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臨床推論3 アッペの数字
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B 5 肺エコー

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B 5 肺エコー

  1. 1. 妙技; 肺エコーオススメ文献Chest 2011;140:1332-41  2011年末までの文献, 情報がまとまった肺エコーのReview
  2. 2. 2肺エコー• 肺のArtifactをエコーで評価. ▫ 前胸部, 側胸部, 背側部, 上, 中, 下肺で評価し, 全部で1分もかからない簡便な検査. ▫ 通常の心 or 腹部エコープローブで評価可能.(3.5MHz-7MHz)• 肺エコーでは何をみているか? ▫ 主に, 胸膜と肺のズレ >> 無ければ気胸 ▫ 小葉間隔壁の肥厚 >> あればConsolidation or 肺うっ血, もしくはGGO ▫ 胸水 ▫ Consolidationそのもの• つまり, 所見, 分布から気胸, 肺炎, 心不全の評価が可能.
  3. 3. 3胸壁
  4. 4. approximately 0.5 mm in diameter. trees; lobules do not arise at a specific Veins can sometimes be seen as linear, branching generation or from a specific 4 Radiology 2006;239:322-38 arcuate, or branching structures 1.0 – type of bronchiole or artery (8). 1.5 cm from the pleural surface or sur- Branching of the lobular bronchiole rounding centrilobular arteries and ap- and artery is irregularly dichotomous 肺の2次小葉h of 1-mm lung slice taken proximately 5–10 mm from the arteries. (10). Most often, bronchioles and arter- Pulmonary veins may also be identified ies divide into two branches of different be. Two well-defined sec- by their pattern of branching; it is com- sizes, one branch being nearly the sameles are visible. Lobules are mon for small veins to arise at nearly right size as the one it arose from and thelobular septa (S) contain- angles to a much larger main branch.branches. Bronchioles (B)(A) are centrilobular. (Re- Centrilobular Region and Centrilobular Figure 5n, from reference 10.) Structures The bronchiole supplying a being smaller. Thus, on thin-sec- clinical scann other pulmonary lobule is best called the “lobular” bron- tion CT scans, there often appears to be member that a single dominant bronchiole or artery CT, intralob Figure 4 in the center of the lobule, with smaller normally visi branches emerging at intervals along its chioles are r length. the pleural Secondary lobules are supplied by (26,27). arteries and bronchioles measuring ap- The per proximately 1 mm in diameter, while tium is a sys intralobular terminal bronchioles and bronchi and arteries measure about 0.7 mm in diam- forms a stron eter and acinar bronchioles and arteries that surroun range from 0.3 mm to 0.5 mm in diam- perihilar lun eter (Figs 1, 2). Arteries of this size can eral continuu
  5. 5. 5心エコープローブ(3.5-5.0MHz) >> 肺エコーにも使用可能.体表エコープローブ(7.5-10.0MHz) >> 胸膜, 胸壁評価に特に有用.  (後述する気胸評価など)
  6. 6. Chest 2008;134:117-125 正常肺エコー像 • 上下の肋骨, 胸膜で構成された エコーを”Bat sign”と呼ぶ • 肋骨―胸膜間は0.5cm, 肋骨―肋骨間は2cm • 胸膜より深部に認められる, 並行したエコーをA lineと言い, 胸膜下のAirを示す (更にその下部にも認める) 肋骨 胸膜 • Mモードにて平行線は表面組織 不均一エコーとなるのは肺実質 A Line • その境目をSeashore signと呼ぶ
  7. 7. 7ARDS患者のCT矢印からエコーを当てたらどう見える?
  8. 8. Chest 2008;134:117-125 B Line • 胸膜より伸びるComet-tail • 高エコーで明確 • A lineを消す • Lung Slidingと共に動く • 1 viewに3つ以上あればB+ Line • B Lineにてその他の異常所見が Maskされることが多い • 間質の水分貯留を示唆する ⇒ 肺水腫, 間質性肺炎
  9. 9. 9スリガラス状陰影(インフルエンザ肺炎)この場合はどう見える?
  10. 10. Chest 2009;136:Issue 4, Oct.B Line Advance• 中央; B7-Line; B Line間の間隔が7mmであり, 胸膜下の小葉間壁の肥厚を意味する(成人の小葉は7mm程度)• 右側; B3-Line; B Line間の間隔が3mmであり, 胸膜下のGround-Glass Lesionを意味する
  11. 11. ここまでの まとめ 11 小葉間隔壁の肥厚, スリガラス陰影の有無と その分布によって, 肺炎, 心不全, その他の判断が可能
  12. 12. 12• 肺炎患者のCT• これはどう見えるか?
  13. 13. Chest 2008;134:117-125 Posterolateral alveolar/ Pleural syndrome(PLAPS) • PE; 臓側―壁側胸膜間のFluid 呼吸により臓側胸膜が変動  ⇒ Sinusoid signが特徴 • AC; 肺胞内に水分貯留があり, 実質状に見える 背側, 下肺でのView; PLAPS(Posterolateral alveolar / Pleural syndrome)  E; 胸水  白い矢印; 臓側, 壁側胸膜  S; 脾臓 実質状に見える LLがAlveolar consolidation 深部はIrregular borderとなる(黒矢印). Air bronchogramはHyperechoicとなる. M-modeではSinusoid signを認める
  14. 14. 14気胸の患者ではどう見えるか?
  15. 15. Chest 2008;134:117-125 Lung Sliding • Lung Slidingは通常認められる • 消失している場合,  >臓側と壁側胸膜間でのSlideが消失   炎症性癒着, 無気肺, 肺拡張障害  >臓側胸膜と壁側胸膜の解離  気胸, 肺切除後 気胸の肺エコー  1番上が 胸膜エコー、  2,3番目がA Line  M modeにてSeashoreが消失 (肺実質がない)
  16. 16. 16Lung SlidingとLung Point 壁側胸膜 壁側胸膜 臓側胸膜 Air 臓側胸膜 正常肺の呼吸では, 吸気時に肺が拡張し, 呼気時に収縮. 肺胞には臓側胸膜が付着し, 胸壁には壁側胸膜が付着しているため, 吸気, 呼気では 臓側-壁側胸膜間でSlidingが起こる
  17. 17. 17 Lung SlidingとLung Point b a 壁側胸膜 Air Available online http://ccforum.com/content/11/1/205 臓側胸膜Figure 7 a; aから見ると, AirがあるのでA lineはあるが,  Slindingが消失している.また肺の動きも  無いため, M modeではSeashoreが消失. b; bから見ると, 正常肺なのでA lineはあり,  Slindingも認められる. また肺の動きはあり,  M modeではSeashoreも認められる. aとbの移行点をLung pointと呼ぶ.Time-motion mode lung ultrasound. (a) Normal lung and (b)pneumothorax patterns using time-motion mode lung ultrasound. Intime motion mode, one must first locate the pleural line (white arrow)
  18. 18. 18
  19. 19. (Fig. 6). Diffuse lung rockets dissemi- pedes ultrasound). The detect nated all over the anterolateral wall de- are smaller than the resoluti 19 fine diffuse interstitial syndrome. The sound. They are present at a test is defined as negative when such B the lung surface. They are sep lines are absent, isolated, or exclusively each other by Յ7 mm. They 肺外要素による所見 Crit Care Med 2007;35:S250-61 • E line (写真左)Figure 6. Interstitial syndrome. These vertical ▫ 一見B lineに見えるが,comet-tail artifacts have the specific peculiaritiesof strictly arising from the pleural line, being 胸膜下から出ていない.well-defined and laser-like, moving with the lungsliding, spreading to the edge of the screen with- Figure 7. Some artifacts: E and Z lines. Left, these well-defined comet tails descend to t ▫ 皮下気腫によるArtifactであり, E lineと呼ぶ (subcutaneous Emphysema)out fading, and erasing normal A lines. This pat- screen. However, the bat sign is absent (as with Fig. 6). This pattern cannot be due ttern defines B lines. Several B lines in a single patient has subcutaneous emphysema with extensive collections of gas between an ▫ 胸膜下から出ているかどうかを評価するには, 肋骨のBat signをみる.view define lung rockets. Diffuse lung rockets tures—a condition generating E lines. Right, the ill-defined comet-tail artifacts (threindicate interstitial syndrome. This patient has arrowheads) arise from the pleural line but do not erase the physiologic A lines (arrow • Z line (写真右)cardiogenic pulmonary edema. vanish without reaching the edge of the screen. These are Z lines. ▫ 胸膜から出ているLineだが,Crit Care Med 2007 Vol. 35, No. 5 (Suppl.) A lineが残っている. B lineならばA lineは消される. ▫ また, 減衰も強く, モニター端まで到達していない. ▫ Z lineは80%の患者で認められる. ▫ 臨床的意義は無く, B lineとの鑑別が重要となる所見.
