Author’s Accepted Manuscript

Thoracic Ultrasound: Technique, Applications and

Interpretation

Suraj H. Rambhia, Catherine A. D′Agostino, Ali

Noor, Robert Villani, Jason J. Naidich, John S.
Pellerito
www.elsevier.com/locate/enganabound

PII: S0363-0188(16)30128-1
DOI: http://dx.doi.org/10.1067/j.cpradiol.2016.12.003
Reference: YMDR476
To appear in: Current Problems in Diagnostic Radiology
Cite this article as: Suraj H. Rambhia, Catherine A. D′Agostino, Ali Noor,
Robert Villani, Jason J. Naidich and John S. Pellerito, Thoracic Ultrasound:
Technique, Applications and Interpretation, Current Problems in Diagnostic
Radiology, http://dx.doi.org/10.1067/j.cpradiol.2016.12.003
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Title: Thoracic Ultrasound: Technique, Applications and Interpretation
Suraj H. Rambhia MD, Catherine A. D’Agostino, MD, Ali Noor MD, Robert Villani, MD, Jason J. Naidich,
MD, and John S. Pellerito, MD

Department of Radiology, North Shore University Hospital, Northwell Health. Manhasset, NY.

Abstract:

Thoracic ultrasound is used at the bedside in emergency and critical care settings. Advantages of
ultrasound include rapid real-time, low-cost, diagnostic information that can direct patient care without
the use of ionizing radiation. We describe methods for how to perform lung ultrasound, with the intent
to educate the radiologist who might otherwise be relatively unfamiliar with thoracic sonography. We
describe and depict the normal sonographic appearance of lung anatomy. We also show the
sonographic appearance of a wide range of lung and pleural pathologic pathologies such as pneumonia,
pneumothorax, as well as lung and pleural masses. We review various lines and signs described in the
literature, such as A-lines, B-lines, the stratosphere sign and the bat-wing sign. Finally, we correlate our
findings with chest x-ray and computerized tomography to emphasize the anatomy.

Teaching Points:

(1) Lung ultrasound is a valuable tool utilized by sonologists who practice largely in the emergency
and critical care settings. Radiologists are beginning to increase their awareness of the growing
role and importance of lung ultrasound as a bedside tool, as well as in the ultrasound suite as a
means of directly probing the lung or characterizing pathology seen incidentally on abdominal,
neck or chest wall sonography.
(2) Proper technique can involve either curved or linear probes based on patient’s body habitus and
need for superficial versus deep penetration into the lung. Combined B-mode and M-mode
coupled with patient’s clinical evaluation is imperative to performing a diagnostic exam.
(3) The presence of air in the lung results in reverberation artifacts called A-lines and B-lines which
can both be seen in normal and pathological settings. While other types of lines and signs are
described in the literature, understanding the role of A-lines and B-lines in normal and abnormal
pathology can help establish a foundation for understanding lung ultrasound.
(4) Formalized lung ultrasound protocols such as BLUE and FALLS have been established to allow for
rapid assessment of patients in critical settings and provide clinical guidance at the bedside.
These entities include dynamic evaluation to assess for fluid resuscitation of a patient in shock
and multi-facetted approach for evaluating of pulmonary embolism.
(5) Lung ultrasound can also be used for guidance of therapeutic procedures such as
thoracocentesis as well as diagnostic procedures such as lung and pleural biopsies in real time.
Introduction

Thoracic ultrasound is a point of care tool used at the bedside in emergency and critical care settings to
assess and triage patients with a wide variety of pulmonary pathologies. Specifically, lung and pleural
ultrasound techniques have been developed to provide rapid real-time, low-cost, diagnostic information
that can direct patient care without the use of ionizing radiation [1-5]. Several studies have described
the value of lung ultrasound in select clinical situations compared to conventional thoracic imaging
modalities such as chest radiographs and computed tomography [1-4]. The clinical indications for lung
and pleural ultrasound include, but are not limited to, dyspnea, hypercapneic or hypoxemic respiratory
failure, undifferentiated shock, suspicion for pneumothorax, assessment of volume status, assessment
of pleural effusions, evaluation for the presence of alveolar consolidation, diaphragmatic function,
abnormal blood gas, trauma (FAST), pleural based masses, as well as planning and guidance for an
invasive thoracic procedure (Table 1). Often neglected when performing dedicated ultrasound
examinations of the abdomen, chest wall, or heart, the lung can be surveyed for evidence of pathology
such as pneumonia, edema, chronic interstitial changes, pleural pathology, and pneumothorax [4-6].
Furthermore, increased utilization of lung ultrasound at the bedside has led to the development of
collaborative guidelines to standardize lung ultrasound technique and provide uniform framework for a
vast array of clinical entities around the world [7].

