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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5795_Библиотеки_им_академика_М_И_Перельмана.pdf
248
M. Riccabona
a
b
c
dd
Fig. 12.10 Pleural cysts and tumours: (a, b) Pleural metastasis, particularly well seen with pleural
effusion. (c) Sagittal view, sector transducer, infant with adrenal carcinoma: tumour has invaded
through diaphragm into thoracic cavity. (d) Cystic midline lesion suggesting midline connection
and mediastinal position (arrow). (e) Same patient as in image d—after insertion of a drain cyst
lled with diluted US contrast agent (intracavitary ce-US) proving left-right connection, but not
demonstrating any drainage (e.g. into pleural space) in a newborn with cystic dilatation of the
thoracic lymphatic duct
• May guide diagnostic/therapeutic aspiration/drainage (Fig.12.11).
• Applicable at bedside, in ICU/NICU, ER, etc.
Additional/Complementary Imaging
• Plain lm, particularly in initial diagnosis, considered compulsory.
• In complex situations ce-US, CT, uoroscopy, MRI, scintigraphy and biopsy.
12 Ultrasound oftheChest
Fig. 12.11 Pleural drainage/puncture: (a) Puncture needle (arrow) entering pleural space. (b) Tip
of chest drain (arrow) visualised in some residual effusion with sedimentation after pleural
haemorrhage
249
12.5 Pathology ofDiaphragm
12.5.1 Diaphragmatic Hernia
Denition
Defect of diaphragm with potential displacement of abdominal structures into chest.
US ndings
• Gap in diaphragm: discontinuity may be difcult to visualise.
• Indirect sign: abnormal shape, displacement of abdominal structures into chest:
– Particularly intestinal structures lled with uid (Fig.12.12).
– Hiatal/Bochdalek hernia: ll stomach/intestines by liquid feed.
– Without structural herniation: difcult to differentiate diaphragmatic eventra-
tion versus hernia, particularly on right side (liver covering defect, usually in
brous part) (Fig.12.12c).
Note Differentiation of small gap from eventration of diaphragm may be impossi-
ble; same applies to reliable “exclusion” of diaphragmatic hernia. For hiatal hernias
lling of stomach for examination is essential for diagnosis (as done also in
uoroscopy).
12.5.2 Diaphragmatic Motion Disturbance
Changes in diaphragmatic mobility easily seen:
• Documented by video clips or M-mode (see Fig.12.2).
• Correlation with respiratory manoeuvres: allows differentiation of relaxation
from palsy or reduced mobility (e.g. secondary to pneumonia or trauma):
250
cd
M. Riccabona
ab
e
f
g
St
Fig. 12.12 Diaphragmatic hernia: (a) Paramedian sagittal section in a neonate with diaphrag-
matic hernia—uid-lled stomach reaches up into left chest through defect, which is only partially
covered by liver. (b) Axial transhepatic view tilted cranially behind liver muscular remnants of
diaphragm seen—but dorsally, liver parenchyma and intestinal loops herniated into right thoracic
cavity. (c) Diaphragm “bump” (eventration) on an axial oblique transhepatic/abdominal view tilted
cranially. (d) A thrombus-like herniation of liver indenting the right atrium (+ …. +), with suspicion of stomach herniation into chest (arrow) through same hiatal hernia (e)—gradually becoming
more obvious when stomach (St) lled with uid (+…+) (f, g)
12 Ultrasound oftheChest
– Diaphragmatic palsy—paradoxical motion.
– Relaxation—absent or minimal motion, but symmetric during respira-
tory cycle.
Note Assessment of diaphragmatic palsy should always be performed without
positive pressure ventilation (will mask abnormal motion).
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12.5.3 Role andPotential ofImaging
US Primary tool in assessment of suspected diaphragmatic pathology.
Additional Imaging Plain lm, uoroscopy, cross-sectional imaging.
• Only in equivocal situations.
12.6 Lung Pathology
12.6.1 Pneumonia
Denition
Inammatory change of various reasons.
• US appearance not specic in terms of aetiology.
US Findings (Fig.12.13):
• Liver-like aspect of fully non-aerated lung tissue, some mass effect.
