Lung ultrasound in the critically ill

Daniel A Lichtenstein
1

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Abstract
Lung ultrasound is a basic application of critical ultrasound, defined as a loop associating urgent diagnoses with immediate therapeutic decisions. It requires the mastery of ten signs: the bat sign (pleural line), lung sliding (yielding seashore sign), the A-line (hori ontal artifact), the quad sign, and sinusoid sign indicating pleural effusion, the fractal, and tissue-li!e sign indicating lung consolidation, the "-line, and lung roc!ets indicating interstitial syndrome, abolished lung sliding with the stratosphere sign suggesting pneumothora#, and the lung point indicating pneumothora#. $wo more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. All of these disorders were assessed using %$ as the &gold standard' with sensiti(ity and specificity ranging from )*+ to ,**+, allowing ultrasound to be considered as a reasonable bedside &gold standard' in the critically ill. $he "L-.-protocol is a fast protocol (/0 minutes), which allows diagnosis of acute respiratory failure. It includes a (enous analysis done in appropriate cases. 1ulmonary edema, pulmonary embolism, pneumonia, chronic obstructi(e pulmonary disease, asthma, and pneumothora# yield specific profiles. 1ulmonary edema, e.g., yields anterior lung roc!ets associated with lung sliding, ma!ing the &"-profile.' $he 2ALL3-protocol adapts the "L-.-protocol to acute circulatory failure. It ma!es sequential search for obstructi(e, cardiogenic, hypo(olemic, and distributi(e shoc! using simple realtime echocardiography (right (entricle dilatation, pericardial effusion), then lung ultrasound for assessing a direct parameter of clinical (olemia: the apparition of "-lines, schematically, is considered as the endpoint for fluid therapy. 4ther aims of lung ultrasound are decreasing medical irradiation: the L-%I2L5 program (most %$s in A563 or trauma can be postponed), a use in traumatology, intensi(e care unit, neonates (the signs are the same than in adults), many disciplines (pulmonology, cardiology7), austere countries, and a help in any procedure (thoracentesis). A ,))8, cost-effecti(e gray-scale unit, without 6oppler, and a microcon(e# probe are efficient. Lung ultrasound is a holistic discipline for many reasons (e.g., one probe, perfect for the lung, is able to scan the whole-body). Its integration can pro(ide a new definition of priorities. $he "L-.-protocol and 2ALL3-protocol allow simplification of e#pert echocardiography, a clear ad(antage when correct cardiac windows are missing.
Keywords: Lung ultrasound, Acute respiratory failure, Acute circulatory failure, Pulmonary oedema, Pulmonary embolism, Pneumonia, Pneumothorax, Interstitial syndrome, luid therapy, !aemodynamic assessment, Intensi"e care unit Go to:

Lung ultrasound in the critically ill

$he possibility of e#ploring the lung using ultrasound, at the bedside and nonin(asi(ely, is gaining popularity among intensi(ists. Lung ultrasound would be of minor interest if the usual tools (bedside radiography, %$) did not ha(e drawbac!s (irradiation, low information content for radiography, need for transportation7). $his re(iew will show that ultrasound can be used instead of %$ in many cases.

9e used ultrasound first in ,):0, on occasion in 2ran;ois 2raisse<s I%- in ,):=>,):), then since ,):) in 2ran;ois ?ardin<s I%-, using the on-site ,):8 A65-@*** de(oted to cardiac assessment, in actual fact suitable for whole body and lung assessment and not larger than nowadays laptops A,B. At this time, although an old idea A8B, ultrasound was not routine in the I%-s and had neglected this (ital organ A0B. Cany doctors thought that lung ultrasound was unfeasible A@,=B. 2or demonstrating that this dogma was wrong, deciphering the artifact code was the easy part, but publishing was the hard one, far from finished. 9e will briefly consider the elements of this code, then maDor clinical uses. Lung ultrasound is part of critical ultrasound, defined as a whole-body approach using simple machines, one uni(ersal probe, new applications AE,FB. 4ur priority was to publish lung ultrasound, lea(ing little time for de(eloping basic fields (search for blood in trauma, (enous line insertion7).
Seven principles of lung ultrasound

