Pleural Cavity

- [Voiceover] A phased array transducer
with an abdomen exam type is used to evaluate
the chest cavity for the presence of fluid.
The procedure is best performed with the subject
in a sitting position, leaning slightly forward,
to allow access to the posterior chest cavity.
The patient is instructed to breathe normally.
And the transducer is placed in a long-axis orientation
over the posterior chest wall
at the eighth or ninth intercostal space,
in the posterior axillary line.
The orientation marker is directed to the patient's head.
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 pleura
against the parietal pleura, with breathing,
generates the lung sliding sign.
The transducer is moved along the posterior axillary line
to identify the bright, hyperreflective diaphragm.
Fluid will appear as a dark anechoic area
in the dependent area of the chest cavity.
Identify the borders of the fluid collection
and the normal appearing lung.
A needle insertion site should be chosen
in the posterior chest,
in a dependent area of the fluid collection.
Adjust the transducer so it is located between two ribs.
The needle should be inserted just below
the center position of the transducer
to allow the needle to pass just superior
to the lower rib to avoid the neurovascular bundle,
which lies on the inferior surface of the rib.
Follow the needle entry by slowly sliding
the transducer in the direction of needle advancement.
The needle will appear as a small bright hyperechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced under direct
ultrasound visualization until the tip is seen
to indent and then puncture the parietal pleura.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip lies
in the fluid collection in the chest cavity.

Brightcove ID

5733273235001

https://youtube.com/watch?v=x1XR4AOi8q0

Case: Ultrasound Guidance for Thoracentesis

Read more about Case: Ultrasound Guidance for Thoracentesis

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This video details how bedside ultrasound imaging can be used to guide thoracentesis, detect pleural fluid levels, and analyze patient anatomy. It also discusses patient positioning during the thoracentesis and probe placement.

