present, note the presence of straight horizontal lines indicating an absence of lung sliding."/>
Figure 4.6 M‐mode chest with the ‘barcode’ or ‘stratosphere’ sign. The thicker first horizontal line is the pleural line. Above the pleural line are (normal) horizontal lines due to the chest wall. Below the pleural line, where the lung should be present, note the (abnormal) presence of straight horizontal lines indicating an absence of lung sliding. Absent lung sliding may indicate a pneumothorax or intact lung with pleurodesis.
Figure 4.7 Pleural effusion. Anechoic fluid (F) surrounding lung (Lu). Note the diaphragm and liver (Li) below. In a real time video, the lung will move dynamically within the anechoic fluid. This is called ‘lung flapping.’
Figure 4.8 Pulmonary edema. Note the vertical lines (B‐lines) descending from the pleural line (arrow) and continuing to the end of the screen.
Figure 4.9 Consolidation. Ultrasound of the right lung demonstrating numerous air bronchograms (arrows) that appear as echogenic areas – circular (transverse) or longitudinal.
Figure 4.10 The potential space between the liver and right kidney is called Morison’s pouch. In this image, the anechoic space between the liver and kidney (arrow) indicates the presence of free intra‐abdominal fluid.
Figure 4.11 Bladder view (transverse orientation) with a Foley (balloon filled with water (anechoic), arrow). In the presence of a Foley, the bladder should be empty. If the bladder is not empty, look for an obstruction in the Foley catheter which may need to be flushed or replaced.
Figure 4.12 Assess for leg vein thrombosis. See text for scanning sequence. (A) Without compression. The vein appears anechoic without echogenic material within. (B) With compression via the US probe the femoral vein (FV) collapses. This indicates the absence of a thrombus in the FV at this level.
Additional material for this chapter can be found online at:
www.wiley.com/go/mayer/mountsinai/criticalcare
This includes multiple choice questions and Videos 4.1 and 4 2 .
CHAPTER 5 Bronchoscopy
Moses Bachan and Zinobia Khan
James J. Peters VA Medical Center, New York, NY, USA
OVERALL BOTTOM LINE
In patients with respiratory insufficiency/emergent evaluation with bronchoscopy can prevent morbidity and mortality.
Bronchoscopy provides a means to evaluate the airways; it can be both diagnostic and therapeutic.It is essential that all intensivists have an understanding of bronchoscopy and be able to perform this life‐saving procedure in critical situations.Some life‐threating situations where bronchoscopy can be used are:Difficult intubations.Complete lung atelectasis secondary to mucus impaction.Lavage for aspiration of blood and stomach contents.Removal of foreign objects.Hemoptysis.
Introduction
Bronchoscopy is a procedure utilized to visualize the airways. There are three types:
Flexible bronchoscopy (or white light bronchoscopy) uses a small (5–6 mm diameter) flexible instrument that can access the distal airways. This requires conscious sedation.
Rigid bronchoscopy is usually done in the OR, using a rigid instrument larger than the flexible scope. It requires general anesthesia and can only access the proximal airways.
Virtual bronchoscopy uses images to reconstruct a 3D picture of the airways. This is a non‐invasive procedure.
In this chapter we will be discussing flexible bronchoscopy which is used by the intensivist in the ICU on critically ill patients.
The bronchoscope
The handle on the top of the bronchoscope is for up and down movement of the bronchoscope tip; the tip moves up and down in one plane. The right thumb is used to flex and re‐flex the handle. The upward movement of the handle moves the tip down and vice versa.
The protruding gray color knob on top is for suctioning of fluid. The right index finger is used on the suction port. Other movement is achieved by movements at the wrist.
The protruding gray color knob second from the top is for instillation of fluid and accessories (working channel).
Indications
Atelectasis.
Large volume aspirate for lavage.
Non‐resolving pneumonia,
