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How to: Pneumothorax Evaluation

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Learn transthoracic lung ultrasound to rule out pneumothorax.

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- Classically, it's been thought
that the lung cannot be ultrasounded.
In fact, that's not true.
We can use ultrasound very easily
to rule out a pneumothorax.
I'm gonna show you, using two different transducers,
how we can see the lung pleural line
to exclude the presence of a pneumothorax.
We're gonna start with our transducers.
We have two different choices of transducers.
We have our phased array transducer
and a linear array transducer.
If you're doing this as part of the fast exam,
most likely you've already have
a phased array transducer in your hand.
Therefore, I'm gonna go ahead
and show you what the images look like
using a phased array transducer.
The exam type has already been set up
in an abdominal preset,
and so we're ready to start scanning.
Now the area that we're gonna scan
is an area where we're gonna expect air to collect
in the presence of a pneumothorax.
That would be the most anterior aspect of the lung.
So if you look at our model right here,
we would expect air to collect more likely
in the anterior surface than more posteriorly.
Therefore, when I do my scanning,
I'm gonna scan about mid-clavicular line
at the most anterior area of the patient's body.
So we're gonna go ahead and start scanning.
Here's our probe marker right here.
We're gonna aim that toward the patient's head,
and I'm scanning right now in a sagittal fashion.
I'm gonna turn my gain up a little bit,
and first thing you're gonna recognize
that our depth is too deep.
Remember, what we're scanning now is really superficial.
We're looking at the lung's surface.
So I'm gonna decrease our depth
so we can see the lung surface quite easily.
Now what we're looking at here on the screen
is a classic shimmering line
that you see with the pleural surface,
that being the parietal and the visceral pleural surface
rubbing against each other.
So we see a rib here on the left.
We see another rib to the right.
And in the center is a line which is horizontal,
and we see shimmering.
That presence of that shimmering,
as well as very small, tiny comet tails
that are coming from the posterior aspect of that,
excludes the presence of a pneumothorax.
If you have time,
you want to use your linear array transducer.
This transducer does high-frequency imaging,
allows you to do much better imaging
of superficial structures.
So we're gonna get a lot better quality,
high-resolution pictures, of the pleural line.
So here's our transducer that I've chosen.
This is the marker here right now.
And I'm gonna go ahead and put a little gel here.
Now I'm gonna cut sagittally
at the highest point in his chest,
in about the mid-clavicular line,
and I notice to the left of the screen
is a rib right here,
and we see another rib right here.
And in between the two, we see the pleural line.
And as he takes a breath, we see shimmering.
These are the two surfaces of the lung,
the visceral surface and the parietal surface,
rubbing together.
We also see little tiny white lines,
your little comet tail lines,
which also show that both surfaces are touching together.
If you see this pattern,
you have reliably excluded a pneumothorax.
You can see in this model
that we can easily see the rib here anteriorly
and another one more inferiorly,
and we see the pleural line easily here in the middle,
we see shimmering.
Now you may want to document this in a still pattern.
That is very easy to do by just activating the M-mode.
We hit the M-mode key here.
And we put the M-mode marker
through the center of the pleural line
where we see shimmering, and with M-mode again.
And what we see now is a pattern
that's called the seashore sign.
And I'm gonna freeze this.
So now we have a frozen image
of the M-mode through the pleural line,
and we see the shimmering line here,
and we see here a classic seashore sign.
And when you see this,
this is still documentation of exclusion of a pneumothorax.
If you do your exam in the mid-clavicular line
at the most anterior portion of the chest,
and you see a good shimmering line,
then you've ruled out a pneumothorax.
If you don't see any shimmering line,
then you most likely are dealing
with a patient with a pneumothorax.
You can then take your transducer
and move it to the patient's left or to his right
or in more superior and inferior
to get a qualitative size of the pneumothorax
you're dealing with.

Brightcove ID

5741746210001

https://youtube.com/watch?v=D3mm9wwlw7g

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3D How To: Lung Examination

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3D animation demonstrating a lung ultrasound exam.

