Bedside Lung Ultrasound In Emergency Research Articles

Effectiveness of Lung Ultrasound for Diagnosis of Acute Respiratory Distress Syndrome in Mechanically Ventilated Patients

Background: Acute respiratory distress syndrome (ARDS) requires rapid diagnosis for early intervention and improved outcomes. Lung ultrasound may be a reasonable alternative to chest X-ray for the identification of ARDS but the effectiveness of lung ultrasound in ARDS diagnosis is still uncertain. The objective of the study is to explore the efficacy of lung ultrasound (LUS) for diagnosis of ARDS in mechanically ventilated patients. Methods: A cross sectional study was conducted among 75 patients in Critical Care Centre, Combined Military Hospital, Dhaka from September 2021 to January 2022. The study was approved by the ethical committee in the hospital. In this study, the Bedside Lung Ultrasound in Emergency (BLUE) protocol for the immediate diagnosis of acute respiratory failure was followed. Purposive sampling technique was used. Data were analyzed by using Statistical Package For Social Sciences (SPSS) version 25.0. Results: A total of 75 patients were assessed. Among them male were 42(56%) and female 33(44%). The median age of patients was 48 years (Interquartile range 30-60). Primary diagnoses were pneumonia (22.67%), pulmonary oedema (20%), sepsis (20%) and trauma (17.33%). A total of 34(45.33%) patients fulfilled ‘CXR-based Berlin Definition’ and a total of 36(48%) patients were diagnosed as ARDS by ‘LUS-based Berlin Definition’. Considering the ‘CXR-based Berlin Definition’ as reference standard, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of lung ultrasound were 85.29%, 82.92%, 80.55%, 87.18% and 84% respectively. Conclusion: Lung ultrasound can be an effective tool for the diagnosis & management of ARDS in the intensive care unit. Bangladesh Armed Forces Med J Vol 56 No (2) December 2023, pp 51-57

Ultrasound on the Frontlines: Empowering Paramedics with Lung Ultrasound for Dyspnea Diagnosis in Adults-A Pilot Study.

Lung transthoracic ultrasound (LUS) is an accessible and widely applicable method of rapidly imaging certain pathologies in the thorax. LUS proves to be an optimal tool in respiratory emergency medicine, applicable in various clinical settings. However, despite the rapid development of bedside ultrasonography, or point-of-care (POCUS) ultrasound, there remains a scarcity of knowledge about the use of LUS in pre-hospital settings. Therefore, our aim was to assess the usefulness of LUS as an additional tool in diagnosing dyspnea when performed by experienced paramedics in real-life, pre-hospital settings. Participants were recruited consecutively among patients who called for an emergency due to dyspnea in the Warsaw region of Poland. All the enrolled patients were admitted to the Emergency Department (ED). In the prehospital setting, a paramedic experienced in LUS conducted an ultrasonographic examination of the thorax, including Bedside Lung Ultrasound in Emergency (BLUE) and extended Focused Assessment with Sonography for Trauma (eFAST) protocols. The paramedic's diagnosis was compared to the ED diagnosis, and if available, to the final diagnosis established on the day of discharge from the hospital. We enrolled 44 patients in the study, comprising 22 (50%) men and (50%) women with a median age of 76 (IQR: 69.75-84.5) years. The LUS performed by paramedic was concordant with the discharge diagnosis in 90.91% of cases, where the final diagnosis was established on the day of discharge from the hospital. In cases where the patient was treated only in the ED, the pre-hospital LUS was concordant with the ED diagnosis in 88.64% of cases. The mean time of the LUS examination was 63.66 s (SD: 19.22). The inter-rater agreement between the pre-hospital diagnosis and ER diagnosis based on pre-hospital LUS and complete ER evaluation was estimated at k = 0.822 (SE: 0.07; 95%CI: 0.68, 0.96), indicating strong agreement, and between the pre-hospital diagnosis based on LUS and final discharge diagnosis, it was estimated at k = 0.934 (SE: 0.03; 95%CI: 0.88, 0.99), indicating almost perfect agreement. In conclusion, paramedic-acquired LUS seems to be a useful tool in the pre-hospital differential diagnosis of dyspnea in adults.

