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When, Where, and How to Use Ultrasonography in Patients With Chronic Obstructive Pulmonar Disease
¿Cuándo, dónde y cómo utilizar la ecografía en pacientes con enfermedad pulmonar obstructiva crónica?
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In COPD, ultrasonography has not been widely used because the acoustic window is believed to be unfavorable due to the large air content, particularly in patients with lung hyperinflation. However, there are different areas where ultrasonography may provide useful information for a complete clinical assessment of COPD patients in addition to classical lung function or radiological tests.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Assessment of Lung Parenchyma</span><p id="par0010" class="elsevierStylePara elsevierViewall">Typically, the ultrasound pattern of lung in COPD is characterized by anterior-predominant bilateral A-lines with lung sliding and no consolidations. Sometimes there is substantially reduced or even abolished lung sliding, without evidence of lung point. Although direct signs of COPD pathology cannot be visualized by ultrasonography, the technique is sensitive to changes in lung parenchyma secondary to concomitant diseases or complications.</p><p id="par0015" class="elsevierStylePara elsevierViewall">COPD and congestive heart failure are common in elderly populations and share common risk factors. Although it is known that they may coexist in a number of patients, in real life usually only one of them is diagnosed when both are present.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> This is likely because the primary manifestations of both conditions are dyspnea and exercise intolerance. Lung function tests can differentiate between COPD and heart failure in the majority of cases, but in the presence of wet lung it may be difficult to evaluate the severity of COPD or to decide which coexisting disease is the major cause of dyspnea. A concomitant alveolar interstitial syndrome can be inferred from the presence of B-lines in lung ultrasonography images.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> A more sensitive assessment of extravascular lung water was recently obtained in mechanically ventilated cardiac patients by quantitative analysis of lung ultrasonography.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> The applicability of this method in patients with concomitant COPD and congestive heart failure needs to be investigated.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Pneumonia is a frequent complication in patients with COPD, but it is not always easy to distinguish it from a COPD exacerbation. Ultrasonography has shown an accuracy comparable with CT scans in the detection of lung consolidations due to community acquired pneumonia.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> Thus, it may be a useful tool for differentiating pneumonias from COPD exacerbations, which needs further evaluation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Assessment of Cardiac Function</span><p id="par0025" class="elsevierStylePara elsevierViewall">Echocardiography is widely used by cardiologists for functional assessment of left and right ventricles and to estimate pulmonary vascular pressures. Pulmonary hypertension and right heart failure are well-recognized consequences of COPD, particularly in hypoxemic patients, and are predictors of hospitalization and mortality in these patients.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> COPD severity is associated with significant changes in the volume of cardiac chambers, heart rate, and left ventricular filling properties,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> adding weight to the hypothesis that altered lung mechanics has a negative impact on both right and left heart function. Several studies have demonstrated a correlation between COPD and cardiovascular fatal and non-fatal events.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are several echocardiographic parameters that can give a more reliable assessment of right ventricle function than ejection fraction alone. The tricuspid annular plane systolic excursion (TAPSE) evaluates the distance traveled by the wall of the right ventricle, as defined by the plane of the tricuspid valve, during systole.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> The Myocardial Performance Index (Tei index) is a measure of the time the right heart spends in isovolumetric contraction and isovolumetric relaxation relative to the time it spends actually pumping blood.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> This method has been studied in pulmonary hypertension and has been found to have good prognostic potential.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a> Three-D echocardiography and tissue Doppler imaging have been developed to provide a more comprehensive picture of the pressure-volume relationship governing right heart function and to quantify the velocity of contraction and blood ejection. Two other echo indices have been proposed, the heart rate-adjusted pulmonary artery acceleration time (PAAcT) and the right ventricular systolic velocity (RVSmVTI). These are simple and reproducible methods that are well correlated with pulmonary artery pressure and pulmonary vascular resistance, and should be considered in the assessment of COPD patients with suspected pulmonary hypertension. They may also be of particular interest in patients with inadequate tricuspid Doppler signal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A more recent technique is speckle-tracking echocardiography, which provides a representation of myocardial deformation during contraction. Both Doppler tissue imaging and speckle tracking can be used to estimate not only chamber anatomy but also a 2-D or 3-D strain pattern for the cardiac muscle. These dynamic measurements provide a more complete mechanical view of the right and left heart chambers, including estimation of pressure-volume relationships, and are currently under investigation for short-term monitoring and long-term prognostic values. In patients with severe COPD undergoing right heart catheterization, speckle-tracking echocardiography was very sensitive in identifying increased pulmonary vascular resistance.