Bedside lung ultrasound in emergency (approach)
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.
It has been designed as a fast (<3 minute), three-point examination for severely dyspneic patients bound for the Intensive Care Unit. Pathophysiologic “profiles,” based on standardized patterns of artifacts ("A" or "B lines"), the presence or abolition of lung sliding, and the presence/absence of alveolar consolidation are considered for six diseases which account for 97% of patients in the emergency department.
The chief aim of the protocol is to suggest a diagnosis with a target overall accuracy just over 90% (90.5%) with a simple, easy-to-purchase machine and a single, universal probe, without Doppler or other amenities.
- bat sign: used to find the pleural line, i.e. if one recognizes the ribs as the "wings" then the bat's ''belly'' is the pleural interface
- A-lines: horizontal artifacts arising from the pleural line at regular intervals which are equal to the skin-pleural interface distance - indicating physiologic air (but also free air)
- B-lines: correlated with interstitial edema; they are defined according to seven criteria:
- comet-tail artifacts
- arising from the pleural line
- laser beam-like
- long, without fading
- erasing A-lines
- moving with lung sliding
- C-lines: alveolar consolidation abutting the pleural line
- A-profile: anterior lung-sliding with A-lines
- A'-profile: A-profile with abolished lung sliding
- B-profile: anterior lung-sliding with lung rockets
- B'-profile: B-profile with abolished lung sliding
- A/B-profile: unilateral B lines, contralateral A-lines
- C-profile: any anterior lung consolidation (a thick, irregular pleural line is an equivalent)
- patient in supine position
- 3.5-5.0 MHz microconvex probe
- manually define anatomy: the operator's left (upper BLUE) hand and right (lower BLUE) hands, the upper placed in apposition to and parallel with the patient's clavicle, the tips of the digits touching the midline
- the upper BLUE point is defined between the third and fourth digits of the upper BLUE hand, at their palmar insertion
- the lower BLUE point corresponds to the middle of the palm of the lower BLUE hand
- anterior lung sliding (at bilateral upper BLUE points) is checked first, as its presence effectively rules out pneumothorax; anterior B lines are simultaneously sought (the B profile suggests pulmonary edema)
- B , A/B, and C profiles suggest pneumonia
- A profile prompts a search for venous thrombosis, if present, pulmonary embolism is considered.
- If absent, PLAPS is sought - its presence (A profile plus PLAPS) suggests pneumonia; its absence suggests COPD/asthma
- patients with COPD commonly show signs on ultrasound mimicking a pneumothorax7,8
- subcutaneous emphysema
- lesions that do not reach the pleura.
- cardiogenic pulmonary edema and antibiotic therapy may result in pneumonia false positives 1
History and etymology
Dr Daniel Lichtenstein, French intensivist, designed the BLUE protocol.
- 1. 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. (2015) PloS one. 10 (6): e0130066. doi:10.1371/journal.pone.0130066 - Pubmed
- 2. Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, Fava C, Frascisco M. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. (2006) The American journal of emergency medicine. 24 (6): 689-96. doi:10.1016/j.ajem.2006.02.013 - Pubmed
- 3. Giovanni Volpicelli, Luciano Cardinale, Giorgio Garofalo, Andrea Veltri. Usefulness of lung ultrasound in the bedside distinction between pulmonary edema and exacerbation of COPD. Emergency Radiology. 15 (3): 145. doi:10.1007/s10140-008-0701-x
- 4. Zhou S, Zha Y, Wang C, Wu J, Liu W, Liu B. [The clinical value of bedside lung ultrasound in the diagnosis of chronic obstructive pulmonary disease and cardiac pulmonary edema]. (2014) Zhonghua wei zhong bing ji jiu yi xue. 26 (8): 558-62. doi:10.3760/cma.j.issn.2095-4352.2014.08.007 - Pubmed
- 5. Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. (1998) Intensive care medicine. 24 (12): 1331-4. Pubmed
- 6. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. (2004) Anesthesiology. 100 (1): 9-15. Pubmed
- 7. Slater A, Goodwin M, Anderson KE, Gleeson FV. COPD can mimic the appearance of pneumothorax on thoracic ultrasound. (2006) Chest. 129 (3): 545-50. doi:10.1378/chest.129.3.545 - Pubmed
- 7. Bob Jarman. Emergency Point-of-Care Ultrasound. (2017) ISBN: 9780470657577