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Utility of lung ultrasound

Article  in  BJA British Journal of Anaesthesia · June 2012

DOI: 10.1093/bja/aes159 · Source: PubMed

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Correspondence
2 Charbit B, Funck-Brentano C, Samain E, Jannier-Guillou V,
Albaladejo P, Marty J. QT interval prolongation after oxytocin
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intervals during caesarean section under spinal anaesthesia.
Anaesthesia 2010; 65: 337– 42
4 Redfern WS, Carlsson L, Davis AS, et al. Relationships between pre-
clinical cardiac electrophysiology, clinical QT interval prolongation
and torsade de pointes for a broad range of drugs: evidence for a
provisional safety margin in drug development. Cardiovasc Res
2003; 58: 32–45
5 Lau CP, Freedman AR, Fleming S, Malik M, Camm AJ, Ward DE.
Hysteresis of the ventricular paced QT interval in response to
abrupt changes in pacing rate. Cardiovasc Res 1988; 22: 67 –72
doi:10.1093/bja/aes158
Utility of lung ultrasound
Editor—A 61-yr-old male patient was admitted to the inten-
sive care unit (ICU) for postoperative monitoring after partial
hepatectomy of segments I and VII and cholecystectomy.
The patient had previously undergone right hemicolectomy
in 2010 and partial hepatectomy of segments IV and VIII
for adenocarcinoma (pT3 N1b M1). The patient had adjuvant
chemotherapy with capecitabine and oxaliplatinum. He had
a history of chronic obstructive pulmonary disease and
smoking (40 pack-years).
The patient was admitted to the ICU at 03:30 h after 12 h
of surgery. He was analgosedated and artificially ventilated,
with stable haemodynamics and a peripheral oxygen satur-
ation of 100%. The fluid balance during surgery was
26160 ml. The first hours after surgery were uneventful. A
postoperative chest X-ray (reported as ‘normal’) and stand-
ard laboratory tests were performed. Monitoring consisted
of continuous invasive arterial pressure, fluid balance, and
arterial blood-gas monitoring performed every 6 h. A
central venous catheter was inserted into the left internal
jugular vein using ultrasound (US) guidance.
On postoperative day 1, at 14:30 h, the patient’s trachea
was successfully extubated and a Venturi mask at F IO2 of
0.5 applied. The patient remained stable haemodynamically,
but PaO2 showed a negative trend during the afternoon. At
21:45 h, the patient was dyspnoeic, agitated, and sweaty.
The arterial PO2 was 7.3 kPa. On auscultation, there were
decreased breathing sounds on the left side with rhonchi,
but the right chest was normal. A chest X-ray was ordered
and performed at 22 h.
A US of the lungs was immediately performed. It showed
an area of consolidation involving the whole left lower lobe,
with minimal pleural effusion, with an estimated volume of
,100 ml, and no pneumothorax. Within the consolidation,
hyperechoic punctiform areas could be seen and were inter-
preted as air bronchograms (Fig. 1).
A fibreoptic bronchoscopy under conscious sedation was
performed at 22:30 h which showed a mucous plug com-
pletely occluding the left bronchus and causing atelectasia.
BJA
Fig 1 Ultrasound imaging of the patient’s lung. It shows an area
of consolidation (defined by an area of hypoechoic hepatizated
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tissue) involving the whole left lower lobe, with minimal pleural
effusion, with an estimated volume ,100 ml, and no pneumo-
thorax. Within the consolidation, hyperechoic punctiform areas
can be seen and were interpreted as air bronchograms.
This plug was aspirated and bronchial washing was per-
formed with normal saline. After the procedure, the patient
showed full regression of symptoms, and chest auscultation
showed bilateral and symmetric breathing sounds with no
added sounds. A post-procedure US examination of the
lungs was performed, showing remission of the consolidation
area in the left lung and a normal lung pattern. Blood-gas
samples acquired after bronchoscopy showed improved
PaO2 and peripheral oxygen saturation above 95%. The
chest X-ray taken during the symptomatic period was
reported as a left pleural effusion.
We present a case underlining the potential usefulness of
performing US imaging of the lungs in a dyspnoeic patient
with a rapidly worsening hypoxaemia and a unilateral re-
duction in breathing sounds. At the base of the left lung,
we detected a ‘lung pulse’ which has a sensitivity of 93%
and a specificity of 100% for the diagnosis of atelectasis.1
The X-ray report, which arrived 15 min after bronchoscopy,
suggested a pattern compatible with minimal pleural effu-
sion. The capacity of US to detect alveolar consolidation is
high, with a sensitivity of 90% and a specificity of 98%,2
while chest radiography data are known to be imprecise.3
We highlight the importance of US imaging of the lungs in
the ICU.
E. Arbeid1*
