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3 lung and thorax

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Lung and Thorax Ultrasound

Published in: Health & Medicine

3 lung and thorax

  1. 1. Lung & thorax SAH & RNSH 2011Critical Care Ultrasound Course Thanks to: Dr Paul Atkinson Dr Bishr Faheem Dr Daniel Lichtenstein
  2. 2. Scanning the lung• Why scan the lung?• Probe & scanner settings• Technique• Landmarks• US findings• Terminology: the lung profiles• Matching the findings to the disease• Sticking needles & tubes in the lung 2
  3. 3. Why scan the lung?• Diagnosis • Air in pleura: PTX • Fluid in pleura: blood, pus • Fluid in lung tissue: APO/ pneumonia / ARDS • Consolidated lung tissue: pneumonia / contusion / infarct (PE) / cancer• Procedures 3
  4. 4. Why bother?• Lung US is more accurate than CXR for: • PTX (>95% versus 50%) • Pleural fluid (20ml versus 200ml) • APO sens 97%, spec 94%, acc 95% • PE?? Sens 74% … 81% if add DVT• It’s also • Faster (2 min versus 19 min) • Safer • Repeatable 4
  5. 5. The Technique 5
  6. 6. Patient position! No need to sit patient up (eg trauma)! In fact, accuracy for PTX is improved if lying flat… just harder to get round the back for pleural fluid! Air rises! Fluid sinks 6
  7. 7. Probe! Ideally the curved probe! Linear array no anatomical info! Phased array poor image quality 7
  8. 8. Preset! Abdo / FAST! Not the commercial ‘lung’ settings! Turn off filters ! Multibeam / compounding ! Tissue harmonics! Why? You are looking for artefacts 8
  9. 9. Depth! Close up consolidation? = 5cm! Just sliding / A / B lines? = 10cm! Base of lung / diaphragm? = 15cm! Making sure rockets are rockets? = 15cm 9
  10. 10. Probe position! Sagittal! Right angles to the ribs! Makes sure that the landmarks (rib shadows) stay in view 10
  11. 11. Find those ribs ‘RIB’ ‘RIB’ 11
  12. 12. Look between the ribs RIB RIB PLEURAL LINE (WHERE THE ACTION IS) 12
  13. 13. So:! Curved probe! FAST / abdo preset! 10-15cm depth! Turn off fancy filters! Sagittal / long axis of patient 13
  14. 14. Where will I scan? Depends on clinical context 14
  15. 15. The basic principle! Air rises " scan highest point of the chest! Fluid sinks " scan lowest point! Some diseases are patchy (eg pneumonia, ARDS) " scan as much of the lung as possible (at least look at each lobe) 15
  16. 16. Where will I scan?! Cardiac arrest: highest point on each side! Shock: 2 anterior (BLUE) points on each side! Breathless: 3 points on each side ! Add 1 posterior (PLAPS) point! Thorough look: as much of each lung as possible (improves accuracy) 16
  17. 17. BLUE points & PLAPS points 17
  18. 18. BLUE points & PLAPS points! What the %$#% ???! Daniel Lichtenstein’s BLUE protocol! BLUE is not an acronym! PLAPS is, though 18
  19. 19. BLUE points & PLAPS points! Upper BLUE point = upper lobe! Lower BLUE point = middle lobe / lingula! PLAPS point = lower lobe 19
  20. 20. Lichtenstein’s BLUE points 20
  21. 21. Lichtenstein’s BLUE points in theory 21
  22. 22. Lichtenstein’s BLUE points in theory 21
  23. 23. Lichtenstein’s BLUE points in practice 22
  24. 24. Lichtenstein’s BLUE points in practice 22
  25. 25. Lichtenstein’s PLAPS point 23
