CHEST ULTRASOUND: PULMONARY EDEMA
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1 WINFOCUS ADVANCED ECHO (WAE) CHEST ULTRASOUND: PULMONARY EDEMA Bill Beninati, MD Intermountain Healthcare
2 Normal findings Pleural Line Pleural Sliding A lines lung LONGITUDINAL SCAN abdomen Normal semiology of the healthy lung is represented exclusively by artifacts. These are 3: 1. A transversal hyperechoic line in the intercostal space, placed 1 or half centimiter below the outer surface of the ribs, the so called pleural line (this is the physical site of the tissue-air interface, represented by the parietal and visceral pleura in touch) 2. The motion of this line with respiration, seen as a sort of glittering. This is called pleural sliding or gliding (it derives from the continual coming and going of the visceral pleura with the tide of lung inflation and deflation) 3. Transversal hyperechoic artifacts, parallel to the pleural line and placed at a regular distance which is a multiple of the distance between the probe footprint and the pleural line itself. This are called A lines. Pleural sliding when minimal can be anyway appreciated with M-Mode. If we hold steadily the probe on the chest, pre-pleural tissues are viewed with M-Mode as steady dots always at the same depth, appearing on the time scale as straight lines. The moving visceral pleura, with its natural irregularity, viceversa generates non aligned artifactual dots, represented on the time scale as irregular lines.
3 Normal findings Pleural Line Pleural Sliding A lines lung LONGITUDINAL SCAN abdomen Normal semiology of the healthy lung is represented exclusively by artifacts. These are 3: 1. A transversal hyperechoic line in the intercostal space, placed 1 or half centimiter below the outer surface of the ribs, the so called pleural line (this is the physical site of the tissue-air interface, represented by the parietal and visceral pleura in touch) 2. The motion of this line with respiration, seen as a sort of glittering. This is called pleural sliding or gliding (it derives from the continual coming and going of the visceral pleura with the tide of lung inflation and deflation) 3. Transversal hyperechoic artifacts, parallel to the pleural line and placed at a regular distance which is a multiple of the distance between the probe footprint and the pleural line itself. This are called A lines. Pleural sliding when minimal can be anyway appreciated with M-Mode. If we hold steadily the probe on the chest, pre-pleural tissues are viewed with M-Mode as steady dots always at the same depth, appearing on the time scale as straight lines. The moving visceral pleura, with its natural irregularity, viceversa generates non aligned artifactual dots, represented on the time scale as irregular lines.
4 lung sliding sign The lung sliding sign indicates normal movement, or sliding, of the visceral pleura against the parietal pleura as seen in this clip Again, please notice the difference between a curvelinear and linear probes. Although we don t see the classical bat sign (as this is a linear probe), we can still see hypoechoic areas in both sides of the clip, indicating shadow arising from the ribs. Point to the pleural line and show the sliding of the pleura against each other
5 lung sliding sign The lung sliding sign indicates normal movement, or sliding, of the visceral pleura against the parietal pleura as seen in this clip Again, please notice the difference between a curvelinear and linear probes. Although we don t see the classical bat sign (as this is a linear probe), we can still see hypoechoic areas in both sides of the clip, indicating shadow arising from the ribs. Point to the pleural line and show the sliding of the pleura against each other
6 A-line artifact An artifact observed in Normal lungs Certain diseased lungs Pneumothorax A line Lichtenstein D. Crit Care Med 2007;35 [Suppl.]:S Roughly horizontal, hyperechoic line Parallel to the pleural line and arising below it Arising at a distance equal to the distance between the skin and the pleural line The physical reason for this artifactual picture to appear on the screen, is that the ultrasound beems bounce between the footprint of the probe and the specular reflector represented by the pleural line, which is a homogeneous tissue-air interface. The machine interpretates the going and coming double travel of the beam as a single travel twice or three times the distance, and projects as artifact the pleural line at distances which are a multiple of the distance from probe surface to pleural line. It is the phenomenon of reverberation.
