Thoracic ultrasound: Indications, advantages, and technique

Author
Paul Mayo, MD
Section Editor
Polly E Parsons, MD
Deputy Editor
Geraldine Finlay, MD
Contributor disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Mar 09, 2016.
INTRODUCTION Portable ultrasound devices are used at the bedside to evaluate pleural
abnormalities and to guide thoracentesis and related procedures, such as pleural drainage catheter
placement and needle aspiration biopsy of pleural or subpleural lung masses. The goals are to
improve accuracy and safety in the characterization of pleural disease and performance of pleural
access procedures.
The indications, contraindications, advantages, disadvantages, and technique of ultrasound-guided
thoracentesis and related procedures will be reviewed here. The diagnostic evaluation and imaging of
a pleural effusion and the technique of diagnostic thoracentesis are discussed separately.
(See "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Diagnostic evaluation of
pleural effusion in adults: Additional tests for undetermined etiology" and "Imaging of pleural effusions
in adults" and"Diagnostic thoracentesis".)
ADVANTAGES Thoracic ultrasound has several advantages over traditional radiographic imaging
of the pleura, including absence of radiation, better portability, real-time imaging, and the ability to
perform dynamic imaging.
Ultrasound is substantially better at determining the location of pleural fluid than bedside physical
examination and, in experienced hands, is associated with a lower rate of complications during
thoracentesis. In addition, ultrasound guidance increases the likelihood of a successful tap compared
to using physical examination for guidance. As an example, in a study of 17 patients who had a failed
thoracentesis without ultrasound imaging, thoracentesis with ultrasound was successful in 15 [1].
(See"Diagnostic thoracentesis", section on 'Site selection'.)
Ultrasound examination of the pleura is more sensitive than a plain chest radiograph at detecting the
presence of pleural fluid and differentiating pleural fluid from lung consolidation. Compared with
computed tomography (CT), pleural ultrasound has a 95 percent sensitivity for detection of pleural
disease in patients with a white out on plain chest radiograph, but is slightly less sensitive in
detecting small amounts of fluid [2,3]. Compared with CT scanning, ultrasound may better differentiate
pleural fluid from pleural thickening and pleural masses [4]. Bedside thoracic ultrasound is also faster
and less resource-demanding than transporting a critically-ill patient to the CT scanner [5].
Ultrasound guidance is associated with a reduced risk of pneumothorax during thoracentesis [6,7]. In
an observational cohort study of insurance database claims for 61,261 thoracenteses, ultrasound
guidance was associated with a reduced likelihood of pneumothorax (OR, 0.81; 95% CI, 0.74-0.90)
[6].
DISADVANTAGES Thoracic ultrasound is an operator dependent technology. Focused, supervised
training is needed to ensure that the operator correctly interprets the sonographic findings [8-10].
Inadequate training may increase the risk of complications.
Ultrasound is not as good as CT imaging for evaluation of the underlying lung parenchyma in the
setting of complex pleural and lung parenchymal disease. Ultrasound guidance is not as good as

guidance by CT imaging for complicated interventional procedures, such as empyema drainage with a
pigtail catheter or biopsy of pleural masses. (See "Imaging of pleural effusions in adults", section on
'Ultrasonography'.)
INDICATIONS The indications for pleural ultrasound include:
Bedside detection of pleural fluid when the plain chest radiograph shows a white out
Bedside detection of a pneumothorax
Guidance for diagnostic and therapeutic thoracentesis
Guidance for placement of thoracostomy tubes
MACHINE REQUIREMENTS A wide variety of portable ultrasound machines with two-dimensional
scanning capability are used for pleural ultrasonography and associated procedures [4,11].
Transducers A 3.5 to 5.0 MHz transducer with a convex sector design works well for pleural
imaging in most instances [12]. Cardiac transducers are particularly effective, as they are designed
with a small footprint, allowing scanning between rib interspaces. An additional advantage of using a
cardiac transducer is that it may be used for other ultrasound applications (eg, cardiac, lung,
abdominal); this reduces equipment costs.
