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

A shot in the dark…

simply a hopeful
attempt to hit an enemy
that you can't see
+

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
+ Objectives


Level 1 sono-anatomy


Right and left hemidiaphragm



Ribs and intercostal spaces



Lungs



Heart



Liver, spleen, kidneys
+

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
+ Diaphragm

C

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

Diaphragm (trans-organ)
RIGHT through liver

LEFT through spleen
+ Diaphragm Function (M-Mode)
Towards probe

RIGHT

LEFT
+

Diaphragm Function (2-D)

 Normal

diaphragm thickens on inspiration

 End-inspiratory

thickness 20% or more above baseline
+

Heart
+

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
+

Spleen

Spleno-renal recess

Spleen
Kidney

Diaphragm
+

Intercostal space

Pleura
+

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
+

Lungs – normal static findings
Rib
Rib

Rib

A lines
B line

Wipe out A lines as they pass

“Bat sign”
+

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
+

Lung sliding
+

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
+

M-Mode seashore sign
Static structures
horizontal lines (waves)

Pleural line

Pleural line reverberations
dynamic – granular (sand)
+

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
+

Lung Pulse Sign
+

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

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
+

Pleural effusion - anechoic
+

Pleural effusion, complex, non-septated

Plankton sign –
mobile swirling
elements in
effusion
+

Pleural effusion, complex, septated
+

Pleural effusion, inverted diaphragm
+

Effusion with atelectasis
+

Clotted haemothorax

Clot

Lung with peripheral
consolidation
(contusion)
+

Organised Haemothorax
+

Pleural effusion - colour doppler

Fluid colour sign – can be used to differentiate small
effusion from pleural thickening
+

Fluid colour sign

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

Pleural thickening

Hypo-echoic pleural plaque
+

Malignant pleural thickening
+

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
+

Lung consolidation
+

Lung tail (atelectasis and consolidation)

Note normal thickening of diaphragm with inspiration
+

Lung consolidation

Note material within effusion
+

Severe consolidation - hepatisation

Hepatised lung

Fluid bronchograms
+

Pneumothorax

 Absent

lung sliding

 Absent

lung pulse

 Absent

lung rockets

 M-Mode

– barcode or stratosphere sign

 Lung-point

sign
+

Pneumothorax – stratosphere sign
+

Pneumothorax – lung point sign
+

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
+

Lung point on 2D US
+

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
+

Diaphragm Dysfunction (M-Mode)
Normal
Towards probe

Paralysis
+

Diaphragm Dysfunction (2-D)
Towards probe

NO thickening
McCool FD, Tzelepis GE. Dysfunction of the Diaphragm. N Engl J Med 2012; 366:932-942
+

Pericardial effusion
Combined pleural and pericardial effusions

Pericardial effusion
+

Pneumothorax US algorithm
Lung
sliding

NO
B-lines

YES

NO

YES

Lung
point

No pneumothorax

YES

NO
Lung
pulse

YES

Pneumothorax

NO

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