Case: Detection of Pleural Fluid
Case: Detection of Pleural Fluid
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This video details the use of bedside ultrasound imaging to detect pleural fluid, grade the amount of fluid in the pleural cavity, and detect loculated pleural effusions.
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<p begin="00:00:14.780" end="00:00:16.571" style="s2">- Hello, my name is Phil Perera</p>
<p begin="00:00:16.571" end="00:00:18.082" style="s2">and I'm the Emergency<br />Ultrasound Coordinator</p>
<p begin="00:00:18.082" end="00:00:21.617" style="s2">at the New York Presbyterian<br />Hospital in New York City.</p>
<p begin="00:00:21.617" end="00:00:24.986" style="s2">And welcome to SoundBytes Cases.</p>
<p begin="00:00:24.986" end="00:00:25.819" style="s2">In this SoundBytes module,</p>
<p begin="00:00:25.819" end="00:00:27.297" style="s2">we're going to look specifically at the</p>
<p begin="00:00:27.297" end="00:00:31.429" style="s2">use of Bedside Ultrasound<br />to detect Pleural Fluid.</p>
<p begin="00:00:31.429" end="00:00:33.778" style="s2">Interestingly enough,<br />Ultrasound has been found</p>
<p begin="00:00:33.778" end="00:00:35.835" style="s2">to detect as little as 20 ccs of fluid</p>
<p begin="00:00:35.835" end="00:00:38.049" style="s2">within the Pleural Space.</p>
<p begin="00:00:38.049" end="00:00:40.752" style="s2">In contrast, a Chest<br />X-Ray will not reliably</p>
<p begin="00:00:40.752" end="00:00:44.600" style="s2">pick up less than 100 to 150 ccs of fluid</p>
<p begin="00:00:44.600" end="00:00:45.767" style="s2">on an AP Film.</p>
<p begin="00:00:46.965" end="00:00:48.579" style="s2">Now this problem is only compounded</p>
<p begin="00:00:48.579" end="00:00:49.814" style="s2">in the Supine Trauma Patient,</p>
<p begin="00:00:49.814" end="00:00:53.090" style="s2">where a Chest X-ray may miss<br />a significant amount of fluid</p>
<p begin="00:00:53.090" end="00:00:55.536" style="s2">as a Hemothorax will layer out Posteriorly</p>
<p begin="00:00:55.536" end="00:00:58.636" style="s2">and can be very difficult<br />to detect on this film.</p>
<p begin="00:00:58.636" end="00:00:59.859" style="s2">For these reasons,</p>
<p begin="00:00:59.859" end="00:01:03.009" style="s2">Bedside Ultrasound may<br />offer a more accurate way</p>
<p begin="00:01:03.009" end="00:01:05.603" style="s2">of diagnosing Pleural Fluid.</p>
<p begin="00:01:05.603" end="00:01:06.788" style="s2">Here's a slide reviewing how to</p>
<p begin="00:01:06.788" end="00:01:08.355" style="s2">perform the Ultrasound examination</p>
<p begin="00:01:08.355" end="00:01:10.612" style="s2">for detection of Pleural Effusions.</p>
<p begin="00:01:10.612" end="00:01:13.155" style="s2">Optimally you'll have<br />a three megahertz probe</p>
<p begin="00:01:13.155" end="00:01:15.771" style="s2">with a small footprint that<br />can easily sit between the ribs</p>
<p begin="00:01:15.771" end="00:01:17.914" style="s2">as we'll be looking into<br />the Right Upper Quadrant</p>
<p begin="00:01:17.914" end="00:01:20.212" style="s2">and Left Upper Quadrant areas.</p>
<p begin="00:01:20.212" end="00:01:22.311" style="s2">In position one, we'll be coming into the</p>
<p begin="00:01:22.311" end="00:01:25.463" style="s2">standard Right Upper<br />Quadrant Trauma FAST exam</p>
<p begin="00:01:25.463" end="00:01:27.178" style="s2">and position the probe into that area</p>
<p begin="00:01:27.178" end="00:01:30.621" style="s2">just above the Liver<br />and below the Diaphragm.</p>
<p begin="00:01:30.621" end="00:01:33.621" style="s2">We can then angle the probe<br />upwards into the Thoracic Cavity</p>
<p begin="00:01:33.621" end="00:01:35.828" style="s2">to look for a Dark or<br />Anechoic Fluid Collection</p>
<p begin="00:01:35.828" end="00:01:38.061" style="s2">signifying Thoracic Fluid.</p>
<p begin="00:01:38.061" end="00:01:40.454" style="s2">We can repeat the exam in the left side</p>
<p begin="00:01:40.454" end="00:01:42.095" style="s2">as shown in probe position two.</p>
<p begin="00:01:42.095" end="00:01:44.021" style="s2">Placing the probe into that area</p>
<p begin="00:01:44.021" end="00:01:47.325" style="s2">of the Left Upper<br />Quadrant Trauma FAST view.</p>
<p begin="00:01:47.325" end="00:01:49.720" style="s2">Look first into the area above the Spleen</p>
<p begin="00:01:49.720" end="00:01:50.912" style="s2">and below the Diaphragm</p>
<p begin="00:01:50.912" end="00:01:52.692" style="s2">and then angle the probe upwards into</p>
<p begin="00:01:52.692" end="00:01:55.004" style="s2">the left Thoracic Cavity.</p>
<p begin="00:01:55.004" end="00:01:56.771" style="s2">If fluid is seen with<br />in the Thoracic Cavity,</p>
<p begin="00:01:56.771" end="00:01:58.506" style="s2">we can then move the probe upwards</p>
<p begin="00:01:58.506" end="00:02:02.435" style="s2">to investigate the extent of the Effusion.</p>
<p begin="00:02:02.435" end="00:02:05.228" style="s2">Here's a video going over how<br />to perform the examination.</p>
<p begin="00:02:05.228" end="00:02:07.162" style="s2">Notice here, we have a probe placed</p>
<p begin="00:02:07.162" end="00:02:10.444" style="s2">into the Right Upper<br />Quadrant Trauma FAST area.</p>
<p begin="00:02:10.444" end="00:02:12.454" style="s2">Notice that we're<br />angling the probe upwards</p>
