• Esaote: Special COVID-19

LUS is an ultrasound technique that is used to create an image of internal body structures LUNGS. Its aim is often to find a source of a disease or to exclude pathology.

LUS signs, either alone or combined with other point-of-care ultrasound techniques, are helpful in the diagnostic approach to patients with acute respiratory failure, circulatory shock or cardiac arrest.

LUS monitoring can be performed at the bedside and used in mechanically ventilated patients to assess the efficacy of treatments, to monitor the evolution of the respiratory disorder, and to help the weaning process.

LUS can be used for early detection and management of respiratory complications under mechanical ventilation, such as pneumothorax, ventilator- associated pneumonia, atelectasis and pleural effusions.

When LUS can be useful in ER:

  • Pleural pathology
  • Pericardial pathology
  • Shortness of breath
  • Cyanosis
  • Cough
  • Shock

Objectives

  1. To show the diagnostic capabilities of Lung Ultrasound in Critical Care.
  2. To illustrate the diagnostic modalities needed.
  3. To highlight the fields of application.
  4. To encourage the use of standardized protocols and terminology.

Convex probe

Linear probe

Sector probe

LUS 10 signs:

NORMAL

  1. Bat sign (pleural line)
  2. Lung sliding
  3. A-line (horizontal artifact)

EFFUSION

  1. Quad sign
  2. Sinusoid sign

CONSOLIDATION

  1. Fractal and tissue-like sign

INTERSTITIAL

  1. B-line (vertical artifact)
  2. Lung rockets

PNEUMOTORAX

  1. Abolished lung sliding with stratosphere sign
  2. Lung point

Two more signs, the lung pulse and dynamic air bronchogram, are used to distinguish atelectasis from pneumonia.

Scoring of findings

NORMAL Lung – A-line

The A-lines are horizontal artifactual repetitions of the pleural line displayed at regular intervals

Pleural EFFUSION

Quad sign (2D LUS)

Pleural EFFUSION

Sinusoid sign (M-mode)

Lung CONSOLIDATION

Massive consolidation of the whole lower lobe without aerated lung tissue and no fractal sign

Lung CONSOLIDATION

Middle lobe consolidation not invading the whole lobe, with fractal border with aerated lung

INTERSTITIAL Syndrome

Pulmonary interstitial edema is designed by diffuse lung rockets. Lung rockets are defined as at least 3 B-lines between two ribs.

PNEUMOTORAX

Abolished lung sliding “stratosphere sign”

PNEUMOTORAX

Anterior abolished lung sliding + A-lines

PNEUMOTORAX

Lung point at the area at the junction between dead air pneumothorax) and living air (inflating lung)

LUNGs approach standardization

Examination technique

  1. Patient in a semi-seated and sitting position for optimal access to posterior-basal lung segments.
  2. Linear probe ( 7.5 -15 MHz) for study of pleural line and subpleural spaces
  3. Convex probe (3.5 -5 MHz) for B-line evaluation, consolidations and collapses
  4. Color-Doppler module for assessing vascularization in consolidation
  5. Appropriate application (abdomen or vascular) with lung preset
  6. Correct general gain and TGC setting for better B-line representation
  7. Bilateral lung multiscansions at conventional thoracic lines and between them (parasteral, emiclave, LAA, LAM, LAP) plus posterior scans (scapula angular and paravertebral)

The longitudinal approach has the advantages of locating the pleural line in all circumstances.

CT vs LUS

Lung CT

  • Thickened pleura
  • Ground glass shadow and effusion
  • Pulmonary infiltrating shadow
  • Subpleural consolidation
  • Translobar consolidation
  • Pleural effusion is rare
  • More than two lobes affected
  • Negative or atypical in lung CT images in the super-early stage, then diffuse scattered or ground glass shadow with the pregress of the disease, further lung consolidation

Lung ultrasound

  • Thickened pleural line
  • B-lines (multifocal, discrete, or confluent)
  • Confluent B-lines
  • Small (centomeric) consolidations
  • Both non-translobar and translobar consolidation
  • Pleural effusion is rare
  • Multilobar distribution of abnormalities
  • Focal B-lines are the main feature in the early stage and in mild infection; alveolar interstitial syndrome is the main feature in the progressive stage and in critical patients; A-lines can be found in the convalescence; pleural line thickening with uneven B-lines can be seen in patients with pulmonary fibrosis

The ultrasound bedside can read dynamically and constantly the airfluid ratio which the CT scan cannot perform. Lung ultrasound is more sensitive than chest X-ray for the diagnosis of pneumothorax and shows similar high specificity.

CT vs LUS
  1. Diagnosis and stage of patient candidates for intubation (forced ventilation)
  2. Patient follow up (no CT scan )
  3. Monitoring and adapt fan therapy effectively by avoiding pneumothorax. Rif (Emergency Ultrasound Guidelines 2008) ACEP The medical use of US for diagnostic evaluation of emergency conditions and diagnoses, resuscitation of the acutely ill, Critically ill or injured, guidance of high risk or difficult procedures, monitoring of certain pathologic states and as an adjunct to therapy.

LUS for monitoring mechanical ventilation

Pneumothorax can be a consequence of barotrauma, mainly when lung compliance is reduced. LUS is accu- rate in the diagnosis of pneumothorax (Lichtenstein et al. 2000) and is superior to supine anterior chest x-ray (Blaivas et al. 2005). The presence of real images (consolidation, effusion), of any pleural movement (sliding, lung pulse) or artefacts deriving from the visceral pleura (B-lines) rules out pneumothorax with 100% negative predictive value. If a static A pattern is visualized, a lung point must be searched moving the probe laterally and inferiorly: the lung point corresponds to the site where the collapsed lung goes back in touch with the parietal pleura and rules in pneumothorax with 100% positive predictive value. If no lung point is identified, the positive predictive value of a static A pattern alone ranges from 55 to 98%, depending on the clinical context; for example, if the lung is completely collapsed, no lung point can be visualised.

LUS for monitoring mechanical ventilation

Our best proposal for LUS

Complete

  • High performance in all the applications
  • Large probes portfolio, convex, linear and phased-array
  • Advanced configurations, including TE probe or Strain package

Fast

  • 2 probes connectors Up to 4 with multiconnector
  • Touchscreen with intuitive menus
  • Long-duration battery and quick boot-up time (15”)

Compact

  • Full screen mode
  • Swivelling monitor
  • Agile trolley easy with 4 swivelling wheels

Connected

  • Follow-up & Multi-modality options to retrieve other imaging modalities
  • eStreaming for real-time imaging streaming
  • eTablet & MyLabRemote for remote storage and control

Probe 1

 

Low-frequency probe to scan lung parenchyma and commonly used in emergency for abdominal organs.

Probe 2

 

High-frequency probe to scan pleural area and superficial structures. Commonly used to scan vessels and support lines’ placement.

Probe 3

 

Low-frequency phased-array probe to scan the lung and commonly used for heart functionality monitoring.

  • Standard care involves handwashing or hand sanitization and use of sterile gloves.
  • Droplet precautions include gown, gloves, headcover, facemask and eye shield.
  • Airborne precautions add special masks (e.g. N-95 or N-99 respirator masks, or powered air purifying respirator - PAPR systems) and shoe covers.
  • Equipment care is critical in the prevention of transmission. Cover probes and machine consoles with disposable plastic and forego the use of ECG stickers.

Echocardiogram machines and probes should be thoroughly cleaned, ideally in the patient’s room and again in the hallway. Smaller, laptop-sized portable machines are more easily cleaned before and after the examination.

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