Emergency sonography in Pediatrics has evolved to become one of the most versatile modalities for diagnosing and guiding treatment of critically ill patients.

1. ETT Placement confirmation
prediction of post extubation stridor, Successful
Extubation & Diaphagramatic Function
Dr. Dinakara Prithviraj
Chief Neonatalogist & pediatric intensivist
Vydehi institute of medical sciences& RC
For Next Generation

2. Introduction
• Emergency sonography in Pediatrics has
evolved to become one of the most versatile
modalities for diagnosing and guiding
treatment of critically ill patients.
• It complements rather than replaces
traditional sonology.

3. Why we need to learn doing U/S in
Pediatrics
• It is usually not feasible to have a cardiologist or
sonographer available on immediate call on a 24-h
basis.
• Allows the ability to perform serial bedside
examinations and allows the important
assessment and reassessment of the adequacy
and efficacy of therapy.

4. ACEP/ SCCM guidelines include
USG by Pediatricians
In critically ill patients physical examination is quite
limited and inaccurate.
• USG has potential to reinvigorate physical exam,
improving accuracy.
• Important attributes: portability, lack of radiation,
repeatability, absence of consumables, being
battery powered , plus Information can be stored for
documentation, transmission & consultation.

5. Remember
• USG may appear complex at first sight but
simply requires a change in thinking.
• Once the process has been learned, a step by
step use will make it a routine

6. Remember
• Inappropriate interpretation or application of
data gained by a poorly skilled user may have
adverse consequences.
• So adequate training is essential and this must be
individualized and tailored to the specific needs
and applications of the user.

10. AIRWAY ULTRASOUND
Trachea

11. AIRWAY ULTRASOUND
Trachea
Tube in Esophagus

12. 2 Signals Bad

15. Transverse View Showing ETT

16. Longitudinal View Showing ETT

17. ETT Position Assesment with Ultrasound
• Proximal ETT Malposition (ETT too High)
-Measure distance from vocal cord to tip of the tube
-Tip of tube should not be visible above sternal notch
• Distal ETT Malposition
-Unilateral pleural sliding may indicate mainstem
intubation
-Combination of both may eleminate the need for chest
x-ray (Study Underway)

19. Laryngeal Ultrasound-An useful method in
predicting post extubation stridor
• Identifying patients at high risk for Re-
intubation due to stridor
-Cuff-leak test: was widely used but its application is
limited due to controversial result
-The air-column width during deflation is a potential
predictor of post extubations stridor

20. • Air column during
balloon calf
inflation(hyper echoic)
• True cords are over both
the side of air
column(Hypo-echoic)
• Cartilages are behind
the true vocal cords &
beside the air column
(hyper echoic)

21. • Air column during
balloon-cuff
deflation
-Air column width
increased
-This patient did not
develop post extubation
stridor

22. • Air column during
baloon cuff defletion
-air column width increased
This patient did not develop
post extubation stridor
• Air column during
baloon cuff
inflation(hyper echoic)
• True cords are over
both side of the air
column(hypoechoic)
• Cartilages are behind
the true vocal cords and
beside the air column
(hyper echoic)

23. LARYNGEAL ULTRASOUND:An USEFUL METHOD IN
PREDICTING POST EXTUBATION STRIADOR
• The air column width during calf deflation is a
potential predictor of post extubation stridor

24. Can you extubate this patient?

26. Diaphragmatic Movement evaluation
with Thorasic Ultrasound
• Thoracic ultrasound
-lack of ionizing radiation
-bedside procedure
-should be the method of choice in the investigation
of suspected hemidiaphgramatic movement
abnormality
• Proposed technique
-changes in diaphragm thickness during contraction
-chronically paralyzed diaphragm is atrophic and
doesn't thicken during inspiration(contraction)

27. Diagnosis of Diaphgramatic Paralysis
• Chest Radiograph
-Elevated hemidiaphragm & atelectasis
• Fluoroscopy
-requires patient transportation
-uses iniozing radiation
-sniff test:paradoxical elevation of paralyzed
hemidiaphragm with inspiration(>90%)

28. Diaphragmatic Paralysis
• Unilateral vs bilateral
• Increase in load on the other respiratory accessory muscle
-respiratory failure
• Clinical manifestations
• -DOE,orthopnoea
• -Rapid shallow breathing
• Paradoxical abdominal wall retraction during inspiration
• Hypoxemia due to atelectasis
• Hypercapnoea & hypoxemia
• Severe cases (Ventilatory failure, severe pulmonary
hypertension, secondary erythrocytosis)

