Point-of-Care Ultrasound of the Lungs

Sharma, Archit; Subramani, Sudhakar

doi:10.1007/978-981-16-7687-1_4

Archit Sharma³ &
Sudhakar Subramani⁴

1471 Accesses

Abstract

Lung ultrasound (LUS) has become as essential a tool as the stethoscope in the management of patients with respiratory disease. Other than its usual application in guiding thoracentesis, intercostal catheter placement, and medical thoracoscopy, currently, LUS is valued as an extension of clinical examination in the evaluation of chest pathologies involving pleural diseases, parenchymal infections and in the emergent evaluation of a hypoxic patient. A comprehensive understanding of the sound properties of tissue, air and fluid and their interaction, to evaluate both normal tissue, pathologies and artifacts is essential for image interpretation. Similarly, sufficient bedside experience in applying point-of-care ultrasound to extend the clinical assessment of pleural and parenchymal disease is needed, and the current generation of clinicians needs to be trained early in these methods. A growing body of evidence attests to fewer procedure-related complications in addition to cost savings associated with ultrasound use. Various management protocols have been suggested to guide diagnosis and management strategies after incorporating clinical signs along with ultrasound examination. The expanding scope of reliable literature indicates an increase in the possibility of using lung ultrasound at the patient’s bedside, especially with the advent of handheld devices.

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Authors and Affiliations

Divisions of Cardiothoracic Anesthesiology, Solid Organ Transplant and Critical Care, Department of Anesthesia, Iowa City, IA, USA
Archit Sharma
Department of Anesthesia, Division of Cardiothoracic Anesthesiology, Iowa City, IA, USA
Sudhakar Subramani

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Archit Sharma
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Sudhakar Subramani
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Correspondence to Sudhakar Subramani .

Editor information

Editors and Affiliations

Department of Anaesthesia, Critical Care and Pain, Tata Medical Center, Newtown, Kolkata, West Bengal, India
Arunangshu Chakraborty
Department of Anaesthesia, National University Hospital, Singapore, Singapore
Balakrishnan Ashokka

4.1 Electronic Supplementary Material

Right upper anterior point using phased array probe (MP4 21617 kb)

Right lower anterior point uisng transverse probe (MP4 9485 kb)

Right posterior-lateral alveolar plueral point (MP4 14008 kb)

Right costophrenic view (MP4 20839 kb)

Self-Assessment Questions: Select the Best Answer

1.
The maximum reflection of ultrasound signals during thoracic ultrasound happens at
1. A.
  Skin and subcutaneous
2. B.
  Subcutaneous and muscle layer
3. C.
  Soft tissue and pleura
4. D.
  Pleura and lung parenchyma
2.
Following are the features of using a linear ultrasound probe in LUS except
1. A.
  Deeper penetration
2. B.
  Has narrow sector width
3. C.
  Large footprint
4. D.
  Not recommended for rapidly moving structures
3.
For better image quality using color Doppler all are recommended except
1. A.
  Using wall filter for rapidly moving structures
2. B.
  High scale velocity
3. C.
  Adjust color gain to get “snowstorm” appearance
4. D.
  Doppler angle must be less than 60°
4.
The structure highlighted in the following image represents
1. A.
  Pleural line
2. B.
  B-line
3. C.
  A-line
4. D.
  Z-line
5.
The most appropriate technique to avoid acoustic shadowing from ribs is
1. A.
  Using curvilinear probe
2. B.
  Scanning in sagittal plane
3. C.
  Phased array probe parallel to rib
4. D.
  Using linear probe
6.
A-lines are one of the common artifacts observed in LUS. The true statement about A-line is
1. A.
  Reflection from bony surface
2. B.
  Refraction from pleural surface
3. C.
  Reverberation from pleural line
4. D.
  Refraction from fascial plane
7.
Following are advantages of using curvilinear probe in LUS except
1. A.
  Smaller footprint
2. B.
  Higher penetration
3. C.
  Ideal for assessment of diaphragm
4. D.
  Lower frequency
8.
Blue protocol is one of the commonly employed methods for comprehensive assessment of lung using ultrasound. A positive blue point represents
1. A.
  Presence of two B-lines
2. B.
  Presence of one B-line
3. C.
  Presence of three B-lines
4. D.
  Presence of four B-lines
9.
Absence of lung sliding is one of the essential features of LUS to diagnose pneumothorax. Presence of the following respiratory condition will cause false lung sliding due to vigorous intercostal muscle contraction
1. A.
  Emphysema
2. B.
  Chronic bronchitis
3. C.
  Acute respiratory distress syndrome
4. D.
  Bronchial asthma
10.
The highlighted structure/artifact in the following ultrasound image represents
1. A.
  A-line
2. B.
  Pleural line
3. C.
  T-line
4. D.
  B-line
11.
You have high peak ventilation pressures after intubating a patient with advanced COPD. You find bilateral anterior B-lines but cannot find lung sliding over the right anterior thorax. What is the most likely cause of high peak pressures?
1. A.
  Pleural effusion
2. B.
  Pulmonary edema
3. C.
  Pneumothorax
4. D.
  Pericardial tamponade
12.
You are taking care of a trauma patient who is admitted after a collision between the car that he was an unrestrained driver in ran into a tree. The patient has multiple rib fractures and has a high oxygen requirement of 70% oxygen on a noninvasive BiPAP machine to maintain oxygenation. He is also complaining of dyspnea and chest fullness. You perform a lung ultrasound, and the attached picture is displayed. What is the most likely reason for his respiratory condition?
1. A.
  Pleural effusion
2. B.
  Pulmonary contusions
3. C.
  Pericardial effusion
4. D.
  Pneumothorax
13.
A 50-year-old patient presents with a week-long history of dyspnea. Fever, and cough. His blood pressure is 90/50 and he is requiring four liters of oxygen to maintain his saturation. The attached picture represents the ultrasound exam with the probe held in place at the base of the lung. What is the most likely diagnosis?
1. A.
  COPD
2. B.
  Pneumonia
3. C.
  Pericardial effusion
4. D.
  Pneumothorax
14.
A 75-year-old woman, with chronic myeloid leukemia presents with dyspnea and fever. She presented to her doctor a week ago with fever and cough, for which she was treated with azithromycin. She was feeling better for a while but has been declining for the past couple of days. Please interpret her lung ultrasound findings
1. A.
  Pleural effusion
2. B.
  Pneumonia
3. C.
  Pericardial effusion
4. D.
  Pneumothorax
15.
You are called on the floor to evaluate a 90-year-old man with diastolic dysfunction. His diuretics have been held for the past week due to renal dysfunction (currently his creatinine has plateaued at 4.2 mg/dL). He has been placed on BiPAP but continues having substantial work of breathing. The following images are obtained from his right thorax. What is the most likely cause of his pulmonary dysfunction, based on the ultrasound findings
1. A.
  Pleural effusion
2. B.
  Pneumonia
3. C.
  Pericardial effusion
4. D.
  Pulmonary edema
16.
A 29-year-old male, weighing 134 kg is brought to the emergency department after a motor vehicle accident. He has lost a lot of blood and is hypotensive and anemic with a Hb of 6.2. An emergent central line is placed in his right internal jugular and is challenging to place, given his body habitus. The patient becomes hemodynamically unstable after line placement and there is some concern that he might have developed an iatrogenic pneumothorax due to accidental puncture during line placement. A lung ultrasound over the right upper chest shows the following picture