7 Abnormal findings Pleural Effusion Hypoechoic space Bounded by chest wall, lung, diaphragm Appropriate dynamic change
8 Abnormal findings Pleural Effusion Hypoechoic space Bounded by chest wall, lung, diaphragm Appropriate dynamic change
9 Abnormal findings Pleural Effusion Hypoechoic space Bounded by chest wall, lung, diaphragm Appropriate dynamic change
10 Abnormal findings Lung Consolidation Loss of aerated lung transmits ultrasound Sonographic air bronchograms punctate, echo bright
11 Abnormal findings Lung Consolidation Loss of aerated lung transmits ultrasound Sonographic air bronchograms punctate, echo bright
12 Abnormal findings Lung Consolidation Loss of aerated lung transmits ultrasound Sonographic air bronchograms punctate, echo bright
13 Abnormal findings B-line Lung rockets lung abdomen LONGITUDINAL SCAN
14 the b-line (lung comet) Normal Pattern B-Line : Longitudinal artifact, well defined, narrow base spreading to screen edge Arising and moving from pleural line, Abolition of A lines Physiological (28% healthy pts) if postero-lateral It is important to understand that the B-lines are comet-tail artifact (a type of reverberation artifact) Comet-tail artifact arises from anatomic structure with significant acoustic impedance gradient (i.e. air and water) It is characterized by artifacts, that can be clearly distinguished from normal artifacts, as you can see by comparison with the normal pattern on the right. Hallmark of this ultrasound pattern is a longitudinal artifact called B line or ULC (depending on which literature you are referring to). It originates from the pleural line, it moves together with it, it is a laser-like well defined artifact reaching the edge of the screen and erasing A lines. When grouped in number greater than 3 per Ultrasound scan sector and distributed at the antero-lateral surface of the lung, B-lines define the A-I Syndrome, and have been named Lung rockets (they resemble the trail of a rocket at its take-off) (again from the fantasy of D. Lichtenstein)
15 the b-line (lung comet) Normal Pattern B-Line : Longitudinal artifact, well defined, narrow base spreading to screen edge Arising and moving from pleural line, Abolition of A lines Physiological (28% healthy pts) if postero-lateral It is important to understand that the B-lines are comet-tail artifact (a type of reverberation artifact) Comet-tail artifact arises from anatomic structure with significant acoustic impedance gradient (i.e. air and water) It is characterized by artifacts, that can be clearly distinguished from normal artifacts, as you can see by comparison with the normal pattern on the right. Hallmark of this ultrasound pattern is a longitudinal artifact called B line or ULC (depending on which literature you are referring to). It originates from the pleural line, it moves together with it, it is a laser-like well defined artifact reaching the edge of the screen and erasing A lines. When grouped in number greater than 3 per Ultrasound scan sector and distributed at the antero-lateral surface of the lung, B-lines define the A-I Syndrome, and have been named Lung rockets (they resemble the trail of a rocket at its take-off) (again from the fantasy of D. Lichtenstein)
16 Lung rockets ALVEOLAR INTERSTITIAL SYNDROME: Lung Rockets, Multiple ( 3) grouped B lines, Diffused anterolateral distribution Lung rockets are pathological They indicate thickened interlobular septa reaching the periphery
17 Transducer Multiple US Beam Reflections NORMAL INTERLOBULAR SEPTA HOMOGENEOUS TISSUE-AIR INTERFACE REVERBERATIONS NORMAL ARTIFACTS (A lines) On the left we see a cartoon of normal lung parenchyma with associated normal lung ultrasound Things become different when fluid accumulate in the lung interstitium leading to thickened interlobular septa and high acoustic impedance gradient, which in turn lead to the numerous B-lines, or lung rocket as seen in the associated ultrasound image on the right
18 Transducer Transducer Multiple US Beam Reflections Multiple US Beam Reflections NORMAL INTERLOBULAR SEPTA HOMOGENEOUS TISSUE-AIR INTERFACE THICKENED INTERLOBULAR SEPTA REVERBERATIONS NORMAL ARTIFACTS (A lines) On the left we see a cartoon of normal lung parenchyma with associated normal lung ultrasound Things become different when fluid accumulate in the lung interstitium leading to thickened interlobular septa and high acoustic impedance gradient, which in turn lead to the numerous B-lines, or lung rocket as seen in the associated ultrasound image on the right
