the most severity. Now look how the lung looks in that case. That's what's really powerful is we're seeing the impact that it's having sonographically. This is the impact that it's having to help us be able to look at the differences from that normal as it progresses to that severity of that. And then serial ones to look at the management from it getting from D as it progresses to C, B, and A. So now getting on to the good stuff, right, that really matters. Now one thing I would say, you guys, is I don't expect you guys from any of these talks to come out of here being proficient. All this is is hopefully to just spur an interest, to show to you guys the importance of how point-of-care ultrasound can help us. This is just an instance of helping us with pulmonary edema, right, CHF. There's tons of other uses of it, too. But hopefully then it gets you guys to start to say, I want to learn more. I want to delve in a little deeper. The pre-conference that we had here, workshop at the beginning of this, was then, again, looking at and understanding more. So I encourage you guys, if you're really interested, and hopefully what this does is spurs that interest for you guys to look at, OK, let me take more. Let me learn more about this. It's not necessarily leaving from this, being able to go there and say, oh, OK, I'm now going to be an expert in this. That's where the clinical competence, that's where the competence comes into, which means that a weekend workshop, right, probably not enough. But looking at how do we get in and get a little more information and add, right, so we can all get stronger. And it's really just scanning, scanning, scanning. Get an ultrasound probe, put it on there, start to learn what normal sonoanatomy, and that's where you start with, is just understand normal, right, before we get into pathology. We don't understand what normal is. It's like not understanding normal physiology. And that's where, again, we're focused a lot of times on pathophysiology, but you need to really understand normal physiology. Same with this, is this is just really showing us that visual. It's understanding anatomy and how the anatomy is being represented. And the difference is that when we start to bring pathology in. So surface anatomy, right? So we see a pleural surface, sound hits the pleural surface, and it's going to bounce back. There's visceral and parietal. So there's two visceral and parietal, a little serous fluid in between those. One's connected to the ribs, one's over the visceral. So when you take a breath, they're going to move apart from each other. And we see that in the presence of what's called lung sliding, right? We don't breathe, our lungs don't move. We get low lung sliding. For instance, if we look at some simple thing of auscultating somebody after intubation, we all do it. The sensitivity of that, the evidence is not very good, but that's our tool. We could use point-of-care ultrasound and put the probe on and look for lung sliding. I see sliding on one side, I see sliding on the other side. I see sliding on the right, but I don't see it on the left. Okay, I got a right mean stem, let me pull it back until I get sliding on both sides. As simple as that is, we can use it instead of auscultating, is using ultrasound to be able to give us better tools for these things. More sensitive, more specific for this stuff, right? That's where it's so impactful. It's not just high-level uses of it. Sometimes it's very simple uses of this that we can integrate into clinical practice. So if you look, it goes down to about the fifth space down there is really what we're kind of looking for them. Here's an example of this video. Now I'd like to add a little snips in here to kind of make it. If you look some of those things, if you look rib, okay, so this is a linear probe. We can use a curved probe, we can use a phased array probe. They all have their strengths and weaknesses to that. The linear run is not going to give us much depth, but you can see that it's a much clearer image. So it's easier for you guys to be able to visualize. But we're focused on one intercostal space. So you see a rib, so the probe is in a sagittal plane, probe markers to the head, okay? So you see a rib and you see a rib. So that's a space that's in between that. Behind the rib, we don't, sound doesn't travel through bones. So we see a shadow behind that. So that's very specific. You can see the rib and then you see the shadow behind the rib. Now obviously you can see that VPPI, well that's visceral, plural, right? That's that interface between those two. That's where we're going to see the plural slide, the lung slide. Now obviously that travels under the rib, but we're not seeing it because just the sound isn't traveling through there. So if we play this, there you can see again, now there's a little beeline that you can see go down there. That's that little vertical line that comes down, but that's okay. One of those is normal. It's when we start to get a lot of those, but we see a lot of those in multiple spaces. And for this talk, if we see that bilateral, because pulmonary