Name: point-of-care lung ultrasound in adults: image acquisition
Uploaded: 2023-03-03T14:45:00
Description: Watch this Scientific Journal Video about Point-of-Care Lung Ultrasound in Adults: Image Acquisition at JoVE.com

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
1. Instrument settings and probe selection
NOTE: Lung POCUS can be performed with a multitude of transducers depending on what question needs to be answered.
<ol>
	<li>Superficial lung in...

<ol>
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L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reducing+iatrogenic+pneumothoraces:+Using+real-time+ultrasound+guidance+for+pleural+procedures.">Reducing iatrogenic pneumothoraces: Using real-time ultrasound guidance for pleural procedures.</a> Critical Care Medicine. 47 (7), 903-909 (2019).</li><li>Tusman, G., Acosta, C. M., Costantini, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonography+for+the+assessment+of+lung+recruitment+maneuvers.">Ultrasonography for the assessment of lung recruitment maneuvers.</a> Critical Ultrasound Journal. 8 (1), (2016).</li><li>McGinness, A., Lin-Martore, M., Addo, N., Shaahinfar, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+unmet+demand+for+point-of-care+ultrasound+among+general+pediatricians:+A+cross-sectional+survey.">The unmet demand for point-of-care ultrasound among general pediatricians: A cross-sectional survey.</a> BMC Medical Education. 22 (1), (2022).</li><li>Liu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Protocol+and+guidelines+for+point-of-care+lung+ultrasound+in+diagnosing+neonatal+pulmonary+diseases+based+on+international+expert+consensus.">Protocol and guidelines for point-of-care lung ultrasound in diagnosing neonatal pulmonary diseases based on international expert consensus.</a> Journal of Visualized Experiments. (145), e58990 (2019).</li><li>Liu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Specification+and+guideline+for+technical+aspects+and+scanning+parameter+settings+of+neonatal+lung+ultrasound+examination.">Specification and guideline for technical aspects and scanning parameter settings of neonatal lung ultrasound examination.</a> The Journal of Maternal-Fetal &amp; Neonatal Medicine. 35 (5), 1003-1016 (2022).</li><li>Volpicelli, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+evidence-based+recommendations+for+point-of-care+lung+ultrasound.">International evidence-based recommendations for point-of-care lung ultrasound.</a> Intensive Care Medicine. 38 (4), 577-591 (2012).</li><li>Fox, W. C., Krishnamoorthy, V., Hashmi, N., Bronshteyn, Y. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pneumonia:+Hiding+in+plain+(film)+sight.">Pneumonia: Hiding in plain (film) sight.</a> Journal of Cardiothoracic and Vascular Anesthesia. 34 (11), 3154-3157 (2020).</li><li>Kok, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparing+lung+ultrasound:+extensive+versus+short+in+COVID-19+(CLUES):+A+multicentre,+observational+study+at+the+emergency+department.">Comparing lung ultrasound: extensive versus short in COVID-19 (CLUES): A multicentre, observational study at the emergency department.</a> BMJ Open. 11 (9), 048795 (2021).</li><li>Kiamanesh, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lung+ultrasound+for+cardiologists+in+the+time+of+COVID-19.">Lung ultrasound for cardiologists in the time of COVID-19.</a> The Canadian Journal of Cardiology. 36 (7), 1144-1147 (2020).</li><li>Picano, E., Scali, M. 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Count backwards from 10 Available from: <a target="_blank" href="https://www.countbackwardsfrom10.com">https://www.countbackwardsfrom10.com</a> (2023)</li><li>Mojoli, F., Bouhemad, B., Mongodi, S., Lichtenstein, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lung+ultrasound+for+critically+ill+patients.">Lung ultrasound for critically ill patients.</a> American Journal of Respiratory and Critical Care Medicine. 199 (6), 701-714 (2019).</li><li>Volpicelli, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lung+ultrasound+B-lines+in+interstitial+lung+disease:+moving+from+diagnosis+to+prognostic+stratification.">Lung ultrasound B-lines in interstitial lung disease: moving from diagnosis to prognostic stratification.</a> Chest. 158 (4), 1323-1324 (2020).</li><li>Retief, J., Chopra, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pitfalls+in+the+ultrasonographic+diagnosis+of+pneumothorax.">Pitfalls in the ultrasonographic diagnosis of pneumothorax.</a> Journal of the Intensive Care Society. 18 (2), 143-145 (2017).</li><li>Lichtenstein, D., Meziere, G., Biderman, P., Gepner, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+comet-tail+artifact:+An+ultrasound+sign+ruling+out+pneumothorax.">The comet-tail artifact: An ultrasound sign ruling out pneumothorax.</a> Intensive Care Medicine. 25 (4), 383-388 (1999).</li><li>Arbelot, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lung+ultrasound+in+emergency+and+critically+ill+patients:+Number+of+supervised+exams+to+reach+basic+competence.">Lung ultrasound in emergency and critically ill patients: Number of supervised exams to reach basic competence.</a> Anesthesiology. 132 (4), 899-907 (2020).</li><li>Soldati, G., Demi, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+lung+ultrasound+images+for+the+differential+diagnosis+of+pulmonary+and+cardiac+interstitial+pathology.">The use of lung ultrasound images for the differential diagnosis of pulmonary and cardiac interstitial pathology.</a> Journal of Ultrasound. 20 (2), 91-96 (2017).</li><li>Schrift, D., Barron, K., Arya, R., Choe, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+POCUS+to+manage+ICU+patients+with+COVID-19.">The use of POCUS to manage ICU patients with COVID-19.</a> Journal of Ultrasound in Medicine. 40 (9), 1749-1761 (2021).</li><li>Narasimhan, M., Koenig, S. J., Mayo, P. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advanced+echocardiography+for+the+critical+care+physician:+part+2.">Advanced echocardiography for the critical care physician: part 2.</a> Chest. 145 (1), 135-142 (2014).</li><li>Balik, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+estimation+of+volume+of+pleural+fluid+in+mechanically+ventilated+patients.">Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients.</a> Intensive Care Medicine. 32 (2), 318 (2006).</li><li>Zieleskiewicz, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+study+of+lung+ultrasound+and+chest+computed+tomography+scan+in+the+assessment+of+severity+of+confirmed+COVID-19+pneumonia.">Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia.</a> Intensive Care Medicine. 46 (9), 1707-1713 (2020).</li><li>Bronshteyn, Y. 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Diagnostic POCUS is the use of ultrasound at the bedside by a patient&#39;s primary treatment provider to answer clinical questions. The questions most amenable to diagnostic POCUS are those that are qualitative or binary in nature and that need to be answered faster than would be possible or practical with consultative ultrasound services.
A few steps are critical for image acquisition. The first one is probe selection. The authors recommend that the initial assessment be performed using the ...