  20. 20. artifacts that do not provide di information. 20 DISCUSSION As an air-filled structure, the an organ for which ultrasound tr ally had a limited diagnostic v fact, lung ultrasound is hardly s to exist (23). Yet the use of bas makes immediate management threatening conditions possible cessible with simple units, lun sound could have been develop the advent of real-time ultrasou first observations were made usi technology (ADR-4000). In addit small size of these devices mad fully suitable for the ICU and th gency department. In the literature, we discover, ingly, that horses have already b from ultrasound— because the ment of the lung toward the ches visible (24). Human studies follo their impact was minimal. In fac knowledge, studies have suffer various shortcomings. Sistrom et al. (25) looked at sitivity of lung sliding and come 13 patients with radiologic pneu rax occurring after chest biops 7-MHz linear probes in units ha sonologists (i.e., nonphysicians quently supervised by radiologis study demonstrated moderate acc ultrasound with 73% sensitivi specificity, 89% negative predicti and 40% positive predictive val can such results be explained? F trasound gives its best, in ourFigure 10. Suggested classification of thoracic artifacts. when used by only one and sam
  21. 21. Chest 2008;134:117-125 急性呼吸不全にてICU入室した301名の 診断と肺エコー所見の比較 BLUE protocol • エコー方法 体位は半横位 Zone 1-3を上下2分し, 計6か所評価 プローブ; 5-MHz microconvex Scan; 縦軸方向にて評価
  22. 22. Chest 2008;134:117-125 各病態とUS所見, 検査特性 病態 US所見 SN(%) SP(%) PPV(%) NPV(%) びまん性の前胸部B+ Line 心原性肺水腫 97% 95% 87% 99% Lung Sliding(+) (B) A lineの増強 + COPD, Asthma PLAPS(-), Lung sliding(+) 89% 97% 93% 95% Lung sliding(-), Lung point(-) 肺塞栓 A line増強 + DVT(+) 81% 99% 94% 98% Lung Sliding(-), B Line(-) 気胸 88% 100% 100% 99% Lung Point(+) びまん性の前胸部B+ Line 11% 100% 100% 70% Lung Sliding(-) (B’) 片側優位の前胸部B+ Line 14.5% 100% 100% 71.5% 肺炎 反対側の前胸部A line増強(A/B) 前胸部Alveolar consolidation(C) 21.5% 99% 90% 73% A Line増強 + PLAPS 42% 96% 83% 78% A Line増強 + PLAPS, B, B’, A/B, C 89% 94% 88% 95%
  23. 23. 正診率 90.5%Stage 3;subposterior analysis
  24. 24. 24つまり, Blue protocolっていうのは,• Step 1; 肺はあるのか?• Step 2; 肺のどの部分に何があるのか? ▫ というのを見ているだけの至って単純なもの. ▫ その所見, 分布で診断を決める• 診断Criteriaなんぞ覚えなくても判断できるでしょ?• Step 1; 肺はあるのか? >> Lung SlidingをCheck ▫ 無いのならば, 気胸か癒着か.  >> 内部がAir(A line) か 小葉間隔壁肥厚, GGO(B line)かで判別可能 ▫ 肺があるならば, 気胸ではない.
  25. 25. 25• Step 2; 肺のどの部分に何がある?▫ 左右, 上下, 前側でエコーをあてて, A line >> 正常領域 B line >> 異常領域, さらにB lineの質(幅)を評価.▫ びまん性にB lineがあれば 肺うっ血, 心不全▫ 全体がA lineならば 喘息, COPD 肺塞栓症
  26. 26. 26• もしくは,▫ 上下, 前側胸部がA lineならば, これかも. PLAPS(Posterolateral alveolar / Pleural syndrome)• 局所的にB lineがあれば, そのような病態は当然肺炎!
  27. 27. 27応用編• 超著明な肺水腫の患者(REPO)• こんなヒトの肺エコーはどう見える?
  28. 28. 29応用編 その2• 前胸部ではA line ~ 軽度B7 lineが両側性に. 側胸部ではB7-B3 lineが両側性に. 背側部では両側性の胸水少量, Consolidation(+). これなあに?
  29. 29. 30Alveolar-interstitial syndromeの評価 Am J Em Med 2006;24:689-96• AIS; びまん性の間質の障害, ガス交換の障害を来す病態. ▫ 慢性の病態では肺線維症, 急性ならばARDS, 肺水腫, 間質性肺炎. ▫ エコーではびまん性のB lineを認める.• ER受診患者295名のSingle-Center prospective study ▫ 135名は心, 肺疾患以外の病態, 160名が心肺疾患, 内75名がAIS(CHF 59, 肺線維症6, IP 3, 粟粒結核3, 両側性肺炎3, ARDS 1). 非AISの84名では, 片側性肺炎32, 肺癌12, COPD26, PE6, 喘息5, 他 Lung ultrasound in the assessment of AIS ▫ ベッドサイドでのUS評価: 臥位で前, 側胸部で評価. ▫ 陽性判定; 1 viewに3本異常のB line+ 片側で2カ所以上  + 両側性で同様の所見を認める.• AISに対するSn85.3%, Sp96.8%
  30. 30. 31• B line(+)の部位. Rt Lt前上 67.2% 65.6%前下 73.4% 71.9%側上 78.1% 85.9%側下 93.8% 93.8%• 当然ながら, より側胸部, 下肺で認めやすい.