Our approach for this discussion is to provide the reader with a guide for lung and pleural ultrasound
image analysis. Here we present an overview of the basics of lung ultrasound, describing normal and
pathologic findings. We acknowledge and draw from the published literature that has been amassed by
our emergency, critical care and radiology colleagues. Their contributions provide the basis for
dedicated lung and pleural ultrasound for a number of clinical applications. This information also
improves detection and recognition of incidental findings that can be seen on ultrasound examinations
of the neck, chest and abdomen.

Scanning technique

Ultrasound of the lungs presents several challenges secondary to rib shadowing and limited penetration
through air filled lung parenchyma. Because of these challenges, lung ultrasound scanning utilizes a
meticulous targeted approach. We maximize coverage with five major positions on the chest wall:
upper anterior, lower anterior, lateral thorax in the mid-axillary line, upper posterior, and lower
posterior medial to the scapular margin (Figure 1A). Standard curvilinear or high frequency linear probe
is positioned in either sagittal, transverse or intercostal (oblique) position. Sagittal or
transverse/intercostal probe orientation allows for optimization of the image with a given lung window
(Figure 1B). When positioned in a rib interspace mild pressure can be placed to splay the ribs and allow
for optimization of the window. This allows for maximal coverage as the transducer is moved over the
chest wall. High-frequency linear probes can also be utilized to provide increased definition of the chest
wall anatomy, which includes the intercostal musculature, rib margins, and pleural anatomy (Figure 2).
Evaluation for pleural based pathology is simultaneously performed at each of the 5 positions with
attention to the apposition of the visceral and parietal pleura. Normal apposition of the visceral and
parietal pleura results in a phenomenon termed ‘lung sliding.’ Pathology of the pleura, which can be
seen using either curvilinear phased array or high frequency linear transducers, includes pleural
effusion, pleural thickening and pleural irregularity. As a general rule, pleural effusions tend to localize
dependently, and so the dynamic evaluation of pleural fluid as a patient changes from a supine to
decubitus position can allow for rapid assessment of complexity of an effusion.

A combination of probe placement, probe selection, B-mode, M-mode and clinical evaluation is utilized
for complete thoracic ultrasound assessment. B-mode sonography is utilized for general visualization of
pulmonary pathology. M-mode sonography allows for observation of dynamic changes of the chest wall
and pleural surface oscillating at a different rate than the lung parenchyma. For example, a normal lung,
demonstrating lung sliding on B-mode will have a characteristic appearance on M-mode.

Lung Ultrasound Findings: Normal and Abnormal

Lung Sliding

Understanding of normal thoracic ultrasound anatomy begins with understanding the anatomy of the
chest wall. As noted earlier, high frequency linear transducers will provide increased definition of the
intercostal musculature, rib shadows, and the pleural line, often producing the characteristic ‘bat-wing’
sign (Figure 2). High frequency transducers, while providing high superficial resolution, will often not
penetrate deeper into the lung parenchyma. For this reason, a lower frequency curved array probe is
often used for providing a wider window with increased depth [5]. The normal lung will demonstrate
sliding of the visceral and parietal pleura, which can be seen in real-time with standard cine clip
recording. Presence of lung sliding has high specificity for the exclusion of pneumothorax [8, 9] and can
be readily visualized in real-time with standard cine clip recording (Video Clip 1). However, while the
absence of lung sliding in the setting of trauma is highly sensitive for the presence of pneumothorax, the
absence of lung sliding has been described in other pathologies such as total lung atelectasis, pleuro-
parenchymal adhesions, one-lung intubation, and sub-pleural blebs or bullae [10].

