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Chest Sonography in Critically
Ill Patients
Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University
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
Risk of transportation
Lung Computed Tomography in
the Critically ill
http://www.reapitie-
univparis6.aphp.fr 02 09 2012
Scanning Positions for Chest Sonography in ICU
Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform images representative of air bronchograms
Pleural
effusion
Lower lobe
the "seashore sign" (Fig.3).
Clinical applications of lung ultrasonography in the
intensive care unit
1. Diagnosis of pulmonary consolidation.
2. Diagnosis of atelectasis
3. Diagnosis of alveolar-interstitial syndrome
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.
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
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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
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univparis6.aphp.fr
02 09 2012
Hemodynamic assessment of circulatory
failure using lung ultrasound: FALLS-
protocol
Is ultrasound useful in shock?
Shock
Clinical situation where there is hypoperfusion of the cells and tissues
Background
Patients with shock 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.
Remember…
Ultrasound is a 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
Contractility-
Hyperdynamic LV- sepsis, hypovolaemia
Hypodynamic- late sepsis, cardiogenic shock
What’s the RV like? – collapsing? Dilated?
Obstructive shock
Gross valvular dysfunction
Cardiac assessment
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
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.
Pericardial Tamponade
Remember tamponade is 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.
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…
IVC
Where to put the probe…
Probe position
Subxiphoid
Orientate probe in
longitudinal plane with
probe indicator to
patient’s head
Slightly to right of
midline
Bowel gas causing problems….
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
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.
Estimating the CVP
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.
American society of Echocardiography 2010 guidelines
Subxiphoid long; shocked and dry
Subxiphoid transverse view of the IVC and aorta
Complicating the picture
Valvular disease
Pulmonary hypertension
Increased intraabdominal pressure
hiMAp eFAST/Aorta scan
himaP
Multiple studies have 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).
To get the lung 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.
Pneumothorax
Abdominal and cardiac evaluation with sonography in the hypotensive patient (ACES)
Category of shock
Cardiac funcion IVC Treatment
Septic Hyperdynamic Narrow IVC, collapses with inspiration
IVF +/-pressors
Cardiogenic Hypodynamic left ventricle
Dilated IVC; little or no collapse with inspiration
Inotropes
Hypovolaemic Hyperdynamic LV Narrow IVC, collapses
IVF/Blood
Tamponade Pericardial effusio, diastolic collapse RV
Dilated IVC, no collapse with inspiration
Pericardiocentesis
PE Dilated RV Dilated IVC with minimal/no collapse
thrombolysis
(Chest. 2008; 133:836-837)
© 2008 American College of Chest Physicians
Ultrasound: The Pulmonologist’s New Best
Friend
Momen M. Wahidi, MD, FCCP
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