<p begin="00:02:12.454" end="00:02:14.478" style="s2">into the Thoracic Cavity<br />to fully investigate</p>
<p begin="00:02:14.478" end="00:02:16.395" style="s2">for a Pleural Effusion.</p>
<p begin="00:02:17.468" end="00:02:18.859" style="s2">Here, I'm just superimposing</p>
<p begin="00:02:18.859" end="00:02:20.415" style="s2">about the level of the Diaphragm</p>
<p begin="00:02:20.415" end="00:02:22.594" style="s2">as shown in the red marker.</p>
<p begin="00:02:22.594" end="00:02:24.004" style="s2">And notice here that the probe</p>
<p begin="00:02:24.004" end="00:02:26.093" style="s2">is positioned coming into that area</p>
<p begin="00:02:26.093" end="00:02:29.963" style="s2">just above the Diaphragm<br />into the Thoracic Cavity.</p>
<p begin="00:02:29.963" end="00:02:30.994" style="s2">Traditionally, the probe should be</p>
<p begin="00:02:30.994" end="00:02:32.502" style="s2">in a long-axis configuration</p>
<p begin="00:02:32.502" end="00:02:36.172" style="s2">with the marker dot<br />towards the patient's head.</p>
<p begin="00:02:36.172" end="00:02:38.120" style="s2">Again, if a Fluid Collection is seen,</p>
<p begin="00:02:38.120" end="00:02:40.001" style="s2">one can then move the probe upwards</p>
<p begin="00:02:40.001" end="00:02:43.377" style="s2">to fully investigate<br />how big the Effusion is.</p>
<p begin="00:02:43.377" end="00:02:44.744" style="s2">To optimize your examination,</p>
<p begin="00:02:44.744" end="00:02:47.395" style="s2">place the patient with<br />the head slightly upwards,</p>
<p begin="00:02:47.395" end="00:02:49.784" style="s2">so that the fluid will layer<br />out above the Diaphragm</p>
<p begin="00:02:49.784" end="00:02:54.085" style="s2">allowing earlier detection<br />of smaller amounts of fluid.</p>
<p begin="00:02:54.085" end="00:02:55.575" style="s2">Now that we know how to perform</p>
<p begin="00:02:55.575" end="00:02:57.720" style="s2">the Ultrasound examination<br />for Pleural Fluid,</p>
<p begin="00:02:57.720" end="00:03:00.115" style="s2">let's take a look at a<br />normal Right Upper Quadrant</p>
<p begin="00:03:00.115" end="00:03:01.974" style="s2">Pleural Examination.</p>
<p begin="00:03:01.974" end="00:03:04.331" style="s2">The probe is configured at<br />a long-axis type orientation</p>
<p begin="00:03:04.331" end="00:03:07.115" style="s2">with the marker towards<br />the patient's head.</p>
<p begin="00:03:07.115" end="00:03:10.108" style="s2">So, we see Superior to the<br />left, Inferior to the right.</p>
<p begin="00:03:10.108" end="00:03:12.262" style="s2">The Liver is in the middle of the image.</p>
<p begin="00:03:12.262" end="00:03:13.848" style="s2">And let's look above the liver.</p>
<p begin="00:03:13.848" end="00:03:16.276" style="s2">Here we see the Diaphragm,<br />that curving, white line</p>
<p begin="00:03:16.276" end="00:03:18.803" style="s2">which is moving up and down<br />as the patient breathes.</p>
<p begin="00:03:18.803" end="00:03:21.693" style="s2">And to the left or<br />Superior to the Diaphragm</p>
<p begin="00:03:21.693" end="00:03:23.151" style="s2">is the Thoracic Cavity.</p>
<p begin="00:03:23.151" end="00:03:25.138" style="s2">Now, while looking at<br />the Thoracic Cavity here,</p>
<p begin="00:03:25.138" end="00:03:27.738" style="s2">what we see is something<br />called Mirror Artifact.</p>
<p begin="00:03:27.738" end="00:03:29.678" style="s2">This occurs as a result of the sound waves</p>
<p begin="00:03:29.678" end="00:03:31.358" style="s2">coming through the Diaphragm</p>
<p begin="00:03:31.358" end="00:03:33.679" style="s2">and reproducing what<br />looks like a mirror image</p>
<p begin="00:03:33.679" end="00:03:35.821" style="s2">of the Liver within the chest.</p>
<p begin="00:03:35.821" end="00:03:39.056" style="s2">This is a normal appearance<br />of the Thoracic Cavity</p>
<p begin="00:03:39.056" end="00:03:40.623" style="s2">and Mirror Artifact is something that</p>
<p begin="00:03:40.623" end="00:03:43.794" style="s2">will be seen commonly<br />on Bedside Sonography.</p>
<p begin="00:03:43.794" end="00:03:45.322" style="s2">Notice, however, the absence of a Dark</p>
<p begin="00:03:45.322" end="00:03:48.470" style="s2">or Anechoic Fluid Collection<br />within the right chest.</p>
<p begin="00:03:48.470" end="00:03:49.878" style="s2">Now, let's take a look at a normal</p>
<p begin="00:03:49.878" end="00:03:52.014" style="s2">Left Upper Quadrant Pleural Exam.</p>
<p begin="00:03:52.014" end="00:03:54.098" style="s2">Again, we're in a long-axis configuration,</p>
<p begin="00:03:54.098" end="00:03:56.808" style="s2">so Superior to the left,<br />Inferior to the right.</p>
<p begin="00:03:56.808" end="00:03:58.758" style="s2">We see the Spleen in<br />the middle of the image</p>
<p begin="00:03:58.758" end="00:04:01.085" style="s2">and we see the Diaphragm<br />moving up and down</p>
<p begin="00:04:01.085" end="00:04:02.895" style="s2">as the patient breathes.</p>
<p begin="00:04:02.895" end="00:04:05.844" style="s2">Let's look above the Diaphragm<br />into the Thoracic Cavity.</p>
<p begin="00:04:05.844" end="00:04:07.907" style="s2">And, again, we see that Mirror Artifact.</p>
<p begin="00:04:07.907" end="00:04:09.978" style="s2">What it looks like is almost like</p>
<p begin="00:04:09.978" end="00:04:13.473" style="s2">reproduction of the Spleen<br />within the Thoracic Cavity.</p>
