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array:24 [ "pii" => "S2387020620300723" "issn" => "23870206" "doi" => "10.1016/j.medcle.2019.11.003" "estado" => "S300" "fechaPublicacion" => "2020-04-10" "aid" => "5038" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2019" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2020;154:260-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0025775319307109" "issn" => "00257753" "doi" => "10.1016/j.medcli.2019.11.001" "estado" => "S300" "fechaPublicacion" => "2020-04-10" "aid" => "5038" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2020;154:260-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "PDF" => 2 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Revisión</span>" "titulo" => "Aplicaciones clínicas de la ecografía pulmonar" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "260" "paginaFinal" => "268" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Clinical applications of pulmonary ultrasound" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2044 "Ancho" => 2917 "Tamanyo" => 602729 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ilustración pulmonar y ecográfica con diferentes tipos de entidades respiratorias. 1) Adenopatía supraclavicular por afectación neoplásica. 2) Ecografía normal en modo B, signo del murciélago y en modo M, el signo de la orilla del mar. 3) Atelectasia pulmonar de tipo obstructivo por lesión endobronquial, en la que se visualiza pequeño derrame pleural y el signo del broncograma líquido. 4) Masa pulmonar periférica. 5) Enfermedad intersticial con engrosamiento y desestructuración de la línea pleural e incremento de las líneas B. 6) Movilidad diafragmática, imagen superior en modo B y en la inferior modo M en las que se observa la excursión diafragmática con la respiración. 7) Derrame pleural en modo B con signo del broncograma aéreo, signo de la medusa e implantes pleurales diafragmáticos. Modo M, signo del sinusoide. 8) Derrame pleural complicado con tabiques en su interior. 9) Consolidación pulmonar infecciosa, ausencia de línea pleural, bordes irregulares y broncograma aéreo. 10) Fractura costal, signo de la chimenea. 11) Neumotórax con punto pulmonar, modo B una parte de la línea pleural presenta líneas B y en la otra mitad están ausentes, lo que corresponde al lugar de contacto y separación de la pleura parietal y visceral. Modo M, signo del punto pulmonar. 12) Neumotórax, en el modo B ausencia de líneas B y del deslizamiento pulmonar con presencia de líneas A. Modo M, signo del código de barras.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Aurelio Luis Wangüemert Pérez" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Aurelio Luis" "apellidos" => "Wangüemert Pérez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020620300723" "doi" => "10.1016/j.medcle.2019.11.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620300723?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775319307109?idApp=UINPBA00004N" "url" => "/00257753/0000015400000007/v1_202003280612/S0025775319307109/v1_202003280612/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2387020620300711" "issn" => "23870206" "doi" => "10.1016/j.medcle.2019.09.004" "estado" => "S300" "fechaPublicacion" => "2020-04-10" "aid" => "5011" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2020;154:269-74" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Acute lymphoblastic leukemia: From aminopterin to CAR T cells" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "269" "paginaFinal" => "274" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leucemia aguda linfoblástica: de la aminopterina a las células CAR T" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 903 "Ancho" => 1667 "Tamanyo" => 67390 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Estimated cure rate of childhood ALL (blue columns) and adult ALL (red columns) from the 1950s to the present.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Josep-Maria Ribera Santasusana" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Josep-Maria" "apellidos" => "Ribera Santasusana" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620300711?idApp=UINPBA00004N" "url" => "/23870206/0000015400000007/v1_202004071208/S2387020620300711/v1_202004071208/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020620300449" "issn" => "23870206" "doi" => "10.1016/j.medcle.2019.07.007" "estado" => "S300" "fechaPublicacion" => "2020-04-10" "aid" => "4962" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2020;154:257-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "New digital healthcare technologies" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "259" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevas tecnologías digitales en la práctica médica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "César Morcillo Serra, Jose Luis González Romero" "autores" => array:2 [ 0 => array:2 [ "nombre" => "César" "apellidos" => "Morcillo Serra" ] 1 => array:2 [ "nombre" => "Jose Luis" "apellidos" => "González Romero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775319305160" "doi" => "10.1016/j.medcli.2019.07.004" "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/S0025775319305160?