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Ultrasonography Fundamentals In Critical Care: Lung Ultrasound, Pleural Ultrasound, Other Potetial Utilities of Ultrasound
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Ultrasonography Fundamentals In Critical Care: Lung Ultrasound, Pleural Ultrasound, Other Potetial Utilities of Ultrasound

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General Principles of Ultrasonography

General Principles of Ultrasonography
Lung Ultrasonography
Pleural Ultrasonography
Other Potential Utilities of Thoracic Ultrasound

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    Ultrasonography Fundamentals In Critical Care: Lung Ultrasound, Pleural Ultrasound, Other Potetial Utilities of Ultrasound Ultrasonography Fundamentals In Critical Care: Lung Ultrasound, Pleural Ultrasound, Other Potetial Utilities of Ultrasound Presentation Transcript

    • Ultrasonography Fundamentals in Critical Care Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois Medical Center at Chicago
      • “ It is crucial that chest physicians take the lead in advocating for ultrasound to become part of our daily practice, create educational opportunities for members of our societies, and incorporate ultrasound training in our fellowship programs.”
      • Dr. David Feller-Kopman
      Bassel Ericsoussi, MD
    • Ultrasonography Fundamentals in Critical Care
      • General Principles of Ultrasonography
      • Lung Ultrasonography
      • Pleural Ultrasonography
      • Other Potential Utilities of Thoracic Ultrasound
      Bassel Ericsoussi, MD
    • Introduction
      • Non-radiologists currently using ultrasound:
        • Intensivists/Interventional Pulmonologists
        • Emergency Physicians
        • Anesthesiologists
        • Cardiologists
        • Obstetricians/Gynecologists
        • Surgeons
      Bassel Ericsoussi, MD
    • Introduction cont.
      • Benefits and advantages of Ultrasound
        • Immediate bedside availability
        • Repeatability
        • Safe (no radiation), reduction in radiation exposure
        • Easy to perform, portable
        • Improves outcome
        • Cost saving
      Bassel Ericsoussi, MD
    • Echogenicity
      • The more ultrasound waves reflected back, the brighter the image
      • Hyperechoic (bright echo)
        • Air
        • Diaphragm
        • Periostium
      • Isoechoic/echogenic
        • Liver
        • Kidney
        • Muscle
      • Hypoechoic (dark echo)
        • Fluid
        • Blood
        • Fat
      Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Modes
      • B-Mode
        • Traditional real-time, cross-sectional scanning mode
      • M-Mode
        • One dimensional display of motion
      Bassel Ericsoussi, MD
    • Image Artifacts
      • Acoustic enhancement
      • Increase amplitude caused by intervening structures with low attenuation
      • Acoustic shadowing
      • Reduced amplitude caused by intervening structures with high attenuation
      Bassel Ericsoussi, MD
    • Artifacts cont.
      • A lines
        • “ Reverberation” artifacts
        • Horizontal lines parallel to the pleural line
        • Distance between A-lines is equal to, or a multiple of, the distance between the skin to the pleural line
        • Seen in normal parenchyma
        • A lines w/o lung sliding
          • Search for PTX
      Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Artifacts cont. B lines/Comet-Tail Artifacts
      • Arise from pleural line, extend to the bottom of the screen
      • Move with lung sliding
      • Efface A lines at their point of intersection
      • Normally seen in the lower lateral lung zones (3-4 lines)
        • lower lung zone interstitial markings are normal
        • Hence, a few Comet Tails in this area are also normal
      • Correlate with the alveolar interstitial pattern (correlate with the presence of extravascular lung water )on CXR or chest/CT
        • 7 mm apart B lines: intra-lobular septa process
          • Diffuse interstitial fibrosis
        • < 3mm apart “closely spaced” B lines: intra-alveolar process
          • Pulmonary edema (smooth pleura) or ARDS (rough pleura)
      Bassel Ericsoussi, MD
    • Explanation Of The Formation Of The B-lines (Comet-tail Artifact).
      • When the US beam meets the thickened interstitial area, it reflects resulting in an artifact composed of all the micro-reflections.
      • Each reflection of the beam is displayed on the screen behind the previous reflection.
      • A distance of about 1 mm separates each reflection.