19 Transducer Transducer Multiple US Beam Reflections Multiple US Beam Reflections NORMAL INTERLOBULAR SEPTA HOMOGENEOUS TISSUE-AIR INTERFACE THICKENED INTERLOBULAR SEPTA INHOMOGENEOUS TISSUE-AIR INTERFACE REVERBERATIONS NORMAL ARTIFACTS (A lines) On the left we see a cartoon of normal lung parenchyma with associated normal lung ultrasound Things become different when fluid accumulate in the lung interstitium leading to thickened interlobular septa and high acoustic impedance gradient, which in turn lead to the numerous B-lines, or lung rocket as seen in the associated ultrasound image on the right
20 Transducer Transducer Multiple US Beam Reflections Multiple US Beam Reflections NORMAL INTERLOBULAR SEPTA HOMOGENEOUS TISSUE-AIR INTERFACE THICKENED INTERLOBULAR SEPTA INHOMOGENEOUS TISSUE-AIR INTERFACE REVERBERATIONS REVERBERATIONS NORMAL ARTIFACTS (A lines) B lines / lung rockets On the left we see a cartoon of normal lung parenchyma with associated normal lung ultrasound Things become different when fluid accumulate in the lung interstitium leading to thickened interlobular septa and high acoustic impedance gradient, which in turn lead to the numerous B-lines, or lung rocket as seen in the associated ultrasound image on the right
21 alveolar-interstitial syndrome: example 1 LUNG ROCKETS CARDIOGENIC PULMONARY EDEMA Lung rockets are not synonymous with a single disease, not even with cardiogenic pulmonary edema, which is the most frequent pathology associated with them.
22 alveolar-interstitial syndrome: example 1 LUNG ROCKETS CARDIOGENIC PULMONARY EDEMA Lung rockets are not synonymous with a single disease, not even with cardiogenic pulmonary edema, which is the most frequent pathology associated with them.
23 alveolar-interstitial syndrome: example 2 LUNG ROCKETS ARDS / ACUTE LUNG INJURY They can be found also in lesional edema
24 alveolar-interstitial syndrome: example 2 LUNG ROCKETS ARDS / ACUTE LUNG INJURY They can be found also in lesional edema
25 alveolar-interstitial syndrome: example 3 LUNG ROCKETS PULMONARY FIBROSIS also in fibrosis
26 alveolar-interstitial syndrome: example 3 LUNG ROCKETS PULMONARY FIBROSIS also in fibrosis
27 alveolar-interstitial syndrome: example 4 LUNG ROCKETS PROTEINOSIS in other diffuse chronic diseases such as alveolar proteinosis
28 alveolar-interstitial syndrome: example 4 LUNG ROCKETS PROTEINOSIS in other diffuse chronic diseases such as alveolar proteinosis
29 alveolar-interstitial syndrome: example 5 LUNG ROCKETS LUNG CONTUSION in contusions, especially associated with peripheral consolidations
30 alveolar-interstitial syndrome: example 5 LUNG ROCKETS LUNG CONTUSION in contusions, especially associated with peripheral consolidations
31 alveolar-interstitial syndrome: example 6 LUNG ROCKETS PNEUMONIA and in pneumonia with the characteristics of interstitial diseases
32 alveolar-interstitial syndrome: example 6 LUNG ROCKETS PNEUMONIA and in pneumonia with the characteristics of interstitial diseases
33 Alveolar-interstitial syndrome LUNG ROCKETS DIFFUSE, BILATERAL Cardiogenic Pulmonary Edema ARDS / ALI Interstitial Fibrosis Alveolar Proteinosis LOCALIZED Pneumonia Lung Contusion Non-ventilated area They are a sonographic finding common to many pathologies, where the common issue is a partial loss of aeration, and the differences are based mainly on distribution
34 Alveolar-interstitial syndrome THICKENED INTERLOBULAR SEPTA THICKENED INTERLOBULAR SEPTA Acute Pulmonary Edema Diffused Interstitial Fibrosis 7 mm spaced comet-tails In terms of physical explanation (which is important to understand their clinical meaning) they were at first associated with thickened interlobular septa.
35 Alveolar-interstitial syndrome Recent bench studies reproduced demonstrated that the so called B-Lines or Ultrasound Lung Comets can be produced by artificial double layers of bubbles, creating a sort of wet foam: discrete 3-dimensional aerated structures at the critical point for reverberation, where fluid-rich bubble interfaces act as specular reflectors.