<p begin="00:04:13.473" end="00:04:15.367" style="s2">So, this is a normal finding.</p>
<p begin="00:04:15.367" end="00:04:18.491" style="s2">And one that is not to<br />be confused with fluid.</p>
<p begin="00:04:18.491" end="00:04:20.119" style="s2">Fluid will appear very differently</p>
<p begin="00:04:20.119" end="00:04:23.281" style="s2">and will have the appearance<br />of a Dark or Anechoic stripe</p>
<p begin="00:04:23.281" end="00:04:25.448" style="s2">right above the Diaphragm.</p>
<p begin="00:04:26.309" end="00:04:28.842" style="s2">Here's an illustration<br />showing a positive examination</p>
<p begin="00:04:28.842" end="00:04:30.397" style="s2">from the Right Upper Quadrant view</p>
<p begin="00:04:30.397" end="00:04:33.399" style="s2">with a Pleural Effusion<br />above the Diaphragm.</p>
<p begin="00:04:33.399" end="00:04:35.402" style="s2">We're in that long-axis configuration,</p>
<p begin="00:04:35.402" end="00:04:37.863" style="s2">so Superior to the left,<br />Inferior to the right.</p>
<p begin="00:04:37.863" end="00:04:40.097" style="s2">We see the Liver in the<br />middle of the image here.</p>
<p begin="00:04:40.097" end="00:04:42.305" style="s2">And the Diaphragm, the white line as seen</p>
<p begin="00:04:42.305" end="00:04:44.196" style="s2">right above the Liver.</p>
<p begin="00:04:44.196" end="00:04:46.254" style="s2">Notice in this image we<br />have a Pleural Effusion</p>
<p begin="00:04:46.254" end="00:04:48.813" style="s2">as represented by the Dark area of fluid,</p>
<p begin="00:04:48.813" end="00:04:51.131" style="s2">which is immediately<br />Superior to the Diaphragm</p>
<p begin="00:04:51.131" end="00:04:54.164" style="s2">and tucks in there right<br />above the Diaphragm</p>
<p begin="00:04:54.164" end="00:04:57.132" style="s2">going up into the Thoracic Cavity.</p>
<p begin="00:04:57.132" end="00:04:59.900" style="s2">So, this will the signature<br />finding of a Pleural Effusion</p>
<p begin="00:04:59.900" end="00:05:02.409" style="s2">as taken from the Trauma FAST Views,</p>
<p begin="00:05:02.409" end="00:05:03.542" style="s2">from the Right Upper Quadrant.</p>
<p begin="00:05:03.542" end="00:05:06.007" style="s2">And the Left Upper Quadrant<br />will also have a similar view,</p>
<p begin="00:05:06.007" end="00:05:08.607" style="s2">although we're just<br />looking above the Spleen</p>
<p begin="00:05:08.607" end="00:05:10.274" style="s2">in that orientation.</p>
<p begin="00:05:12.240" end="00:05:14.713" style="s2">Here's a video clip showing<br />a Small Pleural Effusion</p>
<p begin="00:05:14.713" end="00:05:17.390" style="s2">as taken from the Left<br />Upper Quadrant view.</p>
<p begin="00:05:17.390" end="00:05:19.434" style="s2">Here, we see the Spleen in<br />the middle of the image,</p>
<p begin="00:05:19.434" end="00:05:21.632" style="s2">the Kidney Inferior to the Spleen.</p>
<p begin="00:05:21.632" end="00:05:23.779" style="s2">And the Diaphragm, the curving white line</p>
<p begin="00:05:23.779" end="00:05:26.039" style="s2">that's moving up and down<br />as the patient breathes</p>
<p begin="00:05:26.039" end="00:05:27.997" style="s2">right above the Spleen.</p>
<p begin="00:05:27.997" end="00:05:30.141" style="s2">As we look into that<br />area above the Diaphragm,</p>
<p begin="00:05:30.141" end="00:05:32.131" style="s2">we actually appreciate here, the presence</p>
<p begin="00:05:32.131" end="00:05:34.674" style="s2">of a Dark or Anechoic Fluid Collection</p>
<p begin="00:05:34.674" end="00:05:36.403" style="s2">above the Diaphragm.</p>
<p begin="00:05:36.403" end="00:05:39.163" style="s2">This represents a<br />positive Pleural Effusion.</p>
<p begin="00:05:39.163" end="00:05:41.619" style="s2">Notice that the amount of<br />fluid is relatively small</p>
<p begin="00:05:41.619" end="00:05:44.158" style="s2">and we can actually see<br />the Lung moving up and down</p>
<p begin="00:05:44.158" end="00:05:46.914" style="s2">to the left of the image here.</p>
<p begin="00:05:46.914" end="00:05:48.305" style="s2">Here's a Moderate Plural Effusion</p>
<p begin="00:05:48.305" end="00:05:50.079" style="s2">as taken from the Right<br />Upper Quadrant View.</p>
<p begin="00:05:50.079" end="00:05:53.127" style="s2">We see the Liver to the<br />Inferior Aspect or to the right.</p>
<p begin="00:05:53.127" end="00:05:55.465" style="s2">The curving white line<br />making up the Diaphragm</p>
<p begin="00:05:55.465" end="00:05:57.281" style="s2">in the middle of the image.</p>
<p begin="00:05:57.281" end="00:05:59.057" style="s2">And fluid representing a Pleural Effusion</p>
<p begin="00:05:59.057" end="00:06:00.872" style="s2">Superior to the Diaphragm.</p>
<p begin="00:06:00.872" end="00:06:03.090" style="s2">Interestingly enough, we<br />see the Lung moving around</p>
<p begin="00:06:03.090" end="00:06:04.955" style="s2">and all the fluid compressed down</p>
<p begin="00:06:04.955" end="00:06:06.981" style="s2">by the fluid within the chest cavity</p>
<p begin="00:06:06.981" end="00:06:09.736" style="s2">taking on what appears to<br />like a Liver within the chest.</p>
<p begin="00:06:09.736" end="00:06:12.756" style="s2">And something called<br />Hepatization of the Lung.</p>
<p begin="00:06:12.756" end="00:06:15.626" style="s2">And this is commonly seen<br />with a Pleural Effusion,</p>