A-Lines and B-Lines

Use of a deeper penetrating curved array probe at 4-5Mhz to interrogate a normal lung produces a
characteristic line pattern, which is the result of acoustic reverberation artifact of normally aerated lung.
The so called A-line pattern presents as several echogenic parallel lines emanating deep to the pleural
surface. The distance between the ‘A-lines’ is equal to the skin to pleural surface distance (Figure 3).
Normal A-line pattern of the lung is presented in contrast with contralateral large pleural effusion in a
patient with lung adenocarcinoma (Figure 4). The absolute lack of A-line reverberation artifact of the
contralateral lung in Figure 4 is due to the lack of aeration, what we often refer to as atelectasis. In
contrast, dynamic loss of A-line pattern with expiration is seen in pneumothorax and has been described
as the ‘lung point’ sign. In this process, the partially aerated- partially collapsed lung, comes into and
out of view of a fixed transducer providing the clinician with an intermittent A-line pattern in the field of
view. The M-mode counterpart to the ‘lung point’ sign is referred to as the ‘stratosphere sign.’

B-lines, also described as ‘lung-rockets,’ emanate perpendicularly from the pleural surface and in
isolation, can be seen in normal aerated lung as well. However, with increasing number, generally
above 3 per interspace, suspicion for alveolar-interstitial lung process rises (Figure 5) [4, 11-14]. A
gradual change in the characteristic line pattern line pattern from parallel A-lines to perpendicular lines
known as ‘B-lines’ is seen in patients who transition from having ‘dry-interlobular septa’ (A-line
predominant pattern) to ‘wet-interlobular septa’ (B-line predominant pattern). ICU-based studies in
mechanically ventilated patients have demonstrated that patients with A-line predominant pattern have
a 93% positive predictive value (PPV) for a pulmonary capillary wedge pressure (PCWP) less than
13mmHg and an even higher 97% PPV for PCWP less than 18mmHg [14, 15]. For this reason, an A-line
predominant pattern is correlated with a PCWP less than 18mmHg [15], and a patient with an alveolar-
interstitial syndrome will often show a transition of A-lines to B-lines more dependently.

Along these lines, lung ultrasound has been reported as a way of diagnosing neonatal respiratory
distress syndrome early on, prior to chest radiographic findings [7, 16]. A case of a newborn premature
infant with respiratory distress syndrome is presented (Figure 6) with chest x-ray comparison. Normal
A-line pattern is seen primarily of the right upper lung, however, change in the lung parenchymal line
pattern from A-lines to B-lines is noted of the right lower lung, likely representing dependent interstitial
edema.

Consolidation

Community acquired pneumonia is a highly prevalent clinical entity which can often present as a lobar
consolidation. When seen peripherally in the lung, contact of a consolidation with the pleural surface
allows for optimal detection [10]. Loss of the high impedance of normal air filled lung from fluid filling
the alveoli generates impedence variations resulting in perpendicularly oriented B-lines and the loss of
parallel A-lines. This confluence of B-lines is seen in patients with focal lung consolidation (Figure
7). The lack of aeration of the involved lung results in a tissue-like appearance referred to
“hepatization” as the echotexture is similar to liver parenchyma. The border between the lung
consolidation and the normal aerated lung will appear irregular. The air within the bronchi in an
alveolar consolidation is dynamic in appearance, also another differentiating factor between atelectasis
and pneumonia on ultrasound [17]. It is visualized as bright branching echoes moving through the
bronchi during real time scanning. This finding helps to distinguish pneumonia from resorptive
atelectasis. Another feature supporting the diagnosis of pneumonia is the branching blood flow pattern
in the infected consolidated lung. The lack of color or power Doppler vascular flow in an atelectatic area
of lung may be useful in distinguishing these two entities [18].
Pleural Effusion

The ability of ultrasound to detect minute quantities of pleural fluid has long been known. Conventional
supine chest radiography can detect pleural fluid in the range of 200-500mL [10; 19], with slightly
increased sensitivity on lateral radiographs. Ultrasound, in contrast, has a sensitivity of 0.89-1.00 and
specificity of 0.96-1.00 for fluid volumes in the range of 5-20mL [10; 20-21].

Characteristic signs and patterns have also been described on B-mode and M-mode ultrasound as a
means of evaluating pleural pathology. As described above, the M-mode seashore pattern, representing
normal apposition of the visceral and parietal pleura, results from inherent differences in oscillation of
the chest wall and lung parenchyma. The granular appearance of the lung parenchyma on M-mode
results in the sandy appearance for which the sign is named (Figure 8A). Disruption of the seashore
pattern can be the result of fluid (pleural effusion/hydrothorax) or air (pneumothorax).

