Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Mount Sinai
School of
Medicine
Technique
Goal: to identify blood in
body cavities where it is
not supposed to be
Unclotted blood appears
black on US
Clotted blood appears gray
RUQ
Subxiphoid
LUQ
Suprapubic
Hemothorax
Normal LUQ
Hemoperitoneum - LUQ
Suprapubic View
Pelvic US - Suprise
93%
98%
MR Venography
100%
100%
CT Venography
89-100%
94-100%
Radiology Rounds
A Newsletter for Referring
Physicians
Massachusetts General
Hospital
Department of Radiology
US for Dx of DVT
Is portable
Can be performed by house staff at the
bedside during off hours for US techs
Is most useful when it is clearly positive or
negative
In other cases US techs can help
Addition studies or serial LE US can be
used.
Cardiac Exam
Goal-Directed for SHOCK
SHOCK: Is there a global cardiac
cause?
What are they?
Severe LV dysfunction (ventricular failure)
Severe underfilling of the LV (hypovolemia/RV
failure, ie RV infarct)
Severe RV dysfunction, severe RV pressure
overload ie Massive PE
Tamponade / collapse of chambers
A. Parasternal long
axis the transducer is
aimed from right
shoulder towards the
apex
For the parasternal
short axis the
transducer is rotated to
horizontally section the
RV and LV
Patient Positioning
Lateral decubitus for
parasternal, and apical4C
Left arm raised to open
interspaces
Flat with knees raised and
bent for subcostal
Subcostal or Subxiphoid
Four-chamber view
IVC measured
Percent collapse
(IVC) during
inspiration
<1.5 cm
1.5-2.5 cm
1.5-2.5 cm
>2.5 cm
>50%
>50%
<50%
Little phasicity
0-5
5-10
10-15
15-20
Measuring LV Function
Need to look at:
QUANTITATIVE
EXCURSION
requires precise
NORMAL 30 -50%
measurements Let
movement of wall to a
cardiology do it!
point in the center
THICKENING
Qualitative- global
NORMAL - 40% increase
assessment takes
in wall thickness during
practice make sure
systole
you are not off axis in
MUST see
view - reliable with
endocardium to reliably
experience
asses LV function
2. Hypokinetic
3. Akinetic
Absent thickening
4. Dyskinetic
5. Aneurysmal
PSSAX
Normal LV Function
40% Excursion
40% Thickening
PSSAX
Impaired LV Function
Hypokinetic
10% Excursion
10% Thickening
A4C view
Impaired LV Function
Akinesia
Focal defect
A4C View
Impaired Function
Dyskinesia
Apical defect
PSSAX
Impaired Function
Global hypokinesia
Aneurysm of
Inferoposterior wall
Watch during diastole
What about the RV here?
Dilated Cardiomyopathy
Transthoracic examination of a severely dilated LV in the parasternal long-axis (left) and apical fourchamber (right) views in a 65-year-old patient who presented with flash pulmonary edema and who was
later found to have severe diffuse coronary artery disease.
Global Contractility
dilated cardiomyopathy
A4C VIEW
Global Hypokinesia
Dilated LV
RV hypokinetic
Both atria enlarged
Global Contractility
dilated cardiomyopathy
PSSA VIEW
Global Hypokinesia
Dilated LV
RV ?
LV
RV
IVC
Cardiogenic
(systolic)
Hypokineticlarge
Big
no collapse
Cardiogenic
(diastolic)
Hypertrophied
small cavity
Big
No collapse
Hypovolemic
Hyperkinetic
small cavity
Small
Obstructive
(PE)
Hypokinetic
large cavity
Big
No collapse
Obstructive
(tamponade)
Diastolic
collapse
Big
No collapse
Distributive
Hyperkinetic
small cavity
Small
With collapse
Conclusions
Beside Echocardiography can provide
non-invasive, immediate, clinically relevant
information in critically ill patients
Although there is a significant learning
curve, resident physician can obtain the
necessary skill in a reasonable short
period of time.
Endobronchial Ultrasound:
an Overview
Thomas F. Morley, DO, FACOI, FCCP, FAASM
Professor of Medicine
Director of the Division of Pulmonary, Critical Care and Sleep
Medicine
Types of EBUS
Radial
Convex Probe EBUS
Linear EBUS has the ultrasound transducer incorporated at the distal end of the
bronchoscope.
Supraclavicular
Upper Paratracheal
Prevascular/Retrotracheal
Paratracheal
Subaortic
Paraaortic
Subcarinal
8.
9.
10.
11.
12.
13.
14.
Paraesophageal
Pulmonary ligament
Hilar
Interlobar
Lobar
Segmental
Subsegmental
http://www.radiologyassistant.nl/en/4646f1278c26f
On the left an image at the level of the lower trachea just above the carina.
To the left of the trachea 4L nodes.
Notice that these 4L nodes are between the pulmonary trunk and the aorta,
but are not located in the AP-window, because they lie medially
to the ligamentum arteriosum.
