Pleural ultrasound for clinicians

Porcel, J.M.

doi:10.1016/j.rceng.2016.06.005

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"apellidos" => "Carné" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256516300777" "doi" => "10.1016/j.rce.2016.05.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256516300777?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887416300352?idApp=WRCEE" "url" => "/22548874/0000021600000008/v1_201610290712/S2254887416300352/v1_201610290712/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Pleural ultrasound for clinicians" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "427" "paginaFinal" => "435" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J.M. Porcel" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J.M." "apellidos" => "Porcel" "email" => array:1 [ 0 => "jporcelp@yahoo.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Medicina Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Instituto de Investigación Biomédica de Lleida Fundación Dr. Pifarré (IRBLLEIDA), Lleida, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecografía pleural para clínicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1798 "Ancho" => 2502 "Tamanyo" => 375221 ] ] "descripcion" => array:1 [ "en" => "Pleural fluid echogenicity patterns: anechoic ((A): arrows indicating thickening of the diaphragm with a malignant cause), complex non-septated ((B): arrowheads indicating various echogenic points, and the arrow indicating a malignant diaphragmatic node) complex septated (C) and homogeneously echogenic ((D): hemothorax)." ] ] ] "textoCompleto" => "BackgroundIn recent years, there has been considerable growth in the use of ultrasonography as a diagnostic tool by nonradiology clinicians. Advances in technology have contributed to this growth, not only providing significant improvements in image quality but also developing portable devices for use at the patient's bedside.<a class="elsevierStyleCrossRef" href="#bib0200">1</a> The primary advantages of ultrasonography over plain radiography or computed tomography (CT) include the lack of radiation, its portability and real-time imaging. As with any scan, ultrasonography presents a learning curve for the clinician; however, the learning curve is relatively short. If there were an area of medicine that combines the simplicity of ultrasound investigation and diagnostic yield, it would be pleural diseases. In this review, we will address the application of ultrasonography in detecting pleural effusion (PE) and pneumothoraces, as well as the performance of various invasive pleural procedures.Key concepts and equipmentAn ultrasound device works by applying electric pulses to a piezoelectric crystal (transducer), producing ultrasound waves that penetrate tissue at variable speeds, depending on the tissue's density and elasticity (acoustic impedance). These waves reflect off anatomical structures and return to the transducer where they generate another electric signal, which a processor uses to generate a grayscale digital image. Bone and air are poor conductors of ultrasound. The term “ultra” refers to the fact that the wave frequency (cycles per second) is greater than 20,000Hz or 20kHz, the upper audible limit for humans.<a class="elsevierStyleCrossRefs" href="#bib0200">1,2</a> In clinical practice, ultrasound frequency is measured in megahertz (MHz or 1,000,000Hz).TransducersTransducers or probes are classified according to the ultrasound frequency they generate and the arrangement of the piezoelectric crystals,<a class="elsevierStyleCrossRef" href="#bib0205">2</a> creating low-frequency (2–6MHz) and high-frequency (7–12MHz) transducers. The former provide greater depth but lower image quality, whereas the latter provide greater image resolution but reduced depth. A distinction can also be made between (a) linear transducers, with crystals arranged in a straight line that transmit ultrasound beams in a perpendicular manner and that create a rectangular image (for scanning vascular and skin structures); (b) convex transducers, with a curvilinear arrangement of crystals that create a wedge-shaped image (for abdominal and obstetric examination); and (c) phased-array transducers, which create a triangular or fan-shaped image and have a smaller area, allowing an intercostal approach (cardiac and thoracic examination). To examine the presence of pleural effusion, low-frequency phased-array transducers can be used by applying them perpendicularly to the chest. High-frequency linear transducers are selected for chest wall and parietal pleura examinations (e.g., checking for thickening, pneumothorax and intercostal vessels) and are used in the transverse and sagittal positions on the intercostal area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0205">2</a> Conventionally, transducers have a notch, groove or marker on one of their edges, corresponding to a signal located on the upper-left edge of the screen, providing adequate spatial interpretation of the image.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Ultrasound deviceA number of settings on the ultrasound device need to be adjusted at the start of the examination, such as scan depth, gain (image brightness), time-gain compensation (differential brightness control at different depths) and focus (specific area in which greater image definition is intended). For chest ultrasounds, scan depth is normally set at approximately 4cm for linear transducers and 15cm for phased array-transducers. However, all devices can be used to create presets designed especially for certain examinations.In addition to scanning in B-mode (brightness), which is the standard, most equipment can be used in M-mode (motion, which obtains one-dimensional moving images) and Doppler.<a class="elsevierStyleCrossRefs" href="#bib0200">1,2</a> There is also color Doppler imaging (which detects movement of a fluid and its direction; red showing fluid coming toward the probe and blue showing fluid that is moving away), as well as spectral Doppler (which provides flow velocity information) and power Doppler (which is more sensitive, can detect slow and weak flows and is very useful for assessing small vessels such as intercostal arteries). The echogenicity of a structure or lesion is defined in relation to the liver, which is arbitrarily considered as isoechoic.Patient positionUltrasonography can be used to visualize approximately 70% of the pleural surface.<a class="elsevierStyleCrossRef" href="#bib0210">3</a> The systematic and complete exploration of the chest requires that patients be scanned either in the sitting position, whenever possible, or in the supine position, moving the transducer over intercostal spaces (sagittal, transverse and oblique planes) along craniocaudal and transversal lines (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0205">2,4</a> Copious amounts of acoustic gel need to be applied to the patient's skin in order for the transducer to be passed over it with enough pressure. The patient's position is critical for optimal ultrasound examination, given the free pleural fluid (PF) accumulates in the lower portions of the chest as a result of gravity. Ambulatory patients are placed in an upright position, seated on a stool, leaning forward slightly, with their arms crossed and hands on the opposite shoulder to move the scapula forward.<a class="elsevierStyleCrossRefs" href="#bib0205">2,4</a> In this position, the PF accumulates in the posterior costophrenic recesses, and the scan can be limited to the posterior or posterolateral hemithorax. In critically ill patients or those who are unable to maintain an erect position, the scan is performed with the patient in the supine position and, as far as possible, in the decubitus position contralateral to the PE, or by slightly reclining the patient (allowing for posterior access). The supine position is also the position of choice for diagnosing a pneumothorax; it makes it easier to recognize signs indicating this condition in the anterior section of the chest. Image quality can be negatively affected by factors such as obesity, excessive bodybuilding, chest wall edema, subcutaneous emphysema and poor patient positioning.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Ultrasound-guided pleural surgery can be performed dynamically (direct, real-time visualization) or statically (entry point marked using ultrasonography, performed immediately thereafter, the patient having remained motionless; freehand technique).