Abstract
In an effort to help keep busy clinicians up to date with the latest ultrasound research, our group of experts has selected ten influential papers from the past twelve months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.
Introduction
Point-of-care ultrasound (POCUS), after its initial explosive growth, has settled into a comfortable place in all disciples of acute care medicine. Related literature continues to be produced at an impressive pace, speaking to a healthy discipline moving steadily from expert opinion to evidence-based practice.
Keeping abreast of new developments in academic literature is always challenging. To provide some modest assistance here, our group of POCUS experts has selected ten influential papers from 2025 (or late 2024) and provided a short summary of each, as we’ve done in previous years. For the sake of efficiency our group settled on an informal methodology, rather than attempting a more formal systemic review. Each expert brought forth a list of 4–6 articles that had influenced their clinical practice over the past 12 months, with a focus on their particular area of expertise. During a subsequent conference call, each expert presented their list and thereafter all participants voted to create the final collection of ten articles. Each expert was thereafter charged with summarizing two or three articles, and one author (SJM) provided final editing.
Left ventricular diastolic function (LVDF) is altered in patients with septic shock, but this concept has not been well studied. This multi-center observational study, done in 402 patients with septic shock, involved 22% of patients known to have ischemic cardiomyopathy or left-sided valvulopathy (where such patients are usually excluded). Serial echocardiographic evaluations were done at day 1 (within 12 h following admission) and repeated at day 2 (357 patients) and 3 (281 patients), after ICU discharge (207 patients) and at day 28 or hospital discharge (162 patients). In addition to raw mortality data, respiratory parameters, blood gases and cumulative fluid balance according to LVDF was reported. LV diastolic dysfunction (LVDD) was graded according to the recommendations of the American Society of Echocardiography.
The main result confirms that left ventricular diastolic dysfunction (LVDD) is frequent and reversible in patients with septic shock as it was present at least once in 76% of patients during the first 3 days. The incidence decreased to 56% at ICU discharge and to 44% at hospital discharge (or day 28). Factors associated with LVDD were previous ischemic cardiomyopathy, need for invasive ventilation, higher levels of mean and diastolic blood pressures, and lower LV and RV systolic function. Cumulative fluid balance at day 3 was not different in patients with or without LVDD at day 1, and no difference in 28-day mortality was observed whatever the grade of LVDD. This study is the first to demonstrate the improvement of LVDF in 1/3 of patients after clinical recovery and even its normalization in 28% of cases. The hypothesis of a relationship between LVDD and fluid balance that could explain fluid intolerance and poor outcome in patients with LDD was not confirmed.
Despite the importance of fluid management in patients with the Acute Respiratory Distress Syndrome (ARDS) there is little evidence to guide clinicians. Dynamic parameters recommended to guide fluid responsiveness were generally never tested in patients with ARDS, and there is reason to believe that their predictive power could be diminished due to low tidal volume ventilation, high Positive End Expiratory Pressure, and low lung compliance. In this post-hoc analysis of the Hemopred study (ref AJRCCM), the predictive values of different dynamic parameters [Superior Vena Cava (SVC) variation, Inferior Vena Cava (IVC) variation, and maximal aortic velocity plus pulse pressure variation (PPV)] was tested in 117 patients with ARDS (87% moderate to severe) and 423 non-ARDS patients. A passive leg raise mimicked fluid expansion and then the authors defined fluid responsiveness (FR) as an increase of aortic velocity time integral (VTI) by 10% or more.
Surprisingly, the incidence of a fluid-responsive state did not different between patients with and without ARDS. The reliability of dynamic indices to predict FR was maintained in ARDS patients, although with distinct thresholds. SVC variation, requiring transesophageal echocardiography, was still the best parameter (despite an area under the curve of only 0.76), while IVC variation performed worst. Very interestingly there was a strong relationship between PPV and probability of death in ARDS patients, whether patients were fluid responsiveness or not. This result clearly re-emphasizes that in ARDS patients, PPV may be due to fluid-responsiveness but also to right ventricular (RV) injury, both with a deleterious impact on patient outcome. PPV should be used more as a monitoring tool than a guide to give fluids. When RV injury was observed, FR was less frequent in both ARDS and non-ARDS patients.
Echocardiography is recommended during cardiac arrest to help identify reversible causes and guide resuscitative efforts, but transthoracic imaging is often limited by poor acoustic windows and interruptions to chest compressions. This review summarizes the growing evidence supporting transesophageal echocardiography (TEE) as an alternative approach that provides consistently high-quality images, continuous cardiac visualization during cardiopulmonary resuscitation, and improved diagnostic yield. The authors review how TEE can identify reversible causes of arrest, distinguish true pulseless electrical activity from pseudo-PEA, and allow real-time optimization of chest compression position and depth.
