1

Why such a delay for lung ultrasound to become popular ?

Harrisons 16th ed.

Because ultrasound energy is rapidly dissipated in air, ultrasound imaging is not useful for evaluation of the pulmonary parenchyma Helpful for pleural abnormalities Used as a guide to sample pleural liquid ~ P. 1506
4


50EMT ?
1. 2. 3. 4.
6

Patient position

Ultrasound areas

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Landmarks of the chest wall

Lung surface: 1500cm2 Position: as stethoscope 9 areas
Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)

4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior

Landmarks of the chest wall

Lung surface: 1500cm2 Position: as stethoscope 9 areas
Anterior zone (1-4) Lateral zone (5,6) Posterior zone (S,M,L)

4 stages
1. anterior 2. lateral 3. portion of posterior 4. posterior

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Principles of Lung Ultrasound

1. 2. 3. 4. 5. 6. Dependent v.s. Nondependent disorders Lung surface is extensive All lung signs arise from the pleural line Analyze artifacts Dynamic signs Acute disorders contact the thorax surface 7. A simple & 2-D device meets this task

Earth-Sky Axis
Fluids want to descent, gases to rise. Lung disorders
Dependent: PLE, consolidation, . Non-dependent: PTX, interstitial syndrome, .

Define the scanning situation

Degree of aeration and US signs Key concepts: Air versus Water

Degree Pathologic disorder
100% 98% 95% 80% 10% 5% 0% Pneumothorax Normal lung Ground-glass areas Alveolar consolidation Atelectasis Pleural effusion

Ultrasound pattern
A lines & Lung sliding (-) A lines & Lung sliding (+) B3 lines Hepatization & air bronchograms (++) Hepatization & air bronchograms (-) Anechoic collection

Thickening of the interlobular septa B7 lines

15


?
1. 2. 3. 4.

Interstitial syndrome

?
1. 2. 3. 4. Bat sign A line B line C line

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians


M?
1. 2. 3. 4. Bat sign Lung rocket Shred sign C line

19

Normal Landmark Bat sign & A line

Rib

Pleural line A-line

Interstitialline B syndrome

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Comet-tail artifact

C line

Normal lung surface

1. 2. 3. 4.

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Normal lung surface Lung sliding (+) & A line

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Pneumothorax

1. 2. 3. 4.

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Pneumothorax Lung sliding (-) & A line

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Pleural Effusion
1. Anechoic pattern 2. Static: Sharp sign 3. Dynamic: Sinusoid sign

Discrepant results

The Sharp Sign

The Sinusoid Sign core-surface axis

US application in pleural effusion

Detect the effusion Evaluate its volume Reveal its nature Locate tapping area Visual approach rule
Interpleural space :15mm No interposed organs Locate safe route/depth

Withdrawal pleural effusion

Improve ventilatory mechanics Assist weaning
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transudate exudate pleural effusion ?
1. 2. 3. 4. Fibrin Septation Echogenic fluid Anechoic fluid

34

28F with SOB for days

35

48M, thrombocytopenia

36

51M, TCC with SOB

990109 990125

37

: 79M, SOB, cough & fever

? 1. 2. 3. 4.

38

79M, SOB, cough & fever

39

Pneumothorax

40

Lung ultrasound for pneumothorax

When suspect pneumothorax Cardiac arrest/ unstable patient Radio-occult pneumothorax Limited-resource areas More accurately rules in PTX than supine CXR
41


?
1. 2. 3. 4. McConnellss sign Lung point Comet-tail artifact Lung pulse

42

43


?
1. 2. 3. 4. lung sliding comet-tail artifact lung point lung pulse

44

Normal dynamic lung pattern Lung sliding: all-or-nothing rule Seashore sign

Rule out pneumothorax

 Setting: MICU Patients: Intervention: supine analysis of anterior chest wall Results:
Feasibility Sensitivity Specificity NPV 98.1% 95.3% 91.1% 100% PTX: 43 Control: 68

Lichtenstein DA, et al. Chest 1995;108:1345-48

Rule out pneumothorax all-or-nothing rule

Lichtenstein DA, et al. Inten Care Med 1997;25:383-388

Stratosphere sign (Barcode Sign)

