Lung Ultrasound (LUS) Part 2

July 29, 2021

ID6847

To CiteDCA Citation Guide

00:06OK, so now that we have pneumothorax
00:09and pleural effusion under our belts,
00:11we will move on to lung pocus for
00:14pediatric pneumonia and pearls and
00:15pitfalls necessary to be able to
00:18differentiate this entity from other
00:20causes of lower airway inflammation.
00:24So one of the challenges for us
00:27clinicians in diagnosing pediatric
00:28pneumonia is that the physical
00:30exam has an inherent limitations.
00:33In order for us to accurately
00:35differentiate other causes of
00:37lower airway disease in children.
00:39And this is nicely described in
00:42the JAMA 2017 Rational clinical
00:43Examination Systematic Review series
00:45on the topic of pediatric pneumonia.
00:48And so using an infiltrate on chest X ray
00:52as a reference standard for this diagnosis.
00:55There was no single finding that
00:58could reliably differentiate
00:59pneumonia from other causes of
01:01childhood respiratory illness.
01:03While two of the least important
01:05predictors included tachypnoea and
01:07lung findings on the physical exam.
01:12So this JAMA report is really eye
01:15opening because it really puts into
01:18question how much time we should
01:20even be spending on a lung exam
01:23using a stethoscope as opposed to
01:25harnessing our skills to perform
01:27high quality lung pocus exams with
01:30a general awareness of potential
01:32limitations of this modality as well.
01:38So if you look at what's been published
01:41in terms of lung ultrasound for the
01:44diagnosis of childhood pneumonia,
01:47the findings to date are very encouraging.
01:50We have meta analysis data published
01:52from 2015 and the Journal of Pediatrics
01:56in which they evaluated 8 studies,
01:59of which five used highly skilled
02:02operators with experience in
02:04long ultrasound in 765 children.
02:06Lung point of care.
02:08Ultrasound had a sensitivity
02:09of 96% and specificity of 93%
02:12to detect pediatric pneumonia.
02:14All studies incorporated
02:15the use of the linear probe.
02:18However, the reference standard
02:19did have some heterogeneity as
02:22some studies used at chest X ray
02:24alone as the criterion standard,
02:26while others incorporated both clinical
02:29findings with chest X ray results.
02:34So with the linear probe you will
02:36perform a rapid assessment to
02:38interrogate all six lung zones.
02:41He would start with the probe
02:43and the Midclavicular line and
02:45the anterior lung field with the
02:48indicator towards the patient's head,
02:50and slide the transducer
02:52down towards the diaphragm,
02:53and you're going to repeat these
02:56motions in the midaxillary
02:58line as shown and again to the
03:01posterior lung fields like so.
03:03And you would repeat on
03:05the contralateral side.
03:08Now for the most part,
03:10if everything looks normal on the
03:12monitor and you're seeing good at a
03:14lines with this agile orientation,
03:15you can move on to the next zone.
03:18That said, when something jumps
03:19out at me as being abnormal,
03:21such as a break in the pleural line,
03:23or perhaps there's the
03:24start of some beelines,
03:26I will at this point rotate the
03:28probe on that same spot to change
03:30the angle of insulation and try
03:32to get a good overall picture as
03:34to what's going on in this area
03:36of the lung that has an abnormal.
03:38Finding so let's start by taking a look
03:42at what normal lung ultrasound looks like.
03:45Air, as you know,
03:47is a poor transmitter of ultrasound,
03:49so we're not really seeing
03:50lung tissue on the screen,
03:52but rather the artifacts that are
03:54created by the interface of the pleura
03:57with airfield alviola right behind it.
03:59So in this example you have a ping
04:01pong effect from the ultrasound
04:03beam as it directs that first
04:06bright line in the center of the
04:08screen which is the pleura.
04:10And this ping pong effect will cause
04:13reverberation artifacts known as a
04:15lines that are essentially equidistant
04:18from the distance between the probe on
04:20the patient's chest to the plural line.
04:23And the reason for these equidistant
04:25lines is really the well known formula
04:29distance equals velocity times times.
04:31So the ultrasound beam velocity
04:33is a constant,
04:34so it changes is how long it
04:37takes for the ultrasound beam
04:39to travel to get reflected.
04:41Of the pleura.
