超声chestecho超音波用於胸腔急症

1、胸腔急症的超音波診斷胸腔急症的超音波診斷Chest Radiograph in Critically Ill Patients Too weak to sit up and air-fluid level will be visible unable to inspirate fully because of sedation, consciousness change, pain or fatigue unrecognized rotation of body mobile radiographic equipment has low power techniques and target-

2、film distances varyMirvis SE. Thoracic CT in detecting occult diseasein critically ill patients. AJR 1987;148:685-9Diagnostic Ultrasonography in the Emergency Department Radiology More timely medical imaging of unstable patients hypotension of unknown etiology cardiac tamponade pulmonary embolism ao

3、rtic aneurysm Critically time-sensitive procedures Portable, fast, noninvasive, safe, inexpensive and provides anatomic and functional informationAnn Emerg Med March 1993;592-3Ultrasound in EM The J of EM Med 2007 Trauma Identification of pregnancy Cardiac RUQ abdomen Renal Aorta Procedure CVP Subcu

4、taneous FB detection Thoracentesis and paracentesisDiagnostic and Therapeutic Use of Chest Sonography: value in Critically ill patients Pleural diseases peripheral parenchymal lesions mediastinal lesions consolidation atelectasis transthoracic aspiration biopsy assisting the diagnosis and management

5、 of critically ill patients whose chest radiographs were difficult to interpretCJ Yu. AJR 159:695-701, Oct. 1992 肺部急症的超音波診斷肺部急症的超音波診斷 一、前言一、前言 二、探測方法 三、肋膜腔、縱膈、肺臟的正常超音波 表現 四、肋膜腔疾病的超音波表現 五、縱膈疾病的超音波表現 六、肺部疾病超音波表現前言前言急性胸腔部疾病急性胸腔部疾病: : CXR CXR CT and MRI 超音波超音波 便捷、安全、快速之輔助便捷、安全、快速之輔助 佐以胸腔放液、腫瘤抽吸等技術更加提佐以胸

6、腔放液、腫瘤抽吸等技術更加提高快速治療及診斷率高快速治療及診斷率 肋膜疾病、周邊肺實質病變、縱膈腔疾肋膜疾病、周邊肺實質病變、縱膈腔疾患、心胞膜病變和橫膈病變等患、心胞膜病變和橫膈病變等探探 測測 方方 法法 儀器選擇(with color doppler is better) 2.5 - 5 MHz for pleura and lung 5 - 7.5 MHz for chest wall masses and adenopathy 檢查前準備 CXR, CT scan, MRI if available 體位 檢查方法Transducer Positions A: suprasterna

7、l B: transosseous C: intercostal D: subxyphoid E: subcostalAJR 134:1019-27, May 1980肋膜腔、縱膈、肺臟的正常超音波圖肋膜腔、縱膈、肺臟的正常超音波圖 縱膈縱膈 大血管及心臟。大血管及心臟。aortic archaortic arch。 兒童或嬰兒期，偶可見胸腺一葉或兩葉增大，外有包膜，內為均質低兒童或嬰兒期，偶可見胸腺一葉或兩葉增大，外有包膜，內為均質低回聲區。回聲區。 肺臟肺臟 充滿氣體，強回聲反射，後方衰減，不能顯示其內部構造及回聲狀態。充滿氣體，強回聲反射，後方衰減，不能顯示其內部構造及回聲狀態。 肋膜肋

8、膜 很薄，超音波難以顯示。往往在胸壁後顯示肺的強反射很薄，超音波難以顯示。往往在胸壁後顯示肺的強反射。Comet-tail sign.急性肋膜腔疾病的超音波表現急性肋膜腔疾病的超音波表現 游離性肋膜腔積液游離性肋膜腔積液 包裹性積液包裹性積液(loculated) (loculated) 膿胸膿胸 氣胸氣胸 血胸血胸 肋膜腫瘤肋膜腫瘤 肋膜間皮瘤肋膜間皮瘤mesotheliomamesothelioma 肋膜轉移瘤肋膜轉移瘤metastatic tumormetastatic tumor縱膈疾病的超音波縱膈疾病的超音波惡性腫瘤淋巴結結核神經原性腫瘤大血管疾病心包膜疾病縱膈腔炎急性肺部疾病超音波

9、表現急性肺部疾病超音波表現 肺不張肺不張 肺膿腫肺膿腫 肺炎肺炎 肺癌肺癌 肺含氣體、病變或腫瘤被大量氣體所掩蓋，常不易顯示。肺含氣體、病變或腫瘤被大量氣體所掩蓋，常不易顯示。 但肋膜腔積液或肺實變時，肋膜積水及實變但肋膜腔積液或肺實變時，肋膜積水及實變consolidation)consolidation)為良好的為良好的透聲窗透聲窗acoustic windowacoustic window，而易顯示肺內病變或腫瘤。，而易顯示肺內病變或腫瘤。Differentiation of Lung Abscess and Empyema Empyema lesion adheres to the p

