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390 oracic ultrasound
irregular margins and inhomogeneous echostructure. ere is generally evidence of air
bronchograms (Fig. 8).
AIR BRONCHOGRAMS
PNEUMONIA
Figure 8 – Lung ultrasound in two patients with pneumonia. Typically pneumonia appears as a
consolidation area with air bronchograms (A - B).
PNEUMONIA
AIR BRONCHOGRAMS
➣ Venous compression ultrasonography of the lower limbs (CUS)
Patients with suspected deep vein thrombosis of the lower limbs (DVT) are usually investigated
by compression ultrasound (CUS). Lensing and collaborators demonstrated that the CUS
has a sensitivity of 100% and a specificity of 99% for the diagnosis of DVT31.
e compression may be performed on the common femoral vein in the groin and on the
popliteal artery in the popliteal fossa (Two points CUS) or on the entire deep venous system
(complete CUS). It is evident that the Two points CUS is much more simple and rapid to
perform. Bernardi and co-workers showed that in symptomatic patients with suspected DVT
the two diagnostic strategies were absolutely equivalent32.
It is important to emphasize that in patients with suspected pulmonary embolism a positive
CUS actually makes a CT angiography unnecessary. is occurs in approximately 10% of
cases33.
➣ Integrated ultrasound in cardiac arrest
Patients in cardiac arrest secondary to asystole or pulseless electrical activity (PEA) are not
shockable. ese types of cardiac arrest, usually have a low percentage of survival.
e identification of the cause of arrest in PEA is important as this is often reversible. e most
common causes of PEA are severe hypovolemia, tension pneumothorax, cardiac tamponade
and massive pulmonary embolism. ese conditions should be diagnosed or excluded in the
most shortest time possible34. An integrated echographic approach (heart, lungs, and inferior
vena cava) has high practical value since it allows to obtain in a few seconds diagnostic elements in PEA
Breitkreutz and colleagues have developed an algorithm that includes the performance of
echocardiography simultaneously with resuscitation, without causing any interference with
the current indications on cardiopulmonary resuscitation (CPR)36.
35-36
(Tab. 1) (Figs. 9-12).
Integrated clinical ultrasound 391
Echocardiography is useful in distinguishing between real-PEA (regular ECG rhythm in the
absence of cardiac contractile activity) and pseudo-PEA (regular ECG rhythm in the presence
of cardiac contractile activity) (Clips 10-11). It is known that these two conditions have a
different prognosis. In situations of pseudo-PEA, CPR should be continued as the possibility
of spontaneous restoration are high. In contrast, when there are no movements of ventricles,
atria and valves, and a clear spontaneous echocontrast is seen, the prognosis is generally inauspicious. ese findings have a positive predictive value of 100%
Table 1 – Integrated clinical ultrasound in cardiac arrest. Possible sonographic findings in cardiac
arrest secondary to hypovolemia, massive pulmonary embolism, cardiac tamponade and tension
pneumothorax
CAUSE
Hypovolemia
Massive
pulmonary
embolism
Cardiac
tamponade
Tension PNX
ULTRASOUND
Heart IVC Lung CUS Abdomen
Small and
hyperkinetic heart
chambers
Dilated RV Dilated No B Lines Positive or
Pericardial effusion Dilated No B Lines
Small and
hyperkinetic heart
chambers
Thin • No B Lines
• Massive
hemothorax
Dilated • No lung sliding
• No B Lines
• Lung point
37-39
.
negative
• Free
fluid
• AAA
RV
ICV
LV
LUNG
Figure 9 – Ultrasound in cardiac arrest secondary to hypovolemia. The cardiac chambers are typically
small and hyperkinetic (A), the IVC is thin (B) and the lung is “dry” (C). Ultrasound is also able to
diagnose some causes of hypovolemia as a massive hemothorax (D), abdominal aortic aneurysm (E) or
free fluid in the peritoneal cavity (F).
A LINES
LIVER
KIDNEY
392 oracic ultrasound
RV
RA
A LINES
ICV
THROMBO
Figure 10 – Ultrasound in cardiac arrest secondary to massive pulmonary embolism. A: the right heart
cavities are dilated, B: the IVC is dilated, C: the lung is “dry” D: and CUS shows a thrombosis of the left
femoral vein.
PE
ICV
A LINES
Figure 11 – Ultrasound in cardiac arrest secondary to cardiac tamponade. A: echocardiography
shows the presence of pericardial effusion and signs of cardiac tamponade, B: the IVC is dilated, C: the
lung is “dry”.
