Point of Care Ultrasound (Pocus) : Introduction: George A. Fox

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!

Point of Care Ultrasound


(PoCUS): Introduction
George  A.  Fox  MD,  MSc,  FRCPC,  FCCP  
Financial Disclosure:
Within the past 5 years, I have received
financial sponsorship, honoraria and
hospitality from the following
pharmaceutical companies:

•  Actelion
•  Astra-Zeneca
•  Bayer HealthCare
•  Boehringer Ingelheim
•  InterMune
•  Novartis
Learning Objectives:
At the end of this session and workshop, the
participant(s) will:

•  NOT be skilled ultra-sonographer’s

•  NOT be able to perform a comprehensive “consultative”


ultrasound procedure

•  Recognize that ultrasound equipment in the hands of an


inexperienced operator may cause patient harm

•  Recognize your limitations in bedside ultrasound and outline


steps to improve your skills
PoCUS

Definition:
– An ultrasound examination provided
and performed at the bedside by the
primary care physician (or their
designate), usually as an adjunct to
the physical examination, to identify
the presence or absence of a limited
number of specific findings.
CAR, 2013. www.car.ca
PoCUS
•  Findings from the PoCUS examination
MUST be correctly integrated into the
clinical decision making process.

•  If you are not certain of all, or part of


the PoCUS examination, you should NOT
rely on those uncertain findings in the
clinical decision making process.
Noble,  V.E.,  MGH,  Boston,  MA    
Cook,  T.  MD,    Columbia,  SC  
Moak,  J.H.,  MD,  RDMS;  hFp://www.medicine.virginia.edu  
Moak,  J.H.,  MD,  RDMS;  hFp://www.medicine.virginia.edu  
Moak,  J.H.,  MD,  RDMS;  hFp://www.medicine.virginia.edu  
Cook,  T.  MD,    Columbia,  SC  
Shulich  School  of  Medicine  &  DenOstry,  UWO  
Shulich  School  of  Medicine  &  DenOstry,  UWO  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Moak,  J.H.,  MD,  RDMS;  hFp://www.medicine.virginia.edu  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
Shulich  School  of  Medicine  &  DenOstry,  UWO;  www.slideshare.net  
PoCUS

NEJM  2011,  364;8:  749-­‐57  


!

Thoracic/Pleural Ultrasound
George  A.  Fox  MD,  MSc,  FRCPC,  FCCP  
Learning Objectives:
At the end of this session and workshop, the
participant(s) will be able to:
•  Discuss the appropriate choice of ultrasound probes

•  Identify the structures when examining the lung and pleural space

•  Identify the pleura, and describe the findings of a pneumothorax

•  Describe how B-mode/M-mode are used to identify a pneumothorax

•  Identify common ultrasound “patterns” visualized in the thorax

•  Describe how to perform a thoracentesis using ultrasound guidance

•  Describe static and dynamic ultrasound guidance  


Thoracic Ultrasound:

hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐image-­‐interpretaOon-­‐tutorial  
Thoracic Ultrasound:

hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐image-­‐interpretaOon-­‐tutorial  
Thoracic Ultrasound:
B-mode:  

hFp://www.jrheum.org/content/39/8/1641  
Thoracic Ultrasound:
M-mode:  

hFp://www.icmteaching.com/ultrasound/lung%20ultrasound/styled-­‐125  
Thoracic Ultrasound:  

hFp://www.ncbi.nlm.nih.gov/pubmed/?term=lung+ultrasound  
Thoracic Ultrasound:
Probes:  

                        Phased Array Probe Linear Vascular Probe

hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐basics-­‐tutorial  
Thoracic Ultrasound:
Probe Location:  

Volpicelli, G., Emerg Radiol, 2008: 15:145-51


Thoracic Ultrasound:  

Lichtenstein, D., CHEST 2008, 134:117


Thoracic Ultrasound:  
Sensitivity (%) Specificity (%) PPV (%) NPV (%)

Pleural 94 97 95 90
Effusion
Alveolar
Consolidation 90 98 88 95
(Pneumonia)

Interstitial
Syndrome 93 93 87 99
(CHF, ARDS)

Complete 100 96 100 98


Pneumothorax
Occult 79 100 89 99
Pneumothorax
AECOPD 89 97 93 95

Pulmonary 81 99 94 98
Embolism
Lichtenstein, D., Ann Int Care, 2014; 4:1-12
Thoracic Ultrasound:  

Lichtenstein, D., CHEST 2008, 134:117


Thoracic Ultrasound:  
5 sonographic “signs” used in the BLUE
Protocol:
–  Sliding Lung
–  A Lines
–  B Lines
–  Alveolar Consolidation
–  Pleural Effusion
Thoracic Ultrasound:
Lung Sliding:  

Present

http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial
Thoracic Ultrasound:
Lung Sliding:  

