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OBJECTIVES: Discrete B-lines have clear definitions, but confluent B-lines, consolidations, and pleural line abnormalities are less well defined. We proposed definitions for these and determined their reproducibility using COVID-19 patient images obtained with phased array probes. METHODS: Two raters collaborated to refine definitions, analyzing disagreements on 107 derivation scans from 10 patients. Refined definitions were used by those raters and an independent rater on 1260 validation scans from 105 patients. Reliability was evaluated using intraclass correlation coefficients (ICC) or Cohen's kappa. RESULTS: The agreement was excellent between collaborating raters for B-line abnormalities, ICC = 0.97 (95% confidence interval [CI] 0.97-0.98) and pleural line to consolidation abnormalities, ICC = 0.90 (95% CI 0.87-0.92). The independent rater's agreement for B-line abnormalities was excellent, ICC = 0.97 (95% CI 0.96-0.97) and for pleural line to consolidation was good, ICC = 0.88 (95% CI 0.84-0.91). Agreement just on pleural line abnormalities was weak (collaborators, kappa = 0.54, 95% CI 0.48-0.60;independent, kappa = 0.54, 95% CI 0.49-0.59). CONCLUSION: With proposed definitions or via collaboration, overall agreement on confluent B-lines and pleural line to consolidation abnormalities was robust. Pleural line abnormality agreement itself was persistently weak and caution should be used interpreting pleural line abnormalities with only a phased array probe.

It is of vital importance to identify the pleural line when performing lung ultrasound, as the pleural line not only indicates the interface between the chest wall and lung, but offers additional diagnostic information. In the current clinical practice, the pleural line is visually detected and evaluated by clinicians, which requires experiences and skills with challenges for the novice. In this study, we developed a computer-aided technique for automated pleural line detection using ultrasound. The method first utilized the Radon transform to detect line objects in the ultrasound images. The relation of the body mass index and chest wall thickness was then applied to estimate the range of the pleural thickness, based on which the pleural line was detected together with the consideration of the ultrasonic properties of the pleural line. The proposed method was validated by testing 83 ultrasound data sets collected from 21 pneumothorax patients. The pleural lines were successfully identified in 76 data sets by the automated method (successful detection rate 91.6%). In those successful cases, the depths of the pleural lines measured by the automated method agreed with those manually measured as confirmed with the Bland-Altman test. The measurement errors were below 5% in terms of the pleural line depth. As a conclusion, the proposed method could detect the pleural line in an automated manner in the defined data set. In addition, the method may potentially act as an alternative to visual inspection after further tests on more diverse data sets are performed in future studies.

This paper proposes a quantitative analysis method for lung ultrasound (LUS) images to evaluate the severity of COVID-19 pneumonia. Specifically, biomarkers related to the pleural line, including the thickness of pleural line (TPL) and the roughness of pleural line (RPL), and biomarkers related to the B-lines, including the accumulated width of B-lines (AWBL) and the acoustic coefficient of B-lines (ACBL), are extracted from LUS images to characterize the image patterns associated with the disease severity. 27 patients of COVID-19 pneumonia are enrolled in this study, including 13 moderate cases, 7 severe cases, and 7 critical cases. Patients of moderate cases are regarded as non-severe patients, and patients of severe and critical cases are regarded as non-severe patients. Biomarkers among different cases are compared, and the performances in the binary diagnosis of severe and non-severe patients are assessed using a support vector machine (SVM) classifier with all the biomarkers as the input. The classification performance is optimal using the SVM classifier (area under the receiver operating characteristics curve = 0.93, sensitivity = 0.93, specificity = 0.85). The proposed method may be a promising tool for the automatic grading and follow-up of patients with COVID-19 pneumonia.

