Lung ultrasound in the critically ill

- The BLUE Protocol

MICU 住院醫師教學
2016/08/18
R2 鄭至宏/ VS蔡明儒醫師
 • Lung ultrasound in the critically ill
– Daniel A Lichtenstein
– Ann Intensive Care. 2014 Jan. 9
– Service de Réanimation Médicale,
Hôpital Ambroise-Paré, University
Paris-West, Boulogne, France.
1st ed. 2016 Edition D.Licht@free.fr
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 BLUE-protocol
• 97 % of the patients seen in the ER (or pre-hospital medicine)
and eventually admitted to the ICU of our parisian hospital.

• To get a 90.5 % accuracy in a few minutes !

 The Exclusion
• Exacerbation of chronic interstitial disease(1.4 %)
• Massive pleural effusion as causing agent(1 %)
• Complete atelectasis, foreign body aspiration(0.3 %)
• Tracheal stenosis (0.3 %)
• Fat embolism (0.3 %)
• ……
 BLUE-point
PLAPS-point

Phrenic
BLUE-point point

Phrenic line

Postero-lateral alveolar or pleural syndromes (PLAPS) point

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 shred sign
The Blue bat sign
protocol:
lung sliding
Not use seashore sign
transversa tissue like sign

l scans
A-lines

lung rockets

quad sign
stratosphere sign

sinusoid sign
lung point
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
Pleural Line & Bat Sign

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 A-line
• normal artifact
• indicate air, either
– quasi-pure (normal lung surface)
or pure (pneumothorax).

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Lung Sliding
• Parietal pleura: motionless
• Visceral pleura:
– only when the lung is at the chest wall, moving or not.
 Lung Sliding - Seashore sign

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 A-profile VS A’-profile
• Anterior chest wall, supine
–A-profile: A-lines + lung sliding

–A’-profile: A-lines without lung sliding

• 96 % for the diagnosis of complete pneumothorax
 No lung sliding
• Pneumothorax
• Pleurodesis
• Complete atelectasis
• Massive fibrosis
• Severe acute asthma
• Apnea / Cardiorespiratory arrest
• Esophageal intubation / One lung intubation
• Pulmonectomy
 Stratosphere sign A’-profile

Barcode sign
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 The Lung Point
a Sign Specific to Pneumothorax

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Acute Interstitial Syndrome
• Hemodynamic Pulmonary edema
– fluid overload / cardiogenic pulmonary edema
• Permeability-induced pulmonary edema
– ARDS / infectious processes

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 The B-Line
• Always
– One of Comet-tail artifacts
– From the pleural line
– Moves with lung sliding
• Almost constant features (93–97 %):
– well defined
– long, spreading out
– without fading to the edge of the screen
– obliterates the A-lines.
– hyperechoic. D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Interstitial Syndrome - Lung Rockets
• Three or more B-lines
simultaneously visible between
two ribs, in a longitudinal scan

• Septal Rockets:
– B-lines are 6-/7-mm apart
– 3~4 B-lines between two ribs

Septal lung rockets

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Septal Rockets

thickened
interlobular
septa

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Ground-Glass Rockets

• 6~8 B-lines between two ribs

• separated by 3 mm
• high-degree interstitial syndrome

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 The Birolleau Variant
• Extreme case of
pulmonary edema

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE
Protocol, 1st ed. 2016 Edition
 Ultrasound Diagnosis of an
Acute Respiratory Failure
• One B-line -> completely rules out pneumothorax

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 B-Profile VS B’-Profile
• At the anterior chest wall
• B-Profile: lung rockets associated with lung sliding
• B’-Profile: lung rockets with abolished lung sliding

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 B-Profile VS B’-Profile

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 PLAPS and Pleural Effusion

• Transabdominal approach
– Subcostal approach
– Not definite diagnosis

• Anechoic image enough ?

– hemothorax, pyothorax, …

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 PLAPS and Pleural Effusion

PLAPS-point

turning the patient should be minimal

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 1. One Static Sign: The Quad Sign

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 2. One Dynamic Sign: The Sinusoid Sign

PLAPS-point

D.A. Lichtenstein,
• Not in very viscous or septate effusion
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Jellyfish sign
• A variant of the
sinusoid sign

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 A ghost !

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
PLAPS and Lung Consolidation & the C-profile
• Consolidation:
– Hemodynamic pulmonary edema
– ARDS
– Pneumonia
– pulmonary embolism
– Tumor
– Pneumothorax
PLAPS and Lung Consolidation & the C-profile
• In the BLUE-protocol:
– No anterior interstitial syndrome
– No anterior consolidations A profile
– No abolished lung sliding
– No deep venous thrombosis

• Posterior consolidations  A-no-V–PLAPS profile

 pneumonia
 Non-translobar Consolidations:
The Shred (or Fractal) Sign
• Almost all consolidation seen in the critically ill have irregular
boundaries with the underlying aerated lung

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Non-translobar Consolidations:
The Shred (or Fractal) Sign C-line

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Translobar Consolidations: The Tissue-Like Sign

Mediastinal line
or
Heart line
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Translobar Consolidations: The Tissue-Like Sign

• The distance between the pleural line and the regular deep
limit is 9–11 cm (in adults)
– the translobar size of the lung

• A pleural effusion cannot reach this dimension (5 or 6 cm is an

extreme limit)

D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 The C-Profile and the PLAPS

• C-profile:
– Anterior lung consolidations
• regardless of number and size
– Irregular, thickened pleural lines
• PLAPS
– A-no-V-PLAPS-profile
– posterolateral lung consolidations or just isolated effusions
Regular distributions
Atypical distributions

5% of usually
Rare profiles
pulmonary present: “A”-
irregular A/B-profile
edema no-V-PLAPS-
pneumonia/ARDS
profile
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
D.A. Lichtenstein,
Lung Ultrasound in the Critically Ill: The BLUE Protocol, 1st ed. 2016 Edition
 Take home message
• Air & Fluids
• The pleural line: Bat sign
• Lung sliding: seashore sign
• Pneumothorax: A’ profile (Barcode sign) Lung point (confirmed)
– If no lung point  A’ profile + Physical examination !!!
• One B-line -> completely rules out pneumothorax