Over the past several decades, bedside decision-making and treatment have increasingly been augmented by point-of-care ultrasound (POCUS). POCUS is the use of ultrasound for diagnostic or procedural guidance by a patient&#39;s primary treatment provider. This is in contrast to consultative ultrasound, where the ultrasound exam is requested by a patient&#39;s primary treatment provider but is performed by a separate specialist team1.
This narrative review focuses on diagnostic POCUS of a specific organ system: the lungs. Diagnostic POCUS of the lungs has proven useful in the acute care setting, allowing the diagnosis of potentially life-threatening conditions in scenarios of respiratory failure, shock, trauma, chest pain, and other situations2. Further, procedural lung POCUS is being used to guide needle placement in percutaneous thoracentesis3 and lung recruitment maneuvers4. However, despite its clinical significance, lung POCUS proficiency among physicians&#160;is variable5, limiting the appropriate use of this modality. The purpose of this review is to describe a time-efficient yet thorough image acquisition protocol for diagnostic lung POCUS in adults and to illustrate abnormal findings commonly found in clinical practice. The method described herein is not suitable for newborns and small infants. For information regarding lung POCUS imaging techniques and interpretation in this particular age group, the reader is invited to refer to specific literature6,7.
There are multiple imaging protocols described in the literature, varying from four-point to 28-point exams depending on how much time is available and what questions the exam is seeking to answer8. While the diagnostic accuracy for certain pathologies might be higher when more points are scanned, a focused six-point protocol offers a reasonable trade-off between efficiency and diagnostic accuracy2,9,10,11,12.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Edge 1 ultrasound machine</td>
			<td>SonoSite</td>
			<td>n/a</td>
			<td>Used to obtain two of the abnormal images/clips (Figures 11 and 12)</td>
		</tr>
		<tr>
			<td>Affiniti ultrasound machine</td>
			<td>Philips</td>
			<td>n/a</td>
			<td>Used to obtain all normal and all abnormal images/clips except for Figures 11 and 12</td>
		</tr>
	</tbody>
</table>

