European Heart Journal - Cardiovascular Imaging (2022) 23, 447–449 HOW TO

https://doi.org/10.1093/ehjci/jeab241

How to do lung ultrasound

1
Jan Stassen and Jeroen J. Bax1,2*
1
Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands; and 2Turku Heart Center, University of Turku and Turku
University Hospital, Kiinamyllynkatu 4-8, FI-20520, Turku, Finland

Received 20 September 2021; editorial decision 30 October 2021; accepted 1 November 2021; online publish-ahead-of-print 13 November 2021

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..
Introduction ..
.. Imaging technique
..
Increasing signs and symptoms of pulmonary congestion are the main .. In contrast to transthoracic echocardiography, the acoustic window
reasons why patients with heart failure are admitted to the hospital. .. for LUS is always accessible and patent. The patient can be examined
..
In addition, (sub)clinical pulmonary congestion at discharge is a very .. in a sitting as well as supine position. For serial examinations, how-
strong predictor of poor outcomes and readmission of these .. ever, the position should be consistent because pulmonary fluid
..
patients. Early detection of pulmonary congestion therefore seems .. changes with posture. Using the anterior axillary line as a landmark,
essential to improve outcomes in heart failure patients. However,
.. each chest wall can be divided into four lung regions (upper and
..
physical signs and even chest X-ray have limited sensitivity to detect .. lower parts of the anterior and lateral chest wall) that should be sys-
.. tematically analysed.2 Additional scanning of the posterior chest wall
pulmonary congestion.1 In addition, although elevated natriuretic ..
peptides have a high negative predictive value to rule out heart failure .. can be useful to evaluate the presence of a pleural effusion but is usu-
..
in patients with acute dyspnoea, their specificity is rather low.1 .. ally not necessary for the assessment of pulmonary congestion.
Lung ultrasound (LUS) appears to be one of the most useful tests .. When using a convex probe, the probe can be positioned perpen-
..
to confirm the presence of pulmonary congestion by detecting B- .. dicular to the ribs, as well as along the intercostal spaces. When using
lines, which originate from extravasated fluid into the lung intersti-
.. a cardiac probe, however, the reasonable position is along the inter-
..
tium and alveoli.2 The European Association of Cardiovascular .. costal space, where the length of the probe can occupy the intercos-
.. tal space without touching the ribs. Using the cardiac transducer
Imaging (EACVI), as well as the 2021 European Society of Cardiology ..
(ESC) guidelines for the diagnosis and treatment of acute and chronic .. offers the additional advantage of not having to change the probe
.. after the echocardiographic examination.
heart failure acknowledge the importance of LUS in suspected heart ..
failure.3 The following article is intended to provide guidance on how
..
..
to perform LUS and explain how it can easily be used as an add-on to ..
transthoracic echocardiography to accurately assess pulmonary con-
..
..
Normal patterns in lung
gestion in heart failure patients. .. ultrasound
..
..
.. In a normally aerated lung, the pleural line will be the only structure
..
Transducer and technology .. that can be visualized with LUS. The pleural line is visualized as a
.. hyperechogenic, thin and horizontal line that moves back and forth
Although a 5-MHz convex probe may provide optimal visualization .. with respiration (so-called ‘lung sliding’) and results from the move-
..
of the lung parenchyma, a standard cardiac transducer with a 3.5– .. ment of the visceral pleura against the parietal pleura during the re-
5.0 MHz frequency range allows for sufficient visualization of the .. spiratory cycle. The perpendicular scanning approach, which is
..
pleura and subpleural structures and lowers the threshold to use .. usually performed with a (micro)convex probe, visualizes the upper
LUS as an add-on to standard echocardiography. The small surface of
..
.. and the lower ribs, which are characterized by a posterior shadowing.
the cardiac transducer also allows easy scanning along the intercostal .. Next, the pleural line can be located between both ribs (Figure 1A).
..
spaces. Because no high temporal or spatial resolution is required, .. The visualization of the upper and lower ribs in combination with the
LUS can be performed with relatively simple equipment (e.g. hand- .. pleural line will identify the so-called ‘bat-sign’ (Figure 1B). However,
..
held echocardiography device) which lowers the threshold for its use .. this sign is not always noted with a cardiac probe. It is important to
at the emergency department or for daily use at the heart failure hos- .. notice that the pleural line should be moving with in- and expiration.
..
pitalization unit. . If a motionless horizontal line is visualized, it could be that the

* Corresponding author. Tel: þ31 71 526 2020; Fax: þ31 71 526 6809. E-mail: j.j.bax@lumc.nl
C The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.
Published on behalf of the European Society of Cardiology. All rights reserved. V
448 J. Stassen and J.J. Bax

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Figure 1 (A) Lung ultrasound (LUS) showing the upper and lower ribs (red arrows) with the pleural line between them (blue arrow). (B) The ‘bat
sign’ (white arrows) is created by two ribs forming the wings and the pleural line forming the back of the bat. (C) LUS showing the pleural line (blue
arrow) with additional A-lines arising from the pleural line (red arrows). (D) Visualization of the diaphragm (white arrow) with a pleural effusion (blue
arrow) and the liver (red arrow); a small part of the lung can be seen ‘floating’ in the pleural effusion (green arrow). (E) B-lines (red arrows) arising
from the pleural line (blue arrow). (F) Severe pulmonary congestion with fusion of B-lines, creating confluent, hyperechogenic zones (red arrows).

