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Ghassan A. Shaath , MDAssoc. Const Ped Cardiologist/Cardiac IntensivistKACC, NGHARiyadh, KSA

HE T ULTRA UND

FOR CRITICALLY ILL

Objectives:

Review the Chest US background

Reliability of  US for the lung pathologies

Utility of  US on the lung

Lung pathologies by sonography

Systematic approach for lung US

Should we use it ?

Should we credential Intensivist ?

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History

Auscultation:  ~ 200 yrs 

Laennec RTH et,al J.A.Brosson & J.S. Chaude, Paris 1819 

X‐ray:  > 100 yrs 

Williams FH et,al Boston Med Surg J 1896 

CAT scan:  since 1972, international by 1980’sHounsfield GN et,al Br J Radiol 1973 

CXR & CT Irradiation

David J. Brenner et,al N Engl J Med 2007;357:2277-84 .

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What about US ?

“The ultrasound imaging is not useful for 

evaluation of  the pulmonary parenchyma”

Harrison (Principles of internal Med. 1992 (p 1043) & 2001 (p 1454) 

Essentia   scienti ic i eas are simp e an   can 

be understood by every bodyEinstein The evolution of physics 1937 

Can we assess Vocal cords ?

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 !!Confirm ETT position

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Can we estimate the PCWP ?

TDI in E/ E’ > 15  high PCWP

A cut‐off  value E’ ≥8 cm/second

Partho et,alJACC  2004 

Even Diaphragm Fx !!

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Material and infrastructures

Scanning the Diaphragm.

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Lung Zones

I

II

III

Normal Lung US: A lines

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B lines : pathologic

Alveolar Interstitial Synd (AIS)

Extra‐vasation in the alveoli or interstitium

Exudates 

Transudates

Both

Inflammatory infectious or non‐infectious, 

chronic 

or 

acute 

Like: Acute PE, chronic PE, pneumonia, 

ARDS, fibrosis, …etc

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AIS by Lung US: mild to mod

congestion

AIS by Lung US AIS: severe 

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Are B lines accurate for AIS ?

American Journal of Emergency Medicine (2006) 24, 689–696 

D.Lichtenstein et,al Anaesthesiology 2004 

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Effusion

AIS and B+ lines with edema 

D.Lichtenstein et,al Anaesthesiology 2004 

Thickened inter‐lobar space

B7 lines

D.Lichtenstein et,al Anaesthesiology 2004 

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Can we differentiate ARDS from cardiogenic

 P. 

edema

Cardiovascular  Ultrasound  2008, 6:16

Can we differentiate ARDS from cardiogenic P. edema

Cardiovascular  Ultrasound  2008, 6:16

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Lung US in Acute HF

American Journal of Emergency Medicine (2008) 26, 585–591 

Lung US in Acute HF

American Journal of Emergency Medicine (2008) 26, 585–591 

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Lung US in chronic decompensated HF

J Am Coll Cardiol 2000;35:1638–46 

Lung US in chronic decompensated HF

J Am Coll Cardiol 2000;35:1638–46 

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Lung US: consolidation

Tissue like sign

Shreddin   si n

+Air‐bronchogram

Pleural thickening

If  severe 

hepatization !

US sen 90% 

spec 98%

CXR sen 95%

spec 68% only

+ Effusion 

Occasionally difficult to differentiate 

atelectasis

Pediatr Crit Care Med 2009 Vol. 10, No. 6 

Lung US: Atelectasis (collapse)

homogeneous 

parenchyma

Air bronchogram

especially early

Normal pleura

Has a triangular 

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Lung US: Pneumothorax (always respect gravity)

Artifacts are what we look for:

 

A lines (from air‐pleura interface) prominent

M mode shows a 

stratosphere 

sign 

No B lines could 

    a     b     d    o    m    e    n

lung

Normal  Lung

Collapsed  lung

PNEUMOTHORAX 

    a     b     d    o    m    e    n

EXPIRATION INSPIRATIONbe seen

Look at lung 

point to localize 

the PNX to 

confirm

collapse

dlung

Pneumothorax:Sliding

Sliding No Sliding B line 

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Pneumothorax: A lines and M mode

Stratosphere sign 

No pleural slidingHence A lines are in order with time

Pneumothorax

Seashore sign 

Indicates pleural slidingAs  A lines not in order with time

Normal

Pneumothorax: Lung point

collapsedlung

EXPIRATION INSPIRATION

Positive lung point

Pneumothorax

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Pneumothorax algorithm

With 100% 

sensitivity: 

NO False 

Negatives

Lichtenstein DA. CRIT CARE MED 2005 .

With 

100% 

specificity: NO False 

Positives

Is Lung US accurate for PNX

AJR:188, January 2007 

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Is Lung US accurate for PNX

AJR:188, January 2007 

Lung US: Effusion (always respect gravity)

•Quad sign: pleural line, ribs, Parietal pleura

•B lines underneath

• M mode the sinusoidal sign

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Lung US: Effusion

D.Lichtenstein et,al Anaesthesiology 2004 

Effusion: US techniqueSaggital Axial

    a     b     d    o    m    e    nlung

Pleural  Effusion Pleural  Effusion

lung

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Bedside Lung Ultrasound in Emergency RD

the BLUE protocol

Bedside Lung Ultrasound in Emergency RDthe BLUE protocol

In 260 pt’s 

(PLAPS = posterior/lateral alveolar and/or pleural syndrome)

Daniel A. Lichtenstein et,al CHEST 2008; 134:117–125 

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We’re pediatrician !!

Aren’t 

we 

!!

We’re still pediatrician !!

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Cont’…

No change 

after surfactant of  14 hrs,

Before

May be more time is required ~ 24‐36 hrs 

as RDS needs to clear alveolar fluids

After

Lung US: assess the recruitment

Increasing openingpressure,

consolidation

Emerg Radiol (2009) 16:219–221 

disappeared and Blines started toshow-up which is asign of improvement

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It does help in Pulm. Embolism !

CHEST  2001; 120:1977–1983

Trans‐thoracic US 

manifestations

It does help in Pulm. Embolism !

 

CHEST  2001; 120:1977–1983

.2. Triangular (commonest)3. Polygonal

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Study was for 69 pts

It does help in Pulm. Embolism !

,out of 42 casesdetected most wereof central PE

CHEST  2001; 120:1977–1983

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Take home messages:

This tool is very beneficial

Excellent media for research

Unless you ask for it  apply you wont get it

Know the device

Get credentialed master it 

Apply to your patient  it’s harmless

Know

 

the 

area 

where 

to 

be 

unique

Get Credentialed

With 

Established a partnership to credential physicians to gettarget problem based training in deferent provider levels

WELCOME  TO  JOIN

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