Once an abnormality has been identified, a 7.5 to 10 MHz linear transducer can be used if needed to
obtain more detailed images [9,11].
Image storage Many portable ultrasound machines have digital image storage and transfer
capability that meets the requirements for durable image documentation. Alternatively, the machine
may be equipped with a printer if the clinician prefers a hard copy of the study to place directly in the
patient chart.
Doppler Doppler is generally not required for portable thoracic ultrasound-guided procedures,
although it is occasionally used by ultrasonographers to differentiate a small pleural effusion from
pleural thickening and to identify blood vessels that might be in the path of a needle during a
procedure [13].
SCANNING PROCEDURE
Preprocedure steps The patients identity and planned procedure are confirmed. The results of
other evaluations related to the patients problem are reviewed by the ultrasonographer. In particular,
the chest radiograph is reviewed before the procedure to confirm the side of the pleural abnormality
and the expected location of any masses or loculated accumulations of fluid.
Informed consent for the procedure is obtained, and clotting studies are confirmed to be adequate, if a
thoracentesis or other pleural access procedure is planned.
Acoustic gel is placed on the patients skin in the area of interest to provide an airless interface, as
ultrasound waves do not pass through air well. The gel also permits the ultrasound probe to slide
gently over the skin.
Machine setup The ultrasound machine is positioned so the screen is easily visible from the
operators working position. Ambient lighting is reduced to maximize screen contrast [9]. Typically, the
thorax is scanned using gray-scale, real-time ultrasound [9]. Dynamic noise filters are not used as
they can obscure visualization of lung sliding. (See 'Lung sliding' below.)
The depth setting is adjusted such that the structures of the hemithorax deep to the chest wall are
imaged. Gain is adjusted to maximize the contrast between different tissues [9].

Certain conventions are important to maintain orientation of thoracic anatomy and to standardize
image acquisition. Ultrasound probes have a groove on one side that corresponds to a screen
orientation marker, which appears as a white or blue dot on the screen. By convention, the dot is
typically at the top or on the upper left of the screen (movie 1) [4].
The transducer is held perpendicular to the skin surface with the transducer marker (groove) pointed
cephalad and the scanning plane directed between adjacent ribs. Structures near the skin surface
appear close to the dot and deeper structures appear lower on the screen. A depth guide is usually
located along the right side of the screen, to enable estimation of the depth of a structure relative to
the chest wall.
Patient position Pleural fluid is obedient to the law of gravity, so pleural fluid collects in the
dependent portion of the thorax (unless loculated). The usual position for ultrasound examination of a
pleural effusion is for the patient to sit with arms extended and resting on a firm surface that is just
below the level of the shoulders. Raising the patients ipsilateral arm up to or above their head widens
the intercostal spaces and facilitates scanning [11].
When the patient is sitting, the entire back is accessible for ultrasonographic examination, so freeflowing pleural fluid is readily identified in the dependent lower thorax (image 1). When scanning for a
pneumothorax, the patient is usually positioned supine with the head of the bed elevated slightly.
The situation is more difficult in the critically-ill patient who is in a supine position and attached to
multiple support devices [4]. Patients with severe respiratory and/or hemodynamic failure may be
intolerant of changes in body position. We typically position critically-ill patients supine with the
ipsilateral arm held across the chest towards the opposite side. If the effusion is large, it may be
identified in the mid axillary line. Smaller effusions may require that the transducer be moved medially
such that it is pressed into the mattress and angled upwards to visualize the effusion. This is helpful
for identifying the presence of the effusion, but impractical as a means to guide thoracentesis as the
transducer position cannot be duplicated by the needle/syringe assembly.
Several alternative positions may be considered in order to permit access for ultrasound guided
thoracentesis. These positions include slight elevation of the head of the bed with the patient rotated
towards the lateral decubitus position, a flat bed with the patient in the lateral decubitus position and
the side of the expected pleural effusion up, and the supine position with the patient lying such that
the side with the effusion is at the edge of the bed (picture 1).