  31. 31. 32ARDSで挿管管理中の患者評価に肺USは有用 Anesthesiology 2004;100:9-15• 32名のARDS+挿管管理中の患者と, 10名のControlにおいて,聴診, 胸部XP, 肺USによる病態の評価を比較 (RS; 胸部CT) ▫ 左右, 前側後, 上下肺の計12カ所で評価. 肺USは5 MHz, 9-cm-long probeを使用.• 病態と検査所見の感度, 特異度 病態 聴診 胸部XP 肺エコー 胸水 Sn(%) 42% 39% 92% ▫ Alveolar-intestitial syndrome; GGOや小葉間隔壁の肥厚所見. Sp(%) 90% 85% 93% Dx. Acc 61% 47% 93% ▫ 胸水, 浸潤影, GGO, Alveolar Sn(%) 8% 68% 93% 小葉間隔壁肥厚すべてUSでの Consolidation Sp(%) 100% 95% 100% 診断能が非常に高い. Dx. Acc 36% 75% 97% Alveolar- Sn(%) 34% 60% 98% interstitial Sp(%) 90% 100% 88% syndrome Dx. Acc 55% 72% 95%
  32. 32. Chest 2009;136:Issue 4, Oct.A-Line, B-LineとPulmonary Artery Occlusion Pressureの関連• ICU入室中で, 挿管管理下の患者102名において, Blindされた術者2名が肺エコーを施行し, PAOPの値との関連を評価.• 患者群; Septic Shock 24名, ARDS 28名, 急性肺水腫 13名, 重症外傷9名など• エコー手技 ▫ 心エコープローベを使用し, 仰臥位の体位で施行. エコーは胸壁に垂直にビームを入れるように当てる. ▫ 呼吸アセスメント; 肺尖部 ⇒ 肺底部まで縦断するようにエコーを行う ▫ 血行動態アセスメント; 左右肺を其々4つに分割し, 肺エコーにてB Lineを評価• A-predominance; 両側性のB+ Lineを認めない B-predominance; 両側性にB+ Lineを認める
  33. 33. Chest 2009;136:Issue 4, Oct.A-Line, B-LineとPulmonary Artery Occlusion Pressureの関連• PAOPは=<13mmHg(n=61), =<18mmHg(n=87)をCutoffとし, エコー所見と比較したところ, A-predominanceは Cutoff Sn(%) Sp(%) PPV NPV PAOP =<13 67% 90% 91% 65% PAOP =<18 50% 93% 97% 24%• A-predominanceはDry Lungを強く示唆する所見と言える.  >> 全領域でA-lineがあればPAOP <18mmHgを示唆.    心不全をほぼ否定可能.• 補液はA-predominanceを指標にしつつ行うという手もあり
  34. 34. 肺炎への感度はCRX以上? • ER受診患者で肺炎疑いの49名に対して, ▫ Lung US ⇒ CXR ⇒ Chest CTの順で評価 Lung US, CXRで陽性ならば肺炎と診断, Lung US, CXRで陰性ならば肺炎は否定. Lung USとCXRの結果が一致しなければ胸部CTを撮影し判断. ▫ Lung US; 10年以上の経験者が施行. 上肺野, 中肺野, 下肺野で肋骨に垂直, 斜め, 水平に当てて評価 ▫ Outcome; 32/49(65.3%)が肺炎(+) エコー上陽性が96.9%, CXRでは75%のみ. エコー所見 肺炎(-)患者 肺炎(+)患者 Consolidation 11.8% 96.9% Alveolar-interstitial syndrome 29.4% 68.8% Air bronchogram 0% 50.0% Pleural effusion 17.6% 34.4%Am J Em Med 2009;27:379-84 正常 58.8% 0%
  35. 35. 36USによる肺炎のフォロー Crit Care Med 2010;38:84-92• ICUにおけるVAP患者30名のProspective study ▫ VAP診断初日と7日目でCT評価, 肺US評価を行い, 抗生剤投与による変化を評価.(Aerationを評価.) ▫ USは左右各6カ所(計12カ所)で評価し, 所見によりScore化. 1pt 3pt 5pt -5pt -3pt -1pt B1→N N→B1 B2→N N→B2 B2→B1 C→N N→C B1→B2 C→B1 B1→C C→B2 B2→C B1; 明瞭なB lineで, 間隔も不整. B2; 密集したB line(comets), C; Alveolar consolidation, N; Normal pattern
  36. 36. 37 • US scoreの変化と, 胸部CTにおけるAerationの変化は相関する.A Overall CT lung re-aeration following B A C right lung re-aeration following CT Overall CT lung re-aeration following B C right lung re-aeration following CT antibiotic administration (ml) antibiotic administration (ml) antibiotic administration (ml) antibiotic administration (ml)3000 1500 3000 Right lung 1500 Right lung Rho=0.85; p<0.0001 Rho=0.79; p<0.0001 R Rho=0.79; p<0.0001 R Rho=0.85; p<0.0001 1000 2000 10002000 500 500 10001000 0 0 0 0 -500 -500 -1000 -1000-1000 -1000 -2000 -1500 -20 -10 0 10 20 30 -20 -15 -10 -5 0 5 10 15-2000 -1500 Lung ultrasound re-aeration score Figure 6 Righ lung ultrasound re-aeration score ht -20 -10 0 10 20 30 -20 -15 -10calculated on both lungs -5 0 5 10 15 aeration Lung ultrasound re-aeration score Figure 6. Accuracy of lung ultrasound aeration fre- calculated on both lungs C ht lungCT left lung re-aeration following Righ ultrasound re-aeration score aeration score for quantifying changes in lungpatients antibiotic administration (ml) aeration following antibiotic administration in 30 clos EachC CT left lung re-aeration following 1500 Left lung tient. patients with ventilator-associated pneumonia. CT, antibiotic administration (ml) 1500 ▫ USLeft lung >5改善認める場合, Rho=0.70; p<0.001 score CTでは>400mlのAerationの増加を期待. Each closed circle represents an individual pa- 1000 tient. CT, computed tomography. Rho=0.70; p<0.001 observed US score <-10悪化認める場合, CTでは>400mlのAerationの悪化が予測される. for unde 1000 clinical observed in VAP provides a solid rationale 500 後者の場合, 抗生剤は効いていないと判断できる. for understanding this result of potentialCorre clinical relevance. Aeration 500 0 tion Sco Correlations Between Changes in CT Crit and Lung Ultrasound Reaera-asse for Aeration Care Med 2010;38:84-92 tion has 0 -500 tion Score. Until now, the value of LUS e Tsubo
  37. 37. 38 呼吸苦でER受診した患者の評価; XP vs US MD Consult - Print Previewer • 呼吸苦を主訴にER受診した404名のProspective normal, the most frequen cohort. Of the 404 patients, 157 exhibited a normal ultrasonographic examination radiograph. When conventional radiograph was failure, and acute bronchitis. When ultrasound scan did not show any sign 外傷性は除外. diagnoses were COPD and acute bronchitis. ▫ XP, 肺USで評価行い, 所見の一致性を比較. population was examined, the ultrasonograph andP When the entire study 2). The two modalities overlapped almost completely in the presence of concordance in detecting pulmonary fibrosis pattern (" = 87%), PTX (" = 不一致の場合は胸部CT検査を施行. consolidation (" = 70%). We found lowest concordance values for abnorm ARDS pattern and loculated pleural effusion. ▫ USとXPの一致率はほぼ同等. Table 2 -- Concordance Between Ultrasonograph and Radiograph Positive Diagnosis ▫ 不一致例が118例あり, Clinical Patterns Ultrasonograph Radiograph !% Free pleural effusion 87 76 76.2 [a] 胸部CTにて確認. Loculated pleural effusion 6 5 53.9 [a] Pulmonary edema 21 21 95.0 [a] ARDS pattern 3 1 49.8 [a] Pneumothorax 7 7 85.5 [a] Lung consolidation 122 111 70.5 [a] Pulmonary fibrosis pattern 7 9 87.3 [a] a P < .0001.Can Chest Ultrasonography Replace Standard Chest Radiography for Evaluation of Acute Dyspnea in the ED?Chest - Volume 139, Issue 5 (May 2011)
