applied

sciences
Review
Lung Ultrasound Imaging, a Technical Review
Libertario Demi 1, * , Thomas Egan 2 and Marie Muller 3
1 Department of Information Engineering and Computer Science, University of Trento, 38123 Trento, Italy
2 Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina at Chapel Hill,
Chapel Hill, NC 3290, USA; Thomas_egan@email.unc.edu
3 Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC 3290,
USA; mmuller2@ncsu.edu
* Correspondence: libertario.demi@unitn.it




Received: 30 November 2019; Accepted: 2 January 2020; Published: 8 January 2020


Abstract: Lung ultrasound (LUS) is a growing and fascinating field of application for ultrasound
imaging. Despite the difficulties in imaging an organ largely filled with air, the potential benefits
originating from an effective ultrasound method focusing on monitoring and diagnosing lung diseases
represent a tremendous stimulus for research in this direction. This paper presents a technical review
where, after a brief historical overview, the current limitations of LUS imaging are discussed together
with a description of the physical phenomena at stake. Next, the paper focuses on the latest technical
developments of LUS.

Keywords: lung ultrasound; A-line; B-line; ultrasound imaging; quantitative ultrasound;

wave propagation

1. Introduction
Lung diseases are among the most common pathological conditions worldwide. As an example,
interstitial lung diseases (ILDs) group over 200 diseases including pneumonia, tuberculosis, and
pulmonary fibrosis. Pneumonia alone is the first cause of death in children under five years of
age worldwide, with 808,694 deaths in 2017 (15% of all deaths of children under five) [1]. Chronic
obstructive pulmonary disease (COPD), classified by WHO as an under-diagnosed life-threatening lung
disease, and lower respiratory infections are the third and fourth leading causes of death, respectively,
and are together responsible for six million deaths each year [2]. Idiopathic pulmonary fibrosis (IPF) is
a major public health problem, with 50,000 new cases diagnosed each year [3]. Although it is not a
lung pathology per se, because it often originates from congestive heart failure, pulmonary edema is
also a major health issue, affecting over six million in the U.S. [4], resulting in affected lung compliance
and dyspnea. Accurate diagnosis and monitoring of lung diseases are concerns of global scale. For
some pathologies, the standard imaging techniques used to diagnose and monitor lung pathologies
are chest x-ray and computed tomography (CT). Unfortunately, these modalities are based on ionizing
radiation, representing a hazard to patient’s health in case of high dose or frequent exposure, especially
in the context of frequent monitoring [5–9]. Amongst the risks, the United States Food and Drug
Administration reports an increase in the possibility to develop cancer later in life. This represents a
serious concern for children and adolescents, who are significantly more sensitive to radiation exposure
than adults [10]. Moreover, CT is expensive, often inaccessible, and bedside-unavailable. Some of the
diseases, such as pulmonary edema can’t even be monitored using CT and are currently monitored by
invasive intracardiac hemodynamics and devices, biomarker measurements or chest X-Rays [11].
Ultrasound technologies can potentially overcome the limitations of current monitoring techniques
offering a safer, portable, and cost-effective alternative. Firstly, being a radiation-free modality,
ultrasound is a diagnostic option especially relevant to children, pregnant women and patients

