ULTRASONOGRAPHY

OF THE THORAX

WIDIRAHARDJO
PULMONARY DEPARTMENT, FACULTY OF MEDICINE,
UNIVERSITY OF SUMATERA UTARA/ ADAM MALIK
HOSPITAL
MEDAN
2011

INTRODUCTION
THE SCOPE OF APPLICATION OF CHEST
SONOGRAPHY HAS BEEN SIGNIFICANTLY
WIDENED IN THE LAST FEW YEARS.
ADVANTAGES OF US: ABSENCE OF
RADIATION, PORTABLE, REAL-TIME
IMAGING, DOPPLER ASSESSMENT OF
VASCULARITY WITHOUT USE OF
CONTRAST MEDIUM, ABILITY TO
PERFORM DYNAMIC EVALUATION, NO
TOO DIFFICULT TO LEARN.
AS A STRATEGIC INSTRUMENT TO BE
USED DIRECTLY AFTER THE CLINICAL
INVESTIGATION.

INTRODUCTION, cont
DECIDE VERY RAPIDLY TO
ESTABLISH DIAGNOSES AT THE
PATIENTS BEDSIDE WITH
GREATER ACCURACY AND
EFFICIENCY, WHETHER A
TRAUMATIZED PATIENT.
SEVERAL DIAGNOSES SUCH AS
PNEUMOTHORAX, PNEUMONIA
OR PULMONARY EMBOLISM CAN
BE ESTABLISHED IMMEDIATELY.

INTRODUCTION, cont
SIGNIFICANTLY DEEPENED
KNOWLEDGE OF CHEST
SONOGRAPHY: THE
SONOMORPHOLOGY OF THE
NORMAL PLEURA
THE SONOANATOMY OF THE
UPPER APERTURE OF THE
THORAX HAS BEEN EXTENDED TO
INCLUDE IMAGING OF THE
BRACHIAL PLEXUS

INTRODUCTION, cont
MONUMENTAL STUDIES ON LYMPH
NODE STAGING IN THE PRESENCE OF
BRONCHIAL CARCINOMA IS
MARKEDLY SUPERIOR TO CT.
THE HIGH VALUE OF ENDOLUMINAL
ACCESSES (EBUS) IN GREATER DETAIL
AND WITH GREATER PRECISION.
THE NEW ISSUE ARE CONTRAST
SONOGRAPHY AND THE ELUCIDATION
OF CLINICAL SONOGRAPHY FROM
SYMPTOMS TO DIAGNOSIS.

HISTORY:
FIRST FOUND OF ULTRASOUND
AT 1920 NOT AS A DIAGNOSTIC
TOOLS YET
THEODORE DUSSIK DAN
FREIDERICH AT 1940 EXAMINE
THE TUMOR AND BLOOD VESSELS
OF THE BRAIN
TO BE ADVANTED BY GEORGE
LUDWIG AT 1950
INTRODUCING OF DIGITAL

Thoracic sonography. Respir Care.2001;46:9329.

CARA KERJA USG:

MEMANTULKAN DAN
MENERIMA
SINYAL
KEMBALI GELOMBANG
GELOMBAN
G
BALIK
SUARA
LISTRIK
KRISTA
L
VIBRAS
I

GELOMBAN
G SUARA

TRANSDUCER

KRISTAL
DISTORSI

GELOMBANG
PANTUL

Crit Care Med 2007 Vol. 35, No

PRINSIP DASAR USG TORAKS:

ORGAN DEKAT PERMUKAAN
FREK. TINGGI (7,5 10 MHz)
ORGAN LEBIH DALAM
RENDAH
(2 5 MHz)

FREK.

