Lung ultrasound in the ICU from diagnostic instrument to

Lung Ultrasound In The Icu From Diagnostic Instrument To-Free PDF

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not permitted It is not permitted to remove cover overlay obscure block or change any copyright notices or terms of use which the Publisher may post on the Article It is not permitted to frame or use framing techniques to enclose any trademark logo. COPYRIGHT 2012 EDIZIONI MINERVA MEDICA, means which may allow access to the Article The use of all or any part of the Article for any Commercial Use is not permitted The creation of derivative works from the Article is not permitted The production of reprints for personal or commercial use is. Lung ultrasound in the ICU VIA, This document is protected by international copyright laws No additional reproduction is authorized It is permitted for personal use to download and save only one file and print only one copy of this Article It is not permitted to make additional copies. either sporadically or systematically either printed or electronic of the Article for any purpose It is not permitted to distribute the electronic copy of the article through online internet and or intranet file sharing systems electronic mailing or any other. clear its potential role in the more complex and image of lung tissue is generated Thus the abil. resource rich intensive care environment is still ity to generate real images of lung parenchyma. under investigation This manuscript represents always indicates pathology On the other hand. an ICC LUS conforming 3 description of cur in cases where air is present in the underlying. rent and potential applications of LUS specific parenchyma different types of image artefacts are. to the adult intensive care setting with a focus produced Different artefacts represent normally. on respiratory monitoring It also provides the aerated lung tissue or rather tissue with dimin. intensive care physician with a framework for ished relative aeration whatever the specific un. the practical implementation of this tool at the derlying pathological process Relative aeration. bedside may in fact be diminished either by loss of air. developing atelectasis or by an accumulation, Methods of fluid or cells in the interstitial or alveolar spac. es pneumonia contusion oedema fibrosis or,A systematic literature search January alveolitis. 1990 January 2012 on LUS was performed The generation of ultrasound artefacts by aer. to gather the most recent evidence on the top ated lung tissue is the result of sound wave reflec. ic Terms used in various combinations for the tion and reverberation Both phenomena origi. searches on the National Library of Medicine nate from the high acoustic impedance interface. Medline Cochrane library Google Scholar and between pre pleural watery tissues and the. Embase databases were lung chest pulmonary aerated lung The physical site of this interface. thoracic pleural AND sonographic sonogra is represented by the point of contact of the pa. phy ultrasonographic ultrasonography ultra rietal and visceral pleural layers It appears ultra. sound echographic echography AND bedside sonographically as a hyperechoic transverse line. point of care Initial searches identified N 305 the pleural line located between and deep to. articles Only papers describing sequential LUS the ribs Figure 1A Since nearly all ultrasound. assessment and or studying adult ICU popu waves are reflected at this level visualization of. lations N 57 were further selected as core anything real is impossible beyond the pleural. source of data for the manuscript Where appli layers However different types of artefacts are. cable recommendations from the recent ICC displayed on the far side of the pleural line gen. LUS 3 regarding indications terminology and erated by the bouncing of the ultrasound beam. technique were considered Evidence was sup between this specular reflector and the probe. plemented with experts opinion and personal reverberation artefacts The specific features. clinical experience of these artefacts vary according to the physi. cal properties of the reflector which are in turn, Fundamentals of lung ultrasound determined by the state of aeration of the lung.
immediately beneath the visceral pleura Three, LUS provides a representation of the lung that situations may occur 1 normally aerated lung. is based both on images and on artefacts The generates a homogeneous reflecting surface that. key factor determining the appearance of the yields transverse artefacts parallel to the pleural. imaged area is the relative amount of air lying line A lines Figure 1A 2 partial loss of. beyond the visceral pleura Since sonography is a aeration due to fluid or cells in subpleural lung. or other proprietary information of the Publisher, real time dynamic imaging technique LUS of tissue generates discrete microscopic 3 dimen. fers instantaneous insight both into the state of sional aerated structures aerated alveoli acina. aeration of the lung and into its ventilation surrounded by fluid or cells in these circum. The state of aeration of lung parenchyma is a stances air fluid interfaces act as specular reflec. measure of its air fluid ratio This ratio deter tors discrete foci of reverberation yielding lon. mines the characteristics of the image produced gitudinal laser like artefacts B lines Figure. by LUS In areas of complete consolidation that 1C 4 5 3 complete absence of air beneath the. is where there is complete absence of air a real visceral pleura in areas of consolidation even if. Vol 78 No 11 MINERVA ANESTESIOLOGICA 1283, not permitted It is not permitted to remove cover overlay obscure block or change any copyright notices or terms of use which the Publisher may post on the Article It is not permitted to frame or use framing techniques to enclose any trademark logo. COPYRIGHT 2012 EDIZIONI MINERVA MEDICA, means which may allow access to the Article The use of all or any part of the Article for any Commercial Use is not permitted The creation of derivative works from the Article is not permitted The production of reprints for personal or commercial use is. VIA Lung ultrasound in the ICU, This document is protected by international copyright laws No additional reproduction is authorized It is permitted for personal use to download and save only one file and print only one copy of this Article It is not permitted to make additional copies.
