Chest radiography remains the primary imaging modality for critically ill patients, however images are often limited quality due to patient movement and positioning challenges. Mistakes can occur in assessing conditions like pleural effusions or infiltrates. Routine daily chest x-rays are not recommended for ICU patients unless clinically indicated. Ultrasound is a useful bedside tool for evaluating the lungs, IVC, heart, and detecting pneumothorax. Computed tomography can also be used but requires transporting unstable patients.

2. Thoracic Imaging in Critically
ill Patients
Gamal Rabie Agmy, MD, FCCP
Professor of chest Diseases, Assiut university

4. cc
At the bedside, chest radiography remains the reference for lung
imaging in critically ill patients. However, radiographical images are
often of limited quality
• Movements of the chest wall
• Film cassette posterior to the
thorax
• X-ray beam originating
anteriorly, at a shorter distance
than recommended and not
tangential to the diaphragmatic
cupola .
Mistaken assessment
of :
cc
• Pleural effusion
• Alveolar consolidation
• Alveolar-interstitial
syndrome
Bedside Chest Radiography in the Critically
ill

5. (posterioranterior) position. Note
that the x-ray tube is 72 inches
away.
the supine AP (anteriorposterior)
position the x-ray tube is 40 inches
from the patient.

9. When to do X ray chest forWhen to do X ray chest for
ICU patients?ICU patients?
Routine Vs On demand X ray chest?Routine Vs On demand X ray chest?

10. Recommendation
Routine daily chest radiographs are not indicated for patients
admitted to the ICU.
In stable patients admitted for cardiac monitoring, or in stable
patients admitted for extrathoracic disease only, an initial ICU
admission radiograph is recommended; follow-up radiographs
should be obtained only for specific clinical indications including
clinical worsening and tube or line insertion.

11.  Uses:
› Assisted ventilation
› To secure airway
The tip should lie between the clavicles,
at least 5cm above the carina

13. Dee method for approximating the position o f the carina can
be used. This involves defining the aortic arch and then
drawing a line Inferomedially through the middle of the arch
at a 45 degree angle to t he midline

14. The Ideal position for endotracheal tubes is in the
mid trachea, 5cm from the carina, when the head is
neither flexed nor extended. This allows for
movement of the tip with head movements. The
minimal safe distance from the carina is 2cm.

16.  Tube too far advanced
› Typically, within right main stem bronchus
 Placement within oesophagus
 Tracheal perforation

43. Notice the increased lucency of the cardiophrenic sulci in this patient
with inferior anteromedial pneumothoraces. A CT scan confirms the
diagnosis

44.  a hyperlucent upper
quadrant with
visualization of the
superior surface of the
diaphragm and
visualization of the
inferiorvena cava.
 double-diaphragm
sign

45.  Antero lateral air may
increase the
radiolucency at the
costo phrenicsulcus.
This is called the deep
sulcus sign.

46.  Apicolateral
pneumothorax
(arrows) with right
upper lobe collapse
(arrowheads)

47.  shifting of the heart
border,
 the superior vena cava,
and the inferior vena
cava.
 The shifting of these
structures can lead to
decreased venous return.

48. •Mediastinal shifT is
usually
seen in a tension
pneumothorax.
•The most reliable sign of
tension pneumothorax is
depression of a
hemidiaphragm.

49. Radiographic Signs of Pneumomediastinum
Subcutaneous emphysema
Thymic sail sign
Pneumoprecardium
Ring around the artery sign
Tubular artery sign
Double bronchial wall sign
Continuous diaphragm sign
Extrapleural sign

56. Ginkgo leaf sign
• The ginkgo leaf sign is a chest plain radiography
appearance which is seen at extensive subcutaneous
emphysema of the chest wall. Air outlines the fibers of
the pectoralis major muscle and creates a branching
pattern that resembles the branching pattern in the
veins of a ginkgo leaf.

57. The tip should
lie below the
diaphragm
coiled within
the stomach

58. Risk of transportation
Lung Computed Tomography in
the Critically ill
http://www.reapitie-
02 09 2012

59. Chest Sonography

60. A common language: Color Coding
Black Grey White

61. Chest Sonography

62. BLUE-Protocol and FALLS-Protocol Two
Applications of Lung Ultrasound in the Critically
Ill
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670

65. THE BAT VIEW
Chest wall
Pleural line

67. Normal lung surface
Left panel: Pleural line and A line (real-time).
The pleural line is located 0.5 cm below the rib line in the adult.
Its visible length between two ribs in the longitudinal scan is
approximately 2 cm. The upper rib, pleural line, and lower rib (vertical
arrows) outline a characteristic pattern called the bat sign.

