ULTRASONOGRAPHY OF THE THORAX

ULTRASONOGRAPHY OF THE THORAX

WIDIRAHARDJOPULMONARY DEPARTMENT, FACULTY OF MEDICINE, UNIVERSITY OF SUMATERA UTARA/ ADAM MALIK HOSPITALMEDAN2011

INTRODUCTIONTHE SCOPE OF APPLICATION OF CHEST SONOGRAPHY HAS BEEN SIGNIFICANTLY WIDENED IN THE LAST FEW YEARS. ADVANTAGES OF US: ABSENCE OF RADIATION, PORTABLE, REAL-TIME IMAGING, DOPPLER ASSESSMENT OF VASCULARITY WITHOUT USE OF CONTRAST MEDIUM, ABILITY TO PERFORM DYNAMIC EVALUATION, NO TOO DIFFICULT TO LEARN.AS A STRATEGIC INSTRUMENT TO BE USED DIRECTLY AFTER THE CLINICAL INVESTIGATION. INTRODUCTION, contDECIDE VERY RAPIDLY TO ESTABLISH DIAGNOSES AT THE PATIENTS BEDSIDE WITH GREATER ACCURACY AND EFFICIENCY, WHETHER A TRAUMATIZED PATIENT. SEVERAL DIAGNOSES SUCH AS PNEUMOTHORAX, PNEUMONIA OR PULMONARY EMBOLISM CAN BE ESTABLISHED IMMEDIATELY.

INTRODUCTION, contSIGNIFICANTLY DEEPENED KNOWLEDGE OF CHEST SONOGRAPHY: THE SONOMORPHOLOGY OF THE NORMAL PLEURATHE SONOANATOMY OF THE UPPER APERTURE OF THE THORAX HAS BEEN EXTENDED TO INCLUDE IMAGING OF THE BRACHIAL PLEXUS

INTRODUCTION, contMONUMENTAL STUDIES ON LYMPH NODE STAGING IN THE PRESENCE OF BRONCHIAL CARCINOMA IS MARKEDLY SUPERIOR TO CT. THE HIGH VALUE OF ENDOLUMINAL ACCESSES (EBUS) IN GREATER DETAIL AND WITH GREATER PRECISION. THE NEW ISSUE ARE CONTRAST SONOGRAPHY AND THE ELUCIDATION OF CLINICAL SONOGRAPHY FROM SYMPTOMS TO DIAGNOSIS.

HISTORY:FIRST FOUND OF ULTRASOUND AT 1920 NOT AS A DIAGNOSTIC TOOLS YETTHEODORE DUSSIK DAN FREIDERICH AT 1940 EXAMINE THE TUMOR AND BLOOD VESSELS OF THE BRAINTO BE ADVANTED BY GEORGE LUDWIG AT 1950INTRODUCING OF DIGITAL TRANSDUCER AT 1990: CLEAR IMAGE Thoracic sonography. Respir Care.2001;46:9329.CARA KERJA USG: MEMANTULKAN DAN MENERIMA KEMBALI GELOMBANG SUARA GELOMBANGLISTRIKGELOMBANG SUARAKRISTAL VIBRASISINYAL BALIK KRISTALDISTORSIGELOMBANGPANTUL

Crit Care Med 2007 Vol. 35, No.8TRANSDUCERPRINSIP DASAR USG TORAKS:ORGAN DEKAT PERMUKAAN FREK. TINGGI (7,5 10 MHz)

ORGAN LEBIH DALAM FREK. RENDAH (2 5 MHz)

JENIS TRANSDUCER ATAU PROBE:

Crit Care Med 2007 Vol. 35, No. 8 LINEARCONVEXSECTORSTRUCTURES AND PATHOLOGICAL CHANGES ACCESSIBLE TO SONOGRAPHY

INDICATIONS: 1. THORAX WALL (A) BENIGN LESIONS BENIGN NEOPLASMS (E.G., LIPOMA) HEMATOMA ABSCESS REACTIVATED LYMPH NODES PERICHONDRITIS, TIETZES SYNDROME RIB FRACTURE (B) MALIGNANT LESIONS LYMPH NODE METASTASES (INITIAL DIAGNOSIS AND COURSE OF DISEASE DURING TREATMENT) INVASIVE, GROWING CARCINOMAS OSTEOLYSISINDICATIONS, cont2. PLEURA (A) SOLID STRUCTURES: THICKENING OF THE PLEURA, CALLUS, CALCIFICATION, ASBESTOSIS PLAQUES (B) SPACE-OCCUPYING MASS BENIGN: FIBROUS TUMOR, LIPOMA MALIGNANT: CIRCUMSCRIBED METASTASES, DIFFUSE CARCINOSIS, MALIGNANT PLEURAL MESOTHELIOMAINDICATIONS, cont (C) FLUID: EFFUSION, HEMATOTHORAX, PYOTHORAX, CHYLOTHORAX (D) DYNAMIC INVESTIGATION PNEUMOTHORAX DISTINGUISHING BETWEEN EFFUSION AND CALLUS FORMATION ADHERENCE OF A SPACE-OCCUPYING MASS INVASION BY A SPACE-OCCUPYING MASS MOBILITY OF THE DIAPHRAGMINDICATIONS, cont3. FORMATION OF PERIPHERAL FOCI IN THE LUNG (A) BENIGN: INFLAMMATION, ABSCESS, EMBOLISM, ATELECTASIS (B) MALIGNANT: PERIPHERAL METASTASIS, PERIPHERAL CARCINOMA, TUMOR/ATELECTASISINDICATIONS, cont4. MEDIASTINUM, PERCUTANEOUS (A) SPACE-OCCUPYING MASSES IN THE UPPER ANTERIOR MEDIASTINUM (B) LYMPH NODES IN THE AORTICOPULMONARY WINDOW (C) THROMBOSIS OF THE VENA CAVA AND ITS SUPPLYING BRANCHES (D) IMAGING COLLATERAL CIRCULATION (E) PERICARDIAL EFFUSIONSPECTRUM OF APPLICATION OF SONOGRAPHY FOR PLEURAL AND PULMONARY DISEASE

INDICATIONS FOR INVASIVE SONOGRAPHY

PLEURAL ULTRASONOGRAPHYTECHNIQUE & INSTRUMENTATIONREVIEW CXR, LOCALISE AREA OF INTERESTSCANNING ALONG THE INTERCOSTAL SPACE OR ABDOMINAL APPROACH USING LIVER AND SPLEEN AS A WINDOWDURING QUIET AND ARRESTED RESPIRATION

19Before performing the US examination, it is important to review the patient's chest radiograph to localize the area of interest. Maximum visualization of the lung and pleural space is achieved by scanning along the intercostal spaces. Scanning should be performed during quiet respiration, to allow for assessment of normal lung movement, and in suspended respiration, when a lesion can be examined in detail with gray-scale or color Doppler US

LINEAR PROBE PLACED LONGITUDINAL VIEW ON THE RIGHT PARASTERNAL LINE. M MUSCLE, P LINE OF THE PLEURA

LINEAR PROBE PLACED PARALLEL TO THE RIBS IN THE THIRD INTERCOSTAL SPACE, TRANSVERSE VIEW, M MUSCLE, P LINE OF THE PLEURA

POSITION TO EXAMINE STRUCTURES BEHIND THE SCAPULA

TRANSHEPATIC VIEW, A CONVEX PROBE PLACED SUBCOSTALLY FROM THE RIGHT. SLIGHT TILTING IN CRANIAL DIRECTION. L LIVER, LV LIVER VEIN, ZF DIAPHRAGM, S REFLECTION OF THE LIVER ABOVE THE DIAPHRAGM

23LATERAL VIEW, CONVEX PROBE, LONGITUDINAL VIEW IN THE MID PORTION OF THE RIGHT AXILLARY LINE.D DIAPHRAGM.

A SUBCUTANEOUS HEMATOMA AFTER BLUNT TRAUMA (H) IS LARGELY ANECHOIC. PLEURAL FLUID (E) BEHIND THE CHEST WALLHEMOTHORAX

25FIBROLIPOMA IN THE PARIETAL PLEURA. THE DIAGNOSIS WAS CONFIRMED BY SONOGRAPHY-GUIDED BIOPSY.

