approximately 0.5 mm in diameter. trees; lobules do not arise at a speciﬁc Veins can sometimes be seen as linear, branching generation or from a speciﬁc 4 Radiology 2006;239:322-38 arcuate, or branching structures 1.0 – type of bronchiole or artery (8). 1.5 cm from the pleural surface or sur- Branching of the lobular bronchiole rounding centrilobular arteries and ap- and artery is irregularly dichotomous 肺の2次小葉h of 1-mm lung slice taken proximately 5–10 mm from the arteries. (10). Most often, bronchioles and arter- Pulmonary veins may also be identiﬁed ies divide into two branches of different be. Two well-deﬁned sec- by their pattern of branching; it is com- sizes, one branch being nearly the sameles are visible. Lobules are mon for small veins to arise at nearly right size as the one it arose from and thelobular septa (S) contain- angles to a much larger main branch.branches. Bronchioles (B)(A) are centrilobular. (Re- Centrilobular Region and Centrilobular Figure 5n, from reference 10.) Structures The bronchiole supplying a being smaller. Thus, on thin-sec- clinical scann other pulmonary lobule is best called the “lobular” bron- tion CT scans, there often appears to be member that a single dominant bronchiole or artery CT, intralob Figure 4 in the center of the lobule, with smaller normally visi branches emerging at intervals along its chioles are r length. the pleural Secondary lobules are supplied by (26,27). arteries and bronchioles measuring ap- The per proximately 1 mm in diameter, while tium is a sys intralobular terminal bronchioles and bronchi and arteries measure about 0.7 mm in diam- forms a stron eter and acinar bronchioles and arteries that surroun range from 0.3 mm to 0.5 mm in diam- perihilar lun eter (Figs 1, 2). Arteries of this size can eral continuu
16Lung SlidingとLung Point 壁側胸膜 壁側胸膜 臓側胸膜 Air 臓側胸膜 正常肺の呼吸では, 吸気時に肺が拡張し, 呼気時に収縮. 肺胞には臓側胸膜が付着し, 胸壁には壁側胸膜が付着しているため, 吸気, 呼気では 臓側-壁側胸膜間でSlidingが起こる
17 Lung SlidingとLung Point b a 壁側胸膜 Air Available online http://ccforum.com/content/11/1/205 臓側胸膜Figure 7 a; aから見ると, AirがあるのでA lineはあるが, Slindingが消失している.また肺の動きも 無いため, M modeではSeashoreが消失. b; bから見ると, 正常肺なのでA lineはあり, Slindingも認められる. また肺の動きはあり, M modeではSeashoreも認められる. aとbの移行点をLung pointと呼ぶ.Time-motion mode lung ultrasound. (a) Normal lung and (b)pneumothorax patterns using time-motion mode lung ultrasound. Intime motion mode, one must first locate the pleural line (white arrow)
(Fig. 6). Diffuse lung rockets dissemi- pedes ultrasound). The detect nated all over the anterolateral wall de- are smaller than the resoluti 19 ﬁne diffuse interstitial syndrome. The sound. They are present at a test is deﬁned as negative when such B the lung surface. They are sep lines are absent, isolated, or exclusively each other by Յ7 mm. They 肺外要素による所見 Crit Care Med 2007;35:S250-61 • E line (写真左)Figure 6. Interstitial syndrome. These vertical ▫ 一見B lineに見えるが,comet-tail artifacts have the speciﬁc peculiaritiesof strictly arising from the pleural line, being 胸膜下から出ていない.well-deﬁned and laser-like, moving with the lungsliding, spreading to the edge of the screen with- Figure 7. Some artifacts: E and Z lines. Left, these well-deﬁned comet tails descend to t ▫ 皮下気腫によるArtifactであり, E lineと呼ぶ (subcutaneous Emphysema)out fading, and erasing normal A lines. This pat- screen. However, the bat sign is absent (as with Fig. 6). This pattern cannot be due ttern deﬁnes B lines. Several B lines in a single patient has subcutaneous emphysema with extensive collections of gas between an ▫ 胸膜下から出ているかどうかを評価するには, 肋骨のBat signをみる.view deﬁne lung rockets. Diffuse lung rockets tures—a condition generating E lines. Right, the ill-deﬁned comet-tail artifacts (threindicate interstitial syndrome. This patient has arrowheads) arise from the pleural line but do not erase the physiologic A lines (arrow • Z line (写真右)cardiogenic pulmonary edema. vanish without reaching the edge of the screen. These are Z lines. ▫ 胸膜から出ているLineだが,Crit Care Med 2007 Vol. 35, No. 5 (Suppl.) A lineが残っている. B lineならばA lineは消される. ▫ また, 減衰も強く, モニター端まで到達していない. ▫ Z lineは80%の患者で認められる. ▫ 臨床的意義は無く, B lineとの鑑別が重要となる所見.
