Cardiopulmonary Essentials

Lung Ultrasound

Knowledge

Consider a top down approach when you are evaluating the lungs.

1. Identify visceral-parietal pleural between two ribs. Is there lung sliding?
2. What is the underlying pattern? A-line, B-line, consolidative?
3. What is the distribution of that pattern? Focal/diffuse/patchy?
4. Are there pleural effusions?

Acquisition

Dr. Stone shows how to acquire an image. I personally advocate for a three step process.

1. Slide from toes to feet to center the pleural line in between two ribs.
2. Rock the probe to ensure pleural line is completely horizontal.
3. Fan the probe until you see A-lines/your image resolution appears best - you should aim to match outward curvature of the lungs.

Integration

Take a look at our COVID-19 specific page, but if you want just the brief primer, check out CoreUltrasound's 5 minute video.

Hat tip to POCUS GEEK, CoreUltrasound.com, and Butterfly for making these videos.

Cardiac Ultrasound

Being able to obtain at least 2 standard views of the heart and being able to identify at least pericardial effusion, LV dysfunction, and left atrial + right ventricular enlargement are incredibly useful to help the bedside physician formulate a differential and develop a management plan.

Knowledge

• Pericardial effusion overview from the team at MGH.
• Dr. Smith and the team at 5minsono go over LV function
• Dr. Jared Marx (the POCUS Geek) teaches chamber assessment here.

Acquisition

• Dr. Irene Ma provides instruction to obtaining the PLAX, PSAX, apical 4 chamber, and subcostal standard views of the heart.

Integration

Dr. Mike Wagner gives an overview of the Cardiopulmonary Limited Ultrasound Exam (CLUE) pioneered by Dr. Bruce Kimura.

Advanced Cardiac Applications

• RV Function can be a challenging assessment, but for advanced users POCUS can provide a good initial assessment. Dr. Brian Buchanan gives a nice overview here.

Volume Asessment

JVP Knowledge

A short 10-slide presentation with the fundamentals of evaluating an US-JVP.

JVP Acquisition

Find a 2 min tutorial on acquiring a IJV view for JVP assessment here.

JVP Integration

JVP can be measured by finding the taper point of the IJV, most easily done in short-axis. This correlates nearly perfectly to physical examination JVP. From their, you can use this height as you would your normal JVP evaluation.

IVC Knowlege and Acquisition

Dr. Irene Ma covers the nuts and bolts of IVC ultrasound and volume assessment here.

Few pearls:

1. Try to imaging the IVC going into the right atrium - start with your transducer aligned here.
2. Always identify the RA and the hepatic vein. These structures should be in CLEAR communication with the IVC
3. Always identify aorta (fan probe to the patient's left).

IVC Integration

See charts below. Our thoughts:

1. I usually find IVC is useful at its extremes and to think about in the context of volume tolerance not volume responsiveness.
2. Beware of its use in intubated patients. Intubating patients increases intrathoracic pressure, decreases venous return, and in turn causes distension of the IVC. Therefore it rarely correlates to central venous pressure.