live pulmonary endoscopy transthoracic ultrasound pulmonary endoscopy transthoracic ultrasound aims:...

ERS International Congress Amsterdam

26–30 September 2015

Live pulmonary endoscopy

Transthoracic ultrasound

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Tuesday, 29 September 2015

14:45 – 16:45

Room Auditorium RAI

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Live pulmonary endoscopy

Transthoracic ultrasound

AIMS: Transthoracic ultrasound is a helpful tool for investigating clinical problems such as

suspected pleural fluid, white hemithorax, atelectasis, empyema, and diaphragm function problems.

This session will demonstrate some of the most common investigations that are performed such as:

pleural effusion, white hemithorax, empyema, peripheral located lung tumor, mesothelioma.

TARGET AUDIENCE: General pulmonologists and residents.

CHAIRS: R. Bhatnagar (Bristol, United Kingdom), F. Gleeson (Oxford, United Kingdom)

SESSION PROGRAMME

14:45 Transthoracic ultrasound: technical aspects and artefacts

F. Gleeson (Oxford, United Kingdom)

Patient advocate (AMC)

T. Lapperre (Singapore, Singapore)

Case 1

I. Psallidas (Oxford, United Kingdom)

Case 2

N. Rahman (Oxford, United Kingdom), J. Wrightson (Oxford, United Kingdom)

Case 3

J. Annema (Amsterdam, Netherlands), I. van den Berk (Amsterdam, Netherlands)

Case 4

I. Psallidas (Oxford, United Kingdom)

Case 5

J. Wrightson (Oxford, United Kingdom), N. Rahman (Oxford, United Kingdom)

16:20 Transthoracic ultrasound: question and answer session

F. Gleeson (Oxford, United Kingdom), R. Bhatnagar (Bristol, United Kingdom)

16:30 Transthoracic ultrasound in clinical practice

R. Bhatnagar (Bristol, United Kingdom)

BOOKLET CONTENTS PAGE

Thoracic Ultrasound 4

Transthoracic Ultrasound in Clinical Practice 94

Additional resources 129

Faculty disclosures 120

Faculty contact information 131

Thoracic Ultrasound

Prof. Fergus Gleeson

Department of Radiology

The Churchill Hospital

Oxford OX3 7LJ

UNITED KINGDOM

fergus.gleeson@orh.nhs.uk

Oxford

Pleural

ERS Live Pulmonary Endoscopy

Thoracic Ultrasound

Najib M Rahman

Consultant and Senior Lecturer

Oxford Centre for Respiratory

Medicine

Oxford, UK

Fergus V Gleeson

Professor of Radiology

Oxford University Hospitals

Oxford, UK

Oxford

Pleural

There is no real or perceived conflicts of interest that relate to this presentation:

This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.

Oxford

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Unit Overview

1. Physics and Principles

2. Basics of Scanning

3. Evidence and Training

4. Abnormal Appearances

Oxford

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1. Physics and Principles

Oxford

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Unit What is ultrasound

• A longitudinal wave - particles move in

the same direction as the wave.

• A succession of rarefactions and

compressions transmitted due to elastic

forces between adjacent particles

Oxford

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Unit What is Ultrasound

• Audible sound has frequency 20 Hz to 20 kHz

• Most diagnostic ultrasound has frequencies in

range 2-20 MHz

Oxford

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Unit Important equation!

• Frequency of oscillations inversely

proportional to wavelength

• f = c/ (c ≈ 1540 m s-1 in soft tissue)

• Diagnostic ultrasound of 2-20MHz,

wavelength• = approximately 1 - 0.1 mm in tissue

Oxford

Pleural

Unit Generation of Ultrasound

• US generated by piezoelectric crystal

• Commonest material is lead zirconate titanate

(PZT).

