LUNG ULTRASOUND

Jointly organized by: SPECIAL THANKS TO:

LUCA NERI
Malaysian WINFOCUS, & ENRICO STORTI
SUCCES GABRIELE VIA

ObjectiveS
! To learn the basic PRINCIPLES &
TECHNIQUE of lung ultrasound

! To gain an understanding PHYSIOLOGICAL

& PATHOLOGICAL PATTERNS of lung
ultrasound

KUALA LUMPUR INTERNATIONAL TRAINING UNIT

A poor medium?
“Because ultrasound energy is rapidly
dissipated in air, ultrasound imaging is not
useful for evaluation of the pulmonary
parenchyma.”


US Passage
FORBIDDEN

TISSUE-AIR INTERFACE
KUALA LUMPUR INTERNATIONAL TRAINING UNIT
 IMAGES
(Pathology)

ARTIFACTS
(Normal, Pathology)

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Lung Ultrasound
Basic Technique :The Seven Principles of Lung Ultrasound

1. A Simple ,2D apparatus is the most appropriate for lung ultrasound

2. The thorax is an area where air and water are intimately mingled.
3. The Lung is the largest organ in the human body.
4. All signs arise from pleural line.
5. Lungs signs are mainly based on analysis of artefacts.
6. Most lungs signs are dynamic.
7. Nearly all acute disorders of thorax come in contact with surface

D.A Lichtenstein:Whole Body Ultrasound in

Critically Ill
KUALA LUMPUR INTERNATIONAL TRAINING UNIT

Basic Techniques: Which Probe?

Equipment
Microconvex Probe 4-7 MHz
Curvilinear Probe 4-7 MHz
Linear Probe

Settings
Convention – marker to left of screen
No harmonics (off THI)

7
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 Probe Orientation
LONGITUDINAL SCANS

TRANSVERSAL SCANS

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Where to scan? Topography

1
Sternum 2
3

Anterior
4
Axillary

Posterior
5
Axillary
6

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Lung Ultrasound: Nomenclature

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IMPORTANT LANDMARKS: THE BAT SIGN

The “BAT SIGN”

Lichtenstein D. Crit Care Med 2007 Vol. 35, No. 5 (Suppl.)

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THE PLEURAL LINE

Rib

Pleural Line

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➠ LUNG SLIDING

100% NO PNEUMOTHORAX
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 A Lines
Lungs signs are mainly based on analysis of artifacts.
Artifacts which define the normal lung: the A lines

skin

Pleural line
Air

Air

Air

Ultrasound beams hit pleural

and caused reverberation
shadows in the form of A
lines.
KUALA LUMPUR INTERNATIONAL TRAINING UNIT

B Lines

Beam trapped between the

small mixed system:persistent
to-and-fro movement

A line
Interstitial Syndrome
Air

Air

Air

Fluid in intestitial
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The comet-tail artifact: an ultrasound sign of alveolar-interstitial syndrome.
KUALA LUMPUR INTERNATIONAL TRAINING UNIT DANIEL LICHTENSTEIN J RESPIR CRIT CARE MED 1997;156:1640–1646.

B-LINES
FEATURES OF THE B-
LINE:

1. Vertical bright line (laser like)

2. Arises form the pleural line
3. Spreads without fading to the
edge of the screen
4. Moves synchronous with the
lung sliding
5. Erases horizontal artifacts B - LINE

KUALA LUMPUR INTERNATIONAL TRAINING UNIT

 Transducer Transducer

Multiple US Beam Multiple US Beam

Reflections Reflections

NORMAL
THICKENED INHOMOGENEOUS
INTERLOBULAR HOMOGENEOUS
INTERLOBULAR TISSUE-AIR
SEPTA TISSUE-AIR
SEPTA INTERFACE
INTERFACE

REVERBERATIONS
REVERBERATIONS

NORMAL ARTIFACTS (A lines) COMET TAILS (B lines)

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Pneumothorax
TISSUE-AIR INTERFACE
abdomen

abdomen
lung Collapsed
lung

Normal Lung PNEUMOTHORAX

Air
Air
Air

Air

Normal lung:Sliding sign Pneumothorax

D.A Lichtenstein:Whole Body Ultrasound in
Critically Ill
KUALA LUMPUR INTERNATIONAL TRAINING UNIT

Using the M-mode

“lung sliding” M-Mode “Sea Shore”

D.A Lichtenstein:Whole Body Ultrasound in Critically Ill

KUALA LUMPUR INTERNATIONAL TRAINING UNIT

“Loss of sliding sign” M-Mode “strastosphere sign”

D.A Lichtenstein:Whole Body Ultrasound in Critically Ill

KUALA LUMPUR INTERNATIONAL TRAINING UNIT

Lung Point

M-Mode

" Alternating patterns of pneumothorax (loss of lung

sliding, A-line sign) and normal (presence of lung sliding)
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Pneumothorax
! Presence of lung sliding

" Rules out pneumothorax

! Loss of lung sliding

" Differential diagnoses

! Pleurodesis

! Atelectasis

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 KUALA LUMPUR INTERNATIONAL TRAINING UNIT

APO, Before Rx

APO, after Nitrate and CPAP

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Pleural Effusion

Pleural Septa
Air

Air

Air

Thickened Pleura

D.A Lichtenstein:Whole Body Ultrasound in Critically Ill

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 Differential Diagnosis: Effusion vs. Consolidation

2850 ml Effusion NO Thoracentesis

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Consolidation
Ultrasound Features
- Tissue-like pattern
- “Liver-like”
- Hepartization

• Principles 7: Nearly all acute disorders of

thorax come in contact with surface

KUALA LUMPUR INTERNATIONAL TRAINING UNIT

TRUE CONSOLIDATION ATELECTASIS

KUALA LUMPUR INTERNATIONAL TRAINING UNIT Lichtenstein D. CHEST 2009
“In our opinion,the most severely ill
patient are the ones who benefits least
from CT or MRI. Bedside ultrasound
neatly solves this paradox”

– Daniel Lichtenstein:”Father of
Lung Ultrasound

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Thank You

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