,) Lung (and critical) ultrasound is performed at best using simple equipment. 8) In the thora#, gas and fluids ha(e opposite locations, or are mingled by pathologic processes, generating artifacts. 0) $he lung is the most (oluminous organ. 3tandardi ed areas can be defined A:B. @) All signs arise from the pleural line. =) 3tatic signs are mainly artifactual A),,*B. E) $he lung is a (ital organ. $he signs arising from the pleural line are foremost dynamic. F) Almost all acute life-threatening disorders abut the pleural line, e#plaining the potential of lung ultrasound.
Ten signs

$he ?apanese microcon(e# probe we use is directly applied to the intercostal space. In the "L-.-protocol, three standardi ed points are the upper "L-.-point, lower "L-.-point and 1LA13-point A:B (2igure ,). In A563 (1in!-protocol), a more comprehensi(e analysis includes four stages of in(estigation (anterior, lateral, posterior, apical). $en signs are currently assessed. All our studies directly compared ultrasound with %$.

igure 1 Areas of investigation and the BLUE-points. #$o hands placed this $ay %si&e e'ui"alent to the patient(s hands, upper hand touching the cla"icle, thumbs excluded) correspond to the location of the lung, and allo$ three standardi&ed points to be ...

$he pleural line generates the bat sign, a permanent landmar! (isible in all circumstances (agitated, bariatric patients, subcutaneous emphysema7). It indicates the parietal pleura (2igure 8).

igure * Normal lung surface. Left: +can of the intercostal space, #he ribs %"ertical arro$s), -ib shado$s are displayed belo$, #he pleural line %upper, hori&ontal arro$s), a hori&ontal hyperechoic line, half a centimeter belo$ the rib line in adults, #he proportions ...

$he normal lung surface (2igure 8) associates lung sliding with hori ontal repetitions of the pleural line, called A-lines. $hey indicate gas (physiological or free). Lung sliding is a to-and-fro mo(ement at the pleural line, spreading below. $he C-mode helps to understand that this mo(ement is relati(e to superficial tissues (seashore sign). Lung-sliding indicates that the pleural line also contains the (isceral pleura. Lung-sliding, physiologically more discrete at the upper parts, can be (ery discrete in pathological conditions. 3ome filters, especially a(erage, dynamic noise, can ma!e discrete lung-sliding more difficult to distinguish. 9e usually bypass all filters. 1leural effusion, a familiar field A,,,,B, became of interest to intensi(ists only recently. 4ur short probe is applied at the 1LA13-point, a posterior area accessible in supine patients, locating all free effusions, regardless their (olume A:B. $his direct approach generates standardi ed signs: the quad and sinusoid sign. $he deep boundary of the collection is regular, roughly parallel to the pleural line, and is called the lung line ((isceral pleura). $his draws the quad sign (2igure 0). $he lung-line mo(es toward the pleural line on inspiration. $his draws the sinusoid sign, which also indicates a low (iscosity, allowing fine needle insertion if needed (2igure 0). 4ur definition ma!es independent of the effusion color, traditionally anechoic: the most se(ere cases are echoic: empyema, hemothora#. 2or pleural effusions, sensiti(ity is )0+, specificity )F+ A,8,,0B. 3afe fluid withdrawal is possible e(en in radio-occult effusions in (entilated patients A,8B. 3mall effusions can be withdrawn for diagnostic purpose (e(en if they appear smaller on %$), pro(ided a ,=-mm inspiratory distance is respected A,8B. $his safety distance allows fluid withdrawal without precise (olume assessments, yet rough assessment is possible A,@B. 9e don<t use ultrasound during thoracentesis.

igure . leural effusion. Left and middle: minute pleural effusion at the PLAP+/point, 0elo$ the pleural line, a line regular and roughly parallel to the pleural line can be seen: the lung line, indicating the "isceral pleura %arro$s), #his line, together $ith ...

Lung consolidations are fluid disorders and, therefore, are easily tra(ersed by ultrasound. $his old potential A8,,=,,EB, long underused in I%-s, benefits from a standardi ed approach. Lung consolidations touch the wall in ):+ of cases A,FB, arise at any site, ma!ing ultrasound sensiti(ity dependent on the site, si e, time spent. Cost cases ()*+) locate, howe(er, at the 1LA13-point A,FB. In the critically ill, consolidations are nontranslobar or translobar, an important distinction because this generates different signs, each quite specific (2igure @). $he sign of nontranslobar consolidation (most cases) is the shred sign: the border between consolidated and aerated lung is irregular, drawing the fractal line, fully opposed to the lung line. $he sign of translobar consolidation is the tissue-li!e sign: it loo!s li!e li(er. "oth signs allow for )*+ sensiti(ity (as e#plained) and ):+ specificity A,FB. 4ther signs are reser(ed for difficult cases A,:B. $he dynamic air bronchogram A,FB and the lung pulse, which (isuali es heart beats at the pleural line through a noninflating lung, can distinguish pneumonia from atelectasis. 2or quantitati(e data, see 2igure @.

