Thoracic ultrasound can be used to diagnose pneumothorax in critically ill patients. It is more sensitive than chest x-ray and can detect even very small pneumothoraces. Normal lung ultrasound shows the sliding of the visceral and parietal pleura and A-lines, while a pneumothorax is identified by the absence of sliding, A-lines only, and the lung point sign. Ultrasound can also assess endotracheal tube position and risk of post-extubation stridor.

1. Thoracic Ultrasound for the Respiratory System in Critically Ill Patients Bassel Ericsoussi, MD, PG-Y3 University of Illinois at Chicago Advocate Christ Medical Center

7. Pleural Line (LCWI) B-lines (Comet tails) 3-4 lines A-lines Skin surface to LCWI Multiple (reverberation) Multiple (reverberation) Advocate Christ Medical Center

8. Rib “shadows” Sliding lung sign: visceral and parietal pleura moving relative to one another with the respiratory cycle B-lines (Comet tails) Advocate Christ Medical Center

17. lung consolidation and a pleural effusion (a) Transversal view of consolidated left lower lobe; lung consolidation is seen as a tissular structure (C). In this consolidation, hyperechoic punctiform images (indicated by asterisk) can be seen; these correspond to air bronchograms (air-filled bronchi). Pleural effusion is anechoic (Pl). (b) Cephalocaudal view of consolidated left lower lobe: lung consolidation with air bronchograms. Ao, descending aorta; D, diaphragm; Pl, pleural effusion. Advocate Christ Medical Center

23. Ultrasound for the Diagnosis of Pneumothorax Chan SSW et al Acad Emerg Med Jan 2003 Vol.10 1. Ultrasound Feature Patient Population Sensitivity Specificity No Lung Sliding 328 Surgical And Trauma 95.5% 100% No Lung Sliding 111 Medical ICU 95.3% 91.1% No B Lines “ Comet Tails” 114 Med-surgical Unit 100% 60% Combined 617 100% 96.5% Lung Point 233 Med-surgical Unit 66% 100%

27. Transverse view showing ETT

28. Longitudinal view showing ETT

29. ETT Position Tube position OK Confirm with auscultation, ETCO2 Translaryngeal Ultrasound Tip visible Intratracheal Remove and reintubate May be too high, measure distance below VC Pleural Ultrasound Bilateral sliding pleura Unilateral sliding pleura Mainstem intubation Pull tube back 1-2 cm Yes Yes No No

32. It isn't tough.....