Appl. Sci. 2020, 10, 462; doi:10.3390/app10020462 www.mdpi.com/journal/applsci

 Appl. Sci. 2020, 10, 462 2 of 12

Appl. Sci. 2020, 10, 462 2 of 12

modality, ultrasound is a diagnostic option especially relevant to children, pregnant women and
patients subjected to repeated investigations. Secondly, ultrasound devices are easily transportable
to patient’s
subjected site, including
to repeated in remote Secondly,
investigations. and rural ultrasound
areas, and developing
devices are countries. Thirdly, devices
easily transportable and
to patient’s
examinations are significantly cheaper as compared to CT or MRI, making ultrasound
site, including in remote and rural areas, and developing countries. Thirdly, devices and examinations techniques
accessible
are to a much
significantly broader
cheaper range of facilities,
as compared to CT orthus reaching
MRI, makingmore patients.techniques
ultrasound This makesaccessible
ultrasoundto
especially relevant for sustainable healthcare issues related to aging-society
a much broader range of facilities, thus reaching more patients. This makes ultrasound especiallyand increased chronic
diseases.
relevant for sustainable healthcare issues related to aging-society and increased chronic diseases.
Thecapability
The capability of of ultrasound
ultrasound imaging
imaging to to provide
provide access
access to
to relevant
relevant diagnostic
diagnostic information
informationon on
pulmonary-tissue has been suggested since the 1990s [12–15]. For example, sonographicinterstitial
pulmonary-tissue has been suggested since the 1990s [12–15]. For example, sonographic interstitial
syndrome is a recognizable pattern observable from lung ultrasound-investigation and characterized
syndrome is a recognizable pattern observable from lung ultrasound-investigation and characterized by
by the appearance of several acoustic artifacts known as “comet-tails” or “B-lines” [14–17]. A
the appearance of several acoustic artifacts known as “comet-tails” or “B-lines” [14–17]. A correlation
correlation exists between these artifacts and the increase in extravascular lung water [17], ILDs [18–
exists between these artifacts and the increase in extravascular lung water [17], ILDs [18–20], cardiogenic
20], cardiogenic and non-cardiogenic lung edema [21], interstitial pneumonia [22,23], and lung
and non-cardiogenic lung edema [21], interstitial pneumonia [22,23], and lung contusion [24].
contusion [24].
Moreover, a clearly detectable difference exists between the aforementioned artifacts and the
Moreover, a clearly detectable difference exists between the aforementioned artifacts and the
artefactual pattern generally observable with ultrasound imaging when inspecting a healthy lung.
artefactual pattern generally observable with ultrasound imaging when inspecting a healthy lung.
Figure 1 shows an example of lung ultrasound images with B-lines (vertical artifacts), as obtained
Figure 1 shows an example of lung ultrasound images with B-lines (vertical artifacts), as obtained
with a linear and a convex probe. An example of A-line artifact (horizontal artifacts) is also shown.
with a linear and a convex probe. An example of A-line artifact (horizontal artifacts) is also shown.
B-lines are clinically defined as hyper-echoic vertical artifacts that originate from a point along the
B-lines are clinically defined as hyper-echoic vertical artifacts that originate from a point along the
pleura-line and lie perpendicular to the latter, and are thought to originate from a reduction of the lung
pleura-line and lie perpendicular to the latter, and are thought to originate from a reduction of the
volume originally occupied by air in favor of liquid or tissue. This reduction locally diminishes the
lung volume originally occupied by air in favor of liquid or tissue. This reduction locally diminishes
acoustic impedance mismatch between the intercostal tissues and the lung. Resulting open channels
the acoustic impedance mismatch between the intercostal tissues and the lung. Resulting open
accessible to ultrasound
channels accessible waves ultimately
to ultrasound generate these
waves ultimately patterns.
generate these Differently, A-lines areA-lines
patterns. Differently, visualized
are
invisualized
those conditions where the lung surface behaves essentially as a perfect reflector
in those conditions where the lung surface behaves essentially as a perfect reflector to to ultrasound,
impeding propagation
ultrasound, impeding beyond the pleura
propagation beyond line.
theA-lines
pleuraare due
line. to theare
A-lines multiple-reflections of ultrasound
due to the multiple-reflections
waves that occur between the probe and the lung surface and can be described
of ultrasound waves that occur between the probe and the lung surface and can be described as multiple equidistantas
hyper-echoic horizontal lines which are generally visualized across the entire
multiple equidistant hyper-echoic horizontal lines which are generally visualized across the entireimage and that are
parallel to the
image and pleura
that line. The
are parallel to pleural-line (indicated
the pleura line. by arrows(indicated
The pleural-line in Figure 1)
bycan be defined
arrows as the
in Figure line
1) can
that separates the intercostal tissue and the lung in the image.
be defined as the line that separates the intercostal tissue and the lung in the image.

Figure1.1.B-line
Figure B-line artifacts
artifacts as
as observable with a linear (left)
(left) and
and convex
convex(center)
(center)probe
probeandandA-line
A-lineartifact
artifact
asasobservable
observablewith
withaalinear
linearprobe
probe(right).
(right). The pleura line is also indicated
indicated for
for the
the three
three images.
images.

The possibility to discriminate between a diseased and a healthy lung boosted the clinical interest
in lung ultrasonography (LUS) [13–33]. However, these diagnoses are based on imaging-artifacts, rely
Appl. Sci. 2020, 10, 462 3 of 12

on the qualitative and subjective interpretation by the clinicians [34–37], and are performed using
equipment and modalities inadequate to investigate the lung [36,37].
Indeed, standard ultrasound imaging is designed assuming a high-similarity between the acoustic
properties (e.g., speed of sound) of soft-tissues, which is primarily due to their high water content [38].
This allows sufficient contrast for imaging and at the same time does not impede transmission through
the different tissues, and hence propagation up to the required depths. Moreover, thanks to moderate
variations in speed of sound throughout soft-tissues [39,40], the position and shape of different objects
in the field-of-view can be estimated with sufficient accuracy.
The aforementioned conditions are definitely not applicable to the lungs, which are air-filled
organs, and being air, a medium presenting significant differences in acoustic properties compared
to liquids and soft-tissues [38,41]. This implies that the straightforward application of standard
ultrasound imaging to the inspection of the lung will obviously result in images that do not represent
the actual anatomic structure but can only spot deviations from a healthy condition by displaying
artifacts such as the aforementioned B-lines. The genesis of B-lines and their relationship with the
alterations of the lung still remain an open question.
In addition to medical/clinical-studies, several technical-studies have been performed since the
600 s attempting lung characterization (on restricted frequency ranges) based on standard soft-tissue
acoustic properties, i.e., speed of sound and attenuation [38–43]. This type of characterization is
however insufficient, and certainly not specific, for the accurate diagnosis of lung diseases. Once again,
treating the lung as a conventional soft tissue does not provide optimal results. Instead, dedicated
transmission schemes and signal processing algorithms should be designed and implemented in order
to take into account the specific properties of the lung. In the next two sections, two approaches
attempting to go exactly in this direction are presented and discussed.

