الفهرس 
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Abstract
Postoperative pulmonary complications (PPCs), including atelectasis, pneumonia and pulmonary edema, are common after cardiothoracic surgery, and are associated with adverse outcomes. Early recognition of PPCs might be important for intervention and/or monitoring, as these patients often have compromised physiological reserves. The time from surgery until PPC detection is approximately three days using the most commonly used diagnostics such as chest auscultation, chest X-ray (CXR), arterial oxygen tension, PaO₂/FIO₂ (P/F) ratio, leucocyte count and temperature (59). Chest X-ray (CXR) remains the current standard diagnostic imaging technique to detect PPCs in the intensive care unit (ICU) setting. However, the diagnostic accuracy of CXR is limited, and CXR requires radiation exposure and considerable costs. Bedside lung ultrasound, an alternative imaging modality with high sensitivity and specificity, is increasingly used for the diagnosis of pulmonary pathology in the ICU. Lung ultrasound is without the downside of radiation exposure, and creates distinctive artefacts through the interplay between fluid, air and pleurae. Combinations of these artefacts can help differentiate between various pathological processes, and are combined and deciphered in the bedside lung ultrasound (LUS) in emergency (BLUE) protocol. In the BLUE protocol, profiles have been designed for the main pulmonary complications (pneumonia; congestive heart failure; chronic obstructive pulmonary disease (COPD); asthma; pulmonary embolism; and pneumothorax) have been validated with an accuracy > 90%, and are therefore extensively used in daily critical care (60). For example, the lung sliding artefact, which is a ‘twinkling’ visible at the pleural line during inspiration, excludes a pneumothorax and is part of the definition of a normal lung surface. A-lines are the main horizon artefact and represent a reverberation of the pleural line, indicating air at the pleural line. B-lines are the result of many to-and-fro movements of ultrasound beams between air and fluid, generating this long, vertical hyperechoic artefact. More than two anterior B-lines are pathological; this is the definition of a B-profile in the BLUE protocol, indicating interstitial syndrome or pulmonary edema. Furthermore, detection of pleural effusions and consolidation are part of the posterolateral alveolar and/or pleural syndrome (PLAPS). At the PLAPS point, a disorder can be described when an anechoic pleural effusion is visible or a disorder within the lung tissue is seen; for example, a shredded deep border immediately indicates lung consolidation (61). Cardiac ultrasound has been shown to be valuable in the peri-operative assessment and therapeutic management of patients undergoing surgery. In non-cardiothoracic surgery patients, lung ultrasound performed better than CXR in diagnosing pneumonia, pulmonary edema, pneumothorax and pleural effusion. Until now, however, there have been limited data available for the diagnostic value of lung ultrasound in cardiothoracic surgical patients. In addition, it has to date been unknown whether repeated lung ultrasound is able to detect PPCs at an earlier stage compared with routine CXR (62). The main aim of this study was to study the significance of “use of chest ultrasound in post-operative cardiothoracic surgery” protocol in patients undergoing cardiothoracic surgeries. This prospective descriptive clinical trial study was conducted at Cardiothoracic Surgery Department, Assiut University Hospital in the period from the 1st of January 2021 up to the end of December 2021. The study included 277 patients (191 patients undergoing cardiac surgery, and 86 patients undergoing thoracic surgery). The main results of this study were as following: As regard demographic and clinical data of the studied participants were summarized. The mean age of our whole studied participants was 47.77±15.28 years and ranged from 17 up to 89 years old, the mean age of patients undergoing cardiac surgery was 51.21±13.91 years and ranged from 17 up to 89 years old, and the mean age of patients undergoing thoracic surgery was 40.14±15.49 years and ranged from 18 up to 74 years old. The mean weight of whole studied participants was 76.77±13.20 kg and ranged from 30 up to 119 kg, the mean weight of patients undergoing cardiac surgery was 75.96±13.88 kg and ranged from 30 up to 118 kg, and the mean weight of patients undergoing thoracic surgery was 78.57±11.42 kg and ranged from 54 up to 119 kg. Out of 277 studied cases, 183 (66.1%) were males and 94 (33.9) were females. Regarding to the associated comorbidity among the studied participants; 85 cases (30.7%) were diabetic, 58 (69.0%) on oral anti-diabetic drugs, and 26 (31.0%) received insulin, 66 (78.6%) were controlled, while 18 cases (21.4%) were uncontrolled diabetic patients, 91 cases (32.9%) were hypertensive, 81 cases (29.2%) suffered from COPD, and nine cases (3.2%) were asthmatic. More than one third of the