Scanning strategy The transducer is oriented to scan between the ribs, as ribs block transmission
of ultrasound. This orientation yields an image where the adjacent rib shadows appear on either side
of the image on the screen. By moving the transducer longitudinally from one interspace to another,
multiple interspaces may be examined in a short time. A methodical scanning strategy allows a
comprehensive analysis of the target effusion or other pleural pathology (picture 2). After a general
examination of the thorax using multiple scan lines, the examiner may concentrate on an area of
particular interest in order to correctly identify nearby landmarks and determine the best site for device
insertion, if needed (movie 1).
ULTRASOUND TERMINOLOGY Terminology for thoracic ultrasound provides a description of a
number of sonographic artifacts caused by air-tissue interfaces. The presence or absence of these
artifacts can be used to aid in the diagnosis of pleural disease.
A, B, and E lines
A lines are horizontal lines (roughly parallel to the chest wall) that are brightly echogenic and located
between the rib shadows when the probe is positioned longitudinally [14,15].

B lines arise at the border between aerated and compressed lung and are described as multiple raylike, or comet-tail, vertical lines extending from the pleural line to the lower edge of the screen without
fading (image 2) [16]. B lines move synchronously with the lung during respiration and tend to erase A
lines (movie 2).
E lines are vertical lines extending from the areas of subcutaneous emphysema deep into the chest
[16]. These sonographic artifacts can be confused with B lines and thus contribute to misidentification
of a pneumothorax. The possibility of E lines should be suspected when subcutaneous emphysema
can be palpated on the chest wall and when the vertical lines start at a level external to the ribs.
Lung sliding The sonographic effect of lung sliding (also known as lung gliding or the lung sliding
sign) is created by movement of the lung relative to the chest wall during respiration [17]. The
sonographic appearance is that of a thin, bright line moving horizontally along the pleural line with a
wave-like pattern located above (towards the chest wall) and a granular pattern below. Lung sliding is
an indirect sign indicating adherence of the visceral pleura to the parietal pleura. When air separates
the two pleural layers as in a pneumothorax, the movement disappears (movie 3 and movie 2).
Following a pleural access procedure, the disappearance of lung sliding in an area where it was
previously identified is a strong indicator of a postprocedure pneumothorax [16]. (See 'Identification of
pneumothorax'below.)
Lung pulse The lung pulse is a vertical movement of the pleural line synchronous to the cardiac
rhythm that is more commonly seen on the left hemithorax than the right. The lung pulse is caused by
transmission of heart beats through consolidated, motionless lung. Intrapleural air prevents
transmission of either horizontal or vertical movements to the parietal pleura. Visualization of a lung
pulse excludes a pneumothorax. However, the lung pulse is only of significance if actually present;
absence of a lung pulse is NOT diagnostic of a pneumothorax.
Lung point A lung point is defined as a location where the lung adheres to the parietal pleura in a
patient with a pneumothorax [16,18]. When scanning a patient with a suspected pneumothorax, the
probe is moved laterally along the rib interspaces from the area without lung sliding or B lines to
search for an area where lung sliding is seen intermittently (movie 4). The presence of lung sliding in
one area (ie, the lung point) and not in another is a strong indicator of a pneumothorax. However, a
lung point is not always present, such as when a large pneumothorax causes such extensive lung
collapse that the lung does not abut the pleura [19].
ANATOMIC LANDMARKS AND ULTRASOUND APPEARANCE Knowledge of the normal
sonographic appearance of the chest wall, pleura, and adjacent structures guides accurate diagnosis
of pleural pathology and is essential to safe needle insertion into the pleural space.
