ASSESSMENT OF LUNG PARENCHYMAL ABNORMALITIES

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1 2016 by the author Thank you for viewing this presentation. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author.

2 ASSESSMENT OF LUNG PARENCHYMAL ABNORMALITIES Christian B. Laursen, MD, PhD, Clin Ass Prof Department of Respiratory Medicine, Odense University Hospital, Denmark Mail:

3 Conflict of interest disclosure I have no real or perceived conflicts of interest that relate to this presentation. This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker s presentation. Drug or device advertisement is forbidden.

4 To do list Interstitial Lung Diseases Fluid overload/heart failure Pneumonia Lung tumours Pulmonary emboli - how to distinguish from infectious consolidation? - does ultrasound have a role given the widespread availability of CTPA?

5 Lecture aims Considerations prior to scanning - Setting - Preparation - LUS protocol Interstitial syndrome - The B-line and interstitial syndrome - Cardiogenic pulmonary edema - Interstitial lung diseases - Differentiation between IS causes Lung parenchymal pathology - Lung consolidation (e.g. pneumonia, PE, contusion) - Lung atelectasis - Lung tumor - Differentiation between causes of lung parenchymal pathology Clinical impact - Does ultrasound have a role given the widespread availability of CTPA?

6 CONSIDERATIONS PRIOR TO SCANNING

7 CONSIDERATIONS PRIOR TO SCANNING Setting Preparation - Appropriate transducer selection - Appropriate preset selection US protocol - Focused examination - Diagnostic examination

8 SETTING MATTERS

9 ACUTE RESPIRATORY SYMPTOMS IN THE ED 1. Decompensated HF 2. Pneumonia 3. COPD exacerbation 4. Thromboembolic disease (PE / DVT) 5. Other Ray P et al. Acute respiratory failure in the elderly: Etiology, emergency diagnosis and prognosis. Critical care 2006;10:R82.

10 Chronic Respiratory symptoms 1. Malignancy 2. Interstitial lung disease 3. COPD / Asthma 4. TB / chronic infection 5. Other

11 PREPARATION OF THE US MACHINE

12 APPROPRIATE TRANSDUCER SELECTION

13 APPROPRIATE PRE-SET SELECTION

14 US PROTOCOLS Focused LUS Diagnostic LUS Advanced LUS UL guided procedures efast FATE FASH RUSH. Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-91

15 DIAGNOSTIC VS. FOCUSED APPROACH Diagnostic LUS Pulmonary edema Lung parenchymal pathology -Pulmonary embolism -Pneumonia -Atelectasis -Lung contusion Pleura effusion -Simple effusion -Complex effusion Pneumothorax Malignancy Thickened parietal pleura Trapped lung Diaphragmatic paresis/ paralysis Rib fracture Interstitial lung disease Chest wall pathology Mediastinal pathology Assessment of lymph nodes.. Focused LUS Pulmonary edema: yes/no? Lung parenchymal pathology: yes/no? -Pulmonary embolism -Pneumonia -Atelectasis -Lung contusion Pleura effusion: yes/no? -Simple effusion -Complex effusion Pneumothorax: yes/no? Malignancy Thickened parietal pleura Trapped lung Diaphragmatic paresis/ paralysis Rib fracture Interstitial lung disease Chest wall pathology Mediastinal pathology Assessment of lymph nodes..

16 DIAGNOSTIC THORACIC / LUNG US

17 FLUS EXAMINATION TECHNIQUE Different approaches depending on clinical setting / tradition: -1 zone assessed -2 zones assessed -4 zones assessed -14 zones assessed -. zones assessed Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-91

18 FLUS SCANNING ZONES Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014;2(8):638-46

19 FLUS how to do it Focused questions: - Signs of pneumothorax (yes / no) - Pleural effusion present (yes / no) - Signs of pulmonary edema present (yes/no) - Signs of parenchymal pathology present (yes/no) Noble VE, Nelson BP. Manual of Emergency and Critical Care Ultrasound: Cambridge University Press, 2011.

20 FLUS how to do it Focused questions: - Signs of pneumothorax (yes / no) - Pleural effusion present (yes / no) - Signs of pulmonary edema present (yes/no) - Signs of parenchymal pathology present (yes/no)

21 FLUS how to do it Focused questions: - Signs of pneumothorax (yes / no) - Pleural effusion present (yes / no) - Signs of pulmonary edema present (yes/no) - Signs of parenchymal pathology present (yes/no)

22 FLUS how to do it Focused questions: - Signs of pneumothorax (yes / no) - Pleural effusion present (yes / no) - Signs of pulmonary edema present (yes/no) - Signs of parenchymal pathology present (yes/no)

23 FLUS how to do it Focused questions: - Signs of pneumothorax (yes / no) - Pleural effusion present (yes / no) - Signs of pulmonary edema present (yes/no) - Signs of parenchymal pathology present (yes/no)

24 INTERSTITIAL SYNDROME (IS)

25 DEFINITION OF THE B-LINE B-lines are defined as discrete laser-like vertical hyperechoic reverberation artefacts that arise from the pleural line (previously described as comet tails ), extend to the bottom of the screen without fading, and move synchronously with lung sliding Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-91

