Transcript
- Welcome to the Sonos site behind the scan webinar entitled
Behind the Stethoscope POCUS Guided TRA Triage
and Management in Pediatric Respiratory Failure.
Today our guest speaker is Dr. Michael Litner Rivera from
Indiana University Riley Hospital for Children.
My name is Chris Pennell
and I'll be hosting today's webinar.
Before we begin, let me just go over some important
information about this webinar.
The information in this webinar is
provided for general educational purposes as a supplement
to professional experience education and training
and should not be considered the exclusive source
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to exercise independent clinical judgment in each
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and a session at the end of the presentation.
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presentation is going
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This webinar will be recorded
and archived for future reference on our webinars page
and on the Sono Site Institute.
To get started, let me introduce Dr. Michael.
Dr. Michael Litner Rivera is com has completed his combined
internal medicine pediatrics residency at the University
of Illinois College of Medicine in Peoria.
He then pursued a pediatric critical care medicine
fellowship at Phoenix Children's Hospital
with a strong commitment to global health
and innovative practice.
He completed an additional year of training
with a critical CL care ultrasound fellowship at Western
University in London, Ontario, combined
with a pediatric critical care global health
fellowship in Malawi.
During his time in Malawi,
he conducted influential ultrasound based research on acute
kidney injury in pediatric cerebral malaria,
currently practicing at IU and Riley Children's Hospital.
Dr. Michael continues his involvement in global health
research collaborating on pediatric severe malaria
projects in Uganda.
His primary clinical
and research interests are centered on the intersection
of global health and the utilization of POCUS
and the management of critically ill children,
particularly in lower resource settings.
And with that I'll turn it over
to Dr. Michael to get started.
- Hello, my name is Michael Litner Rivera
and I am a pediatric intensivist at Indiana University
Riley Hospital for children in Indianapolis.
I want to spend some time talking about a tool
that we under utilize in pediatrics
and certainly one of my favorite POCUS applications
and that is lung ultrasound.
This talk is for novice ultrasound users
but would certainly be a good review for I think any of us
that even have some experience.
I know that in pediatrics we are just starting
to adapt this tool,
so we will be discussing the why
of using lung ultrasound
or perhaps some of the benefits
of lung ultrasonography in pediatrics as well as how
to perform lung ultrasound
and describe what the images are representing
or how to interpret those images.
Moving on to why of lung ultrasound.
First, I think lung ultrasound is an extension
of our physical exam.
We are trying to visualize the pathology
that is affecting our patients.
Secondly is very doable.
Lung ultrasound can be intimidating at first,
especially since it's not anatomically accurate
and you'll see what I mean by that.
But basically we will be using artifacts created
by the machine to interpret the images.
Most of the time we won't be seeing an actual lung per se,
and if we do, this is likely pathologic.
Next, it is cost efficient
and timely, especially in the picu.
There are many times where we need answers expedited
and we don't have time to wait for an order to be placed
or for the x-ray tech to come to do the exam.
Additionally, it is repeatable.
I can repeat the study as often and as frequent as I want
or as time allows
and certainly helpful when we are trying
to determine if our interventions have led
to change in our patients.
It is also non-ionizing,
which I know chest x-rays have very little radiation
but over time it can add up.
And finally, this is a clinician's tool.
The gentleman pictured here is Dr. Daniel Lichtenstein.
He's a French intensivist who is responsible for deciphering
what the lung artifacts mean
and is truly the father of lung ultrasound
and critical care ultrasound for that matter.
According to him, he would steal
or perhaps maybe borrow is a better word at the ultrasound
machines from the radiology department
and scan his patients at night until he was finally able
to crack the code of lung ultrasonography.
He has written extensively on lung ultrasound
and I would highly recommend
picking up either his book
or reading some of the manuscripts that he has published.
So we'll move on to a brief literature review on lung
ultrasound with a mixture of both adult
and pediatric literature.
And I just want to highlight the date on these articles.
I can't believe it is that 1995 was actually 30 years ago,
but that is how long the use
of lung ultrasound has been around.
As you can see, we are decades behind our adult colleagues
and these are some sentinel publications by Dr.
Lichtenstein showing the utility of lung ultrasound
to evaluate diseases such as pneumothorax,
pneumonia and pleural effusions
and I would highly recommend them in pediatrics.
