Ultrasound (US) is a cost-effective, portable imaging tool that assists in diagnosing chest diseases, particularly pleural conditions and peripheral pulmonary lesions. It operates by producing mechanical waves that reflect off various tissues, allowing visualization of lung and pleural structures, and thus helping in diagnosing conditions like pleural effusions and pneumothorax. Key techniques for effective use include selecting appropriate transducer frequencies and positioning patients to avoid obstructions from the chest wall.

2. Dr-Mousa El-shamly

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1. Introduction
Ultrasound (US) has been proved to be valuable for the evaluation
of a wide variety of chest diseases,
The advantages of US
1- It is a relatively inexpensive
2-widely available, mobile form of multi-planar
imaging and free from ionizing.
3-Chest US can guides a variety of diagnostic
and therapeutic procedures.
4-Chest US is a useful tool in the diagnosis of
pleural diseases and peripheral pulmonary
lesions.
5- Moreover, endobronchial ultrasound (EBUS) is
the real advance in recent chest medicine.

4. Ultrasound Physics
Sound is a mechanical, longitudinal
wave that travels in a straight line
Sound requires a medium through which
to travel
Ultrasound is a mechanical, longitudinal
wave with a frequency exceeding the
upper limit of human hearing, which is
20,000 Hz or 20 kHz.
 Medical Ultrasound 2MHz to 16MHz
 1MHz=1million Hertz

5. ULTRASOUND – How is it produced?
Produced by passing an electrical current through a
piezoelectrical (material that expands and
contracts with current) crystal

6. Ultrasound Production
 Transducer produces ultrasound pulses .
 These elements convert electrical energy
into a mechanical ultrasound wave
 Reflected echoes return to the scan head
which converts the ultrasound wave into an
electrical signal

7. Frequency vs. Resolution
 The frequency also affects the QUALITY of the
ultrasound image
 The HIGHER the frequency, the BETTER the
resolution
 The LOWER the frequency, the LESS the resolution
 A 12 MHz transducer has very good resolution, but
cannot penetrate very deep into the body
 A 3 MHz transducer can penetrate deep into the
body, but the resolution is not as good as the 12 MHz
Low Frequency
3 MHz
High Frequency
12 MHz

8. Image Formation
Electrical signal produces ‘dots’ on the
screen
 Brightness of the dots is proportional to
the strength of the returning echoes
 Location of the dots is determined by
travel time. The velocity in tissue is
assumed constant at 1540 m/sec
Distance = Velocity
Time

9. • Acoustic impedance (AI) is dependent on the density of
the material in which sound is propagated
- the greater the impedance the denser the material.
• Reflections comes from the interface of different AI’s
• greater  of the AI = more signal reflected
• works both ways (send and receive directions)
Medium 1 Medium 2 Medium 3
Transducer
Interactions of Ultrasound with
Tissue

10. Interactions of Ultrasound
with Tissue
Reflection
Refraction
Transmission
Attenuation

11. Transmission
 Some of the ultrasound waves continue deeper into
the body
 These waves will reflect from deeper tissue
structures
transducer
Interactions of Ultrasound with
Tissue

12. Refraction
Incident
reflective
refraction
Angle of incidence = angle of reflection
Scattered
echoes

13. Attenuation
 Defined - the deeper the wave travels in the
body, the weaker it becomes -3 processes:
reflection, absorption, refraction
 Air (lung)> bone > muscle > soft tissue >blood >
water
Interactions of Ultrasound with
Tissue

14. Refraction
Incident
reflective
refraction
Angle of incidence = angle of reflection
Scattered
echoes

15. Reflected Echo’s
 Strong Reflections = White dots
Diaphragm, tendons, bone
‘Hyperechoic’

16. Weaker Reflections =
Grey dots
 Most solid organs,
 thick fluid – ‘isoechoic’
Reflected Echo’s

17. Reflected Echo’s
 No Reflections = Black dots
 Fluid within a cyst, urine, blood
‘Hypoechoic’ or echofree

18. What determines how far ultrasound waves can
travel?
 The FREQUENCY of the transducer
 The HIGHER the frequency, the LESS it
can penetrate
 The LOWER the frequency, the DEEPER it
can penetrate
 Attenuation is directly related to
frequency

19. Liver metastases

20. www.upei.ca/~vetrad
Attenuation
 Absorption = energy is captured by the
tissue then converted to heat
 Reflection = occurs at interfaces between
tissues of different acoustic properties
 Scattering = beam hits irregular interface –
beam gets scattered

