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100 oracic ultrasound
ATTENUATED PLEURAL LINE
LUNG CONSOLIDATION
Figure 39 – Inflammatory lung consolidation; net attenuation of the pleural line above pneumonia.
Figure 40 – In atelectasis the collapsed lung (to the left, thin arrow) acquires density and becomes
explorable. With the use of color Doppler, ultrasound can show its vascularization (to the right). The thick
arrow on the right indicates residual air, the thin arrow on the right a small pleural effusion.
Almost always, the inflammatory or contusive alveolar syndrome is observed as a core lesion
within interstitial syndrome, white lung and dense or confluent B Lines.
Bronchograms
44,45
Bonchograms appear only in consolidations. ey are divided into air bronchograms and
fluid bronchograms. Air bronchograms are echogenic and reverberant foci or striae (similar
to biliary hepatic branches in case of aerobilia) (Fig. 41). Fluid bronchograms are tubular
structures with hypo-or anechoic content and visible walls. is characteristic makes it possible
to differentiate fluid bronchograms from the vessels, that lack of evident walls (Figs. 42-43).
Semiotics of chest ultrasound 101
AIR BRONCHOGRAMS
Figure 41 – Tree-shaped air bronchograms, in a case of inflammatory lung consolidation.
AIR BRONCHOGRAMS
Fluid bronchograms
Figure 42 – Fluid bronchograms in a case of neoplastic postobstructive consolidation.
A fluid bronchogram should therefore lead to the search for a bronchial obstruction. e
detection of fluid bronchograms is rare in pneumonia in adults. eir detection should suggest the possibility of neoplastic bronchial obstruction. Conversely, the detection of fluid
bronchograms in children is frequent, because of bronchial obstruction by mucus plugs.
Larger the consolidation, deeper can be the exploration with convex probe. Lobar pneumonia
may allow the exploration of lobar and segmental bronchi (if still full of air). Small focuses
of bronchopneumonia allow to display residual air as punctiform images dispersed into the
tissue and representing bronchioles (air bronchiologram).
e visualization of moving air in the bronchi defines the so-called “dynamic air bronchogram”. Its evidence excludes that lung consolidation comes from atelectasis due to bronchial
obstruction (Clips 19-20).
102 oracic ultrasound
Fluid bronchograms
Figure 43 – Fluid bronchograms in a case of postobstructive consolidation (pediatric age). Hyperechoic
walls of the fluid bronchograms are evident.
Clips 19, 20 – Dynamic air bronchogram in pneumonia: evidence of air
in the bronchi moving synchronously with the respiratory activity. Its presence
obviously excludes bronchial obstruction.
Consolidation as acoustic window
Like pleural effusion, lung consolidation creates an acoustic window that allows the visualization of lung tissue. Similarly, the image of the heart, the pulmonary artery, the thoracic
aorta or the presence of hilar masses can be enhanced by the presence of consolidations or
atelectasis (Fig. 44) (Clip 21).
ATELECTASIC LUNG
RIGHT BRANCH OF THE PULMONARY ARTERY
Figure 44 – Complete atelectasis of the right lung. Visualization of the right branch of the pulmonary
artery.
Semiotics of chest ultrasound 103
Clip 21 –
is completely hepatized because of compressive atelectasis. The pleural effusion
and lung hepatization allow a good visualization of the descending thoracic aorta.
Massive left hemothorax. The blood is strongly corpusculated. The lung
Cardiac window
e parasternal and apical cardiac windows normally exist for the contact of the heart-pericardium with the chest wall. During the respiratory cycle, often a lung portion is interposed
between heart and chest cage. With its artifacts, the lung can cover partially or completely
the image of the heart. is sliding is like a curtain, moving with respiration. Here the lung
pulse is maximum (physiological lung pulse).
In case of minimal left pneumothorax, in the supine position, the air collects in paracardiac
regions (deep sulcus sign). On the left, it can cover the image of the heart and eliminates pleural
sliding and pulse (Fig. 45). Air in the pericardium (pneumopericardium) is a very rare situation. It covers the heart but the pleural sliding over the pericardium is preserved and any lung
point is absent. Subcostal cardiac scans are useful to make a correct diagnosis (Clips 22-24).
Clip 22 – Hydropneumopericardium. The parasternal short-axis cardiac
scanning is prevented by the appearance of an air artifact, that moves
synchronously with the heart activity (not with the respiratory activity). This
image can evoke the presence of a lung point.
Clips 23, 24 – The subcostal scans allow to highlight the presence of a
strongly corpusculated pericardial fluid and of air in contact with the parietal
pericardium that moves synchronously with the cardiac systole.
Heart
Figure 45 – Transverse scan at the heart apex, that shows the normal lung curtain over the heart during
inhalation.