Background and objective Lung ultrasound is an inherently user‐dependent modality that could benefit from quantitative image analysis. In this pilot study we evaluate the use of computer‐based pleural line (p‐line) ultrasound features in comparison to traditional lung texture (TLT) features to test the hypothesis that p‐line thickening and irregularity are highly suggestive of coronavirus disease 2019 (COVID‐19) and can be used to improve the disease diagnosis on lung ultrasound. Methods Twenty lung ultrasound images, including normal and COVID‐19 cases, were used for quantitative analysis. P‐lines were detected by a semiautomated segmentation method. Seven quantitative features describing thickness, margin morphology, and echo intensity were extracted. TLT lines were outlined, and texture features based on run‐length and gray‐level co‐occurrence matrix were extracted. The diagnostic performance of the 2 feature sets was measured and compared using receiver operating characteristics curve analysis. Observer agreements were evaluated by measuring interclass correlation coefficients (ICC) for each feature. Results Six of 7 p‐line features showed a significant difference between normal and COVID‐19 cases. Thickness of p‐lines was larger in COVID‐19 cases (6.27 ± 1.45 mm) compared to normal (1.00 ± 0.19 mm), P

BACKGROUND There is no research on quantitative pleural line movement. In this study, we assume that tissue Doppler and its quantitative technology can quantify the pleural line movement and can be used to diagnose pneumothorax. AIM To evaluate the quantitative assessment of pleural line movement measured by tissue Doppler imaging (TDI) for pneumothorax diagnosis. METHODS Adult patients (n = 45) diagnosed with unilateral pneumothorax were included in this study. Each patient underwent TDI of both lungs. The pneumothorax side and contralateral normal lung side were compared using several indices obtained from TDI: peak pleural line velocity (PVmax), peak chest wall tissue velocity (CVmax), peak pleural line strain value (PSmax), peak chest wall tissue strain value (CSmax), PVmax/CVmax and PSmax/CSmax. The receiver operating characteristic analysis was used to evaluate the performance of these quantitative assessments for pneumothorax diagnosis. RESULTS Various quantitative variables of the pneumothorax side were all lower than that of the non-pneumothorax side and included the PVmax (0.36 cm/s vs 0.59 cm/s, P < 0.001), PSmax (1.14% vs 1.90%, P = 0.001), PVmax/CVmax (1.06 vs 4.93, P < 0.001), and PSmax/CSmax (0.76 vs 1.74, P < 0.001). For the discrimination of pneumothorax, the cut-off values of the PVmax, PSmax, PVmax/CVmax, and PSmax/CSmax were calculated as 0.50 cm/s, 0.94%, 1.96, and 1.12, respectively. Similarly, the sensitivities and specificities of PVmax, PSmax, PVmax/CVmax, and PSmax/CSmax were 96% and 62%, 47% and 91%, 93% and 96%, and 82% and 93%, respectively. The area under the receiver operating characteristic curve were 0.84, 0.72, 0.99, and 0.91, respectively, for PVmax, PSmax, PVmax/CVmax, and PSmax/CSmax. CONCLUSION Quantification analysis of pleural line movement using TDI is a useful tool for the diagnosis of pneumothorax.

We used the lung ultrasound score (LUSS) to analyze the ultrasound images and assess the lesions and aeration loss in 12 lung regions of 11 COVID-19 neonates born to mother with COVID-19 and 11 age- and gender-matched controls. In the COVID-19 group, 132 regions were reviewed and 83 regions (62.8%) detected abnormalities. Compared with controls, COVID-19 neonates showed more increased B-lines (83 regions), abnormal A-lines (83 regions), abnormal pleural line (29 regions) and subpleural consolidation (5 regions). among which 49 regions (37%) were normal, 73 regions (55%) scored 1, and 10 regions (8%) scored 2. The LUSS was significantly higher in COVID-19 group. All the lesions were bilateral, multiple regions involved, and mainly located in bilateral lower lobes and right middle lobe. The intra-observer and inter-observer reproducibility of LUSS were excellent. Lung ultrasound is a noninvasive and convenient method for the assessment of neonatal COVID-19 pneumonia and presents typical signs. LUSS provides valuable semi-quantitative information about the lesion distribution and severity.