<p begin="00:06:15.626" end="00:06:17.262" style="s2">as it pushes in on the Lung</p>
<p begin="00:06:17.262" end="00:06:21.065" style="s2">making it more of a solid-type organ.</p>
<p begin="00:06:21.065" end="00:06:23.406" style="s2">Here's a Large Pleural Effusion as taken</p>
<p begin="00:06:23.406" end="00:06:25.019" style="s2">from the Right Upper Quadrant View.</p>
<p begin="00:06:25.019" end="00:06:27.367" style="s2">And what we see here,<br />is the Liver Inferiorly,</p>
<p begin="00:06:27.367" end="00:06:29.368" style="s2">the Diaphragm right above the Liver</p>
<p begin="00:06:29.368" end="00:06:30.997" style="s2">there in the middle of the image.</p>
<p begin="00:06:30.997" end="00:06:33.793" style="s2">And we see a large Dark<br />or Anechoic Collection</p>
<p begin="00:06:33.793" end="00:06:36.340" style="s2">immediately Superior to the Diaphragm.</p>
<p begin="00:06:36.340" end="00:06:39.426" style="s2">This represents a Large Pleural Effusion.</p>
<p begin="00:06:39.426" end="00:06:40.948" style="s2">And in the midst of the Pleural Effusion,</p>
<p begin="00:06:40.948" end="00:06:42.543" style="s2">we can see the Lung waving around</p>
<p begin="00:06:42.543" end="00:06:44.599" style="s2">and compressed down by all</p>
<p begin="00:06:44.599" end="00:06:46.536" style="s2">the fluid within the Thoracic Cavity.</p>
<p begin="00:06:46.536" end="00:06:48.877" style="s2">Again, demonstrating that Hepatization</p>
<p begin="00:06:48.877" end="00:06:53.012" style="s2">of the Lung as it's compressed<br />down by the Pleural Fluid.</p>
<p begin="00:06:53.012" end="00:06:55.028" style="s2">So, this would be a Large Plural Effusion,</p>
<p begin="00:06:55.028" end="00:06:56.713" style="s2">as there's a large amount of fluid</p>
<p begin="00:06:56.713" end="00:06:59.371" style="s2">both Inferiorly between<br />the Lung and the Diaphragm.</p>
<p begin="00:06:59.371" end="00:07:03.538" style="s2">And both Anterior and Posterior<br />to the Lung itself here.</p>
<p begin="00:07:04.682" end="00:07:06.578" style="s2">Unfortunately, not all Plural Effusions</p>
<p begin="00:07:06.578" end="00:07:09.512" style="s2">will be free-flowing or uncomplicated.</p>
<p begin="00:07:09.512" end="00:07:10.996" style="s2">There are occasions where our patients</p>
<p begin="00:07:10.996" end="00:07:12.521" style="s2">can have repeated Pleural Effusion</p>
<p begin="00:07:12.521" end="00:07:14.912" style="s2">that can be Loculated or Complicated.</p>
<p begin="00:07:14.912" end="00:07:17.871" style="s2">Here we see an example of a<br />Loculated Pleural Effusion.</p>
<p begin="00:07:17.871" end="00:07:20.098" style="s2">Notice this Lung here has an attachment</p>
<p begin="00:07:20.098" end="00:07:22.571" style="s2">with a Fibrin area that attaches it</p>
<p begin="00:07:22.571" end="00:07:25.639" style="s2">or glues it onto the Diaphragm Inferiorly.</p>
<p begin="00:07:25.639" end="00:07:28.177" style="s2">Therefore, we have two<br />Loculated areas Effusion,</p>
<p begin="00:07:28.177" end="00:07:32.063" style="s2">both Anterior to the top of<br />the screen and Posterior.</p>
<p begin="00:07:32.063" end="00:07:34.287" style="s2">As the Lung is trapped<br />within the Thoracic Cavity</p>
<p begin="00:07:34.287" end="00:07:36.291" style="s2">by this Fibrinous<br />Attachment to the Diaphragm,</p>
<p begin="00:07:36.291" end="00:07:38.846" style="s2">it may be dangerous to<br />perform an invasive procedure</p>
<p begin="00:07:38.846" end="00:07:41.922" style="s2">like a Thoracentesis or<br />a Chest Tube Placement.</p>
<p begin="00:07:41.922" end="00:07:43.801" style="s2">The needle or the Chest<br />Tube could be guided</p>
<p begin="00:07:43.801" end="00:07:46.063" style="s2">up into the Lung causing a Pneumothorax</p>
<p begin="00:07:46.063" end="00:07:50.571" style="s2">by the Fibrinous Attachment<br />to the Diaphragm.</p>
<p begin="00:07:50.571" end="00:07:52.403" style="s2">So, in conclusion, I'm<br />glad I could share with you</p>
<p begin="00:07:52.403" end="00:07:53.932" style="s2">this SoundBytes module going over the</p>
<p begin="00:07:53.932" end="00:07:57.437" style="s2">Ultrasound Examination for the<br />detection of Pleural Fluid.</p>
<p begin="00:07:57.437" end="00:07:59.240" style="s2">As we've discussed earlier in the module,</p>
<p begin="00:07:59.240" end="00:08:00.729" style="s2">Ultrasound may be more accurate</p>
<p begin="00:08:00.729" end="00:08:03.247" style="s2">in detection of Pleural<br />Fluid than a Chest X-ray.</p>
<p begin="00:08:03.247" end="00:08:05.384" style="s2">And Ultrasound allows easy grading</p>
<p begin="00:08:05.384" end="00:08:08.103" style="s2">of the amount of fluid<br />within the Pleural Cavity.</p>
<p begin="00:08:08.103" end="00:08:10.620" style="s2">It can also detect<br />Complicated Pleural Effusions</p>
<p begin="00:08:10.620" end="00:08:13.387" style="s2">that may be Loculated<br />and can help determine</p>
<p begin="00:08:13.387" end="00:08:16.270" style="s2">which patients may benefit<br />from a Drainage Procedure</p>
<p begin="00:08:16.270" end="00:08:19.742" style="s2">such as a Thoracentesis<br />or a Tube Thoracostomy.</p>
<p begin="00:08:19.742" end="00:08:23.014" style="s2">So, I hope to see you back<br />as SoundBytes continues</p>
<p begin="00:08:23.014" end="00:08:24.008" style="s2">and in further modules,</p>
