Live pulmonary endoscopy Transthoracic ultrasound pulmonary endoscopy Transthoracic ultrasound AIMS:...
131
ERS International Congress Amsterdam 26–30 September 2015 Live pulmonary endoscopy Transthoracic ultrasound Thank you for viewing this document. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author. ©2015 by the author Tuesday, 29 September 2015 14:45 – 16:45 Room Auditorium RAI
Transcript of Live pulmonary endoscopy Transthoracic ultrasound pulmonary endoscopy Transthoracic ultrasound AIMS:...
ERS International Congress Amsterdam
26–30 September 2015
Live pulmonary endoscopy
Transthoracic ultrasound
Thank you for viewing this document.
We would like to remind you that this material is the
property of the author. It is provided to you by the ERS
for your personal use only, as submitted by the author.
©2015 by the author
Tuesday, 29 September 2015
14:45 – 16:45
Room Auditorium RAI
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Live pulmonary endoscopy
Transthoracic ultrasound
AIMS: Transthoracic ultrasound is a helpful tool for investigating clinical problems such as
suspected pleural fluid, white hemithorax, atelectasis, empyema, and diaphragm function problems.
This session will demonstrate some of the most common investigations that are performed such as:
pleural effusion, white hemithorax, empyema, peripheral located lung tumor, mesothelioma.
TARGET AUDIENCE: General pulmonologists and residents.
CHAIRS: R. Bhatnagar (Bristol, United Kingdom), F. Gleeson (Oxford, United Kingdom)
SESSION PROGRAMME
14:45 Transthoracic ultrasound: technical aspects and artefacts
F. Gleeson (Oxford, United Kingdom)
Patient advocate (AMC)
T. Lapperre (Singapore, Singapore)
Case 1
I. Psallidas (Oxford, United Kingdom)
Case 2
N. Rahman (Oxford, United Kingdom), J. Wrightson (Oxford, United Kingdom)
Case 3
J. Annema (Amsterdam, Netherlands), I. van den Berk (Amsterdam, Netherlands)
Case 4
I. Psallidas (Oxford, United Kingdom)
Case 5
J. Wrightson (Oxford, United Kingdom), N. Rahman (Oxford, United Kingdom)
16:20 Transthoracic ultrasound: question and answer session
F. Gleeson (Oxford, United Kingdom), R. Bhatnagar (Bristol, United Kingdom)
16:30 Transthoracic ultrasound in clinical practice
R. Bhatnagar (Bristol, United Kingdom)
BOOKLET CONTENTS PAGE
Thoracic Ultrasound 4
Transthoracic Ultrasound in Clinical Practice 94
Additional resources 129
Faculty disclosures 120
Faculty contact information 131
Thoracic Ultrasound
Prof. Fergus Gleeson
Department of Radiology
The Churchill Hospital
Oxford OX3 7LJ
UNITED KINGDOM
4
Oxford
Pleural
Unit
ERS Live Pulmonary Endoscopy
Thoracic Ultrasound
Najib M Rahman
Consultant and Senior Lecturer
Oxford Centre for Respiratory
Medicine
Oxford, UK
Fergus V Gleeson
Professor of Radiology
Oxford University Hospitals
Oxford, UK
5
Oxford
Pleural
Unit
There is no real or perceived conflicts of interest that relate to this presentation:
This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.
6
Oxford
Pleural
Unit Overview
1. Physics and Principles
2. Basics of Scanning
3. Evidence and Training
4. Abnormal Appearances
7
Oxford
Pleural
Unit
1. Physics and Principles
8
Oxford
Pleural
Unit What is ultrasound
• A longitudinal wave - particles move in
the same direction as the wave.
• A succession of rarefactions and
compressions transmitted due to elastic
forces between adjacent particles
9
Oxford
Pleural
Unit What is Ultrasound
• Audible sound has frequency 20 Hz to 20 kHz
• Most diagnostic ultrasound has frequencies in
range 2-20 MHz
10
Oxford
Pleural
Unit Important equation!
• Frequency of oscillations inversely
proportional to wavelength
• f = c/ (c ≈ 1540 m s-1 in soft tissue)
• Diagnostic ultrasound of 2-20MHz,
wavelength• = approximately 1 - 0.1 mm in tissue
11
Oxford
Pleural
Unit Generation of Ultrasound
• US generated by piezoelectric crystal
• Commonest material is lead zirconate titanate
(PZT).