04:42Depending on the size of the chest
04:45wall and the age of the patient
04:47and so these a lines that are
04:49created behind the pleura are the
04:52same distance from one another.
04:53So the important point here is that a
04:56lines are good and normal and reflect well.
04:59Aerated healthy lung tissue and the
05:01absence of a lines tends to signal
05:03some pathology within the lungs.
05:07So in contrast, B lines are bad and
05:10they are actually created by a different
05:13type of reverberation artifact.
05:15But the lines are a reverberation
05:17artifact nonetheless.
05:18So what tends to happen here
05:20is that when you have wet lung
05:23or fluid filled alveolar sacs,
05:26the ultrasound beam gets trapped within
05:28these fluid filled bubbles and the
05:31ping pong effect rather than occurring
05:33between the probe and the pleura,
05:35actually happens within.
05:37The inflamed and fluid filled
05:39alveoli instead,
05:39and so the images that is created is a
05:43series of tightly packed horizontal lines,
05:46one on top of the other that dive all the
05:49way down to the bottom of the screen,
05:53and as beelines become more diffuse
05:55and more prominent on your monitor,
05:58this is going to be linked with a
06:00more severe process of interstitial
06:03alveolar disease.
06:06OK, so here we have some examples
06:09of abnormal findings by lung
06:11ultrasound in the clip on the left
06:13using high frequency linear probe,
06:15you're able to see a series of the
06:18lines that are all diving down to
06:21the bottom of the screen which are
06:23starting from one area of confluence
06:26between two rib spaces on the
06:28pleura and on the right sided video
06:31clip you can see beelines as would
06:33be created using a phased array.
06:36Transducer again,
06:37these tightly packed horizontal
06:38reverberation artifacts can be
06:40seen to dive all the way down
06:42to the bottom of the screen and
06:44there are no clear lines visible,
06:45so this pattern would always be abnormal
06:48when performing a lung ultrasound.
06:52So when we think about diagnosing lung
06:54alter sound by pony culture sound,
06:57there is a spectrum of findings.
06:59Some of the earlier findings would
07:01be the presence of Beelines alone,
07:03and these can be.
07:05Differentiated into isolated versus conflict,
07:07with confluent being a more concerning
07:10finding and you want to just train
07:13yourself to be a good detective
07:16of pleural changes so you will
07:19become accustomed to disruptions of
07:21the pleural line being a possible
07:24early end concerning finding to
07:26suggest underlying pneumonia and
07:28finally with these plural line
07:31disruptions you can have small sub
07:34centimeter subpleural lesions.
07:35Or collections which are unfortunately
07:38nonspecific and could reflect
07:40either atelectasis or the start
07:42of a infiltrative process.
07:46So here we have a 2 year old boy with
07:49bronchiolitis and reactive airway disease.
07:52You can see over the center of
07:55the screen there is a small divot
07:57and a dip in that pleural line,
08:00so although this would potentially
08:02some lower airway process we should not
08:05be using this finding alone to make
08:07a diagnosis of pediatric pneumonia
08:09by long ultrasound as this is a
08:11very mild and non specific finding.
08:17These following clips show and additional.
08:19I would say progression of
08:21the spectrum of findings.
08:23So on the 1st clip on the left hand side
08:27there is a linear probe and you can see
08:30again disruption of the pleural line.
08:33We would call this an isolated beeline focus
08:37emanating from the same spot in the pleura.
08:40These are tough because they could reflect
08:43early pneumonia versus atelectasis.
08:46On the clip on the right hand side you
08:49can see a greater confluence of the lines,
08:54which again are arising from
08:56a single subpleural focus.
08:58What I would typically do here is
09:02rotate the probe 360 degrees to see
09:05if there are additional findings,
09:08such as air bronchograms or other
09:10signs of nearby lung consolidation.
09:16So here's a good example
09:18of what I'm talking about.
09:19This is a 5 year old with right
09:22upper lobe pneumonia as diagnosed
09:24by lung point of care ultrasound.
09:27With an essentially
09:29unremarkable X-ray at the time,
09:31you can see where the arrow is
09:34placed on the ultrasound image.
09:36There is a confluence of the
09:39lines emanating from the pleura.
09:41As this image is obtained over the
09:44posterior upper lung zone and here
09:46there is a lesion which is bigger
09:48than one centimeter that represents
09:51potential aspiration pneumonia.
