Initially for cardiac echo Subsequent studies non-cardiac applications

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4 Initially for cardiac echo Subsequent studies non-cardiac applications 1973: Goldberg et al in JCUS 30 mediastinal masses in pts. age 1-84 yrs. 1977: Kangarloo et al in Radiology Juxtadiaphragmatic lesions in children, value of liver window 1980: Haller et al in AJR 28 children - 93% success rate; evaluation of opaque hemithorax, characterizing pleural fluid, guiding drainage, integrity of diaphragm 1984: Claus and Coppens in Ann Radiol Value of thymus as a window for US for mediastinal masses 1984: Miller et al in Radiology Water path ultrasound of chest disease in childhood 82 children placed in Octoson to expand windows

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6 1986: Rosenberg HK in RG Complimentary role of US and CXR in differentiating pediatric chest abnormalities 1989: Glasier et al in J Pediatr Modality of choice for opaque chest, mediastinal masses, and pleural disease 1993: Ben -Ami TE et al in RCNA Review 2005: Coley BD in RCNA Review

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8 Generic Non invasive, inexpensive, no contrast, realtime, Doppler, bedside/portable, some tissue characterization Pediatric No radiation Paucity of fat Smaller, more superficial structures Pediatric chest Portable Cartilagenous sternum and ribs Thymic window Pediatric chest Aerated lung Requires parenchymal lesion to be superficial Older children Sternum ossified, thymus small Problem= we believe that AIR is the enemy of US But when pathology is present, air is replaced Both, normal and abnormal lung cause artifacts

9 Problem= we believe that AIR is the enemy of US But when pathology is present, air is replaced Both, normal and abnormal lung cause artifacts Intensivists and ER docs learned to read these artifacts similarly to how they read an EKG Pediatric chest Aerated lung Requires parenchymal lesion to be superficial Older children Sternum ossified, thymus small

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11 Parasternal Subxyphoid Haller et al AJR 1980 Suprasternal Transdiapragmatic Mong, Epelman, Darge Pediatr Radiol 2012

12 Parasternal Haller et al AJR anterior superior 2- anterior basal 3- lateral superior 4- lateral basal Coley BD 2011 Radiol Clinics NA

13 1. Pleural line 2. Lung sliding 3. A lines 4. B lines 5. Pneumothorax 6. M-mode normal lung: seashore sign 7. Pneumothorax real time/m-mode: barcode sign 8. Pneumonia: dynamic air bronchogram sign 9. Estimation of volume of pleural fluid

14 Pleural line: Echogenic line acoustic interface between the soft tissues of the chest wall and the air-filled lung R R R R Lung sliding: Dynamic finding Visceral and parietal surfaces are apposed and the visceral layer moves freely with respirations Subtle shimmering at the pleural line Absence: PTX, massive atelectasis, pleurodesis, apnea, pneumonia A lines: Echogenic, horizontal, usually evenly spaced lines parallel to the pleural interface Reverberation artifacts created by repetitive reflection of the US waves between the pleural line (a strong reflector due to the significant change Normal in acoustic lung in impedance a 2-week-old at the pleura-lung girl interface), and the transducer

15 R R R Vertically oriented comet-tail artifacts Originate from irregularities at the lung-pleura interface Move with lung sliding Obscure A lines Up to 3 per interspace Normal

16 Vertically oriented comet-tail artifacts Originate from irregularities at the lungpleura interface Move with lung sliding Obscure A lines Up to 3 per interspace Normal More than 3 nonspecific markers of several lung disorders (pulm edema, interstitial lung dz, RDS, TTN, etc) Absent with pneumothorax

17 Ex 24 wk, now 25 days old, R/O pleural effusion

18 Grading system for lung ultrasound from Raimondi et al.1 3 Left: type 1 or white-out lung, significant liquid retention associated with respiratory distress syndrome (type 1) is seen between the acoustic shadow cast by the ribs (R). Douglas A Blank et al. Arch Dis Child Fetal Neonatal Ed 2018;103:F157-F162 Copyright BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reserved.

19 Absent lung sliding Accentuated A lines Absent B lines Normal Lung sliding - Movement with respiration B lines -Comet tail artifacts Vague A lines

20 Normal pleura Pneumothorax Lung sliding Movement with respiration B lines Comet tail artifacts Case courtesy Dr. Olga Brook Beth Israel- Boston- MA

21 Considered fairly specific for pneumothorax Found at interface between inflated lung and pleural air Hard to identify Images courtesy of Dr. M. Jagla

22 Pleural line echogenic Soft tissues echog. Lines between pleural line and transducer (no motion) Normal lung sliding grainy or sandy appearance Seashore sign

23 Strong interface between pleura/pneumothorax extensive reverberation artifacts barcode or stratosphere sign deeper reverberation artifacts lines Pneumothorax: barcode or stratosphere sign

24 Pneumothorax: barcode or stratosphere sign

25 11 yo boy with CF exacerbation

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28 In consolidation: Air- or fluid-filled bronchograms can be seen as branching echogenic lines, giving it a hepatized appearance Pleural line is less echogenic than usual Lung sliding may be decreased and even absent

29 3 y.o. F with a Hx of SCD, fever, cough, dyspnea

30 Differentiating consolidation from atelectasis is challenging on CXR US Lichtenstein et al dynamic air bronchogram If dynamic motion of gas bubbles is seen within the air bronchograms indicative of pneumonia PPV of 97% Lichtenstein D et al. Chest 2009; 135:

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32 Principi et al. BMC Pulmonary Medicine (2017) 17:212

33 A B L A 19 month old with a background history of hypoxic ischemic injury and cerebral palsy L Beware!

34 Beware!

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36 Beware!

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39 Transverse section perpendicular to the body axis The maximal distance between parietal and visceral pleura was measured in endexpiration. The lung base is often consolidated and positioned posteriorly. Therefore, the maximum separation is frequently found lateral, rather than posterior V (ml): SEP (mm) x 20

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41 Bedside study Mainly being done as POC studies by non-radiologists Easier than we think The beautiful images provided by current CT and MR imaging techniques are aesthetically seductive, but it should be remembered that US often provides the clinically needed information at lesser cost, without sedation or radiation exposure» From Coley B, RCNA 2005

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