This document provides an introduction to point of care ultrasound (PoCUS) and thoracic ultrasound. It defines PoCUS and outlines important learning objectives. It then discusses various aspects of thoracic ultrasound, including probe selection, lung anatomy visualization, common findings like A-lines and B-lines, consolidation, pleural effusions, and techniques for thoracentesis procedures. Key points are emphasized about integrating ultrasound findings appropriately and recognizing limitations. Overall it aims to educate practitioners on basic thoracic ultrasound skills and interpretations.

1. Point of Care Ultrasound
(PoCUS): Introduction
George
A.
Fox
MD,
MSc,
FRCPC,
FCCP
!

2. Financial Disclosure:
Within the past 5 years, I have received
financial sponsorship, honoraria and
hospitality from the following
pharmaceutical companies:
• Actelion
• Astra-Zeneca
• Bayer HealthCare
• Boehringer Ingelheim
• InterMune
• Novartis

3. Learning Objectives:
At the end of this session and workshop, the
participant(s) will:
• NOT be skilled ultra-sonographer’s
• NOT be able to perform a comprehensive “consultative”
ultrasound procedure
• Recognize that ultrasound equipment in the hands of an
inexperienced operator may cause patient harm
• Recognize your limitations in bedside ultrasound and outline
steps to improve your skills

4. PoCUS
Definition:
– An ultrasound examination provided
and performed at the bedside by the
primary care physician (or their
designate), usually as an adjunct to
the physical examination, to identify
the presence or absence of a limited
number of specific findings.
CAR, 2013. www.car.ca

5. PoCUS
• Findings from the PoCUS examination
MUST be correctly integrated into the
clinical decision making process.
• If you are not certain of all, or part of
the PoCUS examination, you should NOT
rely on those uncertain findings in the
clinical decision making process.

6. Noble,
V.E.,
MGH,
Boston,
MA

7. Cook,
T.
MD,
Columbia,
SC

8. Moak,
J.H.,
MD,
RDMS;
hFp://www.medicine.virginia.edu

9. Moak,
J.H.,
MD,
RDMS;
hFp://www.medicine.virginia.edu

10. Moak,
J.H.,
MD,
RDMS;
hFp://www.medicine.virginia.edu

11. Cook,
T.
MD,
Columbia,
SC

12. Shulich
School
of
Medicine
&
DenOstry,
UWO

13. Shulich
School
of
Medicine
&
DenOstry,
UWO

14. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

15. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

16. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

17. Moak,
J.H.,
MD,
RDMS;
hFp://www.medicine.virginia.edu

18. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

19. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

20. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

21. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

22. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

23. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

24. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

25. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

26. Shulich
School
of
Medicine
&
DenOstry,
UWO;
www.slideshare.net

27. PoCUS
NEJM
2011,
364;8:
749-­‐57

28. Thoracic/Pleural Ultrasound
George
A.
Fox
MD,
MSc,
FRCPC,
FCCP
!

29. Learning Objectives:
At the end of this session and workshop, the
participant(s) will be able to:
• Discuss the appropriate choice of ultrasound probes
• Identify the structures when examining the lung and pleural space
• Identify the pleura, and describe the findings of a pneumothorax
• Describe how B-mode/M-mode are used to identify a pneumothorax
• Identify common ultrasound “patterns” visualized in the thorax
• Describe how to perform a thoracentesis using ultrasound guidance
• Describe static and dynamic ultrasound guidance

30. Thoracic Ultrasound:
hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐image-­‐interpretaOon-­‐tutorial

31. Thoracic Ultrasound:
hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐image-­‐interpretaOon-­‐tutorial

32. Thoracic Ultrasound:
B-mode:
hFp://www.jrheum.org/content/39/8/1641

33. Thoracic Ultrasound:
M-mode:
hFp://www.icmteaching.com/ultrasound/lung%20ultrasound/styled-­‐125

34. Thoracic Ultrasound:
hFp://www.ncbi.nlm.nih.gov/pubmed/?term=lung+ultrasound

35. Thoracic Ultrasound:
Probes:
Phased Array Probe Linear Vascular Probe
hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐basics-­‐tutorial

36. Thoracic Ultrasound:
Probe Location:
Volpicelli, G., Emerg Radiol, 2008: 15:145-51

37. Thoracic Ultrasound:
Lichtenstein, D., CHEST 2008, 134:117

38. Thoracic Ultrasound:
Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Pleural
Effusion
94 97 95 90
Alveolar
Consolidation
(Pneumonia)
90 98 88 95
Interstitial
Syndrome
(CHF, ARDS)
93 93 87 99
Complete
Pneumothorax
100 96 100 98
Occult
Pneumothorax
79 100 89 99
AECOPD 89 97 93 95
Pulmonary
Embolism
81 99 94 98
Lichtenstein, D., Ann Int Care, 2014; 4:1-12

