CHEST Recent Advances in Chest Medicine

Advanced Echocardiography for the Critical

Care Physician
Part 1
Mangala Narasimhan, DO, FCCP; Seth J. Koenig, MD, FCCP; and Paul H. Mayo, MD, FCCP

This is the first of a two-part series that reviews advanced critical care echocardiography (CCE)
techniques designed for critical care physicians. In this section, we review training in basic and
advanced CCE. This is followed by a review of Doppler principles, including pulsed wave, contin-
uous wave, and color flow Doppler. Included are Doppler measurement techniques that are
useful for assessing the patient with cardiopulmonary failure and the common pitfalls of Doppler.
This section ends with a review of the quantitative and semiquantitative measurements of stroke
volume, as well as problems with measurement of stroke volume in the ICU and its useful clinical
applications. Video-based examples will help demonstrate the techniques that are described in
the text. CHEST 2014; 145(1):129–134

Abbreviations: CCE 5 critical care echocardiography; CFD 5 color flow Doppler; CWD 5 continuous wave Doppler;
LV 5 left ventricular; LVOT 5 left ventricular outflow tract; NBE 5 National Board of Echocardiography; PWD 5 pulsed
wave Doppler; SV 5 stroke volume; TTE 5 transthoracic echocardiography; VTI 5 velocity time integral

Echocardiography enables the intensivist to assess

the patient with hemodynamic failure. The exam-
ultrasonography. Depending on their interest and the
requirements of their ICU practice, some frontline
ination allows the clinician to categorize the shock intensivists will want to develop competence in the
state and to develop an effective management strategy. field of advanced CCE.
Early and repeated echocardiography is a valuable
tool for the management of shock in the ICU, and the Basic vs Advanced CCE
frontline intensivist should consider skill at bed-
side echocardiography to be a key element of their Performance of the basic examination requires that
training.1 the clinician have skill in image acquisition, image
The American College of Chest Physicians/Société interpretation, and clinical application of a limited num-
de Reanimation de Langue Française statement of
competence in critical care ultrasonography divides For related article see page 135
critical care echocardiography (CCE) into two parts:
basic and advanced.2 Competence in basic CCE is a
mandatory component of skill in general critical care ber of echocardiographic views. The examination can
be performed in several minutes, is limited in scope,
Manuscript received October 3, 2012; revision accepted June 11, goal directed, and can be repeated as often as the
2013. clinical situation warrants. Competence in basic CCE
Affiliations: From the Division of Pulmonary, Critical Care and
Sleep Medicine, the Hofstra North Shore LIJ School of Medi- is readily achieved with a short course of training.3,4
cine, New Hyde Park, NY. Similar to basic CCE, advanced CCE requires a
Correspondence to: Mangala Narasimhan, DO, FCCP, Division high level of skill in all aspects of image acquisition
of Pulmonary, Critical Care and Sleep Medicine, 410 Lakeville
Rd, Ste 107, New Hyde Park, NY 11040; email: mnarasimhan@ and interpretation. Mastery of advanced CCE means
nshs.edu that the intensivist has a skill level that is similar to a
© 2014 American College of Chest Physicians. Reproduction cardiology-trained echocardiographer, although with
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details. additional skill in image acquisition at the bedside and
DOI: 10.1378/chest.12-2441 more knowledge of relevant critical care applications.