<a class="elsevierStyleCrossRef" href="#bib0220">5</a> Procedures where the radiologist marks the puncture location and the doctor performs the pleural procedure at a later point (the “X marks the spot” technique) are highly discouraged, because it is nearly impossible for the patient to assume the same position they were in when being marked. The dynamic approach might involve a one operator (who performs the ultrasound and the procedure simultaneously) or two (while one is performing the ultrasound, the other performs the procedure under direct observation). When the aspiration of a small PE or one located in a difficult anatomical location is required, it would be advisable to use real-time ultrasonography.Pleural effusion diagnosisAnatomy of the pleuraIn normal circumstances, the pleura is seen as a bright line (hyperechoic), less than 2mm wide, between the acoustic shadows of the 2 adjacent ribs (bat sign) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<a class="elsevierStyleCrossRef" href="#bib0225">6</a> The pleural line is a result of the difference in acoustic impedance between the soft tissues in the chest wall (including the parietal pleura), which are rich in water, and the lung tissue (covered by the visceral pleura), which contains air. When there is no PE, the visceral and parietal pleura slide over one another; this line tends to present a horizontal sliding movement synchronous with respiration (sliding), which is associated with a contiguous signal lower than power Doppler (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0205">2,6</a> The extent of this lung sliding normally increases when passing from the apical area to the basal area. Lung sliding and pleural line movement synchronous with the heartbeat (lung pulse) should not be confused. It is difficult to observe lung pulses in aerated lungs because the pulses are masked by the lung sliding; it is easier to visualize in nonventilated lungs (e.g., complete lung collapse or during voluntary apnea in a healthy subject).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>In aerated lungs, regularly spaced, repeated horizontal, hyperechoic reflections of the pleural line are called A-lines (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). B-lines (comet-tail, laser beam) are hyperechoic vertical reverberation artifacts, with well-defined margins, extending from the pleural line (visceral pleura) to the border of the screen. B-lines erase A-lines when they cross and move in synchrony with respiratory movements (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<a class="elsevierStyleCrossRef" href="#bib0230">7</a> The presence of one or two B-lines detected in the pulmonary bases is considered physiological, but the presence of more than 2 lines is always considered pathological. Another artifact often observed in costophrenic angles of healthy subjects when using B-mode is the intermittent or temporary concealment of upper abdominal organs during inspiration, when the aerated lung moves caudally in front of the transducer (curtain sign).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>In M-mode, the combination of a superficial layer of hyperechoic horizontal lines (static chest wall) and another deeper layer with a granular appearance (lung motion) results in a seashore sign (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A).<a class="elsevierStyleCrossRefs" href="#bib0205">2,6</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Pleural effusionUltrasonography is more sensitive than plain radiography for detecting the presence of PF, and somewhat less sensitive than CT. However, ultrasonography is easier to use, costs less and differentiates between pleural effusion and thickening better than plain radiography. In a meta-analysis of 12 studies involving 1554 patients (42% with PE), ultrasonography yielded a sensitivity and specificity for detecting PE of 94% and 98%, respectively. These figures were significantly higher than with chest radiography (51% and 91%, respectively).<a class="elsevierStyleCrossRef" href="#bib0235">8</a> It is estimated that ultrasonography can detect very small volumes of PF (5–20mL), whereas simple radiography used in an upright position requires 200mL to eliminate the costodiaphragmatic recesses.<a class="elsevierStyleCrossRef" href="#bib0240">9</a> Ultrasound sensitivity is considered to be 100% for PE volumes >100mL.<a class="elsevierStyleCrossRef" href="#bib0245">10</a> In patients with elevated hemidiaphragm, ultrasonography easily differentiates between subpulmonary PE, subphrenic collection and diaphragm paralysis.PF does not reflect ultrasound and appears as a homogeneous black area (anechoic or hypoechoic) delimited by the diaphragm and subdiaphragmatic structures (liver and spleen), chest wall, collapsed lung (visible as a dense tongue-shaped structure that spontaneously undulates through the heartbeat transmission [caput medusae] and with an edge from which multiple B-lines can emerge) and, occasionally, the pericardium or descending aorta on the left side (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>A). Hyperechoic floating particles can be seen swirling in the fluid with respiratory and cardiac movements (swirl or plankton sign).<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Color Doppler and M-mode can complement two-dimensional examinations. PE shows flow through the color Doppler due to the movement of fluid during cardiac pulsation and respiratory excursions (fluid color sign) (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>B). In M-mode, the lung moves, within the effusion, toward and away from the chest wall during respiration (sinusoid sign). The corresponding lack of flow or movement is observed in pleural thickening, pleural or peripheral pulmonary masses and dense pleural loculations.Depending on the PF's internal echogenicity, 4 effusion patterns can typically be distinguished<a class="elsevierStyleCrossRefs" href="#bib0205">2,6</a>: (1) anechoic (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>A); (2) complex nonseptated, in which a combination of echogenic and hypoechoic areas can be observed (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>B); (3) complex septated, in which floating fibrin strands are found in a hypoechoic space (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>C); and (4) homogeneously echogenic (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>D). This classification can be simplified by taking only simple (anechoic) and complex PEs (the remaining previous 3 categories) into account. PF echoes can depict an abundance of protein, fibrin, blood or pus. Whereas anechoic PF can be transudative or exudative, the swirl sign is evidence of an exudate, particularly of a malignant nature.<a class="elsevierStyleCrossRef" href="#bib0250">11</a> There is no absolute correlation, however, between the ultrasound appearance of PF and subsequent classification as a transudate or exudate. In immobile patients, the cellular component of a PE can settle over time through gravitational influence and can create a defined interface with anechoic fluid located above (hematocrit sign).<a class="elsevierStyleCrossRef" href="#bib0255">12</a><elsevierMultimedia ident="fig0035"></elsevierMultimedia>A number of formulas are based on two-dimensional measurements to calculate PE volume. One simple formula establishes that the PF volume in millimeters is the result of multiplying by 16 the distance in millimeters between the visceral and parietal pleura at the diaphragm's middle portion.<a class="elsevierStyleCrossRef" href="#bib0260">13</a> However, formulas described in medical literature are not accurate and are rarely used in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0265">14</a> PE can be considered at least moderate if it extends beyond the area covered by the 3.5MHz phased-array transducer, with the patient in a sitting position.<a class="elsevierStyleCrossRef" href="#bib0270">15</a> Another semiquantitative approach is to define any PE that only covers one intercostal space as small; a PE between 2 and 4 adjacent intercostal spaces as moderate; and a PE that occupies half the hemithorax as large.<a class="elsevierStyleCrossRef" href="#bib0205">2</a>Pleural effusion due to heart failureThe presence of B-lines represents thickened interlobular septa or alveolar interstitial syndrome (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), usually the result of heart failure or, less commonly, interstitial lung disease, pulmonary contusion or respiratory distress. Whereas the pleural line is smooth in cases of heart failure, it is usually thickened (>2mm) or irregular in other cases.