INSPIRATION
104 oracic ultrasound
➣ Interpretation of lung ultrasound
Our considerations can be summarized in a few points. In lung echography, ultrasound detects an imbalance of the normal relationships between air and tissue in the subpleural layer.
is physical change produces a sort of competition between horizontal, vertical artifacts
and white lung. e competition is dynamic, and is only valid when the lung is sufficiently
aerated. e final, critical event in lung density is the consolidation. e anatomic appearance of a consolidation decrees the end of artifacts. According to this view, the doctor has
the opportunity to monitor the disease progression to identify a clinical trend. All that will
appear in the following pages is the variable expression of this stereotype behavior. It is a
further confirmation that, as X-ray and CT, lung ultrasound is just a measurement of density
taking shape.
Figure 46 shows this typical aspect of lung ultrasound.
PNX Normal
air
tissue
Interstitial S.
White lung
Consolidation
Atelactasis
D: Pulmonary cortical density (g/ml)
Figure 46 – Correlation between the degree of pulmonary ventilation and ultrasound images.
Table 2 summarizes the findings of pleuropulmonary semiotics described.
Table 2 – Ultrasound findings of pleuropulmonary semiotics
Ultrasound finding Definition
Lung sliding
Lung point
Lung pulse
A Lines
The pleural respiratory movement indicates a pulmonary region
in contact with the chest wall
Point at which a partially collapsed lung touches the chest
wall. In the image the sliding is present only in one part of the
pleural line
Minimum sliding synchronous with the cardiac systole,
especially in paracardiac lungs. It excludes pneumothorax.
In the absence of respiratory sliding, it indicates decreased
lung compliance, and atelectasis when associated with lung
consolidation
Horizontal reverberations reproducing the pleural line. Normal
finding
Semiotics of chest ultrasound 105
Table 2 – Ultrasound findings of pleuropulmonary semiotics
Ultrasound finding Definition
Z Lines
B Lines
E Lines
Interstitial syndrome
Alveolar syndrome
Bronchograms
Dynamic air bronchogram Its evidence excludes obstructive atelectasis
Static bronchogram Motionless bronchogram
Echogenic vertical enhancements, band-shaped, fixed on the
lung fields, which do not cancel the A Lines. Normal findings
Vertical (ring-down) reverberations, extended to the bottom
of the screen, which cover the A Lines. Interstitial syndrome
(edema, interstitial diseases)
Vertical artifacts, starting from the subcutaneous tissue and
beamed on the lung fields. Subcutaneous emphysema
Change in pulmonary pattern, from horizontal (A Lines) to
vertical artifacts (B lines), sectoral or widespread. Interstitial
disease
Hepatization of a lung field. X-ray alveolar pulmonary
consolidation
Aerated or full of fluid bronchi. They indicate consolidation
or alveolar syndrome. Brochograms contribute to identify the
consolidation as obstructive or not
➤ Recommended readings
Mathis G. Chest sonography. Springer-Verlag, 2008.
Lichtenstein D. Whole body ultrasonography in the critically ill. Springer-Verlag, Berlin-Heidelberg, 2010.
Testa A. Manuale di ecografia clinica in urgenza. Verduci, Roma, 2008.
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5
Pathology of the pleura
Pleural diseases explored with ultrasound include effusions, empyema
and solid lesions. In echography, the dynamic examination of the visceral
pleura is particularly interesting for the diagnosis of pneumothorax. Chest
ultrasound can define uncertain pleural densities, clarify the nature of a
radiological white hemithorax, or guide thoracentesis and pleural biopsy.
Moreover it can differentiate subpulmonary opacity from subphrenic
collections or from elevations of the diaphragm, facilitate the diagnosis of
pleuritic pain, and recognize even small and occult pneumothorax. e use
of pleural ultrasound is extremely important to monitor the echogenicity
of pleural effusions, to evaluate the effectiveness of a pleural drainage and
to follow lung re-expansion after pleural drainages.
➣ Pleural effusions
Hemothorax will be described in the specific chapter about traumatology. Pleural effusions
are the most common manifestation of pleural disease. ey develop whenever a serous
production of fluid is not reabsorbed
Several mechanisms, alone or in combination, are implicated in the effusions: increased
pleural capillary hydrostatic pressure, decreased colloid osmotic pressure, increased capillary
permeability, impaired lymphatic drainage, decreased pressure on the pleural surface and
transdiaphragmatic passage of peritoneal fluid
One of the essential problems regarding pleural effusion is to determine whether it is a transudate or an exudate.
e pleural fluid with low protein content is a transudate. It originates from normal pleura
because of an increased capillary pressure or of a decreased oncotic pressure. It can be a clinical manifestation for heart failure, liver cirrhosis, hypoalbuminemia, nephrotic syndrome,
constrictive pericarditis, atelectasis, pulmonary embolism, renal disease, or myxedema.
e exudate, expression of inflammation or neoplasm, is the result of increased capillary
permeability or decreased lymphatic drainage6.
Light and colleagues7 have well described the criteria for distinguishing a transudate and an
exudate.
e exudate is defined by a ratio of proteins between pleural fluid and plasma greater than
0.5, or a ratio greater than 0.6 relative to LDH. Light’s criteria are considerable for the diagnosis of exudate, but they interpret 25% of true transudates as exudates, especially when
the patient is using diuretics.
1-3
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4,5
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109
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