Lung usg imaging radiology

1. 1

2. • The chest cavity is bounded by the chest wall and
below by the diaphragm.
• It extends upward into the root of the neck about
one fingerbreadth above the clavicle on each side
• The chest cavity can be divided into a median
partition, called the mediastinum , and the laterally
placed pleurae and lungs
Chest Cavity
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3. • Product B
• Feature 1
• Feature 2
• Feature 3
Slide Title
• Feature 1
• Feature 2
• Feature 3
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4. Pleura
• It is a serous membrane arranged as a closed invaginated sac that
covers the lung and lines the chest wall
• Each pleura has two parts:
• 1. Parietal layer (outer layer) , which lines the thoracic wall,
• 2. Visceral layer (inner layer), which completely covers the outer
surfaces of the lungs
• The two layers become continuous with one another at the hilum of
each lung. But below the hilum the two layers hang down as a loose
fold called the pulmonary ligament
• The parietal and visceral layers of pleura are separated from one
another by the pleural cavity (pleural space) that contains a small
amount of the pleural fluid 4

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6. Division of the parietal pleura
• Parietal pleura divided according to the region in which it lies
or the surface that it covers.
• The cervical pleura extends up into the neck. It reaches a level
1 to 1.5 in. (2.5 to 4 cm) above the medial third of the clavicle.
• The costal pleura lines the inner surfaces of the ribs, the
costal cartilages, the intercostal spaces, the sides of the
vertebral bodies, and the back of the sternum
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7.  The diaphragmatic pleura covers the thoracic surface
(upper surface) of the diaphragm.
 The mediastinal pleura covers and forms the lateral
boundary of the mediastinum. At the hilum of the lung, it
is reflected as a cuff around the vessels and bronchi that
constitute the lung root and here becomes continuous
with the visceral pleura.
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9. Nerve Supply of the Pleura
• The parietal pleura is sensitive to pain, temperature, touch, and
pressure and is supplied as follows:
The costal pleura is segmentally supplied by the intercostal nerves.
The mediastinal pleura is supplied by the phrenic nerve.
The diaphragmatic pleura is supplied over the domes by the phrenic
nerve and around the periphery by the lower six intercostal nerves.
• The visceral pleura covering the lungs is sensitive to stretch but is
insensitive to common sensations such as pain and touch. It
receives an autonomic nerve supply from the pulmonary plexus
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10. Anatomy of Lungs
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11. Lungs
• The lungs are the essential organs of respiration.
• They are situated on either side of the heart and other mediastinal
contents
• the lungs are soft, spongy and very elastic.
• Each lung is conical in shape, covered with visceral pleura, being
attached to the mediastinum only by its root
• In the child, they are pink, but with age, they become dark and
mottled
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13. Anatomical features of the lungs
• Each lung has an apex, base, three borders and two surfaces
• Apex each lung has a blunt apex, which projects upward into the neck for about 1 in.
(2.5 cm) above the clavicle;
• Base is concave, and rests upon the upper surface of the diaphragm ;
• The costal surface is smooth and convex which corresponds to the concave chest wall;
• The medial surface has a posterior vertebral part and anterior mediastinal part.
The vertebral part lies in contact with the sides of the thoracic vertebrae and
intervertebral discs
The mediastinal part is deeply concave, and related to the mediastinal content
which causes impressions on this surface. The hilum, where various structures enter
or leave the lung lies on this surface
• The anterior border is thin and overlaps the heart;it is here on the left lung that the
cardiac notch is found.
• The posterior border is thick and lies beside the vertebral column.
• Inferior border
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16. The mediastinal part of the medial
surface
• The mediastinal part is deeply concave, and
related to the mediastinal content which
causes impressions on this surface.
• Also it contains the hilum, where various
structures enter or leave the lung lies on this
surface
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17. Mediastinal surface
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18. Bronchopulmonary Segments
 The bronchopulmonary segments are the anatomic, functional,
and surgical units of the lungs.
 Each lobar (secondary) bronchus, which passes to a lobe of the
lung, gives off branches called segmental (tertiary) bronchi.
 Each segmental bronchus passes to a structurally and
functionally independent unit of a lung lobe called a Broncho
pulmonary segment, which is surrounded by connective tissue.
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21. Alveoli of lung
• They are tiny air containing sacs
and the functional unit of
lung,where gaseous exchange
occurs between the blood and
atmospheric air.
• Number:Adult lung contains
about 150 million alveoli in each
lung.
• Lining epithelium:Simple
squamous epithelium.
So,basically lung is an air containing
organ
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22. Blood Supply of the Lungs
• The bronchi, the connective tissue of the lung, and the visceral
pleura receive their blood supply from the bronchial arteries,
which are branches of the descending aorta.
• The bronchial veins drain into the azygos and hemiazygos veins.
• The alveoli receive deoxygenated blood from the terminal
branches of the pulmonary arteries. The oxygenated blood
leaving the alveolar capillaries drains into the tributaries of the
pulmonary veins, to empty into the left atrium of the heart.
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23. Nerve Supply of the Lungs
 At the root of each lung is a pulmonary plexus composed of efferent and
afferent autonomic nerve fibers.
 The plexus is formed from branches of the sympathetic trunk and
receives parasympathetic fibers from the vagus nerve.
 The sympathetic efferent fibers produce bronchodilatation and
vasoconstriction.
 The parasympathetic efferent fibers produce bronchoconstriction,
vasodilatation, and increased glandular secretion.
 Afferent impulses derived from the bronchial mucous membrane and
from stretch receptors in the alveolar walls pass to the central nervous
system in both sympathetic and parasympathetic nerves. 23