      Bassel Ericsoussi, MD
    • Normal Lung few Comet Tails in the lower lung zone Acute pulmonary edema closely spaced comet-tail artifacts Diffuse interstitial fibrosis comet-tail artifacts are 7 mm apart Bassel Ericsoussi, MD
    • Artifacts cont.
      • E-lines
        • Similar to B lines but Arise from the chest wall , not from the pleural line
        • Vertical laser-like lines that reach the edge of the screen
        • Generated by subcutaneous emphysema
      Bassel Ericsoussi, MD
    • Artifact cont.
      • Z line artifacts
        • Similar to B lines arise from the pleural line
        • Fade away vertically , do not reach the edge of the screen
        • Do not erase the A-lines
        • Do not accompany the lung sliding
        • Does not have a pathologic meaning
      Lichtenstein et al. The comet tail artifact: an ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156,1640-1646 Bassel Ericsoussi, MD
    • Artifacts cont.
      • Mirror image
        • Results from the beam encountering a bright reflector (diaphragm)
        • Produces a false object, deep to the mirror that disappears with subtle changes in transducer position
      Bassel Ericsoussi, MD
    • Probes
      • Cardiac
      • Abdominal
      • Endocavity
      • Vascular
      • Lungs
      • 2.5-3.5 MHz
      • 3.5-5.0 MHz
      • 5.0-7.5 MHz
      • 7.5-10 MHz
      • 5 mhz curvilinear probe is ideal (low frequency for deeper tissue)
      Bassel Ericsoussi, MD
    • 7.5-10 MHz Superficial structures (vessels) 1.0-5.0 MHz Cardiac Lung Abdomen Bassel Ericsoussi, MD
    • Penetration vs. Resolution
      • Higher frequency, less penetration but better resolution
        • Good for vessels “vascular/linear probe” 7.5 Mhz
      • Lower frequency, better penetration but less resolution
        • Good for abdomen, heart, lung “ genera probe” 3.5 Mhz
      Bassel Ericsoussi, MD
    • Knobology
      • Patient ID
      • Mode
      • Depth
      • Gain
      • THI
      • Save
      • Annotations
      Bassel Ericsoussi, MD
    • Disadvantages of US
      • Cost
        • US unit, transducers, gel, sterile sheaths, monitor, printer, docking station (up to $ 50,000)
      • Maintenance
      • Training
        • Attendings, fellows, residents
        • Didactic, hands-on exams
      • Reliance on technology
      Bassel Ericsoussi, MD
    • Ultrasonography Fundamentals in Critical Care
      • General Principles of Ultrasonography
      • Lung Ultrasonography
      • Pleural Ultrasonography
      • Other Potential Utilities of thoracic ultrasound
      Bassel Ericsoussi, MD
    • Lung Ultrasonography Bassel Ericsoussi, MD
    • Lung Ultrasonography Compared to Chest Radiography
      • Lung ultrasonography is superior to supine portable chest radiographs for detection of
        • PTX
        • Normal aeration pattern
        • Alveolar-interstitial pattern
        • Consolidation
        • Pleural effusion
      Bassel Ericsoussi, MD
    • Lung Ultrasonography Compared to Chest CT
      • Lung ultrasonography is similar in yield to chest CT for detection of
        • PTX
        • Normal aeration pattern
        • Alveolar-interstitial pattern
        • Consolidation
        • Pleural effusion
      Lichtenstein D et al. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004 Jan;100(1):9-15. Bassel Ericsoussi, MD
    • Advantages of Lung Ultrasonography
      • Immediate bedside availability
      • Immediate bedside repeatability
      • Rapid goal directed application
      • Cost saving
      • Reduction in radiation exposure
      Bassel Ericsoussi, MD
    • Equipment Requirement
      • 3.5-5.0 MHz transducer
      • Cardiac probe is very effective
        • Has small footprint to fit into narrow intercostal space
      Bassel Ericsoussi, MD
    • Technique
      • Pt supine with arms abducted as needed, lateral decubitus for full examination
      • Transducer in longitudinal orientation
      • Transducer in intercostal space
      • Transducer marker in cephalic position
      Bassel Ericsoussi, MD
    • Ultrasonographic Findings in Normal Lung
      • Sliding lung
      • Lung pulse
      • Pleural Line
      • A lines
      • B lines/Comet-tails
      Bassel Ericsoussi, MD
    • Sliding Lung Sign
      • Represents the movement of visceral against parietal pleura during the respiratory cycle
      • Identified as a shimmering white line at the pleural interface
      • http://www.sonoguide.com/FAST_Video7.html (Shows normal “lung sliding” in its first part.  The second part of the clip shows an abnormal chest view without lung sliding, suspicious for a pneumothorax)
      Bassel Ericsoussi, MD
    • Pleural Line
      • Located 0.5 cm below the rib line
      • Its visible length between two ribs in the longitudinal scan is approximately 2 cm
      • The upper rib, pleural line, and lower rib (vertical arrows) outline a characteristic pattern called the bat sign
      Bassel Ericsoussi, MD
    • A Lines
      • “ Reverberation” artifacts
      • Horizontal lines parallel to the pleural line.