  26. 26. PLAPS point! ‘Postero- Lateral Alveolar / Pleural Syndrome’! What the %$#% ???! Posterolateral = round the back! Alveolar syndrome = consolidation! Pleural syndrome = pleural fluid 24
  27. 27. PLAPS point! The PLAPS point is the lowest point of the lung! The Morisons Pouch of the thorax’ (thanks to Dr Chris Wong)! So this is where you find pleural fluid! If there’s no fluid here, there’s no fluid anywhere in the thorax! 25
  28. 28. How to find the PLAPS point! It’s the posterior continuation of the lower BLUE point (as far around as you can get the probe) 26
  29. 29. How to find the PLAPS point 27
  30. 30. How to find the PLAPS point 27
  31. 31. Tip: watch out for the abdomen!! If you scan the liver / spleen & think you’re still above the diaphragm, it will resemble consolidation! ESP if you are using linear probe 28
  32. 32. Tip: Get round as far back as you can! wrong right 29
  33. 33. Tip: Get round as far back as you can! wrong right 29
  34. 34. Tip: Get round as far back as you can! wrong right 29
  35. 35. Normal lung 30
  36. 36. NB: ‘normal lung’! Pleural line looks like a ‘curtain’ sliding back & forth! Sparkle = scatter from air in lung! You don’t really seeing normal lung at all! If it looks like liver: ! mirror ! hepatization 31
  37. 37. What am I looking for? 32
  38. 38. What am I looking for?! Pleural fluid! Pleural sliding! A lines: reverb artefact from pleural line! B lines: hyperechoic reverberation effect from air/water interface! C: consolidation 33
  39. 39. Pleural fluid 34
  40. 40. Pleural fluid! Site: dependent regions! Appearance: ! black = anechoic (fresh blood, transudate/ exudate) ! echogenic / stuff = blood, exudate! Amount: as little as 20ml! Sensitivity >97%, specificity 99-100% (Sisley et al, J Trauma 1998) 35
  41. 41. Pleural fluid 36
  42. 42. Pleural fluid 36
  43. 43. Pleural fluid 37
  44. 44. Pleural fluid: caveats! Pleural vs pericardial fluid (pericardial = delimited by descending aorta)! Peritoneal fluid (where’s the diaphragm?)! Small traces of fluid: easy to miss 38
  45. 45. Pleural or pericardial fluid? 39
  46. 46. Duh! Just look all over the thorax
  47. 47. A, B & Z lines 41
  48. 48. A, B & Z lines! A lines = horizontal & static = reverberation artefact from pleura! B lines = vertical & move with resps (prev ‘comet tails’) = thick vertical lines which reach to edge of screen & obliterate A lines! Z lines = vertical, fade quickly, don’t move with resps 42
  49. 49. A lines 43
  50. 50. A lines 44
  51. 51. A linesHorizontal artefacts Only air is presentPresent in dry lungs Present in PTX 45
  52. 52. B-line B line 46
  53. 53. B lines Vertical artefacts Air/fluid mix in interlobular septa Equivalent of Kerley B lines Not seen in PTXEven 1 B line rules out PTX at that site 47
  54. 54. B lines Vertical Bright Obliterate A lines Don’t fade!Reach all the way to the edge of the screen! 1 or 2 per lung field is OK 3 or more = ‘rockets’ 48
  55. 55. Z-lines(Note: A line maintained) 49
  56. 56. Z lines! ill defined! DON’T move with respiration! DON’T erase the A lines 50