The review also outlines simplified focused and resuscitative TEE protocols that can be adopted by emergency and critical care physicians, as well as the expanding role of TEE during extracorporeal cardiopulmonary resuscitation and ECMO cannulation. This paper consolidates TEE as a practical and clinically impactful tool in cardiac arrest management and supports its broader integration into contemporary resuscitative care in the ICU and emergency department.
Resuscitation strategies in septic shock continue to rely on fixed physiologic targets despite wide variation in underlying hemodynamic patterns. In this large multicenter randomized controlled trial, the authors evaluated a personalized hemodynamic resuscitation protocol targeting normalization of capillary refill time (CRT), supported by simple bedside hemodynamic variables and focused critical care echocardiography. The intervention used sequential assessment of pulse pressure, diastolic arterial pressure, fluid responsiveness, and cardiac function to guide fluids, vasopressors, and inotropes during the first six hours of shock.
The personalized CRT-guided strategy was superior to usual care for a hierarchical composite outcome that included mortality, duration of vital organ support, and length of hospital stay, with the benefit driven primarily by fewer days requiring organ support. In 35% of cases, echocardiography was needed to normalize CRT. This trial is notable for reaffirming the value of a simple bedside perfusion assessment, while showing that advanced tools such as echocardiography are most effective when used selectively to resolve persistent physiological uncertainty rather than as routine screening tests. This study provides a practical framework for integrating focused echocardiography into early septic shock resuscitation and reinforces ultrasound as a targeted tool to guide therapy rather than a default intervention.
This consensus statement provides guidance on how to perform a lung ultrasound (LUS) aeration score that has clinical utility for the management of patients with respiratory failure. It is particularly relevant to patients on ventilatory support, and uses an iterative Delphic analysis rather than an evidence-based medicine scoring approach. The document presents a series of statements that are highly relevant to LUS aeration scoring and are derived from review of the literature with inclusion of pediatric and neonatal populations. It is particularly noteworthy as it brings order to the field and encourages widespread use of LUS in general, and not only for formal scoring purposes.
The first part of the paper proposes standardization of the semiology of aeration scoring, guidance on how to perform the score, alternative methods of scoring, and presents a useful set of images to guide the clinician. A comprehensive review of the clinical utility of LUS aeration score for a wide variety of clinical problems is provided, including comparison to chest CT and chest radiography. While the focus of the discussion is on the LUS aeration score, this section represents a convincing summary of the utility of lung ultrasound as the primary imaging modality for patients with respiratory failure in the intensive care unit (ICU). Whether formal calculation of a LUS aeration scoring is required on a routine basis for ICU remains an open question; for certain applications such as for management of the patient who is a marginal candidate for extubation, for identification of patterns of ARDS that might respond to prone position, or to track response of pneumonia to antibiotic therapy; it makes sense to utilize LUS aeration scoring. In other situations, the care team may elect to use less formal methods of assessment incorporating LUS. This has corollary with the use of echocardiography in the intensive care unit, where not every study needs to be complete as limited goal directed echocardiography may be sufficient to answer the clinical question at hand.
This study examined the role of LUS for diagnosis of ventilator associated pneumonia (VAP). The investigators performed serial daily LUS examinations using a 12-zone approach on 206 patients who had been on ventilatory support for more than 48 h, of whom 76 developed VAP. The scoring system focused on identification of new consolidations and mobile air bronchograms with comparison of the results to clinical adjudication by an expert panel comprised of three senior clinicians who were blinded to the results of the LUS. The investigators also utilized the Clinical Pulmonary Infection Score (CPIS) but regarded the expert panel decision as the “gold standard” for comparison to the LUS. A secondary outcome was to examine the reaeration pattern following initiation of treatment where the standard LUS reaeration score was used. The results indicated that LUS has a sensitivity and specificity for diagnosis of VAP of 92% and 88% respectively.
The results remind the clinical team that LUS is not a perfect imaging technique. Preexisting or concomitant lung disease may mimic the findings characteristic of pneumonia, and findings consistent with pneumonia may be masked by aerated lung interposed between the transducer and the area of abnormality. Clinical correlation is always a mandate. This study confirms previous studies on detection of VAP using LUS, and when combined with the extensive literature indicating superiority to standard chest radiography, the intensivist is reminded that LUS is the “go to” modality for ICU patients. The authors also mention the utility of ultrasonography in the resource constrained environment, where POCUS (including LUS) has application due to its cost, ease of use, and multipurpose capability. This study also reminds the reader that LUS may be readily performed on serial and daily basis to track the progression of disease and response to therapy.
This study was led by investigators who are preeminent in the field of LUS and who are major proponents of using the LUS aeration score for patients with ARDS. They compared a validated radiographic assessment of lung edema using chest radiography and LUS aeration scores with measurement of PaO2/FIO2, estimated dead space, respiratory system compliance, driving pressure, and mechanical work in 364 patients of whom 127 had ARDS. They hypothesized that there would be a strong correlation between aeration scores and abnormalities in physiological measurements. Surprisingly, there was limited correlation in both the non-ARDS and ARDS patients, although there were trends that supported some relationship between the imaging scores and measurement of physiological function. Another result is that chest radiography and LUS aeration scores were not well correlated.