igure 1

Lung consolidation. #$o signs of lung consolidation, Left: a massi"e consolidation %probe at the PLAP+/ point) in"ades the $hole left lo$er lobe, 2o aerated lung tissue is present, and no fractal sign can be generated, #he deep border is at the mediastinal ...

Interstitial syndrome is a disorder rarely recogni ed with usual tools. Intensi(ists don<t de(ote much energy to its detection, yet this application has basic, une#pected potential. 4ur updated definition of the "-line requires three constant and four quite constant criteria A,)B. $he "-line is always a comet-tail artifact, always arises from the pleural line, and always mo(es in concert with lung-sliding. It is almost always long, well-defined, laserli!e, hyperechoic, erasing A-lines (2igure =). $his definition distinguishes it from all other comet-tail artifacts. "riefly, air and water are simultaneously hit by ultrasound beams, as occurring when subpleural interlobular septa are edematous A8*B. $hree or more "-lines between two ribs are called lung-roc!ets. Lung-roc!ets correlate with interstitial syndrome with )0+ accuracy using al(eolar-interstitial radiographic changes as reference, and full accuracy using %$ A8*B. -p to 0>@ "-lines are called septal roc!ets, correlated with Gerley "-lines A8,B. $wice as many, called ground-glass roc!ets, correlate with ground-glass areas A8*B. In the "L-.protocol, only anterolateral lung-roc!ets are considered: posterior interstitial changes can be due to gra(ity alone. Harmonics of modern machines can alter "-lines. $he "L-.-protocol can distinguish hemodynamic pulmonary edema from A563, %416, and rule out pneumothora# A88,80B as confirmed A8@-8FB.

igure 3 !nterstitial syndrome and the lung roc"ets. #$o examples of interstitial syndrome, Left: four or fi"e 0/lines %see precise description in the text) are "isible, called lung roc4ets %here septal roc4ets correlating $ith thic4ened subpleural interlobular ...

6iagnosis of pneumothora# requires three steps. Abolished lung-sliding, long described in horses A8:B, is found anteriorly in quite all significant cases in supine patients A8)B. It has a )=+ sensiti(ity (,**+ if re(isiting methodology) and ,**+ negati(e predicti(e (alue A0*B. 1neumothora# therefore is confidently discounted each time lung-sliding is present, as confirmed A0,-0@B. Lung-sliding can be e#tremely moderate, up to the lungpulse, an equi(alent of lung-sliding when searching for pneumothora#. 1neumothora# generates a completely motionless pleural line using real-time. C-mode shows a standardi ed stratified pattern below and abo(e the pleural line: the stratosphere sign (2igure E). 6yspnea generates interfering mo(ements abo(e the pleural line. Iascular probes are usually used, but our microcon(e# probe has no drawbac!s, plus the ad(antage of immediate whole-body assessment. Abolished lung-sliding is e(erything but specific: inflammatory adherences (i.e., A563), atelectasis (one-lung intubation), chronic adherences, fibrosis, phrenic palsy, Det (entilation, cardiopulmonary arrest, apnea, esophageal intubation, inappropriate settings, inappropriate probes are usual factors, and frequent in critically ill patients. $he positi(e predicti(e (alue of abolished lung-sliding, only :F+ in a general population A0*B, falls to =E+ in the critically ill A0=B, and to 8F+ in patients with respiratory failure A0EB. $he notion of ultrasound &false-positi(es' ma!es little sense when another sign is added: the A-line sign (i.e., no "-line seen), with E*+ sensiti(ity but ,**+ specificity, a logical finding: interlobular septa come only from (isceral pleura A80B. 4ne motionless "-line discounts pneumothora#. $oo superficial linear probes ma!e it difficult to distinguish "-lines from other comet-tail artifacts (2igure =). Abolished lung-sliding plus absence of "-lines, at the anterior area, in supine patients, is called A<-profile in the "L-.-protocol (2igure E). $he third stepJthe lung pointJis pathognomonic A0=B. It shows in patients with an A<-profile, at a precise location, lung signs suddenly appearing with respiration: transient "-lines, lung-sliding (2igure F). It is e#plained by the inspiratory increase of parietal contact of the collapsed lung. %omple# pneumothoraces with e#tensi(e adherences will not generate any lung-point. $he lung-point indicates that abolished lung-sliding is not lin!ed to technical flaws, modern machines, or e#cessi(e filters (modern equipments with time lags may generate issues). $he sensiti(ity is EE+: fully collapsed lungs cannot reach the wall. 3ensiti(ity for occult pneumothora# is F)+ A0FB, pro(ing that the lung-point indicates pneumothora# (olume: moderate if anterior, massi(e if posterior or

