ddxof: POCUS for Undifferentiated Shortness of Breath
Undifferentiated Shortness of Breath
This is a co-post with our FOAMEd partner The ddxof - project of Dr. Tom Fadial . ddxof: is a compilation of cases based on real patients, each inspiring an algorithm for the evaluation and management of their chief complaint or diagnosis.
If you have any ideas for collaborating with our team don't hesitate to reach out.
Please see the original post here https://ddxof.com/ultrasound-in-dyspnea/
This is a common emergency department scenario: a critically-ill patient with undifferentiated dyspnea. The physical exam can be difficult and indeterminate with huge risks of deterioration. Our CHF patients often have COPD, afib and maybe renal failure. Your decisions matter. Here is a proposed approach for these patients.
Algorithm for the Use of Ultrasound in the Evaluation of Dyspnea
A lines appear as horizontal lines that represent normal aerated lung (dry interlobular septa). They are a reverberation artifact caused by the sound waves bouncing off the highly echogenic pleura and back to the probe, and repeating.
Hannah Kopinski (MS4) and Dr. Lindsay Davis - NYU Emergency Medicine, Matthew Riscinti - Kings County Emergency Medicine
This patient actually had no cough, no crackles and only subtle changes on CXR but in seconds we had diagnosed pneumonia!
Dynamic air bronchograms represent air bubbles moving up and down airways surrounded by alveolar consolidation. Lichtenstein et al compared this finding to static air bronchograms in a 2009 study of 68 ICU patients and found dynamic air bronchograms to be present in 32/52 cases of pneumonia but in only 1/16 cases of atelectasis - a specificity of 94%.
B-lines are vertical artifacts that moves with respiration from the pleural surface. They represent increased water in an area of the lung. In the right clinical context this could represent pulmonary edema. An increase in B-lines correlates with the degree of pulmonary edema.
Keep in mind that in different clinical contexts, they can represent different diagnoses including pulmonary contusions and pneumonia.
Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.
B-lines obtained with curved probe.
B-lines are vertical artifacts that move with respiration from the pleural surface. They represent increased water in an area of the lung. In the right clinical context this could represent pulmonary edema. An increase in B-lines correlates with the degree of pulmonary edema.
3 B-lines in an intercostal space represent a "positive" region of the lung, and if there are two regions of the lung that are positive, you can diagnose pulmonary edema.
Dr. Justin Bowra et al. (Dr. D Browne and Dr. J Knights)
WCUME 2017 Submission for "Best POCUS"
An acutely dyspnoeic patient presents with ventricular tachycardia and has no response to initial chemical cardioversion. Lung POCUS shows widespread bilateral confluent B lines indicating acute pulmonary edema. Unstable tachycardia terminated using synchronized electrical cardioversion.
Dr. Cian McDermott - Dublin, Ireland
Pulmonary embolism can be seen by disruption of the pleural line. 0.5cm to 3cm disruptions are typical for PE. Doing DVT studies and echo can help strengthen your diagnosis.
Dr. Justin Bowra et al.
53yoM with 20+ year history of tobacco and alcohol abuse and newly diagnosed SCC presenting with productive cough and cachexia, found to have multifocal pneumonia likely due to aspiration. Mid-axillary ultrasound of the right lung using linear 13-6 MHz probe in the longitudinal plane demonstrating hepatization of the lung (right) and focal consolidation adjacent to normal lung parenchyma (left). US has high SEN (88%) and SPE (86%) for detecting pneumonia when compared to CXR or chest CT.
This clip, demonstrating a hydropoint, was taken in a 74 year old M with chest trauma after a fall from 3 meters. A hydropoint shows the air/fluid interface which is suggestive for hemato/hydro/pyo-pneumothorax. It is another sign for diagnosing a pneumothorax described by Volpicelli et al. Critical Ultrasound Journal. 2013
Dr. Van Roosmalen
RUQ scan with large R pleural effusion. Spine sign+ (clear view of several thoracic vertebrae through the effusion)
This 80 year old male with a history of Alzheimer's with recent accelerated decline experienced a fall from bed. Though the only visible trauma involved a laceration above the right eye, globally diminished breath sounds were noted, and a prehospital eFAST exam was performed. Pictured is a large, right-sided pleural effusion, with visible spine sign observed during the exam. No other abnormalities were observed.
With the absence of significant chest trauma, the effusion was assumed to be non-traumatic in origin. Due to the patient's recent rapid decline, family elected to manage conservatively, and the patient was admitted to palliative care.
- Tom Hudson, NRP, CCP-C (Richmond Volunteer Rescue Squad)