Chest ultrasound

1. Dr. KAZIM ULLAH
RESIDENT RADIOLOGY
CMH ABBOTTABAD
CHEST ULTRASOUND

2. SEQUENCE
 Introduction
 Sonographic Anatomy
 Instrumentation
 Technique
 Pathologies
 Limitations
 Take home points

3. INTRODUCTION
 The portable chest ultrasound is a routine diagnostic tool used in
the ICU setting to assess patient lung function
 Chest ultrasound is useful only for assessing superficial pulmonary,
pleural-based and chest wall lesions
 Chest ultrasound is increasingly used to guide interventional
procedures of the chest, such as biopsy and placement of
intercostal chest drain

4. Chest ultrasound necessitates the understanding of some basic
signs for interpreting normal and abnormal lung conditions.
SONOGRAPHIC ANATOMY

5. BAT SIGN

6. A LINES

7. LUNG SLIDING

8. SEASHORE SIGN(M-MODE)

9. B LINES

10. INSTRUMENTATION

11. TECHNIQUE

12. SCANNING POSITIONS

13. SCANNING POSITIONS

14. PATHOLOGIES

15. PLEURAL EFFUSION
 The classic appearance of a pleural effusion is an echo free area
between the visceral and parietal portions of the pleura
 Four different appearances are recognized at ultrasound
1. Anechoic 3. Complex and septated
2. Complex but not septated 4. Echogenic

16. PLEURAL EFFUSION

17. PLEURAL THICKENING
 Pleural thickening appears as hypoechoic broadening of the pleura
 Pleural thickening most frequently related to scarring, fibrosis,
empyema and pleuritis

18. PLEURAL THICKENING

19. PLEURAL MASS
 Malignant masses of the pleura include mesothelioma, lymphoma
and metastases
 Mesothelioma is seen as irregular thickening of the pleura that may
appear nodular and is frequently associated with a large pleural
effusion
 Color Doppler ultrasound of a malignant pleural mass may reveal
neovascularity with irregular tortuous vessels

20. MESOTHELIOMA

21. PNEUMOTHORAX
 Use of a combination of absent lung sliding and the loss of comet
tail artifacts has a sensitivity of 100% and specificity of 96.5%
 The key sonographic signs used to diagnose pneumothorax
include
 Absent lung sliding
 Exaggerated horizontal artifacts/A lines
 Loss of comet tail artifacts/B lines
 Broadening of the pleural line to a band

22. DIAGNOSTIC ALGORITHM OF PNEUMOTHORAX

23. LUNG POINT SIGN
 The most specific finding of pneumothorax at ultrasound is the lung
point sign
 The lung point sign represents the boundary between the aerated
lung and pneumothorax

24. LUNG POINT SIGN

25. LUNG POINT SIGN

26. BAR CODE SIGN
 At M mode ultrasound , the area underneath soft tissue-
pneumothorax interface demonstrates multiple horizontal bands of
hyperechoic artifacts caused by the lack of visible lung motion
 This M-mode appearance mimics bar code or stratosphere sign

27. BAR CODE SIGN

28. M-MODE

29. DISEASES OF THE LUNG PARENCHYMA
 In healthy individuals, visualization of the lung parenchyma is not
possible because the large difference in acoustic impedance
between the chest wall and the air with in the lung results in near
total reflection of the ultrasound waves
 However, in parenchymal diseases that extend to the pleural
surface, replacement of air with in the lung creates an acoustic
window, allowing assessment of lung tissue

30. PNEUMONIA
 Consolidation can be visualized on ultrasound
 Appears as hypoechoic area with irregular margins
 Branching echogenic structures are often seen within the
consolidation and represent air bronchograms
 Air bronchogram may be seen as hyperechoic foci moving through
the bronchi(dynamic air bronchogram)within the consolidation
 The branching pattern of vascular flow with in the consolidated
lung segment can be observed by using color Doppler

31. PNEUMONIA

32. LUNG ABSCESS
 A lung abscess can be identified as a hypoechoic lesion with a well
defined or irregular wall
 The center of the abscess is usually anechoic but may contain
internal echoes and septations

33. LUNG ABSCESS

34. ALVEOLAR-INTERSTITIAL SYNDROME
 Abnormally increased lung water content and reduced air in the
alveoli result in fluid leakage into the pulmonary interstitium and
alveolar spaces
 Patient with interstitial disease have an increased number of
vertical, comet tail artifacts called B lines

35. PULMONARY EDEMA
 Pulmonary edema is the most common cause of acute alveolar
interstitial syndrome
 In pulmonary edema, multiple B lines are seen having diffuse
distribution
 At least 3 lines with curvilinear and 6 lines with linear transducer
are considered multiple and consistent with pathologic B lines

36. PULMONARY EDEMA

37. COPD AND ASTHMA
 Multiple B lines at ultrasound are suggestive of alveolar interstitial
syndrome, which can be used to rule out acute COPD exacerbation
 In general, the ultrasound appearance of the lungs and pleura in
asthmatic and COPD patients demonstrates multiple A lines with
normal lung sliding

38. PULMONARY MASS
 PRIMARY LUNG NEOPLASMS
 Appears as a homogenous, well defined mass that is usually
hypoechoic, but may be slightly echogenic
 There is usually posterior acoustic enhancement
 Color Doppler ultrasound is useful in distinguishing malignant
from benign pulmonary masses
 Malignant masses are associated with neovascularity

39. LUNG CANCER

40. METASTATIC
 Peripheral pulmonary metastasis may be detected at sonography,
appearing as multiple sub pleural echogenic nodule measuring 1–2
cm in diameter
 Color Doppler demonstrates the high vascularity of these lesions

41. METASTATIC LUNG TUMOR

42. DISEASES OF THE CHEST WALL
 Soft tissue disease
 Ultrasound is sensitive for the detection of soft tissue masses
arising within the chest wall. most of these are benign, such as
lipoma, sebaceous cyst, hematoma and abscess
 Lymph nodes, particularly within the axilla and supraclavicular
fossa are easily examined with ultrasound

43. LIMITATIONS
 Although the role of chest ultrasound has been well recognized in
evaluation of pleural effusion, pneumothorax, pulmonary edema,
and guidance for thoracentesis or biopsy, the value of ultrasound in
evaluation of the lung remains limited
 Several lung sign at ultrasound are artifacts
 Artifacts are affected by machine factors such as focal zone,
frequency and gain setting

44. LEARNING OBJECTIVES

45. TAKE HOME POINTS
 PNEUMOTHORAX:
 Lung sliding absent, bar code sign or stratosphere sign, lung
point sign , multiple A-lines
 PLEURAL EFFUSION
 Anechoic space between visceral and parietal pleurae
 PNEUMOIA
 Irregular hypoechoic area with serrated margin, dynamic air
brochogram, branching vascular flow
 PULMONARY EDEMA
 Multiple B lines, diffuse homogenous distribution

46. QUIZ

49. THANK YOU

50. INGUNISCROTAL ULTRASOUND BY DR FAZAL
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