Ann Thorac Surg 2009;87:1577-1581. doi:10.1016/j.athoracsur.2008.12.024
© 2009 The Society of Thoracic Surgeons
New Technology
Implementation of Real-Time Ultrasound in a Thoracic Surgery Practice
Aman S. Coonar, FRCS(CTh)a,c,*,
Jacqueline A. Hughes, FRCRa,d,
Susan Walker, RNa,
Marc dePerrot, MDa,
Thomas K. Waddell, MD, PhDa,
Andrew F. Pierre, MDa,
Gail E. Darling, MDa,
Michael R. Johnston, MDb,
Shaf Keshavjee, MDa
a Thoracic Surgery & Lung Transplant, Department of Surgery, Toronto General Hospital, Toronto, Canada
b Thoracic Surgery, Dalhouise University, Halifax, Canada
c Thoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
d Radiology, Addenbrookes Hospital, Cambridge, United Kingdom
Accepted for publication December 1, 2008.
* Address correspondence to Dr Coonar, Thoracic Surgery, Papworth Hospital, Cambridge, CB23 3RE, United Kingdom (Email: aman.coonar{at}papworth.nhs.uk).
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Abstract
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Purpose: The purpose of this study was to implement real-time transthoracic ultrasound in a thoracic surgery and lung transplant practice.
Description: Ultrasound units that are light, small, robust, and portable are now available. Obstacles to use include demarcation issues between specialties, training, and a perception that basic ultrasound may be difficult to use. The experience of implementing this is described.
Evaluation: After a training period, 62 studies were performed in 4 months. Patients and clinicians gave positive feedback. The learning time was short, and with ultrasonic guidance, all interventional procedures were successful at the first attempt, without any complications.
Conclusions: Basic transthoracic ultrasound was found to be easy to learn and use by thoracic surgeons, fellows, and specialist nurses. Patients were appreciative. Real-time use may have genuine advantages to patient care.
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Introduction
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Image-guided treatment is undergoing rapid implementation in different settings. Along with other modalities, such as three-dimensional computed tomographic imaging and cine magnetic resonance imaging, we have implemented ultrasound (US) into our thoracic and lung transplant surgery practice. It has been deployed in three main settings: (1) endoscopic bronchial ultrasound, (2) endoscopic esophageal US, and (3) conventional transthoracic skin-surface US.
The use of US has been enthusiastically taken on by nonradiologists. This has implications for training, accreditation, resource allocation, and practice development. The techniques, indications, and implications for practice development have been widely discussed [1–10]. Some colleges of radiology have produced guidelines encouraging use by nonradiologists and provide helpful guidelines in acquiring skills and having US as part of a practice [10].
For some clinicians there is a perception that performing US examinations may be time-consuming or a poor use of resources. Also, there may be a perception that it is difficult to acquire competency and proficiency at basic ultrasound. In this context we describe our experience of implementing conventional US into a thoracic surgical and lung transplant practice. We describe here four cases illustrating this early experience.
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Technology
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Material and Methods
This is a retrospective chart review of a clinical practice implementation. All patients gave consent at the time of US for the procedure to be performed. Patients are not identified.
Setting
A university center tertiary thoracic surgery and lung transplant practice and some referring hospitals in consultation.
Equipment
A lightweight (1.4 kg) portable (16.3 cm x 26.6 cm x 3.8 cm) ultrasound and transducer unit (L25/10-5: 25-mm broadband [10-5 MHz] linear array) was selected (iLook [SonoSite Inc, Bothell, WA]) (Fig 1). The unit runs on battery or mains, and it is rechargeable. It can be used as a handheld or stand mounted device. The probe we used is normally used for abdominal ultrasound and was considered to be adequate for assessment of the adult chest.
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Technique
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Training was provided by an experienced ultrasonologist. A 30-minute seminar was followed by a 30-minute practical session. After this was conducted, selected patients received US examinations from medical and nursing staff to acquire familiarity with the techniques and equipment. During this period a further formal training session was provided to consolidate skills.
