European Respiratory Society

Thoracic Ultrasound

Edited by Christian B. Laursen, Najib M. Rahman and Giovanni Volpicelli
Thoracic Ultrasound

Thoracic ultrasound is now considered an essential bedside tool in respiratory medicine. Despite this, several aspects are yet to be studied and assessed, and international consensus remains limited. With this in mind, the Guest Editors of this Monograph have selected a broad range of authors who are recognised experts, represent different specialities and use thoracic ultrasound in different settings. The result is that each chapter not only reflects expert opinion at a single site in Europe, but provides a multidisciplinary and multicentre view. Chapters include: physics and basic principles; techniques and protocols; pneumothorax; pneumonia; lung tumours; the upper abdomen; and thoracic ultrasound in newborns, infants and children.

  • ERS Monograph
  1. Page ix
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  4. Page 1
    Abstract
    Bret P. Nelson, Division of Emergency Ultrasound, Dept of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA. E-mail: bretpnelson@gmail.com

    The clinical benefits of LUS manifest in patients ranging from the clinically ill to those who have suffered trauma. Along with the proper hands-on technique at the bedside, the different US modalities and parameters of the US machine must be understood in order to acquire high-quality images on the screen for the physician to translate clinically. Unlike other parts of the body, the normal healthy lungs themselves are not actually visualised using bedside US, and what is depicted on the screen is not a true representation of the lung. Instead, LUS can best be described as the interpretation of US artefacts. Accordingly, the basic US principles and physics behind these artefacts must be understood in order to learn, apply and teach LUS. These tenets are reflected in both normal lung (e.g. A-lines, mirror artefact of the liver above the diaphragm) and diseased or injured lung (e.g. B-lines, pneumothorax).

    Cite as: Alerhand S, Graumann O, Nelson BP. Physics and basic principles. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 1–13 [https://doi.org/10.1183/2312508X.10006017].

  5. Page 14
    Abstract
    Christian B. Laursen, Dept of Respiratory Medicine, Odense University Hospital, Søndre Boulevard 29, 5000 Odense C, Denmark. E-mail: Christian.b.laursen@rsyd.dk

    The use of a systematic approach is essential, no matter whether TUS is performed as a focused or a diagnostic examination. This chapter provides the novice in TUS with a description of the basic concepts and approach required to perform a systematic focused examination of the chest and some basic knowledge regarding a diagnostic examination of the chest. As well as training in practical US skills, inexperienced physicians should also focus on the art of integration of imaging into clinical practice.

    Cite as: Laursen CB, Davidsen JR, Gleeson F. Technique and protocols. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 14–30 [https://doi.org/10.1183/2312508X.10006117].

  6. Page 31
    Abstract
    Maged Hassan, Oxford Centre for Respiratory Medicine, Churchill Hospital, Old Road, Oxford OX3 7LE, UK. E-mail: magedhmf@gmail.com

    US examination of the chest wall and parietal pleura can reveal a number of pathologies and is useful in various clinical settings. Chest wall pathologies that are identifiable during US examination include haematomas, abscesses, rib abnormalities and lymph nodes. Additionally, useful information about pleural infection and neoplasia can be gathered using US. In addition to its diagnostic potential, US provides guidance for safe execution of percutaneous sampling and/or drainage of chest wall and pleural abnormalities.

    Cite as: Hassan M, Rahman NM. Chest wall and parietal pleura. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 31–42 [https://doi.org/10.1183/2312508X.10006217].

  7. Page 43
    Abstract
    Nils Petter Oveland, Gneisveien 1 C, 4027 Stavanger, Norway. E-mail: nils.petter.oveland@me.com

    Pneumothorax (PTX) is common after blunt chest injury, and failure to diagnose and rapidly treat an enlarging PTX may cause patient death. The anteroposterior supine CXR is the least sensitive of all plain radiographic techniques for detecting PTX. Occult PTX (i.e. if missed on CXR) may subsequently be found by CT scans, but both of these diagnostic tools are not readily available for the patient, include a radiation hazard, and have a time delay between ordering and obtaining results. TUS is a harmless point-of-care examination to accurately diagnose PTX. The main message in this chapter is that TUS is a safe and highly accurate diagnostic tool to diagnose PTX and can be used to assess PTX progression. With the appropriate training, all clinicians can perform US examinations to detect PTX, which suggests that this technique should be used as a diagnostic adjunct to the clinical examination of patients with respiratory distress.

    Cite as: Oveland NP. Pneumothorax. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 43–63 [https://doi.org/10.1183/2312508X.10006317].