Here is a meta-analysis from 2015
demonstrating the accuracy of lung ultrasound
for diagnosing pneumonia in children.
This meta-analysis included five studies in all
and found lung ultrasound had an overall sensitivity of
and specificity for diagnosing pneumonia of 96
and 93% respectively.
As we can see here,
and this is another study in neonates and
although the study had a small number of patients,
lung ultrasound had a very high sensitivity
and specificity for diagnosing pneumonia in neonates.
And for those that are in the outpatient world,
there's some literature using lung ultrasound
in in outpatients with a pretty high sensitivity
and specificity for diagnosing pneumonia as well.
This is a more recent meta-analysis from 2024,
which showed lung ultrasound to have a better sensitivity
and specificity than chest x-ray for diagnosing pneumonia
and children.
And finally I wanted to highlight this article
that was published in 2022
about the utility of pediatric pocus in the management
of critically ill children.
Now it's a single center study
and they had 155 patients over 15 months
and during that time the team found
that their focus studies changed management in 40, 42%
of the time that they scanned.
And in particular,
lung ultrasound changed management in over 50%
of cases and this webinar is going to be
on the Cyte Institute website.
So you can review, go back
and find these studies, you'll have time
to look them up and review them on your own.
So now moving on to the the how.
How will I do
or perform the actual lung ultrasound to begin
what pro rule we use?
And this is a common question that that is asked frequently
and the short answer is whatever you have available,
if you have options, my preference is
to use a phased array probe.
I believe it is probably just more versatile than some
of the other probes, especially in critically ill patients
where sometimes you want to move between scanning the heart
and lungs in an expedited fashion
and don't want to switch probes,
which can be a bit time consuming.
And this is the probe that I learned in
during my ultrasound fellowship.
So this is my preference.
I also use the phased array in
the abdominal setting.
There are different software features
and filters in the lung preset compared
to the abdominal preset
and in my opinion,
the abdominal preset just allows better vis visualization
when we're looking at some of the the deeper pathology
that we will see soon.
But overall, the the differences
between these probes is going to be the type
that the they use different frequencies
and higher
or lower frequency may not mean much for a clinician.
Just know that higher frequencies such as the linear probe
don't penetrate as deep but high have higher or
or better resolution for some more superficial structures.
So for using the linear probe, one of the pros is
that has a better resolution.
The cons is that'll miss deeper pathologies such
as consolidations
and for the linear probe I would use a setting exam
and sorry, sorry, the the, I would use the lung setting
and I would use this if I had a smaller patient
such as neonates or when I really wanted
to highlight a more superficial structure such
as the the pleura.
You can also use a a curvilinear probe
and for those of us that do global health or
or work in resource limited areas, you'll find
that many times this may be the only probe available
but yet you can gain or,
or sorry, you can obtain very good images with a,
with a curvilinear probe similar to the phased array,
you can utilize the curvilinear probe for additional studies
and is the probe commonly used for the fast
or the focused assessment with sonography and trauma
or the EFAs, which is you know, looking
for free fluid in the abdominal pleura
or pericardial spaces.
It'll be limited by its large footprint
and may miss some more superficial structures.
Moving on. The lung ultrasound exam can be done in in
varying positions and in the emergency department
or outpatient setting.
Scanning the child in caregiver's arms is certainly an
option in my setting, which is the pediatric ICU.
Our patients are going to be mostly supine
and that is how we will review the, the exam done.
We will focus on, on these regions,
which we're going to be the midclavicular line,
the anterior axillary line, the posterior axillary line and
and an additional mid axillary line.
And we will have the indicator
of our probe always pointed to the patient's head.
And so the scanning will be done in a longitudinal fashion.
We will try to have the probe
as perpendicular to our pleura surface as possible.
And as you can see here, sometimes being perpendicular
to the chest wall does not necessarily mean you are
completely perpendicular to the pleura
and some gentle rocking
or angling of your probe will bring out the
areas of interest.
We will focus on four lung zones, which again is
how I learned lung ultrasound and is my preferred method.
There are multiple lung ultrasound protocols out there in
the literature
and particularly in the
ICU scanning.
Some more posterior lung fields can be challenging when
our patients are supine and critically ill.
Nevertheless scanning these lung zones,
these four lung zones should be sufficed to
to uncover pathology.