Background: The work wants to see if the Lung Sonography (LUS) can be helpful in the evaluation of a new device before and after a respiratory treatment. Aim: Simeox is a new device for airway clearway. The patient activates it using a button during the expiration phase that creates a negative vibratory suction of small volumes of air.The action is directed to the mucus rheology, improves the drainage from the periphery of the lung. Methods: 8 patients (4 female and 4 male), were examined by comparing LUS with traditional parameters such as SpO2 , FC, scales before and after a week’s use of the Simeox device and gym exercises. The ecography machine was set in B-mode with a convex probe oriented horizontally to have a greater view of the pleural line in the four Volpicelli’s zones. We took note on a map of number of the vertical artifacts B lines starting from the pleural line with a score from 0 to 4. Results: Lus and all parameters have improved but some patients, little compliant, were unable to tell if the amount of secretions had changed. The usual exams give the state of health but not the specific state of the lung such as LUS that represents a third eye, inner, in addition to the clinic exam. Conclusion: Our study suggests that LUS is a patient bedside exam modality, safe, reliable, fast to evaluate the alveolar drainage. Further studies are needed to understand the interaction of LUS with the respiratory treatments.

Introduction: Diagnosis and monitoring of interstitial lung disease (ILD) in children are mainly based on chest computed tomography (CT), resulting in significant exposure to x-rays. In adult patients, studies have shown a good sensitivity of the lung ultrasound (LUS) for detecting interstitial lesions, with a high correlation between LUS and CT images. The aim of this pilot study was to assess in children with ILD: (i) the feasibility of lung ultrasound and (ii) the comparability of LUS and CT images. Methods: LUS was performed in 5 children followed in the RespiRare® centre for an ILD of various aetiologies. Images visualized by LUS were described and compared to those seen at the latest chest CT. Results: The 5 children were 1.5, 2.5, 7, 11 and 16 years old respectively. Interstitial lesions were visualized by LUS in 4 of the 5 children, characterized by the presence of more than 3 confluent or spaced B lines per field, associated with an irregularity of the pleural line. Two children presented sub-pleural consolidations that were also seen on their CT. Bilateral pleural effusion was observed by LUS in one child. Only one child had a normal LUS while his CT showed some scattered micro-nodular lesions. Conclusion: This pilot study demonstrated a good correlation between LUS and CT images. As in adult patients, LUS could be an interesting tool for screening and monitoring children with ILD, reducing their exposure to x-rays in comparison to CT.

Objective Evidence for the use of lung ultrasound scan (LUS) examinations in coronavirus 2019 pneumonia is rapidly growing. The safe and non-ionizing nature of LUS drew attention, particularly for pregnant women. This study aimed to contribute to the interpretation of LUS findings in pregnant women for the obstetricians. Materials and methods LUS was performed to pregnant women suspected of or diagnosed as having Severe Acute Respiratory syndrome coronavirus-2 (SARS-CoV-2) in the first 24 hours of admission. Fourteen areas (3 posterior, 2 lateral, and 2 anterior) were scanned per patient for at least 10 seconds along the indicated anatomical landmarks. The scan was performed in supine, right-sided and left-sided positions, respectively. Each area was given a score between 0 and 3 according to the specific pattern. Results In this study, 21 still images and 21 videoclips that enabled dynamic and real-time evaluation were provided. Pleural line assessment, physiologic A-lines, pathologic B-lines, light beam pattern, white lung pattern, and specific patterns for quick recognition and evaluation are described. Conclusion The potential advantages and limitations of LUS and its areas of use for obstetricians are discussed. LUS is a promising supplementary imaging tool during the SARS-CoV-2 pandemic. It is easy to perform and may be feasible in the hands of obstetricians after a brief didactic course. It may be a firstline imaging modality for pregnant women.

