Pleural

3D How To: Lung Examination

Read more about 3D How To: Lung Examination

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3D animation demonstrating a lung ultrasound exam.

Applications

Cardiology

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How To Videos

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Subtitles

- [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: Supraclavicular Nerve Block

Read more about 3D How To: Supraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

Clinical Specialties

Anesthesiology (Regional)

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How To Videos

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Subtitles

- [Voiceover] A linear array transducer with
a nerve exam type is used to perform an ultrasound guided
supraclavicular regional nerve block.
The target depth is approximately one to three centimeters
in an 80 kilogram adult.
The patient is positioned in a 45 degree
reclining position with a pillow under their head
and the neck exposed on the operative side.
The patient's head is rotated toward the contralateral side.
The examination begins by finding the supraclavicular region
of the brachial plexus as a landmark technique.
The transducer is placed posterior
to the midpoint of the clavicle at an acute angle
with the orientation marker directed
to the patient's right at a ten o'clock position
with the transducer aimed into the thorax.
The subclavian artery is seen as a round pulsal tile
structure superior to the bright reflection
of the first rib.
The plura is seen as a bright hyperechoic reflection
deep two, or at the same depth as the first rib.
The nerves of the brachial plexus are posterior
or superior to the subclavian artery.
The nerve trunks appear as hypoechoic dark circles
within the bright hyperechoic fascia of the brachial plexus.
Colored doppler imaging may be used
to identify smaller arterial branches
running through the brachial plexus
or lying in the path of needle advancement.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced
using an in plane technique.
The initial end point of the needle
is just posterior to the artery
immediately above the first rib.
It is important to distinguish the plura
from the first rib to avoid a pneumothorax.
The local anesthetic is injected
incrementally close to the nerves.
The needle can be redirected towards
the upper trunks of the brachial plexus
if the spread of local anesthetic is not deemed adequate.

Brightcove ID

5750031878001

https://youtube.com/watch?v=9vW1uo7mKDc

Body

3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

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.

Applications

Cardiology

Clinical Specialties

Cardiology

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How To Videos

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Subtitles

- [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

/sites/default/files/EFast_LungSliding_HR_Linear_EDU00456_Thumnail.jpg

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

Applications

Cardiology

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How To Videos

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Subtitles

- [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

Body

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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Case Study Videos

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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

How to: Infraclavicular Brachial Plexus Nerve Block

Read more about How to: Infraclavicular Brachial Plexus Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- The infraclavicular block is used for surgery
below the mid-humerus.
Any surgery of the elbow, forearm, wrist or hand
can be performed under a properly executed
infraclavicular block.
Many people use curvilinear, low-frequency
or mid-frequency probe to do the infraclavicular block.
With proper positioning
you can do a infraclavicular block
with a basic linear probe.
I'm gonna demonstrate the infraclavicular block
with a basic linear probe
because most people have a linear probe
in their ultrasound repertoire.
Proper positioning for
the infraclavicular block is important.
We usually keep the patient supine
for infraclavicular block.
We also move the patient completely to the other side
of the bed of the site to be blocked.
Abduction of the arm moves the clavicle down
and out of the way of your needle.
If the arm is down by the side
our needle approach is gonna bump into the clavicle.
Usual depth settings
for infraclavicular block in a normal patient
usually range between four to six centimeters total depth.
Ultrasound probe positioning in the infraclavicular region
is done in the parasagittal plane below the clavicle.
I will orient the probe
so the left side of the screen is caudal
and the right side of the screen is cranial.
This makes sense because if I bring
the needle from the cranial side on the screen
it will also come from the right side.
The first thing we see here
is the pectoralis major
and we also will see a pectoralis minor
if I move slightly lateral.
Here we now have identified both the axillary vein
and the axillary artery.
The vein is found more caudal than the artery.
The artery is found cranial.
Around the artery we now identify our nerves.
The nerves at this level
are the cords of the brachial plexus.
Traditionally the medial cord is described as being
approximately seven to ten o'clock
on the artery in this picture.
The posterior cord is described around
six o'clock on the artery
and the lateral cord is described between three
and six o'clock on this picture.
It's difficult to see individual nerves
because this is a deep block.
So the important thing is to surround the artery
with local anesthetic.
Now if we move more medially
we see some lung on the bottom left side of the screen here.
Lateral approaches to the infraclavicular block are safer
because the more lateral you are
the less likely you are to enter the lung with your needle.
Typically we use about 20 to 30 milliliters
of local anesthetic for infraclavicular block.
Our first injection of the artery
will be below the artery.
Some studies have described a single injection
resulting in a complete brachial plexus block
by depositing our entire local anesthetic below the artery.
Usually I do my first injection below the artery
and look at the spread.
If the spread is adequate I'll stop there.
If I need to position the needle in other places
I'll go either to the lateral cord
or approximately three o'clock
and then lastly at the medial cord
which would be about ten o'clock on the artery.
Complete spread of local anesthetic around the artery
will result in a good brachial plexus block.
In this image of the infraclavicular block
we see the local anesthetic being injected
cranial to the axillary artery.
Superficial we see the pectoralis major.
The pectoralis minor's not very visible on this picture.
Deep to the artery we see the subscapularis.
The needle has now injected on the cranial side
and is being advanced deep to the artery.
And you can see the injection there below the artery
getting local anesthetic around the posterior cord.
We continued to advance the needle
so it injects around the medial cord
on the more caudal side of the artery.