If you are able and you want
to include more posterior lung zones in your practice,
that is certainly reasonable and feasible.
Sorry, feasible and without a doubt including more lung
zones will make your scanning a bit more accurate.
We'll focus on these five sonographic features or
or signatures if you will.
There are certainly more than this and I would recommend Dr.
Lichten Lichtenstein's book lung ultrasound
and the critically ill for those
interested in learning more.
But these five features will allow us
to identify the vast majority
of pathology causing respiratory distress in our patients,
starting with the first zone
or R one L one, depending if we're on the right
or left hemithorax, our reference points will be the
midclavicular line at the second
and third intercostal space as a reference.
We can see
where approximately we'll be placing our probe compared
to this cross-sectional CT scan.
We should from this view we should visualize
the plural line, which is this bright
or hyper coic line seen here along
with the acoustic shadows of the ribs
that border our area of interest.
And just for reference,
the patient's head is towards screen left
and the patient's feet will be towards screen
right, so this would be the superior rib
and this would be the inferior rib.
And again we are scanning longitudinally.
We should see plural sliding, which I hope you can see here
as a shimmering or movement of the pleural line.
Additionally, we should see other bright horizontal
lines deeper within our image, which are a lines
and we review those shortly.
This would be considered a normal lung image
but remember that this only represents this particular lung
zone and you can certainly uncover additional pathology
within other regions.
We scan this cartoon rep
is a representation of what we are seeing with our probe.
First we have our subcutaneous tissue which will be
here followed by the pleura,
which again is this hyper coic line.
We will see ribs
or their at least their acoustic shadow.
And remember that in our younger patients their ribs may not
be fully ossified
and hence we may not see their acoustic shadows
or the acoustic shadows may be not be as dark as
as seen here
and not represented in this cartoon.
Are these again, these horizontal lines which are deeper
and these are called the A lines which we will
review shortly.
But first to review the pleural sliding.
Recall that the pleura is composed of
two opposing layers with the visceral pleura adjacent
to the lung
and the parietal pleura lining the chest wall.
We can imagine as the lung inflates
and these surfaces will slide past one another
creating the sliding that we will see on our image.
As you can imagine, if there is air
or fluid within this space
and the pleura are not in contact,
then plural sliding goes away,
which becomes an important feature
to identify pathologies such
as pneumothorax we will, which we will see later.
So next we have the A lines which are simply
reverberation artifacts.
Recall that ultrasound does not penetrate air.
So when the ultrasound beam reach the plural line,
which is a highly reflected surface,
they will bounce back towards the probe
creating an image.
Some of these beams will bounce back off the probe
again and travel back
to the plural line
and again back to the probe.
Since these echoes took twice as long to be captured
by the probe, the ultrasound machine
gets fooled if you will,
and interprets this as there being a structure twice as deep
again, another ultrasound beam can reflect once more
and another reverberation artifact is
created deeper.
So recall that this isn't lung per se.
I think that is a misinterpretation a lot
of times when we are beginning to utilize lung ultrasound.
These again are just reverberation artifacts.
The it represents that there is air
beyond the pleural surface
and basically
that our lung is well aerated especially well if if there's
pleural sliding and you have a lines, it means that our
- Lung is well aerated
and again we see that here
- And alines can actually
have hemodynamic data in.
So an ALINE pattern
or absence of B lines provides hemodynamic information
and an adult study
and ALINE pattern had strong correlation
with a low pulmonary artery occlusion pressure,
meaning in the context of volume resuscitation,
an ALINE pattern provides pretty good evidence
that our patient will likely tolerate additional fluid
resuscitation.
This does not mean that they will respond to fluids,
but at least at the time of this scan,
if you find an ALINE pattern is additional fluid is
unlikely to harm them.
So our second lung zone
will be in the anterior axillary line at approximately the
sixth or seventh intercostal space
or pretty much at the crux of of the axilla.
Our reference points for the image we want
to bring forth will be the same as in zone one.
We will look for the plural line highlighted
between the acoustic shadows, ensuring we are perpendicular
to the pleura in order to bring forth these A lines.
Moving on to the third lung zone,
we will be at the mid axillary line at the level
of the diaphragm
and we'll use the liver
or spleen, spleen
as an additional reference point depending on
what side of the body we are on.
