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Lung Ultrasound Explained (Point of Care, Bedside, Clinical)

in this video we’re going to introduce
the 10 basic signs of lung ultrasound now Liechtenstein breaks us down into
ten basic signs and we will look at each of these signs in detail in subsequent
videos so the point of this video is just to introduce them and get you to
start recognizing these ten basic signs so the first sign is called the bat sign
and I’ll be honest I don’t know that I can appreciate it as a bat as
Liechtenstein does but I do appreciate the importance of the bat sign and the
importance is to accurately identify the pleural line because if you don’t
accurately identify the pleural line you can misinterpret things in lung
ultrasound so this is going to serve as a key landmark for us the way I like to
think of it is layers from the outside in as we’ve previously discussed so we
have the skin layer the subcutaneous layer we have the muscular layer here
then we have the cortex of the rib with shadowing shadowing and the cortex of
the rib here with shadowing and shadowing we have the intercostal area
between the ribs and then and only then can I identify this hyper echoic line
below the ribs an intercostal area as the pleural line now Lichtenstein sees
this as a bat where the curved ribs are like the wings of the bat it’s like the
bats flying towards you and then below those wings you can call the pleural
line again I don’t know if I can identify it that way but this will serve
as a core landmark for us identifying this hyper echoic pleural line the bat
sign now the second sign is the seashore sign in the seashore sign is identifying
what normal lung sliding looks like in both 2d and M mode so if we look at this
2d picture on the left we see here that we have rib and rib shadow rib and rib
shadow so we know this is the pleural line as we’ve talked about before and
for now just a pre she ate that there’s a movement along
the pleural line if we take an m-mode slice through the pleural line and then
depicted over time that’s what gives us this seashore appearance on M mode on
the right and if we notice in the picture here that everything above the
pleural line is relatively static I mean there’s a little bit movement in the
intercostal and muscular segments but it’s mostly straight lines because it’s
relatively static where everything below the pleural line is relatively dynamic
you see all of this sparkling and movement in this artifact that is
created that is the appearance of normal lung sliding and this is said to look
like a seashore a sandy beach where you have up here the horizon the waves
coming in you hit the seashore and then you have this sandy beach appearance of
everything below it the next sign is the a line and again if we identify that
this is the pleural line what a lines are is horizontal lines that are
reverberation artifact of the original pleural line so we see the original
pleural line here and then we’ll notice that equidistant from the skin to the
original pleural line we have a second horizontal line and then equidistant
again we have a third horizontal line and again these horizontal lines are
reverberation artifact identified as an a-line the next two signs are the quad
sign in the sinusoidal pleural effusions so we’re going to look at them together
now if we look at the image on the bottom left we see our normal anatomy
that we’re used to with the rib and shadow and then below the ribs we see
the parietal pleura and then between the parietal in the visceral pleura we see
that there’s fluid in this fluid takes this quadrangle
misshape because we have the ribbon shadows serving as the side borders and
then the parietal and the visceral pleura serving as the top and bottom
border and if we were to take an M mode right down through the middle of this
pleural effusion and watch it out over time what we would see is the parietal
pleura here and then with inspiration exploration we’d see the visceral pleura
moving in and out which gives us sinusoidal in between the two pleural
layers and that’s the sinusoidal are going to look at together are the Shred
side which is depicted here as well as the tissue like sign which is depicted
here in both of these are signs of consolidation now if we look at this
video down here we see that here we have the diaphragm below the diaphragm is
liver and above the diaphragm we see a little bit of pleural fluid but we see
this tissue like area which is an area of consolidated lung it almost looks
like liver tissue and that’s why some call it hepatis ation of the lung
because here’s the liver but the liver has black blood vessels in it where this
has white areas in it and those white areas are air Branca Graham’s so the
first sign that we’re talking about is this tissue like sign and it’s tissue
like appearance of consolidated lung with white air Branca Graham’s inside of
it the second is the Shred sign in the Shred sign is where the consolidated
