USG Toraks

Deteksi dan Diagnosis Pneumotoraks,

Penyakit Paru Interstisial, Efusi Pleura
dan BLUE Protokol

dr. IKHSAN

Departemen Pulmonologi dan Kedokteran Respirasi

Fakultas Kedokteran Universitas Sumatera Utara
RSUP H. Adam Malik Medan
 INTRODUCTION
• Ultrasound for respiratory conditions has
proliferated → to diagnose and manage the
dyspneic patient
• The role of thoracic ultrasound
→ diagnosis of pneumothorax and
hemothorax
→ diagnose consolidations, infarctions and
inflammatory thoracic condition
→ the safety benefit of ultrasound when
performing procedures (thoracentesis)
 Focused Questions for Fespiratory
Ultrasound
• The questions for airway ultrasound are as
follows:
1. Where is the cricothyroid membrane?
2. Is the intubation successful?
• The questions for chest ultrasound are as
follows:
1. Are A-lines present?
2. Are B-lines present?
Chest sonography zones
Longitudinal and oblique approach to lung ultrasound
Cardiovascular Ultrasound 2014, 12:25
Teknik Pemeriksaan
The supine position is used for exploration of the ventral chest.
Lungs and pleura are best evaluated by modified application of
the transducer in the transverse position.
The sitting or standing position is suitable for assessment of the
lateral chest. Lungs and pleura are best evaluated by modified
application of the transducer in the oblique intercostal position.
The sitting or standing position is suitable for assessment of the
posterior chest. Lungs and pleura are best evaluated by
modified application of the transducer in the longutudinal
position.
The sitting or standing position is suitable for assessment of
the posterior chest. Lungs and pleura are best evaluated by
modified application of the transducer in the subcostal
position.
 Cardiovascular Ultrasound 2014, 12:25
Position of the patient to scan the posterior chest
 Intensive Care Med (2012) 38:577–591.
The 4 chest areas per side considered for complete eight zone lung ultrasound
examination. These areas are used to evaluate for the presence of interstitial
syndrome. Areas 1 and 2 denote the upper anterior and lower anterior chest areas,
respectively. Areas 3 and 4 denote the upper lateral and basal lateral chest areas,
respectively. PSL parasternal line, AAL anterior axillary line, PAL posterior axillary line.
Apa yang harusnya dilihat pada keadaan
normal?
– Tanda sliding paru : Pleura viseral danparietal
bergerak relatif satu sama lain dengan siklus
pernapasan
– Pada M mode : seashore sign
–A-Lines
• Artefak reverberasi karena melewati area kaya udara
• Pararel dengan pleural line
• Jarak antar tiap A line sama dengan atau kelipatan dari jarak
kulit ke pleural line (LCWI= Lung Chest Wall Interface)
 BLUE Exam
• Includes a four-point hemithorax exam.
• Points 1 and 2 visualize the lung parenchyma
of the upper and middles lobes, respectively.
• Points 3 and 4 visualize the costophrenic
pleural recesses and lung parenchyma of the
lower lobe.
Demonstration of a method for locating points 1 and 2 in the BLUE
protocol by placing the hands horizontally over the anterior chest with
the upper fifth finger abutting the clavicle, the digits of both hands
together, and the nails at mid-chest. Point 1 is located between the
third and fourth finger of the upper hand. Point 2 is located in the
middle of the palm of the lower hand. The lower fifth finger will
approximate the lower anterior border of the lung (phrenic line).
 BLUE lung exam points
• Point 1 is located on the mid-clavicular line at
approximately the second intercostal space.
• Point 2 is located on the anterior axillary line at
approximately intercostal space 5, usually just
lateral to the nipple in men.
• Point 3 is located along the diaphragm in mid-
axillary line.
• Point 4 is also called the posterolateral alveolar
pleural syndrome (PLAPS) point and is the most
posterior point along the diaphragm. Note the
probe face is pointing to the sky with patient back
rotated off the bed.
 Pleural Line

Pleural line

A line

Real-time mode

(Crit Care Med. 2005;33:1231–38.)

 Lung Sliding
Time-motion mode

Pleural
(Crit Care Med. 2005;33:1231–38.)

line

Real-time mode
Seashore sign
A homogeneous granular pattern
(rules out pneumothorax)
(J Cardiothorac Vasc Anesth. 2015;29(1):196–203.)
PNEUMOTORAKS
 Ultrasonografi pada Pneumotoraks

• Mudah untuk dipelajari dan dipraktekkan

• Dapat digunakan dengan cepat untuk menyingkirkan
segala pneumotoraks secara bermakna
• Seluruh pengujian dapat diselesaikan dan
diinterpretasi dalam hitungan menit
• Lebih sensitif dari foto toraks dan pemeriksaan fisis
• Dapat mendeteksi pneumotoraks yang sangat kecil
 Teknik evaluasi Pneumotoraks
• Depth (kedalaman) 5 cm
→ hanya untuk melihat dinding toraks dan
tidak perlu melihat struktur yang lebih
dalam
Letakkan probe pada
sela iga 3 dan 4 anterior
di linea midklavikular
saat pasien terlentang,
karena pada kejadian
pneumotoraks, saat
terlentang udara akan ke
atas (anterior) dan
memisahkan pleura
parietalis ke anterior dari
pleura viseralis
 Prinsip Teknik
• Pada pneumotoraks pleural line akan terdiri
dari pleura parietalis saja
• Pleura viseralis akan terpisah dari pleura
parietalis sehingga tidak akan ada yang sliding
menggeser pleura parietal dan menutupi
permukaan luar paru.
 Pneumotoraks
– Hilangnya lung sliding
– Tanda A line
– Tanda Barcode atau stratosphere (M-mode)
– Lung point (M-mode)
– Tak ada B line
Stratosphere atau Barcode Sign pada
Pneumotoraks

