New insights in the use of pleural ultrasonography for diagnosis and treatment of pleural disease

Abstract

The use of transthoracic ultrasound (US) has acquired a wide consensus among respiratory physicians during the last few years. The development of portable devices promotes patient's bedside evaluation providing rapid, real-time and low-cost diagnostic information. The different acoustic impedance between different tissues and organs produces artifacts known as A lines, B lines, sliding sign, lung point, etc. The identification of such artifacts is essential to discriminate normal pleural appearance from the presence of pleural effusion, pneumothorax, thickenings and tumors. Ultrasounds are also a valuable tool during interventional procedures, such as thoracentesis, chest tube insertion and transcutaneous biopsy. Its use is recommended before medical thoracoscopy in order to assess the best site of trocar insertion according to presence, quantity and characteristics of pleural effusion. The aim of this review is to provide practical tips on chest ultrasound in clinical and interventional respiratory practice.

Neonatal and pediatric thoracic ultrasonography

“…'Horizontal reverberations': also known as A-lines, these are the result of repeated reflections of the linear hyperechoic structure caudally to the pleural hyperechoic line [12]. Depending on the power of the transducers employed, such lines tend to fade until they disappear in deeper areas towards the caudal portion of the visual field.…”

Pleural infection: moving from treatment to prevention

“…It is also important to identify younger patients who are at greater risk of developing complex parapneumonic effusion from pneumonia, even if an effusion is not initially present (or does not meet diagnostic criteria for pleural infection), as these groups require close monitoring. Risk factors independently predictive of an increased likelihood of pneumonia progressing to pleural infection include diabetes, immunosuppression, gastroesophageal reflux disease (GERD), alcohol excess, intravenous drug use and poor oral hygiene [4,20,21] Thoracic ultrasound (TUS) is not only vital for guiding the safe sampling of the pleural fluid [22] but can also help to assess for features that are known to be associated with complicated parapneumonic effusions and empyema, such as echogenic swirling (in the presence of pus), septations and loculations [23]. Despite widespread use of TUS, there are limited data regarding its predictive potentials in diagnosing pleural infection [24].…”

Competence in thoracic ultrasound

“…Thoracic ultrasound is a useful guide for pleuro-parenchimal interventional procedures (see dedicated section), such as thoracentesis, 48 insertion of chest drainage, 45 transcutaneous biopsies of the pleura and peripheral lung parenchyma and thoracoscopy. 38,49 Draft clinical report according to eSr and eFSUmB joint recommendation, 50 it is necessary to draft a formal report for all ultrasonographic examinations, as well as to archive both reports and images or videos within hospital information technology (iT) systems. availability or reports and media is important in clinical practice as a record of patient status at the time of examination and as a reference for correlative imaging, future comparison and audit.…”