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620300449?idApp=UINPBA00004N" "url" => "/23870206/0000015400000007/v1_202004071208/S2387020620300449/v1_202004071208/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Clinical applications of pulmonary ultrasound" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "260" "paginaFinal" => "268" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Aurelio Luis Wangüemert Pérez" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Aurelio Luis" "apellidos" => "Wangüemert Pérez" "email" => array:1 [ 0 => "aureliowp@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumología, Hospital San Juan de Dios, Santa Cruz de Tenerife, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aplicaciones clínicas de la ecografía pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2273 "Ancho" => 2500 "Tamanyo" => 291699 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pleural effusions. A) Presence of minimal right pleural effusion (white asterisk). B) Uncomplicated pleural effusion (white dot). C) Colour Doppler. Fluid colour sign. D) Complicated pleural effusion with the presence of septa inside (white arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lung ultrasound (LU) is a complementary test in constant evolution due to the multitude of applications it has for the diagnosis and monitoring of respiratory diseases, as well as for the implementation of interventional techniques. It can be repeated as necessary, as it offers advantages such as the absence of radiation, portability, low cost and real-time imaging. Two of its drawbacks are: air and bone limitation and being operator-dependent.</p><p id="par0010" class="elsevierStylePara elsevierViewall">LU is a tool that complements the case history and physical examination. It should be used in processes that help the diagnostic approach and subsequent treatment, and should not replace other tools (computed tomography, magnetic resonance imaging) when required.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Due to the diversity of lung processes that can be found, it is important to maintain a routine of daily training so as to preserve sharpness and obtain accurate diagnoses: an occasional use for specific procedures is of little use. There is little specific literature related to the learning curve in LU, but it has been described that the indications, systematic lung examination, technical skills and findings increase with experience, with less examination time and with little interobserver variability. LU differs from other tests in that the interpretation of the images and the recognition of the diseases are based on the analysis of the ultrasonographic devices, but this does not become essential in the emergency department and intensive medicine because they need quick responses. However, other services such as pulmonology or radiology use ultrasonography to differentiate more complex diseases or as a guide in invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In recent years, LU has been included in routine clinical practice in different medical and surgical specialties, such as primary care, emergency, pulmonology, internal medicine and thoracic surgery. The application of the <span class="elsevierStyleItalic">Bedside Lung Ultrasound in Emergency</span> (BLUE) protocol has been very useful in intensive care units, as it detects the causes of acute respiratory failure in a few minutes, such as acute pulmonary oedema, exacerbated chronic obstructive pulmonary disease (COPD), pneumonia or pulmonary embolism. Probably, in the near future or even now, the integration of LU can be an important tool in the diagnosis and monitoring of different respiratory diseases. In addition, the creation of a <span class="elsevierStyleItalic">software</span> which assesses the elasticity of pleuropulmonary tissue is already being used to further refine the diagnosis of certain respiratory diseases. This article attempts to address the most important theoretical aspects of LU but does not replace in any way the practical training that the medical professional should receive for the acquisition of the minimum skills.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">General considerations in lung ultrasound</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study of the chest through ultrasound is done with several probes and in multiple ways. It is advisable to have a linear probe (7.5−10 Hz), which deepens less, but offers greater image resolution (studies of the chest wall and pleura) and of a convex probe (3.5−5 Hz), which goes deeper but offers lower image resolution (study of pulmonary processes). It is also useful to use colour doppler to study moving structures and to distinguish anatomical structures.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Before proceeding with the ultrasound examination, we must analyse the complementary tests or case history of the patient. There are different ways to start the ultrasound scan; one of them is based on the division of quadrants in each hemithorax, listing and evaluating them. Another possibility is to start at the lower intercostal spaces at the paravertebral level and go through all the intercostal space until reaching the parasternal area and repeat the same manoeuvre from the base to the apex.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> The important thing is that the examination be orderly and systematic.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The information collected in the examination can be represented in two modes: a) B-mode, the most used method, with which two-dimensional images are obtained in motion; b) M-mode, with which one-dimensional images are obtained in motion over time.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The ultrasound images obtained are shown in a grey scale. The most intense ultrasonogram appears white while the ultrasonogram that does not reflect any sound waves from the organs appears black. The following terms are used to define echogenicity, depending on the amplitude of the reflected wave.</p><p id="par0045" class="elsevierStylePara elsevierViewall">When no sound wave is reflected and the image appears black it is <span class="elsevierStyleItalic">anechoic,</span> as in pleural effusion (PE); it is <span class="elsevierStyleItalic">isoechogenic</span> when the echoes are of intensity comparable to the surrounding tissue (kidneys, spleen); it is <span class="elsevierStyleItalic">hyperechogenic</span> if the echoes are more intense than the tissue (the diaphragm) and is <span class="elsevierStyleItalic">hypoechogenic</span> when it is weaker than tissue (peripheral lung masses).