Objective To explore the reliability and accuracy of lung ultrasound for diagnosing neonatal pneumothorax. Methods This study was divided into two phases. (1) In the first phase, from January 2013 to June 2015, 40 patients with confirmed pneumothorax had lung ultrasound examinations performed to identify the sonographic characteristics of neonatal pneumothorax. (2) In the second phase, from July 2015 to August 2016, lung ultrasound was undertaken on 50 newborn infants with severe lung disease who were suspected of having pneumothorax, to evaluate the sonographic accuracy and reliability to diagnose pneumothorax. Results (1) The main ultrasonic manifestations of pneumothorax are as follows: ① lung sliding disappearance, which was observed in all patients (100%); ② the existence of the pleural line and the A-line, which was also observed in all patients (100%); ③ the lung point, which was found in 75% of the infants with mild-moderate pneumothorax but not found to exist in 25% of the severe pneumothorax patients; ④ the absence of B-lines in the area of the pneumothorax (100% of the pneumothorax patients); and ⑤ no lung consolidation existed in the area of the pneumothorax (100% of the pneumothorax patients). (2) The accuracy and reliability of the lung sonographic signs of lung sliding disappearance as well as the existence of the pleural line and the A-line in diagnosing pneumothorax were as follows: 100% sensitivity, 100% specificity, 100% positive predictive value, and 100% negative predictive value. When the lung point exists, the diagnosis is mild-moderate pneumothorax, whereas if no lung point exists, the diagnosis is severe pneumothorax. Conclusion Lung ultrasound is accurate and reliable in diagnosing and ruling out neonatal pneumothorax and, in our study, was found to be as accurate as chest X-ray.

Objectives Detection of B-line in dyspneic patients is often accompanied by abnormal changes of pleural line on transthoracic ultrasonography (TUS). The aim of the study was to evaluate the relevance and diagnostic performance of pleural line abnormalities and B-lines detected on high-resolution TUS against the computed tomography (CT) findings. Methods Transthoracic ultrasonography was performed in patients admitted to the emergency department with dyspnea. The pleural line and accompanying B-line were assessed using a linear transducer. The TUS findings were assessed against the corresponding high-resolution CT findings in the same location, which were considered to be the gold standard. Results Out of a total of 116 patients, 68.1% had changes of the pleural line on TUS. The characteristic changes of the pleural line were classified into four types: slightly rough pleural line with confluent B-lines on TUS corresponded with CT findings of ground-glass opacity; irregular and interrupted pleural line with confluent B-lines corresponded with parenchymal infiltration; fringed pleural line with confluent B-lines corresponded with superimposed ground-glass and irregular reticular opacities; and fringed pleural line with scattered B-lines corresponded with irregularly thickened interlobular septa. Wavy pleural line indicated subpleural emphysema. The coexistence of more than one abnormal pleural line was also found in 31 cases (26.7%). Conclusions High-resolution TUS may help in the initial assessment of lung pathology by its ability to identify pleural line abnormalities and B-lines that are shown to be associated with CT, which could add diagnostic value in the emergency evaluation of dyspneic patients.

The aim of the study was to assess the significance and diagnostic concert of pleural line aberrations and B-lines detected by high-resolution transthoracic sonography (TS) in contradiction of the high resolution computed tomography (HRCT) findings. The pleural lines and accompanying B-line were assessed using a linear transducer. The TS findings were assessed against the corresponding HRCT findings in the same location, which were considered to be the gold standard. Among 320 patients, pleural line changes were detected in 240 patients (75%) on TS. The characteristic variations of the pleural line were categorized into four types: slightly rough pleural line with confluent B-lines on TS corresponded with HRCT findings of ground-glass opacity; irregular and interrupted pleural line with confluent B-lines corresponded with parenchymal infiltration; fringed pleural line with confluent B-lines corresponded with superimposed ground-glass and irregular reticular opacities; and fringed pleural line with scattered B-lines corresponded with irregularly thickened interlobular septa. Wavy pleural line indicated subpleural emphysema. The coexistence of more than one abnormal pleural line was also found in in 96 cases (30%). In conclusion, High-frequency TS may help in the early assessment of lung pathology by its ability to recognize pleural line anomalies and B-lines that are shown to be associated with CT changes, which could add diagnostic value in the emergency assessment of dyspneic patients.