36 Alveolar-interstitial syndrome Recent bench studies reproduced demonstrated that the so called B-Lines or Ultrasound Lung Comets can be produced by artificial double layers of bubbles, creating a sort of wet foam: discrete 3-dimensional aerated structures at the critical point for reverberation, where fluid-rich bubble interfaces act as specular reflectors.
37 Transducer Transducer Multiple US Beam Reflections INHOMOGENEOUS TISSUE-AIR INTERFACE Multiple US Beam Reflections FLUID FILLED ALVEOLAR SPACES THICKENED INTERLOBULAR SEPTA INHOMOGENEOUS TISSUE-AIR INTERFACE REVERBERATIONS REVERBERATIONS B lines / ULCs B lines / ULCs Roughly what is depicted in this diagram on the left..
38 Alveolar-interstitial syndrome Septal Syndrome A-I Syndrome White Lung EXTRA- VASCULAR LUNG WATER Soldati G, Copetti R. J ULTRASOUND MED Via G. INT CARE MED 2010 As we were saying this lecture is meant to give you the tools to use ultrasound to diagnose pulmonary edema. An important concept, once the bilateral symmetrical presentation has been confirmed, is that the level of crowding of these artifacts (here you see the most recent nomenclature) is correlated in pulmonary edema to the amount of extra vascular fluid accumulation
39 Alveolar-interstitial syndrome Septal Syndrome A-I Syndrome White Lung EXTRA- VASCULAR LUNG WATER Soldati G, Copetti R. J ULTRASOUND MED Via G. INT CARE MED 2010 As we were saying this lecture is meant to give you the tools to use ultrasound to diagnose pulmonary edema. An important concept, once the bilateral symmetrical presentation has been confirmed, is that the level of crowding of these artifacts (here you see the most recent nomenclature) is correlated in pulmonary edema to the amount of extra vascular fluid accumulation
40 Ultrasound vs. EVLW & pulmonary capillary wedge pressure Agricola E, et al. CHEST 2005;127: This has been measured with PiCCO and correlated with the number of B-Lines per scan sector. In cardiogenic APE there also is a correlation with PAOP (even if weaker)
41 Ultrasound vs. EVLW & pulmonary capillary wedge pressure Comet- Tail Score in Pulmonary Edema: correladon with Wedge Pressure (r = 0.48, p < ) and PiCCO EVLW (90% sensidvity, 86% specificity for EVLW > 500 ml) Agricola E, et al. CHEST 2005;127: This has been measured with PiCCO and correlated with the number of B-Lines per scan sector. In cardiogenic APE there also is a correlation with PAOP (even if weaker)
42 Ultrasound vs. BNP The presence of 4 ULCs was found to maximize overall diagnosdc accuracy with a sensidvity of 81% and a specificity of 85%. 9 ULCs had a sensidvity of 73% and a specificity of 100%. The negadve predicdve value was higher for NT- probnp (100% vs 45%). The posidve predicdve value was slightly higher for ULCs (97% vs 92%). Gargani L, et al. Eur J Heart Failure 2008 ;10: With Natriuretic peptides. Even if with a smaller negative predictive value, but with a higher positive predictive value than BNP. Both tests showed excellent AUC, which was slightly better for NT-proBNP
43 Pulmonary edema vs. COPD exacerbation Lichtenstein D, et al. Int Care Med 1998;24:
44 Pulmonary edema vs. COPD exacerbation Lichtenstein D, et al. Int Care Med 1998;24:
45 Pulmonary edema vs. COPD exacerbation Lichtenstein D, et al. Int Care Med 1998;24:
46 Pulmonary edema vs. COPD exacerbation The ultrasound test (A- I Syndrome) was posidve in 100% of padents with pulmonary edema, negadve in 92% of padents with COPD, and negadve in 98.75% of the control group. The comet tail ardfact had a sensidvity of 100% and a specificity of 92% in the diagnosis of pulmonary edema when compared with COPD. Lichtenstein D, et al. Int Care Med 1998;24:
47 early detection of pulmonary edema Oleic Acid-Induced ALI in Pigs Gargani L, et al. Crit Care Med 2007;35: And even more interestingly, B lines appear earlier than crackles or chest X-Ray findings. In an experimental model of ALI in pigs, both PaO2/FiO2 ratio decrase andthe number of ultrasound lung comets increase correlate with time elapsed from oleic acid administration, but ULC appear even earlier (considering that the variation in oxygenation reaches statistical significance later) Top, PaO2/FIO2 data. PaO2/FIO2 decreased over time, but only at 90 mins was a statistically significant decrease registered. *p.05 vs. baseline. Bottom, data on ultrasound lung comets (ULCs). The ULC score index (mean number of the 12 scanning sites) increased over time, with statistically significant differences at all time points.