What is the most accurate statement?
1. A.
  Patient does not have pneumothorax
2. B.
  Patient does not have pneumothorax, at that point. A more comprehensive lung exam is required
3. C.
  Patient needs an emergent chest tube
4. D.
  Patient has a hemothorax that needs to be drained
17.
Which one of the following statements about B-lines is TRUE?
1. A.
  B-lines are reverberation artifacts arising from volumetric variations between aerated and fluid-filled parts of the lung tissue
2. B.
  B-lines are evenly spaced horizontal lines at integer multiples of the distance from the skin to the pleural line
3. C.
  B-lines indicate well-aerated lung
4. D.
  B-lines are diagnostic with for pneumothorax
18.
Absence of pleural lung sliding can occur in all of the following situations except
1. A.
  Pneumothorax
2. B.
  Apnea
3. C.
  Bronchial intubation
4. D.
  Bronchial obstruction
5. E.
  Pleural adhesion
6. F.
  All of the above
19.
A 64-year-old female, with a history of HTN, HLD, and COPD has an onset of shortness of breath and sudden chest pain for the past few hours, after a coughing spell. The physician evaluates the heart and lungs with ultrasound. When looking at the lungs, the physician notices multiple horizontal lines between two hypoechoic columns as well as a lung point however he does not see any lung sliding. What is the most likely diagnosis?
1. A.
  Pleural effusion
2. B.
  Pneumonia
3. C.
  Pericardial effusion
4. D.
  Pneumothorax
20.
A 82-year-old male with a past history of CAD, systolic heart failure with EF of 30%, COPD, and a 3-year history of progressively worsening dyspnea on exertion finally presents to his PCP for workup. The doctor notices distended jugular veins and upon auscultation hears an S3 and a holosystolic murmur over the apex. The physician performs a chest ultrasound exam and sees the following. Based on this exam, which of the following is true?
1. A.
  Patient has a pleural effusion
2. B.
  Patient has fluid in the hepatorenal recess
3. C.
  Patient has free fluid surrounding the bladder
4. D.
  Patient is completely healthy

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Sharma, A., Subramani, S. (2022). Point-of-Care Ultrasound of the Lungs. In: Chakraborty, A., Ashokka, B. (eds) A Practical Guide to Point of Care Ultrasound (POCUS). Springer, Singapore. https://doi.org/10.1007/978-981-16-7687-1_4

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DOI: https://doi.org/10.1007/978-981-16-7687-1_4
Published: 11 September 2022
Publisher Name: Springer, Singapore
Print ISBN: 978-981-16-7686-4
Online ISBN: 978-981-16-7687-1
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