<p begin="00:08:24.008" end="00:08:25.490" style="s2">we'll actually look closer at</p>
<p begin="00:08:25.490" end="00:08:29.657" style="s2">the Thoracentesis Procedure<br />under Ultrasound guidance.</p>
<p begin="00:00:16.571" end="00:00:18.082" style="s2">and I'm the Emergency<br />Ultrasound Coordinator</p>
<p begin="00:00:18.082" end="00:00:21.617" style="s2">at the New York Presbyterian<br />Hospital in New York City.</p>
<p begin="00:00:21.617" end="00:00:24.986" style="s2">And welcome to SoundBytes Cases.</p>
<p begin="00:00:24.986" end="00:00:25.819" style="s2">In this SoundBytes module,</p>
<p begin="00:00:25.819" end="00:00:27.297" style="s2">we're going to look specifically at the</p>
<p begin="00:00:27.297" end="00:00:31.429" style="s2">use of Bedside Ultrasound<br />to detect Pleural Fluid.</p>
<p begin="00:00:31.429" end="00:00:33.778" style="s2">Interestingly enough,<br />Ultrasound has been found</p>
<p begin="00:00:33.778" end="00:00:35.835" style="s2">to detect as little as 20 ccs of fluid</p>
<p begin="00:00:35.835" end="00:00:38.049" style="s2">within the Pleural Space.</p>
<p begin="00:00:38.049" end="00:00:40.752" style="s2">In contrast, a Chest<br />X-Ray will not reliably</p>
<p begin="00:00:40.752" end="00:00:44.600" style="s2">pick up less than 100 to 150 ccs of fluid</p>
<p begin="00:00:44.600" end="00:00:45.767" style="s2">on an AP Film.</p>
<p begin="00:00:46.965" end="00:00:48.579" style="s2">Now this problem is only compounded</p>
<p begin="00:00:48.579" end="00:00:49.814" style="s2">in the Supine Trauma Patient,</p>
<p begin="00:00:49.814" end="00:00:53.090" style="s2">where a Chest X-ray may miss<br />a significant amount of fluid</p>
<p begin="00:00:53.090" end="00:00:55.536" style="s2">as a Hemothorax will layer out Posteriorly</p>
<p begin="00:00:55.536" end="00:00:58.636" style="s2">and can be very difficult<br />to detect on this film.</p>
<p begin="00:00:58.636" end="00:00:59.859" style="s2">For these reasons,</p>
<p begin="00:00:59.859" end="00:01:03.009" style="s2">Bedside Ultrasound may<br />offer a more accurate way</p>
<p begin="00:01:03.009" end="00:01:05.603" style="s2">of diagnosing Pleural Fluid.</p>
<p begin="00:01:05.603" end="00:01:06.788" style="s2">Here's a slide reviewing how to</p>
<p begin="00:01:06.788" end="00:01:08.355" style="s2">perform the Ultrasound examination</p>
<p begin="00:01:08.355" end="00:01:10.612" style="s2">for detection of Pleural Effusions.</p>
<p begin="00:01:10.612" end="00:01:13.155" style="s2">Optimally you'll have<br />a three megahertz probe</p>
<p begin="00:01:13.155" end="00:01:15.771" style="s2">with a small footprint that<br />can easily sit between the ribs</p>
<p begin="00:01:15.771" end="00:01:17.914" style="s2">as we'll be looking into<br />the Right Upper Quadrant</p>
<p begin="00:01:17.914" end="00:01:20.212" style="s2">and Left Upper Quadrant areas.</p>
<p begin="00:01:20.212" end="00:01:22.311" style="s2">In position one, we'll be coming into the</p>
<p begin="00:01:22.311" end="00:01:25.463" style="s2">standard Right Upper<br />Quadrant Trauma FAST exam</p>
<p begin="00:01:25.463" end="00:01:27.178" style="s2">and position the probe into that area</p>
<p begin="00:01:27.178" end="00:01:30.621" style="s2">just above the Liver<br />and below the Diaphragm.</p>
<p begin="00:01:30.621" end="00:01:33.621" style="s2">We can then angle the probe<br />upwards into the Thoracic Cavity</p>
<p begin="00:01:33.621" end="00:01:35.828" style="s2">to look for a Dark or<br />Anechoic Fluid Collection</p>
<p begin="00:01:35.828" end="00:01:38.061" style="s2">signifying Thoracic Fluid.</p>
<p begin="00:01:38.061" end="00:01:40.454" style="s2">We can repeat the exam in the left side</p>
<p begin="00:01:40.454" end="00:01:42.095" style="s2">as shown in probe position two.</p>
<p begin="00:01:42.095" end="00:01:44.021" style="s2">Placing the probe into that area</p>
<p begin="00:01:44.021" end="00:01:47.325" style="s2">of the Left Upper<br />Quadrant Trauma FAST view.</p>
<p begin="00:01:47.325" end="00:01:49.720" style="s2">Look first into the area above the Spleen</p>
<p begin="00:01:49.720" end="00:01:50.912" style="s2">and below the Diaphragm</p>
<p begin="00:01:50.912" end="00:01:52.692" style="s2">and then angle the probe upwards into</p>
<p begin="00:01:52.692" end="00:01:55.004" style="s2">the left Thoracic Cavity.</p>
<p begin="00:01:55.004" end="00:01:56.771" style="s2">If fluid is seen with<br />in the Thoracic Cavity,</p>
<p begin="00:01:56.771" end="00:01:58.506" style="s2">we can then move the probe upwards</p>
<p begin="00:01:58.506" end="00:02:02.435" style="s2">to investigate the extent of the Effusion.</p>
<p begin="00:02:02.435" end="00:02:05.228" style="s2">Here's a video going over how<br />to perform the examination.</p>
<p begin="00:02:05.228" end="00:02:07.162" style="s2">Notice here, we have a probe placed</p>
<p begin="00:02:07.162" end="00:02:10.444" style="s2">into the Right Upper<br />Quadrant Trauma FAST area.</p>
<p begin="00:02:10.444" end="00:02:12.454" style="s2">Notice that we're<br />angling the probe upwards</p>
<p begin="00:02:12.454" end="00:02:14.478" style="s2">into the Thoracic Cavity<br />to fully investigate</p>
<p begin="00:02:14.478" end="00:02:16.395" style="s2">for a Pleural Effusion.</p>
<p begin="00:02:17.468" end="00:02:18.859" style="s2">Here, I'm just superimposing</p>