21. www.upei.ca/~vetrad
Ultrasound Terminology
 Never use dense, opaque, lucent
 Anechoic
 No returning echoes= black (acellular
fluid)
 Echogenic
 Regarding fluid--some shade of grey d/t
returning echoes
 Relative terms
 Comparison to normal echogenicity of the
same organ or other structure
 Hypoechoic, isoechoic, hyperechoic
 Spleen should be hyperechoic to liver

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2. Equipment selection and patient position
1-The suitable probes for chest US are these
equipped with 3.5- to 10-MHz linear, convex, and
sector transducers.
2-The high-frequency linear probe can exam the
detailed signs of pleura and provide assessment
of superficial lesions.
3-Commonly a 3.5–5 MHz probe is used which is
suitable for imaging adequate depth of
penetration of lung.

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4- During chest US examinations, patients
can be in the seated or supine position .
5-The probe is moved along the
intercostals space to avoid interference by
ribs or sternum. The transducer can be
moved longitudinally or horizontally in the
chest wall.

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3. Chest wall: Muscle layers, bone, and
pleura
Because air cannot be visualized by US, the
normal lung parenchyma cannot be detected by
US theoretically.
The image of chest US in chest wall including
muscle, fascia, bone, and pleura .
The soft tissue echogenicity with multiple layers
means muscles and fascia.
The normal ribs appear hyperechoic surfaces
with prominent acoustic shadows beneath the
ribs.

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Approximal 0.5 cm below the ribs shadows,
the visceral and parietal pleura appear as an
enchogenic bright line.
During respiratory movement, the two pleural
lines glide with each other which is referred to
as the “Gliding sign”. Therefore, the “Gliding
sign” means normal parietal and visceral
pleura slide over each other during respiration
and the loss of “Gliding sign” can be seen in
pneumothorax or diffuse pleural thickening

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Lungs –normal static findings
Normal lung considered “invisible” to
ultrasonographer Artefact scan be used to infer
normality or abnormality
A 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 =
Abnormal lung has characteristics that are
clinically useful

29. NORMAL LUNG

31. A lines = default normal
 Horizontal echo
reflection at exact
multiples of
intervals from
surface to bright
reflector.
 Dry lung
 Decay with depth
 Obliterated by B
pleura A
A
A
A
A
A

33. B lines = fluid in alveolus or
interstitium
 Originates from
pleural line
 Reaches base of
screen OR
ALMOST
 MORE THAN 2 at
once is abnormal
EXCEPT in lung base
Remember
as ‘Kerley
Bs’
Not exactly
the same.
RI
B
RI
B
B B B B
B

34. B Lines = Crackles

35. Confluent B lines = Bad Bad
 ‘White’ or ‘shining’
lung
 Means increased
severity
 Probably indicates
thicker fluid in
alveoli eg protein or
inflammatory cells
 % space / 10

36. C = Pleural line abnormalities
Acute
inflammation
Old fibrosis.
Indicates
abnormal
interstitium
RI
B
C

37. C can be grossly abnormalIf CCF is
clinically
likely,
need to
cross
check with
heart or
IVC view.
RI
B

38. B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12

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Lungs –normal dynamic findings
Pleural sliding (lung sliding sign) Pleural line “shimmers”
with respiration Presence of lung sliding rules out
pneumothorax Lung sliding greatest in lower thorax
(greatest expansion) Absence of lung sliding has a
number of causes
1- Pneumothorax
2-Apnoea
3- Pleural adhesions
4-Mainstem bronchial intubation or occlusion
5-Critical parenchymal lung disease e.g. ARDS,
contusion

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4. Pleural disease
4.1. Pleural effusion
For the purpose of investigation pleural fluid can
be divided into three broad categories according
to etiology: infective, malignant and
miscellaneous.
The infective etiologies result in either a para-
pneumonic effusion or an empyema.
Malignant effusions are due to primary or
secondary thoracic disease, which may be
pulmonary or pleural.

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The miscellaneous causes of pleural fluid
include sterile benign effusions,
haemothoraces and chylothoraces.
Pleural effusions are differentiated into
transudates or exudates on the basis of
biochemical analysis of the aspirated fluid.
The erect chest radiograph is the most
common first line radiological investigation

44. PLEURAL EFFUSIONS
VERY BIG MEDIUM

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Whereas approximately 500 ml of pleural fluid is
required before an effusion can be identified
clinically, as little 200 ml will blunt the
costophrenic angle.
US in either a standing or sitting position not only
is able to detect smaller volumes of pleural fluid
than the erect frontal chest radiograph but it also
gives useful information about the nature of the
effusion.
The pleural effusion images in ultrasound
appearances are characterized by an echofree
space between the visceral and parietal pleura
.