So we should be able
to visualize the diaphragm, which is
cur linear line that's moving kind
of deeper away from our probe coddly
or screen right.
We will have the liver or
or spleen if we're on the li left side
and above the diaphragm we should see well a aerated lung
moving in and out of view
and some have called this the curtain sign
which you can imagine kind
of represents a curtain being pulled
in this area above the diaphragm.
We would normally, if there's pathology,
identify if there is an effusion
or consolidation, we would see it
above the diaphragm in this region.
And this is a still image of the left side.
Please note that again, this is not lung per se,
this is actually mirror artifact
of the spleen appearing though it is
above the diaphragm most
of the time mirror artifacts will be easy to spot
and as we will see we can use the spine
to help us determine if it is mirror artifact
or true pathology.
And again, from this is zone
three from the right,
what a normal lateral lung would look like.
And similarly this is on the left, so this would
- Be your spleen.
Now for the fourth
- Lung zone we will place the probe in the posterior
axillary line again at the level
of the diaphragm.
And you can certainly do this in a supine patient,
you just going to try to be
as posterior as we can
that usually this means holding the probe almost like a
like a, a racket in an overhand fashion
and pushing your knuckles into the bed
to highlight some of these structures.
And this is the area roughly
seen here on this axial image
where we'll be placing the probe
- And this is what we will - Be seeing.
It's a more posterior image
and in supine patients there can be quite a bit
of pathology uncovered here, especially for those
who are critically ill.
It is also known as the plats point
or the posterior lateral alveolar pleural syndrome,
which is a term coined by Dr.
Lichtenstein and his original work but origi,
but just remember that is in the posterior axillary line
at the level of the diaphragm.
So moving on to pathology,
we will discuss pneumothorax, pleural effusions
and consolidations use utilizing the five
lung ultras ultra stenographic features including the three
that we have yet to discuss.
Going back to lung sliding, which
as we mentioned should be present in a normal lung.
Well what about the absence of lung sliding
as discussed previously?
It can in it indicates lung sliding indicates that
the pleura are intact
- And I hope you can see - Here in this image
that lung sliding
that shimmering is no longer present.
Hopefully you could appreciate that.
Importantly note that a lines are still being produced
as the ultrasound beams are being reflected off the parietal
pleura, but the lack of lung sliding can indicate that
the visceral pleura is no longer intact
with the parietal pleura which can indicate pathologies
such as pneumothorax.
However, absence
of lung sliding does not necessarily
indicate pneumothorax.
As you can imagine, if you are apnic
and that lung is not being aerated
or if you have a right main stem intubation
and your left side is not being aerated,
you will not see lung sliding Similarly in pathologies such
as ectasis or pneumonia where part of your lung
is not being aerated,
you may not have lung sliding.
Additionally,
if you've had pleural pathology in the past
and if some of your patients may have chemical pleurodesis
where the pleura have been adhered, then they will no longer
be able to slide past each other.
And this cartoon is representing basically
what a pneumothorax is highlighting
that the pleura will no longer be intact.
And again, I hope you see here these are your ribs shadows
and this is the pleural line
with absent sliding.
Another feature we can use on the ultrasound is the M mode,
which stands for motion.
Once we have our image we can use the M mode feature
and the M mode cursor will detect any motion along its path
and represent it graphically as,
or sorry, represent the plural sliding graphically
as we've seen here,
which creates a distinct M mode image which has been called
the sandy beach sign.
And here we can see why the sandy beach image got its name
with the soft tissues representing the water, the pleura,
the waves, and then the
the beach is those structures that are deep
to the plural line.
If there is absence
- Of plural sliding,
the beach disappears.
- And what we see is these continuous
horizontal lines often referred to as the stratosphere sign
or barcode.
Now personally I rarely use this feature
as you can imagine, most of the time in the ICU if I'm
looking for a pneumothorax, it is
because there is some clinical deterioration
or perhaps even during a code situation
and things can be frantic at that time.
Trying to determine if there is a sandy beach
or stratosphere sign can be quite difficult.
And trying to really determine both, you know,
distinguishing these in a stressful
situation can be difficult.
So in the right clinical context, absence of lung sliding,
I would likely call that a pneumothorax
and move forward with needle needle decompression.