Pleural fluid will have its own oscillatory pattern on M-mode, separate from the fine oscillations of the
chest wall and lung parenchyma, often labelled a ‘sinusoidal’ pattern (Figure 8B). The pulsations and
resultant sinusoidal pattern are likely the result of heart motion. Other examples of pleural effusions
are shown on 2-D and M-mode ultrasound in a patients with CHF (Figure 9) and inflammatory breast
cancer (Figure 10). Simple and non-simple effusions have been described in the literature [22-25]. One
characteristic ‘echogenic swirl’ pattern has been used to describe non-simple effusions related to
malignancy [26]. However, the echogenicity or lack thereof in assessing an effusion has not been shown
to correlate with simple/transudative versus other more complex/exudative effusions [27].

Empyema

Increased complexity and loculated pleural collections can be seen in the setting of empyema. A case of
a 3-year-old patient presented with cough and fever and reportedly had non-resolving symptoms after a
failed an antibiotic trial. An air-fluid pleural based collection was suspected on the chest-xray, and was
concerning for empyema. An ultrasound was subsequently performed, allowing for characterization of
the lung consolidation with confluent B-lines and surrounding associated heterogeneous collection in
the pleural space. The collection demonstrated multiple echogenic foci compatible with presence of air
(Figure 11). A CT scan confirmed ultrasound findings. The patient was treated with chest tube drainage
and subsequently improved.

Pneumothorax

In the emergency and critical care settings, the ability to diagnose pneumothorax effectively in a timely
manner at the bedside with ultrasound has proven to be valuable. On B-mode, a normally aerated lung
that is only partially collapsed should present with A-lines intermittently as the patient respires. The
presence of lung sliding effectively excludes pneumothorax. The absence of lung sliding is non-specific
and can be related to other pathologies other than pneumothorax, such as total lung atelectasis, pleuro-
parenchymal adhesions, one-lung intubation, and sub-pleural blebs or bullae [10]. However, presence of
a lung point has been shown to be a highly specific finding [8, 10], described below.
The intermittent appearance of A-lines would occur at the ‘point’ where the pneumothorax occurs, thus
the term ‘lung-point’ sign. M-mode correlates of this finding are the ‘stratosphere sign’ or ‘bar-code’
sign which refers to the apparent layered appearance of the lung and loss of the normal pleural line in
the setting of pneumothorax (Figures 12 and 13). The presence of stratosphere or bar-code signs on M-
mode and/or the presence of a lung point sign on M-mode allows for the diagnosis of pneumothorax.

Evaluation of the lungs is performed with ultrasound routinely before and after thoracentesis.
Evacuation of a simple pleural effusion is demonstrated (Figure 14). Often, the ultrasound will allow for
more sensitive detection for presence of residual fluid or pneumothorax. Evacuation of a larger pleural
effusion in a patient with long standing sarcoidosis demonstrates presence of a trapped lung (Figure 15).
While real-time ultrasound imaging can also demonstrates widening of the pleural space in a similar
manner to that of a pleural effusion, the evaluation for post-procedural pneumothorax would involve
systematic assessment for presence or absence of lung sliding. With absent lung sliding, the finding of a
lung point sign on B-mode or stratosphere sign on M-mode would suggest the presence of
pneumothorax with a high degree of specificity.

Lung ultrasound has been proven to be beneficial in the setting of trauma for the diagnosis of
pneumothorax as comparative chest radiographs taken in the supine, non-upright position
demonstrated lower sensitivity [28].

Emphysematous Disease

Patients with emphysematous changes of the lung and bullous disease may also display irregularity at
the pleural interface with associated with loss of normal A-line pattern (Figure 16). This may, at times,
lead to confusion when evaluating the patient, requiring correlating with patient’s overall clinical status
and laboratory markers for optimal diagnosis. In Figure 16, a patient with extensive bullous changes at
the lung bases and ultrasound findings of irregularity at the pleural interface, loss of normal A-line
aeration pattern and presence of a few B-lines. The less-diseased upper right lung demonstrates faint A-
lines, however, again irregularity at the pleural interface.

