Lung ultrasound has a high sensitivity for interstitial pathology such as pulmonary edema, acute respiratory distress syndrome, ILD, and others. This section will cover the use of ultrasound for detection of an array of interstitial diseases, consolidation, and pneumonia.
Section contributors: Brian Buchanan, Jean Deschamps
Section contributors: Brian Buchanan, Jean Deschamps
Lung ultrasound in decompensated heart failure infographic
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ABSono tutorial
Acquiring lung imagesGenerally lung images are acquired on the chest wall, perpendicular to the pleura in the para-sagittal plane. If the probe is not perpendicular to the pleura, artifacts beneath the pleura will not be shown. In some cases, the probe must be turned transversely or parrallel to interspace if the scanner wants to see a lung point (see pneumothorax tutorial).
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B-linesB-lines play a key role in detecting pathology on lung ultrasound. B-lines are vertical and MUST extend along entire length of the screen from the pleura. The following clip shows key features of B-lines.
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Interstitial patternsThe differential for interstitial disease is broad--as shown here. Differentiation, as it is for most imaging modalities, requires a consideration of details on history and physical examination. While pulmonary edema should be a primary consideration, context is critical. There are some subtle differences that can be used to differentiate cardiogenic vs non-cardiogenic edema (shown on next section).
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Cardiogenic vs non-cardiogenicAn examination of the pleura of a patient with non-cardiogenic pulmonary edema will reveal interrupted pleura, sub-pleural consolidations, and occasional patched of non-sliding. Further, non-cardiogenic pulmonary edema can have areas of relatively normal parenchyma with sliding and A-lines, whereas B-lines are typically diffuse bibasilar or across the chest in pulmonary edema.
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Findings in collapseInterstitial changes can also be found in collapse. Generally, these findings are more localized either unilaterally or bibasilar. These findings can indeed progress from a couple of B-lines to more dense B-lines and to dense consolidation in the latter stages.
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References
Arbelot C, Dexheimer Neto FL, Gao Y, et al (2020) Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence. Anesthesiology 1. https://doi.org/10.1097/ALN.0000000000003096Copetti R, Soldati G, Copetti P (2008) Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovascular ultrasound 6:16. https://doi.org/10.1186/1476-7120-6-16.
Copetti R, Soldati G, Copetti P (2008) Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovascular Ultrasound 6:16. https://doi.org/10.1186/1476-7120-6-16
Lichtenstein D (2009) Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol. Minerva anestesiologica 75:313–317
Lichtenstein D a, Mezière G a (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134:117–25. https://doi.org/10.1378/chest.07-2800
Jambrik Z, Gargani L, Adamicza Á, et al (2010) B-lines quantify the lung water content: A lung ultrasound versus lung gravimetry study in acute lung injury. Ultrasound in Medicine and Biology 36:2004–2010. https://doi.org/10.1016/j.ultrasmedbio.2010.09.003
Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R (2018) Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. The Journal of emergency medicine 1–17. https://doi.org/10.1016/j.jemermed.2018.09.009
Volpicelli G, Elbarbary M, Blaivas M, et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. In: Intensive Care Medicine. pp 577–591.
Vignon P, Repessé X, Vieillard-Baron A, Maury E (2016) Critical care ultrasonography in acute respiratory failure. Critical Care 20:228. https://doi.org/10.1186/s13054-016-1400-8
Copetti R, Soldati G, Copetti P (2008) Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovascular Ultrasound 6:16. https://doi.org/10.1186/1476-7120-6-16
Lichtenstein D (2009) Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol. Minerva anestesiologica 75:313–317
Lichtenstein D a, Mezière G a (2008) Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 134:117–25. https://doi.org/10.1378/chest.07-2800
Jambrik Z, Gargani L, Adamicza Á, et al (2010) B-lines quantify the lung water content: A lung ultrasound versus lung gravimetry study in acute lung injury. Ultrasound in Medicine and Biology 36:2004–2010. https://doi.org/10.1016/j.ultrasmedbio.2010.09.003
Staub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R (2018) Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. The Journal of emergency medicine 1–17. https://doi.org/10.1016/j.jemermed.2018.09.009
Volpicelli G, Elbarbary M, Blaivas M, et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. In: Intensive Care Medicine. pp 577–591.
Vignon P, Repessé X, Vieillard-Baron A, Maury E (2016) Critical care ultrasonography in acute respiratory failure. Critical Care 20:228. https://doi.org/10.1186/s13054-016-1400-8