26 MULTIPLE B-LINE ARTEFACTS

27 MULTIPLE B-LINE ARTEFACTS

28 THE B-LINE ARTEFACT Visible when the density of the interstitial lung tissue has been increased (e.g. pulmonary edema, lung fibrosis)

29 B-LINE PATTERNS B-lines in pathology 2 patterns: - Focal / localized multiple B-lines - Diffuse multiple B-lines: The interstitial syndrome

30 INTERSTITIAL SYNDROME (IS) Defined as: - Multiple B-lines present (>2) in at least 2 of the scanned anterior and lateral zones on each side - Posterior zones not included in definition Volpicelli et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-91

31 FOCAL B-LINES

32 INTERSTITIAL SYNDROME

33 INTERSTITIAL SYNDROME

34 INTERSTITIAL SYNDROME Causes in adults: - Any disease causing diffuse interstitial edema in the lungs

35 INTERSTITIAL SYNDROME Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion -

36 INTERSTITIAL SYNDROME Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion Not seen in: - COPD Exacerbation - Asthma Exacerbation Pivetta E et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the Emergency Department - A SIMEU multicenter study. Chest 2015 Jul;148(1):202-10

37 INTERSTITIAL SYNDROME Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion

38 IS IN PATIENTS ADMITTED TO AN ED Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion Pivetta E et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the Emergency Department - A SIMEU multicenter study. Chest 2015 Jul;148(1):202-10

39 IS IN PATIENTS ADMITTED TO AN ICU Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion Lichtenstein D et al. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest Jul;134(1):

40 IS IN THE ICU WARD Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion

41 IS IN THE OUH OUTPATIENT CLINIC Causes in adults: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion

42 CARDIOGENIC PULMONARY EDEMA IN THE ED Clinical examination - Sens.: 85.3% ( %) - Spec.: 90.0% ( %) NT-pro-BNP - Sens.: 85.0% ( %) - Spec.: 61.7% ( %) CXR -Sens.: 69.5% ( %) -Spec.: 82.1% ( %) FLUS -Sens.: 97.0% ( %) -Spec.: 97.4% ( %) Pivetta E et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the Emergency Department - A SIMEU multicenter study. Chest 2015 Jul;148(1):202-10

43 CASE 68 year old female with severe COPD. Admitted with progressive dyspnoea and coughing. Symptoms had lasted 14 days. Possible fever. Primary assessment: Auscultation: Prolonged expiration, wheezing. No murmurs. No edema or tenderness of the legs.

44 CASE FLUS patterns Pattern 1 Pattern 2

45 FLUS: IS PRESENT? YES/NO Pattern 1 Pattern 2

46 FLUS: IS PRESENT? YES/NO Normal pattern IS pattern Cardiogenic pulm. edema: Excluded COPD exa? Cardiogenic pulm. edema: Suspected

47 INTERSTITIAL SYNDROME How to differentiate between: - Cardiogenic pulmonary oedema - Non-cardiogenic pulmonary oedema - Interstitial lung diseases - Viral pneumonia - Bacterial pneumonia - ARDS - Acute Chest Syndrome - Drowning / near-drowning - Lung contusion

48 DIFFERENTIATION BETWEEN IS CAUSES Zone pattern Appearance of visceral pleura Lung sliding Pleural effusion Consolidation Lung pulse Reassessment Copetti R et al. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound Apr 29;6:16.

49 DIFFERENTIATION BETWEEN IS CAUSES Zone pattern: - Gravidity dependent - Spared areas

50 DIFFERENTIATION BETWEEN IS CAUSES Zone pattern: - Gravidity dependent - Spared areas

51 DIFFERENTIATION BETWEEN IS CAUSES Appearance of visceral pleura: - Normal - Abnormal

52 DIFFERENTIATION BETWEEN IS CAUSES Appearance of visceral pleura: - Normal - Abnormal

53 DIFFERENTIATION BETWEEN IS CAUSES Reassessment: - Highly dynamic - No change

54 INTERSTITIAL LUNG DISEASES ILD with ground glass opacity: B-lines in affected areas ILD with honeycombing: Abnormal visceral pleura, +/- B-lines Rare cystic lung diseases: Normal findings Reissig A et al. Transthoracic Sonography of Diffuse Parenchymal Lung Disease. J Ultrasound Med. 2003;22: Sperandeo M et al. Transthoracic Ultrasound in the Evaluation of Pulmonary Fibrosis. Ultrasound Med Biol May;35(5): Davidsen JR et al. Lung Ultrasound has Limited Value in Rare Cystic Lung Diseases. ATS 2016 Meeting abstract, C104

55 LUNG PARENCHYMAL PATHOLOGY

56 LUNG PARENCHYMAL PATHOLOGY

57 FLUS VS. DIAGNOSTIC LUS

58 FLUS VS. DIAGNOSTIC LUS

59 LUNG PARENCHYMAL PATHOLOGY LUS sonomorphology: - Liver/organlike structure - Hyperechoic - Hypoechoic

60 LUNG CONSOLIDATION: CXR VS. LUS Chest X-ray: Sensi.: 64.3% (95%CI: ) Speci.: 90.0% (95%CI: ) Lung ultrasound: Sensi.: 81.4% (95%CI: ) Speci.: 94.2% (95%CI: ) Nazerian P et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med. 2015;33(6)620-5