Lung Ultrasound Protocols

Minimizing inter-observer variability that occurs in lung ultrasound studies has provided an impetus for
development of scanning protocols to standardize lung and pleural ultrasound imaging. These protocols
have been given names such as: BLUE (bedside lung ultrasound in emergency), PINK (an ARDS specific
protocol given the color name designation specifically for the avoidance of hypoxia that would result
from transporting a patient in ARDS to CT [15, 29], RUSH (rapid ultrasound in shock and hypotension),
FALLS (fluid administration limited by lung sonography), SESAME, and many others [1-4]. Most of these
protocols implement similar basic techniques for probe selection, orientation, and settings with some
variation in probe placement on the chest as we have outlined earlier. The evaluation of the patient
with these protocols often includes dynamic clinical examination, monitoring and assessment along with
ultrasound.
BLUE Protocol

The BLUE protocol, bedside lung ultrasound in emergency, focuses on the immediate diagnosis of
respiratory failure. This evaluation may uncover specific lung pathologies including pneumonia,
congestive heart failure, COPD, asthma, pulmonary embolism and pneumothorax [15] and involves
recognizing set signs and patterns which correlate with normal versus pathological findings. The BLUE
protocol, describes standard points for interrogating the lung: upper anterior thorax, lower anterior
thorax, and posterolateral thorax, with emphasis on following the contour and anatomy of the lung [15].

The BLUE protocol, while serving as a foundation for establishing our own, more comprehensive, lung
ultrasound technique (Figure 1A, 1B), has also served as a foundation for establishment of other more
clinically driven lung ultrasound protocols such as FALLS. FALLS protocol describes the assessment of
the hemodynamically unstable patient with suspected thoracic pathology and is implemented to
expedite the diagnosis of septic shock [15, 29]. Under FALLS, initial evaluation involves assessment for
pericardial effusion, right heart enlargement, and lung sliding (to be discussed later) to assess the
likelihood of pericardial effusion, pulmonary embolism or pneumothorax. Subsequently, the patient is
monitored with ultrasound while fluid is administered to assess lung parenchymal line pattern (also to
be discussed later) [29]. Prior studies have correlated changes in lung parenchymal line patterns on
ultrasound to actual physical pulmonary arterial pressures [15, 29]. Thus, decisions to give or hold fluid
from a patient are made based on ultrasound of the lungs and clinical assessment rather than
conventional chest x-ray or CT. A chest CT certainly would not be suitable for an acutely unstable
patient, thus providing a vital role for lung ultrasound to have real value in the clinical setting.

Role of Lung Ultrasound in Management of Sepsis and Septic Shock

Management of patients in sepsis and septic shock is a common clinical scenario encountered in both
the emergency department and the intensive care unit. In this patient population, identifying
hypovolemia and fluid status is extremely important for clinicians and their management of critically ill
patients. Traditional methods of volume assessment such as jugular venous pressure, measurement of
central venous pressure or use of the pulmonary arterial catheter have each been scrutinized for their
lack of accuracy in critically ill patients [30]. Portable ultrasound units are used at the bedside to
evaluate pleural abnormalities and in cases of pleural effusions, are used to guide for thoracentesis.
Ultrasound was found to be more sensitive for the evaluation of pleural fluid than conventional
radiograph and also demonstrated easy differentiation between loculated pleural fluid and pleural
thickening [31]. Compared with computerized tomography, ultrasound has a 95% sensitivity for
detection of pleural disease in patients with complete opacification of a hemithorax on chest radiograph
[32].

An advantage of thoracic ultrasound in the assessment of pleural fluid includes the ability to position the
patient during real-time imaging. Pleural fluid is dependent on the law of gravity and therefore collects
on the dependent aspect of the thorax. Positioning the patient so that their ipsilateral arm is up to or
above their head widens the intercostal spaces and facilitates acquisition of images [6].
More advanced echocardiographic techniques have also been shown to accurately assess volume status.
Continuous wave Doppler to observe respiratory variation in volume-time integrals from the left
ventricular outflow tract [33]. Alternatively, trans-esophageal echocardiography has been used to assess
superior vena cava size variation for assessment of fluid status [34].

Dynamic sonographic assessment also includes evaluation of parameters such as IVC variability, right
atrial size, and lower extremity venous compression. IVC variability has been described in assessment of
volume status, as means of assessing fluid status in patients presenting with shock and, more
specifically, as a means of assessing response to fluid resuscitation. The reliability of IVC variability
assessment on B-Mode and M-Mode for assessing volume status has been debated in the literature
[10].

Ultrasound for Evaluation of Pulmonary Embolism

While multi-detector CTPA has become the gold standard for diagnosis of pulmonary embolism, there
are certain clinical situations where it would be contraindicated, such as in patients with renal
insufficiency, pregnancy, or overt hemodynamic instability. In such situations, alternative methods have
been sought to use a combined clinical and imaging approach to evaluate a patient with for pulmonary
embolism, namely via ultrasound [35].