Chest wall and pleura The normal thoracic ultrasound has certain characteristic features
[9,20,21]. The intercostal muscles appear as hypoechoic, linear shadows of soft tissue density,
containing echogenic fascial planes. The ribs appear as repeating curvilinear structures with a deeper,
hypoechoic, posterior acoustic shadow that can be mistaken for pleural fluid [22]. The parietal and
visceral pleura normally appear as a single, bright echoic line no wider than 2 mm. A high resolution
ultrasound probe (7.5 to 10 MHz) is sometimes needed to differentiate parietal and visceral portions of
the pleura [11]. The change in acoustic impedance at the pleura-lung interface results in a series of
echogenic parallel lines equidistant from each other just deep to the pleural line.
Diaphragm and subdiaphragmatic recesses The diaphragm must be positively identified before
any pleural procedure to ensure that the needle insertion site and trajectory will remain above the
diaphragm [4,9]. Subdiaphragmatic insertion of a needle or catheter can be catastrophic and
potentially fatal, if the liver or spleen is lacerated.

The diaphragm typically appears as an echogenic line approximately 1 mm thick; downward (caudad)
movement of the diaphragm should be seen with inspiration (image 1) [11]. As a general rule, when
the patient is sitting, the diaphragm is located caudad to the 9th rib. (See "Diagnostic thoracentesis",
section on 'Site selection'.)
In addition to identifying the location of diaphragm, the location of the splenorenal and hepatorenal
recesses should be confirmed, as the curvilinear sonographic appearance of the splenorenal and
hepatorenal recesses is similar to that of the diaphragm (image 3). The splenorenal and hepatorenal
recesses are identified by finding the liver or spleen craniad and the kidney caudad to the respective
recess.
Lung To avoid injury to the lung during an ultrasound guided thoracentesis, the sonographer must
be able to identify the appearance of air-filled, fluid-filled, or atelectatic lung. The air-filled lung has an
ultrasound appearance of bright echoes. When the lung is compressed by a surrounding pleural
effusion, it appears hyperechoic or tissue dense; and, in large effusions, may appear to float in the
effusion (image 2). Smaller effusions cause less compressive atelectasis.
At the border between aerated and compressed lung, multiple ray-like air artifacts termed B lines
may be seen (image 2). Compressed lung frequently exhibits a characteristic flapping movement and
moves with the respiratory cycle (movie 2).
The lung may move closer to the proposed needle path during respiratory cycling and possibly
obscure the ultrasound field. Safe site selection requires that the pleural effusion space be clear
throughout the respiratory cycle and that there is sufficient space between the chest wall and the
visceral pleura to avoid inadvertent puncture of the lung. There is no definite rule as to the minimum
allowable depth of pleural fluid at the needle insertion site. Greater than 10 mm is a reasonable
estimate of a safe distance [9]. By changing transducer position and angle, the examiner selects the
site that yields the greatest distance between the chest wall and the surface of the lung.
Heart Positive identification of the heart is important when performing needle insertion in the left
anterolateral thoracic region. The heart may be surprisingly lateral in position, particularly in supine
patients or when the patient has cardiomegaly or ipsilateral mediastinal shift. Ultrasonography allows
site selection that is well away from the heart. The sonographic appearance of the heart depends on
the axis of viewing (figure 1 and movie 5) and is discussed separately. (See "Transthoracic
echocardiography: Normal cardiac anatomy and tomographic views".)
Pleural loculation may cause the target effusion to be in an unusual intrathoracic position.
Anteromedial loculations require the examiner to identify and avoid adjacent mediastinal structures.
For parasternal needle insertion, the internal mammary artery should be looked for using color
Doppler.
IDENTIFICATION OF PLEURAL FLUID The plain chest radiograph should be reviewed before the
ultrasound guided procedure to confirm the expected site, size, and likelihood of loculations of the
pleural effusion. By convention, the echogenicity of thoracic structures is determined relative to the
liver.