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Normal findings on lung ultrasound</span><p id="par0050" class="elsevierStylePara elsevierViewall">Under normal conditions, the chest wall contains layers of echogenic soft tissue that represent subcutaneous cell tissue and muscle tissue. The ribs appear as an echogenic curved line and, below this line, a posterior acoustic shadow produced by the bone of the rib. The pleural line appears between the ribs and below the rib line. With the transducer in a cross-sectional position to the ribs, the posterior shadow of the ribs and the pleural line make up the <span class="elsevierStyleItalic">bat sign</span>. In real time, we identify the sliding of the 2 pleural surfaces known as the <span class="elsevierStyleItalic">pleural sliding sign</span><a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> and, in M-mode, the <span class="elsevierStyleItalic">seashore sign</span> (horizontal lines above the pleural line and a mottled appearance underneath) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The healthy lung parenchyma is not visible below the pleural line because ultrasound is attenuated by air, producing different artifacts<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a><span class="elsevierStyleSup">−</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Lines A or reverberation artefact: they are horizontal lines that are hyperechogenic, parallel and equidistant from each other, located at a multiple distance below the pleural line between the transducer and the pleural line.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">B lines or comet tail artefact: they are hyperechogenic vertical lines originating from the pleural line that continue to the end of the ultrasound image. They are produced by reflection of the ultrasound inside the interlobular septum. Under normal conditions one or 2 can be detected, in COPD patients they may be decreased and in interstitial lung diseases, pulmonary oedema, acute respiratory distress syndrome or in carcinomatous lymphangitis they may be increased.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Lines <span class="elsevierStyleSmallCaps">C</span>: are horizontal hyperechogenic lines located at a non-multiple distance between the transducer and the pleural line.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Z lines: they are vertical hyperechogenic lines initiated in the pleura, but that do not reach the end of the image.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pathological findings on lung ultrasound</span><p id="par0080" class="elsevierStylePara elsevierViewall">Next, we will describe the ultrasound findings that we find in different diseases but that should always be accompanied by a clinical context to reach a correct diagnosis, since in many cases the ultrasound characteristics are not exclusive to one entity.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Chest wall</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Rib fractures</span><p id="par0085" class="elsevierStylePara elsevierViewall">Thoracic trauma is an excellent indication for LU because of its proximity to the transducer and because it is more sensitive than the chest x-ray for the detection of rib and sternal fractures.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> It is even more precise for acute fractures, in which the interruption of the rib line is seen and even the <span class="elsevierStyleItalic">chimney sign</span>, which are vertical reverberations that start at the beginning of the fracture (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). If the rib fracture has weeks of progression, sonographically we will observe an irregular and pseudonodular linear image in the rib cortex with posterior acoustic shadow, which corresponds to the fracture callus. Hematomas and displacements between 2-bone fragments secondary to a rib fracture will be sonographically visualized as hypoechogenic images around the fracture. Despite this, the complementary test that is currently still used for diagnosis is radiography.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Tumor disease</span><p id="par0090" class="elsevierStylePara elsevierViewall">The chest wall can be affected by both benign and malignant tumour processes. Benign soft tissue lesions, such as lipomas, are characterized by being well circumscribed, usually hypoechogenic, homogeneous and hypovascular. It is important to differentiate malignant lesions of bone tissue, such as bone metastasis, from a rib fracture since, in the 2nd case, there is a rupture of the cortical bone and an increase in soft tissue, but in metastasis there is an increase in the vascularity studied with the colour doppler. Other characteristics of malignant lesions are irregular margins: generally, hypoechogenic texture that is combined with non-homogeneous hyperechogenic portions and invasion of adjacent structures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Neurogenic tumours that are located at the subcostal level can be confused with pleural lesions and in LU they will appear as homogeneous, hypoechogenic and fusiform.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Supraclavicular lymphadenopathies</span><p id="par0100" class="elsevierStylePara elsevierViewall">Ultrasound will allow to characterize lymphadenopathies and guide their puncture-biopsy, if appropriate, with advantages over other tests such as computed tomography. The ultrasonographic characteristics together with a detailed medical history allow us to discern malignancy and benignity and guide the histological study when necessary.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Metastatic lymphadenopathies are characterized by showing a heterogeneous echogenicity, loss of central fatty hilum, poor definition and poor mobility. Their margins show irregularities when there is extracapsular dissemination (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Lymphadenopathy secondary to lymphoma has a homogeneous and hypoechogenic echogenicity, are rounded, well defined and with good mobility. Unlike the previous ones, the echogenicity of inflammatory lymphadenopathies shows hypoechogenic margins, preserve central fatty hilum and are longitudinal. There will also be differences in the vascularity of these lymphadenopathies: they are irregular in metastatic and lymphomas and regular in inflammatory.