Original Article

Bedside Lung Ultrasound in Emergency Protocol as a

Diagnostic Tool in Patients of Acute Respiratory Distress
Presenting to Emergency Department
Chirag J. Patel, Hardik B. Bhatt, Samira N. Parikh, Binit N. Jhaveri, Jyothi H. Puranik
Department of Emergency Medicine, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India

Abstract
Objective: The objective of this study is to determine the accuracy of the bedside lung ultrasound in emergency (BLUE) protocol in giving a
correct diagnosis in patients presenting with acute respiratory distress in emergency department. Materials and Methods: Patients with acute
respiratory distress were evaluated. Ultrasound findings such as artifacts (A line, B line), lung sliding, alveolar consolidation or pleural effusion,
and venous analysis were recorded. Ultrasonography findings were correlated with final diagnosis made by the treating unit. Sensitivity and
specificity were calculated. Results: A total 50 patients were evaluated. The A profile (predominant A line with lung sliding) indicated chronic
obstructive pulmonary disease/asthma (n = 14) with 85.17% sensitivity and 88.88% specificity. B profile (predominant B + lines with lung
sliding) indicated pulmonary edema (n = 13) with 92.30% sensitivity and 100% specificity. The A/B profile (A line on one side and B + line
on other side) and the C profile  (anterior consolidation) and the A profile plus posterolateral alveolar and/or pleural syndrome indicated
pneumonia (n = 17) with 94.11 sensitivity and 93.93% specificity. The A profile plus venous thrombosis indicated pulmonary embolism (n = 1)
with 100% sensitivity and specificity. A’ profile (predominant A line without lung sliding) with lung point indicated pneumothorax (n = 5) with
80% sensitivity and 100% specificity. Conclusion: BLUE protocol was successful in average 90.316% cases. BLUE performed in emergency
department is equivalent to computed tomography scan. BLUE protocol aids in making diagnosis and saves time and cost; avoids the side
effects related to radiation.

Keywords: Bedside lung ultrasound in emergency, emergency medicine, respiratory failure, ultrasound

Introduction the BLUE protocol in giving a correct diagnosis in patients

Point‑of‑care ultrasonography (USG) is emerging as an
important bedside tool. [1] Lung ultrasound imaging is
easily available at bedside, real‑time, and free of radiation
hazards in comparison to conventional imaging modalities
of the lung in critically ill patients.[2] Acute respiratory
failure cases do not always present in conditions that
are ideal for an immediate diagnosis, which sometimes
compromises outcome. [3] The bedside lung ultrasound
in emergency (BLUE) protocol makes exclusive use of
lung and venous ultrasound.[4] Its use as a primary survey
tool in the acutely dyspneic or hypoxemic patient gives
an immediate understanding of the state of the lung and
influences therapeutic decisions.[5]
Study objective
The objective of this study is to determine the accuracy of
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DOI:
10.4103/JETS.JETS_21_17
presenting with acute respiratory distress in the emergency
department.
Materials and Methods
This was an observational study over a period of 2 months
carried out at emergency medicine department of a tertiary
care hospital in Ahmedabad.
Address for correspondence: Dr. Hardik B. Bhatt,
H-83, Sachin Tower, 8th Floor, Shyamal, Anandnagar 100ft road, Beside
Dhananjay Tower, Satellite, Ahmedabad - 380 015, Gujarat, India.
E-mail: drhardikbhatt@gmail.com
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tweak, and build upon the work non-commercially, as long as appropriate credit is given and
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For reprints contact: reprints@medknow.com
How to cite this article: Patel CJ, Bhatt HB, Parikh SN, Jhaveri BN,
Puranik JH. Bedside lung ultrasound in emergency protocol as a diagnostic
tool in patients of acute respiratory distress presenting to emergency
department. J Emerg Trauma Shock 2018;11:125-9.
Received: 11.03.17. Accepted: 08.09.17.

© 2018 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer - Medknow 125
 Patel, et al.: BLUE protocol as a diagnostic tool