edema, CHF is bilateral. It's not a unilateral condition. So there's that presence, there's that lung sliding that's going on. Again, this is just normal, right? This is myself that I did a scan of to put it on there. So if we get to some of the physics, I know I'm going to lose you here. Simple physics. Don't get too worried about this. Here's simple little things. The image is really just showing you beelines. That's what we saw in that image of the rabbit is the beelines. You can see those vertical lines coming down there. They look different than the black. The black is if it's aerated. If you saw the one before, we didn't really see a lot of these. So now what happens is we're seeing a lot of these kind of white vertical lines. It's kind of like seeing on a chest x-ray when you see those lines that come from the edge there. Similar kind of things, what happens, we've changed the parenchyma. Now what happens is the alveolar now have water in between. So now what happens is now sound is traveling through. It's not hitting air. It's hitting water. So we're going to see visually that now sound is traveling through. This is just visually showing us that sound is traveling through the lung, which is the presence of those verticals, which we call beelines. Here if we look at A lines, A lines are lines that go this way. And again, there's images that's going to be a little more impactful to kind of show you that. And then we have those B lines, those bright vertical lines going down. So here's an example of both of those A lines and B lines. Now, if we take distance from the skin down to where we see the pleural line, again, I don't think I can show you on here. No, it's not showing on there. But if you look at about 6 centimeters, 6 and 1⁄2 centimeters with arrow to A lines is there, there's a line. If you look at about 3 centimeters at the top, you see a bright white line. All the one below is that same line repeating itself. So the distance to the pleura, we double that. There's an A line. We triple that. That's an A line. All it is is the sound hitting the pleura, bouncing back, hitting the pleura, bouncing back, hitting the pleura, bounces back. The machine just took, the second time took twice as long than the first time. So it thinks it's twice as deep. That's just an artifact. That, all it means is that sound hitting that pleural line. The vertical lines are the B lines that you're seeing traveling down in there. So again, if we look, there's that B line that's in there. Now this is a curved probe, curved array. So it's giving us a bigger blueprint. Now it's a little grainier. It's not as clear. If we want to see a lot of interspaces or a lot of pleura quickly, then we can add in there and use that. And allow us to be able to see a greater surface area quicker. So A line's normal. Again, it depends on the pathology as far as what those changes of A lines and B lines that come into that are. And if you look at B lines, two are fewer. So we saw one in there. That's okay. That's normal, right? It's when we start to get multiple, that's greater than two, greater than three, and we see those multiple places. That's where we start to get concerned. And again, adding it in to the patient's clinical history as well. Because we have to keep remembering that a big information that we get is from the patient and that clinical correlation of that. We're using this as just another tool to help us confirm what we're already suspicious of. Or if we're suspicious of a number of things to help us narrow down, is it A, B, or C? We think it's A. We put this on, oh no. It's negative pressure pulmonary edema. And now we think, okay, let's change how we manage this patient. Probe selection, right? So here's a number of probes on there. Now, the one optical sensor, the one sensor on there, I use that. Just ignore that. That's used there for needle guidance. So that's a technology I put in there for us to be able to track the needles. What it does is it's an optical sensor that senses the needle path, and I do that for a lot of stuff I look at as far as needle guidance. It uses AI, artificial intelligence, and augmented reality to kind of help us on that stuff. So that's on there just for those purposes. But really, you can see the linear probe, the curve. We can also use a phased array, too, there, which you guys probably know as a cardiac probe, a small little square one, which allows us to be able to kind of get that small blueprint in between the ribs to look at that. Merits of each one of those, right? You can use any one of those, but like I tell my students, it's like, okay, well, if you're going to use one of those, then just give me the advantages. Justify why you're going to use that. They're all okay to use. They all have their value to use. And I personally will use each of those depending on what I'm looking for. If I'm doing already a central line in there, I'm using a linear probe. I'm using what some of you may think of as a vascular probe. So why would I switch to a different probe? I just use that one, slide it down, and be able to assess, right? Makes no sense