studied cases were smokers, 126 cases (45.5%) non-smokers, and 50 cases (18.1%) were ex-smokers. Our results were supported by study of Touw et al., (63) as they reported that the majority of their studied group (71%) were males with mean age 68 years. The mean BMI was 27.5 kg.m2. As regard associated comorbidities; 28% of them had heart failure. Also, in the study of Ariza et al., (64), seventy-six patients (120 hemi thorax) were explored in the postoperative period of thoracic surgery, but sixteen patients were not included in the study due to subcutaneous emphysema. Sixty patients were finally enrolled in the study in a period of 5 months. The majority of them were males with mean age 53 years. The present study showed that as regard diagnosis of patients undergoing cardiac surgery; more than half (58.1%) have IHD, 71 cases (37.2%) have RHD, three cases (1.6%) with emergent surgery, three cases (1.6%) with aortic surgery, three cases (1.6%) with adult congenital cardiac surgery. For diagnosis of patients undergoing thoracic surgery; twenty cases (23.3%) with lung mass, 19 cases (22.1%) have empyema, 16 cases (18.6%) with bullous lung disease, 14 cases (16.3%) with mediastinal surgery, five cases (5.8%) with malignant pleural effusion, four cases (4.7%) with lung abscess, and eight cases (9.3%) with other diagnosis. 192 cases (69.3%) received median sternotomy, 47 cases (16.9%) received thoracotomy, and 38 cases (13.7%) received minimal invasive approach, 131 cases (47.3%) on left side, 72 cases (26.0%) on right side, 25 cases (9.0%) on both sides, and 49 cases (17.7%) received median sternotomy. The approach was elective in the majority of the studied cases (97.1%). Types of cardiac operations include: CABG in 101 cases (52.9%), valve replacement in 75 cases (39.3%), CABG & valve replacement in nine cases (4.7%), bentall operation in three cases (1.6%), ASD closure in two cases (1.0%), and VSD closure in one case (0.5%). Types of thoracic operations include: lung resection in 29 cases (33.7%), decortication in 21 cases (24.4%), mass excision in 16 cases (18.6%), biopsy in 13 cases (15.1%), chest wall surgery, diaphragmatic plication, and sympathectomy in two cases for each (2.3%), and diaphragmatic hernia repair in one case (1.2%)Our results were in line with the study of Touw et al., (63), as they reported that 40% of their patients underwent CABG surgery and 31% of them underwent Valve surgery, 18 % underwent CABG and valve surgery and 6% underwent pulmonary endarterectomy. Whereas in the study of Elshehawi et al., (65), one hundred patients admitted for elective cardiac surgery were enrolled in this trial. They were divided into two groups; the control group (group C) included 50 patients who underwent LUS without LUS guided interventions, and LUS group (group L) included the remaining patients who underwent LUS followed by LUS-guided recruitment maneuver and other interventions according to the finding. Regarding the operations performed, valve replacement was done in 44% and 36% of cases, while CABG was done in 40% and 58% of cases in Groups C and L, respectively. In addition, the combination of the previous two procedures were performed in 6% and 4% of patients in the same two groups, respectively. Operative data showed no significant difference between the two study groups (p > 0.05). CBP time had mean values of 119 and 121.6 minutes, while the same values were 244.6 and 248.4 minutes for the duration of anesthesia in Groups C and L, respectively. Intraoperative fluid balance ranged between ± 500 ml in both study groups. While in the study of Ariza et al., (6), 35% of their studied cases underwent Major pulmonary resection and 30% of them underwent minor pulmonary resection. As regard Type of surgical approach, 61.7% of them were Video-thoracoscopic surgery. 13.3% of them were Thoracotomy. As regard the operated side, 50% were Right hemi thorax, and 40% were left hemi thorax. The current study showed that Pulmonary complications were documented in 215 cases (77.6%) of the studied participants; pleural effusion was documented in 204 cases (73.6%), pulmonary consolidation documented in 104 cases (37.5%), pneumothorax documented in 49 cases (17.7%), and interstitial pattern was documented in only one case (0.4%). Among patients received cardiac operation; pulmonary complications were documented in 153 cases (80.1%); pleural effusion was the commonest documented in 152 cases (79.6%), followed by pulmonary consolidation documented in 74 cases (38.7%), one case (0.5%) with interstitial pattern, and no cases developed pneumothorax. Among patients received thoracic operation; pulmonary complications were documented in 62 cases (72.1%); pleural effusion was the commonest documented in 52 cases (60.5%), followed by pneumothorax documented in 49 cases (57.0%), pulmonary consolidation documented in 30 cases (34.9%), and no cases developed interstitial pattern. While in the study of Ariza et al., (64), 5% of their studied group had Atelectasis and pneumothorax. 