artifacts that do not provide di information. 20 DISCUSSION As an air-ﬁlled structure, the an organ for which ultrasound tr ally had a limited diagnostic v fact, lung ultrasound is hardly s to exist (23). Yet the use of bas makes immediate management threatening conditions possible cessible with simple units, lun sound could have been develop the advent of real-time ultrasou ﬁrst observations were made usi technology (ADR-4000). In addit small size of these devices mad fully suitable for the ICU and th gency department. In the literature, we discover, ingly, that horses have already b from ultrasound— because the ment of the lung toward the ches visible (24). Human studies follo their impact was minimal. In fac knowledge, studies have suffer various shortcomings. Sistrom et al. (25) looked at sitivity of lung sliding and come 13 patients with radiologic pneu rax occurring after chest biops 7-MHz linear probes in units ha sonologists (i.e., nonphysicians quently supervised by radiologis study demonstrated moderate acc ultrasound with 73% sensitivi speciﬁcity, 89% negative predicti and 40% positive predictive val can such results be explained? F trasound gives its best, in ourFigure 10. Suggested classiﬁcation of thoracic artifacts. when used by only one and sam
Chest 2008;134:117-125 急性呼吸不全にてICU入室した301名の 診断と肺エコー所見の比較 BLUE protocol • エコー方法 体位は半横位 Zone 1-3を上下2分し, 計6か所評価 プローブ; 5-MHz microconvex Scan; 縦軸方向にて評価
37 • US scoreの変化と, 胸部CTにおけるAerationの変化は相関する.A Overall CT lung re-aeration following B A C right lung re-aeration following CT Overall CT lung re-aeration following B C right lung re-aeration following CT antibiotic administration (ml) antibiotic administration (ml) antibiotic administration (ml) antibiotic administration (ml)3000 1500 3000 Right lung 1500 Right lung Rho=0.85; p<0.0001 Rho=0.79; p<0.0001 R Rho=0.79; p<0.0001 R Rho=0.85; p<0.0001 1000 2000 10002000 500 500 10001000 0 0 0 0 -500 -500 -1000 -1000-1000 -1000 -2000 -1500 -20 -10 0 10 20 30 -20 -15 -10 -5 0 5 10 15-2000 -1500 Lung ultrasound re-aeration score Figure 6 Righ lung ultrasound re-aeration score ht -20 -10 0 10 20 30 -20 -15 -10calculated on both lungs -5 0 5 10 15 aeration Lung ultrasound re-aeration score Figure 6. Accuracy of lung ultrasound aeration fre- calculated on both lungs C ht lungCT left lung re-aeration following Righ ultrasound re-aeration score aeration score for quantifying changes in lungpatients antibiotic administration (ml) aeration following antibiotic administration in 30 clos EachC CT left lung re-aeration following 1500 Left lung tient. patients with ventilator-associated pneumonia. CT, antibiotic administration (ml) 1500 ▫ USLeft lung >5改善認める場合, Rho=0.70; p<0.001 score CTでは>400mlのAerationの増加を期待. Each closed circle represents an individual pa- 1000 tient. CT, computed tomography. Rho=0.70; p<0.001 observed US score <-10悪化認める場合, CTでは>400mlのAerationの悪化が予測される. for unde 1000 clinical observed in VAP provides a solid rationale 500 後者の場合, 抗生剤は効いていないと判断できる. for understanding this result of potentialCorre clinical relevance. Aeration 500 0 tion Sco Correlations Between Changes in CT Crit and Lung Ultrasound Reaera-asse for Aeration Care Med 2010;38:84-92 tion has 0 -500 tion Score. Until now, the value of LUS e Tsubo
