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260 oracic ultrasound
expiratory diaphragmatic excursion in the first second may be considered analogues of vital
capacity and forced expiratory volume in the first second (FEV1). According to this, the
ratio between forced expiratory diaphragmatic excursion in the first second and maximum
expiratory diaphragmatic excursion, represents an M-Mode index of obstruction (MIO). In
a recent study, a MIO < 77 was identified as a possible cutoff for suspecting an obstructive
spirometric pattern, with a 95.5% positive predictive value59 (Fig. 17).
Figure 17 – First second diaphragm motion in forced expiration analyzed using M Mode ultrasound in an
anterior subcostal approach. The ratio between forced expiratory diaphragmatic excursion in the first second
and maximum expiratory diaphragmatic excursion, represents an M Mode index of obstruction (MIO).
Finally, diaphragm thickening between total lung capacity and residual volume is inversely
related to air trapping indices60.
Sniff test
e sniff test is a fluoroscopic procedure used for years for the functional evaluation of the
diaphragm. is examination is simple to perform and the results are easy to interpret. In
our opinion ultrasound allows to perform a sonographic sniff test much more easily and
without radiant exposure61.
On quiet and deep inspiration, both hemidiaphragms move downward as the anterior chest
wall moves upward. is movement is evaluated by a convex transducer placed under the costal
arch and directed superiorly, taking advantage of the acoustic windows of the liver and spleen.
is maneuver may not be possible to the left for the interposition of the colon. In this case
the location of the probe in the intercostal and semicoronal position can permit an evaluation. e M-mode function allows to obtain a trace of the movement depending on time
1,62
For sniffing, the patient can be explored upright (if possible) and in supine position. He or
she first takes in a deep breath, then breathes all the way out, and finally, with the mouth
closed, breathes in as fast and deeply as possible. On sniffing, both hemidiaphragms move
rapidly downward and M-Mode trace registers a quick positive deflection.
Normally, during a voluntary sniff test the diaphragm shows an excursion of 2.5-3 cm (2.9
± 0.6 cm in men and 2.6 ± 0.5 cm in women for the right hemidiaphragm, 3.1 ± 0.6 cm in
men and 2.7 ± 0.5 in women for the left hemidiaphragm) (Fig. 18).
In diaphragmatic paralysis orthograde excursion is absent and there may be paradoxical motion even on quiet and deep inspiration, but on sniffing there is usually paradoxical motion.
.
Pathology of the diaphragm 261
Figure 18 – Sniff test. M-Mode.
In diaphragmatic weakness excursion is reduced and/or delayed on quiet and deep inspiration,
while on sniffing motion it is usually paradoxical. erefore a pathological sniff test showing paradoxical diaphragmatic movement indicates diaphragmatic dysfunction, but when
a hemidiaphragm is paralyzed, there is no orthograde motion on quiet or deep inspiration.
In eventration, excursion of the affected segment is reduced on quiet and deep inspiration
and the sniff test may be abnormal. However, the posterior aspect of the hemidiaphragm
shows normal motion.
If the patient becomes dyspneic or hypoxemic in the supine position, an ultrasound evaluation of the diaphragmatic dynamics with the patient lying down is useful. Normally, in the
supine position, the diaphragm is higher and its excursion is reduced because the muscle works
against abdominal pressure. A large decrement in diaphragm excursion and lung volume with
the patient supine may be therefore diagnostic.
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9
oracic trauma
oracic trauma occurs in 60% of poly-injured patients and represents an
important cause of mortality and morbidity. Both closed and penetrating
traumas commonly produce intrathoracic injuries, which contribute to
20-25% of the overall mortality of the injuried patient.
Table 1 reports the different organs and pathologies involved in thoracic
1
trauma
Road accidents are the leading cause of closed thoracic injuries (70-80%)
e overall mortality directly tied to these events is around 8/100,000.
Open thoracic traumas are mainly linked to the use of weapons and are more characteristic
of particular urban realities or war contexts3. Most of these traumas concern the chest wall
and the pleural cavity. A fair amount of pulmonary contusions (26%) is often underestimated
or unrecognized.
e general diagnostic and therapeutic approach to the thoracic injuries begins with the
ABCD (Airways, Breath, Circulation, Disability) of the resuscitation, according to the criteria
proposed in the Advanced Trauma Life Support Course (ATLS)4. Instrumental investigations
must observe an appropriate timing considering needs, priorities and integration of methods5.
