THORACIC ULTRASONOGRAPHY:

Clinical Uses and Applications

Moderator: Professor Samuel Yoo (Internist,
pulmonologist)
Presenter: Mesay Assefa (MD, R1)

JUMC, Department of Internal Medicine (October 2021G.C)

 OUTLINE

Introduction

Technique And Instrumentation

Normal Anatomy

Diseases Of The Pleural Space

Diseases Of The Lung Parenchyma

Diseases Of The Chest Wall

Us-guided Thoracic Intervention

Investigational

The BLUE-protocol
 INTRODUCTION
• Ultrasound (US) makes use of probes with an
acoustical frequency.
• Ultrasonography is the medical imaging modality.
• Thoracic ultrasonography (TUS; lung and pleural),
is a key component of critical care
ultrasonography (CCUS).
• Acoustical impedance is a property of the tissues
that make up the interface.
TYPES OF ULTRASOUND
Ultrasound transducers
Copyright RSNA, 2002
Table . Sensitivity
and Specificity of
Auscultation,
Chest
Radiography, and
Lung
Ultrasonography
for Diagnosing
Pleural Effusion,
Alveolar
Consolidation,
and
Alveolar–
Interstitial
Syndrome in 384
Lung Regions in
32
Critically Ill
Patients with
ARDS
Normal Anatomy
The sharp change in the acoustic impedance at
this interface results in reverberation artifacts
(*), appearing as a series of horizontal lines
parallel to the pleural interface. Vertical comet
tail artifacts (+) can also be seen.
On the high-resolution scan, the visceral
and parietal portions of the pleura can be
resolved.
Normal lung surface.

The ribs (vertical arrows). M-mode reveals the seashore.

Rib shadows are displayed below. Above the pleural line, the
The pleural line (upper, horizontal arrows). motionless chest wall displays a
the bat sign. stratified pattern. Below the pleural
the A-line (lower, small horizontal arrows). line, the dynamics of lung sliding
show this sandy pattern.
Extract from “Whole body ultrasonography in the critically ill” (2010 Ed, Chapter 14), with kind permission of Springer Science
 Diseases of the Pleural Space
• US is useful
– for characterizing pleural effusions,
– for distinguishing between pleural effusions and
pleural thickening, and
– in the evaluation of pleural masses
 Pleural Effusions
• The sonographic appearance of pleural effusion
depends on the cause, nature, and chronicity of
the collection.
• The pleural effusion appears as a relatively
hypoechoic space that is surrounded by the
anatomic borders.
• Four different appearances are recognized at US:
– Anechoic, Complex but nonseptated, Complex and
septated, Homogenously Echogenic
The diaphragm is best confirmed
by first identifying the
splenorenal and hepatorenal
recesses.
Although these recesses are
curvilinear structures that may
be confused with the diaphragm,
they are differentiated by the
identification of the associated
organs (spleen, liver, and kidney)
.
Anechoic effusion

The lung is observed

to be a small
consolidated structure
(arrow) within the
large anechoic pleural
effusion (arrowhead).
This image of the lung
represents
compressive
atelectasis from the
effusion.
Homogenously echogenic effusion
The pleural effusion is
observed to be
homogenously echogenic.
Homogenously echogenic
when it is hypoechoic (ie, not
anechoic) and no discrete
echogenic are elements
observed within the effusion.
Complex non-septated effusion
Discrete echogenic elements
are observed within the
pleural effusion (arrow).
Complex non-septated when
discrete echogenic elements
are observed within the
effusion.
Complex septated effusion
Septations are observed
within the pleural
effusion.
Complex septated when
strands or septa are
observed within the
effusion.
A swirling pattern
A swirling pattern (arrow),
defined as floating mobile
echogenic particles within
the effusion, is associated
with an exudative pleural
effusion.
 Pleural Effusions
• Transudates are almost invariably anechoic.
• Exudates usually are complex, septated, or
echogenic.
• Mobile strands of echogenic tissue and septations
are frequently observed in inflammatory effusions.
• Empyema can result in an echogenic collection that
mimics a solid lesion.
• In comparison, malignant effusions are more
frequently anechoic (+nodular pleural thickening)
than echogenic.
 Pleural Effusions..

Lichtenstein Annals of Intensive Care 2014

Pleural Masses
• There are two
pleural
masses within
a pleural
effusion
(arrows).
• These were
found to be
due to
metastatic
carcinoma.
 Pleural Masses…

• Benign pleural masses appear as well-defined

rounded masses of variable echogenicity,
depending on the fat content of the cells.
• Mesothelioma is seen as irregular thickening
of the pleura that may appear nodular and is
frequently associated with a large pleural
effusion.
(a) Malignant mesothelioma. CT scan shows lobulated pleural masses, with an area
of chest wall invasion.
(b) On the US scan, the pleural masses with chest wall infiltration (arrows) are clearly
depicted.
Copyright RSNA, 2002
 Pleural Thickening
• Pleural thickening appears as hypoechoic broadening of the pleura.
• Unlike pleural effusion, pleural thickening does not exhibit the fluid
color sign.