38 呼吸苦でER受診した患者の評価; XP vs US MD Consult - Print Previewer • 呼吸苦を主訴にER受診した404名のProspective normal, the most frequen cohort. Of the 404 patients, 157 exhibited a normal ultrasonographic examination radiograph. When conventional radiograph was failure, and acute bronchitis. When ultrasound scan did not show any sign 外傷性は除外. diagnoses were COPD and acute bronchitis. ▫ XP, 肺USで評価行い, 所見の一致性を比較. population was examined, the ultrasonograph andP When the entire study 2). The two modalities overlapped almost completely in the presence of concordance in detecting pulmonary fibrosis pattern (" = 87%), PTX (" = 不一致の場合は胸部CT検査を施行. consolidation (" = 70%). We found lowest concordance values for abnorm ARDS pattern and loculated pleural effusion. ▫ USとXPの一致率はほぼ同等. Table 2 -- Concordance Between Ultrasonograph and Radiograph Positive Diagnosis ▫ 不一致例が118例あり, Clinical Patterns Ultrasonograph Radiograph !% Free pleural effusion 87 76 76.2 [a] 胸部CTにて確認. Loculated pleural effusion 6 5 53.9 [a] Pulmonary edema 21 21 95.0 [a] ARDS pattern 3 1 49.8 [a] Pneumothorax 7 7 85.5 [a] Lung consolidation 122 111 70.5 [a] Pulmonary fibrosis pattern 7 9 87.3 [a] a P < .0001.Can Chest Ultrasonography Replace Standard Chest Radiography for Evaluation of Acute Dyspnea in the ED?Chest - Volume 139, Issue 5 (May 2011)
39Figure 6 Measure of agreement (expressed as " %) between chest ultrasonograph and chest radiograph according totheir position in the hemithoraces. All " values were highly significant (P < .0001). A, Free pleural effusion. B, Loculatedpleural effusion. C, Pneumothorax. D, Lung consolidation. • 不一致例118例のCT所見と, US, XPの一致率Table 3 -- Comparison of Chest Ultrasonograph and Chest Radiograph With Chest CT Scan as a ReferenceStandard in the 118 Cases of Discordance Between the Two Modalities Radiography Ultrasonography P Value CT Scan Diagnosis No. TC Sensitivity Specificity TC Sensitivity Specificity Radiograph Ultrasound % % % % Free pleural effusion 31 5 10 (2/20) 27 (3/11) 26 90 (18/20) 73 (8/11) < .0001 NS Loculated pleural 5 2 40 (2/5) … 3 60 (3/5) … NS … effusion Pulmonary edema 2 1 … 50 (1/2) 1 … 50 (1/2) … NS ARDS pattern 2 0 … … 2 100 (2/2) … … … Pneumothorax 2 1 50 (1/2) … 1 50 (1/2) … NS … Lung consolidation 49 23 40 (14/35) 64 (9/14) 26 60 (21/35) 36 (5/14) NS NS Pulmonary fibrosis 2 2 100 (2/2) … 0 … … … … pattern NS = not significant; TC = total concordance (true-positive + true-negative). ▫ USはXPよりもCT所見予測に有効. When free この場合(USとXPが不一致の場合), USとCTの一致率は63% higher pleural effusion was analyzed separately in the two hemithoraces, ultrasonography exhibited sensitivity than radiography in both hemithoraces (P < .0001); specificity was 50% in the right hemithorax for both modalities, whereas ultrasonography had higher specificity than radiography in the left hemithorax (90% vs 10%; P = .0011). In all patients with loculated pleural effusion by ultrasonograph and negative radiograph, the CT scan confirmed the presence of loculated pleural effusion (two cases in the left hemithorax and one in the right hemithorax); thus, for the absence of negative CT scan, the specificity was not calculated. Similar limitations were present in the analysis ofCan Chest Ultrasonography Replace Standard Chest Radiography for Evaluationultrasonographic andED? patients with PTX; in fact, only two patients exhibited discordant of Acute Dyspnea in the radiographic results (one detectedChest - Volume 139, Issue and one by radiography), with a positive CT scan for PTX in both cases. When we analyzed the 49 by ultrasonography 5 (May 2011)
Can Chest Ultrasonography Replace Standard Chest Radiography for Evaluation of Acute Dyspnea in the ED?Chest - Volume 139, Issue 5 (May 2011) 40 • US所見の評価方法USパターン マーカー USパターン マーカー 胸膜に挟まれたAnechoic area 呼吸変動(+), 遠位部が不明瞭な低エコー領域Free pleural effusion 肺Consolidation 体位により変化認める Air bronchogram(+), 末梢気道のAir trap(+) 胸膜に挟まれたAnechoic area Air bronchogram(-)Loculated pleural effusion 気管支の分岐が消失し, parallelに走る 体位により変化無し 無気肺 Lung pulse認める肺水腫 B+ lineを全肺野に認める ≥8本/fieldのB line. 局所性のB line 肺線維症パターン MD Consult - Print Previewer 胸膜肥厚, 不整な胸膜を認める 末梢側のConsolidationARDSパターン Lung slidingの消失, 低下 Lung pulseを認める(possible) 保たれた部位を認める Lung sliding消失 Lung pointを認める気胸 A lineを認める Transverse fixed artifactあり