Characteristic features Pleural fluid usually appears as an anechoic (black), or hypoechoic
compared to the liver, area surrounded by typical anatomic boundaries. Three ultrasonographic
criteria must be satisfied to ensure the presence of a pleural effusion (movie 6) [23]:
The finding of an echo free space (appears black and without stippling) within the thoracic
cavity

The finding of typical anatomic boundaries that surround the effusion: the inside of the chest
wall, the diaphragm, and the surface of the lung
The presence of dynamic characteristics that are typical of pleural fluid, such as diaphragmatic
movement, lung movement, movement of echogenic material within the fluid (septations, cellular
debris, fronds), and changes in the shape of the pleural effusion with respiratory cycling.
Initially, the examiner should require that all of the above findings be met for identification of a pleural
effusion. However, certain types of pleural effusions have variable or increased echogenicity, which
can be accurately identified with advanced skill and experience. (See 'Atypical appearances of pleural
fluid' below.)
Unlike intraabdominal fluid, a pleural effusion is not deformable with force application to the
transducer on account of the rigidity of thoracic cage.
Atypical appearances of pleural fluid With experience, the examiner will recognize that some
pleural effusions have an atypical appearance, which may be due to obscuration of the typical findings
or may reflect the characteristic presentation of the underlying process. As examples:
Massive obesity and chest wall edema may degrade the image quality such that typical
ultrasound features are not discernible.
Complex loculated effusions may be hyperechoic and be located in a nondependent part of the
thorax (movie 6). Hemothorax and empyema fluid may be isoechoic with the liver and have no
dynamic changes with respiration.
The presence of pleural or diaphragmatic thickening or nodularity, or an echogenic swirling
pattern is suggestive of a malignant pleural effusion [9,24,25].
The presence of air and fluid together (ie, hemopneumothorax) may present a complex
sonographic picture.
When the examiner is uncertain, a more experienced ultrasonographer should review the findings or
an alternative imaging modality should be used.
IDENTIFICATION OF PLEURAL MALIGNANT DISEASE Morphologic characteristics used for
identification of malignant pleural disease on chest computed tomography (CT) have been adapted for
use in ultrasound examination of the pleura [9,24,26]. (See "Overview of the risk factors, pathology,
and clinical manifestations of lung cancer", section on 'Pleural involvement' and "Management of
malignant pleural effusions".)
The morphologic characteristics of pleural malignancy include:
Diaphragmatic and parietal pleural nodule or nodules
Pleural thickening >1 cm
Hepatic metastasis
In a study of 52 patients with suspected malignant pleural effusion, thoracic ultrasound correctly
identified26/33 malignant effusions and 19/19 benign effusions by using these criteria [24]. However,
ultrasound findings alone are not sufficient to make a diagnosis of pleural malignancy.
IDENTIFICATION OF PNEUMOTHORAX Portable ultrasound is used to detect a pneumothorax is
several situations, such as after a pleural access procedure, in the evaluation of a patient with chest
trauma in the emergency department, and following chest tube placement to assess resolution of a
pneumothorax [16,27-33]. (See "Imaging of pneumothorax" and "Primary spontaneous pneumothorax
in adults" and"Secondary spontaneous pneumothorax in adults".)

As pleural air is usually located in the least dependent area, the patient is scanned in the supine
position. A 3.5 to 5 MHz transducer probe is directed to the third or fourth intercoastal space between
the parasternal and midclavicular lines. The first step is to identify the contiguous ribs on either side of
the field. Next, the pleural line is identified between and under the ribs. For confirmation, the pleural
line should be at the same depth on both sides of the chest. The four key features of a pneumothorax
are the following (movie 7) [16]:
Absence of lung sliding which is a horizontal movement of the lung relative to the pleural line.
(See'Lung sliding' above.)
Absence of B lines. The presence of B lines is strong evidence against a pneumothorax, but
their absence is not a sensitive sign of a pneumothorax (image 2). (See 'A, B, and E
lines' above.)