1.7% of them had bleeding and Atelectasis. Whereas in the study of Elshehawi et al., (65), as a primary outcome, postoperative pulmonary complications were more encountered in group C (6% versus 22% in group L – p = 0.021). Although the incidence of desaturation was comparable between the two groups showing significantly higher in the control group than in the intervention group in postoperative period (64% vs. 36%; P < 0.001). However, the incidences of intraoperative desaturation (40% vs. 30%; P = 0.295) and during transfer to the intensive care unit (14% vs. 4%; P = 0.081) were similar between the control and intervention groups. In the study of Chatzivasiloglou et al., (66), atelectasis was detected in 71% of the patients, pleural effusion in 94%, and alveolar-interstitial syndrome in 26% and consolidation in 14%. Atelectasis was more common in the left hemi thorax, whereas there was no statistically significant difference in the localization of the rest of the findings. Pulmonary complications are frequent in cardiac surgery, representing an important cause of morbidity, prolongation of hospital stay and need for repeated examinations. Chest X-rays (CXR) are done routinely and even multiple times to detect such complications as it is the current standard diagnostic imaging. However, CXR exposes healthcare workers and the patients to ionizing radiations. Lung ultrasonography (LUS) is an alternative test to detect pulmonary complications that can be done easily on bedside. LUS is gaining popularity in recent years as a non-invasive, radiation-free tool for the diagnosis of various pulmonary diseases due to its bedside convenience, accuracy, and easy availability. There is increasing evidence to support the use of LUS in acute care setting and post-cardiac surgical patients are also considered critically ill (67). Our results showed that as regard cardiothoracic surgery, the initial (day 0) positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.721, P<0.001), for pleural effusion both diagnostic procedures show poor agreement (K=0.040, P=0.025), for pulmonary consolidation both diagnostic procedures show moderate agreement (K=0.505, P<0.001), while no cases developed interstitial pattern at day 0 post-operatively. Regarding the 3rd day positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.660, P<0.001), for pleural effusion no agreement was observed between both diagnostic procedures (K=0.021, P=0.168), for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.112, P<0.001), while no cases developed interstitial pattern at the 3rd day post-operatively. Regarding 5th day positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show moderate agreement (K=0.421, P<0.001), for pleural effusion no agreement was observed between both diagnostic procedures (K=0.105, P=0.066), for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.087, P=0.002), while one case with interstitial pattern was diagnosed by transthoracic ultrasound and not detected by chest X-ray at the 5th day post-operatively. Regarding the concordance between transthoracic ultrasound and chest X-ray for the four variables after cardiothoracic surgery. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.765, P<0.001), for pleural effusion both diagnostic procedures show moderate agreement (K=0.422, P<0.001), for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.969, P<0.001), and for interstitial pattern both diagnostic procedures show substantial agreement (K=0.662, P=0.007). Totally both diagnostic procedures show moderate agreement (K=0.585, P<0.001). For the four variables, the concordance is significantly greater than zero. The kappa agreement was highest for pulmonary consolidation, followed by pneumothorax, then interstitial pattern, and lastly pleural effusion (P<0.05, for all). Among the whole studied participants; the time lag to perform cardiothoracic ultrasound examination was highly statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (2 – 19) minute versus 87 (20 – 200) minutes respectively (P<0.001) Regarding the agreement between the techniques for the four main variables after cardiac operation. The kappa agreement was highest for pulmonary consolidation, followed by interstitial pattern then pleural effusion (P<0.05, for all), while for pneumothorax no agreement was observed between both diagnostic procedures (P=1). Among patients received cardiac operation; the time lag to perform cardiothoracic ultrasound examination was statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (2 – 19) minute versus 90 (20 – 200) minutes respectively (P<0.001). Regarding the concordance between transthoracic ultrasound and chest X-ray for the four variables after thoracic surgery. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.661, P<0.001), for pleural effusion; both diagnostic procedures show moderate agreement (K=0.448, P<0.001), while for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.974, P<0.001), no cases developed interstitial pattern either at day 0, 3rd, and 5th day post-operatively. Totally both diagnostic procedures show perfect agreement (K=0.838, P<0.001). The kappa agreement was highest for pulmonary consolidation, followed by pneumothorax, then pleural effusion (P<0.001, for all), while no cases developed interstitial pattern at all studied time points post-operatively. Among patients received thoracic operation; the time lag to perform cardiothoracic ultrasound examination was statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (3 – 12) minute versus 80 (40 – 150) minutes respectively (P<0.001) In the study of Ariza et al., (64), seventy-six patients (120 hemi thorax) were explored in the postoperative period of thoracic surgery, but sixteen patients were not included in the study due to subcutaneous emphysema. Sixty patients were finally enrolled in the study in a period of 5 months. The majority of them were males with mean age 53 years. In comparison with Ariza et al., (64) our study included 86 patient ( 172 hemithorax) were explored in post-operative period of thoracic surgery, but none of them had a surgical emphysema. The majority of them were males with mean age 40 years. So from our point of view this might be adding the existent knowledge and in agreement with Ariza et al., (64) The current study showed that Pulmonary complications were documented in 215 cases (77.6%) of the studied participants; pleural effusion was documented in 204 cases (73.6%), pulmonary consolidation documented in 104 cases (37.5%), pneumothorax documented in 49 cases (17.7%), and interstitial pattern was documented in only one case (0.4%). Among patients received cardiac operation; pulmonary complications were documented in 153 cases (80.1%); pleural effusion was the commonest documented in 152 cases (79.6%), followed by pulmonary consolidation documented in 74 cases (38.7%), one case (0.5%) with interstitial pattern, and no cases developed pneumothorax. Among patients received thoracic operation; pulmonary complications were documented in 62 cases (72.1%); pleural effusion was the commonest documented in 52 cases (60.5%), followed by pneumothorax documented in 49 cases (57.0%), pulmonary consolidation documented in 30 cases (34.9%), and no cases developed interstitial pattern. While in the study of Ariza et al., (64), 5% of their studied group had Atelectasis and pneumothorax. 1.7% of them had bleeding and Atelectasis. Whereas in the study of Elshehawi et al., (65), one hundred patients admitted for elective cardiac surgery were enrolled in this trial. They were divided into two groups; the control group (group C) included 50 patients who underwent LUS without LUS guided interventions, and LUS group (group L) included the remaining patients who underwent LUS followed by LUS-guided recruitment maneuver and other interventions. ,And as a primary outcome, postoperative pulmonary complications were more encountered in group C (6% versus 22% in group L – p = 0.021). Although the incidence of desaturation was comparable between the two groups showing significantly higher in the control group than in the intervention group in postoperative period (64% vs. 36%; P < 0.001). However, the incidences of intraoperative desaturation (40% vs. 30%; P = 0.295) and during transfer to the intensive care unit (14% vs. 4%; P = 0.081) were similar between the control and intervention groups. In the study of Chatzivasiloglou et al., (66), atelectasis was detected in 71% of the patients, pleural effusion in 94%, and alveolar-interstitial syndrome in 26% and consolidation in 14%. Atelectasis was more common in the left hemi thorax, whereas there was no statistically significant difference in the localization of the rest of the findings. Pulmonary complications are frequent in cardiac surgery, representing an important cause of morbidity, prolongation of hospital stay and need for repeated examinations. Chest X-rays (CXR) are done routinely and even multiple times to detect such complications as it is the current standard diagnostic imaging. However, CXR exposes healthcare workers and the patients to ionizing radiations. Lung ultrasonography (LUS) is an alternative test to detect pulmonary complications that can be done easily on bedside. LUS is gaining popularity in recent years as a non-invasive, radiation-free tool for the diagnosis of various pulmonary diseases due to its bedside convenience, accuracy, and easy availability. There is increasing evidence to support the use of LUS in acute care setting and post-cardiac surgical patients are also considered critically ill (67). Our results showed that as regard cardiothoracic surgery, the initial (day 0) positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.721, P<0.001), for pleural effusion both diagnostic procedures show poor agreement (K=0.040, P=0.025), for pulmonary consolidation both diagnostic procedures show moderate agreement (K=0.505, P<0.001), while no cases developed interstitial pattern at day 0 post-operatively. Regarding the 3rd day positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.660, P<0.001), for pleural effusion no agreement was observed between both