20 This means pathology lying deep to air cannot be visualised. Deep venous thrombosis was sought using the same probe. (A) Greyscale sagittal ultrasound scan of the right upper lateral chest in a 25-year-old male presenting with dyspnea, fever, and cough demonstrating non-translobar consolidation/fractal sign identified by tissue-like echotexture, absence of A-lines with an underlying shredded border. Figure 1. The images can provide valuable information for diagnosing and directing treatment for a variety of diseases and conditions. B-lines; Occur due to multiple reflections of sound waves trapped between air and water-rich structures of pulmonary interstitium; 1-2 B-lines may be detected in dependent regions of normal aerated lung. A lines predominate in both hemithoraces (Zones 1 and 2) B Profile. 15 Mosier JM, Malo J, Stolz LA, Bloom JW, Reyes NA, Snyder LS, et al. (, GUID:93A2ACA2-CBFC-4886-9582-9AC98299ADE5, artifacts, dyspnea, lung, pleura, ultrasound. Detection of lung point confirms the diagnosis as pneumothorax. This is the confirmatory sign for establishing a diagnosis of pneumothorax (Figure 11) and helps in determining its size, which is important for clinical decision-making, as larger pneumothoraces are more likely to require thoracostomy. Basic signs of lung ultrasound. (A) Pleural effusion (asterisk) in a 20-year-old female presenting with breathlessness and chest pain identified by visualizing the underlying visceral pleural line/lung line (arrow). ) In our study, the values obtained by physicians who are not ultrasound experts, although slightly lower (86% and 87%, respectively, for lung edema, and 88% and 90%, respectively, for pneumonia), are close to those reported by expert physicians. Traditionally, the diagnosis of pleural effusion is based on visualizing an anechoic/hypoechoic collection. Healthcare providers use ultrasound exams for several purposes, including during pregnancy, for diagnosing conditions and for image guidance during certain procedures. Careers, Unable to load your collection due to an error. (E) Zone R5: with the patient in a sitting position, the posterior chest wall is scanned by placing the transducer on the lower part of the chest along a vertical line passing through the inferior angle of the scapula. The ultrasound findings improved as her clinical condition improved and her viral load decreased. Zanobetti et al. Ana Carolina Tabajara Raupp, Ernesto Dornelles Hospital, Porto Alegre, Brazil. (A-E) A profile. Although these points are standardized, the protocol allows for operator flexibility. The following are the features of a B-lines (Figure 8) as described by Lichtenstein [7]: (1) B-line is a comet tail artifact. Multidisciplinary Intensive Care Unit (Prof. J.J. Rouby), Department of Anesthesiology and Critical Care, Piti-Salptrire Hospital, Assistance Publique-Hpitaux de Paris - AP-HP, Public Assistance-Paris Hospitals - Universit Pierre et Marie Curie - UPMC, Pierre and Marie Curie University - Paris 6, Paris, France. Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil, Universit Pierre et Marie Curie, Paris, France, Hospital Practitioner. In the chest, the pleural line lies parallel to the probe and acts as a reflective interface when the lungs are aerated, giving rise to reverberation artifacts known as A-lines due to repetitive reflections between it and the transducer. (, GUID:F5BF6BA4-D98B-4B93-93D4-7E6175927E65, Supplementary Material 3. (D) Zone R4: transducer placed in the mid-axillary line on the upper part of the lateral chest, in the 3rd intercostal space. The dynamics of regular measurements of liver stiffness indicate a personalized patient risk profile that enables the initiation of individualized treatment strategies. ( The diagnostic accuracy of LUS alone was significantly higher than was that of chest X-ray alone (84% vs. 43%; p = 0.01). O USP baseado no protocolo BLUE foi reproduzvel por mdicos com habilidades bsicas em ultrassonografia e acurado para o diagnstico de pneumonia e de edema pulmonar cardiognico. ), The appeal for using LUS in ARF patients is evident since LUS can detect lung aeration changes in many life-threatening conditions, such as acute lung edema, acute respiratory distress syndrome, pneumonia, and pneumothorax. [15] defined several criteria for pulmonary fibrosis on lung ultrasound based on pleural line abnormalities including irregularity, tightening, fragmentary nature, blurring and thickening of the pleura line. Lung ultrasound is based on the analysis of ultrasound artifacts generated by the pleura and air within the lungs. 