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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



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




胸壁
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 same
les are visible. Lobules are mon for small veins to arise at nearly right size as the one it arose from and the
lobular septa (S) contain-   angles to a much larger main branch.
branches. Bronchioles (B)
(A) are centrilobular. (Re-  Centrilobular Region and Centrilobular         Figure 5
n, 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




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)
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



ARDS患者のCT
矢印からエコーを当てたら
どう見える?
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



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?
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
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




• 肺炎患者のCT
• これはどう見えるか?
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




気胸の患者ではどう見えるか?
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



Lung 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


  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. In
time motion mode, one must first locate the pleural line (white arrow)
18
(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 peculiarities
of 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 lung
sliding, 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 t
tern 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 (thre
indicate 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.
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 our
Figure 10. Suggested classification of thoracic artifacts.   when used by only one and sam
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
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%
正診率 90.5%




Stage 3;
subposterior analysis
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

• 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


• 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



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?
B 5 肺エコー
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?
30



Alveolar-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%
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.
32



ARDS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%
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
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
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%
36




US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
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                                                    1000
2000
                                                                                                                         500
                                                            500
                                                                   1000
1000
                                                                                                                            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
                                                                                                                                                                          Each
C                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
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)
39
Figure 6 Measure of agreement (expressed as " %) between chest ultrasonograph and chest radiograph according to
their position in the hemithoraces. All " values were highly significant (P < .0001). A, Free pleural effusion. B, Loculated
pleural 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 Reference
Standard 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 of
Can 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 detected
Chest - 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)
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Consolidation
ARDS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
• 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.
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
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.
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.)
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. Symptoms
es in the surrounding area (asterisks). This image is
small lung consolidation due to a peripheral infarction.                       Physical examination and history were recorded
osis was pulmonary embolism.                                                presentation by the attending EP. Particular attention w
                                                                            reserved to specific symptoms, such as history of coug
alized the pain. Maximal inspiration and exhala-                            hemoptysis, and fever along with pleuritic pain.
 used to gain access to areas covered by solid
of 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 independe
escribed in a previously published article [3].                             reviewers after a combination of the following procedure
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
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
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
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
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.
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.
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
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?
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
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.
56



MD Consult - Print Previewer




  Figure 4 Radiographic and ultrasonographic detection of pneu
  pneumothoraces missed by chest radiography were confirmed by
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
                                                                                 PU
A                                                                                                  A
U                                                                                                  U
                                   LU                                                       LU
AL                                                                                                AL
                                                  AU                       AU
L                                                                                                  L
U                                                                                                  U

LL                                                AL                       AL                     LL
                                                                                             LL
P                                   LL                                                             P
U                                                                                                  U

PL                                                                                                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)
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.
constant throughout the experiments, and FIO2 was maintained at          reaeration score of 14 or greater was ass
1. Clinical and physiological characteristics are summarized in              Am J Respir Crit Care Med 2011;183:341-7
                                                                                                                 59
                                                                         induced lung recruitment ranging from 75 t
Table 2. Compared with patients with focal loss of aeration, pa-         the ultrasound reaeration score was less ac
tients 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 had
a 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 between
PEEP-induced lung recruitment measured by the PV curve           Among 480 regions of interest, 469 could
method 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 regions
ultrasound reaeration score was accurate for detecting a signif- be examined because of the presence of a
icant 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
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
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
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
63



SBT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
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.
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-Spontaneous
Breathing 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            Low
13–17                                7                        15                        32                      0.91                 0.42–1.99           Basal
>17                                 18                         3                        85                     11.8                  3.78–36.78          High
Total                               29                        57
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
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%   0.000007
Doppler USにて腔周囲のVessel signals(+)         94%   0%    <0.000001
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)
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
• 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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B 5 肺エコー

  • 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.
  • 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 same les are visible. Lobules are mon for small veins to arise at nearly right size as the one it arose from and the lobular septa (S) contain- angles to a much larger main branch. branches. Bronchioles (B) (A) are centrilobular. (Re- Centrilobular Region and Centrilobular Figure 5 n, 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
  • 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
  • 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
  • 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. 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
  • 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
  • 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 Lung 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 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. In time motion mode, one must first locate the pleural line (white arrow)
  • 18. 18
  • 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 peculiarities of 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 lung sliding, 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 t tern 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 (thre indicate 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. 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 our Figure 10. Suggested classification of thoracic artifacts. when used by only one and sam
  • 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. 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%
  • 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 • 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 • 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!
  • 29. 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?
  • 30. 30 Alveolar-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%
  • 31. 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.
  • 32. 32 ARDS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%
  • 33. 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
  • 34. 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
  • 35. 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%
  • 36. 36 US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
  • 37. 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 1000 2000 500 500 1000 1000 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 Each C 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
  • 38. 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)
  • 39. 39 Figure 6 Measure of agreement (expressed as " %) between chest ultrasonograph and chest radiograph according to their position in the hemithoraces. All " values were highly significant (P < .0001). A, Free pleural effusion. B, Loculated pleural 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 Reference Standard 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 of Can 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 detected Chest - 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)
  • 40. 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Consolidation ARDS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
  • 41. • 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.
  • 42. 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
  • 43. 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.
  • 44. 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.)
  • 45. 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. Symptoms es in the surrounding area (asterisks). This image is small lung consolidation due to a peripheral infarction. Physical examination and history were recorded osis was pulmonary embolism. presentation by the attending EP. Particular attention w reserved to specific symptoms, such as history of coug alized the pain. Maximal inspiration and exhala- hemoptysis, and fever along with pleuritic pain. used to gain access to areas covered by solid of 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 independe escribed in a previously published article [3]. reviewers after a combination of the following procedure
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. 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.
  • 51. 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.
  • 52. 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
  • 53. 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?
  • 54. 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
  • 55. 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.
  • 56. 56 MD Consult - Print Previewer Figure 4 Radiographic and ultrasonographic detection of pneu pneumothoraces missed by chest radiography were confirmed by
  • 57. 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 PU A A U U LU LU AL AL AU AU L L U U LL AL AL LL LL P LL P U U PL 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)
  • 58. 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.
  • 59. constant throughout the experiments, and FIO2 was maintained at reaeration score of 14 or greater was ass 1. Clinical and physiological characteristics are summarized in Am J Respir Crit Care Med 2011;183:341-7 59 induced lung recruitment ranging from 75 t Table 2. Compared with patients with focal loss of aeration, pa- the ultrasound reaeration score was less ac tients 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 had a 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 between PEEP-induced lung recruitment measured by the PV curve Among 480 regions of interest, 469 could method 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 regions ultrasound reaeration score was accurate for detecting a signif- be examined because of the presence of a icant 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
  • 60. 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
  • 61. 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
  • 62. 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
  • 63. 63 SBT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
  • 64. 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.
  • 65. 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-Spontaneous Breathing 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 Low 13–17 7 15 32 0.91 0.42–1.99 Basal >17 18 3 85 11.8 3.78–36.78 High Total 29 57
  • 66. 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
  • 67. 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% 0.000007 Doppler USにて腔周囲のVessel signals(+) 94% 0% <0.000001
  • 68. 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)
  • 70. • 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