• by Bruce Carlson
  • February 22 2017


Ultrasound Market: Favorable Trends Abound

Ultrasound Market: Favorable Trends Abound

The ultrasound market is growing driven by several trends.  Here we discuss a few of them.  Prehospital use, volumetric imaging, speckle reduction, mobility, and improvements in cardiac ultrasound are among the trends driving the market noted in Kalorama’s most recent edition of Ultrasound Markets. 

The Most Mobile Modality

 An advantage that ultrasound has over other imaging modalities involves its increasing mobility. From innovations, such as portable handheld devices to wireless transducers, ultrasound has the ability to quickly image internal organs without being hampered by cables or moving bulky machines around in a patient’s room.

  This capability of ultrasound can improve not just the point of care at hospitals, but also the public’s access to medical imaging, especially in developing regions where it is needed. Vendors additionally are working to improve compact ultrasound systems for use in tight premium spaces within hospitals, such as in the operating room.

  For example, Siemens Healthcare is marketing an ultrasound system with wireless transducers, the Acuson Freestyle. Completely untethered from the console, the Acuson’s wireless transducer can be used to image from up to 10 feet away. The system is targeted toward use in interventional applications such as radiology and cardiology. The system uses a proprietary 8 GHz ultra-wideband radio frequency to transmit data to the main console, and also includes Bluetooth wireless control.

  One significant development has been the commercialization of handheld miniaturized devices that offer advanced computational power. This trend has been adopted by more diagnostic ultrasound OEMs with the introduction of portable, hand-carried ultrasound systems. Handheld units are growing at an increasing pace and becoming more popular among clinicians, especially for POC diagnosis. Such systems are primarily used for imaging internal organs, such as the abdomen, kidney, heart and peripheral vasculature. The integration of advanced features at POC diagnosis makes these systems more acceptable by clinicians.

  Facilitating the growth of handheld units has been the evolution of wireless probes, which allow care givers to carry ultrasound into any part of a hospital, physician’s office, or elsewhere. While the standard probe is a 128 element curved array, new probes include a 2D matrix array for volumetric 3D imaging. Probe manufacturers are always on the lookout for new materials that would make probes less expensive to make and better able to withstand heat.

  Another significant development has been the increase in the computational power of ultrasound systems. Such systems use more sophisticated and complex computational algorithms for enhanced image reconstruction and display. Tissue harmonic imaging has been a significant development in ultrasound imaging, in which the image reconstructed from the second harmonic reflected from the tissue helps to remove much of the unwanted noise from the images.

Prehospital Use Drives Market

  Recent advances have made ultrasound more accessible to prehospital providers with the introduction of handheld units that are more affordable, smaller in size, durable, lightweight, and with high-resolution imaging quality. Prehospital ultrasound may be beneficial for diagnosing and managing the critically ill remotely. In such cases, EMS providers can apply training to interpret ultrasound scans with a high degree of accuracy.

  Prehospital focused abdominal sonography for trauma (FAST) exams can reliably provide valuable information about abdominal trauma, leading to more appropriate transport destination decisions. In addition, field ultrasound images can be transmitted enroute to the emergency department to facilitate further evaluation by emergency physicians and trauma surgeons in order to expedite care.

  Prehospital ultrasound is finding a continuously growing list of diagnostic usage.  The enhanced technology enables prehospital professionals to answer focused clinical questions, which translate into faster and more accurate diagnosis and care of patients presenting with time-sensitive emergency conditions, and eventually improved health outcomes.

  Field ultrasound increases the accuracy of diagnosing pulmonary edema and not chronic obstructive pulmonary disease as the cause of acute dyspnea. It is effective in patients with unexplained hemodynamic instability to help differentiate between cardiac and non-cardiac causes of shock. Although advanced training is necessary, some prehospital providers have shown that ectopic pregnancy, placenta previa, and placenta abruption can be identified with about 95% percent reliability by using prehospital ultrasound.

  It has been shown that in patients undergoing CPR, ultrasound helped prehospital providers determine cardiac wall motion when the initial ECG diagnosis was identified as asystole. This was associated with an increased survival to at least hospital admission.

  Meanwhile, prehospital ultrasound for trauma patients with suspected pneumothorax can be effective in preventing unnecessary field needle thoracostomies. Using field ultrasound could help decrease potentially unnecessary needle thoracostomies and other invasive procedures en-route to a hospital.

  Improving the outcome of stroke patients requires early and rapid time-sensitive diagnosis and treatment as well as transport to an accredited stroke center. Early diagnosis using telestroke protocols with field transcranial ultrasound has decreased diagnosis-to-fibrinolytic therapy times and expanded the use of special interventional radiology procedures.

