Pulmonology Book


Bedside Lung Ultrasound in Emergency

Aka: Bedside Lung Ultrasound in Emergency, Blue Protocol, Lichtenstein Dyspnea Evaluation by Ultrasound Protocol
  1. See Also
    1. Lung Ultrasound
    2. Volpicelli Dyspnea Evaluation with Ultrasound Protocol
    3. Lung Ultrasound for Pneumothorax (Sliding Lung Sign, Lung Point)
    4. Ultrasound
    5. Echocardiogram
    6. FAST Exam
  2. Indications
    1. Severe Acute Dyspnea evaluation in Critical Care patients (Acute Respiratory Failure)
    2. Distinguish acute Dyspnea Causes in a Critical Care patient
      1. Pneumothorax
      2. Pneumonia
      3. Acute Cardiogenic Pulmonary Edema
      4. Pulmonary Embolism
      5. Obstructive Lung Disease (COPD, Asthma)
  3. Background: Zones
    1. Zone 1: Anterior chest
      1. Mid-clavicular line at 2nd to 3rd intercostal space
      2. Assess for Sliding Lung Sign and artifacts (A-Lines and B-Lines)
    2. Zone 2: Lateral chest above nipple line
      1. Anterior axillary line lateral and slightly superior to nipple
      2. Assess for Lung Point and artifacts (A-Lines and B-Lines)
    3. Zone 3: Posterior chest
      1. Posterior axillary line at most inferior point above diaphragm
      2. Assess for PLAPS (Pleural Effusion or consolidation)
    4. Images
      1. ultrasoundProbePositionLungBlueZones.jpg
  4. Background: Lung artifact categories
    1. See Lung Ultrasound
    2. See Lung Ultrasound for Pneumothorax
    3. Pneumothorax findings
      1. Sliding Lung Sign
      2. Lung Point
    4. Lung edema
      1. B+ Lines (3 or more B Lines in a single view)
    5. PLAPS (Posterolateral alveolar and/or pleural syndrome)
      1. Pleural Effusion (hypoechoic region)
      2. Consolidation (lung with Ultrasound appearance of liver without the sinusoids)
    6. Profiles
      1. A Profile
        1. A lines predominate in both hemithoraces (Zones 1 and 2)
      2. B Profile
        1. B+ lines predominate in both hemithoraces (Zones 1 and 2)
      3. AB Profile (C profile)
        1. A lines predominate in one hemithorax (Zones 1 and 2)
        2. B lines predominate in the other hemithorax (Zones 1 and 2)
  5. Technique
    1. Cardiac or Linear high frequency Ultrasound probe (Lichtenstein used 5 MHz micro-convex probe)
    2. Ultrasound probe directed longitudinally (indicator toward 12:00)
    3. Turn off all Ultrasound machine automatic features that reduce artifact (technique depends on maximizing artifact)
      1. Tissue harmonic imaging (THI) off
      2. Multi-Beam Imaging (Sono MB) off
  6. Interpretation
    1. Lung Sliding present
      1. A Profile
        1. Perform DVT Ultrasound and Lung Ultrasound of Zone 3
        2. DVT Ultrasound positive
          1. Venous Thromboembolism
        3. PLAPS positive (Pleural Effusion or consolidation)
          1. Pneumonia
        4. PLAPS negative
          1. Obstructive Lung Disease (Asthma or COPD)
      2. B Profile
        1. Pulmonary Edema
      3. AB Profile (C Profile)
        1. Pneumonia
    2. Lung sliding absent
      1. A Profile
        1. Lung Point present
          1. Pneumothorax
        2. Lung Point absent
          1. Obtain additional studies to evaluate
      2. B Profile
        1. Pneumonia
      3. AB Profile (C Profile)
        1. Pneumonia
  7. Efficacy
    1. Protocol delivered diagnosis in 90.5% of Acute Respiratory Failure cases
  8. Pitfalls
    1. Operator dependent (learning curve)
    2. Pulmonary Embolism
      1. High False Negative Rate (approaches 20%)
      2. Use protocol as rule-in (not rule-out)
    3. Diaphragm paralysis
      1. Results in False Positive study
      2. khosla (2010) Chest 137(6):1487-8 [PubMed]
  9. References
    1. Lichtenstein (2009) Minerva Anestesiol 75:313-7 [PubMed]
    2. Lichtenstein (2008) Chest 134: 117-25 [PubMed]

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