48 early detection of pulmonary edema Oleic Acid-Induced ALI in Pigs Gargani L, et al. Crit Care Med 2007;35: And even more interestingly, B lines appear earlier than crackles or chest X-Ray findings. In an experimental model of ALI in pigs, both PaO2/FiO2 ratio decrase andthe number of ultrasound lung comets increase correlate with time elapsed from oleic acid administration, but ULC appear even earlier (considering that the variation in oxygenation reaches statistical significance later) Top, PaO2/FIO2 data. PaO2/FIO2 decreased over time, but only at 90 mins was a statistically significant decrease registered. *p.05 vs. baseline. Bottom, data on ultrasound lung comets (ULCs). The ULC score index (mean number of the 12 scanning sites) increased over time, with statistically significant differences at all time points.
49 Cardiogenic Edema vs. ALI/ARDS Cardiovascular Ultrasound 2008;6:16 APE both share a common LUS typical pattern of bilateral A-I syndrome, but interesting clues to differentiate them can be observed. These are consistent with the non hydrostatic but rather inflammatory genesis of lesional edema.
50 Cardiogenic Edema vs. ALI/ARDS Cardiovascular Ultrasound 2008;6:16 APE both share a common LUS typical pattern of bilateral A-I syndrome, but interesting clues to differentiate them can be observed. These are consistent with the non hydrostatic but rather inflammatory genesis of lesional edema.
51 Cardiogenic Edema vs. ALI/ARDS CARDIOGENIC EDEMA ARDS / ALI Homogeneous distribution Normal sliding Normal pleural thickness Often pleural effusions Inhomogeneous distribution Reduced sliding Thickened irregular pleura Peripheral consolidations Spared areas
52 Cardiogenic Edema vs. ALI/ARDS CARDIOGENIC EDEMA ARDS / ALI Homogeneous distribution Normal sliding Normal pleural thickness Often pleural effusions Inhomogeneous distribution Reduced sliding Thickened irregular pleura Peripheral consolidations Spared areas
53 28 point exam Pratali et al Crit Care Med 2010
54 18 High Altitude Trekkers * Clinical HAPE Pratali et al Crit Care Med 2010
55 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI History, Phisical Examination LUNG ULTRASOUND ECHO CHEST X- RAY BNP PAC All in all, if we compare the tools we have to make a differential diagnosis between cardiogenic and non-cardiogenic APE, each one has its semiology in favour of one or the other option.
56 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI History, Phisical Examination Homogeneous distribution Normal sliding No spared areas LUNG ULTRASOUND ECHO CHEST X- RAY BNP PAC All in all, if we compare the tools we have to make a differential diagnosis between cardiogenic and non-cardiogenic APE, each one has its semiology in favour of one or the other option.
57 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI Homogeneous distribution Normal sliding No spared areas History, Phisical Examination LUNG ULTRASOUND Patchy distribution Reduced/abolished sliding Spared areas Peripheral Consolidations ECHO CHEST X- RAY BNP PAC All in all, if we compare the tools we have to make a differential diagnosis between cardiogenic and non-cardiogenic APE, each one has its semiology in favour of one or the other option.
58 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI Homogeneous distribution Normal sliding No spared areas Depressed Systolic LV function LV Valvular dysfunction LVOT Obstruction Left atrial hypertension History, Phisical Examination LUNG ULTRASOUND ECHO Patchy distribution Reduced/abolished sliding Spared areas Peripheral Consolidations Gravitational distribution Enlarged heart & vasc pedicle Septal lines, Pleural Effusion Peribronchial cuffing BNP > 1200pg/ml CHEST X- RAY BNP PCWP > 18 mmhg PAC All in all, if we compare the tools we have to make a differential diagnosis between cardiogenic and non-cardiogenic APE, each one has its semiology in favour of one or the other option.