US所見 Day 0 Day 5-8 Day 13-16 43 Air bronchogram 86.7% 75.4% 71.2% Fluid bronchogram 8.1% 7.6% 6.1% Local pleural effusion 42.4% 37.3% 21.2% Basal pleural effusion 54.4% 44.3% 23.5% Basal PEの量 (mL) 左側 50[30-200] 10[0-100] 0[0-0] 右側 50[20-150] 10[0-80] 0[0-0] Chest 2012;142:965-972• 肺エコー所見の時間経過.▫ レントゲンと同様, 所見は長期間残存する傾向にあるが, 病変の面積は縮小するため, どの程度の範囲かも チェックすることが大事となる.▫ 胸水量の変化は比較的早い.
44胸膜痛にも肺エコー！ American Journal of Emergency Medicine (2012) 30, 317–324• 胸膜痛を主訴にERを受診し, 胸部XPで所見(-)の90名.▫ 41名がProspective, 49名がRetrospective.▫ 上記において, 血液検査, 肺エコーを施行.▫ 最終診断はフォローとCT画像, PET, 換気血流シンチでの診断. 胸壁由来疾患が57名, 肺/胸膜疾患が33名(肺炎22, 胸膜炎2, PE 7, 肺癌1, 気胸1)▫ 肺エコーは, 肺, 胸膜疾患を 感度 96.97%[84.68-99.46], 特異度 96.49%[88.08-99.03]で検出可能 (偽陰性は1例のみ; 肺炎の症例と, 偽陽性は2例.)
some B-lines in the surrounding area (asterisks). This image is intercostal scan (focal interstitial syndrome), periphe 胸膜ラインの断絶; attending EP. Particular irregularity of t Physical examination and history were recorded 45 typical of a small lung consolidation due to a peripheral infarction. Final diagnosis was pulmonary embolism. alveolar consolidation, or disruption with attention was presentation by the at pleural line to specific symptoms, such as history and 2). reserved with or without effusion (Figs. 1 of cough, 断絶部は鋭角で, 周囲にB lineを伴う patient localized the pain. Maximal inspiration and exhala- hemoptysis, and fever along with pleuritic pain. tion were used to gain access to areas covered by solid 2.3. Blood sample 肺末端部の微小なConsolidationで, structures of the thoracic cage. Breath holding by the patient 2.5. Diagnostic criteria was useful to exclude breath motion–related artifacts. Further details on the technique and pathologic signs塞で典型的な所見.blood determined from at admission a 肺 of A sample of whole were was collected independent All final diagnoses LUS are described in a previously published article . sentreviewers laboratory. D-dimer the following procedures: to the after a combination of plasma level was assess この症例は肺塞栓であった. An examination of the painful thoracic area was by spiral computer tomography (sCT), perfusional scintigraphy, latex-enhanced turbidimetric quantitative test (Dad positron emission tomography (PET), compression ultraso- considered normal in presence of both the respiratory pleural Behring, Milan, Italy; normal value [NV] b283 ng/mL sliding and the scattered aerated image under the pleural line, nography of the legs, follow-up at few days and 1 to 3 months, without visualization of multiple vertical linear echogenic C-reactive protein (CRP) The risk profile for pulmonary and response to treatment. plasma level was assessed artifacts named B lines (B+ pattern) [3,5,6]. Lung ultrasound immunoturbidimetric method (SentinelWells criteria . thromboembolism was recorded after the Diagnostics, Milan was considered positive when direct scanning of the painful Italy; NV patientsmg/dL). White blood cell (WBC)317–324w All b0.71 diagnosed with Medicine (2012) 30, count American Journal of Emergency parietal chest pain of an chest area allowed visualization of at least one of the determined as part of the Multi-Angle-Polarised-Scatte unknown origin were discharged without therapy and following: absence of sliding, B+ pattern on more than 1 Separation (Abbott, IL; NV 4.5-11.6 × 109/L). blood submitted to a 2-step clinical examination and 心陰影に隠れた肺炎像sruption of the pleural line (white arrow) with a wedge-ural-based hypoechoic image with sharp margins and 2.4. Symptomses in the surrounding area (asterisks). This image issmall lung consolidation due to a peripheral infarction. Physical examination and history were recordedosis was pulmonary