Ultrasonography in Emergency – Seeing Beyond the Apparent :AJ Mahendran, Ankit Sharma, Pranav Ish, Nitesh Gupta, Rohit Kumar, Manu Madan, Journal of Advanced Lung Health

POSTGRADUATE FORUM
Year : 2023 | Volume : 3 | Issue : 1 | Page : 36--39

Ultrasonography in Emergency – Seeing Beyond the Apparent

AJ Mahendran, Ankit Sharma, Pranav Ish, Nitesh Gupta, Rohit Kumar, Manu Madan
Department of Pulmonary Medicine, Critical Care and Sleep Medicine, Safdarjung Hospital, New Delhi, India

Correspondence Address:
Dr. Nitesh Gupta
Department of Pulmonary Medicine, Critical Care and Sleep Medicine, Safdarjung Hospital, New Delhi - 110 049
India

Abstract

Bedside ultrasonography holds an indispensable position in emergency medicine today in most of the Western countries. However, its use is still undermined in most of the developing countries. We present a case of a 55-year-old bronchial asthma patient presenting with suspected acute exacerbation; however, was diagnosed with pericardial effusion with tamponade by point-of-care ultrasound. Eventually, she was diagnosed to have a malignant pericardial effusion and treated appropriately. To conclude, the use of point-of-care ultrasound played a key role in timely diagnosis and treatment.

How to cite this article:
Mahendran A J, Sharma A, Ish P, Gupta N, Kumar R, Madan M. Ultrasonography in Emergency – Seeing Beyond the Apparent.J Adv Lung Health 2023;3:36-39

How to cite this URL:
Mahendran A J, Sharma A, Ish P, Gupta N, Kumar R, Madan M. Ultrasonography in Emergency – Seeing Beyond the Apparent. J Adv Lung Health [serial online] 2023 [cited 2023 May 28 ];3:36-39
Available from: https://www.jalh.org//text.asp?2023/3/1/36/365496

Full Text

Introduction

In the fast-developing medical society, technological improvement in emergency medicine is one of the major contributors. The advent of portable USG made the evaluation of the patient at the bedside better.[1] In the last two decades, there was a significant technological improvement that point-of-care ultrasonography (POCUS) has become an integral part of intensive care and emergency medicine in most of the western countries. However, the widespread use of the same in many of the developing countries, including India, is limited. Although the significance of clinical evaluation cannot be undermined, there are always a few pitfalls with the same due to its subjective nature. This can be circumvented using rapid and reliable objective methods of evaluation like point-of-care ultrasonography with specially designed protocols.

Acute asthma is one of the most common diseases with which patients show up in medical emergencies. However, there are a myriad of conditions mimicking the same, causing misdiagnosis and mistreatment, especially in emergencies, where the time to comprehend the situation and act is compromised.

We present a case where a known asthmatic presented with features suggestive of acute asthmatic attack. Nevertheless, the condition turned out to be different altogether, well camouflaged under the history of bronchial asthma (BA). Thanks to the technological advancement of POCUS, an accurate diagnosis was made in time, saving the life of the patient.

Case Report

The current case describes a 55-year-old female, previously diagnosed with BA for 25 years, well-controlled on inhaled corticosteroid (ICS) and a long-acting beta-agonist LABA + ICS inhalers. She presented to the emergency with a history of increased shortness of breath for 2 weeks, gradual onset, progressive, no diurnal variation, poor response to an inhaler. Additional symptoms included cough with mucoid expectoration, slight in amount. However, no hemoptysis was reported.

On examination, she was tachypneic with the use of accessory muscles of respiration. The vitals at admission were respiratory rate (28 breaths/min), pulse (118/min), blood pressure (107/84 mmHg), and saturation of oxygen (spo2): 92% on room air. On auscultation, there was wheezing throughout bilateral lung fields, with normal heart sounds.

With background history and examination findings, a diagnosis of acute asthma exacerbation was made, and the patient was initially managed with inhaled bronchodilators and corticosteroids, with very little response.

A bedside ultrasound revealed a bilateral B line pattern (B3) on lung ultrasound and a large pericardial effusion with diastolic right ventricular collapse suggestive of cardiac tamponade was noted [Figure 1]. With immediate pigtail insertion to drain the pericardial collection, the patient was soon relieved of her respiratory distress, and her vitals improved. The pericardial tap was hemorrhagic with evaluation revealing exudative lymphocytic effusion with low adenosine deaminase and suspicious cells with prominent nuclei suggestive of malignant etiology.{Figure 1}

Subsequently, a chest roentgenogram was performed, suggestive of a right lung upper lobe mass lesion with mediastinal lymphadenopathy. Positron-emission tomography–computed tomography (CT) scan revealed a metabolically active mass lesion in the posterior segment of the right upper lobe with metabolically active mediastinal lymph nodes with an SUV max of 5.69 [Figure 2]. A CT-guided lung biopsy of the mass lesion on histopathological examination suggestive of primary lung adenocarcinoma [Figure 3]a. Molecular testing reports were positive for anaplastic lymphoma kinase fusion oncogenes and ROS (c-ros proto-oncogene 1) 1 [Figure 3]b and [Figure 3]c. The patient was initiated on crizotinib 250 mg twice daily and was discharged in stable condition. She was reviewed after a month to note that she was tolerating the drug. Follow-up 2D echocardiogram showed minimal pericardial effusion [Figure 4]. The timeline of events is summarized in [Table 1].{Figure 2}{Figure 3}{Figure 4}{Table 1}

Discussion

BA affects 1%–18% of the population in different countries of the world.[2] Patients with BA experience diminished quality of life due to repeated hospitalizations and emergency visits. BA is characterized by recurrent attacks of breathlessness and wheezing, which vary overtime and intensity, but both breathlessness and wheezing are suggestive of asthma and lack specificity. Many conditions may mimic asthma in a clinical presentation such as anaphylaxis, central airway obstruction, chronic obstructive pulmonary disease, congestive cardiac failure, foreign-body aspiration, gastroesophageal reflux disease, pulmonary embolism, vocal cord dysfunction, and drug reaction.[3] Medical caregivers and professionals must remain alert to avoid misdiagnosis and, therefore, mistreatment of asthma mimics.

