4/28/2010

Ghassan A. Shaath,MD
Assoc.ConstPed Cardiologist/ CardiacIntensivist KACC,NGHA Riyadh,KSA

CHESTULTRASOUND CHEST ULTRASOUND FORCRITICALLYILL

Objectives:
ReviewtheChestUSbackground ReliabilityofUSforthelungpathologies UtilityofUSonthelung Lungpathologiesbysonography SystematicapproachforlungUS Shouldweuseit? ShouldwecredentialIntensivist?

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History
Auscultation:~200yrs
Laennec RTH et,al J.A.Brosson & J.S. Chaude, Paris 1819

Xray:>100yrs
Williams FH et,al Boston Med Surg J 1896

CATscan:since1972,internationalby1980s
Hounsfield GN et,al Br J Radiol 1973

CXR&CTIrradiation

David J. Brenner et,al N Engl J Med 2007;357:2277-84.

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WhataboutUS?
Theultrasoundimagingisnotusefulfor

evaluationofthepulmonaryparenchyma
Harrison (Principles of internal Med. 1992 (p 1043) & 2001 (p 1454)

Essentialscientificideasaresimpleandcan l f d l d

beunderstoodbyeverybody
Einstein The evolution of physics 1937

CanweassessVocalcords?

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ConfirmETTposition !!

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CanweestimatethePCWP?

TDIinE/E>15 highPCWP AcutoffvalueE 8cm/second

Partho et,al JACC2004

EvenDiaphragmFx !!

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Materialandinfrastructures

ScanningtheDiaphragm.

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LungZones

II

III

NormalLungUS:Alines

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Blines:pathologic

AlveolarInterstitialSynd (AIS)
Extravasation inthealveoliorinterstitium
Exudates Transudates Both

Inflammatoryinfectiousornoninfectious,

chronicoracute Like:AcutePE,chronicPE,pneumonia, ARDS,fibrosis,etc

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AISbyLungUS:mildtomod congestion

AISbyLungUSAIS:severe

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AreBlinesaccurateforAIS?

American Journal of Emergency Medicine (2006) 24, 689696

D.Lichtenstein et,al Anaesthesiology 2004

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Effusion

AISandB+lineswithedema

D.Lichtenstein et,al Anaesthesiology 2004

Thickenedinterlobarspace B7lines

D.Lichtenstein et,al Anaesthesiology 2004

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CanwedifferentiateARDSfrom cardiogenicP.edema

CardiovascularUltrasound2008,6:16

CanwedifferentiateARDSfrom cardiogenicP.edema

CardiovascularUltrasound2008,6:16

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LungUSinAcuteHF

American Journal of Emergency Medicine (2008) 26, 585591

LungUSinAcuteHF

American Journal of Emergency Medicine (2008) 26, 585591

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LungUSinchronicdecompensated HF

J Am Coll Cardiol 2000;35:163846

LungUSinchronicdecompensated HF

J Am Coll Cardiol 2000;35:163846

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LungUS:consolidation

Tissuelikesign Shreddingsign + Airbronchogram Pleuralthickening Ifsevere hepatization ! USsen 90% spec98% CXRsen 95% spec68%only + Effusion Occasionallydifficult todifferentiate atelectasis

Pediatr Crit Care Med 2009 Vol. 10, No. 6

LungUS:Atelectasis(collapse)

homogeneous

parenchyma
Airbronchogram

especiallyearly
Normalpleura Hasatriangular

shape

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LungUS:Pneumothorax (alwaysrespectgravity)
Artifactsarewhat

welookfor:
abdomen

Nolungsliding Alines(fromair
lung

pleurainterface) prominent Mmodeshowsa stratosphere sign NoBlinescould beseen b Lookatlung pointtolocalize thePNXto confirm

Collapsed lung
PNEUMOTHORAX

NormalLung

EXPIRATION

INSPIRATION

collapse dlung

Pneumothorax:Sliding

No Sliding B line

Sliding

abdomen

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Pneumothorax:AlinesandMmode

Stratosphere sign
Nopleuralsliding HenceAlinesareinorderwithtime Pneumothorax

Seashore sign
Indicatespleuralsliding AsAlinesnotinorderwithtime Normal

Pneumothorax:Lungpoint

EXPIRATION

INSPIRATION

Positivelungpoint Pneumothorax
collapse dlung

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Pneumothoraxalgorithm

With100% sensitivity: NOFalse Negatives

With100% specificity: NOFalse Positives

Lichtenstein DA. CRIT CARE MED 2005.

IsLungUSaccurateforPNX

AJR:188, January 2007

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IsLungUSaccurateforPNX

AJR:188, January 2007

LungUS:Effusion(alwaysrespectgravity)

Quadsign:pleuralline,ribs,Parietalpleura Blinesunderneath Mmodethesinusoidalsign

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LungUS:Effusion

D.Lichtenstein et,al Anaesthesiology 2004

Effusion:UStechnique
Saggital Axial

lung

abdomen

lung

PleuralEffusion

PleuralEffusion

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BedsideLungUltrasoundinEmergencyRD theBLUEprotocol

BedsideLungUltrasoundinEmergencyRD theBLUEprotocol
In 260 pts

(PLAPS=posterior/lateral alveolarand/orpleural syndrome)

Daniel A. Lichtenstein et,al CHEST 2008; 134:117125

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Werepediatrician!! Arentwe!!

Werestillpediatrician!!

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Cont

Nochange

Before

after surfactantof 14hrs,

Maybemoretimeis required~2436hrs asRDSneedstoclear alveolarfluids

After

LungUS:assesstherecruitment

Increasing opening pressure, consolidation disappeared and B lines started to show-up which is a sign of improvement
Emerg Radiol (2009) 16:219221

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ItdoeshelpinPulm.Embolism!

TransthoracicUS manifestations

CHEST2001;120:19771983

ItdoeshelpinPulm.Embolism!

1. 1 Round lesions 2. Triangular (commonest) 3. Polygonal

CHEST2001;120:19771983

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ItdoeshelpinPulm.Embolism!
Study was for 69 pts with proven PE, 35 PE out of 42 cases detected most were of central PE

CHEST2001;120:19771983

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Takehomemessages:
Thistoolisverybeneficial Excellentmediaforresearch Unlessyouaskforit applyyouwontgetit Knowthedevice Getcredentialed masterit Applytoyourpatient itsharmless Knowtheareawheretobeunique

GetCredentialed

With

Established a partnership to credential physicians to get target problem based training in deferent provider levels

WELCOMETOJOIN

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