The use of ultrasound in the out-of-hospital environment is increasingly feasible. The potential uses for point-of-care ultrasound (POCUS) by paramedics are many, but have historically been limited to traumatic indications. This study utilized a scoping review methodology to map the evidence for the use of POCUS by paramedics to assess respiratory distress and to gain a broader understanding of the topic.

Databases Ovid MEDLINE, EMBASE, CINAHL Plus, and PUBMED were searched from January 1, 1990 through April 14, 2021. Google Scholar was searched, and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital POCUS performed by non-physicians for non-traumatic respiratory distress.

A total of 591 unique articles were identified, of which seven articles met the inclusion criteria. The articles reported various different scan protocols and, with one exception, suffered from low enrolments and low participation. Most articles reported that non-physician-performed ultrasound was feasible. Articles reported moderate to high levels of agreement between paramedics and expert reviewers for scan interpretation in most studies.

Paramedics and emergency medical technicians (EMTs) have demonstrated the feasibility of lung ultrasound in the out-of-hospital environment. Further research should investigate the utility of standardized education and scanning protocols in paramedic-performed lung ultrasound for the differentiation of respiratory distress and the implications for patient outcomes.

Prehospital use of lung ultrasound (LUS) by paramedics to guide the diagnoses and treatment of patients has expanded over the past several years. However, almost all of this education has occurred in a classroom or hospital setting. No published prehospital use of LUS simulation software within an ambulance currently exists.

The objective of this study was to determine if various ambulance driving conditions (stationary, constant acceleration, serpentine, and start-stop) would impact paramedics’ abilities to perform LUS on a standardized patient (SP) using breath-holding to simulate lung pathology, or to perform LUS using ultrasound (US) simulation software. Primary endpoints included the participating paramedics’: (1) time to acquiring a satisfactory simulated LUS image; and (2) accuracy of image recognition and interpretation. Secondary endpoints for the breath-holding portion included: (1) the agreement between image interpretation by paramedic versus blinded expert reviewers; and (2) the quality of captured LUS image as determined by two blinded expert reviewers. Finally, a paramedic LUS training session was evaluated by comparing pre-test to post-test scores on a 25-item assessment requiring the recognition of a clinical interpretation of prerecorded LUS images.

Seventeen paramedics received a 45-minute LUS lecture. They then performed 25 LUS exams on both SPs and using simulation software, in each case looking for lung sliding, A and B lines, and seashore or barcode signs. Pre- and post-training, they completed a 25-question test consisting of still images and videos requiring pathology recognition and formulation of a clinical diagnosis. Sixteen paramedics performed the same exams in an ambulance during different driving conditions (stationary, constant acceleration, serpentines, and abrupt start-stops). Lung pathology was block randomized based on driving condition.

Paramedics demonstrated improved post-test scores compared to pre-test scores (P <.001). No significant difference existed across driving conditions for: time needed to obtain a simulated image; clinical interpretation of simulated LUS images; quality of saved images; or agreement of image interpretation between paramedics and blinded emergency physicians (EPs). Image acquisition time while parked was significantly greater than while the ambulance was driving in serpentines (Z = -2.898; P = .008). Technical challenges for both simulation techniques were noted.

Paramedics can correctly acquire and interpret simulated LUS images during different ambulance driving conditions. However, simulation techniques better adapted to this unique work environment are needed.

The diagnosis of endotracheal tube (ETT)mal-position may be delayed in extremeenvironments. Several methods are utilized toconfirm proper ETT placement, but these methodscan be unreliable or unavailable in certainsettings. Thoracic sonography, previously utilizedto detect pneumothoraces, has not been tested toassess ETT placement.

Thoracic sonography could correlate withpulmonary ventilation, and thereby, help toconfirm proper ETT placement.

Thirteen patients requiring elective intubationunder general anesthesia, and data from two traumapatients were evaluated. Using a portable,hand-held, ultrasound (PHHU) machine, sonographicrecordings of the chest wall visceral-parietalpleural interface (VPPI) were recorded bilaterallyin each patient during all phases of airwaymanagement: (1) preoxygenation; (2) induction; (3)paralysis; (4) intubation; and (5) ventilation.Results: The VPPI could be well-imaged for all ofthe patients. In the two trauma patients, rightmainstem intubations were noted in which specificpleural signals were not seen in the left chestwall VPPI after tube placement. These signsreturned after correct repositioning of the ETTtube. In all of the elective surgery patients,signs correlating with bilateral ventilation ineach patient were imaged and correlated withconfirmation of ETT placement byanesthesiology.

This report raises the possibility that thoracicsonography may be another tool that could be usedto confirm proper ETT placement. This techniquemay have merit in extreme environments, such as inremote, prehospital settings or during aerospacemedical transports, in which auscultation isimpossible due to noise, or capnography is notavailable, and thus, requires further scientificevaluation.