diagnostic procedures (K=0.021, P=0.168), for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.112, P<0.001), while no cases developed interstitial pattern at the 3rd day post-operatively. Regarding 5th day positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show moderate agreement (K=0.421, P<0.001), for pleural effusion no agreement was observed between both diagnostic procedures (K=0.105, P=0.066), for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.087, P=0.002), while one case with interstitial pattern was diagnosed by transthoracic ultrasound and not detected by chest X-ray at the 5th day post-operatively. Regarding the concordance between transthoracic ultrasound and chest X-ray for the four variables after cardiothoracic surgery. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.765, P<0.001), for pleural effusion both diagnostic procedures show moderate agreement (K=0.422, P<0.001), for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.969, P<0.001), and for interstitial pattern both diagnostic procedures show substantial agreement (K=0.662, P=0.007). Totally both diagnostic procedures show moderate agreement (K=0.585, P<0.001). For the four variables, the concordance is significantly greater than zero. The kappa agreement was highest for pulmonary consolidation, followed by pneumothorax, then interstitial pattern, and lastly pleural effusion (P<0.05, for all). Among the whole studied participants; the time lag to perform cardiothoracic ultrasound examination was highly statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (2 – 19) minute versus 87 (20 – 200) minutes respectively (P<0.001) Regarding the agreement between the techniques for the four main variables after cardiac operation. The kappa agreement was highest for pulmonary consolidation, followed by interstitial pattern then pleural effusion (P<0.05, for all), while for pneumothorax no agreement was observed between both diagnostic procedures (P=1). Among patients received cardiac operation; the time lag to perform cardiothoracic ultrasound examination was statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (2 – 19) minute versus 90 (20 – 200) minutes respectively (P<0.001). Regarding the concordance between transthoracic ultrasound and chest X-ray for the four variables after thoracic surgery. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.661, P<0.001), for pleural effusion; both diagnostic procedures show moderate agreement (K=0.448, P<0.001), while for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.974, P<0.001), no cases developed interstitial pattern either at day 0, 3rd, and 5th day post-operatively. Totally both diagnostic procedures show perfect agreement (K=0.838, P<0.001). The kappa agreement was highest for pulmonary consolidation, followed by pneumothorax, then pleural effusion (P<0.001, for all), while no cases developed interstitial pattern at all studied time points post-operatively. Among patients received thoracic operation; the time lag to perform cardiothoracic ultrasound examination was statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (3 – 12) minute versus 80 (40 – 150) minutes respectively (P<0.001) Our results were supported by study of Ariza et al., (64), as they reported that for the four variables, the concordance is significantly greater than zero. The kappa indices for pneumothorax and pleural effusion were significantly higher than for pulmonary consolidation (p =0,003 and p = 0,039, respectively). As regard the concordance in each of the three postoperative stages considering simultaneously the four types of possible findings. In the three stages, a significant agreement between the techniques has been observed. The kappa indices observed in the intermediate and final stages were significantly higher than those observed in the initial stage (p <0.001 and p = 0.018, respectively), with no significant differences between them (p = 0.168). They found evidence of significant differences between the four variables and between the three postoperative stages, but not between the two hemi-thoraxes, so the results are expressed without differentiating between right and left hemi-thorax. It can be inferred that ultrasound is beneficial for those patients who require monitoring and evaluation for pneumothorax, pleural effusion and interstitial pattern in the intermediate and final postoperative stage or those who have normal ultrasound. In these subgroups, transthoracic ultrasound could be considered as an alternative to chest X ray, thus avoiding the latter. Routine use of transthoracic ultrasound in an intensive care unit has been shown to be associated with a significant reduction in the request for chest X rays and tomography. Performing a bedside transthoracic ultrasound with a portable handheld machine offers many advantages. It accelerates decision-making by decreasing time required to obtain the X-ray, which will be performed during the day. At a cost-effectiveness level, only the initial acquisition of the ultrasound machine represents an