role of sonography in respiratory emergencies
TRANSCRIPT
![Page 1: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/1.jpg)
![Page 2: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/2.jpg)
Role of Chest Sonography in
Respiratory Emergencies
Gamal Rabie Agmy, MD, FCCP Professor of chest Diseases, Assiut university
![Page 3: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/3.jpg)
![Page 4: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/4.jpg)
High Frequency
• High frequency (5-10 MHz)
greater resolution
less penetration
• Shallow structures
![Page 5: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/5.jpg)
Low Frequency
• Low frequency (2-3.5 MHz)
greater penetration
less resolution
• Deep structures
![Page 6: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/6.jpg)
Probes
![Page 7: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/7.jpg)
A common language: Color Coding
Black Grey White
![Page 9: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/9.jpg)
Chest Sonography
![Page 10: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/10.jpg)
BLUE-Protocol and FALLS-Protocol Two
Applications of Lung Ultrasound in the Critically
Ill
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670
![Page 11: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/11.jpg)
![Page 12: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/12.jpg)
![Page 13: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/13.jpg)
THE BAT VIEW
Chest wall
Pleural line
![Page 14: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/14.jpg)
![Page 15: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/15.jpg)
Normal lung surface
Left panel: Pleural line and A line (real-time). The pleural line is located 0.5 cm below the rib line in the adult. Its visible length between two ribs in the longitudinal scan is approximately 2 cm. The upper rib, pleural line, and lower rib (vertical arrows) outline a characteristic pattern called the bat sign.
![Page 16: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/16.jpg)
A lines = default normal
Horizontal echo reflection at exact
multiples of intervals
from surface to bright reflector.
Dry lung OR PNTX
Decay with depth
Obliterated by B
pleura A
A
A
A
A
A
![Page 17: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/17.jpg)
![Page 18: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/18.jpg)
![Page 19: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/19.jpg)
the "seashore sign" (Fig.3).
![Page 20: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/20.jpg)
![Page 21: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/21.jpg)
![Page 22: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/22.jpg)
Confluent B lines = Bad Bad
‘White’ or ‘shining’ lung
Means increased
severity
Probably indicates thicker fluid in alveoli
eg protein or
inflammatory cells
% space / 10
![Page 23: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/23.jpg)
B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12
![Page 24: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/24.jpg)
Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125
![Page 26: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/26.jpg)
![Page 27: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/27.jpg)
![Page 28: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/28.jpg)
![Page 29: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/29.jpg)
Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform images representative of air bronchograms
Pleural
effusion
Lower lobe
![Page 30: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/30.jpg)
![Page 31: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/31.jpg)
![Page 32: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/32.jpg)
![Page 34: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/34.jpg)
![Page 37: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/37.jpg)
![Page 38: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/38.jpg)
![Page 39: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/39.jpg)
![Page 40: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/40.jpg)
![Page 41: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/41.jpg)
Absent lung sliding
Exaggerated horizontal artifacts
Loss of comet-tail artifacts
Broadening of the pleural line to a band
The key sonographic signs of
Pneumothorax
![Page 42: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/42.jpg)
![Page 43: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/43.jpg)
![Page 44: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/44.jpg)
![Page 45: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/45.jpg)
the "seashore sign" (Fig.3).
![Page 46: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/46.jpg)
![Page 47: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/47.jpg)
![Page 48: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/48.jpg)
![Page 49: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/49.jpg)
![Page 50: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/50.jpg)
![Page 51: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/51.jpg)
![Page 52: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/52.jpg)
![Page 53: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/53.jpg)
![Page 54: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/54.jpg)
Pulmonary Embolism
![Page 55: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/55.jpg)
Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration 2003;70:441-452 )
![Page 56: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/56.jpg)
![Page 57: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/57.jpg)
Alveolar-interstitial syndrome
![Page 58: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/58.jpg)
![Page 59: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/59.jpg)
![Page 60: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/60.jpg)
![Page 61: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/61.jpg)
![Page 62: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/62.jpg)
Multiple B-lines - « comet-tails » - interstitial edema (B1)
7 mm apart « B lines » thickened interlobular septa
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997 JJR 25 05 2012
http://www.reapitie-
univparis6.aphp.fr http://www.reapitie-
univparis6.aphp.fr
02 09 2012
![Page 63: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/63.jpg)
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997 30 11 2011
Coalescent B lines - « comet-tails » - alveolar
edema
3 mm apart « B lines » ground-glass areas
http://www.reapitie-
univparis6.aphp.fr
02 09 2012
![Page 67: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/67.jpg)
![Page 69: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/69.jpg)
![Page 70: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/70.jpg)
![Page 71: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/71.jpg)
![Page 72: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/72.jpg)
![Page 73: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/73.jpg)
![Page 74: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/74.jpg)
![Page 75: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/75.jpg)
![Page 76: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/76.jpg)
IVC Sonography
![Page 77: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/77.jpg)
INDICATIONS
IVC Ultrasound
Spontaneously
Breathing
Mechanical
Ventilation
Volume Status / CVP Fluid Responsiveness
![Page 78: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/78.jpg)
INDICATIONS Assessing
Intravascular Volume Status /
CVP
•Volume depleted state :
•Dehydration _ Acute Kidney Injury (?
