Introduction
Materials and methods
Results
Search strategy
Study design | Assessment | Facility | Education tool | Participants | |
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Pre and post-test studies | |||||
Noble et al. [13] | Pre- and post-test | Theoretical pre- and post-test (50 video clips) | Ultrasound video clips | 2 h didactic lecture (one for pneumothorax and one for pulmonary oedema) | 27 physicians working for the SAMU at l’Hôpital Necker in Paris, France |
Oveland et al. [14] | Pre- and post-test and 6-months follow-up | Theoretical pre- and post-test (34 MCQs, 10 US physics questions, 17 recognition pictures, 7 video clips) and hands-on practical examination (6 months follow-up | Healthy live models and porcine models | 8 h attendance course including didactic (2 h), practical (2 h) and experimental (4 h) sessions | 20 first-year to graduate-year medical students (11 at 6 months follow-up) |
Breitkreutz et al. [15] | Pre- and post-test | Theoretical pre- and post-test (15 MCQs and 5 recognition images), post course recognition quiz (15 video clips) and practical post course examination (16 predefined sonoanatomic items) | Healthy live models, patients with chronic or malignant lung diseases or who had recently underwent thoracotomy. Custom-made gel phantoms | Two and a half hour theoretical training (six brief lectures in anatomy, physiology and pathology of thorax and four case presentations). Two and a half hour hands-on training | 54 trainees. Group A: 14 medical students, Group B: 32 anaesthesiologists, Group C: 8 trauma surgeons |
Cuca et al. [16] | Pre- and post-test | Theoretical pre-, post-, and sustainability test (20 MCQs, results compared with THOLUUSE-study [14]) | – | E-learning module including physiological and pathological sonographic patterns (Five topics: basics and pleural effusion, pneumothorax, pulmonary oedema and consolidation, trachea, workflow of LUS) estimated time 30–50 min | 29 medical students and medical doctors |
Hulett et al. [17] | Pre- and post-test | Theoretical pre- and post-test (46 questions including MCQs, true/false, matching items, fill-in-the blank image and video recognition), practical pre- and post course skills | Patients located in medical ICU at the North Carolina Hospital | 1 h didactic instruction, 1 h image interpretation workshop and image acquisition training, in 1 work week supervised hands-on training | Eight critical care medicine fellows |
Bhat et al. [18] | Pre- and post-test and 1-week follow-up | Theoretical (16 MCQs) | Ultrasound images and video clips obtained in the Emergency Department by trained ultrasound physicians | 1 h didactic lecture including basic scan technique, normal ultrasound anatomy, image interpretation of normal or pathological pattern | 57 prehospital providers (19 medical technicians students, 16 paramedic students, 18 certified medical technicians and four certified paramedics |
Connolly et al. [19] | Pre- and post-test | Theoretical pre- and post-test (21 MCQs) and practical examination (real-time scans saved and blinded evaluated by instructors) | Live models and phantom task trainer models and simulators | Five 1-h workshops and 4 h didactic online preparatory training. Hands-on with supervised scans | 24 medical students in MCQ pre- and post-test evaluation and 16 in clinical skill assessment |
Dinh et al. [20] | Pre- and post-test and 3 months follow-up | Theoretical pre-, post-, and sustainability test (50 MCQs—12 pulmonary) (84 point checklist). Pathologic image interpretation (4 cases with each 20 questions each). Ultrasound comfort level and use of ultrasound | Healthy live models, simulators | 2 days course including didactic lectures, live demonstrations, hands-on sessions on healthy models, pathologic image interpretation with cases using ultrasound simulator | Eight ICU fellows, participants with the previous ultrasound experience were excluded |
Heiberg et al. [21] | Pre- and post-test | Theoretical pre- and post-test (56 MCQs) and practical three test sessions | Four healthy medical students | E-learning course including text, pictures, animations and movies (5–8 h) and hands-on session (4 h; 30 min LUS) | 20 medical students |
Sanchez-de-Toledo et al. [22] | Pre- and post-test | Theoretical pre-, and post-test (four written cases). Practical skill test after 60 min hands-on session (four cases) | Porcine models | One and a half hour theoretical and practice-based course | Four veterinaries, eight neonatologists, seven paediatric intensive care specialists, two intensive care nurses, three paediatric surgeons, eight paediatric anaesthesiologists, four paediatricians |
