A Practical Guide to Transthoracic US

8/10/2019 A Practical Guide to Transthoracic US

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Aims

To understand the basic principles and practical application of

transthoracic ultrasound

To be familiar with the sonographic appearance of the normal thorax

To identify basic thoracic pathology

To utilise ultrasound as guidance for transthoracic interventions


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A practical guide to transthoracicultrasound

SummaryTransthoracic ultrasonography is a well-established, yet underutilised imagingmodality in respiratory medicine. It allows for real-time and mobile assessmentof thoracic disorders and can potentially augment the physical examination ofthe chest. Moreover, ultrasonography-assisted interventions can be performedby a single clinician without sedation and with minimal monitoring, even outsideof the operating theatre. Other advantages of chest ultrasonography include thelack of radiation and the short examination time. Many indications for the use ofultrasonography beyond the visualisation of the pleura and related conditions(including effusions, thickening and pneumothorax) have been validated in the lastfew decades. These include the assessment of diaphragmatic dysfunction, pul-monary consolidation, interstitial syndromes, pulmonary embolism, and pulmonaryand mediastinal tumours, provided they abut the pleura. Transthoracicultrasonography is an ideal guide for thoracocentesis. Ultrasonography-assistedfine-needle aspiration and/or cutting-needle biopsy of extrathoracic lymph nodes,and lesions arising from the chest wall, pleura, peripheral lung and mediastinum aresafe and have a high yield in the of hands of chest physicians. Ultrasonography mayalso guide aspiration and biopsy of diffuse pulmonary infiltrates, consolidations andlung abscesses, provided the chest wall is abutted. This review will focus on thebasic indications and applications for transthoracic ultrasonography.

Transthoracic ultrasonography can be performedwith a basic, two-dimensional black-and-whiteultrasound system; more sophisticated mod-alities, like M-mode or colour-flow Doppler, arevery rarely indicated. A low-frequency probe (25 MHz) with a curvilinear shape is suitable forscreening of superficial and deeper structures,where as a high-frequency probe (510 MHz)with a linear shape is used for refined assess-ment. Higher frequency allows for superiorresolution closer to the probe, but at the cost of

reduced penetration [13]. A clinician should befamiliar with the basic controls, including thefreeze, depth and gain functions [13].The freeze function creates still images, onwhich measurements can be performed usingthe track ball. The depth function is a digitalzoom that defines what portion of the scannedimage is displayed on the monitor at a certainmagnification. The scale is displayed on avertical axis. High-frequency scanning is per-formed at a maximum depth of around 34 cm.

Statement of InterestNone declared.

HERMES syllabus link:Module D.3.5

Breathe | December 2012 | Volume 9 | No 2 DOI: 10.1183/20734735.024112

Florian von Groote-

Bidlingmaier,

Coenraad F.N.

Koegelenberg

Stellenbosch Universityand Tygerberg AcademicHospital, Cape Town,South Africa

F. von Groote-Bidlingmaier:Stellenbosch University, POBox 19063, Tygerberg, CapeTown, 7505, South Africa

[email protected]


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The depth should preferably be adjusted toallow the area of interest to fill the digital screen.The gain is, in essence, a measure for theamplification of the echoes and determines thebrightness of the image, and should be adjustedto maximise the contrast between tissues.

Optimal patient position for scanning iscrucial to obtain the best possible images [1, 3].Chest physicians often use available imagery(including chest radiographs or computedtomography scans) to identify the area ofinterest and determine the position of thepatient [1, 2]. The posterior chest is ideallyscanned with the patient sitting using a bedsidetable as an armrest, whereas the lateral andanterior chest wall should be examined with thepatient in either the lateral decubitus or supineposition.

The pleura, peripheral lung tumours andconsolidated lung can be visualised along the

intercostal spaces [1]. Raising the arm abovethe patients head increases the intercostalspace distance and aids in scanning in erector recumbent positions. Folding the patientsarms across their chest displaces the scapu-lae when scanning the upper posterior thorax.Visualisation of superior sulcus pathologycan be achieved apically with the patient inthe supine or sitting position.

Liberal application of gel is the final stepprior to scanning [1]. It is advisable to holdthe probe like a pen with the outer part of the

hand in contact with the skin and to reduceambient lighting. The sonographer shouldmaintain visual contact with the screen whilethe dominant hand moves the probe acrossthe area of interest and the other hand is usedto optimise the digital image by adjusting thedepth and gain. Findings can be comparedwith the contralateral side, which can be usedas a control.

