Focused thoracic ultrasound

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Focused thoracic ultrasound

  1. 1. + Focused Thoracic Ultrasound Sonographic appearances of the normal thorax Dr Andrew Ferguson Consultant in Intensive Care Medicine & Anaesthesia
  2. 2. + A shot in the dark… simply a hopeful attempt to hit an enemy that you can't see
  3. 3. + Why Use Thoracic Ultrasound?  Increasingly “standard  Stop “shooting  of care” issue in the dark” Both for Seldinger and conventional “surgical” drains  Really informative – negative findings also important  Interesting  Enjoyable! and challenging
  4. 4. + Objectives  Level 1 sono-anatomy  Right and left hemidiaphragm  Ribs and intercostal spaces  Lungs  Heart  Liver, spleen, kidneys
  5. 5. + Diaphragm  Double  Easily or triple line seen in presence of effusion from mid-axillary line  Abdominal surface visible with ascites  Curves upwards except with large effusions  Closely applied to liver/spleen – used as acoustic windows  Functional assessment feasible
  6. 6. + Diaphragm C Boussuges A et al. Chest 2009;135:391-400
  7. 7. + Diaphragm (trans-organ) RIGHT through liver LEFT through spleen
  8. 8. + Diaphragm Function (M-Mode) Towards probe RIGHT LEFT
  9. 9. + Diaphragm Function (2-D)  Normal diaphragm thickens on inspiration  End-inspiratory thickness 20% or more above baseline
  10. 10. + Heart
  11. 11. + Liver  Note texture (remember for consolidated lung images)  Artifacts e.g. mirror-image (implies aerated lung above) Liver Liver Kidney Mirror-image Diaphragm Hepato-renal recess
  12. 12. + Spleen Spleno-renal recess Spleen Kidney Diaphragm
  13. 13. + Intercostal space Pleura
  14. 14. + Lungs – normal static findings  Normal lung considered “invisible” to ultrasonographer  Artefacts A can be used to infer normality or abnormality lines  horizontal reverberation artifacts from pleural line  the only finding in 2/3 of normal lung US B lines  vertical narrow bands from pleural line to edge of screen  obliterate the A line  multiple B lines = Ultrasound Lung Rockets = interstitial oedema  Abnormal lung has characteristics that are clinically useful
  15. 15. + Lungs – normal static findings Rib Rib Rib A lines B line Wipe out A lines as they pass “Bat sign”
  16. 16. + Lungs – normal dynamic findings 1  Pleural sliding (lung sliding sign)  Pleural line “shimmers” with respiration  Presence  Lung sliding greatest in lower thorax (greatest expansion)  Absence      of lung sliding rules out pneumothorax of lung sliding has a number of causes Pneumothorax Apnoea Pleural adhesions Mainstem bronchial intubation or occlusion Critical parenchymal lung disease e.g. ARDS, contusion
  17. 17. + Lung sliding
  18. 18. + Lungs – normal dynamic findings 2  M-mode “seashore sign”  Structures superficial to pleural line are static  = Horizontal lines on M-mode (motion against time) = WAVES  Motion of pleural line is “reflected” deep to it  = Granular pattern reflecting motion = SAND
  19. 19. + M-Mode seashore sign Static structures horizontal lines (waves) Pleural line Pleural line reverberations dynamic – granular (sand)
  20. 20. + Lungs – normal dynamic findings 3  “Lung pulse” sign  Cardiac pulsations transmitted via lung to pleura  When seen in the absence of sliding…  Normal if breath-hold  Abnormal in other conditions with no sliding  Presence of lung pulse excludes pneumothorax
  21. 21. + Lung Pulse Sign
  22. 22. + Focused Thoracic Ultrasound Sonographic appearances of the abnormal thorax Dr Andrew Ferguson Consultant in Intensive Care Medicine & Anaesthesia
  23. 23. + Objectives – Level 1 1. Pleural effusion 2. Pleural thickening 3. Consolidated lung 4. Paralysed hemidiaphragm 5. Pericardial effusion 6. Pneumothorax 7. Interstitial syndrome 8. Guided thoracocentesis and drain placement
  24. 24. + Pleural effusion  Characteristics  Anechoic (transudate or exudate)  Echoic  Homogeneously echogenic  Complex non-septated (exudate)  Complex septated (exudate)  Size  Depth on 2-D  Estimates of volume  Inversion of diaphragm if very large
  25. 25. + Pleural effusion - anechoic
  26. 26. + Pleural effusion, complex, non-septated Plankton sign – mobile swirling elements in effusion
  27. 27. + Pleural effusion, complex, septated
  28. 28. + Pleural effusion, inverted diaphragm
  29. 29. + Effusion with atelectasis
  30. 30. + Clotted haemothorax Clot Lung with peripheral consolidation (contusion)
  31. 31. + Organised Haemothorax
  32. 32. + Pleural effusion - colour doppler Fluid colour sign – can be used to differentiate small effusion from pleural thickening
  33. 33. + Fluid colour sign Kalokairinou-Motogna M, et al. Medical Ultrasonography 2010, Vol. 12, no. 1, 12-16
  34. 34. + Pleural thickening Hypo-echoic pleural plaque
  35. 35. + Malignant pleural thickening
  36. 36. + Lung consolidation  Tissue pattern   Boundary or shred line   ragged boundary between consolidated and normal lung Air bronchograms   loss of air barrier leading to a “real” tissue image akin to liver i.e. hepatisation Non-mobile linear or punctate hyper-echoic features Fluid bronchograms  May be partially fluid-filled with material motion visible with breathing
  37. 37. + Lung consolidation
  38. 38. + Lung tail (atelectasis and consolidation) Note normal thickening of diaphragm with inspiration
  39. 39. + Lung consolidation Note material within effusion
  40. 40. + Severe consolidation - hepatisation Hepatised lung Fluid bronchograms
  41. 41. + Pneumothorax  Absent lung sliding  Absent lung pulse  Absent lung rockets  M-Mode – barcode or stratosphere sign  Lung-point sign
  42. 42. + Pneumothorax – stratosphere sign
  43. 43. + Pneumothorax – lung point sign
  44. 44. + Pneumothorax – lung point sign 1) Transient normal pattern as lung reaches chest wall at peak inflation or 2) transition zone where lung is sitting on chest wall
  45. 45. + Lung point on 2D US
  46. 46. + Interstitial/alveolar syndrome  Interlobular  > 3 lung rockets spaced around 7mm apart (B7 lines)  Alveolar  septal thickening/oedema filling/oedema > 3 lung rockets spaced around 3mm apart (B3 lines) Normal B7 B3 Lichtenstein DA, et al. Chest 2009;136:1014-1020
  47. 47. + Diaphragm Dysfunction (M-Mode) Normal Towards probe Paralysis
  48. 48. + Diaphragm Dysfunction (2-D) Towards probe NO thickening McCool FD, Tzelepis GE. Dysfunction of the Diaphragm. N Engl J Med 2012; 366:932-942
  49. 49. + Pericardial effusion Combined pleural and pericardial effusions Pericardial effusion
  50. 50. + Pneumothorax US algorithm Lung sliding NO B-lines YES NO YES Lung point No pneumothorax YES NO Lung pulse YES Pneumothorax NO

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