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> In moderate-to-severe COPD with normal left ventricular ejection fraction, Schoos et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> showed that left ventricular global longitudinal strain was the only independent predictor of all-cause long-term mortality. Decreased global longitudinal strain and impaired left ventricular mechanics were found to be associated with an increased BODE index in patients with COPD.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Assessment of Diaphragm</span><p id="par0040" class="elsevierStylePara elsevierViewall">In patients with severe COPD, the mechanical efficiency of inspiratory muscles is impaired, mainly because of lung hyperinflation, which makes the diaphragm less efficient due to its unfavorable position. This results in a reduced capacity to lower pleural pressure and reduced diaphragm excursion during inspiration.</p><p id="par0045" class="elsevierStylePara elsevierViewall">M-mode ultrasonography has been widely used since the 1960s to assess diaphragmatic excursions, mainly in neuromuscular disorders. More recently, B-mode ultrasonography has been used to assess not only movement but also thickness and thickening of diaphragm during breathing movements.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A reduction of diaphragm mobility was found to correlate with dyspnea, degree of airflow obstruction, increase in residual volume, and CO<span class="elsevierStyleInf">2</span> retention.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Although, neither diaphragm thickness nor contractility differ from normal in the majority of COPD subjects,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> B-mode ultrasound may be useful in the non-invasive assessment of coexisting neuromuscular impairment and in the identification of high-risk patients prior to general anesthesia, mechanical ventilation, and weaning. More recently, the thickness of diaphragm assessed by ultrasonography was found to predict nocturnal desaturation in COPD patients with mild or no daytime hypoxemia.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Ultrasonography is a rapid developing technique widely used in most fields. In patients with COPD it is still underused, but it may be a useful tool for assessing COPD exacerbations, pneumonias, heart-to-lung interactions, and diaphragmatic dysfunction. In comparison with other imaging techniques, ultrasonography has the advantages of being radiation-free, quick, repeatable, portable, widely available, and able to provide a bedside and real-time functional assessment.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Assessment of Lung Parenchyma" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Assessment of Cardiac Function" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Assessment of Diaphragm" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Corradi F, Brusasco C, Brusasco V. ¿Cuándo, dónde y cómo utilizar la ecografía en pacientes con enfermedad pulmonar obstructiva crónica? Arch Bronconeumol. 2017;53:229–230.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The association between COPD and heart failure risk: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. De Miguel Diez" 1 => "J. Chancafe Morgan" 2 => "R. Jimenez Garcia" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "I J Chron Obstruct Pulmon Dis." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 1 | 6 |
| 2024 October | 48 | 25 | 73 |
| 2024 September | 48 | 26 | 74 |
| 2024 August | 74 | 32 | 106 |
| 2024 July | 41 | 26 | 67 |
| 2024 June | 64 | 39 | 103 |
| 2024 May | 76 | 36 | 112 |
| 2024 April | 42 | 27 | 69 |
| 2024 March | 34 | 22 | 56 |
| 2024 February | 45 | 24 | 69 |
| 2023 March | 18 | 2 | 20 |
| 2023 February | 63 | 23 | 86 |
| 2023 January | 41 | 38 | 79 |
| 2022 December | 53 | 36 | 89 |
| 2022 November | 48 | 32 | 80 |
| 2022 October | 39 | 33 | 72 |
| 2022 September | 51 | 31 | 82 |
| 2022 August | 57 | 44 | 101 |
| 2022 July | 56 | 43 | 99 |
| 2022 June | 33 | 32 | 65 |
| 2022 May | 26 | 37 | 63 |
| 2022 April | 39 | 31 | 70 |
| 2022 March | 39 | 52 | 91 |
| 2022 February | 44 | 27 | 71 |
| 2022 January | 34 | 39 | 73 |
| 2021 December | 34 | 41 | 75 |
| 2021 November | 36 | 38 | 74 |
| 2021 October | 35 | 43 | 78 |
| 2021 September | 42 | 38 | 80 |
| 2021 August | 42 | 35 | 77 |
| 2021 July | 27 | 19 | 46 |
| 2021 June | 28 | 44 | 72 |
| 2021 May | 28 | 26 | 54 |
| 2021 April | 70 | 52 | 122 |
| 2021 March | 47 | 23 | 70 |
| 2021 February | 21 | 22 | 43 |
| 2021 January | 24 | 13 | 37 |
| 2020 December | 16 | 14 | 30 |
| 2020 November | 21 | 19 | 40 |
| 2020 October | 16 | 13 | 29 |
| 2020 September | 14 | 4 | 18 |
| 2020 August | 22 | 11 | 33 |
| 2020 July | 24 | 25 | 49 |
| 2020 June | 8 | 6 | 14 |
| 2020 May | 30 | 13 | 43 |
| 2020 April | 21 | 19 | 40 |
| 2020 March | 16 | 11 | 27 |
| 2020 February | 22 | 13 | 35 |
| 2020 January | 34 | 17 | 51 |
| 2019 December | 10 | 10 | 20 |
| 2019 November | 28 | 24 | 52 |
| 2019 October | 5 | 4 | 9 |
| 2019 September | 18 | 12 | 30 |
| 2019 August | 22 | 13 | 35 |
| 2019 July | 33 | 16 | 49 |
| 2019 June | 10 | 7 | 17 |
| 2019 May | 30 | 8 | 38 |
| 2019 April | 18 | 15 | 33 |
| 2019 March | 46 | 13 | 59 |
| 2019 February | 31 | 23 | 54 |
| 2019 January | 19 | 21 | 40 |
| 2018 December | 15 | 6 | 21 |
| 2018 November | 58 | 24 | 82 |
| 2018 October | 96 | 25 | 121 |
| 2018 September | 37 | 7 | 44 |
| 2018 May | 29 | 1 | 30 |
| 2018 April | 24 | 4 | 28 |
| 2018 March | 65 | 4 | 69 |
| 2018 February | 48 | 5 | 53 |
| 2018 January | 150 | 5 | 155 |
| 2017 December | 136 | 5 | 141 |
| 2017 November | 25 | 6 | 31 |
| 2017 October | 19 | 17 | 36 |
| 2017 September | 34 | 14 | 48 |
| 2017 August | 24 | 18 | 42 |
| 2017 July | 3 | 1 | 4 |
| 2017 May | 2 | 1 | 3 |
| 2017 April | 0 | 1 | 1 |
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