Clinical Applications of Chest Sonography

Clinical Applications of

Chest Sonography

Professor Gamal Agmy, MD, FCCP

Professor of chest diseases, Assiut University

• Diagnostic ultrasonography

is the only clinical imaging

technology currently in use

that does not depend on

electromagnetic radiation.

• U/S probes emit and

receive the energy as

waves to form pictures

Ultrasound Transducer

Speaker

transmits sound pulses

Microphone

receives echoes

• Acts as both speaker & microphone Emits very short sound pulse

Listens a very long time for returning echoes

• Can only do one at a time

• Immediate bedside availability

• Immediate bedside repeatability

• Rapid goal directed application

• Cost saving

• Reduction in radiation exposure

Advantages of Transthoracic

Ultrasonography

Probes

High Frequency

• High frequency (5-10 MHz)

greater resolution

less penetration

• Shallow structures

Low Frequency

• Low frequency (2-3.5 MHz)

greater penetration

less resolution

• Deep structures

Displays

• B-mode

– Real time gray scale, 2D

– Flip book- 15-60 images per second

• M-mode

– Echo amplitude and position of moving

targets

– Valves, vessels, chambers

“B” Mode

“M” Mode

A common language: Color Coding

Black Grey White

Image properties

• Echogenicity- amount of energy reflected back from tissue interface

– Hyperechoic - greatest intensity - white

– Anechoic - no signal - black

– Hypoechoic – Intermediate - shades of gray

Hyperechoic

Hypoechoic

Anechoic

Ultrasound Artifacts

• Can be falsely interpreted as real

pathology

• May obscure pathology

• Important to understand and appreciate

Ultrasound Artifacts

• Acoustic enhancement

• Acoustic shadowing

• Lateral cystic shadowing (edge artifact)

• Wide beam artifact

• Side lobe artifact

• Reverberation artifact

• Gain artifact

• Contact artifact

Acoustic Enhancement

• Opposite of acoustic shadowing

• Better ultrasound transmission allows

enhancement of the ultrasound signal

distal to that region

Acoustic Enhancement

Acoustic Shadowing

• Occurs distal to any highly reflective or

highly attenuating surface

• Important diagnostic clue seen in a

large number of medical conditions

– Biliary stones

– Renal stones

– Tissue calcifications

Acoustic Shadowing

• Shadow may be more prominent than

the object causing it

• Failure to visualize the source of a

shadow is usually caused by the object

being outside the plane of the

ultrasound beam

Acoustic Shadowing

Acoustic Shadowing

Reverberation Artifacts

• Several types

• Caused by the echo bouncing back and

forth between two or more highly

reflective surfaces

Reverberation Artifacts

• On the monitor parallel bands of

reverberation echoes are seen

• This causes a “comet-tail” pattern

• Common reflective layers

– Abdominal wall

– Foreign bodies

– Gas

Reverberation Artifacts

Reverberation Artifacts

Gain Artifact

Contact artifact

• Caused by poor probe-

patient interface

Scanning Positions for Chest Sonography

Focused exam – 8 views

Sagittal or coronal views

RIB SHADOWS confirm position and guide you to pleura.

The Regions

1 2

3

4

Volpicelli et al, Am J Emerg Med 2006; 24: 689-696

Region 2 is usually above the nipple

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 characteristic pattern called the bat sign.

THE BAT VIEW

Chest wall

Pleural line

Rock the probe slightly side to side

until the pleura is in sharp focus

Pleura not at right angles

to probe so indistinct

Correct angle =

sharpest edge.

Interpretation

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

B lines = fluid in alveolus or

interstitium

Originates from pleural line

Reaches base of

screen OR ALMOST

MORE THAN 2 at once is abnormal

EXCEPT in lung base

Remember as

„Kerley Bs‟

Not exactly the

same.

RIB RIB

B B B B B

B Lines = Crackles

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

B x 3 x 2 x 2 = CCF

Makes assumption that „globally‟ wet

lungs are most likely to be CCF

12

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 characteristic pattern called the bat sign.

Normal Anatomy

Normal Chest Ultrasound

Superficial tissues

ribs

Poste

rior a

coustic

shadow

ing

Impure

acoustic

shadow

ing

Pleural line

Muscle

Fat

Pleura

Lung

the "seashore sign" (Fig.3).

