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30 oracic ultrasound
Especially through the work of French, Italian, Austrian and German authors, thoracic ultrasound is now among the diagnostic instrumentations for the chest. If its general role has
not been fully defined yet, it is believed that in more important critical settings it appears as
a promising tool. e Emergency and Critical Care practice is almost always poor compared
to the immediate needs. In these settings the simplicity of execution and non invasiveness
of ultrasound are most exploited characteristics, while the radiographic (traditional or CT)
examination, although technically simple, is almost always problematic.
e following pages will describe the anatomy and physics that underlie
the production of pulmonary artifacts. In subsequent chapter ultrasound
semiotics of the chest will be introduced, exploring real and artifactual
findings. In this regard, we will use a radiological terminology, because
we believe that radiology, and especially CT, represents the natural
comparison of all the signs assessed in ultrasound. In our opinion, the
employed terminology must be respectful of the pathologic basis of the
disease, especially in interstitial disease, in which the organ still maintains
an aerated component, but changes in its geometry and topology. It is
not accidental that terms such as “interstitial” or “alveolar syndrome”
are relevant to pathological anatomy, simply expresses as a more or less
“porous” or “heavy” lung.
In this book the clinical chapters will cover the use of ultrasound in
emergency pleuropulmonary pathology, namely the study of pleural effusions, spontaneous pneumothorax, acute inflammatory pathology of
the lung and dyspneic patient. On the latter issue, the discussion covers
three main chapters related to cardiorespiratory dyspnea: left heart failure,
bronchial and vascular embolic pathology.
e use of ultrasound in thoracic trauma is practical and useful, it will
therefore be expanded in a specific part.
e final parts of this textbook exemplify the use of cardiac ultrasound
as an indispensable complement to pleuropulmonary ultrasound, the
applications of ultrasound in neonatology and pediatrics and the interventional applications.
On the contrary there will be no space for the mediastinal pathology,
or for the neoplastic and parietal involvement of the chest, because they
generally represent clinical situations without acute phases and only
infrequently involve the need for immediate diagnosis.
➤ Recommended readings
Below there is a list of useful texts for studying ultrasound in emergency and intensive care,
and to assess the opinions of different authors regarding thoracic ultrasound.
Of course it would be difficult to provide a complete bibliography on very wide topics about
principles, equipments and probes, which are here only hinted at,. We mention therefore a
few volumes fundamental to properly complete all information.
Basic principles 31
Blitz J. Ultrasonics. Methods and applications. Buttersworth, London, 1956.
Fraser RS, Muller NL, Colman NC, Pare PD. Diagnosis of the diseases of the chest. WB Saunders, Philadelphia
PA, 1999.
Guarracino F. Il monitoraggio emodinamico in area critica. Elsevier, Milano, 2009.
Henein M, Sheppard M, Pepper J, Rigby M. Ecocardiografia clinica. Springer-Verlag Italia, Milano, 2006.
Juhl J, Kuhlman JE. Methods of examination, thechniques, and anatomy of the chest. In: Essential of radiologic
imaging (Juhl JH, Crummy AB and Kuhlman JE eds.). Lippincott-Raven, Philadelphia PA, 1998.
Lichtenstein D.Whole body ultrasonography in the critically ill. Springer-Verlag, Berlin-Heidelberg, 2010.
Marincek B, Dondelinger RF. Emergency Radiology. Imaging and intervention. Springer-Verlag, Berlin-
Heidelberg, 2007.
Mathis G. Chest sonography. Springer-Verlag, Berlin-Heidelberg, 2011.
Neri E, Caramella D, Bartolozzi C. Image processing in radiology. Springer-Verlag, Berlin-Heidelberg, 2008.
Rumack CM, Wilson SR, Charboneau JJ, Levine D. Diagnostic Ultrasound. Mosby, St Louis MO, 2011.
Sarti A, Lorini FL (Eds). Echocardiography for Intensivists, Springer-Verlag, Italy, 2012.
Szabo TL. Diagnostic ultrasound imaging. Elsevier Academic Press, Amsterdam, 2004.
Testa A. Manuale di ecografia clinica in urgenza. Verduci, Roma, 2008.
