1) Chest sonography can be used in respiratory emergencies to assess both superficial and deep structures using high and low frequency probes respectively. 2) Common signs seen on sonography include B-lines indicating pulmonary edema, the bat sign of normal lung, and the seashore sign indicating a pneumothorax. 3) Sonography can also assess volume status by measuring the inferior vena cava diameter and calculating the caval index, evaluate lung consolidations and air bronchograms, and detect pulmonary embolism.

2. Role of Chest Sonography in
Respiratory Emergencies
Gamal Rabie Agmy, MD, FCCP
Professor of chest Diseases,Assiut university

4. High Frequency
• High frequency (5-10 MHz)
greater resolution
less penetration
• Shallow structures

5. Low Frequency
• Low frequency (2-3.5 MHz)
greater penetration
less resolution
• Deep structures

6. Probes

7. A common language: Color Coding
Black Grey White

9. Chest Sonography

10. BLUE-Protocol and FALLS-Protocol Two
Applications of Lung Ultrasound in the Critically
Ill
(Daniel A. Lichtenstein , MD , FCCP, CHEST
2015; 147 ( 6 ): 1659 - 1670

13. THE BAT VIEW
Chest wall
Pleural line

15. Normal lung surface
Left panel: Pleural line and A line (real-time).
The pleural line is located 0.5 cm below the rib line in the adult.
Its visible length between two ribs in the longitudinal scan is
approximately 2 cm. The upper rib, pleural line, and lower rib (vertical
arrows) outline a characteristicpattern called the bat sign.

16. A lines = default normal
 Horizontal echo
reflection at exact
multiples of intervals
from surface to
bright reflector.
 Dry lung OR PNTX
 Decay with depth
 Obliterated by B
pleura A
A
A
A
A
A

19. the "seashore sign" (Fig.3).

22. Confluent B lines = Bad Bad
 ‘White’ or ‘shining’
lung
 Means increased
severity
 Probably indicates
thicker fluid in alveoli
eg protein or
inflammatory cells
 % space / 10

23. B x 3 x 2 x 2 = CCF
Makes assumption that ‘globally’ wet
lungs are most likely to be CCF
12

24. Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125

29. Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform
imagesrepresentative of air bronchograms
Pleural
effusion
Lower lobe

41. Absent lung sliding
Exaggerated horizontal artifacts
Loss of comet-tail artifacts
Broadening of the pleural line to a band
The key sonographic signs of
Pneumothorax

45. the "seashore sign" (Fig.3).

54. Pulmonary Embolism

55. Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration2003;70:441-452)

57. Alveolar-interstitial syndrome

62. Multiple B-lines - « comet-tails » - interstitial edema
(B1)
7 mm apart « B lines » thickened interlobular
septa
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997JJR 25 05http://www.reapitie-
http://www.reapitie- 02 09 2012

63. D Lichtenstein et al AJRCCM 156 : 1640-1646 , 199730 11 2011
Coalescent B lines - « comet-tails » - alveolar
edema
3 mm apart « B lines » ground-glass
areas
http://www.reapitie- 02 09 2012

76. IVC Sonography

77. INDICATIONS
IVC Ultrasound
Spontaneously
Breathing
Mechanical
Ventilation
Volume Status / CVP Fluid Responsiveness

78. INDICATIONS
Assessing
Intravascular Volume Status /
CVP
•Volumedepleted state :
•Dehydration
_ AcuteKidneyInjury (?
Prerenal,renal, post renal)
- Diuretictherapy
- Sepsis
* Volumeoverloadedstate:
-Heart Failure
-Cirrhosiswith ascites
- Anasarca

79. INDICATIONS
Assessing
Fluid Responsiveness in Shock
* Measuring the variation in IVC diameter in these
situations can help determine whether the patient’s
blood pressure will respond to fluids or whether
inotropic support (i.e. dobutamine) will be needed
NB: IVC diameter does not correlate with right atrial
pressure in patients who are intubated with shock

80. Respiratory variation
Expands w/ expiration
Contracts w/ inspiration
Due to changing intrathoracic pressures.

81. PROCEDURE
Probe Selection
1 Low frequency 2-5 MHz
2 Curvalinear probe

82. PROCEDURE
Approach #1 – Xiphoid View

83. PROCEDURE
Landmarks
Aproach #1 – Xiphoid View
1 Most common approach
2 Place probe longitudinally just below the
xiphoid process with the probe marker to the
patient’s head
3 Look for IVC going into right atrium – may
need to move probe 1-2cm to patient’s
right and then tilt it slightly towards the
heart

84. IVC Longitudinal

85. PROCEDURE
Approach #2 – Anterior -Mid-Axillary
View

86. PROCEDURE
Landmarks
Aproach #2 – Anterior Mid-Axillary View
1 Place probe longitudinally in right anterior
mid-axillary line with marker towards the
head
2 Look for IVC running longitudinally
adjacent to liver crossing the diaphragm.
3 Track superiorly until it enters right atrium
confirming that it is the IVC and not the
aorta.

87. IVC Anterior Mid-Axillary View

88. Measuring the IVC Diameter
Measure IVC 2cm

89. Inspiratory (Minimal) IVC
Diameter

90. Maximum (Expiratory) IVC
Diameter

91. M-Mode IVC Diameters

92. CAVAL INDEX (CI)
CI =
minimal (inspiratory)
diameter
maximum (expiratory)
diameter
maximum (expiratory)
diameter

93. CAVAL INDEX (CI)
Volume
Depletion
Volume
Overload
0% 100%

94. IVC v CVP
Correlation Between IVC Diameter Plus CI and
CVP
IVC Max Diameter
(cm)
CI CVP
(mmHg)
< 1.5
100%
(total collapse)
0-5
1.5-2.5 > 50% 6-10
1.5-2.5 < 50% 11-15
> 2.5 < 50% 16-20
> 2.5
0%
(no collapse)
>20

95. Echocardiography

97. (Chest. 2008; 133:836-837)
© 2008 American College of Chest Physicians
Ultrasound: The Pulmonologist’s New Best
Friend
Momen M. Wahidi, MD, FCCP