either sporadically or systematically either printed or electronic of the Article for any purpose It is not permitted to distribute the electronic copy of the article through online internet and or intranet file sharing systems electronic mailing or any other. or other proprietary information of the Publisher, Figure 1 Synopsis of lung ultrasound semiotics Main segmental patterns are illustrated left column and described in their dis. tinctive features right column Normal pattern 1A sonographic interstitial syndrome 3 B lines intercostal space 1C and. pneumothorax 1F are mutually exclusive artefact based patterns Pleural sliding 1A and lung pulse 1B are representations of. visceral pleural motion in a ventilated and a non ventilated lung area respectively and are here shown using M Mode imaging. as having a different appearance of artefacts beyond the pleural line M Mode provides representation over time of reflected echoes. from a single scanning line structures perpendicular to the ultrasound beam are represented by dots at a specific depth and ap. pear as straight lines when motionless Effusion 1C and consolidation 1D are image based patterns and their interpretation is. more intuitive 3 9 for a more extensive description E effusion P lung L liver S spleen e loculated effusion asterisks indicate. rib shadows,1284 MINERVA ANESTESIOLOGICA November 2012. not permitted It is not permitted to remove cover overlay obscure block or change any copyright notices or terms of use which the Publisher may post on the Article It is not permitted to frame or use framing techniques to enclose any trademark logo. COPYRIGHT 2012 EDIZIONI MINERVA MEDICA, means which may allow access to the Article The use of all or any part of the Article for any Commercial Use is not permitted The creation of derivative works from the Article is not permitted The production of reprints for personal or commercial use is. Lung ultrasound in the ICU VIA, This document is protected by international copyright laws No additional reproduction is authorized It is permitted for personal use to download and save only one file and print only one copy of this Article It is not permitted to make additional copies. either sporadically or systematically either printed or electronic of the Article for any purpose It is not permitted to distribute the electronic copy of the article through online internet and or intranet file sharing systems electronic mailing or any other. small restores favorable conditions for ultra accuracy to the fact that nearly all lung patholo. sound transmission with only partial reflection gies relevant to the critically ill have a peripheral. generating a representation of lung tissue as a manifestation. solid organ Figure 1E 6, The state of ventilation of aerated scanned ar Lung ultrasound technique a shift.
eas is evidenced by changes in the appearance in concept of lung imaging. of the pleural line over the respiratory cycle Its. respirophasic shimmering lung sliding 3 cor In comparison to the overall lung picture. responds to the continued to and fro motion of displayed by routine techniques monoplane. the visceral pleura on the parietal pleura indicat frontal with chest X ray or multi plane either. ing the presence of ventilation in the inspected coronal sagittal transverse with CT scan LUS. area On the other hand a heart beat synchro provides multisite regional representations of the. nized motion of the pleural line lung pulse lung The clinician must then reconstruct the. 7 implies the absence of ventilation as in early overall three dimensional picture by integrating. atelectasis before alveolar air resorption ensues all segments in his her mind This cognitive proc. A motionless pleural line sliding abolition ess more resembles the interpretation of ausculta. potentially indicates a detachment of the two tion findings rather than interpreting the images. visceral layers with interposition of air 8 provided by CT or a plain radiograph From a. Additionally LUS detects collections in the practical point of view a LUS examination in. pleural space that can be further characterized ICU patients should systematically investigate six. by specific patterns These patterns can be ei areas of interest per side dividing each hemithorax. ther artifactual or image based depending upon into an anterior lateral and posterior region ac. the constituents of the pleural collection air or cording to anatomical landmarks represented by. fluid In the case of a gaseous collection pneu axillary lines and each region into an upper and. mothorax the sliding abolition in a dependent lower region Figure 2 Scanning the patient s. area is matched with the inspiratory coming posterior regions just dorsal to the posterior axil. into view seen as the sudden re appearance of lary line with minimal patient tilting may many. lung sliding of a mobile partially collapsed times suffice Note that the posterior portions of. lung in a more lateral or dorsal site the so called upper lobes are often blind spots The examina. lung point 8 Figure 1F The combination of tion can either be comprehensive every inter. these two signs based on artefacts sliding abo costal space is entirely scanned 10 or simplified. lition and lung point allows the positive diag one representative point per area is scanned. nosis of pneumothorax 8 In the case of a fluid 11 similar to the simplified application of other. collection pleural effusion an image of variable imaging modalities on clinical grounds 12 The. echogenicity is generated between the two pleu time required can thus range from 5 to 15 min. ral layers Figure 1D utes In the simplified approach if an abnormal. Based on these concepts a well defined se ity is identified inspection is further extended. miotics has been validated 3 and relies on easily to define its boundaries For the purpose of lung. distinguishable segmental patterns Figure 1 aeration quantification see below the most se. normality sonographic interstitial syndrome vere pathological finding can be considered rep. pleural effusion consolidation and pneumo resentative of the entire region. or other proprietary information of the Publisher, thorax A detailed description of LUS semiotics The peculiarities intrinsic to LUS imaging. beyond the purpose of this manuscript is out discussed above require specific tools to aid in. lined elsewhere 3 9 It may be understood from communication and clinical use of examination. this short synopsis that LUS relates to the degree findings Archiving and reporting are manda. of aeration of the lung s outer subpleural layer tory Simplified report forms ideally electronic. Only consolidations that reach the visceral pleu are recommended Figure 2 for their ease of use. ra and effusions permit deeper investigation and their effectiveness in promoting learning. LUS is a surface imaging technique and owes its and implementation of LUS in daily practice 13. Vol 78 No 11 MINERVA ANESTESIOLOGICA 1285, not permitted It is not permitted to remove cover overlay obscure block or change any copyright notices or terms of use which the Publisher may post on the Article It is not permitted to frame or use framing techniques to enclose any trademark logo. COPYRIGHT 2012 EDIZIONI MINERVA MEDICA, means which may allow access to the Article The use of all or any part of the Article for any Commercial Use is not permitted The creation of derivative works from the Article is not permitted The production of reprints for personal or commercial use is. Lung ultrasound in the ICU from diagnostic instrument to respiratory monitoring tool G VIA 1 E STORTI 2 G GULATI 3 L NERI 2 F MOJOLI 1 A BRASCHI 1 1First Department of Anesthesia and Intensive Care IRCCS Policlinico San Matteo Foundation University of Pavia

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