Dr Richard Beese Bsc (Hons) MRCP, FRCR St. Georges Hospital, London

Ultrasound findings in the breathless patient

Introduction;

In our NHS practise we are increasingly using ultrasound to examine the chest in symptomatic breathless patients for diagnostics purposes , and to answer questions.

The big question we are most often asked is the shadowing on the chest x-ray in symptomatic patients due to pulmonary pathology or pleural pathology.

What is the pathology at the lung bases on the supine ITU chest xray ?

Conclusion ; In our experience ultrasound can differentiate lung pathology from pleural pathology and also direct drainage of pleural collections.

Is the cause of the temperature due to pulmonary or pleural pathology ?

Is there a left pleural effusion and can it be drained safely ?

Supine ITU chest x-ray the hemidiaphragms are in distinct, this could be due to consolidation or pleural fluid .

Ultrasound can differentiate between consolidation and a pleural effusion

Fig 1 . Demonstrates consolidation in the lower lobe adjacent to the hemidiaphragm,

Fig 2 demonstrates a pleural effusion.

Fig 1. Fig 2.

Ultrasound demonstrates a complex collection in the left pleural space indicating the cause of the sepsis is an empyema.

The chest x-ray demonstrates the loss of the silhouette sign of the left hemidiaphragm and left heart border due to abnormal soft tissue.

There is loss of the silhouette sign of the left heart border and left hemidiaphragm with abnormal soft tissue at the left base with a meniscus sign.

Ultrasound demonstrates a large echo poor collection above the left hemidiaphragm in keeping with a pleural effusion, the effusion fills the screen and can be drained using a seldinger technique and ultrasound guidance.

Austere Ultrasound ‘ Developing World Ultrasound’

M A Shah, R C Beese, Radiology Department ,St. Georges Hospital, London.

• Ultrasound is being used by doctors and healthcare workers in austere and remote locations in the world to answer medical questions.

Particularly in Canada and Australia where modern medicine meets austere / isolated locations.

• According to WHO only 25 % of the world’s population have access to imaging / X-rays.

• Ultrasound units are becoming smaller and more affordable producing images of high quality which are able to give more diagnostic certainty and answer clinical questions.

• There is good evidence ultrasound can differentiate between bone injury and soft tissue injury in trauma.

Bone fractures can be diagnosed with ultrasound and patient sent for x-ray and fracture clinic management in distant hospitals with certainty, soft tissue injuries can be managed locally with RICE.

• Ultrasound can examine the chest and is more sensitive than x-ray for pneumothorax, if a pathology can be detected by percussion then is can be visualise with ultrasound examples pleural effusions and consolidation.

• Sometimes heart failure is difficult to diagnose clinically If heart failure is suspected the heart size can measured , ( experienced operators can assess LV function) the JVP can be measured and assessed and pleural effusions can be detected with ultrasound

• More experienced operators can examine the abdomen for causes of pain or for masses.

• Ulltrasound can be useful in obstetrics to check the viability of the fetus, the presentation and the position of the placenta.

Ultrasound in austere locations is an exciting prospect and can have an impact on the future of developing world medicine.

Ultrasound demonstration of a rib fracture.

Ultrasound demonstration of a pleural effusion.

Ultrasound demonstration of the heart.

Ultrasound demonstration of gall stones.

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Left pleural effusion, the dome of the diaphragm and spleen can be clearly seen, Arrow.

Ultrasound of the chest in ITU patients

Introduction•The chest x-ray can be un helpful, opacification at the lung base on chest x-ray may be due to either consolidation or pleural fluid.

We routinely use ultrasound of the chest to determine the difference between aerated lung consolidated lung and pleural fluid.

Ultrasound of the chest has a short learning curve, has high diagnostic capabilities and can allow direction of intervention such as the draining of pleural fluid.

Technique

Required ultrasound platform and a 3.5mhz ultrasound probe.

The ultrasound window to the chest are the intercostal spaces as bone effects ultrasound and degrades diagnostic images.

The chest can be examined with ultrasound in a similar fashion to using the stethescope

Anteriorly; the upper lobes,

Mid axillary line; right the middle lobes and left the lingula

Posteriorly the lower lobes.

Identify the liver and spleen and hemidiaphragms via an intercostal approach and move up the intercostal spaces to visualise the lung bases.

Normal aerated lung in the right lower lobe the air reflects ultrasound. Arrow

A significant right pleural effusion ultrasound is transmitted through the pleural fluid leading to and echo poor area, Arrow

The left lower lobe is solid and consolidated, the bright lines (Arrow) demonstrate air in the bronchi (an air bronchogram).

CXR demonstrating loss of clarity of both hemidiaphragms which may be due consolidation or fluid.

Here are possible ultrasound findings at the lung bases

Conclusion,

Ultrasound can clearly demonstrate abnormalities at the lung bases and be used to differentiate between pleural pathology and lung pathology. Ultrasound is of value in diagnosing heart failure.

spleen

liver

Ultrasound findings in the breathless patient

Dr Richard Beese Bsc (Hons) MRCP, FRCR St. Georges Hospital, London

Ultrasound can be used to assess LV function and look for bilateral Pleural effusions if heart failure is suspected.