This document provides an overview of chest ultrasound techniques for critically ill patients. It describes the normal ultrasound patterns seen in the lungs including the pleural line, lung sliding, A-lines, and seashore sign. Abnormal patterns are also outlined such as pneumothorax, interstitial edema, alveolar edema, and alveolar consolidation. Techniques for identifying pleural effusions are also reviewed. The document concludes with a brief discussion of the BLUE protocol and management of single ventricle patients.

1. Chest Ultrasound in
Critically ill patient
ALI AHMED MAHAREAK
Assistant Lecturer Of Anesthesiology And Intensive Care ,
Al-Azhar University
Supervised by
Prof. Dr/ Mohamed El-feky
Professor of Anesthesiology and Intensive Care
Faculty of Medicine, Al-Azhar University

2. Advantages of lung ultrasonography
Immediate bedside availability
Immediate bedside repeatability
Fast, non-invasive
 operator dependent technique
Easy to learn
Widely available
Cost saving
Reduction in radiation exposure

4. Equipment requirements
 Curvilinear low frequency (2 – 5 MHz) transducer
 Linear (Vascular transducer) high frequency (5-10
MHz) transducer
 Cardiac transducer effective(small footprint)

5. Scanning technique
 Orientation marker on left of screen
 Transducer in longitudinal orientation
 Marker in cephalad position
 Transducer in intercostal space
 Transducer Moved freely over thorax

11. NORMAL / EXPECTED PATTERNS
 Pleural line
 Lung sliding
 “A” lines
 “Z” lines
 SEASHORE SIGN

12. Pleural line
 The pleural line is a hyper-echogenic line
located 0.5 cm below the rib line
 Its visible length between two ribs in the
longitudinal scan is approximately 2 cm
 The upper rib, pleural line, and lower rib
(vertical arrows) outline a characteristic
pattern called the bat sign.

29. Lung sliding
 Caution sliding sign can be absent in
conditions other than pneumothorax:
 Effusion
 Consolidations with pleural adhesions
 Chest tubes
 Advanced COPD

38.  An obvious difference appears on either side of the
pleural line (arrow).
 The motionless superficial layers generate
horizontal lines.
 Lung dynamics generate lung sliding (sandy
pattern). This pattern is called the seashore sign.

40. Normal lung: M mode

45. Interstitial edema: 7 mm spacing Alveolar edema: 3 mm spacing

49. Alveolar consolidation
Loss of lung aeriation (A- Lines)
Allows US waves to be transmitted deeply (spine)
Consolidation appears as hypoechoic ill defined
areas
Air bronchogram
Sonographic Hepatization

56. PNEUMOTHORAX PATTERN
 High frequency probe
 2nd intercostal space
 Midclavicular
 For 4-5 respiratory cycles
 B-mode and M-mode

57. PNEUMOTHORAX PATTERN
 LUNG SLIDING: absence
 EXCLUSIVE “A” lines
 Absent seashore sign
 “BARCODE SIGN”
 Lung point
 IF presence of “B” lines: NO
PNEUMOTHORAX

58. PNEUMOTHORAX

69. Pleural effusion
 Pleural effusion collects in dependent areas
(fluid is heavier than air)
 Any free pleural effusion is therefore in
contact with the bed in a supine patient
 Coronal view above the diaphragm with
marker towards the head

70. Right lung
10th rib
diaphragm
Parietal
peritoneum
liver
12th rib
Visceral
peritoneum
Parietal pleura,
diaphragmatic part
Pleural cavity,
Cost- phrenic
recess
Visceral pleura
Parietal pleura,
costal part
11th rib
Intercostal vein,
artery and nerve

82. BLUE protocol

83. Management of single ventricle
• The primary goal in the management of
patients with single ventricle physiology is
optimization of systemic oxygen delivery
and perfusion pressure.
• Blalock-Taussig shunt in infancy
• Bidirectional Glenn : SVC is connected to the
pulmonary arteries
• Fontan Procedure : Redirects IVC to
pulmonary arteries