Experience in the use of focused lung ultrasound in the intensive care practice

Surgical interventions, accompanied by a subclavian vein cannulation, are associated with the risk of pneumothorax. Timely detection of this condition reduces the risk of secondary complications. An effective and promising method for the early detection of pneumothorax is lung ultrasound.Aim. To evaluate the routine bedside use of focused lung ultrasound in the early postoperative period in patients after surgical interventions accompanied by subclavian vein cannulation.Material and methods. This retrospective analysis of 304 case records of patients after surgical interventions accompanied by subclavian vein cannulation was carried out. Patients underwent lung auscultation, lung ultrasound according to the Bedside Lung Ultrasound in Emergency (BLUE) protocol 1 and 6 hours after surgery, or unscheduled with a saturation decrease <90%, the appearance of shortness of breath and/or chest pain. When pneumothorax signs were detected, patients underwent an emergency chest x-ray, and an elective x-ray was performed 1 day after the intervention.Results. 304 case records were analyzed, lung ultrasound was performed in 187 (61,5%) men and 117 (38,5%) women. In 8 (2,63%) patients, 1 hour after surgery, an A-profile without lung sliding was detected. In 3 (0,99%) patients, auscultatory breathing weakening was noted, complaints of discomfort and pain during inspiration were noted by 5 (1,64%) patients. In all 8 patients, the diagnosis was confirmed by x-ray. In 5 (1,64%) patients, a mild pneumothorax was detected, which did not require drainage, while 3 patients underwent pleural drainage.Conclusion. Focused lung ultrasound using the BLUE protocol significantly improves the safety profile of patients after subclavian vein puncture, providing high levels of sensitivity and specificity in detecting pneumothorax.

Desenvolvimento de um aplicativo para ensino de ultrassonografia pulmonar em emergência

Abstract: Introduction: The use of ultrasound protocols has revolutionized care in emergency medicine and can help in the diagnosis of respiratory failure in emergency care; therefore, medical training for the use of these protocols has become important. It has also been demonstrated that medical smartphone apps have positive results in daily practice, in addition to being a potentially valuable educational tool. Objective: Thus, the objective was to develop an emergency pulmonary ultrasound application. The “BLUE SIM” is a cell phone application that simulates clinical cases using the “Bedside Lung Ultrasound in Emergency” protocol, which can help students and health professionals regarding the use of pulmonary ultrasound in the care of acute respiratory failure. The hypothesis is that the “BLUE SIM” will be a usable and acceptable application among users. Method: After the development, the application was evaluated with a group of 36 volunteers, which included 18 physical therapists and 18 other professionals consisting of physicians, nurses and medical students. The usability and usefulness of a mobile application for the iOS system was analyzed, using the System Utility Score (SUS) usability scale and the Technology Acceptance Model (TAM) as references. The obtained data were tabulated and analyzed using Fisher’s exact test or Mann-Whitney test. Result: When applying the SUS questionnaire (usability), the application obtained a score of 76.8%. A score of 75% was obtained exclusively among physical therapists, with no statistical difference between the general group of all emergency professionals and the group of physical therapists only (p=0.239). According to the usefulness perception analysis, 93.9% of the emergency professionals had a positive response, while a score of 88.9% was obtained among physical therapists (p=0.04). Conclusion: It was concluded that the developed application was classified as useful in learning the diagnosis of respiratory failure among health professionals; however, they considered that training is necessary for its use.

Lung ultrasound for evaluation of dyspnea: a pictorial review.

Lung ultrasound is based on the analysis of ultrasound artifacts generated by the pleura and air within the lungs. In recent years, lung ultrasound has emerged as an important alternative for quick evaluation of the patient at the bedside. Several techniques and protocols for performing lung ultrasound have been described in the literature, with the most popular one being the Bedside Lung Ultrasound in Emergency (BLUE) protocol which can be utilized to diagnose the cause of acute dyspnea at the bedside. We attempt to provide a simplified approach to understanding the physics behind the artifacts used in lung ultrasound, the imaging techniques, and the application of the BLUE protocol to diagnose the commonly presenting causes of acute dyspnea.