The node lateral to the pulmonary trunk is a station 5 node.
5. Subaortic nodes
Subaortic or aorto-pulmonary window
nodes are lateral
to the ligamentum arteriosum or the
aorta or left pulmonary artery and
proximal to the first branch of the left
pulmonary artery and lie within the
mediastinal pleural envelope.
6. Para-aortic nodes
Para-aortic (ascending aorta or phrenic)
nodes are located anteriorly and laterally
to the ascending aorta and the aortic
arch from the upper margin to the lower
margin of the aortic arch.
7. Subcarinal nodes
These nodes are located caudally to the carina of the trachea,
but are not associated with the lower lobe bronchi or arteries
within the lung.
On the right they extend caudally to the lower border of the
bronchus intermedius. On the left they extend caudally to the
upper border of the lower lobe bronchus.
Above: A station 7 subcarinal node to the right of the esophagus.
8 Paraesophageal nodes
These nodes are below the carinal nodes and extend caudally to the diaphragm.
Above: an image below the carina.
of the esophagus a station 8 node.
10 Hilar nodes
Hilar nodes are proximal lobar nodes, distal to the mediastinal
pleural reflection and nodes adjacent to the intermediate bronchus on
the right. Nodes in station 10 - 14 are all N1-nodes,
since they are not located in the mediastinum.
Mediastinoscopy
Considered gold standard
sensitivity ~ 78 90%, specificity 100%
FN rate ~ 9-11%
The downsides:
unable to reach all nodal stations
5, 6, posterior 7, 8, 9
invasive (mortality 0.2%, morbidity up to 2.5%)
more expensive
non-operable candidates undergoing surgical
procedure
Luke et al, J Thor Cardiovasc Surg 1986; 91: 53
Mediastinoscopy
Mediastinum is + is up to 10% of
patients with clinical stage 1 disease
Only performed in 27% of patients
undergoing lung CA surgery
nodal tissue obtained in 47%
Tahara et al, Am J Surg 2000; 180: 488
Choi et al, Ann Thorac Surg 2003; 75: 364
Little et al, Ann Thorac Surg 2005; 80: 2051
Conventional mediastinoscopy
Conventional mediastinoscopy
Extended mediastinoscopy
Left upper lobe tumors may metastasize to the subaortic lymph nodes (station 5)
and paraaortic nodes (station 6). These nodes can not be biopsied through
routine cervical mediastinoscopy.
Extended mediastinoscopy is an alternative for the anterior-second
Interspace mediastinotomy which is more commonly used for exploration
of mediastinal nodal stations. This procedure is far less easy and therefore
less routinely performed than conventional mediastinoscopy.
Extended mediastinoscopy
Benefits of TBNA
Most stations are
accessible
Couple staging with
diagnostic bronchoscopy
Safe
Less invasive
Less expensive
Precludes surgery in up
to 29%
Am J Respir Crit Care Med 2000; 161: 601
Underused
12 % of pulmonologists routinely use TBNA in
evaluation of malignant disease
training / fear / support
Operator dependent
sensitivity ranges from 37 89%
Failure to place the needle directly into the
lesion
depends on LN size / station and experience
benefit of ROSE
EUS-FNA
PET scan of a 63-year-old man with adenocarcinoma in the right upper lobe.
Chest CT (left panels), EBUS scan (top right, D), cytology (center right, E), and dissected
lower paratracheal lymph node (bottom right, F) obtained in the 63-year-old patient from
Figure 1.
False + CT
False + PET
True - EBUS TBNA
Tests
True
Positive
True
Negative
False
Positive
False
Negative
CT
20
42
34
PET
20
54
23
EBUSTBNA
24
76
EBUS-TBNA
572 nodes in 502 patients
patients confirmed by thoracotomy, VATS or
clinical f/u
Diagnosis in 535 of punctures (94%)
No ROSE
37 non-diagnostic
sarcoid in 2, CA in 35 on surgical Bx
Sens. 94%, Spec. 100%, PPV 100%
No complications
Herth et al, Thorax 2006; 61: 795
Nodes
sampled # %
Sens for
cancer
detection (%)
Spec for
cancer
detection (%)
NPV (%)
Esophageal
229 (37)
89
100
82
Endobronchial
390 (63)
91
100
92
Combined
619 (100)
96
100
96
Bronchoscopy International
Learning curve
30o view
extra-bronchial anatomy
22ga needle
Cant reach levels 5,6, 8, 9 (or L adrenal)
Non-Dx does not mean negative
Hybrid imaging lesser quality image
Medicare removed the technical fee in 1/08
Underused
12 % of pulmonologists routinely use TBNA in
evaluation of malignant disease
training / fear / support
Operator dependent
sensitivity ranges from 37 89%
Failure to place the needle directly into the
lesion
depends on LN size / station and experience
benefit of ROSE
Summary