      • Separated by regular intervals that are equal to the distance between the skin and the pleural line.
      • Seen in normal aeration pattern
      • Predominant A lines plus lung sliding
        • Asthma or COPD
      • Predominant A lines plus absent lung sliding
        • PTX
      Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • B-lines/Comet-Tail Artifacts Lung Rockets
      • Arise from pleural line, extend to the bottom of the screen
      • Move with lung sliding
      • Efface A lines at their point of intersection
      • Normally seen in the lower lateral lung zones (3-4 lines)
        • lower lung zone interstitial markings are normal.
        • Hence, a few Comet Tails in this area are also normal
      • Correlate with the alveolar interstitial pattern (correlate with the presence of extravascular lung water )on CXR or chest/CT
        • 7 mm apart B lines: intra-lobular septa process
          • Diffuse interstitial fibrosis
        • < 3mm apart “closely spaced” B lines: intra-alveolar process
          • Pulmonary edema (smooth pleura) or ARDS (rough pleura)
      Bassel Ericsoussi, MD
    • Normal Lung few Comet Tails in the lower lung zone Acute pulmonary edema closely spaced comet-tail artifacts Diffuse interstitial fibrosis comet-tail artifacts are 7 mm apart Bassel Ericsoussi, MD
    • E-lines
      • Generated by subcutaneous emphysema
        • Vertical laser-like lines that reach the edge of the screen
        • Similar to B lines but Arise from the chest wall , not from the pleural line
      Bassel Ericsoussi, MD
    • Ultrasound Assessment for Extravascular Lung Water in Patients Undergoing Hemodialysis
      • Prospective, observational study
      • 40 pts on hemodialysis with volume overload (extravascular lung water )
      • Chest ultrasound , dyspnea score (0-10), and total fluid volume removed done at three points:
        • Pre-dialysis
        • Mid-dialysis
        • Post-dialysis
      • B-lines were counted and recorded for each time point (B-lines score)
      Noble et al. Ultrasound Assessment for Extravascular Lung Water in Patients Undergoing Hemodialysis. Time Course for Resolution. CHEST June 2009 vol. 135 no. 6 1433-1439 . Bassel Ericsoussi, MD
        • 6 /40: 0-1 B-line pre-dialysis, and none of these 6 patients gained B-lines during dialysis
        • 34/40 patients had reductions in the number of B-lines from pre-dialysis to the midpoint scan and from pre-dialysis to post-dialysis ( p value < 0.001)
      p value < 0.001 Noble et al. Ultrasound Assessment for Extravascular Lung Water in Patients Undergoing Hemodialysis. Time Course for Resolution. CHEST June 2009 vol. 135 no. 6 1433-1439 . Bassel Ericsoussi, MD
      • Percentage of B-lines vs. time
      • Percentage of B-lines vs. volume removed.
