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430 oracic ultrasound
➤ Bibliography
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432 oracic ultrasound
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pneumothorax. Intensive Care Med 2000; 26: 1434-1440.
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14
Interventional chest ultrasound
Interventional (or operational) ultrasound concerns invasive procedures
aimed at targets detectable by ultrasound. e simultaneous visualization
of the region of interest, and the operative device ensure safety and greater
probability of success. Ultrasound is a typically bedside imaging modality, this characteristic allows to transfer many interventional procedures
from the radiology suite, or from the operating room, to the bedside.
In the emergency setting, interventional chest ultrasound is mainly devoted to the diagnosis
and treatment of syndromes due to occupation of serous cavities: pleural and pericardial
effusions, hemothorax and pneumothorax. Almost always all of these procedures can be performed without the use of complex imaging techniques, but there is no doubt that in many
cases ultrasound is useful (Fig. 1).
Figure 1 – Which one would you puncture?
Employing compact equipments anywhere allows to include this technique among the
bedside procedures. Table 1 compares different methods used for interventional procedures
on the chest.
When an access to large venous vessels (jugular and subclavian veins) is deemed necessary,
the ultrasound-guided approach helps to decrease complications and failures.
ese topics will be discussed in detail in the following pages. Although the access to the
internal jugular and subclavian veins does not strictly belong to thoracic operations, ultrasound guidance is now considered essential for a safe cannulation and for avoiding most
chest related complications.
Tracheostomy and cricothyrotomy will be discussed as they are interventional procedures
typically performed on patients with respiratory failure. Interventional thoracic ultrasound
for cytological or histological diagnosis of intrathoracic and parietal lesions will be only briefly
described. Many of the complications of these practices (pneumothorax, hemothorax) avail
themselves of the concepts reported here.
433
434 oracic ultrasound
Table 1 – Comparison of different guiding methods for interventional thoracic ultrasound
Technique
Cost + ++ ++ + +++
Availability +++ ++ ++ +++ +
Radiation (patient/doctor) +/+ ++/0 ++/+ 0/0 0/0
Time of procedure + +++ ++ ++ +++
Access to central lesions + +++ +++ 0 +++
Real-time control +++ 0 ++ +++ +
Mobiliation of the patient +++ + + +++ +
Modified from: Klein JS, Zarka M. Transthoracic needle biopsy: an overview.
232-249.
Fluoroscopy CT Fluoro-CT Ultrasound MR
J Thorac Imag
1997; 12:
➣ Bedside interventional ultrasound: basic concepts
Due to the improvement of machines and ultrasound probes, minimally invasive interventional
maneuvers have progressed considerably in the last twenty years. Ultrasound machines have
enabled the realization of real-time images with optimum sharpness and the miniaturization
of equipment with high standard image, while a cultural growth has allowed ultrasound to
overcome barriers related to specializations. erefore, procedures initially performed in specific environments (operating room, interventional radiology) have begun to be implemented
in the ICU, emergency room or ward, with the same safety and moderate costs1. is has been
achieved for relatively minor interventions, such as central venous cannulations, but also for
more invasive procedures such as chest drains and percutaneous tracheostomy2.
e implementation of bedside chest interventional ultrasound, described in detail below,
decreases the risks associated with the displacement of the patients. It has been observed that
the transfer of a critically ill patient for diagnostic imaging outside of the ICU, involves on
average three people and produces adverse events in two-thirds of these patients3. In one study,
a significant percentage of patients transported in operating or diagnostic rooms, outside a
protected environment, caused ventilatory problems in a significant number of cases, with
two episodes of cardiac arrest in 123 transfers analyzed4.
e performance of interventional bedside procedures, on the other hand, involves specialized
staff, and requires the presence at the bedside of all the equipment and devices needed. Sources
of oxygen, ventilation and monitoring tools are important in case of sudden emergencies.
During an interventional procedure, in relation to the most frequent events such as vasomotor crisis, hypotension, hypoxemia and hemorrhage, a venous access must be in place and
respiratory and circulatory support devices be ready for use. It is also necessary to ensure the
infection control5. e preparation of the operative field and probes will be described below.
Appropriate hand hygiene, aseptic techniques normally used in the operating room, and the
use of sterile clothing may reduce the frequency of device-related infections.
e use of antibiotic prophylaxis for thoracic interventional procedures is another debated
topic. For venous access, antibiotic prophylaxis has not been identified as a benefit in adults and
only minor benefits in children have been reported, considering a likely increase in infections6.
Interventional chest ultrasound 435
In the case of tube thoracostomy, a first-generation cephalosporin should be administered for
no more than 24 hours7. Table 2 summarizes the recommendations of the British oracic
Society.
Table 2 – Principles of ultrasound-guided interventional procedures on the chest
• A theoretical and practical training for physicians performing ultrasound-guided procedures on
the chest is essential with an adequate period of supervised practice
• Interventional procedures on the chest must ensure aseptic conditions
• Non-urgent procedures must be practiced in patients with INR <1.5
• The most common complications of thoracenthesis and pleural drainage are: PNX, failure, pain
and bleeding. The rarest are related to organ lesions
• Obtain a written consent for the procedure, with an accurate description
• In relation to the needs the needle of smallest caliber should be used
• The procedure should be discontinued when no more air or fluid can be aspirated, if the patient
develops symptoms (cough or pain) or if the drainage has reached a volume of 1.5 l
• Post-procedural X-ray is not necessary unless there are complications, air is aspirated or the
patient has symptoms.