to switch to a different probe when I already have one for the procedure that I'm doing. Now say I want to see a bigger area. I want to see multiple interspaces at the same time. That's where the curve is going to allow me to do a more rapid assessment quicker. It's just, again, the depth setting is going to be different, and it's just going to be a different view. So what I would recommend at first is just to use one probe. Get used to using one probe. Probably the easiest would start with a linear, because that's going to be the clearest, right? It's going to focus on where the polarity is. And then as you get comfortable with that, then add the other probes in and start playing with that and understanding that. It's kind of like the whole thing of Mac Miller. They both work, right? We all have our preferences. You hand me a Mac, and I'll try to straighten it and turn it into a Miller, right? We all have our preferences of which one we would like to use. They both work, right? They all work. They all have some advantages and some merits over the other one. So that's all it's saying is, what are we trying to look at? Are we trying to quickly see a lot of spaces, or are we trying to focus in really on one and try to get a clear image of that? So scanning region, key steps, kind of getting into the doing part of it, right? So if we look, here's what you want to kind of do is break the lung into quadrants. All this is, this is Essential Anatomy, and I use this a lot of times in the classroom to help the students kind of understand the anatomy. Allows me to be able to kind of dissect and take things away. So if we look and break it into anterior, and as we go lateral, and then we go posterior to look at different fields. Now, if we look for instance pneumothorax, that's going to be focused anterior, because that's where the sound, or that's where the air is going to rise up there. For this instance, what we're looking for, pulmonary edema, is again, looking and seeing, is it multiple areas that we're seeing these plethora, these number of B lines, right? You don't want to just look on one. And looking bilateral, and comparing one side to the other, are they the same? Is there differences from that side? We're dealing with a bilateral condition, so it's important to be able to look at that. So all this is, is kind of breaking this down for lung ultrasound into different quadrants to start, right, scan, scan down, and then start to move lateral, and then we can start to move posterior on that, again, each side. Now compare anterior, anterior, lateral, lateral, just as if we were auscultating, right? Similar pattern is that ladder pattern when we're doing auscultation. All we're doing is now, instead of auscultating, we're doing a probe and doing a similar thing to that. Right, there you can see the probe as we start to move. Now as far as orientation of that, that's just to show you the orientation we're doing towards the head. The reason for that is when we're getting into doing a procedural performance, this isn't so important. Procedural performance is more orientating the probe, and we can get away with what makes sense to you. It's not so important. When we start to get a point-of-care ultrasound is now we want to be consistent. We want to look at the world the same way, which means we all will put the probe marker in the sagittal plane towards the head, horizontal plane we're going to put it to the right. Otherwise, if we do it the other way, the image is going to get flipped. Now we can still interpret that and still look at that, but then whoever else is there looking at it now, they're having to flip that image and interpret that image differently. So start to just look at the world the same way. We don't want to look at it differently. So get used to always trying to get in a very systematic approach and try to look at looking at the views the same. Otherwise, your mind's going to be constantly trying to flip that. Early, that's more challenging. As you get more expertise, then you can flip it in your mind and it's okay. But really, learn it the right way from the beginning, then as you add and as you keep looking and seeing more images and images, it's going to make sense. As you see a presentation look up there, you're going to understand from looking at here where the probe marker is, what the orientation is, right? Because we're all looking at the world the same way. So it's important, I think, to start to look at how do we systematically look at that. Machine settings. So dials, what do we turn to? Now, the nice thing is, is a lot of the settings, a lot of the probes are now tablets. It's all touch screens. It's taking the knobology out of it. It's not like the old machines where it's all these knobs, all these buttons to turn and it's overwhelming. You go around and you look at the exhibit hall and look at all the different companies that are there. They are very easy to use, right? It's all touch, which makes it much more simplicity, which means, again, it simplifies the process. They all have presets. They have experts in the field that have created