Benign Lymphadenopathy

Malignant LN

Malignant LN: Hypoechoic, no hilar sign, irregular

vascularization

Fracture Rib

Sternum fracture caused by a car accident. + -+

Six mm step. H= organized hematoma.

Osteolytic lesions:

Multiple myeloma: Intense irregular vascularization

Invasion by lung cancer:

Pancost tumor invading the chest wall, irregular vascularization

Peripheral lung tumour invading chest wall

*The amount of pleural fluid can be estimated

by the following formula:

V (ml)= 20 x Sep V = volume, Sep = maximal distance between

the two pleura layers.

*For sitting patients a good method is to

calculate the sum of the basal lung to

diaphragm distance and the lateral height of the

effusion and to multiply the sum by 70.

Quantification of Pleural Fluid:

the "seashore sign" (Fig.3).

Absent lung sliding

Exaggerated horizontal artifacts

Loss of comet-tail artifacts

Broadening of the pleural line to a band

Lung point

Loss of lung impulse

The key sonographic signs of

Pneumothorax

Interstitial syndrome.

Lichtenstein D A , Mezière G A Chest 2008;134:117-125

Thoracic ultrasound examination is considered positive for

interstitial syndrome when at least two scans per side show

multiple B lines:

in this case (cardiogenic pulmonary edema), positive scans are detected all

over the anterolateral chest.

Alveolar-interstitial syndrome

The aurora sign: an ultrasonographic sign suggesting

parenchymal lung disease

© 2003 by the American Institute of Ultrasound in

Medicine

J Ultrasound Med 22:173-180 • 0278-4297

Transthoracic Sonography of Diffuse Parenchymal

Lung Disease

The Role of Comet Tail Artifacts

Conclusions: Diffuse parenchymal lung disease

should be considered if multiple comet tail artifacts

distributed over the whole surface of the lung together

with a thickened and irregular, fragmented pleural line

are visible. Transthoracic sonography may reflect the

distribution of pleural involvement and may show

subpleural alterations.

Am. J. Respir. Crit. Care Med.,

Volume 156, Number 5, November

1997, 1640-1646

The Comet-tail Artifact

An Ultrasound Sign of Alveolar-

Interstitial Syndrome

Pneumonia

• It is commonly visualized by TUS as a

hypoechoic consolidated area of varying size

and shape, with irregular borders.

• The echotexture can appear homogeneous or

inhomogeneous.

• The most common sonographic feature of

pneumonia is the air bronchogram, which is

characterized by lens-shape internal echoes

within the hypodense area or echogenic lines

and corresponds to air inclusions or air-filled

bronchioles and bronchi.

Different B lines

Pneumonia Posterior intercostal scan shows a hypoechoic

consolidated area that contains multiple

echogenic lines that represent an air

bronchogram.

Pneumonia; fluid bronchogram

• Conversely, the fluid

bronchogram is characterized

by anechoic or hypoechoic

tubular structures in the

bronchial tree.

Post-stenotic pneumonia Posterior intercostal scan shows a hypoechoic

consolidated area that contains anechoic,

branched tubular structures in the bronchial tree

(fluid bronchogram).

Pleural effusion and alveolar consolidation; typical

example of PLAPS.

Lichtenstein D A , Mezière G A Chest 2008;134:117-125

A 45-year-old patient presenting in the emergency department with cough, pleuritic pain and

dyspnoea. Double-view chest x-ray showed no sign of pneumonia (A, B). A CT scan (C)

confirmed the presence of a right basal consolidation shown by lung ultrasound (D).

Summarizing Sonographic

findings in pneumonia

• • Liver like in the early stage

• • Air bronchogram

• • Lenticular air trappings

• • Fluid bronchogram (poststenotic)

• • Blurred and serrated margins

• • Reverberation echos in the margin

• • Hypoechoic abscess formation

Lung abscesses

• They typically appear as round or oval, largely

anechoic lesions.

• In the early stage, small abscesses are visible as

a pathological collection of fluid irregularly

settled in a consolidated, liver-like infiltrate.

• Depending on the capsule formation, the edge

of the abscess can be smooth and echodense.

• Microabscesses are often visible as anechoic

areas within the pneumonic consolidation.

Pneumonia complicated by

abscesses.