point-of-care lung ultrasound in adults: image acquisition

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally prevents direct visualization of the lung parenchyma. When showing the lung parenchyma, ultrasound typically generates a number of non-anatomic artifacts. However, over the past several decades, these artifacts have been studied by diagnostic point-of-care ultrasound (POCUS) practitioners, who have identified findings that have value in narrowing the differential diagnoses of cardiopulmonary dysfunction. For instance, in patients presenting with dyspnea, lung POCUS is superior to chest radiography (CXR) for the diagnosis of pneumothorax, pulmonary edema, lung consolidations, and pleural effusions. Despite its known diagnostic value, the utilization of lung POCUS in clinical medicine remains variable, in part because training in this modality across hospitals remains inconsistent. To address this educational gap, this narrative review describes lung POCUS image acquisition in adults, including patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

Normal lung ultrasound findings&#160;(Video 1, Video 2, Video 3, Video 4, Video 5, Video 6, and Supplementary File 1) 
Due to the marked discrepancy in acoustic impedance between the air in the lungs and the superficial tissues, normally all the ultrasound energy that reaches the interface of the parietal and visceral pleurae is immediately reflected back to the ultrasound transducer. As a result, at the depth of the lung parenchyma, the image seen on the screen of an ultrasound machine normally sho...

Watch this Scientific Journal Video about Point-of-Care Lung Ultrasound in Adults: Image Acquisition at JoVE.com

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Point-of-care ultrasound (POCUS) of the lungs provides quick answers in rapidly changing clinical scenarios. We present an efficient and informative protocol for image acquisition for use in acute care settings.

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally ...