  The potential for the evolution of field ultrasound is largely dependent upon data that demonstrates its safety and effectiveness in clinical procedures and timely diagnosing medical and trauma conditions. Most importantly, the value of ultrasound use in the prehospital setting must illustrate how it improves patient outcomes. And, for vendors, developing effective ultrasound training programs for different level providers is important to maximize the use of ultrasound.

New Techniques

New techniques are improving the competitiveness of ultrasound. Speckle reduction, volumetric imaging, and elastography make it possible to reduce artifacts, improve the contrast of an image, reduce image noise, and better gauge tissue stiffness to detect subtle hard-to-spot abnormalities. These technologies increase ultrasound’s accuracy, repeatability, and efficiency, and help keep the modality competitive with other cross-sectional imaging modalities.

Speckle Reduction

The dots -- speckle – that occur in ultrasound when acoustic waves scatter off small particles in the target being scanned. Speckle degrades both the spatial and contrast resolution of ultrasound images and reduces the diagnostic value of the images. The intent of speckle reduction is to remove the distracting speckle pattern without reducing the detail in the ultrasound image—in other words, to make ultrasound images easier to read.   Reducing speckle has several advantages. These include higher perceived tissue contrast, which facilitates the identification of points of increased or decreased echogenicity. Reductions also decrease image noise, which can make the image more pleasing to the eye. Disadvantages include a reduction in frame rate caused by the need to send and receive beams from different directions; a possible loss in spatial resolution; and loss of acoustic enhancement and shadowing, which is often important in diagnosis.

Volumetric Imaging

On another front, the acquisition of image data from a volume of tissue -- volumetric imaging -- can be achieved by moving an ultrasound transducer through an area or organ perpendicular to the plane of the transducer, rather than simply sampling the volume with a small series of images. The result is a series of parallel slices that represent the volume of tissue that has been scanned.

Volumetric imaging has several advantages. The method of display on PACS is similar to that of CT, so it is familiar to radiologists. An entire organ is documented, increasing diagnostic confidence that no abnormality has been missed. Also, less tedious labeling of individual images is needed, resulting in shorter examination times. But it also has its disadvantages. PACS is required to properly interpret volume scans. A larger acoustic window is required, since an entire area or organ will be imaged in a sweep—not just a single slice. Some ultrasound systems cannot transfer large amounts of data quickly, causing delays. 

Elastography

Elastography improves ultrasound's specificity by utilizing conventional ultrasound imaging to measure the compressibility and mechanical properties of a lesion. Since cancerous tumors tend to be stiffer than surrounding healthy tissue or cysts, a more compressible lesion on elastography is less likely to be malignant. Elastography can properly identify lesions that appear to be malignant on a biopsy, as well as lesions that are benign. Elastography also can be more accurate in gauging the size of the lesions.

Various Enhancements to Ultrasound: Enhancements to ultrasound include contrast-enhanced imaging and volume imaging. In addition to providing real-time imaging of internal anatomy, these advances enable physicians to image blood perfusion and blood flow, view real-time 3-D imaging of structures, and more easily differentiate malignant tumors from the benign, among other functions.

  The availability of contrast-enhancing microbubbles gives doctors the ability to more clearly delineate between tissue and fluids. By enhancing the reflection of ultrasound waves, microbubbles create a clearer contrast between individual organs and blood flow in the image. Contrast agents include Bracco’s SonoVue, widely used in Europe, and Lantheus’ Definity, which is more common in the US. Other features of contrast-enhanced ultrasound include the ability to display vascularity in rendering modes and to more easily characterize malignant liver lesions for oncology applications.

 

Cardiac Advances

The value of ultrasound as a diagnostic cardiac modality is unparalleled. It is more portable and less expensive compared with other imaging modalities. Echocardiography makes possible the rapid assessment of cardiac size, structure, function, and hemodynamics.   Cardiac ultrasound finds use across the entire spectrum of patient care from in-utero to the frail elderly patient. Echocardiography is sensitive and specific for a broad range of clinical disorders, allowing evaluation of a wide variety of parameters with well-documented prognostic utility.

  Cardiac ultrasound technology has advanced to keep up with several trends. Advances include improved workflow for greater efficiency, expanded use of qualification metrics, expanded use of 3D echo to speed exam times and improve operator reproducibility, and expanded use of 3D transesophageal echo (TEE) to aid guidance in the growing area of transcatheter structural heart procedures.

  A major issue in ultrasound is the variation between operators, which may lead to different measurements for the same anatomy in the same patient based on operator experience and technique. Operator variability may also limit the use of ultrasound as a cardiac triage tool as it expands into point of care. Three-dimensional echocardiography may solve part of this issue by making it possible to acquire volume datasets, rather than very specific slices of the anatomy. A 3D volume acquisition allows a cardiologist reviewing the exam to select the optimal slices during post-processing, instead of relying on the echo technician to get the specific 2D views. Some high-end ultrasound systems already extract the ideal views automatically.

