1、New international guidelines on pleural and lung ultrasound (PLUS conference)How they will change clinical practiceThe PNEUMOTHORAX2011 SMART CONFERENCEMay 27th, 2011 Milan, ItalyEnrico Storti, MDUSCME Global Education Chair, WinfocusBOD Chair, WinfocusCritical Ultrasound Director, ICU, Niguarda Ca
2、Granda Hospital, Milan ItalyHenry Ford Hospital Ultrasound University Board, Detroit - MI, USAThanks to:Daniel LichtensteinGabriele ViaLuca NeriILC on Lung US 2011 StatementsWhich kind of air is there beyond the pleura ?a bd om enlungNormal LungCollapsed lungPNEUMOTHORAXa bd om enTISSUE-AIR INTERFAC
3、E Absence of moving artifacts Absence of pathological artifacts arising from pleural-lung interface Presence of signs of transition to normal tissue-air interface (in more depending regions)ABSENCE OF THE LUNG BENEATH THE PLEURA (in the explored area)Normal PatternPNEUMOTHORAXLichtenstein DA. AM J R
4、ESP CRIT CARE MED 1997.M-MODE: the “STRATOSPHERE SIGN”1. PLEURAL SLIDING (2D, M-Mode)2. B LINES (A lines alone)3. The “ LUNG POINT ”: I. inspiratory-syncronized change from pneumothorax pattern (no lung sliding, no B lines) to lung patterns (lung sliding and/or B lines) at a critical location on the
5、 chest wall;II. return to pneumothorax pattern at expirationEXCLUSION CRITERIACONFIRMATION CRITERIONThe “Lung Point”Adapted from: Lichtenstein DA. INT CARE MED 2000.collapsedlungEXPIRATION INSPIRATION All or nothing pattern (whether the lung is in contact or not with chest wall) The more anterior, t
6、he smaller the pneumothorax(absent in complete pneumothorax)Loculated Pneumothorax in Severe Late ARDS (RF. 39 yy)ANT VI Intercostal Space LONGITUDINAL SCAN LAT VI Intercostal SpaceMapping PTX ExtensionSoldati G et al. CHEST 2008.“80% agreement on the retroparietal extension of the PTX between CT lu
7、ng scan and lung US”(mean difference of 1.9 cm, range 0-4.5)Ultrasound - Aided PTX DrainageANT IV Intercostal Space LONGITUDINAL SCANPneumothorax in Thoracic Trauma (BS. 71 yy)Anterior Chest Tube PlacementWhat evidences 57:288-95.Lichtenstein D, Meziere G, Biderman P, et al. The “lung point“: an ult
8、rasound sign specific to pneumothorax. Intensive Care Med 2000; 26:1434-40.Lichtenstein DA, Lascols N, Prin S, et al. The “lung pulse“: an early ultrasound sign of complete atelectasis. Intensive Care Med 2003; 29:2187-92.Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in
9、the critically ill. Lung sliding. Chest 1995; 108:1345-8.Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008; 6:16.Gillman LM, Alkadi A, Kirkpatrick AW. The “pseudo-lu
10、ng point“ sign: all focal respiratory coupled alternating pleural patterns are not diagnostic of a pneumothorax. J Trauma 2009; 67:672-3.Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134:117-25.Ball CG, Kirkpat
11、rick AW, Laupland KB, et al. Factors related to the failure of radiographic recognition of occult posttraumatic pneumothoraces. Am J Surg 2005; 189:541-6; discussion 546.Hamilton DR, Sargsyan AE, Kirkpatrick AW, et al. Sonographic detection of pneumothorax and hemothorax in microgravity. Aviat Space
12、 Environ Med 2004; 75:272-7.Lichtenstein DA. Ultrasound in the management of thoracic disease. Crit Care Med 2007; 35:S250-61.Lichtenstein DA, Meziere G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005; 33:1231-8.Sargsyan AE, Hamilton DR, Nicolaou S, et al. Ultrasou
13、nd evaluation of the magnitude of pneumothorax: a new concept. Am Surg 2001; 67:232-5; discussion 235-6.Lichtenstein DA, Pneumothorax and introduction to ultrasound signs in the lung, in General ultrasound in the critically ill, D.A. Lichtenstein, Editor. 2002, Springer: Berlin. p. 105-115.Blaivas M
14、, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005; 12:844-9.Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37:224-32.Cunningham J, Kirkpatrick AW, Nicolaou S,
15、 et al. Enhanced recognition of “lung sliding“ with power color Doppler imaging in the diagnosis of pneumothorax. J Trauma 2002; 52:769-71.Dulchavsky SA, Schwarz KL, Kirkpatrick AW, et al. Prospective evaluation of thoracic ultrasound in the detection of pneumothorax. J Trauma 2001; 50:201-5.Lichten
16、stein D, Meziere G, Biderman P, et al. The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med 1999; 25:383-8.Rowan KR, Kirkpatrick AW, Liu D, et al. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT-initial experience. Radio
17、logy 2002; 225:210-4.Brook OR, Beck-Razi N, Abadi S, et al. Sonographic detection of pneumothorax by radiology residents as part of extended focused assessment with sonography for trauma. J Ultrasound Med 2009; 28:749-55.Noble VE, Lamhaut L, Capp R, et al. Evaluation of a thoracic ultrasound trainin
18、g module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. BMC Med Educ 2009; 9:3.Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008; 133:204-11.Ball CG, Ki
19、rkpatrick AW, Feliciano DV. The occult pneumothorax: what have we learned? Can J Surg 2009; 52:E173-9.Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation 2010; 81:1527-33.Volp
20、icelli G. Usefulness of emergency ultrasound in nontraumatic cardiac arrest. Am J Emerg Med 2011; 29:216-23.Ouellet JF, Trottier V, Kmet L, et al. The OPTICC trial: a multi-institutional study of occult pneumothoraces in critical care. Am J Surg 2009; 197:581-6.Chung MJ, Goo JM, Im JG, et al. Value
21、of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol 2005; 15:930-5.Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post-interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol 2005; 53:463-70.Sartori S, Tombesi P, Tre
22、visani L, et al. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol 2007; 188:37-41.Soldati G, Testa A, Pignataro G, et al. The ultrasonographic deep sulcus sign in traumatic p
23、neumothorax. Ultrasound Med Biol 2006; 32:1157-63.Zhang M, Liu ZH, Yang JX, et al. Rapid detection of pneumothorax by ultrasonography in patients with multiple trauma. Crit Care 2006; 10:R112.Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of alveolar-inters
24、titial syndrome. Am J Respir Crit Care Med 1997; 156:1640-6.Ball CG, Hameed SM, Evans D, et al. Occult pneumothorax in the mechanically ventilated trauma patient. Can J Surg 2003; 46:373-9.Agricola E, Arbelot C, Blaivas M, et al. Ultrasound performs better than radiographs. Thorax 2011.Baumann MH, S
25、trange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphiconsensus statement. Chest 2001; 119:590-602.De Leyn P, Lismonde M, Ninane V, et al. Guidelines Belgian Society of Pneumology. Guidelines on the management of spontaneous pneumothorax.