The normal thoraxThe skin, muscles and facia planes are visible

with a low-frequency probe as a series ofechogenic layers [13]. Ribs appear as convexstructures on transverse (vertical) scanning,with posterior acoustic shadowing. Whenviewed longitudinally, the anterior cortexappears as an uninterrupted echogenic line.The visceral and parietal pleura usually appearas a single highly echogenic line no morethan 2 mm wide representing the pleura andpleuropulmonary interface [13]. On a long-itudinal view, the pleural line will appear

approximately 5 mm deep to the rib cortex [4].The visceral and parietal pleura can be seen astwo distinct echogenic lines on high-resolutionscanning (fig. 1), with the latter seeminglythinner in appearance [1, 2]. The two layersglide over each other during inspiration andexpiration, which gives rise to the lung slidingsign on real-time ultrasonography, which isbest appreciated on longitudinal (vertical)scanning [15]. Its presence has a high negativepredictive value for the diagnosis of a pneu-mothorax [47].

Aerated lung parenchyma cannot be visua-lised on transthoracic ultrasonography [13, 8].The large change in acoustic impedance atthe pleuralung interface, however, results inhorizontal artefacts, so called reverberationartefacts or A-lines, that are seen as a series ofechogenic parallel lines equidistant from oneanother below the pleura [13, 7]. A few short,

vertical comet-tail artefacts can be seen at thelung bases in normal individuals, and in allprobability represent fluid-filled subpleural inter-lobular septa. B-lines are longer, pathologicalvertical artefacts that obliterate A-lines (seelater) [5, 9].

Figure 1

The high-frequency ultrasound appearance of anormal chest. The chest wall (CW) consists ofmultiple layers of echogenicity representing musclesand fascia. The more prominent visceral (Pv) andparietal pleura (Pp) are seen as echogenic bright linesthat slide during respiration. A reverberation artefact,also known as an A-line (A), is present within the lung(L), as well as a single comet tail artefact (C).

Transthoracic ultrasound

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The diaphragm is best visualised throughthe liver or the spleen [13, 5]. It appears as anechogenic line, approximately 12 mm thick,which contracts with inspiration.

Extrathoracic lymph nodesUltrasonography provides visual access to

cervical, supraclavicular and axillary lymphnodes, and it may aid in distinguishing malig-nant from reactive lymph nodes. Inflammatorylymph nodes have oval or triangular shapes andthe fatty hilum appears echogenic on ultrasono-graphy, whereas malignantnodes areoften bulkyand show loss of the fatty hilum leading to ahypoechoic appearance [13]. Irregular borderscan be a sign of extracapsular spread. Ultrasono-graphy has the added advantage that it canvisualise supraclavicular or cervical lymph nodesin patients with superior vena cava obstruction,

particularly when vascular congestion and swel-ling complicate physical palpation.

Supraclavicular lymph nodes are accessibleto ultrasonography-guided fine-needle aspira-tion (FNA), which has the advantage ofproviding a cytological diagnosis and patholo-gical staging (pN3) in one procedure. FNA ofextrathoracic lymph nodes can even be per-formed outside of a dedicated operating theatreat the patients bedside [10].

Chest wall pathologyHigh-frequency ultrasound can detect soft-tissue masses arising from the chest wall,including lipomas, abscesses and many other(mostly benign) lesions. Masses generally havevariable echogenicity and ultrasonographicfindings are too nonspecific to differentiatebetween the various aetiologies [13]. Ultrasono-graphy-assisted transthoracic FNA of thesemasses can readily be performed, as no aeratedlung needs to be transversed during aspiration.Ultrasonography-assisted transthoracic FNA isgenerally performed under local anaesthesia,

ideally with a 22-gauge injection-type or shortspinal needle connected to a 10-mL syringe. Theneedle should contain a removable inner styletto reduce contamination with chest wall tissueand blood [1, 3].

Rib fractures can also be visualised withultrasound, which might even be moresensitive than radiography [11]. Bony metas-tases to the ribs can be detected by meansof sonography and appear as hypoechoicmasses that replace the normal echogenicity

of the rib leading to a disruption of thecortical line [12]. Metastases are amenable toultrasonography-assisted FNA.