2. Ultrasound Spectroscopy
The main hypothesis behind the genesis of B-lines, is that they represent how ultrasound scanners
visualize the signals originating from the multiple reflections experienced by ultrasound waves when
trapped within channels that can form between the lung air spaces in the presence of a pathological
condition [31,36]. In fact, in presence of many alterations of the lung structure, such as edema, fibrosis,
contusions, the volume originally occupied by air can be replaced by fluids, blood or tissue. These
alterations locally reduce the mismatch in acoustical properties with respect to the intercostal-tissue,
and open channels for ultrasound to propagate. Most importantly, the dimensions and shapes of
these channels regulate the spatial distribution and dimensions of the remaining air-spaces and vary
depending on the severity and type of disease. In this context, the periodicity of the reflections, and
hence the frequency content associated to the B-lines, could thus be explored as a way to quantitatively
characterize the channels. This characterization can then be utilized to indirectly assess and grade the
condition of the lung.
Preliminary results obtained on lung mimicking phantoms already proved the possibility to
characterize bubbly structures by analyzing the B-line “native-frequency” [44]. In this study, different
lung-phantoms designed to mimic different pathological conditions where scanned using standard
ultrasound imaging and a dedicated multi-frequency imaging scheme. In particular, two types of
phantoms where fabricated using two distinct mono-disperse microbubble populations. The first
phantom type was made with microbubbles with a diameter equal to 170 µm, the second with
microbubbles with a diameter equal to 80 µm. This allowed for the analysis of B-lines in a controlled
environment where the alveolar size reduction, which is typical of various lung pathologies, was
mimicked. In fact, the typical alveolar diameter in a healthy lung is around 280 µm [45]. In total,
ten phantoms were fabricated, five for each type. These phantoms were scanned using the ULA-Op
research platform in combination with a LA332 (ESAOTE, Flore, Italy) Linear Array probe. Two
different imaging modalities have been tested. First, standard ultrasound imaging at 4.5 MHz. Second,
a multi-frequency imaging method was implemented and tested. In this case, images were sequentially
Appl. Sci. 2020, 10, 462 4 of 12
Appl. Sci. 2020, 10, 462 4 of 12

generated using
sequentially orthogonal
generated using sub-bands
orthogonal centered
sub-bandsat different
centered center frequencies,
at different i.e.,frequencies,
center at 3, 4, 5, andi.e.,6 MHz.
at 3,
The
4, driving
5, and 6 MHz. signals
The were
driving designed such designed
signals were that frequency-orthogonality, at −10 dB, was
such that frequency-orthogonality, guaranteed.
at −10 dB, was
At the same At
guaranteed. timethethe same
same bandwidth
time the sameexcited
bandwidth by theexcited
4.5 MHz by pulse
the 4.5was MHz(globally)
pulse was covered. The
(globally)
analysis of
covered. Thethese data revealed
analysis that B-lines
of these data revealed were
thatonly visible
B-lines were ononly
phantom-type 2 (smaller bubbles)
visible on phantom-type when
2 (smaller
standardwhen
bubbles) ultrasound
standard imaging was used.
ultrasound imagingThiswassuggests
used. aThisrelation between
suggests bubble
a relation size (the
between air-space
bubble size
size)air-space
(the reductionsize) andreduction
increasedand artifact formation.
increased artifactThis observation
formation. is in line with
This observation is inthelinecorrelation
with the
between B-lines
correlation and aB-lines
between pathological
and acondition of thecondition
pathological lung. Moreover,
of the thislung.result also indicates
Moreover, this resultthat, with
also
standard ultrasound
indicates imaging, ultrasound
that, with standard B-lines mayimaging,
be visualizedB-linesonlymay at an
be advanced
visualizedstageonly of atthean pathology,
advanced
since phantom-type
stage of the pathology, 2 wassincemade with microbubbles
phantom-type 2 was made withwitha dimeter much smaller
microbubbles with athan the typical
dimeter much
diameters
smaller thanobserved in a healthy
the typical lung.observed
diameters On the contrary, when lung.
in a healthy the multi-frequency
On the contrary, imaging
whenmethod was
the multi-
used, moreimaging
frequency B-lines were
method visible
was (15
used,vs.more
7). InB-lines
particular,
wereB-lines
visiblewere
(15 vs. also
7).visible for phantom-type
In particular, B-lines were 2.
Additionally,
also visible for thephantom-type
multi-frequency 2. imaging method
Additionally, theallowed to observe that
multi-frequency the B-lines
imaging method obtained
allowed fromto
phantom-type
observe that the2 B-lines
were generated
obtained at higher
from frequencies2(4were
phantom-type to 6 generated
MHz) as compared to those emerging
at higher frequencies (4 to 6
from phantom-type
MHz) as compared to 1 (3 to 5emerging
those MHz). This fromimplies that the native
phantom-type 1 (3 tofrequency
5 MHz). This of the B-lines
implies thatmaythebenative
used
to quantitatively
frequency evaluate
of the B-lines may thebestate
usedof tothe lung surface.
quantitatively Figurethe
evaluate 2 shows
state ofmicroscope
the lung surface. images of the
Figure 2
generated
shows microbubbles
microscope images usedof to fabricate
the generated the phantoms,
microbubbles together
used with a schema
to fabricate theand a picture of
phantoms, a lung
together
with
phantom.a schema and aimages
Ultrasound picture of a lung
generated withphantom.
standard Ultrasound images generated
ultrasound imaging, as obtainedwith with standard
phantom
ultrasound
type 1 and 2, imaging,
are alsoas obtained
shown with with
together phantom type 1 of
the results and
the2,frequency
are also shown together
analysis withasthe
of B-lines results
obtained
of thethe
with frequency analysis imaging
multi-frequency of B-linesmethod.
as obtained
Thiswithgraph the multi-frequency
indicates the frequencyimaging method.
for which theThis graph
maximum
indicates the frequency
of the received for which
power spectrum was the maximum
found, while of the received
spanning power spectrum
the frequency range from was 3 tofound,
6 MHz. whileAs
spanning the frequency
it can be observed, range from
this parameter 3 to 6toMHz.
allowed As it can
distinguish be observed,
between these twothis parameter
phantom types. allowed
This wasto
distinguish
the first study between these two how
demonstrating phantom types. frequency
the native This was the of first study
B-lines demonstrating
could be applied to how the native
characterize
frequency of B-lines
bubbly structures. In could be applied
principle, to characterize
this concept bubbly applied
could be clinically structures. In principle, this
to quantitatively concept
evaluate the
could
state of bethe
clinically appliedand
lung surface, to quantitatively
indirectly grade evaluate
the lungthe condition.
state of the Interestingly,
lung surface, and other indirectly grade
recent studies
the lungproved
already condition. Interestingly,
that B-lines otherdepends
visualization recent studies
(also on already proved
clinical data) thattransmitted
on the B-lines visualization
ultrasound
depends
frequencies (alsoandonintroduced
clinical data) someon basic
the transmitted
models thatultrasound
can be applied frequencies
to betterand introduced
understand thesome basic
formation
models
of thesethat can be
artifacts applied to better understand the formation of these artifacts [46].
[46].

