Why Lung Ultrasound Should Be Adopted by Intensive Care Physiotherapists: Global Lessons and Pragmatic Pathways

The use of lung ultrasound (LUS) in intensive care units (ICU) has evolved substantially, becoming a fundamental bedside tool for pulmonary assessment. It has gained widespread acceptance due to its high diagnostic accuracy across multiple commonly encountered lung pathologies (Lichtenstein 2014). In addition to its role in initial clinical evaluation and diagnostic support, LUS enables monitoring of pulmonary and pleural disease progression, as well as guiding and optimising clinical management. For physiotherapists working in the ICU, LUS represents a transformative tool: portable, repeatable, radiation-free, and complementary to auscultation and chest X-ray (CXR). Its use can directly guide clinical decisions related to mechanical ventilation settings, patient positioning, secretion management, or lung recruitment manoeuvres. Globally, LUS implementation varies widely across ICUs and is determined by governance frameworks, available training pathways, and professional recognition (Lau et al. 2023). While some high-income countries are working to integrate physiotherapist-led LUS within interdisciplinary structures, many low- and middle-income countries (LMICs) are only beginning this journey (S. Hayward et al. 2025). In this context, the Chilean example offers a valuable case of how professional organisation and alignment with international frameworks can enable safe and scalable implementation. Drawing on the experience of Australia and the United Kingdom (UK), where physiotherapists are advancing their skills and training in LUS (Smith et al. 2022), this commentary argues that ICU physiotherapists in Chile and other LMICs should adopt LUS as an essential competency, supported by appropriate governance, accreditation pathways, and interprofessional collaboration. Lung ultrasound provides immediate answers to everyday clinical questions: Is there atelectasis, lung collapse or a pleural effusion? Is consolidation evolving? Is interstitial oedema present? Is the pleural effusion amenable to drainage or positional optimisation? All of this can be achieved with diagnostic accuracy that surpasses CXR. A recent systematic review demonstrates that LUS has superior sensitivity and specificity for detecting pleural effusions and lung collapse or consolidation compared with CXR (Zaki et al. 2024). An international consensus has defined quantitative applications of LUS in adult, paediatric, and neonatal ICUs, highlighting its interdisciplinary nature and its key role in bedside monitoring of lung aeration (Mongodi et al. 2025). These frameworks confirm the notion that LUS does not belong to any single profession; rather, it represents a shared clinical tool in which physiotherapists can contribute meaningfully when supported by adequate training and governance. Existing guidelines for LUS education vary across organisations; although they provide general direction, a universal evidence-based standard defining the competencies required for physiotherapist-led LUS remains absent. As with other diagnostic and therapeutic procedures, LUS training should be guided by learning-curve evidence and supported by clinical validation to ensure safe, high-quality practice (Pietersen et al. 2018). Physiotherapy in the ICU requires the integration of key variables, including gas exchange, lung aeration, lung mechanics, haemodynamics, and patient-centred goals, to optimise secretion clearance, improve oxygenation, promote lung recruitment and assist mechanical ventilation weaning (Tronstad et al. 2022). Lung ultrasound strengthens this integrative process by enabling real-time visualisation of pulmonary and pleural pathology directly at the bedside with direct impact on respiratory physiotherapy decision-making, positioning itself as a fundamental pillar of physiotherapy assessment (Hansell et al. 2021). A recent systematic review reported that approximately 64% of respiratory diagnoses were reclassified when LUS was incorporated into physiotherapy assessment. In pooled analyses, this diagnostic reclassification was associated with modifications in physiotherapy management in around 17% of cases and changes in treatment in up to 48% of cases (Lockstone et al. 2024). These findings are highly relevant to clinical practice, as the physiotherapist's ability to improve diagnosis and adjust treatment plans may influence patient outcomes, such as mechanical ventilation duration and ICU length of stay, contributing to more efficient use of resources (Le Neindre et al. 2016; Lockstone et al. 2023). Australia: The Australasian Society for Ultrasound in Medicine (ASUM) requires a supervised logbook of 40 LUS studies, with a defined proportion of directly observed and clinically indicated scans, in addition to three assessments (two formative and one summative) (Lockstone et al. 2023). The UK: The Intensive Care Society defines a staged accreditation pathway that includes theoretical training, supervised practice, independent scanning, and final evaluation, with mandatory audits and mentorship structures (Intensive Care Society). These models ensure safety, technical competence, and accountability. They also demonstrate that physiotherapists can lead clinical innovation within regulated interdisciplinary structures. To achieve global equity in training, it is proposed that LUS be incorporated into ICU physiotherapy specialisations and postgraduate programmes. Training programmes that combine short introductory courses with longitudinal supervised practice and reflective case logging, have demonstrated high