<a class="elsevierStyleCrossRef" href="#bib0255">12</a>Decompensated heart failure would be a probable diagnosis if a mostly bilateral PE is observed and is accompanied by multiple bilateral B-lines (≥3 with a phased-array transducer or ≥6 with a linear transducer)<a class="elsevierStyleCrossRef" href="#bib0275">16</a> and a vena cava ≥2.1cm in diameter (measured at approximately 2cm from its entry into the right atrium) with inspiratory collapse <50% (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<a class="elsevierStyleCrossRef" href="#bib0280">17</a> In pulmonary edema, abundant B-lines converge and can produce a “white lung” image under ultrasound. By considering the presence of multiple B-lines as an ultrasound sign of acute heart failure, a study of 1005 patients with acute dyspnea (463 with a cardiac cause) showed that ultrasonography alone was significantly more sensitive (90.5%) and specific (93.5%) than plain radiography (69.5% and 82.1%, respectively) in identifying the cardiac etiology of the dyspnea.<a class="elsevierStyleCrossRef" href="#bib0285">18</a> When clinical information (medical history, physical examination, electrocardiogram and arterial blood gases) was integrated with the ultrasound, sensitivity and specificity for diagnosing acute cardiac decompensation rose to 97%.<a class="elsevierStyleCrossRef" href="#bib0285">18</a><elsevierMultimedia ident="fig0040"></elsevierMultimedia>Malignant pleural effusionThe presence of >1cm thickening, liver metastases or both pleural and diaphragmatic nodules is highly indicative of malignant PE (sensitivity and specificity >80%).<a class="elsevierStyleCrossRef" href="#bib0250">11</a> Massive PE, which is frequently malignant,<a class="elsevierStyleCrossRef" href="#bib0290">19</a> is usually associated with the flattening or inversion of the diaphragm and can be associated with a cephalic paradoxical movement during inspiration. The potential utility of ultrasonography has recently been reported for the diagnosis of an unexpandable (trapped) lung before proceeding with draining a malignant PE.<a class="elsevierStyleCrossRef" href="#bib0295">20</a> A trapped lung is a contraindication for pleurodesis, because for optimal pleural symphysis to be achieved, the visceral and parietal pleura need to be attached. Therefore, the ability to predict the existence of an unexpandable lung using ultrasound would favor the use of chronic tunneled catheters rather than pleurodesis as a symptomatic treatment of malignant PE.Infectious pleural effusionAs with hemothoraces, empyema characteristically exhibits strong diffuse echogenicity, although it can be anechoic in early stages. They can also be associated with multiple areas that are bright and reflective within the PF, which represent air bubbles produced by gas-forming bacteria in the infectious collection. However, the presence of air in a PE can be secondary to a bronchopleural or esophageal fistula or a previous thoracentesis. Loculations (separate collections of fluid in different areas of the pleural space) and septa (fibrin bands compartmentalize a single pleural collection) are common.<a class="elsevierStyleCrossRef" href="#bib0225">6</a> CT is good at detecting loculations but not septa, whereas ultrasonography (and magnetic resonance) can easily visualize both. In addition to infections, malignant PE or PE from any other cause that has developed over time might develop septa.<a class="elsevierStyleCrossRef" href="#bib0300">21</a> Patients with empyema or complicated parapneumonic effusions displaying a complex septated sonographic pattern are at greater risk of pleural drainage failure and have a higher mortality probability than those without septa.<a class="elsevierStyleCrossRef" href="#bib0305">22</a>Pneumonias are more often located peripherally and can therefore be detected using ultrasonography. Consolidated lungs have a similar echotexture to that of the liver and are frequently observed as hyperechoic heterogeneous areas with irregular edging. Punctate hyperechoic foci within the consolidation moving through the bronchus are representative of dynamic air bronchograms (as opposed to static, typical of atelectasis).<a class="elsevierStyleCrossRef" href="#bib0275">16</a>Pneumothorax diagnosisUltrasonography has better performance than chest radiography for detecting pneumothoraces. Published meta-analyses have shown that ultrasonography has an average sensitivity of 80–90% compared with 40–50% for plain chest radiography; both techniques have specificities of 99%.<a class="elsevierStyleCrossRefs" href="#bib0310">23–25</a>The presence of lung sliding, lung pulse or B-lines rules out pneumothorax in the examined intercostal space, because the parietal and visceral pleura need to be adjacent for these signs to appear.<a class="elsevierStyleCrossRef" href="#bib0325">26</a> Although the lack of lung sliding is characteristic of pneumothorax, the sliding could be due to other causes (in which lung pulse is frequently detected)<a class="elsevierStyleCrossRef" href="#bib0275">16</a>: apnea or shallow breathing, complete atelectasis, selective intubation of one lung, pleural and pulmonary adhesions (e.g., pleurodesis, previous inflammatory cases or infections and pneumonectomy), severe acute pulmonary lesion or subpleural bullae (blebs). M-mode can be used to easily detect absent lung sliding in the pneumothorax by providing an image with multiple hyperechoic horizontal lines above and below the pleural line (barcode or stratosphere sign) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>B). The lack of sliding can also be demonstrated through the lack of power Doppler signal below the pleural line.The lung point or intersection point between the partially deflated lung (displaying signs of lung sliding) and air from the pleural cavity (absence of sliding) confirm the pneumothorax and can be used to estimate its size (in supine position, the more to the rear the lung point, the greater the pneumothorax).<a class="elsevierStyleCrossRefs" href="#bib0275">16,26</a> Thorough scanning and experience is required to detect a pneumothorax; however, a pneumothorax cannot be detected when the lung has completely collapsed.Guide for performing pleural proceduresThe British Thoracic Society recommends all pleural procedures be performed with ultrasound guidance, due to the reduced complications and the greater degree of success with this technique.<a class="elsevierStyleCrossRef" href="#bib0330">27</a> Ultrasonography is therefore substantially better than physical examinations for identifying suitable puncture points for thoracentesis. One study showed that a needle insertion point determination based on physical examination and chest radiography was inappropriate in 15% of cases (which included the risk of accidentally puncturing an organ), and ultrasonography helped identify a suitable puncture site in 54% of cases in which physical examination was unable to do so.<a class="elsevierStyleCrossRef" href="#bib0335">28</a> Numerous studies have shown that the use of ultrasonography is associated with a decreased risk of iatrogenic pneumothorax following thoracentesis.<a class="elsevierStyleCrossRef" href="#bib0340">29</a> In a series of 9320 thoracenteses (diagnostic or therapeutic) performed using ultrasound guidance, pneumothorax and bleeding only occurred in 0.61% and 0.18% of cases, respectively.<a class="elsevierStyleCrossRef" href="#bib0345">30</a> In another study, no bleeding complications occurred in 706 cases of ultrasound-guided thoracentesis in patients with uncorrected coagulopathy (INR>1.6 or platelets <50,000/μL).<a class="elsevierStyleCrossRef" href="#bib0350">31</a>Ultrasonography can be used to estimate the distance between the skin and parietal pleura and, thus, the depth at which aspiration of the PF is possible. In patients with obesity or edema, applying firm pressure with the transducer on the skin surface can cause this distance to be underestimated. The correct identification of anatomical structures, in particular the diaphragm, is essential for ensuring safe access to the pleural cavity. A relatively common mistake among inexperienced staff is to confuse the spleen with an echogenic PE (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>A) or a splenorenal or hepatorenal recess with the diaphragm. The PE should have an estimated depth of at least 1.5–2cm to attempt a thoracentesis.<a class="elsevierStyleCrossRef" href="#bib0355">32</a>Currently, CT-guided or ultrasound-guided pleural biopsies have replaced the need to perform the biopsies blind, particularly if the parietal pleura is thickened 1cm or more or if the pleura has nodules, in which case, the diagnostic sensitivity is greater than 80%.<a class="elsevierStyleCrossRefs" href="#bib0360">33,34</a> In malignant PEs, the yield increases when at least 6 biopsies are taken in a basal area, just above the diaphragm.