• More or less echogenic stripes with tree-like appearance (sonographic air bronchogram):
– Potentially change with respiration.
– Depend on amount of uid in bronchial structures.
DDx Dys-/atelectasis, infarction, other inltration.
12.6.2 Lung Abscess
Denition
Complication of infection and/or aspiration.
US Findings
Seen if access possible (through pneumonic lung, etc.) (Fig.12.14):
• As any abscess elsewhere: complex cystic mass with membrane-like wall.
• Potentially uid–uid or uid–air levels.
252
Fig. 12.13 Pneumonia. Two typical images of pneumonia—with more or less perceived sonoairbronchogram and reactive pleural effusion
M. Riccabona
abc
Fig. 12.14 Lung necrosis and abscess. Three conglomerating lung abscesses: Depicted on grey
scale (a) without perfusion on CDS (b). aCDS reveals more conspicuously vascularised and nonperfused necrotic areas (c)
CDS No central vascularisation, well-vascularised hyperaemic capsule.
• Potentially bronchial/pleural arterial supply particularly with long history.
DDx Other complex cyst, necrosis (may be indistinguishable) and haemorrhage.
12.6.3 Atelectasis
Denition
Area of hypoination, if completely non-ventilated = atelectasis, if some areas show
residual ventilation = dystelectasis.
US Findings
Similar to pneumonia—liver-like appearance of lung tissue, without any central air
echoes, collapsed aspect with concave surface (Fig.12.15):
12 Ultrasound oftheChest
Fig. 12.15 Atelectasis: (a) Axial transhepatic view: atelectatic, echogenic, concave-shaped
lung—compressed by pleural effusion. (b) Sagittal view: peripherally collapsed lung—minimal
atelectasis of dorsolateral lung with secondary effusion
253
• Potentially bronchial/vascular structures can be discriminated as tubular bands.
• If residual air in central bronchi, sonographic air bronchogram seen:
– Similar to pneumonia.
Note These and pneumonic changes only visible when pathology reaches lung
periphery, becoming accessible for US.
12.6.4 Respiratory Distress Syndrome (RDS)/Hyaline Membrane
Syndrome, Wet lung, Alveolo-interstitial syndrome
Denition
RDS = Surfactant deciency, typically in preterm neonates due to immature lung or
secondary to surfactant consumption—results in secondary collapse of alveolus. Wet
lung = incomplete peripheral, particularly basal aeration of lung after birth; alveolointerstitial syndrome = mixture of entities that cause peripheral lung changes such as
thickened or oedoematous interstitium, alveolar collapse or uid content, etc.
Note Possibly prediction of bronchopulmonary dysplasia (BPD) by lung US:
incomplete resolution of retrodiaphragmatic hyperechogenicity by the second or
third week = high probability for BPD.
US Findings
Typical application of new LUS based on artefact interpretation using different
signs and lines (Table12.1).
• More or less inhomogeneous echogenicity from reduced ventilation—varying
degree of sound penetration, potentially changing with respiration allows some
grading as well as assessment during follow-up
254
M. Riccabona
• Higher echogenicity than in pneumonia or atelectasis, sometimes (mild RDS)
only surface echo visible.
• Potentially atelectasis-like appearance.
• Other appearances: conuent B-lines, pleural line and subpleural abnormalities
without spared areas.
12.6.5 Sequestration
Denition
Lung tissue without function, usually without connection to tracheobronchial system. Part of spectrum of various congenital lung/foregut malformations (Fig.12.16a).
Usually atypical vascular supply:
• Commonly from aorta, potentially draining into systemic vein.
• Typically positioned in lower lobes, particularly left sided.
US Findings
Usually best seen from abdominal approach (Fig.12.16b):
Fig. 12.16 Sequestration and lung malformations: (a) Schematic demonstration of the range of
foregut malformations, graded depending upon amount of tissue and/or vessel alteration. (b)
Typical sagittal US image of in this case an infradiaphragmatic echogenic sequestration in a neonate with right-sided diaphragmatic hernia. NOTE: intrathoracic liver and slight effusion, as well
as preserved part of diaphragm covering sequestration. (c) CDS reveals the systemic vascular supply, in this case deriving from a thoracic artery (chest wall vessel)
12 Ultrasound oftheChest
255
• More or less homogeneous, slightly echoic, space-occupying lesions.