This begs the question as to why the imaging results did not strongly correlate with the measures of physiological function that are commonly performed at the bedside. One possibility is that shunt fraction and dead space were not measured with direct quantitative technique and were therefore somewhat inaccurate. Another possibility is that airless lung may have minimal blood flow due to local pulmonary vasoconstriction combined with absence of ventilation, and therefore does not contribute to either shunt or dead space measurement; this will require further investigation. One potential take home message of this article is that the counterintuitive results simply suggest the chest radiography and LUS are imaging techniques, whereas measurement of physiological variables are not. The clinician should not reject either the imaging results nor the results of standard bedside physiological measurements, but rather integrate one with the other, where clinical correlation is always required.
This prospective single-centre cohort study evaluated the prevalence of venous congestion, measured using the Venous Excess Ultrasound Grading System (VEXUS), and its association with major adverse kidney events at 30 days (MAKE-30) in critically ill adults. Among 138 ICU patients, high VEXUS grades (≥2) were uncommon, observed in only 12% overall, and most changes in VEXUS occurred within the first 72 h of ICU admission. Despite this low prevalence, a VEXUS grade ≥2 was strongly associated with MAKE-30, including severe acute kidney injury or death, even after adjustment for illness severity, fluid balance, and comorbidities. The study also demonstrated good inter- and intra-rater reliability, supporting the feasibility of VEXUS as a bedside tool.
Clinically, this study reinforces the concept that venous congestion, rather than intravascular volume alone, is a key contributor to organ dysfunction in the ICU. The strong association between VEXUS ≥2 and adverse kidney outcomes suggests that VExUS can help identify patients who are no longer fluid tolerant, even when they may still appear fluid responsive. For intensivists, this has important implications for guiding de-resuscitation and avoiding harm from ongoing fluid administration. Given its bedside availability, reproducibility, and prognostic signal, VEXUS may function as a practical adjunct to traditional hemodynamic assessment, particularly early in critical illness when fluid decisions are most impactful. While not a direct measure of volume status, its ability to stratify risk for AKI and death highlights its potential role in individualized fluid management strategies and justifies further interventional studies.
This article is a systematic review and meta-analysis that examined whether POCUS-guided resuscitation improves outcomes in adults with shock. The authors analyzed 18 randomized controlled trials comparing POCUS-guided care with usual care. They found that POCUS slightly influenced clinician decision-making and reduced the use of some diagnostic tests. Most importantly, POCUS-guided resuscitation was associated with improved lactate clearance, shorter duration of vasoactive medication use, and a probable reduction in 28-day mortality, while showing little effect on ICU or hospital length of stay.
The clinical importance of this study lies in its support for POCUS as a useful bedside tool in the management of shock. The findings suggest that POCUS may help clinicians recognize shock physiology earlier and guide more targeted resuscitation, leading to faster shock resolution and improved survival. Although POCUS did not significantly change total fluid volumes or length of stay, its association with lower mortality, improved lactate clearance, and reduced need for prolonged vasoactive support supports its integration into acute and critical care practice, especially in environments where rapid decision-making is essential.
This scoping review examines the role of ultrasonography in identifying and predicting weaning failure from mechanical ventilation in adult ICU patients. Synthesizing evidence from 89 studies involving over 6800 patients, the authors evaluate cardiac, diaphragmatic, lung, and upper airway ultrasound parameters associated with unsuccessful weaning or extubation. The review shows that weaning failure, occurring in about 28% of patients, is commonly linked to ultrasound-detected abnormalities such as left ventricular diastolic dysfunction, diaphragmatic dysfunction, loss of lung aeration or pulmonary oedema, pleural effusions, and post-extubation laryngeal oedema. Overall, the article highlights ultrasound as a versatile bedside tool that provides real-time, physiological insight into the multifactorial causes of weaning failure.
Clinically, this review underscores ultrasonography as a valuable adjunct to traditional weaning assessments, with the potential to improve decision-making, reduce extubation failure, and shorten ICU stays. By allowing dynamic evaluation of heart-lung interactions, diaphragmatic performance, pulmonary aeration, and airway patency, ultrasound helps clinicians identify reversible causes of weaning failure and tailor interventions such as fluid management, ventilatory support strategies, or post-extubation noninvasive ventilation. Although heterogeneity and lack of standardized protocols limit definitive conclusions, the findings strongly support integrating POCUS into routine weaning practice, particularly for patients with difficult or prolonged weaning, while highlighting the need for further standardization and training.
Conclusion
The ten articles selected by our expert group represent important articles published over the past twelve months, each one of which has influenced our daily clinical practice.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Prior Publication
None.
Ten Influential Point-of-Care Ultrasound Papers
2025 in Review.