Present? Absent

http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial
Thoracic Ultrasound:
Lung Sliding, B-mode:  
Thoracic Ultrasound:
Absent Lung Sliding, B-mode:  
Thoracic Ultrasound:
Lung Sliding (B-mode/M-mode)  

http://www.acep.org/
Thoracic Ultrasound:
Absent Lung Sliding:  

Other causes:
–  Pleural adhesion
–  Atelectasis
–  Lobectomy/Pneumonectomy
–  Main-stem intubation

- Compare with other lung


- Look for “Lung Point” (100% specific for
pneumothorax)
Thoracic Ultrasound:
“Lung Point”  
Thoracic Ultrasound:
A Lines:  

•  Horizontal “reverberation” artifacts


•  Generally seen in Aerated Lungs
•  Parallel to the pleural line
•  Decay with increasing depth
•  Obliterated by B Lines
Thoracic Ultrasound:
A Lines:  

•  Seen in normal lung parenchyma


–  PAOP < 13 mmHg
•  DD(x):
–  Obstructive Lung Disease (COPD/Asthma)
–  Pulmonary Embolism
•  A Lines can be seen without lung sliding
–  search for pneumothorax
Thoracic Ultrasound:
A Lines:  

http://www.pneumon.org
Thoracic Ultrasound:
A Lines:  
Thoracic Ultrasound:
B Lines:  
•  Hyperechoic rays projecting vertically
from pleural line to bottom of screen
–  Obliterate A Lines
•  Identifies fluid in interlobular septum
•  “Interstitial” Syndrome
–  Bilateral
•  CHF, ARDS, ILD
–  Unilateral
•  Pneumonia
Thoracic Ultrasound:
B Lines:  

hFp://westernsono.ca/tutorials-­‐3/lung-­‐ultrasound-­‐image-­‐interpretaOon-­‐tutorial  
Thoracic Ultrasound:
B Lines:  

http://www.criticalecho.com
Thoracic Ultrasound:
B Lines:  

http://www.criticalecho.com
Thoracic Ultrasound:
B Lines:  
Thoracic Ultrasound
B Lines:  

Clinical Role of B Lines:

Fluid “Intolerant”
vs
Fluid “Tolerant”
 
Thoracic Ultrasound:
A Lines vs B Lines:  

hFp://www.scielo.br/scielo  
Thoracic Ultrasound:
Consolidation:  

http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial
Thoracic Ultrasound:
Consolidation:

Air bronchograms  

Chest. 2009;135(6):1421-1425
Thoracic Ultrasound:
Consolidation:  

hFp://www.criOcalecho.com/content/tutorial-­‐9-­‐lung-­‐ultrasound  
Thoracic Ultrasound:
Consolidation:  

hFp://www.criOcalecho.com/content/tutorial-­‐9-­‐lung-­‐ultrasound  
Thoracic Ultrasound:
Pleural Effusion:  

http://westernsono.ca/tutorials-3/lung-ultrasound-image-interpretation-tutorial
Thoracic Ultrasound:
Pleural Effusion:  
Thoracic Ultrasound:
Pleural Effusion:  
Thoracic Ultrasound:
Pleural Effusion:  
“Jelly Fish” sign

http://www.critcaresono.com
Thoracic Ultrasound:
Pleural Effusion:  
“Jelly Fish” sign / Lung Flapping
Thoracic Ultrasound:
Pleural Effusion:  
Septations “Plankton” sign
Thoracic Ultrasound:
Thoracentesis:  

http://www.critcaresono.com/
Thoracic Ultrasound:
Thoracentesis:  

Localize deepest “pocket” of fluid in longitudinal and transverse plane

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/bedside-applications-of-ultrasound/
Thoracic Ultrasound:
Thoracentesis:  

Must Identify:
-  Anechoic free space
-  Chest wall
-  Diaphragm
- Above vs below
- Respiratory Movement
-  Compressed Lung
- “Flapping”

http://link.springer.com/referenceworkentry
Thoracic Ultrasound:
Thoracentesis:  

“Static” Guidance “Dynamic” Guidance

http://www.critcaresono.com/
Thoracic Ultrasound:
Thoracentesis:  

“Static” Guidance “Dynamic” Guidance

http://www.pocustoronto.com/articulate/thora/story.html
Thoracic Ultrasound:
Thoracentesis:  

http://www.med.uottawa.ca/courses/
Thoracic Ultrasound:
Thoracentesis:  

http://www.med.uottawa.ca/courses/
Thoracic Ultrasound:
Thoracentesis:  
Pearls  &  Pidalls:  
–  IdenOfy  anatomic  boundaries:  
•  Anechoic  free  space  
•  Chest  wall  
•  Diaphragm  
–  Diaphragm  movement?  
•  Compressed  lung  
–  Lung  flapping?  
–  R/O  ascites:  
•  Hepatorenal/splenorenal  space  vs  pleural  space?  

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