Download - Dr. Dinakar
![Page 1: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/1.jpg)
ETT Placement confirmationprediction of post extubation stridor, Successful Extubation & Diaphagramatic Function
Dr. Dinakara PrithvirajChief Neonatalogist & pediatric intensivistVydehi institute of medical sciences& RC
For Next Generation
![Page 2: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/2.jpg)
Introduction
• Emergency sonography in Pediatrics has evolved to become one of the most versatilemodalities for diagnosing and guidingtreatment of critically ill patients.
• It complements rather than replacestraditional sonology.
![Page 3: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/3.jpg)
Why we need to learn doing U/S inPediatrics
• It is usually not feasible to have a cardiologist orsonographer available on immediate call on a 24-h basis.
• Allows the ability to perform serial bedsideexaminations and allows the important assessment and reassessment of the adequacy and efficacy of therapy.
![Page 4: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/4.jpg)
ACEP/ SCCM guidelines includeUSG by Pediatricians
In critically ill patients physical examination is quitelimited and inaccurate.• USG has potential to reinvigorate physical exam,improving accuracy.• Important attributes: portability, lack of radiation,repeatability, absence of consumables, being battery powered , plus Information can be stored fordocumentation, transmission & consultation.
![Page 5: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/5.jpg)
Remember• USG may appear complex at first sight butsimply requires a change in thinking.
• Once the process has been learned, a step bystep use will make it a routine
![Page 6: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/6.jpg)
Remember
• Inappropriate interpretation or application of data gained by a poorly skilled user may have adverse consequences.
• So adequate training is essential and this must beindividualized and tailored to the specific needsand applications of the user.
![Page 7: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/7.jpg)
![Page 8: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/8.jpg)
![Page 9: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/9.jpg)
![Page 10: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/10.jpg)
AIRWAY ULTRASOUND
Trachea
![Page 11: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/11.jpg)
AIRWAY ULTRASOUND
Trachea
Tube in Esophagus
![Page 12: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/12.jpg)
2 Signals Bad
![Page 13: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/13.jpg)
![Page 14: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/14.jpg)
![Page 15: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/15.jpg)
Transverse View Showing ETT
![Page 16: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/16.jpg)
Longitudinal View Showing ETT
![Page 17: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/17.jpg)
ETT Position Assesment with Ultrasound
• Proximal ETT Malposition (ETT too High)-Measure distance from vocal cord to tip of the tube-Tip of tube should not be visible above sternal notch• Distal ETT Malposition-Unilateral pleural sliding may indicate mainstem intubation -Combination of both may eleminate the need for chest x-ray (Study Underway)
![Page 18: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/18.jpg)
![Page 19: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/19.jpg)
Laryngeal Ultrasound-An useful method in predicting post extubation stridor
• Identifying patients at high risk for Re-intubation due to stridor
-Cuff-leak test: was widely used but its application is limited due to controversial result
-The air-column width during deflation is a potential predictor of post extubations stridor
![Page 20: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/20.jpg)
• Air column during balloon calf inflation(hyper echoic)
• True cords are over both the side of air column(Hypo-echoic)
• Cartilages are behind the true vocal cords & beside the air column (hyper echoic)
![Page 21: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/21.jpg)
• Air column during balloon-cuff deflation
-Air column width increased
-This patient did not develop post extubation stridor
![Page 22: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/22.jpg)
• Air column during baloon cuff defletion-air column width increasedThis patient did not develop post extubation stridor
• Air column during baloon cuff inflation(hyper echoic)
• True cords are over both side of the air column(hypoechoic)
• Cartilages are behind the true vocal cords and beside the air column (hyper echoic)
![Page 23: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/23.jpg)
LARYNGEAL ULTRASOUND:An USEFUL METHOD IN PREDICTING POST EXTUBATION STRIADOR
• The air column width during calf deflation is a potential predictor of post extubation stridor
![Page 24: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/24.jpg)
Can you extubate this patient?