      Noble et al. Ultrasound Assessment for Extravascular Lung Water in Patients Undergoing Hemodialysis. Time Course for Resolution. CHEST June 2009 vol. 135 no. 6 1433-1439 . Bassel Ericsoussi, MD
    • Lung Ultrasound in Lung Contusion
      • 26% of pts with blunt chest trauma will have lung contusion
      • Risk factor for the development of
        • ARDS
        • Pneumonia
        • Long-term respiratory dysfunction
      • 10 to 25% mortality rate
      • Chest/CT in the test of choice, CXR often miss the Dx
      Soldati et al. Chest Ultrasonography in Lung Contusion. CHEST August 2006 vol. 130 no. 2 533-538 Bassel Ericsoussi, MD
    • Lung Ultrasound in Lung Contusion
      • The sonographic patterns indicative of lung contusion
        • Alveolar interstitial syndrome (AIS)
          • Increase in B-line artifacts
        • Peripheral parenchymal lesion (PPL) (lung consolidation)
          • Hypoechoic subpleural focal lesions with or without pleural line gap (C-lines)
      Soldati et al. Chest Ultrasonography in Lung Contusion. CHEST August 2006 vol. 130 no. 2 533-538 Bassel Ericsoussi, MD
      • Normal image with
      • One isolated B-line
        • Alveolar interstitial syndrome
        • Several merging B-lines arising from the pleural line
      Bassel Ericsoussi, MD
    • Peripheral parenchymal lesion
      • Hypoechoic pleural-based focal lesion(s)
      • C-lines artifacts: B-line-like artifacts (asterisks)
      Bassel Ericsoussi, MD
    • Lung Ultrasound in Lung Contusion Soldati et al. Chest Ultrasonography in Lung Contusion. CHEST August 2006 vol. 130 no. 2 533-538 Bassel Ericsoussi, MD ISS: Injury Severity Score
      • US done on all pts followed by CXR and CT
      • The diagnosis of lung contusion was established by CT scan in 37 patients
    • Lung Ultrasound in Lung Contusion Soldati et al. Chest Ultrasonography in Lung Contusion. CHEST August 2006 vol. 130 no. 2 533-538 Bassel Ericsoussi, MD
        • Alveolar Interstitial Syndrome (AIS)
          • - Increase in B-line artifacts
        • Peripheral Parenchymal Lesion (PPL)
          • - Hypoechoic subpleural focal lesions with or without pleural line gap (C-lines)
      Tests CT Lung Contusion Sensitivity Specificity N=88 YES (37) NO (51) Ultrasound AIS + 35 2 94.6% 96% - 2 49 Ultrasound PPL + 7 0 18.9% 100% - 30 51
    • Using Ultrasound to Evaluate for a Pneumothorax
      • Easy to learn and apply
      • It can be used quickly to rule out any significant pneumothorax in acutely dyspneic patient
      • To exclude procedure related PTX
        • More sensitive than CXR
        • Able to detect a very small pneumothorax
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax
      • Probe placement
        • On the anterior chest in the 3-4th intercostal space and midclavicular line
          • Air rises to the anterior chest wall
          • It is possible to examine the anterior chest very rapidly to promptly exclude PTX
        • In a longitudinal position with the marker-dot pointed cephalad
      Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax
      • A high frequency vascular probe but a curvilinear abdominal probe will also work well
      • Decrease the depth setting , so that the ultrasound image shows a maximum depth of about 4 cm. 
