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380 oracic ultrasound
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Echodynamics 381
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12
Integrated clinical ultrasound in critically ill
not traumatized patients. A practical approach
including lung ultrasound
In critical care medicine the accurate assessment of the patient, and rapid
decision paths, are essential to save lives and to improve diagnostic and
therapeutic capabilities.
e causes of hemodynamic instability or cardiac arrest have to be rapidly
identified and treated.
Often, the diagnosis is difficult and can not be made with the only
physical examination.
Ultrasonography has the characteristics of an ideal diagnostic tool, because
it may be performed at the bedside, repeated without discomfort to the
patient and without exposure to ionizing radiation.
Its clinical use is the peculiarity of the emergency ultrasound and in this
sense it may be considered as an extension of the physical examination.
e integration of data that can be quickly obtained by the echographic
evaluation of heart, lungs, inferior vena cava, and the abdominal venous
system of the lower limbs, are often essential for the diagnosis and treatment of critically ill patients.
1
➣ Echocardiography in emergency
e assessment of the cardiac performance is of crucial importance in the treatment of
hemodynamically unstable patients. In emergency most useful information may be obtained
through subcostal and apical 4 chambers scans.
Global ventricular function may be evaluated qualitatively by visual estimation alone (eye
balling). It is shown that this method is effective when used by medical experts2.
e real time evaluation of the kinetics and the size of the heart chambers operated by an
expert physician provides an immediate diagnosis about the global cardiac function. In the
most critical situations it is sufficient to know whether cardiac function is normal, moderately
or severely depressed (Focused Cardiac Ultrasound).
In critically ill patients a significant dysfunction of the left ventricular function is common
and the echocardiographic assessment should be integrated in their treatment.
e quantitative evaluation of the contractility of the left ventricle (LV) requires good quality pictures since the contour of the endocardium should be well displayed. In emergency
contexts endocardial borders may be difficult to detect for the limitations of transthoracic
383
384 oracic ultrasound
echocardiography (TTE) or for the non optimal quality of the images. e TTE provides
sufficient information on LV function in the majority of critically ill patients (> 80%)3. e
transesophageal echo (TEE) is a good alternative when the TTE is not possible or not sufficiently informative.
e evaluation of the diastolic function through the patterns of ventricular filling is especially
important in patients with acute heart failure with preserved systolic function. In this regard,
the presence of significant LV hypertrophy or biatrial dilatation suggest diastolic dysfunction.
e dysfunction of the right ventricle (RV) is quite common in critically ill patients and is
often underestimated4. is may be secondary to an intrinsic depression of the contractility
of the RV, to acute pulmonary embolism, acute increase in pulmonary resistance (frequent
in the case of ARDS), mechanical ventilation, sepsis or infarction of the right ventricle
5-8
.
e RV dysfunction may, for example, explain the lack of response to the volemic expansion in some patients with sepsis8. Finally, echocardiography is proving an extremely useful
tool for the monitoring of myocardial contractility during the infusion of inotropes and/or
vasoactive amines (Clips 1-8).
Clip 1 – Monitoring of LV contractile response to increasing doses of
dobutamine with subcostal 4 chambers scan in a patient with severe LV
systolic dysfunction.
Clip 2 – Monitoring of LV contractile response to increasing doses of
dobutamine with subcostal 4 chambers scan in a patient with severe LV
systolic dysfunction. Echocardiogram with dobutamine infusion at 5 y/kg/m.
No significant changes in contractility.
Clip 3 – Monitoring of LV contractile response to increasing doses of
dobutamine with subcostal 4 chambers scan in a patient with severe LV
systolic dysfunction. Echocardiogram with dobutamine infusion at 7 y/kg/m.
No significant changes in contractility.
Clip 4 – Monitoring of LV contractile response to increasing doses of
dobutamine with subcostal 4 chambers scan in a patient with severe LV
systolic dysfunction. Echocardiogram with dobutamine infusion at 10 y/
kg/m. Slight improvement in contractility.
Clip 5 – Monitoring of LV contractile response to increasing doses of
dobutamine with subcostal 4 chambers scan in a patient with severe LV
systolic dysfunction. Echocardiogram with dobutamine infusion at 11 y/
kg/m. Significant improvement in contractility.