JENIS TRANSDUCER ATAU

PROBE:

LINEAR

CONVEX

SECTOR

Crit Care Med 2007 Vol. 35, No. 8

STRUCTURES AND
PATHOLOGICAL CHANGES
ACCESSIBLE TO SONOGRAPHY

INDICATIONS:
1. THORAX WALL
(A) BENIGN LESIONS
BENIGN NEOPLASMS (E.G., LIPOMA)
HEMATOMA
ABSCESS
REACTIVATED LYMPH NODES
PERICHONDRITIS, TIETZES SYNDROME
RIB FRACTURE
(B) MALIGNANT LESIONS
LYMPH NODE METASTASES (INITIAL
DIAGNOSIS AND
COURSE OF DISEASE DURING TREATMENT)
INVASIVE, GROWING CARCINOMAS
OSTEOLYSIS

INDICATIONS, cont
2. PLEURA
(A) SOLID STRUCTURES:
THICKENING OF THE
PLEURA, CALLUS,
CALCIFICATION,
ASBESTOSIS PLAQUES
(B) SPACE-OCCUPYING MASS
BENIGN: FIBROUS TUMOR,
LIPOMA
MALIGNANT:

INDICATIONS, cont
(C) FLUID: EFFUSION, HEMATOTHORAX,
PYOTHORAX, CHYLOTHORAX
(D) DYNAMIC INVESTIGATION
PNEUMOTHORAX
DISTINGUISHING BETWEEN EFFUSION
AND
CALLUS FORMATION
ADHERENCE OF A SPACE-OCCUPYING
MASS
INVASION BY A SPACE-OCCUPYING MASS
MOBILITY OF THE DIAPHRAGM

INDICATIONS, cont
3. FORMATION OF PERIPHERAL
FOCI IN THE
LUNG
(A) BENIGN: INFLAMMATION,
ABSCESS,
EMBOLISM, ATELECTASIS
(B) MALIGNANT: PERIPHERAL
METASTASIS,
PERIPHERAL CARCINOMA,

INDICATIONS, cont
4. MEDIASTINUM, PERCUTANEOUS
(A) SPACE-OCCUPYING MASSES IN THE UPPER
ANTERIOR MEDIASTINUM
(B) LYMPH NODES IN THE
AORTICOPULMONARY
WINDOW
(C) THROMBOSIS OF THE VENA CAVA AND ITS
SUPPLYING BRANCHES
(D) IMAGING COLLATERAL CIRCULATION
(E) PERICARDIAL EFFUSION

SPECTRUM OF APPLICATION OF
SONOGRAPHY FOR PLEURAL AND
PULMONARY DISEASE

INDICATIONS FOR INVASIVE

SONOGRAPHY

PLEURAL
ULTRASONOGRAPHY

TECHNIQUE &
INSTRUMENTATION
REVIEW CXR, LOCALISE AREA
OF INTEREST
SCANNING ALONG THE
INTERCOSTAL SPACE OR
ABDOMINAL APPROACH
USING LIVER AND SPLEEN AS
A WINDOW
DURING QUIET AND
ARRESTED RESPIRATION

LINEAR PROBE PLACED LONGITUDINAL VIEW ON THE RIGHT PARASTERNAL LINE. M MUSCLE, P LINE OF THE PLEURA

LINEAR PROBE PLACED PARALLEL TO THE RIBS IN THE THIRD INTERCOSTAL

SPACE, TRANSVERSE VIEW, M MUSCLE, P LINE OF THE PLEURA

POSITION TO EXAMINE
STRUCTURES BEHIND THE

TRANSHEPATIC VIEW, A CONVEX PROBE PLACED

SUBCOSTALLY FROM THE RIGHT. SLIGHT TILTING IN
CRANIAL DIRECTION. L LIVER, LV LIVER VEIN, ZF
DIAPHRAGM, S REFLECTION OF THE LIVER ABOVE THE
DIAPHRAGM

LATERAL VIEW, CONVEX PROBE,

LONGITUDINAL VIEW IN THE MID
PORTION OF THE RIGHT AXILLARY LINE.
D DIAPHRAGM.

A SUBCUTANEOUS HEMATOMA AFTER BLUNT TRAUMA (H) IS LARGELY ANECHOIC.

PLEURAL FLUID (E) BEHIND THE CHEST WALLHEMOTHORAX

FIBROLIPOMA IN THE PARIETAL PLEURA.