Diagnostic ultrasound examinations during evacuation of urgent patients by ambulance helicopters: literature review

Relevance. The use of ultrasound diagnostics at the place of providing medical care to an urgent patient is one of the promising directions in the development of emergency medicine. At the same time, of particular interest is the possibility of using diagnostic ultrasound in an ambulance helicopter, given the lack of clear algorithms and standards for its application, as well as the limited number of publications on this problem.Intention. Analysis of publications on the use of urgent ultrasound examination in an ambulance helicopter.Methodology. A search was made for scientific publications on the topic on the electronic resource PubMed, in the Google Scholar search system for the period from 2000 to 2021.Results and discussion. The main algorithms used for ultrasound diagnostics of an urgent patient in an ambulance helicopter are Focused Assessment with Sonography for Trauma (FAST), point-of-care ultrasound (POCUS), Rapid Ultrasound in SHock (RUSH), Bedside Lung Ultrasound in Emergency (BLUЕ), prehospital ultrasonography (PHUS), etc. They help exclude damage to vital organs and emergency pathology – pneumo- and hemothorax, hemoperitoneum, hemopericardium, large fractures and others that affect the tactics of treatment and patient routing; there is also the possibility of ultrasound navigation for a number of medical and diagnostic procedures. According to the results of published studies and clinical observations, prehospital ultrasound examination of urgent patients is successfully used during medical evacuation by an ambulance helicopter in emergency medical services in many countries of the world (both by doctors and other medical personnel), making it possible to diagnose a number of lifethreatening conditions with a fairly high accuracy, without loss of time and without damage to patient’s health. An important aspect of the successful application of the method during flight is the training of qualified personnel. The prospects for the development of the method are the development of more advanced ultrasound scanners and sensors adapted to flight conditions, as well as the use of telemedicine technologies for remote analysis of ultrasound images.Conclusion. The experience of using prehospital diagnostic ultrasound in an ambulance helicopter requires further data accumulation and systematic analysis, but the method is already undoubtedly useful in determining the tactics of treatment and the route of hospitalization of urgent patients with acute trauma and a number of other pathological conditions.

Etiologic diagnosis of acute shortness of breath in the emergency department

Background-Dyspnea is the term applied to sensation of breathlessness and the patient’s reaction to that sensation, In the BLUE (Bedside Lung Ultrasound in Emergency) protocol, lung profiles have been designed for the main etiologies of dyspnea (acute pulmonary edema, COPD, pulmonary embolism, pneumothorax, pneumonia) with an accuracy of >90%. Objectives-•To investigate if BLUE protocol will improve diagnostic accuracy of patients with acute dyspnea •To compare the diagnostic accuracy of BLUE protocol findings alone with final diagnosis in patients with acute dyspnea. Methods-This study was a cross-sectional, hospital-based, follow-up observational study conducted in 130 patients who presented to the Emergency Department of Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala during January 2020 to August 2020, with complains of dyspnea of acute onset. It was done by incorporating the Bedside Lung Ultrasound in Emergency (BLUE) protocol for diagnosing the etiology of dyspnea. Epiinfo 7 was used for analysis. Results-the study sample included 130 subjects who fulfilled the inclusion criteria.Amongthestudypopulation,76(58.5%)weremalesand54(41.5%) were females. The mean age of the study population was 66.6 with a standard deviation of 14.1. The minimum age included in the study was 32 years and the maximum age was 91years.

Performance of bedside lung ultrasound in emergency (BLUE) protocol in the diagnosis of pneumonia

Performance of bedside lung ultrasound in emergency (BLUE) protocol in the diagnosis of pneumonia

Lung Ultrasound versus Pulmonary Auscultation in Detecting Pulmonary Congestion in the Critically Ill