<a class="elsevierStyleCrossRef" href="#bib0370">35</a> Pleural masses can be biopsied with ultrasound guidance, even in the absence of associated PE.Although uncommon, an intercostal artery can accidentally be lacerated during a thoracentesis or pleural biopsy and cause an iatrogenic hemothorax. This can occur due to the tortuosity of the intercostal arteries extending unprotected under the costal groove up to 6–10cm of the costovertebral joint<a class="elsevierStyleCrossRef" href="#bib0300">21</a> and due to the presence of collaterals that cross the intercostal space in a cephalocaudal manner.<a class="elsevierStyleCrossRef" href="#bib0375">36</a> Tortuosity is more prevalent in the elderly population. For this population or in cases in which punctures need to be performed near the spine, vascular Doppler ultrasonography can help identify vulnerable vessels in the intercostal space (sensitivity >85%) and avoid lesions.<a class="elsevierStyleCrossRef" href="#bib0380">37</a>Finally, ultrasonography can guide thoracoscopic access to the pleural cavity, even if there is no PE, so as to be able to identify pleural adhesions.<a class="elsevierStyleCrossRef" href="#bib0385">38</a>ConclusionsUltrasonography should be used for all types of pleural punctures (thoracentesis, drainage tubes and pleural biopsy), provided that the appropriate equipment is available and the operator has at least a minimum of experience. It is particularly useful for bedridden and critically ill patient, and can provide immediate diagnostic information regarding cases such as pneumothoraces, PE, pulmonary edemas and pulmonary consolidation. Ultrasonography is more sensitive than chest radiography for detecting the presence of fluid or air in the pleural cavity and for differentiating between PE and pulmonary condensation or pleural thickening. A-lines are consistent with an aerated lung, whereas an edematous lung typically presents B-lines. Finding pleural or diaphragmatic masses or nodules should lead to the strong suspicion of malignancy, and if complex septated PEs are observed in the context of pleuropulmonary infection, it would be advisable to insert an intrapleural catheter. In the future, ultrasonography could be used to help better distinguish between malignant and benign pleural diseases.<a class="elsevierStyleCrossRef" href="#bib0390">39</a>Conflict of interestThe author declares that there are no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres750234" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec752989" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres750235" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec752990" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Key concepts and equipment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Transducers" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Ultrasound device" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Patient position" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Pleural effusion diagnosis" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Anatomy of the pleura" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Pleural effusion" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Pleural effusion due to heart failure" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Malignant pleural effusion" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Infectious pleural effusion" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Pneumothorax diagnosis" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Guide for performing pleural procedures" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-04-30" "fechaAceptado" => "2016-05-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec752989" "palabras" => array:4 [ 0 => "Thoracic ultrasound" 1 => "Pleural effusion" 2 => "Pneumothorax" 3 => "Thoracentesis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec752990" "palabras" => array:4 [ 0 => "Ecografía torácica" 1 => "Derrame pleural" 2 => "Neumotórax" 3 => "Toracocentesis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Pleural ultrasonography is useful for identifying and characterizing pleural effusions, solid pleural lesions (nodules, masses, swellings) and pneumothorax. Pleural ultrasonography is also considered the standard care for guiding interventionist procedures on the pleura at the patient's bedside (thoracentesis, drainage tubes, pleural biopsies and pleuroscopy). Hospitals should promote the acquisition of portable ultrasound equipment to increase the patient's safety." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La ecografía pleural es útil para identificar y caracterizar derrames pleurales, lesiones pleurales sólidas (nódulos, masas, engrosamientos) y neumotórax. Asimismo, se considera el estándar asistencial para guiar procedimientos intervencionistas sobre la pleura a la cabecera del paciente (toracocentesis, tubos de drenaje, biopsias pleurales y pleuroscopia). Los hospitales deberían favorecer la adquisición de equipos de ultrasonido portátiles en beneficio de la seguridad del paciente." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Porcel JM. Ecografía pleural para clínicos. Rev Clin Esp. 2016;216:427–435." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1877 "Ancho" => 2502 "Tamanyo" => 306014 ] ] "descripcion" => array:1 [ "en" => "Ultrasonography device with phased array and linear probes for thoracic examination." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 788 "Ancho" => 1750 "Tamanyo" => 213381 ] ] "descripcion" => array:1 [ "en" => "Usual patient positions for ultrasound examination of the thorax, following parallel craniocaudal lines." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1160 "Ancho" => 2503 "Tamanyo" => 317956 ] ] "descripcion" => array:1 [ "en" => "Pleural line ((A), arrowheads) with power Doppler signal (B) under the same, indicating the presence of lung sliding. Note the acoustic shadow of the adjacent ribs (asterisks)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 908 "Ancho" => 2503 "Tamanyo" => 154560 ] ] "descripcion" => array:1 [ "en" => "Ultrasonography in B-mode showing lines (A) (arrowheads) and (B) (arrows)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1200 "Ancho" => 2475 "Tamanyo" => 466393 ] ] "descripcion" => array:1 [ "en" => "Ultrasonography in M-mode showing ‘seashore’ signs (A) and ‘barcode’ signs (B). The arrowheads indicate the pleural line." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 911 "Ancho" => 2500 "Tamanyo" => 195088 ] ] "descripcion" => array:1 [ "en" => "Left pleural effusion (PE) with usual anatomical limits (A). Color Doppler (B) showing pleural fluid movement (color fluid sign). Note the presence of B (arrowheads)." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1798 "Ancho" => 2502 "Tamanyo" => 375221 ] ] "descripcion" => array:1 [ "en" => "Pleural fluid echogenicity patterns: anechoic ((A): arrows indicating thickening of the diaphragm with a malignant cause), complex non-septated ((B): arrowheads indicating various echogenic points, and the arrow indicating a malignant diaphragmatic node) complex septated (C) and homogeneously echogenic ((D): hemothorax)." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1760 "Ancho" => 2502 "Tamanyo" => 453897 ] ] "descripcion" => array:1 [ "en" => "Ultrasound images in B-mode of the inferior vena cava (IVC) entering the right atrium (RA). 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If there were an area of medicine that combines the simplicity of ultrasound investigation and diagnostic yield&#44; it would be pleural diseases&#46; In this review&#44; we will address the application of ultrasonography in detecting pleural effusion &#40;PE&#41; and pneumothoraces&#44; as well as the performance of various invasive pleural procedures&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Key concepts and equipment</span><p id="par0010" class="elsevierStylePara elsevierViewall">An ultrasound device works by applying electric pulses to a piezoelectric crystal &#40;transducer&#41;&#44; producing ultrasound waves that penetrate tissue at variable speeds&#44; depending on the tissue&#39;s density and elasticity &#40;acoustic impedance&#41;&#46; These waves reflect off anatomical structures and return to the transducer where they generate another electric signal&#44; which a processor uses to generate a grayscale digital image&#46; Bone and air are poor conductors of ultrasound&#46; The term &#8220;ultra&#8221; refers to the fact that the wave frequency &#40;cycles per second&#41; is greater than 20&#44;000<span class="elsevierStyleHsp" style=""></span>Hz or 20<span class="elsevierStyleHsp" style=""></span>kHz&#44; the upper audible limit for humans&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;2</span></a> In clinical practice&#44; ultrasound frequency is measured in