09:53That clinically was patient
09:55had some risk factors for so.
09:58Although the X ray was unremarkable,
10:00we did initiate a course of augmentin
10:03and I happened to call the mom the next
10:05day or so who reported improved fever
10:08and also improved worker breathing.
10:10So we were pretty happy with this
10:12outcome that we were able to use
10:14ultrasound to augment our physical exam
10:16to provide the best possible treatment.
10:19Recommendations for this family.
10:23And so here in this patient it was
10:25a five week old with the left upper
10:28lobe infiltrate as diagnosed by X-ray.
10:31And you can see on ultrasound
10:33with the linear probe.
10:34There are confluent be lines
10:36which are spanning across multiple
10:38rib spaces so that it's not just
10:40emanating from a single focus or
10:42a single area of the pleura.
10:44And so this pattern where there is
10:47a larger area of lung involvement
10:49is of course a more concerning.
10:51Finding requires careful interpretation.
10:52And judicious next steps,
10:54especially in a patient that's so young.
10:57So if these findings are diffused
10:59and seen to all long,
11:01then I would interpret as bronchiolitis or
11:05diffuse multifocal pneumonia as opposed to.
11:07In this case it was a symmetric.
11:10So this would suggest some more focal
11:13process of lung tissue consolidation.
11:16Here is another example using
11:18a curvilinear probe.
11:19As this patient is having an
11:21assessment of the loan basis for
11:24likely for a pleural effusion X-ray
11:27consistent with the right middle lobe
11:29infiltrate and you can once again see.
11:34Confluent felines spanning multiple rib
11:35spaces in this patient with pneumonia.
11:38So the tradeoff here is penetration
11:40for resolution.
11:41This is a cover linear probe eval
11:43probably for a pleural effusion,
11:46which is not present.
11:47So although we don't see the pleura
11:50as large and as crisply as we've
11:52been viewing with the linear probe,
11:55you can still get a sense that
11:57these be lines.
11:59Dip all the way down to the
12:01bottom of the screen, even when a.
12:04Lower frequency transducer is
12:06used to scan the lungs.
12:11And finally, here's a 6 year
12:13old drowning victim who arrived
12:15vomiting a pool water but was not
12:18intimidated at the time of this scan.
12:20You can see that there's diffuse
12:22beelines seen throughout all longfields,
12:25and so these are some extra findings
12:27on linear probe interrogation of
12:30the right lung in the left lung and
12:33the bee lines can be seen using the
12:36cardiac or phased array probe as well,
12:39although the beeline artifacts in
12:40this case actually stem from the
12:43diaphragm with otherwise good mirror
12:45imaging and no thoracic spine sign,
12:47so this would exclude pleural
12:49effusion or any.
12:51Lower lobe pneumonia in this area.
12:56And so here in the next set of images
12:59that we're going to look at will be
13:03more advanced findings for pneumonia,
13:05and so these include air bronchograms,
13:08which can either be static or dynamic.
13:13The presence of a shred sign, pleural,
13:16shred sign and hepatization of lung tissue.
13:22So in this three year old patient with
13:25left upper lobe pneumonia by X ray,
13:27which can be seen at pretty clearly
13:29on at the lateral projection.
13:32Lung ultrasound shows static air
13:34bronchograms which are created by
13:36these white punctate spots where
13:39you would otherwise expect to have
13:41a lines if there was normal aerated
13:44lung tissue and I really love this
13:46clip because you can see towards
13:48the left of the screen above the
13:51rib there's an area of multiple
13:54beelines with some confluence,
13:56which if I had seen that alone I
13:58would have been suspicious about
14:01surrounding atelectasis.
14:02Or lung tissue consolidation.
14:06A static or bronchograms can be
14:08tricky because they could be seen
14:10in both pneumonia and atelectasis,
14:12so you really have to correlate
14:15this finding to the clinical exam,
14:17and these are probably instances where
14:19you want to get a chest film as well,
14:23and together with the lung ultrasound you
14:25can make a more accurate interpretation
14:27of the ultrasound findings. In contrast,
14:30dynamic air bronchograms as seen here,
14:32which are reflected by fluid mucus,
14:34phlegm buildup within the
14:36bronchi and bronchioles.
14:37Are the most specific finding for
14:39pediatric pneumonia by lung ultrasound.