  8. Page 64
    Abstract
    Ioannis Psallidas, Oxford University NHS Foundation Trust, Old Road, Churchill site, Oxford, OX3 7LE, UK. E-mail: ioannis.psallidas@ndm.ox.ac.uk

    Pleural effusions represent a significant disease burden globally. TUS, performed by both radiologists and physicians, has increasingly become an essential tool in the evaluation and management of pleural effusions. It detects pleural effusions with higher sensitivity and specificity than CXR, and provides valuable information about the size and depth of the pleural effusion, the echogenicity of the fluid, the presence of septated or loculated fluid, pleural thickening and nodularity, and the presence of any contralateral pleural effusion. TUS can provide information on diaphragm position and movement with respiration, and can assess the presence of lung sliding and the accessibility of pockets of fluid in loculated pleural effusions, thereby improving the success rate and safety of pleural procedures. Given the added detail that US provides and its increasing availability, it is no surprise that its use is increasingly expanding in clinical practice.

    Cite as: Merrick C, Asciak R, Edey A, et al. Pleural effusion. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 64–74 [https://doi.org/10.1183/2312508X.10014817].

  9. Page 75
    Abstract
    Luna Gargani, Institute of Clinical Physiology, National Research Council, via Moruzzi 1 – 56124, Pisa, Italy. E-mail: gargani@ifc.cnr.it

    B-lines are probably the most “revolutionary” sign of LUS and can be used for the evaluation of interstitial syndrome. They indirectly visualise different degrees of partial deaeration of the pulmonary parenchyma, and therefore can be seen in the presence of both hydrostatic and inflammatory pulmonary oedema, as well as in pulmonary fibrosis. Assessment of B-lines can thus be applied to many different diseases, such as heart failure, end-stage renal disease, acute lung injury, interstitial lung disease and pre-eclampsia. To differentiate these conditions, a thorough integration with the clinical picture is absolutely necessary, but some LUS characteristics can also significantly improve B-line specificity and overall LUS diagnostic accuracy (pattern of distribution over the thorax, response to therapy and association with other LUS signs, such as pleural line alterations, small and large consolidations, and pleural effusion). The clinical usefulness of B-lines has been demonstrated not only for diagnosis but also for monitoring and prognosis.

    Cite as: Gargani L. Interstitial syndrome. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 75–86 [https://doi.org/10.1183/2312508X.10006517].

  10. Page 87
    Abstract
    Gebhard Mathis, Dr Summer-Strasse 3, 6830, Rankweil, Austria. E-mail: Gebhard.mathis@cable.vol.at

    Several studies suggest that LUS could be useful for the diagnosis of pneumonia. It also has a more favourable safety profile and a lower cost than chest radiography or CT. The characteristic sonographic signs of pneumonia are a hypoechoic liver- or tissue-like subpleural consolidation and a marked dynamic bronchoaerogram. The borders are blurred and serrated, often accompanied by comet tail artefacts. A parapneumonic effusion can be detected in 55% of cases. Abscess formations are better seen in LUS than in CXR. They can be treated under US guidance. LUS cannot rule out pneumonia. However, accuracy is >90%. These patients should therefore be treated immediately according to clinical presentation and laboratory findings, without further imaging procedures. In cases of tuberculosis and diseases of the frame of the lung, sonography is the optimum method of visualising small pleural effusions and subpleural consolidations.

    Cite as: Mathis G. Pneumonia. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 87–101 [https://doi.org/10.1183/2312508X.10006617].

  11. Page 102
    Abstract
    Giovanni Volpicelli, Dept of Emergency Medicine, San Luigi Gonzaga University Hospital, Torino, Italy. E-mail: giovi.volpicelli@gmail.com

    The diagnosis of pulmonary embolism is often a complex process that starts from clinical suspicion and is guided by risk stratification in selected populations. LUS may have a role in this process, as it is a valid technique that is highly specific for diagnosing typical peripheral lung infarctions and highly sensitive in ruling out alternative pulmonary diagnoses to pulmonary embolism. Either alone, or in particular in combination with cardiac and venous US, sonographic examination of the lung represents a valid alternative to a multidetector CT scan when the latter is unavailable or contraindicated. Moreover, when integrated in the pre-test clinical risk score assessment of pulmonary embolism, a multiorgan US based on evaluation of pulmonary peripheral infarctions and deep vein thrombosis is useful to improve the performance of the Wells score. Integration of US in the process to assess the risk score for pulmonary embolism may significantly reduce the number of unnecessary CT scans. Finally, LUS is also useful in all undifferentiated emergency situations, such as cardiac arrest, shock and respiratory failure, to orientate the diagnosis and include the possibility of unexpected pulmonary embolism.

