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Thoracic Imaging in critically ill patients
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.
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Thoracic Imaging in critically ill patients
- 2. Thoracic Imaging inCritically 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 thex-ray tube is 72 inches away. the supine AP (anteriorposterior) position the x-ray tube is 40 inches from the patient.
- 9. When to doX 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 chestradiographs 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: › Assistedventilation › To secure airway The tip should lie between the clavicles, at least 5cm above the carina
- 13. Dee method forapproximating 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 positionfor 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 toofar advanced › Typically, within right main stem bronchus Placement within oesophagus Tracheal perforation
- 43. Notice the increasedlucency of the cardiophrenic sulci in this patient with inferior anteromedial pneumothoraces. A CT scan confirms the diagnosis
- 44. a hyperlucentupper quadrant with visualization of the superior surface of the diaphragm and visualization of the inferiorvena cava. double-diaphragm sign
- 45. Antero lateralair may increase the radiolucency at the costo phrenicsulcus. This is called the deep sulcus sign.
- 46. Apicolateral pneumothorax (arrows) withright upper lobe collapse (arrowheads)
- 47. shifting ofthe 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 seenin a tension pneumothorax. •The most reliable sign of tension pneumothorax is depression of a hemidiaphragm.
- 49. Radiographic Signs ofPneumomediastinum 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 liebelow the diaphragm coiled within the stomach
- 58. Risk of transportation LungComputed Tomography in the Critically ill http://www.reapitie- 02 09 2012
- 59.
- 60. A common language:Color Coding Black Grey White
- 61.
- 62. BLUE-Protocol and FALLS-ProtocolTwo Applications of Lung Ultrasound in the Critically Ill (Daniel A. Lichtenstein , MD , FCCP, CHEST 2015; 147 ( 6 ): 1659 - 1670
- 65. THE BAT VIEW Chestwall Pleural line
- 67. Normal lung surface Leftpanel: 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 3x 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 DA , Mezière G A Chest 2008;134:117-125
- 81. Tissue pattern representativeof 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 Exaggeratedhorizontal 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.
- 107. Schematic representation ofthe parenchymal, pleural and vascular features associated with pulmonary embolism.(Angelika Reissig, Claus Kroegel. Respiration 2003;70:441-452 )
- 109.
- 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 etal 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.
- 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 Lowfrequency 2-5 MHz 2 Curvalinear probe
- 132. Where to putthe 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 putthe probe… Probe position Subxiphoid Orientate probe in longitudinal plane with probe indicator to patient’s head Slightly to right of midline
- 135.
- 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 IVCDiameter Measure IVC 2cm
- 139.
- 140.
- 141.
- 142. CAVAL INDEX (CI) CI= minimal (inspiratory) diameter maximum (expiratory) diameter maximum (expiratory) diameter
- 143.
- 144. IVC v CVP CorrelationBetween 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.
- 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 at4th -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 tamponadeis 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…