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Critical Care

Recent advances in the use of thoracic ultrasound for pleural disease

Lung ultrasound is a necessary, key component in both pulmonary and critical care settings due to its high diagnostic accuracy and physicians’ ability to perform it at the bedside. In cases of pleural disease, lung ultrasound could be an essential component of care, from the initial diagnosis through clinical management and treatment.

Last year, Cook Medical had two physicians with expertise in the use of thoracic ultrasound for pleural disease share recent advances of this technique at two major industry conferences: the European Respiratory Society (ERS) International Congress and the CHEST Annual Meeting.

ERS International Congress

Luigi Vetrugno, MD, is a Professor of Anaesthesia and Intensive Care at the University Hospital of Udine in Udine, Italy. In his presentation, Thoracic ultrasound for pleural effusion, he discussed several studies he has published in recent years about the important role ultrasound plays in diagnosing and treating pleural effusion.

“Ultrasound plays a significant role in the education of physicians,” Dr. Vetrugno said. “They will need to be trained to view this technology as an extension of their senses, just as many generations have viewed the stethoscope in a similar way.”

In one study co-authored by Dr. Vetrugno and published in Critical Care Medicine, thoracic ultrasound is said to not only help physicians visualize pleural effusion, but also to help them distinguish between the different types that can be present.1

Additionally, “TUS [thoracic ultrasound] is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF [pleural effusion].”1

An observational study co-authored by Dr. Vetrugno assessed “the prevalence of complications related to ultrasound-guided percutaneous small-bore pleural drain insertion.”2

He stated that “small-bore pleural drainage device insertion has become a first-line therapy for the treatment of pleural effusions.” In this study, ultrasound was used to assess the safety and complication rates in patients with pleural effusions. The study’s authors found ultrasound-guided placement to be a “safe procedure,” however, in the future, estimating the amount of pleural effusion by ultrasound will be necessary to standardize the procedure. The authors also concluded that for resident physicians “training and proficiency assessment should be formalized.”2

An additional article by Dr. Vetrugno in favor of ultrasound guidance can be found in Critical Ultrasound Journal, Respiratory and Pulmonary Medicine, and Annals of Intensive Care.

He has also submitted letters to the editor regarding the importance of patient position during ultrasound procedures.

In one letter, Dr. Vetrugno advised for the patient to remain in supine position with a mild torso elevation of 15 degrees, not a semi-recumbent position with the torso at 40-45 degrees as previous authors stated.3 “This means that as fluid follow the law of gravity, an overestimation of the maximal distance between partial and visceral pleura could be obtained,” he said. This theory “overestimates in tall males with large thoracic circumference small effusions under 200 mL and in large ones above 1000 mL.”3

According to Dr. Vetrugno, this equation allows for a high mean prediction error, however, it is recognized that “an urgent standardization of the method to assess PLEFF [pleural effusion fluid] with lung ultrasound is needed to reach a definite conclusion.”3

In another letter to the editor, Dr. Vetrugno echoed his concerns that larger and more standardized clinical studies should be performed before a definite conclusion is reached.4

CHEST Annual Meeting

Seth Koenig, MD, FCCP, is the Director of Education and Professor of Medicine in the Division of Pulmonary Medicine at Montefiore Medical Center in New York City, New York. In his presentation, Ultrasonography for the diagnosis and management of pleural disease, he presented about the extensive benefits of using ultrasound, most notably regarding patient safety.

Dr. Koenig started his presentation with an important question, “How do we maximize the things we can do for our patients safely without using another service? And how does ultrasound help?”

To this question, the majority of the physician audience said that they routinely use ultrasound for general purposes, however, Dr. Koenig urged them to consider ultrasound for pleural effusions. “For me, I use ultrasound to do everything,” he said.

Dr. Koenig explained that the use of ultrasound prevents a concept commonly known as “clinical and time dissociation.”

“When you ask for another service, you invoke the ancient art of clinical and time dissociation,” he said. “For example, if you ask for a CAT scan, you will most likely have to involve a surgeon, an infectious disease doctor, and a pulmonologist. This can be confusing for the patient. Someone else reads the exam, you get the results of that exam, but they’re not intimately involved in the patient. This takes time for the exams to come in, plus, you have to move the patient. Is this what you do, or should we figure out a better way?”

Ultrasound, according to Dr. Koenig, not only provides added clarity in terms of a diagnostic approach, but it may also reduce the number of specialists involved in the diagnostic process.

“Every single patient that we see from the pulmonary and from critical care departments gets an ultrasound,” he said.

Additional advantages of ultrasound, according to Dr. Koenig, include:

Dr. Koenig also said that using ultrasound alleviates the need to precisely place a chest tube in the “triangle of safety,” a small, preferred site of insertion as determined by the British Thoracic Society.5

“The triangle isn’t a problem anymore,” he said. “As long you have a nice space, you can stick the needle wherever is convenient for you and the patient because you can see everything. As long as you know where you are and your wire guide is well placed, it doesn’t matter what you insert after. The point is, if you can see it, you can do something about it.”

Dr. Koenig ended his lecture by emphasizing the most important reason physicians should consider the use of ultrasound for pleural diseases: the patients.

“We have to think about our patients before we do things,” he said. “In 2019, I believe patients see too many doctors. They get a doctor for this, they get a doctor for that, what happens is, patients get really confused, and so if you can decrease the number of people and the number of procedures that a person has, they thank you for it, believe it or not. In conclusion, ultrasound is good for the patient, but it’s also good for you. Ultrasound helps with diagnostic and therapeutic planning. It helps to diagnose complications. It’s helpful to follow the progress of a pleural effusion, and it’s obviously extremely good for documenting post-procedure pneumothoraces.”

Dr. Vetrugno is not a paid consultant of Cook Medical.
Dr. Koenig is a paid consultant of Cook Medical.

1. Brogi E, Gargani L, Bignami E, et al. Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment. Crit Care. 2017;21:325.

2. Vetrugno L, Guadagnin GM, Barbariol F, et al. Assessment of pleural effusion and small pleural drain insertion by resident doctors in an intensive care unit: an observational study. Clin Med Insights Circ Respir Pulm Med. 2019;13: 1179548419871527.

3. Vetrugno L, Bove T. Lung ultrasound estimation of pleural effusion fluid and the importance of patient position. Ann Intensive Care. 2018;8:125.

4. Vetrugno L, Brogi E, Barbariol F. “A message in the bottle.” Anesthesiology. 2018;128(3):677.

5. Griffiths JR, Roberts N. Do junior doctors know where to insert chest drains safetly? Postgrad Med J. 2005;81:456-458.