BY

WIDIRAHARDJO

PULMONARY DEPARTEMENT SUMATERA UTARA UNIVERSITY

MEDAN
2023
• PMK NO: 24, 2020: PERATURAN MENTERI KESEHATAN
TENTANG PELAYANAN RADIOLOGI KLINIK

• LAYANAN STANDART (USG) YANG SUDAH DISEPAKATI

BERSAMA BISA DILAKUKAN OLEH LEBIH DARI 25.000
SPESIALIS, LEBIH DARI 16 SPESIALIS → 1.500
RADIOLOGIST (PROF ZAINAL MUTAQIN SpBS)
BEDSIDE LUNG ULTRASOUND IN EMERGENCY (BLUE)
PROTOCOL

• FIRST DESCRIBE BY DANIEL A LICHTENSTEIN IN 2008

• LAST REVISED ON 22 JUN 2021
• BLUE PROTOCOL IS A BASIC POINT-OF-CARE ULTRASOUND (POCUS)
EXAMINATION PERFORMED FOR UNDIFFERENTIATED RESPIRATORY
FAILURE AT THE BEDSIDE, IMMEDIATELY AFTER THE PHYSICAL
EXAMINATION, AND BEFORE ECHOCARDIOGRAPHY.
• SUCCESSFUL IN AVERAGE 90.316% CASES.
• BLUE PROTOCOL IN EMERGENCY DEPARTMENT IS EQUIVALENT TO
COMPUTED TOMOGRAPHY SCAN.
BEDSIDE LUNG ULTRASOUND IN EMERGENCY (BLUE)
PROTOCOL

• SIMPLE AND DICHOTOMOUS, AND TAKES FEWER THAN 3 MINUTES

TO COMPLETE. IT ANALYSES THREE STANDARDISED POINTS ON
EACH HEMITHORAX IN PATIENTS WITH ACUTE RESPIRATORY
FAILURE, AND SEEKING TO ESTABLISH THE PRESENCE OR ABSENCE
OF :
– LUNG SLIDING
– ANTERIOR LUNG ROCKETS
– POSTERIOR AND/OR LATERAL ALVEOLAR AND/OR PLEURAL
SYNDROME (PLAPS)
– A NON-COMPRESSIBLE DEEP VEIN
 THREE STANDARDISED POINTS ON EACH
HEMITHORAX

- THE UPPER ANTERIOR POINT,

- THE LOWER ANTERIOR POINT,
- PLAPS (POSTERIOR LATERAL ALVEOLAR OR
PLEURAL) POINT.
 TERMINOLOGY

• BAT SIGN : CORTICES AND POSTERIOR ACOUSTIC SHADOWING OF

THE RIBS ARE THE WINGS, THE HYPERECHOIC "BELLY" BEING THE
PLEURAL LINE

• A-LINES : HORIZONTAL ARTIFACTS ARISING FROM THE PLEURAL

LINE AT REGULAR INTERVALS WHICH ARE EQUAL TO THE SKIN-
PLEURAL INTERFACE DISTANCE - INDICATING PHYSIOLOGIC AIR
(BUT ALSO FREE AIR)
 TERMINOLOGY

• B-LINES : CORRELATED WITH INTERSTITIAL OEDEMA, THEY ARE

DEFINED ACCORDING TO SEVEN CRITERIA:
– COMET-TAIL ARTIFACTS:
– ARISING FROM THE PLEURAL LINE
– HYPERECHOIC
– LASER BEAM-LIKE:
– LONG, WITHOUT FADING
– ERASING A-LINES
– MOVING WITH LUNG SLIDING

• C-LINES : CENTIMETRIC IN SIZE, CONCAVE OR CURVILINEAR IN

SHAPE, ALVEOLAR CONSOLIDATION
 BEDSIDE LUNG ULTRASOUND IN EMERGENCY (BLUE)
PROTOCOL

• PATIENTS WITH ACUTE RESPIRATORY DISTRESS:

– A LINE (HORIZONTAL LINES -SEA SHORE)
– B LINE (LUNG ROCKETS)
– C LINE (SHRED SIGN)
– LUNG SLIDING,
– STRATOSPHERE SIGN
– VENOUS ANALYSIS

• EQUIPMENT: LOW FREQUENCY (2–5 MHZ)

