New lung ultrasound consensus arrives 14 years late, and critics say it falls short

Point-of-care lung ultrasound has come a long way since Daniel Lichtenstein and colleagues first turned a bedside ultrasound probe into a rapid diagnostic tool in the late 1990s. Unlike abdominal or cardiac ultrasound, which developed primarily as diagnostic disciplines, early lung ultrasound was conceived as a simplified clinical method performed at the patient’s side. The following decade brought a proliferation of studies, diverse scanning techniques and an increasingly complex vocabulary, culminating in the 2012 international evidence-based recommendations for point-of-care lung ultrasound, a landmark consensus document that organized the field into 67 statements across six domains: pneumothorax, interstitial syndrome, consolidation, monitoring, neonatology and pediatrics, and pleural effusion.

That 2012 document was methodologically rigorous for its time. It relied on an epidemiologist- and librarian-led literature search and combined established and cutting-edge frameworks, including GRADE, the RAND appropriateness method and the Delphi process. The authors originally suggested a four-year update cycle, but that cadence was never maintained. The gap proved consequential. Interest in and research output on lung ultrasound grew steadily, and the COVID-19 pandemic then triggered an unprecedented surge in publications. An updated consensus during that era could have significantly streamlined protocols and techniques during a global crisis in which clinicians worldwide were scanning lungs with little standardization to guide them.

Now Volpicelli and colleagues have published a long-overdue update to the 2012 framework. Led by a small subset of the original authors, the new effort integrated 21 experts and 1,154 publications into 83 new or modified statements across seven expanded domains. The resulting guidance is practical, focusing on terminology, acquisition technique, and the diagnosis, monitoring and prognosis of four key findings: pneumothorax, interstitial syndrome, consolidations and pleural effusions. The accompanying figures are excellent, though the inclusion of videos in the supplementary material would have added significant value. Crucially, the authors reiterate that point-of-care lung ultrasound is a component of a multimodal assessment, reminding clinicians to treat the patient, not the image.

Writing in Intensive Care Medicine, Martin Girard, Silvia Mongodi and Laurent Muller welcome the update but argue that it suffers from methodological regressions compared with its predecessor. Their first concern involves the literature review. The new recommendations were seemingly PRISMA-informed rather than strictly adherent to PRISMA guidelines, potentially omitting key evidence. No information specialist appears to have participated in developing the search strategy, which seemingly omits key information, such as language restrictions, and was conducted in only a single database, PubMed. Similarly, while the authors state that they followed the ACCORD criteria, it is unclear whether they adhered strictly to all ACCORD items.

The second and arguably more consequential regression is the omission of GRADE certainty-of-evidence ratings. The authors justify this by noting the observational and diagnostic nature of lung ultrasound data, but the editorial authors argue this represents a step backward from the 2012 consensus. Without such ratings, readers cannot easily distinguish between statements rooted in high-certainty evidence and those based on expert opinion. The editorial authors acknowledge that this approach is not inherently methodologically flawed, but they contend it substantially limits the reader’s ability to assess the strength of the evidence underlying individual statements. The systematic inclusion of supporting references for each statement would have improved evidence traceability and could have partially addressed this limitation.

Panel composition raises further questions. Although knowledge of lung ultrasound across different medical fields expanded substantially over the last decade, a limited number of experts, smaller than in the previous edition, were entrusted to represent all medical specialties, potentially leading to under-representation of current experts in the field. Bibliometric selection criteria may appear objective, but they do not guarantee disciplinary balance, methodological independence, geographical diversity, gender equity, or inclusion of emerging scientific perspectives. Furthermore, the decision to refrain from commenting on the statements, while intended to maintain objectivity, leaves some recommendations lacking context. Given these significant methodological differences, the editorial authors question whether the new document should be regarded as the direct formal successor to the 2012 consensus, rather than as another expert consensus inspired by and building upon the 2012 document. Importantly, they stress, these expert recommendations should not be confused with formal clinical practice guidelines, and their statements should be interpreted accordingly.

The positioning of the new recommendations within the broader literature also remains ambiguous. The authors rightfully avoided some areas with existing guidelines, such as pediatrics and education, and simply referred to them. But the editorial authors argue they passed up an opportunity to engage with the substantial body of literature that emerged from the COVID-19 pandemic, ignored areas with no existing guidelines, such as perioperative point-of-care lung ultrasound, and overlooked another recent update to the 2012 framework published by a different group of experts. There are also instances where statements duplicate or contradict the recently published ESICM–ESPNIC international expert consensus on quantitative lung ultrasound in intensive care. Given that some experts overlap across the various committees, this lack of synthesis is surprising. A dedicated discussion comparing similarities and disparities between competing recommendations would have been invaluable for a skeptical clinical audience. As it stands, the editorial authors warn, the current work may contribute to fragmentation in the field, the opposite of the standardization that such recommendations should seek to achieve.

Despite these criticisms, the editorial authors find genuine value in the new document for intensive care physicians. For instance, the recommendation to consider immediate chest drainage in cases of severe respiratory failure and/or shock in the absence of lung sliding, B-lines and lung pulse in cases of suspected pneumothorax is described as both pragmatic and useful. Such statements translate directly into bedside decision-making, where seconds can matter and a negative lung sliding sign combined with a lung pulse can effectively rule out a pneumothorax in a deteriorating patient.

A deeper tension runs through the field itself, between the keep-it-simple bedside approach and the push toward sophisticated quantitative analytics. The exclusion of ultrasound physics, artifact research, artificial intelligence and engineering expertise from the new panel is difficult to reconcile with the current state of the field, the editorial authors argue. Lung ultrasound is no longer only a bedside semiology exercise. Some experts insist on the different physical phenomena responsible for B-lines of various origins, for example cardiogenic pulmonary edema versus pulmonary fibrosis, and the impact various imaging parameters may have on their detection, while the new recommendations state these do not significantly alter the clinical significance of B-lines. Rather than viewing these positions as mutually exclusive, the editorial authors argue, the field should embrace both: maintaining simplicity for rapid screening while adopting more sophisticated approaches for precision monitoring and diagnosis.

Ultimately, the editorial authors conclude that the new recommendations are a useful collection of practical statements for bedside point-of-care lung ultrasound. Clinicians can adopt them, but should contextualize them by reading other similar works. For future groups undertaking an update of the original 2012 recommendations, the prescription is clear: be prospectively registered, base the work on librarian-led systematic reviews, support it with independent evidence appraisal and statement-level certainty grading, and assemble a broader panel including clinicians, methodologists, physicists, engineers, artificial intelligence experts and early-career investigators. Such a process, they argue, would produce recommendations that are not merely consensual, but genuinely traceable, reproducible and credible for the next decade of lung ultrasound.

Subject of Research: An expert consensus update on point-of-care lung ultrasound and a critical editorial assessing its methodology

Article Title: Updating the foundations of point-of-care lung ultrasound—a long-awaited but only partially fulfilled need?

Article References: Girard, M., Mongodi, S., & Muller, L. (2026). Updating the foundations of point-of-care lung ultrasound—a long-awaited but only partially fulfilled need?. Intensive Care Medicine. https://doi.org/10.1007/s00134-026-08619-8

Image Credits: AI Generated

DOI: 10.1007/s00134-026-08619-8

Keywords: lung ultrasound, point-of-care ultrasound, consensus recommendations, GRADE certainty ratings, pneumothorax, interstitial syndrome, pleural effusion, COVID-19, intensive care, PRISMA, methodology, critical care