Lung ultrasound evaluation for pulmonary embolism involves finding either a normal aeration pattern or
unilateral consolidation pattern, as would be seen in patients with pulmonary infarct. By adding limited
echocardiography to evaluate for right heart strain and a lower extremity duplex study to evaluate for
DVT, the radiologist and clinician are afforded additional data to assess patient’s risk for having a PE. A
study has established a 90% sensitivity and 86.2% specificity for diagnosis of pulmonary embolism, using
this three-pronged approach [36]. In this study, lung ultrasound was the highest performer with a
sensitivity of about 60%. The gold standard remains multidetector CT pulmonary angiography [37].

Ultrasound compared to CT

Role of Ultrasound in Biopsy Technology

New advances in ultrasound technology have enabled sonographers to interrogate much more of the
human body than ever before [38-43]. Endobronchial Ultrasound (EBUS) is a method which has proved
to be effective for detection and biopsy of lung lesions, however it is invasive and costly and requires
sedation. Transthoracic Ultrasound (TTUS) detection of lung and pleural based lesions has reached a
point where many such lesions can be located, characterized and percutaneously biopsied. Two cases of
biopsied lung and pleural lesions are shown (Figures 17 and 18, respectively).

Current ultrasound machines with the latest technology have excellent resolution while evaluating
the lung and are able to find many lesions, especially peripheral ones, which were difficult to evaluate in
the past. Lesions of the peripheral lung are also well visualized in most cases. Lesions of the peripheral
lung, pleural based lung masses, and superficial soft tissues are well visualized, and thus are amenable
to ultrasound guided biopsy. Masses of the anterior mediastinum are accessible for ultrasound guided
biopsy as well.
Traditionally percutaneous lung biopsy has been performed via CT guidance. This is because
many lung nodules/masses are deep within the lung parenchyma shielded from ultrasound by the air
content of the alveoli. CT guidance works well on such lesions, however there are several problems. CT
guided lung biopsy is essentially a blind procedure as the needle is advanced, time consuming and
costly, and employs ionizing radiation. Ultrasound offers an improved method for percutaneous biopsy
when a lesion is visible and allows for real time guidance. Lack of ionization radiation and lower cost
favor ultrasound as well.

Summary

Thoracic ultrasound is a point of care tool used in emergency and critical care settings. We
demonstrated normal lung anatomy and primary lung pathology using ultrasound as the primary
modality. Further awareness of pathology of the lung on ultrasound in the radiology literature will allow
for improved characterization of lung pathology using primary global and targeted approaches in the
emergency and critical care settings. This will also aid detection and characterization of incidental lung
pathology on other more routine ultrasound examinations.

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Table 1. Clinical Indications for Thoracic Ultrasound

Dyspnea
Hypercapneic or hypoxemic respiratory failure
Undifferentiated shock
Suspicion for pneumothorax
Assessment of volume status
Assessment of pleural effusions
Evaluation for the presence of alveolar consolidation
Diaphragmatic function
Abnormal blood gas
Trauma (FAST)
Pleural based lesion evaluation
Planning/guidance for an invasive thoracic procedure

Figure Captions:
Figure 1. A. General lung ultrasound protocol at our institution involves 5-points of interrogation, the
(1) upper anterior chest, (2) lower anterior chest, (3) mid-axillary line, (4) upper posterior chest, and (5)
lower posterior chest. B. Sagittal and intercostal probe orientations can be implemented to optimize
the window of image acquisition.

Figure 2. High frequency evaluation of the thoracic wall demonstrates intercostal musculature, rib
shadows and thin echogenic line in between corresponding to the pleural line. Due to higher frequency
approach, there is limited penetration of the lung parenchyma on this image, albeit with increased
definition of the superficial structures. Corresponding CT image, shown as inset, demonstrates clear
lungs and no pleural pathology.

Figure 3. Configuration of ‘A-lines’ in a normally aerated lung, with use of a deeper penetrating curved
array probe at 4-5MHz, which is the result of acoustic reverberation artifact of appropriately aerated
lung. A-line pattern presents as several echogenic parallel lines emanating deep to the pleural surface.
The distance between the ‘A-lines’ is equal to the skin to pleural surface distance. Comparison chest CT
is provided demonstrating normally aerated lungs.

Figure 4. 85 year old male with adenocarcinoma of the lung and malignant left pleural effusion. Note
the normal aerated right lung, demonstrating ‘A-line’ pattern, in stark contrast to the atelectatic left
lung with surrounding large left pleural effusion.

