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2a: Emergency TUS operator pathway
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| To be able to practice independently in emergency TUS to enable safe intervention in context of an emergency life threatening situation due to large, simple pleural effusion | By the end of training and entrustment at CiP level 4 emergency operators will:Have completed a local introductory TUS session, focusing on: The basics of ultrasound examination Familiarity with the local ultrasound machine(s) including depth, gain and probe orientation
Be able to correctly identify normal structures (lung, heart, hemi diaphragm, liver, kidneys, spleen and ribs) Be able to correctly identify a clinically large free flowing pleural effusion of greater than 5 cm on ultrasound Accurately measure depth of any pleural fluid identified Appropriately identify a sonographically safe site for safe aspiration / drainage of fluid in a large effusion Recognise when ultrasound appearances are atypical for large, simple, free flowing pleural effusion and where onward referral to a more exert practitioner is made before any intervention Be aware of own limitations and subsequent onward referral rate Demonstrate annual review and appraisal of practice
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2b: Primary TUS operator pathway
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To be able to practice independently in TUS to
allow identification and characterisation of pleural fluid in a variety of clinical scenarios and to enable a safe pleural procedure where
applicable. | By the end of training and entrustment at CiP level 4, primary TUS operators will:Demonstrate they have met all objectives within the emergency operator pathway Have completed a structured TUS training course covering: Basic understanding of the principles of ultrasound Modes of ultrasound Sonographic anatomy of thoracic cavity Training with supervised practical (hands on) ultrasound experience
Be able to correctly identify free flowing pleural fluid of all depths Be able to accurately differentiate pleural fluid from other ‘solid’ pathology such as pleural thickening/tumour nodules or mass/consolidated lung Correctly assess presence of normal lung, as evidenced by normal lung sliding and A lines Correctly identify features associated with exudative pleural effusions (echogenic fluid, septations) Characterise the degree of pleural fluid septations and loculations Correctly identify gross malignant changes for example, pleural/diaphragmatic nodularity Recognise the potential for the role of ultrasound in the assessment of diaphragmatic paralysis Appropriately identify site for safe aspiration/drainage of pleural fluid in the context of a complex, non-free flowing pleural effusion Recognise when ultrasound appearances are atypical for pleural fluid and where onward referral is made before any intervention Be aware of own limitations and subsequent onward referral rate Demonstrate annual review and appraisal of practice
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2c: Advanced TUS operator
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| To be able to demonstrate independent practice and expertise in more advanced ultrasound techniques and practice independently in more complex cases of pleural disease | By the end of training and entrustment at CiP level 4, Advanced TUS operators will be able to:Demonstrate they have met all objectives within emergency and primary TUS pathway Demonstrate a minimum of 2 years practice at Primary TUS level with ongoing practice Correctly identify and characterise pleural thickening Correctly determine the absence of lung sliding in the context of pneumothorax or pleurodesis using B and M mode Be able to identify TUS artefacts including B-line and be aware of the potential relation to pathology Develop an awareness of the assessment of diaphragm paralysis on ultrasound using the sniff test Perform real-time ultrasound-guided or direct visualisation pleural aspiration and chest drain insertion when required Use ultrasound to guide the site for indwelling pleural catheter insertion (scanning patients in lateral decubitus position) Be aware of own limitations and subsequent onward referral rate Demonstrate annual review and appraisal of practice including standardised outcome measures
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2d: Expert TUS operator
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| To be able to demonstrate independent practice at an expert level of TUS using more complex adjuncts to imaging and more invasive diagnostic interventions | By the end of training and entrustment at EPA level 4, expert TUS operators will be able to:Demonstrate they have met all objectives within emergency, primary and advanced pathways Demonstrate ongoing practice of over 70 TUS examinations per year Correctly use and interpret findings using advanced modes, that is, M-mode, colour and Doppler Accurately assess diaphragm function on ultrasound—to identify movement impairment rather than frank paralysis Safely and accurately obtain pleural biopsies under direct ultrasound guidance and maintain an awareness of the benefits and limitations of TUS guided pleural biopsy versus CT-guided biopsy. Use ultrasound to establish if pneumothorax induction at thoracoscopy is possible and safe Be aware of own limitations and subsequent onward referral rate Demonstrate annual review and appraisal of practice including standardised outcome measures
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