Role of ward-based pleural Role of ward-based pleural ultrasoundultrasound

Dr R Teoh

Department of Respiratory Medicine

Castle Hill Hospital

Reason for study:To assess position of right chest drain inserted into the eighth intercostal space, but is projecting over the right upper quadrant on the abdominal x-ray.

Report:In the abdomen the chest drain has been inserted through the lower right hemidiaphragm into the right lobe of the liver.

This crosses through the right lobe of the liver to the left lobe avoiding both main branches of the portal vein.

It exits the left lobe through its inferior surface and runs anterior to the distal stomach and terminates just anterior to the hepatic flexure of the colon.

The drain is not passing through the pleural cavity.

255 procedures

Puncture site identified:172/255 (67%)

Accurate:147/172 (85%)

Inaccurate:25/172 (15%)

8: Insufficient fluid 5: Lung12: Liver or spleen

USS identified accurate site in

20/25 (80%)

No puncture site identified:83/255 (33%)

US - Site found:45/83 (54%)

US - No site found:38/83 (46%)

Accuracy of pleural puncture sites: Accuracy of pleural puncture sites: Clinical examination versus ultrasoundClinical examination versus ultrasound

Diacon et al. Chest 2003; 123: 436-441Diacon et al. Chest 2003; 123: 436-441

15% (25/172) of “blind” puncture sites 15% (25/172) of “blind” puncture sites inaccurateinaccurate

US potentially prevented organ puncture in US potentially prevented organ puncture in 10% (17/172)10% (17/172)

US increased localisation of accurate site by US increased localisation of accurate site by 26% (65/255)26% (65/255)

Ultrasound findings following failed, Ultrasound findings following failed, clinically directed thoracentesisclinically directed thoracentesis

Weingardt JP etl al. J Clin Ultrasound, 1994; 22: 419-426.Weingardt JP etl al. J Clin Ultrasound, 1994; 22: 419-426.

US appearance of previous thoracentesis site

Fluid detected with US

Number of patients (n=26)

Percentage

No fluid seen No 8 31%

No fluid seen (site below diaphragm) Yes 7 27%

No fluid seen (site above

pleural effusion)

Yes 3 11%

Loculated fluid Yes 3 11%

Intervening consolidation Yes 3 11%

Intervening chest wall mass Yes 1 4%

Failed US-guided thoracentesis Yes 2 8%

8/26 (31%) had no pleural fluid on US8/26 (31%) had no pleural fluid on US 10/26 (38%) blind thoracentesis were misdirected10/26 (38%) blind thoracentesis were misdirected 14/16 (88%) US-guided thoracentesis successful14/16 (88%) US-guided thoracentesis successful

US-guided thoracentesis: US-guided thoracentesis: Complication ratesComplication rates

Complication Frequency (n=941)

Historical controls

Pneumothorax 24 (2.5%) 5.7 – 19%

Small 16 (1.7%)

Large 8 (0.9%) 1 – 6.7%

Bleeding 2 (0.2%)

Subcutaneous haematoma 2 (0.2%)

Dry tap 3 (0.3%)

Jones et al, Chest 1990; 123: 418-423Jones et al, Chest 1990; 123: 418-423

Prospective descriptive study (n=941)Prospective descriptive study (n=941) Interventional radiologistsInterventional radiologists Lower complication rate with US guidance compared to historical controlsLower complication rate with US guidance compared to historical controls

RCT comparing US guided versus RCT comparing US guided versus blind thoracentesisblind thoracentesis

Grogan et al, Arch Intern Med 1990; 150: 873-877Grogan et al, Arch Intern Med 1990; 150: 873-877

Needle

(n=15)

Cannula

(n=18)

US guided

(n=19)

Pneumothorax 3 7 0

Haematoma 0 2 0

Dry tap 1 2 0

p=0.01

RCT (n=52)RCT (n=52) Medical and radiology residentsMedical and radiology residents Lower complication rate with US guidanceLower complication rate with US guidance

US guided thoracentesis: US guided thoracentesis: Success rateSuccess rate

Kohan JM et al. Am Rev Respir Dis 1985; 133: 1124-26.Kohan JM et al. Am Rev Respir Dis 1985; 133: 1124-26.

Pleural effusion Blind thoracentesis failures

US guided failures P-value

Small 12/36 (33%) 5/49 (10%) P<0.01

Large 3/66 (5%) 1/54 (2%) NS

Loculated 5/8 (63%) 3/20 (15%) P<0.02

Prospective RCT (n=205)Prospective RCT (n=205) Physician-performed thoracentesis with and without US guidance (X-marks the spot)Physician-performed thoracentesis with and without US guidance (X-marks the spot) US guidance increases yield in small and loculated pleural effusionsUS guidance increases yield in small and loculated pleural effusions

Normal lung & rib shadow

Diaphragm, liver & pleural effusion

Small pleural effusion

Septations

Compressive atelectasis

Consolidation with air bronchograms

Ultrasound study in unilateral Ultrasound study in unilateral hemithorax opacificationhemithorax opacification

Yu CJ et al. Am Rev Respir Dis, 1993: 147: 430-434Yu CJ et al. Am Rev Respir Dis, 1993: 147: 430-434

US findings Number of patients

(n=50)

Pleural effusion 41

No pleural effusion 9

Collapsed lung 3

Consolidation 3

Pulmonary hypoplasia 1

Fibrothorax 1

Pseudocyst 1

Advantages of ward-based Advantages of ward-based

pleural ultrasoundpleural ultrasound 1.1. Detects pleural pathologyDetects pleural pathology

