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Marek Nalos: Lung: The Final Frontier
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Marek Nalos: Lung: The Final Frontier

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Marek Nalos gives us the finer details of using ultrasound as a diagnostic tool for respiratory illness.

Marek Nalos gives us the finer details of using ultrasound as a diagnostic tool for respiratory illness.

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  • 1. Lung Ultrasound Marek Nalos Department of Intensive care Nepean Hospital Penrith, NSW AUSTRALIA
  • 2. Chest space - the final frontier • These are the voyages of the starship Ultrasound • Its continuing mission: – to explore strange new pictures – to seek out life – and new meanings • To boldly go where only horse has gone before
  • 3. Normal lung - no lung image just artifacts just artifacts • Soft tissue/air interface 99% of ultrasound waves is reflected • Lung is full of air if normal so ultrasound cannot be used to image healthy lung, only the pleura • But... – with disease process lung loosing aeration – less US beam reflection and more penetration
  • 4. Normal lung = air Reverberation artifact Reverberation artifact QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. A - line pleural line A - line rib shadow rib shadow
  • 5. Asthma lung - anterior QuickTime™ and a H.264 decompressor are needed to see this picture. A - line Pleura
  • 6. Normal - A profile - lung base QuickTime™ and a H.264 decompressor are needed to see this picture. Diaphragm Liver Lung Spine Curtain sign
  • 7. Lung consolidation Contiguous B-lines B-lines, (lung rockets) Daniel Lichtenstein et al. Anesthesiology 2004
  • 8. QuickTime™ and a decompressor are needed to see this picture. rib shadow rib shadow Wet lung = air/fluid interfaceReverberation artifact B - line
  • 9. 10 Non cardiogenic pulmonary oedema QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 10. cardiogenic pulmonary oedema anterior QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. right left
  • 11. QuickTime™ and a H.264 decompressor are needed to see this picture. lung base QuickTime™ and a Microsoft Video 1 decompressor are needed to see this picture. spleen left kidney lung lung liver right left
  • 12. QuickTime™ and a decompressor are needed to see this picture. Spleen Consolidated lung Vertebral column Diaphraghm
  • 13. Consolidation - solid tissue QuickTime™ and a decompressor are needed to see this picture. Right lung base rib artifact
  • 14. Consolidation - solid tissue QuickTime™ and a decompressor are needed to see this picture. Left lung base No pleural sliding
  • 15. Lung consolidation - air bronchgrams QuickTime™ and a decompressor are needed to see this picture.
  • 16. • sensitivity - 93.4% (95% CI, 89.2%-96.3%) • specificity - 97.7% (95% CI, 93.4%-99.6%) • Positive LR - 40.5 (95% CI, 13.2-123.9) • Negative LR - 0.07 (95% CI, 0.04-0.11) • A combination of auscultation and LUS increased the positive LR to 42.9 (95% CI, 10.8-170.0) and decreased the negative LR to 0.04 (95% CI, 0.02-0.09) Lung Ultrasound in the Diagnosis and Follow-up of Community-Acquired Pneumonia: A Prospective, Multicenter, Diagnostic Accuracy Study Angelika Reissig, MD; Roberto Copetti, MD; Gebhard Mathis, MD; Christine Mempel; Andreas Schuler, MD; Peter Zechner, MD; Stefano Aliberti, MD; Rotraud Neumann, MD; Claus Kroegel, MD, PhD; Heike Hoyer, MSc
  • 17. Differentiating viral and bacterial pneumonia in children
  • 18. Fluid bronchograms -Tracheo- esophageal fistula QuickTime™ and a decompressor are needed to see this picture.
  • 19. Diseased lung QuickTime™ and a decompressor are needed to see this picture. pleural line B-line pleural effusion consolidation
  • 20. Pneumothorax • Absence of lung sliding • Absence of any B-line • Potential presence of a lung point
  • 21. Pneumothorax Lung point Lung point QuickTime™ and a decompressor are needed to see this picture. Curtesy of Dr. Martin Balik
  • 22. Ruling out pneumothorax after subclavian line insertion QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. Presence of pleural sliding or B-lines rules out pneumothorax with 100% accuracy pleural sliding + _
  • 23. Pleural effusion QuickTime™ and a Cinepak decompressor are needed to see this picture.
  • 24. Differentiate basal lung field opacities on portable CXR QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture.
  • 25. Parapneumonic effusion QuickTime™ and a Cinepak decompressor are needed to see this picture.
  • 26. Empyema QuickTime™ and a Cinepak decompressor are needed to see this picture.
  • 27. 28 QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Pneumonia - legionella QuickTime™ and a decompressor are needed to see this picture. detail
  • 28. 51 post Tetralogy of Fallot repair acute on chronic respiratory failure
  • 29. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 30. 31 QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 31. 74 yrs old lady - Nissen fundoplication postoperative acute respiratory failure
  • 32. 33 Perforated oesophagus QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 33. Mediastinitis QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 34. 21 yrs old boy - dyspnoea, can’t raise left arm
  • 35. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 36. 37 QuickTime™ and a Photo - JPEG decompressor are needed to see this picture. QuickTime™ and a Photo - JPEG decompressor are needed to see this picture.
  • 37. Case • 20 y old driver, multitrauma –mild head injury –rib fractures, lung contusions, haemopneumothorax, –liver laceration and ankle fractures • One week in ICU, still intubated, febrile, sudden desaturation, tachycardia, hypotension, tachypnoea
  • 38. QuickTime™ and a Microsoft Video 1 decompressor are needed to see this picture. • Echocardiography demonstrates normal LV and RV function and size
  • 39. In the meantime, CXR arrived...?
  • 40. QuickTime™ and a Microsoft Video 1 decompressor are needed to see this picture. Blunt chest trauma - sudden hypoxia. Left lower lung collapse Bronchoscopy - removal of thick sputum plug from left lower lobe bronchus
  • 41. Failure to wean QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture. QuickTime™ and a H.264 decompressor are needed to see this picture.
  • 42. 43 H1N1 - ARDS - TOE QuickTime™ and a decompressor are needed to see this picture.
  • 43. You can’t hide from the frontier
  • 44. The beautiful frontier is close and all you need is to look
  • 45. Lung ultrasound is feasible • Bedside, point of care test • Quick, easy to repeat • No radiation exposure • Dynamic nature – visualization of pleural/lung interface during inspiration and expiration
  • 46. Lung ultrasound in ICU • Often more useful then CXR • Steep learning curve • Provides quick answers to simple clinical questions arising from history and clinical examination • - in parallel
  • 47. Iris Ting Daniel Lichtenstein
  • 48. Thank you