ATLS criteria point out an approach that is both diagnostic and therapeutic to life-threatening
conditions such as asphyxia and circulatory arrest.
e clinician who evaluates an injured patient first considers the nature of the event, its
dynamics (as a function of involved mechanical energy) and the clinical objectivity. In the
Table 1 – Injuries associated with thoracic trauma
Chest wall 45%
Lung 26%
Hemothorax 25%
Pneumothorax 20%
Heart 09%
Diaphragm 07%
Aorta and great vessels 04%
Esophagus 0.5%
Miscellany 21%
. e vast majority of trauma associates different injuries.
chest, much more than in other location,
priority is given to the patency of airways
and to ventilation (A and B).
e first diagnosis should aim to remove
critical situations for vital functions. Any
diagnostic act must be immediate and
directed to a therapeutic act, which is the
resolution or at least the control of a compromised vital function.
e operating algorithm must therefore
be simple and functional. To each “yes”
from the diagnostic input (ABCD related),
a damage control action must match
2
.
265
266 oracic ultrasound
(example: B, massive pneumothorax = immediate drainage). e negation of a diagnostic
hypothesis induces a fast operative shift (example from Breath to Circulation). However,
periodic revaluations of the previous steps are essential in this approach.
It is obvious that this kind of logic can hardly lean on complex instrumental investigations
requiring time and interrupting the contact with patients. In the Emergency Room, during
ABCD, the functional impairment is tested on a clinical basis, using traditional physical
examination or little more.
erefore, inspection, auscultation and palpation have a primary role in the assessment of
an injured subject during the primary survey. e diagnostic accuracy of these actions is
high with regard to A and B, but not for minor damage. However, it is low with regard to
incipient hemodynamic instability or impeding shock. is latter aspect is true for the chest
and for the abdomen.
e clinical accuracy of non-massive hemoperitoneum does not exceed 40%. A low sensitivity
of the clinical examination for hemothorax is characteristic6.
With a closed chest trauma, hemodynamic instability indicates hypovolemia (hemothorax,
intrathoracic vessels injuries, external bleeding) or a mechanical reason (massive pneumothorax, haemopericardium or blunt cardiac trauma). Of course, in the injured patient an agonal
hemodynamic instability preceding cardiac arrest is seen in all the situations that cause acute
respiratory failure and severe hypoxia (airway obstruction rupture, bilateral pneumothorax,
massive hemothoraces etc.). e delayed recognition of these situations considerably worsens
the patient’s prognosis.
In the chest, airway damage is associated with hemodynamic impairment and, conversely,
bleeding in the chest may alter the dynamics of breath. ese pathophysiological bidirectional links must be borne in mind for many practical reasons, but also because they hugely
complicate the clinical objectivity.
In chest trauma, an altered respiratory mechanics is an inspective finding. More specifically,
the problem may be a parietal modification (flail chest), the occupation of the pleural cavity
and/or the pulmonary structural integrity and compliance, as in contusions and in ARDS.
After controlling airways and breathing, the recognition of bleeding is a priority (Circulation).
Inside the chest cage, hemorrhage cannot only induce shocks, as in other body areas as well,
but it is a cofactor of respiratory and cardiac failure.
Finally, chest trauma can affect myocardial function through a direct damage of the heart
muscle, valves and great vessels.
About 85% of patients with closed chest trauma can be treated conservatively: for these subjects clinical observation, thoracostomy, pain control, respiratory support and physiotherapy
are sufficient. e majority of invasive interventions in chest trauma includes the treatment
of pneumothorax or hemothorax7 and represents a complex problem. e identification and
early treatment of pleural injuries avoids important complications as the retained hemothorax
and empyema, while the control of lung contusions is a precautionary tool for ARDS and
respiratory failure. Only 10-15% of all patients with closed chest trauma requires thoracotomy
to treat uncontrollable parenchymal airway and vascular lesions.
e approach to open chest trauma is more stringent. Patients with hemodynamic instability
usually require immediate surgery, and echocardiography is probably the only necessary diagnostic test. In these cases, the most important question is what type of thoracotomy incision
oracic trauma 267
should be used. Patients with hemodynamic stability benefit of the use of CT, which is very
accurate in defining existing lesions8.