US demonstrates pleural
thickening as a
hypoechoic band, just
superficial to the
echogenic pleural-lung
interface.
Copyright RSNA, 2002
EVALUATION FOR PNEUMOTHORAX
• The presence of lung sliding and/or lung pulse is a
definitive finding that excludes pneumothorax.
• The absence of lung sliding suggests the
possibility of pneumothorax, but it is not specific,
so clinical correlation is always required.
• The presence of a lung point is diagnostic of
pneumothorax, but may not always be present.
 Excluding a pneumothorax
1. Lung sliding and lung pulse

Absence of lung sliding due to pneumothorax

A lines are present and derive from a normally aerated lung (panel A) or from the presence of
air within the pneumothorax space (panel B).
 Excluding a pneumothorax…

Pseudo lung sliding

(A) Lung sliding: This image shows lung sliding.

(B) Pseudo lung sliding: This image shows movement of the pleural line that is caused by
contraction of the intercostal muscle.
 Excluding a pneumothorax…

Lung pulse
Lung pulse is the cardiophasic movement of the visceral parietal pleural surface.
 Excluding a pneumothorax…
2. B lines and lung consolidation

B lines indicate the presence of an interstitial process. B lines (arrows) develop at the visceral
pleural surface, so their presence indicates that the lung is fully inflated at the site of probe
placement on the chest wall, so there is no pneumothorax at that examination site. Likewise, the
identification of consolidated lung rules out pneumothorax at the site of probe placement on
the chest wall, as air within a pneumothorax space blocks all transmission of ultrasound.
 Confirming a pneumothorax
1. Absence of lung sliding and/or lung pulse
– Absent lung sliding should not be used as the sole
criterion in the diagnosis of pneumothorax.
– Lung sliding may be absent in patients with
• ARDS, atelectasis (one-lung intubation), chronic
adherences, fibrosis, phrenic palsy, jet ventilation,
cardiopulmonary arrest, apnea, esophageal intubation,
inappropriate settings, inappropriate probes are usual
factors, and frequent in critically ill patients.
 Pneumothorax and the stratosphere sign
• Left: pleural line with A-lines, indicating gas below the pleural line. Not visible on the left
image, lung sliding is totally absent.
• Right: here on M-mode, the abolition of lung sliding is visible through the
stratosphere sign (which replaces the seashore sign) and indicates total absence of
motion. This suggests pneumothorax as a possible cause. Arrows: location of the pleural
line.
 Confirming a pneumothorax…
• Abolished lung-sliding has a 95% sensitivity and 100%
negative predictive value.
• The positive predictive value of abolished lungsliding,
only 87% in a general population, falls to 56% in the
critically ill, and to 27% in patients with respiratory
failure.
• The notion of ultrasound “false-positives” makes little
sense when another sign is added: the A-line sign (i.e.,
no B-line seen), with 60% sensitivity but 100%
specificity.
• One motionless B-line discounts pneumothorax.
 Confirming a pneumothorax…
2. Lung Point—is pathognomonic

A lung point represents the

interface between the
partially collapsed lung and
the pneumothorax space. The
aerated lung is seen to enter
the pneumothorax space in
synchrony with the
respiratory cycle.
Lung point is 100 percent
specific and 66 percent
sensitive for detection of
pneumothorax
 Confirming a pneumothorax…

Lung Point

In the image obtained with the 7.5 MHz probe (panel B), the lung comes into pneumothorax
space underneath a rib. The finding of a lung point is diagnostic of a pneumothorax.
• The left image shows the pleural line just before the visceral pleura
appears.
• The right image shows (arrow) the very moment the visceral pleura
has touched the parietal pleural.
 Diseases of the Lung Parenchyma
Pneumonia and Lung Abscesses
• The sign of nontranslobar consolidation (most cases) is the shred sign
(RIGHT): the border between consolidated and aerated lung is irregular,
drawing the fractal line, fully opposed to the lung line.
• The sign of translobar consolidation is the tissue-like sign (LEFT): it
looks like liver.
• Both signs allow for 90% sensitivity (as explained) and 98% specificity.
The pattern is tissue-like, similar to the spleen (S). a shredded, fractal boundary between the consolidation
and the underlying aerated lung (arrows):

