Role of trans-thoracic ultrasound in diagnosis and interventions in pleural diseases

2. Ultrasound Guided Pleural
Procedures
Gamal Rabie Agmy ,MD ,FCCP
Professor of Chest Diseases, Assiut University

4. OVERVIEW
• Evidence base for use of thoracic ultrasound
– diagnostic and interventional
• Pleural effusion
– Characteristics of effusions
– Transudates vs exudates
– Colour fluid sign
– Formulas for volume estimation
• Pneumothorax
• Pleural thickening
Identification, DD with pleural effusion
• Pleural tumours

5. WHY ULTRASOUND?
• Not all opacification is fluid… 1
1 Psallidas et al. Clin Med 2014

6. WHY ULTRASOUND?
• Higher diagnostic sensitivity vs. plain chest radiography
– pleural effusion +/- consolidation
• Accessible to clinician and patient
– instant feedback to inform decision-making process
• Provides additional diagnostic information
– echogenicity, septations, pleural thickening, underlying viscera
• Improves procedural outcomes
– eliminates “dry tap”, limits risk of iatrogenic complications

7. THE EVIDENCE FOR FLUID
• Better than clinical examination 1
– 15% of clinically specified puncture sites inaccurate / “at risk”
– 80% of these successfully aspirated / accessible with TUS
– If clinical site not identified, TUS achieved in 54%
– TUS prevented iatrogenic organ puncture in 10% of cases
• Reduces cost / complications in thoracentesis 2
– 61,261 thoracenteses, 47% performed without TUS
– MV modelling and analysis
– TUS reduced risk of pneumothorax by 19%
– OR 0.81; 95% CI 0.74-0.90
1 Diacon et al. Chest 2003
2 Mercaldi et al. Chest 2013

8. INTERVENTIONS
• Thoracic ultrasound (TUS)
– necessary for any pleural intervention for fluid
– more sensitive than CXR for detection of fluid 1
– improves diagnostic accuracy and reduces complications 2
• BTS Pleural Disease Guidelines 3
1 Eibenberger KL et al. Radiology 1994
2 Diacon AH et al. Chest 2003
3 BTS Pleural Disease Guidelines. Thorax 2010

11. Normal lung surface
Left panel: Pleural line and A line (real-time).
The pleural line is located 0.5 cm below the rib line in the adult.
Its visible length between two ribs in the longitudinal scan is
approximately 2 cm. The upper rib, pleural line, and lower rib (vertical
arrows) outline a characteristic pattern called the bat sign.

18. SIZE OF EFFUSION ON US
Size / Volume measurement1:
• 2cm depth of fluid = 480mls
• 4cm depth of fluid = 960mls
Supine patients2:
• Size calculation:
» Visceral – parietal (mm) x 20 = volume (mls)1
» Distance between posterior chest wall and lung of >50mm
predicts >500ml thoracentesis vol2
1 = Balik, ICM 2006
2 = Roch, Chest 2005
Relative precision on estimating the fluid
1 rib space small
2-3 rib spaces moderate
4>rib spaces large

19. Sonography Guided
Interventions

20. 1-Pleural effusion

21. Different Models of Cope Needle

22. Abrams Needle

23. Lung Biopsy Needles

26. Instruments for Ultrasound – guided
Biopsy Forceps of the Pleura

29. • Compared to thoracoscopy the sensitivity
of ultrasound guided forceps pleural biopsy
in the diagnosis of malignant and
tuberculous lesions was 85% and 88%
respectively.
• The technique was absolutely specific in
the diagnosis of malignant and tuberculous
lesions.

30. Instruments for Ultrasound –
guided Pleural Brushing

31. Procedure
9 (41%)PFC
9 (41%)PB
15 (68%)BFP
16 (72%)PFC + BFP
12 (55%)PB + PFC
18 (82%)PB + BFP
19 (86%)PB + PFC + BFP
Diagnostic Yield

33. Different Models of Catheters for
Pleural Drainage

34. 2-Pneumothorax

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

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

42. 3-Pleural thickening

44. 4-Pleural tumors