21 BLUE: bedside lung ultrasound in Emergency. Another useful sign is the quad sign which refers to the rough quadrilateral appearance of the effusion framed by the pleural line superiorly, visceral line inferiorly and rib shadows on either side. Lichtenstein D, Mezire G, Biderman P, Gepner A. (A) M-mode with the cursor over the pleural line illustrating the seashore sign. The motionless portion of the chest above the pleural line creates horizontal waves, (bracket) and the lung sliding below the pleural line creates a granular pattern, the sand (brace). The more lateral or posterior the lung-point sign is identified, the larger the pneumothorax. (B) Cine US clip demonstrating the same (Supplementary Material 2). 15 (3): 145. , However, LUS is currently performed with standard ultrasound imaging . 1 Lung ultrasound in the critically ill: The BLUE protocol. Lung ultrasound for the cardiologist-a basic application: The B-profile of the Bedside Lung Ultrasound in Emergencies protocol for diagnosing haemodynamic pulmonary oedema Arch Cardiovasc Dis . ( BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Thoracic ultrasonography for the pulmonary specialist. 2. An abolished lung sliding combined with B lines is called B profile. , They were blinded to patient medical history and were not involved in diagnostic or therapeutic decisions. As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiognico (n = 15). We attempt to provide a simplified approach to understanding the physics behind the artifacts used in lung ultrasound, the imaging techniques, and the application of the BLUE protocol to diagnose the commonly presenting causes of acute dyspnea. Tutino L, Cianchi G, Barbani F, Batacchi S, Cammelli R, Peris A. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating . Deep impact of ultrasound in the intensive care unit: the "ICU-sound" protocol. Peris A, Tutino L, Zagli G, Batacchi S, Cianchi G, Spina R, et al. 5. (2) It always arises from the pleural line. - ), After attending 5 hours of theoretical training and performing 10 supervised LUS examinations, 4 non-ultrasound experts participated in the study. Paradoxical movement indicates phrenic nerve palsy. raised intra-abdominal pressure, and muscle weakness. The normal physiological movement of the lungs results in sliding of the visceral pleura against the motionless parietal pleura resulting in a twinkling, to-and-fro motion called lung sliding [8]. Graduate Program in Respiratory Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Saving You Time. The occult pneumothorax: what have we learned? (B) B-lines (asterisks) are vertical artifacts deriving from the pleural line, moving synchronously . 2015;147(6):1659-1670. doi:10.1378/chest.14-1313. The lung point was however visualized in posterolateral lung zones, indicating a large pneumothorax. Other advantages include delaying or even avoiding the need for patient transportation to the radiology suite or for radiation exposure and guiding life-saving therapies in extreme emergency. B-lines, also referred to as lung rockets, are a comet-tail artifact arising from the pleura (Figure 2). Viera AJ, Garrett JM. ) In a study conducted in Italy, the use of bedside LUS was associated with a 26% reduction in the total number of chest X-rays and a 47% reduction in the total number of CT scans. Cine US clip demonstrating 'Stratosphere sign' on M - mode: horizontal lines above and below the pleural line. At the time the article was last revised Daniel J Bell had no recorded disclosures. No potential conflict of interest relevant to this article was reported. These are similar to comet-tail artifacts but arise from fluid trapped between air. Dexheimer FL, Neto, Dalcin Pde T, Teixeira C, Beltrami FG. Lichtenstein DA. Sagittal grey scale ultrasound scan (A) with M-mode tracing (B) in a 6-year old boy with history of dyspnea, chest pain and previous intercostal chest tube drainage for empyema revealed abolished lung sliding in the form of stratosphere sign: horizontal lines above and below the pleural line, in the left anterior and lateral lung zones with presence of A-lines and absent B-lines (known as A profile). ) a normal profile (bilateral lung sliding with A-lines) should be combined with screening for leg vein thrombosis. (B) Cine US clip depicting the same (Supplementary Material 1). The site is secure. ( ( To help a doctor guide a biopsy needle into a suspicious area to take a sample. Critical care ultrasound training: a survey of US fellowship directors. posterolateral alveolar and/or pleural syndrome profile. 