Patients of acute respiratory distress requiring Intensive Inclusion criteria

Care Unit (ICU) admission were evaluated. Ultrasound was
performed in emergency department by same emergency
physician without interrupting patients’ management.
Micromax ultrasound system, sonosite was used to evaluate
the patients. Both low frequency (2–5 MHz) curvilinear probe
and high frequency (5–10 MHz) linear probe were used to get
best possible findings.
Patients were examined in either supine or semirecumbent
position. Areas of each chest were divide in anterior
(sternum to anterior axillary line), lateral (between anterior
and posterior axillary line), and posterolateral alveolar
pleural syndrome (PLAPS) point. PLAPS point was observed
at posterior region after minimal turning of the patient
to opposite side. Each was further divided in the upper
zone and lower zone (roughly by horizontal line passing
through nipple), respectively. Each lung was thus divided
in 6 zones.
Ultrasound findings such as artifacts  (A line, B line), lung
sliding, alveolar consolidation or pleural effusion, and venous
analysis were recorded for each zone. Venous analysis was
carried out after performing lung ultrasound in selected patients
showing A profile. Venous analysis to visualize echogenic
thrombus was carried out with high‑frequency linear probe
over internal jugular vein, subclavian vein, femoral vein, iliac
veins, superior venacava, and inferior venacava. Combined
results were noted in the pro forma to select diagnosis
according to BLUE protocol.
Treating units were blinded by the findings of ultrasound.
The patient was prospectively followed and results of various
investigations such as computed tomography (CT) scan,
two‑dimensional echo, chest X‑ray, and other specific tests
which were used by the treating unit to reach diagnosis were
recorded [Table 1]. USG findings were correlated with final
diagnosis made by the treating unit. Sensitivity and specificity
were calculated for the each profile observed.
Ethical Committee approval was taken.
• Patients having age >12 years were included
• Patients and/or relatives giving informed consent
• Patients of acute respiratory distress requiring ICU
admission were included.
Following were the ICU admission criteria:
Vital Signs
• Pulse <40 or >150 beats/mine
• Systolic arterial pressure <80 mm Hg or 20 mm Hg below
the patient’s usual pressure
• Mean arterial pressure <60 mm Hg
• Diastolic arterial pressure >120 mm Hg
• Respiratory rate >35 breaths/min.
Arterial blood gas analysis
• PaO2 <50 mm Hg
• pH <7.1 or >7.7.
Exclusion criteria
• Patients having prior diagnosis were excluded for nonbias
study
• Patients and/or relatives not giving consent were excluded.
Results
Totally 50 patients of acute respiratory distress were evaluated
with mean age of 59.64 years. 32 patients were male, and
18 patients were female.
Normal lung ultrasound images are explained in
Figures 1 and 2.
Chronic obstructive pulmonary disease/asthma
Chronic obstructive pulmonary disease (COPD) was
diagnosed in 14 patients. The A profile (predominant
A line with lung sliding) indicated COPD/asthma.
A profile was found in 14 patients with 85.17% sensitivity

Table 1: Methods of diagnosis

Disease Investigations
COPD/asthma History, responds to bronchodilator treatment, chest
radiography, and COPD was confirmed by functional tests
Pulmonary Chest radiography, evaluation of cardiac function using
edema echocardiography, responding to diuretics
Pneumonia Infectious profile, radiologic asymmetry, microorganism
isolated (blood), recovery with antibiotics
Pulmonary Helical CT
embolism
Pneumothorax Chest radiography (CT if necessary)
For all patients: History, clinical examination, basic blood tests and
specific blood investigations (arterial blood gas analysis, D-dimer),
electrocardiography, radiography reporting by radiologists, CT as needed,
favorable clinical progression under treatment was followed along
with. COPD: Chronic obstructive pulmonary disease, CT: Computed Figure 1: Two rib shadows are shown in figure, hyper echoic pleura is
tomography seen, suggesting of normal lung ultrasound image