See et al. [23] | Pre- and post-test | Theoretical pre- and post-test (20 MCQs) and hands-on (blinded evaluation of image acquisition and interpretation) | Mechanically ventilated patients or patients with respiratory failure, requiring at least 40% inspired oxygen fraction to maintain an oxygen saturation of 90% | 30 min didactic introduction, 1 month self-study (powerpoint slides, criticalecho.com and court.net). Supervised scans with immediately feedback with focus on image acquisition, afterwards image interpretation by blinded observer | 22 respiratory therapists |
Greenstein et al. [24] | Pre- and post-test | Theoretical pre- and post-test (20 MCQs) and hands-on assessment | Healthy human models | 3 days course including didactic lectures with real-time ultrasound scan on healthy models, image interpretation sessions and hands-on training | 363 critical care physicians, hospitalists, surgeons, physician assistants, advanced practice nurses and medical residents |
Descriptive studies | |||||
Krishnan et al. [25] | Post course evaluation and sustainability test | Theoretical post- and sustainability test (20 video clips ± pneumothorax) | Ultrasound video of 53 patients before and after elective thoracic surgery. In all, 99 videos were compiled (52 without pneumothoraces and 47 with) | 5-min online presentation of the use of ultrasound for detection of pneumothorax | 79 (70 at 6 month follow-up) residents and faculty members from Department of anaesthesia |
Abbasi et al. [26] | Prospective cross-sectional study | Hands-on assessment (± pneumothorax) | Healthy live models and patients admitted in Emergency Department with thoracic trauma | 2 h training course including 30 min didactic lecture, 30 min hands-on training on healthy volunteers, 1 h training on patients | Four emergency physicians |
Gargani et al. [27] | Post course evaluation | Online assessment of uploaded LUS examinations and theoretical assessment of b-line interpretation (44 videos) | Patients | Part A: web-based training program; 26 min educational video with focus on b-line assessment. Upload of 7 self-performed lung ultrasound videos, when videos were approved by experts, trainees proceed to Part B: b-line interpretation | Thirty nephrologists and 14 cardiologists |
Randomized controlled trial | |||||
Edrich et al. [28] | Randomized controlled trial with 4 weeks follow-up | Theoretical pre-, post-, and sustainability test (10 MCQs and one video clip) and practical examination (blinded reviewers) | Healthy live models | Group I: web-based (powerpoint 25 min and online demonstration 5 min). Group II: Classroom-based (powerpoint) 45 min didactic lectures and 20 min hands-on training. Group III: No education or hands-on training. Blinded reviewers | 138 anaesthesiologists from four academic hospitals. Participants with the previous ultrasound experience excluded |
Statistical analysis | Outcome measures | Study conclusion | Level of evidence | |
---|---|---|---|---|
Noble et al. [13]. Evaluation of thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. 2009 | Paired t test compared mean score of pre- and post-test | Improvement in pre- and post-test scores | With minimal didactic and image recognition skill sessions are needed before physicians can recognize the key artifacts, which lead to the diagnosis of pulmonary edema and pneumothorax. | 4 |
Oveland et al. [14]. Animal laboratory training improves lung ultrasound proficiency and speed. 2013 | Sensitivity, specificity, positive and negative predictive value | Confidence level, scan time, improvement in theoretical score and sensitivity/specificity | Novices can quickly learn how to diagnose PTX using lung US. Training in an animal facility imparts a high level of long-term diagnostic proficiency and speed for diagnosing PTX | 4 |
Breitkreutz et al. [15]. Thorax, trachea and lung ultrasonography in Emergency and Critical care medicine: Assessment of an Objective Structured training concept. 2013 | Non-parametric Wilcoxon matched pairs (within groups), Mann–Whitney U test (between groups) | Improvement in pre- and post-test scores. Recognition and interpretation skill scores. Practical imaging performance scores | 1-day training program like THOLUUSE significantly improves theoretical and practical skills for sonographic diagnosis of including PLE and PTX | 4 |