Prerenal,renal, post renal)
- Diuretic therapy
- Sepsis
* Volume overloaded state:
-Heart Failure
-Cirrhosis with ascites
- Anasarca
![Page 79: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/79.jpg)
INDICATIONS Assessing
Fluid Responsiveness in Shock
* Measuring the variation in IVC diameter in these
situations can help determine whether the patient’s
blood pressure will respond to fluids or whether
inotropic support (i.e. dobutamine) will be needed
NB: IVC diameter does not correlate with right atrial
pressure in patients who are intubated with shock
![Page 80: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/80.jpg)
Respiratory variation
Expands w/ expiration
Contracts w/ inspiration
Due to changing intrathoracic pressures.
![Page 81: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/81.jpg)
PROCEDURE Probe Selection
1 Low frequency 2-5 MHz
2 Curvalinear probe
![Page 82: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/82.jpg)
PROCEDURE
Approach #1 – Xiphoid View
![Page 83: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/83.jpg)
PROCEDURE
Landmarks
Aproach #1 – Xiphoid View
1 Most common approach
2 Place probe longitudinally just below the
xiphoid process with the probe marker to the
patient’s head
3 Look for IVC going into right atrium – may
need to move probe 1-2cm to patient’s
right and then tilt it slightly towards the
heart
![Page 84: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/84.jpg)
IVC Longitudinal
![Page 85: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/85.jpg)
PROCEDURE
Approach #2 – Anterior -Mid-Axillary
View
![Page 86: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/86.jpg)
PROCEDURE Landmarks
Aproach #2 – Anterior Mid-Axillary View
1 Place probe longitudinally in right anterior
mid-axillary line with marker towards the
head
2 Look for IVC running longitudinally
adjacent to liver crossing the diaphragm.
3 Track superiorly until it enters right atrium
confirming that it is the IVC and not the
aorta.
![Page 87: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/87.jpg)
IVC Anterior Mid-Axillary View
![Page 88: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/88.jpg)
Measuring the IVC Diameter
Measure IVC 2cm
distal to right atrium
![Page 89: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/89.jpg)
Inspiratory (Minimal) IVC
Diameter
![Page 90: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/90.jpg)
Maximum (Expiratory) IVC
Diameter
![Page 91: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/91.jpg)
M-Mode IVC Diameters
![Page 92: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/92.jpg)
CAVAL INDEX (CI)
CI =
minimal (inspiratory)
diameter
maximum (expiratory)
diameter
maximum (expiratory)
diameter
![Page 93: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/93.jpg)
CAVAL INDEX (CI)
Volume
Depletion
Volume
Overload
0% 100%
![Page 94: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/94.jpg)
IVC v CVP
Correlation Between IVC Diameter Plus CI and
CVP
IVC Max Diameter
(cm)
CI CVP
(mmHg)
< 1.5 100%
(total collapse) 0-5
1.5-2.5 > 50% 6-10
1.5-2.5 < 50% 11-15
> 2.5 < 50% 16-20
> 2.5 0%
(no collapse) >20
![Page 95: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/95.jpg)
Echocardiography
![Page 96: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/96.jpg)
![Page 97: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/97.jpg)
(Chest. 2008; 133:836-837)
© 2008 American College of Chest Physicians
Ultrasound: The Pulmonologist’s New Best
Friend
Momen M. Wahidi, MD, FCCP
![Page 98: Role of Sonography in Respiratory Emergencies](https://reader031.vdocument.in/reader031/viewer/2022030310/58f9b1a2760da3da068bc2b4/html5/thumbnails/98.jpg)