This protocol is a simple, but high yield approach to lung ultrasound image acquisition that evaluates three zones per hemithorax to screen for plural and pulmonary pathology. This technique efficiently samples each of the five lobes of the lung, in contrast to shorter protocols that omit posterior lung zones entirely, or longer protocols that are time consuming. This entire protocol can be performed by busy acute care providers in less than five minutes.To begin, perform lung POCUS using a linear high-frequency probe. Use a low-frequency ultrasound probe to evaluate anything deeper than the interface of the visceral and parietal pleurae. To preset the machine, select abdomen, select varying depth, then select harmonic imaging disabled, followed by an indicator to the left of the screen.Perform most of the study in a two-dimensional gray-scale mode called, brightness mode. Perform the studies with the patient sitting up or supine. Divide each hemithorax into three regions reflecting the anatomic segmentation of the lungs.In the left chest, treat the lingula as the left side analog of the right middle lobe. Apply ultrasound gel to the transducer. Scan the right hemithorax by placing the probe in the mid clavicular line in the first to third intercostal spaces.Position the probe in the parasagittal orientation, with the indicator mark pointing cranially. Now, click axis"and center the axis on the plural line, so that the cranial and codal rib shadows are visible on the edges of the images. If the dominant pattern is A lines with more than, or equal to, two B lines, decrease the depth so that only a single A line is visible.If there are three B lines or more, increase the depth until at least two A lines are visible. Next, select the overall gain and adjust the gain until the plural line and A lines are visible as distinctly echogenic lines and the spaces between the plural line and A-lines are hypo-echoic. Then, click on acquire.To visualize the right-middle lobe, place the probe in the anterior axillary line in the fourth to fifth intercostal space. Position the probe midway between the parasagittal and coronal orientations with the indicator mark pointing cranially. Set the axis, depth and overall gain as demonstrated earlier, and click acquire.To image the right lower lobe, place the probe in the mid to posterior axillary line, in the fifth to seventh intercostal space. Position the probe in the coronal plane, with the indicator mark pointing cranially. Now, click the axis and center the axis on the diaphragm, such that both the sub-diaphragmatic and super-diaphragmatic structures are visible at the same time.Click depth"and increase the depth until the subdiaphragmatic spine is visible. Click overall gain"and increase the gain until the liver or spleen appears slightly hyper-echoic. Next, scan the left hemothorax, and image the left upper lobe, by placing the probe in the mid clavicular line in the first to third intercostal space.Position the probe in the parasagittal orientation with the indicator mark pointing cranially. Set the axis, depth and overall gain as shown previously and acquire the images. To visualize the lingula of the left upper lobe, place the probe in the anterior axillary line in the fourth to fifth intercostal space.Position the probe midway between the parasagittal and coronal orientations with the indicator mark pointing cranially. Set the axis, depth and overall gain as shown while imaging the right upper lobe and acquire the images. Similarly, visualize the left lower lobe by placing the probe in the mid to posterior axillary line in the fifth to seventh intercostal space, and positioning the probe in the coronal plane with the indicator mark pointing cranially.Again, set the axis, depth and overall gain as demonstrated while imaging the right lower lobe and acquire the images. The B-mode clip shows a static plural line consistent with a pneumothorax. However, the M-mode tracing shows a barcode intermittently interrupted by a seashore pattern.This situation occurs commonly when trying to use M-mode to screen for pneumothorax. When a pneumothorax is present, The M-mode findings are often more ambiguous than the B-mode findings. A linear high-frequency transducer shows the L1 view with normal lung sliding and likely B-lines, and the R2 view without any of the following.No lung sliding, no lung pulse, and no B-lines. The absence of these three findings is highly suggestive of pneumothorax. The only finding that is thought to be pathognomonic for pneumothorax is a lung point.A lung point refers to the presence of lung sliding entering into, and then retreating completely, from an otherwise static plural line. The static plural line indicates the location of the pneumothorax. One to two thin B-lines per rib interspace are considered within the range of normal.However, three or more B-lines, or a large confluent B-line occupying most of an interspace is considered pathological. An anechoic or hypo-echoic space between the parietal and visceral pleurae, indicating a plural effusion, is seen. R-3 view obtained in a patient in the setting of pericardiac arrest showed heterogeneous plural effusion with free floating debris.This was due to acute bleeding into a chronic right plural effusion, creating a right-sided hemothorax. An L3 view showing two signs of lung consolidation shred sign and dynamic air bronchograms. Shred sign refers to the presence of an irregular hyper-echoic line in the middle of the lung parenchyma, from which vertical ring down artifacts propagate.Dynamic air bronchograms are point-like, round decogenic areas within a consolidation that move during the respiratory cycle. When performing this procedure, it is important to adjust each view until the key expected structures are seen. The key structures for anterior, slash, intra-lateral views, are the plural line and ribs.For posterior lateral views, the key structures are the following:the diaphragm, the subdiaphragmatic spine, the liver, slash, spleen, and the super diaphragmatic space. This protocol is designed to rapidly narrow the differential diagnosis of acute pulmonary dysfunction. Types of pulmonary dysfunction that would justify this lung ultrasound protocol include any of the following:tachypnea, dyspnea, hypoxemia and or hypercapnia.

Research

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