24. Ultrasonogram of lungs
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25. Seminar on Ultrasonogram of Lung
Presented by-
Dr. Tania Kabir
Resident,Phase A,R-12
Department of Radiology & Imaging
BSMMU
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26. Ultrasonogram of lungs
• Lung US has dramatically increased in popularity over
the last decade and is routinely performed at the
patient’s bedside, specially in the emergency
department and the intensive care unit. As this
modality becomes an imaging staple, the diagnostic
radiologist should be fluent in lung US performance
and interpretation to maintain relevance and assist
the ordering clinician. This seminar will provide an
overview of lung US to equip the knowledge needed
to interpret this modality 26

27. Ultrasonogram of lungs:continue…
• Meta-analysis suggest that lung US has higher
sensitivity and specificity compared with chest
radiography for evaluation of some pulmonary
conditions, including pneumonia, pleural effusion,
pneumothorax and pulmonary edema.
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28. Lung US vs Chest Radiography
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Ref:Lung Ultrasound: The Essentials Thomas J. Marini, MD • Deborah J. Rubens, MD • Yu T. Zhao, BA • Justin
Weis, MD • Timothy P. O’Connor, MD • William H. Novak, MD • Katherine A. Kaproth-Joslin, MD, PhD

29. Advantages of lung US
• It is radiation free
• Low cost
• Simple procedure
• Portable
• Allow real time examination of pulmonary structures
• Can be done on severely ill or ICU patients
• Can guide interventional procedures, including
thoracocentesis and biopsy with less complication
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30. Limitations
• It is an operator dependent process, so its quality varies
by practitioner
• Another limitation is the time needed to perform the
examination, complete lung US can take 20 minutes
• Technically challenging: Due to rib shadow, built of the
patient etc.
• Can only detect pathology that reaches the lung
periphery
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31. Indications of lung US
• Pleural pathology
• Pericardial pathology
• Shortness of breath
• Cyanosis
• Cough
• Shock
• Basically as a part of a physical exam in symptomatic
patient 31

32. Ultrasound techniques
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33. This discussion will review….
• Control and functions of the US machine
• Techniques for acquiring images
• Interpretation of key lung US findings
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34. Before each scan…
1. Choose your probe
2. Select your exam pre-set
3. Adjust your gain
4. Set your depth
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35. Before each scan…..
1.Choose your probe
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37. Before each scan…
1. Choose your probe
2. Select your exam pre-set
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38. Exam Pre-set
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39. Before each scan…
1. Choose your probe
2. Select your exam pre-set
3. Adjust your gain
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42. Before each scan…
1. Choose your probe
2. Select your exam pre-set
3. Adjust your gain
4. Set your depth
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45. Image acquisition
• The supine position is perfect for scanning the anterior
chest,whereas the lateral chest may be examined in the
semi-supine position.The ideal position for scanning the
posterior chest is with the patient sitting on the
bed,his/her back turned to the operator.
• Complete lung US involves examining each hemithorax in
the anterior,lateral and posterior lung zones.These three
lung zones again can be divided into 06 zones
numerically.They are zone 1,2,3,4,5 and 6
• All lung fields should also be examined in transverse and
longitudinal orientation 45