Adapted from “Whole body ultrasonography in the critically ill” (2010 Ed, Chapter 16)
(a)US demonstrates an area of
consolidation within the right lower
lobe. The texture of the consolidated
lung appears isoechoic to the liver.
Multiple echogenic foci are seen
within the consolidated lung and
correspond to air-filled airways.
(b)On the color Doppler scan, a
pulmonary artery branch supplying
the segment is clearly seen.
Copyright RSNA, 2002
 Pneumonia and Lung Abscesses …
• Although pneumonia is the most common cause of lung
consolidation, its appearance is nonspecific.
– Infarction, hemorrhage, vasculitis, lymphoma, and
brochoalveolar carcinoma can result in consolidation that
appears similar to that of pneumonia at US.
• The dynamic air bronchogram and the lungpulse can
distinguish pneumonia from atelectasis.
• A lung abscess can be identified at US as a hypoechoic
lesion with a well-defined or irregular wall .
• The center of the abscess is usually anechoic but may
contain internal echoes and septations.
 Interstitial syndrome
• The B-line is always a comet-tail artifact, always arises from the pleural line,
and always moves in concert with lung-sliding.
• It is almost always long, well-defined, laser-like, hyperechoic, erasing A-lines.
• Three or more B-lines between two ribs are called lung-rockets.
• Lung-rockets correlate with interstitial syndrome with 93% accuracy using alveolar-
interstitial radiographic changes as reference, and full accuracy using CT.
 Diseases of the Chest Wall
• Soft-Tissue Disease.
– sonography of chest wall masses is frequently nonspecific,
showing a mass of variable echogenicity.

Lipoma of the chest wall. (a) T1-weighted coronal MRI shows a high-signal-intensity
subcutaneous left chest wall mass. (c) At US, the lesion shows mixed echogenicity. Note the
underlying ribs (arrows) appearing as curvilinear echogenic structures with strong posterior
acoustic shadowing.
Lymph Nodes
Sonography can be helpful in distinguishing reactive (inflammatory) lymph nodes from those infiltrated by a malignant
process.

Reactive lymph nodes Malignant lymph nodes

• are oval or triangular in • usually appear plump,
shape, demonstrating an rounded, hypoechoic, with
echogenic fatty hilum that loss of the fatty hilum.
may become even more • Irregularity in the borders of
prominent with these lymph nodes suggests
inflammation. extracapsular spread.
• At color Doppler US,
increased vascularity may be
demonstrable within these
infiltrated lymph nodes.
 (a) Hyperplastic lymph
A B
node shows
preservation of the
normal central
echogenicity due to fat.
(b) On the power
Doppler image, no
appreciable vascularity
is detected within the
lymph node.
(c) In another patient
with metastatic breast
carcinoma, abnormal
enlarged lymph nodes
are detected within the
C axilla, appearing
rounded and diffusely
D hypoechoic. There is
loss of the normal
echogenic center.
(d) In the same patient,
abnormal vascularity is
detected within these
lymph nodes on the
power Doppler image.
 Rib Abnormalities
• US is more sensitive than radiography in the detection of rib fracture.
• Fracture appears as a gap, step, or displacement of the cortex of the rib.
• The fracture may be associated with a localized hematoma, effusion, or soft-
tissue swelling.

When a normal rib is scanned along its long

axis, the anterior cortex appears as a
smooth, continuous echogenic line.
In this example of an acute rib fracture, a
visible gap with loss of continuity of the
anterior cortex of the rib is seen. A small,
hypoechoic hematoma bridges the gap.

Copyright RSNA, 2002

 US-guided Thoracic Intervention

• Thoracocentesis and Catheter Drainage.

• Pleural Biopsy.
• Chest Wall Biopsy.
• Lung Cancer.
• Biopsy of Mediastinal Masses.
 Investigational
• Titration of PEEP in ARDS.
• Weaning Failure.
• Resolution of ventilator associated pneumonia.
• Diagnosis of pulmonary embolism – peripheral wedge-
shaped abnormalities.
• Assessment of PAOP - cardiogenic pulmonary edema
(elevated PAOP) from those with acute lung injury
(normal PAOP).
• Predicting the development of ARDS after blunt chest
trauma.
 The approach to acute respiratory failure:
The BLUE-protocol
• The BLUE-protocol is a fast protocol (<3 minutes),
which allows diagnosis of acute respiratory failure.
• It provides a step-by-step diagnosis of the main
causes of acute respiratory failure, i.e., six diseases
seen in 97% of patients in the emergency room,
offering an overall 90.5% accuracy.
• This was devised following an observational study
of 260 consecutive patients admitted to ICU in
France with respiratory failure.
 The BLUE-protocol …
• In the BLUE-protocol, three standardized
points are the upper BLUE-point, lower BLUE-
point and PLAPS-point.

Figure, Areas of investigation and the BLUE-points.

 The BLUE-protocol …
• The BLUE-protocol combines signs, associates them with a
location, resulting in seven profiles.
1. The A-profile associates anterior lung-sliding with A-lines.
2. The A’-profile is an A-profile with abolished lung-sliding.
3. The B-profile associates anterior lung-sliding with lung-rockets.
4. The B’-profile is a B-profile with abolished lung-sliding.
5. The C-profile indicates anterior lung consolidation, regardless of
size and number. A thickened, irregular pleural line is an
equivalent.
6. The A/B profile is a half A-profile at one lung, a half B-profile at
another.
 The BLUE-protocol …

• Schematic of the BLUE protocol. Note ‘ indicates absence of lung sliding

The BLUE-protocol …
 References
• ©2021 UpToDate®
• American College of Chest
Physicians
• Transthoracic US of the Chest: Clinical Uses
and Applications © RSNA, 2002
• Lichtenstein Annals of Intensive Care 2014
THANK YOU!