Multiple small collections of fluid are irregularly settled in a consolidated liver-like infiltrate. Loc:

Loculation; Microloc: Microloculation

Lung abscess with air inside the lesion

A: High amplitude echoes

are clearly visible (arrow), as

well as multiple echogenic

small air inclusions

(arrowheads);

B: Corresponding computed

tomography scan shows the

same findings

Contrast-enhanced ultrasonography

of pneumonia

A: Baseline scan shows

a hypoechoic

consolidated area

B: Seven seconds after

iv bolus of contrast

agent, the lesion shows

marked and

homogeneous enhancement

C: The lesion remains

substantially unmodified

after 90 s.

Contrast-enhanced ultrasonography evaluation of

pneumonia with pleural effusion.

Baseline scan shows parenchymal

consolidation with air bronchogram

(arrows) and subtle surrounding

effusion (arrowheads)

After iv bolus of contrast agent, the

consolidation is enhanced and better

demarcated from the effusion

Lung abscess at CEUS .A: An anechoic oval

lesion is surrounded

by an echodense

capsule;

B: After iv bolus of

contrast agent, the

lesion shows no

contrast agent uptake,

whereas the capsule is

strongly enhanced

Contrast-enhanced

ultrasonography of

pulmonary infarction

After iv bolus of

contrast agent, the

lesion shows no

contrast agent

uptake in the

arterial phase,

which suggests

the absence of

blood supply.

Contrast-enhanced ultrasonography of bronchial

carcinoma

A: Baseline scan shows a hypoechoic

lesion with irregular borders

Ten seconds after iv bolus of contrast agent, the pulmonary parenchyma near the lesion is already enhanced (arrows), whereas the lesions is still unenhanced

B: Twenty seconds later, the lesion shows delayed inhomogeneous enhancement, which indicates a preferential bronchial arterial supply

Pulmonary embolism (PE)

• The sensitivity of TUS for PE has been estimated to

range from 80% to 94%, the specificity from 84%

and 92%, and the overall accuracy from 82% to

91%.

• Although CTPA is undoubtedly the method of

choice to obtain a definitive diagnosis of PE, TUS

should be taken into consideration in some

circumstances, particularly in critically ill patients

who might not tolerate transport for other imaging

modalities, in cases of pregnancy, contrast agent

allergy, or renal failure.

Pulmonary infarction.

Posterior

intercostal scan

shows a

triangular-shaped

hypoechoic lesion

with central

hyperechoic

structures that

indicate the

presence of air

occupying the

affected

bronchiole

Dynamic course of pulmonary infarction

A: Lateral intercostal scan of

the right lung shows a typical

triangular-shaped peripheral

lesion;

B: computed tomography scan

of the lateral segment of the

lower right lobe shows a

triangular pleural-based lesion

with the vertex towards the

hilum

C: After 40 d, the lesion is no

longer visible by computed

tomography scan;

D: The lesion appears reduced in size at transthoracic

ultrasonography examination.

Pulmonary embolism. A 1.2 – 1.5 mm triangular subpleural

lung consolidation. B. Vascular sign at the margin, not central

•On color Doppler sonography,

PE-based peripheral lesions do

not show flow signals inside,

a phenomenon defined as

“consolidation with little

perfusion”

Sonomorphology of peripheral pulmonary

embolism

• Echopoor

• Well demarcated

• 1-3 (0.5-7) cm in size

• Pleural based

• Triangular > rounded

• Central bronchial reflexion (> 3 cm)

• Vascularization stop

• 2.5 lesions/patient on average

• 2/3 dorsobasal located

• Small pleural effusion

Schematic representation of the parenchymal, pleural and vascular

features associated with pulmonary embolism.(Angelika Reissig, Claus

Kroegel. Respiration 2003;70:441-452 )

The Late sign of atelectasis:

• The late sign appeared when the air inside the

consolidation was progressively absorbed, which

yielded a loss of volume of the lesion with the

typical static air bronchogram inside.

• Pleural effusion is almost always associated with

compression atelectasis and frequently with

obstructive atelectasis.

• In the case of compression atelectasis, the

effusion is typically larger compared to that

associated with obstructive atelectasis.

Relaxation atelectasiss

Posterior intercostal scan shows a liver-like consolidation with the typical shape of a jelly bag cap

surrounded by pleural effusion.

