The role of ultrasound in lung recruitment - MSICmsic.org.my/sfnag402ndfbqzxn33084mn90a78aas0s9g/asmic2018/… · Basic Principles Of Lung Ultrasound 1. A simple, 2D apparatus is
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The role of ultrasound in lung recruitment
Dr Chor Yek Kee
Sarawak General Hospital
Outline
•History, principle and practise of lung ultrasound
•Comparing lung ultrasound with CXR, CT scan and MRI
•The role of lung ultrasound in lung recruitment and evidence
“The lung is a major hindrance to the use of ultrasound at the thoracic level” - 1992
Harrison’s Principles of Internal Medicine, 1992: p1043
“Ultrasound imaging is not useful for evaluation of the lung parenchyma” - 2001 Harrison’s Principle of Internal Medicine, 2001; p1454
Removed - 2012 Harrison’s principle Of Internal Medicine. 18th edition New York ; McGraw-Hill: 2012
Prof. Daniel Lichtenstein
Ultrasound vs CXR
Sensitivity Ultrasound CXR
Interstitial syndrome 94% 46%
Consolidation 100% 38%
Pleural effusion 100% 38%
Pneumothorax 88% 52% N. Xirouchaki, E. Magkanas, K. Vaporidi, et al.: Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med.37:1488-1493 2011 W. Ding, Y. Shen, J. Yang, et al.: Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 140:859-866 2011
Ultrasound Vs CT Thorax
• 14 patient elective brain MRI, intubated and perform lung MRI then lung ultrasound to compare
MRI VS LUS
• Taking MRI as reference for the diagnosis of atelectasis
• LUS showed
• 88% of sensitivity (95% CI, 74 to 96%), • 89% of specificity (95% CI, 83 to 94%), • 88% of accuracy (95% CI, 83 to 92%)
Basic Principles Of Lung Ultrasound
1. A simple, 2D apparatus is the most appropriate for lung ultrasound.
2. Signs are aroused from pleural line
3. The thorax is an area where air and water are intimately mingled.
4. Lungs signs are mainly based on analysis of artifacts
5. Most lungs signs are dynamic
6. Nearly all acute disorders of thorax come in contact with surface, deep structure defect might be missed
Other additional benefit of US
1. Assessment can be done at bedside and fast
2. Reduced radiation and cost
3. Pleural fluid can be • Characterized : Hematocrit sign/plankton sign • Quantified • US guided drainage • Post procedure evaluation
4. Differentiating different lung pathology namely pneumonia, pulmonary edema, ARDS and pneumothorax
5. Ventilation recruitment
The Machine
The probe
• Equipment • Microconvex probe 4 – 7 MHz • Curvilinear Probe 4 – 7 MHz • Linear probe 7 – 15 MHZ
• Setting • Convention- marker to left of screen • No harmonic
• Techniques • Probe place perpendicular to the rib
Area of Scanning
Lung Ultrasound
IMAGE OF LUNG ULTRASOUND
LUNG ULTRASOUND IN SMALLER CHILDREN USING CURVILINEAR PROBE
Air filled alveolar Fluid filled alveolar
• This paper is to describe the usefulness of lung sonography (LUS) to conduct and personalize RM in a real-time way at the bedside.
• Deciding opening and closing pressure using ultrasound
N B1 B2 C
Ultrasound Reaeration Score VS Aeration calculation from CT scan
• Intervention : Antibiotic • Single center, • 30 patients • Compare reaeration
measured at day 0 and day 7 of VAP by • CXR • LUS • CT thorax
N B1 B2 C
• Lung US reaeration score > 5 • CT reaeration >400 mL and • Successful antimicrobial therapy.
• LUS reaeration score < –10 • loss of CT aeration >400 mL • Failure of antibiotics.
Ultrasound Reaeration Score
Compare Pressure-volume (PV) curve with lung ultrasound for assessing lung recruitment in patient with ARDS/ALI
• A highly significant correlation was found between PEEP-induced lung recruitment measured by PV curves and ultrasound reaeration score (Rho 50.88;P,0.0001).
• LUS reaeration score > 17 : PEEP lung recruitment greater than 600 ml. • LUS reaeration score < 15 : PEEP lung recruitment between 75 to 450ml • PEEP-induced lung recruitment can be adequately estimated with
bedside LUS.
B line Consolidation
Prof Dr Song’s Lung Scoring system
Ultrasound-guided recruitment manoeuvres with positive end-expiratory pressure proved useful in reducing the incidence of anaesthesia-induced atelectasis in infants
0
1
2
3
0
1
2
3
B line Consolidation
Prof Dr Song’s Lung Scoring system
Ultrasound-guided recruitment manoeuvres with positive end-expiratory pressure proved useful in reducing the incidence of anaesthesia-induced atelectasis in infants
0
1
2
3
0
1
2
3
Consolidation B line Pleural effusion
Prof Dr Song’s Lung scoring version 2
RCT looking at effect of ultrasound guided peri-
operative lung recruitment in term of outcome vs
control
Tidal Recruitment • Histological • Repetitive opening and closing of collapsed
alveoli during the mechanical respiratory cycle • The resultant high tissue stress in these
atelectatic zones, and especially in the boundary areas between collapsed and open lung areas,
• It can trigger a local inflammatory response and injure the alveolar–capillary membrane.
• This is one of the proposed mechanisms of ventilator-induced lung injury (VILI) that impairs the outcome of patients with acute respiratory distress syndrome.
Before Recruitment
After Recruitment
TIDAL RECRUITMENT
68 years old
3 years old
Example
Lung ultrasound of posterior lobe
24 Hours post Prone nursing
Case 2 Pre-recruitment
4 hours post recruitment
Anterior Lung Field
Posterior Lung Field
Summary
1. Lung ultrasound (LUS) assessment can be done at bedside and fast
2. LUS reduced radiation and cost as compare to CXR, CT scan and MRI
3. LUS can be used in ventilation recruitment
THANK YOU
Confluent B line
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