ARC Journal of Radiology and Medical Imaging Volume 4, Issue 2, 2019, PP 1 -14 www.arcjournals.org Role of Chest X-Ray with Ultrasonography in Evaluation of Pneumonia in an Icu Setting: A Prospective Study Dr. Som Biswas* DMRD, M.S., Dr. Satish Pande. M.D., D.N.B, Ph.D. Department of Radiodiagnosis, King Edward Memorial Hospital, Pune, India *Corresponding Author: Som Biswas, Resident, Department of Radio diagnosis, KEM Pune, India Email: [email protected] Abstract Aim: Evaluation of role of Chest X-ray & Ultrasonography in pneumonia in an ICU setting. Introduction: Critically ill patients frequently need thoracic imaging due to dynamic nature of their clinical conditions. I studied the role of Chest X-ray & Ultrasonography in patient with pneumonia in an ICU setting in KEM Hospital, Pune. Materials and Methods: The present study was carried out at KEM Hospital, Pune in the Intensive Care Unit from 1st June 2018 to 31st May 2019 on patients with findings of pneumonia. Sample size: 150 patients as per calculation Summary and Conclusion Lung sonography was able to evaluate homogeneous opacities, air bronchogram, Kerley- A line, Kerley- B line, fluid in pleural space. The limitations of ultrasonography were non visualization of inhomogeneous opacities and volume loss. Thus lung sonography is complimentary for evaluation of pneumonia along with chest radiography. 1. INTRODUCTION cause of death worldwidede, preceded only by ischemic heart disease and cerebrovascular Critically ill patients frequently need thoracic diseases. It is the leading infectious cause of imaging due to dynamic nature of their clinical death and one of the most common reasons for conditions. Computed Tomography (CT) scans emergency room (ER) visits and hospital remain the gold standard imaging technique for admissions. In patients with clinically suspected thoracic evaluation, but transportation of pneumonia, a correct diagnosis is essential for patients outside the ICU may be difficult and proper treatment orientation. Diagnostic and potentially harmful 1. Chest CT scans expose treatment delays and failure can entail a patients to large doses of radiation and are significant increase in mortality. Traditionally, reserved for specific situations (e.g., the the diagnosis of pneumonia is based on three evaluation of mediastinal pathologies and mainstays: clinical and laboratory data, imaging confirmation of pulmonary embolism) 2–4. techniques, and microbiological studies. Chest Bedside chest X-ray (CXR) is still considered X-ray (CXR) currently constitutes the first the standard of care for many diagnostic approach in suspected pneumonia, where the applications in the Intensive Care Unit (ICU). presence of a new infiltrate is the characteristic However, this imaging technique has important radiographic finding. However, several studies limitations and does not show soft tissues point to CXR’s low sensitivity for the diagnosis clearly5,6. Furthermore, radiation is also present. of pneumonia. Besides, image quality is lower Bedside sonography has become essential in the in patients in decubitus position and when using ICU for several indications.7-11 portable devices. Ultrasound can play a Pneumonia is an inflammatory condition of the significant role in this scenario. lung affecting primarily the alveoli12. Typically I studied the role of Chest X-ray & symptoms include some combination of Ultrasonography in patient with pneumonia in productive or dry cough, chest pain, fever, and an ICU setting in KEM Hospital, Pune. Few trouble breathing.13 Pneumonia ranks as the third studies have been done on this topic in India. ARC Journal of Radiology and Medical Imaging Page | 1 Role of Chest X-Ray with Ultrasonography in Evaluation of Pneumonia in an Icu Setting: A Prospective Study This is the first such study in our hospital. pneumonia admitted in ICU. Routine Chest X-ray will be done and The patients with lung pathologies like ultrasound will be done on patients with pleural effusion, empyema, consolidation, findings of pneumonia. collapse, pneumothorax will be assessed. 2. AIMS AND OBJECTIVES 2. Exclusion Criteria Aim: Evaluation of role of chest radiography Patients not admitted in ICU. & ultrasonography in pneumonia in an ICU Patient not having pneumonia. setting. Patients so severely sick that lung Objectives ultrasound or chest X-ray may be difficult. 