effectiveness (Mongodi et al. 2024). Continuing professional development and peer review are essential for maintaining high standards of LUS performance and interpretation (Tan et al. 2024). In Chile, physiotherapists are a vital part of ICU teams, offering 24/7 respiratory care (Aranis et al. 2019). However, the formal integration of LUS into physiotherapy practice is still limited. In 2023, the Chilean Physiotherapy Ultrasound Interest Group (GIE-Chile) was formed to promote the responsible and evidence-based application of LUS (Colegio de Kinesiólogos de Chile). The Chilean experience demonstrates a scalable implementation model, starting with professional recognition, the development of supervised training pathways, and encouraging interprofessional collaboration under standardised protocols. This model shows how professional bodies and associations can help introduce advanced diagnostic tools through local governance frameworks and alignment with international standards (S. Hayward et al. 2025). Such an approach could be adopted in other LMICs aiming to formally include LUS into physiotherapy practice. The use of ultrasound by any health professional without adequate training may raise concerns related to misdiagnosis and inappropriate patient care. As LUS becomes progressively integrated into respiratory physiotherapy practice, it is essential to implement structured training pathways, establish a regulatory framework, and ensure appropriate clinical governance to address and mitigate these concerns (Smith et al. 2022). We outline key considerations aligned with international standards. One- or two-day introductory course on basic physics, scanning technique, prevention of cross-contamination and probe handling. Mentored logbook phase (e.g., 40 supervised scans) with reflective case documentation. Final competency assessment by an accredited sonographer, intensivist, or experienced physiotherapist. Fast-track methods are useful when supervision options are limited (Ntoumenopoulos et al. 2024). Ongoing education, supported by periodic supervision and knowledge-exchange opportunities, is essential to maintain LUS competence (Tan et al. 2024). Modern portable ultrasound systems have transformed feasibility: they are practical at the bedside, easy to handle and disinfect, and can integrate with hospital Picture Archiving and Communication Systems (PACS) (Dadon et al. 2022). Necessary features include linear and curvilinear or phased-array transducers, basic measurement tools and video-clip storage. In LMICs settings, ultrasound equipment must be shared across all members of the ICU team to optimise clinical utility. Clinical governance is a fundamental pillar for the safe and sustainable implementation of LUS in physiotherapy practice. In line with current recommendations, a shared objective across specialities and levels of care is the standardisation of infrastructure, documentation, and image archiving/retention processes, which enhances the integration of ultrasound findings into clinical records and improves traceability, continuity of care, and data accessibility (Ma et al. 2025). Within this framework, governance committees or designated working groups should define technical standards, training pathways, audit procedures, and quality-assurance requirements, ensuring that physiotherapist-led LUS develops under principles of patient safety, professional accountability, and clinical excellence (Colegio de Kinesiólogos de Chile). Despite its technological maturity and strong evidence-base, physiotherapist-led LUS implementation faces common barriers across settings, including scarcity of supervisors, lack of formal accreditation pathways, and limited institutional resources (Lau et al. 2023; Hansell et al. 2023). Overcoming these challenges requires not only technical training, but also a cultural shift that recognises the diagnostic capabilities of physiotherapists within safe governance structures. For LMICs, pragmatic strategies include shared access to equipment within ICUs, development of local mentorship networks, and participation in regional image registries to support quality monitoring. Thus, the global expansion of physiotherapist-led LUS does not shift professional boundaries; instead, it reinforces the interdisciplinary value of the ICU team. The Chilean experience demonstrates that preparedness for integrating LUS relies more on governance than on resources. The principles of standardised training, structured supervision, and interdisciplinary collaboration are universal and easily replicable. However, the limited availability of accredited mentors in Chile poses an additional challenge, underscoring the need to strengthen training programmes and to develop local teaching capacity. Despite the extensive evidence supporting the utility of LUS in ICU settings, physiotherapist-led LUS has yet achieved widespread clinical integration. Experiences from Australia and the UK demonstrate that when implementation is structured, supervised, and collaborative, LUS can transform physiotherapy practice in ICU. Global adoption of LUS, particularly in LMICs, depends on local resource availability, clear governance frameworks, sustainable mentorship, and strong cross-disciplinary collaboration. The challenge ahead is to move towards common international standards through the development of an international consensus, led by professional bodies, educators, and policy leaders, with the aim of establishing governance-driven frameworks that enable safe, effective, and clinically impactful physiotherapist-led LUS practice worldwide. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report.