![Page 25: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/25.jpg)
![Page 26: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/26.jpg)
Diaphragmatic Movement evaluation with Thorasic Ultrasound
• Thoracic ultrasound-lack of ionizing radiation-bedside procedure-should be the method of choice in the investigation of suspected hemidiaphgramatic movement abnormality• Proposed technique-changes in diaphragm thickness during contraction-chronically paralyzed diaphragm is atrophic and doesn't thicken during inspiration(contraction)
![Page 27: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/27.jpg)
Diagnosis of Diaphgramatic Paralysis• Chest Radiograph-Elevated hemidiaphragm & atelectasis• Fluoroscopy-requires patient transportation-uses iniozing radiation-sniff test:paradoxical elevation of paralyzed hemidiaphragm with inspiration(>90%)
![Page 28: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/28.jpg)
Diaphragmatic Paralysis• Unilateral vs bilateral• Increase in load on the other respiratory accessory muscle-respiratory failure• Clinical manifestations• -DOE,orthopnoea• -Rapid shallow breathing• Paradoxical abdominal wall retraction during inspiration• Hypoxemia due to atelectasis• Hypercapnoea & hypoxemia• Severe cases (Ventilatory failure, severe pulmonary
hypertension, secondary erythrocytosis)
![Page 29: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/29.jpg)
Challanges• During DB, descending lung may obscure the
diaphragm -The probe should be displaced caudally with angle adjustment to maintain a perpendicular approach of the hemi diaphragmatic motion• Patients with respiratory disease and dysonoea-increased respiratory effort can result in greater chest wall movement and cause the ribs & lung to obscure the images• Visualization of the left hemidiaphragm is recognised
as more difficult due to the smaller window of the spleen as compared with the liver window
![Page 30: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/30.jpg)
Diaphragmatic Movement & contractility evaluation by thoracic ultrasound
• Always identify the diaphragm• Don’t confuse the hepato renal pouch or
spleen renal recess for diaphragm• Sub diaphragmatic device insertion may have
lethal effect• Exercise particular caution in post CABG cases• Unilateral diaphragmatic dysfunction
![Page 31: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/31.jpg)
![Page 32: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/32.jpg)
![Page 33: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/33.jpg)
Probe position for dome movement
![Page 34: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/34.jpg)
DIAOHGRAM MOVEMENT AND CONTRACTILITY EVALUATION BY THORASIC ULTRASOUND
![Page 35: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/35.jpg)
![Page 36: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/36.jpg)
![Page 37: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/37.jpg)
![Page 38: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/38.jpg)
Diaphragmatic Paralysis: The use of M Mode Ultrasound for Diagnosis in Adult
• Normal diaphragm-Sniff test: sharp upstroke(normal caudal movement of the diaphragm during inspiration)
• Diaphragmatic Paralysis-No active caudal movement of the diaphragm with inspiration-sniff test: abnormal paradoxical movement (cranial movement on inspiration)
![Page 39: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/39.jpg)
Manoever begun at the end of normal expiration
• Quiet Breathing(QB):-Diaphragm excursion(inspiratory amplitude)1.5-2 cm-lower limit for women 0.9 cm-lower limit for men 1 cm
• Voluntary Sniffing (VS)-Diaphragm excursion(inspiratory amplitude)2.5-3cmLower limit for women 1.6cmLower limit for men 1.8cmNormal caudal movement (sharp upstroke)of the diaphragm during inspiration
• Deep Breathing(DB)Diaphragm excursion (inspiratory amplitude) 6-7cm-lower limit ofor woman 3.7 cm-lower limit for men 4.7 cm
![Page 40: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/40.jpg)
Diaphragmatic Paralysis: The Use of M mode ultrasound for diagnosis in adult
• Sniff Test• -Normal DiaphragmSharp upstroke (normal caudal movement of diaphragm during inspiration)
-Diaphragmatic Paralysis No caudal movement of diaphragm with inspirationAbnormal paradoxical cranial movement on inspiration
2
![Page 41: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/41.jpg)
Ultrasonography Diagnostic criterion for severe diaphragmatic dysfunction after CABG
• After cardiac surgery-surgery related phrenic nerve injury
-severe diaphragmatic dysfunction can prolong mechanical ventilation
-(US)probe is positioned on right mid-axillary line
-Diaphragmatic excursion measured from the end of normal expiration(c) to end of maximal inspiratory effect (D)
![Page 42: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/42.jpg)
Ultrasonography Diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery
• Best E< 25 mm was associated with severe diaphragmatic dysfunction
• None of the patients with uncomplicated post operative course have best E< 25mm, either before or after surgery
• Excellent negative likehood ratio of best E<25 mm
![Page 43: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/43.jpg)
![Page 44: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/44.jpg)
Paralysis weakness
![Page 45: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/45.jpg)
Probe position for diaphragm muscle thickness
![Page 46: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/46.jpg)
1. MOTION
2. AMPLITUDE
3.FORCE OF VELOCITY
Thickness inspiratory - thickness expiratory
WEAKNESS
PARALYSIS
LOW AMPLITUDE
PARADOXICAL MOVEMENT1.Can follow up with US
2.If phrenic nerve damage or paralysis
- Prolonged ventilation needed
4.THICKNESSthickness expiratory
TF[2.3]=
inspiratory[25mm]
expiratory [17mm]
Post operative diaphragm Amplitude maximum inspiration should be >25 (good)Weaning from ventilation – liver/spleen 1.1 cm displacement
1.Successful extubation-(a). Amplitude >25mm (b).TDI % >30%2. D/D (a) weakness (b) paralysis 3.Follow up of diapgramatic motion strength
![Page 47: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/47.jpg)
Ventilation and Asynchrony
![Page 48: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/48.jpg)
Ventilation and synchrony
![Page 49: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/49.jpg)
CONCLUTION• M mode ultrasonography is a relatively simple and
accurate test for diagnosing paralysis of diaphragm
• Diaphragmatic function assessment with ultrasound is important in patients with prolonged ventilation
• Ultrasonography should be considered to exclude severe diaphragmatic dysfunction following cardiac surgery in daily practice with the advantages of being fully non invasive & easilty available in ICU
![Page 50: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/50.jpg)
Remember• USG may appear complex at first sight butsimply requires a change in thinking.
• Once the process has been learned, a step bystep use will make it a routine
![Page 51: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/51.jpg)
Remember cont..
• Inappropriate interpretation or application of data gained by a poorly skilled user may have adverse consequences.
• So adequate training is essential and this must beindividualized and tailored to the specific needsand applications of the user.
![Page 52: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/52.jpg)
Lung Ultrasound Ready for Prime TimeIt is for you
![Page 53: Dr. Dinakar](https://reader035.vdocuments.pub/reader035/viewer/2022062412/587ae3b11a28ab542b8b6e2b/html5/thumbnails/53.jpg)