Chest
Recent Advances in Chest MedicineBLUE-Protocol and FALLS-Protocol: Two Applications of Lung Ultrasound in the Critically Ill
Section snippets
History
Lung ultrasound originally was not meant to be used in emergent care. Except for echocardiography used in cardiology and sonography used in obstetrics, ultrasound in general was a tool for radiologists, and the lung in particular was not considered suitable for this imaging technology.3 Since 1989, François Jardin's ICU explored, applied, and made lung ultrasound with a portable unit a standard of care in critically ill patients. Based on our 25 years of experience using lung ultrasound in the
Tools Used for the BLUE-Protocol
One application of lung ultrasound is the onsite exploration of acute respiratory failure: the bedside lung ultrasound in emergency (BLUE)-protocol. Although the new generation of intensivists benefits from a variety of excellent machines, we keep using our 1992 technology (last updated in 2008) for several reasons: We like its resolution; 32-cm width in settings where each lateral centimeter counts; 7-s start-up time; flat, easy-to-clean, fluid-proof design; 5-MHz microconvex probe allowing
Patients, Diseases, and Profiles in the BLUE-Protocol
The BLUE-protocol was developed based on the study of 300 consecutive adults with acute respiratory failure who were admitted to our ICU and given a diagnosis. The most frequent cause of respiratory failure was pneumonia (32%) followed by acute hemodynamic pulmonary edema (24%); exacerbated COPD (18%); severe asthma (13%); pulmonary embolism (8%); pneumothorax (4%); and countless rare causes, including easy-to-diagnose ones, such as massive pleural effusion (3%). We excluded rare, unknown, and
The BLUE-Protocol: When and How Is it Used, What Occurs Practically, With How Much Accuracy?
The BLUE-protocol is done each time the physician has clinical doubts after the physical examination. The machine is brought to the bedside, the probe applied at the anterior standardized points, and the BLUE-protocol begun (Fig 10), first searching for lung sliding. If lung sliding is present, the association with predominant A-lines defines the A-profile, and a venous scan is done following a sequential order.62 An A-profile associated with a DVT is 99% specific to pulmonary embolism. For
A Development of the BLUE-Protocol: Lung Ultrasound for Diagnosing Acute Circulatory Failure—the FALLS-Protocol
For this major concern, successive tools have been used, with echocardiography currently being one of the most popular.1, 2 Many others are competing, providing an impressive list of parameters when combined, suggesting that no gold standard is currently available. The fluid administration limited by lung sonography (FALLS)-protocol is not yet supported by clinical studies but should be considered as a potential source of help in difficult situations. It is based on sequential concepts:
How Can These Protocols Affect the Routine of Several Disciplines?
Lung ultrasound in critical care is a holistic tool. A concept is holistic when the understanding of each of its multiple components is necessary to fully understand the whole.45 The result generates a whole-body approach in addition to the main vital organ. This allows for simplification of expert domains such as echocardiography, if associated with lung ultrasound. In the case of suboptimal cardiac windows, the B-profile suggests pulmonary edema and the A-profile hypovolemia, schematically.
Conclusions
The BLUE-protocol and the FALLS-protocol, two main applications of LUCI, are simple to use at each step, beginning with the choice of equipment (one simple unit, one microconvex probe for the whole body). The BLUE-protocol directly scans the lung to assess the cause of a respiratory failure. The FALLS-protocol considers a direct marker of fluid overload at the lung surface in patients with septic shock. With these applications, lung ultrasound appears once again as a visual stethoscope (from
Acknowledgments
Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Other contributions: The author thanks François Jardin, MD, who made everything possible, and Gilbert Mezière, MD, for precious advice. Additional material (videos) can be seen at www.CEURF.net, section BLUE-protocol.
References (85)
- et al.
American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography
Chest
(2009) - et al.
Safety of ultrasound-guided thoracentesis in patients receiving mechanical ventilation
Chest
(2004) - et al.
Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water
Am J Cardiol
(2004) - et al.
Usefulness of ultrasonography in predicting pleural effusions > 500 mL in patients receiving mechanical ventilation
Chest
(2005) - et al.
Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients
Chest
(2005) - et al.
Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome
Am J Emerg Med
(2006) - et al.
Chest ultrasonography in lung contusion
Chest
(2006) - et al.
Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema
Chest
(2007) - et al.
Prognostic value of extravascular lung water assessed with ultrasound lung comets by chest sonography in patients with dyspnea and/or chest pain
J Card Fail
(2007) - et al.
Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure
Am J Emerg Med
(2008)
Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department
Chest
Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution
Chest
Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery
Chest
Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study
Chest
Using thoracic ultrasonography to accurately assess pneumothorax progression during positive pressure ventilation: a comparison with CT scanning
Chest
Diseases of the thorax
Vet Clin North Am Equine Pract
Ultrasonographic approach to diagnosing hydropneumothorax
Chest
A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding
Chest
Relevance of lung ultrasound in the diagnosis of acute respiratory failure
Chest
A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill
Chest
Integrating lung ultrasound in the hemodynamic evaluation of acute circulatory failure (the fluid administration limited by lung sonography protocol)
J Crit Care
Low value of routine chest radiographs in a mixed medical-surgical ICU
Chest
The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis
Chest
Influence of positive end-expiratory pressure on left ventricular performance
N Engl J Med
Echocardiography in the intensive care unit: from evolution to revolution?
Intensive Care Med
Diagnostic procedures in respiratory diseases
Intensive use of general ultrasound in the intensive care unit. Prospective study of 150 consecutive patients
Intensive Care Med
Thoracic ultrasound diagnosis of pneumothorax
J Trauma
Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion?
Am J Respir Crit Care Med
Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT—initial experience
Radiology
Transthoracic sonography of diffuse parenchymal lung disease: the role of comet tail artifacts
J Ultrasound Med
Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST)
J Trauma
A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax
Acad Emerg Med
Quantitative assessment of pleural effusion in critically ill patients by means of ultrasonography
Crit Care Med
Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients
Intensive Care Med
Clinical review: bedside lung ultrasound in critical care practice
Crit Care
The ‘double lung point': an ultrasound sign diagnostic of transient tachypnea of the newborn
Neonatology
Early detection of acute lung injury uncoupled to hypoxemia in pigs using ultrasound lung comets
Crit Care Med
Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome
Cardiovasc Ultrasound
Ultrasound lung comets in systemic sclerosis: a chest sonography hallmark of pulmonary interstitial fibrosis
Rheumatology (Oxford)
Whole lung lavage: a unique model for ultrasound assessment of lung aeration changes
Intensive Care Med
Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment
Am J Respir Crit Care Med
Cited by (0)
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.