Pulmonary Consolidations
Tanping Wong
1. An 82-year-old woman with a history of hypertension, atrial fibrillation, and heart failure with preserved ejection fraction presents with 1 week of shortness of breath, cough, 10-kg weight gain, and increasing lower extremity edema. Her admission chest X-ray shows bilateral pleural effusions and increased interstitial markings. She is treated with diuresis for respiratory failure secondary to decompensated heart failure in the setting of rhinovirus infection and improves over the course of the week. However, 1 week later, she develops worsening dyspnea and hypoxia. She is afebrile with a HR of 70 bpm and has crackles in bilateral lung fields, despite improved lower extremity edema. A repeat chest X-ray shows persistent central vascular congestion and increased bibasilar opacities. A point-of-care ultrasound is performed as shown in Figure 54.1A (
Video 54.1A) and Figure 54.1B (
Video 54.1B).
Video 54.1A) and Figure 54.1B ( Video 54.1B). Figure 54.1 |
What is the most appropriate next step in management for this patient?
A. Start broad-spectrum antibiotics as the patient has developed pneumonia.
B. Continue diuresis given her improvement over the course of the past week.
C. Increase diuresis because the patient has worsening heart failure.
D. Perform thoracentesis given the change in clinical status of the patient and X-ray showing pleural effusion.
View Answer
1. Correct Answer: A. Start broad-spectrum antibiotics as the patient has developed pneumonia.
Rationale: Figure 5.1A, B and 
Videos 54.1A, B show bilateral consolidations in the lower lung fields without significant pleural effusion, likely representing pneumonia. The accuracy of lung ultrasound in the diagnosis of pneumonia has been shown to be superior to the accuracy of X-ray. The improved lower extremity edema, as well as the consolidations on ultrasound argue against worsening heart failure, and drainage of the effusions is not necessary at this time.
Videos 54.1A, B show bilateral consolidations in the lower lung fields without significant pleural effusion, likely representing pneumonia. The accuracy of lung ultrasound in the diagnosis of pneumonia has been shown to be superior to the accuracy of X-ray. The improved lower extremity edema, as well as the consolidations on ultrasound argue against worsening heart failure, and drainage of the effusions is not necessary at this time.Selected References
1. Alzahrani SA, Al-Salamah MA, Al-Madani WH, Elbarbary MA. Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia. Crit Ultrasound J. 2017;9(1):6. doi:10.1186/s13089-017-0059-y.
2. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systemic review and meta-analysis. Respir Res. 2014;15:50.
2. An 87-year-old woman with a history of pulmonary fibrosis, severe obstructive lung disease (FEV1 36% predicted), who is dependent on home oxygen (3 L nasal cannula), presents with 4 days of worsening cough and shortness of breath. She also has a history of heart failure and pulmonary hypertension with right ventricular dilation. In the Emergency Department, she is noted to be in respiratory distress, with a RR of 28/min, HR 120 bpm BP of 100/70 mm Hg, and SpO2 is 95% on 3 L nasal cannula. She is afebrile. On physical examination, jugular venous distention, diffuse wheezing, and basilar crackles are noted. A portable chest X-ray shows diffuse increased interstitial markings and increased opacity of the right lower lung field. Her white blood cell count (WBC) is 13,000/mm3 with 85% neutrophils. A point-of-care ultrasound is performed (Figure 54.2 and 
Video 54.2).
Video 54.2). Figure 54.2 |
Which of the following conclusions is most accurate?
A. The patient likely has a viral infection leading to exacerbation of her obstructive lung disease.
B. The patient likely has pneumonia, given the consolidation seen on ultrasound.
C. The patient likely has an exacerbation of heart failure, given the pleural effusion seen on ultrasound.
D. The patient likely has progression of her underlying pulmonary fibrosis.
View Answer
2. Correct Answer: B. The patient likely has pneumonia, given the consolidation seen on ultrasound.
Rationale: Possible etiologies for this patient’s respiratory distress include progression of her pulmonary fibrosis, exacerbation of her obstructive lung disease, worsening heart failure, viral infection, and bacterial pneumonia. Ultrasound is useful in the evaluation of such patients, as they are often unstable for further imaging with a CT scan. The ultrasound shows dense consolidation in the right lower lung field (left side of Figure 54.2, above the curved diaphragm), with surrounding pleural effusion, suggesting pneumonia and parapneumonic effusion. A heart failure exacerbation, chronic obstructive pulmonary disease (COPD) exacerbation, or progression of pulmonary fibrosis would not be expected to produce this type of consolidation.
Selected References
1. Ye X, Xiao H, Chen B, Zhang SY. Accuracy of lung ultrasonography versus chest radiography for the diagnosis of adult community-acquired pneumonia: review of the literature and meta-analysis. PLoS One. 2015;10(6):e0130066.
2. Zanobetti M, Scorpiniti M, Gigli C, et al. Point-of-care ultrasound for evaluation of acute dyspnea in the ED. Chest. 2017;151(6):1295-1301.
