POCUS FOCUS: Lung Ultrasound for Pneumonia

BY: MAX RUBINSTEIN, MD

The Case: A 5 year old previously healthy boy presents to the ED with three days of fever and progressive shortness of breath. His exam is notable for course rhonchi and decreased aeration in the right anterior lung. There was no personal or family history of asthma, eczema, or food allergies. He received an albuterol nebulizer with no effect.

The Diagnostic Intervention: Lung Ultrasound

Point of Care Lung Ultrasound:

Point of care lung ultrasound is highly useful in detecting pulmonary pathology commonly encountered in the emergency department, most notably pneumothorax, pulmonary edema, and pneumonia.  The basic technique of lung ultrasound in children is the same no matter what underlying process is suspected. The linear probe is used and oriented perpendicular to the rib in the longitudinal axis. This allows detailed visualization of the pleural line. This is perhaps the most important aspect of lung ultrasonography as 90% of respiratory dysfunction attributable to the lungs affects the pleura.1 Differences in the appearance of the pleural line help the clinician distinguish between causes of respiratory distress. There are several techniques described to adequately assess the lungs by ultrasound, the simplest of which is to image at three interspaces in the midclavicular, mid-axillary, and posterior lung fields.1,2

Figure 1.  Normal Lung Anatomy on Ultrasound

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Pneumonia on Ultrasound:

Pneumonia on lung ultrasound has a characteristic appearance. One can see “hepatization” of the lung as this normally echogenic and artifact filled tissue (see Figure 1) becomes echo-poor and increasingly tissue-like, resembling the liver on ultrasound (see Figure 2).  This is accompanied by “dynamic air bronchograms,” a branching lesion that courses through affected lung and moves with breathing. 3 This mobility helps distinguish pneumonia from atelectasis. A recent study found that dynamic air bronchograms have a 97% positive predictive value for pneumonia.4

How good is lung ultrasound for detecting pneumonia?

  • Sensitivity & Specificity in children > 90%5
  • When performed by emergency medicine physicians who have received a 1 hour training session, sensitivity drops to 86% but specificity is 97%.6
  • Ultrasound may also be better at detecting small pneumonias than standard chest x-ray.6 However, the clinical significance of this finding has yet to be determined.

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The Neonate in Shock: When to think CARDIAC

Clinical Case:

2-week-old male with history of “funny breathing” since birth presents to ED with 1 day of decreased feeding, now with 30 second apneic and cyanotic episode at home tonight.

Sternal_retractions-3** Neonates in shock MAY show obvious signs/sx of end-organ dysfunction (similar to adults), but their presentation may be subtle and progress rapidly!**

 Signs/Symptoms of Shock in Neonate:

  • History
    • Poor feeding
    • Respiratory distress (tachypnea, cyanotic/apneic episode)
    • Altered mental status (irritability, difficulty awakening)
  • Physical Exam
    • Tachycardia
    • Tachypnea
    • Hypotension
    • Poor Perfusion: Decreased capillary refill, mottled skin

Differential Diagnosis:

Think of “THE MISFITS” to recall critical diagnoses in the neonate in shock:

T –       Trauma (accidental and non-accidental)
H –       Heart disease and Hypovolemia
E –       Endocrine (congenital adrenal hyperplasia, hypothyroid, etc)
M –      Metabolic
I –        Inborn errors of metabolism
S –       Sepsis
F –      Feeding problems, Formula mishaps (under- or over-dilution)
I –        Intestinal catastrophes (NEC, volvulus, etc)
T –       Toxins
S –       Seizures

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Emergent Umbilical Venous Catheter (UVC) Placement

In a sick neonate where peripheral venous access is not possible, placement of an umbilical venous catheter (UVC) may be lifesaving!
The umbilical vein may remain patent for up to 10 days after birth.

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http://www.uichildrens.org/insertion-of-umbilical-vessel-catheters/

Indication:

  • Emergency resuscitation and stabilization of neonates (to give volume or medications, such as epinephrine

Contraindications:

  • Abdomen doesn’t look normal (omphalocele, gastroschisis, omphalitis, peritonitis, necrotizing enterocolitis)
  • Vascular compromise of the lower limbs

 

Umbilical Vessel Anatomy:

Neonatal Anatomy

From Robert and Hedge’s Clinical Procedures in Emergency Medicine

  • Umbilical cord has 2 arteries and 1 vein
    • Vein is thin-walled, usually at 12 o’clock
    • Arteries are smaller and thick-walled
  • Neonatal blood flow:
    • Umbilical vein –> ductus venosus –> IVC –> RA –> PA –> ductus arteriosus –> aortic arch
    • Umbilical arteries –> internal iliac arteries

 

Finding your Materials:

  • In Hasbro ED:
    • Locate UVC Tray and UVC lines in Hasbro Trauma Bay
    • Other materials not in kit:
      • 3-0 silk suture on a curved needle
      • Infusion solution (usually NS or D10W)
      • Three-way stopcock
      • Tegaderm and tape

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