Seashore sign
• Tanda lung point akan muncul pada titik dimana paru
menyentuh dinding (panah kuning)
• Area batas sliding paru dengan B-line di satu area dg bagian
paru yang terpisah dari dinding
• Pada M-mode : lung point akan muncul pada posisi persis
dimana seashore berganti ke tanda barcode
• Adalah penanda yang sangat spesifik bagi pneumotoraks,
akan bisa mendeteksi minimal (skala milimeter)
pneumotoraks, yang sering terlewatkan oleh foto toraks
 Theoretical Explanation of the Lung Point

(Crit Care Med. 2005;33:1231–38.)

Left (at expiration), the pneumothorax has a defined volume. A probe
placed at a point slightly anterior to the lung level will display a
pneumothorax pattern.
Right (at inspiration), we must imagine that the lung volume slightly
increases, therefore increasing the surface of the lung in contact with
the wall. The probe remaining at the same location will immediately
display fleeting lung patterns.
 Lung Point in Patient with Pneumothorax

(Crit Care Med. 2005;33:1231–38.)

The time-motion mode (right) clearly objectifies the precise
moment (arrow) when the collapsed lung is (left of the arrow) or
is not (at the right) in contact with the chest wall. The lung point
designates this sudden replacement of the normal granular
pattern by a horizontal pattern, at a defined location. The lung
point is a specific sign of pneumothorax.
(J Cardiothorac Vasc Anesth. 2015;29(1):196–203.)
 Decision Tree

(Crit Care Med. 2005;33:1231–38.)

PENYAKIT PARU INTERTISIAL
(A) A normal echographic lung is shown in a longitudinal view.
(B)Between the ribs, pleural line and multiple A lines are
clearly visualized. B lines indicate alveolar-interstitial
syndrome: they arise from pleural line reaching the bottom of
the screen and erasing A-line pattern.
Am J Emerg Med. 2009;27:379–84.
 B lines

(Crit Care Med. 2005 33:1231–38.)

Real-time mode
Four or five comet-tail artifacts are visible fanning out from the pleural line,
vertically oriented, well-defined, laser-beam-like, erasing A lines, and
spreading up to the edge of the screen without fading, that is, ultrasound B
lines. Several B lines visible in a single view are suggestive of a rocket at liftoff,
hence the label “lung rockets.” B lines rule out pneumothorax at the place
they are observed and, at the same time, indicate interstitial syndrome.
Evaluation for Pulmonary Edema
(Interstitial Syndrome)

Pleural line with B-lines

 Various stages of increasing severity in
alveolar-interstitial syndrome

Interstitial syndrome (panel A) Alveolar-interstitial syndrome (panel B)

 Various stages of increasing severity in
alveolar-interstitial syndrome

More severe alveolar interstitial Alveolar-interstitial syndrome with

syndrome with spared area (star) and ground-glass attenuation, irregular
thickening of pleural line (panel C) pleural line and spared area (star) (panel
D).
Am J Emerg Med. 2009;27:379–84.
Am J Emerg Med. 2009;27:379–84.
Visualization of spared area (star) and thickened pleural line
in an acute respiratory distress syndrome (ARDS) case.
Evaluation for Consolidation
(Alveolar Syndrome)

Air bronchogram
 Critical Care 2007, 11:205
Cephalocaudal view of consolidated left lower lobe with
a peripheral abscess. The abscess (A) appears as rounded
hypoechoic lesions inside a lung consolidation (C). Ao,
descending aorta; D, diaphragm; Pl, pleural effusion.
Visualization of a pulmonary consolidation and
associated air bronchogram in a patient with ARDS.
EFUSI PLEURA
(J Cardiothorac Vasc Anesth. 2015;29(1):196–203.)
(J Cardiothorac Vasc Anesth. 2015;29(1):196–203.)
 Chest wall anatomy for thoracentesis

Measurement of distances
between the skin surface and
parietal and visceral pleura.
Ultrasound-Guided Tube Thoracostomy
Large anterior thoracic mass abutting chest wall
Moderate-size peripheral lung mass is seen
abutting chest wall
BLUE PROTOCOL
 BLUE PROTOCOL—EXAM POINTS
• BLUE exam includes a four-point hemithorax
exam.
• Points 1 and 2 visualize the lung parenchyma
of the upper and middles lobes, respectively.
• Points 3 and 4 visualize the costophrenic
pleural recesses and lung parenchyma of the
lower lobe.
Algotritma USG Toraks pada Sesak Napas Berat

Chest 2008;134:117–25.
Differential for Ultrasound Findings

(J Cardiothorac Vasc Anesth. 2015;29(1):196–203.)

 Kesimpulan
• USG toraks dapat dipelajari dan diterapkan
• USG dapat digunakan dengan cepat untuk
menemukan pneumotoraks, edema paru,
pneumonia dan efusi pleura
• Normal sliding lung menyingkirkan
pneumotoraks
• Bisa lebih sensitif dari foto toraks dan
pemeriksaan fisis
• Dapat mendeteksi pneumotoraks yang kecil