2.2. Pleural versus parenchymal lesionsPleural versus parenchymal lesions

3.3. Guides pleural proceduresGuides pleural procedures

4.4. Monitors pleural diseaseMonitors pleural disease

5.5. Performed at bedsidePerformed at bedside

6.6. No delaysNo delays

7.7. No radiationNo radiation

Disadvantages of ward-based Disadvantages of ward-based

pleural ultrasoundpleural ultrasound 1.1. High capital costHigh capital cost

2.2. Inadequate environmentInadequate environment

3.3. Operator-dependentOperator-dependent

4.4. Training requirementsTraining requirements

The impact of ward-based pleural The impact of ward-based pleural ultrasound in a respiratory unitultrasound in a respiratory unit

Chest ultrasounds performed in the radiology department between 2002-2006 at HRI and CHH

63

4655

34

17

80 77

100

117125

0

20

40

60

80

100

120

140

2002 2003 2004 2005 2006

Chest Medicine

Non-chest medicine

Ultrasound purchased

The impact of ward-based pleural The impact of ward-based pleural ultrasound in a respiratory unitultrasound in a respiratory unit

102 patients

Pleural effusion present: 88Clinical detectable: 63/88

Clinically undetectable: 25/88

Small31/88(35%)

Large:46/88 (52%)

US guided chest drain 41/88 (47%)

No pleural effusion present: 14

Loculated:11/88 (13%)

Thoracentesis: 8/88 (9%)US guided chest drain: 7/88 (8%)

54/102 (53%) had US within 54/102 (53%) had US within 24 hours of admission24 hours of admission

30/102 (29%) had no or 30/102 (29%) had no or insufficient pleural fluid to insufficient pleural fluid to aspirate or drainaspirate or drain

Guided 15/88 (17%) Guided 15/88 (17%) procedures in small or procedures in small or loculated effusionloculated effusion

No complicationsNo complications

Overall ward-based Overall ward-based ultrasound affected ultrasound affected management in 45/102 management in 45/102 (44%) of cases(44%) of cases

Indications for pleural Indications for pleural

ultrasoundultrasound 1.1. To clarify the nature of pleural shadowingTo clarify the nature of pleural shadowing2.2. To guide thoracentesis and drainage of pleural To guide thoracentesis and drainage of pleural

effusions, especially those which are small or effusions, especially those which are small or loculatedloculated

3.3. To determine the nature of hemithorax “white-out”To determine the nature of hemithorax “white-out”4.4. To differentiate between subpulmonary effusion, To differentiate between subpulmonary effusion,

subphrenic collection or elevated hemidiaphragmsubphrenic collection or elevated hemidiaphragm5.5. To localise pleural thickening or pleural tumours prior To localise pleural thickening or pleural tumours prior

to biopsyto biopsy6.6. To exclude post-intervention pneumothoraxTo exclude post-intervention pneumothorax

Adapted from Tsai et al, Curr Opin Pulm Med 2003; 9: 282-290Adapted from Tsai et al, Curr Opin Pulm Med 2003; 9: 282-290

Tom & Katie’sTom & Katie’s

Ultrasound machinesUltrasound machines Portable +/- standPortable +/- stand Fewest knobsFewest knobs Transducer:Transducer:

Phase: 3.75 MhzPhase: 3.75 Mhz Linear: 5 to 10 MhzLinear: 5 to 10 Mhz

Consider Colour Doppler modeConsider Colour Doppler mode Warranty 2-5 yearsWarranty 2-5 years New or second handNew or second hand Manufacturers: Sonosite, GE, PhilipsManufacturers: Sonosite, GE, Philips ““Ultrasound equpiment business case” Ultrasound equpiment business case”

http://www.collemergencymed.ac.uk/temp/1509-Business-http://www.collemergencymed.ac.uk/temp/1509-Business-case-for-EMUS.pdfcase-for-EMUS.pdf

RCR recommendations for RCR recommendations for physician-operated thoracic USphysician-operated thoracic US

Ultrasound courseUltrasound course

Observing 20 chest USObserving 20 chest US

Performing:Performing: 20 US on normal patients20 US on normal patients 10 US in patients with pleural effusions10 US in patients with pleural effusions 5 diagnostic aspirations or drain placements5 diagnostic aspirations or drain placements

Supervised by Level II practitionerSupervised by Level II practitioner

““Business case for practical training in ultrasound for non-Business case for practical training in ultrasound for non-radiologist”. http://www.bmus.org/about/businesscase1.pdfradiologist”. http://www.bmus.org/about/businesscase1.pdf

Chest ultrasound coursesChest ultrasound courses

James Cook HospitalMiddlesborough19 June 2009

St. James’s University Hospital, Leeds

Pilgrim HospitalBoston

St. George’s HospitalLondon

Bromley HospitalOrpington

Royal Preston Hospital

Pleural ultrasound:Pleural ultrasound:Is it worth a look?Is it worth a look?

Ward-based physician-operated Ward-based physician-operated ultrasound can improve the yield and ultrasound can improve the yield and safety of diagnostic and therapeutic safety of diagnostic and therapeutic pleural procedurespleural procedures

High capital cost and training High capital cost and training requirements may limit its implementation requirements may limit its implementation across the UKacross the UK