Both chest wall masses and thoracic bonymetastases can be sampled by means ofcutting-needle biopsy (CNB). These devicesare more invasive and carry a higher risk ofvisceral or vascular trauma [3, 13]. Potentialvisceral trauma can be caused by inadver-tently passing the device through the ribs, asosteolytic rib metastases may provide lessresistance than expected.

Pleural pathologyPleural effusions

Transthoracic ultrasonography is ideal for thedetection and quantification of pleural effu-sions, and is more sensitive than decubitusexpiratory films in identifying minimal or

loculated effusions [14]. A pleural effusion isusually seen as a homogeneous, anechoicspace between the parietal and visceral pleura(fig. 2). The space changes shape duringrespiration, although adhesions between thetwo pleural surfaces may result in the absenceof lung motion above the effusion [13]. Atongue-like atelectatic lung is often seen insidea larger effusion.

Four ultrasonographic appearances ofpleural effusions are recognised based onthe internal echogenicity [13]:

1) anechoic2) complex non-septated3) complex septated4) homogenously echogenic

Transudates typically appear as anechoicand non-septated, free-flowing effusions,whereas complex, septate or echogenic effu-sions are mostly exudates [15, 16]. Malignanteffusions are often anechoic, and pleuralthickening .10 mm, pleural and diaphrag-matic nodularity, and diaphragmatic thickening

.7 mm are highly suggestive of malignantdisease [17]. Strands of echogenic material andsepta that show more or less mobility withrespiration are indicative of inflammatory effu-sions [1, 2]. The identification of septa (fig. 3)has clinical implications. Several studies haveshown that patients with septated effusionsneeded longer chest tube drainage, longerhospital care and were more likely to requirefibrinolytic therapy or surgery compared tothose with non-septated effusions [18, 19].




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One practical way to classify the volume ofan effusion is simply to classify effusions as:

1) minimal, if the echo-free space is confinedto the costophrenic angle

2) small, if the space is greater than thecostophrenic angle but still within the

range of the area covered with a 3.5-MHzcurvilinear probe

3) moderate, if the space is greater than a one-probe range but within a two-probe range

4) large, if the space is greater than a two-probe range [14]

Ultrasonographic guidance improves thesuccess rate of pleural aspiration and mini-mises the risk of visceral puncture [20, 21].Moreover, the risk of pneumothorax following

aspirations is reduced, irrespective of the sizeof the effusion [21]. Depending on operatorexperience, ultrasonography may also guidefurther decisions regarding the need fortube drainage, intrapleural fibrinolytic ther-apy, pleuroscopy or surgical intervention [22].

Ultrasonography is also ideal for identify-ing the optimal site for safe and effectiveintercostal drainage [21, 23]. Most operatorsutilise the freehand technique: a safe inser-tion site is identified and marked, then a drainis inserted. The intended site should havesufficient depth of pleural fluid of at least10 mm, no intervening lung and minimal riskof visceral trauma [23]. Ultrasonographicassistance does not always prevent lacerationof the intercostal neurovascular bundle, asthese structures may have a torturous coursethat may run medially to the angle of the rib[23, 24].

As an alternative, real-time ultrasonographicguidance may be employed. Ultrasonography isused for direct fluid aspiration, whereafter aguide wire is inserted, which is used to guidedilatation of a tract and deployment of a small-

bore catheter (814 F). These tubes are bettertolerated than large bore (2024 F) intercostaldrains [25]. Some prospective studies havefound that 812 F pigtail catheters or 1014 Fcatheters inserted under ultrasonographic gui-dance are at least as effective as larger catheters[2628].

Transthoracic ultrasonography is an extre-mely helpful guide for biopsies of the pleura[13, 12]. Ultrasonography can identify focalpleural abnormalities. Moreover, measuring the

Figure 3

A complex septate effusion (viewed with low-frequency ultrasonography) with multiple septa (S)and loculations (L).

Figure 2A pleural effusion (PE) gives r ise to an anechoic spacebetween the visceral (Pv) and parietal pleura (Pp).Compressive atelectasis of the lung (L) is seen on thishigh-frequency ultrasonogram. D: diaphragm.




