Objectives Ultrasound in the Dyspneic Patient Pericardial ... - Knight, Starr - Dyspneic US.pdfThe comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med.

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Ultrasound in the Dyspneic Patient

R. Starr Knight, M.D.High Risk Emergency Medicine

February 14, 2013

Objectives• Heart Failure• COPD• Pericardial Effusion/Tamponade• Pulmonary Embolism• Pneumonia• Pneumothorax• Pleural Effusion

Ultrasound Protocols

• RUSH• RADiUS• Triple Scan• ACES• FALLS

Case #1: SOB

• 58 ♂ with HTN, CHF, COPD now with 3 days of worsening SOB and DOE

VS: 37.0 200/110 100 28 85%RA

Neck: ?JVD →CV: Tachy, Reg →

Pulm: Wheezes & Bibasilar Rales →

Gen: Dyspneic, Obese

Extr: +1 Pedal edema →

Goals of the Exam

Assess for Pulmonary Edema

Evaluate Pump Function

Interrogate IVC

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Protocol

1. Cardiac Ultrasound

2. Lung Ultrasound

3. IVC Ultrasound

Parasternal Long

DTA

Parasternal Long

Parasternal Long Parasternal Short

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Parasternal Short

Subxiphoid / Subcostal Subxiphoid

Protocol

1. Cardiac Ultrasound

2. Lung Ultrasound

3. IVC Ultrasound

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Rib Rib

Linear Probe

Rib1234567891011

Normal Lung: Comet Tails

Pulmonary EdemaB Lines•Arise from the pleural line

•Well-defined

•Move with lung sliding

•Reach the edges of the

screen Acute pulmonary edema

•Arise from the pleural line

•Well-defined

•Move with lung sliding

•Reach the edges of the screen

B linesB lines

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B linesB lines•Highly sensitive•Cardiogenic pulmonary edema

•ARDS•Pulmonary contusion•Pulmonary fibrosis•Interstitial pneumonia

Rib

Alveoli

RibShadow

Normal Lung: Sliding Visceral Pleura

Rib RibParietal Pleura

Visceral PleuraComet Tails

(Artifact)

LocationLocationLocation

B lines = increased fluid in the interstitium

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Hyperinflated Lungs

HFHFNon-HFNon-HF

Protocol

1. Cardiac Ultrasound

2. Lung Ultrasound

3. IVC Ultrasound

Liver

IVC

RA

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COPD

• Presence of A line• Lack of B lines• Clinical signs of COPD

COPD COPD

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Pericardial Effusion Pericardial Effusion

Cardiac Tamponade

• Right Heart Collapse during diastole• RV or RA• Can be subtle

• Diastole• Correlate with Mitral Valve Opening

• IVC Plethora

Cardiac Tamponade

Cardiac TamponadePulmonary Embolism

• RV Dilitation (RV:LV > 1:1)• RV Systolic Dysfunction• Free-Floating Thrombus

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Pulmonary Embolism

• IVC Dilatation• Presence of DVT in LE• McConnell’s Sign

Pneumonia

• Air Bronchograms• static and dynamic

• B Lines adjacent to consolidation• Associated pleural effusions

Pneumonia

Pneumonia

Pneumothorax

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Air goes upAir goes up

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Rib

AIR

Rib

Abnormal Lung: Pneumothorax

Parietal Pleura

Visceral Pleura

Parietal Pleura

Air(Scatter)

Normal Pneumothorax

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References• Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of

alveolar-interstitial syndrome. Am J Emerg Med. Oct 2006;24(6):689-696.

• Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med. May 2009;27(4):379-384.

• Cortellaro F, Colombo S, Coen D, et al. Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. Emerg Med J. Oct 28 2010.

• Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med. Apr 1999;25(4):383-388.

• Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med. Nov 1997;156(5):1640-1646.

• Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest. Nov 1995;108(5):1345-1348.

• Alrajhi K, Woo M, Vaillancourt C. Test Characteristics of Ultrasonography for the Detection of Pneumothorax. CHEST.141(3) MARCH 2012

• Wu Ding W, Yuehong S ,Yang J. Diagnosis of Pneumothorax by Radiography and Ultrasonography.CHEST.140 (4) OCTOBER, 2011

Thank You

Apical 4 chamber 4 Chamber

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4 Chamber