B: Right-sided pneumothorax
Discussion
The ultrasound m-mode image is an example of a ‘lung point’ sign that
is highly specific for diagnosing a pneumothorax (image 1). Lung
sliding is seen as artifact created by the visceral-parietal pleural
interface and is seen in the contralateral lung as displayed in video 1. The right lung is shown in video 2
and lung sliding is not seen because of the pneumothorax. This patient
most likely developed a pneumothorax related to the rupture of septic
pulmonary emboli from intravenous drug use. She underwent emergent chest
tube insertion and decompression of the pleural space.
Point of care ultrasound is an extremely effective tool in patients
with cardiopulmonary compromise. It provides a trained clinician quick
answers by serving as an extension of the physical exam.1 The
2 commonly observed signs on lung ultrasound in the setting of a
pneumothorax are the absence of lung sliding and the finding of a lung
point. Although the absence of lung sliding has a lower specificity of
91.1% in the critically ill population2 and can be seen in
other processes such as mucus plugging (causing severe atelectasis) or
after pleurodesis, the finding of a lung point has a sensitivity of 66%
and specificity of 100%.3 Overall lung ultrasound has a
better diagnostic profile when compared to anteroposterior chest
radiographs (sensitivity of 31.8% and specificity of 100%) and can be
performed rapidly.4
To evaluate for a pneumothorax using ultrasound, the probe is placed
on the anterior chest wall with the orientation marker pointing
cephalad, and multiple intercostal spaces on both sides of the chest
wall are scanned.5
Lung sliding is seen in a lung without a pneumothorax, but may not be
appreciable in all patients. The use of m-mode makes this finding more
apparent. A normal lung appears as a ‘seashore sign’ on m-mode while a
pneumothorax will not show any lung sliding and will appear as a
‘barcode sign’. When both the barcode and seashore signs are seen on an
m-mode image in succession as seen in image 1, it is termed a lung
point, denoting the edge of the pneumothorax.
Though CT examination is the gold standard for diagnosing
pneumothoraces, ultrasound can provide a diagnosis in a time sensitive
manner in critically ill patients. 5 We highly recommend the
use of lung ultrasound in addition to cardiac ultrasound in any cardiac
arrest to evaluate for pneumothorax.
References
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Wernecke K, Galanski M, Peters PE, Hansen J. Pneumothorax: Evaluation
by ultrasound-preliminary results. J Thorac Imaging. 1987;2:76–8.
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Lichtenstein, D A DA. "A Bedside Ultrasound Sign Ruling out Pneumothorax in the Critically Ill. Lung Sliding." Chest, vol. 108, no. 5, pp. 1345–8.
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Lichtenstein D, Meziere G, Biderman P, Gepner A. The "lung point": An
ultrasound sign specific to pneumothorax. Intensive Care Med.
2000;26:1434–40.
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Nagarsheth, Khanjan K. "Ultrasound Detection of Pneumothorax Compared with Chest X-Ray and Computed Tomography Scan." American Surgeon, The, vol. 77, no. 4, pp. 480–4.
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Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. Journal of Emergencies, Trauma, and Shock. 2012;5(1):76-81.