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 Patel, et al.: BLUE protocol as a diagnostic tool
and 88.88% specificity. In one case, A profile plus
PLAPS (posterolateral alveolar syndrome) was observed
and in one case A/B profile was observed. A lines are
shown in Figure 3.
Pulmonary edema/interstitial syndrome
Interstitial syndrome was diagnosed in 13 patients. The B
profile  (predominant B  +  lines with lung sliding) indicated
pulmonary edema. B  profile was found in 12  patients with
92.30% sensitivity and 100% specificity. Normal profile was
found in one case. B lines are shown in Figure 4.
Pneumonia
Pneumonia was diagnosed in 17  patients. The A/B profile
(A line on one side and B + line on other side), the C
profile (anterior consolidation) and the A profile plus PLAPS
indicated pneumonia. The A/B profile was found in 6 patients
with 35.29% sensitivity and 96.96% specificity. The A profile
plus PLAPS was found in 1 patient with 5.88% sensitivity
Figure 2: Normal sea‑shore pattern of lung on M‑mode. M‑mode
shows horizontal lines suggestive of the chest wall and granular pattern
suggestive of lungs
Figure 4: B  lines reflect the coexistence of fluid and air. Fluid at the
subpleural interlobular septum surrounded by air‑filled alveoli gives B
lines. 1 or 2 B lines in a single‑ultrasound view have no significance
Journal of Emergencies, Trauma, and Shock  ¦  Volume 11  ¦  Issue 2  ¦  April-June 2018
and 96.96% specificity. The C profile was found in 9 patients
with 52.94% sensitivity and 100% specificity. Combined
(C profile + A/B profile + A profile plus PLAPS) profiles in
17 patients suggested pneumonia with 94.11% sensitivity
and 93.93% specificity. Normal profile was seen in one case.
Figure 5 shows pneumonia with irregular pleura.
Pulmonary embolism
Pulmonary embolism was found in one patient showing A
profile plus venous thrombosis. With 100% sensitivity and
specificity, venous thrombosis was found in femoral vein.
Pneumothorax
P n e u m o t h o r a x w a s f o u n d i n 5   p a t i e n t s . T h e A’
profile (predominant A line without lung sliding) with lung
point indicated pneumothorax. A’ profile was found in
5 patients and with lung point in 4 patients with 80% sensitivity
and 100% specificity. Barcode sign was observed. Figure 6 is
suggestive of pneumothorax.
Figure 7 shows Pleural effusion on M‑mode.
Figure 3: A lines are the repetitive horizontal artifacts arising from the
pleural line generated by subpleural air, which, either intraalveolar (normal)
or abnormal (pneumothorax), blocks ultrasound waves
Figure 5: Consolidation which does not invade the whole lobe, will
generate a shredded (Shred Sign), fractal boundary between the
consolidation and the underlying aerated lung. Lung sliding may be
present or absent
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 Patel, et al.: BLUE protocol as a diagnostic tool

Profiles observed were as shown below in Table 2. Ultrasound
Accuracy of various profiles is as shown in Table 3.
BLUE protocol was successful in average 90.316% cases.
Discussion
Briefly, a normal profile indicated COPD/asthma in an
acutely breathless patient. The B profile (anterior interstitial
syndrome with lung sliding) indicated pulmonary edema. The
B’ profile (lung sliding abolished) indicated pneumonia. The
A/B profile  (asymmetric anterior interstitial syndrome) and
the C profile  (anterior consolidation) indicated pneumonia,
as did the A profile plus PLAPS. The A profile plus venous
thrombosis indicated pulmonary embolism.[3]
The pleural line is superficial. Most acute disorders reach it;
acute interstitial changes involve deep as well as subpleural
areas; most (98.5%) cases of acute alveolar consolidation abut
the pleura; pneumothorax and pleural effusions always abut
the wall. The high‑acoustic impedance gradient between air
and fluid generates artifacts. Air stops ultrasounds, and fluid
facilitates their transmission.[3]
Chronic obstructive pulmonary disease/asthma
In COPD/Asthma, subpleural aeration is not disturbed and lung
sliding is present.[2] Our study showed normal profile/A profile

Figure 6: Ultrasound findings of absent lung sliding with stratosphere Figure 7: Ultrasound suggestive of pleural effusion (anechoic). The
sign on M‑mode suggests pneumothorax. The lung point (not featured inspiratory shift of the lung line toward the pleural line is called the sinusoid
here) confidently rules in the diagnosis sign visualized on M‑mode

Table 2: Combined results

Diagnosis Normal profile A profile plus PLAPS A’ profile B profile B’ profile C profile A/B profile Lung point
Pneumonia (17) 1 1 0 0 0 9 6 0
Pneumothorax (5) 0 0 1 0 0 0 0 4
Pulmonary edema (13) 1 0 0 12 0 0 0 0
COPD (14) 12 1 0 0 0 0 1 0
Pulmonary embolism (1) 1 0 0 0 0 0 0 0
COPD: Chronic obstructive pulmonary disease, PLAPS: Posterolateral alveolar pleural syndrome

Table 3: Ultrasound accuracy

Final diagnosis Ultrasound signs observed Sensitivity Specificity PPV NPV
Pneumonia (n=17) Anterior alveolar consolidation (C profile) 52.94 (9/17) 100 (33/33) 100 (9/9) 80.48 (33/41)
A profile plus PLAPS 5.88 (1/17) 96.96 (32/33) 50 (1/2) 66.66 (32/48)
Predominant anterior A line on one side and 35.29 (6/17) 96.96 (32/33) 85.71 (6/7) 74.41 (32/43)
Predominant B+ line on one side (A/B profile)
All profile 94.11 (16/17) 93.93 (31/33) 88.88 (16/18) 96.87 (31/32)
Pneumothorax (n=5) Absent lung sliding and absent anterior b lines 80 (4/5) 100 (45/45) 100 (4/4) 97.82 (45/46)
with lung point
Pulmonary edema (n=13) Diffuse bilateral B+ line (B profile) 92.30 (12/13) 100 (37/37) 100 (12/12) 97.36 (37/38)
COPD (n=14) A profile 85.17 (12/14) 88.88 (32/36) 75 (12/16) 94.11 (32/34)
Pulmonary embolism (n=1) A profile plus venous thrombosis 100 (1/1) 100 (49/49) 100 (1/1) 100 (49/49)
COPD: Chronic obstructive pulmonary disease, PLAPS: Posterolateral alveolar pleural syndrome, PPV: Positive predictive value, NPV: Negative predictive
value