➤ Bibliography
1. Langlois SP. Focused ultrasound training for clinicians. Crit Care Med 2007; 35: S138-S143.
2. Cunningham JJ. Gray scale echography of the lung and pleural space: current application of oncologic
interest. Cancer 1978; 41: 1329-1339.
3. Joyner Cr, Herman RJ, Reid JM. Reflected ultrasound in the detection and localization of pleural effusion. JAMA 1967; 200: 399-402.
4. Mathis G. oraxsonography part II: Peripheral pulmonary consolidations. Ultrasound Med Biol 1997;
23: 1141-1153.
5. Mathis G. Chest sonography, 3rd ed. Springer-Verlag, Berlin-Heidelberg, 2011.
6. Rantanen NW. Diseases of the thorax. Vet Clin North Am Equine Pract 1986; 2: 49-66.
7. Wernecke K, Galansky M, Peters PE, Hansen J. Pneumothorax: evaluation with ultrasound – preliminary
results. J orac Imaging 1987; 2: 76-78.
8.Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs
for the identification of pneumothorax after blunt trauma. Acad Emerg Med 2010; 17: 11-17.
9. Lichtenstein D, Mezière G, Biderman P, et al: e comet-tail artifact: An ultrasound sign of alveolarinterstitial syndrome. Am J Respir Crit Care Med 1997; 156: 1640-1646.
10. Lichtenstein D, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung
sliding. Chest 1995; 108: 1345-1348.
11. Soldati G. Lung sonography: artifact, movement or echotexture? G Ital Ecografia 2001; 4: 329-338.
12. Mathis G. orax sonography: part I. Chest wall and pleura. Ultrasound Med Biol 1997; 23: 1131-1139.
13. Beckh S, Bolcskei PL, Lessnau KD. Real time chest ultrasonography. A comprehensive review for the
pulmonologist. Chest 2002; 122: 1759-1773.
14. Soldati G. Sonographic findings in pulmonary diseases. Radiol Med 2006; 111: 507-515.
15. Jambrik Z, Monti S, Coppola V et al. Usefulness of ultrasound lung comets as a nonradiologic sign of
extravascular lung water. Am J Cardiol 2004; 93: 1265-1270.
16. Frassi F, Gargani L, Gligorova S et al. Clinical and echocardiographic determinants of Ultrasound Lung
Comets. Eur J Echocardiogr 2007; 8: 474-479.
32 oracic ultrasound
17. Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from Acute respiratory distress syndrome. Cardiovasc Ultrasound 2008; 6: 16.
18. Soldati G, Sher S, Testa A. Lung and ultrasound: time to reflect. Eur Rev Med Pharmacol Sci 2011; 15:
223-227.
19. Quaia E. Contrast media in Ultrasonography. Basic principles and clinical applications. Springer Verlag,
Berlin, 2005.
20. Meek P, Schwatzstein R et al. Dyspnea. Mechanisms, assessment, and management: a consensus statement. American oracic Society. Am J Respir Crit Care Med 1999; 159: 321.
21. Jesse RL, Kontos MC, Roberts C. Diagnostic strategies for the evaluation of the patient presenting with
chest pain. Prog Cardiovasc Dis 2004; 46: 417-437.
22. Juhl J, Kuhlman JE. Methods of examination, thechniques, and anatomy of the chest. In: Essential of ra-
diologic imaging (Juhl JH, Crummy AB and Kuhlman JE eds.). Lippincott-Raven, Philadelphia PA, 1998.
23. Fraser RG, Pare JAP et al. Diagnosis of the diseases of the chest. WB Saunders, Philadelphia PA, 1988.
24. Henschke CI, Yankelevitz DF et al. Chest radiography in the ICU. Clinical Imaging 1997; 21: 90-103.
25. Henschke CI, Pasternack GS, Schroeder S et al. Bedside chest radiography: diagnostic efficacy. Radiology
1983; 149: 23-26.
26. Simon PM, Schwartzstein RM, Weiss JW et al. Distinguishable types of dyspnea in patients with shortness
of breath. Am Rev Respir Dis 1990; 142: 1009.
27. Lichtenstein D, Goldstein I, Mourgeon E et al. Comparative diagnostic performances of auscultation, chest
radiography, and lung ultrasonography in acute respiratory distress syndrome. Anestesiology 2004; 100: 9-15.
