Pulmonary and Critical Care Medicine Point Of Care Ultrasound (POCUS) education by @Edwin_J_Jr. RDCS & NBE CCE & ccTEE Diplomate
Indianapolis, IN
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What is the short clip challenge? Check out this clip from our 2024 @IUSMDeptMed Grand Rounds. Are you ready to take the challenge? sign up here-->pulmonarypocus.com/contact-u…
@NephroP @IUPCCM @OSUPCCM_Fellows @accpchest @POCUSJournal
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What is the dyssynchrony present in the picture? Poll and treatment options below!
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Can the plateau pressure be higher than the peak?
The answer may surprise you! Check it below!
52%
Yes
48%
No
280 votes • Final results
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You have a pt with a balloon pump on PSV. You notice this fast sequence of breaths that are marked by the ventilator as being patient-triggered (arrowheads under Paw waveform). What do you do next?
POLL BELOW
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Short Clip Challenge week 109
You’re evaluating a cardiac M-mode tracing through the mitral valve. During early diastole, the anterior leaflet moves maximally toward the interventricular septum.
What is the specific peak highlighted at the green arrow?
Extra credit what cardiac view was used?
Take the full week 109 challenge here pulmonarypocus.com/short-cli…
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The pulmonary valve isn’t called the “neglected valve” for nothing.
In this sexagenarian with a BAV, it’s easy to focus all your attention on the aortic valve - and miss the pulmonary valve pathology.
Don’t forget to look beyond the obvious. #echofirst
🕵️♂️ intraop TEE
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One of my ICU rules:
Venous access saves lives. Arterial line gives data
I have never seen a patient die because an arterial catheter wasn't placed promptly. I have seen plenty of patients getting hurt (or die) because reliable venous access came too late (or never)
Place the venous catheter first. Sweat about the arterial line later
And yes. I place a lot of arterial lines and I was not pleased with how many people interpreted the EVERDAC trial
(NEJM 2025; 393: 1875-88 -
DOI: 10.1056/NEJMoa2502136)
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#JADEL
We've heard about atrial septal pouches.
We may have even seen one.
But, did you ever think you'd see a thrombus-in-situ within an atrial pouch?
CASE reports help expand our understanding of uncommon events.
New in CASE @CASEfromASE
@ASE360
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A huge thank you to everyone who participated in the #ShortClipChallenge this year. It has been incredible to see the enthusiasm, engagement, and commitment to improving bedside ultrasound skills week after week.
After tallying the results, I'm excited to announce our 2025-2026 champions:
🥇 Pulmonary POCUS Champion: Dr. Joseph Vroegop (IUSM Internal Medicine)
🏆 5 weekly wins (Weeks 84, 82, 70, 67, and 64)
🎁 $100 Gift Card + Certificate of Excellence
🥈 Runner-Up: Dr. Lauren Pavlik (IUSM Pulmonary & Critical Care Medicine)
🏆 4 weekly wins (Weeks 91, 71, 58, and 52)
🎁 $50 Gift Card
Congratulations to both on an outstanding achievement.
One of the best parts of these challenges is the discussion, clinical reasoning, and learning that emerges from each case. Thank you to everyone who participated and helped make this community both educational and fun.
Think you can beat this year's champions? Test yourself here:
pulmonarypocus.com/short-cli…
The Short Clip Challenge returns for the 2026-2027 academic year on July 14th.
#POCUS #CriticalCare #MedEd #FOAMed #Ultrasound #PulmonaryPOCUS #MedicalEducation #InternalMedicine #PCCM
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When performing TEE, don’t chase the multiplane angle (rotation sign). Chase the anatomy. Identify the landmarks that define the target view and use probe manipulation to bring those structures into the imaging plane. The angle displayed on the screen is only a guide #echofirst
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Waveform analysis case:
You admit a pt after esophagectomy complicated by inadvertent tracheal injury due to the tumor being plastered into it. Pt has a chest tube with active leak (see video).
How can you tell by looking at these waveforms that this patient has a leak?
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Thanks for having me!
EMCrit 427 - Advancing Concepts in Shock Physiology. As an intro to a 3-part series, I go over two papers discussing new ways to assess and understand shock hemodynamics.
(@emnerd, @thinkingcc, @saracrager)
[#MembersOnly]
emcrit.org/427
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@DanRozenbaum
Curious on what you think. I thought this was early cycle dyssynchrony. Tried to increase I time but did not help. Increased opioid infusions but did not help.
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What an honor to receive the Golden Lung Teaching Award from our graduating Indiana University PCCM/CCM fellows!
Teaching mechanical ventilation and critical care to this incredible group has been an absolute privilege. Thank you for this recognition!
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Congratulations to this week's short clip challenge winner Maya Haouili, from IU IM residency! Congratulations Maya, enjoy a cup of coffee on us!
Here's a quick recap of last week's metrics:
We received 97 responses.
Question 1: You are visualizing a pleural effusion. Looking at the footprint of the probe, which transducer is being used?
Answer 2 The correct answer is the phased array transducer. 40% of respondents answered this question correctly.
Question 2: What structure is the white arrow pointing towards?
Answer 2: The correct answer is the diaphragm. 98 % of respondents answered this question correctly.
Key points:
See all Key points here—> pulmonarypocus.com/short-cli…
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Interesting and scary #echofirst image (TEE)
A case of infective endocarditis caused by Tropheryma whipplei.
#POCUS #FOAMed
From 🔗 IDCases. 2023;32:e01800. doi: 10.1016/j.idcr.2023.e01800.
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Hepatic vein Doppler waveform components explained.
#POCUS #VExUS #Nephpearls
🔗piped.video/7KII6btTGJ8?si=YsnK…
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The 60/60 sign is a cardiac #POCUS finding used to support the bedside diagnosis of acute pulmonary embolism. It refers to the simultaneous presence of two measurements, both involving the number 60.
RV outflow tract (RVOT) acceleration time ≤60 ms - This is the time from the onset of blood flow through the pulmonary valve to its peak velocity. In acute PE, the sudden obstruction causes blood to accelerate and decelerate abnormally fast, producing a "truncated" or shortened flow profile.
Pulmonary artery systolic pressure (PASP) ≤60 mmHg (but >30 mmHg) - estimated via the tricuspid regurgitation jet.
In acute PE, the thin-walled right ventricle cannot generate very high pressures because it has not had time to adapt. A PASP above 60 mmHg suggests a chronic process (e.g., chronic pulmonary hypertension) where the RV has hypertrophied over time
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In patients with a left-to-right shunt across a PFO undergoing OPCAB, intermittent apnea used to optimize surgical exposure may induce RV dysfunction and subsequent shunt reversal, resulting in worsening hypoxemia. #echofirst 👉 TEE is crucial
What about the last 2 🎞️ (ACT 300)?
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Teaching point:
If tidal volumes are constant between the two measurements, the PEEP associated with the best static compliance is the one associated with the lowest driving pressure. Titrating to best static compliance vs to driving pressure becomes semantics.
However, if tidal volumes change between measurements, you can’t look at the driving pressure alone (the driving pressure is associated with BOTH static compliance AND tidal volume).
If your patient is on Pressure Control, like the one above, and the increase in PEEP worsens static compliance, tidal volumes will drop for the same applied inspiratory pressure. In a case like this, you MUST look at the static compliance!
We did insp and exp holds to calculate static compliance and got:
At a totPEEP of 12: 317/(32-12) = ~16ml/cmH2O
At a totPEEP of 15: 272/(34-15) = ~14ml/cmH2O
Since compliance was better at a PEEP of 12, we kept it as our ideal PEEP.
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1/2 Congratulations to this week's short clip challenge winner Raul Gregg from IU Internal Medicine! Congratulations, Raul, enjoy a cup of coffee on us!
Here's a quick recap of last week's metrics: We received 102 responses.
Answer 1: The correct answer is the Inferior Vena Cava. 87% of respondents answered this question correctly.
Answer: 2 The correct answer is guidewire migration into the IVC, pull the wire back and continue the procedure. 85% of respondents answered this question correctly. @NephroP
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Key points
1.The SVC sits directly above the IVC anatomically. During central line placement, the guidewire will often pass from the SVC into the right atrium and then straight down into the IVC. This can be seen in real time using a subxiphoid short-axis (“snail”) view.
2.This same pathway is used in several VV ECMO cannulation strategies. In the Avalon technique, a guidewire is advanced from the right internal jugular vein into the IVC, followed by sequential dilation and placement of the Avalon cannula with the distal port in the IVC and the middle port directed toward the tricuspid valve. ( see below)
Avalon cannulation technique.A: Guidewire is placed to the inferior vena cava from right internal jugular veinB: Sequential dilatation of the access site is doneC: The Avalon cannula is placed with distal port in the inferior vena cava and middle port facing to the tricuspid valve
Shaheen, Aisha & Tanaka, Daizo & Cavarocchi, Nicholas & Hirose, Hitoshi. (2016). Veno-Venous Extracorporeal Membrane Oxygenation (V V ECMO): Indications, Preprocedural Considerations, and Technique. Journal of cardiac surgery. 31. 10.1111/jocs.12690.
3. As you perform more POCUS-guided procedures, you will occasionally see PICC lines and guidewires end up in the IVC. One study showed that during standard central venous catheter insertion, about one-third of guidewires migrated into the IVC. Importantly, wires in the IVC often do not produce ectopy or arrhythmias. Because of this, the absence of arrhythmias should never be used to confirm appropriate wire position. The side or site of insertion also does not predict whether the wire will enter the IVC versus remain in the right heart.
pulmonarypocus.com/short-cli…
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