Basic chest

ultrasound
How to do it?
Gabriela Jimborean, Edith Simona Ianosi
UMF Tg. Mures
 Thoracic ultrasound -TUS
• Advantages
– REAL TIME INVESTIGATION

– Noninvasive, comfortable

– Available without special patients preparation

– Repeatable, reproducible

– Ofers unique details (including function, motion -M, 3D)

– Fast learning curve

– Short investigation time, nonexpensive

– Can be performed at the patients bedside,

ICU, surgical room, ambulatory

– Completes dynamic description of

other investigation , chestX ray, CT, IRM

 Diagnostic indications
1. Pleural pathology
 Detection of pleural effusion and encysted PE
 Differentiation between pleural effusion and subdiafragm or parietal collection
 Dgn of phrenic paresis or diaphragmatic pathology – hernia
 Differentiation between pleural collection and
 Pahipleuritis
 Mezothelioma
 Pleural plaques
2. Consolidation - pneumonia
3. Interstitial disease + pn, ALI/SDRA
4. Tumors pf the chest wall, diapragm, peripheral lung, mediastinum

Tratat de ultrasonografie clinica fara CD - Volumul II - Radu I. Badea, Petru A. Mircea ,2010
 Guidance for Therapeutic maneuvers
- Pleural biopsy, chest wall biopsy, peripheral
mass biopsy
- Thoracentesis

- Talcosis guidance

- Central vein Catheter insertion

- Chest drain insertion SELDINGER

Tom Havelock, Richard Teoh, Diane Laws, et al. Pleural procedures and thoracic ultrasoundBTS pleural diseases guideline 2010
Wayne DB, Barsuk JH, O'Leary KJ, et al - Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008;3:48–54
Morrison MC, Mueller PR, Lee MJ, Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters. AJR 1992
Jos A Stigt, Harry J M Groen - Percutaneous Ultrasonography as Imaging Modality and Sampling Guide for Pulmonologists , Respiration 2014;87(6):441-451.
Mayo PH, et al. Safety of ultrasound-guided thoracentesis in patients receiving mechanical ventilation. Chest. 2004; 125:1059-1062
 Equipment
• Large types of devices
– 90% without Doppler!!!
– Portable patient’bed, ICU, surgery
room
– Smartphone!!! superportable
• Transductor – 3,5 – 5 and 7,5 – 10 for
more superficial layers
Doppler is not mandatory
• Curvilinear transducer
2-5 MHz for deeper structures
• Linear transducer - high
frecquency 5-10 MHz - for
structures closer to the probe
Patient agreement
Verbal -
Written - invasive manouvers

• Patient positioned
either in the sitting
position or lateral
decubitus
Doppler technique

• Vessels location and development ( large in malignant tissues)

• Avoiding the vessels/organ punction and hemorhagies
• Diff between pleural thickening , plaques, MPM small colections
over or under the diaphragm
• Biosy
• EBUS TBNA
 Technical Impediments for TUS

• Air

• Bones

• Obesity

• Chest wall Edema

• Not so many details of the lung, cavities content

• No emphysema evaluation or bullae

• Expensive ( Doppler)
Sonographic –air - tissues interfaces cause artifacts
 The presence or absence of artifacts help a lot the diagnosis

US Gray scale
Echogenicity is the ability to bounce an echo, e.g. return the signal in
ultrasound examinations

 Anechogenic area

 Isoechogenic area
- comparable to the liver, spleen

 Hypoechogenic area

 Hyperechogenic area
 Ferestre acustice
1.Trans-diafragmatică – reg.
suprahepatica si suprasplenica

2. Intercostală inferior

3. Intercostală axilară

4. Intercostală post
1 2
5. Intercostală ant. (sp II Ic PTX)
6. Substernala si suprasternala
(mediastin si inima)
7. Fosa supraclaviculara

Gabriela Jimborean, Edith Ianosi, Roxana Nemes, Tudor Toma – basic thoracic ultrasound for the respiratory physician, Pneumologia vol 64/3, 12 - 18
 2

Gabriela Jimborean, Edith Ianosi, Roxana nemes, Tudor Toma – basic thoracic
ultrasound for the respiratory physician, Pneumologia 64/3/2015, 12 - 17
4
 A “step by step” approach to scaning
Start to scan longitudinally, below the diaphragm, on the anterior axillary line on the right, or
posterior axillary line on the left. In this way multiple interspaces can be examined in a short time and the
reference organs can be quickly identified.

