Thorax Online First, published on April 14, 2017 as 10.1136/thoraxjnl-2016-209340 State of the art review State of the art thoracic ultrasound: intervention Thorax: first published as 10.1136/thoraxjnl-2016-209340 on 14 April 2017. Downloaded from and therapeutics John P Corcoran,1,2 Rachid Tazi-Mezalek,3 Fabien Maldonado,4 Lonny B Yarmus,5 Jouke T Annema,6 Coenraad F N Koegelenberg,7,8 Victoria St Noble,9 Najib M Rahman1,2,10 1Oxford Centre for Respiratory ABSTRACT clinical work, and the evidence relevant to patient Medicine, Oxford University The use of thoracic ultrasound outside the radiology safety that underpins this. The impact of TUS on Hospitals NHS Foundation Trust, Oxford, UK department and in everyday clinical practice is becoming basic and more advanced procedures will be 2University of Oxford increasingly common, having been incorporated into described, together with an overview of how Respiratory Trials Unit, standards of care for many specialties. For the majority outcome prediction and future research will con- Churchill Hospital, Oxford, UK 3 of practitioners, their experience of, and exposure to, tinue to change the way we practise in years to Department of Thoracic thoracic ultrasound will be in its use as an adjunct to come. Oncology, Pleural Diseases and Interventional Pulmonology, pleural and thoracic interventions, owing to the widely Hôpital Nord, Aix-Marseille recognised benefits for patient safety and risk reduction. University, Marseille, France However, as clinicians become increasingly familiar with PRACTICAL CONSIDERATIONS 4 Division of Allergy, Pulmonary the capabilities of thoracic ultrasound, new directions for Clinical practitioners who regularly use TUS must and Critical Care Medicine, have completed training according to an approved its use are being sought which might enhance practice – Vanderbilt-Ingram Cancer syllabus3 5 under appropriate supervision, and Center, Vanderbilt University and patient care. This article reviews the ways in which School of Medicine, Nashville, the advent of thoracic ultrasound is changing the maintain a record of practice that is subject to audit Tennessee, USA (internal or external) and demonstrates continued 5 approach to the investigation and treatment of Division of Pulmonary and respiratory disease from an interventional perspective. competence. All practitioners must recognise their Critical Care Medicine, John This will include the impact of thoracic ultrasound on own limitations, those of colleagues and of their Hopkins University, Baltimore, working environment; ideally, there should be a Maryland, USA areas including patient safety, diagnostic and therapeutic 6Department of Pulmonology, procedures, and outcome prediction; and will also clear upward referral pathway that allows access to Academic Medical Centre, consider potential future research and clinical directions. the support of experienced colleagues either in the University of Amsterdam, radiology department or via a multidisciplinary Amsterdam, The Netherlands team interaction. The skills and experience a practi- 7Division of Pulmonology, Department of Medicine, tioner needs to acquire in the use of TUS will vary Stellenbosch University, Cape INTRODUCTION according to their specialty and geographical area Town, South Africa Thoracic ultrasound (TUS) has, in recent years, of practice. Much will depend on what is needed http://thorax.bmj.com/ 8 Tygerberg Academic Hospital, become as essential a tool as the stethoscope in the for an individual’s everyday clinical responsibilities, Cape Town, South Africa management of patients with respiratory disease. and what their workload is likely to allow them to 9Department of Radiology, Oxford University Hospitals There has been a change in attitude among physi- maintain competence in performing. NHS Foundation Trust, Oxford, cians with growing recognition that clinical examin- Conventional brightness (B)-mode ultrasound UK ation and plain chest radiography are often provides the operator with sufficient information 10 NIHR Oxford Biomedical imprecise.12This evolution of clinical practice has for the majority of thoracic TUS applications and Research Centre, University of Oxford, Oxford, UK been facilitated in part by technological progress, interventions, but most modern machines will offer with the increasing availability of high-specification the operator a selection of other options, including on September 25, 2021 by guest. Protected copyright. Correspondence to portable ultrasound machines that can be easily motion (M)-mode and colour flow Doppler scan- Dr John P Corcoran, University brought to the patient’s bedside. Alongside this, the ning. A low-frequency (2–5 MHz) curvilinear of Oxford Respiratory Trials incorporation