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Thoracic ultrasound: it’s not all about the pleura
  1. Andrew Walden1,
  2. Nicholas Smallwood2,
  3. Martin Dachsel2,
  4. Ashley Miller3,
  5. Jennifer Stephens4 and
  6. Michael Griksaitis5
  1. 1 Department of Acute Medicine, Royal Berkshire Hospital, Reading, UK
  2. 2 Department of Acute Medicine, East Surrey Hospital, Redhill, UK
  3. 3 Department of Intensive Care Medicine, Shrewsbury and Telford Hospitals, Shrewsbury, UK
  4. 4 Department of Intensive Care Medicine, Royal Cornwall Hospital, Truro, UK
  5. 5 Department of Paediatric Intensive Care, Southampton Children’s Hospital, Southampton, UK
  1. Correspondence to Andrew Walden; andrew.walden{at}

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As clinicians who deal with acutely and critically unwell adult and paediatric patients we welcome the recently published guidelines aspiring to provide a 24/7 service to deliver safe pleural procedures to patients.1 The move away from the previously unwritten mandate that all pleural procedures sampling fluid require Royal College of Radiologists (RCR) ‘level one’ ultrasound competence can only be of benefit; as the guideline concedes, confusion around which standard this required (focused vs non-focused) has not been useful. We entirely agree with the authors that the training requirements for the RCR standards do not fit well with the way pleural interventions are currently delivered. In our practice we are very aware that delays in treating pleural disease can lead to rapid patient deterioration and on occasions may be the trigger for admission to intensive care.

The vertical integration model chosen for the delivery of thoracic ultrasound (TUS) with emergency-level operators at the bottom, overseen by advanced operators at the top is also to be commended. This system is similar to existing models of ultrasound training and delivery within our specialties. Core UltraSound in Intensive Care (CUSIC) training has advanced operators known as supervisors who are experienced intensive care and acute medicine clinicians, and consultant radiologists. To date there are 170 CUSIC mentors and supervisors around the country. Similar structures exist in other established point-of-care ultrasound training pathways such as Focused Acute Medicine UltraSound (FAMUS), Focused Intensive Care Echocardiography and Children’s ACuTe UltraSound.

It must also be said that the move to separate the process of ultrasound guidance and procedural competency is sensible, since these are two very separate skills that have often been conflated. Of course they will frequently be undertaken by the same appropriately trained operator, but not necessarily.

Where we do have concerns with this …

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