Integrated clinical ultrasound 385
Clip 6 – Monitoring of LV contractile response to increasing doses of
dobutamine with subcostal 4 chambers scan in a patient with severe LV
systolic dysfunction. Echocardiogram with dobutamine infusion at 11 y/
kg/m. A further improvement in contractility is observed. If the dose of
dobutamine is further increased and there are no further improvements, the
correct dosage for this patient is 12 y/kg/m.
Clip 7 – Monitoring of LV contractile response to increasing doses of
dobutamine with apical 4 chambers scan in a patient with mechanical mitral
prosthesis and severe LV systolic dysfunction. Baseline echocardiogram.
Clip 8 – Monitoring of LV contractile response to increasing doses of
dobutamine with 4 chambers apical scan in a patient with mechanical
mitral prosthesis and severe LV systolic dysfunction. Echocardiogram with
dobutamine infusion at 5 y/kg/m. Significant improvement in contractility.
Echocardiography quickly highlights the presence of pericardial effusion and signs of cardiac
tamponade (Fig. 1).
Pericardial
Eusion
Right Atrium
Collapse
Figure 1 – Apical 4 chambers scan in a patient with hypotension in the emergency room. A pericardial
effusion and the collapse of the right atrium are observed.
Even a rapid qualitative assessment of the size of the cardiac chambers may be of extreme
usefulness in critically ill patients. In the apical 4 chambers scan, the LV is normally larger
than the RV (no more than 5.5 cm, while the RV is only two thirds of the LV). e atria are
the same size (no more than 5 cm).
In a patient in shock, if the right cavities are larger than the left ones, for example, a massive
pulmonary embolism is likely (Fig. 2).
386 oracic ultrasound
RV
RV
LV
RA
RA
LA
Figure 2 – A: apical 4 chambers scan of a normal heart. The right and the left atrium have the same
dimensions. The left ventricle (LV) is about two-thirds larger than the right ventricle (RV). B: apical 4
chambers scan in a patient in shock. The right cavities are dilated, suggesting a possible acute pulmonary
embolism.
e end-systolic obliteration of the LV suggests a severe hypovolemia, and this may anticipate hypotension9. It should also be noted that other clinical situations, such as a reduction
in peripheral resistance, aortic and mitral insufficiency and severe septal defect, can lead to
the end-systolic obliteration of the LV. Normally, LV end diastolic area (4 chambers view) is
33±8 cm2 and LV end systolic area is 11±3 cm2.
Valvular diseases can be diagnosed quickly through the echocardiographic examination.
e severe stenosis or mitral or aortic insufficiency can result in a dramatic reduction in
cardiac output.
Many of the complications of acute myocardial infarction (acute mitral regurgitation secondary
to rupture or ischemic papillary muscle dysfunction, myocardial extended RV, rupture of the
interventricular septum or the free wall of the LV), generally result in a state of cardiogenic
shock quickly diagnosed by echocardiography at the bedside.
➣ Ultrasonographic assessment of the volume status
e echographic evaluation of the diameter and collapsibility index of the inferior vena cava
(IVC) is an accurate method to measure the right atrial pressure and thus the central venous
pressure (CVP)
is method is very reliable in discriminating between right atrial pressure less than or greater
than 10 mmHg12. A dilated inferior vena cava (>20 mm) in the absence of the physiological
reduction of the inspiratory diameter (> 50%) indicates high levels of pressure in the right
atrium.
In patients with hypovolemia, the IVC is generally thin (<1.7 cm) and collapses completely
during inspiration (Fig. 3) (Clip 9). e ventricles appear small with end-systolic obliteration
of the LV and lung ultrasonography shows a “dry” lung for the absence of B.
e echocardiographic assessment of RV function is crucial for the correct interpretation of
the values of CVP or the diameter of the IVC. Patients with RV dysfunction may have high
values of right atrial pressure even in hypo- or normovolemia (Fig. 4).
10,11
.
Integrated clinical ultrasound 387
IVC
Figure 3 – Longitudinal scan of the IVC. A: M-Mode of IVC in a hypovolemic patient: the IVC is thin
and collapses completely during inspiration. B: M-Mode of IVC in a patient with elevated central venous
pressure: the IVC is dilated with minimal changes in diameter during inspiration.
Clip 9 – Longitudinal transabdominal scan of the IVC in a patient with severe
hypovolemia. The IVC is thin and collapses completely during inspiration.