BACKGROUND: In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound (LUS) as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. AIM: The aim of this study was to compare LUS versus pulmonary auscultation for detecting pulmonary edema in critically ill patients. PATIENTS AND METHODS: Sixty-one patients were included in this study, all included patients underwent clinical examination, chest auscultation of anterior and lateral (axillary) chest wall and back in each hemithorax in supine position was done, followed by LUS using Bedside LUS in Emergency (BLUE) protocol. LUS score was recorded; abnormal auscultation was defined as the presence of rales or wheezes. Laboratory tests were done on admission such as pro-BNP, renal function, and blood gases. Pro-BNP was used as diagnostic tool for volume overload and was correlated with LUS and stethoscope for detecting pulmonary edema. Pneumonia was excluded with normal total leukocyte counts, C-reactive protein, and absence of fever. RESULTS: This study included 61 patients with diagnosis of pulmonary edema, all data were recorded on admission and showed that there was statistically significant good positive correlation between LUS and Pro-BNP (p < 0.05), and Pearson correlation between LUS and Pro-BNP among the studied patients is statistically significant at the 0.01 level (two-tailed). Furthermore, we found that both LUS and Pro-BNP were statistically significant higher among patients with rales (p < 0.05) only 36 (59%) patients were positive as pulmonary edema with pulmonary auscultation (presence of rales) and 25 (41%) patients were negative for pulmonary edema (NO RALES) while they were positive for pulmonary edema with LUS (high LUS score)and pro-BNP. CONCLUSION: Pulmonary auscultation has poor sensitivity for pulmonary congestion while LUS had statistically significant higher sensitivity for pulmonary edema.

Diagnostic Accuracy of Bedside Lung Ultrasound in Emergency Protocol for the Diagnosis of Acute Respiratory Failure.

Background:The multifactorial etiology of acute respiratory failure (ARF) often complicates diagnosis at an early stage of clinical presentation. Despite being a common life-threatening disorder, accurate and timely diagnosis is hindered by bad quality of bedside radiographs and nonavailability of immediate computed tomography imaging. This study was an attempt to evaluate the diagnostic accuracy of ultrasound in diagnosing ARF.Methods:This hospital-based cross-sectional study investigated the underlying etiological factor in 130 patients presenting with ARF and admitted to the intensive care unit. Lung ultrasound was performed according to the Bedside Lung Ultrasound in Emergency (BLUE) protocol. The diagnostic accuracy of lung ultrasound by emergency protocol was measured against each final diagnosis.Results:The mean age observed was 49.28 ± 14.9 years among the cohort. Of the 130 patients, pneumonia was the most common cause of ARF, seen in 42 patients. Breathlessness (56.15%) and fever accompanied by cough (25.38%) were the chief complaints. Diagnostic accuracy of ultrasound lung emergency protocol was 95.38% in the diagnosis of pulmonary edema, 100% for pneumothorax, 93.85% for pneumonia, 96.92% for chronic obstructive pulmonary disease, 99.23% for pulmonary thromboembolism, and 95.38% for acute respiratory distress syndrome.Conclusion:Lung ultrasound is a reliable modality that provided accurate and timely diagnosis of ARF in this study. Therefore, BLUE protocol is feasible, easily implementable in the intensive care unit, and must be scaled up in respiratory health-care settings.

Lung ultrasound score based on the BLUE-plus protocol is associated with the outcomes and oxygenation indices of intensive care unit patients.

The primary objective was to demonstrate the relationship between lung ultrasound (LUS) manifestations and the outcomes of intensive care unit (ICU) patients. The secondary objective was to determine the characteristics of LUS manifestations in different subgroups of ICU patients. This prospective multi-center cohort study was conducted in 17 ICUs. A total of 1702 patients admitted between August 31, 2017 and February 16, 2019 were included. LUS was performed according to the bedside lung ultrasound in emergency (BLUE)-plus protocol, and LUS scores were calculated. Data on the outcomes and oxygenation indices were analyzed and compared between different primary indication groups. The LUS scores were significantly higher for non-survivors than for survivors and were significantly different between the oxygenation index groups, with higher scores in the lower oxygenation index groups. The LUS score was an independent risk factor for the 28-day mortality. The area under the receiver operating characteristic curve was 0.663 for prediction of the 28-day mortality and 0.748 for prediction of an oxygenation index ≤100. The LUS score based on the BLUE-plus protocol was an independent risk factor for the 28-day mortality and was important for the prediction of an oxygenation index ≤100. An early LUS score within 24 hours of ICU admission helps predicting the outcome of ICU patients.