• May have complex inhomogeneous appearance with cysts (hybrid lesion).
• Large tubular structures often seen represent vessels.
• Displaces lung, rarely also intraabdominal.
CDS Commonly large-supplying artery deriving from abdominal aorta
(Fig.12.16c):
• Draining vein depictable if drains into abdominal inferior cava; allows differen-
tiation of intra-versus extralobar sequestration.
Note Sequestration may also occur infradiaphragmatically.
Duplex Findings
• If waveform resembles aorta/systemic veins, indicates systemic vascular sup-
ply—extralobar sequestration.
• If ow pattern resembles pulmonary artery/pulmonary vein, indicates vascular
supply from pulmonary circulation—intralobar sequestration.
12.6.6 Congenital Cystic Adenomatoid Malformation (CCAM)
Denition
Part of spectrum of foregut malformations (see Fig. 12.17a). Typically three types
differentiated, depending on cyst size:
• Type 1 = large cyst(s) >2cm.
• Type 2 = multiple medium-sized cysts around 1cm.
• Type 3 = pseudosolid mass with multiple microcysts not resolvable by US.
US Findings
More or less echoic, complex mass (Fig.12.17):
• Varying number and size of cysts depending on type.
• Between cysts there can be echogenic septae.
CDS No large vessels, some vascular supply sometimes seen.
DDx Atypical form of sequestration, hybrid lesion, bronchial atresia with non-
aerated malformed lung tissue, if more homogenous—thoracic kidney (usually in
the dorsal paramedian basal part of the chest).
256
M. Riccabona
a b
Fig. 12.17 (a) CCAM: CCAM type I (large macrocysts, + +)—difcult to differentiate from
other uid-lled/cystic mass (bronchogenic, cystic sequestration, etc.). (b) More solid looking
mass with only a few cysts (types II–III)
12.6.7 Cysts
Denition
Fluid- or (if connected to tracheobronchial system) air-containing lesions:
• Seen only if positioned close to lung surface.
US Findings
Simple cyst(s) of varying size (Fig.12.18a):
• Posterior acoustic enhancement, smooth surface.
• Separation from other entities difcult.
• If lled with air, bright reverberation echoes without change during respiratory
cycle, thus distinguishable from normal lung (Fig.12.18b).
• Bronchial cysts—potentially air-uid levels (may be difcult to depict)
(Fig.12.18c).
DDx Echinococcus/hydatid cyst (focus on typical wall appearance):
• Complicated cysts (echoes within lumen, aetiology not denable by US).
• Pericardial/pleural cysts.
• Postinammatory cysts, abscess, AV-malformation (use CDS).
12.6.8 Infarction
Denition
Pulmonary artery embolism (PAE).
US Findings
Pneumonia-like subpleural triangular areas without perfusion.
12 Ultrasound oftheChest
Fig. 12.18 Cyst: (a) Fluid-lled bronchial cyst—could be any kind of chest cyst adjacent to
mediastinum. (b) Air-lled bronchogenic cyst. (c) Huge bronchial cyst connected to bronchial
system—air-uid level
257
• Usually hypoechoic, liver-like appearance, often relatively homogeneous:
– Beginning—some ventilation possible.
– Later stage—completely resemble pneumonia, but no pulmonary vessels
depicted by (a)CDS.
CDS No central vascularisation/ow, no pulmonary vascular supply (Fig.12.19):
• Some pleural vessels may be depicted.
Note Perfusion decit for other reasons (cardiac, postoperative, etc.) sometimes
difcult to distinguish, but tends to be more global, with less pronounced changes
of the lung echotexture; physilogically also less vascularity in unventilated collapsed lung of any other cause.
12.6.9 Tumours andSpace-Occupying Lesions
Denition
Lung tumours rare in children. US has limited role:
• One may visualise tumours if reaches lung surface.
US Findings
US ndings vary depending on tumour and composition (Fig.12.20):
• More or less echogenic, potentially necrotic areas or calcications.
• Sometimes origin depictable—allows speculation on aetiology.
CDS Evaluate vascularisation, depict necrosis, asses supplying/draining vessels: