Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol.
TL;DR: Lung ultrasound can help the clinician make a rapid diagnosis in patients with acute respiratory failure, thus meeting the priority objective of saving time.
About: This article is published in Chest.The article was published on 2008-07-01 and is currently open access. It has received 1510 citations till now. The article focuses on the topics: Respiratory disease & Lung.
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Gonzaga University1, King Saud University2, Northside Hospital3, Praxis4, Foothills Medical Centre5, Cornell University6, National Research Council7, Harvard University8, University of Pennsylvania9, Icahn School of Medicine at Mount Sinai10, University of Jena11, Pierre-and-Marie-Curie University12, University of California, Davis13, University of South Carolina14
TL;DR: This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound and utilizes the RAND appropriateness method for panel judgment and decisions/consensus.
Abstract: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings. A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus. Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear. This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.
2,073 citations
TL;DR: The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock.
482 citations
TL;DR: Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions, and a holistic discipline for many reasons, which can provide a new definition of priorities.
Abstract: 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 (<3 minutes), which allows diagnosis of acute respiratory failure. It includes a venous analysis done in appropriate cases. Pulmonary edema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax yield specific profiles. Pulmonary edema, e.g., yields anterior lung rockets associated with lung sliding, making the “B-profile.” The FALLS-protocol adapts the BLUE-protocol to acute circulatory failure. It makes sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography (right ventricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical volemia: the apparition of B-lines, schematically, is considered as the endpoint for fluid therapy. Other aims of lung ultrasound are decreasing medical irradiation: the LUCIFLR program (most CTs in ARDS or trauma can be postponed), a use in traumatology, intensive care unit, neonates (the signs are the same than in adults), many disciplines (pulmonology, cardiology…), austere countries, and a help in any procedure (thoracentesis). A 1992, cost-effective gray-scale unit, without Doppler, and a microconvex probe are efficient. Lung ultrasound is a holistic discipline for many reasons (e.g., one probe, perfect for the lung, is able to scan the whole-body). Its integration can provide a new definition of priorities. The BLUE-protocol and FALLS-protocol allow simplification of expert echocardiography, a clear advantage when correct cardiac windows are missing.
482 citations
Cites background from "Relevance of lung ultrasound in the..."
...Hemodynamic edema generates the B-profile in 97% of cases; ARDS generates a profile of pneumonia in 86% of cases [36]....
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...The positive predictive value of abolished lungsliding, only 87% in a general population [30], falls to 56% in the critically ill [35], and to 27% in patients with respiratory failure [36]....
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...Falsepositives and false-negatives are of interest, because ultrasound provided data that questioned a posteriori the value of the “gold standard” [36]....
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TL;DR: Two protocols adapted from lung ultrasound are described: 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.
448 citations
TL;DR: In the unselected general ICU population lung ultrasound has a considerably better diagnostic performance than CXR for the diagnosis of common pathologic conditions and may be used as an alternative to thoracic CT.
Abstract: Purpose
To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard.
367 citations
Cites background or methods or result from "Relevance of lung ultrasound in the..."
...The normal lung generates lung sliding and A-lines (repetition lines parallel to the pleural line) [8, 9]....
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...In our study lung ultrasound had a sensitivity and diagnostic accuracy of 94%, comparable to those reported in patients with ARDS or respiratory failure [8]....
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...The shred sign, specific for consolidation, was not used [8]....
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...This disorder is of prime importance for diagnosing acute respiratory failure [8], acute circulatory failure [14], and control of hemodialysis [19] among others....
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...also contribute to low specificity [8]....
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References
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Book•
01 Jan 1950
TL;DR: In this article, Cardinal Manifestations of Disease Genetics and Disease Clinical Pharmacology Nutrition Infectious Disease Disorders Of The Cardiovascular System Disorders Of the Kidney And Urinary Tract Disorders Of Gastrointestinal System Disorders of The Immune System, Connective Tissue And Joints Hematology And Oncology Endocrinology And Metabolism Neurologic Disorders Environmental And Occupational Hazards.