• Electric field applied:

• crystal rings at a resonant frequency

• determined by its thickness

• Same or similar crystal used as receiver:

• produces electrical signal when struck by the returning

ultrasound wave

Oxford

Pleural

UnitUltrasound Transducer

Matching layer

Piezoelectric crystalAcoustic insulator

Converts electricity to sound and vice versa

Backing

Co-axial cable

Plastic housing

Oxford

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Unit Speed of ultrasound in tissue

• Speed of US in tissue depends on:

• Stiffness

• Density

• Stiffer material (more solid) transmits

ultrasound faster

Oxford

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Unit Speed of ultrasound in tissue

Medium Speed of sound

(ms-1)

Air 331

Muscle 1,585

Fat 1,450

Soft Tissue (average) 1,540

Oxford

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Unit Interaction of US with tissue

Ultrasound which enters tissue may :

• Transmit

• Attenuate

• Reflect

Oxford

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Unit Attenuation

• If particles in a tissue are small enough:• Move as a single entity

• Transmit sound in an orderly manner

• Coherent vibration

• Sound

• If large molecules are present:• Chaotic vibration

• Heat

• Loss of coherence loss of ultrasound energy

• Alter with gain control on machine

Oxford

Pleural

UnitGain too high

Oxford

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Unit Gain reduced

Oxford

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UnitAbsorption of

ultrasound / gain

• Absorption of ultrasound:

• Lower tissues return less ultrasound

• Some absorbed as heat

• Some reflected/refracted out of field of probe.

• To ensure a uniform picture

• (so deeper areas not darker)

• Use Time Gain Compensation (TGC).

• TGC:

• Applies progressively increasing amplitude to later

echoes in proportion to their depth

• i.e differential amplification

Oxford

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Unit TGC

• TGC can be varied by users

• Used to compensate for artefactual increased

brightness

• Beware previous user adjusting TGC controls

Oxford

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Unit TGC incorrect

Oxford

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Unit TGC corrected

Oxford

Pleural

• Absorption proportional to ultrasound

frequency

• Higher frequency probes:

• Smaller depth penetration

• Better resolution

• Many US machines allow user to alter

frequency up to maximum/minimum allowed

Attenuation and

depth penetration

Oxford

Pleural

Pleura on 3.5 MHz

curvilinear probe

Oxford

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Pleura on high resolution

linear probe

Oxford

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Reflection

Importance of Reflection:• Allows generation of the ultrasound signal

• Leads to loss of ultrasound signal

• Determines the appearance of tissue

• Can cause artefacts

Oxford

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Unit Reflection

Reflection occurs when:

• Ultrasound crosses an interface between two tissues with

different impedance

• Amount depends on difference in impedance

• Ultrasound which is not reflected:

• Continues

• Is used to image deeper structures

Oxford

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Unit Reflection

Interface Reflection co-efficient

Soft Tissue - Air 99

Soft Tissue - Bone 66

Fat - Muscle 1.08

Muscle - Liver 1.5

Oxford

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Unit Ribs preventing

US transmission

Oxford

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Unit US avoiding ribs

Oxford

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Reflection –

consequences

1. Need coupling material between probe

and patient skin

2. Cannot see through aerated lung

3. Cannot see through bone

Oxford

Pleural

Unit Artefacts

Mirror artefact• Occurs at smooth curved surfaces eg

diaphragm

• Reflection occurs

• Projects image of organ under diaphragm eg liver, above diaphragm

• Reflections of liver into chest can give false impression consolidated lung

Oxford

Pleural

Unit Acoustic shadowing

• Artefact:• Causing shadowing behind certain structures

• Prevents user seeing beyond them

• Caused by absorption or reflection

• Occurs at fibrous tissue eg scars and fat (eg fatty liver)

Oxford

Pleural

Unit Fatty liver

Oxford

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Unit Gas shadows

• Proportion of incident US reflected

• Unable to continue through the tissue for imaging

• At gas-tissue interfaces:• Almost all US is reflected

• Lung:• Clean shadow

• Bowel gas shadows:• ‘Dirty shadows’

• Partly filled by reverberant echoes due to multiple gas-tissue reflectors

Oxford

Pleural

Unit Gas shadows

‘Clean’ Shadow ‘Dirty’ Shadow

Oxford

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Oxford

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2. Basics of Scanning

Oxford

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Unit Equipment

• Machine able to achieve depth of at least 10cm

• Dynamic range of transducer:• Low Hz (3-5MHz) probe better for depth (e.g. abdominal)

• High Hz (7-12MHz) better for detail (e.g. small parts)

• Shape of transducer:• Linear

• Curvilinear

• Small footprint

• Machines much the same for standard use

Scanning Position

Image Orientation

Oxford

Pleural

Unit Normal Appearance

Thoracic structures:• Ultrasound unable to see through air

• Ribs are in the way

• Unable to penetrate normal lung• “Comet tails”

• Lung sliding

Other organs• Liver

• Spleen

Oxford

Pleural

Normal Appearance

Costophrenic angle

Oxford

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Normal Appearance

Mid thorax

Oxford

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Unit Normal Lung

Diagnosis of aerated lung:• “Comet tails”

• Lung sliding

Caution:• Unable to comment on what is below

• “Lung” not really seen - artefact

Oxford

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Unit Normal Subdiaphragm

Liver Spleen

Recognition of normal structure is key to safe practice57

Oxford

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Unit SummaryKey points:

• US relies on sound creation, reflection and detection

• In tissues, US can transmit / attenuate / reflect

• Decrease attenuation by increasing power (gain)

• Higher frequency, better penetration

• Interface of tissues determines how much is reflected

• Artefacts:• Mirror• Shadowing

Oxford

Pleural

Unit Ultrasound tips

• Use highest frequency for necessary depth penetration

• Use tissue harmonics for larger patients

• Try moving patient into different positions eg to move ribs apart/move bowel gas out of way

• Use ‘optimise’ button

• Reduce size of sector for improved resolution

• More jelly and press harder

Oxford

Pleural

Oxford

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3. Evidence and Training

Oxford

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Unit Thoracic US

• Should physicians perform thoracic US?

• Evidence

• Training

• Equipment

• Examples

Oxford

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Unit Thoracic US

Advantages:• Higher sensitivity for the detection of pleural fluid

• Smaller volumes of pleural fluid detectable

• Locules detectable

• Intervention safer:• Marking

• Real-time procedures

• Diagnostic value (PTx / malignancy)

Disadvantages:• Training required

• Support required

• Limitations of technique and operator need to be known

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 64

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 2008

Oxford

Pleural

UnitTraining in Thoracic US

(UK guidelines)

http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf

Oxford

Pleural

Unit Training in Thoracic US

Oxford

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Unit FAST guidelines

Oxford

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Unit FAST guidelines

Oxford

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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:• Radiologists only

Oxford

Pleural

Unit Training in Thoracic US

Key Issues in training:• Friendly radiologist

• Regular scanning time

• Familiar with machine

• Normal appearances

Key issues in Practise:• Know limits

• Access to experience if required

Oxford

Pleural

Oxford

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4. Abnormal Appearances

Oxford

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Unit Simple Effusion

Oxford

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Hemidiaphragm

FluidVisceral pleura

Parietal Pleura

Oxford

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Unit Simple Effusion

Additional information:• Size / Volume measurement

(2cm = 480mls, 4cm = 960mls)

• Lung atelectasis (cardiac pulsation)

Oxford

Pleural

Atelectatic Lung

Oxford

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Effusion

Ascites

Oxford

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Unit Simple effusion

Diagnostics:• Echogenic swirling

• Inverted hemidiaphragm

• Pleural thickening /nodularity

Oxford

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Inverted

Diaphragm

Oxford

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Unit Aetiology

• The Clinical Utility of Ultrasound in Detecting

Malignant Pleural Disease in the Presence of a

Pleural Effusion

– Aim: To determine the diagnostic accuracy of US in the

detection of malignancy in patients with suspected

malignancy and pleural effusion

Qureshi et al. Thorax

Oxford

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Oxford

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Unit Diagnosis of malignant

pleural effusion

Qureshi et al, Thorax 200883

Oxford

Pleural

Conclusions• US detects a significant number of abnormalities in pts

with suspected malignant pleural effusions

• US appears to have a high specificity and PPV for

malignancy

• Pleural and diaphragmatic thickening is common in

patients with malignant effusions

• Nodularity and irregularity are strongly suggestive of

malignancy

Oxford

Pleural

Complex effusions

Oxford

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Septations

Oxford

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Parietal

Thickening

Visceral Thickening

Oxford

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Adherent Lung

Fluid Fluid

Oxford

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UnitLung Consolidation

Oxford

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ConsolidationLiver

Oxford

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Unit Interventions

Options:

• “Marking” the skin • Simple

• Movement

• Delay

• Overconfidence

• Real-time US (“direct vision”):• See what you are doing!

