PHYSICS
Physics of ultrasound
Alexander EJ Powles
David J Martin
Irving TP Wells
Christopher R Goodwin
Abstract
Ultrasound is a form of non-ionizing radiation that uses high-frequency
sound waves to image the body. It is a real-time investigation which
allows assessment of moving structures and also facilitates measure-
ment of velocity and directionality of blood flow within a vessel. It can
be used for a variety of purposes in the intensive care setting, for
example to aid central venous catheter and pleural drain insertion.
When using this imaging modality it is vital to understand the relevant
physical principles and how the images are created. This article will
explain these principles, including the use of Doppler ultrasound and
the interpretation of common artefacts.
Keywords Doppler effect; echoes; imaging artefacts; sound
attenuation; ultrasound safety; ultrasound waves
Royal College of Anaesthetists CPD Matrix: 1A03
Wave characteristics
Sound is a mechanical wave that causes disturbance in a me-
dium, transferring energy from one point to another. As the
sound wave travels through a medium, the energy is propagated
through collisions of adjacent particles which oscillate around
their resting position without net displacement. Sound waves can
be longitudinal or transverse depending on the direction of their
oscillations in relation to the direction of the energy travelling
through the medium. Only solids can propagate sound waves
transversely, whereas all materials can support a longitudinal
wave, and this is therefore how ultrasound is transmitted
through the soft tissues and fluid within the body (Figure 1).
The frequency of a sound wave (measured in hertz, Hz) is the
number of oscillations (or cycles) per second. If a particle com-
pletes one full oscillation per second, its frequency is 1 Hz.
Alexander EJ Powles BA BMBCh is an ST3 Specialty Registrar in the
South Wales Radiology Training Scheme, UK. Conflict of interest:
None declared.
David J Martin MBBCh MRCP FRCR is a Consultant Radiologist at
Morriston and Singleton Hospitals, Swansea, Wales, UK. Conflict of
interest: None declared.
Irving TP Wells MBBS MRCP FRCR is a Consultant Radiologist at
Morriston and Singleton Hospitals, Swansea, Wales, UK. Conflict of
interest: None declared.
Christopher R Goodwin MB ChB MRCS (Eng) FRCR is a Consultant
Radiologist at Princess of Wales Hospital, Bridgend, Wales, UK.
Conflict of interest: None declared.
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Learning objectives
After reading this article, you should be able to:
C describe the characteristics of sound waves
C explain how ultrasound waves are produced, how they interact
with the tissues they encounter to produce echoes and how
they are then interpreted to form a two-dimensional image
C identify common ultrasound imaging artefacts
C explain the Doppler effect and its use in ultrasound imaging
Ultrasound refers to sound waves that have too high a frequency
for the human ear to detect, that is above 20 kilohertz (kHz);
however, the frequencies used in medical imaging are far greater,
typically 2e10 megahertz (MHz).
Wavelength is the distance travelled by sound in one cycle. It is
inversely proportional to the frequency, i.e. the shorter the
wavelength the higher the frequency (Figure 2). Shorter wave-
lengths result in higher resolution images but less penetration
into the soft tissues. Therefore, in medical imaging higher fre-
quency probes (5e10 MHz) are used for superficial structures,
(e.g. peripheral vessel visualization) and lower frequency probes
(2e5 MHz) for imaging deeper structures (e.g. the abdominal
and pelvic organs).
Ultrasound image production
Production of echoes
Ultrasound waves are produced by briefly passing an electrical
current through a piezoelectric crystal within the ultrasound
probe. The resulting pulse of ultrasound waves is delivered to the
tissues. The crystal then waits for the rebounding echoes to be
received before transmitting the next pulse. The pulse duration is
typically 1 ms repeated at 1 ms intervals. Each crystal therefore
emits ultrasound waves 0.1% of the time and receives the
returning echoes for the remaining 99.9% of the time. In practice,
the probe contains a phased array of many piezoelectric crystals
which are stimulated sequentially by electronic pulses which
sweep from one side of the probe to the other.
As the ultrasound wave passes through the patient it en-
counters interfaces between different tissues. At these interfaces
a proportion of the wave’s energy is reflected and the remainder
is transmitted. If the angle between the interface and transducer
is greater than around 60 degrees then some of the reflected
echoes will return to the transducer. The piezoelectric crystal
converts the reflected sound waves into electrical pulses, and
these are interpreted into a two-dimensional (2D) image. The
more energy in the returning echoes, the brighter the image
displayed.
The amount of energy reflected at an interface between tissues