But that is my practice
and certainly based on my clinical setting
and everyone should adapt their findings through their own
clinical settings and patient scenarios.
However, a sonographic feature
that can help rule in a pneumothorax is the lung point.
As you can see here, there is
part of the pleura that appears to be sliding
and while half
of this screen there is absent pleural slide sliding
and this represents an area
where the probe is at the edge
of the pneumothorax if you will.
As you can as hopefully you can pick up here in this
axial CT image, you're just at the edge
of normal lung and the no and the pneumothorax.
Additionally, we can sometimes see what is referred to
as a lung pulse, which are these rhythmic pulsations
of the pleura and are transmitted from cardiac contraction.
These signifies that the visceral parietal pleura are
opposed and again rules out a pneumothorax.
So when evaluating for pneumothorax,
these are four sonographic features that we can employ.
Lung sliding, which the presence rules out pneumothorax.
Lung pulse, again, that presence of lung pulse means
that the pleura are opposed
and again, rules out pneumothorax a lung point which is
presence nearly.
It's a hundred percent specific for the presence
of pneumothorax
and beelines which indicate that the,
which arise from the pleura line
and indicate that the pleura are opposed
and rule out help rule out a pneumothorax
and we will review beelines next.
So what are beelines?
They sono graphically they're seen
as these bright hyper coic vertical lines
originating from the pleura
and extending all the way to the bottom of this screen.
This is an important feature that the fact that they have
to go all the way
to the bottom is there sometimes other signatures
that just don't make it all the way to the bottom.
And this by definition then are not beelines.
So I try to help learners remember
that they are B lines are vertical, if you will,
is just a mnemonic that I use
Anything more than U up to two can be normal.
Three or more will be pathologic again, they extend
to the bottom and they will abolish your A lines.
And how do B lines originate is
always a common question.
They represent fluid in your interlobular septe,
which are these thin walls of connective tissue
that separate or pulmonary lobules.
They run inward from the pleura
and can sometimes be seen on CT
imaging when they are thickened.
So B lines are fluid in the interlobular sep
day and the fluid can be due to hydrostatic forces such
as pulmonary edema or due to inflammatory infectious causes.
Importantly, they can be an early sign of pulmonary edema
and can be seen
before pulmonary edema is seen on chest x-ray.
Importantly, this occurs
before alveolar edema is present
and hence you can find beelines
before patients develop symptoms.
However, once alveolar edema is present,
then they can certainly, once alveolar edema is
present, the beelines will be more confluent.
As you can see, they're not these
single solitary bright lines as we saw before,
and confluent BB lines, especially when they're this thick,
can represent alveolar edema
and patients would certainly be symptomatic when you have
this degree of B lines.
This was a patient that got admitted to our PICU
and she ended up having pulmonary
- Cytosis.
Moving on to the detection of
- Consolidation with ultrasound,
and these can be partial
or subpleural consolidations is seen here.
Here we're not
seeing the regular flora
nor a normal curtain sign
as we would see in this area, in this kind of lateral area
of lung imaging.
Instead we see part of the image
with this hypoechoic structure,
which is a consolidation followed by what would appear
as a normal aerated lung.
And this area of separation has
becau has been called the the shred sign,
which represents the a,
the line separating the consolidation from the
normal or well aerated
- Lung.
A trans
- Lobar consolidation is usually easier
to see here the entire lobe is consolidated
and we can also identify a small rim of pleural effusion.
There can be within the
consolidation you can see these bright
hyper coic spots which are broncho grams
and they can be static as you can see here.
Every once in a while you can find some dynamic broncho
grams which are, which were,
which represent fluid within the
smaller airways and are quite sensitive for pneumonia.
And the last lung signature is the effusion,
which is usually hypoechoic,
but as we can see here,
it is not necessarily anti coic
and in fact some of these brighter
effusions or some sometimes effusions can be seen
to have these kind of hypoechoic coic
bubbles in them, if you will.
And that raises suspicion for a complex effusion.
Additionally, we can see within
the effusion you can certainly pick up septations of,
of an empaa which
seen here in this patient that I got admitted to our unit
who had A-M-R-S-A pneumonia
and went on to require
- Ecmo. Now
- Moving on to limitations, I think one
of the big ones, particularly in pediatrics is going to be
bronchoconstriction.
