Point of Care Ultrasound UCSF Continuing Medical Education October - - PowerPoint PPT Presentation

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Point of Care Ultrasound UCSF Continuing Medical Education October - - PowerPoint PPT Presentation

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Point of Care Ultrasound UCSF Continuing Medical Education October 21-22, 2018 Disclosure I have no relevant financial relationships with any companies related to the content of this course. Lung Ultrasound and Thoracentesis Stephanie

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October 21-22, 2018

Point of Care Ultrasound UCSF Continuing Medical Education

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Disclosure

I have no relevant financial relationships with any companies related to the content of this course.

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Lung Ultrasound and Thoracentesis

Stephanie Conner, MD UCSF Medical Center at Parnassus Heights

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Objectives

  • Basic principles of lung ultrasound
  • Key findings with lung ultrasound
  • Overview of thoracentesis
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Probe Selection

Linear

10-15 MHz 25 mm

Curvilinear Phased Array

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Patient Position

  • Chest. 2011;140(5):1332-1341. doi:10.1378/chest.11-0348
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Hospitalized Patient Technique

  • Interstitial findings
  • Anterior: A or B lines
  • Lateral Bases: normal to

have some B-lines

  • Look for effusions
  • Probe orientation
  • Vertical (longitudinal)
  • Midclavicular line

posterior axillary line

Used with permission from Arun Nagdev

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Findings on lung ultrasound

  • Normal Lung
  • Alveolar and interstitial changes (pulmonary

edema, fibrosis, etc.)

  • Consolidation
  • Pleural Effusion
  • Pneumothorax
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Findings, continued

A-Lines B-lines Effusions Consolidations Pneumothorax

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A Lines and B Lines

  • Curvilinear or Phased Array Probe
  • Increase Gain
  • Depth 12-16cm
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Normal Lung

  • Normal aerated lung scatters ultrasound waves,

can’t be seen

  • A-lines are horizontal hyper echoic lines

representing artifact: reverberations between the highly reflective pleura and transducer

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A lines = non-thickened interstitial septa

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Alveolar Interstitial Changes

  • Widening of the interlobular septa allows for

propagation of ultrasound waves and the formation of b-lines.

  • Seen in pulmonary edema, PNA, ARDS, ILD
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Rib Rib Tissue Air/Water Interface “B” Lines

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Acute Interstitial Syndrome

Arise from the pleural line Well-defined Move with lung sliding 3 per rib space Reach screen edge

B lines = interstitial syndrome

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Lung US: Dynamic Monitoring

Liteplo et al. Real-time resolution

  • f sonographic B-lines in a patient

with pulmonary edema on CPAP. AJEM (2010)

  • Case: Hx CHF, ESRD,

dyspnea, orthopnea

  • Initial US: Diffuse B-lines
  • After CPAP x 3.5hrs: A-lines
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Review

A-lines vs B-lines Curvilinear or Phased Array Which Probe? Scan Where? Anterior Midclavicular What are B-lines? Interstitial Syndrome CHF PNA ARDS Fibrosis Are B-lines pathologic in lateral zones? NO! A-Lines B-Lines

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Alveolar Consolidation

  • “Hepatization of

lung”

  • 98.5% PNAs abut

pleura

  • US vs CT: 


(Lichtenstein 2007)

  • Sens: 0.91
  • Spec: 0.98
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Case: 50 y/o male with cough & fever

Liver

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Pleural Effusion

  • Identification of a hypoechoic or echo-free

space surrounded by typical anatomic boundaries:

  • diaphragm (and abdominal organs)
  • chest wall
  • Ribs
  • visceral pleura
  • normal/consolidated/atelectatic lung
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Positioning

Start South then Go North

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RUQ/Perihepatic view: Normal

Morison’s Pouch Costophrenic Recess Diaphragm

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Pleural Effusion

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Pleural Effusion

  • US more sensitive than XR
  • r exam:
  • Exam > 300mL
  • CXR >200mL
  • US > 20 mL

  • Scan dependent zones

  • Fluid is hypoechoic (black)
  • Large effusions generally

more symptomatic

Effusion Lung Liver

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Simple vs complex effusions

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Consolidation and Effusion Summary

  • More sensitive than physical exam or X-ray
  • Faster to acquire than CXR
  • Less radiation
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Pneumothorax

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Probe Selection

Linear

10-15 MHz 25 mm

Curvilinear

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Rib Alveoli Rib Shadow

Normal Lung: Sliding Visceral Pleura

Slide used with permission of Arun Nagdev

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Is Pleural Sliding Present?

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Is Pleural Sliding Present?

Pneumothorax

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Soft Tissue Normal Lung

Beach Ocean

Normal M-mode of Lung

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Soft Tissue

Abnormal Lung

Ocean / Barcode

Abnormal Lung M-mode: PNEUMOTHORAX

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OVERVIEW

Confirm: M-Mode

Pneumothorax No Pneumothorax Ocean + Beach Ocean

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The Lung Point

  • Sensitivity: 0.66
  • Specificity: 1.00

(Lichtenstein 233 ICU pts vs CT)

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US: Pneumothorax

  • Outperforms CXR in supine patients
  • Much higher sensitivity, similar specificity
  • Lower specificity critically ill ICU patients
  • False positives with pulmonary scarring,

TB, ARDS (specificity 60-91%)

  • Lung Point: 100% specificity
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Lung US Review

  • A-Lines: R/O CHF. Likely COPD/PE/Normal
  • B-Lines: Diffuse: CHF, ARDS, PNAs.
  • B-Lines: Focal: PNA
  • Hepatization likely consolidation
  • Effusions: scan posterior and lateral bases. Find

the diaphragm!

  • Pneumothorax: absence of lung sliding, lung

point highly specific

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Thoracentesis

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US Guidance in Thoracentesis

  • Find fluid on ultrasound
  • Establish landmarks for safe needle insertion

with adequate depth

  • Usually not done under direct US guidance
  • Check for lung sliding after the procedure
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Safe for thoracentesis?

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Safe for thoracentesis?

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