• Electric field applied:
• crystal rings at a resonant frequency
• determined by its thickness
• Same or similar crystal used as receiver:
• produces electrical signal when struck by the returning
ultrasound wave
12
Oxford
Pleural
UnitUltrasound Transducer
Matching layer
Piezoelectric crystalAcoustic insulator
Converts electricity to sound and vice versa
Backing
block
Co-axial cable
Plastic housing
13
Oxford
Pleural
Unit Speed of ultrasound in tissue
• Speed of US in tissue depends on:
• Stiffness
• Density
• Stiffer material (more solid) transmits
ultrasound faster
14
Oxford
Pleural
Unit Speed of ultrasound in tissue
Medium Speed of sound
(ms-1)
Air 331
Muscle 1,585
Fat 1,450
Soft Tissue (average) 1,540
15
Oxford
Pleural
Unit Interaction of US with tissue
Ultrasound which enters tissue may :
• Transmit
• Attenuate
• Reflect
16
Oxford
Pleural
Unit Attenuation
• If particles in a tissue are small enough:• Move as a single entity
• Transmit sound in an orderly manner
• Coherent vibration
• Sound
• If large molecules are present:• Chaotic vibration
• Heat
• Loss of coherence loss of ultrasound energy
• Alter with gain control on machine
17
Oxford
Pleural
UnitGain too high
18
Oxford
Pleural
Unit Gain reduced
19
Oxford
Pleural
UnitAbsorption of
ultrasound / gain
• Absorption of ultrasound:
• Lower tissues return less ultrasound
• Some absorbed as heat
• Some reflected/refracted out of field of probe.
• To ensure a uniform picture
• (so deeper areas not darker)
• Use Time Gain Compensation (TGC).
• TGC:
• Applies progressively increasing amplitude to later
echoes in proportion to their depth
• i.e differential amplification
20
Oxford
Pleural
Unit TGC
• TGC can be varied by users
• Used to compensate for artefactual increased
brightness
• Beware previous user adjusting TGC controls
21
Oxford
Pleural
Unit TGC incorrect
22
Oxford
Pleural
Unit TGC corrected
23
Oxford
Pleural
Unit
• Absorption proportional to ultrasound
frequency
• Higher frequency probes:
• Smaller depth penetration
• Better resolution
• Many US machines allow user to alter
frequency up to maximum/minimum allowed
Attenuation and
depth penetration
24
Oxford
Pleural
Unit
Pleura on 3.5 MHz
curvilinear probe
25
Oxford
Pleural
Unit
Pleura on high resolution
linear probe
26
Oxford
Pleural
Unit
Reflection
Importance of Reflection:• Allows generation of the ultrasound signal
• Leads to loss of ultrasound signal
• Determines the appearance of tissue
• Can cause artefacts
27
Oxford
Pleural
Unit Reflection
Reflection occurs when:
• Ultrasound crosses an interface between two tissues with
different impedance
• Amount depends on difference in impedance
• Ultrasound which is not reflected:
• Continues
• Is used to image deeper structures
28
Oxford
Pleural
Unit Reflection
Interface Reflection co-efficient
(%)
Soft Tissue - Air 99
Soft Tissue - Bone 66
Fat - Muscle 1.08
Muscle - Liver 1.5
29
Oxford
Pleural
Unit Ribs preventing
US transmission
30
Oxford
Pleural
Unit US avoiding ribs
31
Oxford
Pleural
Unit
Reflection –
consequences
1. Need coupling material between probe
and patient skin
2. Cannot see through aerated lung
3. Cannot see through bone
32
Oxford
Pleural
Unit Artefacts
Mirror artefact• Occurs at smooth curved surfaces eg
diaphragm
• Reflection occurs
• Projects image of organ under diaphragm eg liver, above diaphragm
• Reflections of liver into chest can give false impression consolidated lung
33
34
Oxford
Pleural
Unit Acoustic shadowing
• Artefact:• Causing shadowing behind certain structures
• Prevents user seeing beyond them
• Caused by absorption or reflection
• Occurs at fibrous tissue eg scars and fat (eg fatty liver)
35
Oxford
Pleural
Unit Fatty liver
36
