Thoracic Ultrasound For Diagnosing Pulmonary Embolism

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Information about Thoracic Ultrasound For Diagnosing Pulmonary Embolism
Health & Medicine

Published on February 26, 2009

Author: basselericsoussi

Source: slideshare.net

Thoracic Ultrasound for Diagnosing Pulmonary Embolism (TUSPE): A Prospective Multicenter Study of 352 Patients Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois College of Medicine

Pulmonary Embolism The incidence of PE in the United States is 23 to 69 per 100,000 CT pulmonary angiography (CTPA) is the method of choice for the diagnosis of central PE CT is not a standard procedure to investigate subpleural lesions in PE Not available in some centers Patients with unstable hemodynamics cannot easily be transported Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

The incidence of PE in the United States is 23 to 69 per 100,000

CT pulmonary angiography (CTPA) is the method of choice for the diagnosis of central PE

CT is not a standard procedure to investigate subpleural lesions in PE

Not available in some centers

Patients with unstable hemodynamics cannot easily be transported

Sonomorphology of PE on the B-mode Sonographic Image Lung infarcts in autopsy lungs of patients with PE Ultrasound images from living patients were similar to the image of the autopsy lung Location, form and size corresponded exactly with pathological findings Ultrasound showed wedge-shaped hypoechoic areas Fresh infarct: homogeneous and more hypoechoic. Older infarct: well demarcated and showed a hyperechoic reflex in the center corresponding to the bronchiole Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol 1993;17,170-174

Lung infarcts in autopsy lungs of patients with PE

Ultrasound images from living patients were similar to the image of the autopsy lung

Location, form and size corresponded exactly with pathological findings

Ultrasound showed wedge-shaped hypoechoic areas

Fresh infarct: homogeneous and more hypoechoic.

Older infarct: well demarcated and showed a hyperechoic reflex in the center corresponding to the bronchiole

Technique Arms should be raised, hands should be placed at the back of the head in order to slightly extend the intercostal spaces and rotate the scapula outward. The surface of the lung was scrutinized for subpleural lesions on standardized longitudinal sections and along the intercostal spaces 3.5 to 6 MHz 5 curvilinear probe is ideal Place the probe on the chest wall longitudinally and along the intercostal spaces Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

Arms should be raised, hands should be placed at the back of the head in order to slightly extend the intercostal spaces and rotate the scapula outward.

The surface of the lung was scrutinized for subpleural lesions on standardized longitudinal sections and along the intercostal spaces

3.5 to 6 MHz 5 curvilinear probe is ideal

Place the probe on the chest wall longitudinally and along the intercostal spaces

TUS Criteria for PE PE confirmed: 2 or more typical lesions (triangular or rounded pleural-based) PE probable: 1 typical lesion + pleural effusion PE possible: small subpleural lesions (< 5 mm) or a single pleural effusion alone Normal TUS findings Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

PE confirmed: 2 or more typical lesions (triangular or rounded pleural-based)

PE probable: 1 typical lesion + pleural effusion

PE possible: small subpleural lesions (< 5 mm) or a single pleural effusion alone

Normal TUS findings

TUSPE Study Prospective Multicenter Study 352 patients with clinically suspected PE 194 patients (55%) had a final diagnosis of a PE. CT pulmonary angiography (CTPA) was used as the reference method TUS and CTPA were definitely concurrent with regard to the location and the size of lesions However, lesions are visualized larger on CTPA than on TUS 2.3 lesions per patient are seen on sonography vs. 1.5 lesions on CTPA

Prospective Multicenter Study

352 patients with clinically suspected PE

194 patients (55%) had a final diagnosis of a PE.

CT pulmonary angiography (CTPA) was used as the reference method

TUS and CTPA were definitely concurrent with regard to the location and the size of lesions

However, lesions are visualized larger on CTPA than on TUS

2.3 lesions per patient are seen on sonography vs. 1.5 lesions on CTPA

2 or more typical lesions 1 typical lesion + pleural effusion Small subpleural lesions (< 5 mm) or a single pleural effusion

Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

Results Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

The majority (66%) of lesions were seen in the posterior basal segments of the lung.