megahertz &#40;MHz or 1&#44;000&#44;000<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Transducers</span><p id="par0015" class="elsevierStylePara elsevierViewall">Transducers or probes are classified according to the ultrasound frequency they generate and the arrangement of the piezoelectric crystals&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> creating low-frequency &#40;2&#8211;6<span class="elsevierStyleHsp" style=""></span>MHz&#41; and high-frequency &#40;7&#8211;12<span class="elsevierStyleHsp" style=""></span>MHz&#41; transducers&#46; The former provide greater depth but lower image quality&#44; whereas the latter provide greater image resolution but reduced depth&#46; A distinction can also be made between &#40;a&#41; linear transducers&#44; with crystals arranged in a straight line that transmit ultrasound beams in a perpendicular manner and that create a rectangular image &#40;for scanning vascular and skin structures&#41;&#59; &#40;b&#41; convex transducers&#44; with a curvilinear arrangement of crystals that create a wedge-shaped image &#40;for abdominal and obstetric examination&#41;&#59; and &#40;c&#41; phased-array transducers&#44; which create a triangular or fan-shaped image and have a smaller area&#44; allowing an intercostal approach &#40;cardiac and thoracic examination&#41;&#46; To examine the presence of pleural effusion&#44; low-frequency phased-array transducers can be used by applying them perpendicularly to the chest&#46; High-frequency linear transducers are selected for chest wall and parietal pleura examinations &#40;e&#46;g&#46;&#44; checking for thickening&#44; pneumothorax and intercostal vessels&#41; and are used in the transverse and sagittal positions on the intercostal area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> Conventionally&#44; transducers have a notch&#44; groove or marker on one of their edges&#44; corresponding to a signal located on the upper-left edge of the screen&#44; providing adequate spatial interpretation of the image&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ultrasound device</span><p id="par0020" class="elsevierStylePara elsevierViewall">A number of settings on the ultrasound device need to be adjusted at the start of the examination&#44; such as scan depth&#44; gain &#40;image brightness&#41;&#44; time-gain compensation &#40;differential brightness control at different depths&#41; and focus &#40;specific area in which greater image definition is intended&#41;&#46; For chest ultrasounds&#44; scan depth is normally set at approximately 4<span class="elsevierStyleHsp" style=""></span>cm for linear transducers and 15<span class="elsevierStyleHsp" style=""></span>cm for phased array-transducers&#46; However&#44; all devices can be used to create presets designed especially for certain examinations&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition to scanning in B-mode &#40;brightness&#41;&#44; which is the standard&#44; most equipment can be used in M-mode &#40;motion&#44; which obtains one-dimensional moving images&#41; and Doppler&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;2</span></a> There is also color Doppler imaging &#40;which detects movement of a fluid and its direction&#59; red showing fluid coming toward the probe and blue showing fluid that is moving away&#41;&#44; as well as spectral Doppler &#40;which provides flow velocity information&#41; and power Doppler &#40;which is more sensitive&#44; can detect slow and weak flows and is very useful for assessing small vessels such as intercostal arteries&#41;&#46; The echogenicity of a structure or lesion is defined in relation to the liver&#44; which is arbitrarily considered as isoechoic&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Patient position</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ultrasonography can be used to visualize approximately 70&#37; of the pleural surface&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> The systematic and complete exploration of the chest requires that patients be scanned either in the sitting position&#44; whenever possible&#44; or in the supine position&#44; moving the transducer over intercostal spaces &#40;sagittal&#44; transverse and oblique planes&#41; along craniocaudal and transversal lines &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;4</span></a> Copious amounts of acoustic gel need to be applied to the patient&#39;s skin in order for the transducer to be passed over it with enough pressure&#46; The patient&#39;s position is critical for optimal ultrasound examination&#44; given the free pleural fluid &#40;PF&#41; accumulates in the lower portions of the chest as a result of gravity&#46; Ambulatory patients are placed in an upright position&#44; seated on a stool&#44; leaning forward slightly&#44; with their arms crossed and hands on the opposite shoulder to move the scapula forward&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;4</span></a> In this position&#44; the PF accumulates in the posterior costophrenic recesses&#44; and the scan can be limited to the posterior or posterolateral hemithorax&#46; In critically ill patients or those who are unable to maintain an erect position&#44; the scan is performed with the patient in the supine position and&#44; as far as possible&#44; in the decubitus position contralateral to the PE&#44; or by slightly reclining the patient &#40;allowing for posterior access&#41;&#46; The supine position is also the position of choice for diagnosing a pneumothorax&#59; it makes it easier to recognize signs indicating this condition in the anterior section of the chest&#46; Image quality can be negatively affected by factors such as obesity&#44; excessive bodybuilding&#44; chest wall edema&#44; subcutaneous emphysema and poor patient positioning&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Ultrasound-guided pleural surgery can be performed dynamically &#40;direct&#44; real-time visualization&#41; or statically &#40;entry point marked using ultrasonography&#44; performed immediately thereafter&#44; the patient having remained motionless&#59; freehand technique&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> Procedures where the radiologist marks the puncture location and the doctor performs the pleural procedure at a later point &#40;the &#8220;X marks the spot&#8221; technique&#41; are highly discouraged&#44; because it is nearly impossible for the patient to assume the same position they were in when being marked&#46; The dynamic approach might involve a one operator &#40;who performs the ultrasound and the procedure simultaneously&#41; or two &#40;while one is performing the ultrasound&#44; the other performs the procedure under direct observation&#41;&#46; When the aspiration of a small PE or one located in a difficult anatomical location is required&#44; it would be advisable to use real-time ultrasonography&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pleural effusion diagnosis</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Anatomy of the pleura</span><p id="par0040" class="elsevierStylePara elsevierViewall">In normal circumstances&#44; the pleura is seen as a bright line &#40;hyperechoic&#41;&#44; less than 2<span class="elsevierStyleHsp" style=""></span>mm wide&#44; between the acoustic shadows of the 2 adjacent ribs &#40;bat sign&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">6</span></a> The pleural line is a result of the difference in acoustic impedance between the soft tissues in the chest wall &#40;including the parietal pleura&#41;&#44; which are rich in water&#44; and the lung tissue &#40;covered by the visceral pleura&#41;&#44; which contains air&#46; When there is no PE&#44; the visceral and parietal pleura slide over one another&#59; this line tends to present a horizontal sliding movement synchronous with respiration &#40;sliding&#41;&#44; which is associated with a contiguous signal lower than power Doppler &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;6</span></a> The extent of this lung sliding normally increases when passing from the apical area to the basal area&#46; Lung sliding and pleural line movement synchronous with the heartbeat &#40;lung pulse&#41; should not be confused&#46; It is difficult to observe lung pulses in aerated lungs because the pulses are masked by the lung sliding&#59; it is easier to visualize in nonventilated lungs &#40;e&#46;g&#46;&#44; complete lung collapse or during voluntary apnea in a healthy subject&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In aerated lungs&#44; regularly spaced&#44; repeated horizontal&#44; hyperechoic reflections of the pleural line are called A-lines &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; B-lines &#40;comet-tail&#44; laser beam&#41; are hyperechoic vertical reverberation artifacts&#44; with well-defined margins&#44; extending from the pleural line &#40;visceral pleura&#41; to the border of the screen&#46; B-lines erase A-lines when they cross and move in synchrony with respiratory movements &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> The presence of one or two B-lines detected in the pulmonary bases is considered physiological&#44; but the presence of more than 2 lines is always considered pathological&#46; Another artifact often observed in costophrenic angles of healthy subjects when using B-mode is the intermittent or temporary concealment of upper abdominal organs during inspiration&#44; when the aerated lung moves caudally in front of the transducer &#40;curtain sign&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In M-mode&#44; the combination of a superficial layer of hyperechoic horizontal lines &#40;static chest wall&#41; and another deeper layer with a granular appearance &#40;lung motion&#41; results in a seashore sign &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;6</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pleural effusion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Ultrasonography is more sensitive than plain radiography for detecting the presence of PF&#44; and somewhat less sensitive than CT&#46; However&#44; ultrasonography is easier to use&#44; costs less and differentiates between pleural effusion and thickening better than plain radiography&#46; In a meta-analysis of 12 studies involving 1554 patients &#40;42&#37; with PE&#41;&#44; ultrasonography yielded a sensitivity and specificity for detecting PE of 94&#37; and 98&#37;&#44; respectively&#46; These figures were significantly higher than with chest radiography &#40;51&#37; and 91&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> It is estimated that ultrasonography can detect very small volumes of PF &#40;5&#8211;20<span class="elsevierStyleHsp" style=""></span>mL&#41;&#44; whereas simple radiography used in an upright position requires 200<span class="elsevierStyleHsp" style=""></span>mL to eliminate the costodiaphragmatic recesses&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a> Ultrasound sensitivity is considered to be 100&#37; for PE volumes &#62;100<span class="elsevierStyleHsp" style=""></span>mL&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> In patients with elevated hemidiaphragm&#44; ultrasonography easily differentiates between subpulmonary PE&#44; subphrenic collection and diaphragm paralysis&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">PF does not reflect ultrasound and appears as a homogeneous black area &#40;anechoic or hypoechoic&#41; delimited by the diaphragm and subdiaphragmatic structures &#40;liver and spleen&#41;&#44; chest wall&#44; collapsed lung &#40;visible as a dense tongue-shaped structure that spontaneously undulates through the heartbeat transmission &#91;caput medusae&#93; and with an edge from which multiple B-lines can emerge&#41; and&#44; occasionally&#44; the pericardium or descending aorta on the left side &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#41;&#46; Hyperechoic floating particles can be seen swirling in the fluid with respiratory and cardiac movements &#40;swirl or plankton sign&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Color Doppler and M-mode can complement two-dimensional examinations&#46; PE shows flow through the color Doppler due to the movement of fluid during cardiac pulsation and respiratory excursions &#40;fluid color sign&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>B&#41;&#46; In M-mode&#44; the lung moves&#44; within the effusion&#44; toward and away from the chest wall during respiration &#40;sinusoid sign&#41;&#46; The corresponding lack of flow or movement is observed in pleural thickening&#44; pleural or peripheral pulmonary masses and dense pleural loculations&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Depending on the PF&#39;s internal echogenicity&#44; 4 effusion patterns can typically be distinguished<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;6</span></a>&#58; &#40;1&#41; anechoic &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>A&#41;&#59; &#40;2&#41; complex nonseptated&#44; in which a combination of echogenic and hypoechoic areas can be observed &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>B&#41;&#59; &#40;3&#41; complex septated&#44; in which floating fibrin strands are found in a hypoechoic space &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>C&#41;&#59; and &#40;4&#41; homogeneously echogenic &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>D&#41;&#46; This classification can be simplified by taking only simple &#40;anechoic&#41; and complex PEs &#40;the remaining previous 3 categories&#41; into account&#46; PF echoes can depict an abundance of protein&#44; fibrin&#44; blood or pus&#46; Whereas anechoic PF can be transudative or exudative&#44; the swirl sign is evidence of an exudate&#44; particularly of a malignant nature&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> There is no absolute correlation&#44; however&#44; between the ultrasound appearance of PF and subsequent classification as a transudate or exudate&#46; In immobile patients&#44; the cellular component of a PE can settle over time through gravitational influence and can create a defined interface with anechoic fluid located above &#40;hematocrit sign&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A number of formulas are based on two-dimensional measurements to calculate PE volume&#46; One simple formula establishes that the PF volume in millimeters is the result of multiplying by 16 the distance in millimeters between the visceral and parietal pleura at the diaphragm&#39;s middle portion&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> However&#44; formulas described in medical literature are not accurate and are rarely used in clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a> PE can be considered at least moderate if it extends beyond the area covered by the 3&#46;5<span class="elsevierStyleHsp" style=""></span>MHz phased-array transducer&#44; with the patient in a sitting position&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> Another semiquantitative approach is to define any PE that only covers one intercostal space as small&#59; a PE between 2 and 4 adjacent intercostal spaces as moderate&#59; and a PE that occupies half the hemithorax as large&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pleural effusion due to heart failure</span><p id="par0080" class="elsevierStylePara elsevierViewall">The presence of B-lines represents thickened interlobular septa or alveolar interstitial syndrome &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; usually the result of heart failure or&#44; less commonly&#44; interstitial lung disease&#44; pulmonary contusion or respiratory distress&#46; Whereas the pleural line is smooth in cases of heart failure&#44; it is usually thickened &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>mm&#41; or irregular in other cases&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Decompensated heart failure would be a probable diagnosis if a mostly bilateral PE is observed and is accompanied by multiple bilateral B-lines &#40;&#8805;3 with a phased-array transducer or &#8805;6 with a linear transducer&#41;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> and a vena cava &#8805;2&#46;1<span class="elsevierStyleHsp" style=""></span>cm in diameter &#40;measured at approximately 2<span class="elsevierStyleHsp" style=""></span>cm from its entry into the right atrium&#41; with inspiratory collapse &#60;50&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a> In pulmonary edema&#44; abundant B-lines converge and can produce a &#8220;white lung&#8221; image under ultrasound&#46; By considering the presence of multiple B-lines as an ultrasound sign of acute heart failure&#44; a study of 1005 patients with acute dyspnea &#40;463 with a cardiac cause&#41; showed that ultrasonography alone was significantly more sensitive &#40;90&#46;5&#37;&#41; and specific &#40;93&#46;5&#37;&#41; than plain radiography &#40;69&#46;5&#37; and 82&#46;1&#37;&#44; respectively&#41; in identifying the cardiac etiology of the dyspnea&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> When clinical information &#40;medical history&#44; physical examination&#44; electrocardiogram and arterial blood gases&#41; was integrated with the ultrasound&#44; sensitivity and specificity for diagnosing acute cardiac decompensation rose to 97&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Malignant pleural effusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">The presence of &#62;1<span class="elsevierStyleHsp" style=""></span>cm thickening&#44; liver metastases or both pleural and diaphragmatic nodules is highly indicative of malignant PE &#40;sensitivity and specificity &#62;80&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a> Massive PE&#44; which is frequently malignant&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">19</span></a> is usually associated with the flattening or inversion of the diaphragm and can be associated with a cephalic paradoxical movement during inspiration&#46; The potential utility of ultrasonography has recently been reported for the diagnosis of an unexpandable &#40;trapped&#41; lung before proceeding with draining a malignant PE&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">20</span></a> A trapped lung is a contraindication for pleurodesis&#44; because for optimal pleural symphysis to be achieved&#44; the visceral and parietal pleura need to be attached&#46; Therefore&#44; the ability to predict the existence of an unexpandable lung using ultrasound would favor the use of chronic tunneled catheters rather than pleurodesis as a symptomatic treatment of malignant PE&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Infectious pleural effusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">As with hemothoraces&#44; empyema characteristically exhibits strong diffuse echogenicity&#44; although it can be anechoic in early stages&#46; They can also be associated with multiple areas that are bright and reflective within the PF&#44; which represent air bubbles produced by gas-forming bacteria in the infectious collection&#46; However&#44; the presence of air in a PE can be secondary to a bronchopleural or esophageal fistula or a previous thoracentesis&#46; Loculations &#40;separate collections of fluid in different areas of the pleural space&#41; and septa &#40;fibrin bands compartmentalize a single pleural collection&#41; are common&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">6</span></a> CT is good at detecting loculations but not septa&#44; whereas ultrasonography &#40;and magnetic resonance&#41; can easily visualize both&#46; In addition to infections&#44; malignant PE or PE from any other cause that has developed over time might develop septa&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> Patients with empyema or complicated parapneumonic effusions displaying a complex septated sonographic pattern are at greater risk of pleural drainage failure and have a higher mortality probability than those without septa&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">22</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Pneumonias are more often located peripherally and can therefore be detected using ultrasonography&#46; Consolidated lungs have a similar echotexture to that of the liver and are frequently observed as hyperechoic heterogeneous areas with irregular edging&#46; Punctate hyperechoic foci within the consolidation moving through the bronchus are representative of dynamic air bronchograms &#40;as opposed to static&#44; typical of atelectasis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pneumothorax diagnosis</span><p id="par0105" class="elsevierStylePara elsevierViewall">Ultrasonography has better performance than chest radiography for detecting pneumothoraces&#46; Published meta-analyses have shown that ultrasonography has an average sensitivity of 80&#8211;90&#37; compared with 40&#8211;50&#37; for plain chest radiography&#59; both techniques have specificities of 99&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">23&#8211;25</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The presence of lung sliding&#44; lung pulse or B-lines rules out pneumothorax in the examined intercostal space&#44; because the parietal and visceral pleura need to be adjacent for these signs to appear&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> Although the lack of lung sliding is characteristic of pneumothorax&#44; the sliding could be due to other causes &#40;in which lung pulse is frequently detected&#41;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a>&#58; apnea or shallow breathing&#44; complete atelectasis&#44; selective intubation of one lung&#44; pleural and pulmonary adhesions &#40;e&#46;g&#46;&#44; pleurodesis&#44; previous inflammatory cases or infections and pneumonectomy&#41;&#44; severe acute pulmonary lesion or subpleural bullae &#40;blebs&#41;&#46; M-mode can be used to easily detect absent lung sliding in the pneumothorax by providing an image with multiple hyperechoic horizontal lines above and below the pleural line &#40;barcode or stratosphere sign&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46; The lack of sliding can also be demonstrated through the lack of power Doppler signal below the pleural line&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The lung point or intersection point between the partially deflated lung &#40;displaying signs of lung sliding&#41; and air from the pleural cavity &#40;absence of sliding&#41; confirm the pneumothorax and can be used to estimate its size &#40;in supine position&#44; the more to the rear the lung point&#44; the greater the pneumothorax&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">16&#44;26</span></a> Thorough scanning and experience is required to detect a pneumothorax&#59; however&#44; a pneumothorax cannot be detected when the lung has completely collapsed&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Guide for performing pleural procedures</span><p id="par0120" class="elsevierStylePara elsevierViewall">The British Thoracic Society recommends all pleural procedures be performed with ultrasound guidance&#44; due to the reduced complications and the greater degree of success with this technique&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a> Ultrasonography is therefore substantially better than physical examinations for identifying suitable puncture points for thoracentesis&#46; One study showed that a needle insertion point determination based on physical examination and chest radiography was inappropriate in 15&#37; of cases &#40;which included the risk of accidentally puncturing an organ&#41;&#44; and ultrasonography helped identify a suitable puncture site in 54&#37; of cases in which physical examination was unable to do so&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a> Numerous studies have shown that the use of ultrasonography is associated with a decreased risk of iatrogenic pneumothorax following thoracentesis&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">29</span></a> In a series of 9320 thoracenteses &#40;diagnostic or therapeutic&#41; performed using ultrasound guidance&#44; pneumothorax and bleeding only occurred in 0&#46;61&#37; and 0&#46;18&#37; of cases&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">30</span></a> In another study&#44; no bleeding complications occurred in 706 cases of ultrasound-guided thoracentesis in patients with uncorrected coagulopathy &#40;INR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;6 or platelets &#60;50&#44;000&#47;&#956;L&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Ultrasonography can be used to estimate the distance between the skin and parietal pleura and&#44; thus&#44; the depth at which aspiration of the PF is possible&#46; In patients with obesity or edema&#44; applying firm pressure with the transducer on the skin surface can cause this distance to be underestimated&#46; The correct identification of anatomical structures&#44; in particular the diaphragm&#44; is essential for ensuring safe access to the pleural cavity&#46; A relatively common mistake among inexperienced staff is to confuse the spleen with an echogenic PE &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#41; or a splenorenal or hepatorenal recess with the diaphragm&#46; The PE should have an estimated depth of at least 1&#46;5&#8211;2<span class="elsevierStyleHsp" style=""></span>cm to attempt a thoracentesis&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Currently&#44; CT-guided or ultrasound-guided pleural biopsies have replaced the need to perform the biopsies blind&#44; particularly if the parietal pleura is thickened 1<span class="elsevierStyleHsp" style=""></span>cm or more or if the pleura has nodules&#44; in which case&#44; the diagnostic sensitivity is greater than 80&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">33&#44;34</span></a> In malignant PEs&#44; the yield increases when at least 6 biopsies are taken in a basal area&#44; just above the diaphragm&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a> Pleural masses can be biopsied with