Cuca et al. [16]. Assessment of a new e-learning system on thorax, trachea and lung ultrasound. 2013 | Wilcoxon matched pairs test. Self-assessment survey | Improvement in pre- and post-test score and sustainability test, qualitative program evaluation score | Results of written tests from the e-learning attendance course are comparable and with same progress as attendance-based courses | 4 |
Hulett et al. [17]. Development and Preliminary Assessment of Critical Care Ultrasound Course in an Adult Pulmonary and Critical Care Fellowship Program. 2014 | Paired t-test on pre- and postcourse performances | Improvement in pre- and post-test scores, practical pre- and postcourse skill score and self-assessment score | A formal curriculum dedicated to critical care ultrasound can be developed and implemented on site in a fellowship training program. After validation studies testing longer term retention of knowledge and bedside skills on trainees at other broadly representative medical centres, the curriculum described here might form the basis of a widely applicable onsite critical care ultrasound course curriculum | 4 |
Bhat et al. [18]. Prehospital Evaluation of Effusion, Pneumothorax and standstill (PEEPS): Point-of-care Ultrasound in emergency medical services. 2015 | Two-tailed, paired t test | Improvement in pre-, post- and sustainability test. Level of confidence | This study showed potential promise for training prehospital EMS providers in accurate US interpretation through a 1-h didactic lecture focused on US technique and anatomy for the assessment of pericardial effusion, pneumothorax, and cardiac standstill | 4 |
Connolly et al. [19]. Ultrafest: a novel Approach to Ultrasound in Medical Education Leads to Improvement in Written and Clinical Examinations, 2014 | Paired t test analysis | Improvement in pre- and post-test score and practical pre- and postcourse skill score | A 1-day, 9-h, small group instruction and practice symposium improved student knowledge on trauma and pulmonary US, and improved image acquisition, but the latter fell short of significant proficiency | 4 |
Dinh et al. [20]. Impact of a 2-day critical care ultrasound course during fellowship training: a pilot study. 2015 | Students t test, Chi square or ANOVA | Improvement in pre-, post-, and 3 month follow-up test score, comfort level score. Number of self-reported scans | Introduction of a 2-day critical care ultrasound course has both a positive short- and long-term impact on fellows’ confidence and proficiency with ultrasound use. Utilizing tools such as written tests to assess basic knowledge, live models to teach practical skills, and ultrasound simulators to teach pathological image identification can help standardize critical care ultrasound training | 4 |
Heiberg et al. [21]. Point-of-care clinical ultrasound for medical students. 2015 | Paired Students t test, Wilcoxon rank sum test, Chi squared test, linear regression | Improvement in pre- and post-test score and practical pre- and postcourse skill score | Medical students with no previous experience of ultrasound techniques demonstrated a significant increase in their ability to acquire and interpret an ultrasound image after completion of interactive e-learning, and this competence was further improved after 4 h of systematic hands-on training | 4 |
Sanchez-de-Toledo et al. [22]. Teaching chest ultrasound in an porcine model. 2016 | Sensitivity, specificity, positive and negative predictive values | Improvement in sensitivity and specificity after 30 and 60 min | Brief training in theory combined with animal models facilitates learning for medical professionals with no previous training in US and enables them to recognize the three most relevant thoracic US patterns. The introduction of advanced simulation with animal models can facilitate training of personnel in the recognition and management of acute lung disease | 4 |
See et al. [23]. Lung ultrasound training: curriculum implementation and learning trajectory among respiratory therapists. 2016 | Paired t test. Three patients block (36 images) Overall performance score with linear regression | Improvement in pre- and post-test scores and practical skill scores | We devised a pragmatic lung ultrasound curriculum, which involved building rapport, stimulating self-directed learning, and avoiding cognitive overload. Our training method allowed RTs to acquire the ability to independently perform lung ultrasound after at least ten directly supervised scans | 4 |