Oxford
Pleural
Unit Gas shadows
• Proportion of incident US reflected
• Unable to continue through the tissue for imaging
• At gas-tissue interfaces:• Almost all US is reflected
• Lung:• Clean shadow
• Bowel gas shadows:• ‘Dirty shadows’
• Partly filled by reverberant echoes due to multiple gas-tissue reflectors
37
Oxford
Pleural
Unit Gas shadows
‘Clean’ Shadow ‘Dirty’ Shadow
38
Oxford
Pleural
Unit
39
Oxford
Pleural
Unit
2. Basics of Scanning
40
Oxford
Pleural
Unit Equipment
• Machine able to achieve depth of at least 10cm
• Dynamic range of transducer:• Low Hz (3-5MHz) probe better for depth (e.g. abdominal)
• High Hz (7-12MHz) better for detail (e.g. small parts)
• Shape of transducer:• Linear
• Curvilinear
• Small footprint
• Machines much the same for standard use
41
Scanning Position
42
Image Orientation
43
F
D
VP
PP
44
Oxford
Pleural
Unit Normal Appearance
Thoracic structures:• Ultrasound unable to see through air
• Ribs are in the way
• Unable to penetrate normal lung• “Comet tails”
• Lung sliding
Other organs• Liver
• Spleen
45
Oxford
Pleural
Unit
Normal Appearance
Costophrenic angle
46
47
L
48
49
L
50
51
L
52
Oxford
Pleural
Unit
Normal Appearance
Mid thorax
53
54
55
Oxford
Pleural
Unit Normal Lung
Diagnosis of aerated lung:• “Comet tails”
• Lung sliding
Caution:• Unable to comment on what is below
• “Lung” not really seen - artefact
56
Oxford
Pleural
Unit Normal Subdiaphragm
Liver Spleen
Recognition of normal structure is key to safe practice57
Oxford
Pleural
Unit SummaryKey points:
• US relies on sound creation, reflection and detection
• In tissues, US can transmit / attenuate / reflect
• Decrease attenuation by increasing power (gain)
• Higher frequency, better penetration
• Interface of tissues determines how much is reflected
• Artefacts:• Mirror• Shadowing
58
Oxford
Pleural
Unit Ultrasound tips
• Use highest frequency for necessary depth penetration
• Use tissue harmonics for larger patients
• Try moving patient into different positions eg to move ribs apart/move bowel gas out of way
• Use ‘optimise’ button
• Reduce size of sector for improved resolution
• More jelly and press harder
59
Oxford
Pleural
Unit
60
Oxford
Pleural
Unit
3. Evidence and Training
61
Oxford
Pleural
Unit Thoracic US
• Should physicians perform thoracic US?
• Evidence
• Training
• Equipment
• Examples
62
Oxford
Pleural
Unit Thoracic US
Advantages:• Higher sensitivity for the detection of pleural fluid
• Smaller volumes of pleural fluid detectable
• Locules detectable
• Intervention safer:• Marking
• Real-time procedures
• Diagnostic value (PTx / malignancy)
Disadvantages:• Training required
• Support required
• Limitations of technique and operator need to be known
63
Oxford
Pleural
Unit Evidence
Higher sensitivity vs. chest radiography1
Higher procedure accuracy:• 97% aspiration success2
Low complication rate:• PTx 2%, bleeding 0.4% 3
Added diagnostic information:• Echogenic fluid excludes transudate
• Septations / pleural thickening
• Homogenous echogenicity 41 = Eibenberger et al, Radiology 19942 = O’Moore et al, AJR 19873 = Jones et al, Chest 20034 = Yang et al, AJR 1992 64
Oxford
Pleural
Unit Evidence
Better than clinical examination1:• 15% clinically specified puncture sites inaccurate
• 80% of these aspirated under US
• When clinical site not identified – US achieved in 54%
• US avoids organ puncture in 10%
Pneumothorax:• More sensitive in detection post lung biopsy than CXR2,3
• Sensitivity 95% post trauma4
• Detects “occult” PTx post trauma4
1 = Diacon et al, Chest 20032 = Sartori et al, AJR 20073= Goodman et al, Clin. Rad 19994 = Soldati et al, Chest 2008
65
Oxford
Pleural
UnitTraining in Thoracic US
(UK guidelines)
