A quick recap on identifying salient markers in lung ultrasound for rapid differentiation of common lung conditions in the Emergency Department

1. Point of Care Lung
Ultrasonogram
Dr. Anoop James George
Asst. Professor, Dept. of Emergency Medicine
Jubilee Mission Medical College and Research Centre
Kerala, India

2. Key Points of Discussion
A glimpse into history
Lung signatures and lung profiles
LUS Protocols
Recent advances in LUS

3. Humble Beginnings
Lazzaro Spallazani - ECHOLOCATION
First to describe that sound waves could
be used for communication
Performed studies on bats in 1794
Concluded that they could navigate using
sound rather than sight

4. Early Days...
“Hydrophone” -
1915
R.M.S TITANIC
April 11, 1912

6. Chapte
r 1
• Austrian neurologist Karl Theodore
Dussik is credited with being the
first to use sonography for medical
diagnoses.
• He transmitted ultrasound beams
through the human skull in an
attempt to detect brain tumors

8. Prof. Dr. Daniel
Lichtenstein
Medical Intensivist, Ambroise-
Paré Hospital
Paris France since 1989
President – CEURF (Cercle des
Echographistes d'Urgence et de
Réanimation Francophones) BLUE Protocol
 FALLS Protocol
 SESAME Protocol
 LUCI -FLR

9.  A non-profit organization
 Purpose – to promote the use of general ultrasound to
resuscitation and emergency
 Teach critical ultrasound as a holistic approach – whole body US
in critically ill
 Uses simple (grey scale) equipment (without Doppler)
 One universal probe (micro-convex probe) for whole body
 Emphasis on lung, adapted venous ultra-sound and simple cardiac
sonography
CEURF
(CIRCLE OF FRANCOPHONE EMERGENCY AND REANIMATION ECHOGRAPHS)

10. Lung
Signs
Normal Lung
1. Bat Sign
2. Lung Sliding
3. A Lines
Pleural
Effusion
4. Quad Sign
5. Sinusoid
Sign
Lung Consolidation
6. Fractal Sign
7. Tissue-like sign
Interstitial Syndrome
8. Lung Rockets or B+ line
Pneumothorax
9. Stratosphere Sign
10. Lung Point

11. Rib
Line
Normal
Lung:
1. Lung
Sliding
2. A Lines
3. Bat Sign
A
Line
Pleural
Line –
Lung
Sliding
Acoustic
Shadow
Cast by
Rib
Bat Sign

12. Lung Sliding

13. Keyes’ Space
Merlin’s Space

14. Absent Lung Sliding
•Inflammatory
adherences
•Atelectasis
•Apnoea
•Pneumonectomy
•Pneumothorax
Diminished Lung Sliding
• Hypoventilation
• Regional
hypoventilation –
obstructive lung
disease
• Contralateral
bronchial intubationLichtenstein, D. A., & Mezière, G. A. (2008). Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure: The BLUE Protocol. Chest, 134(1), 117–125.

15. Pleural Effusion – Quad Sign and Sinusoid Sign
Pleural
Line
Lung
Line
Rib
Margin
QUAD
Sign
SINUSOI
D Sign

16. Pneumoni
a
•Fractal Sign
(Shred
Sign)
•Tissue Like
Sign
Shred Sign
Tissue-like
Sign

17. Interstitial Syndrome – B Lines, Lung
Rockets

18. B Lines
1. Hydroaeric comet-tail artifacts
2. Hyperechoic
3. Well defined
4. Spreading up indefinitely
5. Erasing A-lines
6. Arising from Pleural line
7. Moves with lung sliding ( when it’s present)

19. Lung Rockets

20. B-Lines

21. Pneumothorax – Stratosphere
Sign
Sea-shore Sign
Stratosphere Sign
(Bar Code Sign)

22. Lung Point

23. Lung Point:
M-Mode
• A Lines with
absent lung
sliding – check
for lung point
• Alternating Sea-
shore and
Stratosphere
Sign
• 100% specific

24. Lung Profiles
1. A Profile – Lung sliding + A lines (Normal, COPD,
Asthma)
2. A’ Profile – Absent lung sliding + A lines (Pneumothorax)
3. B Profile – B+ lines, lung rockets (Interstitial Syndrome)
4. B’ Profile – B profile without lung sliding (Pneumonia)
5. A/B Profile – Anterior predominant B+ lines on one side
and A lines on the other (Pneumonia)
6. C Profile – C lines /Shred Lines (Pneumonia)
7. A Profile with PLAPS (Pneumonia)
8. A Profile with Venous Thrombosis – (Pulmonary
Embolism)

25. “If your patient is
blue, promptly
perform BLUE
protocol”
Lichtenstein, D. A., & Mezière, G.
A. (2008). Relevance of Lung
Ultrasound in the Diagnosis of Acute
Respiratory Failure: The BLUE
Protocol. Chest, 134(1), 117–125.

26. FALLS
SESAM
EETUDE
S
RADiUS
RUSH
BLUE
Lung Ultrasound Protocols

27. Lung Ultrasound Protocols
Bedside Lung Ultrasound In Emergency
Fluid Administration Limited by Lung Sonography
Sequential Echocardiographic Scanning Assessing Mechanism
or Origin
of Severe Shock of Indistinct Cause
Emergency Thoracic Ultrasound in Differentiation of
Shortness of Breath
Rapid Assessment of Dyspnea with Ultrasound
Rapid Ultrasound for Shock and Hypotension
Extended- Focused Assessment with Sonography in Trauma
BLUE
FALLS
SESAME
ETUDES
RADiUS
RUSH
E-FAST

28. Falls Protocol
Lichtenstein, D. A. Lung Ultrasound for the Diagnosis and Management of an Acute Circulatory Failure: The FALLS-Protocol (Fluid
Administration Limited by Lung Sonography) – One Main Extension of the BLUE-Protocol. Lung Ultrasound in the Critically Ill. 2016:227–259.

30. Pit “FALLS”
• B-Profile on Admission – Pulmonary edema
vs “Lung Sepsis”
• No Validation – Non-comparable to any
standard references
• Not suitable for all patients – e.g. Fulminans
Sepsis
• Cannot identify a right heart failure
Lichtenstein, D. A. Lung Ultrasound for the Diagnosis and Management of an Acute Circulatory Failure: The FALLS-Protocol
(Fluid Administration Limited by Lung Sonography) – One Main Extension of the BLUE-Protocol. Lung Ultrasound in the Critically
Ill. 2016:227–259.

31. SESAME Protocol
• Sequential approach in a victim of cardiac arrest
• Daniel Lichtenstein and Manu Malbrain
• “SESAMOOSSIC” - “Sequential Echographic
Scanning Assessing Mechanism Or Origin of
Severe Shock of Indistinct Cause”
• Helps to determine mechanism and/or cause of
cardiac arrest
Lichtenstein D, Malbrain ML. Critical care ultrasound in cardiac arrest. Technological requirements for performing the SESAME-protocol--a
holistic approach. Anaesthesiol Intensive Ther. 2015;47(5):471-81.

32. 1
2
3
4
5
Step 1: Ruling Out
Pneumothorax
• First scan the lungs
• B – Profile = no change
management
• A’ Profile = suspect
pneumothorax
• A Profile = start correction
for hypovolemia by FALLS
protocol and move to the
limbs to rule out DVT
Step 2: Ruling out DVT
• Done at V point for
femoral veins
• A Profile + DVT = 99%
specific for DVT
• Confirm with STEP 5
• If no DVT, move to Step
3
Step 3: Diagnosis of
hypovolemic cardiac arrest
• Scan the abdomen for fluid
collections
• Ultraquick scan of the IVC
• Pleural effusions (
hemothorax in context of
trauma
• If none, proceed to step 4
Step 4: Ruling Out Cardiac
Tamponade
• Pericardial effusion
• Diagnostic and therapeutic
• Subcostal view preferred
• If no tamponade, go to step
5
Step 5: Ruling Out Cardiac
Causes
• No contraction = asystole
• Dilated RA/RV = Pulmonary
embolism
• RV collapsibility =
Pulmonary embolism
• LV collapsibility/ hyper
contractibility = hypovolemia