preset settings for these. So we're going to do a lung ultrasound is put it to the preset lung. So if you're using a linear probe, go down and put it in a lung setting and a linear probe. And what it's going to do, it's going to auto set it to doing a lung ultrasound. You're going to do a gastric ultrasound, change it to gastric or change it to abdominal, so it auto sets it to that. It gives you a good starting point. Then you can make adjustments based on that, as opposed to you just turning it on and then all of a sudden it's the depth is off, the settings are all off, right? Do that and that gives you a starting point. So some of those things you can look at, frequency, again, depending on the probe that you're looking at, gain setting, make it a little low, a little darker. The other is if the room is really bright, turn some lights down so you don't get that glare on there. It'll make it visually seeing it a little easier. It's like trying to, has anybody done transillumination with a trach light? I know I'm taking myself back in ages here. My God, now I'm feeling really old. So trying to do transillumination in a bright room is challenging, right? Versus turning some lights down so we can see it illuminate through and it visually makes it a little easier to be able to see that. Some of the things is control the condition, control the room, don't let it control you. So put it into how it best works for you. Ergonomically, we don't talk about this very often either, is also think of ergonomics. And that's not just for this. I'm a big proponent for ergonomics for everything. It's because think of us doing this for 30 years That repetitive motion is you wonder why we have back issues, we have cervical issues, we have thoracic issues. It's because of those poor ergonomics over and over and over again. So build in that. Put the machine on the side so we're not looking way behind us. Get yourself into a comfortable setting for that. Sonographers set up rooms because of this and they have special chairs and things like this because of that repetitive motion. Here all this is is some different methods of looking at this. All it is is dividing the chest into eight zones. Similar to what I said is they're dividing into those eight zones to be able to create a format to scan. And then what we're doing is again, same thing is we're comparing one side to the other. Looking at the anterior one side to the other. The lateral to the lateral of the other side. So it's just kind of a systematic approach to kind of doing that. And then is it positive if it has three or more of those B lines in there? And then looking at how many of those zones are positive for that. That's really kind of a simple, it's not that complicated really. Now if we look here, here's an example of B lines. Now this is again curved. You see that bright black line coming down on the image on the left there for you guys. Or right I should say. Is you see that black, that's a rib shadow. So what we're doing is we're looking for that space in between. You see the gray that's in there, that's in between. You see a bright white line to the top of the screen. That's the pleural. You see another white line that's a little below that if you look at the side, the markings, that's about four centimeters. That's an A line. That's that horizontal line coming across. The reason why I put on a curved is because you get a bigger view for you guys to visually see that. If I get a linear probe and do that, then it narrows the focus a little bit and it's hard for you to see that overall interpretation. So I'm using a curved probe here for the purposes of helping you guys understand the anatomy overall to give you a little bigger visual representation to see A lines, to be able to see B lines. So if we look here, there, if you look those vertical, those are B lines. It's very visually different than if we stop the image, isn't it? So I mean, it's not complicated. It's just getting that understanding of what the normal is when we didn't start the video and you didn't see any of these, to now we start the video and you see all those B lines, all those vertical lines that are going through there. So it's kind of looking at the number of those and seeing those in multiple spaces. Pretty impactful, pretty easy, right? And that's what that fear is, getting over that fear is it shouldn't be that, it isn't that complicated. All we need to know is understand just what we need to look at, right? You don't have to be an expert. You don't have to be the best at this. All it is, is giving you information to help you tie into all that other clinical tools. Give you some information and make a decision, an informed decision on how to best manage the patients. To me, that's the excitement of being able to use point of care ultrasound over procedural performance. It's gonna help us make decisions and rapid decisions, the right decisions, right? Here's, again, just kind of looking at the difference of B lines and that's just showing what the evidence is showing for all those. So that's here, again, for you guys to be able to look at this at