embolism. presentation by the attending EP. Particular attention w reserved to specific symptoms, such as history of cougalized the pain. Maximal inspiration and exhala- hemoptysis, and fever along with pleuritic pain. used to gain access to areas covered by solidof the thoracic cage. Breath holding by the patient 2.5. Diagnostic criteria l to exclude breath motion–related artifacts.tails on the technique and pathologic signs of All final diagnoses were determined from independeescribed in a previously published article . reviewers after a combination of the following procedure
肺エコーによる心不全の評価 Am J Emerg Med. 2008;26:585-91 B lineの特徴(Comet tail) 1. 胸膜より始まる 2. レーザーのように明確 3. 減衰せずに末梢まで見える 4. Aラインを消す 5. 肺の動きとともに移動する A; Normal B; 縦軸での断層象 肋骨間のComet tail(+) C; 斜軸での断層象 D; 多数のB line(+), Shining, White lung
sepsis (n = 6;were prospectively collected during 12 months of left and right pleuralby looking in terms of correlati sedation 7.4%), heart failure due to valvular dys- and on chest ultrasound effusions for the presence of function (n = 6; 2004. Overall, failure (n = 5; 6.2%) and with pleural separation did not show signiﬁcant differen of 2003 and 7.4%), liver 802 patients were admitted anterior pleural sliding, which has negative predictive 49 acute pancreatitis (n = 3; 3.7%). The mean heightinitial (r = 0.74 (L); r. (R); p = 0.46). during this period. Patients were included after and value of 100% = 0.71 thoracic circumference were on supine chest X-ray ± 10 cm, suspicion of pleural ﬂuid 172 ± 10 cm and 94 (blunting Statistical analysis was performed using Statistica respectively. Forty-four effusions associated with an opaci- software, version 6.0. The data distribution was checked of the lateral costophrenic angle were right-sided and• 人工呼吸器管理中で, 胸水を認めた81名のProspective study ﬁcation covering at least the lower lobe) and pre-puncture using Kolmogorov-Smirnov test showing normal distri- 37 left-sided. Sep was 35 ± 13 conﬁrming effusion.320 ml. Signiﬁcant Discussion0.1 for pleural volume; p = 0.06 for pleural ultrasonography mm; V was 658 ± An interpleural dis- bution (p = correlation was foundmm was required to include a=patient Ultrasound evaluation of pleural effusion is SD. Cor- tance of at least 10 between Sep and V (r 0.72; separation). Results are expressed as mean ± important▫ 肺エコーにて胸水量を評価. r2 = 0.52; p < 0.001;inclusion was dependent on the presence two ways: (1) it helps quantify the pleural ﬂuid using t in the study. The Fig. 2). The amount of pleural ﬂuid relation between volume of pleural ﬂuid and Sep was of an intensivist experienced in chest ultrasound. The examined by linear regression (Pearson product moment volume can to perform thoracentesis wasand the derived simpliﬁed formula V (ml) = 20 × Sep (mm) and hen decision be calculated using Sep made on clinical correlation). The mean prediction error was calculated▫ formula: もしくは15度 head-upで肺底部, the in deciding whether between the predicted shou 患者は臥位, V = 18.3andSep +not protocol-driven. To purposes helps mean of the differences or not thoracentesis and grounds alone × was 19.4. For practical eliminate as 腋窩後線上を胸郭に垂直に評価 the amount of of possible deformations of pleural space, be performed in high-risk Presence of complications the effects pleural ﬂuid can be estimated with the observed effusion volumes. patients; and (2) it provid▫ 吸気終末における,usingpatients × Sep (mm). deformities, visual guidance for pleural layers and volumeratepleural ra simpliﬁed formula: V (mL) = 20 with thoracic Mean pre- was recorded. The impact of PEEP Thethe relationship the authors excluded 臓側胸膜-壁側胸膜間距離の最大径をSepとしたとき, compar thoracentesis. on complication diction error of V or with diaphragm pathology. ml and in