28. Sears BW, Luchette FA, Esposito TJ et al. Old fashion clinical judgment in the era of protocols: Is mandatory chest X-ray necessary in injured patients? J Trauma 2005; 59: 324-332.
➤ Updated Bibliography
Koegelenberg CF, von Groote-Bidlingmaier F, Bolliger CT. Transthoracic ultrasonography for the respiratory
physician. Respiration. 2012;84:337-50.
Smargiassi A, Inchingolo R, Soldati G, Copetti R, Marchetti G, Zanforlin A, Giannuzzi R, Testa A, Nardini
S, Valente S. e role of chest ultrasonography in the management of respiratory diseases: document II.
Multidiscip Respir Med. 2013;8(1):55.
Zanforlin A, Giannuzzi R, Nardini S, Testa A, Soldati G, Copetti R, Marchetti G, Valente S, Inchingolo
R, Smargiassi A. e role of chest ultrasonography in the management of respiratory diseases: document I.
Multidiscip Respir Med. 2013;8(1):54.
Demi L, Demi M, Smargiassi A, Inchingolo R, Faita F, Soldati G. Ultrasonography in lung pathologies: new
perspectives. Multidiscip Respir Med 2014;9:27.
Four comprehensive reviews on chest ultrasound for pulmonary medicine specialists.
2
Anatomy of chest ultrasound
Introduction
To use chest ultrasound the clinician needs to know the chest anatomy
in its parietal and visceral components, and to understand the acoustic
interactions that make ultrasound a multiplanar tomographic imaging
method. is chapter covers the cross-sectional anatomy and topography
of the chest, while the following one will focus on the acoustic interaction on solid and aerated structures. e different behavior of ultrasound
on solid and porous tissues needs an overwiew of the chest anatomy:
wall, pleura and lung, but also of tissutal geometry and topology. As the
ultrasound anatomy of the heart is well known and systematized, a brief
description will appear in the chapter on echocardiography.
➣ Thoracic wall
Ultrasound allows the definition of the chest wall in relation to the frequencies used. Since
the wall thickness is typically within 4 cm in adults and less than 2 cm in many areas , a linear
probe operating with frequency around 10 MHz is the best choice. Skin, subcutaneous tissue,
cartilaginous and osseous ribs, muscles and pleura are therefore well represented and included
in the scanning of this probe (Fig. 1).
Subcutaneous tissue
Muscle
Rib
Pleural line
Figure 1 – Thoracic wall represented in a longitudinal scan using 10 MHz linear probe.
Rib muscles
33
34 oracic ultrasound
e skin appears as a strong linear echo that originates from the jump in acoustic impedance
caused by the transition from ultrasound gel to the epidermid. e dermis appears echogenic. e subcutaneous fat is hypoechoic in relation to the dermis, although its echogenicity depends on its structure and arrangement. e arrangement is areolar and constituted
of adipose lobules surrounded by thin echogenic septa, particularly evident in subjects with
abundant adipose layer.
e muscles are hypoechoic and their fibers are separated by echogenic interfaces. Hyperechoic
bands surround the individual muscles and outline the muscle groups.
e costal cartilages are relatively hypoechoic and well-defined, separated from the contiguous
osseous portion, which shows a highly reflective cortical bone and causes acoustic barrage.
e osseous cortex of the ribs reflects ultrasound with an intensity that will produce transverse
reverberations similar to the visceral pleural plane (Fig. 2).
Figure 2 – Longitudinal scans of the chest wall with 10 MHz linear probe. A: cartilaginous rib which
allows to posteriorly observe the pleural line. B: osseous rib with posterior acoustic barrage.
Finally, the echogenic and reflective pleural plane appears immediately below the ribs in the
intercostal spaces and marks the boundary of the real ultrasound of the chest wall.
From a topographical point of view, which also has clinical relevance, it is useful to distinguish
in the chest the supraclavicular regions, the upper opening, the anterior and the lateral chest
walls, the axillary regions, the posterior wall and the lower opening.
Each supraclavicular region is part of the lower aspect of the posterior triangles of the neck.