a later date, or again, I forgot to mention all the everybody that's virtually attending too. So that's really there for you guys to be able to look at a later date, that's all. I'm not gonna take a deep dive into this. That's just looking at the evidence and what everybody's kind of showing for all that stuff. Here, if we look at the protocol, right? The blue protocol is, now this isn't just pulmonary edema. This is a number, but how do we come to decide? We have this ultrasound of this lung. How do we decide to interpret it, right? That's all this is, is creating you an algorithm, like an airway algorithm, although the airway algorithm, I think is more complex than this, is it's not that complex. Really kind of where does it start is you look at the top there, is lung sliding present? Do we see the pleura moving? It's either yes or no. And then we take two paths. It's kind of like, can we ventilate yes or no? So, so far, not bad. Now we've split it into half, either way kind of thing. Now for this talk, the answer is yes, there's going to be sliding. As we go no, we're getting down to where there's apnea, where there's no movement of the parenchyma. We're getting into pneumothorax. We're going into a total different pathology. So we're not going down that pathway of no, it's not moving. We're still seeing moving of the pleura. Okay, well what's the next step that you look at then? Then you look at, is there B lines? Is there a number of B lines? Yes, right? Or is it no? The number of B lines, again, there's a correlation, strong correlation by number of B lines to the severity of that. We saw that rabbit of the severity of that, and then we saw the image of the lung based on that severity. So there's a strong correlation with the number of B lines with each one of those images and the severity of that. And then again, pulmonary edema. So very simple lung sliding, yes. Now what do we look at? Now we're looking at B lines, A lines, and looking at those artifacts to see changes in those artifacts, right? Now, can we get deeper into this? Absolutely. Can we get deeper into this? Is this cardiac, non-cardiac? Can we get in there and we can do IVC assessment to see, again, volume? Can we look at the heart to see EF? All of those are gonna give us extra data points to help us manage that patient, right? Help us determine if it's cardiac, non-cardiac. This is, again, just a good tool to start to give us information quickly, right? It's like doing gastric ultrasound. So do we do a qualitative or quantitative assessment? That's the argument. Do we need to know the exact volume in a gastric ultrasound? Some will argue, yes, and some will argue, no, I just wanna make a clinical decision. I wanna know good, bad, or ugly, right? I wanna know if I need to change my plan, if they're high risk or not high risk. Do I need to cancel the case? Do I need to delay the case? Or do I need to do an RSI? Versus, nope, we can do it as is, and we can do an LMA as planned or whatever as planned. That's all we need to know, right? Is being able to make that. So really, that's kind of, to be honest, AI is gonna take over a lot of this stuff. AI is gonna auto-calculate all of this stuff. It's already identifying anatomy for us when you look at regional anesthesia. So it's going to, the future is, it's going to simplify this process. AI is gonna be a big part of helping us interpret. It's going to be able to identify a lot of this stuff, and it's gonna auto-calculate all this stuff. It's gonna give you that risk stratification for all of this stuff, which is great, right? Those are great tools to be able to help us make more clinical decisions. Right now, we're not there yet, right? We're not there widespread yet, which means we're learning, first of all, the ultrasound, how to do it in the future, then that's going to change and simplify that process. Again, if we look at the suspected. So initial A lines, B line, comatose, so kind of looking at that, the normal, and then checking presence of B lines. Similar thing that we saw in that protocol. This is just, again, parenthetically, kind of showing the same thing that you saw in that algorithm, that figure on there. And then you can get a multiple and look at the diffuse of that, which, again, was very impactful when we looked at that rabbit image as we could see the perforation of that and how vastly different it was from normal to the last one, which was severity. Now, here, what I wanted to do is this is a real case study. As a colleague of mine, an intensivist, provided this information for me, which was very interesting. So if we look, here's the patient, 75-year-old, hypertension, admitted to the ICU post-cardiac arrest. Suspected aspiration. Now, resuscitated five liters of fluids. Chest x-ray, CT scan is also there. So again, it's gonna show you a lot of different testing to show that evidence or what it was. EF on the patient was 15%, okay? You can see multiple ultrasound B lines that we're gonna get into. We can see that, and we'll see a full stomach. So now, we're using point-of-care. We're talking about pulmonary edema, but we have