Contrast-enhanced ultrasonography

evaluation of compression atelectasis.

Baseline scan shows a liver-like

consolidation surrounded by

multiloculated pleural effusion

Twelve seconds after iv bolus of contrast agent,

the consolidation shows marked and

homogeneous enhancement, whereas pleural

effusion shows no enhancement.

Obstructive atelectasis

• It shows a liver-like and inhomogeneous

echotexture with secretion-filled bronchi (fluid

bronchogram) and variable shape.

• The real-time TUS visualization of

bronchograms during breathing movements can

often enable one to distinguish between

obstructive atelectasis and pneumonia.

• The presence of the dynamic air bronchogram

indicates pneumonia, while a static air

bronchogram suggests obstructive atelectasis.

Posterior intercostal scan shows a hypoechoic consolidated area that contains anechoic, branched tubular structures in

the bronchial tree (fluid bronchogram).

CEUS in Peripheral bronchial carcinomas

CEUS can help to define better necrotic areas that are depicted as anechoic regions inside the enhanced viable tumor.

The infiltrative growth of solid tissue without regard to anatomical structures is characteristic of malignancy

Peripheral bronchial carcinoma.

Posterior intercostal scan shows a hypoechoic consolidation with relatively well-delineated borders. The air bronchogram is absent.

Contrast-enhanced ultrasonography evaluation of bronchial carcinoma.

Baseline scan shows consolidation with inhomogeneous echotexture.

Twenty seconds after iv bolus of contrast agent, necrotic areas can be depicted as anechoic regions inside the enhanced viable tumor

Bronchial carcinoma infiltrating the pleural wall.

A: Posterior intercostal scan shows a hypoechoic lesion accompanied by rib destruction (arrows);

B: Twenty-four seconds after iv bolus of contrast agent, the lesion appears inhomogeneously enhanced; the disrupted rib appears more echogenic than the tumor (arrowheads), as a consequence of the incomplete tissue suppression due to the strong echogenicity of bone tissue.

Pulmonary metastasis Posterior intercostal scan shows a round-shaped, clear-

bordered lesion.

Prof . Maha K Ghanem, MD, FCCP

Lung cancer. A rounded, tumoral fringes, central echopoor necrotic lesion with B irregular neovasculaization

Sonomorphology of pulmonary carcinomas • Hypoechoic, inhomogeneous

• Rounded, polycyclic

• Sharp, serrated margins

• Ramifications and fringes

• Infiltration of chest wall

• Irregular vascularization

Us is increasingly used to guide interventional procedures of the chest including:

1- Interventional procedures of the pleural space.

* Thoracentesis and catheter drainage.

* Pleural biopsy.

2-Pulmonary interventional procedures

* Us guided lung biopsy (Lung cancer – Pneumonia).

* Drainage of lung abscesses.

3- Mediastinal intervention.

* Biopsy of mediastinal mass and lymph nodes.

4- Chest wall intervention.

* Biopsy of chest wall mass.

For performance of the US guided thoracic

intervention, the following are required:

1- The procedures could be performed on an out patient basis.

2- The procedures may be carried out in any room.

3- Special puncturing equipment should be available.

4- The patient must be informed of the course and risk of the procedure.

5- The coagulation status should be known.

6- Acknowledging preexisting finding (bronchoscopy – chest radiograph – CT).

7- The sonographic status of the thorax is evaluated.

The US guided procedure can be performed

with either of the following:

A) The free- hand technique after sonographic location.

B) The free- hand technique under sonographic observation.

C) The guided technique through applicator added to

the US probe.

D) The guided technique by special transducer probe with a notch in the middle allows the insertion of the needle in a fixed direction.

The free - hand technique after

sonographic location.

The free- hand technique under

sonographic observation.

The guided technique through applicator

added to the US probe.

The guided technique by special transducer

probe with a notch in the middle allows the

insertion of the needle in a fixed direction.

Follow – up after intervention:

Three hours of surveillance after

intervention.

Sonographic check before discharge.

Instruction for patient (immediate return to

the hospital in case of symptoms).

Contraindications:

A) Absolute (severe blood coagulation disorders)

* International normalized ratio (INR) more than 1.8.

* Partial thromboplastin time (PTT) more the 50s.

* Platelet count below 50,000.