expenditure, subsequently requiring no additional costs except maintenance and repair (68). Similarly, Ghotra et al., (69) revealed that a total of 34 cases of PPCs were observed. Of these, 32 each were detected by clinico-radiologic examination and LUS alone. Addition of LUS improved total number of PPCs detected in the early postoperative period but not in the late postoperative period. Preoperative and early postoperative LUS scores were superior to CXR scores in predicting occurrence of PPC (area under receiver operating characteristics curve [AUROC] 0.920 v 0.732; p < 0.001 preoperatively; AUROC 0.987 v 0.858, p = 0.001 at 12 hours postoperatively). Multivariate analysis suggested LUS score as an independent predictor of PPC, and LUS score along with aortic cross-clamp time as independent predictors of duration of mechanical ventilation and intensive care unit stay. In addition, Bajracharya et al., (70) have shown that LUS had high overall sensitivity, specificity, diagnostic accuracy for diagnosing pleural effusion. In the bedside assessment of effusion on critically ill patients done by Kocijancic et al., (71) LUS showed a better sensitivity and reliability than CXR, which is highly dependent on the necessity of the upright view. In another study by Balik et al., (72) bedside CXR rarely detects small effusions and can also miss effusions of up to 500 ml. On the other hand, the sensitivity and specificity of LUS for the detection of PLE are as high as 93%, compared with computed tomography (CT) in a study done by Lichtenstein et al., (73) This suggests that lung ultrasound might perform better than CXR in detecting pleural effusion which is in line with our study. Moreover, Bajracharya et al., (70) have found that LUS had high specificity and diagnostic accuracy for diagnosing consolidation. There were two published meta-analyses conducted by Hu et al., (74) and Chavez et al., (75) which evaluated the diagnostic accuracy of ultrasound for detecting pneumonia with very high sensitivity (97% and 94%) and specificity (94% and 96%).In a study done by Xiong Ye, (76) in patients with community acquired pneumonia, LUS had a pooled sensitivity of 0.95 (0.93-0.97) and a specificity of 0.90 (0.86 to 0.94), CXR had a pooled sensitivity of 0.77 (0.73 to 0.80) and a specificity of 0.91 (0.87 to 0.94). A meta-analysis showed that LUS had a high sensitivity (94%) and specificity (96%) for diagnosing pneumonia in adults and was superior to CXR.LUS also had a consistently high diagnostic accuracy of pneumonia when compared with chest CT scan as the gold standard (77). Of note, previous research has shown that lung ultrasound potentially facilitates prompt diagnosis of pulmonary complications, it might be used as a primary imaging technique to screen for complications after cardiac surgery. Yu et al., (78) found that in some cases with total or near-total opacification of the hemithorax, LUS has a high sensitivity in differentiating between consolidation of atelectasis and pleural effusion, whereas CXR is unable to make this distinction. LUS has been used in diagnosing atelectasis in children, and its sensitivity was 100% in research conducted by Lichtenstein et al. (79). However, in the study done by W Abdalla, (80) lung ultrasound showed a considerable higher sensitivity (86.1% vs. 52.7%) and diagnostic accuracy against CXR (95.3% vs. 90.6%). Study done by Reissig et al., (81) showed that CXR has low sensitivity for the diagnosis of post-procedural pneumothorax. LUS revealed an optimal diagnostic accuracy, with superior sensitivity and similar specificity to CXR, for the detection of pneumothorax in the emergency department (82). In the study of Touw et al., (63), lung ultrasound identified 159 (90%) postoperative pulmonary complications on the day of admission compared with 107 (61%) identified with chest X-ray (p < 0.001). Lung ultrasound identified 11 out of 17 patients (65%) and chest X-ray 7 out of 17 patients (41%) with clinically-relevant postoperative pulmonary complications (p < 0.001). The clinically-relevant postoperative pulmonary complications were detected earlier using lung ultrasound compared with chest X-ray (p = 0.024). Overall inter-observer agreement for lung ultrasound was excellent (j = 0.907, p < 0.001). Following cardiothoracic surgery, lung ultrasound detected more postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications than chest X-ray, and at an earlier time-point CONCLUSION: The diagnostic concordance between transthoracic ultrasound and chest radiography in the postoperative period of thoracic surgery was fair in the initial stage, but significantly higher in the intermediate and final stages. Moreover, the agreement was higher for the diagnosis of pneumothorax, pleural effusion and interstitial pattern than for the diagnosis of pulmonary consolidation. These results suggest that the use of transthoracic ultrasound in the intermediate and final stages of postoperative thoracic surgery may alleviate the use of chest X ray It is well known that cardiothoracic surgery