lung ultrasound in surgical ICU a new era

1. Bedside lung ultrasound(BLUE)
a new era in Care ill patients
Dr. Radhwan Hazem Alkhashab
Consultant anaesthesiologist & intensivist
Aljamhori teaching hospital
2023

2. Introduction
Point-of-care ultrasonography
(POCUS) is widely used by
intensivists managing critically ill
patients whereby they can
accurately and rapidly assess for
many pathologies, This modality
includes sonography of the heart,
lungs, abdomen, kidneys, and
vascular system.

3. Lung ultrasound
In the thorax, air and water mingle: this explains the signs of lung
ultrasound. Because of the difference in acoustic impedance
between air in the lung and superficial tissues, ultrasound cannot
penetrate the lung, and artifacts are generated by the pleura.
(LUS)
Acoustic impedance is the resistance to the passage of
ultrasound waves, the greater the acoustic impedance,
the more resistant that tissue is to the passage of
ultrasound waves.

4. Indication of BLUE
The injured lung has an abnormal echotexture because of the presence of
fluid, secretions or air.
1. Shortness of breath or abnormal chest movement.
2. Pneumonia or other recurring infections
3. Acute Respiratory Distress Syndrome (ARDS)
4. COPD/Asthma.
5. Abnormal air entry to one or both lungs.
6. Traumatic patient.

5. Probe type & positioning

6.  Place your probe at the mid-clavicular line at the 2nd
intercostal space of the right (R1) and left (L1) lungs
respectively
 Place your probe at the right (R2) or left (L2) Midaxillary
line around the 6-7th intercostal space. This should be just
lateral to the nipple line in males.
 at the intersection of the posterior axillary line and a rib
space between the 10th and 12th ribs. This point is
commonly known as the PLAPS point (“posterior and/or
lateral alveolar and/or pleural syndrome”). The PLAPS will
be most relevant for assessing the presence of pleural
effusions and consolidations.
Probe positioning

7. Normal sonographic picture of lung
Bat sign

8. A- lines & seashore sign
2D mode M mode
View should be obtained in between
the ribs so that the pleural line
(A lines) is visible which are
reverberated from pleural artifact. The
“pleural line” slides with each breath.
This sliding pattern is referred to as
“lung sliding”. On the M-mode, this
line and the aerated lung below
create the “seashore sign.

9. Interstitial lung diseases
An isolated vertical B line may be visible in some normal lungs .
These are described to be:
1) They arise from the pleural line;
2) They move with the pleural line (if the pleural line is mobile);
3) They are hyperechoic.
4) They reach the bottom of the screen.
5) They efface A-lines at their point of intersection.
The presence of three or more B-lines in between two ribs
indicates the presence of interstitial syndrome with 93%
accuracy

10. Pneumothorax:
the presence of air in the pleural space leads to separation of the visceral and
parietal pleural interposition. This leads to a series of findings on lung US.
There is absence of lung sliding and B-lines. if lung sliding is present, you can
rule out pneumothorax with 100% sensitivity.

11. Pleural effusion
1st sign is Quad Sign
A pleural effusion has an anechoic
appearance often delineated by
the pleural line, the rib shadows,
and the lung line, called the “Quad
Sign.”

12. Pleural effusion
2nd sign is Sinusoid sign:
You can turn on M-mode to look for the Sinusoid
sign (looks like a sine wave). It is caused by the
parietal and visceral pleura moving closer and
further apart while the patient breathes. (White
arrows point to the lung line/visceral pleura while
black arrows point to the pleural line/parietal
pleura).

13. Consolidations
As even more fluid builds up in the lung, parts of the lung can
become completely fluid-filled, leading to consolidation. This is
commonly seen in pneumonia. ultrasound findings will progress from
multiple B-lines, confluent B-lines, subpleural consolidation, to a dense
consolidation. Once the air is completely gone from the lung and
replaced with fluid this will result in an echogenic structure on
ultrasound similar to echogenicity of the liver.

14. 1. Subpleural consolidation

15. 2. Shred sign
The border at which the fluid or
pus-filled lung tissue meets air
looks like a jagged echoic edge
which is known as the “Shred
sign”.
This image shows a subpleural
consolidation abutting the
pleural line (arrowheads) with a
tissue-like pattern. This figure
highlights the shredded lower
border, limited by the arrows

16. You can find this presentation in
www.mosulitu.ahlamontada.net