Figure 2. Microscope
Microscopeimages
imagesof
ofthe
thegenerated
generatedmicrobubbles,
microbubbles,together
togetherwith
witha aphantom
phantomschema
schema and a
and
picture
a pictureofofa alung
lungmimicking
mimickingphantom
phantom(on
(on the
the left).
left). Ultrasound
Ultrasound images
images generated
generated with
with standard
together with
ultrasound imaging, as obtained with phantom type 1 and 2, together with the
the results
results of
of the
the frequency
frequency
analysis of B-lines as obtained with the multi-frequency imaging method.
Appl. Sci. 2020, 10, 462 5 of 12
Appl. Sci. 2020, 10, 462 5 of 12

As an example,
example,Figure
Figure33shows
showsultrasound
ultrasoundimages asas
images obtained with
obtained a clinical
with scanner.
a clinical During
scanner. the
During
investigation, the imaging frequency was varied from 3 MHz to 6 MHz. As it can be seen, B-lines
the investigation, the imaging frequency was varied from 3 MHz to 6 MHz. As it can be seen, B-lines were
visualized only at
were visualized 6 MHz.
only at 6 MHz.

Figure 3. Ultrasound
Ultrasound images
images obtained
obtained during patients investigation using a clinical
clinical scanner.
scanner. The
imaging frequency was varied from 3 MHz (left) to
to 66 MHz
MHz (right).
(right).

These results show that, with the currently available hardware, a frequency characterization of
these vertical artifacts is possible. The question is, what can this characterization provide us with, in
terms of the capability to grade and distinguish between lung pathologies? pathologies?
important aspect
Another important aspect concerns
concerns the possibility
possibility to implement,
implement, in real-time, a system able to
detect and
and localize
localizethese
theseartifacts.
artifacts.This
This could
could aidaid
thethe clinician
clinician in thein visualization
the visualization of B-lines,
of B-lines, and
and most
most importantly,
importantly, wouldwould be extremely
be extremely helpful
helpful in order
in order to limit
to limit the computational
the computational loadload needed
needed for
for the
the additional signal processing operations required for the characterization of
additional signal processing operations required for the characterization of the B-lines. Recent work the B-lines. Recent
work has shown
has shown how ahow a simple
simple convolution
convolution neuralneural network
network can be can be trained
trained for purpose
for this this purpose [47].[47]. In
In this
this work,
work, B-line
B-line detection
detection and localization
and localization was performed
was performed in a weakly-supervised
in a weakly-supervised fashion fashion
throughthrough
class
class activation mapping. The method was applied both on phantom and
activation mapping. The method was applied both on phantom and patient data. Moreover, images patient data. Moreover,
images acquired
acquired with bothwith both research
research ultrasound
ultrasound platforms
platforms and standard
and standard clinicalclinical ultrasound
ultrasound scanners
scanners have
have used.
been been used. An accuracy,
An accuracy, sensitivity,
sensitivity, specificity,
specificity, negative
negative and positive
and positive predictive
predictive value value
equal toequal to
0.917,
0.917, 0.915, 0.918, 0.950, and 0.864 were achieved in-vitro, respectively. In-vivo, these
0.915, 0.918, 0.950, and 0.864 were achieved in-vitro, respectively. In-vivo, these statistics were 0.892, statistics were
0.892, 0.930,
0.871, 0.871, 0.798,
0.930, and
0.798, and 0.958,
0.958, respectively.
respectively. Most importantly
Most importantly the proposed
the proposed method method
allowed allowed
B-line
detection in real-time, reaching an inference rate of 276 frames/second when exploiting GPU
B-line detection in real-time, reaching an inference rate of 276 frames/second when exploiting
acceleration (Titan Xp, NVIDIA). Figure 4 shows, as an example, example, two ultrasound images obtained
examinations, together
during patient examinations, together with
with the
the results
results obtained
obtained with with the
the method
method described
described above.
above.
The heat map overlaid to the ultrasound image indicated indicated thethe estimated
estimated location
location of of the
the B-line
B-line artifact.
artifact.
Results are shown from the data generated with an open research platform, as well as from a clinical
ultrasound scanner.
Appl. Sci. 2020, 10, 462 6 of 12