Comparison of Efficacy of LUS and CXR in the Diagnosis of Children Presenting with Respiratory Distress to Emergency Department.

ABSTRACTIntroductionRespiratory distress (RD) in children is a life-threatening condition. Delay in diagnosis has a deleterious effect on morbidity and mortality. The bedside lung ultrasound in emergency (BLUE) is a fast method that aims to accelerate the diagnosis with minimal radiological exposure. We targeted to evaluate the efficacy of BLUE protocol to speed and increase the precision of recognizing the cause of RD compared with chest X-ray (CXR) in the emergency department.Materials and methodsA cross-sectional study on 63 children with RD attended the emergency of a tertiary, university-affiliated, pediatric medical center between January 2017 and January 2018.ResultsMost cases were males 52.4%. We designed to estimate the value of BLUE as a diagnostic tool for RD and comparing it with CXR. Pneumonia with or without pleural effusion was the main etiology of RD detected by BLUE in 47.7% of studied children, pulmonary edema in 22.2%, bronchiolitis and asthma in 17.4%, and pneumothorax in 12.7%. Lung ultrasound (LUS) was superior to CXR in the diagnosis of RD cause, and most cases, 47.7% were diagnosed with pneumonia with a sensitivity of 93.5% and specificity 96.9%.ConclusionBedside lung ultrasound in emergency is an effective tool for identifying the cause of RD which is more sensitive and specific compared with CXR.How to cite this articleHegazy LM, Rezk AR, Sakr HM, Ahmed AS. Comparison of Efficacy of LUS and CXR in the Diagnosis of Children Presenting with Respiratory Distress to Emergency Department. Indian J Crit Care Med 2020;24(6):459–464.

Can echocardiographic assessment of interatrial septum shape and motion improve the accuracy of the BLUE protocol?

Acute respiratory failure is one of the most challenging critical conditions due to a wide variety of differential diagnosis. Bedside lung ultrasound in emergency (BLUE) protocol allows accurate differen-tiation between the most common under-lying causes of acute respiratory failure in up to 90% of the cases. The assessment of left atrial pressure affecting left ventricular filling is essential in critically ill patients guiding volume substitution, optimization of left ventricular function and prevention of pulmonary congestion, thus ensuing haemodynamic stability. A simple, non-in-vasive method of left atrial pressure evalu-ation is the echocardiographic assessment of interatrial septum shape and motion, which is affected by interatrial pressure gradient. Aiming to improve the accura-cy of the BLUE protocol, we propose the simple, non-invasive echocardiographic assessment of interatrial septum shape and motion as an upgrade, providing ad-ditional information of the loading of left and right atrium thus distinguishing the most common causes of acute respiratory failure.

Basic Insights of Lung Ultrasonography in Critical Care Setting.

Lung ultrasonography has a tailored diagnostic and therapeutic approach in the critical care setting. Lung ultrasonography in critically ill (LUCI) is a helpful modality for the early detection and assessment of various lung pathologies and guides the management protocol for the same. The aim of this review was to highlight the basics of an ultrasound machine, the fundamentals of a lung ultrasound and the importance of lung artifacts in detecting the anatomy and pathology of the lung disease. In addition, we have also discussed regarding the effective approach to lung ultrasonography through the two protocols: the Bedside Lung Ultrasound in Emergency (BLUE) protocol and the Fluid Administration Limited by Lung Sonography (FALLS) protocol.

Practical aspects of use of emergency sonography for differential diagnosis of critical respiratory incidents (Blue-protocol “Bedside Lung Ultrasound in Emergency”)

