Objectives Heart Failure Ultrasound in the COPD Dyspneic Patient - - PDF document

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Objectives Heart Failure Ultrasound in the COPD Dyspneic Patient - - PDF document

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2/1/2013 Objectives Heart Failure Ultrasound in the COPD Dyspneic Patient Pericardial Effusion/Tamponade Pulmonary Embolism R. Starr Knight, M.D. Pneumonia High Risk Emergency Medicine February 14, 2013 Pneumothorax

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Ultrasound in the Dyspneic Patient

  • R. Starr Knight, M.D.

High Risk Emergency Medicine February 14, 2013

Objectives

  • Heart Failure
  • COPD
  • Pericardial Effusion/Tamponade
  • Pulmonary Embolism
  • Pneumonia
  • Pneumothorax
  • Pleural Effusion

Ultrasound Protocols

  • RUSH
  • RADiUS
  • Triple Scan
  • ACES
  • FALLS

Case #1: SOB

  • 58 ♂ with HTN, CHF, COPD now with 3

days of worsening SOB and DOE

VS: 37.0 200/110 100 28 85%RA

Neck: ?JVD → CV: Tachy, Reg → Pulm: Wheezes & Bibasilar Rales →

Gen: Dyspneic, Obese

Extr: +1 Pedal edema →

Goals of the Exam

Assess for Pulmonary Edema Evaluate Pump Function Interrogate IVC

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Protocol

  • 1. Cardiac Ultrasound
  • 2. Lung Ultrasound
  • 3. IVC Ultrasound

Parasternal Long

DTA

Parasternal Long Parasternal Long Parasternal Short

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Parasternal Short Subxiphoid / Subcostal Subxiphoid

Protocol

  • 1. Cardiac Ultrasound
  • 2. Lung Ultrasound
  • 3. IVC Ultrasound
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Rib Rib Linear Probe Rib 1 2 3 4 5 6 7 8 9 10 11

Normal Lung: Comet Tails

Pulmonary Edema

B Lines

  • Arise from the pleural line
  • Well-defined
  • Move with lung sliding
  • Reach the edges of the

screen

Acute pulmonary edema

  • Arise from the pleural line
  • Well-defined
  • Move with lung sliding
  • Reach the edges of the screen

B lines B lines

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B lines B lines

  • Highly sensitive
  • Cardiogenic pulmonary

edema

  • ARDS
  • Pulmonary contusion
  • Pulmonary fibrosis
  • Interstitial pneumonia

Rib Alveoli Rib Shadow

Normal Lung: Sliding Visceral Pleura

Rib Rib

Parietal Pleura Visceral Pleura Comet Tails (Artifact)

Location Location Location

B lines = increased fluid in the interstitium

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Hyperinflated Lungs

HF HF Non-HF Non-HF

Protocol

  • 1. Cardiac Ultrasound
  • 2. Lung Ultrasound
  • 3. IVC Ultrasound

Liver

IVC

RA

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COPD

  • Presence of A line
  • Lack of B lines
  • Clinical signs of COPD

COPD COPD

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Pericardial Effusion Pericardial Effusion Cardiac Tamponade

  • Right Heart Collapse during diastole
  • RV or RA
  • Can be subtle
  • Diastole
  • Correlate with Mitral Valve Opening
  • IVC Plethora

Cardiac Tamponade Cardiac Tamponade

Pulmonary Embolism

  • RV Dilitation (RV:LV > 1:1)
  • RV Systolic Dysfunction
  • Free-Floating Thrombus
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Pulmonary Embolism

  • IVC Dilatation
  • Presence of DVT in LE
  • McConnell’s Sign

Pneumonia

  • Air Bronchograms
  • static and dynamic
  • B Lines adjacent to consolidation
  • Associated pleural effusions

Pneumonia Pneumonia Pneumothorax

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Air goes up Air goes up

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Rib AIR Rib

Abnormal Lung: Pneumothorax

Parietal Pleura Visceral Pleura

Parietal Pleura

Air (Scatter) Normal Pneumothorax

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References

  • Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of

alveolar-interstitial syndrome. Am J Emerg Med. Oct 2006;24(6):689-696.

  • Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of

pneumonia in the ED. Am J Emerg Med. May 2009;27(4):379-384.

  • Cortellaro F, Colombo S, Coen D, et al. Lung ultrasound is an accurate diagnostic tool for the

diagnosis of pneumonia in the emergency department. Emerg Med J. Oct 28 2010.

  • Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact: an ultrasound sign ruling
  • ut pneumothorax. Intensive Care Med. Apr 1999;25(4):383-388.
  • Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of

alveolar-interstitial syndrome. Am J Respir Crit Care Med. Nov 1997;156(5):1640-1646.

  • Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically
  • ill. Lung sliding. Chest. Nov 1995;108(5):1345-1348.
  • Alrajhi K, Woo M, Vaillancourt C. Test Characteristics of Ultrasonography for the Detection of
  • Pneumothorax. CHEST.141(3) MARCH 2012
  • Wu Ding W, Yuehong S ,Yang J. Diagnosis of Pneumothorax by Radiography and

Ultrasonography.CHEST.140 (4) OCTOBER, 2011

Thank You

Apical 4 chamber 4 Chamber

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4 Chamber