More lung ultrasound tips and examples from Drs. Jim Tsung and Brittany Pardue Jones!
Bacterial pneumonia will manifest as lung consolidation with air bronchograms. The A-line pattern of normal lung will begin to be replaced by B-lines in the area of affected lung:
Here we’ve highlighted the consolidation from the above video as well:
In contrast, subpleural consolidations and confluent B-lines are more suggestive of viral pneumonia.
So what do these look like?
Subpleural consolidation:
and another example:
Confluent B-Lines:
occur when multiple B-lines coalesce. In contrast, the next example demonstrates multiple discrete B-lines.
Multiple B-Lines:
And now for something completely different
Z-Lines: Comet tails that arise from the pleural line but DO NOT make it to the bottom of the ultrasound screen. These are not B-lines. These artifacts have not been associated with any pathology, and they do not obliterate A-lines.
For more details on the sonographic appearance of viral lung pathology, check out this article by Jim Tsung.
Thoracic sonography is one of the most rapidly growing areas of emergency and critical care ultrasound. One very important emerging indication is to assess for lung consolidation. The characteristic appearance of consolidated lung is very sensitive and specific for pneumonia, but novices should heed some important pitfalls in making the diagnosis.
Special thanks to Jim Tsung, MD, MPH and Brittany Jones, MD for their tips, videos, and ongoing research in this important field! For further reading on this topic, please see this article.
Pitfall #1 – confusing thymus for a consolidation
Normal thymus in sagittal view:
Thymus (top half of screen) and heart (bottom right). Don’t confuse thymus for lung consolidation. Note there are no air bronchograms, but thymus has a faint speckled appearance.
Normal thymus in transverse view:
Thymus (top half of screen) and heart (bottom right). Don’t confuse thymus for lung consolidation. Note there are no air bronchograms, but thymus has a faint speckled appearance
Pneumonia adjacent to Thymus in transverse view:
Lung consolidation with air bronchograms (top left) adjacent to normal thymus (speckled appearance on top right) with heart (bottom right)
Pitfall #2 – mistaking spleen for consolidation.
This is an important pitfall for everyone to know about. The same issue applies to the liver & stomach. The sensitivity of lung US for pneumonia rises >90% if this mistake is avoided.
Left lower chest- sagittal view:
Be careful scanning the left lower chest (left anterior and left axillary line) – air in stomach and spleen may look like pneumonia if you don’t realize that you have scanned inferior to the diaphragm and past the end of the pleural line. Most common error by novices.
Left lower chest- transverse view:
Be careful scanning the left lower chest (left anterior and left axillary line) – air in stomach and spleen may look like pneumonia if you don’t realize that you have scanned inferior to the diaphragm and past the end of the pleural line.
Pitfall #3- missing pleural effusion
Here are a few examples to refresh your memory.
Left pleural effusion:
Identify:
Pleural effusion (anechoic wedge just beneath ribs and pleura)
Lung
Diaphragm
Spleen
Air in stomach
Do not confuse spleen and air in stomach for pneumonia.
The Mount Sinai Department of Emergency Medicine hosted its annual ultrasound CME conference held on March 22 at the Stern Auditorium.
Faculty, fellows and PAs from a number of institutions took part in our eighth annual conference.
The course was directed by Bret Nelson, MD and topics included ultrasound physics (Leila PoSaw, MD, MPH) and assessment of airway and breathing (Jim Tsung, MD, MPH), circulation (Daniel Singer, MD), disability/trauma (Phil Andrus, MD) and procedure guidance (Danny Duque, MD).
Great lectures by Sinai’s Emergency Ultrasound faculty were followed by an intensive hands-on scanning session.
Congratulations to Sinai’s own Dr. Jim Tsung, who recently coauthored a major evidence-based consensus guideline on point-of-care lung ultrasound. The manuscript is the result of a multi-national effort by pioneering clinician-sonographers, and was just published in the journal Intensive Care Medicine:
Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T; International Liaison Committee on Lung Ultrasound (ILC-LUS) for the International Consensus Conference on Lung Ultrasound (ICC-LUS).
Intensive Care Med. 2012 Mar 6. [Epub ahead of print]
Sinai’s own Dr. Lana Friedman, Pediatric Emergency Medicine Fellow, was just named one of three recipients of the prestigious SPR Fellow Clinical Research Award. Her abstract entitled, “Accuracy of Point-of-Care Ultrasound (PoCUS) by Novice Pediatric Emergency Sonologists in the Diagnosis of Skull Fractures,” was selected from a very competitive pool of submissions. She will present the abstract at the PAS meeting in Denver in April.
Congratulations to Dr. Friedman and her research advisor, Dr. Jim Tsung!
32 year old female with no past medical history presents with cough for two weeks, no fever, no sputum. Multiple sick contacts with same symptoms at work. She acutely presents with left rib pain for several days. She reports no trauma, and noted the sharp, positional pain during a fit of coughing. Her vital signs are all within normal limits. She is breathing comfortably, with good air movement, no wheezes, rales, or ronchi. She displays point tenderness over her anterior left 8th rib at the anterior axillary line. A chest x-ray was ordered; images are below.
Sonopalpation of the tender area revealed the following:
The first World Congress on Ultrasound in Medical Education has come to a close. The event was a great success, with excellent plenary sessions in the morning, hands-on teaching in the afternoon and southern hospitality in the evening. It was nice to see so many familiar faces, and although we couldn’t capture everyone, we had to record a few for posterity.
Check out the slideshow or click through from the gallery below to download any of these from my flickr account.
More lung ultrasound tips and examples from Drs. Jim Tsung and Brittany Pardue Jones!
