EMERGENCY ULTRASOUND

Focused Ultrasound for Respiratory

Distress: The BLUE Protocol
Tricia Smith, MD; Todd Taylor, MD; Jehangir Meer, MD

Lung ultrasound using the BLUE protocol provides

critical information within minutes of initial evaluation.

A
cute dyspnea, with or without hypoxia, is a Relevant Findings
common patient presentation in the ED, and can A-line Artifact
be the result of a myriad of mainly cardiac, pul- The A-line seen on lung ultrasound (Figure 1) origi-
monary, and metabolic conditions—many of which are nates from the pleura and can be seen in a normal lung.
life-threatening. Therefore, it is crucial to determine or Multiple A-lines can exist, and will be spaced at regular
narrow the diagnosis promptly and initiate appropriate intervals corresponding to the depth between the chest
treatment. Focused ultrasound of the lungs can provide wall and pleural line. When A-lines are present in a pa-
important information that can change a patient’s clini- tient with respiratory distress, and there is no lung slid-
cal course within minutes of initial evaluation. ing (back and forth horizontal movement at the pleural
line), pneumothorax, extrapulmonary disease, and un-
Background common pulmonary conditions should be considered.
Prior to the 1990s, the lung was considered unsuitable
for evaluation by ultrasound given the scatter of the ul- B-line Artifact
trasound beam that is produced by the presence of aer- B-lines, also referred to as “lung rockets,” are a comet-tail
ated tissue. Lung pathology, however, produces distinct artifact arising from the pleura (Figure 2). In their patho-
artifacts and signs on ultrasound that correspond with logical form, B-lines occur as three or more lines, or are
specific disease patterns. confluent, erase A-lines, and reach a depth of 13 to 15 cm.
The Bedside Lung Ultrasound in Emergencies (BLUE) If lung sliding is also present, B-lines will move with it.
protocol1 was developed by Daniel Lichtenstein, a
French intensivist, and published in 2008. The goal Lung Profiles
of the examination is to improve the speed and preci- A patient can have one of three predominant lung pro-
sion of identifying common causes of acute dyspnea. files: A-profile, B-profile, or AB-profile.
The sensitivity of ultrasound for cardiogenic pulmo- A-profile. A-lines appear bilaterally with lung sliding
nary edema, asthma/chronic obstructive pulmonary in the anterior surface of lungs, suggestive of COPD, or
disease (COPD), and pneumothorax were reported as pulmonary embolism. Exacerbation of congestive heart
exceeding 88%.2 Strictly speaking, the BLUE protocol failure can be ruled out.
includes an evaluation of the deep veins as well to ex- B-profile. The appearance of prominent B-lines bilat-
clude thrombus; however, this article will focus on ul- erally, suggestive of heart failure, essentially rules out
trasound imaging of the lung. COPD, pulmonary embolism, and pneumothorax.

Dr Smith is a senior associate and attending emergency physician, department of emergency medicine, Emory University School of Medicine,
Atlanta, Georgia. Dr Taylor is an assistant professor and assistant residency director, department of emergency medicine, Emory University
School of Medicine, Atlanta, Georgia. Dr Meer is an assistant professor and director of emergency ultrasound, department of emergency medi-
cine, Emory University School of Medicine, Atlanta, Georgia.
Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.
DOI: 10.12788/emed.2018.0077

