Pleural Ultrasound Dr Eid Elagamy Lecturer of chest diseases Faculty of medicine Alazhar university

2. PLEURAL ULTRASOUND
Dr: EiD ELaGamY
Lecturer Of Chest Diseases
Al-Azhar University

3. Anatomy

4. Preparation
Normal Findings
Pneumothorax
Pleural effusion
Pleural effusion
Interventions

5. PREPARATION FOR PLEURAL U/S

6. Which Probe

7. M- mode
B- Mode
Colour Doppler
Which Mode

8. Parallel to ribs
Which Plan
Perpendicular to ribs

9. Which Position
The correct position
- the optimal for patient and operator’s comfort
throughout the examination and subsequent procedure.
- the optimal for diagnosing or excluding as condition

10. Which Protocol
The correct protocol is the optimal to reach the diagnosis

11. US- terms
Hyper-echoic
Iso-echoic
An-echoic
Hypo-echoic

12. NORMAL FINDINGS

13. B- Mode

15. lung curtain sign
Spines

16. pleural line
“Bat Or Bat-wing sign”

17. Chest wall
Pleura
A- lines

18. Assessment of pleural line
1- Lung sliding sign
2- Lung pulse sign
3- B Lines

19. 1) Lung sliding or gliding sign = horizontal movement of pleural line in synchrony with the
respiration, indicating a sliding movement of the visceral pleura against the parietal pleura
Pleura

20. NORMAL
LUNG SLIDING
WITH A LINES

21. improve Lung Sliding
Visualization
Normal lung sliding
becoming more visible
with decreased gain.

22. Sea-shore sign
M- Mode

23. No Sliding
- pneumothorax
- pleural fibrosis in ILD , prior pleural empyema , prior
intrathoracic operation, successful pleurodesis
Decreased Sliding
-Lung zone scanned
- patient tidal volume
- in ventilated patients when ventilation is suspended
- at the apices in patients with severe emphysema,
- adjacent to large bullae

24. 2) Lung pulse sign = movement of
the pleura with cardiac pulsation
Not always present in healthy persons
————
Easiest to visualise in areas where the lung is in
close contact with the pericardium and heart.
————
Easiest to visualise non ventilated > ventilated
lung
————
Like lung sliding, the lung pulse indicates that the
visceral and parietal pleural surfaces are
juxtaposed at the location of the probe

25. 3) B Lines = long, continuous, hyperechoic, laser-like, vertical reverberation artifact originating
from the pleural line to the bottom of the screen & erase A lines & move with respiration
B-lines move in synchrony with
the lung sliding
Seen normally in a healthy
adult
- at the last intercostal space
above the diaphragm
- over the area of an inter-lobar
fissure.

26. ———————— Abnormal b lines ————————
≥3 B-lines “lung rockets” as in diseases causing
thickening of the interlobular septa (e.g., interstitial
edema, lymphangitis, interstitial lung disease)
normal B lines
Vertical , cont.
< 3 B-lines
A lines
Horizontal

28. Diaphragmatic pleura
seen best in deep inspiration through transabdominal approach using liver and spleen as an acoustic window
(this is especially true on the right side due to the excellent sonographic window that the liver provides)
Costal pleura
Apical pleura
directly detectable through
the supraclavicular approach.
mediastinal pleura
invisible by transthoracic
examination ( parts can be seen va
parasternal approach)
Back
scapula as an osseous obstacle can be
shifted or rotated by arm movements
in medial or lateral direction.

