Lung Ultrasound in Cardiac Care
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A lecture on the principles and the value of Lung Ultrasound in Cardiac Intensive Care
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Lung Ultrasound in Cardiac Care
- 1. Lung Ultrasound in Intensive Care Senior Clinical Fellow Adult Intensive Care Royal Brompton Hospital, London, UK Dr. Hatem Soliman Aboumarie MBBS, MRCP, MSc, PGDip (Cardio), EDICM, ASCeXAM
- 5. Principles of LUS What’s normal? Advantages Requirements Evidence Overview ? What is the evidence ? Take Home Messages Challenges
- 6. Historically The lung, not suitable for ultrasound? The lungs are a major hindrance for the use of ultrasound at the thoracic level”. In Harrison PR. Principles of Internal Medicine. 1992:1043 Simply wrong
- 7. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749-57. Recently PubMed, May 2018. Lung ultrasound has emerged as a new sonographic technique to evaluate many pulmonary conditions 1972
- 8. Principles Ultrasound is not transmitted through areated tissue Normal parenchyma is not visible Interface between pleura and lung (different acoustic impedence) reflects US Intercostal space acoustic window
- 9. Advantages of Lung Ultrasound Immediate bedside availability Cost saving Immediate bedside repeatability Rapid goal directed application Reduction in radiation exposure
- 10. Equipment requirements Cardiac transducer effective (small footprint) Curvilinear transducer may be used Vascular transducer is used for lung sliding, small consolidations
- 11. Zones
- 12. Probe location Heart Failure: Dependent zones Pleural Effusion: Costophrenic angles Consolidation: Painful zones Pneumothorax: Non-dependent zones
- 13. The Bat Sign The pleural line and the upper and lower ribs make a permanent Landmark Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
- 14. What’s Normal?
- 15. Lung Sliding Slight and bright horizontal movement of the pleural line due to sliding of the parietal and visceral pleurae. Normal Lungs Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
- 16. Normal LungsSeashore Sign Waves on a sandy beach Sea - Waves Shore – Sandy Beach Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
- 17. A-lines Horizontal reverberation of the pleural line Can be found in pneumothorax as well!
- 18. Lung Pulse Vertical movement of the pleural line synchronous to the cardiac rhythm. Caused by the transmission of the heart beats through Lung tissues Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
- 19. Absence of Lung Sliding Pneumothorax Massive atelectasis Mainstem intubation Pleural fibrosis/adhesions Cardiorespiratory arrest
- 20. Pneumothorax Stratosphere sign = Barcode Sign
- 21. Pneumothorax Diagnosis A lines: present Lung pulse: absent B lines: absent Lung sliding: absent Lung point: present The diagnosis of PNX depends on the correct combination of these signs
- 22. Transition Zone Pneumothorax Lung Point
- 23. B-lines Laser-like vertical hyperechoic artifacts Arises from the pleural line. Pleural Line Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4. Long and well-defined Erases A-lines Moves with lung sliding Extravascular Lung Water = Interstitial syndrome
- 25. B-lines Clinical Applications Heart Failure Interstitial Lung Disease Dialysis ALI/ARDS Diagnosis Monitoring and therapy titration Prognosis
- 26. 100% 0% Soldati G, Copetti R. Ecografia del torace 2006. B-lines Interstitial Syndrome Lung Air
- 27. Gargani Cardiovascular Ultrasound 2011, 9:6 B-lines Interstitial Syndrome
- 28. 97 patients. Compared LUS with a previously validated clinical congestion score (CCS); NT-proBNP, E/e’ ratio, chest x-ray, and 6-min walk test. Evidence • In an HF outpatient clinic, B-lines were significantly correlated with more established parameters of decompensation. • A B-line >=15 cut-off could be considered for a quick and reliable assessment of decompensation in outpatients with HF.
- 29. Eur Heart J. 2016;37(15):1252-1254 Evidence
- 30. LUS used to examine 195 NYHA class II–IV HF patients during routine cardiology outpatient visits. Evidence Patients with ≥3 B-lines had a four-fold higher risk of the primary outcome compared with those with less number of B lines and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P = 0.001).
- 31. Copetti R, Soldati G, Copetti P. Cardiovasc Ultrasound. 2008;6:16 Cardiogenic Pulmonary EdemaARDS Subpleural consolidations Spared area Thickened & irregular pleural line B-lines: non-uniform distribution Vs.
- 32. Cardiogenic Pulmonary EdemaARDS Vs.
- 33. Cardiogenic Pulmonary EdemaARDS Vs.
- 35. Lung Consolidation spleen or liver diaphragm Real image (not artefactual) Tissue-like pattern (similar to liver echotexture) Anatomic boundaries Air bronchograms
- 36. Pleural Effusion Diagnosis Jellyfish Sign
- 37. Chest 2015 Jun;147(6):1659-70 Protocols BLUE: Bedside Lung US in Emergency
- 38. Expert Rev Respir Med. 2012 Apr;6(2):155-62 Protocols FALLS: Fluid Administration Limited by Lung US
- 44. Gargani L. Cardiovascular Ultrasound 2011;9:6 Recommended Reading
- 45. Challenges Accreditation Quality Control. How to ensure we are doing it right? Courses
- 46. Air is the enemy of Ultrasound but Lungs are good friends! Lung Ultrasound should be an integral part of the Echo study B-lines can be used reliably for monitoring treatment of heart failure 1 2 3 Take-home messages5 Integrated approach is crucial4