<p begin="00:02:18.859" end="00:02:20.415" style="s2">about the level of the Diaphragm</p>
<p begin="00:02:20.415" end="00:02:22.594" style="s2">as shown in the red marker.</p>
<p begin="00:02:22.594" end="00:02:24.004" style="s2">And notice here that the probe</p>
<p begin="00:02:24.004" end="00:02:26.093" style="s2">is positioned coming into that area</p>
<p begin="00:02:26.093" end="00:02:29.963" style="s2">just above the Diaphragm<br />into the Thoracic Cavity.</p>
<p begin="00:02:29.963" end="00:02:30.994" style="s2">Traditionally, the probe should be</p>
<p begin="00:02:30.994" end="00:02:32.502" style="s2">in a long-axis configuration</p>
<p begin="00:02:32.502" end="00:02:36.172" style="s2">with the marker dot<br />towards the patient's head.</p>
<p begin="00:02:36.172" end="00:02:38.120" style="s2">Again, if a Fluid Collection is seen,</p>
<p begin="00:02:38.120" end="00:02:40.001" style="s2">one can then move the probe upwards</p>
<p begin="00:02:40.001" end="00:02:43.377" style="s2">to fully investigate<br />how big the Effusion is.</p>
<p begin="00:02:43.377" end="00:02:44.744" style="s2">To optimize your examination,</p>
<p begin="00:02:44.744" end="00:02:47.395" style="s2">place the patient with<br />the head slightly upwards,</p>
<p begin="00:02:47.395" end="00:02:49.784" style="s2">so that the fluid will layer<br />out above the Diaphragm</p>
<p begin="00:02:49.784" end="00:02:54.085" style="s2">allowing earlier detection<br />of smaller amounts of fluid.</p>
<p begin="00:02:54.085" end="00:02:55.575" style="s2">Now that we know how to perform</p>
<p begin="00:02:55.575" end="00:02:57.720" style="s2">the Ultrasound examination<br />for Pleural Fluid,</p>
<p begin="00:02:57.720" end="00:03:00.115" style="s2">let's take a look at a<br />normal Right Upper Quadrant</p>
<p begin="00:03:00.115" end="00:03:01.974" style="s2">Pleural Examination.</p>
<p begin="00:03:01.974" end="00:03:04.331" style="s2">The probe is configured at<br />a long-axis type orientation</p>
<p begin="00:03:04.331" end="00:03:07.115" style="s2">with the marker towards<br />the patient's head.</p>
<p begin="00:03:07.115" end="00:03:10.108" style="s2">So, we see Superior to the<br />left, Inferior to the right.</p>
<p begin="00:03:10.108" end="00:03:12.262" style="s2">The Liver is in the middle of the image.</p>
<p begin="00:03:12.262" end="00:03:13.848" style="s2">And let's look above the liver.</p>
<p begin="00:03:13.848" end="00:03:16.276" style="s2">Here we see the Diaphragm,<br />that curving, white line</p>
<p begin="00:03:16.276" end="00:03:18.803" style="s2">which is moving up and down<br />as the patient breathes.</p>
<p begin="00:03:18.803" end="00:03:21.693" style="s2">And to the left or<br />Superior to the Diaphragm</p>
<p begin="00:03:21.693" end="00:03:23.151" style="s2">is the Thoracic Cavity.</p>
<p begin="00:03:23.151" end="00:03:25.138" style="s2">Now, while looking at<br />the Thoracic Cavity here,</p>
<p begin="00:03:25.138" end="00:03:27.738" style="s2">what we see is something<br />called Mirror Artifact.</p>
<p begin="00:03:27.738" end="00:03:29.678" style="s2">This occurs as a result of the sound waves</p>
<p begin="00:03:29.678" end="00:03:31.358" style="s2">coming through the Diaphragm</p>
<p begin="00:03:31.358" end="00:03:33.679" style="s2">and reproducing what<br />looks like a mirror image</p>
<p begin="00:03:33.679" end="00:03:35.821" style="s2">of the Liver within the chest.</p>
<p begin="00:03:35.821" end="00:03:39.056" style="s2">This is a normal appearance<br />of the Thoracic Cavity</p>
<p begin="00:03:39.056" end="00:03:40.623" style="s2">and Mirror Artifact is something that</p>
<p begin="00:03:40.623" end="00:03:43.794" style="s2">will be seen commonly<br />on Bedside Sonography.</p>
<p begin="00:03:43.794" end="00:03:45.322" style="s2">Notice, however, the absence of a Dark</p>
<p begin="00:03:45.322" end="00:03:48.470" style="s2">or Anechoic Fluid Collection<br />within the right chest.</p>
<p begin="00:03:48.470" end="00:03:49.878" style="s2">Now, let's take a look at a normal</p>
<p begin="00:03:49.878" end="00:03:52.014" style="s2">Left Upper Quadrant Pleural Exam.</p>
<p begin="00:03:52.014" end="00:03:54.098" style="s2">Again, we're in a long-axis configuration,</p>
<p begin="00:03:54.098" end="00:03:56.808" style="s2">so Superior to the left,<br />Inferior to the right.</p>
<p begin="00:03:56.808" end="00:03:58.758" style="s2">We see the Spleen in<br />the middle of the image</p>
<p begin="00:03:58.758" end="00:04:01.085" style="s2">and we see the Diaphragm<br />moving up and down</p>
<p begin="00:04:01.085" end="00:04:02.895" style="s2">as the patient breathes.</p>
<p begin="00:04:02.895" end="00:04:05.844" style="s2">Let's look above the Diaphragm<br />into the Thoracic Cavity.</p>
<p begin="00:04:05.844" end="00:04:07.907" style="s2">And, again, we see that Mirror Artifact.</p>
<p begin="00:04:07.907" end="00:04:09.978" style="s2">What it looks like is almost like</p>
<p begin="00:04:09.978" end="00:04:13.473" style="s2">reproduction of the Spleen<br />within the Thoracic Cavity.</p>
<p begin="00:04:13.473" end="00:04:15.367" style="s2">So, this is a normal finding.</p>
<p begin="00:04:15.367" end="00:04:18.491" style="s2">And one that is not to<br />be confused with fluid.</p>
<p begin="00:04:18.491" end="00:04:20.119" style="s2">Fluid will appear very differently</p>