http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf
66
Oxford
Pleural
Unit Training in Thoracic US
http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf
67
Oxford
Pleural
Unit FAST guidelines
68
Oxford
Pleural
Unit FAST guidelines
69
Oxford
Pleural
Unit Levels of Competence
Level I (most chest physicians):• Normal anatomy
• Diagnosis of pleural fluid
• Fluid characteristics
• Basic procedures
Level II:• More complex disease
• More complex procedures
• Competent at lung / lymph node biopsy
• Able to receive referral from level I
Level III:• Radiologists only
70
Oxford
Pleural
Unit Training in Thoracic US
Key Issues in training:• Friendly radiologist
• Regular scanning time
• Familiar with machine
• Normal appearances
Key issues in Practise:• Know limits
• Access to experience if required
71
Oxford
Pleural
Unit
72
Oxford
Pleural
Unit
4. Abnormal Appearances
73
Oxford
Pleural
Unit Simple Effusion
74
Oxford
Pleural
Unit
Hemidiaphragm
FluidVisceral pleura
Parietal Pleura
75
Oxford
Pleural
Unit Simple Effusion
Additional information:• Size / Volume measurement
(2cm = 480mls, 4cm = 960mls)
• Lung atelectasis (cardiac pulsation)
76
Oxford
Pleural
Unit
Atelectatic Lung
77
Oxford
Pleural
Unit
Effusion
Ascites
78
Oxford
Pleural
Unit Simple effusion
Diagnostics:• Echogenic swirling
• Inverted hemidiaphragm
• Pleural thickening /nodularity
79
Oxford
Pleural
Unit
Inverted
Diaphragm
80
Oxford
Pleural
Unit Aetiology
• The Clinical Utility of Ultrasound in Detecting
Malignant Pleural Disease in the Presence of a
Pleural Effusion
– Aim: To determine the diagnostic accuracy of US in the
detection of malignancy in patients with suspected
malignancy and pleural effusion
Qureshi et al. Thorax
81
Oxford
Pleural
Unit
82
Oxford
Pleural
Unit Diagnosis of malignant
pleural effusion
Qureshi et al, Thorax 200883
Oxford
Pleural
Unit
Conclusions• US detects a significant number of abnormalities in pts
with suspected malignant pleural effusions
• US appears to have a high specificity and PPV for
malignancy
• Pleural and diaphragmatic thickening is common in
patients with malignant effusions
• Nodularity and irregularity are strongly suggestive of
malignancy
84
Oxford
Pleural
Unit
Complex effusions
85
Oxford
Pleural
Unit
Septations
86
Oxford
Pleural
Unit
Parietal
Thickening
Visceral Thickening
87
Oxford
Pleural
Unit
Adherent Lung
Fluid Fluid
88
Oxford
Pleural
UnitLung Consolidation
89
Oxford
Pleural
Unit
ConsolidationLiver
90
Oxford
Pleural
Unit Interventions
Options:
• “Marking” the skin • Simple
• Movement
• Delay
• Overconfidence
• Real-time US (“direct vision”):• See what you are doing!
• Difficult to learn
• Specific equipment
91
Oxford
Pleural
Unit When to ask for help…
• Radiologist more skilled in all aspects of US
• Radiologist has access and understanding of
other techniques
• Need to improve CXR interpretation
• MUST know own limits
92
Oxford
Pleural
Unit Summary
Thoracic Ultrasound• Very useful technique
• Will become standard of care for interventions
(data is supportive)
What you need:• Adequate training
• Adequate kit
• Supportive radiologist / experienced practitioner
93
Transthoracic Ultrasound in Clinical Practice
Dr Rahul Bhatnagar
Academic Respiratory Unit
Learning and Research Building
Southmead Hospital
BS10 5NB Bristol
UNITED KINGDOM
94
TRANSTHORACIC ULTRASOUND IN CLINICAL
PRACTICE
Rahul Bhatnagar
Academic Clinical Lecturer
University of Bristol, United Kingdom
95
Conflict of interest disclosure
I have no, real or perceived, direct or indirect
conflicts of interest that relate to this presentation.
This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation.Drug or device advertisement is strictly forbidden.