Background Interstitial lung disease (ILD) evaluation is challenging, given the low sensitivity of X-ray and pulmonary function tests, and limited accessibility and radiation linked to repetitive HRCT. Lung Ultrasound (US) has shown potential in the evaluation of ILD of autoimmune diseases including systemic sclerosis. Objectives To define and asses the reliability of definitions of US-detected findings in ILD. Methods A taskforce (TF) within the OMERACT US WG performed a literature review (LR) to identify US lesions in ILD, a Delphi exercise to define these lesions and a web-based exercise to test the reliability of these definitions by using either intraclass correlation coefficient (ICC) or kappa statistics. Prior to the Delphi exercise all participants received training files and were subsequently asked to provide clips on BL, PLI and normal findings. Based on the results of the LR, which identified B-lines (BL) and pleural line irregularity (PLI) as main US findings in ILD, the Delphi exercise contained statements on US definitions on BL and PLI. After reaching agreement (> 75%) on the above mentioned items, a set of 80 high-quality clips (30 for PLI, 50 for BL), was selected and distributed to the TF members in order to score them (semiquantitatively, 0-2 for PLI and total number for BL) Results The 3 Delphi rounds and the web-based exercise were completed by 24 and 22 sonographers, respectively. Final definitions are reported in Table I. The web-based exercise showed moderate inter-reader reliability for both BL (ICC=0.61) and PLI (kappa=0.69). Table I: definitions of PLI and BL Pleural line irregularity (PLI): a loss of regularity that may be associated with an increase in thickness, focal, diffuse, or nodular B-line (BL): a vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen without fading, and move synchronously with lung sliding Conclusion US is a candidate imaging modality to identify and monitor ILD in rheumatic diseases; US consensus based definitions of main US findings were defined and endorsed. Further development is planned for validating US as an outcome measurement instrument for ILD. Disclosure of Interests Andrea Delle Sedie Speakers bureau: Abbvie, UCB, Celgene, MSD, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, George Bruyn : None declared, Tomas Cazenave: None declared, stavros chrysidis: None declared, Mario Diaz: None declared, Marco Di Carlo: None declared, Marilena Frigato: None declared, Luna Gargani: None declared, Marwin Gutierrez: None declared, ALOJZIJA HOCEVAR: None declared, Annamaria Iagnocco: None declared, Aaron Juche: None declared, Peter Mandl: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer, UCB, Lilly, Novartis, Janssen, and Celgene GmbH, Mohammed A Mortada: None declared, Carlos Pineda: None declared, Francesco Porta: None declared, Viviana Ravagnani: None declared, Carlo Alberto Scire: None declared, Teodora Serban: None declared, Kate Smith: None declared, Maria Stoenoiu Grant/research support from: Abbvie, Roche, Wyeth, Marika Tardella: None declared, Karina Torralba: None declared, Richard Wakefield: None declared, Maria-Antonietta d’Agostino: None declared

Ultrasound examination of the chest has advanced in recent decades. This imaging modality is currently used to diagnose several pathological conditions and provides qualitative and quantitative information. Acoustic barriers represented by the aerated lungs and the bony framework of the chest generate well-described sonographic artifacts that can be used as diagnostic aids. The normal pleural line and A, B, C, E and Z lines (also known as false B lines) are artifacts with specific characteristics. Lung consolidation and pneumothorax sonographic patterns are also well established. Some scanning protocols have been used in patient management. The Blue, FALLS and C.A.U.S.E. protocols are examples of algorithms using artifact combinations to achieve accurate diagnoses. Combined chest ultrasonography and radiography are often sufficient to diagnose and manage lung and chest wall conditions. Chest ultrasonography is a highly valuable diagnostic tool for radiologists, emergency and intensive care physicians. RESUMO O exame ultrassonográfico do tórax avançou nas últimas décadas, sendo utilizado para o diagnóstico de inúmeras condições patológicas, e fornecendo informações qualitativas e quantitativas. Os pulmões aerados e o arcabouço ósseo do tórax representam barreira sonora para o estudo ultrassonográfico, gerando artefatos que, bem conhecidos, são utilizados como ferramentas diagnósticas. Eco pleural normal, linhas A, linhas B, linhas C, linhas E e Z (conhecidas como falsas linhas B) são artefatos com características peculiares. Os padrões de consolidação e de pneumotórax também são bem estabelecidos. Alguns protocolos têm sido utilizados no manuseio dos pacientes: Blue Protocol, Protocolo FALLS e Protocolo C.A.U.S.E são exemplos de três propostas que, por meio da associação entre os artefatos, permitem sugerir diagnósticos precisos. A ultrassonografia de tórax, aliada à radiografia de tórax, muitas vezes é suficiente para o diagnóstico e a conduta das afecções pulmonares e da parede torácica. Trata-se de ferramenta diagnóstica de grande valia para médicos radiologistas, emergencistas e intensivistas.