33. ETUDES Protocol
• “Emergency Thoracic Ultrasound in the Differentiation of the
Etiology of Shortness of Breath”
• Andrews Liteplo et al
• B-lines and NT-Pro-BNP in congestive heart failure
• Prospective observational study in 100 convenient samples
• Conclusions: Thoracic US can be used alone or can provide
additional predictive power to NT-Pro-BNPLiteplo, A. S., Marill, K. A., Villen, T., Miller, R. M., Murray, A. F., Croft, P. E., … Noble, V. E. (2009). Emergency Thoracic Ultrasound in
the Differentiation of the Etiology of Shortness of Breath (ETUDES): Sonographic B-lines and N-terminal Pro-brain-type Natriuretic Peptide
in Diagnosing Congestive Heart Failure. Academic Emergency Medicine, 16(3), 201–210.

34. RADiUS Protocol
• “Rapid Assessment of Dyspnea with Ultrasound”
• William Manson & Nadim Mike Hafez
• 4 step process
(1) a focused cardiac examination
(2) a focused IVC evaluation
(3) evaluation of the thoracic cavity for pleural
effusions,
(4) assessment of the pleural line
Manson, W., Hafez, N. M. The Rapid Assessment of Dyspnea with Ultrasound: RADiUS. Ultrasound Clinics. 2011:6(2),
261–276.

35. What’s
New?

36. Newer Lung Signs
• Confluent B-lines
• Alveolar-interstitial syndrome (AIS)
• Compact B-line
• White lung
• Lung pulse
• Dynamic air-bronchogram
• Double lung point
• Power doppler

37. Newer Lung Signs
Confluent B-
lines
Alveolar-
interstitial
syndrome (AIS)
Compact B-line White lung

38. Newer Lung Signs
Lung pulse
Dynamic air-
bronchogram
Double lung-
point
Power sliding

39. Newer Applications
Bronchiolitis in children
Cystic fibrosis
Bronchiectasis
Weaning in ventilated patients
Interstitial lung disease

40. Newer LUS Protocols
E-BLUE protocol – Extended BLUE Protocol*
FASH Protocol - Focused assessment with sonography
for HIV-associated tuberculosis
FUSA Protocol - Focused ultrasonography in anesthesia
TRACE Protocol - ThoRacic and Abdominal sonography in
Cardiac arrEst
*Lichtenstein, D. A. (2016). The Extended-BLUE-Protocol. Lung Ultrasound in the Critically Ill, 309–326.

41. Cutting Edge – NEONATAL LUS
Transient tachypnea of the newborn (TTN)
Pneumonia of the newborn
Meconium aspiration syndrome (MAS)
Pulmonary hemorrhage of the newborn
(PHN)
Liu, J., Copetti, R., Sorantin, E., Lovrenski, J., Rodriguez-Fanjul, J., Kurepa, D., … Shang, L.-L. (2019). Protocol and Guidelines for Point-
of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus. Journal of Visualized
Experiments, (145).

42. Cutting Edge – NEONATAL LUS
Pulmonary atelectasis of the newborn
Pneumothorax of the newborn
Pulmonary edema in cardiac insufficiency
Examining correct ETT placement and
position
Liu, J., Copetti, R., Sorantin, E., Lovrenski, J., Rodriguez-Fanjul, J., Kurepa, D., … Shang, L.-L. (2019). Protocol and Guidelines for Point-
of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus. Journal of Visualized
Experiments, (145).

43. Take Home Message
LUS for evaluation and diagnosis of dyspneic patients
Potential for research
Practice makes perfect
Beware of pitfalls

44. Thank You !!
anoopjamesgeorge@gmail.com