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ASSESSMENT

OF

LUNG PARENCHYMAL ABNORMALITIES

Christian B. Laursen, MD, PhD, Clin Ass Prof

Department of Respiratory Medicine, Odense University Hospital, Denmark

Mail: [email protected]

Conflict of interest disclosure

I have no real or perceived conflicts of interest that relate to this presentation.

This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.

To do list

Interstitial Lung Diseases

Fluid overload/heart failure

Pneumonia

Lung tumours

Pulmonary emboli

- how to distinguish from infectious consolidation?

- does ultrasound have a role given the widespread availability of

CTPA?

Lecture aims

Considerations prior to scanning

- Setting

- Preparation

- LUS protocol

Interstitial syndrome

- The B-line and interstitial syndrome

- Cardiogenic pulmonary edema

- Interstitial lung diseases

- Differentiation between IS causes

Lung parenchymal pathology

- Lung consolidation (e.g. pneumonia, PE, contusion)

- Lung atelectasis

- Lung tumor

- Differentiation between causes of lung parenchymal pathology

Clinical impact

- Does ultrasound have a role given the widespread availability of CTPA?

CONSIDERATIONS PRIOR TO SCANNING

CONSIDERATIONS PRIOR TO SCANNING

Setting

Preparation

- Appropriate transducer selection

- Appropriate preset selection

US protocol

- Focused examination

- Diagnostic examination

SETTING MATTERS

ACUTE RESPIRATORY SYMPTOMS IN THE ED

1. Decompensated HF

2. Pneumonia

3. COPD exacerbation

4. Thromboembolic disease (PE / DVT)

5. Other

Ray P et al. Acute respiratory failure in the elderly: Etiology, emergency diagnosis and prognosis. Critical care 2006;10:R82.

“Chronic” Respiratory symptoms

1. Malignancy

2. Interstitial lung disease

3. COPD / Asthma

4. TB / chronic infection

5. Other

PREPARATION OF THE US MACHINE

APPROPRIATE TRANSDUCER SELECTION

APPROPRIATE PRE-SET SELECTION

US PROTOCOLS

Focused LUS

Diagnostic LUS

Advanced LUS

UL guided procedures

eFAST

FATE

FASH

RUSH

….

Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-91

DIAGNOSTIC VS. FOCUSED APPROACH

Diagnostic LUS Pulmonary edema

Lung parenchymal pathology

-Pulmonary embolism

-Pneumonia

-Atelectasis

-Lung contusion

Pleura effusion

-Simple effusion

-Complex effusion

Pneumothorax

Malignancy

Thickened parietal pleura

Trapped lung

Diaphragmatic paresis/ paralysis

Rib fracture

Interstitial lung disease

Chest wall pathology

Mediastinal pathology

Assessment of lymph nodes

………..

Focused LUS Pulmonary edema: yes/no?

Lung parenchymal pathology: yes/no?

-Pulmonary embolism

-Pneumonia

-Atelectasis

-Lung contusion

Pleura effusion: yes/no?

-Simple effusion

-Complex effusion

Pneumothorax: yes/no?

Malignancy

Thickened parietal pleura

Trapped lung

Diaphragmatic paresis/ paralysis

Rib fracture

Interstitial lung disease

Chest wall pathology

Mediastinal pathology

Assessment of lymph nodes

………..

DIAGNOSTIC THORACIC / LUNG US

FLUS EXAMINATION TECHNIQUE

Different approaches depending on clinical setting / tradition:

-1 zone assessed

-2 zones assessed

-4 zones assessed

-14 zones assessed

-…. zones assessed


FLUS SCANNING ZONES

Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014;2(8):638-46

FLUS – how to do it

Focused questions:

- Signs of pneumothorax (yes / no)

- Pleural effusion present (yes / no)

- Signs of pulmonary edema present (yes/no)

- Signs of parenchymal pathology present (yes/no)

Noble VE, Nelson BP. Manual of Emergency and Critical Care Ultrasound: Cambridge University Press, 2011.


Focused questions:






Focused questions:






Focused questions:






Focused questions:





INTERSTITIAL SYNDROME (IS)

DEFINITION OF THE B-LINE

“B-lines are defined as discrete laser-like

vertical hyperechoic reverberation

artefacts that arise from the pleural line

(previously described as ‘‘comet tails’’),

extend to the bottom of the screen without

fading, and move synchronously with lung

sliding”

Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound.