Transthoracic lung ultrasound (TLU) is a non-invasive and easily accessible method for diagnosing diseases of the pleura and lung. No ionizing radiation allows its use in people with diseases such as Nijmegen breakage syndrome (NBS) or pregnant women. Possibility of repeated studies allows to monitoring therapy. The method uses the artifacts caused by changes out to the periphery of the lungs. Visualization of specific artifacts in lung ultrasound in conjunction with the medial examination often allows the correct diagnosis. In addition, the sensitivity and specificity of TLU are often comparable to the radiological examination and computed tomography. Another advantage is the availability and the short duration of the study which is important in emergency cases. The article presents study techniques and basic artifacts evaluated in TLU. Proper pleural line is characterized by equal outlines, without irregularities. The movement of the pleura is called “lung sliping sign”. Acoustic shadows of two adjacent ribs and pleural line form the so-called “bat sign”. The main artifacts assessed in TLU include artifacts line A, line B and line Z.

Knowledge of lung ultrasound characteristics of coronavirus disease 2019 pneumonia might be useful for early diagnosis and clinical monitoring of patients, and lung ultrasound can help to control the spread of infection in healthcare settings. In this case report, a 36-year-old man with severe acute respiratory syndrome coronavirus 2 infection was diagnosed by reverse transcription-polymerase chain reaction testing of a nasopharyngeal swab. The lung ultrasound findings for this patient were the interstitial-alveolar damage showing bilateral, diffuse pleural line abnormalities, subpleural consolidations, white lung areas and thick, irregular vertical artifacts. When the patient recovered from the severe acute respiratory syndrome coronavirus 2 infection, lung ultrasound images showed a normal pleural line with A-lines regularly reverberating. Performing lung ultrasound at the bedside minimizes the need to move the patient, thus reducing the risk of spreading infection among healthcare staff. Lung ultrasound is useful for early diagnosis and evaluation of the severity of coronavirus disease 2019 pneumonia and for monitoring its progress over the course of the disease.

Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (horizontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-like sign indicating lung consolidation, the B-line, and lung rockets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothorax, and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using CT as the “gold standard” with sensitivity and specificity ranging from 90% to 100%, allowing ultrasound to be considered as a reasonable bedside “gold standard” in the critically ill. The BLUE-protocol is a fast protocol (

This paper presents a novel automatic method for detection of B-lines (comet-tail artifacts) in lung ultrasound scans. B-lines are the most commonly used artifacts for analyzing the pulmonary edema. They appear as laser-like vertical beams, which arise from the pleural line and spread down without fading to the edge of the screen. An increase in their number is associated with presence of edema. All the scans used in this study were acquired using a BK3000 ultrasound scanner (BK Ultrasound, Denmark) driving a 192-element 5.5 MHz wide linear transducer (10L2W, BK Ultrasound). The dynamic received focus technique was employed to generate the sequences. Six subjects, among those three patients after major surgery and three normal subjects, were scanned once and Six ultrasound sequences each containing 50 frames were acquired. The proposed algorithm was applied to all 300 in-vivo lung ultrasound images. The pleural line is first segmented on each image and then the B-lineartifacts spreading down from the pleural line are detected and overlayed on the image. The resulting 300 images showed that the mean lateral distance between B-lines detected on images acquired from patients decreased by 20% in compare with that of normal subjects. Therefore, the method can be used as the basis of a method of automatically and qualitatively characterizing the distribution of B-lines.

The previous chapter detailed the first three of the seven main principles of lung ultrasound, just evoking the four last. Now it is time to take the probe. Chapter 1 showed how we hold it and how we don’t. The probe is perpendicular to the anterior chest wall and tries to stay perpendicular at the PLAPS-point.

