MAB RESOURCES · August 23rd, 2021
Product Review: Butterfly iQ Ultrasound
From November 2020 through January 2021, the NVA Medical Advisory Board conducted a trial of an affordable handheld portable ultrasound device, the Butterfly iQ, at four NVA hospitals. The intent of the trial was to determine ease of use and integration into GP practice, evaluation of the Butterfly app, and subjectively assess image quality.
The Butterfly iQ is intended for point of care ultrasound (POCUS), and as a screening tool to determine the need for further medical evaluation. The hand-held probe is unique in that it utilizes micro-machined sensors to emulate different types of traditional piezo crystal ultrasound probes (linear, curved, or phased), and attaches via cable to easily transportable Apple and android devices for image viewing. A wireless charger accompanies the device and provides 2 hours of use from 5 hours of charge time. Controls and adjustments are accessible via the Butterfly app.
The system features 12 presets depending on what anatomy is being evaluated. These include abdomen, bladder, several cardiac options, musculoskeletal, vascular, and others. Additionally, color Doppler, B-mode, and M-mode are options for cardiac and vascular studies. Other features are gain and depth adjustability via touchscreen swiping, linear and elliptical measurement capabilities, and the ability to create annotations on images.
Images and studies can be saved and organized on a secure Butterfly Cloud server, which provides for viewing on other devices as well as evaluation by other clinicians. Images may also be e-mailed or texted, are dicom compatible, convertible to PDF, and able to be downloaded into electronic medical records. There is no direct telemedicine function within the system.
The Butterfly app includes instructions and a help section entitled “Master the iQ” which details how to manipulate controls and settings. There is also an Education section that links to instructional videos embedded in the application. These videos feature human patients and anatomy, as the Butterfly was initially launched in the human health market.
For veterinarians who purchase a unit, Butterfly has partnered with the third-party educational platform WAVE, to offer a free introductory course: Basic FAST (fast assessment study) with Rita Echandi, DVM, DACVR. This instructional video gives an excellent overview of how to perform both abdominal and thoracic fast assessment studies in small animals.
The Butterfly iQ veterinary model list price is $2,419, very inexpensive in the world of ultrasound devices. For unlimited scanning, capture, storage, sharing, and full access to all imaging modes and advanced tools, the Pro Individual yearly membership fee is $420/year, billed annually. The Pro Team membership, which can cover up to five users, costs $1,200 annually.
The NVA MAB members who trialed the device set out to answer a set of questions regarding the technology, giving both numerical scoring and commentary in response. The scoring system utilized a 1-5 scale, with 5 being the most positive response. Conclusions were as follows:
Getting started with the Butterfly iQ is easy, the set-up is smooth, and the device is user-friendly. The average numerical score was 4.5.
The training provided was also evaluated. Instructions for settings and controls are part of the app and are clear, concise, and intuitive. From that standpoint, the Butterfly scored well at 4.5. The app does not provide general ultrasound training applicable to veterinary medicine, though the WAVE educational video that can be accessed separately is very informative and detailed for those clinicians learning to perform FAST studies.
Image quality was assessed subjectively. It is important to note that the Butterfly iQ is a screening tool, intended to identify abnormalities that require further evaluation; it is not designed to provide in-depth ultrasonographic diagnoses. That being said, our subjective assessment is that the image provides a relatively narrow field of view, and image quality is comparable or less favorable to that of certain relatively inexpensive ultrasound units already located in the practices where we trialed the device.
For simple tasks such as determining the presence/absence of effusions, and locating structures such as the urinary bladder, cryptorchid testes, and superficial blood vessels, we found the Butterfly iQ to be adequate. If connected to an iPhone, the small screen size made assessment more difficult, (though this has obvious portability advantages.)
Our reviews were mixed as to whether the Butterfly iQ image quality was suitable for POCUS in a GP setting. Two of the four clinicians felt that the image quality if used to answer simple questions as noted above, was very good with a score of 4-5. The remaining two doctors felt that the image quality made its use for even this purpose less than ideal, with a score of 2. This variance may partly depend on the overall ultrasound experience or comfort level of doctors, and to what other devices they are accustomed.
Ultrasound devices to which our clinicians subjectively compared the image Butterfly iQ were varied and included: a SonixOne, a Xario 100, an EDAN DUS60, and a Sonoscape A6V.
Perception of image quality influenced whether or not participants found that the Butterfly iQ increases the accessibility of point-of-care ultrasound in the general practice setting. The overall score here was 3.25, reservations being that image quality allowed at best for only simple observations as described above, but not more.
The functionality of the Butterfly app was found to be excellent with an overall score of 4.5. This includes the controls for color-flow Doppler, freezing and saving images, and taking measurements.
Participants also opined on whether the Butterfly iQ is recommended as a stand-alone option for ultrasound capability in GP practice. The combined scored response was 1.75, with one respondent noting that if the only goal was to gather the simple information noted, the score would clearly be higher.
As to whether the Butterfly iQ is recommended as an add-on option to practices that already utilize ultrasound technology, the combined score was 3.5. Factors to consider are its advantages in portability and convenience relative to that of the devices already in the practice, the utility for simple screening purposes and locating anatomic structures, and its low cost.
It should be noted that financial barriers have often been an obstacle to the introduction of ultrasound into many general practices. Oftentimes ROI on expensive units is not realized for varied reasons, including inadequate US training, clinician confidence level, and accessibility of boarded radiologists. The Butterfly iQ can potentially circumvent the cost barrier. The main disadvantage discovered was that of image quality.
Overall, the MAB trial gave a better than neutral recommendation for its use as an add-on ultrasound device. There were mixed results as to whether the image quality was adequate, even for POCUS purposes.