this study was zero. Our pneumothorax of post-lung surgery Sep was 149.3 ± 164.4 Patients between separation of 158.4 ± 160.6 presence the simpliﬁed formula. Statistically favourably with using a test of homogeneity of slopes. with the ml from of empyema, haemothorax or pres- ﬂuid was studied studies on ventilated patients by Lic 推定胸水量V(ml) = 20 x Sep(mm)が成り立つ.data and is and right pleural effusions  were ence of atelectasis were found between V and thoracic The γ=0.72. signiﬁcant correlations without effusion on initial ultrasound tenstein from left less than that reported by Mayo  circumference (r = 0.30; excluded from the study. V and Fartoukh . analysis of covariance. examination were also p = 0.03) and between compared using▫ Mean height (r = 0.31;were 0.02). No signiﬁcance was found thoracentesis and was approvedwith primary indication for prediction15°. investigated probe (intercostal probe, The study included patientssmall pleural ethics com- Patients errorは158.4±160.6ml p= supine with mild trunk The authors excluded collections for correlations between Sep and thoracic circumference excluding patients with pleuralthe hospital smaller th elevation at Ultrasound by separation 2.5 Mhz, Image Point, Hewlett-Packard, Andover, MA, 10 mm on initial ultrasound examination. It was al USA) was moved in cranial direction in posterior axillary suggested Intensive relationship may not be as line that the Care Med 2006;32:318-21 line. The transverse section perpendicular to the body axis was obtained with pleural separation visible as an ane- and clinically important for pleural separations belo choic or hypoechoic layer between two pleural layers. The 17 mm [1, 5, 11]. Potential sources of error were t visceral layer moved during the respiratory cycles with variability of ventilator setting and variable mean a an inspiratory decrease of the interpleural separation. The way pressures, regardless of the fact that the impact lung behind the pleural effusion appeared either aerated PEEP was insigniﬁcant. These settings can be relat or consolidated in the case of large pleural effusions. The to the degree of lung recruitment, and they modify t maximal distance between parietal and visceral pleura shape and size of pleural cavity. The volume can (Sep, Fig. 1) was measured off line at the lung base after underestimated, to a certain degree, due to lower lo freezing the image in end-expiration. The diaphragm, liver collapse in large effusions over 1,000 ml, which m and spleen had to be clearly visualised before tap to avoid lead to displacement of pleural ﬂuid [1, 12]. Sonograph accidental puncture. The lung base is often consolidated measurement is also inﬂuenced by the size of thorac and positioned posteriorly in the pleural cavity in venti- cavity. In large thoraces in tall people, the layer me lated patients. Thus, the maximum separation is frequently sured by ultrasound may cause underestimation of t found between lung and lateral, rather than posterior, chest wall (Fig. 1). Thoracentesis was performed in a posterior actual volume of pleural ﬂuid. The results could al axillary line at the previous probe position; however, it was be inﬂuenced by interobserver variability. The tran not directly guided by ultrasound. The ultrasonographic ducerSep measurement (Sep maximal separationwhich base) res Fig. 1 must not be angled or tilted, at lung may
50肺エコーによる気胸の評価 Critical Care 2007;11:205• 肺エコーの中で最も難しい評価▫ 胸膜と肺のSliding, A lineを評価する. 高周波のプローブ(5-10MHz)を使用した方がBetter▫ 臥位, 前胸部で評価するが, 部分的な気胸を評価する為には側胸部まで調べた方が無難. Available online http://ccforum.com/content/11/1/205▫ M-modeを使用すれば, 肺の拡張運動も評価可能であり, Figure 6 Figure 7 それが消失してA lineのみが平行に認めるならばそれは肺ではなく, 胸腔. つまり気胸と判断できる.