• Difficult to learn

• Specific equipment

Oxford

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Unit When to ask for help…

• Radiologist more skilled in all aspects of US

• Radiologist has access and understanding of

other techniques

• Need to improve CXR interpretation

• MUST know own limits

Oxford

Pleural

Unit Summary

Thoracic Ultrasound• Very useful technique

• Will become standard of care for interventions

(data is supportive)

What you need:• Adequate training

• Adequate kit

• Supportive radiologist / experienced practitioner

Transthoracic Ultrasound in Clinical Practice

Dr Rahul Bhatnagar

Academic Respiratory Unit

Learning and Research Building

Southmead Hospital

BS10 5NB Bristol

UNITED KINGDOM

rahul@bhatnagar.me.uk

TRANSTHORACIC ULTRASOUND IN CLINICAL

PRACTICE

Rahul Bhatnagar

Academic Clinical Lecturer

University of Bristol, United Kingdom

Rahul.Bhatnagar@Bristol.ac.uk

Conflict of interest disclosure

I have no, real or perceived, direct or indirect

conflicts of interest that relate to this presentation.

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation.Drug or device advertisement is strictly forbidden.

INTRODUCTION

• Establish why thoracic US is important

• Explore practical applications of respiratory physician-

delivered thoracic US

• Highlight limitations, cautions and tips

THORACIC ULTRASOUND

Advantages:• Higher sensitivity for the detection of pleural fluid

• Smaller volumes of pleural fluid detectable

• Locules detectable

• Intervention safer:» Marking

» Real-time procedures

• Diagnostic value (PTx / malignancy)

Disadvantages:• Training required

• Support required

• Limitations of technique and operator need to be known

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 4

1 = Eibenberger et al, Radiology 19942 = O’Moore et al, AJR 19873 = Jones et al, Chest 20034 = Yang et al, AJR 1992 99

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 2008

EVIDENCE

• Ultrasound guidance decreases complications and improves

the cost of care among patients undergoing thoracentesis and

paracentesis

• Retrospective cohort over 2 year period

• 61,261 thoracenteses (45% US-guided)

• 2.7% pneumothorax rate overall

• Ultrasound reduced risk of pneumothorax by 19%

• Which in turn reduced costs of hospitalisation

Mercaldi et Al, Chest 2013 101

WHY SHOULD RESPIRATORY PHYSICIANS

TRAIN?

• Radiology department capacity (cost per annum associated with

149 bed days while awaiting TUS in one teaching hospital = £18,000

– Bateman et al Resp Med 2010)

• Ultrasound at time of procedure superior to remote X-marks the

spot (no better than blind procedure)

• Part of overall patient assessment and management – ‘one

stop’ approach

• Individual competence and timely availability are most

important

USES – RESPIRATORY WARD AND

PROCEDURE ROOM

• Guidance for all diagnostic and therapeutic aspirations and

Seldinger chest drain insertions

PROCEDURE ROOM

Seldinger chest drain insertions.

• Safe drain placement in lateral decubitus position.

• Identification of complicated parapneumonic effusions

requiring tube drainage.

PROCEDURE ROOM

seldinger chest drain insertions.

• Identify presence of pleural effusion when CXR unclear.

PROCEDURE ROOM

seldinger chest drain insertions.

• Confirm drainage complete – pre talc pleurodesis or

before chest tube removal.

PROCEDURE ROOM

Seldinger chest drain insertions.

• Confirm drainage complete – pre talc pleurodesis or before

chest tube removal.

USES - OUTPATIENT CLINIC

• Part of overall initial clinical assessment towards differential

diagnosis (fluid characteristics , pleural thickening, diaphragmatic

nodularity, pericardial effusion).

PATIENT WITH COUGH, SWEATS, CRP 152,

PLEURAL FLUID PH 6.9

USES – OUTPATIENT CLINIC

diagnosis (fluid characteristics , pleural thickening,

diaphragmatic nodularity, pericardial effusion).

• Fluid volume assessment - choosing best first pleural procedure.

• Planning LA thoracoscopy or indwelling pleural catheter (IPC)

placement.