IVC
RV
LV
Figure 12 – Ultrasound in cardiac arrest secondary to tension PNX. The cardiac chambers are typically
small and hyperkinetic (A), the IVC is dilated, (B) lung ultrasound shows the absence of B Lines and
pleural sliding; in non-massive pneumothorax presence of lung point that represents the boundary
between pneumothorax and ventilated lung (C).
Integrated clinical ultrasound 393
Clip 10 – Subcostal 4 chambers scan obtained during cardiac arrest. It does
not show any movement of the ventricular walls, atrial and valves. In the right
cavities there is spontaneous echocontrast. This is a situation of real-PEA.
Clip 11 – Subcostal 4 chambers scan obtained during cardiac arrest.
Evidence of contractile activity of the left ventricle. This is a situation of
pseudo-PEA.
Capnography has been studied in patients in cardiac arrest. Levine and co-workers have found
that no one survived when the end-tidal CO2 (ETCO2) was less than 10 mmHg39. Salen and
colleagues compared the presence of contractile activity with the values of ETCO2 as predictors of survival and concluded that the sonographic demonstration of contractile activity
and ETCO2 values greater than 16 mm Hg were associated with a significant percentage of
success of CPR40.
ese data are obviously useful and can help the doctor in the difficult decision to interrupt
CPR.
➣ Integrated ultrasound in shock/hypotension
Shock is a clinical syndrome characterized by tissue hypoperfusion, which results in organ
dysfunction. If its recognition and treatment are delayed, the multi-organ dysfunction inevitably leads to death.
Shock may be classified into 4 categories:
• Distributive
• Cardiogenic
• Hypovolemic
• Obstructive.
Massive pulmonary embolism and cardiac tamponade are considered forms of obstructive
shock that obviously have many features in common with cardiogenic shock.
➣ Integrated ultrasound in septic shock
Septic shock is the most frequent form of distributive shocks. Hemodynamic changes include
reduction in peripheral resistance resulting in severe vasodilatation, absolute or relative reduction in blood volume and, in some patients abnormalities of the systolic function of LV, RV,
or both (sepsis-related cardiomyopathy)41. In order to reduce mortality the source of infection
should be identified as soon as possible, preferably within 6 hours of presentation41. In this
regard, ultrasound may quickly find many causes of infection, such as acute cholecystitis,
pyonephrosis, liver or splenic abscesses, pneumonia, pleural empyema, subphrenic abscesses,
endocarditis and ascites.
e volume expansion is a crucial point in septic shock and is optimally guided by monitoring IVC, heart and lungs. Echocardiography is essential to identify patients who develop
394 oracic ultrasound
sepsis-related cardiomyopathy. In these situations the infusion of vasoactive amines may lead
to a dramatic reduction in cardiac output. Even the infusion of inotropes may be implemented
by monitoring its effects in order to determine the most suitable dosage (Tab. 2) (Fig. 13).
Table 2 – Sonographic findings in septic shock
Heart IVC Lung Abdomen
Small and hyperkinetic
cardiac chambers
Sepsis-related
cardiomyopathy
Contractility and
monitoring of the
volemic expansion
Endocarditis
PNEUMONIA
Thin • No B Lines
• ARDS
Monitoring of the
volemic expansion
FIBRIN
• Pneumonia
• Empyema
Monitoring of the
volemic expansion
(monitoring of B Lines)
• Subphrenic
abscesses
• Cholecystitis
• Pyonephrosis
• Hepatic or splenic
abscesses
• Ascites
IDRONEPHROSIS
ACUTE CHOLECYSTITIS
Figure 13 – In septic patients ultrasound can quickly identify infections such as pneumonia (A), pleural
empyema (B), pyonephrosis (C), acute cholecystitis (D), splenic and liver abscesses (E) or endocarditis (F).
ABSCESS
ENDOCARDITIS
➣ Sepsis-related cardiomyopathy
It is useful to devote a separate discussion to this issue, as it is often misunderstood because
echocardiography is not still widely practiced in the Intensive Care and Emergency Medicine
departments.
Different forms of cardiac involvement have been described in sepsis:
• Takotsubo cardiomyopathy (apical akinesia of the left ventricle - LV)
• Inverted Takotsubo cardiomyopathy (akinesia of the basal segments of the LV)
• Different kinds of LV, RV, or biventricular dysfunction.
Integrated clinical ultrasound 395
e development of left ventricular dysfunction, Takotsubo and inverted Takotsubo cardiomyopathy, seem closely related to catecholamine stress. In these situations the use of vasoactive amines (e.g. noradrenaline) may play a decisive role. Vasoactive amines are often used in
high doses to maintain adequate values of mean arterial pressure. is treatment may lead
to not always recognized severe reduction in cardiac output, due to the onset of severe left
ventricular dysfunction.
e following are some clinical cases illustrating the fundamental role of echocardiographic
monitoring in septic patients.
