B
Discussion
Lung sonography showed bilateral diffuse B lines (video), pleural
sliding was preserved but the pleura was thickened (> 2mm) with areas
of sub-pleural consolidation (figure 1). There were spared areas seen
anteriorly on two points of examination (figure 1), pleural effusions
were absent on either side and there was an area of consolidation seen
anteriorly (figure 2).
The cause of acute hypoxemic respiratory failure (AHRF) can be
difficult to ascertain in the early phase of the process. Sekiguchi
et.al.1 identified cardiac and thoracic ultrasonography
measurements to help identify the same during the early course of
critical illness. In their study they identified the following variables
that were significant in diagnosing CPE: presence of left-sided pleural
effusion > 20 mm in the left posterolateral zone, degree of LV
systolic dysfunction (moderate or severe dysfunction) and an IVC
diameter > 23 mm. To facilitate clinical use of their prediction
model they developed a simplified scoring system to help identify the
likely cause of AHRF, with a score ≤ 3 consistent with a diagnosis of
ARDS. In our patient the IVC was 15 mm, LV function was normal, there
was no pleural effusion and he had a score of 1 based on the simplified
scoring system in the study. Although the study has a reasonable
diagnostic accuracy (sensitivity 77%, specificity 69%) it has
limitations and it can be difficult to differentiate CPE for ARDS in
certain patients. Those with pre-existing systolic dysfunction or
pulmonary hypertension where the IVC can be dilated or patients with
ARDS can have elevated pulmonary artery pressures which can cause the
IVC to dilate. The significance of normal diastolic function with a low
E/e’ ratio is that this indicates normal left ventricular filling
pressures, which decreases the likelihood of cardiogenic pulmonary
edema.2
Copetti et.al.3 in their study identified characteristic
pleuro-pulmonary signs useful in the diagnosis of CPE and ARDS. As per
their study the main signs that can be recognized by lung ultrasound in
ARDS are as follows:
B-lines: In ARDS, B-lines should be bilateral and greater than 3 or more to confluence in a completely “white lung.”
In the anterior lung fields, B-lines are not homogeneously distributed,
whereas in the posterior lung fields B-lines are more compact and
homogeneous, producing the image of a global white lung. While this
finding is very sensitive for differentiating ARDS from cardiogenic
pulmonary edema, it has poor specificity.
Spared areas: Areas of normal lung that are
observed in at least one intercostal space, surrounded by areas of
B-lines or white lung (usually in the anterior lung fields). This
finding is very sensitive and specific for differentiating ARDS from
cardiogenic pulmonary edema.
Consolidations: Areas of
hyperechoic echotexture with punctiform elements or “hepatization,” with
presence of static or dynamic air bronchograms. In ARDS, consolidations
may be located in the posterior lung fields, especially at the bases.
Consolidation is very specific and moderately sensitive for
differentiating ARDS from cardiogenic pulmonary edema.
Pleural line abnormalities: Thickening is
greater than 2 mm, and there is irregularity of the pleural line as well
as evidence of small sub-pleural consolidations. In ARDS, the pleural
line is always involved, and this leads to a reduction of lung sliding. In white lung areas, lung sliding might be absent and the pleural line may appear to move according to the heartbeat (lung pulse sign). The absence of lung sliding is very sensitive and specific for differentiating ARDS from cardiogenic pulmonary edema.
Pleural effusion: Anechoic and homogeneous
pleural areas with no evidence of gas inside, limited by the diaphragm
and pleura. If pleural effusion is likely to create a mechanical
compression, the lower lung lobe can be visualized as collapsed and
floating. Pleural effusion is less frequently observed in ARDS, although
is often present (66.6% vs 95% in cardiogenic pulmonary edema).
However, this is equally dependent on the primary cause of ARDS (e.g.,
pancreatitis, lower respiratory tract infection).
References
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Sekiguchi H, Schenck LA , Horie R et al. Critical Care
Ultrasonography Differentiates ARDS, Pulmonary Edema, and Other Causes
in the Early Course of Acute Hypoxemic Respiratory Failure. Chest
2015;148(4):912-918.
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Nagueh S, Middleton K, Kopelen H et al. Doppler Tissue Imaging: A
Noninvasive Technique for Evaluation of Left Ventricular Relaxation and
Estimation of Filling Pressures. JACC 1997; 30(6):1527-1533.
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Copetti R, Soldati G, Copetti P: Chest sonography: a useful tool to
differentiate acute cardiogenic pulmonary edema from acute respiratory
distress syndrome. Cardiovasc Ultrasound 2008; 6: pp. 16.