1. To evaluate the role of Chest X-ray with Methodology Ultrasonography in pneumonia in an ICU The study protocol was reviewed and approved setting. by the scientific & ethics committees; it was 2. To analyze the advantages and therefore performed in accordance with ethical disadvantages of Chest X-ray & standards. An informed consent for the use of Ultrasonography in pneumonia in an ICU personal data was obtained. setting. The patient data and clinical history was 3. MATERIAL AND METHODS recorded as per proforma attached (Annexure – A). Study Area Technical Parameters The present study was carried out at KEM Hospital, Pune in the Intensive Care Unit from USG was done using Sonosite WK2VYO 1st June 2018 to 31st May 2019 on patients with Ultrasound machine in ICU. findings of pneumonia. Probes used were: Study Population: A total of 150 patients of 1. Straight linear array probe- 5 – 12 MHz, clinically diagnosed pneumonia were included 2. Curvilinear probe- 2-5 Mhz, in the study. X-ray was taken using GE Healthcare Brivo XR115 portable x-ray machines and CR Study Design: Prospective, observational study. (computed radiography) cassettes. Technique of Performing Lung Sonography Sample Size: The sample size comes to N = Used in My Study 150 I have used Sonosite WK2VYO portable Sample Size Calculation machine available in the ICU of our hospital. We calculated sample size by the following Straight linear array probe (5 – 12 MHz) and formula: curvilinear probe (2-5 Mhz) was used. Patients was examined posteriorly while sitting or in lateral position if extremely sick and anteriorly in the supine position. A systematic examination of all intercostals was performed. Sample Size = My diagnostic aim was to explore the accessible pleural surface in order to find pleural-based consolidations. However, it should be noted that only lesions that extend up to the pleura are Population Size = N | Margin of error = e | z- detected by LUS. Several areas remain hidden score = z behind other anatomical structures or are barely e is percentage, put into decimal form (for example, visible. In particular, part of the left lung is 3% = 0.03). covered by the heart. One way to partially avoid The sample size comes to N = 150 these limitations is to have the patients in a sitting position with their hands behind their Study Duration: The duration of the study was neck and use a subcostal approach. The probe 12 months ranging from May 2018 to April was positioned and moved in both the 2019. longitudinal and transverse direction. The 1. Inclusion Criteria longitudinal scan was obtained by positioning Patients with clinically suspected the probe over the cranio-caudal axis, allowing ARC Journal of Radiology and Medical Imaging Page | 2 Role of Chest X-Ray with Ultrasonography in Evaluation of Pneumonia in an Icu Setting: A Prospective Study visualization of a large part of the pleural line. within consolidated areas comparable to the air This approach is limited by the shadows caused bronchogram visible on X-ray and CT. by the ribs, which partially hide the pleural line. Lines: Lungs were assessed for the presence of The transverse scan was obtained by positioning A lines, B lines. the probe over the horizontal axis. This positioning allows the study of the pleural line A lines: Horizontal, regularly spaced without any acoustic interference from the ribs, hyperechogenic lines representing but within the limits of a single intercostal reverberations of the pleural line. space. As in other situations, the upper pane of B lines: These are diffuse bright echogenic the ultrasound screen represents the superficial lines arising from the pleural line to the edge of layers and the bottom of the screen the deeper the ultrasound screen. These occur due to layers. In the longitudinal scan the cranial parts accumulation of fluid in the interstitium. When are displayed on the left of the screen. In the several B lines are visible, the term used is "lung transverse scan the left pane shows the right side rockets". These are seen in pulmonary oedema of the patient, and vice-versa. giving ‘B’ profile. Each hemithorax is divided into three different Pleural effusion: Effusions are looked for in the areas: anterior, lateral and posterior. The dependent lung areas delineated by the chest anterior region extends from the parasternal to wall and the diaphragm. The standard the anterior axillary line, the lateral region from curvilinear ultrasound probe was used. The the anterior axillary line to the posterior and, probe was placed in the intercostal space with finally, the posterior region from the posterior the long axis of the foot of the probe parallel to axillary to the paravertebral line. Each of these the adjacent rib. The effusion appears as a regions was divided into upper and lower hypoechoic (i.e. dark) and homogenous halves. Examination of the supradiaphragmatic structure in the dependent areas which is present region plays an important role in LUS. Each both in inspiration and expiration. lung was divided into 6 segments by anterior and posterior axillary lines. 4. FINDINGS AND SIGNS OF PNEUMONIA ON SONOGRAPHY IN MY STUDY Sono-Morphology of Pneumonia This ultrasound image of 45 year old man shows Pneumonia has echo poor echogenicity and an A-lines in left lung lower lobe. A –line defines inhomogeneous echotexture. The most normal lung surface. It indicates gas movement characteristic sign is a positive air bronchogram. and the echoes are produced due to air within The air bronchogram reflects residua of air normal lung. Linear lines are due to air in the lung. Rib shadowing is seen distally. Image1. „A‟-Line This ultrasound image of 52 year old woman hyperechogenic lines that erase the A -lines.