    Cite as: Volpicelli G. Pulmonary embolism. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 102–114 [https://doi.org/10.1183/2312508X.10006717].

  12. Page 115
    Abstract
    Christian Görg, Universitatsklinikum Giessen und Marburg – Standort Marburg. E-mail: goergc@med.uni-marburg.de

    The diagnostic value of TUS of lung tumours, especially bronchial carcinomas, is limited and dependent on the localisation of the tumour. Focused clinical use is to be distinguished in the context of primary diagnosis, staging, therapy response and tumour growth. Symptom-oriented practice is important at the bedside for palliative patients, in point-of-care sonography, in the emergency room and in intensive care units. Different US-based procedures, such as transcutaneous US, EUS and EBUS are used for distinct approaches to lung tumours. B-mode imaging, colour Doppler sonography, CEUS and US-controlled interventions are the sonographic modalities used in daily clinical practice and for special clinical questions. In special clinical indications, US is the primary guideline diagnostic procedure. Transthoracic LUS is limited by physical factors such as absorption and reflection and, in principle, by a high interobserver variability, as well as differences in device and examining competence.

    Cite as: Görg C, Trenker C, Schuler A. Lung tumours. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 115–128 [https://doi.org/10.1183/2312508X.10006817].

  13. Page 129
    Abstract
    Giovanni Ferrari, Pneumologia, Ospedale Mauriziano Umberto I, Largo Turati 62, 10128 Torino, Italy. E-mail: giovanniferrarister@gmail.com

    This chapter covers US evaluation of diaphragm function, and describes the methods and US techniques used to measure movement and thickening of the diaphragm. Current validated techniques that assess diaphragm function are often invasive or expose the patient to ionising radiation. US is a noninvasive, easily repeatable bedside tool allowing direct visualisation of the muscle. There are a number of applications of DUS, from assessment and emergency medicine to respiratory medicine. DUS has become a useful tool in evaluating diaphragm dysfunction, suggesting its use to predict discontinuation from mechanical ventilation and to evaluate muscle atrophy during mechanical ventilation. It also has an important role in assessing respiratory effort, and in evaluating diaphragm paralysis and the mechanical consequences of pleural effusion. Thus, DUS is a fast, easy procedure that can identify diaphragm dysfunction, monitor muscle activity over time and provide useful information during invasive procedures such as thoracentesis.

    Cite as: Ferrari G, Helbo Skaarup S, Panero F, et al. The diaphragm. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 129–147 [https://doi.org/10.1183/2312508X.10006917].

  14. Page 148
    Abstract
    Stefan Posth, Kløvervænget 25, 5000 Odense C, Denmark. E-mail: stefan.posth@rsyd.dk

    When carrying out an US scan of the thorax, the examiner will also detect structures in the upper abdomen. Incidental abdominal pathologies may be detected with varying frequency during TUS. In this chapter, we provide an overview of the most common pathologies. Clinicians should be aware of the technical challenges when interpreting abnormal US patterns. Examiners who normally only examine the thorax may not be familiar with the abdominal organs. It is therefore essential that a specialist opinion is requested when a possible pathology is detected.

    Cite as: Posth S, Graumann O. The upper abdomen. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 148–160 [https://doi.org/10.1183/2312508X.10007417].

  15. Page 161
    Abstract
    Felix J.F. Herth, Dept of Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Röntgenstr. 1, D-69126 Heidelberg, Germany. E-mail: Felix.herth@med.uni-heidelberg.de

    The number of patients suffering from lung diseases is increasing worldwide. Lung cancer, for example, is now one of the most common cancers. Many of these diseases having mediastinal lymph node involvement. Accurate diagnosis or possible staging of the mediastinum is important not only to determine the prognosis but to decide the most suitable treatment plan. CT, MRI, PET and PET-CT are used for noninvasive imaging of the mediastinum. If a cytological or histological conformation is required, EBUS-TBNA is the preferred test. This chapter will focus on technique, procedures and limitations.

    Cite as: Herth FJF. The mediastinum. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 161–171 [https://doi.org/10.1183/2312508X.10007017].

  16. Page 172
    Abstract
    Michael S. Kristensen, Dept of Anaesthesia, Center of Head and Orthopaedics, Section 3071, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. E-mail: Michael.seltz.kristensen@regionh.dk

    US is an important tool in the provision of safer airway management for patients. Using a high-frequency linear probe affixed to conventional bedside portable US machines, the patient's upper airways from the mandible to the jugular notch can be depicted with US such that when the US beam penetrates to the luminal surface of the airway, as for example in the trachea, a strong echo arises yielding a distinct hyperechoic white line on the screen, the “tissue–air border”, and everything beyond that visualised on the screen is mere artefact. There are numerous indications for the use of US for airway management; only the most clinically valuable will be described in detail in this chapter. These include: US identification of the cricothyroid membrane in preparation for management of a difficult airway where emergency airway access via the anterior neck might become necessary, identification of the ideal interspace between tracheal rings for tracheostomy, and simultaneous scanning of the trachea and oesophagus just cranial to the jugular notch to observe whether a tube enters the airway or the oesophagus.