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The classifications of the volume of pleural
effusion known currently are minimal, small,
moderate, and massive.
The minimal effusion indicate the echo- free
space is seen within the costophrenic angle;
small effusion indicates the space is greater than
costphrenic angle but still within a one-probe
range; moderate effusion indicates the space is
greater than one-probe range but within a two-
probe; and massive effusion indicates the space
is bigger than two-probe range.

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49. Pleural effusion.
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4.2. Pleural effusion echogenicity
. Four basic ultrasounds patterns of internal
echogenicity of pleural effusion were identified and they
can be subclassified as anechoic, complex
nonseptated, complex septated, and homogenously
echogenic
Anechoic effusion is defined as echo-free spaces
between visceral and parietal pleura.
Complex nonseptated effusion is defined as
heterogenous echogenic materials inside the pleural
effusions.
Complex septataed effusion is defined as fibrin strands
or septa floating inside the pleural effusions.
Homogenously enchogenic effusion is defined as
echogenic spots density evenly distributed within the

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A purely anechoic collection is found in exudates
and transudates with equal frequency.
However, internal echoes in the form of
septations or focal areas of debris are due
invariably to exudates. US presentations in
transudative pleural effusions are not always in
an anechoic pattern.
Tran‐ sudative pleural effusions may have a
complex nonseptated pattern or an anechoic
pattern

52. Pleural thickening.
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There was no transudative pleural effusion with complex
septated or homogenously echogenic pattern .
The applications of sonographic appearances in
effusions of febrile patients in the intensive care unit
(ICU) can determine the necessity of thoracentesis in
high risk patients with effusion in ICU
This study reported that complex nonseptated and
relatively hyperechoic, complex septated and
homogenously echogenic pleural effusion patterns might
predict the possibility of empyema in febrile patients in
the ICU.
The sonographic septation in lymphocyte-rich exudative
pleural effusions can help us differentiate tuberculosis
pleurisy from malignant pleural effusion

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5. Pneumothorax
Chest US may be help in the diagnosis of
pneumothoraces.
Normal parietal and visceral pleura slide over each other
during respiration and a pneumothorax is suspected
when this ‘Gliding sign’ is absent in chest US
A recently published systemic review, chest US had a
sensitivity of 90.0% and a specificity of 98.2% .
The confirmation of lung gliding has a 100% negative
predictive value for the absence of pneumothorax .
The use of M-mode can also objectify the presence or
absence of lung gliding

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56. Pneumothorax
Normal Lung
Pneumothorax

57. M-mode for sliding - normal
straight
speckled

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59. Pneumothorax
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5.1. Pulmonary lesions
The normal aerated lung is difficult to image
because the dramatic change in acoustic impe‐
dance between chest wall and lung results in
specular reflection of ultrasound waves at the
pleura. However, consolidated lung has a tissue
density and echo-texture similar to liver,
analogous to pathological hepatisation. This
removes the change in acoustic impedance at the
pleural interface, and ultrasound waves pass
directly into the affected lung

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When patient with lobar or segmental
pneumonia and the lesion is adjacent to pleura
or in the pleural effusion, the pneumonia may be
detected by chest US. A marked consolidation
with air-bronchogram and treelike ramifications
is easily seen Within the consolidated area,
hyperechoic (white) foci may be visible, again
representing a change in acoustic impedance,
but this time at the tissue interface between solid
lung and air-filled bronchi. Subpleural nodule
also can be seen in chest US

62. Pneumonia complicated by
abscess
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Chest US with color Doppler is a powerful tool for
differentiating the peripheral air-fluid abscess from
empyema .
The empyema can be detected by chest US with an
image of a hypoechoic lesion with complex-septated
effusions, passive atelectasis, width uniformity, and
smooth luminal and outer margins.
Color Doppler ultra‐ sound could not identify vessel
signals in pericavitary atelectasis.
The lung abscess in the US image reveals hypoechoic
lesion with typical pulmonary consolidation, irregular wall
width, and irregular luminal and outer margins.
Color Doppler ultrasound could identify vessel signals in
pericavitary consolidation

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.2. Alveolar interstitial syndrome
Alveolar interstitial syndrome constitutes a group
of diseases that is caused by an increase in lung
fluid and/or a reduction in its air content.
The result of this thickening of the interlobular
septa causes a particular artifact that is seen
arising from pleura line.
The ultra‐ sound appearance of alveolar
interstitial syndrome is a vertical artifact, called B-
line. Presence of the comet-tail artifact allowed
diagnosis of alveolar-interstitial syndrome by
chest ultrasound