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size of an associated effusion decreases the riskof visceral lacerations, which is particularlyimportant in cases with minimal pleural fluid [1,3]. Unaided closed pleural biopsy has a verymodest diagnostic yield of less than 60% forpleural malignancy [29]. The diagnostic yield ofunaided closed pleural biopsy for pleuraltuberculosis is generally much higher, due tothe more homogenous distribution of tubercu-lous granulomata, and may even be as high as87% if at least six specimens are harvested[3032]. Recent studies have suggested thatimage-guidance may significantly increase theyield for malignancy while decreasing the riskof complications [12, 3336]. CHANG et al. [35]found the diagnostic yield of ultrasonography-guided Tru-Cut (UK Medical Ltd, Sheffield, UK)pleural biopsy to be 77% for malignancies andDIACONet al. [36] showed that this figure may beas high as 100% for malignant mesothelioma

extending at least 20 mm in any accessibledimension on ultrasonography. In a recent study,we found that the yield of an ultrasonography-assisted Abrams needle may be as high as 83%for malignant effusions [33].

Pleural thickening

Pleural thickening is often defined as a focallesion that is greater than 3 mm in width, arisingfrom the visceral or parietal pleura with orwithout an irregular margin [13]. Distinguishingpleural thickening from small effusions can bechallenging, as both may appear hypoechoic onultrasonography [37]. Lack of movement relativeto the chest wall with respiration and theabsence of a fluid colour sign seen with colourDoppler scanning are ultrasonographic evi-dence in favour of pleural thickening [13].

Pneumothorax

The diagnosis of a pneumothorax by means ofultrasonography requires more experience thanthe detection of pleural fluid [13]. Nevertheless,

a recent meta-analysis concluded that bedsideultrasonography performed by clinicians had ahigher sensitivity and similar specificity for thediagnosis of a pneumothorax when comparedto chest radiography [38]. The absence ofnormal lung sliding and lung pulse, exaggeratedhorizontal reverberation artefacts (A-lines) andthe absence of B-lines are reliable signs of apneumothorax [1, 2, 5, 11, 38]. The lung pulseis caused by cardiac oscillation and refers to thesubtle movements of the visceral pleura in

relation to the parietal pleura [5]. In certainconcomitant diseases, including diaphragmaticparalysis, prior pleurodesis or pleural adhesionsand emphysema, the sensitivity of ultrasono-graphy for the diagnosis of pneumothorax maybe lower [1, 2, 3840]. Ultrasonography may beused routinely to screen for post-proceduralpneumothorax after transthoracic interventionsas well as after transbronchial biopsy, and mayobviate the need for routine post-proceduralchest radiographs [41].

Pulmonary pathologyPractically any pathological process within thelung parenchyma can become detectable withultrasonography, provided aerated lung tis-sue is replaced by consolidated or solid lungtissue and pleural contact is present. Often,the acoustic window is too narrow to allow

assessment of the full dimension of thepathological process, but depth can almostalways be determined accurately.

Consolidation is a nonspecific termreferring to a subpleural, echo-poor region orone with tissue-like echotexture [5], whichcan be present in a range of diseases, includ-ing pneumonia, pulmonary embolism, lungtumours, atelectasis and pulmonary contusion.Additional signs may aid in distinguishing thevarious causes [5]. Pulmonary consolidationcan easily be differentiated from an interstitialsyndrome. Long, laser-like vertical hyperechoicartefacts that obliterate A-lines are called B-lines, and are pathognomonic of an interstitialsyndrome. Additional signs are needed todistinguishing the various causes, which mayinclude pulmonary oedema and pulmonaryfibrosis [5].

Early pneumonic consolidation appearsdiffusely echogenic and very similar inappearance to the texture of liver tissue.Both air and fluid bronchograms may be seenwithin the consolidated lung (fig. 4). Airbronchograms appear as dynamic echogenic

branches and foci that fluctuate with therespiratory cycle [13, 5]. Fluid bronchogramsare seen as anechoic tubular structures andrepresent fluid-filled airways [2, 10]. Further-more, ultrasonography is ideally suited toscreen for parapneumonic effusions and todifferentiate dense consolidation from pleuraleffusions in critically ill patients (fig. 5).Ultrasonography-assisted transthoracic FNAof pneumonic consolidation is not oftenperformed, yet it has a diagnostic yield greater




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than 90% with respect to the confirmation ofthe offending pathogen and has been shown tobe safe [3]. Ultrasonography should also beused routinely to exclude a pneumothoraxfollowing transthoracic FNA, particularly inmechanically ventilated patients.

Lung abscesses abutting the chest wallpleura appear as hypoechoic lesions with awell-defined or irregular wall [13]. The centreof the abscess is most often anechoic, butinternal echoes may be seen. It is worthwhile

scanning the patient in different positions if anairfluid level is suspected, as the appearance

may alter accordingly. The vast majority oflung abscesses are visible on ultrasonographyand transthoracic FNA is more than 90% likelyto be diagnostic for a specific pathogen.