Case 1
47-year-old woman with septic shock starting from the abdomen. Clip 12 documents the
baseline echocardiography (apical 4 chambers scan that shows a hyperkinetic heart). e
patient has a mean BP less than 65 mmHg despite adequate volume expansion. e infusion
of norepinephrine is therefore started up to obtain a mean arterial pressure of 75 mmHg. e
therapeutic goal is achieved. However the echocardiographic control shows the appearance
of a severe left ventricular dysfunction, which shows an inverted Takotsubo alteration of the
kinetics (Clips 13-14).
e reduction in the dose of norepinephrine along with dobutamine infusion allow to rapidly
restore the systolic function of the LV (Clip 15).
Clip 12 – Apical 4 chambers scan that shows a hyperkinetic heart.
Clips 13, 14 – Subcostal and apical 4 chambers scans. Inverted Takotsubo
pattern: the apex has a normal kinetics while the basal portions appear
markedly hypokinetic.
Clip 15 – With the reduction of the dose of norepinephrine and dobutamine
infusion, there is a rapid recovery of the systolic function of the left ventricle.
Case 2
58-year-old man with septic shock secondary to pneumonia. Infusion of norepinephrine is
initiated because of hypotension despite an adequate volume expansion. An echocardiographic
monitoring is performed, which detects the early onset of extensive apical akinesia (Takotsubo
cardiomyopathy) (Clip 16). e infusion of dobutamine is started and the dosage of norepinephrine is reduced. In less than 24 hours the function of the LV is normalized (Clip 17).
396 oracic ultrasound
Clip 16 – Apical 4 chambers scan showing Takotsubo cardiomyopathy with
extensive akinesia of the apical segments.
Clip 17 – After 24 hours from the suspension of norepinephrine and from
the start of the dobutamine infusion apical akinesia disappears.
Case 3
64-year-old man with septic shock starting from the abdomen. He is hypotensive
(85/50 mm Hg) despite adequate volume expansion. e central venous saturation (SVO2)
is 75 mmHg. According to guidelines the infusion of vasoactive amines should be started.
However, echocardiography shows a severe biventricular dysfunction (most evident for the
RV) (Clip 18). Dobutamine infusion is preferred, because it rapidly improves the biventricular
function and restores normal blood pressure (Clips 18-24).
Clip 18 – Apical 4 chambers scan showing a severe biventricular dysfunction,
most evident for the right ventricle.
Clips 19, 20, 21, 22, 23, 24 – The dobutamine infusion at increasing
doses results in a net improvement of the biventricular kinetics. Associated
with a marked improvement in blood pressure.
➣ Integrated ultrasound in cardiogenic shock
Cardiogenic shock corresponds to an inadequate tissue perfusion resulting from a cardiac
dysfunction.
Echocardiography is an essential diagnostic tool that can provide rapid and accurate information about systodiastolic function, severe valvular heart disease, cardiac tamponade, massive
pulmonary embolism and mechanical complications of acute myocardial infarction.
In cardiogenic shock the IVC is dilated without changes related to the breathing activity.
e lung ultrasound shows “wet” lungs with multiple B Lines. In cardiogenic shock second-
ary to massive pulmonary embolism or cardiac tamponade, the lungs appear “dry” with no
evidence of B Lines. Pleural effusions can also be easily diagnosed.
Finally, the CUS is an additional diagnostic tool in patients with suspected pulmonary embolism (Tab. 3) (Figs. 14, 4, 11).
Integrated clinical ultrasound 397
Table 3 – Sonographic findings in cardiogenic shock
Heart IVC Lung CUS
Systodiastolic function Dilated • “Wet” lung
• Pleural effusion
Valvular diseases Dilated • “Wet” lung
• Pleural effusion
Mechanical complications of the EPI Dilated • “Wet” lung
• Pleural effusion
Massive pulmonary embolism Dilated Dry lung It can be negative or
positive
Cardiac tamponade Dilated Dry lung
RV
AOV
RA
LA
IVC
MV
Figure 14 – Echocardiographic findings in cardiogenic shock. A: dilation of the left ventricle in a
patient with severe systolic dysfunction, B: important biatrial dilation in a patient with severe diastolic
dysfunction, C: aortic valve stenosis, D: mitral stenosis, E: dilated IVC, F: “wet” lung and pleural effusion.
B LINES
LIVER
PE
➣ Integrated ultrasound in hypovolemic shock
Hypovolemic shock is a multi-organ failure determined by medical or surgical conditions
where a rapid loss of fluids results in hypoperfusion.
