Lung Point-of-Care Ultrasound for Unexpected Hypoxemia during Anesthesia

This is a case report showing acute hypoxemia during anesthesia. Immediate differentiation using lung POCUS (point-of-care ultrasound), in addition to physical examination and portable chest radiography, was made. This is the first case report of sputum impaction due to pneumonia causing hypoxemia that has been detected by lung POCUS during anesthesia.

The Role of Ultrasonography in the Diagnosis and Decision Algorithm for the Management of Pneumothorax after Transbronchial Lung Cryobiopsy

<b><i>Background:</i></b> Pneumothorax is one of the main complications of transbronchial lung cryobiopsy (TBLC). Chest ultrasound (CUS) is a radiation-free alternative method for pneumothorax detection. <b><i>Objective:</i></b> We tested CUS diagnostic accuracy for pneumothorax and assessed its role in the decision algorithm for pneumothorax management. Secondary objectives were to evaluate the post-procedure pneumothorax occurrence and risk factors. <b><i>Methods:</i></b> Eligible patients underwent TBLC, followed by chest X-ray (CXR) evaluation 2 h after the procedure, as our standard protocol. Bedside CUS was performed within 30 min and 2 h after TBLC. Pneumothorax by CUS was defined by the absence of lung sliding and comet-tail artefacts and confirmed with the stratosphere sign on M-mode. Pneumothorax size was determined through lung point projection on CUS and interpleural distance on CXR and properly managed according to clinical status. <b><i>Results:</i></b> Sixty-seven patients were included. Nineteen pneumothoraces were detected at 2 h after the procedure, of which 8 (42.1%) were already present at the first CUS evaluation. All CXR-detected pneumothoraces had a positive CUS detection. There were 3 discordant cases (κ = 0.88, 95% CI: 0.76–1.00, <i>p</i> &#x3c; 0.001), which were detected by CUS but not by inspiration CXR. We calculated a specificity of 97.5% (95% CI: 86.8–99.9) and a sensitivity of 100% (95% CI: 87.2–100) for CUS. Pneumothorax rate was higher when biopsies were taken in 2 lobes and if histology had pleural representation. Final diagnosis was achieved in 79.1% of patients, with the most frequent diagnosis being hypersensitivity pneumonitis. Regarding patients with large-volume pneumothorax needing drainage, the rate of detection was similar between CUS and CRX. <b><i>Conclusion:</i></b> CUS can replace CXR in detecting the presence of pneumothorax after TBLC, and the lung point site can reliably indicate its size. This useful method optimizes time spent at the bronchology unit and allows immediate response in symptomatic patients, helping to choose optimal treatment strategies, while preventing ionizing radiation exposure.

Signs and lines in lung ultrasound

Point-of-care ultrasound has become firmly established in acute and critical care settings, and is now increasingly being used as an important tool in the assessment of the lungs. In this article, we briefly describe the technique of lung ultrasound and the various lines and signs commonly encountered during sonography of the lung, namely the normally visualised A- and T-lines and the bat sign, sliding sign (power slide sign on colour Doppler), sea-shore sign, curtain sign, and the lung pulse. We have also described signs seen in various pathological conditions like B-lines seen in cases of increased lung density; the quad sign, sinusoid sign, thoracic spine sign, plankton sign and the jelly fish sign seen in pleural effusion; the stratosphere sign and the lung point sign seen in pneumothorax; the shred/fractal sign and tissue-like sign in consolidation, and the double lung point sign seen in transient tachypnoea of the newborn. With adequate and appropriate training, lung ultrasound can be effectively utilised as a pointof-care investigation.