29. PNEUMOTHORAX

30. To Define Pneumothorax using US (4 item)
Absence of lung sliding sign
Absence of B- Lines
1
2
3
Absence of lung pulse sign
Presence of lung point
sign
4

31. How to detect
Intra- pleural air tends to accumulate in
the least-dependent parts of the chest due to gravity effect

32. Pt: Supine
Hold probe perpendicular to the skin surface
Start in anterior–inferior chest area (at the 3rd to 4th
intercostal space) between the parasternal and the
midclavicle line
1
Pleural Line
“Bat Or Bat-wing sign”

33. 2
Visualise the echogenic pleural line in extended view
without interfering rib shadows
Hold probe parallel to ribs ( in the space)
Then follows the curve of the lateral and inferior chest (i.e.
the direction indicated by the arrow drawn on the chest)
At any level, search for
Lung Sliding “Horizontal”
B- Line “Vertical”
Present NO Pneumothorax
Absent Probable Pneumothorax

34. pleural line
B lines
B lines
pleural line
The seashore pattern
Present Lung sliding and/or B-lines
NO Pneumothorax

35. the stratosphere (barcode) sign
Absent Lung sliding and B-lines
Suggest Pneumothorax

36. stratosphere pattern
seashore pattern
Presence of lung
sliding exclude
pneumothorax
Absent lung sliding
Not confirm
pneumothorax
BUT
In history of chest
trauma absence of
lung sliding indicate
Pneumothorax

37. 3
Move the probe towards the lateral - inferior chest
wall to look for the area where the collapsed lung is
still in contact with the inside of the chest wall.
This location is called the Lung point and
corresponds to the place where lung sliding
and/or B-lines intermittently appear during
respiration

38. 3
useful to evaluate the size of a PTX as it marks
the lateral extension of intrapleural air inside
the chest. The more lateral the lung points,
the more extensive the intrapleural air
volume (i.e. PTX size).
pleural line
B lines
Lung point
cutaneous projections of
the observed lung points

39. pleural line
Lung point

40. Pathognomonic of
Pneumothorax 100%
Large PTX ==> complete lung collapse with elimination of lung sliding in
the anterior, lateral and posterior locations on the chest, and thus no
lung point
Pleural adhesions => may also cause motionless pleura and thereby limit
the likelihood of obtaining this sign.
Unfortunately, Not all
patients present this sign.
Lung Point

41. Double Lung Point Sign=
Small pneumothorax

43. E lines -subcutaneous
emphysema
Hyperechoic irregular lines are
seen superficial to the ribs
Subcutaneous emphysema
obscures the rib shadow and
pleural line that lie below it
==> the pleural line lies
underneath the level of the ribs,
subcutaneous emphysema lies
above the level of the ribs

44. PLEURAL EFFUSION

45. Echo-free (anechoic or hypoechoic) area
• Pleural effusion
• Large liver or renal cyst
• Ascites
• Stomach distended with fluid
• Dilated and poorly
contracting left ventricular
cavity X
X

46. To Define pleural effusion using US (3 item)
Hypoechoic space
associated dynamic
findings
1
2
3
Surrounded by typical
anatomic boundaries

47. 1- Hypoechoic space
2- Anechoic = echofree (black)
3- Complex nonseptated when
echogenic material is observed within
the effusion
4- Complex septated when strands or
septa are observed within the effusion
Hypoechoic space
associated
dynamic findings
1 2 3
Surrounded by typical
anatomic boundaries

48. 1- 2- = echo-free (black)

49. 3-
= floating material + No septation
4-
= Septations + Loculations

50. Septations = Linear strands of fibrin within single pleural fluid collection => partially or
completely divide it into many “pockets”
# Sensitivity of detection of septations (US > CT > CXR)
Early septations: Thin - easily deformed as a
result of pleural fluid movement (more
fibrinous septations)
Extensive septations : thicker and less
deformed (more collagenous
septations)

51. Loculation = multiple separate collections of fluid within the same area or
different areas of the pleural space for example, separate collections within
the apical and inferior parts of the hemithorax.
# Loculations=
Compartmentalisation
=> may or may not
communicate with one
another.
# Sensitivity of detection
of loculations
CT > US > CXR

52. free-flowing, nonseptated, no debris
Complex pleural effusion
b) Septated or Loculated
a) Non septated
Simple pleural effusion

53. 1- Diaphragm
2- Chest wall
3- Lung
4- Pericardium and heart
Hypoechoic space
associated
dynamic findings
1 2 3
Surrounded by typical
anatomic boundaries