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- 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 SoundBytes module I'd like to begin by discussing
the case of a patient who presented with worsening
shortness of breath
and had a chest X-ray which revealed this finding.
Notice here we have the presence of
an opacified left hemithorax
and notice here that the trachea is pushed away
from the left hemithorax
suggesting the presence of a very large pleural effusion
as the cause of our patient's dyspnea.
Now if in fact this was a large pleural effusion causing
our patient's shortness of breath
a therapeutic thoracentesis would be in order
to relieve her symptoms.
This leads into the topic for this SoundBytes module
which is the use of bedside ultrasound to perform the
thoracentesis procedure.
In this module I'd like to go through how sonography
can potentially make the thoracentesis procedure
a safer one for our patients
with a decrease in the inherent complications of the
procedure, such as pneumothorax or perforation
of the diaphragm.
Before a performance of a thoracentesis procedure
it's mandatory to look with sonography
to make sure that there's enough pleural fluid
amenable for a safe thoracentesis.
Notice here we have the patient positioned in
an upright position
so that the fluid will layer out above the level
of the diaphragm.
Notice here we note the diaphragm as shown by the red line
across the patient's anterior chest wall
Notice here we have the probe positioned along the lateral
aspect of the patient's chest with a marker dot towards
the patient's head.
We can angle the probe above the diaphragm
to look for a dark or anechoic collection of fluid
consistent with a pleural effusion.
This is the ultrasound image that corresponds to the
chest X-ray from the patient as we discussed in
the beginning of the module.
We have the probe positioned across the patient's left
side of the chest,
coming in with a probe marker toward the patient's head.
We can see here, superior towards the left and
inferior towards the right,
We note the spleen and the kidney,
inferior in the abdominal compartment
and we see the white line that is the diaphragm
moving up and down as the patient breathes.
We note above the diaphragm,
superior in the chest cavity,
the presence of a large, dark or anechoic
collection of fluid,
consistent with a very large pleural effusion,
and we fail to appreciate any lung within
this pleural effusion.
Just to emphasize the point that it's very important
to look with sonography, prior to performance of a
thoracentesis procedure,
we know this pleural effusion is taken from the right chest
we see the liver towards the inferior aspect of the patient
towards the right here,
and we note above the diaphragm here,
which is moving up and down as the patient breathes,
the presence of a dark or anechoic fluid collection,
but we also see here lung within the pleural effusion
and an attachment of the lung,
a fibrinous attachment,
that attaches the lung down to the diaphragm.
So this could be potentially a complicated performance
of a thoracentesis as the needle that goes into that
chest cavity could be pushed by that fibrinous attachment
up into the lung causing a pneumothorax.
This is the first traditional position of the patient
for the thoracentesis procedure.
This is the recumbent position in which we have the patient
lying down with the head of the bed elevated.
This will encourage the fluid to layer out above
the diaphragm,
and make it more amenable to a puncture attempt.
Here we see a pleural effusion within the left hemithorax,
note the effusion as denoted by the yellow liquid
around the red lung.
Here the black star indicates the appropriate position
for the needle for the puncture point for the thoracentesis.
When performing a thoracentesis procedure the needle should
be positioned above the level of the rib,
so as to avoid the neurovascular bundle,
which as shown in this illustration lies just below
to the rib.
Here I'm demonstrating the appropriate position of the probe
to investigate for the lateral approach to the thoracentesis
this time on the right chest.
Notice the positioning of the probe,
in this case the 3 MHz probe,
on the lateral chest wall,
right above the level of the diaphragm,
to look for a pleural effusion.
Here I'll indicate the orientation of the ribs
across the lateral chest wall,
and here's about the orientation of the diaphragm.
Now remember that that diaphragm will move up and down
as the patient breathes, so we want to place the probe
above the level of the diaphragm,
to look into the thoracic cavity
for a suitable collection of fluid.
Therefore here we note the position of the needle
for the appropriate positioning of the needle
for the lateral puncture approach
to the thoracentesis procedure.
And we note again that the level of the diaphragm,
on the lateral chest wall is shown by the red line,
and we note the needle above the diaphragm,
so that it can safely enter into the thoracic cavity
and not cause a complication such as puncture the diaphragm
during the thoracentesis procedure.
Here we note the second traditional positioning of
the patient for the thoracentesis procedure,
which is the standard upright position,
in which the needle would come in from a posterior approach.
And we note the patient bending forward over a stand
or a table.
Here we see a pleural effusion within the right chest
and we note here the patient has a puncture point
that would come in, into the pleural effusion,
below the scapula but above the layer of the diaphragm.
In this video clip I'll outline some of the surface anatomy
important for the posterior approach to the
thoracentesis procedure.
Here's about the level of the scapula on the
posterior chest wall,