So patients that are presenting with
respiratory distress due to asthma
are lung ultrasound findings aren't going to detect that.
So as you can imagine in bronchoconstriction
an obstructive process, our lungs are going to be hyperinflated
and what we will see with our ultrasound is going to be
pleural sliding and a lines.
So it would appear as if those lungs are normal,
but hopefully that is disease process that can be detected
with a physical exam.
Another limitation is
that ultrasound is certainly user dependent
and so it takes time
and practice in order to
obtain not only the images that we are hoping for,
but learn how to interpret them as well in the
in the clinical context.
And that is all thanks for your time
and now we will open it up to some questions.
Thanks.
- All right, that is our presentation. Thank you so much Dr.
Vera for this awesome presentation everybody, it is q
and A time, so if you're on the zoom stream you can put your
q and A questions into the q and a box on the bottom
or the side of your screen.
And if you are on the LinkedIn page
or the YouTube page, you can put your questions in there
and we will get to those.
Also, it looks like we already have one in here.
Do you use the lung score for your patients
and if so, how does that score help you guide treatment?
- I don't particularly use the, the lung score.
I know that there are some manuscripts
and publications that utilize lung score.
I think there are, I've seen some with, for A RDS,
I've seen others and neonates
and so I,
I have not adapted it to my practice.
I think there are some, I've seen an interesting
article or I think it was a webinar that used the lung score
for respiratory therapists for them to adapt
kind of maybe airway clearance.
I thought it was interesting,
but I don't necessarily use it.
So I think I just use lung ultrasound
and adapt my therapies based on the pathology, right.
If there is pulmonary edema from
hydrostatic reasons, then you know, diaries,
if we're finding consolidations that we were suspicious for,
we will treat either as as pneumonia
or perhaps it can be atelectasis if there's a fusions
and you know, can decide to drain.
But I don't base it really on a, on a score.
I base it on the ultrasound findings
and, and the clinical context.
- Excellent. All right.
Next question is, what would you suggest for someone trying
to start an ultrasound program for rts?
- What, so I think
having a champion is, is for ultrasound program for, for any
in any context.
I think that having
somebody that will kind of champion your, your cause
and, and be willing to teach
and qa the, the ultrasounds
and the images obtained I think is probably
the most important.
I think that finding
tools, I shouldn't say,
but you know, for example, like that webinar
that I mentioned that I forget where I saw it, I wish I,
I I, I could recall
but I, I believe it was from Australia
that it was respiratory therapists using lung ultrasound
to, to implement different airway clearance.
And so it would be, you know, showing that there's a proof
of concept out there that that RTS can use, can utilize it
and that it's beneficial for rts.
And then like I said, finding a champion within your
division that can help, you know, support the concept.
- Great. Next question is lifeline using ultrasound on
transport for neonates or pediatrics,
- But not that I understand.
So in our transport services here,
I don't believe we have
our critical care transport services
utilizing ultrasound yet.
I think it'd be, it'd be great
and I think it'd be a, a valuable tool particularly
for some of those longer
- Transports, but we're not using those.
- Next is one of the limitations
for detecting pneumothoraces is appreciating size.
How do you clinically use the information you gather from
POCUS on your decision making to place a chest tube?
- Yeah, and I think it's clinical context, right?
I think that right
before, let's say ultrasound was being used to detect
pneumothorax, it was all clinical, right?
You, you, you didn't really want to get an x-ray
of a large pneumothorax
because it means you're,
you are late in in decompressing it.
So in a clinical situation where you have
a DYS patient that requires immediate intervention, I think
finding absence of lung sliding would
likely indicate that you probably need to decompress.
Another way to do that as well would be
to just slide down your, you know, usually your anterior
chest wall and determining how many rib spaces perhaps
that where you're, your lung sliding is absent.
Difficult I think to, to truly quantify
how large a pneumothorax is.
But again, I think in the,
in the appropriate clinical context,
it would probably indicate that it,
that it it you needs to be drained.
Similarly, if you've got a patient who is asymptomatic
and you happen to find absent lung sliding
even in the large area,
I probably wouldn't put a chest tube there
instead I would probably, you know, try to
discover other reasons as, as
to why there may be absent lung sliding.
- Alright, next question is,
have you found POCUS helpful in differentiating atelectasis
versus developing pneumonia,
which is a common CXR interpretation?