For exploring the most voluminous organ, three points allow standardized protocols, expedite the investigation of critically ill patients, and warrant the accuracy published in the BLUE-protocol native article.

The monitoring of vital functions, based on technologically advanced instruments, is pivotal in intensive care unit.

Adding LUCI in the armamentarium of critical ultrasound should result in a change of priorities, by training the intensivist (emergency physician, etc.) to the essential of the BLUE-protocol first. This physician should then be free to take as long time as needed for learning the complex expert echocardiography, during as many years as necessary, but will be ready to face night emergencies, using the best of the BLUE- or FALLS-protocol.

The intensive care unit is the priority step for developing the BLUE-protocol, but ultrasound is welcome everywhere: the intensivist’s experience can be extrapolated to several disciplines and countless settings. We estimated that a dozen of clinical disciplines would be interested. The best for making it a reality would be to implement lung ultrasound in the medical studies: the shortest way. Not whole body ultrasound, because this would result in making longer medical studies. Just lung ultrasound, because it is the simplest, and because all future doctors dealing with the lung would benefit from it. Another aspect of the paradox of LUCI. Therefore, please expect some decades (hopingly less) for seeing ultrasound a natural component of each of these specialties.

A few seconds are sufficient to rule out pneumothorax, less than 1 min to rule it in, at the bedside. This justifies the length of the present chapter.

Notions of the physical properties of ultrasound are not indispensable for the user (as we wrote in our 1992, 2002, 2005, 2010, and 2011 editions). Interested readers will find them in any ultrasound textbook.

Lung ultrasound is a standardized domain. Each of its components is based upon pathophysiological realities. As for any novelty, a new terminology had to be considered. The one used in the BLUE-protocol favors fast communication, in the spirit of aviation language: maximal information in minimal time.

Introduction: Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement. Methods: This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigatorusing first the low-frequency (5–1 MHz) followed by the high-frequency (10–5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation ofTT placement. Results: Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10–5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode. Conclusion: Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10–5 MHz) linear transducer. [West J Emerg Med. 2012;13(4):305–311.]

Supported by an increasing number of papers, chest ultrasound is rising as the first step diagnostic tool in emergency situations.

Lung ultrasound (LUS) has recently been proposed as a new sonographic application to image pulmonary interstitial syndrome through evaluation of B-lines, discrete laser-like vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen, and move

To the editor:I read with interest the article from Caiulo and colleagues[2].Since Lichtenstein described new applications of chestsonography in adults [3],some authorshave published onitsapplication in children, and this topic has become verypopulargiven the absence of radiation. The article by Caiuloet al. focused on bronchiolitis, defined as infection of thesmall airways and whose radiologic clues are hyperinflationand peripheral atelectasis [1].It is therefore surprising that, in their study, hyperinfla-tion was evident in only 1/52 infants with bronchiolitis.Concerning the ultrasound (US) pattern, we are doubtfulabout the real meaning of small subpleural lung consolida-tions and pleural line abnormalities. US cannot reliablydifferentiate pneumonia from atelectasis, which is—on theother hand—often associated with severe pneumonia [5].Furthermore, according to the experience derived from chestCT in early childhood, these aspects can be related also toincomplete expansion of the alveoli [4], which are oftenincidentally observed in healthy lungs investigated for otherreasons.

Among the investigations performed daily in the intensive care unit (ICU), bedside chest x-rays (CXRs) are trivialized. However, they are a source of discomfort and irradiation for the patients, and carry a potential risk of accidental removal of devices (catheters, tubes) and microbial dissemination, all resulting in additional cost for the community. It is, therefore, essential to assess current practices in order to establish recommendations for prescription of CXRs and to determine whether it is possible to reduce the number of CXRs performed during an ICU stay without impairing quality of care. We will discuss alternatives to CXRs in specific situations (such as placement of feeding tubes and central venous lines). We will also consider bedside CXR prescription strategies, without considering medico-economic aspects such as the possible savings resulting from a reduction in the number of CXRs performed in the ICU. Indeed, the real cost of performing a bedside CXR is unknown because it integrates multiple parameters, such as cost of consumables, depreciation of equipment, working time of the x-ray technician and logistical costs.

