Post on 21-Apr-2017
Role of Chest Sonography in
Respiratory Emergencies
Gamal Rabie Agmy, MD, FCCP Professor of chest Diseases, Assiut university
High Frequency
• High frequency (5-10 MHz)
greater resolution
less penetration
• Shallow structures
Low Frequency
• Low frequency (2-3.5 MHz)
greater penetration
less resolution
• Deep structures
Probes
A common language: Color Coding
Black Grey White
Chest Sonography
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
THE BAT VIEW
Chest wall
Pleural line
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.
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
the "seashore sign" (Fig.3).
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
B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12
Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125
Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform images representative of air bronchograms
Pleural
effusion
Lower lobe
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
the "seashore sign" (Fig.3).
Pulmonary Embolism
Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration 2003;70:441-452 )
Alveolar-interstitial syndrome
Multiple B-lines - « comet-tails » - interstitial edema (B1)
7 mm apart « B lines » thickened interlobular septa
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997 JJR 25 05 2012
http://www.reapitie-
univparis6.aphp.fr http://www.reapitie-
univparis6.aphp.fr
02 09 2012
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997 30 11 2011
Coalescent B lines - « comet-tails » - alveolar
edema
3 mm apart « B lines » ground-glass areas
http://www.reapitie-
univparis6.aphp.fr
02 09 2012
IVC Sonography
INDICATIONS
IVC Ultrasound
Spontaneously
Breathing
Mechanical
Ventilation
Volume Status / CVP Fluid Responsiveness
INDICATIONS Assessing
Intravascular Volume Status /
CVP
•Volume depleted state :
•Dehydration _ Acute Kidney Injury (?
Prerenal,renal, post renal)
- Diuretic therapy
- Sepsis
* Volume overloaded state:
-Heart Failure
-Cirrhosis with ascites
- Anasarca
INDICATIONS Assessing
Fluid Responsiveness in Shock
* Measuring the variation in IVC diameter in these
situations can help determine whether the patient’s
blood pressure will respond to fluids or whether
inotropic support (i.e. dobutamine) will be needed
NB: IVC diameter does not correlate with right atrial
pressure in patients who are intubated with shock
Respiratory variation
Expands w/ expiration
Contracts w/ inspiration
Due to changing intrathoracic pressures.
PROCEDURE Probe Selection
1 Low frequency 2-5 MHz
2 Curvalinear probe
PROCEDURE
Approach #1 – Xiphoid View
PROCEDURE
Landmarks
Aproach #1 – Xiphoid View
1 Most common approach
2 Place probe longitudinally just below the
xiphoid process with the probe marker to the
patient’s head
3 Look for IVC going into right atrium – may
need to move probe 1-2cm to patient’s
right and then tilt it slightly towards the
heart
IVC Longitudinal
PROCEDURE
Approach #2 – Anterior -Mid-Axillary
View
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.
IVC Anterior Mid-Axillary View
Measuring the IVC Diameter
Measure IVC 2cm
distal to right atrium
Inspiratory (Minimal) IVC
Diameter
Maximum (Expiratory) IVC
Diameter
M-Mode IVC Diameters
CAVAL INDEX (CI)
CI =
minimal (inspiratory)
diameter
maximum (expiratory)
diameter
maximum (expiratory)
diameter
CAVAL INDEX (CI)
Volume
Depletion
Volume
Overload
0% 100%
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
Echocardiography
(Chest. 2008; 133:836-837)
© 2008 American College of Chest Physicians
Ultrasound: The Pulmonologist’s New Best
Friend
Momen M. Wahidi, MD, FCCP