46. Image acquisition:continue
• The probe must be held perpendicular to the skin to
ensure perpendicular orientation to the pleura.
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47. Image acquisition:continue
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48. Lung zones
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49. Longitudinal vs Transverse approach
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51. Physics of lung US
• Lung US is predominantly artifact based,in contrast to other US
examinations in which anatomy is directly visualized.Most US
waves are reflected at the pleura in an air filled lung owing to
the acoustic impedance mismatch at the air and soft tissue
interface that results in a hyperechoic pleural line.Thus,the air
filled lung parenchyma cannot be directly visualized at US.
• When the air content decreases and lung density increases due
to the presence of exudate,transudate,collagen or blood in the
lung,the acoustic mismatch between the lung and the
surrounding tissues is lowered,the US beam can be partly
reflected at deeper zones and creates some artifacts through
which we can interpret the clinical condition. 51

52. Physics of lung US:continue…
• When the air content further decreases,such as in lung
consolidations,the acoustic window on the lungs becomes
completely open,and the lung may be directly visualized as a
solid parenchyma,like the liver or spleen
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53. Some important lung findings…..
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54. Pleural line
• A pleural line is a hyperechoic reflection formed by
the difference in acoustic impedance between the
pleura-lung surface interface.It represents the
parietal pleura
• It appears as a smooth,regular and relatively straight
hyperechoic line.Blurring,irregularities,interruption
of continuity or absence of pleural line indicates
abnormalities.
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55. Longitudinal lung view:
Pleural line
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56. The Bat sign
• The Bat sign refers to the characteristic appearance
of the pleural line along with the adjacent ribs.The
ribs resemble the wings of the bat,while the pleural
line which lies about half a centimeter below the ribs
mimics the body of the bat
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57. Longitudinal lung view:
Pleural line
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58. Longitudinal lung view:
Bat sign
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59. 59
Bat sign:continue…

60. A-lines
• An A-line is a type of reverberation artifact caused by
multiple reflections of the pleura when the probe is
perpendicular to the ribs for scanning.
• A-lines are situated below the pleural line and present as
a series of smooth,clear,regular and equidistant
hyperechoic parallel lines.
• The echoes of the A-lines gradually diminish as they
move deeper into the lung field where they ultimately
disappear
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61. A-lines:continue
• The A-lines predominates in normal
air filled lungs.Thus,A-lines means
air lines
• Pathologic conditions with air filled
lungs,such as asthma,COPD,mild
viral illness and pulmonary
embolism also have A-line artifact
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62. A line:continue
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63. 63
A line:continue…

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65. 65

66. B-lines
• A single B-line is a type of linear hyperechoic reflection
of an artifact caused by an US wave encountering the
alveolar gas-liquid interface
• B-lines arise from and are vertical to the pleural line
• They are well defined,laserlike,spread downwards to
the edge of the screen without fading and move in
syncronusly with the lung sliding.So,they are also called
lung rockets
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67. B-lines:continue
• B-line artifacts replace normal A-lines.
• < 3 B-lines per intercostal space is
normal whereas >3 B-lines per
intercostal space is pathologic
• B-lines are diffusely present in
pulmonary edema,pulmonary fibrosis
and pnemonitis
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69. B lines
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70. Z -Line
Z-lines (reverberation artifacts)could
be randomly found in any part of the
lungs during lung US exam and are
likely to be caused by short-paths
reverberations between the parietal
pleural and the endothoracic fascia.
Because of the extra-pulmonary
location, they are often seen as static
vertical artifacts which do not move
with lung sliding. Z-lines do not have
any clinical significance except that
they could easily be misinterpreted as
B-lines 70

