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Role of ward-based pleural ultrasound

Role of ward-based pleural ultrasound. Dr R Teoh Department of Respiratory Medicine Castle Hill Hospital. Reason for study: To assess position of right chest drain inserted into the eighth intercostal space, but is projecting over the right upper quadrant on the abdominal x-ray. Report:

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Role of ward-based pleural ultrasound

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  1. Role of ward-based pleural ultrasound Dr R Teoh Department of Respiratory Medicine Castle Hill Hospital

  2. Reason for study: To assess position of right chest drain inserted into the eighth intercostal space, but is projecting over the right upper quadrant on the abdominal x-ray. Report: In the abdomen the chest drain has been inserted through the lower right hemidiaphragm into the right lobe of the liver. This crosses through the right lobe of the liver to the left lobe avoiding both main branches of the portal vein. It exits the left lobe through its inferior surface and runs anterior to the distal stomach and terminates just anterior to the hepatic flexure of the colon. The drain is not passing through the pleural cavity.

  3. Accuracy of pleural puncture sites: Clinical examination versus ultrasound • 15% (25/172) of “blind” puncture sites inaccurate • US potentially prevented organ puncture in 10% (17/172) • US increased localisation of accurate site by 26% (65/255) 255 procedures Puncture site identified: 172/255 (67%) No puncture site identified: 83/255 (33%) Accurate: 147/172 (85%) Inaccurate: 25/172 (15%) US - Site found: 45/83 (54%) US - No site found: 38/83 (46%) 8: Insufficient fluid 5: Lung 12: Liver or spleen USS identified accurate site in 20/25 (80%) Diacon et al. Chest 2003; 123: 436-441

  4. Ultrasound findings following failed, clinically directed thoracentesis • 8/26 (31%) had no pleural fluid on US • 10/26 (38%) blind thoracentesis were misdirected • 14/16 (88%) US-guided thoracentesis successful Weingardt JP etl al. J Clin Ultrasound, 1994; 22: 419-426.

  5. US-guided thoracentesis: Complication rates • Prospective descriptive study (n=941) • Interventional radiologists • Lower complication rate with US guidance compared to historical controls Jones et al, Chest 1990; 123: 418-423

  6. RCT comparing US guided versus blind thoracentesis p=0.01 • RCT (n=52) • Medical and radiology residents • Lower complication rate with US guidance Grogan et al, Arch Intern Med 1990; 150: 873-877

  7. US guided thoracentesis: Success rate • Prospective RCT (n=205) • Physician-performed thoracentesis with and without US guidance (X-marks the spot) • US guidance increases yield in small and loculated pleural effusions Kohan JM et al. Am Rev Respir Dis 1985; 133: 1124-26.

  8. Septations Normal lung & rib shadow Compressive atelectasis Diaphragm, liver & pleural effusion Consolidation with air bronchograms Small pleural effusion

  9. Ultrasound study in unilateral hemithorax opacification Yu CJ et al. Am Rev Respir Dis, 1993: 147: 430-434

  10. Advantages of ward-based pleural ultrasound • Detects pleural pathology • Pleural versus parenchymal lesions • Guides pleural procedures • Monitors pleural disease • Performed at bedside • No delays • No radiation

  11. Disadvantages of ward-based pleural ultrasound • High capital cost • Inadequate environment • Operator-dependent • Training requirements

  12. The impact of ward-based pleural ultrasound in a respiratory unit Ultrasound purchased

  13. The impact of ward-based pleural ultrasound in a respiratory unit • 54/102 (53%) had US within 24 hours of admission • 30/102 (29%) had no or insufficient pleural fluid to aspirate or drain • Guided 15/88 (17%) procedures in small or loculated effusion • No complications • Overall ward-based ultrasound affected management in 45/102 (44%) of cases 102 patients Pleural effusion present: 88 Clinical detectable: 63/88 Clinically undetectable: 25/88 No pleural effusion present: 14 Small 31/88(35%) Loculated: 11/88 (13%) Large: 46/88 (52%) Thoracentesis: 8/88 (9%) US guided chest drain: 7/88 (8%) US guided chest drain 41/88 (47%)

  14. Indications for pleural ultrasound • To clarify the nature of pleural shadowing • To guide thoracentesis and drainage of pleural effusions, especially those which are small or loculated • To determine the nature of hemithorax “white-out” • To differentiate between subpulmonary effusion, subphrenic collection or elevated hemidiaphragm • To localise pleural thickening or pleural tumours prior to biopsy • To exclude post-intervention pneumothorax Adapted from Tsai et al, Curr Opin Pulm Med 2003; 9: 282-290

  15. Tom & Katie’s

  16. Ultrasound machines • Portable +/- stand • Fewest knobs • Transducer: • Phase: 3.75 Mhz • Linear: 5 to 10 Mhz • Consider Colour Doppler mode • Warranty 2-5 years • New or second hand • Manufacturers: Sonosite, GE, Philips • “Ultrasound equpiment business case” http://www.collemergencymed.ac.uk/temp/1509-Business-case-for-EMUS.pdf

  17. RCR recommendations for physician-operated thoracic US • Ultrasound course • Observing 20 chest US • Performing: • 20 US on normal patients • 10 US in patients with pleural effusions • 5 diagnostic aspirations or drain placements • Supervised by Level II practitioner • “Business case for practical training in ultrasound for non-radiologist”. http://www.bmus.org/about/businesscase1.pdf

  18. Chest ultrasound courses James Cook Hospital Middlesborough 19 June 2009 Royal Preston Hospital St. James’s University Hospital, Leeds Pilgrim Hospital Boston Bromley Hospital Orpington St. George’s Hospital London

  19. Pleural ultrasound:Is it worth a look? • Ward-based physician-operated ultrasound can improve the yield and safety of diagnostic and therapeutic pleural procedures • High capital cost and training requirements may limit its implementation across the UK

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