Airway and Breathing ultrasound

Sunday, November 14, 2010

Suthaporn Lumlertgul MDEmergency Unir

KIng Chulalongkorn Hospital


Airway and Lung in Ultrasound Perspective

Suthaporn Lumlertgul MDEmergency Unir

KIng Chulalongkorn Hospital



Detect intubation

One Lung?

Wet and Dry Dyspnea


Airway by ultrasound

• Direct visual trachea position

• Direct visual of Endotracheal tube, cuff

• Assess absent of lung movement in one lung intubation

• Assess Diaphragm movement


One lung intubation?





Understand Lung Pulse












Lung Ultrasound


Lung UltrasoundIt is really happening


• Normal Lung Picture

• Air-Fluid Ratio

• A-B-C.......Z of Lung Ultrasound

• Wet VS Dry dyspnea (BLUE protocol)

Pleuropulmonary Ultrasound


The ten signs of lung ultrasound in the critically ill : Lichtenstein Expert Rev. R esp. Med. 4(5), (2010)


Second Principle:

Understand Air-Fluid Ratio


LUNG: Semiotics, Window, Pathologies

Air

Water

Air

Water

Pleural effusion

Pneumothorax


Locating area of investigation



Air

Fluid


Normal Lung Findings and Artifact


* ** *


Normal Lung Findings

A line

A line

Pleural line* *

Skin


Normal Lung Findings

A line

A line

Pleural line* *

Skin


Pneumothorax by Lung Ultrasound


Comet tail

Reference ; Lichtenstein D, MÉZIÈRE G., The comet tail artifact, an ultrasound sign of aloveolar-interstitial syndrome. Am J Respir Crit Care Med 1997. Vol156:1640–1646.

Comet tail artifacts results from sliding of patrietal against visceral pleura. Lack of Lung sliding occur in (inflammatory adherences, loss of lung expansion, atelectasis,apnea, chronic symphysis) or is separated (pneumothorax, pneumonectomy

Comet



Document Pneumothorax by M mode


M Mode of Normal lung

* *

Reference ; Lichtenstein D, General Ultrasound in the Critically ill. 1st Edition



* *




* *




* *




**

Strastrophere sign

M Mode of Pneumothorax

(or sometimes look like Barcode)

7 54 6 0 8 1 9


A: Stratrophere Sign.B; Gliding of pleura results in Granular pattern which are seperated by white pleural line are called “Seashore sign”

Pleural line

Soft tissueA

B

Pleural line

Soft tissue

B


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Comet tail

Schematic drawing of Lung Sliding results in Granular effect below pleura line: Seashore sign in M Mode

2D M


When the collapsed lung is not contact chest wall, it will create horizontal pattern(before and after yellow arrow). On the contray, when it expands and in contact with chest wall, it will create granular pattern(below the arrow). This is called the lung point, which is a specific sign of pneumothorax.


Detecting pulmonary edema by ultrasound bedside?




Transducer

Multiple US Beam

Reflections

NORMAL

INTERLOBULAR

SEPTA

Transducer

THICKENED

INTERLOBULAR

SEPTA

Multiple US Beam

Reflections

REVERBERATIONS

NORMAL ARTIFACTS (A lines)

REVERBERATIONS

COMET TAILS (B lines)

www.WINFOCUS.org


http://www.WINFOCUS.org



*= B line narrow-based hyperechoic column laser like arise from bright pleural line as vertical to the edge of the screen moving during breathing indicated interlobular septal infiltration

** * *

Pleural line

B line: To detect interlobular septal thickening, infiltration

DIfferential Diagnosis of B line: Cardiogenic Pulmonary Edema, ARDS, Pneumonia, Lung Contusion (Trauma)

*






Falls Protocol



The BLUE protocol

To differentiate acute pulmonary disease by bedside ultrasound application


The BLUE protocol

Reference: Lichtenstein D. and Gilbert A. Relevance of Lung Ultrasound in the diagnosis of Acute Respiratory Failure. Chest 2008;134;117-125


The BLUE protocol

Reference: Lichtenstein D. and Gilbert A. Relevance of Lung Ultrasound in the diagnosis of Acute Respiratory Failure. Chest 2008;134;117-125


Pleural Effusion Assessment by ultrasound

Pleural lineCurtain sign obliterate liver

Liver

Diaphragm Diaphragm

Liver

Effusion

Lung

Lung

31


Pleural Effusion Assessment by ultrasound

ABDOMENLUNG

PLEURAL EFFUSION

Semiquantitative assessment of pleural effusion volume(IP=Interpleural space)End expiratory distance IP at 5th intercostal space at > 5 cm estimated > 500 ccEnd Expiratory IP at Basal lung > 4.5 cm (Right lung base) > 5 cm (Lt lung base) →estimated pleural effusion volume > 800 cc

Best thoracocentesis point 1.Safe puncture area : ultrasound check > 3 intercostal spaces with IP distance > 1.5 cm 2.Absence of interposition of lung, heart, liver, spleen 3.Interpleural distance variation Mark best puncture point, fixed patient position.

Roch A, CHEST 2005

Vignon P, CRIT CARE 2005.www.WINFOCUS.org





Health & Medicine

Airway and Breathing ultrasound