  38. 38. 39Figure 6 Measure of agreement (expressed as " %) between chest ultrasonograph and chest radiograph according totheir position in the hemithoraces. All " values were highly significant (P < .0001). A, Free pleural effusion. B, Loculatedpleural effusion. C, Pneumothorax. D, Lung consolidation. • 不一致例118例のCT所見と, US, XPの一致率Table 3 -- Comparison of Chest Ultrasonograph and Chest Radiograph With Chest CT Scan as a ReferenceStandard in the 118 Cases of Discordance Between the Two Modalities Radiography Ultrasonography P Value CT Scan Diagnosis No. TC Sensitivity Specificity TC Sensitivity Specificity Radiograph Ultrasound % % % % Free pleural effusion 31 5 10 (2/20) 27 (3/11) 26 90 (18/20) 73 (8/11) < .0001 NS Loculated pleural 5 2 40 (2/5) … 3 60 (3/5) … NS … effusion Pulmonary edema 2 1 … 50 (1/2) 1 … 50 (1/2) … NS ARDS pattern 2 0 … … 2 100 (2/2) … … … Pneumothorax 2 1 50 (1/2) … 1 50 (1/2) … NS … Lung consolidation 49 23 40 (14/35) 64 (9/14) 26 60 (21/35) 36 (5/14) NS NS Pulmonary fibrosis 2 2 100 (2/2) … 0 … … … … pattern NS = not significant; TC = total concordance (true-positive + true-negative). ▫ USはXPよりもCT所見予測に有効. When free この場合(USとXPが不一致の場合), USとCTの一致率は63% higher pleural effusion was analyzed separately in the two hemithoraces, ultrasonography exhibited sensitivity than radiography in both hemithoraces (P < .0001); specificity was 50% in the right hemithorax for both modalities, whereas ultrasonography had higher specificity than radiography in the left hemithorax (90% vs 10%; P = .0011). In all patients with loculated pleural effusion by ultrasonograph and negative radiograph, the CT scan confirmed the presence of loculated pleural effusion (two cases in the left hemithorax and one in the right hemithorax); thus, for the absence of negative CT scan, the specificity was not calculated. Similar limitations were present in the analysis ofCan Chest Ultrasonography Replace Standard Chest Radiography for Evaluationultrasonographic andED? patients with PTX; in fact, only two patients exhibited discordant of Acute Dyspnea in the radiographic results (one detectedChest - Volume 139, Issue and one by radiography), with a positive CT scan for PTX in both cases. When we analyzed the 49 by ultrasonography 5 (May 2011)
  39. 39. Can Chest Ultrasonography Replace Standard Chest Radiography for Evaluation of Acute Dyspnea in the ED?Chest - Volume 139, Issue 5 (May 2011) 40 • US所見の評価方法USパターン マーカー USパターン マーカー 胸膜に挟まれたAnechoic area 呼吸変動(+), 遠位部が不明瞭な低エコー領域Free pleural effusion 肺Consolidation 体位により変化認める Air bronchogram(+), 末梢気道のAir trap(+) 胸膜に挟まれたAnechoic area Air bronchogram(-)Loculated pleural effusion 気管支の分岐が消失し, parallelに走る 体位により変化無し 無気肺 Lung pulse認める肺水腫 B+ lineを全肺野に認める ≥8本/fieldのB line. 局所性のB line 肺線維症パターン MD Consult - Print Previewer 胸膜肥厚, 不整な胸膜を認める 末梢側のConsolidationARDSパターン Lung slidingの消失, 低下 Lung pulseを認める(possible) 保たれた部位を認める Lung sliding消失 Lung pointを認める気胸 A lineを認める Transverse fixed artifactあり
  40. 40. • ERにて肺炎が疑われた120名のProspective cohort ▫ 最終診断は入院中のCT検査で, 肺炎であったのは81名(67.5%) ▫ ERでの胸部XPは, 感度67%[56.4-76.9], 特異度85%[73.3-95.9]で肺炎を示唆. LR(+) 4.3[2.04-37.7], LR(-) 0.39[0.20-0.76]  ▫ 一方, 肺エコーは, 感度98%[93.3-99.9], 特異度95%[82.7-99.4]で肺炎を示唆. LR(+) 19.3[4.99-74.2], LR(-) 0.01[0.002-0.09] Emerg Med J 2012;29:19-23.
  41. 41. 42 • 市中肺炎が疑われた362名のProspective study. ▫ 身体所見, 病歴, 肺USを行い, 肺炎を評価. RSはXPとCT検査(XPで不明の場合はCT) ▫ 最終的にCAPと判断されたのは63.3%. 肺エコーの感度, 特異度は, Chest 2012;142:965-972 感度 特異度 LR(+) LR(-)肺エコーのみ 93.4%[89.2-96.3] 97.7%[93.4-99.6] 40.5[13.2-123.9] 0.07[0.204-0.11]身体所見+US 42.9[10.8-170.0] 0.04[0.02-0.09] • 肺炎の時間経過と所見の変化. Day 0 Day 5-8 Day 13-16 症状の数 3[1-5] 1[0-5] 1[0-4] 聴診異常あり 73.0% 44.7% 13.5% LUSで所見あり 100% 80.9% 50.4% 肺炎領域の面積 15.3[6.6-36.3]cm2 6.0[1.5-17.1]cm2 0.2[0.0-6.0]cm2
  42. 42. US所見 Day 0 Day 5-8 Day 13-16 43 Air bronchogram 86.7% 75.4% 71.2% Fluid bronchogram 8.1% 7.6% 6.1% Local pleural effusion 42.4% 37.3% 21.2% Basal pleural effusion 54.4% 44.3% 23.5% Basal PEの量 (mL)  左側 50[30-200] 10[0-100] 0[0-0]  右側 50[20-150] 10[0-80] 0[0-0] Chest 2012;142:965-972• 肺エコー所見の時間経過.▫ レントゲンと同様, 所見は長期間残存する傾向にあるが, 病変の面積は縮小するため, どの程度の範囲かも チェックすることが大事となる.▫ 胸水量の変化は比較的早い.
