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Principles and Practice of Anesthesia for Thoracic Surgery pp 457–469Cite as

Pulmonary Ultrasound

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Abstract

Pulmonary ultrasound, as a diagnostic tool, is rapidly increasing in its adoption in acute care specialties. With relative ease, frontline clinicians can learn a few simple pulmonary sonographic signs, enabling them to narrow down the differential diagnosis of respiratory failure in a very expeditious manner. Accurate assessments of lung fluid overload, pneumothorax, lung consolidation, and pleural effusions are all readily performed using ultrasound with much greater sensitivity than chest X-rays. Mastering this technique, however, requires an understanding of the physical principles that are key to the development of pulmonary sonographic artifacts and ultrasound findings. A method of collecting, storing, and labeling images taken in each hemithorax is described in this chapter. In addition, state-of-the-art practical perioperative applications of pulmonary ultrasound are discussed. When used in conjunction with a clinical assessment, pulmonary ultrasound can be used for interval scanning of critically ill patients, eliminating or decreasing the need for serial chest X-rays or CT scans, and, more importantly, guiding informed patient management decisions.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, Western University, London Health Sciences, London, ON, Canada

    Nathan Ludwig

  2. Departments of Anesthesiology and Critical Care Medicine, Western University, London Health Sciences, London, ON, Canada

    Ahmed F. Hegazy

Authors
  1. Nathan Ludwig
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  2. Ahmed F. Hegazy
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Corresponding author

Correspondence to Nathan Ludwig .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Electronic Supplementary Material

Lung sliding and A-lines. Image obtained using a curvilinear probe, with rib shadows causing acoustic shadowing. Pleural line shows a slow back and forth movement with respiration (lung sliding). Underneath the pleural line, horizontal equidistant repetitious lines (A-line artifacts) are observed. The presence of both lung sliding and A-lines indicates the absence of pneumothorax and normal lung aeration at the point of probe placement (MOV 1760 kb)

Lung pulse and A-lines. Image obtained using a phased array probe. Pleural line showing a fast shimmering coinciding with cardiac activity (lung pulse). The presence of a lung pulse indicates the absence of a pneumothorax at the point of probe placement. Underneath the pleural line, a horizontal A-line artifact is observed (MP4 634 kb)

Absent lung sliding. Pleural line showing no lung sliding. This is suggestive of a pneumothorax but is not specific. Image obtained using a phased array transducer (MP4 221 kb)

Lung point. The transition point between sliding and absent lung sliding is demonstrated. This is very specific for pneumothorax (specificity 100%) (MP4 201 kb)

B-lines characteristics. B-lines extending from the pleural line to the end of the screen and moving synchronously with lung sliding. As seen in this video, three or more B-lines (or a coalescence of B-lines) are considered pathological (MP4 450 kb)

Consolidated (hepatized) lung with dynamic air bronchograms. Consolidated lungs could be secondary to pneumonia or atelectasis. Dynamic air bronchograms (seen in this video) are commonly seen with pneumonia, but are not necessarily specific (MP4 784 kb)

Pleural effusion (dynamic features). Pleural effusion characterized by being an anechoic space, within typical anatomical boundaries, with dynamic features. Diaphragmatic descent, as a dynamic feature, is demonstrated (MP4 585 kb)

Plankton sign. Floating debris, moving with cardiac activity and diaphragmatic movement within a pleural effusion, is named the “plankton sign.” Also note the different densities within the effusion fluid which also favors this being an exudative process (MP4 1279 kb)

B-line predominance in the right anterior chest wall. Multiple vertical hyperechoic comet tails on pulmonary ultrasound. This B-line predominance indicates abnormal lung aeration at the point of probe application (MP4 1069 kb)

B-line predominance in the right anterior axillary line. A coalescence of B-lines is demonstrated, indicating abnormal lung aeration at the point of probe application. Diffuse homogeneous B-line predominance is very characteristic of pulmonary edema (MP4 708 kb)

Case Presentation

Case Presentation

The postanesthesia care unit (PACU) nurse asks for your help. A 55-year-old lady underwent a left video-assisted thoracoscopic surgery (VATS) talc pleurodesis for a chronic left pleural effusion, 2 h earlier, and has since been in the PACU with high oxygen requirements. The nurse mentions that all attempts at weaning her oxygen requirements to get her ready for ward transfer have been unsuccessful and she currently remains on an FiO2 of 0.6 by face mask. Her past medical history is significant for an ischemic cardiomyopathy with an estimated left ventricular ejection fraction of 35%. The anesthesiologists’ records document stable hemodynamics throughout the procedure, minimal blood loss, and a slight positive fluid balance of only 500 ml.

The patient appears to be fully awake and has good motor strength. Her BP is 105/60 mmHg, HR 82 beats/min, and her SpO2 92%. A portable chest X-ray, performed in PACU, was inconclusive (Fig. 28.12). A lung and pleural ultrasound is performed to further delineate the cause of her hypoxemia.

Fig. 28.12
figure 12

Plain portable chest X-ray of patient with undifferentiated hypoxia. Plain chest radiograph suggestive, but not conclusive, of pulmonary edema. As a modality, the sensitivity of plain chest X-rays in pulmonary edema detection is 50–68%

Full size image

Case Resolution

Using a phased array transducer, her nonoperative right lung was scanned at two points: the anterior chest wall (Video 28.9) and the anterior axillary line (Video 28.10). Due to the surgical dressing covering large portions of her operative side, only her nonoperative side was scanned. Acquired images demonstrated a diffuse B-line pattern, consistent with an interstitial alveolar syndrome. With a working diagnosis of pulmonary edema, furosemide 40 mg was administered intravenously. Over the next 90 min, the patient diuresed 800 ml of urine, and her oxygen requirements were weaned to 3 L/min oxygen by nasal prongs. After meeting PACU discharge criteria, the patient was transferred safely to the ward.

The sensitivity of ultrasound in detecting pulmonary edema far surpasses that of plain chest X-rays (100% vs. 65%) [36, 37]. As a modality, ultrasound is quick and easy to use at the bedside and can be used either to make a diagnosis or, in this case, confirm a clinical suspicion. B-lines are defined as vertical hyperechoic comet tails that (a) emanate from the pleural line, (b) extend all the way to the end of the screen, (c) move with lung sliding, and (d) dominate over any other aeration patterns (i.e., dominate over A-lines). A clinically significant B-line pattern indicative of an interstitial syndrome is present when three or more B-lines or a coalescence of B-lines is visible on the same screen. The differential diagnosis for B-line predominance includes pulmonary edema, ARDS, early pneumonia, and subsegmental atelectasis. In this case, the relatively uniform B-line presence throughout the anterior and lateral chest was diagnostic of pulmonary edema.

This case highlights the value of ultrasound in dismissing diagnostic uncertainties. In general, the indications of perioperative ultrasound include assessing undifferentiated hypoxia, evaluating undifferentiated opacities on chest X-rays, and determining the safety of further fluid resuscitation. Point-of-care ultrasound empowers clinicians to make diagnoses at the bedside and may therefore expedite appropriate management and improve timely patient care.

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Ludwig, N., Hegazy, A.F. (2019). Pulmonary Ultrasound. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_28

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_28

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-00858-1

  • Online ISBN: 978-3-030-00859-8

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