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Transthoracic ultrasound in the assessment of pleural and pulmonary diseases: use and limitations

  • Chest Radiology
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Abstract

Interest in transthoracic ultrasound (US) procedures increased after the availability of portable US equipment suitable for use at the patient’s bedside. It is possible to detect space-occupying lesions of the pleura, pleural effusion, focal or diffuse pleural thickening and subpleural lesions of the lung, even in emergency settings. Transthoracic US is useful as a guidance system for thoracentesis and peripheral lesion biopsy, where it minimises the occurrence of pneumothorax and haemorrhage. Transthoracic US imaging is strongly influenced by physical interaction of the ultrasonic beam at the tissue/air interface, which gives rise to reverberations classified as simple (A-line), “comet tail” and “ring down”(B-line) artifacts. Although these artifacts can be suggestive of a disease condition, they are essentially imaging errors present even in normal subjects and in empty-pleura post-pneumonectomy patients. In order to clarify some confusion and to report on the state of the art, we present a review of the literature on transthoracic US in diseases of the pleura and peripheral lung regions and our own clinical experience over 3 decades. The review focuses on quality assurance procedures and their value in diagnostic imaging and patient monitoring and warns against possible inappropriate indications and misleading information. Thoracic US is much more than “fishing for the moon in the well”.

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Conflict of interest

Marco Sperandeo, Antonio Rotondo, Giuseppe Guglielmi, Daniela Catalano, Beatrice Feragalli, and Guglielmo M. Trovato declare no conflict of interest.

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Authors and Affiliations

  1. IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, University of Foggia, Foggia, Italy

    Marco Sperandeo & Giuseppe Guglielmi

  2. Department of Radiology, University of Naples 2, Naples, Italy

    Antonio Rotondo

  3. Department of Internal Medicine, University of Catania, Catania, Italy

    Daniela Catalano & Guglielmo M. Trovato

  4. Department of Clinical Sciences and Bioimaging, Institute of Radiology, SS Annunziata Hospital, Chieti, Italy

    Beatrice Feragalli

Authors
  1. Marco Sperandeo
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  2. Antonio Rotondo
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  3. Giuseppe Guglielmi
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  4. Daniela Catalano
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  5. Beatrice Feragalli
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  6. Guglielmo M. Trovato
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Corresponding author

Correspondence to Guglielmo M. Trovato.

Appendix 1

Appendix 1

Key points of transthoracic ultrasound (TUS)

Context

  • Wider dissemination of competence in noninvasive diagnostic procedures for outpatient clinic, elective, emergency and intensive medicine

  • Benefits of imaging assistance for safer invasive procedures.

Contribution

  • US is primarily and almost exclusively an imaging technology: the quality requisites are the greatest possible correspondence and, hopefully, a good overlap with the real anatomy, reproducibility of methods and reliable predictivity.

  • In echocardiography, vascular US (both involving Doppler techniques), elastography and CEUS imaging is linked with physical measurements which, by association and relationship, rely on actual morphology and function.

  • TUS is a significant part of US knowledge skills and expertise and requires adequate comprehensive training and professional qualified certification.

  • The invasive US-guided procedures are diagnostic FNAB, useful also for lung and mediastinal nodes, therapeutic procedures, such as US-assisted puncture of liquid cavities (pleural, pericardial, cystic, others) or intervention therapy, such as ablations, scarcely used for lungs.

  • Reliable and affordable noninvasive procedures, such as TUS, must be appropriately used concurrently.

Caution

  • Noninvasive TUS has a good safety level.

  • TUS does not allow for time-wasting procedures or uncomfortable patient positioning: both can be even harmful and distress the patients.

  • Invasive US-guided procedures are safer when provided by expert and appropriately trained specialists with adequate equipment within well-articulated facilities.

Implications

  • Studies claiming advantages from any TUS procedure are meaningless and should not be considered within any evidence-based medicine report if the methodology is unreliable and there is no robust analysis of predictivity.

  • The cost-benefit ratio depends mostly on the actual expertise of the operators.

  • Clinical expertise in the specific field of medicine and knowledge and skills acquired by adequate preliminary and ongoing training are the conditions for achieving satisfactory information and beneficial outcomes.

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Sperandeo, M., Rotondo, A., Guglielmi, G. et al. Transthoracic ultrasound in the assessment of pleural and pulmonary diseases: use and limitations. Radiol med 119, 729–740 (2014). https://doi.org/10.1007/s11547-014-0385-0

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  • DOI: https://doi.org/10.1007/s11547-014-0385-0

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