e(en absent. Lateral lung-points correlate with a )*+ need for drainage (ersus :+ with anterior lung-point A0FB, as confirmed A0@,0:B. 3ome seconds are required for well-trained physicians to determine lung-sliding, "-lines, or their absenceJless than , minute to detect a lung-point.

igure 5 neumothora# and the stratosphere sign. Left: same pattern as in igure *, i,e,, pleural line $ith A/lines, indicating gas belo$ the pleural line, 2ot "isible on the left image, lung sliding is totally absent, -ight: here on 6/mode, the abolition ...

igure 7 neumothora# and the lung point. A specific sign of pneumothorax, -eal/time mode allo$s detection of the inspiratory increase in "olume of the collapsed lung, 8hen reaching the chest $all $here the probe is laid, it ma4es a sudden change in the ultrasound ...

$he lung-pulse is useful for immediate diagnosis of an atelectasis (one-lung intubation included) A0)B. $he diaphragm is interesting, but we do not de(ote much time to careful analysis: locating the thoracoabdominal frontline and its respiratory mo(ement shows where it is and how it wor!s A@*B.
Clinical applications of lung ultrasound in the critically ill

How can lung ultrasound become a daily tool for the intensi(istK "y applying fast protocols de(oted to acute respiratory or circulatory failure or cardiac arrest, by limiting irradiation, mainly.
The approach to acute respiratory failure: the BLUE-protocol

Acute respiratory failure is a life-threatening condition whose cause is sometimes difficult to recogni e immediately. Initial mista!es ha(e deleterious consequences A@,B. $he e#treme patient<s suffering legitimi es the use of any tool that e#pedites relief. 5educing the time needed to pro(ide this relief is the aim of the "L-.protocol. $he "L-.-protocol, performed on dyspneic patients who will be admitted to the I%-, is a fast protocol: 0 minutes are required using suitable machines and the standardi ed points of analysis. Lo(ices can ta!e longer (this time depends on the simplicity and adequacy of their equipment, of the standardi ation of their training). "ased on pathophysiology, it pro(ides a step-by-step diagnosis of the main causes of acute respiratory failure, i.e., si# diseases seen in )F+ of patients in the emergency room, offering an o(erall )*.=+ accuracy A8:,@8B. $he "L-.-protocol combines signs, associates them with a location, resulting in se(en profiles (2igure :).

igure 9 $he BLUE-protocol decision tree. #his decision tree, slightly modified from the original article %Chest *::9;1.1:117<1*3), $ith the permission of Chest, indicates a $ay proposed for immediate diagnosis of the main causes of acute respiratory failure, ...

$he A-profile associates anterior lung-sliding with A-lines. $he A<-profile is an A-profile with abolished lung-sliding. $he "-profile associates anterior lung-sliding with lung-roc!ets. $he "<-profile is a "-profile with abolished lung-sliding. $he %-profile indicates anterior lung consolidation, regardless of si e and number. A thic!ened, irregular pleural line is an equi(alent. $he AM" profile is a half A-profile at one lung, a half "-profile at another. $he 1LA13-profile designates 1osteroLateral Al(eolar andMor 1leural 3yndrome. 1LA13 are sought for after detection of an A-profile (a pattern compatible with pulmonary embolism) and of a free (enous networ! (a pattern ma!ing the diagnosis of embolism less li!ely). $he profile combining A-profile, free (eins, and 1LA13 is called A-I-1LA13-profile. .ach profile is associated with a disease, schematically, with accuracy indicated in $able ,.