  In addition, with the growing number of new transcatheter procedures for mitral valve repair, transcatheter aortic valve repair, left atrial appendage closure, and closure of atrial septal defects and ventricular septal defects, 3D transesophageal echo (TEE) is becoming an essential tool for procedural navigation. Philips is marketing its CX50 xMatrix portable ultrasound system to interface with its live 3D TEE. The smaller footprint is expected to make it more competitive in the catheter laboratory and hybrid operating room environments. GE’s Vivid E9 Breakthrough 2012 cardiac ultrasound system includes a 3D/4D TEE probe, offering tools to improve workflow through simplified image acquisition. It is designed for intuitive navigation and easy-to-use quantification. The TEE probe allows 4D dataset acquisitions. The probe includes triplane imaging, 4D views, and high frame rates.

  Siemens fourSight TEE View enables 3D acquisition, reconstruction, and display at the point of care. Both 2D and 3D assessment can be combined with the use of a transducer. Reconstruction can be done immediately or at a later date.

Ultrasound for Biomarkers

 Advances in imaging technology and a better understanding of molecular and cellular processes have led to a number of new indicators that can facilitate pharmaceutical development. Novel indicators -- imaging biomarkers -- can show the presence or progress of disease; the effectiveness or toxicity of a proposed drug; and the response to therapy at the cellular and molecular levels. Industry, funding agencies, and regulators see these imaging biomarkers as a new way to improve the selection of drug candidates to take into expensive clinical trials, to shorten the trials themselves, and to accelerate regulatory approval.

  A computerized analysis of ultrasound images of the carotid artery may provide quantitative disease biomarkers and can potentially serve as a second opinion in the diagnosis of carotid atherosclerosis. A Hough-Transform-based technique for automatic segmentation of the arterial wall allows the estimation of the intima-media thickness and the arterial distension waveform, two widely used determinants of arterial disease. Texture features extracted from Fourier-, wavelet-, and Gabor-filter-based methods can characterize symptomatic and asymptomatic atheromatous plaque.

  Targeted ultrasound contrast agents can be used as molecular imaging agents to visualize the expression of endothelial molecules -- biomarkers. In a murine tumor model, three biomarkers for tumor vasculature were imaged using targeted ultrasound contrast agents and a commercial high frequency ultrasound system. Three biomarkers were targeted: VCAM-1, selectins (P and E), and VEGF receptors. Targeting was determined by ultrasound contrast imaging in tumors ranging in size from 3 up to 40 mm2.

  Depending on the tumor size, targeting of ultrasound contrast agents to the tumor vasculature resulted in significant signal enhancement when compared to the control contrast agent. Each targeted contrast agent had its own accumulation level during tumor growth, indicating a differential expression pattern of the target molecules during tumor growth. High frequency imaging with targeted ultrasound contrast can provide dynamic and quantitative information about the molecular profile of tumor vasculature. This can open the possibility for patient-tailored therapy and can provide a tool for monitoring the effect of the therapy.

POC Ultrasound Growth

  Point-of-care (POC) ultrasound is a very useful tool. POC ultrasound is an extension of the clinical examination. There are extensive efforts underway trying to design low-cost portable ultrasound systems by changing the transducer design, the transmission and reception circuitry needs, or the beam forming algorithms which may lead to horizontal expansion of the use of reliable non expensive portable ultrasound machines.

  POC ultrasound has the potential to save billions of dollars on an annual basis across health systems. It has the capacity to revolutionize patient care and improve procedural efficacy, decrease complications, and limit pain and suffering. Advances in ultrasound technology have fueled the emergence of POC ultrasonography, based on ease-of-use, superior image quality, and lower cost ultrasound units. The main barrier to future universal adoption is the lack of widespread, efficient, and affordable training solutions. The need and demand for ultrasonography training has grown in parallel to the expanded use of ultrasound technology.

  While traditional methods of performing a physical examination are of critical importance, health care practitioners who become skilled in the use of POC ultrasonography become uniquely empowered. POC ultrasound comprises a large number of sub-segments, including the emergency department, critical care, anesthesiology, and musculoskeletal clinical applications. These areas have not traditionally relied on ultrasound for their diagnostic evaluations. However, due to technological improvements and reductions in the cost of ultrasound equipment, these areas are rapidly adopting ultrasound as a tool for diagnostic and guidance.

  Not all health care facilities own POC ultrasound systems, and those that do are likely to purchase additional units in the future. Additional units are especially useful in hospital emergency rooms where multiple patients require treatment simultaneously.