Intensive Care Med DOI 10.1007/s00134-015-4169-3
Silvia Mongodi Be´laı¨d Bouhemad Giorgio Antonio Iotti Francesco Mojoli
IMAGING IN INTENSIVE CARE MEDICINE
An ultrasonographic sign of intrapulmonary shunt
Lung ultrasound is a valuable bedside tool for the differential diagnosis of hypoxemia, a frequent issue in critically ill patients. In particular, a tissue-like pattern visualized above the diaphragm corresponds to complete Ó Springer-Verlag Berlin Heidelberg and ESICM 2015 loss of aeration, defined as lung consolidation (Fig. 1a). A Electronic supplementary material The online version of this consolidated lobe may have a variable impact on oxyarticle (doi:10.1007/s00134-015-4169-3) contains supplementary genation, depending on hypoxic vasoconstriction and material, which is available to authorized users. degree of intrapulmonary shunt. Color Doppler ultrasound S. Mongodi ()) G. A. Iotti F. Mojoli may be used to identify vessels within consolidations: in Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San some patients, intrapulmonary arteries can be visualized Matteo, University of Pavia, Pavia, Italy (Fig. 1b), identified by a pulsing pattern synchronous with e-mail: [email protected] heartbeats. In these patients, the non-aerated lobe appears to be well perfused, which corresponds to the definition of B. Bouhemad Anesthesia and Intensive Care, Centre Hospitalier Universitaire de intrapulmonary shunt. Although no quantification is posDijon, Dijon, France sible, the visualization of a main vessel within a Received: 18 November 2015 Accepted: 24 November 2015
Fig. 1 Longitudinal scan of left costophrenic sinus. a A tissuelike pattern is visualized above the diaphragm, corresponding to a left lower lobe consolidation. b Color Doppler ultrasound visualizes arterial and venous vessels within the consolidation: the non-aerated lung lobe is well perfused, which corresponds to intrapulmonary shunt definition. c Chest X-ray. L lung, dotted line and d diaphragm, S spleen
consolidation is strongly suggestive of significant shunt and therefore of an important impact of consolidation on oxygenation. This pattern appeared in a mechanically ventilated patient affected by diffuse alveolar hemorrhage (Fig. 1c), in which PaO2/FiO2 suddenly worsened from 130 to 65. Once an intrapulmonary shunt is identified, hypoxemia treatment should focus on improving lung aeration and/or reorienting blood flow (fiberbronchoscopy, recruitment maneuver, prone/lateral position,
nitric oxide). In our patient, reaeration of lower lobes was obtained by fiberbronchoscopic suction of obstructing clots, with subsequent dramatic improvement of oxygenation. Compliance with ethical standards Conflicts of interest
None.
Silvia Mongodi Be´laı¨d Bouhemad Giorgio Antonio Iotti Francesco Mojoli
IMAGING IN INTENSIVE CARE MEDICINE
An ultrasonographic sign of intrapulmonary shunt
Lung ultrasound is a valuable bedside tool for the differential diagnosis of hypoxemia, a frequent issue in critically ill patients. In particular, a tissue-like pattern visualized above the diaphragm corresponds to complete Ó Springer-Verlag Berlin Heidelberg and ESICM 2015 loss of aeration, defined as lung consolidation (Fig. 1a). A Electronic supplementary material The online version of this consolidated lobe may have a variable impact on oxyarticle (doi:10.1007/s00134-015-4169-3) contains supplementary genation, depending on hypoxic vasoconstriction and material, which is available to authorized users. degree of intrapulmonary shunt. Color Doppler ultrasound S. Mongodi ()) G. A. Iotti F. Mojoli may be used to identify vessels within consolidations: in Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San some patients, intrapulmonary arteries can be visualized Matteo, University of Pavia, Pavia, Italy (Fig. 1b), identified by a pulsing pattern synchronous with e-mail: [email protected] heartbeats. In these patients, the non-aerated lobe appears to be well perfused, which corresponds to the definition of B. Bouhemad Anesthesia and Intensive Care, Centre Hospitalier Universitaire de intrapulmonary shunt. Although no quantification is posDijon, Dijon, France sible, the visualization of a main vessel within a Received: 18 November 2015 Accepted: 24 November 2015
Fig. 1 Longitudinal scan of left costophrenic sinus. a A tissuelike pattern is visualized above the diaphragm, corresponding to a left lower lobe consolidation. b Color Doppler ultrasound visualizes arterial and venous vessels within the consolidation: the non-aerated lung lobe is well perfused, which corresponds to intrapulmonary shunt definition. c Chest X-ray. L lung, dotted line and d diaphragm, S spleen
consolidation is strongly suggestive of significant shunt and therefore of an important impact of consolidation on oxygenation. This pattern appeared in a mechanically ventilated patient affected by diffuse alveolar hemorrhage (Fig. 1c), in which PaO2/FiO2 suddenly worsened from 130 to 65. Once an intrapulmonary shunt is identified, hypoxemia treatment should focus on improving lung aeration and/or reorienting blood flow (fiberbronchoscopy, recruitment maneuver, prone/lateral position,
nitric oxide). In our patient, reaeration of lower lobes was obtained by fiberbronchoscopic suction of obstructing clots, with subsequent dramatic improvement of oxygenation. Compliance with ethical standards Conflicts of interest
None.
