This document discusses the use of chest sonography in critically ill patients. It notes that bedside chest radiography has limitations in critically ill patients. Chest sonography can help diagnose various lung conditions at the bedside including pulmonary consolidation, atelectasis, edema, effusions, and pneumothorax. It reviews the sonographic signs and patterns associated with these conditions. The document also discusses using lung ultrasound and IVC views to assess shock states and guide treatment. Overall, it promotes the use of bedside lung ultrasound as a valuable tool to complement radiography in critically ill patients.

2. Chest Sonography in Critically
Ill Patients
Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University

4. 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

5. Risk of transportation
Lung Computed Tomography in
the Critically ill
http://www.reapitie-
02 09 2012

7. Scanning Positions for
Chest Sonography in ICU

18. Tissue pattern representative of Alveolar
Consolidation
Presence of hyperechoic punctiform
imagesrepresentative of air bronchograms
Pleural
effusion
Lower lobe

21. the "seashore sign" (Fig.3).

23. Clinical applications of lung ultrasonography in the
intensive care unit
1. Diagnosis of pulmonary consolidation.
2. Diagnosis of atelectasis
3. Diagnosis of alveolar-interstitialsyndrome
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.

33. Absent lung sliding
Exaggerated horizontal artifacts
Loss of comet-tail artifacts
Broadening of the pleural line to a band
The key sonographic signs of
Pneumothorax

37. the "seashore sign" (Fig.3).

46. Pulmonary Embolism

47. Schematic representation of the parenchymal, pleural and vascular
features associated with pulmonary embolism.(Angelika Reissig, Claus
Kroegel. Respiration2003;70:441-452)

49. Alveolar-interstitial syndrome

54. Multiple B-lines - « comet-tails » - interstitial edema
(B1)
7 mm apart « B lines » thickened interlobular
septa
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997JJR 25 05http://www.reapitie-
http://www.reapitie- 02 09 2012

55. D Lichtenstein et al AJRCCM 156 : 1640-1646 , 199730 11 2011
Coalescent B lines - « comet-tails » - alveolar
edema
3 mm apart « B lines » ground-glass
areas
http://www.reapitie- 02 09 2012

65. Hemodynamic assessment of circulatory
failure using lung ultrasound: FALLS-
protocol

66. Is ultrasound useful in shock?

67. Shock
Clinical situation where there is
hypoperfusion of the cells and tissues

68. 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.

69. 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

70.  Contractility-
 Hyperdynamic LV- sepsis, hypovolaemia
 Hypodynamic-late sepsis, cardiogenic shock
 What’s the RV like? – collapsing? Dilated?
 Obstructive shock
 Gross valvular dysfunction

71. Cardiac assessment

72. 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

73. 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.

75. PericardialTamponade
 Remember tamponadeis 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.

76. Tamponade using ultrasound
 A moderate-large effusion.
 Right atrial collapse
 Atrial contractionnormal 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…

77.  IVC

78. 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

79. Bowel gas causing problems….

80. 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

81. 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.

82. Estimating theCVP
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.

83. American society of Echocardiography
2010 guidelines

85. Subxiphoid long; shocked and dry

88. Subxiphoid transverse view of the IVC
and aorta

89. Complicating the picture
 Valvular disease
 Pulmonary hypertension
 Increased intraabdominal pressure

90. hiMAp
eFAST/Aorta scan

91. 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).

92. 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.

93. Pneumothorax

94. Abdominal and cardiac evaluation with sonography in the
hypotensive patient (ACES)
Category of
shock
Cardiac funcion IVC Treatment
Septic Hyperdynamic Narrow IVC,
collapseswith
inspiration
IVF +/-pressors
Cardiogenic Hypodynamicleft
ventricle
Dilated IVC;little
or no collapse
with inspiration
Inotropes
Hypovolaemic HyperdynamicLV Narrow IVC,
collapses
IVF/Blood
Tamponade Pericardial
effusio, diastolic
collapseRV
Dilated IVC, no
collapsewith
inspiration
Pericardiocentesi
s
PE Dilated RV Dilated IVC with
minimal/no
collapse
thrombolysis

99. (Chest. 2008; 133:836-837)
© 2008 American College of Chest Physicians
Ultrasound: The Pulmonologist’s New Best
Friend
Momen M. Wahidi, MD, FCCP