<p begin="00:04:20.119" end="00:04:23.281" style="s2">and will have the appearance<br />of a Dark or Anechoic stripe</p>
<p begin="00:04:23.281" end="00:04:25.448" style="s2">right above the Diaphragm.</p>
<p begin="00:04:26.309" end="00:04:28.842" style="s2">Here's an illustration<br />showing a positive examination</p>
<p begin="00:04:28.842" end="00:04:30.397" style="s2">from the Right Upper Quadrant view</p>
<p begin="00:04:30.397" end="00:04:33.399" style="s2">with a Pleural Effusion<br />above the Diaphragm.</p>
<p begin="00:04:33.399" end="00:04:35.402" style="s2">We're in that long-axis configuration,</p>
<p begin="00:04:35.402" end="00:04:37.863" style="s2">so Superior to the left,<br />Inferior to the right.</p>
<p begin="00:04:37.863" end="00:04:40.097" style="s2">We see the Liver in the<br />middle of the image here.</p>
<p begin="00:04:40.097" end="00:04:42.305" style="s2">And the Diaphragm, the white line as seen</p>
<p begin="00:04:42.305" end="00:04:44.196" style="s2">right above the Liver.</p>
<p begin="00:04:44.196" end="00:04:46.254" style="s2">Notice in this image we<br />have a Pleural Effusion</p>
<p begin="00:04:46.254" end="00:04:48.813" style="s2">as represented by the Dark area of fluid,</p>
<p begin="00:04:48.813" end="00:04:51.131" style="s2">which is immediately<br />Superior to the Diaphragm</p>
<p begin="00:04:51.131" end="00:04:54.164" style="s2">and tucks in there right<br />above the Diaphragm</p>
<p begin="00:04:54.164" end="00:04:57.132" style="s2">going up into the Thoracic Cavity.</p>
<p begin="00:04:57.132" end="00:04:59.900" style="s2">So, this will the signature<br />finding of a Pleural Effusion</p>
<p begin="00:04:59.900" end="00:05:02.409" style="s2">as taken from the Trauma FAST Views,</p>
<p begin="00:05:02.409" end="00:05:03.542" style="s2">from the Right Upper Quadrant.</p>
<p begin="00:05:03.542" end="00:05:06.007" style="s2">And the Left Upper Quadrant<br />will also have a similar view,</p>
<p begin="00:05:06.007" end="00:05:08.607" style="s2">although we're just<br />looking above the Spleen</p>
<p begin="00:05:08.607" end="00:05:10.274" style="s2">in that orientation.</p>
<p begin="00:05:12.240" end="00:05:14.713" style="s2">Here's a video clip showing<br />a Small Pleural Effusion</p>
<p begin="00:05:14.713" end="00:05:17.390" style="s2">as taken from the Left<br />Upper Quadrant view.</p>
<p begin="00:05:17.390" end="00:05:19.434" style="s2">Here, we see the Spleen in<br />the middle of the image,</p>
<p begin="00:05:19.434" end="00:05:21.632" style="s2">the Kidney Inferior to the Spleen.</p>
<p begin="00:05:21.632" end="00:05:23.779" style="s2">And the Diaphragm, the curving white line</p>
<p begin="00:05:23.779" end="00:05:26.039" style="s2">that's moving up and down<br />as the patient breathes</p>
<p begin="00:05:26.039" end="00:05:27.997" style="s2">right above the Spleen.</p>
<p begin="00:05:27.997" end="00:05:30.141" style="s2">As we look into that<br />area above the Diaphragm,</p>
<p begin="00:05:30.141" end="00:05:32.131" style="s2">we actually appreciate here, the presence</p>
<p begin="00:05:32.131" end="00:05:34.674" style="s2">of a Dark or Anechoic Fluid Collection</p>
<p begin="00:05:34.674" end="00:05:36.403" style="s2">above the Diaphragm.</p>
<p begin="00:05:36.403" end="00:05:39.163" style="s2">This represents a<br />positive Pleural Effusion.</p>
<p begin="00:05:39.163" end="00:05:41.619" style="s2">Notice that the amount of<br />fluid is relatively small</p>
<p begin="00:05:41.619" end="00:05:44.158" style="s2">and we can actually see<br />the Lung moving up and down</p>
<p begin="00:05:44.158" end="00:05:46.914" style="s2">to the left of the image here.</p>
<p begin="00:05:46.914" end="00:05:48.305" style="s2">Here's a Moderate Plural Effusion</p>
<p begin="00:05:48.305" end="00:05:50.079" style="s2">as taken from the Right<br />Upper Quadrant View.</p>
<p begin="00:05:50.079" end="00:05:53.127" style="s2">We see the Liver to the<br />Inferior Aspect or to the right.</p>
<p begin="00:05:53.127" end="00:05:55.465" style="s2">The curving white line<br />making up the Diaphragm</p>
<p begin="00:05:55.465" end="00:05:57.281" style="s2">in the middle of the image.</p>
<p begin="00:05:57.281" end="00:05:59.057" style="s2">And fluid representing a Pleural Effusion</p>
<p begin="00:05:59.057" end="00:06:00.872" style="s2">Superior to the Diaphragm.</p>
<p begin="00:06:00.872" end="00:06:03.090" style="s2">Interestingly enough, we<br />see the Lung moving around</p>
<p begin="00:06:03.090" end="00:06:04.955" style="s2">and all the fluid compressed down</p>
<p begin="00:06:04.955" end="00:06:06.981" style="s2">by the fluid within the chest cavity</p>
<p begin="00:06:06.981" end="00:06:09.736" style="s2">taking on what appears to<br />like a Liver within the chest.</p>
<p begin="00:06:09.736" end="00:06:12.756" style="s2">And something called<br />Hepatization of the Lung.</p>
<p begin="00:06:12.756" end="00:06:15.626" style="s2">And this is commonly seen<br />with a Pleural Effusion,</p>
<p begin="00:06:15.626" end="00:06:17.262" style="s2">as it pushes in on the Lung</p>
<p begin="00:06:17.262" end="00:06:21.065" style="s2">making it more of a solid-type organ.</p>
<p begin="00:06:21.065" end="00:06:23.406" style="s2">Here's a Large Pleural Effusion as taken</p>