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 Advanced CCE avoids the time delays and clinical Competence in Adult Echocardiography. Many car-
disassociation that are intrinsic to standard echocar- diologists choose not to take the NBE echocardiog-
diography, as the examination is performed by the raphy examination, and prefer to satisfy the American
intensivist who has full knowledge of the patient’s Heart Association/American College of Cardiology
clinical condition. The advanced CCE examination is requirement for competence in the field (which does
flexible in scope, becoming as goal directed or com- not require passing the NBE examination). Although
prehensive as the situation demands. It can be per- they are optional, we recommend that the interested
formed immediately and repeated as often as required, intensivist takes the echocardiography board exami-
an approach that contrasts with the traditional practice nation, as it is a clear demonstration of a comprehen-
of performing a comprehensive exam that is often sive knowledge base.
delayed and rarely repeated. This article will review some important aspects of
advanced CCE. These include measurement of SV,
Training in Advanced CCE evaluation of left ventricular (LV) function, identifi-
cation of segmental wall abnormalities, measurement
Achieving competence in advanced CCE is chal- of left-sided filling pressures, evaluation of right-sided
lenging and time consuming. It should be regarded as heart function, and identification of preload sensi-
an optional part of critical care practice, unlike com- tivity. This article will not review the evaluation of
petence in basic CCE. The intensivist must develop a valvular function using advanced CCE techniques, as
comprehensive knowledge of cognitive elements of this requires a separate discussion. The primary focus
the field that may be found in standard literature.5,6 is on measurements that are made with transthoracic
In addition, the intensivist must have definitive train- echocardiography (TTE) and will not include a com-
ing in image interpretation. This requires consider- prehensive discussion of transesophageal echocardi-
able time spent interpreting a large number of full ography. Illustrative video clips are found throughout
echocardiographic studies under the direct supervi- the text and are a key element of the article. The
sion of an expert level reader. Unlike the cardiologist reader is encouraged to be connected to the CHEST
who relies on highly skilled technicians for image video supplements and to call up the video images in
acquisition, the intensivist must spend many hours sequence with the text. This will greatly augment the
personally performing full echocardiographic studies. utility of the article. This article is not a comprehen-
High-level skill at image acquisition is a requirement sive review of the subject; the emphasis will be on
for advanced CCE. measurements that have immediate practical applica-
Part of competence in advanced CCE is that the tion and that can be performed rapidly at the bedside
intensivist understands the limitations and unique appli- of the critically ill patient.
cations relevant to their skill set. For example, diag-
nosis of complex congenital heart disease, guidance Principles of Doppler
of intraoperative valve repair, or detailed analysis of
artificial valve function requires an echocardiographer Advanced CCE requires comprehensive knowledge
with expertise in these areas. However, determina- of Doppler measurements. It is beyond the scope of
tion of preload sensitivity by real-time measurement this article to review in detail the physical principles
of stroke volume (SV) variation or straight leg raising, of Doppler measurements. For this information, the
identification and treatment of adverse heart-lung reader is referred to comprehensive discussions that
interactions related to ventilator settings, or integra- are found in standard texts.9 Instead, this section will
tion of lung ultrasonography into echocardiographic summarize some key concepts and limitations of bed-
results are areas where intensivists have expertise. side Doppler measurements.
A recent statement described training standards for The Doppler phenomenon occurs when the sound
both basic and advanced CCE.7 The working group source (the transducer) and the object reflecting the
held that advanced CCE required a formal certifica- source (blood cells or myocardium) are moving rela-
tion process, given its complexity. In the United States, tive to one another as opposed to the case where the
there is no formal method for certification in advanced transducer and the reflector are both immobile. In
CCE at the national level. The National Board of the case of moving reflectors, the frequency of the
Echocardiography (NBE) offers certification in echo- returning sound wave will be different than the trans-
cardiography only to physicians who have completed mitted wave. The Doppler equation uses the mea-
cardiology fellowship training. An alternative approach sured frequency difference between the transmitted
that intensivists may follow is to satisfy the American and reflected sound waves to derive the velocity of
Heart Association/American College of Cardiology the reflector. In this way, the velocity and direction of
requirements for competence in echocardiography8 blood flow may be measured within the cardiovascular
and then to take the NBE Examination of Special system. The angle of incidence between the direction

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 of blood flow and the ultrasound beam is of utmost operator may use several strategies: (1) use a shallower
importance in making Doppler measurements. If the sample volume, (2) decrease the ultrasound frequency,
angle of incidence is , 20°, the velocity measurement (3) optimize incident angle, (4) use CWD. The main
is of acceptable accuracy. At values above this, the pitfalls of PWD relate to suboptimal incident angle of
velocity will be increasingly underestimated, such that interrogation, poor sample volume placement, trans-
at an incident angle of 90°, the velocity measurement lational artifact-related movement of the heart with
will be zero (Fig 1). The operator, therefore, must the respiratory cycle, and placement of the sample
align the axis of Doppler interrogation as close as volume too close to a stenotic point, so that flow
possible with direction of blood flow. Doppler mea- acceleration gives an overestimation of velocity.
surement of blood flow velocity will never overesti-
mate velocity. It can easily underestimate it, however, Color Flow Doppler
if the operator is not successful in optimal beam
CFD is a form of PWD whereby multiple sample
alignment. Under some circumstances, the absolute
volumes are created within an area selected by the
velocity of blood flow is not as important as changes
operator. The direction and velocity measured in each
in the velocity, as might occur during the respiratory
sample volume is displayed by a specific color and
cycle when making serial semiquantitative measure-
color intensity, respectively. This color-coded grid is
ments of SV. When making serial measurements of
superimposed over the two-dimensional image, allow-
velocity variation, the operator must focus on obtain-
ing for assessment of flow directions and velocities
ing the same angle with each measurement. Other-
over a designated area. To optimize functionality of
wise, changes in velocity might be caused by changes
CFD, the operator seeks the shallowest and smallest
of the incident angle rather than by changes in phys-
map area for CFD measurement.
iologic function.
Beyond the problems of PWD related to incident
The most commonly used Doppler modalities are
angle, CFD has specific pitfalls. It is gain dependent,
pulsed wave Doppler (PWD), color flow Doppler (CFD),
such that under- or overgaining the color map will
and continuous wave Doppler (CWD). Some prac-
predictably under- or overestimate the severity of val-
tical suggestions for their use are as follows.
vular regurgitation (“dial a jet”) (Video 1). A practical
method to set proper CFD gain is to turn on a CFD
Pulsed Wave Doppler
map without the transducer on the patient and to
PWD has utility for the measurement of blood flow turn the gain down until the map area is completely
velocity at a specific location within the cardiovas- black. The gain is then turned up slowly until a few
cular system. PWD cannot be used to measure high color dots are visible. Another problem with CFD
velocities of blood flow. It has utility in measuring occurs in the estimation of the severity of eccentric
velocities in normal physiologic range, such as during valvular regurgitation. CFD jets that are directed
SV measurement in the LV outflow tract (LVOT) or along the wall of the atrium will systematically under-
during mitral valve inflow. To control aliasing, the estimate the severity of the regurgitation (Video 2).

Figure 1. Brachial artery pulse wave velocity Doppler measurements demonstrating the dependence
of velocity on incident angle. The angle of the transducer has been changed such that the incident angle
of Doppler interrogation is reduced with a resultant increase in the measured velocity.

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 In this case, other techniques must be used for accurate the diameter of the LVOT from the parasternal long-
determination of the severity of regurgitation.10 Finally, axis view immediately below the hinge point of the
it is important to understand that the color map is aortic valve leaflets (Fig 2). The LVOT area (cm2) is
measuring velocity; the operator may erroneously calculated from this diameter measurement using the
assume that the size of the color jet represents a flow formula:
map. Unlike contrast used in cardiac catheterization,
LVOT area cm2
5 LVOT diameter 2
3 3.14
2
the size of the color map may have variable relation-
ship to the severity of regurgitation. The advantage of
CFD is its ease of application; its disadvantages are Next, the operator places the PWD sample vol-
these unrecognized pitfalls. ume in the LVOT to measure the systolic velocity
envelope of blood flow in the LVOT, using the five-
Continuous Wave Doppler chamber apical view (Video 3). Integration of the result-
Unlike PWD, CWD is capable of detecting high- ing velocity-time envelope yields the velocity time
flow velocity but it is unable to pinpoint the location integral (VTI), which represents the distance in cen-
of the high velocity at a specific point along the ultra- timeters that blood has moved over the course of
sound beam. The advantage of CWD lies with its systole through the LVOT. The SV is calculated as
ability to measure high velocities, but its disadvan- follows:
tage rests with this range ambiguity of the modality. It
is used most commonly for detection of high-velocity SV cm3 or mL
5 LVOT area cm2
3 VTI cm

blood flow that occurs with stenotic or regurgitant val-

vular dysfunction. Although free of aliasing limitation, Normal values of VTI are between 18 and 22 cm,
it is susceptible to problems related to incident angle. while LVOT diameter varies according to body size.
The Doppler techniques described in the previous Typical values in clinical practice for LVOT diameter
section allow for the measurement of intracardiac range between 1.8 and 2.2 cm.
blood flow velocities. Using these Doppler-derived
values for velocity, the intensivist is able to calculate Problems With Measurement of SV
intracardiac pressures using the following simplified Measurement of LVOT diameter must be very
Bernoulli equation: accurate, as any inaccuracy will be squared when cal-
culating the area. For example, if the LVOT diameter
Pressure gradient DP
5 4 3 Vpeak

2
measurement is 1.8 cm and the VTI is 18 cm, the
resultant SV will be 46 mL; if the LVOT measure-
Where DP is pressure gradient, and V is maximal ment is 2.1 cm and the VTI is 18 cm, the resultant
flow velocity. The velocity across the orifice is related SV will be 62 mL. A 3-mm error in LVOT diameter
directly to the pressure difference or drop between measurement yields a substantial error in SV. Mea-
the proximal and distal portions of the orifice. This surement of LVOT diameter requires a good-quality,
formula forms the basis for measurements of cardiac
pressures with echocardiography.

Measurement of SV
The cardiac SV may be accurately measured with
echocardiography.11 Multiplication of SV by heart
rate yields the cardiac output. Both values may be
indexed to body surface area and used to calculate a
variety of derived values such as systemic or pulmo-
nary vascular resistance and oxygen delivery. Measure-
ment of SV allows accurate, quantitative, noninvasive
assessment of hemodynamic function without the
need for a pulmonary artery thermodilution catheter.
Bedside measurement of SV is a key skill for the
intensivist with interest in advanced CCE.

Measurement Technique
Figure 2. Magnified, parasternal, long-axis view of left ventricular
The measurement of SV is usually made at the LVOT. outflow tract. The calipers have been placed at the hinge point of
When using the TTE approach, the operator measures the aortic valve leaflets with a diameter placement of 2.01 cm.

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 parasternal, long-axis view with clear endomyocardial constant on the screen, but the LVOT may move due
borders and caliper orientation that is strictly perpen- to respiratory translational motion, thereby yielding
dicular to the walls of the LVOT. If the measurement an inconstant VTI measurement. Finally, in patients
is critical for clinical operations, the LVOT diameter with an irregular heart rhythm such as atrial fibrilla-
should be measured several times. tion, SV changes according to R-R interval. In this
Determination of the VTI is subject to problems situation, an average SV needs to be calculated by
related to Doppler measurement. The site of the mea- averaging the VTI over a number of beats, typically
surement is important.12 The PWD sample volume is at least 10.
placed just proximal to the aortic valve at the location
where the LVOT measurement was made. The VTI
Quantitative vs Semiquantitative SV Measurement
recording should show a smooth velocity curve, a
well-defined peak, and a narrow band of velocities When compared with other techniques, the mea-
throughout systole. The sample volume may need to surement of SV using ultrasonography is accurate,
be moved slowly toward the apex to obtain a smooth and there are circumstances when it is important to
velocity curve. Placement of the PWD interrogation have an explicit measurement of the value. Alterna-
box too close to the aortic valve will overestimate the tively, semiquantitative measurements may be suffi-
VTI, particularly if there is any stenosis of the aortic cient to make important decisions at the bedside. The
valve. The VTI is angle dependent. Measurement of LVOT area does not change during the cardiac cycle
the systolic velocity envelope when the interrogation or with change of loading conditions. Given that the
angle is not well aligned along the axis of blood flow LVOT area is constant, changes in VTI represent
will yield an underestimate of the VTI. At times, the changes in SV, even if the exact VTI is not calculated
best measurement axis is not achieved from the best with each cardiac cycle. Given this principle, the VTI
two-dimensional image orientation. The operator may or the peak velocity of the VTI, rather than the abso-
need to adjust the image position on the machine lute value of the SV, may be used to assess hemody-
screen for best angle of Doppler measurement. This namic function. In the patient in sinus rhythm who is
may require using the three-chamber view or a five- completely passive on mechanical ventilation, changes
chamber view. Translational movement of the heart in VTI that occur during ventilator cycle may be used
during the respiratory cycle may also be a challenge. to determine preload sensitivity, as these changes
The position of the Doppler sample volume may be reflect changes in SV, as will be discussed.

Figure 3. Measurement of serial left ventricular outflow tract VTI with augmenting doses of dobu-
tamine. This patient had severe left ventricular failure. At 4-min intervals, dobutamine dose was raised
in increments of 5 mg/kg/min, with a resulting major increase in stroke volume. VTI 5 velocity time
integral.

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 Clinical Utility of SV Measurement CCE, specifically Doppler theory and the practical use
and pitfalls of Doppler in the critically ill patient. The
The intensivist with skill in basic CCE identifies
measurement of SV is discussed in detail along with
qualitatively whether the LV is compromised. While
common problems with this measurement and its clin-
this has use in identifying a cause for hemodynamic
ical application.
failure and allows for design of management strat-
egy, measurement of the SV adds information to the
visual analysis of LV function. For rapid evaluation of
LV function, the finding of a very low VTI in a patient Acknowledgments
in shock may be sufficient to identify low cardiac Financial/nonfinancial disclosures: The authors have reported
output without the need to measure an accurate SV. to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis-
Measurement of SV is helpful if there is a discrep- cussed in this article.
ancy between the contractile function of the LV and Additional information: The Videos can be found in the “Sup-
the resultant cardiac output. For example, the patient plemental Materials” area of the online article.
with under-resuscitated septic shock with hyperdy-
namic LV function and a high ejection fraction may
have, paradoxically, a low SV and cardiac output. Like- References
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