14:42However, the incidence of finding
14:44dinamico bronchograms is relatively low,
14:46but you can see here on this clip
14:48motion of the fluid filled bronchi
14:51and you can almost make out the airway
14:54tree and so this is a great example
14:57of what you would be looking for in
15:00terms of dynamic air bronchograms
15:02which have been found to be the most
15:06specific finding for pneumonia.
15:08Using lung ultrasound.
15:10Here we have a 6 year old with
15:14sickle cell disease and acute chest
15:17syndrome as seen by X ray.
15:20In order to have bibasilar airspace
15:23opacities and of course the differential
15:26would be pneumonia versus atelectasis
15:29versus vaso occlusive changes by ultrasound.
15:33You can see a pleural disruption
15:36and shred sign in both the right
15:39and the left posterior lung fields.
15:42The pathology on the right is
15:44somewhat smaller.
15:45Here you can see towards the right
15:48of the screen the diaphragm,
15:50the double line of the diaphragm
15:53with the liver right below it and you
15:57can see disruption and shred of the
16:00pleura with B lines that are diving down.
16:04From the pleural interface and so
16:06the lesion on the left is actually
16:09much much bigger.
16:11There you don't see that clear,
16:13crisp pleura that echogenic
16:15line between the rib spaces.
16:17Because there is tissue consolidation
16:19there instead.
16:20So the shred sign is actually far
16:23lower on the screen about where
16:26the four centimeter marker is,
16:28and this is correlated with the X
16:31ray that appeared to be far worse.
16:34On the left compared to the right.
16:39And here we have a 12 year old with asthma
16:42who also presented with respiratory distress,
16:46found to have pneumonia by X ray and
16:48on lung ultrasound. You can see a
16:51clear hepatization of the lung tissue.
16:53So the probe in this case is a phased
16:56array probe which is placed in the
16:59left anterior zone above the heart.
17:02As you can see on the ultrasound image
17:05the heart is beating on the right side.
17:08And what appears to be liver above it.
17:12But in fact this is diseased lung
17:15tissue which would be reflective
17:17of more advanced pneumonia.
17:20So lines are missing.
17:21And because the disease process is
17:24parenchymal and not solely at the level
17:27of the alveolae or the interstitium,
17:30you do not see any B lines on this image
17:34but just advanced lung tissue consolidation.
17:38Otherwise known as Hepatization because
17:41of the similarities in appearance
17:43when comparing this to the normal
17:46appearance of liver by ultrasound.
17:51So we don't know what the future
17:54impact of lung focus will be.
17:57I believe there are three potential outcomes,
18:00one with integration of the clinical exam.
18:03We hope that pediatric pneumonia
18:06diagnosis can become more reliable.
18:08Ideally, we can make a earlier
18:10diagnosis and reduce the overall
18:13burden of chest radiography.
18:15Another potential impact is over
18:18prescription of antibiotics as.
18:20There's no way to fees abli or reliably
18:23differentiate a viral pneumonia from
18:26a bacterial pneumonia by ultrasound.
18:29And finally,
18:30there's a possibility that we may
18:33actually prescribe less antibiotics.
18:35Given again,
18:36the limitations in the physical
18:38exam and lack of reliability
18:41that X ray has to differentiate
18:44a viral from bacterial process.
18:49So this would be an example of the
18:52first outcome, greater position
18:53and more accurate diagnosis.
18:55So 6 year old male with Hemoglobin SC
18:58presented with fever for two days and
19:01shortness of breath on exam had some
19:03slight elevation in the heart rate,
19:06but otherwise normal oxygen saturation
19:08exam with wheezing and diminished
19:10breath sounds on the left side.
19:12High typical work up was done for SC disease
19:15with fever to include a chest X ray and.
19:19Lab work which revealed no
19:21Leukocytosis on the X ray.
19:24There was no acute cardio
19:26thoracic abnormality as per
19:28the radiologist interpretation.
19:32However, by lung focus there is clear
19:36shred sign in the left posterior
19:39lung field with disruption of
19:42the pleura and beelines emanating
19:45from this jagged pleural edge.
19:48This patient was subsequently admitted
19:51with early recognition of acute
19:53chest on given ceftriaxone and is it
19:56through myosin as per our hematology
19:59treatment recommendations and
20:00incurred a three day hospitalization?
20:03How luckily did not require any
20:06PRBC transfusion and had multiple
20:08negative blood cultures.