#able 1 Detailed performances of the 0L=>/protocol

$he "-profile suggests acute hemodynamic pulmonary edema with )F+ sensiti(ity and )=+ specificity. $he Aprofile associated with 6I$ pro(ides an :,+ sensiti(ity and ))+ specificity for pulmonary embolism. $he "<profile, AM"-profile, %-profile, and A-I-1LA13 profile are typical profiles indicating pneumonia. An A-profile without 6I$ or 1LA13 (the nude profile) is li!ely to be se(ere asthma or e#acerbated %416. $he A<-profile and a lung-point is specific to pneumothora#. $he "L-.-protocol is initiated Dust after the physical e#amination and followed by echocardiography, cardiac windows permitting, restricted to a basic, real-time analysis. %alled simple cardiac sonography at %.-52, this approach is increasingly de(eloping A@0B.

3pace lac!s to describe many subtleties. Hemodynamic pulmonary edema generates transudate, a !ind of oil e#plaining conser(ed lung-sliding ("-profile). 1neumonia generates e#udate, a !ind of glue, e#plaining the "<profile. $his partly e#plains the potential for distinguishing A563 from hemodynamic pulmonary edema. Hemodynamic edema generates the "-profile in )F+ of casesN A563 generates a profile of pneumonia in :E+ of cases A0EB. $his is found again in the Italian literature, under the name of spared areas (AM"-profile), lung consolidations (%-profile), pleural line modifications (%-profile) A@@B. %ountless subtleties (such as the %<-profile, a %-profile with abolished lung sliding) will be included in the e#tended "L-.-protocol, a definiti(e (ersion of the "L-.-protocol, which must be considered as a preliminary approach using simplicity. Auscultation data, echocardiographic data also will be included. 5egarding rare, double, absent causes, read A@8B. 2alse-positi(es and false-negati(es are of interest, because ultrasound pro(ided data that questioned a posteriori the (alue of the &gold standard' A0EB. Let us remind that, more than simple %$ (which isolated does not ha(e a perfect discriminatory power for a gi(en disease), the &gold standard' was the final diagnosis of the hospitali ation report.
He odyna ic assess ent of circulatory failure using lung ultrasound: !ALLS-protocol

Acute circulatory failure is associated with high mortality. Cany tools ha(e been successi(ely used A@=B. .chocardiography is one of the most popular A,B. $his presupposes e#pertise, suitable cardiac windows, or transesophageal approach. Here, we use a fast protocol again based on pathophysiology. $he heart approach is limited to the simple cardiac sonography. $he lung approach will compensate for any lac! of echocardiographic e#pertise, considering a direct parameter of clinical (olemia. 6ata for using the 2ALL3-protocol (2luid Administration Limited by Lung 3onography) ha(e been published, showing the correlation between an A-profile or equi(alents (AM"-profile) and a low pulmonary artery occlusion pressure (1A41), with a ,:-mmHg (alue occurring when "-lines appear A@EB. %a(al (ein analysis is associated to the 2ALL3-protocol, especially in the case of initial "-profile. $he 2ALL3-protocol follows 9eil<s classification of shoc!. It first searches for substantial pericardial effusion (li!ened to pericardial tamponade in acute circulatory failure), then for right (entricle dilatation (suggesting, in this conte#t, pulmonary embolism, schematically). If the cardiac windows are suboptimal, the "L-.-protocol is used instead. $hen, tension pneumothora# is sought for. If these disorders are absent, obstructi(e shoc! can be discounted, schematically. %ardiogenic shoc! from the left heart (i.e., most cases) is defined by low cardiac output and high 1A41. In the absence of a "-profile, such cardiogenic shoc! can be discounted. $he remaining causes are hypo(olemic and distributi(e shoc!. At this step, patients with the A-profile or equi(alents, pro(ing dry lungs, are called 2ALL3-responders. $hey are those who can, but mostly must, recei(e fluids, a therapy common to both causes. $he 2ALL3-protocol per se begins: fluid administration. A hypo(olemic mechanism will benefit from fluid therapy, with corrections of the circulatory failure, and unchanged A-profile. If no clinical impro(ement occurs, fluids e(entually penetrate the lung, which is normally fluid-free. Interstitial edema always precedes al(eolar edema A@FB and is detected by ultrasound at an early step clinically silent, before gas e#change impairment A@:,@)B. $he change from A- to "-lines indicates the endpoint for fluid therapy. Associated with no impro(ement of circulatory failure, this indicates, schematically, the only remaining mechanism: distributi(e shoc!, meaning in current practice septic shoc! (ob(ious diagnoses such as anaphylactic shoc! or rarities being e#cluded). $his septic shoc! has Dust benefited from one maDor therapy,

