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

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

Introduction
Non-radiologists currently using ultrasound:
Intensivists/Interventional Pulmonologists
Emergency Physicians
Anesthesiologists
Cardiologists
Obstetricians/Gynecologists
Surgeons

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

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

Modes
B-Mode
Traditional real-time, cross-sectional scanning mode
M-Mode
One dimensional display of motion

Image Artifacts
Acoustic enhancement
Increase amplitude caused by intervening structures with low attenuation
Acoustic shadowing
Reduced amplitude caused by intervening structures with high attenuation

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

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)

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.

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

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

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)

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

Knobology
Patient ID
Mode
Depth
Gain
THI
Save
Annotations

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

Other Potential Utilities of thoracic ultrasound

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

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

Equipment Requirement
3.5-5.0 MHz transducer
Cardiac probe is very effective
Has small footprint to fit into narrow intercostal space

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

Ultrasonographic Findings in Normal Lung
Sliding lung
Lung pulse
Pleural Line
A lines
B lines/Comet-tails

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)

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

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

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)

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

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

Peripheral parenchymal lesion
Hypoechoic pleural-based focal lesion(s)
C-lines artifacts: B-line-like artifacts (asterisks)

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

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

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.

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)

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)

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

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

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

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)

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

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%

http://www.youtube.com/watch?v=fntJ7GLjCSU&feature=PlayList&p=B9E542E5A7E42CD3

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

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

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.

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
Pulmonary embolism
Normal lung ultrasound plus DVT
Pneumothorax
Predominant A lines with absent lung sliding with lung point
Pneumonia
Prominent unilateral B lines with abolished lung sliding
alveolar consolidations w/wo pleural effusion

Predominant bilateral A lines plus lung sliding
COPD
Asthma
Nearly rules out
Pulmonary edema (predominant bilateral B line)

Predominant bilateral B lines plus lung sliding
Pulmonary edema,
Nearly rules out
COPD (predominant bilateral A lines)
PE
PTX ( absent B lines)

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 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

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.

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

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

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

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

Exudative Pleural Effusion
Echogenic space with debris due to proteinacious or highly cellular exudate between the parietal and the visceral pleurae

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

Parapneumonic effusion with consolidation
The presence of consolidation is suggestive of parapneumonic effusion

Pleural Effusion Associated with Nodules
Pleural effusion associated with nodules is characteristic of malignancy

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

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%)

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

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

HEPATORENAL RECESS 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

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 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 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)

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

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

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).

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).

Air-column during balloon-cuff deflation
Air-column width increased
This patient didn’t developed post-extubation stridor

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

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

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

by Bassel Ericsoussi, MD

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