Appl. Sci. 2020, 10, 462 6 of 12

Appl. Sci. 2020, 10, 462 6 of 12

Figure 4. Ultrasound images obtained during patients investigation using an open research platform
(on the
Figure 4.left)
Figure 4.and
Ultrasound clinical
Ultrasound scanner
images
images (on the
obtained
obtained right).
during
during The result
patients
patients in terms
investigation
investigation of detection
using an an
using open and localization
research
open platform
research as
platform
(on
obtained
(on the left)
by and
the left) and clinical
the computer scanner (on
aided system
clinical scanner the right).
(on theinright). The
also shown.result in terms of detection and localization as
The result in terms of detection and localization as
obtained
obtained by computer
by the the computer aided
aided systemininalso
system alsoshown.
shown.
3. Ultrasound Multiple-Scattering Characterization
3. Ultrasound
3. Ultrasound Multiple-ScatteringCharacterization
Multiple-Scattering Characterization
As discussed in the introduction, one of the main obstacles to conventional B-mode lung imaging
As discussed in the introduction,one oneof ofthe
the main obstacles
obstaclesto conventional B-mode lung imaging
is theAs discussed
multiple in the
scattering introduction,
of ultrasound waves bymain
the millions oftoair-filled
conventional alveoliB-mode
in the lung imaging
parenchyma.
is the multiple scattering of ultrasound waves by the millions of air-filled alveoli in the parenchyma.
is the leads
This multiple to scattering
more of ultrasound wavespaths
complex by theand millions of air-filled alveoli in the parenchyma.
This leads to more complexpropagation
propagation paths and impairs
impairs thethelinear
linear relationship
relationship between between
This leads
propagation to more complex
timetime
andand propagation
propagation paths and impairs the linear relationship between propagation
propagation propagationdistance,
distance, whichwhich is isthe
thebasis
basisofof conventional
conventional ultrasound
ultrasound imaging.imaging.
time and
However, propagation
However, when when andistance,
an ultrasound
ultrasound which
wave ispropagates
the basis of
wavepropagates inconventional
in aacomplex
complexmedium ultrasound
medium suchsuchas imaging.
as the
the lunglung However,
parenchyma,
parenchyma, when
an ultrasound
each each
scattering wave
scatteringevent propagates
eventis also the
is also the in a complex
opportunity
opportunity for medium
the wave
for the such as
wavetotoaccumulatethe lung
accumulate parenchyma,
quantitative
quantitative each scattering
information
information on on
event is also
the
the microstructurethe opportunity
microstructure of the
of the for theIn
medium.
medium. wave
Inaahighlyto accumulate
highly scattering quantitative
scattering medium
medium such
such information
as as
thethe on theultrasound
parenchyma,
parenchyma, microstructure
ultrasound
of thewaves
waves medium.diffuse
diffuse In rather
a highly
rather thanthanscattering
propagate.
propagate. medium such as
ItItisispossible
possible to the
takeparenchyma,
totake advantage
advantage of ofultrasound
this. In fact,
this. waves
by
In fact, diffuse rather
quantitatively
by quantitatively
than characterizing
propagate. Itthe
is properties
possible to of the
take diffusive
advantage phenomenon,
of this. In it is
fact,
characterizing the properties of the diffusive phenomenon, it is possible to extract properties possible
by to extract
quantitatively properties of theof the
characterizing the
scatterers
properties of (the
the air-filledphenomenon,
diffusive alveoli) and their it is spatial
possibledistribution,
to extract which
properties can be of diagnostically
the scatterers relevant.
(the air-filled
scatterers (the air-filled alveoli) and their spatial distribution, which can be diagnostically relevant.
As an
alveoli) andexample,
their diseases
spatial such as pulmonary
distribution, whichedema edema
can beand pulmonary fibrosis
diagnostically willAsincrease the distance
As an example, diseases such as pulmonary and pulmonaryrelevant. fibrosis will an example,
increase the diseases
distance
between healthy air-filled alveoli on average, by increasing the volume of fluid buildup or fibrotic
such
betweenas pulmonary
healthy edema and
air-fillededema, pulmonary
alveolithe onincrease
average, fibrosis will increase the distance between healthy air-filled
tissue. In pulmonary in by increasing
interstitial fluidthe volume
leads to anofincrease
fluid buildup
in the size or fibrotic
of
alveoli
tissue. on
In average,
pulmonary by increasing
edema, the theincrease
volume in of interstitial
fluid buildup fluidor fibrotic
leads totissue.
an In pulmonary
increase in the edema,
size of
interstitial spaces. In pulmonary fibrosis, the interstitium will contain increased amounts of collagen
the increase
interstitial in interstitial
spaces. In pulmonary
and inflammatory fluid leads to
fibrosis,
cells. If air-filled alveoli an increase
theare in
interstitium the
scatterers towill size of
the contain interstitial
ultrasound increased spaces.
wave, bothamounts In pulmonary
diseasesof will
collagen
fibrosis, the interstitium
and inflammatory
effectively cells.
increase will
the contain
Ifmean
air-filled increased
distancealveoli
between areamounts
scatterers
scatterers, of thereby
collagen and inflammatory
to the ultrasound
affecting the wave,
diffusion cells.
both Ifwave
air-filled
diseases
of the will
alveoliin are
effectively scatterers
the parenchyma
increase the to(Figure
the
mean ultrasound
5). wave, both
distance between diseasesthereby
scatterers, will effectively
affecting increase the mean
the diffusion of thedistance
wave
between scatterers, (Figure
in the parenchyma thereby 5). affecting the diffusion of the wave in the parenchyma (Figure 5).