  57. 57. Lung rockets‘When several B lines are visible in a single scan, the pattern evokes a rocket at lift-off, and we have adopted the term ‘lung rockets’’ (Lichtenstein p106) 51
  58. 58. Lung rockets3 or more B lines per lung field = ‘rockets’ 52
  59. 59. Not ‘comets’International consensus dropped the term (terminology is confusing enough already) 53
  60. 60. Rockets 54
  61. 61. Rockets 54
  62. 62. Top TipUp to 1/3 normal patients have rockets in dependent regions So if you see rockets in PLAPS points, it doesn’t matter! 55
  63. 63. Lung rockets = wet lungs! Just in the bases = normal! In all windows = cardiogenic oedema! Patchy, with spared areas = non cardiogenic oedema / widespread pneumonia! Localised = pneumonia / chronic interstitial diseases eg fibrosis 56
  64. 64. TestRemember: 1 or 2 B lines are OK. Lung is still dry at that point! 57
  65. 65. A, B or Z lines? Dry or wet? 58
  66. 66. A, B or Z lines? Dry or wet? 59
  67. 67. A, B or Z lines? Dry or wet? 60
  68. 68. A, B or Z lines? Dry or wet? 61
  69. 69. Applications of lung rockets! Diagnosis ! Is it his CCF or COPD playing up today?! Fluid status ! is this guy with a crap LV overloaded today?! Guiding fluid resuscitation ! Fill him up until the rockets appear ! Dialyse him until the rockets disappear 62
  70. 70. Validation! Volpicelli et al, Am J Emerg Med 2006 (24): 689-696 ! N=300 (75 had AIS) ! Combined gold standard incl 1 month follow up ! sens spec ! Rockets 85.7% 97.7% 63
  71. 71. Just remember ! Not all vertical lines are B lines ! Z lines = puny ! pseudo-rockets with subcut emphysema (don’t move with respiration, & can’t see normal rib shadow above them) ! Not all rockets = fluid ! widespread pneumonia ! widespread fibrosis! rockets can be normal in lowest intercostal space! Posterior lung rockets can be normal in supine patients 64
  72. 72. Lung sliding 65
  73. 73. Lung sliding! Visceral pleura glides on parietal pleura! Why is it important?! A lines + sliding = dry lung = A profile! A lines without sliding = PTX = A’ profile! Rockets + sliding = APO = B profile! Rockets without sliding = ARDS / pneumonia = B’ profile 66
  74. 74. Lots of things can prevent lung sliding! CAL! Apices! Failure to ventilate ! eg R main stem intubation (L lung doesn’t move) ! Eg pain (chest splinting)! Pneumothorax! Pneumonia & ARDS 67
  75. 75. Lots of things can prevent lung sliding! CAL! Apices! Failure to ventilate ! eg R main stem intubation (L lung doesn’t move) ! Eg pain (chest splinting)! Pneumothorax! Pneumonia & ARDS … ??? 68
  76. 76. How the hell do pneumonia / ARDS reduce lung sliding? 69
  77. 77. Here’s how: ARDS/ disseminated APO: pneumonia: Transudate Exudate Lung sliding is Proteinaceous preserved, smooth ‘sticky’ pleural lineReduced / absent lung B profile sliding, irregular pleural line B’ profile
  78. 78. Is sliding preserved?
  79. 79. Is sliding preserved?
  80. 80. Is sliding preserved?
  81. 81. Is sliding preserved?
  82. 82. Is sliding preserved?
  83. 83. So how do I diagnose PTX? 74
  84. 84. Diagnosis of PTX1. No lung sliding2. No B lines3. Ideally, a lung point 75
  85. 85. 1. a o lung sliding N 76
  86. 86. Which side is the PTX?
  87. 87. Which side is the PTX?
  88. 88. Which side is the PTX?