55. Inverted right hemidiaphragm caused by
a large pleural effusion

56. 1- Diaphragmatic movement
2- Heart movement
3- Lung movement
4- Movement of strands, septations,
and echogenic material within the
effusion.
Hypoechoic space
associated
dynamic findings
1 2 3
Surrounded by typical
anatomic boundaries

57. 1-
pleural eff
+ ascites
pl. eff. with poorly moving left
hemidiaphragm

58. NORMAL
-ve Spine sign
+v curtain sign
Pleural effusion (- ve curtain sign)
+ve Spine sign (clear view of several
thoracic vertebrae through the effusion)

59. 2
Large pericardial effusion + pleural fluid

60. 3- (respirophasic & cardiophasic movement of the collapsed lung)
atelectatic lung “swimming” in anechoic large pleural effusion
Jellyfish sign

61. Sinusoid sign

62. 4-
effusion with swirling (floating) hyperechoic material
Plankton
(swirling) sign

63. Septations movements
floating strand

64. The red and blue colors represent
pleural fluid moving with the cardiac
pulsation
+ve “fluid color” sign ==> diagnostic
of pleural fluid moving under cardiac
pulsation or respiratory movements
and implies (but does not prove) the
absence of significant septations
preventing fluid movement.
Fluid color sign
differentiate: pleural fluid (+ve fluid color sign)
from Large areas of pleural thickening (-ve fluid color sign
negative)

65. multiple and brightly reflecting areas
within the fluid ==> indicate either
- Empyema due to gas forming organism
- effusion in the case of bronchopleural
fistula
- subsequent to pleural aspiration.
Air bubbles within pleural fluid

66. Large volume heavily echogenic pleural
effusion
increased echo signals within pleural fluid in homogenous manner with no
particular structure, occur in effusion with dense pleural fluid collections==>
thick pus OR hemothorax

67. anechoic effusion is usually a transudate (may be exudate)
But the followings suggestive of exudate
- Plankton sign
- Septations and loculation
- Pleural thickness > 3mm
categorization of pleural
effusion based on US findings

68. Multiple formula ??? Multiple practice ???
• Balik formula
• Eibenberger formula
• Goecke formula
Estimation of pleural effusion volume using US

71. Traditionally ==> the depth of effusion is measured from parietal pleural
to underlying structure (for example, visceral pleura) at the lowest point
of the hemithorax & at the deepest part of the effusion.
==> However, this distance will vary according to the point in the
respiratory cycle, the complexity of the pleural fluid collection, as well as
the fact that a given intrapleural distance represents different volumes in
patients of different sizes.

72. As a rough guide
a depth of pleural fluid of > 2 cm ==> a fluid volume of around 500 ml.
Another practice
(in upright position with scanning of posterior chest )
fluid in < 2 space (<1 probe) = small effusion
fluid in 2 - 4 spaces (1-2 probes) = moderate effusion
fluid in > 4 spaces (>2 probes) ==> 1/2hemithorax = large effusion

73. air/fluid interface which is suggestive for
hemo/hydro/pyo-pneumothorax.
It is another sign for diagnosing a
pneumothorax
Hydropoint sign

74. Chest tube seen within a large
pleural effusion.

75. 1. Parietal pleural thickening > 1 cm
2. Nodular pleural thickening
3. Visceral pleural nodules
4. diaphragmatic nodules
US in malignant pleural effusion

76. PLEURAL THICKENING & MASS LESIONS

77. Benign
• Bi or unilateral
• smooth
• echogenic
• > 5 cm width
• > 3m thickness but < 1cm
• 8 cm in craniocaudal extent
• no invasion
• Doppler: may be avascular, scanty or vascular
Malignant
• mostly unilateral
• irregular or nodular
• hypoechogenic or variable echogenicities
• > 1 cm thickness
• circumferential
• involve mediastinal,diphragmatic pleura
• +/- invasion
• Doppler: vascular (neoangiogenesis)
Pleural thickening
- focal lesion > 3 mm in width arising from either pleural surface
- in US: can be anechoic or hypoechoic or variable

78. Longitudinal US
image pleural
thickening (1.4 cm)
the pleura is
hyperechoic; the
echogenicity of
malignant pleural
thickening is
variable