THE DIAGNOSIS WAS CONFIRMED BY
SONOGRAPHY-GUIDED BIOPSY.

RIB FRACTURE WITH A STEP OF

1.5 MM. THIS FRACTURE COULD
NOT BE SEEN ON X-RAYS.

EPIDERMOID CARCINOMA AT THE RIGHT APEX

OF THE LUNG, INVADING THE CHEST WALL,
IRREGULAR VASCULARIZATION PATTERN

CHEST WALL WITH NORMAL SMOOTH VISCERAL

PLEURA (ARROW 1). ON THE OUTSIDE, THE ECHOPOOR PLEURAL GAP (ARROW 2) AND THEN THE
ECHOGENIC (ECHO-RICH) PARIETAL PLEURA (ARROW
3).

NUMEROUS COMET-TRAIL
ARTIFACTS ON THE
DIAPHRAGMATIC PLEURA

DIAGNOSIS OF PLEURAL EFFUSION

CONVENTIONALLY USING CHEST
RADIOGRAPH
BLUNTING OF COSTOPHRENIC
ANGLE AND HOMOGENEOUS
OPACITY WITH MENISCUS SIGN
ABOUT 200ML BEFORE IT CAN BE
SEEN
LATERAL DECUBITUS
RADIOGRAPH MAY DETECT
EFFUSION AS SMALL AS 10ML
CANNOT BE DISTINGUISHED
FROM PLEURAL THICKENING

ESTIMATING THE VOLUME OF

PLEURAL EFFUSION

ECHOGENIC PROTEIN-RICH
EFFUSION

HOMOGENOUS ECHOGENIC
PLEURAL EFFUSION CHYLOTHORAX

MALIGNANT PLEURAL EFFUSION.

OPEN (ARROW) SMALL PLEURAL
METASTASIS ON THE
DIAPHRAGM

HONEYCOMB-LIKE
APPEARANCE OF A
POSTINFLAMMATORY
EFFUSION, LOCULATED
LESIONS OR SEPTATION.

REGULAR AND WELL DELINEATED THICKENING

OF
THE PARIETAL AND VISCERAL PLEURA IN AN
ALREADY DRAINED EMPYEMA. SMALL AIR
BUBBLES IN THE COMPLETELY EMPTIED CAVITY
(ARROWS)

METASTASIS OF BREAST CANCER, SITTING ON

THE OTHERWISE UNCHANGED PARIETAL
PLEURA PARIETALIS. A SURROUNDING LARGE
PLEURAL EFFUSION

INITIAL DIAGNOSIS OF A PLEURITIC

MESOTHELIOMA, COVERING, IN A
WALLPAPER-LIKE FASHION

MESOTHELIOMA:
WIDESPREAD INFILTRATION OF THE
THORACIC WALL WITH SPREAD AROUND
THE RIBS (ARROW HEADS), AS WELL
INFILTRATION OF THE LUNG (ARROW)

PNEUMOTHORAX:
THE LEFT HEALTHY SIDE (A) SHOWS A
RESPIRA- .
TORY SHIFTING PLEURAL REFLEX AND
CLEARLY LESS REVERBERATIONS. ON THE
SIDE OF THE PNEUMOTHORAX (B), THE
REVERBERATIONS ARE INTENSIFIED AND NO
RESPIRATORY SHIFT IS VISIBLE

SONOMORPHOLOGY
PNEUMOTHORAX:
ABSENCE OF THE GLIDING SIGN
ROUGH REPETITIVE ECHOES
(REVERBERATION)
NO VISUALIZATION OF THE
PLEURAL GAP
NO COMET-TAIL ARTIFACTS

PNEUMONIA

PNEUMONIA WITH MICROABSCESS

SONOMORPHOLOGY OF PNEUMONIA:

SIMILAR TO THE LIVER IN THE EARLY

STAGE
LENTIL-SHAPED AIR TRAPPINGS
BRONCHOAEROGRAM
FLUID BRONCHOGRAM (POSTSTENOTIC)
BLURRED AND SERRATED MARGINS
REVERBERATION ECHOES AT THE
MARGIN
HYPOECHOIC TO ANECHOIC IN THE
PRESENCE
OF ABSCESS (MICROABSCESSES!)