F. Forfori1
G. Bernardeschi 1
F. Giunta1
T. M. Hemmerling 2
1
Pisa, Italy
2
Montreal, Canada
*
E-mail: erikarbeid@gmail.com
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BJA
1 Lichtenstein D. The ‘lung pulse’: an early ultrasound sign of com-
plete atelectasis. Intensive Care Med 2003; 29: 2187–92
2 Lichteinstein D. Lung ultrasound in the intensive care unit. Recent
Res Dev Respir Crit Care Med 2001; 1: 83– 93
3 Wiener MD, Garay SM, Leitman BS, Wiener DN, Ravin CE. Imaging
of the intensive care unit patient. Clin Chest Med 1991; 12: 169– 98
doi:10.1093/bja/aes159
Ultrasound-guided nerve blocks
in the Charcot– Marie– Tooth disease
and Friedreich’s ataxia
Editor—Peripheral nerve blocks (PNBs) are of concern in
patients with underlying neurological disease.1 The response
to electrical stimulation may be impaired, increasing the
risk of nerve damage.1 The use of ultrasound has been
described only in one case of neurofibromatosis.2 We
describe here the use of ultrasound-guided PNBs in hyper-
trophic peripheral neuropathy [Charcot– Marie–Tooth
disease type 1 (CMTD1)] and degenerative disease
[Friedreich’s ataxia (FRA)].
CMTDs include various genetic peripheral motor and
sensory neuropathies.3 CMTD1 is characterized by an auto-
somal dominant inherited hypertrophic proliferation of
Schwann cells (histological ‘onion bulb’), leading to second-
ary demyelination. The patient was a 22-yr-old male (178
cm, 60 kg) with end-stage arthritis in the right ankle second-
ary to CMTD1. He had realignment surgery with multiple foot
and ankle osteotomies under general anaesthesia. Despite
intraoperative analgesics (paracetamol, ketoprofen, continu-
ous i.v. ketamine) followed by morphine and ketamine titra-
tion in the recovery room, his pain remained severe. An
ultrasound-guided sciatic block was proposed to the
patient after a thorough explanation of the potential risks
and benefits. The sciatic nerve was best seen at the mid-
thigh. It appeared as a 21×9 mm hyperechoic structure,
with some small rounded uncompressible hypoechoic
areas, similar to those described in neurofibromatosis2
(Fig. 1). Using an in plane technique, ropivacaine 0.475%
(20 ml) was injected around the nerve, without pain or
right
lateral
Fig 1 Transverse sonograms of sciatic nerves at the midthigh in a patient with a Charcot– Marie– Tooth disease (left image), and in a patient
with Friedreich’s ataxia (middle and right images). In each sonogram, the sciatic nerve is indicated by the white arrow.
1042
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Correspondence
nerve swelling. Pain relief occurred within 15 min and
lasted 10 h. Thereafter, oral analgesics provided adequate
analgesia. No neurological complications were observed at
6 month follow-up.
FRA is a recessive autosomal mutation of the frataxin
gene, causing degenerative atrophy of the posterior
columns of the spinal cord, pyramidal tract, dorsal root
ganglia, peripheral nerve sensory fibres, and the cerebellar
cortex in advanced cases.4 It is associated with scoliosis,
hypertrophic cardiomyopathy, and diabetes. Walking gener-
ally becomes impossible within 15–20 yr. The patient was a
34-yr-old male (182 cm, 70 kg) undergoing bilateral tenoto-
mies (Achille’s tendon, toe flexor, flexor hallucis longus).
There was no sensory loss in the lower limbs. General an-
aesthesia was considered too risky due to sleep apneoa
syndrome, restrictive respiratory disease (dyspnoea after
minimal effort), and severe problems with swallowing.
Some cases of regional anaesthesia have been reported,
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but it was considered too difficult in this case due to
marked kyphoscoliosis. Thus, surgery without tourniquet
under bilateral popliteal blocks was proposed and accepted
by the patient. Both sciatic nerves were well identified from
the popliteal fossa to the midthigh, without any unusual
features and no size reduction (at midthigh: 18×5 mm on
the left and 21×6 mm on the right; Fig. 1). Mepivacaine
1.5% was injected around the peroneal (6 ml) and tibial
nerves (13 ml), at the popliteal fossa, without pain or neur-
onal swelling. Surgery started 35 min later, without any
supplemental anaesthesia. The sciatic nerve blocks lasted
240 min. No neurological impairment was observed at
1 month follow-up.
These cases suggest that the ultrasound dimensions of
peripheral nerves with hypertrophic or degenerative
nervous diseases are quite similar to normal nerves
(13+4×7+3 mm in 40 healthy patients).5 Hypertrophic
neuropathy may appear as small hypoechoic rounded
uncompressible areas distributed in an otherwise
normally shaped nervous structure. Even though no
neurological complications occurred during or after
these ultrasound-guided blocks, PNBs must still be
reserved for patients for whom general anaesthesia pre-
sents major risks.
left right
medial