10、arietal pleura and moves with chest wall but not with the parenchyma on respiration Abscess lesion adjacent to visceral pleura. If inflammatory process does not extend into the pleural space or there is no adhesion between visceral and parietal pleura, abscess moves with the lung parenchyma but not

11、chest wall Adams FV. Chest 1979;75:330-9Sonographic observation of pulmonary infarction and early infarctions by pulmonary embolism Pulmonary embolism/infarct wedge-shaped, hypoechoic, pleural-based lesions Later stage sharply outlined, triangular or rounded to the hilus, pleueal based lesion with a

12、n hyperechoic bronchiole in the centre. Small pleural effusion in 52% G. Mathis. Eur Heart J 14, 1993, 804-8Pulmonary Infarction: Use of Color Doppler Sonography for Diagnosis and Assessment of Reperfusion of the Lung Initial Wedge-shaped consolidations with air bronchograms No visible blood flow Af

13、ter Treatment Reperfusion Diagnosis and Response of treatment AJR:160, Feb 1993, 419-420Thoracentesis ComplicationsComplicationsPatient No. (%)Procedures, No941(605Pts)Pain25 (2.7)Pneumothorax24 (2.5)Chest tubes8 (0.8)Shortness of breath9 (1.0)Cough8 (0.8)Vasovagal6 (0.6)Bleeding2 (0.2)Hematoma2 (0.

14、2)Re-expansion pulmonary edema2 (0.2)Disadvantages of CT Scans Difficulty in Transporting Cost Repeating examinations inconvenient or impractical Lack of real-time guidance and Bed side availability Clinics in Chest Medicine, March 1991Disadvantages of Chest Sonography Ultrasonic wave is easily hind

15、ered by air Poor visualization of the Mediastinum, hilum and airway Restricted field of view Operator dependence Wiener MD. Imaging of the intensive care unit patients Clin Chest Med 1991;12;169-198Value of Sonography in the Diagnosis of Critically Ill Patients Categories No. of patients (n=41)Assis

16、ting diagnosis 27 (66%) Made diagnosis 12 Changed diagnosis 8 Provided additional 7 informationNo benefit 14 (34%) (Yu et al AJR 1992) Influence of Sonography on the Managementof Critically Ill Patients Categories No. of patient (n=41)Helped management 37 (90%) Affected decision 8 Affected decision

17、and guided thoracemtesis 10 Affected decision and guided aspiration 7 Guided thoracentesis only 12No benefit 4 (10%) (Yu et al AJR 1992) Diagnostic Contribution of Chest Sonography Changed the diagnosis provided additional diagnostic information didnt not provided any additional diagnostic informati

18、onAnn Yuan, J Clin Ultrasound Vol 29, No. 2, Feb. 2001;78-85Impact of Chest Sonography on Patient Management New information that contributed new management Guidance for invasive diagnostic or therapeutic procedures No benefitAnn Yuan, J Clin Ultrasound Vol 29, No. 2, Feb. 2001;78-85ConclusionReal-t

19、ime imagingProvide information not available from standard radiographDiagnosis of pleural, pulmonary and aortic disease etc.肺部急症的超音波診斷肺部急症的超音波診斷 一、前言一、前言 二、探測方法 三、肋膜腔、縱膈、肺臟的正常超音波 表現 四、肋膜腔疾病的超音波表現 五、縱膈疾病的超音波表現 六、肺部疾病超音波表現前言前言急性胸腔部疾病急性胸腔部疾病: : CXR CXR CT and MRI 超音波超音波 便捷、安全、快速之輔助便捷、安全、快速之輔助 佐以胸腔放液、腫瘤

20、抽吸等技術更加提佐以胸腔放液、腫瘤抽吸等技術更加提高快速治療及診斷率高快速治療及診斷率 肋膜疾病、周邊肺實質病變、縱膈腔疾肋膜疾病、周邊肺實質病變、縱膈腔疾患、心胞膜病變和橫膈病變等患、心胞膜病變和橫膈病變等縱膈疾病的超音波縱膈疾病的超音波惡性腫瘤淋巴結結核神經原性腫瘤大血管疾病心包膜疾病縱膈腔炎急性肺部疾病超音波表現急性肺部疾病超音波表現 肺不張肺不張 肺膿腫肺膿腫 肺炎肺炎 肺癌肺癌 肺含氣體、病變或腫瘤被大量氣體所掩蓋，常不易顯示。肺含氣體、病變或腫瘤被大量氣體所掩蓋，常不易顯示。 但肋膜腔積液或肺實變時，肋膜積水及實變但肋膜腔積液或肺實變時，肋膜積水及實變consolidation)consolidation)為良好的為良