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 AB-profile. The appearance of predomi- (Figure 1) for lung sliding. This is best
nant B-lines on one lung and predomi- accomplished by setting the depth to no
nant A-lines on the other lung, is consis- more than 5 cm so that the focal zone of
tent with an AB profile. This is usually the ultrasound beam is directed at the
associated with unilateral pneumonia, es- pleural line, and it is centered on the
pecially if seen with other findings such screen. If no sliding is present, it is be-
as subpleural consolidation (Figure 3) cause the visceral and parietal pleura are
and air bronchograms (Figure 4). not apposed to one another. There are
many pathological entities that can cause
Lung Point this finding, but one of the more common
The lung point sign is the only specific is pneumothorax.
finding in the BLUE protocol, and signifies After evaluating the pleural line, the
the limits of a pneumothorax by showing Figure 1. Ultrasound image depth will then need to be switched to 15
the interface between normal lung sliding demonstrating an A-line (rever- cm to evaluate for B-lines. If B-lines are
beration artifact) arising from the
and the edge of the pneumothorax. With- pleural line, equidistant from the present without lung sliding, pneumonia
out a specific search for the lung point, surface of probe to the pleura. should be strongly considered. The ap-
it may not be seen in the anterior assess-
ment of lung sliding, although lung sliding will still be
abolished. On the left side, the heart may cause the ap-
pearance of a false-positive lung point. Normal lung will
show the “seashore sign” (Figure 5) on M-mode.

Imaging Technique
The mid-to-high frequency phased array transducer is
used to examine the anterior and posterolateral chest.
The original BLUE protocol assesses three zones, but
the most relevant information can be obtained from per-
forming the ultrasound in the anterior and posterolat-
eral locations (Figures 6 and 7).
Figure 2. Ultrasound image demonstrating multiple vertical B-lines
Anterior Pleural Assessment originating from the pleural surface. The presence of B-lines bilaterally,
The first step is to evaluate the pleural line anteriorly is highly suggestive of pulmonary edema.

Figure 3. Ultrasound image demonstrating subpleural consolidation Figure 4. Ultrasound image showing hyperechoic linear structures in
or “C-sign” (red arrow) in a patient with pneumonia. The pleural line consolidated lung tissue, representing air bronchograms (red arrows),
can appear irregular or “ratty.” signifying pneumonia.

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 EMERGENCY ULTRASOUND

Figure 5. Ultrasound image demonstrating the “seashore sign.” The

M-mode is applied through the pleural surface and produces a graph Figure 6. Photo demonstrating proper probe position for anterior as-
of motion over time at the bottom of the screen. Notice how the sessment of lung sliding and B-lines.
pattern changes at the middle of the screen, which represents the
appearance of normal lung, where the lower half of the M-mode trac-
ing corresponds with movement of the lung and visceral pleura. This
finding excludes pneumothorax.

Figure 7. Photo demonstrating the proper probe position for postero-

lateral assessment of the lung. The patient should be placed supine Figure 8. Ultrasound image demonstrating posterolateral pleural
for evaluation of pleural effusions. effusion with lower lobe consolidation.

pearance of B-lines with lung sliding signifies alveolar nized approach to this evaluation. Often, the protocol is
interstitial fluid, commonly from pulmonary edema. combined with focused examinations of the heart, inferi-
or vena cava, and/or deep veins to complete the clinical
Posterolateral Assessment picture. It is important to keep in mind that patients may
The posterolateral assessment (Figure 7) evaluates for have two or more pathological conditions (eg, asthma
pleural effusion and consolidation. The dome of the and pneumonia) that can affect the ultrasound findings.
diaphragm is the landmark above which abnormal lung For this reason, ultrasound interpretation should always
and artifacts will be seen. Effusions appear as anechoic occur in the context of the clinical condition. If it does
(black) collections, adjacent to atelectatic lung, from al- not exclude important diagnoses, additional investiga-
veolar consolidation (Figure 8). Pneumonia and parap- tions such as plain radiography, cross-sectional imaging,
neumonic effusion can give this appearance, but other or ventilation/perfusion studies should be pursued.
causes of pleural effusion will have a similar appearance.
References
Summary 1. Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applica-
tions of lung ultrasound in the critically ill. Chest. 2015;147(6):1659-
Lung ultrasound can help narrow the differential diagno- 1670. doi:10.1378/chest.14-1313.
2. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the
sis for acute dyspnea within the first few minutes of the diagnosis of acute respiratory failure: the BLUE protocol. Chest.
patient encounter. The BLUE protocol provides an orga- 2008;134(1):117-125. doi:10.1378/chest.07-2800.

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