It is delimited inferiorly by the clavicle, medially by the sternocleidomastoid muscle and
postero-laterally by the trapezius. e deep part is muscular and includes the levator scapulae and the splenius muscle, and the three scalene muscles. It contains the accessory nerve,
the external jugular vein, the omohyoid muscle, lymph nodes, subclavian artery and vein,
and the brachial plexus. e muscle layers of its floor lead to the upper opening of the chest
area bounded by the first ribs, the sternum and the body of the first thoracic vertebra. e
upper thoracic opening contains the lung apices, which are precisely explored by ultrasound
through this anatomical region.
e anterior wall, which extends about 18 cm from the jugular notch to the xiphoid apophysis,
consists of the sternum and the costal cartilages of the first 10 ribs.
e muscles of the chest wall are arranged, as in the abdomen, in three layers but separated
by the ribs. e two outer layers, made of the external and internal intercostal muscles, are
clearly visible in the intercostal space where, in deep, the parietal pleura and the lung appear.
Anatomy of chest ultrasound 35
e intercostal neurovascular bundle runs deep down the second muscle layer, below the
superior rib. About two inches from the sternal margin, and parallel to this, there are the
internal mammary vessels, easily viewable in the first intercostal spaces, especially using the
color Doppler function. Externally to the anterior costal plane, the chest wall also includes
the big and small pectoral muscles, that support the breasts.
rough the anterior right wall, part of the upper lung lobes (infraclavicular portion) and
the right middle lobe are explored. rough the anterior left wall, the infraclavicular part of
the upper lobe and the lingula are explored. On the right, the small fissure, which separates
the upper from the middle lobe, follows the fourth intercostal space (Fig. 3). e oblique
fissure, beams anteriorly from the right axilla, and intercepts the mid-clavicular line in the
fifth intercostal space.
FOURTH RIB
LOWER
LOBE
SIXTH RIB
UPPER
LOBE
MIDDLE LOBE
Figure 3 – Scan of the right lung lobes on the anterior thoracic surface.
UPPER
LOBE
LOWER
LOBE
MIDDLE LOBE
SIXTH RIB
ON THE MAMMARY LINE
FOURTH INTERCOSTAL SPACE
MIDAXILLARY LINE
Figure 4 – Representation of the lobes of the right lung on the lateral surface of the chest.
36 oracic ultrasound
Figure 5 – Scan of the axillary apex to the upper lobe (left) and suprascapular to the apex of the lung
(right).
3rd dorsal vertebra
Medial border
of the scapula
Figure 6 – Scan of the lung lobes on the posterior thoracic surface.
Upper lobe
Lower lobe
e lateral thoracic walls are formed by the last 10 ribs and the intercostal muscles. e serratus anterior muscle overlies this plane, originating from eight upper ribs and inserting along
the costal border and on the inferior angle of the scapula. rough the side wall of the chest,
lower lobes and a small part of middle lobe on the right are explored (Fig. 4).
Lateral portions of the upper lobes are seen through the upper axilla and its apex (Fig. 5).
e posterior chest wall consists of 12 thoracic vertebrae and 12 ribs. It is closed at the top
by the articulation of the shoulder and by the scapula (Fig. 6).
e trapezius muscle superficially covers the posteromedial surface of the upper chest, and
originates from a median line that goes from the occiput to the twelfth thoracic vertebra,
fitting on the collarbone, on the acromion and on the spine of the scapula. Deeply down the
trapezius are the muscles that originate from the spine and are placed on the medial border
of the scapula (levator scapula, rhomboids and latissimus dorsi). e latter, originating from
the spinous processes of the six lower thoracic vertebrae, from the lumbar segment, the last six
ribs and the posterior iliac crest, inserts into the bicipital groove of the humerus. e erector
muscles of the spine lie deeply down the rhomboids, to the side of the column. e presence
of thick muscle mass and bone structures makes it difficult to explore with ultrasound the
pleuropulmonary area from the back. is must be carried out at intercostal level, in the area
below the scapula and between scapula and spine (dorsal part of the lower lobes).