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Cardiology

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- [Voiceover] A phased array transducer
with a long exam type is used to evaluate lung sliding.
The anterior, lateral, and posterior zones of the chest wall
should be evaluated.
The transducer is placed in a long-axis orientation
over the anterior chest wall at the third or fourth
intercostal space in the anterior axillary line.
The orientation marker is directed to the patient's head.
A shallow scanning depth is used.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified as a bright,
hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral pleural
against the parietal pleural with breathing
generates the lung sliding sign.
Evaluate the pleural movement for A line and B line
reverberation artifacts.
To evaluate the posterior pleural space,
move the transducer distally to the level
of the seventh intercostal space.
Slide the transducer posteriorly to the midaxillary line.
Increase the scanning depth to view the interface
between the pleural space and diaphragm.
In a normal patient, a mirror image artifact
of the liver or spleen will appear the diaphragm.

Brightcove ID

5741728173001

https://youtube.com/watch?v=LnqxLEbsTZY

3D How To: Inferior Vena Cava Exam

Read more about 3D How To: Inferior Vena Cava Exam

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3D animation demonstrating an Inferior Vena Cava ultrasound exam.

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Cardiology

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- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
an Inferior Vena Cava ultrasound exam.
The Inferior Vena Cava is evaluated
at the level of the liver and diaphragm.
The transducer is placed to the right
of the epigastric midline,
with the orientation marker to the patient's feet.
As an alternative approach,
this exam may be performed using an abdomen exam type
with the orientation marker to the patient's head.
The liver, diaphragm, right atrium,
and Inferior Vena Cava are identified in this view.
Sweep from side-to-side to differentiate
the Inferior Vena Cava from the aorta.
The aorta is thicker walled and pulsatile.
The superior mesenteric and celiac branches of the aorta
are identified at this level.
The Inferior Vena Cava is thin walled
and changes caliber with respiration.
The diameter of the Inferior Vena Cava
decreases with inspiration and increases with expiration.

Brightcove ID

5508114165001

https://youtube.com/watch?v=ci9W4MvyMHI

3D How To: eFAST Lung Sliding Detection (Phased)

Read more about 3D How To: eFAST Lung Sliding Detection (Phased)

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3D animation demonstrating how to detect lung sliding with a phased array transducer while performing the eFAST exam.

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Cardiology

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- [Voiceover] A phased array transducer is used
to evaluate lung sliding as an extension of the FAST exam.
The orientation marker is positioned
in the direction of the patient's head.
The transducer is placed in a long-axis orientation
over the anterior chest wall at the third
or fourth intercostal space
in the anterior axillary or midclavicular line.
A superficial scanning depth is used.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified
as a bright hyperechoic line between the rib shadows.
The normal to and fro sliding movement
of the visceral pleural against the parietal pleural
with breathing generates the lung sliding sign.
If desired, the delineation of the lung sliding interface
may be enhanced by changing to a linear array transducer.

Brightcove ID

5753042634001

https://youtube.com/watch?v=n9J12nmNhUU

How To Detect Lung Sliding with Ultrasound

Read more about How To Detect Lung Sliding with Ultrasound

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3D animation demonstrating how to detect lung sliding with a linear transducer while performing the eFAST exam.

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Cardiology

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- [Voiceover] A linear array transducer is used
to evaluate lung sliding as an extension of the FAST exam.
The orientation marker is positioned in the direction
of the patient's head.
The transducer is placed in a long access orientation
over the anterior chest wall
at the third or fourth intercostal space
in the interior axillary to mid-clavicular line.
The ribs are identified in the near field of the image
as bright interface with a posterior shadow.
The plural line is identified
as a bright hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral plural
against the parietal plural with breathing
generates the lung sliding sign.

Brightcove ID

5741746239001

https://youtube.com/watch?v=26RQyxk5vGc

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3D animation demonstrating how to detect lung sliding with a linear transducer while performing the eFAST exam.

Case: Ultrasound for Pneumothorax

Read more about Case: Ultrasound for Pneumothorax

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The video demonstrates how to use long and short axis configurations, as well as M-mode, to detect and diagnose both a complete and partial pheumothorax.