3. Which of the following findings (Figure 54.3 and 
Video 54.3) on ultrasound does not support a diagnosis of pneumonia?
Video 54.3) on ultrasound does not support a diagnosis of pneumonia? Figure 54.3 |
A. Hepatization of the lung parenchyma
B. Shred sign
C. A-lines
D. Dynamic air bronchograms
View Answer
3. Correct Answer: C. A-lines
Rationale: Characteristics on ultrasound that are highly suggestive of pneumonia include hepatization, dynamic air bronchograms, and the shred sign. Hepatization refers to the hypoechoic appearance of the lung formed by pus-filled bronchi. The shred sign is a shredded deep border of the tissue-like image adjacent to the aerated lung. Air bronchograms are linear or punctiform hyperechoic features seen within the consolidation from regions of aerated airspaces. Mobile or dynamic air bronchograms are specific for the diagnosis of pneumonia. In this situation, the respiratory movement of gas bubbles within the bronchi indicates patency of the airway. This is in contrast to static air bronchograms, which are seen in atelectasis. Limitations of dynamic air bronchograms include being off-plane during examination (which will cause air bronchogram to transiently disappear, but not because of actual movement of air bubbles) and the development of atelectasis (with static air bronchograms) within pneumonia. The combined presence of hepatization, shred sign, and air bronchograms has a positive likelihood ratio of 12 and a negative likelihood ratio of 0.16 for the diagnosis of pneumonia. A-line represent a strong reflection from aerated lung tissue, and would not be expected in the presence of consolidated lung tissue.
Selected References
1. Alzahrani SA, Al-Salamah MA, Al-Madani WH, Elbarbary MA. Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia. Crit Ultrasound J. 2017;9(1):6. doi:10.1186/s13089-017-0059-y.
2. Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142(4):965-972. doi:10.1378/chest.12-0364.
4. A 57-year-old previously healthy man presents with fever, cough, and fatigue. His symptoms began as nasal congestion and rhinorrhea 1 week prior, when his young children were also sick at home. He was treated with oral azithromycin for 5 days, with a worsening cough and new onset of fever. On presentation, his temperature is 39°C, with HR 100 bpm, BP 100/60 mm Hg, RR 22/min with SpO2 94% on 3 L of oxygen via nasal cannula. His leukocyte count is 3000 cells/mm3. A portable chest X-ray shows opacity in the right lower lung field with pleural effusion. A point-of-care ultrasound for evaluation of the pleural effusion is performed (Figure 54.4 and 
Video 54.4).
Video 54.4). Figure 54.4 |
What is the most appropriate next step in his management?
A. Perform diagnostic thoracentesis to rule out the presence of empyema.
B. The ultrasound shows a complex loculated pleural effusion; call expert consultation for chest tube placement.
C. Start intravenous (IV) antibiotics for the treatment of community-acquired pneumonia.
D. Place a nasogastric tube to evacuate the stomach contents seen on ultrasound.
View Answer
4. Correct Answer: C. Start intravenous (IV) antibiotics for the treatment of community-acquired pneumonia
Rationale: This patient developed a right lower lobe pneumonia. His hypoxemia and fever after antibiotic therapy warrant additional treatment. There is no pleural effusion on the ultrasound, thus thoracentesis is not indicated. Although gastric content can appear as hyperechoic specks, the stomach is located under the diaphragm (to the right side of the image), and ultrasound typically shows a mix of hypo- and hyperechogenic content. The liver is visualized below the diaphragm of Figure 54.4. Ultrasound is useful in clarifying nonspecific opacities seen in the lower lung fields of chest X-rays.
The ultrasound shows consolidated lung above the diaphragm (left side of Figure 54.4), containing hyperechoic lines and dots that move with respiration. These are dynamic air bronchograms that represent trapped air within the small airways, with a sensitivity of 94% and specificity of 61% in the diagnosis of pneumonia.
Selected References
1. Alzahrani SA, Al-Salamah MA, Al-Madani WH, Elbarbary MA. Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia. Crit Ultrasound J. 2017;9(1):6. doi:10.1186/s13089-017-0059-y.
2. Lichtenstein D, Meziere G, Seitz J. The dynamic air bronchogram* a lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest. 2009;135:1421-1425.
5. An 84-year-old woman who is a resident of a nursing home presents with fatigue and anorexia. She was noted to have low-grade fevers and suprapubic tenderness. She reports a chronic cough, but does not have shortness of breath or chest pain. Her temperature is 37°C, HR 84 bpm, BP 116/72 mm Hg, RR 12/min, and SpO2 95% on room air. Her portable chest X-ray is hazy at the lower lung fields bilaterally. A point-of-care ultrasound is performed for better visualization of her lung fields (Figure 54.5 and 
Video 54.5).
Video 54.5). Figure 54.5 |
Which of the following is seen on the ultrasound image?