• The most common complications small catheters insertion are: pain, infection and blockage of
the catheter. The most serious complication are the visceral injuries
• The most common complications of insertion of large bore catheters are: pleural infection,
parietal infection, visceral lesions and the blocking of drainage
• Antibiotic prophylaxis is not recommended after catheter insertion in the absence of trauma. It
can be taken into consideration in the case of patients with penetrating trauma
• Small drains should be used as first choice in case of pneumothorax, pleural fluid, pleural infections
• Analgesic premedication, anesthesia (skin/periosteum/pleura) and sedation, if appropriate and
not contraindicated, should be encouraged
• Dilators should not be placed in the chest cavity for more than 1 cm, old introduction points are
not to be reused for new drains, the placement of a tube should not be corrected by pushing it
in depth but extracting it
• Ultrasound is the first check of the chest at the end of the procedure. This evaluation is aimed
at the control of the residual fluid, the persistence or presence of pneumothorax, the placement
of the drainage in the pleural cavity, the appearance of interstitial syndrome (re-expansion
edema)
Modified from: Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic ultrasound:
British Thoracic Society pleural disease guideline 2010. Thorax 2010; 65 (Suppl. 2): 61-76.
➣ Instruments
In common medical practice dedicated equipment and materials for interventional ultrasound
are often not available. An ultrasound portable machine offering essential Doppler modalities
436 oracic ultrasound
is enough to perform a complete echo-guided procedure. Many specially designed probes
with variously configured channel that allows the passage of the needle, or external adapters
mounted on the probe, are marketed but usually are not necessary.
Figure 2 – Convex probe with lateral adapter for the needle.
Figure 3 – Linear probe with lateral adapter for the needle.
Dedicated operative systems consist in convex or sector probes equipped with a coaxial or
eccentric needle. ese systems will facilitate the visualization of the needle on its way to
the target (Figs. 2-3), coupling the needle in the tissues with the probe and with the twodimensional image generated. erefore the needle, its echogenic tip and the target are well
displayed on the screen.
It is much more frequent that in usual and emergency settings, the operator should proceed
with the technique of “free hand”, i.e. without dedicated systems (Figs. 4-5).
Interventional chest ultrasound 437
is technique, performed by a single operator, is the preferred method for several reasons:
• holding the probe in one hand and the operating system (needle, trocar etc.) in the other,
it is easier for a single operator to synchronize the movements, compared to two different
operators;
• when inserting a device inside the tissue beneath the probe, the operator is free to move the
needle (and the probe) in many directions, in order to visualize it. Moreover the physician
is able to correct a wrong access. is is impossible using specific guides;
• no additional tools have to be purchased or sterilized.
Figure 4 – “Free-hand” ultrasound-guided cannulation of the right internal jugular vein.
Figure 5 – “Free-hand” ultrasound-guided cannulation of the right subclavian vein.
Except for special cases (for example, the use of contrast media or the mapping of vessels to
be avoided), the normal two-dimensional images in real time are suitable to recognize and
acquire a target. e use of color Doppler may be useful to avoid the unexpected prick of
vascular structures. Considering the “physiological” echogenicity of a needle into the tissues,
it is desirable to diminish their brilliance with the gain. e focus should be placed in an
intermediate position along the planned route of the needle, and in the vicinity of the target
for the phase of the actual acquisition.
438 oracic ultrasound
In our opinion, operative ultrasound may be performed with any type of probe. e use of
convex or linear transducers is preferred because of the wide contact with the skin and the
better image generated. In the case of sloping accesses, sector probes are more suitable, even
if their low frequency does not facilitate the recognition of the needle.
e choice of the probe depends on the depth of the target. If it is between 3-4 cm, the linear
probe allows an accurate definition of the image.
Regardless of whether the adapters are available or not, the “free hand” technique allows to
perform various movements of the needle after its introduction, the exchange of the scan
plans, and the tactile sensitivity throughout the procedure. We therefore find this method
more practical than that performed with probes or dedicated devices, although more time is
needed to acquire the necessary skills.
➣ Asepsis
e execution of any ultrasound guided invasive maneuver should be performed under aseptic
conditions. e sterility of the material and the probes that have to be in contact with the
skin is mandatory.
An advantage of the “free hand” technique is to allow the use of normal not sterilized probes,
wrapped in sterile drapes (e.g. Steri Drape) or, much more simply, in a surgical glove or a
sterile condom (Fig. 6).
Figure 6 – Sterility can be obtained simply by coating the probe with a sterile glove.
For protecting the connecting cable of the probe, plastic devices used in laparoscopic surgery
are very practical (Fig. 7).
For the acoustic coupling with the skin gel or sterile vaseline may be used. Normal ultrasound
gel may be placed inside the glove or condom that covers the probe. e acoustic coupling
with the skin is carried out effectively by the iodopovidone used for disinfection of the skin.
A recent study showed that infections after interventional procedures are quite rare, with an
incidence rate of 0.1%8.
Interventional chest ultrasound 439
Figure 7 – When used for invasive procedures, the probe must be adequately covered in order to
ensure asepsis.
➣ Materials
In order to drain thoracic collections, a lot of material is not necessary. It is often enough to
use regular syringes and needles for thoracentesis. e Veres needle (16G) with its accessories
(tubes, bag and three-way stopcock) is very practical and safe (Fig. 8).
is needle has a retractable tip that disappears when it reaches the cavity to be drained. Once
penetrated into the liquid, the Veres needle behaves as a simple blunt cannula. It is good
practice to use the less traumatic needle, and therefore the more subtle compatibly with the
characteristics of the material to be aspirated.
Since almost all fluid collections may be aspirated with 18-gauge needles (G) (1.2 mm), it is
rarely necessary to use larger calibers (1.3-1.6mm / 17-14G) to aspire thick liquid, like pus
or fluid with necrotic debris. In the event of particularly dense material, 14G needles are not
sufficient, it is thus necessary to use 10Fr or larger caliber catheters.
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