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax
      • http://www.sonoguide.com/FAST_Video7.html (Shows normal “lung sliding” in its first part.  The second part of the clip shows an abnormal chest view without lung sliding, suspicious for a pneumothorax)
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax
      • The presence of sliding lung rules out PTX with 100% certainty at the site of the transducer
      • However the lack of sliding lung indicates the possibility of PTX
          • PTX
          • Apnea
          • Pleural adhesions
          • Mainstem intubation
          • Mainstem occlusion
          • Very severe parenchymal lung (infiltrates/contusion/ARDS/Atelectasis)
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax B-mode vs. M-mode Normal Lung
      • B-mode: sliding lung
      • M-mode: Seashore Sign
        • Horizontal lines (“waves”) representing the static chest wall
        • granular pattern (“sand”) representing the dynamic artifacts beyond the pleural line
      Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • SEASHORE SIGN Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax B-mode vs. M-mode PTX
      • B-mode: Lack of sliding lung
      • M-mode: Stratosphere or Barcode Sign
        • The granular pattern disappear. The seashore sign turn to barcode sign
      Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • STRATOSPHERE SIGN Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax B-mode vs. M-mode Lung Point
      • M-mode: Lung Point Sign
        • appear at the precise line where the seashore sign switch to Stratosphere /barcode sign
        • It is a very specific sign for PTX
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax
      • Identifying the lung point is 100% diagnostic for PTX
        • Found at the area where the lung reaches the chest wall
        • http://www.sonoguide.com/FAST_Video8.html (Visceral and parietal pleural movement shows the lung point of a pneumothorax)
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax
      • Identifying the lung point is 100% diagnostic for PTX
      • Absence of lung sliding on B-mode, or stratosphere/barcode sign on M-mode (indicates the possibility of PTX)
          • PTX
          • Apnea
          • Pleural adhesions
          • Mainstem intubation
          • Mainstem occlusion
          • Very severe parenchymal lung (infiltrates/contusion/ARDS/Atelectasis)
      • A-lines with no B-lines/comet-tails is suggestive of PTX
      Bassel Ericsoussi, MD
    • Using Ultrasound to Evaluate for a Pneumothorax American Academy of Emergency Medicine : Chan SSW et al Acad Emerg Med Jan 2003 Vol.10 1. Bassel Ericsoussi, MD Ultrasound Feature Patient Population Sensitivity Specificity No Lung Sliding 328 Surgical And Trauma 95.5% 100% No Lung Sliding 111 Medical ICU 95.3% 91.1% No B Lines “ Comet Tails” 114 Med-surgical Unit 100% 60% Combined 617 100% 96.5% Lung Point 233 Med-surgical Unit 66% 100%
    • Using Ultrasound to Evaluate for a Pneumothorax
      • http://www.youtube.com/watch?v=fntJ7GLjCSU&feature=PlayList&p=B9E542E5A7E42CD3
      Bassel Ericsoussi, MD
    • Alveolar Consolidation
      • Fluid-filled alveoli/airless lung
      • Sonographic hepatization
        • Consolidated lung looks like liver
        • Sonographic air bronchograms indicate whether the bronchus is open
      • Think about
        • Pneumonia
        • Atelectasis
      Bassel Ericsoussi, MD
    • Probe Position for Right Sided Pleural Fluid Evaluation Bassel Ericsoussi, MD
    • Normal View Right Pleura and Lung Bassel Ericsoussi, MD
    • Sonographic Hepatization AIR BRONCHOGRAMS LIVER Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Probe Position for Left Sided Pleural Fluid Evaluation Bassel Ericsoussi, MD
    • Pleural Effusion Next to Left Diaphragm and Spleen PLEURAL EFFUSION LUNG SPLEEN DIPHRAGM Bassel Ericsoussi, MD
    • The Shred Line/The Transition Zone
      • a lower-lobe alveolar consolidation (LL) yields a tissular pattern, characteristically limited by the lung line (or the pleural line when there is no effusion) and in depth by an irregular border (black arrows), the shred line, as in connection with aerated lung.
      Bassel Ericsoussi, MD
    • THE SHRED LINE Bassel Ericsoussi, MD
    • Lung Ultrasound in the Diagnosis of Acute Respiratory Failure The BLUE Protocol
      • 4 years observational study
      • 301 patients with acute respiratory failure
        • 250 patients with a definite diagnosis
        • 140 men and 120 women
      Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Bassel Ericsoussi, MD
      • Patients were in a semirecumbent position or supine (if intubated )
