1
Oxford
Pleural
Unit
Thoracic Ultrasound in practice
ERS Thoracic Ultrasound Course
Oxford
Pleural
Unit Evidence
Higher sensitivity vs. chest radiography1
Higher procedure accuracy:• 97% aspiration success2
Low complication rate:• PTx 2%, bleeding 0.4% 3
Added diagnostic information:• Echogenic fluid excludes transudate
• Septations / pleural thickening
• Homogenous echogenicity 41 = Eibenberger et al, Radiology 19942 = O’Moore et al, AJR 19873 = Jones et al, Chest 20034 = Yang et al, AJR 1992
2
Oxford
Pleural
Unit Evidence
Better than clinical examination1:• 15% clinically specified puncture sites inaccurate
• 80% of these aspirated under US
• When clinical site not identified – US achieved in 54%
• US avoids organ puncture in 10%
Pneumothorax:• More sensitive in detection post lung biopsy than CXR2,3
• Sensitivity 95% post trauma4
• Detects “occult” PTx post trauma4
1 = Diacon et al, Chest 20032 = Sartori et al, AJR 20073= Goodman et al, Clin. Rad 19994 = Soldati et al, Chest 20085 = Mathis et al, Chest 2005
Oxford
Pleural
Unit UK Training
in Thoracic US
http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf
Oxford
Pleural
Unit Levels of Competence
Level I (most chest physicians):• Normal anatomy• Diagnosis of pleural fluid• Fluid characteristics
• Basic procedures
Level II:• More complex disease• More complex procedures
• Competent at lung / lymph node biopsy• Able to receive referral from level I
Level III:• Advanced operators only
3
Oxford
Pleural
Unit Equipment
• Machine able to achieve depth of at least 10cm
• Curvilinear low Hz (3-5MHz) probe better for depth
Scanning Position
Image Orientation
4
F
D
VP
PP
Oxford
Pleural
Unit Normal Appearance
Lung• Ultrasound unable to see through air
• Unable to penetrate normal lung
• “Comet tails”
• Lung sliding
Other organs• Liver
• Spleen
7
Oxford
Pleural
Unit Simple effusion
Diagnostics:
• Echogenic swirling
• Inverted hemidiaphragm
• Pleural thickening /nodularity
8
Oxford
Pleural
Unit Diagnosis of malignant
pleural effusion
Qureshi, Rahman and Gleeson; Thorax 2008
9
Oxford
Pleural
Unit
Complex effusions
10
Lung abnormalities
11
Oxford
Pleural
Unit Pneumothorax
Advantages:• Sensitive and specific
• Increased specificity compared to CXR
Problems:• Unable to quantify size (binary test)
• Problems in interpretation in COPD (Slater et al, Chest 2006)
• ? Any practical use
12
Oxford
Pleural
Unit Interventions
Options:
• “Marking” the skin • Simple
• Movement
• Delay
• Overconfidence
• Real-time US (“direct vision”):• See what you are doing
• More difficult to learn
• Specific equipment
*Raptopoulos V, Davis LM, Lee G, Umali C, Lew R, Irwin RS. Am J Roentgenol 1991; 156(5):917-920
Complication rate
similar to unguided*
Oxford
Pleural
Unit When to ask for help…
• Images often not this clear
• Radiologist:• more skilled in all aspects of US
• access and understanding of other techniques
• Trust your own CXR interpretation
• MUST know own limits
Oxford
Pleural
Unit Summary
Normal Appearances• Liver / spleen / bowel / kidneys
• US unable to penetrate normal aerated lung:• Comet tails
• Pleural slide
Effusion:• Parietal and visceral pleura identified
• Echo poor area which you can see past
• Diaphragm easily seen