29. Challanges
• During DB, descending lung may obscure the
diaphragm
-The probe should be displaced caudally with angle
adjustment to maintain a perpendicular approach
of the hemi diaphragmatic motion
• Patients with respiratory disease and dysonoea
-increased respiratory effort can result in greater
chest wall movement and cause the ribs & lung to
obscure the images
• Visualization of the left hemidiaphragm is
recognised as more difficult due to the smaller
window of the spleen as compared with the liver
window

30. Diaphragmatic Movement & contractility
evaluation by thoracic ultrasound
• Always identify the diaphragm
• Don’t confuse the hepato renal pouch or
spleen renal recess for diaphragm
• Sub diaphragmatic device insertion may have
lethal effect
• Exercise particular caution in post CABG cases
• Unilateral diaphragmatic dysfunction

33. Probe position for dome movement

34. DIAOHGRAM MOVEMENT AND CONTRACTILITY EVALUATION BY THORASIC
ULTRASOUND

38. Diaphragmatic Paralysis: The use of M Mode
Ultrasound for Diagnosis in Adult
• Normal diaphragm
-Sniff test: sharp upstroke(normal caudal
movement of the diaphragm during inspiration)
• Diaphragmatic Paralysis
-No active caudal movement of the diaphragm
with inspiration
-sniff test: abnormal paradoxical movement
(cranial movement on inspiration)

39. Manoever begun at the end
of normal expiration
• Quiet Breathing(QB):
-Diaphragm excursion(inspiratory
amplitude)1.5-2 cm
-lower limit for women 0.9 cm
-lower limit for men 1 cm
• Voluntary Sniffing (VS)
-Diaphragm excursion(inspiratory
amplitude)2.5-3cm
Lower limit for women 1.6cm
Lower limit for men 1.8cm
Normal caudal movement (sharp
upstroke)of the diaphragm during
inspiration
• Deep Breathing(DB)
Diaphragm excursion (inspiratory
amplitude) 6-7cm
-lower limit ofor woman 3.7 cm
-lower limit for men 4.7 cm

40. Diaphragmatic Paralysis: The Use of M mode ultrasound for
diagnosis in adult
• Sniff Test
• -Normal Diaphragm
Sharp upstroke (normal caudal movement of diaphragm during
inspiration)
-Diaphragmatic Paralysis
No caudal movement of diaphragm with inspiration
Abnormal paradoxical cranial movement on inspiration
2

41. Ultrasonography Diagnostic criterion for severe
diaphragmatic dysfunction after CABG
• After cardiac surgery
-surgery related phrenic
nerve injury
-severe diaphragmatic
dysfunction can prolong
mechanical ventilation
-(US)probe is positioned
on right mid-axillary line
-Diaphragmatic excursion
measured from the end
of normal expiration(c) to
end of maximal
inspiratory effect (D)

42. Ultrasonography Diagnostic criterion for severe
diaphragmatic dysfunction after cardiac surgery
• Best E< 25 mm was
associated with
severe
diaphragmatic
dysfunction
• None of the
patients with
uncomplicated post
operative course
have best E< 25mm,
either before or
after surgery
• Excellent negative
likehood ratio of
best E<25 mm

44. Paralysis weakness

45. Probe position for diaphragm muscle thickness

46. 1. MOTION
2. AMPLITUDE
3.FORCE OF VELOCITY
Thickness inspiratory - thickness expiratory
WEAKNESS
PARALYSIS
LOW AMPLITUDE
PARADOXICAL MOVEMENT
1.Can follow up with US
2.If phrenic nerve damage or
paralysis
- Prolonged ventilation needed
4.THICKNESS
thickness expiratory
TF[2.3]=
inspiratory[25mm]
expiratory [17mm]
Post operative diaphragm Amplitude maximum inspiration should be >25 (good)
Weaning from ventilation – liver/spleen 1.1 cm displacement
1.Successful extubation-(a). Amplitude >25mm (b).TDI % >30%
2. D/D (a) weakness (b) paralysis
3.Follow up of diapgramatic motion strength

47. Ventilation and Asynchrony

48. Ventilation and synchrony

49. CONCLUTION
• M mode ultrasonography is a relatively simple
and accurate test for diagnosing paralysis of
diaphragm
• Diaphragmatic function assessment with
ultrasound is important in patients with
prolonged ventilation
• Ultrasonography should be considered to exclude
severe diaphragmatic dysfunction following
cardiac surgery in daily practice with the
advantages of being fully non invasive & easilty
available in ICU

50. Remember
• USG may appear complex at first sight but
simply requires a change in thinking.
• Once the process has been learned, a step by
step use will make it a routine

51. Remember cont..
• Inappropriate interpretation or application of
data gained by a poorly skilled user may have
adverse consequences.
• So adequate training is essential and this must be
individualized and tailored to the specific needs
and applications of the user.

52. Lung Ultrasound Ready for Prime Time
It is for you