<p begin="00:06:23.406" end="00:06:25.019" style="s2">from the Right Upper Quadrant View.</p>
<p begin="00:06:25.019" end="00:06:27.367" style="s2">And what we see here,<br />is the Liver Inferiorly,</p>
<p begin="00:06:27.367" end="00:06:29.368" style="s2">the Diaphragm right above the Liver</p>
<p begin="00:06:29.368" end="00:06:30.997" style="s2">there in the middle of the image.</p>
<p begin="00:06:30.997" end="00:06:33.793" style="s2">And we see a large Dark<br />or Anechoic Collection</p>
<p begin="00:06:33.793" end="00:06:36.340" style="s2">immediately Superior to the Diaphragm.</p>
<p begin="00:06:36.340" end="00:06:39.426" style="s2">This represents a Large Pleural Effusion.</p>
<p begin="00:06:39.426" end="00:06:40.948" style="s2">And in the midst of the Pleural Effusion,</p>
<p begin="00:06:40.948" end="00:06:42.543" style="s2">we can see the Lung waving around</p>
<p begin="00:06:42.543" end="00:06:44.599" style="s2">and compressed down by all</p>
<p begin="00:06:44.599" end="00:06:46.536" style="s2">the fluid within the Thoracic Cavity.</p>
<p begin="00:06:46.536" end="00:06:48.877" style="s2">Again, demonstrating that Hepatization</p>
<p begin="00:06:48.877" end="00:06:53.012" style="s2">of the Lung as it's compressed<br />down by the Pleural Fluid.</p>
<p begin="00:06:53.012" end="00:06:55.028" style="s2">So, this would be a Large Plural Effusion,</p>
<p begin="00:06:55.028" end="00:06:56.713" style="s2">as there's a large amount of fluid</p>
<p begin="00:06:56.713" end="00:06:59.371" style="s2">both Inferiorly between<br />the Lung and the Diaphragm.</p>
<p begin="00:06:59.371" end="00:07:03.538" style="s2">And both Anterior and Posterior<br />to the Lung itself here.</p>
<p begin="00:07:04.682" end="00:07:06.578" style="s2">Unfortunately, not all Plural Effusions</p>
<p begin="00:07:06.578" end="00:07:09.512" style="s2">will be free-flowing or uncomplicated.</p>
<p begin="00:07:09.512" end="00:07:10.996" style="s2">There are occasions where our patients</p>
<p begin="00:07:10.996" end="00:07:12.521" style="s2">can have repeated Pleural Effusion</p>
<p begin="00:07:12.521" end="00:07:14.912" style="s2">that can be Loculated or Complicated.</p>
<p begin="00:07:14.912" end="00:07:17.871" style="s2">Here we see an example of a<br />Loculated Pleural Effusion.</p>
<p begin="00:07:17.871" end="00:07:20.098" style="s2">Notice this Lung here has an attachment</p>
<p begin="00:07:20.098" end="00:07:22.571" style="s2">with a Fibrin area that attaches it</p>
<p begin="00:07:22.571" end="00:07:25.639" style="s2">or glues it onto the Diaphragm Inferiorly.</p>
<p begin="00:07:25.639" end="00:07:28.177" style="s2">Therefore, we have two<br />Loculated areas Effusion,</p>
<p begin="00:07:28.177" end="00:07:32.063" style="s2">both Anterior to the top of<br />the screen and Posterior.</p>
<p begin="00:07:32.063" end="00:07:34.287" style="s2">As the Lung is trapped<br />within the Thoracic Cavity</p>
<p begin="00:07:34.287" end="00:07:36.291" style="s2">by this Fibrinous<br />Attachment to the Diaphragm,</p>
<p begin="00:07:36.291" end="00:07:38.846" style="s2">it may be dangerous to<br />perform an invasive procedure</p>
<p begin="00:07:38.846" end="00:07:41.922" style="s2">like a Thoracentesis or<br />a Chest Tube Placement.</p>
<p begin="00:07:41.922" end="00:07:43.801" style="s2">The needle or the Chest<br />Tube could be guided</p>
<p begin="00:07:43.801" end="00:07:46.063" style="s2">up into the Lung causing a Pneumothorax</p>
<p begin="00:07:46.063" end="00:07:50.571" style="s2">by the Fibrinous Attachment<br />to the Diaphragm.</p>
<p begin="00:07:50.571" end="00:07:52.403" style="s2">So, in conclusion, I'm<br />glad I could share with you</p>
<p begin="00:07:52.403" end="00:07:53.932" style="s2">this SoundBytes module going over the</p>
<p begin="00:07:53.932" end="00:07:57.437" style="s2">Ultrasound Examination for the<br />detection of Pleural Fluid.</p>
<p begin="00:07:57.437" end="00:07:59.240" style="s2">As we've discussed earlier in the module,</p>
<p begin="00:07:59.240" end="00:08:00.729" style="s2">Ultrasound may be more accurate</p>
<p begin="00:08:00.729" end="00:08:03.247" style="s2">in detection of Pleural<br />Fluid than a Chest X-ray.</p>
<p begin="00:08:03.247" end="00:08:05.384" style="s2">And Ultrasound allows easy grading</p>
<p begin="00:08:05.384" end="00:08:08.103" style="s2">of the amount of fluid<br />within the Pleural Cavity.</p>
<p begin="00:08:08.103" end="00:08:10.620" style="s2">It can also detect<br />Complicated Pleural Effusions</p>
<p begin="00:08:10.620" end="00:08:13.387" style="s2">that may be Loculated<br />and can help determine</p>
<p begin="00:08:13.387" end="00:08:16.270" style="s2">which patients may benefit<br />from a Drainage Procedure</p>
<p begin="00:08:16.270" end="00:08:19.742" style="s2">such as a Thoracentesis<br />or a Tube Thoracostomy.</p>
<p begin="00:08:19.742" end="00:08:23.014" style="s2">So, I hope to see you back<br />as SoundBytes continues</p>
<p begin="00:08:23.014" end="00:08:24.008" style="s2">and in further modules,</p>
<p begin="00:08:24.008" end="00:08:25.490" style="s2">we'll actually look closer at</p>
<p begin="00:08:25.490" end="00:08:29.657" style="s2">the Thoracentesis Procedure<br />under Ultrasound guidance.</p>
Brightcove ID
5729244712001
https://youtube.com/watch?v=X1E7OgOLzw0