12 breathless algorithm

The breathless patientAdapted from Lichtensteins BLUE protocol (with permission) 1

Summary1 (Ongoing resus) Clinical assessment: formulate the question2 Rapid screen3 Form a working diagnosis4 Continue resuscitation5 Re-scan / monitor progress / further investigations 2

1. Formulate the question

1. Formulate the question Why is the patient breathless? 4

Why is the patient breathless?• Pneumothorax (PTX)• Pneumonia• Acute cardiogenic pulmonary oedema (APO)• Pulmonary embolism (PE)• Asthma / COPD• (Other: rare) 5

2. The BLUE protocol

Curved probe, abdominal preset• Machine settings: as for arrest screen 7

A 3-step scan1. Anterior lung fields: 2 points2. If A profile: scan the upper & lower limb veins for DVT3. If no DVT: PLAPS points 8

The BLUE protocol scan 9

Step 1: anterior chest: upper & lower BLUE points 10

Step 1: anterior chest: upper & lower BLUE points• Probe sagittal, midclavicular line• 2 spots on each side• i.e. upper chest & lower chest 11

Recall: upper & lower BLUE points 1 1 2 2 12

Step 1 findings One lung not Both lungs sliding slidingA’ profile B’ profile A profile B profile A/B or C profile

Step 1 findings One lung not Both lungs slidng slidingA’ profile: B’ profile: A profile B profile: A/B or C PTX? Pneumonia Pulmonary profile: Look for Treat. Oedema Pneumonialung point, Treat. Treat. consider DDX. Step 2 Treat

Step 2: the veins 15

Step 2 (if dry lungs) Compression scans UL & LL veins Upper limb: IJV, SCVLower limb: femoral confluence, lower SFV, calf veins!

Step 2: scan the veins Scan the veins DVT seen = PE Treat. DVT not seen: Proceed to step 3

Step 2 noteThis is rule-in, not rule-out. Even with 81% sensitivity in the hands of an expert, you’ll still miss 19% of patients with PE.

Step 3: the PLAPS points 19

What are the PLAPS points?= the most dependent part of the lungsAs far behind & as low as you can scan without hitting the diaphragm‘The Morison’s Pouch of the lung’ [thanks Dr Chris Wong]

Recall: PLAPSPosterolateral alveolar &/or pleural syndrome Not as bad as it sounds!

Posterolateral alveolar &/or pleural syndromeIf you see effusion or If you see anything consolidation at else (A lines, B PLAPS points its lines), its PLAPS- PLAPS positive’ negative

PLAPS-positive?

Step 3: the PLAPS points PLAPS points PLAPS seen: Pneumonia (PE still possible but much less likely) PLAPS not seen: Treat. COPD Asthma PE is still possible Reassess patient; consider other tests.

Now what? You’ve reached the end of the scan Patient still breathless You’ve ruled out APO, PTX, pneumonia …but not PE.If it’s still on your list, you need a different test. 27

The BLUE protocol One lung not sliding Both lungs slidng A’ profile: B’ profile: A profile B profile: A/B or C PTX? Pneumonia Pulmonary profile: Look for Oedema Pneumonia lung point, Step 2consider DDX. Scan the Veins DVT not seen DVT seen: PE PLAPS seen: Step 3 PLAPS not seen: Pneumonia PLAPS points COPD / asthma / PE

BLUE protocol: important notes 29

BLUE protocol: notes• Controversial eg for DVT: • Scans below the knee • Scans the upper limbs (increases sensitivity for PE by 4%)• Does not make use of cardiac / IVC windows (and misses 19% PE in the hands of an expert)• Accurate in hands of expert lung sonologist. Not yet validated in multicentre trials of all comers with breathlessness, by non-experts 30

Suggestions1. Add cardiac/IVC scan to the protocol to increase sensitivity for PE (Rule-in, not rule –out: if cardiac/ IVC scan negative, could still be PE)• E.G. as step 4 (PTO)• Or as step 3 (before veins)2. Include upper limb & below knee in your DVT scan? Leave to operator discretion3. Perform validation studies & review this advice 31

Step 4: heart / IVC Dry lungs, no DVT, no PLAPS:High pressure RV Heart / IVC Grossly normal:+ distended IVC: COPD Massive PE Asthma PE is still possible Inadequate view: Reassess patient; Get help, or finish consider other the scan & tests. arrange other tests

Modified BLUE protocol Step 1 One lung not sliding The lungs Both lungs sliding A’ profile: B’ profile: A profile B profile: A/B or C PTX? Pneumonia Pulmonary profile: Look for Oedema Pneumonia lung point, Step 2consider DDX. The veins DVT not seen DVT seen: PE PLAPS seen: Step 3 PLAPS not seen: Pneumonia PLAPS points Step 4 heart /IVC Grossly normal: COPD / Asthma High pressure RV PE is still possible + distended IVC: Reassess patient; consider other tests. Massive PE

Modified BLUE protocol scan 34

Oustanding issues• Does RV/IVC distension occur in status asthmaticus / severe COPD? If so, this could limit its use as a discriminator for massive PE (and is the reason Lichtenstein does not include it on the BLUE protocol)• BUT realistically a sensible dr can pick asthma/COPD clinically, so this should not be an issue• Scanning for DVT • Include upper limb? Only adds 4% sensitivity • Include below knee? This will be controversial for many • Details less important than the understanding that this is ‘rule- in’, not ‘rule-out’• Validation studies by non-experts are needed 35

Summary: the modified BLUE protocol Step 1: anterior lungs Step 2: the veins Step 3: the PLAPS points Step 4: heart & IVC 36

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12 breathless algorithm

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