Figure 5. Blue = air-filled alveoli. (Top): ultrasound wave into normal lung experiences multiple
scatters. Diffusion will be slow (Middle): Fibrotic lungs have smaller alveoli, thicker alveolar walls,
and
Figure 5.more = air-filled
Bluetissue betweenalveoli.
alveoli, so diffusion
(Top): will be faster.
ultrasound wave (Bottom): Edematous
into normal lung lung. Some alveoli
experiences multiple
Figure 5. Blue = air-filled alveoli. (Top): ultrasound wave into normal lung experiences multiple
may be fluid filled (white) which will further increase the distance between scatterers.
scatters. Diffusion will be slow (Middle): Fibrotic lungs have smaller alveoli, thicker alveolar walls,
scatters. Diffusion will be slow (Middle): Fibrotic lungs have smaller alveoli, thicker alveolar walls,
and more tissue between alveoli, so diffusion will be faster. (Bottom): Edematous lung. Some alveoli
and more tissue between alveoli, so diffusion will be faster. (Bottom): Edematous lung. Some alveoli
may be fluid filled (white) which will further increase the distance between scatterers.
may be fluid filled (white) which will further increase the distance between scatterers.
Appl. Sci. 2020, 10, 462 7 of 12

Appl. Sci. 2020, 10, 462 7 of 12

In a diffusive medium, the diffusion constant (D) measures the rate of growth of the diffusive halo.
In a diffusive
If the scatterer encountersmedium, the (diseased
are rare diffusion constant (D)density
lung, low measuresofthe rate ofair-filled
healthy growth ofalveoli),
the diffusive
the wave
halo. If the scatterer encounters are rare (diseased lung, low density of healthy air-filled alveoli), the
will diffuse rapidly in the parenchyma, propagating straight in between the rare scattering events,
wave will diffuse rapidly in the parenchyma, propagating straight in between the rare scattering
leading to large values of D. In a healthy parenchyma on the contrary, scattering events will occur
events, leading to large values of D. In a healthy parenchyma on the contrary, scattering events will
more occur
often.more
The rate
often.atThe
which
ratethe wave will
at which makewill
the wave progress
make will be lower,
progress leading
will be lower, to lowertovalues
leading lower of D,
by definition
values ofofD,the diffusion of
by definition constant (Figure
the diffusion 6). (Figure 6).
constant

Figure
Figure 6. (Left):
6. (Left): TwoTwo heterogeneous
heterogeneous mediawith
media with different
different scattering
scatteringproperties
properties(top: weakly
(top: scattering
weakly scattering
medium,
medium, bottom:
bottom: highly
highly scatteringmedium).
scattering medium). (Center)
(Center) and
and(right):
(right):propagation
propagation of aofplane in these
a plane in these
two media
two media at two
at two differenttimes.
different times. In
Inthe
themedium
medium with a lower
with scatterer
a lower density,density,
scatterer the wavethemakes
waverapid
makes
progress (top). In the medium with a dense scatterer distribution (bottom), the wave makes slower
rapid progress (top). In the medium with a dense scatterer distribution (bottom), the wave makes
progress.
slower progress.
This new paradigm can be exploited for the quantitative characterization of the lung
This new paradigm can be exploited for the quantitative characterization of the lung parenchyma.
parenchyma. To do so, D can be estimated using a conventional ultrasound probe, as follows.
To do so, D can be estimated using a conventional ultrasound probe, as follows.
3.1. Measurement of the Diffusion Constant Using a Conventional Ultrasound Probe
3.1. Measurement of the Diffusion Constant Using a Conventional Ultrasound Probe
The diffusion constant can be measured using a conventional ultrasound probe connected to a
The diffusion
multiple channelconstant
ultrasoundcanscanner,
be measured using a conventional
in an unconventional way. As an ultrasound
example, inprobe connected
a recent study, a to a
multiple
openchannel
researchultrasound scanner,
platform, i.e., in an
Verasonics unconventional
Vantage way. Kirkland,
128 (Verasonics, As an example,
WA, USA), in awas
recent
usedstudy,
to a
open test
research
these platform, i.e., No
concepts [48]. Verasonics
beamforming Vantagewas128 (Verasonics,
performed. Kirkland,
Instead, the 128 WA, USA),
elements wasused
were usedoneto test
these by one to transmit
concepts [48]. No2 beamforming
cycle Gaussian was pulses (centered at
performed. 5 MHz or
Instead, theat128
7.8 elements
MHz). Forwere
each transmit,
used onethe by one
signals backscattered from the lung parenchyma were collected
to transmit 2 cycle Gaussian pulses (centered at 5 MHz or at 7.8 MHz). For each transmit, on the whole array. With
the128
signals
elements on
backscattered thethe
from array,
lungthisparenchyma
led to the acquisition of a 128X128XN
were collected inter-element
on the whole array. response
With 128matrix (IRM),
elements on the
N being the number of time points. The IRM matrix is symmetric due to reciprocity. The
array, this led to the acquisition of a 128X128XN inter-element response matrix (IRM), N being the
antisymmetric of the IRM was calculated and both the IRM and the anti-symmetric IRM were split
number of time points. The IRM matrix is symmetric due to reciprocity. The antisymmetric of the
into overlapping time windows. This allowed to extract only the incoherent part of the backscattered
IRM was calculated
intensity. Detailsand
of theboth the IRM
method and the in
are described anti-symmetric IRM
[48]. In a diffusive were split
medium, into overlapping
the spatial spread of the time
windows.
incoherent intensity grows over time, and this rate of growth is determined by the diffusionDetails
This allowed to extract only the incoherent part of the backscattered intensity. constantof the
method are described in [48]. In a
D according to the following equation: diffusive medium, the spatial spread of the incoherent intensity
grows over time, and this rate of growth is determined by the diffusion 𝒓𝟐
constant D according to the
𝑰𝒊𝒏𝒄𝒐𝒉𝒆𝒓𝒆𝒏𝒕 𝒓, 𝑻 = 𝑰 𝑻 × 𝒆𝒙𝒑 − , (1)
following equation: 𝟒𝑫𝑻
2
!
r, being the emitter-receiver distance and r
Iincoherent (r,TTthe
) =time
I (Twindow.
) × exp −To calculate
, D, the incoherent intensity (1)
for each time window was fitted with a Gaussian curve. The width 4DT(variance) of this Gaussian, when
plotted against time, gives a linear trend, whose slope is equal to 2D.
r, being the emitter-receiver distance and T the time window. To calculate D, the incoherent intensity
for each time window was fitted with a Gaussian curve. The width (variance) of this Gaussian, when
plotted against time, gives a linear trend, whose slope is equal to 2D.
Appl. Sci. 2020, 10, 462 8 of 12
Appl. Sci. 2020, 10, 462 8 of 12
Appl. Sci. 2020, 10, 462 8 of 12

3.2.Model
3.2. Modelof of Pulmonary
Pulmonary Edema
Edema ExEx Vivo
Vivo
3.2. Model of Pulmonary Edema Ex Vivo
An An ex-vivo
ex-vivo study
study waswas then
then performed
performed inin lungs
lungs from
from anan anesthetized
anesthetized Sprague-Dawley
Sprague-Dawley rat.
rat. After
After
An ex-vivo study was then performed in lungs from an anesthetized Sprague-Dawley rat. After
tracheotomy
tracheotomy and and heparinization,
and heparinization,
heparinization, lungs lungs were
lungs were flushed
were flushed
flushed with with cold
with cold Perfadex™
cold Perfadex™
Perfadex™ and and stored
and stored
stored cold cold overnight.
coldovernight.
overnight.
tracheotomy
A A stopcock was attached to the tracheotomy tube and connected to a 5 mL syringe, to allow control
A stopcock
stopcock waswas attached
attached to to the
the tracheotomy
tracheotomy tube tube and
and connected
connected toto aa 55 mL
mL syringe,
syringe, to to allow
allow control
control
over
over the the air volume fraction. Lungs were fully inflated. D evaluation was performed as described
over the air
air volume
volume fraction. Lungs were
fraction. Lungs were fully
fully inflated. D evaluation
inflated. D evaluation waswas performed
performed as as described
described
above,
above, with
with coupling
coupling gel
gel directly
directly onto
onto the
the lung
lung surface.
surface. After
After removing
removing 1 1 mL
mL of of air,
air, PBSPBS was
was injected
injected
above, with coupling gel directly onto the lung surface. After removing 1 mL of air, PBS was injected
into
into the
the airway
airway in in 1 mL increments. For each PBS volume fraction, D was calculated (Figure 7). This
into the airway in 11 mL
mL increments.
increments. For For each
each PBS
PBS volume
volume fraction,
fraction, D
D was
was calculated
calculated (Figure
(Figure 7). This
7). This
was
was the first demonstration that ultrasound could quantify changes in lung water [48].
was the
the first
first demonstration
demonstration that that ultrasound
ultrasound could
could quantify
quantify changes
changes inin lung
lung water
water [48].
[48].

Figure
Figure 7. 7.
DD increases
increases when
when PBS
PBS is instilled
is instilled into
into thethe lung,
lung, simulating
simulating edema
edema ex-vivo.
ex-vivo. Three
Three readings
readings
Figure 7. D increases when PBS is instilled into the lung, simulating edema ex-vivo. Three readings
were
were taken
taken forfor each
each measurement.
measurement. TheThe variability
variability is demonstrated
is demonstrated bybythethe error
error bars.
bars. mean
mean DD ± SEM.
± SEM.
were taken for each measurement. The variability is demonstrated by the error bars. mean D ± SEM.
3.3.
3.3.Model
Model of of
Pulmonary
Pulmonary Edema
Edema In-Vivo
In-Vivo
3.3. Model of Pulmonary Edema In-Vivo
AA preliminary
preliminary in-vivo study
in-vivo was performed
study was performed in a rodent
in a model
rodentofmodel
pulmonary edema. After
of pulmonary sedation
edema. After
A preliminary
a sedation
tracheotomy was in-vivo
performed study on was
6 performed
rats ventilated inwitha rodent
a modelrodent
Harvard of pulmonary
ventilator. edema. After
Anesthesia
a tracheotomy was performed on 6 rats ventilated with a Harvard rodent ventilator.
sedation
was a tracheotomy
maintained was isoflurane.
performedAon left6thoracotomy
rats ventilated waswith a Harvard therodent ventilator.
Anesthesia waswith titrated
maintained with titrated isoflurane. performed
A left thoracotomy was inperformed
fourth in interspace.
the fourth
Anesthesia
Heparin waswas maintained with titrated isoflurane.
administered A left thoracotomy was performed in the fourth
interspace. Heparin wasintravenously
administeredto intravenously
prevent clotting toduring
prevent ischemia.
clottingAnduring
aneurysm clip
ischemia. wasAn
interspace.
applied Heparin
across the leftwaslung administered
hilum to intravenously
render the left lung toischemic
prevent for clotting
one during
hour to ischemia.
create ischemia.An
aneurysm clip was applied across the left lung hilum to render the left lung ischemic for one hour to
aneurysm
The clipthen
clipischemia.
was was applied
removed across
to then the left
allow lung hilum
reperfusion of to render
the the left
ischemic lung ischemic for one hour to
create The clip was removed to allow reperfusion oflung; this
the ischemic ischemia-reperfusion
lung; this ischemia-
create
injury ischemia. The clip was
causes pulmonary edemathen[49,50].
removed Theto right
allowlung
reperfusion of theaischemic lung; this ischemia-
reperfusion injury causes pulmonary edema [49,50]. wasThe used
rightaslung control.
was used A sternotomy
as a control. was A
reperfusion
performed, injury
and causes
theperformed, pulmonary
sternal edges were edema [49,50]. The right lung was used as a control. A
sternotomy was and thespread
sternalmaximally
edges were to expose
spread both lungs. Ultrasound
maximally to expose both coupling
lungs.
sternotomy
gel was appliedwas performed,
directlygel onto and
each the sternal
lung and edges were
the diffusion spread
constant maximally to expose both lungs.
Ultrasound coupling was applied directly onto each lung was and evaluated.
the diffusion Theconstant
results arewas
Ultrasound
shown on coupling
Figure 8 gel wasdifferences
Significant applied directly
were onto each
observed betweenlungtheand the and
control diffusion
edematousconstant was
rat lungs.
evaluated. The results are shown on Figure 8 Significant differences were observed between the
evaluated.
As expected, The results are proved
shown onbe Figure 8 in
Significant differences were observed between the
control and the D values
edematous rat lungs.toAs higher
expected, theDedematous
the values provedlung,to likely because
be higher in of
thethe longer
edematous
control and edematous
propagation ratfluid
lungs. As lung.
expected, theresults
D values proved tothe
be higher in constant
the edematous
lung, likelypaths
becausein ofthe the longerfilled
propagation These paths in thesuggest that
fluid filled lung.diffusion
These results suggest could
that
lung,
bethe
usedlikely
for because
detecting ofpulmonary
the longer propagation
edema and paths in the fluid
demonstrate the filledof
proof lung. Thesefor
concept results
using suggest
ultrasoundthat
diffusion constant could be used for detecting pulmonary edema and demonstrate the proof of
the diffusion constant
multiple could pulmonary
be used foredema detecting pulmonary edema and demonstrate the proof of
conceptscattering
for using to detect
ultrasound multiple scattering in the lung [48].
to detect pulmonary edema in the lung [48].
concept for using ultrasound multiple scattering to detect pulmonary edema in the lung [48].