51• ICU患者において, 胸部XP, CT, 肺エコーを施行した197名のRetrospective Study (Crit Care Med 2005;33:1231-8)▫ 197名にて, 左右あわせて, 345肺を評価. 内43例にOccult pneumothorax.▫ 肺USのそれぞれの所見; Lung sliding(-), A line, Lung pointを評価. US所見 Sn(%) Sp(%) Lung sliding(-) 100% 78% LS(-) + A line 95% 94% LS(-) + A line + Lung point 79% 100%▫ Lung Slidingがあれば, 気胸は先ず除外可能.▫ LS(-) + αがあればほぼ気胸と診断可能.
52 多発外傷患者における, 肺エコーによる気胸の診断 Critical Care 2006;10:R112 • 135名の多発外傷患者のProspective study ▫ ERにて肺エコーを行い, 気胸を判断. RSはドレナージ or 胸部CT ▫ 29名(21.5%)が外傷性気胸(+)であった.検査 Sn(%) Sp(%)肺US 86.2[73.7-98.8] 97.2[94.0-100]胸部XP 27.6[11.3-43.9] 100[100-100] ▫ 感度は有意に肺USの方が良好. 特異度は有意差無し. ▫ USを使用した気胸の診断は, 胸部XPよりも有意に迅速 (2.3±2.9 vs 19.9±10.3 min, p<0.001) ▫ 気胸の評価にはレントゲンよりUSがBetter
56MD Consult - Print Previewer Figure 4 Radiographic and ultrasonographic detection of pneu pneumothoraces missed by chest radiography were confirmed by
OF THE LUNGS arrows), their acoustic shade, and the pleural line, 0.5 57 cm from an imaginary line connecting the ribs (rib line), Visualization of the lungs requires a 5 mHz transducer, indicated by the vertical arrow in the figure. The pleural肺エコー評価表 appropriate for transthoracic examination. Various pro- line corresponds to 2007;20:134-41 より一部改変 Pneumon the surface of the lung. The remain- INTENSIVE CARE UNIT, UN.H.H. PROFESSOR: Georgopoulos D. PATIENT NAME: ……………………………………………………………… RN: ……………………………. DATE: ……………………….Rt A B3 B7 C L M Lt A B3 B7 C L M PU PUA AU U LU LUAL AL AU AUL LU ULL AL AL LL LLP LL PU UPL PL PL PL PNEUMOTHORAX PNEUMOTHORAX PLEURAL EFFUSION PLEURAL EFFUSION FIGURE 1. Protocol for lung examination A line, B3: the line, B7: B7 line, C; Consolidation, A: Atelectasis, P: Pulmonary oedema, A: followed in B3 Intensive Care Unit. C: Consolidation, I: Infiltrations L: Lung sliding, M; M mode(でのLung pointの有無)
characterize Pressure–Volume Curves and Measurement of PEEP-induced Lung Recruitment Am J Respir Crit Care Med 2011;183:341-7 c score was examined i PV curves were measured using a ventilator equipped with speciﬁc 肺エコーを用いての software. In anesthetized and paralyzed patients, after a prolonged expiratory pause at PEEP 0 or PEEP 15 cm H2O, each patient’s respiratory system was inﬂated by a constant 8 l/min ﬂow until an Protocol The order curves and inspiratory pressure of 40 cm H2O was reached. Simultaneously, (Figure 1), PEEPによるLung recruitmentの評価 pressures, ﬂows, and volumes were recorded. Decrease in end-expiratory lung volume (DEELV) was deﬁned as was analyz ventilator s the difference in lung volume between PEEP 0 and PEEP 15 cm H2O after a PEEP release maneuver. PEEP-induced lung recruitment was Statistical measured according to lung morphology assessed on chest radiography • 40名のALI/ARDS(重症FaO2/FiO2≤100を除く)において, (13, 14). In patients with focal loss of aeration, PEEP-induced lung recruitment was quantiﬁed as follows: PV curves in PEEP 0 and PEEP Correlation lung recrui Statistical a 15 cm H2O were placed on the same pressure and volume axes. PEEP- PEEP 0, 15cmH2Oをかけて, lung recruitmentと induced lung recruitment was deﬁned as the difference in lung volumes between PEEP 0 and PEEP 15 cm H2O at an airway pressure of 15 cm tical signiﬁ H2O (16). In patients with diffuse loss of aeration, PEEP-induced lung RESULTS 肺エコー所見の関連を評価. recruitment was deﬁned as DEELV. Patients Lung Ultrasound Forty con ▫ 肺エコーは, 左右, 上下, 前側後の12カ所で評価. スコア化して変化を評価NAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 183 2011 LUS was performed using a 