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a></p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Thoracic cavity</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pleura</span><p id="par0110" class="elsevierStylePara elsevierViewall">The pleura is involved in numerous disorders that occur as an isolated disease, or as a complication of respiratory, chest or abdominal wall diseases. LU has become an essential tool for the evaluation and diagnosis of this type of diseases.</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pneumothorax</span><p id="par0115" class="elsevierStylePara elsevierViewall">Currently, LU is a useful technique for the detection, extent assessment and resolution evaluation of pneumothorax, with greater sensitivity than a chest radiograph and a similar specificity.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The absence of DSLPL and B lines along with the presence of A lines and the <span class="elsevierStyleItalic">lung point sign</span> (point of separation of the visceral and parietal pleura) determine the diagnosis of pneumothorax (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The location of the lung point makes it possible to assess the magnitude of the pneumothorax and the need for endothoracic drainage; it is necessary if the location is in the mid axillary line and a conservative attitude should be maintained if it is anterosuperior, at the level of the second intercostal space.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17–19</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Ultrasound is also becoming very important after interventional diagnostic procedures (ultrasound-guided lung biopsies, central venous catheterization or thoracentesis) or when pneumothorax is suspected, since it is a quick and comfortable bedside examination, preventing the use of radiation techniques.</p><p id="par0130" class="elsevierStylePara elsevierViewall">There are also cases with absence of pneumothorax but with DSLPL decrease or even without it. For example: COPD with pulmonary emphysema also has a decrease in B lines. In respiratory distress syndrome, B lines are increased, and atelectasis or selective intubation will have absence of DSLPL due to lack of lung tissue airing.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In patients with subcutaneous emphysema secondary to a pneumothorax or due to other causes, the characteristic feature is the presence of E lines, which are vertical hyperechogenic lines originating from the start of the ultrasound image.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–23</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pleural effusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">The diagnosis of PE is achieved by radiography from 150 ml of pleural fluid in the posteroanterior projection and 75 ml in lateral projection, approximately. However, ultrasound detects it from 5 ml (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>), with a sensitivity and specificity of 94 and 99% compared to the chest X-ray, which is 51 and 91%, respectively.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24–26</span></a> The greater sensitivity of the ultrasound in pleural effusion makes it almost essential for routine clinical practice in this area.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Depending on the origin of the PE, LU can show different types of images (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>): a) internal echoes without septa (uncomplicated PE); b) internal echoes with septa (complicated PE); c) diffuse echogenic (haemothorax); d) anechogenic (heart failure). Transudates are usually anechoic, while exudates can be anechoic by up to 14%.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,28</span></a> (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>).</p><p id="par0150" class="elsevierStylePara elsevierViewall">In the most basal regions, a passive lung atelectasis that moves over the PE can be observed and, together with the heartbeat, generates the <span class="elsevierStyleItalic">jellyfish sign</span>. The breathing movement of the visceral pleura on M-mode produces the <span class="elsevierStyleItalic">sinusoid sign</span>.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Malignant PEs can produce the <span class="elsevierStyleItalic">swirl sign</span>, which are echoes inside the PE that move in a spiral and, although they are not pathognomonic, they do guide towards this etiology.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,30</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The volume of the PE can be calculated by different formulas or qualitatively, depending on the experience of the examining physician. A simple and approximate method is to measure the maximum distance between the lung with atelectasis and the chest wall in maximum inspiration and multiply it by 20.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The entire PE should be examined for the possible identification of pleural nodules, which constitutes the most specific sign of malignancy. They are usually nodules greater than 5 mm and the most affected region is the diaphragmatic pleura.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,32</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In cases of doubt between a pleural thickening or a PE, the colour doppler will be observed in the case of the latter, due to PE movement in the pleural cavity: this is known as the <span class="elsevierStyleItalic">fluid colour sign</span><a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><p id="par0175" class="elsevierStylePara elsevierViewall">A hydropneumothorax can be identified by reverberation artefacts inside the PE: it is indicative of the presence of air and it is known as the <span class="elsevierStyleItalic">curtain sign</span>.