Extended Scope Practice - Lung Ultrasound
“To be honest, I don’t bother with auscultation and I can’t rely on chest xrays!”
These words were said to me three years ago by one of the consultant anaesthetists on my intensive care unit. In one sentence he had annihilated two of the main physiotherapy skills from my “toolbox”.
“What do you use?” I asked. “Lung ultrasound.” was his reply. “Do you want me to show you?” Little did I know where this revelation would take me and the story seems to keep on going.
Over the following two years I can only describe my lung ultrasound (US) experience as casual. When I came across a chest xray that looked ambiguous or when auscultation didn’t give me the answers I wanted, I would turn to lung US. I kept asking my consultant colleague if we could scan this patient and that patient together but eventually he told me to go, do it myself and let him know what I found.
When scanning on my own I didn’t feel comfortable at all, so I went about finding how to get training. Like most skills it comes down to competence. Learn the skill and get someone who is competent and with more experience to sign you off. Fortunately for me, the person that introduced me to lung US was also an Intensive Care Society registered ultrasound mentor. So together we have set up a training programme involving lectures, practical sessions and supervised patient scans. Six Physiotherapists, including myself, have started the training. We have a curriculum, a reporting system, a feedback system and a competency exam.
Scanning a patient takes time so you have to make a concerted effort to make time. Changing your practice is difficult but with perseverance we will get quicker and more efficient. It is still very early days but some of the experiences we have had so far have been hugely rewarding.
Seven days after his cardiac surgery a patient of ours started to deteriorate. His chest xray showed bibasal consolidation and unfortunately despite treatment he ended up re-intubated. Out of interest one of my fellow lung US trainees scanned him and found huge bilateral pleural effusions that weren’t evident on xray. Two chest drains and four litres of fluid later he was extubated and on room air. This example is only the beginning; each day we are experiencing more and more cases that positively impact patient care.
At this moment in time I have no idea how useful a skill lung US will be to Physiotherapists but I’m very excited to find out. Once you know how to use the machine, the dual skills of image acquisition and image interpretation are challenging but not impossible. Lung ultrasound has the potential to further inform our treatment choices and allow us to be much more targeted in our approach. I can only hope that in the near future, either as an individual or as part of a team, I can add some solid evidence to support its use.
Simon Hayward - Critical Care Physiotherapist - Blackpool Teaching Hospitals NHS Foundation Trust
