Lung Ultrasound Part 2

Transcript

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