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Solid pleural disease</span><p id="par0180" class="elsevierStylePara elsevierViewall">Pleural disease can be benign and malignant.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Benign pleural disease is rare and will be visualized as an echogenic and well-defined image, such as lipomas. The fibrous tumour of the pleura is defined sonographically as a homogeneous, hypoechogenic pleural mass with preserved margins. The malignancy of the lesion should be suspected when anechogenic or hyperechogenic foci due to necrosis or haemorrhage are observed.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Malignant pleural disease, such as pleural metastases, will appear with PE and will favour the examination of the entire pleural cavity. They manifest as nodular or flattened and broad-based, hypoechogenic or echogenic lesions.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Mesotheliomas will occur with PE along with irregular, heterogeneous and hypoechogenic thickening, with invasion of the chest wall and diaphragm.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Diaphragm</span><p id="par0195" class="elsevierStylePara elsevierViewall">The diaphragm evaluation can be used in different clinical situations: diaphragmatic paralysis, post-surgical diaphragmatic dysfunction, critical patient evaluation, evaluation of the <span class="elsevierStyleItalic">weaning</span> in mechanical ventilation, diaphragmatic function in COPD, etc.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The study of the diaphragmatic movement will be carried out with a convex probe in B-mode and with the patient in dorsal decubitus position. The transducer will be located at the subcostal-abdominal level, taking as reference the liver for the right diaphragm and the spleen for the left diaphragm in B-mode. The left hemithorax implies more difficulties due to the gastric chamber. Once located, we change to M-mode, we measure the diaphragmatic excursion (amplitude of the diaphragm), which will be different if the breathing is deep (1−7 cm), slow (0.3–1.8 cm) or <span class="elsevierStyleItalic">sniffing</span> (nasal) (0.5–2.9 cm), and its contraction speed. The thickness of the diaphragm is measured with a linear probe in the so-called phrenic point, which is located in the anterior axillary line, where the diaphragm displaces the lung with respiratory movements. Under normal conditions it measures between 1.5 and 2.8 mm. Due to the changes in the thickness of the diaphragm in the respiratory cycle, we must calculate the thickening fraction to assess the proper functioning of the diaphragm (thickening fraction = [final thickness inspiration-final thickness expiration]/final thickness expiration) with normal values between 28 and 96%. With all this, ultrasound is a reproducible method with little interobserver variability that allows dynamic observation in the recovery of diaphragmatic dysfunction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39–43</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Pulmonary parenchyma</span><p id="par0205" class="elsevierStylePara elsevierViewall">Peripheral lung parenchyma abnormalities can be examined with LU, although chest computed tomography continues to be the method of choice for the assessment of the entire lung parenchyma. A non-pathological lung parenchyma would result in a normal ultrasound, although, sometimes, we can study the central respiratory processes depending on its extension to the periphery and the ultrasonographic window offered.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Atelectasis</span><p id="par0210" class="elsevierStylePara elsevierViewall">LU will visualize atelectasis with subpleural involvement, and the findings will depend on the cause.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Passive atelectasis is caused by lung compression due to the existence of PE. The parenchyma would show a triangular arrangement with irregular margins. A lung consolidation can be observed inside the parenchyma. If this consolidation has trapped air that does not move with inspiration, it is called a <span class="elsevierStyleItalic">static air bronchogram</span>. But if the air inside the consolidation moves with the respiratory movements it is called <span class="elsevierStyleItalic">dynamic air bronchogram</span>. Colour-doppler will have its utility, since it will show increased flows in a consolidation.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Obstructive atelectasis is caused by endobronchial lesions or mucus plugs; the obstructive central lesion will be visualized as a homogeneous and hypoechogenic consolidation with minimum PE and anechogenic lines without colour doppler signal, known as <span class="elsevierStyleItalic">fluid bronchogram sign</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). When there is partial obstruction of the airway, the passage of air generates liquefaction phenomena and rounded images are observed with mobile internal echoes. Colour doppler should be applied to distinguish between metastases (vascularized) or abscesses (non-vascularized) in the findings of nodular lesions in obstructive atelectasis. Although caution should be exercised at this point, because depending on the capacity of the equipment and the experience of the operator it could lead to a misdiagnosis.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Adhesive atelectasis will manifest itself as small linear consolidations, increase in B lines and decrease in DSLPL. Scarring atelectasis will be difficult to visualize, although a decrease in DSLPL can be observed. Round atelectasis will show a subpleural consolidation, a pleural thickening along with an echogenic line that goes from the pleura into the atelectasis due to invagination of the visceral pleura.