  89. 89. Tip 1: compare sides 78
  90. 90. Tip 1: compare sides 78
  91. 91. Tip 1: compare sides 78
  92. 92. Tip 2: M-mode can help! Sliding = seashore sign! No sliding = stratosphere sign! But beware ‘false seashore’ with chest wall movement! 79
  93. 93. Normal: seashore sign 80
  94. 94. PTX: stratosphere sign 81
  95. 95. Stratosphere sign! M-mode = motion mode! If something isn’t moving, it’s a straight line 82
  96. 96. 2. No B lines• i.e. the A’ profile (air is dry)• Even a single B line rules out PTX• Because B lines = air/fluid interface• Absent sliding + B line = LUNG • EG not ventilating • EG pneumonia 83
  97. 97. 3. The lung point sign! Specific to PTX! the site where normal lung gives way to PTX! on one side of the image sliding is present! on the other side it is absent. 84
  98. 98. Lung point sign 85
  99. 99. What if there’s no lung point sign?there might still be a massive PTX which has collapsed the entire lung. Go back to the clinical picture & decide whether you need to go ahead & decompress the chest. 86
  100. 100. Can I trust lung US for PTX? If you are just starting out: ! If you want to find all PTX: get a CT ! Stable patient, Negative CXR, positive EFAST: get a CT … or ask a friend to scan ! Unstable patient, Negative CXR, positive EFAST: decompress the chest ! Rushing to OT/ chopper, neg CXR, pos EFAST: warn anaesthetist or insert ICC 87
  101. 101. Test 88
  102. 102. Sliding or not? 89
  103. 103. Sliding or not? 90
  104. 104. Sliding or not? 91
  105. 105. Sliding or not? 92
  106. 106. Consolidationa.k.a. the C profile 93
  107. 107. Alveolar consolidation! If you can see lung tissue, it ain’t normal!! It ain’t aerated ! Collapse ! Consolidation ! Atelectasis ! Contusion ! Infarction (PE) 94
  108. 108. Alveolar consolidation 95
  109. 109. Putting it all together 96
  110. 110. Terminology• A profile = A lines (or no lines), sliding preserved• A’ profile = A lines (or no lines), sliding absent• B profile = lung rockets in all windows, sliding preserved• B’ profile = lung rockets in all windows, sliding reduced / absent• A/B profile = patchy rockets alternate with normal areas• C profile = areas of consolidation• PLAPS positive = consolidation / effusion at bases• PLAPS negative = anything else at bases (A lines / B lines / rockets)
  111. 111. A word of advice about the A profile• All A lines = A profile• No lines seen? Still = A profile• Up to 2 B lines per window are OK! Still = A profile• Z lines? Still = A profile
  112. 112. Test 99
  113. 113. A, A’, B, B’ or C?
  114. 114. A, A’, B, B’ or C?
  115. 115. A, A’, B, B’ or C?
  116. 116. A, A’, B, B’ or C?
  117. 117. A, A’, B, B’ or C?
  118. 118. A, A’, B, B’ or C?
  119. 119. A, A’, B, B’ or C?
  120. 120. A, A’, B, B’ or C?
  121. 121. A, A’, B, B’ or C?
  122. 122. A, A’, B, B’ or C?
  123. 123. A, A’, B, B’ or C?
  124. 124. A, A’, B, B’ or C?
  125. 125. A, A’, B, B’ or C? (NB trick question)
  126. 126. A, A’, B, B’ or C? (NB trick question)
  127. 127. PLAPS: positive or negative?
  128. 128. PLAPS: positive or negative?
  129. 129. PLAPS: positive or negative?
  130. 130. PLAPS: positive or negative?
  131. 131. PLAPS: positive or negative?
  132. 132. PLAPS: positive or negative?
  133. 133. Normal lungs• A profile• Up to 2 B lines per window are OK• PLAPS negative
  134. 134. Pneumothorax• A’ profile = A lines (or no lines), sliding absent• There are no B lines at all on that side• There will be a lung point unless lung is completely collapsed
  135. 135. Acute cardiogenic pulmonary oedema (APO)• B profile = • lung rockets in all windows • lung sliding preserved
  136. 136. ARDS or pneumoniaB’ profile =• lung rockets in all windows• lung sliding reduced / absent• And pleural line may be irregularA/B profileC profileA profile anteriorly, PLAPS positive
  137. 137. Pulmonary embolus A profile anteriorly, PLAPS positive or negative i.e.lungs can look normal Sometimes C profile (pulmonary infarcts)
  138. 138. Asthma / COPD lungs look ‘normal’• A profile• PLAPS negative
  139. 139. Sticking needles in thorax 11 6
  140. 140. Chest drains/ thoracocentesis! Same rationale as central line placement! Ensures you don’t stick ICC in the liver! Tricks: ! Get patient to take maximal inspiration & expiration ! Scan in 2 planes ! Scan in same position you’ll insert ICC ! Use real time US 11 7
  141. 141. Let’s wrap this up 11 8
  142. 142. Lung US: top tips! Curved probe / FAST preset! At right angles to the ribs! Is there sliding? Tip: compare sides! A or B or C?! PLAPS or no PLAPS? 11 9
  143. 143. Any questions?

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