1. +
Focused Thoracic Ultrasound
Sonographic appearances of the normal thorax
Dr Andrew Ferguson
Consultant in Intensive Care Medicine & Anaesthesia

2. +
A shot in the dark…
simply a hopeful
attempt to hit an enemy
that you can't see

3. +
Why Use Thoracic Ultrasound?
 Increasingly “standard
 Stop “shooting

of care” issue
in the dark”
Both for Seldinger and conventional “surgical” drains
 Really
informative – negative findings also important
 Interesting
 Enjoyable!
and challenging

4. + Objectives

Level 1 sono-anatomy

Right and left hemidiaphragm

Ribs and intercostal spaces

Lungs

Heart

Liver, spleen, kidneys

5. +
Diaphragm
 Double
 Easily
or triple line
seen in presence of effusion from mid-axillary line
 Abdominal
surface visible with ascites
 Curves
upwards except with large effusions
 Closely
applied to liver/spleen – used as acoustic windows
 Functional
assessment feasible

6. + Diaphragm
C
Boussuges A et al. Chest 2009;135:391-400

7. +
Diaphragm (trans-organ)
RIGHT through liver
LEFT through spleen

8. + Diaphragm Function (M-Mode)
Towards probe
RIGHT
LEFT

9. +
Diaphragm Function (2-D)
 Normal
diaphragm thickens on inspiration
 End-inspiratory
thickness 20% or more above baseline

10. +
Heart

11. +
Liver

Note texture (remember for consolidated lung images)

Artifacts e.g. mirror-image (implies aerated lung above)
Liver
Liver
Kidney
Mirror-image
Diaphragm
Hepato-renal recess

12. +
Spleen
Spleno-renal recess
Spleen
Kidney
Diaphragm

13. +
Intercostal space
Pleura

14. +
Lungs – normal static findings
 Normal
lung considered “invisible” to ultrasonographer
 Artefacts
A
can be used to infer normality or abnormality
lines

horizontal reverberation artifacts from pleural line

the only finding in 2/3 of normal lung US
B
lines

vertical narrow bands from pleural line to edge of screen

obliterate the A line

multiple B lines = Ultrasound Lung Rockets = interstitial oedema
 Abnormal
lung has characteristics that are clinically useful

15. +
Lungs – normal static findings
Rib
Rib
Rib
A lines
B line
Wipe out A lines as they pass
“Bat sign”

16. +
Lungs – normal dynamic findings 1
 Pleural
sliding (lung sliding sign)
 Pleural
line “shimmers” with respiration
 Presence
 Lung
sliding greatest in lower thorax (greatest expansion)
 Absence





of lung sliding rules out pneumothorax
of lung sliding has a number of causes
Pneumothorax
Apnoea
Pleural adhesions
Mainstem bronchial intubation or occlusion
Critical parenchymal lung disease e.g. ARDS, contusion

17. +
Lung sliding

18. +
Lungs – normal dynamic findings 2

M-mode “seashore sign”

Structures superficial to pleural line are static

= Horizontal lines on M-mode (motion against time) = WAVES

Motion of pleural line is “reflected” deep to it

= Granular pattern reflecting motion = SAND

19. +
M-Mode seashore sign
Static structures
horizontal lines (waves)
Pleural line
Pleural line reverberations
dynamic – granular (sand)

20. +
Lungs – normal dynamic findings 3
 “Lung
pulse” sign
 Cardiac
pulsations transmitted via lung to pleura
 When
seen in the absence of sliding…
 Normal if breath-hold
 Abnormal in other conditions with no sliding
 Presence
of lung pulse excludes pneumothorax

21. +
Lung Pulse Sign

22. +
Focused Thoracic Ultrasound
Sonographic appearances of the abnormal thorax
Dr Andrew Ferguson
Consultant in Intensive Care Medicine & Anaesthesia

23. + Objectives – Level 1
1.
Pleural effusion
2.
Pleural thickening
3.
Consolidated lung
4.
Paralysed hemidiaphragm
5.
Pericardial effusion
6.
Pneumothorax
7.
Interstitial syndrome
8.
Guided thoracocentesis and drain placement

24. +
Pleural effusion
 Characteristics
 Anechoic
(transudate or exudate)
 Echoic
 Homogeneously
echogenic
 Complex non-septated (exudate)
 Complex septated (exudate)
 Size
 Depth
on 2-D
 Estimates of volume
 Inversion of diaphragm if very large

25. +
Pleural effusion - anechoic

26. +
Pleural effusion, complex, non-septated
Plankton sign –
mobile swirling
elements in
effusion

27. +
Pleural effusion, complex, septated

28. +
Pleural effusion, inverted diaphragm

29. +
Effusion with atelectasis

30. +
Clotted haemothorax
Clot
Lung with peripheral
consolidation
(contusion)

31. +
Organised Haemothorax

32. +
Pleural effusion - colour doppler
Fluid colour sign – can be used to differentiate small
effusion from pleural thickening

33. +
Fluid colour sign
Kalokairinou-Motogna M, et al. Medical
Ultrasonography 2010, Vol. 12, no. 1, 12-16

34. +
Pleural thickening
Hypo-echoic pleural plaque

35. +
Malignant pleural thickening

36. +
Lung consolidation

Tissue pattern


Boundary or shred line


ragged boundary between consolidated and normal lung
Air bronchograms


loss of air barrier leading to a “real” tissue image akin to liver i.e.
hepatisation
Non-mobile linear or punctate hyper-echoic features
Fluid bronchograms

May be partially fluid-filled with material motion visible with breathing

37. +
Lung consolidation

38. +
Lung tail (atelectasis and consolidation)
Note normal thickening of diaphragm with inspiration

39. +
Lung consolidation
Note material within effusion

40. +
Severe consolidation - hepatisation
Hepatised lung
Fluid bronchograms

41. +
Pneumothorax
 Absent
lung sliding
 Absent
lung pulse
 Absent
lung rockets
 M-Mode
– barcode or stratosphere sign
 Lung-point
sign

42. +
Pneumothorax – stratosphere sign

43. +
Pneumothorax – lung point sign

44. +
Pneumothorax – lung point sign
1) Transient normal
pattern as lung
reaches chest wall
at peak inflation or
2) transition zone
where lung is sitting
on chest wall

45. +
Lung point on 2D US

46. +
Interstitial/alveolar syndrome
 Interlobular

> 3 lung rockets spaced around 7mm apart (B7 lines)
 Alveolar

septal thickening/oedema
filling/oedema
> 3 lung rockets spaced around 3mm apart (B3 lines)
Normal
B7
B3
Lichtenstein DA, et al. Chest 2009;136:1014-1020

47. +
Diaphragm Dysfunction (M-Mode)
Normal
Towards probe
Paralysis

48. +
Diaphragm Dysfunction (2-D)
Towards probe
NO thickening
McCool FD, Tzelepis GE. Dysfunction of the Diaphragm. N Engl J Med 2012; 366:932-942

49. +
Pericardial effusion
Combined pleural and pericardial effusions
Pericardial effusion

50. +
Pneumothorax US algorithm
Lung
sliding
NO
B-lines
YES
NO
YES
Lung
point
No pneumothorax
YES
NO
Lung
pulse
YES
Pneumothorax
NO