and this is about the level of the diaphragm,
so the appropriate positioning for the needle for
the thoracentesis procedure
would be about the level of my finger here.
And we'll just freeze that down,
there's the scapula,
and here's about the level of the diaphragm.
Notice my finger safely above the diaphragm,
so as not to puncture through the diaphragm
into the abdominal cavity.
As shown by the black star this would be the appropriate
positioning of the needle for the thoracentesis procedure.
Prior to the thoracentesis procedure
we'll investigate the pleural effusion using a 3 MHz probe.
Notice the 3 MHz probe is placed along the
posterior chest wall,
at first with the probe marker on the long axis trajectory
with the orientation of the marker towards
the patient's head.
We can then swivel the probe into the lateral orientation,
with the probe marker lateral to further investigate
above the diaphragm,
for a suitable collection of pleural effusion amenable
to a thoracentesis procedure.
A clinical pearl that can be very helpful in further
delineating the pleural effusion with regard to the
patient's anatomy is to look further with a
10 MHz high frequency linear array type probe
prior to the thoracentesis puncture.
Notice here we're placing the high frequency probe along the
posterior chest wall in the long axis configuration with the
probe marker swiveled toward the patient's head.
We can also orient the probe in between the patient's ribs
in the lateral orientation as well,
to further investigate the anatomy.
This illustration shows what the anatomy of a pleural
effusion will look like using a high frequency 10 MHz probe.
In this illustration the probe is configured in the
long axis orientation.
So we have superior to the left and inferior to the right.
We see anteriorly the chest wall and we see the
superior rib to the left and the inferior rib to the right.
We know that the parietal pleura,
that white line just deep to the ribs,
and below the parietal pleura we can see the darker
anechoic pleural effusion.
In this illustration we're actually showing here
the visceral pleura, that coats the outside of the lung,
and we can actually see the distance between the pleura
layers, the parietal pleura and the visceral pleura,
which would be the full extent of the pleural effusion.
This would be your safety zone,
or the area in which it would be safe to place a needle.
It would be not safe to place a needle any deeper
than that safety zone,
as a needle could puncture through the visceral pleura
and into the lung, causing a pneumothorax.
Here's an ultrasound image showing a very large pleural
effusion as taken with a high frequency 10 MHz probe.
Superior towards the left, inferior towards the right.
We can see the hyperechoic, or bright bone tables of the rib
both superior and inferior,
which will show us the areas of the rib to avoid
during the thoracentesis procedure.
We'd actually want to come in over the top of the inferior
rib to avoid the neurovascular bundle.
We can see here the white line making up the parietal pleura
and deep to the parietal pleura we note a large amount of
pleural effusion.
We note here the absence of a lung in the pleural effusion
so we can place the needle pretty deeply here
without causing a pneumothorax.
This ultrasound image is again taken with a high frequency
10 MHz probe,
but in this orientation the probe is configured between
the ribs in the lateral orientation.
So, all we see is the chest wall, anteriorly,
we see the parietal pleura, that white line deep to the
chest wall,
and just deep to the parietal pleura we can see the
pleural effusion as made up by the darker anechoic
collection of fluid.
Now, note here that we also see the lungs sliding
back and forth as the patient breathes,
and we can see the full extent of the pleural effusion,
or the safety zone for performance of
the thoracentesis procedure.
In this ultrasound image,
again taken with a 10 MHz high frequency probe,
we can see the diaphragm moving back and forth as
the patient breathes,
defining the lower aspect of the thoracic cavity.
Thus, it would probably be unsafe to perform a
thoracentesis at this level of the chest wall,
because we might go through the diaphragm and into
the spleen with a needle.
So, it's important to look first to ascertain
the level of the diaphragm,
and make sure that the thoracentesis needle is going
safely above the diaphragm so as not to puncture
into the abdominal compartment.
In this video clip we'll first place the
high frequency 10 MHz probe along the posterior
aspect of the chest wall to define the proper
orientation for the puncture for the posterior approach
to thoracentesis procedure.
The needle can then come in directly underneath the probe
as shown here.
Now, I'll show a wide angle shot here and note this is
the proper position for the thoracentesis needle,
as definied by sonography from the posterior approach
to thoracentesis.
In conclusion, thanks for tuning in for this SoundBytes
module going over ultrasound guidance for the
thoracentesis procedure.
Sonography can potentially make the procedure a safer one
for our patients with a decrease in the complication rate,
such as pneumothorax or perforation of the diaphragm.
We'll want to use both the 3 MHz and higher frequency 10 MHz
probes to fully evaluate the effusion in relation to
the patient's anatomy, prior to a puncture attempt.
We can either use the static technique where we position
the patient appropriately and then mark off the
puncture spot with sonography,
prior to the thoracentesis procedure.
Or, we can use a dynamic technique,
where we place the probe in a sterile sheet
and watch the needle in real-time go into the chest cavity.
So, I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5733895862001