L
3. Identify pleural 5. Scan the
line. Check for the remaining chest
presence of pleural windows
T 2. Identify the lung. Progress
longitudinally, upwards, until
sliding
4. Focus on the
the lung movement becomes lung or pleural
apparent. Check for the pathology
“curtain sign”
1. Identify the
reference organ:
liver (right) and
spleen (left) 1. Longitudinal positioning of the transducer
2. Transversal positioning of the transducer
Gabriela Jimborean, Edith Ianosi, Roxana nemes, Tudor Toma – basic thoracic ultrasound for the respiratory physician, Pneumologia 64/3/2015, 12 - 17
1. Identify the reference organ: liver (right) and spleen (left)
 Identify the lung and
“Courtain sign”
• Invite the patient to take deep breaths, in

order to assess the lung movement and the

ultrasound artefacts that are present with a

normal lung

• Once the lung comes into the echo window

no further structures can be visualised beneath

Liver
the lung (the curtain sign) and the characteristic

artefacts described forwards become visible

“Bat sign” identifying
- Rib and acoustic shadowing
- Intercostal space, pleural line
- Rib and acoustic shadowing
 Acoustic enhancement – Acoustic shadowing
Increase amplitude caused by Reduced amplitude caused by
structures with low intervening structures with
attenuation high attenuation ( ribs)
 Longitudinal position of the
transducer
Recognize each layer and
echoes produced by
• Skin
• Subcutaneous tissue
• Intercostal muscles
• Fascia
• Ribs
• Pleural membranes
and the lungs
 Skin, Subcutaneous
tissue

• Skin – hyperechogenic
• Subcutaneous tissue
– Fat - hypoechogenyc – areola
– Conective tissue – parallel hyperechoic
septae
• Ribs – repetitive hyperechoic curved
image with acoustic shadow
• Intercostal muscles
- hypoechogenyc, linear forms
containing echogenic lines - fascia
 Pleural line
Pleural line - parietal and visceral
pleura produce together a
hyperechogenic line well seen between
the ribs ( inferior)
It is situated 0.5 cm below the rib line
With the 7,5 – 10 MHz transducer it
may differentiate the 2 membranes: PP
and VP
Kline JP, Dionisio D, Sullivan K, Early T, Wolf J, Kline D. Detection of pneumothorax with ultrasound. AANA J 2013;81(4):265-271.
Volpicelli G. Lung sonography. J Ultrasound Med 2013;32(1):165-171.
Diacon AH, Theron J, Bolliger CT. Transthoracic ultrasound for the pulmonologist. Curr Opin Pulm Med 2005;11(4):307-312
 ”Lung sliding”
”Lung sliding” = The rhythmic movement of the
lung (with the pleura and pleural line) during
breathing
“Lung slidding " disappears in specific conditions:
 Pleural effusion
 Pneumothorax
 Tumors
 Pleural plaques
 Advanced COPD
 Pulmonary Infarction
 Date of download: 10/24/2016
Copyright © American College of Chest Physicians. All rights reserved.

Thoracic Ultrasound for Diagnosing Pulmonary Embolism*: A Prospective Multicenter Study of 352 Patients

Chest. 2005;128(3):1531-1538. doi:10.1378/chest.128.3.1531

Pulmonary Infarction

Gebhard Mathis, MD; Wolfgang Blank, MD; Angelika Reißig, MD; Peter
Lechleitner, MD; Joachim Reuß, MD; Andreas Schuler, MD; Sonja Beckh, MD
Figure Legend:
Ultrasound image showing triangular lung (top) and rounded lung infarct (bottom). Both lesions are pleural based, open to
transcutaneous ultrasound examination.
 Date of download: 10/24/2016
Copyright © American College of Chest Physicians. All rights reserved.