Figure 5. B-line pattern seen within an intercostal space. B-lines, also described as ‘lung-rockets,’
emanate perpendicularly from the pleural surface (arrows) and in isolation can be seen in a normal
aerated lung. However, when seen in greater number, more than three per interspace, B-lines can be a
sign of interstitial lung disease.

Figure 6. 1-day-old premature infant with respiratory distress syndrome. Lung ultrasound demonstrates
both A-lines and B-lines. Normal A-line pattern is seen primarily of the right upper lung, however,
change in the lung parenchymal line pattern from A-lines to B-lines is noted of the right lower lung, likely
representing dependent interstitial edema. Corresponding chest x-ray is provided for comparison.

Figure 7. Left lower lobe consolidation noted on CT chest in a middle aged patient. There is a normal
right lung demonstrating A-line pattern. Loss of A lines and confluent B lines are noted of the left lower
lung on 2-D ultrasound, corresponding to the left lower lobe pneumonia seen on the CT scan. The lack
of aeration of the involved lung results in a tissue-like appearance referred to “hepatization” as the
echotexture is similar to liver parenchyma.

Figure 8. A. The seashore sign is an M-mode finding that represents normal apposition of the visceral
and parietal pleural. Anything occupying the pleural space will disrupt the normal seashore pattern. B.
Pleural fluid results in the characteristic sinusoidal pattern on M-mode, resulting from oscillation of the
lung parenchyma as it is bathed in pleural fluid.

Figure 9. Elderly patient in congestive heart failure was shown to have small left pleural effusion, simple
in appearance, seen on 2-D grayscale ultrasound and M-Mode. Corresponding chest CT image is
provided for comparison.

Figure 10. Patient with inflammatory breast cancer patient demonstrating large malignant right pleural
effusion seen on 2-D grayscale ultrasound and M-Mode. Corresponding chest x-ray and chest CT images
are provided for comparison.

Figure 11. 3 year old male with cough and fever and reported failed antibiotic trial. Found to have
loculated air and fluid collection on X-ray. An ultrasound was subsequently performed, allowing for
characterization of the lung consolidation with confluent B-lines and surrounding associated
heterogeneous collection in the pleural space. The collection demonstrated multiple echogenic foci
compatible with presence of air highly concerning for empyema. Note displacement of the pleural line
and evidence of ‘B’ lines in perpendicular orientation to lung/pleura interface. See video clip 2.
Figure 12. Left sided pneumothorax on chest x-ray, denoted by asterisk, with corresponding
‘stratosphere’ sign on M-mode ultrasound. Real-time ultrasound imaging can also demonstrates
widening of the pleural space in a similar manner to that of a pleural effusion.

Figure 13. Patient with new-onset right sided pleuritic chest pain, found on ultrasound to have
‘stratosphere sign’ and loss of lung sliding. Chest x-ray performed minutes later demonstrated large
right pneumothorax, denoted by asterisk, and was subsequently treated with chest tube placement.

Figure 14. Ultrasound guided thoracentesis of a simple pleural effusion. Pre- and post-thoracentesis
ultrasound images demonstrate trace residual effusion. Partially re-expanded lung is seen on the right
ultrasound image.

Figure 15. Ultrasound guided evacuation of a left sided pleural effusion in a patient with long standing
sarcoidosis. Pre-thoracentesis image demonstrates pleural effusion. Post-thoracentesis, the lung was
not fully re-expended, however, demonstrated marked irregularity on the lung surface which may have
been a combination of under-expansion and long standing parenchymal disease. Corresponding chest x-
ray was obtained.

Figure 16. 80 year old male with prior CT chest showing extensive bullous change and fibrosis.
Ultrasound demonstrates irregularity of the lung contour at the pleural interface and loss of normal
aeration pattern at areas of more diseased lung primarily involving the right lung base. Lung ultrasound
findings include, irregularity at the pleural interface, loss of normal A-line aeration pattern and presence
of a few B-lines. These findings, which may coincide with other lung pathology, may lead to confusion,
and thus would require correlation with patient’s clinical status and history to arrive at a proper
diagnosis.

Figure 17. Biopsy proven lung adenocarcinoma with corresponding CT images. Needle is localized to
the pleural based nodule, which is seen immediately adjacent to the heart.

Figure 18. CT and corresponding ultrasound images demonstrating biopsy of pleural based nodule.