• Fluid volume assessment - choosing best first pleural

procedure.

placement.

• Planning IPC removal / need for fibrinolytics

• Fluid volume assessment - choosing best first pleural

procedure.

placement.

• Planning IPC removal/ need for fibrinolytics

• Rapid effusion management in best supportive care of patients

with pleural malignancy (particularly MPM).120

USES – PLEURAL PROCEDURE LIST

• Assess need/ feasibility of therapeutic aspiration

pre- procedure.

• Guidance of induced pneumothorax in small

effusions.

USES – PLEURAL PROCEDURE LIST

• Assess need/ feasibility of therapeutic aspiration

pre- procedure.

• Guidance of induced pneumothorax in small

effusions.

• ‘On table’ safe site selection for LAT port placement

(16.7% failure with blind approach requiring other

procedure vs 0% with US (P<0.05) – Medford et al Thorax 2009).

TRAINING IN THORACIC US

(UK GUIDELINES)

TRAINING IN THORACIC US – UK

http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf 124

LEVELS OF COMPETENCE – UK

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• Radiologists only

TRAINING IN THORACIC US

Key Issues in training:

• Friendly radiologist

• Regular scanning time

• Familiar with machine

• Normal appearances

Key issues in practice:

• Know your own limits

• Access to experience if required

WHEN TO ASK FOR HELP…

• Radiologist more skilled in all aspects of US

• Radiologist has access and understanding of

other techniques

• MUST know own limits

SUMMARY POINTS

• Evidence suggests thoracic US improves safety and

accuracy of pleural procedures

• Know its limitations and, more importantly, your limitations

• Use of US in untrained/ inexperienced hands provides false confidence and may be harmful – access to machines with level 1 certificate or under supervision only

• Radiologists are highly trained in ultrasound – work closely and maintain a mentor after achieving basic training

Additional course resources

Readings, guidelines and E-learning resources

1. Solomon SD1, Saldana F., Point-of-care ultrasound in medical education--stop listening and

look, N Engl J Med. 2014 Mar 20;370(12):1083-5. doi: 10.1056/NEJMp1311944

2. Von Groote-Bidlingmaier F., Koegelenberg C.F.N., A practical guide to transthoracic

ultrasound, Breathe 2012 Dec2012 9, no 2. Doi: 10.1183/20734735.024112

Faculty disclosures

There are no faculty disclosures for this session.

Faculty contact information

Prof. Dr Jouke T. Annema

Academic Medical Center

Postbus 22660

1100 DD Amsterdam

NETHERLANDS

j.t.annema@amc.nl

Dr Rahul Bhatnagar

Academic Respiratory Unit

Learning and Research Building

Southmead Hospital

BS10 5NB Bristol

UNITED KINGDOM

rahul@bhatnagar.me.uk

Prof. Fergus Gleeson

Department of Radiology

The Churchill Hospital

Oxford OX3 7LJ

UNITED KINGDOM

fergus.gleeson@orh.nhs.uk

Dr Therese Lapperre

Department of Respiratory and Critical care

Medicine

Singapore General Hospital

Outram Rd

Singapore 169608

SINGAPORE

lapperre@me.com

Dr Najib Rahman

Oxford Centre for Respiratory Medicine

Churchill Hospital

Old Road

Headington

Oxford OX3 7LJ

UNITED KINGDOM

naj_rahman@yahoo.co.uk

Dr Ioannis Psallidas

Oxford Centre for Respiratory Medicine

Oxford Respiratory Trials Unit

Old Road

Headington

Oxford OX3 7LJ

UNITED KINGDOM

jpsallidas@med.uoa.gr

ioannis.psallidas@ouh.nhs.uk

Dr Inge van den Berk

Academic Medical Center

Meibergdreef 9

1105 AZ Amsterdam Zuid-Oost

NETHERLANDS

i.a.vandenberk@amc.uva.nl

Dr John Wrightson

Experimental Medicine Divison

John Radcliffe Hospital

Headley Way

Oxford OX3 9DU

UNITED KINGDOM

johnwrightson@yahoo.co.uk

live pulmonary endoscopy transthoracic ultrasound pulmonary endoscopy transthoracic ultrasound aims:...

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