20:09This case was several years before we
20:12were routinely obtaining procalcitonin to
20:15help rid stratified bacterial versus viral.
20:18Pneumonia and a viral swab is not
20:20performed as his patient was managed
20:22in the hospital who did well and
20:24completed his course for community
20:26acquired pneumonia as an outpatient.
20:31Here's another example of how we may
20:34provide more efficient care with lung pocus.
20:37So in this clinical case,
20:39a 9 month old presented with
20:42respiratory distress, and this was the
20:443rd ER visit for the same illness.
20:47Had a prior rhinovirus positive
20:49tests in an X ray,
20:51which during the first visit was
20:53more in keeping with Perihilar and
20:56peribronchial interstitial markings,
20:58likely viral airway inflammation.
21:00Most likely bronchiolitis, however,
21:02ongoing fevers cough and some
21:04posts of emesis and increasing
21:05work of breathing and there was
21:08strong family history of asthma.
21:10This infant was takach Arctic with
21:12takip NIA and exam was notable for
21:14attractions and coarse breath sounds,
21:16but no audible wheezes were present,
21:18and the clinical team not only
21:20did a long ultrasound,
21:22but performed a cardiac ultrasound
21:23as well to rule out any other
21:26potential causes of compensated shock.
21:31So interestingly, this infant had one
21:34specific lung area of abnormality
21:36in the left posterior lung field.
21:39You can see here between those ribs.
21:43There is an absence of that
21:46pleural line and shred sign,
21:48so we have a lesion that is certainly
21:51abnormal and needs more thorough evaluation.
21:57So a scan performed on the opposite side,
22:01the right posterior lung field
22:03is here as a comparison,
22:05and you can see the intact pleura throughout.
22:10Spaces and. There are essentially normal
22:15a lines in the different lung zone.
22:18As the probe slides from the top
22:20of the patient down towards the
22:23diaphragm in a sagittal plane.
22:27And so we go back to the left side and
22:31get another clear look here at this sub,
22:35pleural abnormality,
22:36where there's a break in the pleural line.
22:40There's a shed sign and there are
22:43static air bronchograms in this lesion,
22:46demarcated by the arrow.
22:48And So what you do here is you
22:52turn the probe 90 degrees to try
22:54and assess a complete picture.
22:57Of this lesion, so when the probe
23:00is rotated in a transverse plane,
23:03you essentially see a confluence
23:06of beelines dropping down from the
23:09pleura as on the second ultrasound
23:11clip here and again.
23:13If you were to rotate it 90 degrees
23:16with the indicator towards the
23:19patient's head in a sagittal plane,
23:22you would have made out this abnormal
23:25consolidation which is highly suggestive.
23:28Of a pneumonia.
23:31So the clinical course was interesting
23:34for this infant was admitted for
23:36respiratory monitoring after
23:38initiation of hydros amoxicillin for
23:41this long ultrasound finding and X
23:43ray at the time was not obtained and
23:46had a pretty brief hospitalization.
23:48Had no fever, antibiotics ended up
23:50being a discontinued and was discharged
23:53home after some period of monitoring,
23:55which he seemed to do quite well.
24:01Then three days later, he came back,
24:04this now being the 4th ER visit with
24:07persistent fever and respiratory distress,
24:09at which point in X ray was repeated,
24:13showing bilateral findings concerning
24:15for pneumonia and amoxicillin was re
24:18prescribed and able to be discharged home,
24:20and he actually did quite well
24:23without any further emergency
24:24visits for labored breathing.
24:29OK, so the next possible outcome is that
24:32lung focus has the potential to lead to
24:35the prescription of more antibiotics.
24:38And I say this only because it is far
24:40more sensitive to pick up abnormalities
24:43when compared to X ray and viral
24:46pneumonia findings and bacterial
24:48pneumonia findings will have overlapped
24:50and this has been well documented
24:53to date with all the non specific
24:56findings we see with COVID pneumonia.
24:59Here in this case,
25:00we present a 27 month old with respiratory
25:03distress and fever in January 2020,
25:06when COVID pneumonia may have been
25:09circulating in the community.
25:10We don't know for 100%
25:13the symptoms consisted of.
25:16Two to three weeks of cough worse
25:18at night and one day a fever.
25:21Ah was ill appearing on exam
25:23with tachycardia,
25:23low oxygen saturation and takip NIA.