Figure 8. The D values are significantly higher in the edematous lung than in the control lung.
Figure 8. The D values are significantly higher in the edematous lung than in the control lung. *: p <
***: p < 8.
Figure 0.005.
The D values are significantly higher in the edematous lung than in the control lung. *: p <
0.05. ***: p < 0.005.
0.05. ***: p < 0.005.

4. Discussion
4. Discussion
Appl. Sci. 2020, 10, 462 9 of 12

4. Discussion
It appears clearly that the future of lung ultrasound lies in the development of robust and
quantitative techniques specifically developed for lung tissue. This is what directed the recent research
effort of the growing lung ultrasound research community. Lung ultrasound has remained limited
to the critically ill and to emergency care. This is a missed opportunity that could be seized if more
reliable, reproducible, and quantitative techniques were developed. We see multiple advantages to
developing quantitative techniques. First, the potential availability of an absolute measure would
enable standardized ultrasound lung evaluation across centers, potentially with thresholds that could
be used to guide and inform treatment. Second, it would then be possible to follow the progress of a
disease or to monitor the response to a treatment over time, for a given patient longitudinally. This
would be of considerable help for the monitoring of pulmonary edema, which could be an indirect
marker of cardiac health in the case of cardiogenic edema. It could also be an extraordinary tool for the
evaluation of the efficacy of novel treatments for pulmonary fibrosis [51,52]. It should be noted that
significant and promising research efforts are also being made in the area of surface wave elastography
and its applications to the lung. However, they are out of the scope of the present contribution, which
focuses on the application of longitudinal waves in the parenchyma [53].
Although much progress has been made in the recent years in the quantitative ultrasonic evaluation
of the lung, potential bioeffects have not been fully investigated yet. Research efforts need to be
conducted in order to ensure a fully responsible use of ultrasound for these new applications. Adverse
effects of ultrasound in the lung are different than in other organs due to the presence of air. Cavitation
effects leading to hemorrhage have been demonstrated in rodent lungs, but no such effects have been
observed in the human lung [54–56]. On the contrary, lung ultrasound has been performed extensively
in the clinic without any obvious adverse effect. However, Frizell et al. have demonstrated that the
cavitation thresholds are much lower in the lung than in other organs [55]. Absorption by the air in
alveoli may lead to thermal effects. The cavitation effects are more likely to occur at low frequencies
while the thermal effects are more likely to occur at higher frequencies. Church et al. have established
a new formulation of the mechanical index (MI) specific to the lung, which accounts for the frequency,
the pulse repetition frequency, as well as the pulse duration. According to the literature, this index
will enable us to predict risk. The MI, thermal index, and the modified MI defined by [56] should be
fully investigated, although knowing the exact local pressure in the lung will not be trivial. Generally
speaking, the relatively shallow depths to be investigated (the pleura lays approximately at a depth
of 2 cm) allows for the use of a low MI without compromising the capability to gather information
by ultrasound.

Author Contributions: Conceptualization, L.D. and M.M.; introduction, L.D. and M.M.; ultrasound spectroscopy
L.D.; ultrasound multiple-scattering characterization M.M. and T.E.; discussion L.D. and M.M.; writing—original
draft preparation, L.D. and M.M.; review and editing, L.D., M.M. and T.E.; All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: The authors want to acknowledge M.D. Gino Soldati for providing the clinical ultrasound
images presented in this paper.
Conflicts of Interest: The authors declare no conflict of interest.

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