Anatomy of chest ultrasound 37
Table 1 – Lobar and segmental subdivision of the lungs
Right lung Left lung
Upper lobe
Middle lobe
Lower lobe
Table 2 – Lobar and segmental relationships of the lungs with the lung walls
Posterior thoracic wall
Right lateral wall
Left lateral wall
Right anterior wall
Left anterior wall
Apical (1)
Posterior (2)
Anterior (3)
External (lateral) (4b)
Internal (medial) (5b)
Superior (apical) (6)
Internal basal (7)
Anterior basal (8)
Lateral basal (9)
Posterior basal (10)
Upper lobes with posterior segments (up to 6 cm below the apex
or, at paravertebral level, to the spinous process of the third dorsal
vertebra) and lower lobes with posterior and (partly) lateral basal
segments are displayed. They are evident in the scapula-vertebral
spaces and below the shoulder blades.
The upper lobe (anterior and posterior segments) is displayed up to
the point where the middle axillary line crosses the fourth rib: the
middle lobe is in front of this point (lateral segment) and the inferior
lobe (lateral basal and, partly, posterior and anterior segments) is
behind this point.
The two lobes of the left lung are displayed. The superior lobe with
the anterior, posterior segments and the superior lingular segment;
the inferior lobe with the apical (partly), anterior basal (partly) and
lateral basal segments, according the scheme on the right.
The upper (anterior segment) and middle lobe (internal and part of
the external segment) are displayed.
Left superior lobe (anterior segment) and lingula are displayed.
Upper lobe
Lower lobe
Apical (1)
Posterior (2)
Anterior (3)
Superior lingular (4a)
Inferior lingular (5a)
Superior (apical) (6)
Internal basal (7)
Anterior basal (8)
Lateral basal (9)
Posterior basal (10)
e axillary regions are pyramidal spaces with a front wall (pectoralis major and minor
muscle and subclavian muscle) and a rear wall (latissimus dorsi, subscapularis muscle and
teres major). e medial wall is relevant for the sonographer. It is formed by the costal and
intercostal plane, coated by the serratus anterior muscle, corresponding to the upper lobes.
e lower thoracic opening is occupied by the diaphragm. It is circumscribed by the twelfth
vertebra, the ribs along their costal cartilages (from the seventh to twelfth rib) and by the
xiphoid process. For its functional implications, the anatomy of the diaphragm will be described in a separate paragraph.
Tables 1 and 2 illustrate the lobe-segmental topography of the lungs and its relationships with
the thoracic walls. Figures 7, 8 and 9 graphically illustrate these aspects.
38 oracic ultrasound
Midclavicular
line
Apices
Clavicle
position
Fourth
rib
Fifth
intercostal
space
Lower lobe
Upper
Middle
lobe
lobe
Upper
lobe
Lingula
Lower lobe
Clavicle
position
Fourth
rib
Figure 7 – Tracheobronchial tree with a schematic division into lobes (anterior view). The clavicle
defines the apical segments at the top. The fourth rib the upper lobes at the bottom.
Posterior
Apex
Anterior
Lateral
Medial
Lower and upper
lingula
Fourth rib
position
Axillary apex
Anterior
basal
Lateral
basal
Posterior
basal
Apical
Subapical
Figure 8 – Lobar subdivision and lung segmentation, lateral, right and left view, with its skin markers.
Anatomy of chest ultrasound 39
Figure 9 – A: Display of lung lobes on the anterior thoracic wall; B: posterior; C: left lateral; D: right
lateral.
➣ Pleura
I
n healthy subjects, the visceral and parietal pleura and their intervening space have no
evidence with conventional imaging methods. Anatomically the pleural membranes have a
thickness of 0.2-0.4 mm and contain between them
a fluid volume of about 4-18 ml, layered on a 5-10
micron thick lamina. e peripheral pleural surface
is adjacent to the chest wall. It includes the costal
pleura and it is the most represented mesothelium in
the chest. e mediastinal and diaphragmatic pleura
are respectively located medially, and inferiorly to
cover the diaphragm. Usual ultrasound does not
easily differentiate the individual components of
the mesothelial envelope of the lungs. With lower
ultrasound frequencies (in the range between 7
and 13 MHz), as well as with TC, it is possible
to highlight only the combination of parietal and
visceral pleura without evidence of the physiological fluid interposed. e ultrasound image is
normally a pleural echogenic line, which represents
the specular echoes of the interface between solid
tissues of the thorax and the pulmonary aerated
“sponge” (Fig. 10).
Figure 10 – Pleural line displayed with a
13 MHz linear probe.
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