      • Scans were longitudinal
      • Zone 1: anterior chest wall
      • Zone 2: lateral wall
      • Zone 3: posterolateral chest wall
      • Each wall is divided into upper and lower halves, resulting in six areas of investigation
      Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Lung Ultrasound in the Diagnosis of Acute Respiratory Failure The BLUE Protocol Bassel Ericsoussi, MD
    • Lung Ultrasound in the Diagnosis of Acute Respiratory Failure The BLUE Protocol
      • Status asthmaticus/COPD
        • Predominant bilateral A lines with lung sliding
        • 89% sensitivity and 97% specificity
      • Pulmonary edema
        • Predominant bilateral B lines with lung sliding
        • 97% sensitivity and 95% specificity
      • Pulmonary embolism
        • Normal lung ultrasound plus DVT
        • 81% sensitivity and 99% specificity
      • Pneumothorax
        • Predominant A lines with absent lung sliding with lung point
        • 81% sensitivity and 100% specificity
      • Pneumonia
        • Prominent unilateral B lines with abolished lung sliding
        • alveolar consolidations w/wo pleural effusion
        • 89% sensitivity and 94% specificity
      Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Bassel Ericsoussi, MD
      • Predominant bilateral A lines plus lung sliding
        • COPD
        • Asthma
        • Nearly rules out
          • Pulmonary edema (predominant bilateral B line)
      Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Bassel Ericsoussi, MD
      • Predominant bilateral B lines plus lung sliding
        • Pulmonary edema,
        • Nearly rules out
          • COPD (predominant bilateral A lines)
          • PE
          • PTX ( absent B lines)
      Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Bassel Ericsoussi, MD
      • Predominant unilateral B lines
        • Pneumonia
        • Nearly rules out
          • Cardiogenic pulmonary edema (predominant bilateral B lines)
      Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Bassel Ericsoussi, MD
    • Lichtenstein et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. CHEST July 2008 vol. 134 no. 1 117-125 Anterior predominant bilateral B lines with lung sliding Anterior predominant bilateral A lines associated with lung sliding Scan zone 3 posterolateral chest wall looking for PLAPS posterolateral alveolar and/or pleural syndrome A/B: Anterior predominant B lines on one side, predominant A lines on the other C: Anterior alveolar consolidation Predominant bilateral B lines without lung sliding ??? Bassel Ericsoussi, MD
    • Ultrasonography Fundamentals in Critical Care
      • General Principles of Ultrasonography
      • Lung Ultrasonography
      • Pleural Ultrasonography
      • Other Potential Utilities of Thoracic Ultrasound
      Bassel Ericsoussi, MD
      • Transverse Image
      • Longitudinal Image
      Normal Pleura Bassel Ericsoussi, MD
    • Normal Pleura: The Bat Sign
      • The upper rib, pleural line, and lower rib (vertical arrows) outline a characteristic normal pattern called the bat sign.
      Bassel Ericsoussi, MD
    • Anatomic Boundaries of the Pleural Effusion
      • Diaphragm
      • Inside of chest wall
      • The surface of the lung
      PLEURAL EFFUSION LUNG SPLEEN DIPHRAGM Important to identify the inside of chest wall to determine depth of needle penetration Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Lung Movement: Curtain Sign
      • The lung that slides into the effusion during the respiratory cycle
      • Avoid puncturing the lung, device insertion may have lethal effect
      Bassel Ericsoussi, MD
    • Lung Movement Lung Flapping Sign or Jelly Fish Sign Bassel Ericsoussi, MD
    • Pleural Effusion: Sinusoid Sign
      • Dynamic sign of pleural effusion (M-mode)
      • The inspiratory shift of the lung line toward the pleural line
      Bassel Ericsoussi, MD
    • Pleural Effusion with Alveolar Consolidation Bassel Ericsoussi, MD
    • Pleural Effusion with Atelectasis Bassel Ericsoussi, MD
    • Transudative Pleural Effusion
      • Anechoic space between the parietal and the visceral pleurae
      Bassel Ericsoussi, MD
    • Exudative Pleural Effusion
      • Echogenic space with debris due to proteinacious or highly cellular exudate between the parietal and the visceral pleurae
      Bassel Ericsoussi, MD
    • Plankton Sign
      • Swirling debris ( plankton sign ): Debris agitated by cardiac or respiratory motion in a pleural effusion
      • The Plankton sign also indicates that the effusion is an exudate and is reach in particles
      Bassel Ericsoussi, MD
    • Parapneumonic effusion with consolidation