➣ X-ray diagnostics in chest trauma
Radiographic tests9, conventional radiography and computed tomography (CT), have an
eminently functional and practical purpose for the evaluation of chest trauma. Each diagnostic test, however performed, is aimed at the type of trauma to which it is addressed.
In this perspective, clinically obvious and serious lesions (e.g. pneumothorax with tracheal
deviation, hemodynamic instability and respiratory effort) do not have to wait for radiographic scans, but should be treated. For example, CT may be appropriate for diagnosing
a hemopericardium, but, in front of a hypotensive patient with jugular turgor, there is no
time for a complex diagnostics. e first option is immediate treatment, possibly preceded
by a quick bedside investigation.
ATLS rules give indication to perform a chest X-ray early in the secondary survey10. It is accepted that the radiography is performed in suboptimal technical conditions, resulting less
sensitive and specific than a standard two-view-X-ray with the patient in the upright position.
erefore, chest X-ray is widely used in the emergency room for assessing parietal or bone
damages and pleural or pulmonary lesions (hemothorax and pneumothorax). A “screening”
examination is used for the vast majority of traumatized patients and it remains an excellent tool for early detection of life threatening thoracic injuries. In the emergency room, a
radiologic “quick read” helps out in patient triage. Moreover, chest X-ray is used to detect the
correct positioning of the devices (endotracheal tube, central venous access), and to identify
subtle signs of mediastinal or vascular injuries.
However, many thoracic injuries are difficult to recognize in chest radiography and the use
of CT has been steadily increasing in recent years.
Not technically perfect chest X-ray can miss 50% or more of hemothoraces and 50% of
pneumothorax and it has very low sensitivity for lung and mediastinal lesions. Anyway, the
appreciation for chest-X-ray lies in its historical weight, in its overview ability and, last but
not least, in the absence of more sensitive but equally practical alternative methods. Currently
CT with intravenous contrast is the diagnostic gold standard for thoracic injuries.
ere is no doubt that if every subject with chest injury underwent CT, false negativities
would be drastically reduced, at the cost of overdiagnosis in a number of cases and with an
economic and biologic burden.
CT is hugely sensitive for pneumothorax, pleural effusions and parenchymal lung damage,
and it is sufficiently accurate for vascular lesions. In patients with chest trauma and normal
chest X-ray, CT scan showed lesions in 39% of cases, but influenced treatment decisions only
in 5% of cases. However, literature reports a more important role of this exam in influencing
clinical decisions (30%). is suggests that CT has a maybe too high sensitivity11 for situations
with low clinical relevance and that it would be reserved for patients with high probability
of injury (elders, with associated injuries of the abdomen and pelvis)12. Finally, accurate
diagnosis of aortic and mediastinal lesions can be made only with the use of angiographic
methods (angio-CT)13. Unfortunately, CT is not commonly performed at the bedside in the
Emergency Room. In addition, every reasonable protocol currently requires that any subject
undergoing CT is in hemodynamically stable conditions.
268 oracic ultrasound
e current trend is to refer to CT any patient with significant chest trauma. According to
this strategy, hemodynamically stable subjects with minor trauma are studied. However,
difficulties would arise on more severe, hemodynamically unstable patients for the temporal
gap due to stabilization before performing CT scans.
In many institutions hemodynamically stable blunt trauma patients routinely receive a supine chest X-ray in the trauma room and many of these patients also receive CT imaging of
the chest, cervical spine, abdomen and pelvis. According to the previous considerations, a
practical approach based both on chest X-ray and chest CT is redundant, time consuming
and expensive. eoretically, omitting routine chest X-ray would eliminate an unnecessary
test that, in this population, does not add useful information, and incurs significant costs as
well as unnecessary radiation exposure.