This article contains rather motivating than teaching information. It is a synthesis of analysis of authoritative global scientific publications and personal experience. The modern approaches to diagnosis of critical respiratory incidents using ultrasound, superficial theoretical review of the core of the method and our own experiences regarding effective protocol of sonographic lung assessment are presented here. Several interesting clinical cases emphasize the advantages of routine use of diagnostic ultrasound in patients with critical uncompensated respiratory disaster as well as in sub-compensated and compensated patients.
 The main principles of bedside lung ultrasound in emergency that should encourage wider implementation and use of this method by doctors of different specialties are: “Lung ultrasound is very easy to perform using simple equipment”, and “BLUE-protocol is a simple protocol that allows quick (< 3 min) diagnosis of the cause of respiratory failure”.
 Lung sonographic assessment allows not only to determine quickly the cause of critical respiratory failure and counteract it starting the etiotropic treatment as soon as possible, but also visualize the dynamics of pathological changes in response to therapy, thus allowing us to evaluate its effectiveness properly.
 The use of ultrasound in diagnosing enables more adequate decision making regarding the need of interventional therapy. It also leads to setting the right diagnosis faster, improving the quality of medical care, shortening the length of stay of patients in ICU, decreasing the total cost of the treatment.
 Identification and analysis of the amount of sonographic signs “B-lines – lung rockets” provides an opportunity to measure the volume/amount of interstitial lung fluid properly and track this marker/indicator in dynamics in response to the treatment.
 The unified method of protocolized assessment should be used within one medical facility in order to boost effectiveness and make evaluation and dynamic evaluation of pathological changes more objective by the same one or different medical specialists.
 Diagnostic ultrasound has a very low cost and there is no radiation exposure to patients which allows performing as many examinations as needed, without limitations.

Bedside Lung Ultrasound in Emergency Protocol as a Diagnostic Tool in Patients of Acute Respiratory Distress Presenting to Emergency Department.

Objective:The objective of this study is to determine the accuracy of the bedside lung ultrasound in emergency (BLUE) protocol in giving a correct diagnosis in patients presenting with acute respiratory distress in emergency department.Materials and Methods:Patients with acute respiratory distress were evaluated. Ultrasound findings such as artifacts (A line, B line), lung sliding, alveolar consolidation or pleural effusion, and venous analysis were recorded. Ultrasonography findings were correlated with final diagnosis made by the treating unit. Sensitivity and specificity were calculated.Results:A total 50 patients were evaluated. The A profile (predominant A line with lung sliding) indicated chronic obstructive pulmonary disease/asthma (n = 14) with 85.17% sensitivity and 88.88% specificity. B profile (predominant B + lines with lung sliding) indicated pulmonary edema (n = 13) with 92.30% sensitivity and 100% specificity. The A/B profile (A line on one side and B + line on other side) and the C profile (anterior consolidation) and the A profile plus posterolateral alveolar and/or pleural syndrome indicated pneumonia (n = 17) with 94.11 sensitivity and 93.93% specificity. The A profile plus venous thrombosis indicated pulmonary embolism (n = 1) with 100% sensitivity and specificity. A’ profile (predominant A line without lung sliding) with lung point indicated pneumothorax (n = 5) with 80% sensitivity and 100% specificity.Conclusion:BLUE protocol was successful in average 90.316% cases. BLUE performed in emergency department is equivalent to computed tomography scan. BLUE protocol aids in making diagnosis and saves time and cost; avoids the side effects related to radiation.

The impact of the BLUE protocol ultrasonography on the time taken to treat acute respiratory distress in the ED

Respiratory distress is one of the most common complaints in the emergency department (ED) [1]. In extreme scenarios, during which respiratory distress becomes respiratory failure, the survival of the patients will significantly drop [2]. For instance, a recent cohort study showed that the mortality rate among hospitalized patients with respiratory distress was as much as 10% [3]. Hence, in the management of a patient with respiratory distress, using a timely approach to differentiate the underlying causes and initiating specific therapies (decompression of the pneumothorax, intubation and ventilation support, bronchodilators or corticosteroid nebulization, anticoagulation and fibrinolytic therapy in pulmonary thromboembolisms, etc.) is of undisputed importance. In 2008, the Bedside Lung Ultrasound in Emergency (BLUE) protocol was developed to guide the diagnosis of respiratory distress [4]. Lichtenstein and his colleagues who proposed the BLUE protocol, showed that the diagnostic accuracy of lung ultrasound (LUS) in the Intensive Care Unit (ICU) was 90.5%. Similarly, Silva et al. demonstrated that LUS was more accurate in cases of acute respiratory failure than routine approaches (patient history and physical examination, radiologic and laboratory evidence) [5]. The BLUE protocol enables physicians to differentiate the underlying causes of respiratory failure. More to the point, LUS was proved to be effective in the monitoring of therapeutic responses in acute respiratory distress syndrome (ARDS) [6]. The BLUE protocol can be applied using a simple ultrasound machine equipped with a micro-convex array transducer [7]. Nevertheless, performing an accurate LUS requires specific training [8]. Although current evidence encourages the use of LUS in treating respiratory distress in critical care, it is not widely accepted in EDs [9]. We hypothesized that utilizing a bedside testing protocol such as the BLUE protocol in the ED may shorten the time interval between patient admission and the delivery of any definitive treatment [10]. We have therefore conducted a randomized clinical trial to assess whether or not the application of the BLUE protocol by a trained emergency physician has an impact on the timely diagnosis and treatment of respiratory distress in the ED.