KHẢO SÁT ĐẶC ĐIỂM CỦA SIÊU ÂM TRONG VIÊM PHỔI CÓ BIẾN CHỨNG Ở TRẺ EM

Mục tiêu: Khảo sát một số đặc điểm của siêu âm ở bệnh nhi bị viêm phổi có biến chứng. Đối tượng, phương pháp: Dân số chọn mẫu là những đối tượng bệnh nhân ở trên được chẩn đoán viêm phổi tại khoa Hô hấp và các khoa khác tại Bệnh viện Nhi đồng I – Thành phố Hồ Chí Minh từ tháng 9/2018 đến tháng 7/2019. Phương pháp nghiên cứu: nghiên cứu hồi cứu kết hợp tiến cứu (mô tả ca bệnh). Nghiên cứu mô tả đặc điểm siêu âm phổi ở bệnh nhi viêm phổi có biến chứng với X-quang cắt lớp vi tính là tiêu chuẩn vàng chẩn đoán. Kết quả: Các dấu hiệu tổn thương viêm phổi cơ bản thường gặp theo thứ tự là dấu hiệu đông đặc, mất dấu hiệu trượt màng phổi và đường B với tỷ lệ lần lượt là 94,3%, 28,6% và 20,0%. Các dấu hiệu tổn thương của biến chứng viêm phổi hay gặp theo thứ tự là dấu hiệu quad, dấu hiệu signoid và dấu hiệu lung point với tỷ lệ lần lượt là 53,4%, 25,7% và 14,3%. Xẹp phổi, tràn dịch màng phổi, viêm phổi hoại tử và tràn khí màng phổi là các biến chứng hay gặp của viêm phổi, với tỷ lệ tương ứng là 62,9%, 57,1%, 40% và 14,3%. Kết luận: Siêu âm phổi là phương tiện chẩn đoán hình ảnh không xâm lấn có giá trị kinh tế cao so với các phương tiện chẩn đoán hình ảnh khác như chụp X-quang cắt lớp vi tính ngực, Chụp cộng hưởng từ...

Lung Point Sign in Ultrasound Diagnostics of Pneumothorax: Imitations and Variants

Background. Pulmonary ultrasound plays a key role in the diagnosis of pneumothorax in emergency and intensive-care medicine. The lung point sign has been generally considered a pathognomonic diagnostic sign. Recently, several other situations have been published that can mimic the lung point, as well as a few different variants of the true lung point sign. Materials and Methods. Based on years of monitoring the literature and collecting our database of ultrasound findings, we prepared a review of ultrasound findings mimicking the lung point sign and ultrasound variants of the true lung point sign. Results. We present four imitations of the lung point sign (physiological lung point sign, pseudo-lung point sign, bleb point sign, and pleurofascial point sign) and two variants of the true lung point sign (double lung point sign and hydro point sign) documented by images and video records. Conclusions. Knowledge of ultrasound imitations and variants of the lung point sign may increase the reliability of pneumothorax diagnosis and may reduce the risk of performing unindicated interventions.

Echocardiography and thoracic ultrasound

Thoracic ultrasound is a rapidly evolving method in assessing diseases of the chest and particularly in emergency conditions for the evaluation of dyspnoeic and hypoxic patients. An increased number of B-lines are an unspecific sign for an increased quantity of fluid in the lungs, resembling interstitial syndromes such as cardiogenic pulmonary oedema. The presence of a B-line pattern allows the differentiation between a cardiogenic and a respiratory origin of acute respiratory failure. Also, ultrasound can be used for the diagnosis and monitoring of pulmonary consolidation, for the diagnosis and quantification of pleural fluid, and for the diagnosis of pneumothorax using the ‘lung point’. Finally, thoracic ultrasound can be used for guided pleural fluid aspiration, closed intercostal tube drainage, and central vessel catheterization.

Thoracic Trauma

More than 85% of blunt and penetrating trauma to the thorax results in injury to the lungs or ribs. Among civilians, blunt trauma is the most common mechanism, while penetrating trauma is the most common among military sectors. This review describes the assessment and stabilization, diagnosis, treatment and disposition, and outcomes of thoracic trauma. Videos shows the “lung point” sign on M-mode and two-dimensional ultrasonography, and a transthoracic echocardiogram clip of pericardial clot and tamponade due to a gunshot wound. Figures show a sonogram showing the “lung point sign”, a chest x-ray and computed tomographic scan demonstrating right-sided hemothorax in a patient with a right chest stab wound, and a three-dimensional computed tomographic scan and chest x-ray of a blunt trauma patient with displaced fractures of the left lateral sixth to ninth ribs. Tables list types of injuries, NEXUS chest decision instrument imaging criteria, level 2 evidence-based recommendations for the management of pulmonary contusion and flail chest by the Eastern Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma practice guidelines for managing issues with pulmonary contusion and flail chest, and the Vancouver simplified and University of Washington grading systems for blunt aortic injury. This review contains 2 videos, 4 highly rendered figures, 10 tables, and 94 references.