Lung sliding (-) Sensitivity 100% Specificity 78% A line sign (No B line) Sensitivity 100% Specificity 60%

Pneumothorax

Sensitivity 66% Specificity 100%

Lung point

Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440

Sensitivity 66% Specificity 100%

Lung point

Pneumothorax
Lichtenstein DA, et al. Inten Care Med 2000;26:1434-1440

Explanation of lung point

Accuracy of US for PTX

Lung sliding (-)
LS (-) + A line sign LS (-) + A line sign + lung point LS (-) LS (-) + A line sign LS (-) + A line sign + lung point

Pneumothorax Control Group 43 of 43 65 of 302 41 of 43 16 of 302 34 of 43 0 of 302 Sensitivity, % Specificity, % 100 78 95 94 79 100
Lichtenstein DA, et al. CCM 2005;33:1231-1238

Power slide sign

Sensitivity 93% Specificity 100%

Rule out Pneumothorax

Algorithm for PTX

1. 2. 3. 4. 5. Recognition of PTX (Emergency or Pre-hospital) Visual approach drainage Monitoring evolution Post-intervention F/U Pregnancy/Children consideration

57

21M with chest pain and SOB

58

16M with right chest pain and SOB

59

Pneumothorax
1. Lung point(s) (+) 2. Lung sliding (-) 3. B-lines (-) 4. Lung pulse (-)

Interstitial Syndrome
3 B-lines in a longitudinal plane between 2 ribs Thickening of interlobular septa (B7 lines) Ground-glass areas (B3 lines)

Normal static lung pattern A line & B line

A lines and B lines cannot be visible at the same location

8 region scanning for interstitial syndrome

63

B versus b line

Lung rockets

Comet-tail artifact Lung rockets

B-line

Rule out pneumothorax Indicate interstitial syndrome D/D APE & COPD with AE (Sen 100%/Spe 92%)

two or more positive regions bilaterally

Positive exam:

66

APE versus Normal

Normal versus APE

US B lines Kerley B lines

: Comet-tail artifacts
lung edema?

Comet-tail artifact Lung rockets

B-line

Rule out pneumothorax Indicate interstitial syndrome

Comet tail artifact

Z-line

Comet-tail artifact

E-line

Parietal emphysema

Causes of interstitial syndrome

Pulmonary edema of various causes Interstitial pneumonia or pneumonitis

Diffuse parenchymal lung disease ( pulmonary fibrosis)

73

74

75

76

ARDS vs cardiogenic pulmonary edema

Anterior sub-pleural consolidations Absence or reduction of lung sliding spared areas of normal parenchyma Pleural line abnormalities (irregular thickened fragmented pleural line) Non-homogenous distribution of B-lines

77

Focal (localized) interstitial syndrome

Pneumonia & pneumonitis Atelectasis Pulmonary contusion Pulmonary infarction Pleural disease Neoplasia Normal lung
78

Aurora sign

Be careful

39F, jumping from bridge with drowning and hypothermia

81

64M with SOB

82

55M with right side paralysis and SOB

83

Alveolar Consolidation
98.5% of cases abut the pleura Sensitivity 90%/ Specificity 98%

C line

 Locate in the thorax Arise from the pleural line or associated PLE Tissue-like pattern Static
Irregular deep boundary

Alveolar consolidation
Air bronchogram
Dynamic
pneumonia

Static
Atelectasis Lung pulse

Dynamic
Absence of any sinusoidal component

Assess volume Detect abscess or necrotizing areas

Hepatization & Air Bronchogram

Pleural effusion and alveolar consolidation; typical example of PLAPS

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125 PLAPS: PosteroLateral Alveolar and/or Pleural Syndrome
2008 by American College of Chest Physicians

20M, R chest pain with cough and fever

89

46M with cough and chest pain

Consolidation Localized B lines PLE

90

28M with PN and worsening pain

91

81M with respiratory failure

92

40M with left chest pain and cold sweating

93

59F with severe left flank pain

94

43F with chest pain and fever

95

81M with fever and cough

1st day 2nd day

96

71M with fever and SOB

97

fever, cough and chest pain for one week

990602 990816

38M with CKD on HD,

98

Bedside Lung Ultrasound in Emergency (BLUE protocol)