59 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI Homogeneous distribution Normal sliding No spared areas Depressed Systolic LV function LV Valvular dysfunction LVOT Obstruction Left atrial hypertension History, Phisical Examination LUNG ULTRASOUND ECHO Patchy distribution Reduced/abolished sliding Spared areas Peripheral Consolidations No Left sided cardiac disease Non elevated LAP Gravitational distribution Enlarged heart & vasc pedicle Septal lines, Pleural Effusion Peribronchial cuffing CHEST X- RAY Peripheral, patchy distribution Air bronchograms No septal lines BNP > 1200pg/ml BNP BNP < 200pg/ml PCWP > 18 mmhg PAC PCWP < 18 mmhg All in all, if we compare the tools we have to make a differential diagnosis between cardiogenic and non-cardiogenic APE, each one has its semiology in favour of one or the other option.
60 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI History, Phisical Examination LUNG ULTRASOUND ECHO CHEST X- RAY BNP PAC But if history and clinics are important, we all know how inaccurate they are. Among the other tools, the quickest are with no doubt Echo and LUS. And combined they reach very high PPV and NPV
61 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI History, Phisical Examination LUNG ULTRASOUND ECHO CHEST X- RAY BNP PAC But if history and clinics are important, we all know how inaccurate they are. Among the other tools, the quickest are with no doubt Echo and LUS. And combined they reach very high PPV and NPV
62 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI History, Phisical Examination LUNG ULTRASOUND ECHO CHEST X- RAY BNP PAC But if history and clinics are important, we all know how inaccurate they are. Among the other tools, the quickest are with no doubt Echo and LUS. And combined they reach very high PPV and NPV
63 Differential diagnosis in pulmonary edema Likely CARDIOGENIC Likely ARDS / ALI History, Phisical Examination LUNG ULTRASOUND ECHO CHEST X- RAY BNP PAC But if history and clinics are important, we all know how inaccurate they are. Among the other tools, the quickest are with no doubt Echo and LUS. And combined they reach very high PPV and NPV
64 take home message
65 take home message Easy and accurate detection of APE (Diffuse bilateral AIS): High sensitivity & specificity: 100% and 92% vs COPD; 90% overall accuracy vs other causes of dyspnea
66 take home message Easy and accurate detection of APE (Diffuse bilateral AIS): High sensitivity & specificity: 100% and 92% vs COPD; 90% overall accuracy vs other causes of dyspnea Cardiogenic vs. ALI/ARDS: clues to differential DGN esp.: GREY AREA of BNP, COEXISTENCE OF COPD (early APE, wheezing) CHRONICALLY ELEVATED WEDGE
67 take home message Easy and accurate detection of APE (Diffuse bilateral AIS): High sensitivity & specificity: 100% and 92% vs COPD; 90% overall accuracy vs other causes of dyspnea Cardiogenic vs. ALI/ARDS: clues to differential DGN esp.: GREY AREA of BNP, COEXISTENCE OF COPD (early APE, wheezing) CHRONICALLY ELEVATED WEDGE PRESSURE
68 take home message Easy and accurate detection of APE (Diffuse bilateral AIS): High sensitivity & specificity: 100% and 92% vs COPD; 90% overall accuracy vs other causes of dyspnea Cardiogenic vs. ALI/ARDS: clues to differential DGN esp.: GREY AREA of BNP, COEXISTENCE OF COPD (early APE, wheezing) CHRONICALLY ELEVATED WEDGE PRESSURE Correlation with EVLW: Monitoring
69 take home message Easy and accurate detection of APE (Diffuse bilateral AIS): High sensitivity & specificity: 100% and 92% vs COPD; 90% overall accuracy vs other causes of dyspnea Cardiogenic vs. ALI/ARDS: clues to differential DGN esp.: GREY AREA of BNP, COEXISTENCE OF COPD (early APE, wheezing) CHRONICALLY ELEVATED WEDGE PRESSURE Correlation with EVLW: Monitoring Integration with ECHO
70 take home message 2 from Auscultation That s why I strongly suggest you to put your probe no only on the heart but also on the lung.
71 take home message 2 from Auscultation...to Insonation That s why I strongly suggest you to put your probe no only on the heart but also on the lung.
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