Marek Nalos: Lung: The Final Frontier

Lung Ultrasound

Marek Nalos

Department of Intensive care

Nepean Hospital

Penrith, NSW

AUSTRALIA

Chest space - the final frontier

• These are the voyages of the starship Ultrasound

• Its continuing mission:

– to explore strange new pictures

– to seek out life

– and new meanings

• To boldly go where only horse has gone before

Normal lung - no lung imagejust artifacts

• Soft tissue/air interface 99% of ultrasound waves is reflected

• Lung is full of air if normal so ultrasound cannot be used to image healthy lung, only the pleura

• But...

– with disease process lung loosing aeration

– less US beam reflection and more penetration

Normal lung = airReverberation artifact

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A - line

pleural line

A - line

rib shadow rib shadow

Asthma lung - anterior

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A - line

Pleura

Normal - A profile - lung base



Diaphragm

LiverLung

Spine

Curtain sign

Lung consolidation

Contiguous B-lines

B-lines, (lung rockets)

Daniel Lichtenstein et al. Anesthesiology 2004

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rib shadow rib shadow

Wet lung = air/fluid interfaceReverberation artifact

B - line

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Non cardiogenic pulmonary oedema



cardiogenic pulmonary oedemaanterior





right left



pulmonary oedemalung base

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spleen

left kidney

lung

lungliver

right left



Spleen

Consolidated lung

Vertebral column

Diaphraghm

Consolidation - solid tissue



Right lung baserib artifact

Consolidation - solid tissue



Left lung base

No pleural sliding

Lung consolidation - air bronchgrams



• sensitivity - 93.4% (95% CI, 89.2%-96.3%)

• specificity - 97.7% (95% CI, 93.4%-99.6%)

• Positive LR - 40.5 (95% CI, 13.2-123.9)

• Negative LR - 0.07 (95% CI, 0.04-0.11)

• A combination of auscultation and LUS increased the positive LR to 42.9 (95% CI, 10.8-170.0) and decreased the negative LR to 0.04 (95% CI, 0.02-0.09)

Lung Ultrasound in the Diagnosis and Follow-up of Community-Acquired Pneumonia: A Prospective, Multicenter, Diagnostic Accuracy Study

Angelika Reissig, MD; Roberto Copetti, MD; Gebhard Mathis, MD; Christine Mempel; Andreas Schuler, MD; Peter Zechner, MD; Stefano Aliberti, MD; Rotraud Neumann, MD; Claus Kroegel, MD, PhD; Heike Hoyer, MSc

Differentiating viral and bacterial pneumonia in

children

Fluid bronchograms -Tracheo-esophageal fistula



Diseased lung



pleural lineB-line

pleural effusion

consolidation

Pneumothorax• Absence of lung sliding • Absence of any B-line • Potential presence of a lung point

PneumothoraxLung point



Curtesy of Dr. Martin Balik

Ruling out pneumothorax after subclavian line insertion





Presence of pleural sliding or B-lines rules out pneumothorax with 100% accuracy

pleural sliding

+ _

Pleural effusion

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Differentiate basal lung field opacities on

portable CXR





Parapneumonic effusion



Empyema



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Pneumonia - legionella



detail

51 post Tetralogy of Fallot repair acute on chronic respiratory failure




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74 yrs old lady - Nissen fundoplication postoperative acute respiratory failure

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Perforated oesophagus





Mediastinitis





21 yrs old boy - dyspnoea, can’t raise left arm







37





Case

• 20 y old driver, multitrauma–mild head injury–rib fractures, lung contusions,

haemopneumothorax,–liver laceration and ankle fractures

• One week in ICU, still intubated, febrile, sudden desaturation, tachycardia, hypotension, tachypnoea


• Echocardiography demonstrates normal LV and RV function and size

In the meantime, CXR arrived...?


Blunt chest trauma - sudden hypoxia.Left lower lung collapse

Bronchoscopy - removal of thick sputum plug from left lower lobe bronchus

Failure to wean







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H1N1 - ARDS - TOE



You can’t hide from the frontier

The beautiful frontier is close and all you need is to look

Lung ultrasound is feasible

• Bedside, point of care test

• Quick, easy to repeat

• No radiation exposure

• Dynamic nature– visualization of pleural/lung

interface during inspiration and expiration

Lung ultrasound in ICU

• Often more useful then CXR

• Steep learning curve

• Provides quick answers to simple clinical questions arising from history and clinical examination

• - in parallel

Iris Ting Daniel Lichtenstein

Thank you

Education

Marek Nalos: Lung: The Final Frontier