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,44,45</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Pneumonia</span><p id="par0230" class="elsevierStylePara elsevierViewall">Pneumonia will present fragmentation and irregularity of the pleural line with a decrease in DSLPL. In the affected lung parenchyma, there will be a decreased echogenicity similar to the liver with irregular margins, of variable size, hyperechogenic lines with branching in their interior due to the static and dynamic air bronchogram. In obstructive pneumonia, the fluid bronchogram may be present due to the airways filled with secretions<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">37,46–49</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Interstitial lung diseases</span><p id="par0235" class="elsevierStylePara elsevierViewall">Under normal conditions, there are about 2–3 B lines per scanned field, but their increase and distribution may reveal the existence of interstitial lung disease, pulmonary oedema or acute respiratory distress.</p><p id="par0240" class="elsevierStylePara elsevierViewall">B lines take center stage in interstitial lung diseases due to the thickening of the interlobular septa, with a diffuse, bilateral and non-homogeneous distribution. The B lines due to thickening of the septa are called B<span class="elsevierStyleInf">7</span> because there is a separation of 7 mm from each other, measured at the level of the pleural line. In addition, there will be thickening, irregularity and fragmentation of the pleural line, preserving the DSLPL.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The distribution of B lines in pulmonary oedema will be homogeneous, bilateral and symmetrical, without abnormalities in the pleural line, preserving its sliding and usually accompanied by PE. In this case, the B lines separate 3 mm from each other and are classified as B<span class="elsevierStyleInf">3 lines.</span></p><p id="par0250" class="elsevierStylePara elsevierViewall">The distribution of B lines in acute respiratory distress will be heterogeneous, with delimited lung areas. The pleural line will be irregular, thickened with decrease or absence of DSLPL and mild PE<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50–52</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Tumor processes</span><p id="par0255" class="elsevierStylePara elsevierViewall">Neoplasms will be visualized when there is no air interposition. Those that are not in contact with the chest wall will only be visualized if there is an airless lung parenchyma between the chest wall and the lesion, such as atelectasis or consolidation.</p><p id="par0260" class="elsevierStylePara elsevierViewall">Normally, neoplasms will be isoechogenic, hypo- or hyperechogenic, an aspect that is not distinguishable from benign lesions. Large lesions (>5 cm) will be heterogeneous due to the presence of bleeding and necrosis. The ultrasound criteria that will determine a malignant lung lesion are: irregular contours of the lung surface, well-defined margins with a healthy lung parenchyma and invasion of neighbouring structures such as parietal pleura (with absence of lesion movement with breathing) or invasion of visceral pleura (with decreased movement), neovascularity, destruction of normal architecture and vessel displacement<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">53,54</span></a> (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Pulmonary thromboembolism</span><p id="par0265" class="elsevierStylePara elsevierViewall">The lesions of the peripheral lung parenchyma due to ischemic involvement secondary to pulmonary thromboembolism are pleural-based, hypoechogenic, with triangular morphology and surrounding hyperechogenic areas, poorly defined in early stages and differing from the infectious consolidation due to the absence of air bronchogram.</p><p id="par0270" class="elsevierStylePara elsevierViewall">LU may be an option when there is contraindication in performing CT angiography, in pregnant women or in case of chronic renal failure and if there is a high clinical suspicion of pulmonary thromboembolism.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,55</span></a></p></span></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Applications of lung ultrasound in interventional pulmonology</span><p id="par0275" class="elsevierStylePara elsevierViewall">Pleuropulmonary procedures should be performed with ultrasound due to its safety and non-invasiveness. It also avoids complications, such as puncturing vascular structures and healthy lungs, as well as the patient's admission associated to certain interventional techniques.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Pleural disease</span><p id="par0280" class="elsevierStylePara elsevierViewall">Diagnostic thoracentesis as drainage in pleural effusion is a fast and safe technique with the help of LU, which avoids the complications that may arise when performed blindly. Ultrasound indicates the place of thoracentesis, drainage placement in patients with localized effusions or even in the pneumothorax. This favours the monitoring of the disease and a decrease in the number of radiographs. In procedures such as permanent pleural drainage placement or thoracoscopy, LU is also of great importance.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56,57</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">In pleural thickening or implants that are candidates for a biopsy, the diagnostic yield will be greater if it is guided by ultrasound, since the introduction of the needle into the lesion is observed in real time, ensuring that the biopsy is performed in the pathological site.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Lung disease: neoplasms</span><p id="par0290" class="elsevierStylePara elsevierViewall">Given the suspicion of lung neoplasm, ultrasound is an important complement to the clinical history but, at present, computed tomography or magnetic resonance imaging continue to have great value in the study and extension of this entity. In addition, ultrasound is very useful and with a high diagnostic yield to guide punctures for histological study.