causes different types of pulmonary complications like residual pleural effusion and pneumothorax, as a classical technique a daily chest X-ray is performed from first day of surgical intervention to hospital discharge to assess the amount of residual pleural effusion so drainage removal can be done or not. Using chest ultrasound is a good alternative for chest X-ray because it is a bedside, easier, more sensitive and accurate in detection of pulmonary complications. Its main advantages represented in avoiding the danger of ionizing radiations, easier device portability, low cost and a rapid learning curve, So it is easy and less time consuming to correlate between ultrasound findings and clinical data and assist in invasive procedures. The diagnostic concordance between transthoracic ultrasound and chest radiography in the postoperative period of thoracic surgery was fair in the initial stage, but significantly higher in the intermediate and final stages. Moreover, the agreement was higher for the diagnosis of pneumothorax, pleural effusion and interstitial pattern than for the diagnosis of pulmonary consolidation. The main results of the study revealed that: Among patients received cardiac operation; pulmonary complications were documented in 153 cases (80.1%); pleural effusion was the commonest documented in 152 cases (79.6%), followed by pulmonary consolidation documented in 74 cases (38.7%), one case (0.5%) with interstitial pattern, and no cases developed pneumothorax. Among patients received thoracic operation; pulmonary complications were documented in 62 cases (72.1%); pleural effusion was the commonest documented in 52 cases (60.5%), followed by pneumothorax documented in 49 cases (57.0%), pulmonary consolidation documented in 30 cases (34.9%), and no cases developed interstitial pattern. The initial (day 0) positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.721, P<0.001), for pleural effusion both diagnostic procedures show poor agreement (K=0.040, P=0.025), for pulmonary consolidation both diagnostic procedures show moderate agreement (K=0.505, P<0.001), while no cases developed interstitial pattern at day 0 post-operatively. The 3rd day positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.660, P<0.001), for pleural effusion no agreement was observed between both diagnostic procedures (K=0.021, P=0.168), for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.112, P<0.001), while no cases developed interstitial pattern at the 3rd day post-operatively. The 5th day positive and negative findings of transthoracic ultrasound and chest X-ray. Regarding to pneumothorax; both diagnostic procedures show moderate agreement (K=0.421, P<0.001), for pleural effusion no agreement was observed between both diagnostic procedures (K=0.105, P=0.066), for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.087, P=0.002), while one case with interstitial pattern was diagnosed by transthoracic ultrasound and not detected by chest X-ray at the 5th day post-operatively. The concordance between transthoracic ultrasound and chest X-ray for the four variables after cardiothoracic surgery. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.765, P<0.001), for pleural effusion both diagnostic procedures show moderate agreement (K=0.422, P<0.001), for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.969, P<0.001), and for interstitial pattern both diagnostic procedures show substantial agreement (K=0.662, P=0.007). The agreement between the techniques for the four main variables. For the four variables, the concordance is significantly greater than zero. The kappa agreement was highest for pulmonary consolidation, followed by pneumothorax, then interstitial pattern, and lastly pleural effusion (P<0.05, for all). The time lag to perform cardiothoracic ultrasound examination was highly statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (2 – 19) minute versus 87 (20 – 200) minutes respectively (P<0.001). The initial (day 0) positive and negative findings of transthoracic ultrasound and chest X-ray among patients received cardiac operation. Regarding to pleural effusion; both diagnostic procedures show no agreement (K=0.015, P=0.363), while for pulmonary consolidation both diagnostic procedures show moderate agreement (K=0.518, P<0.001), no cases developed pneumothorax and/or interstitial pattern at day 0 post-operatively. The 3rd positive and negative findings of transthoracic ultrasound and chest X-ray among patients received cardiac operation. Regarding to pleural effusion; both diagnostic procedures show no agreement (K=0.013, P=0.444), while for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.069, P=0.019), no cases developed pneumothorax and/or interstitial pattern at day 0 post-operatively. The 5th positive and negative findings of transthoracic ultrasound and chest X-ray among patients received cardiac operation. Regarding to pulmonary consolidation both diagnostic procedures show poor agreement (K=0.049, P=0.090), no cases developed pneumothorax, twelve cases with