A hypoechoic appearance with posterioracoustic enhancement and irregular borders istypical for lung tumours (fig. 6). The visceralpleural line is interrupted once the visceralpleura is infiltrated, and loss of movementwith respiration on low- or high-frequencyscanning is indicative of extension beyond theparietal pleura. In fact, high-resolution ultra-sonographic scanning is known to be superiorto routine chest computed tomography scan-ning in evaluating tumour invasion of thepleura and chest wall [42, 43], which has adirect impact on tumour staging.

For ultrasonography-assisted biopsy of pul-monary tumours, the technique is used bymost clinicians. It can be utilised for both

ultrasonography-assisted transthoracic FNAand CNB. Following patient positioning, theintended site of needle insertion is identified byultrasonography and marked while the direc-tion, depth of interest and safety range for theprocedure are determined [1, 2]. It is essentialthat the patient must not alter their position inorder to prevent a positional shift of the area ofinterest relative to the skin mark. TransthoracicFNA can be performed with spinal needles ofvarious sizes (usually 22-gauge) and lengths (40or 90 mm) connected to a 10-mL syringe, with

Figure 4

The low-frequency ultrasonographic appearance of adensely consolidated lung (L) abutting the chest wall(CW). Note the multiple air bronchograms (echo-genic branches and foci; arrow) and as well as fluid(hypodense) bronchograms.

Figure 5

This low-frequency ultrasonogram confirmed thepresence of a parapneumonic pleural effusion (PE).Note the early fibrin strands (F) extending from thevisceral pleura of the underlying consolidated lung (L).

Figure 6

A low-frequency ultrasonographic image of a periph-eral lung tumour infiltrating the chest wall. Note thatthe acoustic window is too narrow to demonstrate thewhole circumference of the lesion, but it allowsdetermination of its full depth. Note the extension ofthe lung tumour (T) beyond the pleura (P) into thechest wall (CW).




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local anaesthesia (lignocaine, 1%). Aspiratesfrom at least four slightly different directionsand depths should be collected by moving theneedle in and out while applying a negativepressure. The material should immediately beexpressed onto slides and stained. Rapid on-siteevaluation (ROSE) of the cytology specimens, ifavailable, should be employed to assess theneed for CNB in the same setting. CNB willharvest tissue but carries a higher risk of visceralinjury and pneumothorax. It should only beused if a sufficient safety range can be assured.Current evidence suggest that ultrasonography-assisted transthoracic FNA is superior to CNBin confirming a diagnosis of epitheloid carcino-mas of the lung (95% versus 81%), whereas CNBis superior in cases of benign lesions andnoncarcinomatous tumours [44, 45].

Pulmonary embolism may give rise toinfarction, which is visualised on ultrasono-

graphy as a peripheral wedge-shaped hypo-echoic region, with or without an associatedpleural effusion [46, 47]. Pulmonary embo-lism should be considered to be presentwhen more than one characteristic triangularpleura-based lesion is present and probable ifat least one typical lesion with a correspond-ing pleural effusion is present [47]. MATHISet al. [47] found these criteria to have asensitivity of 74%, specificity of 95%, positivepredictive value of 95% and negative pre-dictive of 75% for pulmonary embolism.

B-lines generally extend to the bottom ofthe screen and are considered pathologicaland indicative of an interstitial syndrome [5].Lung rockets refer to the presence of severalB-lines [39]. LICHTENSTEINet al. [48] found thatB-lines were absent in most patients withchronic obstructive airway disease but presentin more than 90% of patients with interstitialsyndromes. The presence of bilateral B-lines inthe setting of patients with acute dyspnoea is,therefore, a very reliable sign to differentiatepatients with pulmonary oedema (fig. 7) fromthose with chronic obstructive airway disease

[5, 48]. Acute respiratory distress syndromeand pulmonary fibrosis tend to give rise tomore patchy involvement (with spared areas)and a nonhomogeneous distribution of B-lines, as well as an irregular thickened orfragmented pleural line [5].

Another indication for the use of transthor-acic ultrasonography is the assessment ofpulmonary and pleural-based cysts including,for example, hydatid disease (fig. 8). Cystscommonly appear as large, round anechoic

lesions. Rounded atelectasis may give rise to apleural based mass with associated pleuralthickening and extrapleural fat. The invaginatedpleura may be visualised as an echogenic linerunning from the pleura into the apparent mass.