other uses that are on here I'm gonna show you here, too, which, to me, is hopefully helping drive home to you how impactful its use is. Yes, we're talking about one aspect of it, but there's also other aspects with just this case of its use. So if we look, here's cardiac view, okay? So here's a four-chamber view that we're looking at. So that's looking at, again, the left ventricle. We have a lung ultrasound in the middle. And we have a gastric ultrasound all the way on the other side. Now, three uses for one patient to help us get clinical information. Now, think about if we wanted to do each one of those tests individually. We need to call somebody to come do an echo, right? We need to call somebody to come do a chest X-ray. The gastric ultrasound, we have no way of assessing that. Right? Are we taking them to the CT, throwing them in the CT? Think about the time, the complexity of doing that. That's what's so impactful, you guys, is we're talking about pulmonary edema, but now we're using uses outside of that as well, okay? So I don't wanna blur the conversation or the talk. I just wanna bring it in just because we have this data for this case to really highlight to you its use as far as the talk goes, but also its use outside of the talk to help with that. So if we look at the images, there you can see. Now, when you're looking at the heart, obviously, if it empties, you're gonna see it squeeze and refill. So we look at the E-up as the difference between diastole and systole, again, looking at the circumference and the changes of that to see how much was emptied out of that. So if you look there, you see the heart barely moving, which means there's not a lot of emptying, filling going on there. So that's that low E-up that we have on this patient versus somebody has a normal one, we're gonna see it fully empty and fully closed, okay? So now we can see from there, low E-up, right? So we look at the next one, add in lung ultrasound. Now, again, you see all those B lines going down. Now, I apologize because it's a very short clip that I just, right? But you can see all those B lines. Now, again, this is all one segment, but this would have happened in multiple segments and seeing that multiple different, when we look at multiple different spaces. So now you can see a correlation between a low E-up and multiple B lines, a patient post-resuscitation of five liters. All kind of tying together to give us a clinical decision, right? Now, just to add more to it, now we're on a gastric ultrasound. Is over in the corner, you can see the liver and then that's the stomach full of stuff. Visually impactful, isn't it? Simple to do. Now helps us get some information. So if we now take this and look at, here's the chest X-ray on there, right? So if you would have taken a chest X-ray, you can see there, you can see that fluffy infiltrate, you can see on both sides of that pulmonary edema. You look at the CT scan, coronal and axial CT scans on there, just to add on there, again, what we're seeing on this individual. Now, one thing of also interest finding on here, that again, doesn't really have anything to do with the talk but has to do with the case study is another use of ultrasound. Is, there's a rib fracture. We can see that on the ultrasound. You can see it on the chest X-ray. You can see it on the CT scan. So if you look on the ultrasound, there's a little white on the top there. There's a rib, and you see the rib has two parts to it. It's not connected here as a continuous line. And you'll see this a little bit when we look at the image and put it live there a little bit, is it kind of looks like this. That's also the ultrasound of the same area on the chest X-ray as the CT scan. So we can see on those, the clear fracture on those, and we're also seeing it on ultrasound. So we look there, is it's over on this side of the ultrasound. If we look at it, well, one, two, right, two and a half notches down, is you see two white lines, one going up and one coming in here. They should be continuous. So you're seeing this. That's that rib fracture that's on there, right? So now, see the information how powerful this tool is yes, we're talking about pulmonary edema, but we also then see a low EF, we see gastric ultrasound, and now we're seeing rib fractures that are on there, which means rib fractures on there, we should be looking again, is there pneumothorax? We could use this to then also help us determine pneumothorax, right? So kind of just to recap before we kind of get to questions here, is again, things to look at. Those lung rockets, pleural sliding, right? Normal thickened pleural lines, that's not so much for this, but that's getting into other pathology is getting into some of those things. So really, I hope again, like I've said before, is I hope this is just opens your eyes and maybe spurs an interest in you guys to consider or delve in a little more information to learn a little more about the impact of point-of-care ultrasound can have for us in our day-to-day clinical care. I don't want to think that this is something very obscure. It's something that we can all