Triangular or rounded pleural-based hypoechoic lung infarct

Triangular lesion Small rounded lesions

Peripheral Hemorrhages – Incomplete Infarctions Transient hemorrhages: reabsorbed within a few hours or days 70 to 90% of thromboemboli mainly occur in the lower lobes of the lung (account on hemodynamics) In TUSPE, 66% of the lesions were located in the posterior-basal segments TUSPE study showed 2.3 lesions per patient are seen on TUS vs. 1.5 lesions on CTPA Due to the time factor of spontaneous lysis until the CTPA is performed Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

Transient hemorrhages: reabsorbed within a few hours or days

70 to 90% of thromboemboli

mainly occur in the lower lobes of the lung (account on hemodynamics)

In TUSPE, 66% of the lesions were located in the posterior-basal segments

TUSPE study showed 2.3 lesions per patient are seen on TUS vs. 1.5 lesions on CTPA

Due to the time factor of spontaneous lysis until the CTPA is performed

Doppler Ultrasound Is a problematic procedure for diagnosing peripheral PE Many lesions tend to reperfuse early In some cases, we find a characteristic circulation stop due to the clut Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

Is a problematic procedure for diagnosing peripheral PE

Many lesions tend to reperfuse early

In some cases, we find a characteristic circulation stop due to the clut

Limitations Experience required Differential diagnosis between PE and peripheral pulmonary lesions of other origin Pneumonia , carcinomas and metastases, compression atelectasis Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8 PE Pneumonia Carcinomas Compression atelectasis Peripheral venous malformation Smaller Larger Color Doppler ultrasound. Narrow Well demarcated Blurred margins rounded or polycyclic Concave on at least one side Homogeneous Inhomogeneous (Bronchoaerograms) Inhomogeneous (central necroses) Float in the effusion

Experience required

Differential diagnosis between PE and peripheral pulmonary lesions of other origin

Pneumonia , carcinomas and metastases, compression atelectasis

Pneumonia

Carcinomas

Compression atelectasis

Peripheral venous malformation

Conclusion TUS is a noninvasive method to diagnose peripheral PE. TUS is a suitable tool to demonstrate a PE at the bedside and in the emergency setting In the absence of CTPA Pregnancy, contrast agent allergy, or renal failure TUS is able to detect larger number of lesions but smaller lesions than CTPA Negative chest ultrasound result does not rule out a PE Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

TUS is a noninvasive method to diagnose peripheral PE.

TUS is a suitable tool to demonstrate a PE at the bedside and in the emergency setting

In the absence of CTPA

Pregnancy, contrast agent allergy, or renal failure

TUS is able to detect larger number of lesions but smaller lesions than CTPA

Negative chest ultrasound result does not rule out a PE

Take Home Message Two or more triangular or rounded lesions with a pleural base, 0.5 to 3 cm in size, may be regarded as confirmation of a clinically suspected PE A typical pleural-based triangular or rounded lesion accompanied by a small pleural effusion makes a diagnosis of PE very likely Subpleural lesions < 5 mm in size are very nonspecific and should not be considered as a PE Thoracic ultrasound for diagnosing pulmonary embolism. Chest. 2005 Sep;128(3):1531-8

Two or more triangular or rounded lesions with a pleural base, 0.5 to 3 cm in size, may be regarded as confirmation of a clinically suspected PE

A typical pleural-based triangular or rounded lesion accompanied by a small pleural effusion makes a diagnosis of PE very likely

Subpleural lesions < 5 mm in size are very nonspecific and should not be considered as a PE

The source, transmission, and arrival of thromboembolic disease can be detected with a single ultrasound system, thus “killing three birds with one stone.”

References Mathis G, Blank W, Reissig A, Lechleitner P, Reuss Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005 Sep;128(3):1531-8 Mathis, G, Dirschmid, K Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol 1993;17,170-174

Mathis G, Blank W, Reissig A, Lechleitner P, Reuss Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005 Sep;128(3):1531-8

Mathis, G, Dirschmid, K Pulmonary infarction: sonographic appearance with pathologic correlation. Eur J Radiol 1993;17,170-174

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