In hypovolemic shock, echography typically reveals the following findings:
• Small and hyperkinetic heart cavities
• Collapsed inferior vena cava
• “Dry” lungs.
Ultrasound is very useful for the etiological diagnosis of some causes of hemorrhagic shock,
such as massive hemothorax, hemoperitoneum, abdominal aortic aneurysm and ectopic
398 oracic ultrasound
pregnancy. It also optimizes the administration of fluids through the monitoring of heart,
inferior vena cava and lungs (Tab. 4) (Fig. 5).
Table 4 – Sonographic findings in hypovolemic shock
Heart IVC Lung Abdomen
Small and hyperkinetic
heart cavities
Monitoring of volemic
expansion
Thin • No B Lines
• Massive hemothorax
Monitoring of volemic
expansion
Monitoring of volemic
expansion
• Haemoperitoneum
• AAA
• Ectopic pregnancy
➣ Integrated ultrasound in acute dyspnea
Acute respiratory distress is a common symptom in different diseases, such as acute heart
failure, pulmonary embolism, pneumothorax, and exacerbation of chronic lung diseases.
Lung ultrasound has a high sensitivity in differentiating “dry” from “wet” lung and a high
specificity in distinguishing APE from ARDS14. In patients with severe dyspnea and “wet
cardiogenic” lung, echocardiography is indispensable in order to define the cause. In patients
with dyspnea and “dry” lung, a cardiogenic cause may be excluded and other causes will be
taken into consideration, such as pulmonary embolism, asthma, COPD, pneumonia or
pneumothorax (Fig. 15).
ACUTE DYSPNEA
“DRY” LUNG
LUNG
ULTRASOUND
• COPD
• PNX
• Pulmonray embolism
• Asthma
• Pneumonia
• Atelectasis
• Other
Figure 15 – Flow-chart in patients with acute dyspnea. Ultrasound evaluation starts from the study of
the lung. In the case of “dry” lung a cardiogenic cause can be excluded. In the case of “wet cardiogenic”
lung a careful and comprehensive echocardiographic assessment is necessary.
“WET CARDIOGENIC
LUNG”
ECHOCARDIOGRAPHY
• Assessement systo-diastolic
function
• Valvular assessment
• Other
Integrated clinical ultrasound 399
Pneumothorax may be quickly diagnosed by lung ultrasound and its hemodynamic impact
may be derived from the integration with the evaluation of heart and IVC.
In pulmonary embolism lung ultrasound shows “dry” lungs and, in a high percentage of patients, small subpleural consolidations. In massive pulmonary embolism, echocardiography
detects dilatation of the right ventricle and dilated IVC. CUS may detect the presence of
proximal vein thrombosis to the lower limbs (Tab. 5).
Table 5 – Ultrasound findings in dyspnea
CAUSE
Acute pulmonary
edema
ARDS
Massive
pulmonary
embolism
Hypertensive
PNX
• COPD
• Asthma
• Pneumonia
ULTRASOUND
Heart IVC Lung CUS
• Systolic or diastolic
dysfunction
• Valvular pathology
Variable Variable • “Wet” lung
Right ventricular
dilatation
Small and hyperkinetic
cardiac chambers
Variable Variable • “Dry” lung
Dilated • “Wet cardiogenic” lung
• Pleural effusion
• Spared areas
• Alterations of the
pleural line
Dilated • “Dry” lung
• Small subpleural
consolidations
Dilated • No lung sliding
• No B Lines
• Lung point
• Big consolidations in
pneumonia
Positive or
negative
➤ Bibliography
1. Copetti R, Copetti P, Reissig A. Clinical integrated ultrasound of the thorax including causes of shock
in nontraumatic critically ill patients. A practical approach. Ultrasound Med Biol 2012; 38(3): 349-359.
2. Mueller X, Stauffer JC, Jaussi A et al. Subjective visual echocardiographic estimate of left ventricular
ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast
angiography. Clin Cardiol 1991; 14: 898-902-
3. Poelaert J, Schmidt C, Colardyn F. Transoesophageal echocardiography in the critically ill. Anaesthesia
1998; 53: 55-68.
4. Enger EL, O’Toole MF. Noncardiogenic mechanisms of right heart dysfunction. J Cardiovasc Nurs 1991;
6: 54-69.
5. Vieillard-Baron A, Schmitt JM, Augarde R et al. Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis. Crit Care Med
2001; 29: 1551-1555.
6. Vieillard-Baron A, Page B, Augarde R et al. Acute cor pulmonale in massive pulmonary embolism: incidence,
echocardiographic pattern, clinical implications and recovery rate. Intensive Care Med 2001; 27: 1481-1486.
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