airway and breathing ultrasound
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พญ.สุธาพร ล้ำเลิศกุลTRANSCRIPT
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Sunday, November 14, 2010
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Suthaporn Lumlertgul MDEmergency Unir
KIng Chulalongkorn Hospital
Sunday, November 14, 2010
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Airway and Lung in Ultrasound Perspective
Suthaporn Lumlertgul MDEmergency Unir
KIng Chulalongkorn Hospital
Sunday, November 14, 2010
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Sunday, November 14, 2010
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Detect intubation
One Lung?
Wet and Dry Dyspnea
Sunday, November 14, 2010
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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
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One lung intubation?
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Understand Lung Pulse
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Sunday, November 14, 2010
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Lung Ultrasound
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Lung UltrasoundIt is really happening
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• Normal Lung Picture
• Air-Fluid Ratio
• A-B-C.......Z of Lung Ultrasound
• Wet VS Dry dyspnea (BLUE protocol)
Pleuropulmonary Ultrasound
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The ten signs of lung ultrasound in the critically ill : Lichtenstein Expert Rev. R esp. Med. 4(5), (2010)
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Second Principle:
Understand Air-Fluid Ratio
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LUNG: Semiotics, Window, Pathologies
Air
Water
Air
Water
Pleural effusion
Pneumothorax
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Locating area of investigation
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Sunday, November 14, 2010
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Air
Fluid
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Normal Lung Findings and Artifact
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* ** *
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Normal Lung Findings
A line
A line
Pleural line* *
Skin
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Normal Lung Findings
A line
A line
Pleural line* *
Skin
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Pneumothorax by Lung Ultrasound
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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
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Document Pneumothorax by M mode
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M Mode of Normal lung
* *
Reference ; Lichtenstein D, General Ultrasound in the Critically ill. 1st Edition
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M Mode of Normal lung
* *
Reference ; Lichtenstein D, General Ultrasound in the Critically ill. 1st Edition
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M Mode of Normal lung
* *
Reference ; Lichtenstein D, General Ultrasound in the Critically ill. 1st Edition
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M Mode of Normal lung
* *
Reference ; Lichtenstein D, General Ultrasound in the Critically ill. 1st Edition
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Sunday, November 14, 2010
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**
Strastrophere sign
M Mode of Pneumothorax
(or sometimes look like Barcode)
7 54 6 0 8 1 9
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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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!"
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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
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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.
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Detecting pulmonary edema by ultrasound bedside?
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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
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*= 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)
*
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Falls Protocol
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The BLUE protocol
To differentiate acute pulmonary disease by bedside ultrasound application
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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
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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
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Pleural Effusion Assessment by ultrasound
Pleural lineCurtain sign obliterate liver
Liver
Diaphragm Diaphragm
Liver
Effusion
Lung
Lung
31
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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
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