IVC
IVC
RV
RA
Figure 4 – Abdominal ultrasonography shows a dilated inferior vena cava (A) and in apical 4 chambers
scan the right cavities are dilated (B). In this patient with acute pulmonary embolism, the diameter of the
IVC reflects the high right atrial pressure and not a volume overload.
During the volemic expansion, monitoring the diameter and collapsibility of the IVC, the
size of the heart chambers and their contractility and the pulmonary pattern (“dry” or “wet”)
is a non-invasive mode practicable at the bedside and it is more accurate than the only values
of CVP (Fig. 5). Moreover, it is now widely accepted that the values of CVP alone can not
be considered sufficient for the management of intravascular volume13.
388 oracic ultrasound
IVC
RV
LV
RV
IVC
LV
Figure 5 – Longitudinal abdominal scan of the IVC and subcostal 4 chambers scan of the heart.
A: echographic pattern of hypovolemia: the IVC is thin with full inspiratory collapse. LV end-systolic
obliteration. B: after volume expansion, the IVC diameter increases and the LV end-systolic obliteration
disappears.
➣ Lung ultrasound in emergency
e presence of multiple and diffuse B Lines indicates interstitial syndrome (IS). Its most
common sources are represented by pulmonary edema due to different causes, interstitial
pneumonia and pulmonary fibrosis. In the critically ill patient, most often, the presence of
bilateral and diffuse B Lines is expression of increased extravascular lung water
of multiple B lines identifies, therefore, a “wet” lung, while their absence a “dry” lung (Fig. 6).
PLEURAL LINE
A LINES
Figure 6 – A: “dry” lung; regular pleural line and presence of A Lines. B: “wet” lung; multiple B Lines.
PLEURAL LINE
B LINES
14-17
. e presence
Integrated clinical ultrasound 389
In critically ill patients the differential diagnosis between cardiogenic acute pulmonary edema
(CAPE) and ARDS can be very difficult (see Chapter 7).
e pathophysiological difference between ARDS (pulmonary lesions) and CAPE (hydrostatic
edema) results in different sonographic patterns with regard to the distribution of the interstitial
syndrome. In ARDS, the integrity of the alveolar-capillary membrane is compromised and
this causes early, widespread and heterogeneous edema, ranging from areas of ground glass
to pulmonary consolidations. e heterogeneous involvement of the lung in ARDS explains
the presence of “spared areas”. In addition, changes in the pleural line are the rule in patients
with ARDS. e areas of ground glass evident on computed tomography correspond to areas
in which, on echography, coalescing B Lines appear in the lung (white lung). In cardiogenic
acute pulmonary edema (CAPE) the interstitial syndrome (IS) is distributed in a homogeneous way, involving both the front and rear fields.
In CAPE the upper lung may be less affected by the IS, but spared areas can not be observed
on the basis of the pathophysiological mechanism of CAPE (hydrostatic edema that responds
to the law of all or nothing, starting from the pulmonary basis and subsequently spreading
to the upper lung fields) (Fig. 7)14.
“SPARED AREA”
B MULTIPLE LINES
Figure 7 – A: homogeneous distribution of B Lines in cardiogenic acute pulmonary edema. B: lung
area with normal pattern (“spared area”) between two areas of coalescing B Lines in ARDS.
In patients with massive pulmonary embolism, acute exacerbation of COPD and asthma, in
the absence of other co-morbidities, the lung is “dry” and there are no B Lines18. It should
also be noted that in about 70-80% of cases of pulmonary embolism, subpleural consolidating lesions can be viewed on echography
Lung ultrasound is highly accurate for the diagnosis of pneumothorax (PNX) at the bedside
19-22
.
23-25
e absence of sliding in the anterior scans and the presence of lung points have a sensitivity
of 88% and a specificity of 100% for the diagnosis of PNX17. e volume of PNX is not
quantifiable by ultrasound but the hemodynamic impact may be inferred from the cardiac
and caval evaluation (small and hyperkinetic heart chambers associated with a dilated and
hypomobile IVC represent typical findings of hypertensive PNX).
Echography is the best method for the diagnosis of pleural effusion and also has the ability
to discriminate between exudates and transudates
Ultrasound is also an excellent diagnostic tool for diagnosing pulmonary consolidations
26-27
.
19,28-30
Pneumonia is typically represented by hypoechoic areas of various size and shape, with
.
.
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