39. Thoracic Ultrasound:
Lichtenstein, D., CHEST 2008, 134:117

40. Thoracic Ultrasound:
5 sonographic “signs” used in the BLUE
Protocol:
– Sliding Lung
– A Lines
– B Lines
– Alveolar Consolidation
– Pleural Effusion

41. Thoracic Ultrasound:
Lung Sliding:
http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial
Present

42. Thoracic Ultrasound:
Lung Sliding:
http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial
Present? Absent

43. Thoracic Ultrasound:
Lung Sliding, B-mode:

44. Thoracic Ultrasound:
Absent Lung Sliding, B-mode:

45. Thoracic Ultrasound:
Lung Sliding (B-mode/M-mode)
http://www.acep.org/

46. Thoracic Ultrasound:
Absent Lung Sliding:
Other causes:
– Pleural adhesion
– Atelectasis
– Lobectomy/Pneumonectomy
– Main-stem intubation
- Compare with other lung
- Look for “Lung Point” (100% specific for
pneumothorax)

47. Thoracic Ultrasound:
“Lung Point”

48. Thoracic Ultrasound:
A Lines:
• Horizontal “reverberation” artifacts
• Generally seen in Aerated Lungs
• Parallel to the pleural line
• Decay with increasing depth
• Obliterated by B Lines

49. Thoracic Ultrasound:
A Lines:
• Seen in normal lung parenchyma
– PAOP < 13 mmHg
• DD(x):
– Obstructive Lung Disease (COPD/Asthma)
– Pulmonary Embolism
• A Lines can be seen without lung sliding
– search for pneumothorax

50. Thoracic Ultrasound:
A Lines:
http://www.pneumon.org

51. Thoracic Ultrasound:
A Lines:

52. Thoracic Ultrasound:
B Lines:
• Hyperechoic rays projecting vertically
from pleural line to bottom of screen
– Obliterate A Lines
• Identifies fluid in interlobular septum
• “Interstitial” Syndrome
– Bilateral
• CHF, ARDS, ILD
– Unilateral
• Pneumonia

53. Thoracic Ultrasound:
B Lines:
hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐image-­‐interpretaOon-­‐tutorial

54. Thoracic Ultrasound:
B Lines:
http://www.criticalecho.com

55. Thoracic Ultrasound:
B Lines:
http://www.criticalecho.com

56. Thoracic Ultrasound:
B Lines:

57. Thoracic Ultrasound
B Lines:
Clinical Role of B Lines:
Fluid “Intolerant”
vs
Fluid “Tolerant”

58. Thoracic Ultrasound:
A Lines vs B Lines:
hFp://www.scielo.br/scielo

59. Thoracic Ultrasound:
Consolidation:
http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial

60. Thoracic Ultrasound:
Consolidation:
Air bronchograms
Chest. 2009;135(6):1421-1425

61. Thoracic Ultrasound:
Consolidation:
hFp://www.criOcalecho.com/content/tutorial-­‐9-­‐lung-­‐ultrasound

62. Thoracic Ultrasound:
Consolidation:
hFp://www.criOcalecho.com/content/tutorial-­‐9-­‐lung-­‐ultrasound

63. Thoracic Ultrasound:
Pleural Effusion:
http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial

64. Thoracic Ultrasound:
Pleural Effusion:

65. Thoracic Ultrasound:
Pleural Effusion:

66. Thoracic Ultrasound:
Pleural Effusion:
“Jelly Fish” sign
http://www.critcaresono.com

67. Thoracic Ultrasound:
Pleural Effusion:
“Jelly Fish” sign / Lung Flapping

68. Thoracic Ultrasound:
Pleural Effusion:
Septations “Plankton” sign

69. Thoracic Ultrasound:
Thoracentesis:
http://www.critcaresono.com/

70. Thoracic Ultrasound:
Thoracentesis:
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/bedside-applications-of-ultrasound/
Localize deepest “pocket” of fluid in longitudinal and transverse plane

71. Thoracic Ultrasound:
Thoracentesis:
Must Identify:
- Anechoic free space
- Chest wall
- Diaphragm
- Above vs below
- Respiratory Movement
- Compressed Lung
- “Flapping”
http://link.springer.com/referenceworkentry

72. Thoracic Ultrasound:
Thoracentesis:
“Static” Guidance “Dynamic” Guidance
http://www.critcaresono.com/

73. Thoracic Ultrasound:
Thoracentesis:
“Static” Guidance “Dynamic” Guidance
http://www.pocustoronto.com/articulate/thora/story.html

74. Thoracic Ultrasound:
Thoracentesis:
http://www.med.uottawa.ca/courses/

75. Thoracic Ultrasound:
Thoracentesis:
http://www.med.uottawa.ca/courses/

76. Thoracic Ultrasound:
Thoracentesis:
Pearls
&
Pidalls:
– IdenOfy
anatomic
boundaries:
• Anechoic
free
space
• Chest
wall
• Diaphragm
– Diaphragm
movement?
• Compressed
lung
– Lung
flapping?
– R/O
ascites:
• Hepatorenal/splenorenal
space
vs
pleural
space?