ultrasound guidance&#44; even in the absence of associated PE&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Although uncommon&#44; an intercostal artery can accidentally be lacerated during a thoracentesis or pleural biopsy and cause an iatrogenic hemothorax&#46; This can occur due to the tortuosity of the intercostal arteries extending unprotected under the costal groove up to 6&#8211;10<span class="elsevierStyleHsp" style=""></span>cm of the costovertebral joint<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> and due to the presence of collaterals that cross the intercostal space in a cephalocaudal manner&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">36</span></a> Tortuosity is more prevalent in the elderly population&#46; For this population or in cases in which punctures need to be performed near the spine&#44; vascular Doppler ultrasonography can help identify vulnerable vessels in the intercostal space &#40;sensitivity &#62;85&#37;&#41; and avoid lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">37</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Finally&#44; ultrasonography can guide thoracoscopic access to the pleural cavity&#44; even if there is no PE&#44; so as to be able to identify pleural adhesions&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Ultrasonography should be used for all types of pleural punctures &#40;thoracentesis&#44; drainage tubes and pleural biopsy&#41;&#44; provided that the appropriate equipment is available and the operator has at least a minimum of experience&#46; It is particularly useful for bedridden and critically ill patient&#44; and can provide immediate diagnostic information regarding cases such as pneumothoraces&#44; PE&#44; pulmonary edemas and pulmonary consolidation&#46; Ultrasonography is more sensitive than chest radiography for detecting the presence of fluid or air in the pleural cavity and for differentiating between PE and pulmonary condensation or pleural thickening&#46; A-lines are consistent with an aerated lung&#44; whereas an edematous lung typically presents B-lines&#46; Finding pleural or diaphragmatic masses or nodules should lead to the strong suspicion of malignancy&#44; and if complex septated PEs are observed in the context of pleuropulmonary infection&#44; it would be advisable to insert an intrapleural catheter&#46; In the future&#44; ultrasonography could be used to help better distinguish between malignant and benign pleural diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The author declares that there are no conflicts of interest&#46;</p></span></span>"
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            0 => "Thoracic ultrasound"
            1 => "Pleural effusion"
            2 => "Pneumothorax"
            3 => "Thoracentesis"
          ]
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          "titulo" => "Palabras clave"
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            0 => "Ecograf&#237;a tor&#225;cica"
            1 => "Derrame pleural"
            2 => "Neumot&#243;rax"
            3 => "Toracocentesis"
          ]
        ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pleural ultrasonography is useful for identifying and characterizing pleural effusions&#44; solid pleural lesions &#40;nodules&#44; masses&#44; swellings&#41; and pneumothorax&#46; Pleural ultrasonography is also considered the standard care for guiding interventionist procedures on the pleura at the patient&#39;s bedside &#40;thoracentesis&#44; drainage tubes&#44; pleural biopsies and pleuroscopy&#41;&#46; Hospitals should promote the acquisition of portable ultrasound equipment to increase the patient&#39;s safety&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a pleural es &#250;til para identificar y caracterizar derrames pleurales&#44; lesiones pleurales s&#243;lidas &#40;n&#243;dulos&#44; masas&#44; engrosamientos&#41; y neumot&#243;rax&#46; Asimismo&#44; se considera el est&#225;ndar asistencial para guiar procedimientos intervencionistas sobre la pleura a la cabecera del paciente &#40;toracocentesis&#44; tubos de drenaje&#44; biopsias pleurales y pleuroscopia&#41;&#46; Los hospitales deber&#237;an favorecer la adquisici&#243;n de equipos de ultrasonido port&#225;tiles en beneficio de la seguridad del paciente&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Porcel JM&#46; Ecograf&#237;a pleural para cl&#237;nicos&#46; Rev Clin Esp&#46; 2016&#59;216&#58;427&#8211;435&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography device with phased array and linear probes for thoracic examination&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Usual patient positions for ultrasound examination of the thorax&#44; following parallel craniocaudal lines&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pleural line &#40;&#40;A&#41;&#44; arrowheads&#41; with power Doppler signal &#40;B&#41; under the same&#44; indicating the presence of lung sliding&#46; Note the acoustic shadow of the adjacent ribs &#40;asterisks&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography in B-mode showing lines &#40;A&#41; &#40;arrowheads&#41; and &#40;B&#41; &#40;arrows&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography in M-mode showing &#8216;seashore&#8217; signs &#40;A&#41; and &#8216;barcode&#8217; signs &#40;B&#41;&#46; The arrowheads indicate the pleural line&#46;</p>"
        ]
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Left pleural effusion &#40;PE&#41; with usual anatomical limits &#40;A&#41;&#46; Color Doppler &#40;B&#41; showing pleural fluid movement &#40;color fluid sign&#41;&#46; Note the presence of B &#40;arrowheads&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pleural fluid echogenicity patterns&#58; anechoic &#40;&#40;A&#41;&#58; arrows indicating thickening of the diaphragm with a malignant cause&#41;&#44; complex non-septated &#40;&#40;B&#41;&#58; arrowheads indicating various echogenic points&#44; and the arrow indicating a malignant diaphragmatic node&#41; complex septated &#40;C&#41; and homogeneously echogenic &#40;&#40;D&#41;&#58; hemothorax&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ultrasound images in B-mode of the inferior vena cava &#40;IVC&#41; entering the right atrium &#40;RA&#41;&#46; In M-mode&#44; the IVC is noted to be 2&#46;1<span class="elsevierStyleHsp" style=""></span>cm during expiration &#40;Exp&#41; that collapses during inspiration &#40;Insp&#41;&#46;</p>"
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                      "titulo" => "BLUE-protocol and FALLS-protocol&#58; two applications of lung ultrasound in the critically ill"
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                      "doi" => "10.1378/chest.14-1313"
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                      "titulo" => "Screening performance characteristic of ultrasonography and radiography in detection of pleural effusion&#58; a meta-analysis"
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                            2 => "X&#46;W&#46; Cui"
                            3 => "A&#46; Ignee"
                            4 => "M&#46; Hocke"
                            5 => "T&#46;O&#46; Hirche"
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                  "host" => array:1 [
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                            4 => "E&#46; Antipa"
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                      "titulo" => "The diagnostic value of transthoracic ultrasonographic features in predicting malignancy in undiagnosed pleural effusions&#58; a prospective observational study"
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                          "etal" => true
                          "autores" => array:6 [
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                            1 => "D&#46; Ferreira"
                            2 => "S&#46;S&#46; Dias"
                            3 => "M&#46; Schuhmann"
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                      "titulo" => "Ultrasonographic evaluation of the pleura"
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                          "autores" => array:3 [
                            0 => "J&#46; Cardenas-Garcia"
                            1 => "P&#46;H&#46; Mayo"
                            2 => "E&#46; Folch"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46; Usta"
                            1 => "M&#46; Mustafi"
                            2 => "G&#46; Ziemer"
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                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1510/icvts.2009.222273"
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