..
operator is looking at muscle fascia or, in cases of acute and unex- .. pulmonary zones of normally aerated lungs, the presence of more
plained dyspnoea, there may be an underlying pneumothorax.2 Some .. than two B-lines is almost always a pathological sign. However, be-
..
additional, hyperechogenic, horizontal lines can arise at regular inter- .. cause B-lines are only an expression of lung aeration loss, they are
vals from the pleural line and are called ‘A-lines’ (Figure 1C). These A-
.. not pathognomonic for lung congestion. To make the diagnosis of
..
lines are reverberation artefacts that represent a sign of normal or .. lung congestion, B-lines have to be multiple (two or more B-lines
increased (e.g. chronic obstructive pulmonary disease) content of air
.. within a single scanning zone), diffuse (detection of B-lines within mul-
..
in the lung. The sonographer should also always try to locate the dia- .. tiple scanning zones), and bilateral. B-lines that are restricted to one
..
phragm because pulmonary consolidations and pleural effusions are .. or two zones could be the sign of an underlying pneumonia or con-
mostly found in dependent lung regions and can therefore be differ- .. solidation, whereas an inhomogeneous distribution with spared areas
..
entiated from intra-abdominal organs once the diaphragm has been .. could be the sign of acute respiratory distress syndrome or pulmon-
identified (Figure 1D). Because air causes a complete reflection of the .. ary fibrosis.
..
ultrasound beam, pulmonary parenchyma cannot be visualized in the .. The number of B-lines correlates well with the degree of lung aer-
normally aerated lung.
.. ation loss. In addition, the number of B-lines decreases immediately
..
.. after the initiation of decongestive treatment, making LUS a valuable
.. tool to follow-up improvement of pulmonary congestion during diur-
..
Abnormal patterns in lung .. etic treatment. When there are only few B-lines, they can be counted
..
ultrasound ..
..
individually and the sum of the B-lines found in each lung region pro-
vides a total score that demonstrates the severity of the alveolar-
..
With increasing pulmonary congestion and aeration loss, lung density .. interstitial syndrome and allows a more objective follow-up after the
increases and the acoustic mismatch between the lung and the sur- .. initiation of diuretic treatment.2 When B-lines are numerous, they
..
rounding tissues is lowered. This creates vertical reverberation arte- .. tend to merge and form well-distinct, hyperechogenic, confluent
facts which are also known as ‘B-lines’. B-lines are well defined, laser- .. zones (Figure 1F). In these cases, the percentage of the scanning site
..
like, vertical artefacts that move in synchrony with the pleural line. .. occupied by these ‘white zones’ can be used as a semiquantitative
They have a hyperechogenic appearance, arise from the pleural line .. measurement.2
..
and reach the edge of the screen2 (Figure 1E). Although less than one .. Besides B-lines, the presence of pleural effusion could also be a
or two B-lines can sometimes be detected in the dependent
.. sign of progressive lung congestion. With LUS, it is easy to
How to do LUS 449

differentiate between pleural effusion and a consolidation, whereas

.. initial management as well as in the follow-up of heart failure patients
..
with chest X-ray, it can sometimes be very difficult to distinguish be- .. presenting with pulmonary congestion.
..
tween these two conditions. When looking for pleural effusions, the ..
operator should first look at the dependent regions of both lungs. A .. Funding
..
pleural effusion will mostly be seen as a hypo- or anechogenic struc- .. J.S. received funding from the European Society of Cardiology (ESC
ture which is delineated by the chest wall and the diaphragm
.. Training Grant App000064741).
..
(Figure 1D). Although the aetiology of a pleural effusion cannot always .. Conflict of interest: The Department of Cardiology of the Leiden
..
be accurately detected by LUS, a transudate (observed in pulmonary .. University Medical Centre received unrestricted research grants from
congestion) is always anechogenic. Very severe lung congestion, lung .. Abbott Vascular, Bayer, Biotronik, Bioventrix, Boston Scientific, Edwards
..
oedema, or large pleural effusions compressing lung parenchyma can .. Lifesciences, GE Healthcare and Medtronic. J.J.B. received speaker fees
all induce an extensive loss of pulmonary aeration. In these patients, .. from Abbott Vascular.
..
the acoustic window on the lung becomes completely open, showing ..

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the presence of compression atelectasis (Figure 1D). A compression
.. References
..
atelectasis appears as a hyperechogenic tissue structure that may be .. 1. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient
.. in the emergency department have congestive heart failure? JAMA 2005;294:
visualized as solid parenchyma (such as the liver). .. 1944–56.
.. 2. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW et
.. al.; International Liaison Committee on Lung Ultrasound (ILC-LUS) for
..
.. International Consensus Conference on Lung Ultrasound (ICC-LUS). International
Conclusion .. evidence-based recommendations for point-of-care lung ultrasound. Intensive Care
.. Med 2012;38:577–91.
LUS is an essential skill for every physician caring for heart failure .. 3. Neskovic AN, Skinner H, Price S, Via G, De Hert S, Stankovic I et al.; Reviewers:
.. This document was reviewed by members of the 2016–2018 EACVI Scientific
patients and can be easily used as an add-on to standard transthoracic ..
echocardiography. Adequate knowledge of LUS enables the timely .. Documents Committee. Focus cardiac ultrasound core curriculum and core sylla-
.. bus of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc
diagnosis of pulmonary congestion and can help the clinician in the . Imaging 2018;19:475–81.