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- Hello, my name is Phil Perera,
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this module we're going to look specifically
at Ultrasound of the Lung to Evaluate for Pneumothorax.
Interestingly enough,
a classical belief was that the lung was not optimal
for ultrasound imaging.
However newer findings have shown
that actually ultrasound is an excellent modality
for viewing the pleura and for detecting pnemothoraces.
There's been a lot of research looking at this
and what's interesting is that ultrasound
has been found now to be more sensitive than chest X-ray
in the diagnosis of pneumothorax especially
in the supine trauma patient.
And now we're going to add on views of the lungs
looking for pneumothorax as part
of our Extended FAST Exam,
or the E-FAST exam that we'll be performing
in trauma patients.
We can also detect pneumothoraces as well
in our medical patients.
Now let's learn how to perform the ultrasound examination
for the pneumothorax detection.
Here we have the high frequency linear type array probe
positioned on the anterior chest wall
at about the midclavicular line
looking in to about intercostal space three.
Now in most cases of pneumothorax with the patient supine
the air would be predominantly seen in this area.
Note we're looking in a long axis configuration
between the ribs with the marker dot
oriented superiorly towards the patient's head.
Once we've identified both the ribs and the pleura
we can swivel the probe into the short axis configuration
to further look at the pleura
and to detect pneumothorax.
Here we have the probe oriented in a transverse
or short axis orientation between the ribs
looking directly down at the pleura.
Notice in this case the marker dot is located
towards the lateral aspect of the patient.
Using both long and short axis configurations
will allow you to detect a pneumothorax
with a high degree of accuracy.
If no lung is seen on the anterior chest wall
one can size out a pneumothorax
by looking in the lateral positions as shown here.
Notice the probe on the lateral chest wall
in the short axis configuration between the ribs.
If lung is seen here laterally but not anteriorly,
this would tell you it was an incomplete pneumothorax.
We can complement the short axis view
by locating the probe into the long axis configuration
with the marker dot towards the patient's axilla
to further examine into these lateral areas
of the chest wall.
Here's a nice pictorial showing
the normal findings of a lung
in a long axis type configuration.
Superior rib to the left,
inferior rib to the right.
Notice that the ribs cast shadows posteriorly
due to the inability of the soundwaves
to permeate the hard calcifications of the rib.
We see the chest wall anteriorly,
and note here the two layers of the pleura.
And we see here the outer parietal pleura,
and the inner visceral pleura.
Now while I've depicted these as two separate layers,
in reality on ultrasound examination
they're seen as a single shimmering white line
that moves back and forth as the patient breathes.
And as the patient breathes we can see white comet tails,
or linear lines, vertical lines,
coming off the pleura down deep into the lung.
So that will be the normal finding of a lung
on long axis configuration.
Here's a nice ultrasound image
showing a normal lung
and what we see here,
we're in the long axis configuration,
so the superior rib is to the left,
inferior rib to the right.
Chest wall anteriorly,
and we see here the lung sliding
which is the opposition of the outer parietal
and the inner visceral pleura.
And we see the vertical comet tails
coming off the back of the pleura.
Thus this is a completely normal exam.
No pneumothorax.
But note the location of the pleura deep to the ribs,
and that classic shimmering line back and forth
as the patient takes a breath.
Here we see more dramatic comet tails
coming off the shimmering parietal and visceral pleura.
In this patient we see the comet tails
shooting off the back,
telling us that this lung is up and there's no pneumothorax.
So vertical lines coming off the back of the pleura
always mean that the lung is up and are always a good sign
on lung ultrasound sonography.
As we mentioned we should also swivel the probe
into the short axis configuration
to further examine the lung,
and what we see here is a normal lung
in short axis configuration.
Note here we're looking in between the ribs
so all we see is the dome of the lung
and notice that it slides back and forth
as the patient breathes,
and we see the vertical comet tails
coming off the back.
So a completely normal examination in the short axis plane.
Here's another ultrasound image
taken from the short axis configuration.
Note here we see very prominent comet tails
coming off the back of the lung as it slides back and forth.
Again it's that opposition
of the parietal and visceral layers of the pleura
that allow the lung shimmering,
but notice here all the comet tails coming off the back.
In this case this patient had some pulmonary edema
associated with the lung
and these comet tails are more pronounced