depends on the difference in acoustic impedance of those tis-
sues. The acoustic impedance (Z) of a tissue is the product of its
density and the velocity that sound travels through it. Air has a
much lower density than water or soft tissue, which in turn have
a much lower density than bone. The larger the difference in
acoustic impedance between two materials at an interface, the
more energy will be reflected, and the brighter the resulting
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 PHYSICS
At rest
Transverse
propagation
Longitudinal
propagation
Figure 1 Diagrammatic representation of the propagation of a me-
chanical force transversely as can occur only in solids or longitudinally
as occurs with sound in the tissues of the body.
High-frequency wave
Time
Wavelength
Low-frequency wave
Time
Wavelength
Figure 2 Displays the relationship between wavelength and frequency.
image. At the interface of tissues of similar densities, such as
liver and kidney, less than 1% of the wave’s energy is reflected.
However at the interface between soft tissue and air or bone,
nearly all of the wave’s energy is reflected. No energy is trans-
mitted, and hence no information can be gained about tissues
which lie deeper than this point. This explains why ultrasound is
generally not useful for assessment of bone, bowel, or lung. It
also explains why a coupling gel is required between the probe
and patient’s skin and why air bubbles must be avoided to
minimize any reflection at the skin/probe interface.
To create a 2D image, the depth (d) of the tissue interface
must be calculated. Ultrasound travels at an average speed (c) of
1540 ms
1 through soft tissue. The time (t) taken for the ultra-
sound pulse to travel the distance (d) to the interface, and for the
reflected wave to return to the transducer, is:
t ¼ 2d/c
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Rearranging, the tissue interface depth is therefore:
d ¼ ct/2
Sound attenuation and compensation
As a sound wave passes through the body it gradually loses its
energy in a process called attenuation. The causes of this are:
reflection, refraction, scatter and absorption (Figure 3).
Reflection and refraction occur at the interfaces between tissues.
Reflection, as already described, is responsible for the produc-
tion of the required echoes. Refraction causes a transmitted
wave to be deflected from its original direction where it passes
through an interface between tissues having differing wave
speed. Scatter describes the scattering of the wave in all di-
rections which occurs when a wave encounters a structure much
smaller than its wavelength, typically occurring on interaction
with red blood cells. The majority of attenuation, however, oc-
curs due to absorption. The energy of the sound wave is con-
verted into friction between oscillating tissue particles and is lost
in the form of heat.
The combination of general attenuation through all tissue
types, and the fact that only a small proportion of the wave’s
energy is reflected at many of the tissue interfaces (which is
then attenuated further as it travels back towards the probe),
means that the ultrasound transducer will only receive a very
small amount of energy from the returning echoes, particularly
from deeper structures. To compensate for this loss of energy
the ultrasound machine uses a process called time gain
compensation. This gives greater amplification to those echoes
which take longer to return to the transducer, producing a more
even image.
Image resolution
Spatial resolution is the ability of an imaging system to distin-
guish two points as separate in space.
Axial or depth resolution is the ability to distinguish between
two structures in the direction parallel to the beam, that is, along
the same scan line. A structure can only be visualized if it is
larger than several wavelengths of the emitted ultrasound.
Remembering that wavelength is inversely proportional to fre-
quency, the higher the frequency (shorter the wavelength) the
better the axial resolution. Hence a high-frequency probe is
required to image small structures. However, as discussed above,
higher frequency waves are attenuated more rapidly, and there-
fore will only be able to visualize superficial structures.
Lateral resolution is the ability to distinguish two structures
lying side by side at the same depth. This is dependent on the
beam width being narrower than the distance between the two
structures and is also improved by focussing. By exploiting the
phased array of the probe, if a delay is introduced energizing the
outermost elements first with a short time interval to the inner
elements and finally central element, there will be a point at
which the pulses all arrive together and thus reinforce allowing
the beam to be focussed. Practically it is important that the
operator correctly positions the focal zone when scanning to
ensure the best lateral resolution for assessment of a given
structure.
2 Ó 2018 Published by Elsevier Ltd.
 PHYSICS