25:25Also was listless with flaring
25:27and accessory muscle use and
25:28diminished breath sounds throughout,
25:30but perhaps were sitting in the right
25:32upper lung field and the next rate
25:34is shown showed no focal infiltrate.
25:40Lang Focus performed in the right upper
25:42lobe showed the following abnormality.
25:45Disruption of the pleura,
25:47shred sign belines and this lesion was
25:51measured to be 1 1/2 centimeter and
25:54concerning for the start of a pneumonia.
26:00So this channel is emitted to the
26:02ICU and IBM PASILAN was initiated
26:05was treated with Bipap and required
26:07continuous albuterol and steroids.
26:10Interestingly, a procalcitonin test
26:11came back normal chest X ray done.
26:14The subsequent date revealed and was
26:16read as a right upper lobe infiltrate
26:19consolidation versus atelectasis,
26:20and this correlated perfectly with the area
26:23of the lung that was imaged the day before.
26:27With that abnormal finding.
26:29Had a three day hospitalization.
26:32Was managed as a bronchiolitis,
26:35a therapy with treatment of
26:38reactive bronchospasm and all
26:40viral tests were negative,
26:42so this child improved fully without
26:46completing a full course of antibiotics.
26:50And finally,
26:51lung ultrasound may have the potential
26:53to decrease antibiotic overuse.
26:55So here's a great example of a
26:5810 month old male with a fever
27:01and suspected pneumonia,
27:02as per clinicians that are referring
27:05hospital who had initiated amoxicillin
27:07with an X ray obtained was read
27:10as haziness in the left lung zone.
27:13Suspicious for pneumonia.
27:14However,
27:15there are definitely some other
27:17things going on clinically to include
27:20a prior COVID positive PCR test
27:2210 days before this presentation
27:24and daily fever for four days.
27:27Popular rash on the torso.
27:29Some lesions to the lip,
27:31gums,
27:31and some swelling to the hands and
27:34feet so multisystem picture and this
27:37infant actually looked quite well
27:39appearing and no respiratory distress.
27:42Playful and unremarkable
27:43physical examination,
27:44and you can see the labs there had a
27:47little thrombocytosis and a slight.
27:50Elevation in the ESR and the CRP.
27:56So in the PDE complete 6 zone,
27:59longer sound was performed and well
28:02tolerated and it revealed essentially the
28:05following findings which run remarkable.
28:08You can see a lines throughout all
28:12the lung zones being interrogated,
28:15and occasionally there's a little divot
28:18at the level of the pleura, but no true.
28:23B line with stacked,
28:25horizontal reverberation dipping down all
28:28the way down to the bottom of the screen.
28:31No shred sign.
28:33No static air bronchograms,
28:34and certainly no signs of hepatization.
28:37So based on these findings we
28:39actually made the recommendation
28:41to discontinue the amoxicillin.
28:46And this little infant was actually
28:49somewhat fascinating as it seemed to
28:52have some sort of mild inflammatory
28:55picture with a slightly elevated
28:58BNP and a slightly elevated D dimer
29:01was admitted for surveillance with
29:03concern for MIC normal echocardiogram
29:06during the admission, and there was
29:09no progression or decompensation,
29:11so the team was able to.
29:14The first steroids and IVIG.
29:17And had a great follow up visit
29:1910 days later with normalization
29:21of the inflammatory markers and
29:23was clinically well appearing and
29:26back to herself at this point.
29:31So there's lots of further inquiry that
29:34is necessary so that we can fine tune
29:37how to integrate lung pocus as part of
29:41our workups for pediatric pneumonia.
29:43And it's possible that we will have to
29:46incorporate long ultrasound findings
29:48with not only physical exam but also
29:51some laboratory values to make good
29:54decisions about antibiotic stewardship.
29:56And there's also some instances
29:58where lung ultrasound.
30:00Will have to be incorporated in
30:02parallel with chest radiography
30:04in certain instances to minimize
30:06our risk for misdiagnosis.
30:11And so here in this final case you can
30:15see we have a 21 year old with fever,
30:18wheezing and decreased
30:19breath sounds on the right.
30:21On this frontal projection of the X ray,
30:24you can see that there is an
30:26obvious abnormality that could
30:28be interpreted as pneumonia.