learn, and we can all use, and we can all incorporate in some aspect. So thank you, and we'll open up for some questions. Thank you. Thank you, Shane, for an outstanding presentation. We do have two questions. One came through the app, and one I was text, somebody text messaged me the question. So let me read the one from the app first. This individual is writing in and says, many nurse anesthesia residents are not familiar with POCUS due to the shift in educational training. How do you suggest the nurse anesthesia resident implement POCUS lung assessments when preceptors may be unfamiliar or hesitant to use this unfamiliar technology? So it's an important question to ask, right? And there's a shift right now, and we're all facing that. And the problem is is that there isn't a lot of people with the expertise. So that's where the importance of us that are experts that use it is to be able to, how do we do talks like this, right? How do we do workshops like this? How do we get this information to the masses? And to be honest, that's one of the things I hope as your new chief science and practice officer is for us to focus on some of that. And I really want to look at that as how can we take this to a national level, right? It's important information that we need to learn, and it's how do we disseminate that to those. And also to focus in on how do we create toolkits or how do we create information for programs, right? To help program faculty learn this content so that they can integrate it and weave it into their curriculum. Now, for one instance, on the teaching side of things I use this to teach anatomy. It's one thing for them to be able to see a textbook or to see an app. It's quite another to see something live. Imagine them scanning. It's those aha moments that you see. Having them run around the room and then re-scan themselves and to see the changes that happen physiologically from that. That's impactful. On a side note is I like to do it in the classroom because I can do my heart and they can actually see I have a heart, right? Sometimes they question it, right? So it allows us to see that. But I think the thing is, is we have to not be afraid to pick up a probe and start somewhere, right? And I think we do need to look at how do we integrate this in. I think programs, students are actually gonna be the change agents. They're gonna come out of programs with a superior knowledge than us as clinicians have. And I really rely on them being able to be those change agents and disseminate it. And it's already happening. My students are already helping clinicians do scans in the clinical setting and helping seasons providers to do it, to guide them through that. It's amazing to see. Perfect, thank you for that. And again, if you have a question, please do come up to the mic. We have probably time for one more question after this one. The next question was, is there a certification? Is there a micro-credential, or is there a badge that will certify somebody in POCUS that you're aware of? Well, again, that's where we wanna go. So hold on, the future's there, and that's part of where we need to look at this. And if we do, from the ANA side to side, if we can drive this information, then what we can do is create, how do we create certifications? How do we self-govern ourselves, right? As opposed to relying on other entities to be able to do that. So I think it's important too, and I think it's something we need to tackle as a profession, right? Not only how we get that information out of there, but also how do we get ourselves those credentials so that we can go to the institutions and say, no, we've proven that we have, right? That we can do this. There are some entities out there that can already do it, but again, that's some of the struggles as CRNAs that we're all facing and everything is again, trying to get that. Because to me, the future is institutions are going to make us have to get credentialed for this information, right? They already are, and it's probably gonna be more and more so to say, okay, if you're skilled to use this. Interesting topic of this is that when we first started using ultrasound, where I was in this long time ago, is the institution wanted us to prove. We could prove that it was part of our training. There was a surgeon that was there for 30 years. They did not credential him to use ultrasound. He had to learn from us. It was a very interesting dynamics, but that's what's happening. As we're starting to look at, we need to be able to prove. And that's where, again, if we do it in programs, students can show this is my curriculum. This is what I have done. This is how many hours of training I've done. Taking a record of your scans, right? Of supervised scans, so that we can create that evidence to be able to help drive that. Any other questions? All right, it's a pleasure, you guys. Um. Thank you, Dr. Holcomb, thank you.

CE credits

evaluations

Dr. Shane Holguin

American Association of Nurse Anesthesiology

Point of Care Ultrasound

pulmonary edema

diagnostic capabilities

real-time assessments

sonographic findings

credentialing