  43. 43. 44胸膜痛にも肺エコー! American Journal of Emergency Medicine (2012) 30, 317–324• 胸膜痛を主訴にERを受診し, 胸部XPで所見(-)の90名.▫ 41名がProspective, 49名がRetrospective.▫ 上記において, 血液検査, 肺エコーを施行.▫ 最終診断はフォローとCT画像, PET, 換気血流シンチでの診断.  胸壁由来疾患が57名,  肺/胸膜疾患が33名(肺炎22, 胸膜炎2, PE 7, 肺癌1, 気胸1)▫ 肺エコーは, 肺, 胸膜疾患を 感度 96.97%[84.68-99.46], 特異度 96.49%[88.08-99.03]で検出可能 (偽陰性は1例のみ; 肺炎の症例と, 偽陽性は2例.)
  44. 44. some B-lines in the surrounding area (asterisks). This image is intercostal scan (focal interstitial syndrome), periphe 胸膜ラインの断絶; attending EP. Particular irregularity of t Physical examination and history were recorded 45 typical of a small lung consolidation due to a peripheral infarction. Final diagnosis was pulmonary embolism. alveolar consolidation, or disruption with attention was presentation by the at pleural line to specific symptoms, such as history and 2). reserved with or without effusion (Figs. 1 of cough,  断絶部は鋭角で, 周囲にB lineを伴う patient localized the pain. Maximal inspiration and exhala- hemoptysis, and fever along with pleuritic pain. tion were used to gain access to areas covered by solid 2.3. Blood sample  肺末端部の微小なConsolidationで, structures of the thoracic cage. Breath holding by the patient 2.5. Diagnostic criteria was useful to exclude breath motion–related artifacts. Further details on the technique and pathologic signs塞で典型的な所見.blood determined from at admission a  肺 of A sample of whole were was collected independent All final diagnoses LUS are described in a previously published article [3]. sentreviewers laboratory. D-dimer the following procedures: to the after a combination of plasma level was assess  この症例は肺塞栓であった. An examination of the painful thoracic area was by spiral computer tomography (sCT), perfusional scintigraphy, latex-enhanced turbidimetric quantitative test (Dad positron emission tomography (PET), compression ultraso- considered normal in presence of both the respiratory pleural Behring, Milan, Italy; normal value [NV] b283 ng/mL sliding and the scattered aerated image under the pleural line, nography of the legs, follow-up at few days and 1 to 3 months, without visualization of multiple vertical linear echogenic C-reactive protein (CRP) The risk profile for pulmonary and response to treatment. plasma level was assessed artifacts named B lines (B+ pattern) [3,5,6]. Lung ultrasound immunoturbidimetric method (SentinelWells criteria [7]. thromboembolism was recorded after the Diagnostics, Milan was considered positive when direct scanning of the painful Italy; NV patientsmg/dL). White blood cell (WBC)317–324w All b0.71 diagnosed with Medicine (2012) 30, count American Journal of Emergency parietal chest pain of an chest area allowed visualization of at least one of the determined as part of the Multi-Angle-Polarised-Scatte unknown origin were discharged without therapy and following: absence of sliding, B+ pattern on more than 1 Separation (Abbott, IL; NV 4.5-11.6 × 109/L). blood submitted to a 2-step clinical examination and 心陰影に隠れた肺炎像sruption of the pleural line (white arrow) with a wedge-ural-based hypoechoic image with sharp margins and 2.4. Symptomses in the surrounding area (asterisks). This image issmall lung consolidation due to a peripheral infarction. Physical examination and history were recordedosis was pulmonary embolism. presentation by the attending EP. Particular attention w reserved to specific symptoms, such as history of cougalized the pain. Maximal inspiration and exhala- hemoptysis, and fever along with pleuritic pain. used to gain access to areas covered by solidof the thoracic cage. Breath holding by the patient 2.5. Diagnostic criteria l to exclude breath motion–related artifacts.tails on the technique and pathologic signs of All final diagnoses were determined from independeescribed in a previously published article [3]. reviewers after a combination of the following procedure
  45. 45. 肺エコーによる心不全の評価 Am J Emerg Med. 2008;26:585-91  B lineの特徴(Comet tail) 1. 胸膜より始まる 2. レーザーのように明確 3. 減衰せずに末梢まで見える 4. Aラインを消す 5. 肺の動きとともに移動する  A; Normal B; 縦軸での断層象   肋骨間のComet tail(+) C; 斜軸での断層象 D; 多数のB line(+),   Shining, White lung
  46. 46. 肺エコーによる心不全の評価 Am J Emerg Med. 2008;26:585-91  11か所; 前胸部(上・中・下), 側胸部(上・中・下) x (左・右)  縦断層象にて肋骨, 胸膜を明らかにする  その後肋間の走行に沿って描出(B C)Area 来院時 4日後Right (N=81) (N=70) Area 来院時 4日後 Left前上胸部 73% 4.3% (N=81) (N=70)前中胸部 77% 2.9% 前上胸部 74% 8.6%前下胸部 93% 5.7% 前中胸部 83% 8.6%側上胸部 91% 7.1% 側上胸部 90% 8.6%側中胸部 96% 14% 側中胸部 100% 16%側下胸部 97% 30% 側下胸部 100% 29% 重症度との相関性は低いが, モニタリングとしては有用
  47. 47. 48胸水評価 Critical Care 2007;11:205• 肺エコーは胸水評価に最適な方法の1つ.▫ 肝臓, 脾臓 - 横隔膜周囲で判別しやすく, 特に難しくもない手技.• 肺エコー所見と胸水量の推定▫ 臥位で, 肺底部にて評価した際, 深さが≥50mmあれば, 胸水量は≥500ml
  48. 48. sepsis (n = 6;were prospectively collected during 12 months of left and right pleuralby looking in terms of correlati sedation 7.4%), heart failure due to valvular dys- and on chest ultrasound effusions for the presence of function (n = 6; 2004. Overall, failure (n = 5; 6.2%) and with pleural separation did not show significant differen of 2003 and 7.4%), liver 802 patients were admitted anterior pleural sliding, which has negative predictive 49 acute pancreatitis (n = 3; 3.7%). The mean heightinitial (r = 0.74 (L); r[13]. (R); p = 0.46). during this period. Patients were included after and value of 100% = 0.71 thoracic circumference were on supine chest X-ray ± 10 cm, suspicion of pleural fluid 172 ± 10 cm and 94 (blunting Statistical analysis was performed using Statistica respectively. Forty-four effusions associated with an opaci- software, version 6.0. The data distribution was checked of the lateral costophrenic angle were right-sided and• 人工呼吸器管理中で, 胸水を認めた81名のProspective study fication covering at least the lower lobe) and pre-puncture using Kolmogorov-Smirnov test showing normal distri- 37 left-sided. Sep was 35 ± 13 confirming effusion.320 ml. Significant Discussion0.1 for pleural volume; p = 0.06 for pleural ultrasonography mm; V was 658 ± An interpleural dis- bution (p = correlation was foundmm was required to include a=patient Ultrasound evaluation of pleural effusion is SD. Cor- tance of at least 10 between Sep and V (r 0.72; separation). Results are expressed as mean ± important▫ 肺エコーにて胸水量を評価. r2 = 0.52; p < 0.001;inclusion