71. Lung sliding
• In a real time US,the pleural line moves in a to- and
fro- pattern,synchronized with respiratory
movement.This kind of movement is called lung
sliding
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72. Lung Sliding
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73. Sandy beach/Sea shore sign
• Now if we put a longitudinal scan of sliding lung under
M-mode US,as the tissues superficial to the pleural line
remains stationary,they show smooth horizontal lines.
• Deep to the pleura,the lung motion interrupts the
lines,creating a finely interrupted granular or “sandy”
pattern.This normal pattern is called the “sea shore sign”
as it depicts the boundary between the stationary chest
wall (ocean) and moving lung (sand)
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74. Lung sliding:M mode
Sea shore sign
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75. Sea shore sign:continue
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76. Bar code sign
• If lung sliding is absent as in pneumothorax,and we
examined at M-mode US,here the structures above
and below the pleural line are both stationary,so they
shows smooth,horizontal,uninterrupted lines.This
appearance is called ‘Bar code’ sign.
• The key to identify this sign is that everything above
the pleural line and below the pleural line are
identical
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78. Absent lung
sliding:M mode
Bar code sign
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79. Lung point
• Lung point is a transition between the pneumothorax
or air in the pleural space and normal lung.The
appearance of an alternate area where lung sliding is
present and then absent is called a lung point.
• It is a pathognomonic sign of pneumothorax and can
accurately locate the position of the gas boundary
when a mild-moderate pneumothorax is present
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80. Lung point:continue
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81. Consolidation
• In consolidation,during lung
US,lung fields may have a tissue like
density.A completely consolidated
lung mimics the solid appearance
of the liver;this is known as
‘Hepatization’.
• Lung consolidation may be
accompanied by air bronchogram
which manifested as hyperechoic
foci within consolidated lung
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83. Consolidation/
Hepatization/
Tissue like sign
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84. Pleural effusion
• US directly images pleural fluid.Simple effusions commonly
present as anechoic fluid in the posterior dependent part of
lung
• However it should be reminded that loculated pleural
effusion will be present in the non dependent part of the
lung
• Complex pleural fluid collections,including chronic
effusions,malignant effusions,haemothorax and empyema
are heterogenous in appearance on US depending on the
extent of debris,septations and pleural thickening
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86. COVID-19 infection
• Viral infections,including COVID-19 can also be assessed
and monitored using lung US.Lung US can
diagnose,stratify risk and monitor COVID-19
infection,although findings can lack specificity.
• B-line artifact of varying severity,consolidation and
pleural irregularities have all been visualized in COVID-19
infection
• In areas of focal ground glass opacity,diffuse confluent B-
lines are present with loss of A-lines.
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87. COVID-19 infection:continue
• During the recovery phase,the B-lines decrease and
the A-lines typically return.
• It is important to note that,lung US performed on
patients with COVID-19 presents a risk to the
operator.This risk can be minimized with proper use
of protective equipment
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88. COVID-19 infection on lung US. A, Anteroposterior chest radiograph, B, axial
chest CT image, and C, lung US image from the same 74-year-old man, who
tested positive for COVID-19 5 days prior to imaging. The chest radiograph
shows bilateral peripheral opacity, which presents with a ground-glass
appearance on the chest CT image. Lung US imaging in this patient
demonstrated numerous B-lines throughout the parenchyma
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89. Summary
• For years,chest radiography and chest CT have been
the staples of regular thoracic diagnostic imaging.As
a versatile and highly accurate imaging modality,lung
US has the potential to substantially alter the
thoracic diagnostic imaging milieu for the better
89

90. Summary: continue
• But as the use of lung US increases,diagnostic radiologists
stand at a crossroads.Should we leave lung US to
clinicians?Or,might we stake our own claim to the
modality?We feel that there is a role for both clinicians and
radiologists in performing and interpreting lung US.
• Routine use as a point-of-care screening tool in the
emergency department may be performed by the
clinician.In more complicating cases,however a radiologist
may offer expertise that is best suited to a formal diagnostic
examination
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91. Take home message…
• Lung US is predominantly artifact based as opposed to most
other US examination
• The A-line artifact is seen in air filled lung
• B-line artifact is seen in conditions like pulmonary edema
and or fibrosis
• Pleural effusions and consolidation are directly visualized
• For a complete examination of the deeper thoracic
structures,chest radiography and/or CT imaging are
preferred.
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contusions-interstitial-syndrome-a-b-c-e-i-and-z-lines-explored
• J Ultrasound Med. 2009 Feb;28(2):163-74.Sonographic interstitial syndrome: the sound of lung water. Soldati G1, Copetti R, Sher
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lung contusion SadiaHelmya,Bassem,Beshayb,MohamedAbdel, HadybAbdel,menamMansour
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• Lung Ultrasound: The Essentials,Thomas J. Marini , Deborah J. Rubens, Yu T. Zhao, Justin Weis, Timothy P. O’Connor, William H. Novak, Katherine A.
Kaproth-Joslin
• Lung Ultrasound: The EssentialsThomas J. Marini, MD • Deborah J. Rubens, MD • Yu T. Zhao, BA • Justin Weis, MD • Timothy P. O’Connor, MD •
William H. Novak, MD • Katherine A. Kaproth-Joslin, MD, PhD
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• Thanks for Your Kind Attention