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Learning Objectives
Lung Zones
R/L1 (1-2 places in the anterior chest along the midclavicular line), R/L2 (Midaxillary line), R/L3 (Posterior Axillary line) and PLAPS (posterior and/or Lateral Alveolar and/or Pleural Syndrome) point.
Lung US Terminology/Signs
Lung sliding, A-lines, B-lines, lung pulse, lung point, lung consolidation/hepatization, effusion, PLAPS
Common Diagnoses to Assess for:
pneumothorax, pneumonia, pleural effusion, cardiogenic pulmonary edema, acute respiratory distress syndrome, pulmonary embolism, and COPD/asthma
BLUE Protocol
Key Points
Probe orientation: Indicator cephalad (towards head)
Pneumothorax: absence of lung sliding, with lung point as pathognomonic finding.
Pneumonia: can appear as a lung consolidation (lung hepatization, with dynamic air bronchograms) or as a B-line pattern (fluid, pus, or inflammation in the lung field in place of air),
Pleural Effusion: best seen at PLAPS point to evaluate fluid accumulation
Asthma/COPD Exacerbation, and Pulmonary Embolism will often have unremarkable lung ultrasound findings, excluding cases where Pulmonary Embolism is large enough to result in pulmonary infarct.
R1/L1: anterior chest - To assess lung slides and B lines (for pneumothorax and/or interstitial edema)
Start with probe at midclavicular line at 2nd intercostal space
R2/L2: lateral chest-To assess lung slides and B lines (for pneumothorax and/or interstitial edema)
Probe along midaxillary line around 6-7th intercostal space.
R3/L3 (PLAPS point): posterior chest- To assess for pleural effusions and consolidations
Along posterior axillary line between 10th and 12th intercostal space.
Main location to identify diaphragm and start of intraabdominal structures (liver or spleen, kidney)
A lines- indication of healthy lung expansion within the chest cavity
Zones: Typically 1/2
Probe: Typically linear ('vascular')
A-Lines ("A Profile) - these are horizontal lines of the pleura reflecting off the probe. Multiple lines before dissipating can indicate healthy aeration of alveoli
Lung Sliding - normal finding where visceral and parietal pleura slide back and forth during respiration. Rules out: pneumothorax
Curtain Sign - seen in healthy aerated lungs at PLAPS point. Looks like a “curtain” sweeping as lungs fill with air.
Absence of Lung Sliding - may bee seen with pneumothorax (with air separating the visceral and parietal pleura), but can also be seen with large consolidations (pneumonia/atelectasis), fibrotic lung disease, or in patients with prior pleurodesis
Lung point - pathognomonic of a pneumothorax, delineating where there is an absence of lung sliding and where there is normal lung sliding
Seashore Sign - seen in normal lungs, there is a distinct differentiation between chest wall and positive motion lung.
Barcode/stratosphere Sign - seen in pneumothorax, showing no chest wall or lung motion.
B Lines- nonspecific indicator of lung parenchymal pathology
Zones: Any
Probe: Ideally phased array for deeper penetration
B-Lines ("B Profile") - non-specific, formed when interlobular septa and lung tissue thickens or fill with fluid. They are ray-like hyperechoic vertical lines that move with respirations and extend the entirety of the image depth. More than two B-Lines in a lung field is an abnormal finding (may represent a variety of pathologies including pulmonary edema, infection, fibrosis)
Confluent B-lines (right) appear as more fluid/inflammation builds up. This correlates with ground glass opacities seen on CT imaging
Reminder: A-Lines (above)) - these represent healthy lung tissue
Pleural Effusions
Zone: Typically R3/L3(PLAPS) due to dependent nature of fluid accumulation
Probe: Phased array
Pleural Effusion - anechoic (black) pocket of fluid most commonly found in the lower lung fields. Effusions are classified as simple when there are no septations or debris seen.add arrow noting diaphragm
Jellyfish Sign - area of consolidated/collapsed lung ('compressive atelectasis') seen floating/swimming within the pleural effusion.
Complicated Pleural Effusions - note the septations in the pleural space, which can be seen with infectious processes or with more chronic effusions.
Consolidation- poorly aerated lung, can represent pneumonia, atelectasis, or even neoplasm
Zone: Any
Probe: Phased array
Consolidation- Note the hypoechoic region near the top of the image.
Dynamic Air Bronchograms - Note the hyperechoic areas which move with respiration. These represent air filled bronchi made visible by opacification of surrounding alveoli. This finding is 94% specific and has a 97% positive predictive value for pneumonia.
Shred Sign- Consolidation with irregular borders that breaks up the plerual line (A line pattern).
Hepatization of lung - note similar appearance of lung (left, cephalad to diaphragm (hyperechoic crescent)) and liver (right, caudal to diaphragm). The liver finding is a normal expected finding, while the lung finding demonstrates consolidation of lung parenchyma.
BLUE Protocol -Designed for acute shortness of breath
Images / information from: https://www.pocus101.com/lung-ultrasound-made-easy-step-by-step-guide/
https://nephropocus.com/2019/07/01/dynamic-air-bronchograms-ultrasound-sign-of-pneumonia/
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