80. Diaphragmatic nodule

81. Extensive
diaphragmatic &
visceral pleural
nodularity
consistent with
malignancy

82. pleural thickening mostly Malignant

83. Pleural metastases
and pleural effusion

84. Fluid color sign
Pleural fluid +ve fluid color sign
Pleural thickening-ve fluid color sign negative

85. Benign pleural thickening with minimal
effusion and minimal vascularity

86. Vascularized pleural
mass that biopsy
proved to be a benign
fibrous tumor

87. So US cannot confirm the aetiology based on the
morphology of the pleural thickening
The role of US
Detect findings - guide intervention

88. INTERVENTIONS

89. Basic 1- Thoracentesis 2- Tube thoracotomy
Ultrasound
Guided pleural
intervention
A) STATIC
GUIDANCE
B) DYNAMIC
GUIDANCE
Advanced 3- Pleural biopsy

90. Pre-procedur
Preparation ==> planned basis, patient factors, equipment, work environment, supporting
staff.
Procedure
Rules for each procedure
Post-procedure
a further TUS assessment
1) to look for complications by TUS
a. iatrogenic Pneumothorax (a loss of sonographic visualisation due to free air in the pleural
space, with the subsequent absence of normal lung sliding or B-line artefacts)
b. intrapleural bleeding at the site of intervention ( increased fluid or doppler)
2) to look for residual of effusion

91. intrapleural bleeding
post-intervention==>
pulsatile colour Doppler
“plume” (solid arrow)
from the parietal
pleural surface and
deposition of highly
echogenic material
(dotted arrow) into a
dependent area of the
pleural space

92. • Advantage of TUS guided procedure
• reduces the risk of fail “dry tap”
• reduce iatrogenic complications
• Disadvantage
• False confidence and encourage
physician to stray outside the
anatomical safe triangle

93. • Ideal position ==> the easily accessible , the safest, the most comfortable position
• Thorough TUS examination to characterise the size and nature of the pleural collection
• patient in supine or semisupine==> in the anatomical safe triangle OR as laterally as the pleural collection will allow.
• patient sitting ==> intervention in the Back
Take care —> risk of injury of the intercostal vessels, which may become exposed in the middle of the rib space with
increasing proximity to the spine ==> colour Doppler minimise the risk of iatrogenic intrapleural bleed ??
• If a more posterior approach is unavoidable, the patient’s consent should be obtained for the additional risk of
vascular injury associated with this, and use colour Doppler to screen for vulnerable intercostal vessels.
• mark the safe site for intervention ==> sufficient depth of fluid and no obvious incursion by either the lung or
diaphragm during respiration.
• measure the distance between the skin surface and pleural space
• Neither does the use of US screening obviate good practice and anatomical landmarks; a needle should always be
introduced immediately superior to the rib for safety reasons.
• The depth of fluid indicating a safe volume for thoracentesis depends on the skill level of the operator and the
patient’s clinical circumstances (minimum of 10 mm, others suggest 20 mm)

94. septated pleural collection.
Introducer needle
the guidewire
J-tip
agitated saline flush used to confirm the drain
position as hyperechoic bubbles of air
Catheters for Pleural
Drainage

95. Closed pleural biopsy
==> blind procedure So, only performed in the presence of at least a moderate effusion or
pneumothorax to minimize the risk of lung injury
With ultrasound
- Can guide the location of closed pleural biopsies to thickened areas
- May allow performance even in the absence of a large pleural effusion.
Abrhams Needle
Core biopsy cutting
needle

96. Example of a core biopsy cutting
needle
irregular diaphragmatic and parietal pleural thickening with effusion
Closed
pleura
l
biopsy

97. TUS in Medical thoracoscopy
• to look before the procedure
• facilitate thoracoscopy in patient with little fluid
• facilitate thoracoscopy in patient with No fluid but with
other abnormalities suspicious for pleural disease ==> after
artificial PTX is needed (use TUS to watch the passage of
instruments through the chest wall and confirm the
successful development of a PTX without waiting for a
lateral decubitus chest radiograph)