was dependent on the presence two ways: (1) it helps quantify the pleural fluid using t in the study. The Fig. 2). The amount of pleural fluid relation between volume of pleural fluid and Sep was of an intensivist experienced in chest ultrasound. The examined by linear regression (Pearson product moment volume can to perform thoracentesis wasand the derived simplified formula V (ml) = 20 × Sep (mm) and hen decision be calculated using Sep made on clinical correlation). The mean prediction error was calculated▫ formula: もしくは15度 head-upで肺底部, the in deciding whether between the predicted shou 患者は臥位, V = 18.3andSep +not protocol-driven. To purposes helps mean of the differences or not thoracentesis and grounds alone × was 19.4. For practical eliminate as 腋窩後線上を胸郭に垂直に評価 the amount of of possible deformations of pleural space, be performed in high-risk Presence of complications the effects pleural fluid can be estimated with the observed effusion volumes. patients; and (2) it provid▫ 吸気終末における,usingpatients × Sep (mm). deformities, visual guidance for pleural layers and volumeratepleural ra simplified formula: V (mL) = 20 with thoracic Mean pre- was recorded. The impact of PEEP Thethe relationship the authors excluded 臓側胸膜-壁側胸膜間距離の最大径をSepとしたとき, compar thoracentesis. on complication diction error of V or with diaphragm pathology. ml and in this study was zero. Our pneumothorax of post-lung surgery Sep was 149.3 ± 164.4 Patients between separation of 158.4 ± 160.6 presence the simplified formula. Statistically favourably with using a test of homogeneity of slopes. with the ml from of empyema, haemothorax or pres- fluid was studied studies on ventilated patients by Lic 推定胸水量V(ml) = 20 x Sep(mm)が成り立つ.data[5] and is and right pleural effusions [11] were ence of atelectasis were found between V and thoracic The γ=0.72. significant correlations without effusion on initial ultrasound tenstein from left less than that reported by Mayo [6] circumference (r = 0.30; excluded from the study. V and Fartoukh [4]. analysis of covariance. examination were also p = 0.03) and between compared using▫ Mean height (r = 0.31;were 0.02). No significance was found thoracentesis and was approvedwith primary indication for prediction15°. investigated probe (intercostal probe, The study included patientssmall pleural ethics com- Patients errorは158.4±160.6ml p= supine with mild trunk The authors excluded collections for correlations between Sep and thoracic circumference excluding patients with pleuralthe hospital smaller th elevation at Ultrasound by separation 2.5 Mhz, Image Point, Hewlett-Packard, Andover, MA, 10 mm on initial ultrasound examination. It was al USA) was moved in cranial direction in posterior axillary suggested Intensive relationship may not be as line that the Care Med 2006;32:318-21 line. The transverse section perpendicular to the body axis was obtained with pleural separation visible as an ane- and clinically important for pleural separations belo choic or hypoechoic layer between two pleural layers. The 17 mm [1, 5, 11]. Potential sources of error were t visceral layer moved during the respiratory cycles with variability of ventilator setting and variable mean a an inspiratory decrease of the interpleural separation. The way pressures, regardless of the fact that the impact lung behind the pleural effusion appeared either aerated PEEP was insignificant. These settings can be relat or consolidated in the case of large pleural effusions. The to the degree of lung recruitment, and they modify t maximal distance between parietal and visceral pleura shape and size of pleural cavity. The volume can (Sep, Fig. 1) was measured off line at the lung base after underestimated, to a certain degree, due to lower lo freezing the image in end-expiration. The diaphragm, liver collapse in large effusions over 1,000 ml, which m and spleen had to be clearly visualised before tap to avoid lead to displacement of pleural fluid [1, 12]. Sonograph accidental puncture. The lung base is often consolidated measurement is also influenced by the size of thorac and positioned posteriorly in the pleural cavity in venti- cavity. In large thoraces in tall people, the layer me lated patients. Thus, the maximum separation is frequently sured by ultrasound may cause underestimation of t found between lung and lateral, rather than posterior, chest wall (Fig. 1). Thoracentesis was performed in a posterior actual volume of pleural fluid. The results could al axillary line at the previous probe position; however, it was be influenced by interobserver variability. The tran not directly guided by ultrasound. The ultrasonographic ducerSep measurement (Sep maximal separationwhich base) res Fig. 1 must not be angled or tilted, at lung may
  49. 49. 50肺エコーによる気胸の評価 Critical Care 2007;11:205• 肺エコーの中で最も難しい評価▫ 胸膜と肺のSliding, A lineを評価する. 高周波のプローブ(5-10MHz)を使用した方がBetter▫ 臥位, 前胸部で評価するが, 部分的な気胸を評価する為には側胸部まで調べた方が無難. Available online http://ccforum.com/content/11/1/205▫ M-modeを使用すれば, 肺の拡張運動も評価可能であり, Figure 6 Figure 7 それが消失してA lineのみが平行に認めるならばそれは肺ではなく, 胸腔. つまり気胸と判断できる.
  50. 50. 51• ICU患者において, 胸部XP, CT, 肺エコーを施行した197名のRetrospective Study (Crit Care Med 2005;33:1231-8)▫ 197名にて, 左右あわせて, 345肺を評価. 内43例にOccult pneumothorax.▫ 肺USのそれぞれの所見; Lung sliding(-), A line, Lung pointを評価. US所見 Sn(%) Sp(%) Lung sliding(-) 100% 78% LS(-) + A line 95% 94% LS(-) + A line + Lung point 79% 100%▫ Lung Slidingがあれば, 気胸は先ず除外可能.▫ LS(-) + αがあればほぼ気胸と診断可能.
  51. 51. 52 多発外傷患者における, 肺エコーによる気胸の診断 Critical Care 2006;10:R112 • 135名の多発外傷患者のProspective study ▫ ERにて肺エコーを行い, 気胸を判断. RSはドレナージ or 胸部CT ▫ 29名(21.5%)が外傷性気胸(+)であった.検査 Sn(%) Sp(%)肺US 86.2[73.7-98.8] 97.2[94.0-100]胸部XP 27.6[11.3-43.9] 100[100-100] ▫ 感度は有意に肺USの方が良好. 特異度は有意差無し. ▫ USを使用した気胸の診断は, 胸部XPよりも有意に迅速 (2.3±2.9 vs 19.9±10.3 min, p<0.001) ▫ 気胸の評価にはレントゲンよりUSがBetter
  52. 52. 53胸部外傷患者119名のProspective cohort Chest 2012;141:1177-83• 身体所見+胸部XP vs 肺USで肺損傷所見を評価.▫ RSは胸部CT. 237肺中, 気胸53, 血胸35, 肺挫傷147.▫ 各所見に対する感度, 特異度は, Sn(%) Sp(%) LR(+) LR(-) 気胸 所見+XP 19% 100% - 0.8 53% 95% 9.7 0.5▫ やはり所見, XPよりは 肺US 血胸 所見+XP 17% 94% 2.9 0.9 USの方が感度良好 肺US 37% 96% 9.4 0.7 肺挫傷 所見+XP 29% 94% 5.2 0.7• 今までのStudyと比較して 肺US 61% 80% 3 0.5気胸に対するUSの感度が低い.▫ 胸部外傷では体表損傷なども合併し, 診にくくなるかも?