96
INTRODUCTION
AIMS
• Establish why thoracic US is important
• Explore practical applications of respiratory physician-
delivered thoracic US
• Highlight limitations, cautions and tips
97
THORACIC ULTRASOUND
Advantages:• Higher sensitivity for the detection of pleural fluid
• Smaller volumes of pleural fluid detectable
• Locules detectable
• Intervention safer:» Marking
» Real-time procedures
• Diagnostic value (PTx / malignancy)
Disadvantages:• Training required
• Support required
• Limitations of technique and operator need to be known
98
EVIDENCE
Higher sensitivity vs. chest radiography1
Higher procedure accuracy:• 97% aspiration success2
Low complication rate:• PTx 2%, bleeding 0.4% 3
Added diagnostic information:• Echogenic fluid excludes transudate
• Septations / pleural thickening
• Homogenous echogenicity 4
1 = Eibenberger et al, Radiology 19942 = O’Moore et al, AJR 19873 = Jones et al, Chest 20034 = Yang et al, AJR 1992 99
EVIDENCE
Better than clinical examination1:• 15% clinically specified puncture sites inaccurate
• 80% of these aspirated under US
• When clinical site not identified – US achieved in 54%
• US avoids organ puncture in 10%
Pneumothorax:• More sensitive in detection post lung biopsy than CXR2,3
• Sensitivity 95% post trauma4
• Detects “occult” PTx post trauma4
1 = Diacon et al, Chest 20032 = Sartori et al, AJR 20073= Goodman et al, Clin. Rad 19994 = Soldati et al, Chest 2008
100
EVIDENCE
• Ultrasound guidance decreases complications and improves
the cost of care among patients undergoing thoracentesis and
paracentesis
• Retrospective cohort over 2 year period
• 61,261 thoracenteses (45% US-guided)
• 2.7% pneumothorax rate overall
• Ultrasound reduced risk of pneumothorax by 19%
• Which in turn reduced costs of hospitalisation
Mercaldi et Al, Chest 2013 101
102
103
WHY SHOULD RESPIRATORY PHYSICIANS
TRAIN?
• Radiology department capacity (cost per annum associated with
149 bed days while awaiting TUS in one teaching hospital = £18,000
– Bateman et al Resp Med 2010)
• Ultrasound at time of procedure superior to remote X-marks the
spot (no better than blind procedure)
• Part of overall patient assessment and management – ‘one
stop’ approach
• Individual competence and timely availability are most
important
104
USES – RESPIRATORY WARD AND
PROCEDURE ROOM
• Guidance for all diagnostic and therapeutic aspirations and
Seldinger chest drain insertions
105
USES – RESPIRATORY WARD AND
PROCEDURE ROOM
• Guidance for all diagnostic and therapeutic aspirations and
Seldinger chest drain insertions.
• Safe drain placement in lateral decubitus position.
• Identification of complicated parapneumonic effusions
requiring tube drainage.
106
107
108
USES – RESPIRATORY WARD AND
PROCEDURE ROOM
• Guidance for all diagnostic and therapeutic aspirations and
seldinger chest drain insertions.
• Safe drain placement in lateral decubitus position.
• Identification of complicated parapneumonic effusions
requiring tube drainage.
• Identify presence of pleural effusion when CXR unclear.
109
110
111
USES – RESPIRATORY WARD AND
PROCEDURE ROOM
• Guidance for all diagnostic and therapeutic aspirations and
seldinger chest drain insertions.
• Safe drain placement in lateral decubitus position.
• Identification of complicated parapneumonic effusions
requiring tube drainage.
• Identify presence of pleural effusion when CXR unclear.
• Confirm drainage complete – pre talc pleurodesis or
before chest tube removal.
112
USES – RESPIRATORY WARD AND
PROCEDURE ROOM
• Guidance for all diagnostic and therapeutic aspirations and
Seldinger chest drain insertions.
• Safe drain placement in lateral decubitus position.
• Identification of complicated parapneumonic effusions
requiring tube drainage.
• Identify presence of pleural effusion when CXR unclear.
• Confirm drainage complete – pre talc pleurodesis or before
chest tube removal.
113
USES - OUTPATIENT CLINIC
• Part of overall initial clinical assessment towards differential
diagnosis (fluid characteristics , pleural thickening, diaphragmatic
nodularity, pericardial effusion).
114
PATIENT WITH COUGH, SWEATS, CRP 152,
PLEURAL FLUID PH 6.9
115
116
117
USES – OUTPATIENT CLINIC
• Part of overall initial clinical assessment towards differential
diagnosis (fluid characteristics , pleural thickening,
diaphragmatic nodularity, pericardial effusion).
• Fluid volume assessment - choosing best first pleural procedure.
• Planning LA thoracoscopy or indwelling pleural catheter (IPC)
placement.
118
USES – OUTPATIENT CLINIC
• Part of overall initial clinical assessment towards differential
diagnosis (fluid characteristics , pleural thickening,
diaphragmatic nodularity, pericardial effusion).