8. International evidence-based recommendations for point-of-care lung ultrasound. LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). (B) Three B-lines representing the lung rocket pattern were noted only on the left side. (B) Zone R2: transducer placed in the 4th intercostal space in the mid-clavicular line. A B profile characterized by symmetric bilateral B-lines suggested hemodynamic lung edema. Federal government websites often end in .gov or .mil. 15 Cine US clip demonstrating Lung sliding on M-mode with the cursor over the pleural line illustrating the seashore sign. The motionless portion of the chest above the pleural line creates horizontal waves, and the lung sliding below the pleural line creates a granular pattern, the sand. The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). Previously, the B-lines were called comet-tail artifacts. As originally described, it has seven defining features 1: B-line distribution corresponds with sub-pleural thickened interlobular septa, as demonstrated by CT, and are absent under normal conditions and present in alveolar-interstitial syndromes 2. Before 10 ( ( They are almost always long, well-defined, laser-like, hyperechoic, erasing A-lines, and are considered significant when 3. Use of this Web site is subject to the medical disclaimer. As we were concerned about the accuracy of bedside LUS performed by physicians who are not ultrasound experts, we therefore decided to investigate the diagnostic accuracy of the BLUE protocol for ARF. ) In the present study, in order to homogenize the interpretation of LUS findings, we arbitrarily chose a total of 5 hours of theoretical training and 10 supervised ultrasound examinations. ( Lung ultrasound (also known as chest ultrasound, thoracic ultrasound, and pulmonary ultrasound) is a Point of Care Ultrasound (POCUS) application that can be used to diagnose almost any lung pathology in seconds while outperforming chest x-ray! B+ lines predominate in both hemithoraces (Zones 1 and 2) AB Profile (C profile) A lines predominate in one hemithorax (Zones 1 and 2) B lines predominate in the other hemithorax . Bouhemad B, Zhang M, Lu Q, Rouby JJ. Without a specific search for the lung point, it may not be seen in the anterior assessment of lung sliding, although lung sliding will still be abolished. 18, 19 With increasing density or fluid, more B-lines will appear and coalesce into "lung rockets.") 15 ( 9 The A-line seen on lung ultrasound (Figure 1) originates from the pleura and can be seen in a normal lung. The appearance of prominent B-lines bilaterally, suggestive of heart failure, essentially rules out COPD, pulmonary embolism, and pneumothorax. Noninvasive or invasive positive-pressure ventilation was required in 92% of the patients (Table 2). Early fluid loading in acute respiratory distress syndrome with septic shock deteriorates lung aeration without impairing arterial oxygenation: a lung ultrasound observational study. Its major drawback was poor penetration of the ultrasound beam due to the overlying thoracic cage and air content within the lung which led to artifacts. Sometimes one or two B-lines with lung sliding may also be seen and are also included under A-profile. An abdominal ultrasound is a noninvasive procedure used to assess the organs and structures within the abdomen. (, GUID:1DA1514B-739E-4411-90F7-13A3489035D6, Supplementary Material 5. 3 Fortunately much pulmonary pathology does involve . Graduate Program in Respiratory Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil, Ernesto Dornelles Hospital, Porto Alegre, Brazil. Remrand F, Dellamonica J, Mao Z, Ferrari F, Bouhemad B, Jianxin Y, et al. Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil. Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil. BLUE: bedside lung ultrasound in Emergency; PLAPS: posterolateral alveolar and/or pleural syndrome. As a rule, LUS was performed within 20 minutes of admission, by one non-ultrasound expert. (C) Right upper lobe consolidation with air bronchograms was similarly noted on Chest X-ray, correlating with the ultrasound findings. the contents by NLM or the National Institutes of Health. Chest. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar beira do leito em situaes de emergncia) demonstrou elevado rendimento diagnstico em pacientes com insuficincia respiratria aguda (IRpA). http://creativecommons.org/licenses/by-nc/4.0/, https://doi.org/10.4266/acc.2022.00780.v001, https://doi.org/10.4266/acc.2022.00780.v002, https://doi.org/10.4266/acc.2022.00780.v003, https://doi.org/10.4266/acc.2022.00780.v004, https://doi.org/10.4266/acc.2022.00780.v005. Ernesto Dornelles Hospital, Porto Alegre, Brazil. The latter also included additional sonographic findings like pleural alterations and consolidations of varying sizes. Bedside lung ultrasound in emergency (BLUE) is a basic point-of-care ultrasound (POCUS) examination performed for undifferentiated respiratory failure at the bedside, immediately after the physical examination, and before echocardiography. The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients. (2004) Anesthesiology. ( ). The inclusion criteria were age 18 years and admission to the ICU for ARF, defined by one of the following: a respiratory rate 30 breaths/min; a PaO2 60 mmHg; an oxygen saturation on room air 90%, as measured by pulse oximetry; or a carbon dioxide tension (PCO2) 45 mmHg with an arterial pH 7.35. In a 65-year old patient, an. In this study, LUS accuracy was significantly higher than was that of chest X-ray (84% vs. 43%; p = 0.009). C profile: consolidation image appearing as a tissue structure containing white points consisting of lung parenchyma. Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. (G) Zone R7: transducer placed further cranially, medial to the upper part of the scapula. Baldi G, Gargani L, Abramo A, D'Errico L, Caramella D, Picano E, et al. 1. (A) The radiologist first compares their hands with the patient's and places one hand just below the clavicle with fingertips at the midline. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, et al. Diffuse interstitial syndrome on ultrasound, diagnosed by the presence of multiple (3) B-lines in >1 scanning zone in anterolateral chest wall on each side in a patient presenting with acute dyspnea and hemoptysis. Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. 147 (6): 1659-1670. Pleural effusion. In the critically ill, diffuse interstitial syndrome is almost always due to pulmonary edema, either hemodynamic (fluid overload or cardiogenic) and permeability induced (acute respiratory distress syndrome [ARDS]/post-infectious, etc.). 15 In accordance with the BLUE protocol (Table 1),( Traditionally, the role of chest ultrasound in the evaluation of dyspnea was limited to the diagnosis of pleural effusion and guiding interventions like thoracocentesis. As previously described, 5 patients with rare diagnoses were excluded from the final analysis (2 patients with pulmonary fibrosis, 1 patient with hypersensitivity pneumonitis, 1 with leptospirosis, and 1 with abdominal compartment syndrome). If no sliding is present, it is because the visceral and parietal pleura are not apposed to one another. Appointments & Locations. ( A-lines appear bilaterally with lung sliding in the anterior surface of lungs, suggestive of . The same artifacts were used by Lichtenstein to develop the principles of lung ultrasound. 15 In the extended BLUE protocol [7], the physician performing the scan can extend the BLUE protocol at will and utilize clinical details suggestive of pulmonary embolism e.g. Few B-lines may be normally seen in basal lung zones. 10 The mean hospital length of stay before ICU admission was 7.9 7.7 days. Federal University of Rio Grande do Sul, Porto Alegre, Brazil. Ultrasound profiles. Multiplane ultrasound approach to quantify pleural effusion at the bedside. B profile (B-lines): hyperechoic vertical artifacts that move in synchrony with the respiratory cycle. Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. {"url":"/signup-modal-props.json?lang=us"}, Carroll D, Bell D, Kang O, et al. The goal of the examination is to improve the speed and precision of identifying common causes of acute dyspnea. "A profile" prompts a search for venous thrombosis, if present, If absent, PLAPS is sought - its presence (A profile plus PLAPS) suggests. The AB profile was characterized by asymmetric findings between the hemithoraces, suggestive of pulmonary infection as the etiology of ARF. 16 (1) Abolished lung sliding [8]: the presence of air between the parietal and visceral pleura in the case of pneumothorax results in a lack of lung sliding. Similarly, auscultation to hear wheezing can be done if there is a strong suspicion of COPD/asthma. 