    Cite as: Kristensen MS, Teoh WH. Ultrasound of the neck for airway management. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 172–183 [https://doi.org/10.1183/2312508X.10007517].

  17. Page 184
    Abstract
    Gabriele Via, Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland. E-mail: gabriele.via@winfocus.org

    FoCUS is a targeted, simplified, cardiac US examination that is rapidly expanding in use in the management of critically ill patients. Performed by the clinician at the point of care, it provides essential information on the pathophysiology of shock, haemodynamic instability in trauma and nonshockable cardiac arrest syndromes. A growing body of evidence supports its use in a number of critical settings, including pre-hospital and austere/remote scenarios, emergency medicine, perioperative and intensive care, and respiratory and acute cardiac care. When integrated into the clinical diagnostic workup, FoCUS narrows the differential diagnosis (when not providing the conclusive diagnosis) and hastens and guides timely treatment. A detailed overview of the principles, aims, technique, applications, pitfalls and limitations of FoCUS is provided.

    Cite as: Via G, Dean A, Casso G, et al. Focused cardiac ultrasound. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 184–205 [https://doi.org/10.1183/2312508X.10007117].

  18. Page 206
    Abstract
    Francesco Raimondi, Dept of Translational Medical Sciences, Università “Federico II” di Napoli, via Sergio Pansini 5, I-80131 Naples, Italy. E-mail: raimondi@unina.it

    Chest US is a rapidly growing field in the imaging of the developing human, and is based on the same images and artefacts employed by adult emergency physicians. Solid evidence has recently been published about the US features of respiratory distress syndrome, transient tachypnea of the neonate and meconium aspiration syndrome. Tension pneumothorax can be accurately diagnosed with US and rapidly treated. Research into endotracheal tube positioning and chronic lung disease is ongoing. Semiquantification of the US signal has generated an intriguing comparison with the conventional radiogram with regard to the role of the first-line technique in several respiratory diagnoses. In the infant and the child, LUS can be applied in the work up of lung consolidations and several groups have investigated its accuracy in diagnosing pneumonia and bronchiolitis. Further paediatric applications include the study of chest wall masses and pleural effusions; focused assessment with sonography for trauma protocol remains an important area of current investigation.

    Cite as: Raimondi F, Migliaro F, Giannattasio A, et al. Newborns, infants and children. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 206–225 [https://doi.org/10.1183/2312508X.10007217].

  19. Page 226
    Abstract
    John P. Corcoran, Dept of Respiratory Medicine, Derriford Hospital, Plymouth, PL6 8DH, UK. E-mail: jpcorcoran@doctors.org.uk

    It is in the field of interventional pulmonology and as an adjunct to pleural procedures that TUS has gained its greatest foothold over the past decade, and where the evidence base for its continued use is undoubtedly strongest. There are many advantages to using TUS as a guide for invasive procedures, including a reduction in the risk of iatrogenic complications, increased diagnostic yield, patient and clinician satisfaction, cost savings and the avoidance of ionising radiation. This chapter will provide the reader with an overview of the published data underpinning current established practice in this field, alongside expert opinion from across the world on less commonly used techniques and how future research may potentially have an impact on clinical care and the way we work in the longer term.

    Cite as: Corcoran JP, Hew M, Maldonado F, et al. Ultrasound-guided procedures. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 226–243 [https://doi.org/10.1183/2312508X.10007317].

  20. Page 244
    Abstract
    Christian B. Laursen, Dept of Respiratory Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark. E-mail: Christian.b.laursen@rsyd.dk

    Although the number of published studies describing the clinical use of TUS is steadily increasing, several aspects are yet to be studied and assessed in clinical trials. Most importantly, the use of TUS is yet to find its place in major guidelines describing some of the conditions that can be assessed using US. It is hoped that future additional research will help to provide an evidence-based approach that indicates how TUS should be incorporated into the relevant guidelines.

    Cite as: Laursen CB, Rahman NM, Volpicelli G. Future directions. In: Laursen CB, Rahman NM, Volpicelli G, eds. Thoracic Ultrasound (ERS Monograph). Sheffield, European Respiratory Society, 2018; pp. 244–252 [https://doi.org/10.1183/2312508X.10007617].