- Yes, and I think that, you know, I I
perhaps should have discussed that a bit more in, in the,
in the PowerPoint that most of the time, and,
and again I think clinical context is useful in the ICU
where patients going to be, are going to be supine
for quite some time and,
and, and mechanically ventilated bilateral
consolidations, especially in the absence of fever
and things like that are, are likely going to be atelectasis.
Now that's not necessarily the case,
but you know, again, in, in a clinical context,
if I find a consolidation in a patient who has been supine
with no fevers or other inflammatory markers,
I i I probably would not consider it ammonia.
If it, if there is, you know,
unilateral consolidation,
especially if you're having broncho grams
or especially dynamic air broncho grams,
I would be very suspicious of pneumonia.
And then I was also taught that it, you know,
depending on your consolidation relative to the,
to your effusion, so if you have a,
if your consolidation is small relative
to a larger pleural effusion, then
that is probably more likely compressive atelectasis,
whereas a large dense consolidation with relatively
smaller effusion, then it, it, it is likely that that's
a, a pneumonia.
But, but I think that one of the things that, that I like
to look for are broncho grams,
especially the dynamic broncho grams.
You won't always see those,
but I think those are, are very useful.
And then again, your your clinical context, remember
that POCUS is, is a, is a, is biased, right?
We're, we're clinicians.
We know what the, the, the,
the clinical context of the clinical situation is.
Usually I hope we, we have a, a question that we're trying
to answer with, with pocus.
And so, you know, depending on what we find it,
it certainly will, will inform our, our, our practice.
- Okay. Next question.
Have you found that lung ultrasound has significantly
decreased the use of x-ray
or is it still used as an adjunct in your practice?
- I, I wish it, it, it decreases
x-rays, but not yet.
I, I think that it eventually it will, I think there's pros
and, and, and maybe cons of each imaging.
I I certainly think that
ultrasound is, is a better tool for diagnosing pneumonia.
I think ultrasound is a better tool
to detect pleural effusions
and certainly for pneumothorax as well.
I think one of the advantages of x-rays that it kind
of gives you a, a, you know, a,
a bigger picture, it kind of has everything together
and so it is nice to kind of see, see that,
but I think that
that ultrasound certainly has its advantages
as well at this time.
I don't think lung ultrasound has been adapted
universally by any means or,
or enough at least to, to start diminishing the amount
of x-rays, but hopefully, hopefully in the future.
- All right. How many scans would you say
that you usually need
or usually do for like a good clinical snapshot of a patient
- For, oh, so I use the lung zones,
so usually eight is enough, right?
We're doing four per hemithorax.
And so that usually i, I is enough.
Sometimes I'll take if, if there's enough,
if there's pathology kind of laterally or,
or posteriorly, sometimes I'll, I'll take different clips
just because sometimes when, when you review them on,
on a quality assurance software,
sometimes you will detect things that, that you hadn't seen
while you were scanning.
So, you know, like things like air broncho grams,
sometimes when you look back you'll,
you'll, you'll catch them.
But in general, eight scans, eight clips is,
is usually enough.
And once you start, once you have practice with it, it,
it's really a matter of of of minutes to,
to get them all to, to be able
to get all lung zones
- Wonder.
Right. It looks like we've gotten through all
of the questions here.
If anybody else has any other questions, you can go ahead
and put those in the q and a box.
And in the meantime, what, what were some of the barriers
to adopting lung ultrasound in your
practice, if you had any?
- I think that common barriers identified, especially
by learners are, you know, some of the lack of, perhaps lack
of, of people that have been trained in ultrasound
or at least that are comfortable teaching it.
I think that that having somebody
to review your scans is important.
Somebody to, to kind of show you where to, where
to place the probe is, is,
is just as important.
And so I think that that's a big one is,
is unfortunately in pediatrics, maybe some of the lack
of trained providers or, or, or teachers.
I think some,
you know, perhaps lack of, of, of knowledge of,
of maybe the utility of it or,
or kind of where we've gone, you know, remember 30 years ago
people thought that lung ultrasound was not possible.
You know, that I think that the, the thought was is that
because air
or the, you know, the sonographic waves don't penetrate or,
or better better said they, they scatter in air
that lung ultrasound was, was, was not possible.