  53. 53. 54気胸の評価; XP vs US, Meta-analysis• 20 trialのMeta-analysisでは, Chest 2011;140:859-66 ▫ USによる気胸の評価は感度88%[85-91], 特異度99%[98-99] ▫ XPによる気胸の評価は感度52%[49-55], 特異度100%[100-100] ▫ XPでは気胸の半分を見逃す一方で, USではほぼ9割近くを検出可能.• CTをRSとした8 trialsのMeta Chest 2012;141:703-708 ▫ USは感度 90.9%[86.5-93.9], 特異度 98.2%[97.0-99.0] ▫ XPは感度 50.2%[43.5-57.0], 特異度 99.4%[98.3-99.8]で気胸を検出
  54. 54. 55 気胸ドレナージ後の評価もUSで Chest. 2010 Sep;138(3):648-55• 気胸で入院し, ドレナージを施行した44名のProspective, DB study. ▫ ドレナージからの気泡漏出が消失後1hr, ドレーンをクランプしてから6hr後, ドレーンを抜去してから6hr後で肺US, 胸部XPを評価. ▫ RS; 肺USで気胸(+), 胸部XPで気胸(-)ならば肺CTを施行し, 判断.  胸部XPで気胸(+)ならば気胸と判断. ▫ 70.5%がprimary spontaneous pneumothorax.• Outcome; ▫ 胸部レントゲンでは14名に計20の気胸を認めた. それら全て, USでも気胸(+). ▫ 肺USではさらに14の気胸を検出(CXRでは気胸(-)), 内, CTで13例が気胸(+) それら13例は全例, ドレナージ, 手術などの手技を必要とした.
  55. 55. 56MD Consult - Print Previewer Figure 4 Radiographic and ultrasonographic detection of pneu pneumothoraces missed by chest radiography were confirmed by
  56. 56. OF THE LUNGS arrows), their acoustic shade, and the pleural line, 0.5 57 cm from an imaginary line connecting the ribs (rib line), Visualization of the lungs requires a 5 mHz transducer, indicated by the vertical arrow in the figure. The pleural肺エコー評価表 appropriate for transthoracic examination. Various pro- line corresponds to 2007;20:134-41 より一部改変 Pneumon the surface of the lung. The remain- INTENSIVE CARE UNIT, UN.H.H. PROFESSOR: Georgopoulos D. PATIENT NAME: ……………………………………………………………… RN: ……………………………. DATE: ……………………….Rt A B3 B7 C L M Lt A B3 B7 C L M PU PUA AU U LU LUAL AL AU AUL LU ULL AL AL LL LLP LL PU UPL PL PL PL PNEUMOTHORAX PNEUMOTHORAX PLEURAL EFFUSION PLEURAL EFFUSION FIGURE 1. Protocol for lung examination A line, B3: the line, B7: B7 line, C; Consolidation, A: Atelectasis, P: Pulmonary oedema, A: followed in B3 Intensive Care Unit. C: Consolidation, I: Infiltrations L: Lung sliding, M; M mode(でのLung pointの有無)
  57. 57. characterize Pressure–Volume Curves and Measurement of PEEP-induced Lung Recruitment Am J Respir Crit Care Med 2011;183:341-7 c score was examined i PV curves were measured using a ventilator equipped with specific 肺エコーを用いての software. In anesthetized and paralyzed patients, after a prolonged expiratory pause at PEEP 0 or PEEP 15 cm H2O, each patient’s respiratory system was inflated by a constant 8 l/min flow until an Protocol The order curves and inspiratory pressure of 40 cm H2O was reached. Simultaneously, (Figure 1), PEEPによるLung recruitmentの評価 pressures, flows, and volumes were recorded. Decrease in end-expiratory lung volume (DEELV) was defined as was analyz ventilator s the difference in lung volume between PEEP 0 and PEEP 15 cm H2O after a PEEP release maneuver. PEEP-induced lung recruitment was Statistical measured according to lung morphology assessed on chest radiography • 40名のALI/ARDS(重症FaO2/FiO2≤100を除く)において, (13, 14). In patients with focal loss of aeration, PEEP-induced lung recruitment was quantified as follows: PV curves in PEEP 0 and PEEP Correlation lung recrui Statistical a 15 cm H2O were placed on the same pressure and volume axes. PEEP- PEEP 0, 15cmH2Oをかけて, lung recruitmentと induced lung recruitment was defined as the difference in lung volumes between PEEP 0 and PEEP 15 cm H2O at an airway pressure of 15 cm tical signifi H2O (16). In patients with diffuse loss of aeration, PEEP-induced lung RESULTS 肺エコー所見の関連を評価. recruitment was defined as DEELV. Patients Lung Ultrasound Forty con ▫ 肺エコーは, 左右, 上下, 前側後の12カ所で評価. スコア化して変化を評価NAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 183 2011 LUS was performed using a 2- to 4-MHz probe. All intercostal spaces were incl of upper and lower parts of anterior, lateral, and posterior regions of a tidal vol left and right chest wall were examined (3, 6). Videos were stored on tained bet TABLE 1. ULTRASOUND REAERATION SCORE Quantification of reaeration* Quantification of loss of aeration 1 point 3 points 5 points 5 points 3 points 1 point B1 / N B2 / N C/N N/C N / B2 N / B1 B2 / B1 C / B1 B1 / C B1 / 2 C / B2 B2 / C B1; B7-line, B2; B3-line, C; lung consolidation, spaced Definition of abbreviations: B1 5 multiple well-defined either regularly 7-mm apart or irregularly spaced B lines (moderate loss of lung aeration); B2 5 N; normal(A line)(severe loss of lung aeration); C 5 lung consolidation; multiple coalescent B lines N 5 normal pattern (normal lung aeration). * The ultrasound reaeration score was calculated as follows: In a first step, ultrasound lung aeration (N, B1, B2, and C) was assessed in each of the 12 lung ▫ PVカーブは regions examined before and after application of positive end-expiratory pressure 15 cm H2O. In a second step, ultrasound lung reaeration score was calculated as the sum of each score characterizing each lung region examined according to the 鎮静, 筋弛緩状態で評価 scale shown in the table.