      • The presence of consolidation is suggestive of parapneumonic effusion
      Bassel Ericsoussi, MD
    • Pleural Effusion Associated with Nodules
      • Pleural effusion associated with nodules is characteristic of malignancy
      Bassel Ericsoussi, MD
    • Parapneumonic effusion with Thick Septations Bassel Ericsoussi, MD
    • Complex Pleural Effusion with Septations caused by a Malignant Mesothelioma. Bassel Ericsoussi, MD
    • The Role of Ultrasound in the Assessment of Pleural Effusion Bassel Ericsoussi, MD
    • The Role of Ultrasound in the Assessment of Pleural Effusion Bassel Ericsoussi, MD
    • The Role of Ultrasound in the Assessment of Pleural Effusion Bassel Ericsoussi, MD
    • The Role of Ultrasound in the Assessment of Pleural Effusion Bassel Ericsoussi, MD
      • 211 pts with pleural effusion on mechanical ventilation
      • 232 ultrasound-guided thoracentesis (USTs)
        • Performed by intensivists without radiology support
      • CXR reviewed for possible post-procedure PTX
      • PTX occurred in 3 of 232 USTs (1.3%)
      Bassel Ericsoussi, MD
    • Ultrasound-guided Thoracentesis
      • Easy to learn
      • Real-time evaluation of the pleural space
      • Improves yield
      • Reduces complication rate
      • The standard of care
      Feller-Kopman. Ultrasound-Guided Thoracentesis. CHEST June 2006 vol. 129 no. 6 1709-1714 Bassel Ericsoussi, MD
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    • Ultrasonography Fundamentals in Critical Care
      • General Principles of Ultrasonography
      • Lung Ultrasonography
      • Pleural Ultrasonography
      • Other Potential Utilities of Thoracic Ultrasound
      Bassel Ericsoussi, MD
    • Diaphragm Movement and Contractility Evaluation by Thoracic Ultrasound Ultrasonography Determination of Diaphragmatic Excursion
      • Always identify the diaphragm
      • Don’t confuse the hepatorenal or splenorenal recess for the diaphragm
      • Sub-diaphragmatic device insertion may have lethal effect
      • Exercise particular caution in post CABG pts: unilateral diaphragmatic dysfunction
      Bassel Ericsoussi, MD
    • HEPATORENAL RECESS Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Boussuges et al. Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST February 2009 vol. 135 no. 2 391-400 Diaphragm Movement and Contractility Evaluation by Thoracic Ultrasound Ultrasonography Determination of Diaphragmatic Excursion Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • Diaphragm inspiratory time Diaphragm expiratory time Diaphragm inspiratory amplitude Boussuges et al. Diaphragmatic Motion Studied by M-Mode Ultrasonography Methods, Reproducibility, and Normal Values. CHEST February 2009 vol. 135 no. 2 391-400 Bassel Ericsoussi, MD
      • Maneuver began at the end of normal expiration:
      • Quiet Breathing (QB):
      • Diaphragm excursion (inspiratory amplitude)1.5-2 cm
        • Lower limit for women 0.9 cm
        • Lower limit for men 1 cm
      • Voluntary Sniffing (VS)
      • Diaphragm excursion (inspiratory amplitude) 2.5-3 cm
        • Lower limit for women 1.6 cm
        • Lower limit for men 1.8 cm
      • “ normal caudal movement (sharp upstroke) of the diaphragm during inspiration”
      • Deep Breathing (DB)
      • Diaphragm excursion (inspiratory amplitude) 6-7 cm
        • Lower limit for women 3.7 cm
        • Lower limit for men 4.7 cm
      Bassel Ericsoussi, MD CHEST February 2009 vol. 135 no. 2 391-400
    • Diaphragmatic Paralysis: The Use of M Mode Ultrasound for Diagnosis in Adults
      • Sniff test
        • Normal diaphragm:
          • sharp upstroke (normal caudal movement of the diaphragm during inspiration)
        • Diaphragmatic paralysis:
          • No caudal movement of the diaphragm with inspiration
          • Abnormal paradoxical cranial movement on inspiration
      Spinal Cord. 2006 Aug;44(8):505-8. Epub 2005 Dec 6. Bassel Ericsoussi, MD
    • Ultrasonographic Diagnostic Criterion for Severe Diaphragmatic Dysfunction After CABG
      • After Cardiac Surgery
        • Surgery-related phrenic nerve injury
        • Severe diaphragmatic dysfunction can prolong mechanical ventilation
        • (US) probe is positioned on right midaxillary line
        • Diaphragmatic excursion measured from the end of normal expiration ( C ) to end of maximal inspiratory effort (D)
      Bassel Ericsoussi, MD
    • Thoracic Ultrasound for Diagnosing Pulmonary Embolism (TUSPE): A Prospective Multicenter Study of 352 Patients
      • Prospective Multicenter Study
      • 352 patients with clinically suspected PE
      • 194 patients (55%) had a final diagnosis of a PE.