After 1 week of familiarization, US was routinely used according to the clinical situation. This was mostly for the evaluation of pleural effusions and chest wall lesions, and to determine if urethral catheterization for bladder drainage was needed.
After an explanation of the procedure, the patient was positioned appropriately. The probe was cleaned with a disposable anti-microbial wipe. The skin was cleaned, and water-based transducing gel was used to improve the interface. Landmarks were established, and a search was made for the lesion. The lesion was cannulated either with simultaneous US guidance or by pressure marking of the skin. A cannula sheath applied firmly to the skin for a few seconds is ideal for this purpose and leaves a mark visible in both light and dark skins for several minutes. We found this technique to be very easy and preferable to simultaneous ultrasound for most cases of effusion. If imaging was performed during the actual cannulation, the skin site was first cleaned with topical antiseptic, and then using a sterile transducer bag (or a sterile glove, which is an ideal, cheap, and easily available alternative) imaging was performed simultaneously with sterile instrumentation. This can be done safely by a single operator.
Bladder assessment was performed in cases of uncertainty of cause of low perioperative urine output.
After use, we cleaned the probe with a disposable anti-microbial wipe, and the unit was stored in a locked room off the main ward. It was available to any trained member of the thoracic surgery medical and nursing team. The unit is mains rechargeable with a reported battery life of more than 30 minutes, which we found to be accurate. We found full recharging would take 1 to 2 hours. Initially, studies were performed on the thoracic surgery ward. As users became familiar with the equipment and appearances of simple and complicated effusions, empyema, and the chest wall masses, we expanded its use to the clinic, intensive care unit, operating room, and to referrals elsewhere in the hospital and neighboring hospitals.
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Clinical Experience
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Results
The US studies were undertaken in a pragmatic way if the equipment was immediately available and time permitted. Therefore, the number of studies performed is a subset of all potential cases. After the training period, for 4 months, 62 consecutive studies were performed (45 studies of the pleural space were performed with the aim of performing thoracocentesis or chest tube insertion if appropriate, and 4 studies were performed to evaluate chest wall lesions). With the use of US, all procedures were successful in achieving drainage or adequate fine needle samples. No repeat punctures were needed. Thirteen assessments of bladder filling were performed in cases of low urine output.
Selected Patients
All the patients presented as follows were performed by thoracic surgeons or thoracic specialist nurses without significant previous experience in transthoracic US.
Patient 1
An 82-year-old man, after esophageal rupture, underwent a left thoracotomy and repair. In addition to the changes on the left side, the postoperative CT also showed a large right pleural effusion (Fig 2). The US of the right chest (Fig 2) showed a simple pleural effusion with a collapsed lung. As it was simple without loculation, we performed immediate successful tube placement and drainage.
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Fig 2. Computed tomographic scan after a left thoracotomy for esophageal rupture (left). Ultrasound of the right chest identified a simple pleural effusion (right).
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Patient 2
A 53-year-old female known to have advanced lung cancer was referred at night with severe dyspnea. We consulted on her in a nearby hospital where she had been admitted. Her chest roentgenogram (Fig 3) showed a large right pleural effusion. She had not had a recent computed tomographic scan, and the anatomy of the collection was not known with certainty. To expedite her care, rather than arrange for a specialist to do radiological tests, we performed an US. This showed a complicated pleural collection (Fig 4), which was immediately drained by US-guided thoracocentesis. The post-drainage chest roentgenogram (Fig 3) showed a lung mass that was avoided by US guidance.
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Fig 3. Chest roentgenogram showing a large right pleural effusion in patient with advanced lung cancer: preoperative (left) and postoperative (right) ultrasound-guided drainage.
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Patient 3
A 26-year-old man presented with symptoms of right subclavian vein compression and thoracic outlet obstruction. The computed tomographic scan (Fig 5) identified a mass, and he was referred to the thoracic surgery clinic. In the outpatient clinic during his first consultation with a thoracic surgeon, US was performed, which showed a low-density lesion (Fig 5). Doppler US evaluation showed no flow in it, but suggested a vessel with flow behind it (Fig 6). In the clinic, we performed immediate US-guided core biopsy of the mass, samples from which identified a non-Hodgkin lymphoma. We were mindful of the location of the vessel seen at US, and this procedure was not complicated by bleeding or pneumothorax. At subsequent staging, CT contrast given through the right arm showed good concordance with these US images (Fig 6). The fact that US-guided biopsy was performed during his first consultation with the thoracic surgeon represents to us a particular example of the advantages of familiarity with this technology.