lung meets normal aerated lung it creates the shredded like pleural line
it’s not the pleural line it’s where the interface between the consolidation of
the lung and the aerated lung meet it doesn’t create a straight line like
the lung line or the pleural line but this irregular shredded like line so the
Shred sign in the tissue lake sign are both signs of consolidation the eighth
sign that we’re going to talk about our lung Rockets now long rockets by
definition are greater than or equal to three B lines per interspace and B lines
are an artifact that we’re going to identify here now C rib rib with shadow
and shadow that should be familiar to you now with the pleural line then seen
just below that but notice how off of the pleural line there’s coming a bright
white vertical artifact I imagined it as a bright white almost flashlight beam
beaming off of the pleural line off of the screen notice that it comes from the
pleural line it’s vertical it’s bright white it moves with the pleural line and
it obliterates this a line so B lines when they’re present obliterate the a
line and if there’s greater than two or equal three B lines we call that lung
Rockets and lung Rockets are a sign of interstitial syndrome the next sign is
called the stratosphere sign or some call it the barcode sign and this is the
m-mode equivalent of lack of lung sliding so if we look at this 2d video
clip here we see rib shadowing rib a little bit of shadowing so we know below
that is this hyper coline that we’ve identified as the pleural line but
notice looking at this pleural line that there’s no movement along it there’s
movement of the chest wall but there’s not movement of the pleural line back
and forth in opposition to each other so if we contrast that to the seashore sign
we’ve seen before we can identify that everything above the pleural line is
still relatively static I mean again we see the movement in the intercostal and
muscular layers from time to time that’s movement of respiration but below
it we don’t see that Sandy Beach in fact above in below the pleural line are now
mirrored they look exactly the same and this is what Lichtenstein refers to as
the stratosphere sign are almost like the smoke jets coming from a jet plane
in the stratosphere or others have identified as a barcode or straight
lines all the way across so the key to identifying this sign is when everything
above the pleural line in below the pleural line are identical
that’s the stratosphere sign and it equals lack of lung sliding the last
sign we’re going to talk about is the lung point in the lung point is the
transition between a pneumothorax or air in the pleural space in normal lung
sliding and if we look on this video on the Left we see rib shadow rib shadow
and so we know this is the pleural line but we see movement along the pleural
line on this part and so that is lung sliding and on the other side we see no
lung sliding so this transition point between the two is the lung point and if
we were to place m-mode on this we would see that above the pleural line we have
the static area so no significant movement below the pleural line on this
side we see the sandy beach sign with lung sliding and then that lung sliding
goes away here where we have the stratosphere sign all in the same
intercostal segment this is pathognomonic for pneumothorax so burn
this in your memory the lung point all right let’s review real quickly then
the ten basic signs of lung ultrasound number one the bat sign identifying the
pleural line number two the sea shore sign or the m-mode equivalent of normal
lung sliding now number three a lines reverberation
artifact horizontal lines equidistant from the pleural line number four the
quad sign or fluid between the visceral and parietal pleura indicative of
pleural effusion number five the sinusoidal inspiration
and expiration the visceral pleura coming towards and away from the prado
pleura with fluid in between creating this sinusoidal indicative of a pleural
effusion number six the Shred sign or the uneven lung line below the area of
consolidation the shredded lung sign indicative of consolidation number seven
the tissue like sign or tissue with air Branca Graham’s in it inside the lung
which is indicative of consolidation as well number eight lung Rockets these
vertical flashlight like beams coming off of the pleural line moving with the
pleural line obliterating the a line these are indicative of interstitial
syndrome number nine the stratosphere sign or the barcode sign which is
indicative of lack of lung sliding and then number ten the lung point which is
indicative of pneumothorax and that’s where you have lung sliding and lack of
lung sliding in the same intercostal segment you

8 thoughts on “Lung Ultrasound Explained (Point of Care, Bedside, Clinical)

  1. Join us for the rest of the Lung Ultrasound Explained Clearly videos:

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