A. Consolidation
B. Complex pleural effusion
C. Mirror artifact with curtain sign
D. Diffuse B-lines
View Answer
5. Correct Answer: C. Mirror artifact with curtain sign
Rationale: Liver tissue is visible on the right of 
Video 54.5, as well as the hyperechoic diaphragm in the center. To the left of the diaphragm is a mirror artifact. The curtain sign is seen coming into view during respiration.
Video 54.5, as well as the hyperechoic diaphragm in the center. To the left of the diaphragm is a mirror artifact. The curtain sign is seen coming into view during respiration.The mirror image artifact is seen when there is a highly reflective surface such as the diaphragm in the path of the primary beam, which is reflected back to the transducer. The reflection of the liver is seen beyond the diaphragm and may be confused for hepatized lung. This artifact can be distinguished from hepatization of the lung by the absence of the spine sign and the presence of the curtain sign (Figure 54.16).
 Figure 54.16 |
Selected Reference
1. Chichra A, Makaryus M, Chaudhri P, Narasimhan M. Ultrasound of the pulmonary consultant. Clin Med Insights Circ Respir Pulm Med. 2016;10:1-9.
6. A 27-year-old man was an unrestrained backseat passenger in a motor vehicle collision 1 week prior to presentation. He was seen in the Emergency Department at the time of the accident. A chest X-ray done at that time did not show pneumothorax or rib fractures. Since the accident, he’s been experiencing pleuritic chest pain, and over the past 3 days, he has a cough and low-grade fever. A repeat chest X-ray is reported as normal. Ultrasound at the site of reproducible chest wall tenderness is shown (
Video 54.6).
Video 54.6). Figure 54.6 |
Based on Figure 54.6, which of the following is the most likely explanation for his symptoms?
A. A displaced rib fracture is seen.
B. The ultrasound shows subcutaneous emphysema, suggesting a pneumothorax.
C. The patient likely suffered lung contusion that developed into pneumonia.
D. Normal lung parenchyma is seen. The patient likely suffered a chest wall contusion.
View Answer
6. Correct Answer: C. The patient likely suffered lung contusion that developed into pneumonia
Rationale: Lung contusion is common after blunt chest trauma and can be missed on an initial chest X-ray. On ultrasound, lung contusion can appear as hypoechoic subpleural peripheral parenchymal lesions. It can also appear as an alveolointerstitial syndrome with B-line artifacts. Complications like infection can develop from contusions. Pain control, improvement of respiratory mechanics, and secretion clearance are the main treatments. Antibiotics may be necessary if superinfection develops.
Selected References
1. Helmy S, Beshay B, Hady MA, Mansour A. Role of chest ultrasound in the diagnosis of lung contusion. Egypt Soc Chest Dis Tuberc. 2015;64:469-475. doi:10.1016/j.ejcdt.2014.11.021.
2. Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasound in lung contusion. Chest. 2006;130(2):533-538.
7. A 25-year-old man with a past history of asthma presents with 1 week of fever, cough, right-sided pleuritic chest pain, and shortness of breath. On presentation to the Emergency Department, he has an RR of 32/min and SpO2 68% on room air. On auscultation, wheezing and bronchial breath sounds are noted on the right lower lung field. He is emergently intubated for respiratory distress. A point-of-care ultrasound is performed and shown in Figure 54.7 and 
Video 54.7.
Video 54.7. Figure 54.7 |
What is the most likely diagnosis of this patient’s clinical presentation?
A. The patient is having a severe asthma exacerbation.
B. The patient presents with severe community-acquired lobar pneumonia.
C. The patient has a complex pleural effusion, likely empyema.
D. The patient likely suffered blunt trauma, as hemothorax is seen on ultrasound.
View Answer
7. Correct Answer: B. The patient presents with severe community-acquired lobar pneumonia
Rationale: The ultrasound (Figure 54.7 and 
Video 54.7) shows complete consolidation of the right lung with dynamic air bronchograms. This dense consolidation is often referred to as “hepatization,” as it has a similar appearance to the sonographic appearance of the liver. It is formed by bronchi filled with pus and secretions that appear hypoechoic. The trapped air bubbles form linear or punctate hyperechoic structures referred to as air bronchograms. The spine is seen in the far-field, indicating the presence of lung transmitting the sound wave, which is abnormal. Normally aerated lung reflects ultrasound waves and the spine cannot be visualized through the pleura This patient’s bronchoalveolar lavage culture subsequently grew Streptococcus pneumoniae.
Video 54.7) shows complete consolidation of the right lung with dynamic air bronchograms. This dense consolidation is often referred to as “hepatization,” as it has a similar appearance to the sonographic appearance of the liver. It is formed by bronchi filled with pus and secretions that appear hypoechoic. The trapped air bubbles form linear or punctate hyperechoic structures referred to as air bronchograms. The spine is seen in the far-field, indicating the presence of lung transmitting the sound wave, which is abnormal. Normally aerated lung reflects ultrasound waves and the spine cannot be visualized through the pleura This patient’s bronchoalveolar lavage culture subsequently grew Streptococcus pneumoniae.Stay updated, free articles. Join our Telegram channel
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