https://youtube.com/watch?v=6ThpUpgjSiM

Case: Detection of Pleural Fluid

Read more about 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.

Applications

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- 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 SoundBytes module,
we're going to look specifically at the
use of Bedside Ultrasound to detect Pleural Fluid.
Interestingly enough, Ultrasound has been found
to detect as little as 20 ccs of fluid
within the Pleural Space.
In contrast, a Chest X-Ray will not reliably
pick up less than 100 to 150 ccs of fluid
on an AP Film.
Now this problem is only compounded
in the Supine Trauma Patient,
where a Chest X-ray may miss a significant amount of fluid
as a Hemothorax will layer out Posteriorly
and can be very difficult to detect on this film.
For these reasons,
Bedside Ultrasound may offer a more accurate way
of diagnosing Pleural Fluid.
Here's a slide reviewing how to
perform the Ultrasound examination
for detection of Pleural Effusions.
Optimally you'll have a three megahertz probe
with a small footprint that can easily sit between the ribs
as we'll be looking into the Right Upper Quadrant
and Left Upper Quadrant areas.
In position one, we'll be coming into the
standard Right Upper Quadrant Trauma FAST exam
and position the probe into that area
just above the Liver and below the Diaphragm.
We can then angle the probe upwards into the Thoracic Cavity
to look for a Dark or Anechoic Fluid Collection
signifying Thoracic Fluid.
We can repeat the exam in the left side
as shown in probe position two.
Placing the probe into that area
of the Left Upper Quadrant Trauma FAST view.
Look first into the area above the Spleen
and below the Diaphragm
and then angle the probe upwards into
the left Thoracic Cavity.
If fluid is seen with in the Thoracic Cavity,
we can then move the probe upwards
to investigate the extent of the Effusion.
Here's a video going over how to perform the examination.
Notice here, we have a probe placed
into the Right Upper Quadrant Trauma FAST area.
Notice that we're angling the probe upwards
into the Thoracic Cavity to fully investigate
for a Pleural Effusion.
Here, I'm just superimposing
about the level of the Diaphragm
as shown in the red marker.
And notice here that the probe
is positioned coming into that area
just above the Diaphragm into the Thoracic Cavity.
Traditionally, the probe should be
in a long-axis configuration
with the marker dot towards the patient's head.
Again, if a Fluid Collection is seen,
one can then move the probe upwards
to fully investigate how big the Effusion is.
To optimize your examination,
place the patient with the head slightly upwards,
so that the fluid will layer out above the Diaphragm
allowing earlier detection of smaller amounts of fluid.
Now that we know how to perform
the Ultrasound examination for Pleural Fluid,
let's take a look at a normal Right Upper Quadrant
Pleural Examination.
The probe is configured at a long-axis type orientation
with the marker towards the patient's head.
So, we see Superior to the left, Inferior to the right.
The Liver is in the middle of the image.
And let's look above the liver.
Here we see the Diaphragm, that curving, white line
which is moving up and down as the patient breathes.
And to the left or Superior to the Diaphragm
is the Thoracic Cavity.
Now, while looking at the Thoracic Cavity here,
what we see is something called Mirror Artifact.
This occurs as a result of the sound waves
coming through the Diaphragm
and reproducing what looks like a mirror image
of the Liver within the chest.
This is a normal appearance of the Thoracic Cavity
and Mirror Artifact is something that
will be seen commonly on Bedside Sonography.
Notice, however, the absence of a Dark
or Anechoic Fluid Collection within the right chest.
Now, let's take a look at a normal
Left Upper Quadrant Pleural Exam.
Again, we're in a long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Spleen in the middle of the image
and we see the Diaphragm moving up and down
as the patient breathes.
Let's look above the Diaphragm into the Thoracic Cavity.
And, again, we see that Mirror Artifact.
What it looks like is almost like
reproduction of the Spleen within the Thoracic Cavity.
So, this is a normal finding.
And one that is not to be confused with fluid.
Fluid will appear very differently
and will have the appearance of a Dark or Anechoic stripe
right above the Diaphragm.
Here's an illustration showing a positive examination
from the Right Upper Quadrant view
with a Pleural Effusion above the Diaphragm.