Intensive Care Med. 2012;38:577-91

MULTIPLE B-LINE ARTEFACTS

MULTIPLE B-LINE ARTEFACTS

THE B-LINE ARTEFACT

Visible when the density

of the interstitial lung tissue

has been increased

(e.g. pulmonary edema, lung fibrosis)

B-LINE PATTERNS

B-lines in pathology – 2 patterns:

- Focal / localized multiple B-lines

- Diffuse multiple B-lines: The interstitial syndrome

INTERSTITIAL SYNDROME (IS)

Defined as:

- Multiple B-lines present (>2) in at

least 2 of the scanned anterior and

lateral zones on each side

- Posterior zones not included in

definition


FOCAL B-LINES

INTERSTITIAL SYNDROME



Causes in adults:

- Any disease causing diffuse

interstitial edema in the lungs


Causes in adults:

- Cardiogenic pulmonary oedema

- Non-cardiogenic pulmonary oedema


- Viral pneumonia

- Bacterial pneumonia

- ARDS

- Acute Chest Syndrome

- Drowning / near-drowning

- Lung contusion

- ……


Causes in adults:




- Viral pneumonia


- ARDS



- Lung contusion

Not seen in:

- COPD Exacerbation

- Asthma Exacerbation

Pivetta E et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the Emergency Department - A SIMEU multicenter study. Chest 2015 Jul;148(1):202-10


Causes in adults:




- Viral pneumonia


- ARDS



- Lung contusion

IS IN PATIENTS ADMITTED TO AN ED

Causes in adults:




- Viral pneumonia


- ARDS



- Lung contusion


IS IN PATIENTS ADMITTED TO AN ICU

Causes in adults:




- Viral pneumonia


- ARDS



- Lung contusion

Lichtenstein D et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25.

IS IN THE ICU WARD

Causes in adults:




- Viral pneumonia


- ARDS



- Lung contusion

IS IN THE OUH OUTPATIENT CLINIC

Causes in adults:




- Viral pneumonia


- ARDS



- Lung contusion

CARDIOGENIC PULMONARY EDEMA IN THE ED

Clinical examination

- Sens.: 85.3% (81.8-88.4%)

- Spec.: 90.0% (87.2-92.4%)

NT-pro-BNP

- Sens.: 85.0% (80.3-89.0%)

- Spec.: 61.7% (54.6-68.3%)

CXR

-Sens.: 69.5% (65.1-73.7%)

-Spec.: 82.1% (78.6-85.2%)

FLUS

-Sens.: 97.0% (95.0-98.3%)

-Spec.: 97.4% (95.7-98.6%)


CASE

68 year old female with severe COPD. Admitted with progressive dyspnoea and coughing. Symptoms had lasted 14 days. Possible fever.

Primary assessment: Auscultation: Prolonged expiration, wheezing. No murmurs. No edema or tenderness of the legs.

CASE – FLUS patterns

Pattern 1 Pattern 2

FLUS: IS PRESENT? YES/NO

Pattern 1 Pattern 2

FLUS: IS PRESENT? YES/NO

Normal pattern IS pattern

Cardiogenic pulm. edema:

Excluded – COPD exa?

Cardiogenic pulm. edema:

Suspected


How to differentiate between:




- Viral pneumonia


- ARDS



- Lung contusion

DIFFERENTIATION BETWEEN IS CAUSES

Zone pattern

Appearance of visceral pleura

Lung sliding

Pleural effusion

Consolidation

Lung pulse

Reassessment

Copetti R et al. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound. 2008 Apr 29;6:16.


Zone pattern:

- Gravidity dependent

- Spared areas


Zone pattern:

- Gravidity dependent

- Spared areas


Appearance of visceral pleura:

- Normal

- Abnormal


Appearance of visceral pleura:

- Normal

- Abnormal


Reassessment:

- Highly dynamic

- No change

INTERSTITIAL LUNG DISEASES

ILD with ground glass opacity: B-lines in affected areas

ILD with honeycombing: Abnormal visceral pleura, +/- B-lines

Rare cystic lung diseases: Normal findings

Reissig A et al. Transthoracic Sonography of Diffuse Parenchymal Lung Disease. J Ultrasound Med. 2003;22:173-180 Sperandeo M et al. Transthoracic Ultrasound in the Evaluation of Pulmonary Fibrosis. Ultrasound Med Biol. 2009 May;35(5):723-9. Davidsen JR et al. Lung Ultrasound has Limited Value in Rare Cystic Lung Diseases. ATS 2016 Meeting abstract, C104

LUNG PARENCHYMAL PATHOLOGY


FLUS VS. DIAGNOSTIC LUS

FLUS VS. DIAGNOSTIC LUS


LUS sonomorphology:

- Liver/organlike structure

- Hyperechoic

- Hypoechoic

LUNG CONSOLIDATION: CXR VS. LUS

Chest X-ray:

Sensi.: 64.3% (95%CI: 51.9-75.4)

Speci.: 90.0% (95%CI: 83.2-94.7)

Lung ultrasound:

Sensi.: 81.4% (95%CI: 70.7-89.7)

Speci.: 94.2% (95%CI: 88.4-97.6)

Nazerian P et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med. 2015;33(6)620-5


Characteristic US patterns:

Consolidations: Pneumonia, PE, contusion

Atelectasis: Compression, obstruction

Tumor: Malignant, benign

Uncharacteristic: -

Reissig A et al. Transthoracic Ultrasound of Lung and Pleura in the Diagnosis of Pulmomary Embolism: A Novel Non-Invasive Bedside Approach. Respiration 2003;70:441-452

CASE

PNEUMONIA

PNEUMONIA

PNEUMONIA

PNEUMONIA DIAGNOSTIC ACCURACY

Lung ultrasound

- Sens.: 94% (92-96%)

- Spec.: 96% (94-97%)

- PLR: 16.8 (7.7-37.0)

- NLR: 0.07 (0.05-0.10)

Chavez et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 2014:23;15:50

CASE

COMPRESSION ATELECTASIS

ATELECTASIS US PATTERN

Courtesy of Dr. Olav Petersen

OBSTRUCTION ATELECTASIS

OBSTRUCTION ATELECTASIS

CASE

FLUS FINDINGS IN ZONE L2

PULMONARY EMBOLISM

PULMONARY EMBOLISM

Joyner CR Jr et al. Reflected ultrasound in the detection of pulmonary embolism. Trans Assoc Am Physicians. 1966;79:262-77.

PE DIAGNOSTIC CRITERIA

PE confirmed

Two or more typical lesions

Sensi.: 44.4%

Speci.: 98.7%

PPV: 97.4%

NPV: 62.1%

PE probable

One typical lesion and low grade

pleural effusion

Sensi.: 71.0%

Speci.: 94.9%

PPV: 93.8%

NPV: 75.1%

Mathis G et al. Thoracic Ultrasound for Diagnosing Pulmonary Embolism: A Prospective Multicenter Study of 352 Patients. Chest 2005;128:1531-1538

PE DIAGNOSTIC ACCURACY

LUS for diagnosis of PE

Metaanalysis:

- Sens.: 80% (75-83%)

- Spec.: 93% (89-96%)

Niemann T et al. Transthoracic sonography for the detection of pulmonary embolism–a meta-analysis. Ultraschall Med 2009 30:150–156

CASE

LUNG CANCER

LARGE LUNG CANCER IN UPPER LOBE

Laursen CB et al. Contrast Enhanced Ultrasound Guided Transthoracic Lung Biopsy. Am J Respir Crit Care Med. 2016 Jun 28. [Epub ahead of print]

SARCOMA

DIFFERENTIATION OF PARENCHYMAL PATHOLOGY

Reissig A et al. Transthoracic Ultrasound of Lung and Pleura in the Diagnosis of Pulmomary Embolism: A Novel Non-Invasive Bedside Approach. Respiration 2003;70:441-452

SPOT THE CANCER(S)


Pitfalls:

- Uncharacteristic pattern

- FLUS missing lesions

- LUS cannot “rule-out”

parenchymal pathology

- Malignancy

Help:

- Other forms of imaging

- Advanced lung ultrasound

- US-guided tissue sampling

CLINICAL IMPACT

PATIENTS WITH SUSPECTED PE

Need of additional of imaging?

- CT

- V/Q scintigrafi

- LUS

PATIENTS WITH RESPIRATORY SYMPTOMS

Ultrasound

Need of additional of imaging?

- CT

- V/Q scintigrafi

- Advanced LUS

WHOLE-BODY US APPROACH

Focused US assessment of:

- Lungs (FLUS)(PTX, IS, effusion, parenchymal path.)

- Heart (FCUS / FATE)(PE, HV strain, LV failure)

- Deep veins (LCU)(DVT)

Laursen CB et al. Focused sonography of the heart, lungs, and deep veins identifies missed life-threatening conditions in admitted patients with acute respiratory symptoms. Chest. 2013 Dec;144(6):1868-75

CLINICAL IMPACT IN ED PATIENTS

Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014;2(8):638-46

IMPACT IN PATIENTS WITH SUSPECTED PE

Clinical assessment without US:

- Sensitivity 80.0%, specificity 96.7%

Whole-body US (deep veins, heart & lungs)

- Sensitivity 90.0%, specificity 86.2%

Clinical assessment with integrated US:

- Sensitivity 100%, specificity 95.3%

Nazerian et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014 May;145(5):950-7 Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014;2(8):638-46

CLINICAL IMPACT IN CHILDREN

Substitution of CXR with LUS in children suspected of having

pneumonia:

-No cases of missed pneumonia

-No difference in adverse events

-38.8% reduction (95% CI, 30.0%-48.9%) in CXR use

Jones BP et al. Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial. Chest. 2016 Jul;150(1):131-8.

Important “Side-effects”

Howard ZD et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014;46(1):46-53.

Hope to see you in Odense for the ERS course in Thoracic Ultrasound!

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Thank you for viewing this presentation. We would like to remind … · 2016-08-07 · Thank you for viewing this presentation. We would like to remind you that this material is the