2. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
At the end of the lecture, you should be able to
Understand the basic techniques of lung ultrasound
Understand the sonoanatomy of lung ultrasound
Recognise abnormal artifacts and signs
Lecture Objectives
3. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Introduction: Principles of lung ultrasound
Techniques
Lung ultrasound patterns
Normal
Pathological
Pearls & pitfalls
Clinical case
Conclusion
Lecture Outline
4. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
What was once considered ‘not useful’, is now an
essential practice in critical care ultrasound
First used as point-of-care modality in 1980’s in ICU. The
challenge was in deciphering artifacts & publishing data.
Introduction
5. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
28 experts from 8 countries
Looked at data from 1966 - 2010
Discussed 73 statements
Recommendations (Grade A to C) on each statement
6. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Lung signs are mainly analysis of artifacts
Most lung signs are dynamic
Ultrasound signs are the result of air-fluid interaction in
the lung
Pathology can be seen with loss of lung aeration
Nearly all (>90%) acute lung conditions involve the lung
surface
Lichtenstein, D. Lung ultrasound in the critically ill. Annals of Intensive Care 2014, 4:1
Principles of Lung Ultrasound
7. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
To interpret lung ultrasound signs, you must understand
how normal and pathological signs arise
Statement
8. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Appropriate probe:
Curvilinear / phase array (low frequency)
Linear (high frequency) for detailed pleural analysis
Depth for tissue analysis: depends on body habitus
Settings:
Indicator to left of screen
Modes used:
B-mode
M-mode
Techniques
9. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Probe orientation:
Perpendicular to ribs
Indicator cephalad
Techniques
LONGITUDINAL SCANS
TRANSVERSAL SCANS
10. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Basic 8 region lung
ultrasound technique
Where should you look for
pathology?
Techniques
11. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Bat Sign
Lung Ultrasound Patterns: Normal Lung
15. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
A-lines
Reverberation artifacts from the pleural line
Bright horizontal lines
Static
Repeated at same depth intervals
Implies aerated lung
Lung Ultrasound Patterns: Normal Lung
17. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Curtain Sign
Looks at the lung base
The diaphragm is obscured by lung downward movement with
respiration
Lung Ultrasound Patterns: Normal Lung
19. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Seashore Sign
Lung Pulse
Due to cardiac pulsations conducted to chest wall
Lung Ultrasound Patterns: Normal Lung in M-Mode
20. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Review: Normal Lung in B-Mode
Seashore
sign
22. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
B-lines
Vertical hyperechoic laser-like lines
Arise from Pleural Line
Extends to bottom of screen without fading
Moves synchronously with respiration
Lung Ultrasound Patterns: Pathology
24. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
To interpret lung ultrasound signs, you must understand
how normal and pathological signs arise
Pearls & Pitfalls
25. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Basis: There is loss of interaction between visceral pleura
and parietal pleura
What can you expect to see on ultrasound?
B-Mode:
Loss of Sliding Sign
A-lines present
No B-lines
Lung Ultrasound Pathology: Pneumothorax
28. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
What can you expect to see on ultrasound?
M-Mode
Stratosphere Sign
No Lung Pulse
Lung Point
Lung Ultrasound Pathology: Pneumothorax
M Mode
30. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Lung Point
Lung Point
• Lung point
• Alternating pattern of
pneumothorax and
normal lung at the
junction of the
pneumothorax
• May not be seen in
large pneumothorax
32. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Lung Ultrasound Pathology: Pneumothorax
Volpicelli, G. et. al. International evidence-based recommendations for point-of-care lung
ultrasound. Intensive Care Med. 2012
33. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Positive region (B-pattern): 3 or more B-lines in
longitudinal plane between 2 ribs
Interstitial Syndrome:
2 or more positive regions
Focal (unilateral) vs. Diffuse (bilateral)
Volpicelli, G. et. al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive
Care Med. 2012
Lung Ultrasound Pathology: Interstitial Syndrome
35. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
M-mode interpretation can be flawed
History of pleural disease or surgery does not equate to pneumothorax
Operator dependant
Limitations / Pitfalls
36. Paediatric Emergency and Critical Care Ultrasound (PERCUSS)
Know the features of normal & pathological lung
ultrasound patterns
The lung ultrasound is a useful adjunct in clinical
assessment of patients with respiratory presentations
Lung ultrasound aids in diagnosis, management &
monitoring treatment in a breathless patient
Summary