We're in that long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Liver in the middle of the image here.
And the Diaphragm, the white line as seen
right above the Liver.
Notice in this image we have a Pleural Effusion
as represented by the Dark area of fluid,
which is immediately Superior to the Diaphragm
and tucks in there right above the Diaphragm
going up into the Thoracic Cavity.
So, this will the signature finding of a Pleural Effusion
as taken from the Trauma FAST Views,
from the Right Upper Quadrant.
And the Left Upper Quadrant will also have a similar view,
although we're just looking above the Spleen
in that orientation.
Here's a video clip showing a Small Pleural Effusion
as taken from the Left Upper Quadrant view.
Here, we see the Spleen in the middle of the image,
the Kidney Inferior to the Spleen.
And the Diaphragm, the curving white line
that's moving up and down as the patient breathes
right above the Spleen.
As we look into that area above the Diaphragm,
we actually appreciate here, the presence
of a Dark or Anechoic Fluid Collection
above the Diaphragm.
This represents a positive Pleural Effusion.
Notice that the amount of fluid is relatively small
and we can actually see the Lung moving up and down
to the left of the image here.
Here's a Moderate Plural Effusion
as taken from the Right Upper Quadrant View.
We see the Liver to the Inferior Aspect or to the right.
The curving white line making up the Diaphragm
in the middle of the image.
And fluid representing a Pleural Effusion
Superior to the Diaphragm.
Interestingly enough, we see the Lung moving around
and all the fluid compressed down
by the fluid within the chest cavity
taking on what appears to like a Liver within the chest.
And something called Hepatization of the Lung.
And this is commonly seen with a Pleural Effusion,
as it pushes in on the Lung
making it more of a solid-type organ.
Here's a Large Pleural Effusion as taken
from the Right Upper Quadrant View.
And what we see here, is the Liver Inferiorly,
the Diaphragm right above the Liver
there in the middle of the image.
And we see a large Dark or Anechoic Collection
immediately Superior to the Diaphragm.
This represents a Large Pleural Effusion.
And in the midst of the Pleural Effusion,
we can see the Lung waving around
and compressed down by all
the fluid within the Thoracic Cavity.
Again, demonstrating that Hepatization
of the Lung as it's compressed down by the Pleural Fluid.
So, this would be a Large Plural Effusion,
as there's a large amount of fluid
both Inferiorly between the Lung and the Diaphragm.
And both Anterior and Posterior to the Lung itself here.
Unfortunately, not all Plural Effusions
will be free-flowing or uncomplicated.
There are occasions where our patients
can have repeated Pleural Effusion
that can be Loculated or Complicated.
Here we see an example of a Loculated Pleural Effusion.
Notice this Lung here has an attachment
with a Fibrin area that attaches it
or glues it onto the Diaphragm Inferiorly.
Therefore, we have two Loculated areas Effusion,
both Anterior to the top of the screen and Posterior.
As the Lung is trapped within the Thoracic Cavity
by this Fibrinous Attachment to the Diaphragm,
it may be dangerous to perform an invasive procedure
like a Thoracentesis or a Chest Tube Placement.
The needle or the Chest Tube could be guided
up into the Lung causing a Pneumothorax
by the Fibrinous Attachment to the Diaphragm.
So, in conclusion, I'm glad I could share with you
this SoundBytes module going over the
Ultrasound Examination for the detection of Pleural Fluid.
As we've discussed earlier in the module,
Ultrasound may be more accurate
in detection of Pleural Fluid than a Chest X-ray.
And Ultrasound allows easy grading
of the amount of fluid within the Pleural Cavity.
It can also detect Complicated Pleural Effusions
that may be Loculated and can help determine
which patients may benefit from a Drainage Procedure
such as a Thoracentesis or a Tube Thoracostomy.
So, I hope to see you back as SoundBytes continues
and in further modules,
we'll actually look closer at
the Thoracentesis Procedure under Ultrasound guidance.

Brightcove ID

5729244712001

https://youtube.com/watch?v=X1E7OgOLzw0

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3D How To: Ultrasound Guided Thoracentesis

3D How To: Ultrasound Guided Thoracentesis

Case: Ultrasound Guidance for Thoracentesis

Case: Ultrasound Guidance for Thoracentesis

Case: Detection of Pleural Fluid

Case: Detection of Pleural Fluid

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