Abstract: Introduction To Clinical Medicine Cardinal Manifestations Of Disease Genetics And Disease Clinical Pharmacology Nutrition Infectious Disease Disorders Of The Cardiovascular System Disorders Of The Kidney And Urinary Tract Disorders Of The Gastrointestinal System Disorders Of The Immune System, Connective Tissue And Joints Hematology And Oncology Endocrinology And Metabolism Neurologic Disorders Environmental And Occupational Hazards.
12,186 citations
TL;DR: The facts are summarized about CT scans, which involve much higher doses of radiation than plain films, and the implications for public health are summarized.
Abstract: The number of computed tomographic (CT) studies performed is increasing rapidly. Because CT scans involve much higher doses of radiation than plain films, we are seeing a marked increase in radiation exposure in the general population. Epidemiologic studies indicate that the radiation dose from even two or three CT scans results in a detectable increase in the risk of cancer, especially in children. This article summarizes the facts about this form of radiation exposure and the implications for public health.
7,601 citations
"Relevance of lung ultrasound in the..." refers background in this paper
...Clinical implications Using lung ultrasound saves time, decreases the need for CT, whose drawbacks include delayed care implementation, irradiation [32-34], cost (therefore available only in resourcerich countries), the required supine position, etc....
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TL;DR: It is suggested that pediatric CT will result in significantly increased lifetime radiation risk over adult CT, both because of the increased dose per milliampere-second, and the increased lifetime risk per unit dose.
Abstract: OBJECTIVE. In light of the rapidly increasing frequency of pediatric CT examinations, the purpose of our study was to assess the lifetime cancer mortality risks attributable to radiation from pediatric CT.MATERIALS AND METHODS. Organ doses as a function of age-at-diagnosis were estimated for common CT examinations, and estimated attributable lifetime cancer mortality risks (per unit dose) for different organ sites were applied. Standard models that assume a linear extrapolation of risks from intermediate to low doses were applied. On the basis of current standard practice, the same exposures (milliampere-seconds) were assumed, independent of age.RESULTS. The larger doses and increased lifetime radiation risks in children produce a sharp increase, relative to adults, in estimated risk from CT. Estimated lifetime cancer mortality risks attributable to the radiation exposure from a CT in a 1-year-old are 0.18% (abdominal) and 0.07% (head)—an order of magnitude higher than for adults—although those figures st...
3,023 citations
"Relevance of lung ultrasound in the..." refers background in this paper
...Clinical implications Using lung ultrasound saves time, decreases the need for CT, whose drawbacks include delayed care implementation, irradiation [32-34], cost (therefore available only in resourcerich countries), the required supine position, etc....
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TL;DR: The results indicate that in the UK about 0.6% of the cumulative risk of cancer to age 75 years could be attributable to diagnostic X-rays, equivalent to about 700 cases of cancer per year.
1,623 citations
TL;DR: Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact.
Abstract: Can ultrasound be of any help in the diagnosis of alveolar-interstitial syndrome? In a prospective study, we examined 250 consecutive patients in a medical intensive care unit: 121 patients with radiologic alveolar-interstitial syndrome (disseminated to the whole lung, n = 92; localized, n = 29) and 129 patients without radiologic evidence of alveolar-interstitial syndrome. The antero-lateral chest wall was examined using ultrasound. The ultrasonic feature of multiple comet-tail artifacts fanning out from the lung surface was investigated. This pattern was present all over the lung surface in 86 of 92 patients with diffuse alveolar-interstitial syndrome (sensitivity of 93.4%). It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specificity of 93.0%). Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact. In conclusion, presence of the comet-tail artifact allowed diagnosis of alveolar-interstitial syndrome.
947 citations
"Relevance of lung ultrasound in the..." refers background in this paper
...B+ lines indicate the subpleural part of interstitial syndrome [16]....
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...Most acute disorders reach it: acute interstitial changes involve deep as well as subpleural areas [16, 24]; most (98....
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