Thoracic Ultrasound for Diagnosing Pulmonary Embolism*: A Prospective Multicenter Study of 352 Patients

Chest. 2005;128(3):1531-1538. doi:10.1378/chest.128.3.1531

Figure Legend:
Thirty-six-year-old patient postoperatively. Top: PE confirmed in CTPA. Center: Triangular lesion on ultrasound. Bottom, left, c, and
right, d: small rounded lesions on ultrasound.

Gebhard Mathis, MD; Wolfgang Blank, MD; Angelika Reißig, MD;

Peter Lechleitner, MD; Joachim Reuß, MD; Andreas Schuler,
MD; Sonja Beckh, MD
 A lines
• A lines - horizontal, hyper echoic
repetitive parallel lines and parallel
with the pleural line ( echoes of the
pleural first line = normal pleura)
A = Air (in the normal lung)
• A lines = Reverberation artifacts
• Located equidistant from each other
The absence of the A lines means that the
normal air was replaced with something that
transmits US)
• Pulmonary edema
Mod M
• Diffuse interstitial fibrosis See shore
• Tumors
• Contusion
• The presence of blood
Liniile B lines – “Comet tails” “lung rockets”

B lines – vertical lines which arise from the pleural line

and extend to the bottom
1 isolated B line - They move with the lung sliding and efface A lines at
their point of intersection
- The width of the comet-tail artifacts increases with
the depth, to a value of about 1 cm
- The presence in the Lower lung zone is normal
- They are pathological when long, multiple and and
thick (7 mm apart line B - intralobular septa; under 3
mm apart closely spaced B lines (intraalveolar
process)
- Interstitial and alveolar edema
- ARDS
- Pneumonia
- ILD
- Sonograpfic equivalence of Kerley lines
• E lines small vertical, laser – like lines that reach the
edge of the screen
• Similar to B lines but they arise from the chest wall not
from the pleural line

• Ground glass - sandy apearance (B mode)

• “Seashore sign” (M mode):
– Horizontal lines below the
pleural line with granular pattern

Volpicelli G. Lung sonography. J Ultrasound Med 2013;32(1):165-171.

Diacon AH, Theron J, Bolliger CT. Transthoracic ultrasound for the pulmonologist. Curr Opin Pulm Med 2005;11(4):307-312.
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65 Suppl
2:ii61-ii76
 B= brightness, 2D image; intensity of the brightness: strength of the echo

M = motion (stationary stuff : straight line, moving things: curve/dot

B
mode M
mode

Brightness mode See shore

Classic image “bat sign”
Rib - pleural line – rib
+ acoustic shadow
 B - mode
M mode – “see shore”
Pleural line
A lines

Pleural
line

A lines

Lung
point

See shore Bare code

 1. Pleural pathology
– Small and encysted collections (5 - 10ml)

– Diff between consolidation and collection,

atelectasis, plaque

– Diff between over and under the diphragm

collection

– Dgn. In emergency of the most important sign PTX,

athelectasis, Pulmonary edema , Pneumonia,
pleural effusion

Tratat de ultrasonografie clinica fara CD - Volumul II - Radu I. Badea, Petru A. Mircea ,2010
Tom Havelock, Richard Teoh, Diane Laws Fergus Gleeson, - Pleural procedures and thoracic ultrasound: BTS pleural disease guideline,
Thorax 2010;65:i61-i76
 TUS

Tom Havelock, Richard Teoh, Diane Laws, Fergus Gleeson - Pleural procedures and thoracic ultrasound: BTS pleural disease guideline, Thorax
2010;65:i61-i76;
 Pleural effusion
• Location , extension

• Volum V (ml) = 20 x Sep (mm)

(distanța end – expiratory between the

pleural membranes in expire

• Sepate

• Density

• Surrounded organ

Intensive Care Med. 2006 Feb;32(2):318-21. Epub 2006 Jan 24.

Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients.
Balik M1, Plasil P, Waldauf P, Pazout J, Fric M, Otahal M, Pachl J
Fluid Vol (ml) – Sep (mm) x20
Lung with bronchogram
 Simple pleural effusion
• Anecogenic image with posterior
enhancement
TUS
• Fluid volume measurement
• Pleural membrane analysis
• Peripheral lung aspect
• Subdiaphragmatic organ aspect
(liver, spleen)
• +/- ascitis
• Diaphragm movement
 Malignant
mesothelioma
Pleural mesothelioma + hemoragic
fluid pleural thickening
Empyema
 2. Abdominal US
+++ subdiafragmatic pathology
2. TUS for Pneumothorax
 ICU, emergency

1. Absence of lung movement and “lung sliding” in mod B ( because of pleural

separation)
2. Absence “comet tails” and “B lines” in mode B
3. Absence of the “sea shore” aspect under the pleural line in mode M
4. Bare code or stratosphere sign – mod M
5. ”Lung point” “Transition point” - the last contact point between the lung to
the parietal pleura

PTX
 Blue protocol
in emergencies
• Blue point sup.
• Blue point inf.
• PLAPS - Posterolateral Alveolar
or Pleural Syndromes (PLAPS) –
intersection of: a horizontal line at
the level of the lower BLUE-point;
a vertical line at the posterior axillary line

Lung ultrasound in the critically ill, Daniel A LichtensteinEmail author, Annals of

Intensive Care20144:1
Bedside Lung Ultrasound in Emergency
Tutorial 9 - Lung ultrasound, ICU Sonography
Disparition of the “sliding lung”

Sugestive for PTX

• Atelectasis
• Simphisis, pleurodesis
• Pneumonia
• Apneea
• Inserted drain
• Advanced COPD
 Code bare sign or stratosphere in M
mode

Sea shore -
normal
 Lung point

B mode PTX M mode

Lung ultrasound in the critically ill, Daniel A LichtensteinEmail author, Annals

of Intensive Care20144:1
 3. Interstitial syndrome - fibrosis, IPE, APE

Few A lines
”Comet tails” or linii B (ant/lat
pulm)
7 mm –thickening of the
interlobular septae
3 mm alveolar edema

NORMAL
 4. Consolidation

Cavity

Dr. Gilles Mangiapan – Hopital Intrecommunal de Creteil - Astra Zeneca

Group G - ECHO
Gabriela Jimborean, Edith Ianosi, Roxana Nemes, Tudor Toma – basic thoracic ultrasound for the respiratory physician, Pneumologia vol 64/3, 12 - 18
5. Peripheral lung
tumors and MPM
• Dgn. and characterisation
• Parietal invasion of the MPM
• Staging of lung Cancer of MPM
- T2 Tu - visceral pleura
- T3 Parietal pleura invasion
• Uncomplicated Pancoast TU -
T3

Gabriela Jimborean, Edith Ianosi, Roxana Nemes, Tudor Toma – basic thoracic ultrasound for the respiratory physician, Pneumologia vol 64/3, 12 - 18
N R Qureshi, N M Rahman, F V Gleeson, Thoracic ultrasound in the diagnosis of malignant pleural effusion, Thorax 2009;64:139-143
6. Pachipleuritis 7. Diaphragm

Agnes Harmath – chest and lung malformation – Donald school of US in

Obstetroics and Ginecology, 2007 – 19 – 97
 TUS – guidance tool
- Biopsy – pleura, lung, chest wall
- Pleural aspiration

- Chest drain insertion

- Guidance - talcosis

- Ghidarea CV catheter insertion

Tom Havelock, Richard Teoh, Diane Laws, et al. Pleural procedures and thoracic ultrasoundBTS pleural diseases guideline 2010
Wayne DB, Barsuk JH, O'Leary KJ, et al - Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008;3:48–54
Morrison MC, Mueller PR, Lee MJ, Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters. AJR 1992
Jos A Stigt, Harry J M Groen - Percutaneous Ultrasonography as Imaging Modality and Sampling Guide for Pulmonologists , Respiration 2014;87(6):441-451.
Mayo PH, et al. Safety of ultrasound-guided thoracentesis in patients receiving mechanical ventilation. Chest. 2004; 125:1059-1062
Thoracentesis guidance
 Chest drain
insertion Seldinger
 TT heart US
• Pericarditis
• Cardiac cavities, valves, flows,
ventricular performance
• Great vessels

Pericarditis