</p><p id="par0295" class="elsevierStylePara elsevierViewall">Neoplasms that can be visualized by ultrasound (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) and, therefore, allow ultrasound-guided biopsies are those that are in contact with the chest wall, regardless of both, the size of the lesion and the lesion’s chest wall contact area. The biopsy of the lesion can be performed with a guide in the transducer that facilitates the procedure and the needle should always be visualized when inserted into the lesion. The tip of the biopsy needle should be placed at a point of the lesion that allows the forward movement of 1−2 cm with the shot and visualize the advancement of the needle. We will use colour doppler to avoid damaging vascular structures such as the thoracic artery in the previous lung lesions.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">56–60</span></a></p></span></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Applications of lung ultrasound in other processes</span><p id="par0300" class="elsevierStylePara elsevierViewall">Pulmonary processes may be related to diseases outside the respiratory system, such as the cardiovascular system. Therefore, it is also recommended to consider some aspects of echocardiography and vascular ultrasound. In the case of the heart, the study of a minimum of 4 projections will be important, since each one can demonstrate different diseases and study almost the entire cardiac structure: a) subxiphoid, which assesses the existence of pericardial effusion; b) apical, which displays a 4-chamber image that studies contractility and valvulopathies in the mitral and tricuspid valves; c) longitudinal or long-axis parasternal, which observes the left ventricle outflow tract, the mitral valve, the left ventricle, as well as the anterior aortic wall and interventricular septum; d) left parasternal or short axis, which studies major arteries, ventricles and mitral and tricuspid valves.</p><p id="par0305" class="elsevierStylePara elsevierViewall">In this chapter, one of the most important aspects in the circulatory system is the study of deep vein thrombosis; for this, a systematic review of the entire deep venous system in both lower limbs will be done in colour doppler mode. The presence of echogenic material within the circulatory system, the absence of flow and the absence of compressibility with the application of pressure would establish the diagnosis of deep venous thrombosis.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">61</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">A great utility has been observed in the specialties that use LU, as it allows a rapid diagnostic approach compared to other complementary imaging tests. To this end, protocols have been created in which ultrasound scanning at specific lung points allows disease to be ruled out in a few minutes. The BLUE protocol evaluates acute respiratory failure with a systematic lung ultrasound examination through 4 points and defines the findings in 5 patterns (normal, alveolus-interstitial pattern, consolidation, pleural effusion and pneumothorax). With these 5 patterns, a series of profiles and their association with the underlying disease are defined.</p><p id="par0315" class="elsevierStylePara elsevierViewall">There are also other protocols, such as the <span class="elsevierStyleItalic">Rapid Ultrasound for Shock</span> (RUSH) protocol which, in addition to adding the echocardiogram scan, detects abdominal free fluid and performs a vascular study (abdominal aorta and signs of deep vein thrombosis). All this would help the study of possible causes of acute dyspnoea, such as venous thromboembolic disease (pulmonary thromboembolism and deep venous thrombosis).<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusions</span><p id="par0320" class="elsevierStylePara elsevierViewall">LU is a tool that offers a lot of information but requires training to correctly interpret what it gives us. Therefore, previous theoretical and practical courses are required, as well as subsequently ensuring daily use, since the skills needed in the recognition and diagnosis of the images offered by this operator-dependent technique could be lost. Despite this, it must be progressively integrated into daily clinical practice to improve the quality of care, given the large amount of information provided in a short time.</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0325" class="elsevierStylePara elsevierViewall">The author declares no conflict of interest directly or indirectly related to the contents of the paper.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1324845" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1221416" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1324844" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1221415" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "General considerations in lung ultrasound" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Normal findings on lung ultrasound" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Pathological findings on lung ultrasound" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0025" "titulo" => "Chest wall" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Rib fractures" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Tumor disease" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Supraclavicular lymphadenopathies" ] ] ] ] ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Thoracic cavity" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0050" "titulo" => "Pleura" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Pneumothorax" ] 1 => array:2 [ "identificador" => "sec0060" "titulo" => "Pleural effusions" ] 2 => array:2 [ "identificador" => "sec0065" "titulo" => "Solid pleural disease" ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Diaphragm" ] 4 => array:2 [ "identificador" => "sec0075" "titulo" => "Pulmonary parenchyma" ] 5 => array:2 [ "identificador" => "sec0080" "titulo" => "Atelectasis" ] 6 => array:2 [ "identificador" => "sec0085" "titulo" => "Pneumonia" ] 7 => array:2 [ "identificador" => "sec0090" "titulo" => "Interstitial lung diseases" ] 8 => array:2 [ "identificador" => "sec0095" "titulo" => "Tumor processes" ] 9 => array:2 [ "identificador" => "sec0100" "titulo" => "Pulmonary thromboembolism" ] ] ] ] ] 9 => array:3 [ "identificador" => "sec0105" "titulo" => "Applications of lung ultrasound in interventional pulmonology" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0110" "titulo" => "Pleural disease" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0115" "titulo" => "Lung disease: neoplasms" ] ] ] ] ] 10 => array:2 [ "identificador" => "sec0120" "titulo" => "Applications of lung ultrasound in other processes" ] 11 => array:2 [ "identificador" => "sec0125" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0130" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-15" "fechaAceptado" => "2019-11-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1221416" "palabras" => array:5 [ 0 => "Lung ultrasound" 1 => "Pneumothorax" 2 => "Pleural effusion" 3 => "Peripheral lung lesion" 4 => "Ultrasound-guided" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1221415" "palabras" => array:5 [ 0 => "Ecografía pulmonar" 1 => "Neumotórax" 2 => "Derrame pleural" 3 => "Lesión pulmonar periférica" 4 => "Ecografía guiada" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Pulmonary ultrasound is becoming very important for the diagnosis and monitoring of respiratory diseases in different areas, such as emergency departments, outpatient clinics, inpatient areas, etc. The review topic entitled “Clinical applications of pulmonary ultrasound” attempts to encompass most of the applications and utilities of thoracic ultrasound in daily clinical practice. For this, the review focuses on how the ultrasound image would be visualized in each of the pleuro-pulmonary pathologies to which it has access and its use in interventional pulmonology. In addition, a schematic illustration with the most frequent pathologies and their ultrasound representation is presented, in order to better understand what we are seeing with this complementary test of great diagnostic value.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La ecografía pulmonar está adquiriendo una gran importancia para el diagnóstico y seguimiento de enfermedades respiratorias en diferentes ámbitos, ya sea urgencias, consultas, hospitalización, etc. El tema de revisión titulado “Aplicaciones clínicas de la ecografía pulmonary” intenta englobar la mayoría de las aplicaciones y las utilidades que tiene la ecografía torácica en la práctica clínica diaria. Para ello, la revisión se centra en cómo se visualizaría la imagen ecográfica en cada una de las patologías pleuro-pulmonares a las que tiene acceso y su uso en la neumología intervencionista. Además se presenta una ilustración esquemática con las patologías más frecuentes y su representación ecográfica, con el objetivo de entender mejor lo que estamos viendo con esta prueba complementaria de gran valor diagnóstico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Wangüemert Pérez AL. Aplicaciones clínicas de la ecografía pulmonar. Med Clin (Barc). 2020;154:260–268.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1475 "Ancho" => 2167 "Tamanyo" => 273044 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Normal lung ultrasound. A) Mode B. Muscle plane (white arrow). Rib with posterior acoustic shadow (white dot). Pleural line (white asterisk). Pulmonary parenchyma (white triangle). B) Mode M. Sea shore sign.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2044 "Ancho" => 2917 "Tamanyo" => 602729 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lung and ultrasound illustration with different types of respiratory entities. 1) Supraclavicular adenopathy due to neoplastic involvement. 2) Normal ultrasound in B-mode, sign of the bat and in M-mode, the sign of the seashore. 3) Obstructive pulmonary atelectasis due to endobronchial lesion, in which small pleural effusion and the sign of the fluid bronchogram are visualized. 4) Peripheral lung mass. 5) Interstitial disease with thickening and de-structuring of the pleural line and increase of the B lines. 6) Diaphragmatic mobility, upper image in B mode and M-mode in the lower image, in which the breathing-dependent diaphragmatic excursion is observed. 7) Pleural effusion in B mode with air bronchogram sign, jellyfish sign and diaphragmatic pleural implants. M-mode, sinusoid sign. 8) Complicated pleural effusion with partitions inside. 9) Infectious lung consolidation, absence of pleural line, irregular margins and air bronchogram. 10) Rib fracture, chimney sign. 11) Pneumothorax with lung point, B-mode one part of the pleural line has B lines and in the other half they are absent, which corresponds to the place of contact and separation of the parietal and visceral pleura. M-mode, lung point sign. 12) Pneumothorax, in B-mode absence of B lines and pulmonary sliding with presence of lines A. Mode M, bar code sign.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2273 "Ancho" => 2500 "Tamanyo" => 291699 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pleural effusions. A) Presence of minimal right pleural effusion (white asterisk). B) Uncomplicated pleural effusion (white dot). C) Colour Doppler. Fluid colour sign. D) Complicated pleural effusion with the presence of septa inside (white arrow).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 2227 "Ancho" => 2500 "Tamanyo" => 340663 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A) Lung cancer. A1) Pulmonary mass (white arrow) in contact with chest wall. A2) Thickening and de-structuring of the pleural line (white point), abundant B lines (black point) due to involvement of interlobular septa secondary to carcinomatous lymphangitis. B) Lung cancer with obstructive pneumonitis. B1) Lung consolidation. 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