of ultrasound training standards into probe is the most useful if only one can be selected, Unit, Churchill Hospital, 3–5 fi Oxford OX3 7LE, UK; postgraduate medical curricula has led to a new allowing both super cial and deep structures to be [email protected] generation of clinicians emerging with a set of clin- evaluated as a consequence of the tissue penetra- ical skills and interests that mean the use of TUS is tion on offer. This is at the expense of image Received 23 August 2016 continually expanding and evolving. quality, and if depth can be sacrificed (eg, when Revised 14 March 2017 fi Accepted 23 March 2017 This revolution is clearly seen in the eld of assessing chest wall and/or parietal pleural disease) interventional pulmonology, where the advent of then a high-frequency (5–10 MHz) linear probe TUS has dramatically altered the range of proce- will provide additional detail and resolution. If dures and the way in which they are performed. default or preset ultrasound settings are offered by For many practitioners, TUS may be considered as the machine, these should be chosen to suit the little more than a means of confirming the presence work being done—‘abdominal’ mode will serve for or absence of pleural fluid before intervention. In interventions where depth of view is important (eg, this review article we aim to demonstrate how and assessment of pleural effusions and distal structures, To cite: Corcoran JP, Tazi- why this way of thinking is only the beginning; such as lung and mediastinum); whereas ‘thyroid’ Mezalek R, Maldonado F, inviting the reader to consider the current or ‘musculoskeletal’ mode should be selected for et al. Thorax Published Online First: [please include capabilities of TUS, alongside the way in which proximal work dealing with the chest wall or super- Day Month Year] ongoing work is changing the way we investigate ficial lymph nodes. In many cases, further optimisa- doi:10.1136/thoraxjnl-2016- and treat patients with respiratory disease. We will tion of image quality can be achieved by spending 209340 examine the practicalities of using TUS in everyday time at the start of any ultrasound assessment Corcoran JP, et al. Thorax 2017;0:1–10. doi:10.1136/thoraxjnl-2016-209340 1 Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd (& BTS) under licence. State of the art review adjusting parameters, such as gain, depth and time-gain com- Doppler assessment,17 18 allowing the operator to select the Thorax: first published as 10.1136/thoraxjnl-2016-209340 on 14 April 2017. Downloaded from pensation—the success of such fine tuning will depend on the safest site for subsequent pleural intervention and minimising experience of the operator and their familiarity with the the likelihood of vascular injury.19 Large-scale studies are characteristics of a specific machine. needed to assess the utility of this technique, given the relative Achieving a safe and controlled environment for intervention, infrequency with which this complication occurs and additional including optimal patient positioning, is important yet often skills required for widespread practice. underappreciated. Many practitioners will be familiar with The role played by TUS in improving patient safety does not emergency ‘point of care’ diagnostic TUS in the acutely unwell end when the procedure begins. Other than providing the patient, where scanning is unpredictable and performed at all ability to allow real-time guidance of any pleural intervention, hours, usually by a single bedside operator with the patient in a TUS also offers the operator an opportunity to identify any supine position and using a zonal approach.6 By contrast, inter- iatrogenic complications as early as possible. This allows appro- ventional TUS is largely used in an elective theatre or clean priate treatment to be instituted promptly, limiting the risk of room setting by a clinical team where consideration can be further harm. Postprocedural ultrasound screening at the site of given to the patient’s position according to the area of potential intervention can identify either active bleeding from the parietal interest, determined in advance from prior imaging (eg, CT). pleural surface20 or the rapid accumulation of highly echogenic This may require the patient to be scanned while sitting upright fluid within the pleural space, demonstrating a swirling or gradi- and leaning forward (posterior chest wall); in a lateral decubitus ent effect as heavier cellular material is deposited in the more position (lateral chest wall); or semi-supine (anterior chest wall dependent part of the collection.21 including superior sulcus). Minimising patient movement and A number of studies have also shown that TUS can be used to the time delay between