99

Ultrasound profiles

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125

2008 by American College of Chest Physicians

Normal PV demo

Deep Vein Thrombosis

Combined Results
Normal Profile, and A Profile Without PLAPS 0 751 109 1 3

Diagnoses Pulmonary edema COPD or asthma

A Profile Plus PLAPS

2 4 108

B Profile 621 3 0 0 6

B Profile 0 0 0 0 9

C Profile 0 1 10 0 18 0 0 0 0

A/B Profile 0 0 0 8 0

Lung Point

Pulmonary embolism

Pneumotho rax 0 Pneumonia 35

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Accuracy of the Ultrasound Profiles

Disease Cardiogenic pulmonary edema Ultrasound Signs Used Diffuse bilateral anterior B+ lines associated with lung sliding (B profile) Predominant anterior A lines without PLAPS and with lung sliding (normal profile), or with absent lung sliding without lung point Predominant anterior bilateral A lines plus venous thrombosis Absent anterior lung sliding, absent anterior B lines and present lung point Diffuse bilateral anterior B+ lines associated with abolished lung sliding (B profile) Sensitivity, % Specificity, % Positive Predictive Value, % Negative Predictive Value, % 97 (62/64) 95 (187/196) 87 (62/71) 99 (187/189)

COPD or asthma Pulmonary embolism

89 (74/83)

97 (172/177)

93 (74/79)

95 (172/181)

81 (17/21)

99 (238/239)

94 (17/18)

98 (238/242)

Pneumothorax Pneumonia

88 (8/9)

100 (251/251)

100 (8/8)

99 (251/252)

11 (9/83) Predominant anterior B+ lines on one side, predominant anterior A lines on the other (A/B profile)

100 (177/177)

100 (9/9)

70 (177/251)

14.5 (12/83) Anterior alveolar consolidation (C profile) A profile plus PLAPS A profile plus PLAPS, B, A/B or C profile

100 (177/177) 21.5 (18/83) 42 (35/83) 89 (74/83)

100 (12/12) 99 (175/177) 96 (170/177) 94 (167/177)

71.5 (177/248) 90 (18/20) 83 (35/42) 88 (74/84)

A decision tree utilizing lung ultrasonography to guide diagnosis of severe dyspnea.

Lichtenstein D. A., Mezire G. A. Chest 2008;134:117-125 BLUE: Bedside Lung Ultrasound in Emergency
2008 by American College of Chest Physicians

Airway Control
Tracheal rapid ultrasound exam (T.R.U.E.) for confirming ET placement during emergency intubation Chou HC, el. Resuscitation 2011 Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency Intubation Sim SS. el. Resuscitation 2012

Sensitivity 93% Specificity 100%

Rule out Pneumothorax Possible one lung intubation

Endotracheal tube confirmation

Endotracheal tube confirmation

Others

Comet-tail artifact

E-line

Parietal emphysema

Sternal fracture

J Ultrasound Med 2006;25:1263-1268

Rib fracture

US may replace post-interventional radiography

Lung Contusion

Pulmonary embolism

Chest. 2005;128:1531-1538

Advantages of US for PTX

High feasibility High sensitivity Rapidity Ability to predict the extent of pneumothorax Simple technique Short learning curve Simple logistics Wide-ranging applications Non-invasive method

Limitations and pitfalls of US

Parietal emphysema Posterior locations of pneumothorax Anterior septate pneumothorax Imperfect specificity of certain signs Dyspnea Large dressings Technical errors

Clinical consideration
Lung US: answer to the traditional quandary of radiography or CT in the ICU Approach to a dyspneic patient A field to be defined: For whom ? A field to be defined: By whom ? Lung US: a space for simplicity Versatility: an access to the neighboring organs Hamlessness, Cost savings Limitations of lung US Training in lung US

Clinical applications
Pleural effusion Pneumothorax Interstitial syndrome Alveolar consolidation Airway control Others


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