pleural effusion were diagnosed by transthoracic ultrasound and not detected by chest X-ray, also one case with interstitial pattern was diagnosed by transthoracic ultrasound and not detected by chest X-ray. The concordance between transthoracic ultrasound and chest X-ray for the four variables after cardiac surgery. No agreement was observed between both diagnostic procedures regarding to pneumothorax (K=0.005, P=1), for pleural effusion both diagnostic procedures show fair agreement (K=0.374, P<0.001), for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.978, P<0.001), and for interstitial pattern both diagnostic procedures show substantial agreement (K=0.664, P=0.010). The agreement between the techniques for the four main variables after cardiac operation. The kappa agreement was highest for pulmonary consolidation, followed by interstitial pattern then pleural effusion (P<0.05, for all), while for pneumothorax no agreement was observed between both diagnostic procedures (P=1). The time lag to perform cardiothoracic ultrasound examination was statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (2 – 19) minute versus 90 (20 – 200) minutes respectively (P<0.001 The initial (day 0) positive and negative findings of transthoracic ultrasound and chest X-ray among patients received thoracic operation. Regarding to pneumothorax; both diagnostic procedures show moderate agreement (K=0.572, P<0.001), for pleural effusion; both diagnostic procedures show poor agreement (K=0.146, P=0.010), while for pulmonary consolidation both diagnostic procedures show moderate agreement (K=0.482, P=0.004), no cases developed interstitial pattern at day 0 post-operati+vely. The 3rd day positive and negative findings of transthoracic ultrasound and chest X-ray among patients received thoracic operation. Regarding to pneumothorax; both diagnostic procedures show moderate agreement (K=0.589, P<0.001), for pleural effusion; both diagnostic procedures show no agreement (K=0.049, P=0.333), while for pulmonary consolidation both diagnostic procedures show fair agreement (K=0.221, P=0.004), no cases developed interstitial pattern at 3rd day post-operatively The 5th day positive and negative findings of transthoracic ultrasound and chest X-ray among patients received thoracic operation. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.720, P<0.001), for pleural effusion; both diagnostic procedures show no agreement (K=0.318, P=0.068), while for pulmonary consolidation both diagnostic procedures show poor agreement (K=0.181, P=0.025), no cases developed interstitial pattern at 5th day post-operatively. The concordance between transthoracic ultrasound and chest X-ray for the four variables after thoracic surgery. Regarding to pneumothorax; both diagnostic procedures show substantial agreement (K=0.661, P<0.001), for pleural effusion; both diagnostic procedures show moderate agreement (K=0.448, P<0.001), while for pulmonary consolidation both diagnostic procedures show perfect agreement (K=0.974, P<0.001), no cases developed interstitial pattern either at day 0, 3rd, and 5th day post-operatively The agreement between the techniques for the four main variables after thoracic operation. The kappa agreement was highest for pulmonary consolidation, followed by pneumothorax, then pleural effusion (P<0.001, for all), while no cases developed interstitial pattern at all studied time points post-operativelyThe time lag to perform cardiothoracic ultrasound examination was statistically lower than the time lag to perform chest radiograph examination, median (range) was 7 (3 – 12) minute versus 80 (40 – 150) minutesrespectively (P<0.001 because it is a bedside, easier, more sensitive and accurate in detection of pulmonary complications and it is easy and less time consuming to correlate between ultrasound findings and clinical data and assist in invasive procedures, so it`s an effective way to Detection Of Post-operative Pulmonary Complications After Cardiothoracic Surgery. The diagnostic concordance between transthoracic ultrasound and chest radiography in the postoperative period of thoracic surgery was fair in the initial stage, but significantly higher in the intermediate and final stagesMoreover, the agreement was higher for the diagnosis of pneumothorax, pleural effusion and interstitial pattern than for the diagnosis of pulmonary consolidation. These results suggest that the use of transthoracic ultrasound in the intermediate and final stages of postoperative thoracic surgery may alleviate the use of chest X ray. Further studies with larger sample size are needed to confirm the current results. Further multicenter studies are needed to confirm the current results. We recommend using Chest Ultrasound in Detection of Post-operative Pulmonary Complications after Cardiothoracic Surgery for follow up of patients. We recommend the combination between Chest Ultrasound and other diagnostic methods for better accuracy. We recommend using Chest Ultrasound because it decreases the exposure to ionizing radiation time and costs