That it is, you know, people still don't really know how to,
how to use it or how to interpret it.
And I think the, the lack of
it, it it being not an anatomically accurate
study or, or, you know, diagnostic tool.
And by that I mean that when you're,
when you're scanning a normal lung,
those lines are not a lung.
And so I think it causes confusion,
whereas if you put a probe over the heart,
everybody can tell that that's a heart.
If you put a probe and you see sliding
and some lines that does not look like a lung and it,
and it shouldn't and, you know, thanks to to, you know,
some of the pioneers like Dr.
Lichtenstein, we, we know what those means.
But once you start learning what, what those artifacts mean,
then I then I think it, it becomes very manageable.
But I think in other barrier is that initially it, it,
it seems it's, it's a bit intimidating
because you don't know what you're seeing.
- Great. Well it looks like we don't have any more questions
so Dr. Michael Rivera, thank you so much for,
for being here and sharing your presentation with us.
It was really great.
We had some really excellent questions
too, which is awesome.
It looks like we are done for today,
so we really appreciate all of you viewers coming
and watching our webinar.
Quick reminder, you can watch previous webinars
and sign up for upcoming webinars on sonos site.com/behind
the scan webinar and you can go ahead
and scan that QR code there on the screen
to visit our webinars page.
Thank you so much again to Dr. Michael Litner Rivera
for coming to speak to us today.
And thank you all for joining us
and we'll see you all at the next one.
- Thank you.
Learn how lung ultrasound supports pediatric respiratory triage and management at the bedside in this Behind the Scan webinar from Sonosite. Designed for novice users and valuable as a refresher, this session shows how point-of-care ultrasound (POCUS) extends the physical exam, delivers rapid answers in the PICU, and supports repeatable, non-ionizing reassessment after interventions—often faster than waiting for radiography.
The webinar walks you through a practical, easy-to-apply lung scanning approach using common probe options and a simple four-zone method per side. You learn how to optimize probe position, where to scan in supine or caregiver-held children, and what “normal” looks like—then how key ultrasound artifacts and signs translate into clinical decisions. The presentation clearly explains pleural sliding, A-lines, and B-lines, and connects these findings to common pediatric problems such as pulmonary edema and inflammatory lung disease. You also learn how to recognize consolidation patterns (including shred sign and air bronchograms) and identify pleural effusions, including features that raise concern for complex effusions.
A focused pneumothorax framework helps you integrate bedside findings—such as absent sliding, lung point, and lung pulse—into time-sensitive decision-making. The session also addresses real-world limitations, including why asthma and bronchoconstriction may appear “normal” on lung ultrasound, and why training, image review, and local champions matter for adoption.
If you want a clear, clinically relevant roadmap for bringing lung ultrasound into pediatric care—while supporting speed, confidence, and patient-centered decision-making—this webinar delivers immediately usable skills.
What You'll Learn
- Identify and perform the standard probe positions and techniques required for a comprehensive pediatric Lung Ultrasound exam in patients with acute respiratory failure.
- Differentiate between the characteristic ultrasound findings (e.g., A-lines, B-lines, consolidation, pleural effusion) that represent the major causes of pediatric respiratory failure (e.g., pneumonia, pulmonary edema, pneumothorax, atelectasis).
- Integrate POCUS findings into the clinical decision-making process.
- Recognize the key limitations of POCUS in the pediatric respiratory patient and evaluate its role as a rapid method to obtain chest images at the bedside.
Dr. Michael completed his combined Internal Medicine-Pediatrics residency at the University of Illinois College of Medicine, Peoria. He then pursued a Pediatric Critical Care Medicine fellowship at Phoenix Children’s Hospital. With a strong commitment to global health and innovative practice, he completed an additional year of training: a Critical Care Ultrasound Fellowship (Western University, London, ON) combined with a Pediatric Critical Care Global Health Fellowship (Blantyre, Malawi). During his time in Blantyre, he conducted influential ultrasound-based research on Acute Kidney Injury (AKI) in pediatric cerebral malaria.
Currently practicing at IU and Riley Children’s Hospital, Dr. Michael continues his involvement in global health research, collaborating on pediatric severe malaria projects in Uganda. His primary clinical and research interests are centered on the intersection of global health and the utilization of POCUS in the management of critically ill children, particularly in lower-resource settings.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.