B) Relative

* Bullous pulmonary emphysema.

* pulmonary hypertension.

(N.B) when respiratory function is severely impaired or blood gas values are poor, the procedure should only be performed when the patients condition is expected to be improved by the therapeutic intervention.

Risks of US guided thoracic interventions:

* The rate of pneumothorax is 2.8 %; 1%

require drainage.

* Hemorrhage or hemoptysis is observed in

0-2 %.

* Tumor dissemination through the

procedure of puncture is very rare (Less

than 0.003 % of cases).

Advantages:

* Fast availability.

* Bedside application.

* Low rate of complications.

* Absence of radiation exposure.

* Low cost.

Limitations:

* If the space – occupying mass is hardly or not at all visible percutaneously on sonography.

* If the puncture channel is not safe.

Color-Doppler Ultrasonography

Black and White Ultrasonography

Lung Biopsy Needles

Different Models of Cope Needle

Abrams Needle

Instruments for Ultrasound – guided

Biopsy Forceps of the Pleura

Instruments for Ultrasound –

guided Pleural Brushing

Different Models of Catheters for

Pleural Drainage

c

At the bedside, chest radiography remains the reference for lung imaging in

critically ill patients. However, radiographical images are often of

limited quality

• Movements of the chest wall

• Film cassette posterior to the thorax

• X-ray beam originating anteriorly, at a shorter distance than

recommended and not tangential to the diaphragmatic cupola .

Mistaken assessment

of :

c

• Pleural effusion

• Alveolar consolidation

• Alveolar-interstitial

syndrome

Bedside Chest Radiography in the Critically

ill

02 09 2012

Risk of transportation

Lung Computed Tomography in

the Critically ill

http://www.reapitie-

univparis6.aphp.fr 02 09 2012

Clinical applications of lung ultrasonography in the

intensive care unit

1. Diagnosis of pulmonary consolidation.

2. Diagnosis of atelectasis

3. Diagnosis of alveolar-interstitial syndrome

4. Differentiating between pulmonary oedema and ARDS

5. Differentiating between pulmonary oedema and COPD

6. Diagnosis of pulmonary embolism

7. Diagnosis of pneumothorax

8. Diagnosis and estimation of volume and nature of pleural effusion.

9. Diagnostic and therapeutic ultrasound-guided thoracentesis.

Duplex Doppler sonogram of a 5 x 3 cm hypoechoic mass

(adenocarcinoma) in upper lobe of left lung shows blood flow

at margin of tumor near pleura. Spectral waveform reveals

arteriovenous shunting: low-impedance flow with high

systolic and diastolic velocities. Pulsatility index = 0.90,

resistive index = 0.51, peak systolic velocity = 0.47 m/sec, end

diastolic velocity =0.23 m/sec, peak frequency shift = 3.8 kHz,

Duplex Doppler sonogram in 67-year-old man with pulmonary

tuberculosis in lower lobe of left lung shows several blue and

red flow signals in massiike lesion. Spectral waveform reveals

high-impedance flow. Pulsetility index = 4.20, resistive index =

0.93, peak systolic velocity = 0.45 m/sec, end diastolic

velocity = 0.03 m/sec, Doppler angle = 21#{

Hemodynamic assessment of circulatory

failure using lung ultrasound: FALLS-

protocol

Is ultrasound useful in shock?

Shock

Clinical situation where there is hypoperfusion of the cells and tissues

Background

Patients with shock have high mortality rates and these rates are correlated to the amount and duration of hypotension.

Diagnosis and initial care must be accurate and prompt to optimise patient outcomes.

Studies have demonstrated that initial integration of bedside ultrasound into the evaluation of the patient with shock results in a more accurate initial diagnosis with earlier definitive treatment.

Bedside USS allows direct visualisation of pathology or abnormal physiological states.

Remember…

Ultrasound is a tool to aid diagnosis, but it won’t tell you everything…

When using it we should always have a clinical question you would like it to answer

Himap-THE PUMP

Contractility-

Hyperdynamic LV- sepsis, hypovolaemia

Hypodynamic- late sepsis, cardiogenic shock

What’s the RV like? – collapsing? Dilated?