Mediastinal pathologyThe differential diagnosis of mediastinalmasses is broad and computed tomographyscanning followed by biopsy is performed inpractically all cases. Mediastinoscopy, med-iastinotomy or related surgical procedureshave diagnostic yields in excess of 90%, butthey have to be performed in theatre undergeneral anaesthesia and are associated with acomplication rate of up to 5%.

Ultrasonography-assisted biopsy of med-iastinal masses provides a minimally invasive,safe and cheap alternative to mediastinoscopy

or mediastinotomy in the assessment ofmediastinal masses [7]. Attention needs tobe paid to identifying a safe biopsy tract, given

Figure 7

This high-frequency ultrasonogram was obtained froma patient with severe mitral stenosis who presentedwith pulmonary oedema. Note the widespread B-lines(B), a reliable sign of interstitial pulmonary oedema, aswell as the associated small pleural effusion (PE).




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the vicinity of the heart and great vessels.Furthermore, mediastinal structures may besignificantly displaced in the diseased state.

In a recent study we performed ultrasono-graphy-assisted transthoracic FNA with ROSEon patients with anterior mediastinal masses,immediately followed by CNB in cases where aprovisional diagnosis of epithelial carcinoma ortuberculosis could not be established [49]. Anaccurate cytological diagnosis was made in 73%of cases, and was more likely to be positive in

cases of epithelial carcinoma or tuberculosisthan all other pathology (p,0.001). CNByielded a diagnosis in 88%. Overall, 93% ofpatients were diagnosed by this sequentialsingle-session approach without the assistanceof a specialist radiologist or thoracic surgeon.

ConclusionsAll trainees in thoracic medicine should betaught the basics transthoracic ultrasonogra-phy, given its usefulness as a diagnosticmodality, and its ability to guide diagnosticand therapeutic interventions. The investiga-tion of chest wall abnormalities, pleuralthickening and pleural tumours, and thequalitative and quantitative description ofpleural effusions remain the major indicationsfor the use of transthoracic ultrasonography.Other indications include the visualisation of

lung tumours, pulmonary consolidation andother parenchymal pulmonary processes pro-vided they abut the pleura. Ultrasonography isthe ideal tool to assist with pleural aspiration.Ultrasonography-assisted biopsy of lesionsarising from the chest wall, pleura, peripherallung and mediastinum is safe and has a highyield comparable to more invasive techniques.Other applications of transthoracic ultrasono-graphy include the diagnosis of a pneu-mothorax and pulmonary embolism.

Figure 8

The low-frequency ultrasound appearance of ahydatid cyst. A reverberation artefact (R) is presentdue to the high water content of the cyst (C).

Tips for clinical practice

N Take sufficient time to appropriately position the patient. Use available imagery to be guided in terms of area ofinterest and patient position.

N Appreciate that peripheral lymph nodes, chest wall pathology, anterior mediastinal masses and consolidating pulmonarypathology that abut the chest wall can be visualised by means of transthoracic ultrasonography.

N Classify a pleural effusion as minimal, moderate or large based on ultrasonographic assessment.N Look for the absence of normal lung sliding and lung pulse, exaggerated horizontal reverberation artefacts (A-lines), the

absence of B-lines and the presence of a lung point to diagnose a pneumothorax.N Use the freehand technique to perform biopsy of various pathologies. Make sure the patient does not alter their position

during the procedure and use adequate local analgesia (to minimise pain and to avoid sudden movements).

Furthermore, avoid puncture of intercostal arteries (inferior to the ribs), the internal thoracic/mammarian artery (12 cmlateral to the sternum), and subclavian and major intrathoracic vessels when attempting a biopsy.

N Always identify the diaphragm and subdiaphragmatic viscera prior to performing lower transthoracic biopsies, as thesestructures may be displaced cephalad, given a false impression of a solid mass or consolidated lung.

N Once a specimen is obtained by means of needle aspiration for cytology, expel material onto slides within seconds.The quality of smear preparation is as important as the biopsy technique.

N Utilise ROSE to provisionally confirm the presence of diagnostic material.N Where epithelial carcinoma or an infectious process are not suspected or identified on ROSE, perform a CNB,

provided a safety range can be guaranteed.N Use ultrasonography to screen for post-procedural pneumothoraces.




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A Practical Guide to Transthoracic US

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