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 Patel, et al.: BLUE protocol as a diagnostic tool
Table 4: Comparison of efficacy
Diagnosis Sensitivity (%)/specificity (%)
Our study Lichtenstein Dexheimer
and Mezière[3] Neto et al.[6]
Pneumonia 94.11/93.93 89/94 88/90
COPD 85.17/88.88 89/97 67/100
Pulmonary edema 92.3/100 97/95 85/87
Pneumothorax 80/100 88/100 ‑
COPD: Chronic obstructive pulmonary disease
in 14 cases. 1 case was with A profile plus PLAPS. 1 case was
with A/B profile which was later found to be associated with
acute heart failure.
Pulmonary edema
Bilateral B + lines (more than two B lines) in two or more zones
out of six‑zone examination with or without pleural line and
subpleural abnormalities are suggestive of diagnosis. Regularly
spaced B lines suggest septal or interstitial edema. Crowded
or coalescent B lines are suggestive of alveolar edema.
Inhomogeneous B lines with pleural abnormalities irregularly
spaced suggest acute respiratory distress syndrome, pleural
fibrosis, or some other condition.[2] 12  cases B profile was
observed. 1 case normal profile was seen. Causes of B + lines
can be differentiated with the help of echocardiography and
clinical features.
Pneumonia
The appearance of ultrasound images depends on the
relative aeration of alveoli. [2] Pleural abnormalities may
be found. Lung sliding may be abolished because of
inflammatory exudates.[3] Early small alveolar consolidations
appear as subpleural defects showing shred sign which
gradually enlarges to form wedge‑shaped deformity. Fully
formed consolidation appears solid liver‑like, suggestive
of tissue sign.[5] Inhomogeneous unilateral/bilateral and
focal/multifocal positive areas for B lines with pleural
abnormalities (thickened, fragmented pleura, and subpleural
consolidation) and reduced or absent lung sliding are seen in
LUS in interstitial and bronchopneumonia.[2] These explain
various signs observed in pneumonia. B’ profile  (bilateral
B + lines with abolished lung sliding) was not observed in
our study. In our study A/B profile was found in 6 patients,
A profile plus PLAPS was found in 1 patient, and C profile
was found in 9 patients.
Pulmonary embolism
Normal profile is found mostly in pulmonary embolism.
Venous scans improved sensitivity of diagnosis.[3] In our study,
only 1 patient had normal profile with femoral vein thrombosis.
Pulmonary embolism was proved by high‑resolution CT
thorax.
Pneumothorax
With collection of air between pleural layers results in the
absence of lung sliding and as air blocks ultrasound waves,
thus producing A’ profile. M‑mode shows horizontal lines,
Journal of Emergencies, Trauma, and Shock  ¦  Volume 11  ¦  Issue 2  ¦  April-June 2018
stratosphere sign.[2] Localized pneumothorax will produce
lung point whereas gross pneumothorax does not produce
lung point. Lung point indicates junction of normal lung and
pneumothorax.[5] In our study, A’ profile was found in 5 cases,
4 cases showed lung point.
In our study, BLUE protocol was successful in average 90.316%
cases. Lichtenstein and Mezière found similar accuracy of 90.5%
in their study. Comparision of Efficacy is as shown in Table 4.
Stefano Parlamento et  al., in their study, found pneumonia
in 96.9% cases with the use of ultrasound.[7] Blaivas et al. in
their study found pneumothorax with 98.1% sensitivity and
99.2% specificity.[8]
Limitation
The limitation of this study was its small sample size and the
fact that it was conducted in a single center. Micro convex
probe with small footprint gives better visualization. It was
unavailable in our setting and thus linear probe and curvilinear
probes were used. Observers were not blinded to the patient’s
clinical presentation.
Conclusion
Lung ultrasound provided the accuracy of 90.31% in diagnosis
of acute respiratory distress patients. It helped to start the
primary initial management of patient in the emergency room.
BLUE protocol avoided the need for urgent transfer of unstable
patients for CT scans and other definitive investigations,
and it allowed better resuscitation in the emergency room. It
can therefore be added as an adjuvant in initial methods of
investigation for respiratory distress patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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