It is advisable to document the presence and location of lung sliding or B-lines prior to any procedure
associated with a risk of pneumothorax as the disappearance of lung sliding or B-lines after the
procedure confirms the interval development of a pneumothorax. Two other signs, absence of lung
pulse and identification of the lung point, have been described as consistent with a pneumothorax, but
these signs are generally not used as they are less accurate than the findings of absence of lung
sliding and absence of B lines [16,18]. (See 'Lung pulse' above and 'Lung point' above.)
In a patient with COPD, the ultrasound appearance of emphysematous areas can mimic a
pneumothorax [34]. A chest computed tomography exam may be needed to accurately identify a
pneumothorax in a patient with emphysematous bullae. In addition, subcutaneous emphysema can
lead to sonographic artifacts, such as E lines that are created by the subcutaneous air and mimic B
lines.
SUMMARY AND RECOMMENDATIONS
Portable ultrasound is a useful technique for evaluation of the pleural abnormalities at the
bedside. Pleural ultrasound improves the accuracy of the physical examination and enables a
better understanding of pleural pathology than the plain chest radiograph alone.
(See 'Advantages' above.)
Ultrasound guidance for thoracentesis has several advantages over traditional radiographic
imaging of the pleura, including absence of radiation, better portability, real-time imaging, and
the ability to perform dynamic imaging. (See 'Advantages' above.)
Use of a portable ultrasound machine requires additional, focused training to ensure that the
operator correctly interprets the sonographic findings. (See 'Disadvantages' above.)
The indications for pleural ultrasound include bedside detection of pleural fluid or a
pneumothorax, guidance for diagnostic and therapeutic thoracentesis, and guidance for
placement of thoracostomy tubes. (See 'Indications' above.)
A two dimensional ultrasound machine with a 3.5 to 5 MHz transducer with a convex head is
typically used for thoracic ultrasound (movie 1). (See 'Machine requirements' above.)
Terminology for thoracic ultrasound provides a description of a number of sonographic artifacts
caused by air-tissue interfaces, such as A, B, and E lines, lung sliding, lung pulse, and lung point
(image 2and movie 2 and movie 4). The presence or absence of these artifacts is used in the
diagnosis of pleural diseases (image 2). (See 'Ultrasound terminology' above.)
Knowledge of the normal sonographic appearance of the chest wall, pleura, and adjacent
structures guides accurate diagnosis of pleural pathology and is essential to safe needle
insertion into the pleural space. (See 'Anatomic landmarks and ultrasound appearance' above.)

Three ultrasonographic criteria must be satisfied to ensure the presence of a pleural effusion:
(See'Identification of pleural fluid' above.)
The presence of an echo free space (appears black and without stippling) within the
thoracic cavity (image 1 and movie 6).
The identification of typical anatomic boundaries that surround the effusion: the inside of
the chest wall, the diaphragm, and the surface of the lung (image 1 and image 3).
The presence of dynamic characteristics that are typical of pleural fluid, such as
diaphragmatic movement, lung movement, movement of echogenic material within the fluid
(septations, cellular debris, fronds), and changes in the shape of the pleural effusion with
respiratory cycling (image 4).
Pleural fluid may have an atypical appearance in certain situations, such as when a thick chest
wall degrades the ultrasound image, when the fluid is septated (eg, complex parapneumonic
effusion or empyema), when malignancy causes a nodular or thickened pleura, or when air and
fluid are both present (eg, hemopneumothorax) (image 4 and movie 6). (See 'Atypical
appearances of pleural fluid'above and 'Identification of pleural malignant disease' above.)
The ultrasound characteristics that suggest the presence of pleural malignancy include:
diaphragmatic and parietal pleural nodule or nodules, pleural thickening >1 cm, and hepatic
metastasis. (See'Identification of pleural malignant disease' above.)
Ultrasound signs of a pneumothorax include absence of lung sliding, absence of B lines,
absence of a lung pulse, and absence of a lung point (movie 7 and movie 3). (See 'Identification
of pneumothorax'above and 'Ultrasound terminology' above.)
ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge Peter Doelken,
MD, FCCP, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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