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The Basics of Lung Ultrasound

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Kylie Baker's guide to the basics of bedside lung ultrasound

Published in: Health & Medicine, Business
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The Basics of Lung Ultrasound

  1. 1. Kylie Baker Ipswich Hospital, Qld
  2. 2. Ultrasound is not for everyone, but everyone can understand the terminology, recognise a good scan from a poor one, and understand its error rate. DISCLAIMER
  3. 3. This talk:-  Background  Rationale- screening tool vs definitive.  Acquisition  Interpretation  Tweaks
  4. 4. Background The Comet-tail Artifact An Ultrasound Sign of Alveolar- Interstitial Syndrome DANIEL LICHTENSTEIN, GILBERT MÉZIÈRE, PHILIPPE BIDERMAN, AGNÈS GEPNER, and OLIVIER BARRÉ Service de Réanimation Médicale and Service de Radiologie, Hôpital Ambroise-Paré, Boulogne (Paris), and Service de Réanimation Polyvalente, Centre Hospitalier Général, Saint-Cloud (Paris), France AM J RESPIR CRIT CARE MED 1997;156:1640–1646.
  5. 5. International evidence-based recommendations for point-of-care lung ultrasound Intensive Care Med DOI 10.1007/s00134-012-2513-4 Giovanni Volpicelli Mahmoud Elbarbary Michael Blaivas Daniel A. Lichtenstein Gebhard Mathis Andrew W. Kirkpatrick Lawrence Melniker Luna Gargani Vicki E. Noble Gabriele Via Anthony Dean James W. Tsung Gino Soldati Roberto Copetti Belaid Bouhemad Angelika Reissig Eustachio Agricola Jean-Jacques Rouby Charlotte Arbelot Andrew Liteplo Ashot Sargsyan Fernando Silva Richard Hoppmann Raoul Breitkreutz Armin Seibel Luca Neri Enrico Storti Tomislav Petrovic International Liaison Committee on Lung Ultrasound (ILC-LUS) for the International Consensus Conference on Lung Ultrasound (ICC-LUS) CONFERENCE REPORTS AND EXPERT PANEL International evidence-based recommendations for point-of-care lung ultrasound  Published online March 2012
  6. 6. “This pattern was present all over the lung surface in 86 of 92 patients with diffuse alveolar- interstitial syndrome (sensitivity of 93.4%). It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specific- ity of 93.0%).” Rationale
  7. 7. Approaches to Lung scanning 1. Screening tool - ED 2 - 8 views (3 minutes) 2. Blue Protocol –ICU (multisystem views) 3. Detailed inspection – Resp Physicians 28 views(30 minutes) 4. Endobronchial/Contrast studies.
  8. 8. LUS as a screening tool  Resp/Med equivalent of FAST  Tells you that there is extra-vascular lung water/thickening( >400ml )  Tells you distribution  Tells you rough quantity  Does NOT tell you what sort  Does NOT tell you how old
  9. 9. Limits of the SCREENING TOOL  DOES NOT interrogate post/basal  CAN NOT interrogate hilum  Does not consider asymmetry  You still have to ‘be a doctor’ (quoting Justin Bowra for the umpteenth time)
  10. 10. Diagnostic accuracy 85% Doctor + CXR > diagnostic accuracy 72%
  11. 11. STEPPING STONE  SAFE for novices  Dichotomous question  Feasible/storable/auditable  Experience informs interpretation  MANY extra signs  In expert hands, better than CXR (Zanobetti M 2011, Xirouchaki N 2011)
  12. 12. AIM for today  Acquisition of standard protocol  Interpretation using basic terminology  Tweak the protocol  Introduce the extra signs Volpicelli G et al International evidence-based recommendations for point- of-care lung ultrasound, Intensive care med, 2012; 38: 577-591.