Greenstein et al. [24]. Effectiveness of a Critical Care ultrasonography Course. 2016 | Two-tailed student t test | Improvement in pre- and post-test score and practical pre- and postcourse skill score | This 3-day CHEST CCUS course is an effective method to train large groups of clinicians in the skills requisite for CCUS. The majority of learners demonstrated improved performance in both image interpretation and hands-on ultrasonography skills across all educational domains at the completion of the course | 4 |
Krishnan et al. [25]. Efficacy of an online education program for ultrasound diagnosis of pneumothorax. 2013 | Sensitivity and specificity at the time of educational program and after 6 months | Improvement in sensitivity/specificity, use of ultrasound from baseline to follow-up | After viewing a 5-min online training video, physicians can reliably rule out pneumothorax on an optimal ultrasound image. They are also able to retain this skill for up to 6 months | 4 |
Abbasi et al. [26]. Accuracy of emergency physician-performed ultrasound in detecting traumatic pneumothorax after 2-h training course. 2012 | Sensitivity and specificity, positive after 5, 10 and 20 ultrasound examinations, × 2-test for proportions and the Student t test for continuous variables | Improvement in sensitivity/specificity after 5, 10 and 20 examinations | By a brief learning course, the emergency physicians easily diagnosed PTX in trauma patients with a reasonable accuracy in comparison with CT scan as the gold standard | 4 |
Gargani et al. [27]. Efficacy of a remote web-based lung ultrasound training for nephrologists and cardiologists: an LUST trial sub-project. 2016 | Mean number of b lines ± SD. Pearsons correlation coefficient (trainer vs. trainee). Intraclass correlation coefficient and confidence interval. Interobserver agreement by Bland–Altman plot | Test-score agreement (trainee vs. trainer) | In conclusion, this study performed in the framework of the LUST trial shows that nephrologists and cardiologists can be effectively trained to measure lung congestion by an entirely web-based educational program | 4 |
Edrich et al. [28]. A comparison of web-based with traditional classroom-based training of lung ultrasound for the exclusion of pneumothorax. 2016 | Agreement of reviewers results assessed with Krippendorff test. Total score in percent. One-sided, 2-sample t test | Improvement in pre-, post-, and sustainability test score and practical test | When training anaesthesiologists to perform LUS for the exclusion of pneumothorax, we found that web-based training was not inferior to traditional classroom-based training and was effective, leading to test scores that were similar to a group of clinicians experienced in LUS | 2 |
Study design
Participants
Learning strategy
Hands-on training facilities
Assessment
Selection bias | Performance bias | Detection bias | Attrition bias | Reporting bias | Other bias | Overall risk of bias | ||
---|---|---|---|---|---|---|---|---|
Random sequence generation | Allocation concealment | Blinding of participants and personnel | Blinding of outcome assessment | Incomplete outcome data | Selective reporting | Other sources of bias | ||
Pre and post-test studies | ||||||||
Noble et al. [13]. 2009 | # | # | 1 | 1 | 1 | 1 | ? | Low |
Oveland et al. [14]. 2013 | # | # | ? | 0 | 0 | 0 | ? | High |
Breitkreutz et al. [15]. 2013 | # | # | 1 | 0 | 1 | 1 | ? | Low |
Cuca et al. [16]. 2013 | # | # | 0 | 1 | 0 | 1 | ? | High |
Hulett et al. [17]. 2014 | # | # | 0 | 0 | 1 | 0 | ? | High |
Bhat et al. [18]. 2015 | # | # | 0 | 0 | 0 | 1 | ? | High |
Connolly et al. [19]. 2014 | # | # | 1 | 0 | 0 | 0 | ? | High |
Dinh et al. [20]. 2015 | # | # | 0 | 0 | 1 | 1 | ? | High |
Heiberg et al. [21]. 2015 | # | # | 0 | 0 | 1 | 0 | ? | High |
Sanchez-de-Toledo et al. [22]. 2016 | # | # | 1 | 1 | 1 | 1 | ? | Low |
See et al. [23]. 2016 | # | # | 0 | 0 | 1 | 1 | ? | High |
Greenstein et al. [24]. 2016 | # | # | 1 | 0 | 0 | 0 | ? | High |
Descriptive studies | ||||||||
Krishnan et al. [25]. 2013 | # | # | 0 | 1 | 1 | 1 | ? | Low |
Abbasi et al. [26]. 2012 | # | # | 0 | 0 | 1 | 1 | ? | High |
Gargani et al. [27]. 2016 | # | # | 0 | 0 | 1 | 1 | ? | High |
Randomized controlled trial | ||||||||
Edrich et al. [28]. 2016 | ? | 0 | 1 | 1 | 1 | 1 | ? | Low |