Artefacts Posterior acoustic shadowing (Figure 4d) occurs when the ul-
trasound beam encounters a strongly attenuating or highly
Imaging artefacts can lead to misinterpretation but can also aid
reflective structure or surface. There is little or no through
the operator in certain circumstances.
transmission and this creates a dark area beyond the surface.
Reverberation artefact (Figure 4a) occurs when sound waves
bounce back and forth between two reflective surfaces before
returning to the transducer. These returning echoes will arrive
later than the original echo in a sequential manner creating
numerous evenly spaced lines, as the processor believes these
echoes to be returning from deeper structures.

Ring-down artefact (Figure 4b) occurs when sound waves hit a

small structure, such as a small air bubble, that then resonates
at the same frequency as ultrasound and emits sound. The
sound is produced after the original wave has been reflected
back to the transducer. It will therefore be interpreted as a
second echo originating from a deeper structure and is dis-
played as a bright line deep to the original target. Practically this
artefact can be utilized to aid identification of air within the
biliary tree.

Mirror artefact (Figure 4c) occurs at highly reflective surfaces.

The original beam is reflected from a surface and then en-
counters an adjacent structure, at which point the original echo
is reflected back towards the highly reflective surface, before
being reflected back again to the transducer. This is interpreted
as returning from a deeper structure which appears to be on the
opposite side of the reflective surface. This is classically seen at
the diaphragm.

a b

c d

Figure 4 Ultrasound artefacts. (a) Reverberation artefact e evenly

Figure 3 (a) Absorption; (b) reflection; (c) scatter; and (d) refraction
all contribute to the overall attenuation of the ultrasound wave seen
in (e).
spaced lines in the bladder. (b) Ring-down artefact e bright white line
caused by air within the biliary tree. (c) Mirror artefact e liver ‘reflected’
on the other side of the diaphragm. (d) Posterior acoustic shadowing e
caused by two gallstones in the gallbladder. (e) Posterior acoustic
enhancement e due to simple liver cyst.

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 PHYSICS
Visualization of any structure deep to this point is therefore
diminished. Practically this artefact can help identify calcified
structures such as gallstones and renal calculi.
Posterior acoustic enhancement (Figure 4e) occurs when the
ultrasound beam passes through a weakly attenuating structure,
such as fluid in a simple cyst or urine within the bladder. The
structures posterior to the cyst will appear brighter, as more
energy of the original beam will reach them, and hence an echo
of greater energy will be reflected back to the probe.
Doppler
The Doppler Effect describes the change in frequency of the
incident wave that occurs when it is reflected at a moving
interface, and is the reason the pitch of a horn from a moving
vehicle appears to change as it approaches and passes by a sta-
tionary observer.
Doppler shift frequency is measured as the difference between
the transmitted and observed frequency (f
f1). If the object(s)
being imaged (e.g. blood cells) are moving towards the trans-
ducer, their motion will cause the reflected waves to be com-
pressed and return back to the transducer more rapidly,
shortening the wavelength and increasing the frequency. The
opposite occurs when the blood cells are moving away from the
transducer, resulting in a decrease in frequency of the reflected
wave. The change in frequency is proportional to the velocity of
the moving interface:
change of frequencyðf
f1 Þ 2  velocity of the interfaceðvÞ
¼ Feldman MK, Katyal S, Blackwood MS. US artifacts. Radiographics
original frequencyðfÞ velocity of soundðcÞ
The Doppler shift frequency is also related to the cosine of the
angle between the probe and the vessel being imaged:
(f
f1)/f ¼ 2(v/c) cosq
The cosine of 90 degrees is 0, therefore no Doppler signal will be
present when the probe is perpendicular to the vessel. Ideally the
probe should be positioned such that the flow of the vessel is
directly toward it. In practice this is difficult, and if measurement
of velocity is required an angle less than 60 degrees can be used
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in conjunction with the angle correction function on the ultra-
sound machine.
Doppler imaging can provide information about flow direc-
tionality which is typically displayed using colour mapping, with
red conventionally representing flow towards the probe and blue
away from it. Alternatively, it can be displayed as a graph of
velocity against time, i.e. spectral Doppler, which allows the
operator to obtain measurements of flow velocity.
Safety
Ultrasound is safe and does not use ionizing radiation. Known
bio-effects fall into two main categories: mechanical and ther-
mal. Mechanical effects are related to tiny bubbles which are
produced within tissues as ultrasound propagates through
them. If these bubbles collapse rapidly (microcavitation), en-
ergy is released which can damage tissues. Thermal effects
occur from the heat produced from the friction of oscillating
particles.
In routine medical imaging neither of these bio-effects causes
any significant or lasting damage but it is good practice to keep
the examination time to a minimum and to use appropriate set-
tings to minimize the power, particularly during foetal
scanning. A
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