Obstructive shock

Gross valvular dysfunction

Cardiac assessment

Parasternal long axis

Transducer at left sternal

edge between 2nd -4th

intercostal space

Probe marker pointing to

patients R shoulder

Probe aligned along the

long axis: from R shoulder

to cardiac apex.

Useful view to assess contractility

Apical 4 chamber

Transducer at 4th-6th intercostal space in the midclavicular to anterior-axillary line.

Probe directed towards patient’s right shoulder with the marker directed towards the left shoulder.

Important view to give relative dimensions of L and R ventricle.

Normal ventricular diameter ratio of R ventricle to L ventricle is <0.7.

Pericardial Tamponade

Remember tamponade is a clinical diagnosis based on patient’s haemodynamics and clinical picture.

Ultrasound may demonstrate early warning signs of tamponade before the patient becomes haemodynamically unstable.

Haemodynamic effects

Its PRESSURE NOT SIZE THAT COUNTS!

Rate of formation affects pressure-volume relationship and is therefore more important than volume of fluid.

Tamponade using ultrasound

A moderate-large effusion.

Right atrial collapse

Atrial contraction normal in atrial systole

Collapse throughout diastole or inversion is abnormal.

RV collapse during diastole when meant to be filling (‘scalloping’ seen)

Whats seen in the IVC…

hImap

IVC

Where to put the probe…

Probe position

Subxiphoid

Orientate probe in

longitudinal plane with

probe indicator to

patient‟s head

Slightly to right of

midline

Bowel gas causing problems….

The FAST view…

Probe goes longitudinally in right mid axillary line with marker towards head.

Look for IVC running longitudinally adjacent to the liver crossing the diaphragm

Track superiorly until it enters the RA confirms it’s the IVC not the aorta

Assessing the IVC

During inspiration, intrathoracic pressure becomes more negative, abdominal pressure becomes more positive, resultant increase in the pressure gradient between the supra and infra-diaphragmatic vena cava, increases venous return to the heart.

Given the extrathoracic IVC is a very compliant vessel this causes diameter of IVC to decrease with normal inspiration.

In patients with low intravascular volume, the inspiration to expiration diameters change much more than those who have normal or high intravascular volume.

Estimating the CVP

IVC Diameter (mm) % collapse Estimated CVP (cm H2O)

<20 >50 5

<20 <50 10

>20 <50 15

>20 0 20

Right atrial pressures, representing central venous pressure, can be estimated

by viewing the respiratory change in the diameter of the IVC.

American society of Echocardiography 2010 guidelines

Subxiphoid long; shocked and dry

Subxiphoid transverse view of the IVC and aorta

Complicating the picture

Valvular disease

Pulmonary hypertension

Increased intraabdominal pressure

hiMAp eFAST/Aorta scan

himaP

Multiple studies have shown ultrasound to be more sensitive than supine CXR for the detection of pneumothorax.

Sensitivities ranged from 86-100% with specificities from 92-100%.

Furthermore USS can be performed more rapidly at the bedside.

Detection with ultrasound relies on the fact that free air is lighter than normal aerated lung tissue, and thus will accumulate in the nondependent areas of the thoracic cavity. (ie anteriorly when patient is supine).

To get the lung window

Patient should be supine.

Use high frequency linear

array or a phased array

transducer.

Position in the

midclavicular line, 3rd to 4th

intercostal space with

probe oriented

longitudinally.

Position between ribs.

Pneumothorax

Abdominal and cardiac evaluation with sonography in the hypotensive patient (ACES)

Category of shock

Cardiac funcion IVC Treatment

Septic Hyperdynamic Narrow IVC, collapses with inspiration

IVF +/-pressors

Cardiogenic Hypodynamic left ventricle

Dilated IVC; little or no collapse with inspiration

Inotropes

Hypovolaemic Hyperdynamic LV Narrow IVC, collapses

IVF/Blood

Tamponade Pericardial effusio, diastolic collapse RV

Dilated IVC, no collapse with inspiration

Pericardiocentesis

PE Dilated RV Dilated IVC with minimal/no collapse

thrombolysis

(Chest. 2008; 133:836-837)

© 2008 American College of Chest

Physicians

Ultrasound: The Pulmonologist’s New

Best Friend

Momen M. Wahidi, MD, FCCP

Durham, NC

Director, Interventional Pulmonology, Duke

University Medical Center, Box 3683,

Durham, NC 27710