Integrated use of bedside lung ultrasound and echocardiography to manage pediatric patients with respiratory failure and shock in pediatric intensive care unit

Objective To evaluate the value of integrated use of bedside lung ultrasound and echocardiography in PICU. Methods Two cases with respiratory failure and shock were monitored using integrated bedside lung ultrasound and echocardiography.Breathing and circulation support solutions were adopted according to Bedside Lung Ultrasound in Emergency(BLUE) and Fluid Administration Limited by Lung Sonography(FALLS). Results Case 1 with acute lymphoblastic leukemia complicated with severe phneumonia was measured asB-profilethroughout both lung fields which interpreted as pulmonary edema according to the BLUE protocol.He was diagnosed as acute respiratory distress syndrome later and supported by non-invasive ventilation according to the lung ultrasonography.After 4 days, the numbers of B line were significantly reduced with PaO2/FiO2>300 mmHg(1 mmHg=0.133 kPa) and the improvement in chest X radiography was found, ventilation was weaned accordingly.Case 2 was diagnosed as septic shock and acute respiratory distress syndrome with volume resuscitation and mechanical ventilation.According to FALLS protocol, we ruled out obstructive and cardiogenic shock, and assessed the variation in inferior vena cava diameter and aortic systolic velocity-time integral as a guide to fluid therapy.At the 8th hour in PICU, case 2 recovered from shock. Conclusion Integrated use of bedside lung ultrasound and echocardiography is clinically significant for the rescue of critically ill patient with respiratory failure and shock. Key words: Lung ultrasound; Respiratory failure; Shock; Critical care; Children,

BLUE-Protocol and FALLS-Protocol: Two Applications of Lung Ultrasound in the Critically Ill

This review article describes two protocols adapted from lung ultrasound: the bedside lung ultrasound in emergency (BLUE)-protocol for the immediate diagnosis of acute respiratory failure and the fluid administration limited by lung sonography (FALLS)-protocol for the management of acute circulatory failure. These applications require the mastery of 10 signs indicating normal lung surface (bat sign, lung sliding, A-lines), pleural effusions (quad and sinusoid sign), lung consolidations (fractal and tissue-like sign), interstitial syndrome (lung rockets), and pneumothorax (stratosphere sign and the lung point). These signs have been assessed in adults, with diagnostic accuracies ranging from 90% to 100%, allowing consideration of ultrasound as a reasonable bedside gold standard. In the BLUE-protocol, profiles have been designed for the main diseases (pneumonia, congestive heart failure, COPD, asthma, pulmonary embolism, pneumothorax), with an accuracy > 90%. In the FALLS-protocol, the change from A-lines to lung rockets appears at a threshold of 18 mm Hg of pulmonary artery occlusion pressure, providing a direct biomarker of clinical volemia. The FALLS-protocol sequentially rules out obstructive, then cardiogenic, then hypovolemic shock for expediting the diagnosis of distributive (usually septic) shock. These applications can be done using simple grayscale machines and one microconvex probe suitable for the whole body. Lung ultrasound is a multifaceted tool also useful for decreasing radiation doses (of interest in neonates where the lung signatures are similar to those in adults), from ARDS to trauma management, and from ICUs to points of care. If done in suitable centers, training is the least of the limitations for making use of this kind of visual medicine.

Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients.

Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.