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Ultrasonography in Critically Ill Patients
This document discusses the use of chest sonography in critically ill patients. It notes that bedside chest radiography has limitations in critically ill patients. Chest sonography can help diagnose various lung conditions at the bedside including pulmonary consolidation, atelectasis, edema, effusions, and pneumothorax. It reviews the sonographic signs and patterns associated with these conditions. The document also discusses using lung ultrasound and IVC views to assess shock states and guide treatment. Overall, it promotes the use of bedside lung ultrasound as a valuable tool to complement radiography in critically ill patients.
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Ultrasonography in Critically Ill Patients
- 2. Chest Sonography inCritically Ill Patients Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
- 4. c 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 : c • Pleural effusion • Alveolar consolidation • Alveolar-interstitial syndrome Bedside Chest Radiography in the Critically ill 02 09 2012
- 5. Risk of transportation LungComputed Tomography in the Critically ill http://www.reapitie- 02 09 2012
- 7. Scanning Positions for ChestSonography in ICU
- 18. Tissue pattern representativeof Alveolar Consolidation Presence of hyperechoic punctiform imagesrepresentative of air bronchograms Pleural effusion Lower lobe
- 21. the "seashore sign"(Fig.3).
- 23. Clinical applications oflung ultrasonography in the intensive care unit 1. Diagnosis of pulmonary consolidation. 2. Diagnosis of atelectasis 3. Diagnosis of alveolar-interstitialsyndrome 4. Differentiating between pulmonary oedema and ARDS 5. Differentiating between pulmonary oedema and COPD 6. Diagnosis of pulmonary embolism 7. Diagnosis of pneumothorax 8. Diagnosis and estimation of volume and nature of pleural effusion. 9. Diagnostic and therapeutic ultrasound-guided thoracentesis.
- 33. Absent lung sliding Exaggeratedhorizontal artifacts Loss of comet-tail artifacts Broadening of the pleural line to a band The key sonographic signs of Pneumothorax
- 37. the "seashore sign"(Fig.3).
- 46.
- 47. Schematic representation ofthe parenchymal, pleural and vascular features associated with pulmonary embolism.(Angelika Reissig, Claus Kroegel. Respiration2003;70:441-452)
- 49.
- 54. Multiple B-lines -« comet-tails » - interstitial edema (B1) 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
- 55. 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 http://www.reapitie- 02 09 2012
- 65. Hemodynamic assessment ofcirculatory failure using lung ultrasound: FALLS- protocol
- 66. Is ultrasound usefulin shock?
- 67. Shock Clinical situation wherethere is hypoperfusion of the cells and tissues
- 68. Background Patients withshock have high mortality rates and these rates are correlated to the amount and duration of hypotension. Diagnosis and initial care must be accurate and prompt to optimise patient outcomes. Studies have demonstrated that initial integration of bedside ultrasound into the evaluation of the patient with shock results in a more accurate initial diagnosis with earlier definitive treatment. Bedside USS allows direct visualisation of pathology or abnormal physiological states.
- 69. Remember… Ultrasound isa tool to aid diagnosis, but it won’t tell you everything… When using it we should always have a clinical question you would like it to answer
- 70. Contractility- HyperdynamicLV- sepsis, hypovolaemia Hypodynamic-late sepsis, cardiogenic shock What’s the RV like? – collapsing? Dilated? Obstructive shock Gross valvular dysfunction
- 71.
- 72. 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
- 73. Apical 4 chamber 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.
- 75. PericardialTamponade Remember tamponadeisa 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.
- 76. Tamponade using ultrasound A moderate-large effusion. Right atrial collapse Atrial contractionnormal 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…
- 77.
- 78. Where to putthe probe… Probe position Subxiphoid Orientate probe in longitudinal plane with probe indicator to patient’s head Slightly to right of midline
- 79. Bowel gas causingproblems….
- 80. The FAST view… Probe goes longitudinally in right mid axillary line with marker towards head. Look for IVC running longitudinally adjacent to the liver crossing the diaphragm Track superiorly until it enters the RA confirms it’s the IVC not the aorta
- 81. Assessing the IVC During inspiration, intrathoracic pressure becomes more negative, abdominal pressure becomes more positive, resultant increase in the pressure gradient between the supra and infra-diaphragmatic vena cava, increases venous return to the heart. Given the extrathoracic IVC is a very compliant vessel this causes diameter of IVC to decrease with normal inspiration. In patients with low intravascular volume, the inspiration to expiration diameters change much more than those who have normal or high intravascular volume.
- 82. Estimating theCVP IVC Diameter(mm) % collapse Estimated CVP (cm H2O) <20 >50 5 <20 <50 10 >20 <50 15 >20 0 20 Right atrial pressures, representing central venous pressure, can be estimated by viewing the respiratory change in the diameter of the IVC.
- 83. American society ofEchocardiography 2010 guidelines
- 85. Subxiphoid long; shockedand dry
- 88. Subxiphoid transverse viewof the IVC and aorta
- 89. Complicating the picture Valvular disease Pulmonary hypertension Increased intraabdominal pressure
- 90.
- 91. himaP Multiple studieshave shown ultrasound to be more sensitive than supine CXR for the detection of pneumothorax. Sensitivities ranged from 86-100% with specificities from 92-100%. Furthermore USS can be performed more rapidly at the bedside. Detection with ultrasound relies on the fact that free air is lighter than normal aerated lung tissue, and thus will accumulate in the nondependent areas of the thoracic cavity. (ie anteriorly when patient is supine).
- 92. To get thelung window Patient should be supine. Use high frequency linear array or a phased array transducer. Position in the midclavicular line, 3rd to 4th intercostal space with probe oriented longitudinally. Position between ribs.
- 93.
- 94. Abdominal and cardiacevaluation with sonography in the hypotensive patient (ACES) Category of shock Cardiac funcion IVC Treatment Septic Hyperdynamic Narrow IVC, collapseswith inspiration IVF +/-pressors Cardiogenic Hypodynamicleft ventricle Dilated IVC;little or no collapse with inspiration Inotropes Hypovolaemic HyperdynamicLV Narrow IVC, collapses IVF/Blood Tamponade Pericardial effusio, diastolic collapseRV Dilated IVC, no collapsewith inspiration Pericardiocentesi s PE Dilated RV Dilated IVC with minimal/no collapse thrombolysis
- 99. (Chest. 2008; 133:836-837) ©2008 American College of Chest Physicians Ultrasound: The Pulmonologist’s New Best Friend Momen M. Wahidi, MD, FCCP