Chest
Volume 140, Issue 5, November 2011, Pages 1332-1341
Journal home page for Chest

Recent Advances in Chest Medicine
Thoracic Ultrasonography for the Pulmonary Specialist

https://doi.org/10.1378/chest.11-0348Get rights and content

Thoracic ultrasonography is a noninvasive and readily available imaging modality that has important applications in pulmonary medicine outside of the ICU. It allows the clinician to diagnose a variety of thoracic disorders at the point of care. Ultrasonography is useful in imaging lung consolidation, pleural-based masses and effusions, pneumothorax, and diaphragmatic dysfunction. It can identify complex or loculated effusions and be useful in planning treatment. Identifying intrathoracic mass lesions can guide sampling by aspiration and biopsy. This article summarizes thoracic ultrasonography applications for the pulmonary specialist, related procedural codes, and reimbursement. The major concepts are illustrated with cases. These case summaries are enhanced with online supplemental videos and chest radiograph, chest CT scan, and ultrasound correlation.

Section snippets

Equipment Requirements

Most modern portable ultrasound machines are capable of all aspects of thoracic imaging. A phased array transducer (frequency range 3.5-5.0 MHz) with a small footprint designed for cardiac imaging can be used for most aspects of the thoracic examination. This transducer type offers adequate penetration and resolution of deep structures in the thorax. For detailed examination of the pleural surface and adjacent chest wall the examiner will need to use a high-frequency linear vascular transducer

How to Perform Thoracic Ultrasonography

Thoracic ultrasonography is best performed with the patient in the seated position. By convention, the transducer is held in longitudinal scanning plane with the transducer indicator in a cephalad position. With standard machine setup, this means that images on the left side of the screen are cephalad structures. Knowledge of machine control is integral to image acquisition. Total, near, and far field gain must be adjusted for optimal image quality. Depth should be set to place the target

Lung Ultrasonography

Lung ultrasonography may be integrated into bedside evaluation as a valuable adjunct to the standard chest radiograph and CT scan and, as an extension conceptually, to physical examination of the thorax. It is paired with ultrasonographic evaluation of the pleural space, but it also has usefulness independent of pleural pathology. This section will review applications of lung ultrasonography that are of interest to the pulmonary consultant.

Pleural Ultrasonography

Pleural ultrasonography is an easy-to-use modality that aids in the identification and characterization of pleural abnormalities. It can also be used to guide pleural procedures. Equipment requirements and scanning tactics are identical to those used for lung ultrasonography as described previously.

Thoracentesis

Ultrasonography allows the pulmonary consultant to perform thoracentesis in a safe and efficient manner. Ultrasonography reduces complications, such as pneumothorax, and increases success of fluid retrieval when compared with traditional methods of guidance.23, 24

The examiner should seek unequivocal identification of a pleural effusion. The assignment is simple: identification of the best site, angle, and depth for needle insertion that avoids injury to organs that may be adjacent to the

Practical Use of Bedside Ultrasonography: A Case Example

A common cause for pulmonary consultation is evaluation of dyspnea. We were called to evaluate a patient with sickle cell disease who presented in the ED with hypoxemia, fever, purulent sputum, and pleuritic chest pain over the lower posterior left thorax. The chest radiograph was clear (Fig 14). The admitting team had ordered a chest CT scan to rule out pulmonary embolism. Thoracic ultrasonography was performed and showed generalized A-line pattern including the anterior chest and a focal area

Limitations of Thoracic Ultrasonography

Limitations of image quality of thoracic ultrasonography are obesity, heavy musculature, edema, and an inability to properly position a patient for a complete examination. However, even with these limitations, an experienced examiner can generally obtain important information. The rate of incomplete, ambiguous, or noninterpretable studies depends on the examiner and the population being examined. Another limitation of thoracic ultrasonography is the difficulty in documentation of the imaging

Barriers to Implementation

Thoracic ultrasonography requires training in image acquisition, image interpretation, and cognitive background that allows integration of the results into the clinical management of the patient, as the pulmonary consultant assumes all responsibility for the performance and interpretation of the study. Thoracic ultrasonography requires specific training in image acquisition, image interpretation, and in the cognitive elements of the field.

Charges, Coding, and Reimbursement

There are routine charges, defined as a global fee, a technical fee, and a professional fee, where the global fee is the combined sum of the technical and professional charges. If thoracic ultrasonography is performed in the hospital setting, all of the technical costs are absorbed by the institution, as the hospital owns the machine and provides the supplies required for scanning. The clinician receives payment only for the professional component of the procedure. In contrast, office-based

Conclusion

Thoracic ultrasonography is a safe, easy-to-learn, portable imaging modality that has usefulness for the pulmonary consultant. The authors routinely take a portable ultrasound machine on hospital rounds when performing pulmonary consultations. The history and physical examination is followed, when indicated, by a goal-directed ultrasound examination. Diagnostic and therapeutic procedures may be guided with ultrasonography at the point of care, minimizing ionizing radiation. Ultrasound can also

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: This work was performed at Long Island Jewish Medical Center, New Hyde Park, NY.

Additional information: The Videos can be found in the online version of the article at http://chestjournal.chestpubs.org/content/140/5/1332.full.

References (29)

Cited by (0)

Editor's Note: The online version of this article includes three videos intended to enhance the major concepts presented. The videos can be viewed at: http://chestjournal.chestpubs.org/content/140/5/1332.full

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

View full text