TUBERCULOSIS

SONOMORPHOLOGY OF LUNG
TUBERCULOSIS:
NARROW PLEURAL EFFUSIONS
THICKENED AND FRAGMENTED
VISCERAL
PLEURAL REFLEXES
A FEW OR NUMEROUS
HYPOECHOIC LESIONS
IN SUBPLEURAL LOCATION
PNEUMONIC LESIONS
FORMATION OF CAVITIES

TUMOR

TUMOR

ECHOTEXTURE OF TUMOR

INHOMOGENEOUS
HYPOECHOIC
RARELY ECHOGENIC
RARELY UNECHOIC
NECROTIC AREAS

PULMONARY EMBOLISM

SONOMORPHOLOGY OF
PULMONARY EMBOLISM:
HOMOGENEOUS STRUCTURES WITH
A PLEURAL BASE THAT IS
OCCASIONALLY A LITTLE PROTRUDED
HYPOECHOIC
SMOOTH MARGINS PROTRUDED AND
ROUNDED
CENTRAL BRONCHIAL REFLEX IS
EITHER WEAK OR ABSENT
A CLEAR BRONCHOAEROGRAM IS
NOT SEEN IN
ANY EARLY LUNG INFARCTION

COMPRESSED ATELECTASE

SONOMORPHOLOGY OF
COMPRESSED ATELECTASE:
PLEURAL EFFUSION, THE MARGIN
TOWARDS THE ADJACENT
AERATED LUNG TISSUE IS BLURRED
DURING INSPIRATION SONOGRAPHY
REVEALS AN INCREASING QUANTITY OF
AIR IN ATELECTATIC REGIONS AND THE
FORMATION OF A SO-CALLED AIR
BRONCHOGRAM
CONCOMITANT INFLAMMATORY
INVASION OF PARENCHYMA IN
ATELECTATIC TISSUE IS A FURTHER
LIMITATION. IT LEADS TO CONGESTIVE
PNEUMONIA

OBSTRUCTIVE ATELECTASE

SONOMORPHOLOGY OF
OBSTRUCTIVE ATELECTASE:
MILD TO NO PLEURAL EFFUSION
HOMOGENOUS HYPOECHOIC
TRANSFORMATION OF LUNG PARENCHYMA
HYPERECHOIC REFLEXES MAY BE SEEN
(FLUID BRONCHOGRAM)
FOCAL INTRAPARENCHYMATOUS LESIONS
MAY BE SEEN :
- LIQUEFACTION OF PARENCHYMA
- MICROABSCESSES, GROSS ABSCESSES
- METASTASES
A CENTRAL SPACE-OCCUPYING LESION MAY
BE SEEN
NO REVENTILATION DURING INSPIRATION

TRANSTHORACIC MEDIASTINAL
SONOGRAPHY

TRANSTHORACIC MEDIASTINAL
SONOGRAPHY

THYMOMA

CYSTIC BENIGN TERATOMA.

A 32-YEAR-OLD PATIENT, LEFT PARASTERNAL
SECTION IN SUPINE POSITION, CLEARLY
DELINEATED MASS WITH ECHOGENIC SEPTUMLIKE STRUCTURES. IN THE CENTER , HIGH
AMPLITUDE REFLEXES WITH DORSAL
SHADOWING (CENTRAL CALCIFICATIONS).

ENDOBRONCHIAL
ULTRASONOGRAPHY
(EBUS)
INDICATIONS:
EARLY CANCER
ADVANCED CANCER
PERIPHERAL LESIONS
LYMPH NODE STAGING
ENDOBRONCHIAL SONOGRAPHY
IN THERAPEUTIC INTERVENTIONS

ENDOBRONCHIAL
ULTRASONOGRAPHY (EBUS)

TU tumor, LN lymph node, AOA ascending aorta, TR trachea, ES

endoscopic probe, ln small lymph
node, VC vena cava
.
6
Chapter 134 6 Mediastinum

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