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

71. the "seashore sign" (Fig.3).

74. 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

75. B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
PER
VIEW
ZO
NES
SIDES
12

76. Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125

81. Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform
images
Presence of hyperechoic punctiform
imagesrepresentative of air bronchogramsrepresentative of air bronchograms
Pleural
effusion
Lower lobe

93. Absent lung sliding
Exaggerated horizontal artifacts
Loss of comet-tail artifacts
Broadening of the pleural line to a band
The key sonographic signs of
Pneumothorax

97. the "seashore sign" (Fig.3).

106. Pulmonary Embolism

107.
Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration 2003;70:441-452 )

109. Alveolar-interstitial syndrome

114. Multiple B-lines - « comet-tails » - interstitial edema
(B1)
7 mm apart « B lines » thickened interlobular
septa
7 mm apart « B lines » thickened interlobular
septa
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997JJR 25 05http://www.reapitie-
http://www.reapitie- 02 09 2012

115. D Lichtenstein et al AJRCCM 156 : 1640-1646 , 199730 11 2011
Coalescent B lines - « comet-tails » - alveolar
edema
3 mm apart « B lines » ground-glass
areas
3 mm apart « B lines » ground-glass
areas
http://www.reapitie- 02 09 2012

128. IVC Sonography

129. INDICATIONS
IVC Ultrasound
Spontaneously
Breathing
Mechanical
Ventilation
Volume Status / CVP Fluid Responsiveness

130. Respiratory variation
Expands w/ expiration
Contracts w/ inspiration
Due to changing intrathoracic pressures.

131. PROCEDURE
Probe Selection
1 Low frequency 2-5 MHz
2 Curvalinear probe

132. Where to put the probe…
 Probe position
 Subxiphoid
 Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
 Slightly to right of
midline

133. PROCEDURE
Approach #1 – Xiphoid View

134. Where to put the probe…
 Probe position
 Subxiphoid
 Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
 Slightly to right of
midline

135. IVC Longitudinal

136. PROCEDURE
Approach #2 – Anterior -Mid-Axillary
View

137. PROCEDURE
Landmarks
Aproach #2 – Anterior Mid-Axillary View
1 Place probe longitudinally in right anterior
mid-axillary line with marker towards the head
2 Look for IVC running longitudinally
adjacent to liver crossing the diaphragm.
3 Track superiorly until it enters right atrium
confirming that it is the IVC and not the aorta.

138. Measuring the IVC Diameter
Measure IVC 2cm

139. Inspiratory (Minimal) IVC
Diameter

140. Maximum (Expiratory) IVC
Diameter

141. M-Mode IVC Diameters

142. CAVAL INDEX (CI)
CI =
minimal (inspiratory)
diameter
maximum (expiratory)
diameter
maximum (expiratory)
diameter

143. CAVAL INDEX (CI)
Volume
Depletion
Volume
Overload
0% 100%

144. IVC v CVP
Correlation Between IVC Diameter Plus CI and
CVP
IVC Max Diameter
(cm)
CI CVP
(mmHg)
< 1.5
100%
(total collapse)
0-5
1.5-2.5 > 50% 6-10
1.5-2.5 < 50% 11-15
> 2.5 < 50% 16-20
> 2.5
0%
(no collapse)
>20

145. Echocardiography

146. Parasternal long axis
 Transducer at left sternal
edge between 2nd
-4th
intercostal space
 Probe marker pointing to
patients R shoulder
 Probe aligned along the
long axis: from R shoulder
to cardiac apex.
 Useful view to assess
contractility

147.  Transducer at 4th
-6th
intercostal
space in the midclavicular to
anterior-axillary line.
 Probe directed towards patient’s
right shoulder with the marker
directed towards the left
shoulder.
 Important view to give relative
dimensions of L and R ventricle.
 Normal ventricular diameter
ratio of R ventricle to L ventricle
is <0.7.

149. PericardialTamponade
 Remember tamponade is a clinical diagnosis based on
patient’s haemodynamics and clinical picture.
 Ultrasound may demonstrate early warning signs of
tamponade before the patient becomes haemodynamically
unstable.
 Haemodynamic effects
 Its PRESSURE NOT SIZE THAT COUNTS!
 Rate of formation affects pressure-volume relationship and
is therefore more important than volume of fluid.

150. Tamponade using ultrasound
 A moderate-large effusion.
 Right atrial collapse
 Atrial contraction normal in atrial systole
 Collapse throughout diastole or inversion is abnormal.
 RV collapse during diastole when meant to be filling
(‘scalloping’ seen)
 Whats seen in the IVC…