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Lung Ultrasound in Cardiac Care
1. Lung Ultrasound in Intensive Care
Senior Clinical Fellow
Adult Intensive Care
Royal Brompton Hospital, London, UK
Dr. Hatem Soliman Aboumarie
MBBS, MRCP, MSc, PGDip (Cardio), EDICM, ASCeXAM
5. Principles of LUS
What’s normal?
Advantages Requirements
Evidence
Overview
?
What is the evidence ?
Take Home Messages
Challenges
6. Historically
The lung, not suitable for ultrasound?
The lungs are a major hindrance for the
use of ultrasound at the thoracic level”.
In Harrison PR. Principles of Internal Medicine. 1992:1043
Simply wrong
7. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749-57.
Recently
PubMed, May 2018.
Lung ultrasound has emerged as a new sonographic
technique to evaluate many pulmonary conditions
1972
8. Principles
Ultrasound is not transmitted through areated tissue
Normal parenchyma is not visible
Interface between pleura and lung (different acoustic impedence)
reflects US
Intercostal space acoustic window
10. Equipment requirements
Cardiac transducer effective (small footprint)
Curvilinear transducer may be used
Vascular transducer is used for lung
sliding, small consolidations
15. Lung Sliding
Slight and bright horizontal movement of the pleural line due to sliding
of the parietal and visceral pleurae.
Normal Lungs
Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
16. Normal LungsSeashore Sign
Waves on a sandy beach
Sea - Waves
Shore – Sandy Beach
Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
18. Lung Pulse
Vertical movement of the pleural line synchronous to the cardiac rhythm.
Caused by the transmission of the heart beats through Lung tissues
Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
21. Pneumothorax Diagnosis
A lines: present
Lung pulse: absent
B lines: absent
Lung sliding: absent
Lung point: present
The diagnosis of PNX depends on the correct
combination of these signs
23. B-lines
Laser-like vertical hyperechoic artifacts
Arises from the pleural line.
Pleural Line
Lichtenstein, D. Intensive Care Med. 1998 Dec;24(12):1331-4.
Long and well-defined
Erases A-lines
Moves with lung sliding
Extravascular Lung Water = Interstitial syndrome
28. 97 patients. Compared LUS with a previously validated clinical
congestion score (CCS); NT-proBNP, E/e’ ratio, chest x-ray, and 6-min
walk test.
Evidence
• In an HF outpatient clinic, B-lines were significantly correlated with
more established parameters of decompensation.
• A B-line >=15 cut-off could be considered for a quick and reliable
assessment of decompensation in outpatients with HF.
30. LUS used to examine 195 NYHA class II–IV HF patients during routine
cardiology outpatient visits.
Evidence
Patients with ≥3 B-lines had a four-fold higher risk of the primary outcome
compared with those with less number of B lines and spent a significantly
lower number of days alive and out of the hospital (125 days vs. 165 days;
adjusted P = 0.001).
31. Copetti R, Soldati G, Copetti P. Cardiovasc Ultrasound. 2008;6:16
Cardiogenic Pulmonary EdemaARDS
Subpleural consolidations
Spared area
Thickened & irregular pleural line
B-lines: non-uniform distribution
Vs.
46. Air is the enemy of Ultrasound but Lungs are good friends!
Lung Ultrasound should be an integral part of the Echo study
B-lines can be used reliably for monitoring treatment of heart failure
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Take-home messages5
Integrated approach is crucial4