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Fig 5. Computed tomographic scan showing right supraclavicular mass (left) and ultrasound shows low-density lesion (right).
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Fig 6. Ultrasound with color Doppler evaluation (left) and subsequent computed tomographic scan with contrast via right arm show good concordance (right).
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Patient 4
A 67-year-old man presented to the outpatient clinic with a lower left chest wall mass. Computed tomographic scan showed areas of calcification within an expanded rib (Fig 7). The US showed areas of low and high echogenicity. With US guidance, immediate core biopsies were obtained that were subsequently diagnostic for chondrosarcoma. There were no complications, and US was useful in gauging depth and avoiding areas with the highest echogenicity, which may have been calcified.
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Fig 7. Computed tomographic scan (left) and ultrasound of the same expanded rib (see arrow) shows areas of varying density (right).
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Comment
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Transthoracic US has been used to evaluate pleural diseases (ie, pleural effusion, pneumothorax, and pleural masses), parenchymal diseases (ie, pneumonia, neoplasms, infarct, and atelectasis), chest wall abnormalities (ie, chest wall tumor and rib fracture), and the diaphragm (ie, function and mass). Ultrasound may also be used to assist diagnosis and to guide interventional procedures [1–10].
Until recently, the use of ultrasound may have required dedicated space, a radiological specialist or technician, and an expensive relatively large and cumbersome US machine. With the increasing availability of economical and portable US units that also have good image resolution, it is reasonable to consider that US could become a day-to-day tool for interested clinicians. The unit we used had standard settings and simple menus that helped to make the change in practice more acceptable. It was also designed as a fairly robust unit, suited for regular and busy use without the need for re-calibration or special housing.
Given that thoracic surgeons have expertise in neck, chest, and upper abdominal anatomy, correlation with ultrasound images should be easy, and additional training may be relatively modest. Real-time availability means that only a few minutes are required to perform a diagnostic study. Once a target site is identified, the patient is already positioned. The skin can be marked prior to skin preparation and the procedure can be performed immediately under sterile conditions and to the satisfaction of the surgeon.
We were careful when establishing our US use to obtain training from experienced users, and one of the authors is a consultant radiologist with considerable US experience. In our experience, in appropriate cases, all thoracic surgeon-guided instrumentation procedures were successful without the need for repeat puncture. Also, we were surprised and satisfied at the ease of use for chest wall lesions. In this small series, we experienced no pneumothorax or other complications and other authors have also reported reduced pneumothorax rates with US guidance.
The availability of the technique has been positively received by patients who particularly commented on the lack of delay and avoiding the need to involve another specialist. We have found it beneficial in speeding up the patient pathway and in being able to perform immediate guided instrumentation with the patient well positioned.
Authors implementing US in other specialties have mentioned both the possibility of demarcation issues between specialties, and in certain jurisdictions, funding and remuneration concerns. Of course, these important issues sometimes arise at times of change. Each problem will require local resolution. Ultimately the implementation of this straightforward technology may be beneficial to both patients and all the involved clinicians (ie, patients, who can go through faster; thoracic specialists, who can work more efficiently; and radiologic specialists, who can be less distracted by straightforward cases to be able to concentrate their expertise more effectively).
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Disclosure and Freedom of Investigation
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The authors had full control of the design of the study, methods used, outcome measurements, analysis of data, and production of the written report. The US unit described was purchased by the hospital for use by the thoracic surgery department. The company provided its standard training to purchasers.
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Acknowledgments
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Dr Jacqueline A. Hughes is supported by the Biomedical Research Centre, Cambridge University Hospitals NHS Trust, United Kingdom.
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Footnotes
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Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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Abstract
Introduction