30:30If you put the lung probe as was done
30:33in this case, right over this lesion,
30:35you can see a mass like finding which
30:38could be misconstrued as hepatization.
30:40There is no lines.
30:42There are no body lines.
30:44There is no shred sign.
30:46There is no static air bronchograms
30:49and this tissue doesn't quite look
30:51hypothesized like in the prior example.
30:54So if you're up to obtain
30:57a lateral chest X ray,
30:59this diagnosis is more consistent
31:01with the anterior mediastinal mass,
31:03and this young man was subsequently
31:06diagnosed with a lymphoma.
31:07So the important point here
31:10is that a chest wall mass.
31:13We can mimic potentially the
31:15appearance of hepatocytes lung tissue,
31:17and this needs to be carefully
31:19accounted for during the clinical
31:21assessment of our patients.
31:25A couple of other pitfalls and
31:28potential false positives in the right
31:31clinical scenario, sinus can appear.
31:35Is a homogeneous you know appearing mass
31:39typically is this is found anteriorly.
31:44In front of the heart and can be seen.
31:47In my experience both on the right side
31:50and in the left side of the chest with
31:53integration of the anterior lung fields.
31:56So we must be able to recognize thymus
31:58tissue as normal and actually one
32:01of the keys for me is the plural.
32:04So in this image of thymus you
32:06can still make out the echogenic
32:08bright pleura in between the rib
32:11spaces and so that to me is a clear
32:14indicator that this is not consistent.
32:17With long hair participation or pneumonia.
32:21Finally, in the left upper quadrant,
32:24especially when assessing for.
32:27A fusion with the curvilinear probe,
32:30the stomach, when it is filled
32:32with mixed content to include air,
32:34can give off a bright echogenic appearance.
32:37So you really want to be very
32:39clear as to whether these findings
32:42are above or below the diaphragm.
32:44So in this particular image you're
32:46not seeing the diaphragm clearly,
32:48but you're seeing pleura at the
32:51top of the screen,
32:52next to the P with the lung sliding.
32:55And so you see, pleura rib pleura.
32:58Read you don't quite see the diaphragm,
33:01but the spleen.
33:02Is there,
33:03UM,
33:03right adjacent to the rib shadow
33:05that is in the center of the screen
33:08and the stomach with airfield and
33:11mixed contents is giving off a
33:13bright appearance behind this plane.
33:16So location, location,
33:17location and pattern recognition
33:18and knowing your landmarks and what
33:21you're looking for are going to
33:23be very important to minimize your
33:25false positive interpretations.
33:29So this is such an exciting modality,
33:32but we're clearly not doing this
33:34protocolized on every patient,
33:36and there are lots of reasons why this is so.
33:40Number one from a practical standpoint,
33:42it takes time, which it takes a longer
33:45time for the setup and the process
33:47of completing a high quality long
33:50ultrasound in a infant and a toddler as
33:53opposed to an X ray is just a quick.
33:58Picture with a plate on the
33:59back or on the side.
34:01Patient cooperation does come into play here,
34:04so you really have to.
34:07Engage, you know the caregiver
34:09to be a partner, and you know,
34:12sometimes you know.
34:13Patients just are not going to
34:16tolerate either the gel or the probe,
34:19or just the whole process in general and
34:23we need adequate training and we need to
34:26reach a level of competency across the
34:30board that is not yet been well established.
34:33And unfortunately,
34:34when doing research around this topic.
34:37There are serious challenges related
34:40to assigning an incontrovertible
34:42referenced or criterion standard,
34:43but for resource limited settings and
34:46for individuals who are comfortable
34:48at performing lung ultrasound and
34:51are able to interpret findings
34:53in the clinical context,
34:55this is an invaluable tool with tremendous
34:58promise for the future care of our
35:01pediatric patients with respiratory
35:03distress or unexplained chest pain,
35:06and there is certainly a lot of enthusiasm.
35:10And momentum behind for lung pocus
35:13to increase our position in emergency
35:16medicine when we are challenged to make
35:19clinical decisions with oftentimes
35:22imperfect and limited information.
35:28This concludes our introduction
35:30to lung ultrasound Part 2.
35:32We hope you find this
35:35information useful and.
35:36If there are any questions,
35:38please don't hesitate to reach out,
35:40otherwise we will see you
35:41soon and this content will be
35:43updated as deemed necessary.