Newborns, infants, and children do not show at lung ultrasound examination a different picture than adults. Also, the pathological changes described in adults diseases are similar.

In the past several years attention has been drawn to an important anatomical landmark in the study of lesions of the thoracic spine known as the linear thoracic paraspinal shadow or posteromesial pleural line (1, 4, 5, 6). In many lesions of the thoracic spine there is found to be a fusiform shadow produced by lateral displacement of the pleural borders which aids materially in the diagnosis of spinal disease in this region. It is the purpose of this paper to draw attention to the occurrence of unilateral displacement of this line, rather than the well recognized bilateral or fusiform shadow. Anatomy Careful anatomical studies by Lachman (6), Garland (5), and Brailsford (1) have demonstrated that on the left this posteromesial line is formed by the mediastinal pleural border of the left lung. In the lower portion of the thorax it lies perpendicular to the central rayon anteroposterior roentgenograms of the thorax. Normally the line lies immediately adjacent to and parallel to the lateral border of the th...

Background The use of lung ultrasound (LUS) in ICU is increasing but ultrasonographic patterns of lung are often difficult to quantify by different operators. The aim of this study was to evaluate the accuracy and quality of LUS reporting after the introduction of a standardized electronic recording sheet. Methods Intensivists were trained for LUS following a teaching programme. From April 2008, an electronic sheet was designed and introduced in ICU database in order to uniform LUS examination reporting. A mark from 0 to 24 has been given for each exam by two senior intensivists not involved in the survey. The mark assigned was based on completeness of a precise reporting scheme, concerning the main finding of LUS. A cut off of 15 was considered sufficiency. Results The study comprehended 12 months of observations and a total of 637 LUS. Initially, although some improvement in the reports completeness, still the accuracy and precision of examination reporting was below 15. The time required to reach a sufficient quality was 7 months. A linear trend in physicians progress was observed. Conclusions The uniformity in teaching programme and examinations reporting system permits to improve the level of completeness and accuracy of LUS reporting, helping physicians in following lung pathology evolution.

The previous chapters dealt with more or less usual fields. We now go deeper within this vital organ that has been slightly overlooked by the academics, demonstrating that the diagnosis of pleural effusion or alveolar disorders was just an appetizer. If lung ultrasound is a raison d’etre of critical ultrasound, the potential of interstitial syndrome is the raison d’etre of lung ultrasound. Based on artifact analysis, it changes the approach to the critically ill. The lung was reputed to be inaccessible to ultrasound mainly because of the artifacts, which were qualified as indesirable [ 1, 2]. Therefore, the physician was not ready for making diagnoses based on artifacts. Similarly, when we began to define the field of critical ultrasound, we saw at the thoracic area various kinds of fog, snow, and parasites. We could have chosen to be resigned to this like the whole community but decided to persist. This was a vital organ after all. Little by little, we wondered whether these parasites, sometimes horizontal, sometimes vertical, could not be a language? Perhaps it was a simple language that we just did not understand. This initiated a work of observation, assessment, classification, and, above all, of endless submissions.

In patients with a hyperlucent lung, radiological differentiation between a pneumothorax and a giant bulla is not always definitive. This may result in a chest tube insertion into a pulmonary bulla with devastating results or a delay in initiating appropriate treatment for pneumothorax. Usually, distinctions between the pleural line of a pneumothorax and the bulla wall can be made by computed tomography (CT). In addition, the double wall sign of pneumothorax (parallel bulla wall and chest wall outlined by air outside the bulla) is useful in recognising the coexistence of bullae and pneumothoraces.1 Here we report a case of vanishing lung syndrome, which was diagnosed by CT in a man who presented with sudden onset of …

Hydropneumothorax may be diagnosed on a supine radiograph by recognition of a pleural line with increased density lateral to it in the pleural space. Recognition of this condition may have implications for therapeutic chest tube placement.

Widening of the paraspinal pleural line on the supine anteroposterior overexposed grid roentgenogram of the chest is proposed as an early diagnostic indicator of free pleural effusions. This finding is more often observed on the left than on the right side.