  13. 13. Acquisition
  14. 14. Focused exam – 8 views Sagittal or coronal views RIB SHADOWS confirm position and guide you to pleura.
  15. 15. THE BAT VIEW Chest wall Pleural line
  16. 16. Rock the probe slightly side to side until the pleura is in sharp focus Pleura not at right angles to probe so indistinct Correct angle = sharpest edge.
  17. 17. SIZE MATTERS (and focus) SAME SPACE, SAME TIME, SAME PATIENT………. F> F> F> F>
  18. 18. The Regions 1 2 3 4 Volpicelli et al, Am J Emerg Med 2006; 24: 689-696 Region 2 is usually above the nipple
  19. 19. Interpretation
  20. 20. NORMAL LUNG
  21. 21. A lines = default normal  Horizontal echo reflection at exact multiples of intervals from surface to bright reflector.  Dry lung OR PNTX  Decay with depth  Obliterated by B pleura A A A A A A
  22. 22. B lines = fluid in alveolus or interstitium  Originates from pleural line  Reaches base of screen OR ALMOST  MORE THAN 2 at once is abnormal EXCEPT in lung base Remember as ‘Kerley Bs’ Not exactly the same. RIB RIB B B B BB
  23. 23. B Lines = Crackles
  24. 24. Confluent B lines = Bad Bad  ‘White’ or ‘shining’ lung  Means increased severity  Probably indicates thicker fluid in alveoli eg protein or inflammatory cells  % space / 10
  25. 25. C = Pleural line abnormalities  Acute inflammation  Old fibrosis. Indicates abnormal interstitium  Resistant to APO  APO not excluded RIB C
  26. 26. C can be grossly abnormal If CCF is clinically likely, need to cross check with heart or IVC view.RIB
  27. 27. PLEURAL LINE ABNORMALITIES OBVIOUS SUBTLE
  28. 28. B x 3 x 2 x 2 = CCF Makes assumption that ‘globally’ wet lungs are most likely to be CCF 12
  29. 29. CASE A. RIGHT LUNG
  30. 30. CASE A. LEFT LUNG
  31. 31. XRAY A
  32. 32. Case B RIGHT LUNG
  33. 33. Case B LEFT LUNG
  34. 34. XRAY B
  35. 35. False Positive False negative  Global fibrosis  Bilateral pneumonitis  ARDS  Resolving CCF (pleural effusions)  Low focus  Dual diagnosis
  36. 36. Tweaks
  37. 37. ‘DRY’ BY PROTOCOL POSSIBLE PE, LOOK FOR SUBPLEURAL ABNORMALITIES ?RESOLVING APO, LOOK FOR PLEURAL EFFUSIONS
  38. 38. ‘WET’ BY PROTOCOL RIGHT HEART LARGER THAN LEFT > ?FIBROSIS LOOK FOR COLLAPSING IVC > ? pneumonia
  39. 39. View IVC for fluid tolerance
  40. 40. EXTRA SIGNS….
  41. 41. SUB-PLEURAL ABNORMALITIES CONSOLIDATION OR COLLAPSE SUB PLEURAL FLUID
  42. 42. Pneumonia with air bronchograms
  43. 43. ..pneumonias, PE, mets….
  44. 44. HEPATISATION VS COLLAPSE SOLID, NO CHANGE WITH RESPIRATION COLLAPSE – CONCAVE EDGES, CHANGE WITH RESPIRATION
  45. 45. PLEURAL EFFUSIONS VERY BIG MEDIUM
  46. 46. Pneumothorax Normal Lung Pneumothorax
  47. 47. M-mode for sliding - normal straight speckled
  48. 48. No sliding – PNTX or Adhesion straight straight
  49. 49. No sliding- PNTX or adhesion VERY SENSITIVE, LESS SPECIFIC WALL MOTION ARTIFACT PLEURA straight speckled
  50. 50. Additional PNTX signs LUNG PULSE NO PNTX LUNG POINT PNTX OR ADHESION
  51. 51. Sliding traps BREATH HOLD NO BREATH HOLD
  52. 52. Recap  Terminology? = 12 B lines  Good scan? = Rib shadow, sharp pleura and high focus  Errors? =15% with pre-existing fibrosis, dual pathology or resolving APO.
  53. 53. Summary  Lung scanning is easy  Cheap/quick/safe/portable  International acceptance  8 views/12 B lines  Not infallible : 85% DA  Better than auscultation + CXR

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