CURVILINEAR PROBE AND HIGH FREQUENCY
(5–10 MHZ) LINEAR PROBE
BEDSIDE LUNG ULTRASOUND IN EMERGENCY (BLUE)
PROTOCOL
PROFILES

• A-PROFILE: ANTERIOR LUNG-SLIDING WITH A-LINES

• A'-PROFILE: A-PROFILE WITH ABOLISHED LUNG SLIDING
• B-PROFILE: ANTERIOR LUNG-SLIDING WITH LUNG ROCKETS
• B'-PROFILE: B-PROFILE WITH ABOLISHED LUNG SLIDING
• A/B-PROFILE: UNILATERAL B LINES, CONTRALATERAL A-LINES
• C-PROFILE: ANY ANTERIOR LUNG CONSOLIDATION (A THICK,
IRREGULAR PLEURAL LINE IS AN EQUIVALENT)
NORMAL LUNG ULTRASOUND IMAGES
- TWO RIB SHADOWS ARE SHOWN IN FIGURE
- HYPER ECHOIC PLEURA IS SEEN
 NORMAL LUNG ON M-MODE
- HORIZONTAL LINES (SEA SHORE) SUGGESTIVE OF THE
CHEST WALL
- GRANULAR PATTERN SUGGESTIVE OF LUNGS
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE/ASTHMA

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
PULMONARY EDEMA/INTERSTITIAL SYNDROME

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
PNEUMONIA

A SHREDDED (SHRED SIGN), FRACTAL BOUNDARY BETWEEN

THE CONSOLIDATION AND THE UNDERLYING AERATED LUNG.
PNEUMOTHORAX

- ABSENT LUNG SLIDING

- STRATOSPHERE SIGN ON M-MODE
- THE LUNG POINT (NOT FEATURED HERE) CONFIDENTLY
RULES IN THE DIAGNOSIS
PLEURAL EFFUSION

- ANECHOIC
- THE INSPIRATORY SHIFT OF THE LUNG LINE
TOWARD THE PLEURAL LINE IS CALLED THE
SINUSOID SIGN VISUALIZED ON M-MODE
PULMONARY EMBOLISM

• NORMAL PROFILE IS FOUND MOSTLY IN PULMONARY

EMBOLISM.
• VENOUS SCANS IMPROVED SENSITIVITY OF DIAGNOSIS WITH
FEMORAL VEIN THROMBOSIS.
• PULMONARY EMBOLISM WAS PROVED BY HIGH-
RESOLUTION CT THORAX.
 VENOUS ANALYSIS
• PEMBULUH VENA NORMALNYA AKAN KOLAPS SAAT DILAKUKAN
KOMPRESI. ALIRAN PEMBULUH DARAH VENA PROKSIMAL
NORMALNYA AKAN MENINGKATKAN SAAT DILAKUKAN KOMPRESI
PADA DISTAL PEMBULUH DARAH VENA. ABSENNYA PENINGKATAN
ALIRAN DARAH SAAT DILAKUKAN KOMPRESI PADA DISTAL
PEMBULUH VENA DAPAT MEMBERIKAN PETUNJUK ADANYA
BEKUAN DARAH (CLOT) DI ANTARA PEMBULUH VENA YANG
DILAKUKAN KOMPRESI DAN PROBE USG.

• PADA PEMERIKSAAN USG EKSTREMITAS BAWAH, TROMBUS PADA

PEMBULUH VENA DAPAT DIIDENTIFIKASI OLEH ADANYA
GAMBARAN HYPERECHOIC DAN PEMBULUH VENA YANG TIDAK
KOLAPS PADA SAAT DILAKUKAN KOMPRESI.
FEMORAL VEIN
FEMORAL VEIN DOPPLER ULTRASOUND NORMAL VS
ABNORMAL IMAGE APPEARANCES | DEEP VEIN
THROMBOSIS USG SCAN
LIMITATION

• FALSE NEGATIVES
– PATIENTS WITH COPD COMMONLY SHOW SIGNS ON
ULTRASOUND MIMICKING A PNEUMOTHORAX 7,8
– OBESITY
– SUBCUTANEOUS EMPHYSEMA
– LESIONS THAT DO NOT REACH THE PLEURA

• FALSE POSITIVES
– CARDIOGENIC PULMONARY OEDEMA AND ANTIBIOTIC
THERAPY MAY RESULT IN PNEUMONIA FALSE POSITIVES
WIDIRAHARDJO - 2023