The Year of Ultrasound Brings Implementation and Innovation

Ultrasound isn’t a new tool, and it’s little secret this imaging method provides invaluable studies without the use of radiation. But now there are enough advancements and technological changes to the modality to capture the industry’s attention all over again.

In fact, the American Institute for Ultrasound in Medicine (AIUM) has dubbed 2013 the “Year of Ultrasound.” The goal: increasingly integrate ultrasound education and use throughout all levels of health professions education and clinical application.

But, why?

Many practitioners in the field point to the warning bells in recent years calling for even more vigilance in restricting radiation exposure in adults and children. These concerns have led to the ALARA - As Low As Reasonably Achievable - principle and the Image Wisely and Image Gently campaigns. However, it’s more than that, said Leann Linam, MD, a pediatric radiologist at Arkansas Children’s Hospital.

“One of the beautiful things about ultrasound imaging is its lack of radiation, but there’s also been a huge push for other specialties to get involved with ultrasound,” she said. “Giving other providers a portable imaging modality that can be done at the bedside is a major reason why this is the Year of Ultrasound.”

[[{"type":"media","view_mode":"media_crop","fid":"14167","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7089046510327","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"695","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Michael Blaivas, MD","typeof":"foaf:Image"}}]]According to Michael Blaivas, MD, AIUM’s third vice president and president of the Society of Ultrasound in Medical Education, the industry is also seeing a rapid expansion in the functionality ultrasound is able to offer throughout the healthcare system.

The Focus on Ultrasound

Ultrasound’s popularity has steadily grown, Blaivas said, making it a commonly used tool in a plethora of specialties and subspecialties over the past few decades. The wider use is a positive step, he said, but the most encouraging development has been the increase in number of medical school – and other health professions – curricula that now offer ultrasound instruction throughout all years of training.

“We’re seeing ultrasound adopted in every specialty now as the standard of care. From A to Z, with the exception of pathology and psychology – it’s being used across the gamut. For many things in the emergency department to standard use for central line placement,” Blaivas said. “There’s also a significant groundswell for use by nurses and physicians assistants.”

In fact, he said, 2013 has been the biggest year for raising awareness of the benefits ultrasound offers – mainly the lack of radiation, lower cost than other modalities, and comparable image quality.

Ultimately, he said, this increased education could one day enable providers to offer more focused diagnoses throughout body systems and could play a significant role in image-guided procedures. Using ultrasound in that fashion could make invasive procedures faster and safer.

Not everyone in the global radiology community is wholly comfortable with non-radiologists performing ultrasounds, however. There is a significant portion of radiologists who oppose the practice altogether, but a small faction support it because they believe it ensures a low-cost, high-quality imaging service will be available to more patients, said Levon Nazarian, MD, a musculoskeletal radiologist at Jefferson University Hospitals and editor-in-chief of the AIUM's Journal of Ultrasound in Medicine.

“There are radiologists who resent any imaging being done by other specialties. Their main concerns are quality and economics - they don’t like the idea of someone taking over their turf,” he said. “The second, though smaller, camp is filled with people want to see ultrasound better utilized to deliver high-quality imaging and guided interventions to patients. The thought is that it would mean better healthcare for all.”

There is a sticking point, however, he said. The need for ultrasound interpretation in all fields, especially obstetrics and sports medicine, is far greater than the current number of providers can sift through. And many, he added, have little interest or expertise is conducting these studies. The solution, he said, is to open the door for other specialties to offer ultrasound as long as practitioners receive the proper training despite pushback from industry leaders and experts.

In fact, in February 2012, the Royal College of Surgeons in Ireland published a statement in support of allowing properly-trained non-radiologists to perform ultrasounds.

What’s Next for Ultrasound?

Although ultrasound is an increasingly popular modality in the United States, providers still underutilize it, Blaivas said. Elsewhere in the world, however, radiologists are already using ultrasound for more extensive chest and abdominal imaging.

For example, European providers for the past decade have been expanding the use of lung ultrasound in the diagnosis of pneumonia and pulmonary edema. Other radiologists in Asia have begun using ultrasound to image the abdomen, successfully identifying incidences of appendicitis and gastrointestinal reflux. Historically, he said, American providers have opted to use CT in these situations.

“In many cases, ultrasound is far more sensitive and better than chest CT, and it certainly pales in comparison to the cost of CT,” Blaivas said. “Not to mention, it’s portable and can be done at the bedside, giving us greater opportunity to evaluate our most critically-ill patients.”

In fact, he said, the next technological milestone for ultrasound will likely benefit critical and emergency patients the most. Vendors are currently shrinking the machines down to the size of a smartphone, such as the GE VScan. Improved functionality and better image quality will likely follow in subsequent generations.

European radiologists are also beginning to use contrast agents with ultrasound as a way to enhance image quality and improve information gathering, Linam said. Known as microbubbles, these contrast agents are gas-filled and are administered intravenously. They’re highly sensitive and easily reflect ultrasound waves off the body’s soft tissues. Currently, microbubble contrast is only being used as a research method in the United States, she said, but internationally, providers already use it clinically to image blood perfusion in organs and to measure blood flow rate in the heart.

The Promise of 4D Ultrasound

In addition to an increase in portability and expanded functionality, there is great interest within the industry in 4D ultrasound, Blaivas said. Outside of fetal imaging, the most significant research and application, to date, has been with cardiac studies.

“Using 4D ultrasound will be very helpful with critically-ill patients,” Blaivas said. “We’ll be able to get real-time variation and flow within blood vessels, and we might be able to correlate that with total body fluid status or intervascular volume and central venous pressure.”

Currently, GE, Phillips, and Samsung Medison are among the vendors offering 4D ultrasound equipment. While interest in 4D technology is growing, this capability is still not available in all clinical environments.

4-D ultrasound could also have applications outside of radiology, Blaivas said. It can be used to non-invasively assess an athlete’s dehydration level, for example. Simply using the ultrasound the image the vena cava – the large vein carrying de-oxygenated blood back to the heart – can quickly identify if the body has enough fluid for proper function, he said.

The Limitations of Ultrasound

Ultimately, the “Year of Ultrasound” aims to increase the number of medical practitioners who successfully provide this type of imaging in the hopes that the modality will be more frequently used. It’s important to note, however, that ultrasound does have its limitations.

Ultrasound waves can’t penetrate through bone, air or gas, and they can only scan about four inches into the body. Consequently, it isn’t the optimal choice for brain or joint scans and is usually passed over for scans of the lungs, bowels, stomach, and intestines. In addition, if a patient is overweight or obese, it may be difficult to obtain accurate images through ultrasound.

Despite the modality’s constraints, Nazarian said, radiology needs to strongly consider how to best bring ultrasound to more patients.

“Radiology needs to wake up. It’s a field that isn’t nurturing ultrasound enough, so they should only be surprised, shocked, or dismayed if other specialties are doing a bad job at ultrasound,” he said. “Not just anyone should do it. But, if radiology isn’t going to, other people must be properly trained. The bottom line is that expanding the numbers who can do it will provide the best care to patients in a cost-effective manner.”