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The major causes of alveolar interstitial
syndrome include pulmonary edema, acute
respiratory distress syndrome (ARDS), and
interstitial fibrosis. In the advanced study,
application of chest ultrasound in the patients
with respiratory failure, chest ultra‐ sounds can
help the clinician make a rapid diagnosis in
patients with acute respiratory failure according
the BLUE protocol

67. Acute Pulmonary oedema
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68. Acute pulmonary oedema
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70. Consolidation
 Irregular hypoechic area of varying size and
shape.
 Echotexure can appear homogenous or
inhomogenous.
 The most common sonographic feature is the
air bronchogram which is characterized by lens
shaped internal echoes within hypodene area
or echogenic lines.
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74. COLLASPE OF LUNG
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75. Peripheral bronchial carcinoma
 Can help to define better necrotic areas that
are depicted as anehoic region inside the
tumour.
 The infiltrative growth of solid tissue
without regard to anatomical structures is
characteristic of malignancy.
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76. Lung ca infiltrating chest wall.
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77. Pulmonary metastasis
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78. Pheripheral bronchial ca.
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6. Ultrasound-guided intervention
6.1. Diagnostic thoracentasis
The aim of the initial assessment of pleural fluid is to identify
malignancy or infection and starts with a visual inspection of the
aspirate prior to laboratory analysis.
Therefore diagnostic thoracentesis is mandatory. When
performed with image guidance thoracentesis provides clinically
useful information in more than 90% of cases.
If the pleural effusion spans three intercostal spaces and its
presence can be confirmed clinically by percussion then aspiration
can be performed safely at the bedside without the aid of image
guidance. When the effusion is small,
loculated or associated with underlying pulmonary collapse this
becomes more difficult and hazardous. In all these situations US
examination is required to confirm the presence of fluid and to
guide thoracentesi

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6.4. Endobronchial Ultrasound (EBUS)
Endobronchial ultrasound (EBUS) technology is a relatively new
bronchoscopic method of visualizing the tracheobronchial tree, the
surrounding pulmonary parenchyma, and the mediastinal
structures, with a particular role in lung cancer diagnosis, staging,
and treatment .
There are 2 types of probes used in EBUS: the peripheral or radial
probe (RP) and the linear or convex probe (CP) EBUS, which
have technical differences and distinct diagnostic abilities. Both
are used for EBUS-guided biopsies and transbronchial needle
aspirations (TBNA), which increases the diagnostic yield over
conventional bronchoscopic techniques, thus providing advanced
information on staging, diagnosis, and treatment. The 20-MHz
RP- EBUS is positioned inside a water-inflatable balloon and is
inserted through the working channel of the bronchoscope.

81. Acute pulmonary oedema
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82. Pneumothorax
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85. Consolidation
 Irregular hypoechic area of varying size and
shape.
 Echotexure can appear homogenous or
inhomogenous.
 The most common sonographic feature is the
air bronchogram which is characterized by lens
shaped internal echoes within hypodene area
or echogenic lines.
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89. Summarizing sonographic
finding in consolidation
 Liver like in early stage
 Air bronchogram
 Fluid bronchogram
 Blurred and serrated margin
 Reberberation echoes in the margin
 Hypoechoic abscess formation
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90. COLLASPE OF LUNG
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91. Pleural effusion.
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94. Pleural thickening.
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95. Lung abscess
 They typically appear as round or oval
anechoic lesions
 Margin may be smooth and echodense
 Microabscess are often visible as anechoic
areas within the pneumonic consolidation.
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96. Peripheral bronchial carcinoma
 Can help to define better necrotic areas that
are depicted as anehoic region inside the
tumour.
 The infiltrative growth of solid tissue
without regard to anatomical structures is
characteristic of malignancy.
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97. Pheripheral bronchial ca.
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98. Lung ca infiltrating chest wall.
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100. Pulmonary metastasis
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101. Summary of pulmonary ca
 Hypoechoic, inhomogenous.
 Rounded, nearly rounded.
 Sharp,serrated margins
 Infiltration of chest wall
 Irregular vascularization
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102. Limitation of lung ultrasound
 Require formal training ,knowledge and skills.
 Obese patients are frequently difficult to examine.
 The presence of subcutaneous emphysema.
 Lung ultrasound cannot detect lung overinflation.
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103. Conclusion
 Easy to learn and apply
 It can be used quickly to rule out any
significant pneumothorax in critically ill
patient.
 More sensitive than cxr in pleural effusion or
pleural pathology.
 The routine use of lung ultrasound appears
attractive alternative to bedside chest
radiography
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104. Cp5