Chest X-ray, with its documented low diagnostic accuracy is located between clinical examination and CT. is diagnostic gap might be filled by an instrumental survey capable of
improving the diagnostic power of chest X-ray. We think that ultrasound is a good candidate.
Recently, a decision instrument (NEXUS chest) for selective chest imaging in blunt trauma
has been proposed. Its role is the identification of blunt trauma patients with very low risk of
thoracic injuries on chest imaging. Seven clinical criteria (age >60 years, rapid deceleration
mechanism (fall >20 ft, MVC >40 mph), chest pain, intoxication, abnormal mental status,
distracting painful injury, tenderness to chest wall palpation) are risk factors. Chest imaging
is unnecessary in patients without risk criteria (sensitivity 98.8%, negative predictive value
98.5%). In our opinion, chest ultrasound may be the elective investigation in low-risk subjects
that did not undergo traditional chest imaging.
➣ Applications of ultrasound in thoracic traumatology
Until recently, the indications for chest ultrasonography in trauma patients were inusual and
only the FAST (Focused Assessment with Sonography for Trauma)14 used the left ascending subcostal and coronal projections of pleural sacs for the evaluation of pleuropericardial
effusions.
A more anatomic use of chest ultrasound for lung injury appeared as an excess, because it was
believed that the lung was not an optimal target for ultrasound and that it could be studied
with a simple X-ray (Fig. 1).
However, the growing practice of placing the ultrasound probe in the intercostal spaces and
experiences of pleural ultrasound have shown that some diagnosis (pneumo- and hemothorax,
hemopericardium) could be possible with echography, obviating the need to carry radiology
equipment and staff in emergency areas. On the other hand, the increased use of CT created
a diagnostic gold standard in this setting, showing the limitations of chest radiography.
is new vision has progressively increased with the increasing skills that emergency and ICU
physicians acquired in this field.
e consequence was the birth of “focused” and “point of care” ultrasound, no longer as a
radiological tool, but relevant to various professionals who needed to make diagnosis15. In
few years, from 2005 to 2010, a cultural growth got ultrasound off the ground, in emergency
and intensive care. Ultrasound was just a particular examination helping eyes, hands and ears
of physicians.
According to this perspective, ultrasound must be applied to each chest trauma, even if it had,
for the critical condition of the injured patient, the same diagnostic accuracy of chest X-ray.
oracic trauma 269
Figure 1 – Chest X-ray performed in the emergency department in a polyinjured supine patient. The
quality is not good. It allows to effectively monitor the positioning of the devices (note the thoracostomic
bilateral tubes and the endotracheal tube into the right bronchus), but it does not effectively allow the
determination of the effects of trauma on rib cage, pleura, lung and mediastinum.
e preceding pages on non-traumatic pathology showed the diagnostic potential of ultrasound to assess many chest pathologies, indicating stereotyped but typical expressions of
echographic imaging.
e implementation of ultrasound in chest trauma patients is relatively easy by virtue of
the common general principles that govern the production of pleuropulmonary images in
ultrasound.
For these reasons, we believe that in injured subjects echography, according to the concept
of focused examination (such as FAST) can and should extend far above the diaphragm with
synthetic directions: study of pleural dynamics and content, evaluation of the acoustic lung
properties and assessment of the heart and pericardium16.
A coordinated approach to the injured patient, generally referred as extended FAST or E-FAST,
has already had its initial and convincing validation in the literature, at least regarding its use
in the Emergency Room.
In the following pages, the use of chest ultrasound in trauma patients will be described, considering its benefits and limitations, the possibility to select secondary surveys, its applications
for studying lung parenchyma and the patient monitoring.
➣ Methodology
To perform ultrasound in thoracic trauma, 3.5-5 MHz convex and sector probes are used,
depending on the explored organs (pleural fields, lung, heart), and the resolution or the depth
required. According to the principles of chest ultrasound, the linear probe (7-10 MHz) is
used when the pleural details have to be exalted, as it can occur in the difficult diagnosis of
pneumothorax.
e thorax is studied performing anterior, lateral and, if possible, posterior scans, placing
the probe in the intercostal spaces or longitudinally on the skin. e cardiac area is explored
through subdiaphragmatic, parasternal, apical and suprasternal scans.
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