6 [6], based on principles of Lichtenstein and Volpicelli, using a curved array low-frequency transducer placed in a longitudinal axis over an intercostal space with the patient in a supine position. B-profile. 2015;147(6):1659-1670. doi:10.1378/chest.14-1313.2. Lung US is a highly sensitive and specific modality that aids in the evaluation of the lungs for many different abnormalities, including pneumonia, pleural effusion, pulmonary edema, and pneumothorax. Ultrasound assessment of antibiotic-induced pulmonary reaeration in ventilator-associated pneumonia. There was only one patient with pulmonary embolism (in this patient, LUS was normal as expected, but it was not possible to identify deep vein thrombosis) and none with pneumothorax. Bethesda, MD 20894, Web Policies It is best performed with a small footprint probe (C, D) which is held like a tennis racket, placed perpendicular to the PLAPS point, and directed as cranially as possible for a wider scanning window. These protocols range from comprehensive 28-site scanning evaluation at multiple intercostal spaces in the anterolateral chest wall with/without additional posterior chest evaluation described by Jambrik et al. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. National Library of Medicine A profile. The https:// ensures that you are connecting to the Conceptualization: all authors. A-lines can be seen parallel to the pleural line. The https:// ensures that you are connecting to the Normally, the transducer emits a short ultrasound pulse which is transmitted into the body and undergoes reflections and scatterings at various levels as it passes through the tissues. Indeed, bedside LUS has been shown to have superior accuracy when evaluating patients with atelectasis, pneumothorax, pneumonia, or acute respiratory distress syndrome, compared with chest X-ray. Lung Ultrasound Interpretation Key Points Accurate identification of normal and pathologic lung ultrasound patterns is necessary for appropriate application of diagnostic algorithms. Although the linear transducer is usually used for evaluating the pleura, lung ultrasound is widely performed with convex or micro convex transducers, the latter being preferred if available. Ultrasound has long shown its utility for plain organs. We just advocate to have, before the current trend, defined critical ultrasound using . Acute dyspnea, with or without hypoxia, is a common patient presentation in the ED, and can be the result of a myriad of mainly cardiac, pulmonary, and metabolic conditionsmany of which are life-threatening. 8 Since 1989 in our ICU, using devoted logistics, 9 the concept of whole-body ultrasound was developed and extended to the lungs for managing critical situations . The other hand is applied just below the upper one, excluding the thumb. These techniques are preferred in stable patients. Pulmonary embolism, pneumonia, and COPD/asthma. (A) Zone R1: transducer placed in the 2nd intercostal space, a few centimeters away from the sternum. The main diagnoses, including pneumonia, acute hemodynamic lung edema, obstructive lung disease (i.e., decompensated COPD or asthma), and pneumothorax, were evaluated. The BLUE protocol diagnosis made at admission by physicians who are not ultrasound experts had a perfect agreement with the final diagnosis in 84% of the patients (overall kappa, 0.81). The Lung line is a regular line which outlines the effusion, indicating the visceral pleural line, roughly parallel to the pleural line (parietal pleura). This sign is specific for pleural effusion. Lung Approach in Critical Care Physical examination: insufficientfor fine diagnosis Bedsidechest radiography: limited accuracy Chest computedtomography: risk of transportationand limitedavailability Lung UltraSound(LUS): Easy available, Low cost Lung Ultrasound (LUS) In Emergency When LUS can be useful in ER: Pleural pathology Pericardial pathology ), The main limitations of this study are its small sample size and the fact that it was conducted in a single center. All patients were placed in a semirecumbent position and were evaluated with the same curvilinear probe with a range of 3-5 MHz (Toshiba Tosbee(r); Toshiba, Tokyo, Japan). Corresponding author: Aparna Murali Department of Radiodiagnosis, Maulana Azad Medical College, 2 Bahadur Shah Zafar Marg, Near Delhi Gate, Maulana Azad Medical College Campus, Balmiki Basti, Delhi 110002, India E-mail: Received 2022 Jun 24; Revised 2022 Sep 2; Accepted 2022 Sep 19.

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