      • CTA was used as the reference method
      Mathis at al. Thoracic Ultrasound for Diagnosing Pulmonary Embolism. Chest 2005;128;1531-1538 Bassel Ericsoussi, MD
    • Thoracic Ultrasound for Diagnosing Pulmonary Embolism (TUSPE): A Prospective Multicenter Study of 352 Patients
      • Lung infarcts on US: wedge-shaped pleura-based hypoechoic areas
        • Fresh infarct: homogeneous and more hypoechoic.
        • Older infarct: well demarcated and showed a hyperechoic reflex in the center corresponding to the bronchiole
      Mathis at al. Thoracic Ultrasound for Diagnosing Pulmonary Embolism. Chest 2005;128;1531-1538 Bassel Ericsoussi, MD
    • Bassel Ericsoussi, MD
    • The majority (66%) of lesions were seen in the posterior basal segments of the lung. Bassel Ericsoussi, MD
    • 2 or more typical lesions 1 typical lesion + pleural effusion Small subpleural lesions (< 5 mm) or a single pleural effusion Bassel Ericsoussi, MD
    • Results Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8 Bassel Ericsoussi, MD
      • Negative chest ultrasound result does not rule out a PE
      Bassel Ericsoussi, MD
    • ETT Position Assessment with Ultrasound
        • Proximal ETT malposition “ETT too high “
          • measure distance from vocal cord to tip of tube
          • Tip of tube should not be visible above sternal notch.
        • Distal ETT malposition:
          • Unilateral pleural sliding may indicate mainstem intubation.
        • Combination of both may eliminate the need for chest x-ray (study underway).
      Bassel Ericsoussi, MD
    • Transverse view showing ETT Bassel Ericsoussi, MD
    • Longitudinal view showing ETT Bassel Ericsoussi, MD
    • ETT Position Tube position OK Confirm with auscultation, ETCO2 Translaryngeal Ultrasound Tip visible Intratracheal Remove and reintubate May be too high, measure distance below VC Pleural Ultrasound Bilateral sliding pleura Unilateral sliding pleura Mainstem intubation Pull tube back 1-2 cm Yes Yes No No Bassel Ericsoussi, MD
    • Laryngeal Ultrasound: A Useful Method in Predicting Post-extubation Stridor
      • Identifying Patients at High Risk for Reintubation Due to Stridor
        • cuff-leak test: was widely used but its application is limited due to controversial results.
        • The air-column width during cuff deflation is a potential predictor of post-extubation stridor
      Ding LW, Wang HC, Wu HD, et al. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur resp J 2006; 27-384-389 Bassel Ericsoussi, MD
      • Air-column during balloon-cuff inflation (hyper-echoic ).
      • True cords are over both sides of the air-column (hypo-echoic).
      • Cartilages are behind the true vocal cords and beside the air-column (Hyper-echoic).
      Ding LW, Wang HC, Wu HD, et al. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur resp J 2006; 27-384-389 Bassel Ericsoussi, MD
      • Air-column during balloon-cuff deflation
        • Air-column width increased
        • This patient didn’t developed post-extubation stridor
      Bassel Ericsoussi, MD
    • Laryngeal Ultrasound: A Useful Method in Predicting Post-extubation Stridor
        • The air-column width during cuff deflation is a potential predictor of post-extubation stridor
      Ding LW, Wang HC, Wu HD, et al. Laryngeal ultrasound: a useful method in predicting post-extubation stridor. A pilot study. Eur resp J 2006; 27-384-389 Bassel Ericsoussi, MD
    • Lung/Pleural Ultrasound Take Home Points
      • A great bedside tool: fast, simple, flexible, takes 1-2 min
      • Can be used in an algorhythmic approach to make a rapid diagnosis in patients with acute respiratory failure
      • Useful to clarify ambiguous CXR: much more information than the CXR
      • Pre and post procedure to rule out PTX
      Bassel Ericsoussi, MD