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Thoracic Ultrasound For Diagnosing Pulmonary Embolism
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Thoracic Ultrasound For Diagnosing Pulmonary Embolism

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  • 1. Thoracic Ultrasound for Diagnosing Pulmonary Embolism (TUSPE): A Prospective Multicenter Study of 352 Patients Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois College of Medicine
  • 2. Pulmonary Embolism
    • The incidence of PE in the United States is 23 to 69 per 100,000
    • CT pulmonary angiography (CTPA) is the method of choice for the diagnosis of central PE
      • CT is not a standard procedure to investigate subpleural lesions in PE
      • Not available in some centers
      • Patients with unstable hemodynamics cannot easily be transported
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 3. Sonomorphology of PE on the B-mode Sonographic Image
    • Lung infarcts in autopsy lungs of patients with PE
      • Ultrasound images from living patients were similar to the image of the autopsy lung
      • Location, form and size corresponded exactly with pathological findings
    • Ultrasound showed wedge-shaped hypoechoic areas
    • Fresh infarct: homogeneous and more hypoechoic.
    • Older infarct: well demarcated and showed a hyperechoic reflex in the center corresponding to the bronchiole
    Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol 1993;17,170-174
  • 4. Technique
    • Arms should be raised, hands should be placed at the back of the head in order to slightly extend the intercostal spaces and rotate the scapula outward.
    • The surface of the lung was scrutinized for subpleural lesions on standardized longitudinal sections and along the intercostal spaces
    • 3.5 to 6 MHz 5 curvilinear probe is ideal
    • Place the probe on the chest wall longitudinally and along the intercostal spaces
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 5. TUS Criteria for PE
    • PE confirmed: 2 or more typical lesions (triangular or rounded pleural-based)
    • PE probable: 1 typical lesion + pleural effusion
    • PE possible: small subpleural lesions (< 5 mm) or a single pleural effusion alone
    • Normal TUS findings
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 6. TUSPE Study
    • Prospective Multicenter Study
    • 352 patients with clinically suspected PE
    • 194 patients (55%) had a final diagnosis of a PE.
      • CT pulmonary angiography (CTPA) was used as the reference method
      • TUS and CTPA were definitely concurrent with regard to the location and the size of lesions
      • However, lesions are visualized larger on CTPA than on TUS
      • 2.3 lesions per patient are seen on sonography vs. 1.5 lesions on CTPA
  • 7. 2 or more typical lesions 1 typical lesion + pleural effusion Small subpleural lesions (< 5 mm) or a single pleural effusion
  • 8. Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 9. Results Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 10. The majority (66%) of lesions were seen in the posterior basal segments of the lung.
  • 11. Triangular or rounded pleural-based hypoechoic lung infarct
  • 12. Triangular lesion Small rounded lesions
  • 13. Peripheral Hemorrhages – Incomplete Infarctions
    • Transient hemorrhages: reabsorbed within a few hours or days
    • 70 to 90% of thromboemboli
    • mainly occur in the lower lobes of the lung (account on hemodynamics)
    • In TUSPE, 66% of the lesions were located in the posterior-basal segments
    • TUSPE study showed 2.3 lesions per patient are seen on TUS vs. 1.5 lesions on CTPA
      • Due to the time factor of spontaneous lysis until the CTPA is performed
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 14. Doppler Ultrasound
    • Is a problematic procedure for diagnosing peripheral PE
      • Many lesions tend to reperfuse early
    • In some cases, we find a characteristic circulation stop due to the clut
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 15. Limitations
    • Experience required
    • Differential diagnosis between PE and peripheral pulmonary lesions of other origin
      • Pneumonia , carcinomas and metastases, compression atelectasis
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8 PE
      • Pneumonia
      • Carcinomas
      • Compression atelectasis
      • Peripheral venous malformation
    Smaller Larger Color Doppler ultrasound. Narrow Well demarcated Blurred margins rounded or polycyclic Concave on at least one side Homogeneous Inhomogeneous (Bronchoaerograms) Inhomogeneous (central necroses) Float in the effusion
  • 16. Conclusion
    • TUS is a noninvasive method to diagnose peripheral PE.
    • TUS is a suitable tool to demonstrate a PE at the bedside and in the emergency setting
      • In the absence of CTPA
      • Pregnancy, contrast agent allergy, or renal failure
    • TUS is able to detect larger number of lesions but smaller lesions than CTPA
    • Negative chest ultrasound result does not rule out a PE
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 17. Take Home Message
    • Two or more triangular or rounded lesions with a pleural base, 0.5 to 3 cm in size, may be regarded as confirmation of a clinically suspected PE
    • A typical pleural-based triangular or rounded lesion accompanied by a small pleural effusion makes a diagnosis of PE very likely
    • Subpleural lesions < 5 mm in size are very nonspecific and should not be considered as a PE
    Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8
  • 18. The source, transmission, and arrival of thromboembolic disease can be detected with a single ultrasound system, thus “killing three birds with one stone.”
  • 19. References
    • Mathis G, Blank W, Reissig A, Lechleitner P, Reuss Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005 Sep;128(3):1531-8
    • Mathis, G, Dirschmid, K Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol 1993;17,170-174