61 LUNG PARENCHYMAL PATHOLOGY Characteristic US patterns: Consolidations: Pneumonia, PE, contusion Atelectasis: Compression, obstruction Tumor: Malignant, benign Uncharacteristic: - Reissig A et al. Transthoracic Ultrasound of Lung and Pleura in the Diagnosis of Pulmomary Embolism: A Novel Non-Invasive Bedside Approach. Respiration 2003;70:

62 CASE

63 PNEUMONIA

64 PNEUMONIA

65 PNEUMONIA

66 PNEUMONIA DIAGNOSTIC ACCURACY Lung ultrasound - Sens.: 94% (92-96%) - Spec.: 96% (94-97%) - PLR: 16.8 ( ) - NLR: 0.07 ( ) Chavez et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res 2014:23;15:50

67 CASE

68 COMPRESSION ATELECTASIS

69 ATELECTASIS US PATTERN Courtesy of Dr. Olav Petersen

70 OBSTRUCTION ATELECTASIS

71 OBSTRUCTION ATELECTASIS

72 CASE

73 FLUS FINDINGS IN ZONE L2

74 PULMONARY EMBOLISM

75 PULMONARY EMBOLISM Joyner CR Jr et al. Reflected ultrasound in the detection of pulmonary embolism. Trans Assoc Am Physicians. 1966;79:

76 PE DIAGNOSTIC CRITERIA PE confirmed Two or more typical lesions PE probable One typical lesion and low grade pleural effusion Sensi.: 44.4% Speci.: 98.7% PPV: 97.4% NPV: 62.1% Sensi.: 71.0% Speci.: 94.9% PPV: 93.8% NPV: 75.1% Mathis G et al. Thoracic Ultrasound for Diagnosing Pulmonary Embolism: A Prospective Multicenter Study of 352 Patients. Chest 2005;128:

77 PE DIAGNOSTIC ACCURACY LUS for diagnosis of PE Metaanalysis: - Sens.: 80% (75-83%) - Spec.: 93% (89-96%) Niemann T et al. Transthoracic sonography for the detection of pulmonary embolism a meta-analysis. Ultraschall Med :

78 CASE

79 LUNG CANCER

80 LARGE LUNG CANCER IN UPPER LOBE Laursen CB et al. Contrast Enhanced Ultrasound Guided Transthoracic Lung Biopsy. Am J Respir Crit Care Med Jun 28. [Epub ahead of print]

81 SARCOMA

82 DIFFERENTIATION OF PARENCHYMAL PATHOLOGY Reissig A et al. Transthoracic Ultrasound of Lung and Pleura in the Diagnosis of Pulmomary Embolism: A Novel Non-Invasive Bedside Approach. Respiration 2003;70:

83 SPOT THE CANCER(S)

84 LUNG PARENCHYMAL PATHOLOGY Pitfalls: - Uncharacteristic pattern - FLUS missing lesions - LUS cannot rule-out parenchymal pathology - Malignancy Help: - Other forms of imaging - Advanced lung ultrasound - US-guided tissue sampling

85 CLINICAL IMPACT

86 PATIENTS WITH SUSPECTED PE Need of additional of imaging? - CT - V/Q scintigrafi - LUS

87 PATIENTS WITH RESPIRATORY SYMPTOMS Ultrasound Need of additional of imaging? - CT - V/Q scintigrafi - Advanced LUS

88 WHOLE-BODY US APPROACH Focused US assessment of: - Lungs (FLUS)(PTX, IS, effusion, parenchymal path.) - Heart (FCUS / FATE)(PE, HV strain, LV failure) - Deep veins (LCU)(DVT) Laursen CB et al. Focused sonography of the heart, lungs, and deep veins identifies missed life-threatening conditions in admitted patients with acute respiratory symptoms. Chest Dec;144(6):

89 CLINICAL IMPACT IN ED PATIENTS Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014;2(8):638-46

90 IMPACT IN PATIENTS WITH SUSPECTED PE Clinical assessment without US: - Sensitivity 80.0%, specificity 96.7% Whole-body US (deep veins, heart & lungs) - Sensitivity 90.0%, specificity 86.2% Clinical assessment with integrated US: - Sensitivity 100%, specificity 95.3% Nazerian et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest 2014 May;145(5):950-7 Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014;2(8):638-46

91 CLINICAL IMPACT IN CHILDREN Substitution of CXR with LUS in children suspected of having pneumonia: -No cases of missed pneumonia -No difference in adverse events -38.8% reduction (95% CI, 30.0%-48.9%) in CXR use Jones BP et al. Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial. Chest Jul;150(1):131-8.

92 Important Side-effects Howard ZD et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014;46(1):46-53.

93 Hope to see you in Odense for the ERS course in Thoracic Ultrasound! Questions or comments?