In our case, although not suggested by clinical clues, pericardial effusion turned out to be the cause of bronchospasm. In pericardial effusion, there is compression of all four cardiac chambers, venous return to the heart diminishes, decreased left ventricle filling, and decreased ejection fraction. Pulmonary edema from left ventricular failure leads to bronchiolar compression and increased airway resistance resulting in subsequent wheezing.

We highlight the use of POCUS in our patients which led to prompt diagnosis and management. Patients presenting with respiratory symptoms are usually evaluated with a detailed history and clinical examination along with a chest X-ray and/or a CT scan. Although the importance of history and clinical examination cannot be undermined, they cannot always confirm a specific diagnosis. Furthermore, chest X-ray through cost-effective, is a challenge to perform in a patient with severe respiratory distress, and interpretation of a supine/portable film can be challenging; a CT scan cannot be performed emergently in a patient with respiratory distress.

The Lung and pleural USG utility is increasing in acute respiratory failure patients. The principles of lung ultrasound in the critically ill include a simple technique where the lung is the widest organ which is vital (dynamic) and filled with air and sometimes water; thus, the description should be from that place where these two elements coexist. The lung movement and pattern help in making an early diagnosis of the underlying cause of respiratory distress. The glittering movement of the pleural lines is referred to as lung sliding which is synchronous with the respiratory cycle and best seen at lung bases. While the presence of lung sliding practically rules out pneumothorax, the absence of sliding can be seen in pneumothorax, main stem intubation, apnea, intraluminal occlusion, or even in acute respiratory distress syndrome. However, loss of lung sliding following a procedure is strong evidence for a pneumothorax (PTX), provided lung sliding was documented before the procedure. Similarly, loss of sliding with a lung point (where sliding and loss of sliding can be seen in the same frame) is diagnostic of PTX. USG M-mode or "motion" mode is one which can document tissue movement in a still image. B-mode (brightness mode) on the other hand, is when a linear array of transducers generates a two-dimensional image on the screen. Now, it is commonly referred to as 2D mode. In a PTX seen with the M-mode of USG, the typical sea-shore pattern of the pleura and the lung becomes a barcode-like picture.[4]

Below the pleura, the lung is classified into A, B, or C patterns. Normal lung window shows the subcutaneous tissue followed by the pleural line which is followed by parallel short horizontal lines which are the reverberation artifacts of the pleural line only (referred as A pattern). B pattern is formed when B lines are seen. B lines are lung USG artifacts are defined by seven characteristics – a comet-tail artifact, arising from the pleural line, well-defined-laser-ray-like, hyperechoic, long (does not fade/vanish), erases A pattern, and moves with lung sliding. C pattern is defined by punctate echogenic foci seen collaborating with the tree-in-bud appearance in CT. While A pattern is seen in the normal healthy lung, B pattern is often seen in pulmonary edema, and C pattern denotes consolidation. A change in the A to C pattern in a ventilated patient can help in the early diagnosis of ventilator-associated pneumonia and appropriate antibiotic therapy.[4],[5]

Bedside echocardiography using a cardiac probe or even the USG probe in intensive care unit can help in assessing the cardiac status and the cardiopulmonary interactions of various diseases. The subcostal is the easiest probe position which is ideal for rapid evaluation for tamponade. The apical (2 and 4 chambers) view and the parasternal (long and short) axis view are the other positions to see pericardial effusion, cardiac chambers, valves, and left ventricular outflow tract.[6]

Conclusions

Point-of-care ultrasound has become a widely available diagnostic tool, can be easily performed and used for early bedside evaluation in emergency or critically ill patients, and is cost-effective.[7] Proper analysis of patients with breathlessness using validated protocol such as bedside lung ultrasound in the emergency protocol allows confirmation of clinical diagnosis and throws light on hidden and unexpected diagnoses, making management more manageable and lifesaving.[4] Therefore, POCUS should be considered an extension of bedside physical examination to aid in early diagnosis and management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1	Leidi A, Rouyer F, Marti C, Reny JL, Grosgurin O. Point of care ultrasonography from the emergency department to the internal medicine ward: Current trends and perspectives. Intern Emerg Med 2020;15:395-408.
2	GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396:1204-22.
3	Kann K, Long B, Koyfman A. Clinical mimics: An emergency medicine-focused review of asthma mimics. J Emerg Med 2017;53:195-201.
4	Lichtenstein DA. BLUE-protocol and FALLS-protocol: Two applications of lung ultrasound in the critically ill. Chest 2015;147:1659-70.
5	Lichtenstein D. Novel approaches to ultrasonography of the lung and pleural space: Where are we now? Breathe (Sheff) 2017;13:100-11.
6	Johri AM, Durbin J, Newbigging J, Tanzola R, Chow R, De S, et al. Cardiac point-of-care ultrasound: State-of-the-art in medical school education. J Am Soc Echocardiogr 2018;31:749-60.
7	Zieleskiewicz L, Lopez A, Hraiech S, Baumstarck K, Pastene B, Di Bisceglie M, et al. Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: An observational, prospective, controlled study. Crit Care 2021;25:34.