Brightcove ID

5508104662001

https://youtube.com/watch?v=1xTsXuiUNiw

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

How To Perform A Supraclavicular Nerve Block

Read more about How To Perform A Supraclavicular Nerve Block

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The Sonosite SII ultrasound machine supports regional anesthetic techniques used during supraclavicular blocks – serving as an alternative or adjunct to general anesthesia needed for postoperative pain control for upper extremity surgeries (mid-humerus through the hand). Anesthesiologist Dr. David Auyong MD of Seattle, Washington here reviews scanning techniques and sonographic landmarks for the ultrasound guided nerve block. Dr. Auyong highlights patient position, the type of transducer used, the needle position and injection technique. The ability to image the plexus, rib, pleura, and subclavian artery increases safety due to improved monitoring of anatomy and needle placement.

Media Library Type

How To Videos

Media Library Tag

Subtitles

- The supraclavicular block is used
for surgery below the shoulder.
A proper supraclavicular block will effectively block
the elbow, forearm, wrist and hand.
The reason we use supraclavicular blocks
is because the nerves are located very tightly together
and our needle movements can usually get
all the brachial plexus with minimal movements
of the needle.
The supraclavicular block has made a resurgence
since using ultrasound.
The reason is we are able to visualize
some important structures, such as the first rib
the subclavian artery and the pleura.
To start a supraclavicular block,
it's very important to position the patient properly.
The way we position patients for the supraclavicular block,
is to move the pillow all the way over to the side,
so our hands have plenty of room
to come from the posterior side of the patient.
We also turn the patient's head away
from the site to be blocked.
Then we elevate the head of the bed
30 to 45 degrees.
And that gives us the ability to have
our hands in a comfortable position while we do the block.
We use a high frequency linear probe
for the supraclavicular block.
Our nerves should be found half a centimeter
to two centimeters below the skin.
I have oriented the probe so the left side
of the screen is anterior
and the right side of the screen is posterior.
In this setting we now see a bright white strip
going across the screen
with a pulsating subclavian artery
sitting on this bright white stripe.
This stripe can be either first rib
or it can be pleura.
Your needle tip should never be below this stripe.
We call the area below this stripe the no fly zone.
On the screen we now see from left to right
the anterior scaling on the left,
the pulsating subclavian artery,
the most important place to make sure
you have local anesthetic is between
the pulsating subclavian artery and the first rib.
This is because the inferior trunk lies in this area.
And some people have difficulty
with the supraclavicular block
because area is ulnar sparing.
Usually I do two injections for this supraclavicular block.
I put one injection down in the corner
between the pulsating artery and the first rib
and then I put a second injection up higher
by the superior trunk.
My needle position for the supraclavicular block
comes posterior to anterior
and starts about a centimeter away from the probe.
If I start a centimeter or more away from the probe
my needle angel will be flat
and it will be visualized better on the ultrasound machine.
It's very important to have my needle
completely in plane with the ultrasound probe
so it will be visualized during it's entire length.
Give some injection of local anesthetic.
Usually about one to two milliliters
to see the spread of the local anesthetic
on the ultrasound screen.
Injections below the nerves will push
the rest of the brachial plexus more shallow
making the rest of the block easier.
I usually inject about 20 to 30 millimeters
of local anesthetic in the supraclavicular region.
This example of a supraclavicular injection.
The first injection is lateral to the nerves.
Our needle is barely visible because it is at a steep angle.
As the needle is flattened out we will see it better.
You can see the pulsating subclavian artery
sitting on the first rib.
And you can even see pleura out more laterally.
As the injection is put into the pocket between
the artery and the first rib,
notice the artery is even lifted off
the first rib during this injection.
Now you can see the needle much better,
because it is at a flat needle angle.
You can see the nerve just posterior to the artery
and the hypoechoic local anesthetic spreading
below the nerves.

Brightcove ID

5750036243001

https://youtube.com/watch?v=YOOoNT27Irg

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3D How To: Lung Examination

3D How To: Lung Examination

3D How To: Supraclavicular Nerve Block

3D How To: Supraclavicular Nerve Block

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

How to: Infraclavicular Brachial Plexus Nerve Block

How to: Infraclavicular Brachial Plexus Nerve Block

How To Perform A Supraclavicular Nerve Block

How To Perform A Supraclavicular Nerve Block

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