due to the presence of water within the pleura.
But notice all these vertical lines coming off the back
telling us this lung is up.
A way to document that the lung is up
to print out for the chart is to put M-Mode,
and generally what we do is locate it so the M-Mode cursor
is down right at the pleura.
And what we see is the classic seashore sign,
or waves on the beach.
If we look anteriorly we'll see the classic waves,
or no motion of the chest wall,
and below that,
deep to the pleura we'll see the positive motion of the lung
making up the beach.
So waves on the beach,
or the seashore sign,
and M-Mode documentation that the lung is up
and that there's no pneumothorax.
Now that we understand what a normal lung looks like
on bedside examination,
let's take a look at a pictorial showing a pneumothorax
in a long axis view.
We see here that the parietal pleura
is now split from the visceral pleura,
which is attached to the lung
by a layer of air shown by the yellow color.
It's the splitting of the parietal and visceral pleura
that now causes a lack of lung sliding.
And instead of the opposed visceral and parietal pleura
sliding back and forth as the patient breathes,
all we see is a single line,
the parietal pleura,
with a lack of vertical comet tails coming off the back.
Here's an ultrasound image taken from a patient
who was stabbed to the left chest
and who had shortness of breath.
What we see here is a long axis view of a pneumothorax.
Let's take a look at the chest wall anteriorly,
and right below that we see the parietal pleura,
the single white line located directly inferior to the ribs.
But notice the classic lack of the lung sliding.
All we see here is a single white line
that fails to slide back and forth as the patient breathes.
Notice also the absence of the vertical comet tails.
Here's another image of a pneumothorax
in a long axis configuration,
and we see here the chest wall anteriorly,
and the single white line which is the parietal pleura.
Now this patient was acutely dyspneic,
so notice that there is some motion of the chest wall
and that the parietal pleura moves up and down,
but notice the failure of horizontal sliding.
Notice also the absence of any vertical comet tails
coming off the back of the pleura.
Now let's inspect a pneumothorax from the short axis view.
We see the chest wall anteriorly,
the parietal pleura as shown as a single,
non-mobile white line in the middle of the image.
Note the failure of movement back and forth,
the lack of vertical comet tails,
and what we see here is repeating horizontal air lines
from the pneumothorax.
To document the absence of lung sliding
and the presence of a pneumothorax,
we'll again turn to M-Mode.
If we put the M-Mode cursor down on the pleura,
what we'll see is a set of linear repeating lines.
This documents no motion of both the chest wall
and of the lung,
making up a finding known as the bar code sign.
Here's a pictorial showing interesting finding.
The signature of an incomplete pneumothorax,
known as lead point.
And what we see is an incomplete pneumothorax
with air collecting to the superior aspect
of the image to the left.
Thus splitting the parietal from the visceral layers
and causing an absence of lung sliding superiorly.
However, as the lung is coming up against the chest wall
to the right or inferiorly,
that's where we'll see the presence
of horizontal lung sliding,
and the presence of the vertical comet tails.
Here's an ultrasound image showing the lead point,
and what we see here is the lung sliding to the right,
the area where the lung touches up against the chest wall,
and to the left the area of absence of lung sliding
telling you there that air has collected
between the visceral and parietal layers.
So the ultrasound equivalent of the image
that we just looked at telling you
that this is an incomplete pneumothorax.
But here we see that lead point,
or transition point,
very well on bedside sonography.
In conclusion I'm glad I could share with you
this ultrasound module going over ultrasound of the lung
to evaluate for pneumothorax.
This is an excellent tool for viewing the pleura
and making the diagnosis of pneumothorax,
and there's been some research showing that it may be
more sensitive than chest X-ray in the diagnosis
of pneumothorax,
allowing rapid diagnosis of pneumo
in both your trauma and medical patient,
thus facilitating more timely management
of these most critical patients.
So I hope to see you back as SoundBytes continues.

Brightcove ID

5508134309001

https://youtube.com/watch?v=Xxdedx1HtHo

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How to: Pneumothorax Evaluation

How to: Pneumothorax Evaluation

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3D How To: Lung Examination

3D How To: Lung Examination

3D How To: Inferior Vena Cava Exam

3D How To: Inferior Vena Cava Exam

3D How To: eFAST Lung Sliding Detection (Phased)

3D How To: eFAST Lung Sliding Detection (Phased)

How To Detect Lung Sliding with Ultrasound

How To Detect Lung Sliding with Ultrasound

Case: Ultrasound for Pneumothorax

Case: Ultrasound for Pneumothorax

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