2- to 4-MHz probe. All intercostal spaces were incl of upper and lower parts of anterior, lateral, and posterior regions of a tidal vol left and right chest wall were examined (3, 6). Videos were stored on tained bet TABLE 1. ULTRASOUND REAERATION SCORE Quantiﬁcation of reaeration* Quantiﬁcation of loss of aeration 1 point 3 points 5 points 5 points 3 points 1 point B1 / N B2 / N C/N N/C N / B2 N / B1 B2 / B1 C / B1 B1 / C B1 / 2 C / B2 B2 / C B1; B7-line, B2; B3-line, C; lung consolidation, spaced Deﬁnition of abbreviations: B1 5 multiple well-deﬁned either regularly 7-mm apart or irregularly spaced B lines (moderate loss of lung aeration); B2 5 N; normal(A line)(severe loss of lung aeration); C 5 lung consolidation; multiple coalescent B lines N 5 normal pattern (normal lung aeration). * The ultrasound reaeration score was calculated as follows: In a ﬁrst step, ultrasound lung aeration (N, B1, B2, and C) was assessed in each of the 12 lung ▫ PVカーブは regions examined before and after application of positive end-expiratory pressure 15 cm H2O. In a second step, ultrasound lung reaeration score was calculated as the sum of each score characterizing each lung region examined according to the 鎮静, 筋弛緩状態で評価 scale shown in the table.
constant throughout the experiments, and FIO2 was maintained at reaeration score of 14 or greater was ass1. Clinical and physiological characteristics are summarized in Am J Respir Crit Care Med 2011;183:341-7 59 induced lung recruitment ranging from 75 tTable 2. Compared with patients with focal loss of aeration, pa- the ultrasound reaeration score was less actients with diffuse loss of aeration had a higher lung injury severity smaller changes of lung aeration. A sta • PEEPをかけた後, LUS scoreが+8以上ならば,score, were ventilated with a higher respiratory rate, and hada higher level of PEEP-induced lung recruitment (Table 2). correlation was found between the LUS r a PEEP-induced increase in PaO2 (Figure 2 was tighter in patients with diffuse loss of l Lung recruitmentは>600mlを期待できる.Diagnostic Accuracy of LUS for Quantifying PEEP-induced patients with focal loss of lung aeration.Lung Recruitment Ultrasound Analysis of Regional Lung Reae ▫ しかしながら, +4以上の場合は75-400mlのrecruitmentであり,A highly statistically signiﬁcant correlation was found betweenPEEP-induced lung recruitment measured by the PV curve Among 480 regions of interest, 469 couldmethod and the ultrasound reaeration 軽度のrecruitmentの場合はUSでの評価が難しい バラツキが大きい → score (Figure 2A). The and after application of PEEP (11 regionsultrasound reaeration score was accurate for detecting a signif- be examined because of the presence of aicant increase in lung aeration (Figure 2B). PEEP-induced lung sound reaeration after PEEP was predom F t s a e ( c p m o t i r l i P m
Am J Respir Crit Care Med 2011;183:341-7 60 344• 部位別のUS所見の変化(PEEP前後) 前胸部 上部 前胸部 下部
AMERICAN JOURNAL Crit Care Med 2011;183:341-7 Am J Respir OF RESPIRATORY AN 61側胸部 上部側胸部 下部
N JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Care Med183 2011 Am J Respir Crit VOL 2011;183:341-7 62 背側 上部 背側 下部 前胸部, 側胸部の所見は PEEPにより改善しやすい. 背側, 下部のAir入りは 改善しにくい傾向あり
63SBT前後の肺エコーで抜管後のDistressを予測する Crit Care Med 2012; 40: 2064–2072• ICU患者100名において, SBT→抜管を施行.▫ SBT前, SBT後1時間, 抜管後4時間で肺, 心エコー, BNP評価し, 抜管後のDistressとの関連性を評価.▫ SBTはT-tubeを用いて観察.▫ 肺USは2-4MHzのプローブを用い, 左右上下, 前側後肺の12箇所で評価し, Score化 所見 Score 正常; A line もしくは B lineが2本未満 0 中等度の虚脱; 複数のB line 1 高度な虚脱; 放射状のB line 2 完全虚脱; Consolidationを認める 3