26、Acta Chir Belg 2005; 105:265-7.Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58 Suppl 2:ii39-52.Engdahl O, Toft T, Boe J. Chest radiograph-a poor method for determining the size of a pneumothorax. Chest 1993; 103:26-9.B-D1-S1 (Strong recomme
27、ndation - very good consensus)The sonographic signs of pneumothorax include: Presence of lung point(s) Absence of lung sliding Absence of B-lines Absence of lung pulse.ILC on Lung US 2011 StatementsLung PointNo Sliding, No Pulse,No B LinesB-D1-S2 (Strong recommendation - very good consensus)In the s
28、upine patient, the sonographic technique consists of exploration of the least gravitationally dependent areas progressing more lateral.Adjunct techniques such as M-Mode and color Doppler may be used.ILC on Lung US 2011 StatementsAIRWATERB-D1-S3 (Weak recommendation - some consensus)Ultrasound scanni
29、ng for pneumothorax may be a basic ultrasound technique with a steep learning curve.ILC on Lung US 2011 StatementsB-D1-S4 (Strong recommendation - very good consensus)Lung ultrasound should be used in clinical settings when a pneumothorax is in the differential diagnosis.ILC on Lung US 2011 Statemen
30、ts Literature has shown with evidence that lung ultrasound is highly accurate in the diagnosis of PTX at bedside Significant differences of diagnostic accuracy between conventional chest X-ray (CXR) and other imaging techniques, like computerized tomography and ultrasound, led the community to coin
31、the term “radio-occult” PTXILC on Lung US 2011 StatementsSettings where lung ultrasound not only is recommended, but also should be considered mandatory:Cardiac arrest/unstable patientsRadio-occult PTXRemote and underserved areasILC on Lung US 2011 StatementsB-D1-S5 (Strong recommendation - very goo
32、d consensus)Lung ultrasound more accurately rules in the diagnosis of pneumothorax than supine anterior chest X-ray.ILC on Lung US 2011 Statements Over the last decade, at least 9 comparative trials have been conducted, with each noting a higher sensitivity for ultrasound in the detection of PTX Des
33、pite wide ranges of sensitivities (from 49% to 100%) depending on the clinical setting, in each of these comparative studies the sensitivity of ultrasound was significantly higher than CXRILC on Lung US 2011 StatementsILC on Lung US 2011 StatementsB-D1-S6 (Strong recommendation - good consensus)Lung
34、 ultrasound more accurately rules out the diagnosis of pneumothorax than supine anterior chest X-ray.a bd om enlungNormal LungCollapsed lungPNEUMOTHORAXa bd om en The statement reflects the panelists understanding that the signs of normality are more accurate using ultrasound rather than with the su
35、pine anterior CXR In this sense observing the ultrasound signs of “normality” (presence of lung sliding and presence of B-lines) are much more accurate (for ruling out a PTX) than a normal radiographILC on Lung US 2011 StatementsAuthors Patients Standard Sens Spec PP NPBlaivas 05 176 blunt trauma pa
36、tients CT, chest tube 98 99 98 99Rowan 02 27 ED trauma getting CT CT 100 94 92 100Dulchavsky 01 382 trauma patients CXR 94 100 95 99.4Lichtenstein 99 115 ICU patients CXR, CT 100 96.5 89 100Lichtenstein 95 111 hemithoraces in ICU CXR, CT 95.3 91.1 87 100ILC on Lung US 2011 StatementsB-D1-S7 (Strong
37、recommendation - good consensus) Lung ultrasound when compared to supine chest X-ray may be a better diagnostic strategy as an initial diagnostic study in critically ill patients with suspected pneumothorax, and may lead to better patient outcome.ILC on Lung US 2011 Statements While there are no con
38、trolled outcome studies, it was the opinion of the panel that the efficiencies in diagnosis of potentially life-threatening conditions, coupled with a lack of physical side effects, would likely lead to better patient care As with any ultrasound technique, proper training and experience is necessary to avoid errors in this operator-dependant examinationILC on Lung US 2011 Statements
