Airway and Breathing ultrasound

Suthaporn Lumlertgul MD
Emergency Unir
KIng Chulalongkorn Hospital
Sunday, November 14, 2010

Airway and Lung in Ultrasound
Perspective
Suthaporn Lumlertgul MD
Emergency Unir
KIng Chulalongkorn Hospital

Detect intubation
One Lung?
Wet and Dry Dyspnea

Airway by ultrasound
• Direct visual trachea position
• Direct visual of Endotracheal tube, cuff
• Assess absent of lung movement in one
lung intubation
• Assess Diaphragm movement

One lung intubation?

Understand Lung Pulse

Lung Ultrasound

Lung Ultrasound
It is really happening

• Normal Lung Picture
• Air-Fluid Ratio
• A-B-C.......Z of Lung Ultrasound
• Wet VS Dry dyspnea (BLUE protocol)
Pleuropulmonary Ultrasound

The ten signs of lung ultrasound in the critically ill : Lichtenstein Expert Rev. R esp.
Med. 4(5), (2010)

Second Principle:
Understand Air-Fluid Ratio

LUNG: Semiotics,Window, Pathologies
Air
Water
Air
Water
Pleural
effusion
Pneumothorax

Locating area of investigation

Air
Fluid

Normal Lung Findings and Artifact

* *
* *

Normal Lung Findings
A line
A line
Pleural line
* *
Skin

Pneumothorax by Lung Ultrasound

Comet tail
Reference ; Lichtenstein D, MÉZIÈRE G., The comet tail artifact, an ultrasound sign of aloveolar-interstitial syndrome.
Am J Respir Crit Care Med 1997. Vol156:1640–1646.
Comet tail artifacts results from sliding of patrietal against visceral pleura. Lack of Lung sliding
occur in (inﬂammatory adherences, loss of lung expansion, atelectasis,apnea, chronic symphysis)
or is separated (pneumothorax, pneumonectomy
Comet

Document Pneumothorax
by M mode

M Mode of Normal lung
* *
Reference ; Lichtenstein D, General Ultrasound in the Critically ill. 1st Edition

**
Strastrophere sign
M Mode of Pneumothorax
(or sometimes look like Barcode)
7 54 6 0 8 1 9

A: Stratrophere Sign.
B; Gliding of pleura results in Granular pattern
which are seperated by white pleural line are called
“Seashore sign”
Pleural line
Soft tissue
A
B
Pleural line
Soft tissue
B

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#$%"&$'(%)"*++,-"
./-,01/"/(%-"
2(3"4516$7"
Comet tail
Schematic drawing of Lung Sliding results in Granular
effect below pleura line: Seashore sign in M Mode
2D M

When the collapsed lung is not contact chest wall, it will create horizontal pattern(before and
after yellow arrow). On the contray, when it expands and in contact with chest wall, it will
create granular pattern(below the arrow). This is called the lung point, which is a speciﬁc sign
of pneumothorax.

Detecting pulmonary edema
by ultrasound bedside?

Transducer
Multiple US Beam
Reflections
NORMAL
INTERLOBULAR
SEPTA
Transducer
THICKENED
INTERLOBULAR
SEPTA
Multiple US Beam
Reflections
REVERBERATIONS
NORMAL ARTIFACTS (A lines)
REVERBERATIONS
COMET TAILS (B lines)
www.WINFOCUS.org

*= B line narrow-based hyperechoic column laser like arise from bright pleural line as vertical to
the edge of the screen moving during breathing indicated interlobular septal
inﬁltration
*
* *
*
Pleural line
B line:To detect interlobular septal thickening, inﬁltration
DIfferential Diagnosis of B line: Cardiogenic Pulmonary Edema, ARDS,
Pneumonia, Lung Contusion (Trauma)
*

Falls Protocol

The BLUE protocol
To differentiate acute pulmonary disease by bedside ultrasound application

The BLUE protocol
Reference: Lichtenstein D. and Gilbert A. Relevance of Lung Ultrasound in the
diagnosis of Acute Respiratory Failure. Chest 2008;134;117-125

Pleural Effusion Assessment by ultrasound
Pleural line
Curtain sign obliterate liver
Liver
Diaphragm Diaphragm
Liver
Effusion
Lung
Lung31

Pleural Effusion Assessment by ultrasound
ABDOMEN
LUNG
PLEURAL
EFFUSION
Semiquantitative assessment of pleural effusion volume(IP=Interpleural space)
End expiratory distance IP at 5th intercostal space at > 5 cm estimated > 500 cc
End Expiratory IP at Basal lung > 4.5 cm (Right lung base)
> 5 cm (Lt lung base)
→estimated pleural effusion volume > 800 cc
Best thoracocentesis point
1.Safe puncture area : ultrasound check > 3 intercostal spaces with IP distance > 1.5 cm
2.Absence of interposition of lung, heart, liver, spleen
3.Interpleural distance variation
Mark best puncture point, ﬁxed patient position.
Roch A, CHEST 2005
Vignon P, CRIT CARE 2005.
www.WINFOCUS.org

Airway and Breathing ultrasound

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Airway and Breathing ultrasound