  58. 58. constant throughout the experiments, and FIO2 was maintained at reaeration score of 14 or greater was ass1. Clinical and physiological characteristics are summarized in Am J Respir Crit Care Med 2011;183:341-7 59 induced lung recruitment ranging from 75 tTable 2. Compared with patients with focal loss of aeration, pa- the ultrasound reaeration score was less actients with diffuse loss of aeration had a higher lung injury severity smaller changes of lung aeration. A sta • PEEPをかけた後, LUS scoreが+8以上ならば,score, were ventilated with a higher respiratory rate, and hada higher level of PEEP-induced lung recruitment (Table 2). correlation was found between the LUS r a PEEP-induced increase in PaO2 (Figure 2 was tighter in patients with diffuse loss of l Lung recruitmentは>600mlを期待できる.Diagnostic Accuracy of LUS for Quantifying PEEP-induced patients with focal loss of lung aeration.Lung Recruitment Ultrasound Analysis of Regional Lung Reae ▫ しかしながら, +4以上の場合は75-400mlのrecruitmentであり,A highly statistically significant correlation was found betweenPEEP-induced lung recruitment measured by the PV curve Among 480 regions of interest, 469 couldmethod and the ultrasound reaeration 軽度のrecruitmentの場合はUSでの評価が難しい バラツキが大きい → score (Figure 2A). The and after application of PEEP (11 regionsultrasound reaeration score was accurate for detecting a signif- be examined because of the presence of aicant increase in lung aeration (Figure 2B). PEEP-induced lung sound reaeration after PEEP was predom F t s a e ( c p m o t i r l i P m
  59. 59. Am J Respir Crit Care Med 2011;183:341-7 60 344• 部位別のUS所見の変化(PEEP前後) 前胸部 上部 前胸部 下部
  60. 60. AMERICAN JOURNAL Crit Care Med 2011;183:341-7 Am J Respir OF RESPIRATORY AN 61側胸部 上部側胸部 下部
  61. 61. N JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Care Med183 2011 Am J Respir Crit VOL 2011;183:341-7 62 背側 上部 背側 下部 前胸部, 側胸部の所見は PEEPにより改善しやすい. 背側, 下部のAir入りは 改善しにくい傾向あり
  62. 62. 63SBT前後の肺エコーで抜管後のDistressを予測する Crit Care Med 2012; 40: 2064–2072• ICU患者100名において, SBT→抜管を施行.▫ SBT前, SBT後1時間, 抜管後4時間で肺, 心エコー, BNP評価し, 抜管後のDistressとの関連性を評価.▫ SBTはT-tubeを用いて観察.▫ 肺USは2-4MHzのプローブを用い, 左右上下, 前側後肺の12箇所で評価し, Score化 所見 Score 正常; A line もしくは B lineが2本未満 0 中等度の虚脱; 複数のB line 1 高度な虚脱; 放射状のB line 2 完全虚脱; Consolidationを認める 3
  63. 63. Crit Care Med 2012; 40: 2064–2072 64 • 結果; 100名中SBT成功し, 抜管したのは86名. ▫ 86名中29名で抜管後Distressを認めた. その14/29が再挿管, 15/29がNIPPVで管理され, NIPPVの15例中6例が再挿管.(再挿管は19/29) • 肺US score, BNPの値の変化 全患者(100) SBT失敗(14) SBT成功(86) P SBT前の肺US 12[9-15] 13[10-17] 12[8-15] NS SBT後の肺US 13[9-17]* 15[13-21]* 13[8-17]* 0.002 SBT前のBNP(pg/mL) 227[80-590] 180[75-823] 241[79-541] NS SBT後のBNP 205[75-628]* 207[75-1260]* 201[82-553] NS Distress(-)(57) Distress(+)(29) P SBT前の肺US 10[6-13] 15[13-17] <0.001 SBT後の肺US 10[7-13] 19[16-21]* <0.001 Distress(+)群では SBT前のBNP(pg/mL) 139[64-316] 475[232-689] 0.003 SBT後のBNP 137[65-315] 459[152-958] 0.002 SBT前後のLUS増悪が * SBT前後の比較で有意差あり. 顕著に認められる.
  64. 64. 65 • SBT後の肺US score 14をCutoffとすると, Crit Care Med 2012; 40: 2064–2072 ▫ 抜管後のDistressは感度82%, 特異度79%で予測. ▫ 13-17はグレーゾーンであり, ≤12ptならば低リスク, >17ならば高リスクと考える.Table 3. Interval likelihood ratios for the prediction of postextubation distress using lung ultrasound score measured at the end of spontaneous breathing trial End-SpontaneousBreathing Trial Lung Failure Success % of Postextubation 95% Confidence Ultrasound Score Number of Patients Number of Patients Distress Likelihood Ratio Interval Risk<13 4 39 9 0.20 0.08–0.5 Low13–17 7 15 32 0.91 0.42–1.99 Basal>17 18 3 85 11.8 3.78–36.78 HighTotal 29 57
  65. 65. 膿胸 vs 肺膿瘍 Chest 2009;135:Issue 6. June• 膿胸ではExternal drainageが必須であるが, 肺膿瘍ではPostural drainage, 抗生剤で対応する.• 胸部レントゲンでは, Air-Fluid Levelを形成している場合, 判別が困難 ▫ Air-Fluid Levelと胸郭で形成される形で判別がつく場合もあるが (膿胸では紡錘状, 膿瘍では球状), 境界面が胸壁に接している場合, 判別が困難なことも多い. ▫ 造影CTで確定可能だが, 患者によっては造影困難な場合もある ⇒ エコーで違いがあるか? ▫ 34名の肺膿瘍, 30名の膿胸患者でエコーを施行し, 所見を評価
  66. 66. Air-Fluid Levelを形成した肺膿瘍, 膿胸患者で 胸部エコーを施行し, 所見を評価 • Reference Standardは臨床経過, 胸部CT • 肺膿瘍, 膿胸を合併した症例は除外し, 肺膿瘍34名, 膿胸30名で評価エコー所見 肺膿瘍 膿胸 p値隔壁 均一の厚さ 9% 48% 0.003 内腔はスムーズ 9% 52% 0.001 外壁がスムーズ 9% 50% 0.0003胸壁のAngle 鋭角 28% 45% 0.19 鈍角 31% 14% 0.14 両方 41% 41% 0.98 Split pleura sign 0% 3% 0.28 Sn 94%, Sp 100%で肺内腔の輝度 Suspended microbubble sign 15% 23% 0.38 膿瘍を示唆する Complex-septated effusions 0% 40% 0.00004 Passive atelectasis 0% 47% 0.000007Doppler USにて腔周囲のVessel signals(+) 94% 0% <0.000001
  67. 67. a; 膿胸患者のエコー所見Complex-septated effusion(←)Passive atelectasis(▼)壁厚は均一で, 内側, 外側壁はスムーズ.Color Doppler USでは周囲の血流(-)b; 肺膿瘍患者のエコー所見Consolidationの内部にHypoechoic Leisionを認める(▼)(Air bronchogram)壁は不均一であり, スムーズではないColor Doppler USでは周囲の血流(+)(Vessel signals)
  68. 68. 胸部レントゲンでは同様のAir-Fluid Level(+). エコーでも不均一の壁と,Microbubble Sign(▼)を同様に認める.Color Dopplerにて,fではVessel sign(+)cではVessel sign(-)⇒ aは膿胸, dは肺膿瘍
  69. 69. • d; 膿胸 VesselはPassive atelectasis内に存在 (比較的Straight, Air bronchogram様に見える)• h; 肺膿瘍 VesselがPericavitary consolidationに存在する
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