RIB FRACTURE WITH A STEP OF 1.5 MM. THIS FRACTURE COULD NOT BE SEEN ON X-RAYS.

EPIDERMOID CARCINOMA AT THE RIGHT APEX OF THE LUNG, INVADING THE CHEST WALL, IRREGULAR VASCULARIZATION PATTERN

CHEST WALL WITH NORMAL SMOOTH VISCERAL PLEURA (ARROW 1). ON THE OUTSIDE, THE ECHO-POOR PLEURAL GAP (ARROW 2) AND THEN THE ECHOGENIC (ECHO-RICH) PARIETAL PLEURA (ARROW 3).

NUMEROUS COMET-TRAIL ARTIFACTS ON THE DIAPHRAGMATIC PLEURA

DIAGNOSIS OF PLEURAL EFFUSIONCONVENTIONALLY USING CHEST RADIOGRAPHBLUNTING OF COSTOPHRENIC ANGLE AND HOMOGENEOUS OPACITY WITH MENISCUS SIGNABOUT 200ML BEFORE IT CAN BE SEENLATERAL DECUBITUS RADIOGRAPH MAY DETECT EFFUSION AS SMALL AS 10MLCANNOT BE DISTINGUISHED FROM PLEURAL THICKENINGUS IS A SENSITIVE METHOD DETECTING SMALL EFFUSION OF A FEW ML. 31The sonographic appearance of pleural effusion depends on the cause, nature, and chronicity of the collection (Fig 3). Four different appearances are recognized at US ESTIMATING THE VOLUME OF PLEURAL EFFUSION

32The sonographic appearance of pleural effusion depends on the cause, nature, and chronicity of the collection (Fig 3). Four different appearances are recognized at US ECHOGENIC PROTEIN-RICH EFFUSION

HOMOGENOUS ECHOGENIC PLEURAL EFFUSION - CHYLOTHORAX

MALIGNANT PLEURAL EFFUSION.OPEN (ARROW) SMALL PLEURAL METASTASIS ON THE DIAPHRAGM

HONEYCOMB-LIKE APPEARANCE OF A POSTINFLAMMATORY EFFUSION, LOCULATED LESIONS OR SEPTATION.

REGULAR AND WELL DELINEATED THICKENING OFTHE PARIETAL AND VISCERAL PLEURA IN AN ALREADY DRAINED EMPYEMA. SMALL AIR BUBBLES IN THE COMPLETELY EMPTIED CAVITY (ARROWS)

METASTASIS OF BREAST CANCER, SITTING ON THE OTHERWISE UNCHANGED PARIETAL PLEURA PARIETALIS. A SURROUNDING LARGE PLEURAL EFFUSION

INITIAL DIAGNOSIS OF A PLEURITIC MESOTHELIOMA, COVERING, IN A WALLPAPER-LIKE FASHION

MESOTHELIOMA: WIDESPREAD INFILTRATION OF THE THORACIC WALL WITH SPREAD AROUND THE RIBS (ARROW HEADS), AS WELL INFILTRATION OF THE LUNG (ARROW)

PNEUMOTHORAX: THE LEFT HEALTHY SIDE (A) SHOWS A RESPIRA- .TORY SHIFTING PLEURAL REFLEX AND CLEARLY LESS REVERBERATIONS. ON THE SIDE OF THE PNEUMOTHORAX (B), THE REVERBERATIONS ARE INTENSIFIED AND NO RESPIRATORY SHIFT IS VISIBLE

SONOMORPHOLOGY PNEUMOTHORAX: ABSENCE OF THE GLIDING SIGN ROUGH REPETITIVE ECHOES (REVERBERATION) NO VISUALIZATION OF THE PLEURAL GAP NO COMET-TAIL ARTIFACTSPNEUMONIA

PNEUMONIA WITH MICROABSCESS

SONOMORPHOLOGY OF PNEUMONIA:

SIMILAR TO THE LIVER IN THE EARLY STAGE LENTIL-SHAPED AIR TRAPPINGS BRONCHOAEROGRAM FLUID BRONCHOGRAM (POSTSTENOTIC) BLURRED AND SERRATED MARGINS REVERBERATION ECHOES AT THE MARGIN HYPOECHOIC TO ANECHOIC IN THE PRESENCE OF ABSCESS (MICROABSCESSES!)TUBERCULOSIS

SONOMORPHOLOGY OF LUNG TUBERCULOSIS:

NARROW PLEURAL EFFUSIONS THICKENED AND FRAGMENTED VISCERAL PLEURAL REFLEXES A FEW OR NUMEROUS HYPOECHOIC LESIONS IN SUBPLEURAL LOCATION PNEUMONIC LESIONS FORMATION OF CAVITIESTUMOR

TUMOR

ECHOTEXTURE OF TUMORINHOMOGENEOUSHYPOECHOICRARELY ECHOGENICRARELY UNECHOICNECROTIC AREASPULMONARY EMBOLISM

SONOMORPHOLOGY OF PULMONARY EMBOLISM:HOMOGENEOUS STRUCTURES WITH A PLEURAL BASE THAT IS OCCASIONALLY A LITTLE PROTRUDED HYPOECHOIC SMOOTH MARGINS PROTRUDED AND ROUNDEDCENTRAL BRONCHIAL REFLEX IS EITHER WEAK OR ABSENTA CLEAR BRONCHOAEROGRAM IS NOT SEEN IN ANY EARLY LUNG INFARCTIONCOMPRESSED ATELECTASE

SONOMORPHOLOGY OF COMPRESSED ATELECTASE: PLEURAL EFFUSION, THE MARGIN TOWARDS THE ADJACENTAERATED LUNG TISSUE IS BLURRED DURING INSPIRATION SONOGRAPHY REVEALS AN INCREASING QUANTITY OF AIR IN ATELECTATIC REGIONS AND THE FORMATION OF A SO-CALLED AIR BRONCHOGRAMCONCOMITANT INFLAMMATORY INVASION OF PARENCHYMA IN ATELECTATIC TISSUE IS A FURTHER LIMITATION. IT LEADS TO CONGESTIVE PNEUMONIAOBSTRUCTIVE ATELECTASE

SONOMORPHOLOGY OF OBSTRUCTIVE ATELECTASE:MILD TO NO PLEURAL EFFUSIONHOMOGENOUS HYPOECHOIC TRANSFORMATION OF LUNG PARENCHYMAHYPERECHOIC REFLEXES MAY BE SEEN (FLUID BRONCHOGRAM)FOCAL INTRAPARENCHYMATOUS LESIONS MAY BE SEEN : - LIQUEFACTION OF PARENCHYMA - MICROABSCESSES, GROSS ABSCESSES - METASTASES A CENTRAL SPACE-OCCUPYING LESION MAY BE SEEN NO REVENTILATION DURING INSPIRATIONTRANSTHORACIC MEDIASTINAL SONOGRAPHY

TRANSTHORACIC MEDIASTINAL SONOGRAPHY

THYMOMA

CYSTIC BENIGN TERATOMA.A 32-YEAR-OLD PATIENT, LEFT PARASTERNAL SECTION IN SUPINE POSITION, CLEARLY DELINEATED MASS WITH ECHOGENIC SEPTUM-LIKE STRUCTURES. IN THE CENTER, HIGH AMPLITUDE REFLEXES WITH DORSAL SHADOWING (CENTRAL CALCIFICATIONS).

ENDOBRONCHIAL ULTRASONOGRAPHY (EBUS)INDICATIONS:EARLY CANCER ADVANCED CANCER PERIPHERAL LESIONS LYMPH NODE STAGING ENDOBRONCHIAL SONOGRAPHY IN THERAPEUTIC INTERVENTIONS ENDOBRONCHIAL ULTRASONOGRAPHY (EBUS)

TU tumor, LN lymph node, AOA ascending aorta, TR trachea, ES endoscopic probe, ln small lymphnode, VC vena cava.6Chapter 134 6 Mediastinum