• Fluid volume assessment - choosing best first pleural
procedure.
• Planning LA thoracoscopy or indwelling pleural catheter (IPC)
placement.
• Planning IPC removal / need for fibrinolytics
119
USES – OUTPATIENT CLINIC
• Part of overall initial clinical assessment towards differential
diagnosis (fluid characteristics , pleural thickening,
diaphragmatic nodularity, pericardial effusion).
• Fluid volume assessment - choosing best first pleural
procedure.
• Planning LA thoracoscopy or indwelling pleural catheter (IPC)
placement.
• Planning IPC removal/ need for fibrinolytics
• Rapid effusion management in best supportive care of patients
with pleural malignancy (particularly MPM).120
USES – PLEURAL PROCEDURE LIST
• Assess need/ feasibility of therapeutic aspiration
pre- procedure.
• Guidance of induced pneumothorax in small
effusions.
121
USES – PLEURAL PROCEDURE LIST
• Assess need/ feasibility of therapeutic aspiration
pre- procedure.
• Guidance of induced pneumothorax in small
effusions.
• ‘On table’ safe site selection for LAT port placement
(16.7% failure with blind approach requiring other
procedure vs 0% with US (P<0.05) – Medford et al Thorax 2009).
122
TRAINING IN THORACIC US
(UK GUIDELINES)
http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf
123
TRAINING IN THORACIC US – UK
http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf 124
LEVELS OF COMPETENCE – UK
Level I (most chest physicians)
• Normal anatomy
• Diagnosis of pleural fluid
• Fluid characteristics
• Basic procedures
Level II• More complex disease
• More complex procedures
• Competent at lung / lymph node biopsy
• Able to receive referral from level I
Level III• Radiologists only
125
TRAINING IN THORACIC US
Key Issues in training:
• Friendly radiologist
• Regular scanning time
• Familiar with machine
• Normal appearances
Key issues in practice:
• Know your own limits
• Access to experience if required
126
WHEN TO ASK FOR HELP…
• Radiologist more skilled in all aspects of US
• Radiologist has access and understanding of
other techniques
• MUST know own limits
127
SUMMARY POINTS
• Evidence suggests thoracic US improves safety and
accuracy of pleural procedures
• Know its limitations and, more importantly, your limitations
• Use of US in untrained/ inexperienced hands provides false confidence and may be harmful – access to machines with level 1 certificate or under supervision only
• Radiologists are highly trained in ultrasound – work closely and maintain a mentor after achieving basic training
128
Additional course resources
Readings, guidelines and E-learning resources
1. Solomon SD1, Saldana F., Point-of-care ultrasound in medical education--stop listening and
look, N Engl J Med. 2014 Mar 20;370(12):1083-5. doi: 10.1056/NEJMp1311944
2. Von Groote-Bidlingmaier F., Koegelenberg C.F.N., A practical guide to transthoracic
ultrasound, Breathe 2012 Dec2012 9, no 2. Doi: 10.1183/20734735.024112
129
Faculty disclosures
There are no faculty disclosures for this session.
130
Faculty contact information
Prof. Dr Jouke T. Annema
Academic Medical Center
Postbus 22660
1100 DD Amsterdam
NETHERLANDS
Dr Rahul Bhatnagar
Academic Respiratory Unit
Learning and Research Building
Southmead Hospital
BS10 5NB Bristol
UNITED KINGDOM
Prof. Fergus Gleeson
Department of Radiology
The Churchill Hospital
Oxford OX3 7LJ
UNITED KINGDOM
Dr Therese Lapperre
Department of Respiratory and Critical care
Medicine
Singapore General Hospital
Outram Rd
Singapore 169608
SINGAPORE
Dr Najib Rahman
Oxford Centre for Respiratory Medicine
Churchill Hospital
Old Road
Headington
Oxford OX3 7LJ
UNITED KINGDOM
Dr Ioannis Psallidas
Oxford Centre for Respiratory Medicine
Oxford Respiratory Trials Unit
Old Road
Headington
Oxford OX3 7LJ
UNITED KINGDOM
Dr Inge van den Berk
Academic Medical Center
Meibergdreef 9
1105 AZ Amsterdam Zuid-Oost
NETHERLANDS
Dr John Wrightson
Experimental Medicine Divison
John Radcliffe Hospital
Headley Way
Oxford OX3 9DU
UNITED KINGDOM
131