following the current guidelines A=*B, with two ad(antages. .arly fluid therapy in sepsisK 2ar before the diagnosis of septic shoc!. Cassi(eK -p to the last admissible drop using pathophysiological basis. $he intensi(ist can now consider that this fluid therapy, generating interstitial edema (e(en silent), has positioned the heart at the beginning of the flat portion of the 2ran!-3tarling cur(e. Cinute fluid withdrawal is achie(ed, from hemodiafiltration if already present, re(ersion of passi(e leg raising (&2ALL3-1L5'-protocol), to simple blood cultures, specifically useful here, with a (iew to positioning the heart at the ideal point of the cur(e. If a "-profile is seen on admission, the 2ALL3-protocol cannot be used. $he diagnosis is usually cardiogenic shoc!, but sometimes lung sepsis. $he inferior ca(al (ein roughly correlates with (olemia A=,,=8B. $he superior ca(al (ein is accessible to our microcon(e# probe. 3mall dimensions, inspiratory collapse suggest hypo(olemia A=0B. Ouestions are answered in A=@B. 4ne cannot pretend that the 2ALL3-protocol answers such a comple# fieldN it is open to any criticism. A (alidation should raise the issue of the choice of a pertinent &gold standard.' 1hysicians can surround the 2ALL3-protocol with traditional tools. $he change from A-lines to "-lines, which defines septic shoc! in the 2ALL3-protocol, can be considered as a direct mar!er of clinical (olemia. 3chematically, Alines indicate fluid responders, "-lines an endpoint for fluid therapy, ma!ing 2ALL3-protocol not comparable to approaches assessing cardiac output. It pro(ides a parameter independent of usual limitations (transmural pressures, cardiac arrhythmia, in(asi(e procedures, etc.). 4ne point should be understood: the ca(al (ein is usually analy ed for predicting fluid responsi(eness: fluid is gi(en, cardiac output monitored. 2ALL3-protocol does not search for any cardiac output increase. In the described sequence, the A-profile indicates that fluid can (and must) be administered. $he "-profile on admission (or appearing during fluid therapy) indicates that the patient is (or becomes) an equi(alent of not fluid-responder. 2ALL3-protocol pro(ides a static parameter, which therefore can be used at the start (unli!e dynamic parameters).
Cardiac arrest: the opportunity for technical considerations

-ltrasound plays a maDor role when showing re(ersible causes. $he 3.3AC.-protocol, a fast protocol de(oted to cardiac arrest, assesses the lung before the heart, because pneumothora# can be discounted in 8 seconds, with in addition, windows usually a(ailable. $his apparently futile property influences the choice of equipment. $he following section is personal and subDecti(e. A (aluable combination may be our !ind of equipment, coupled with high-le(el .cho machines used e(ery time needed, as we repeatedly wrote A==B. Lowadays machines are good. .ach probe is good for its de(oted application ((ascular, cardiac, abdominal). 9e Dust ad(ocate to ha(e, before the current trend, defined critical ultrasound using (after the perfectly suitable A65-@***) a unit built from ,))8 to 8*,* which was not inferior, especially in the specific setting of cardiac arrest, and made e(ery step more simple AEB. $his machine that we now use e(ery day is 0*-cm wide on the cart (no matter its height), i.e., narrower than most machines, laptops with carts included. $his answered to the problem of the economy of room in busy I%-s, 45s, .5s, where each sa(ed centimeter ma!es a difference. It starts in F seconds, a critical point in cardiac arrest (in machines with longer start-up, there is nothing to do but wait). Its microcon(e# probe is a compromise allowing in a few seconds, lungs, heart, (essels, abdomen assessment e#ploiting its ,F-cm range, re(ealing re(ersible causes (pneumothora#, tamponade, (enous thrombosis, abdominal bleeding7). It is flat, therefore cleanable, !eyboard highlights three basic !nobs useful in e#treme emergencies: gain, depth, C-mode. Its technology does not filter out the artifacts and does not create time lags. Its low cost was an opportunity for most patients on .arth. .ach detail interacts with the others, e.g., our single probe lies on our machine top, not laterally, a detail that sa(es lateral width. 4ur main wor! was to optimi e each step. 4ur slim machine is permanently configurated &cardiac arrest,' which wor!s the same, without necessary change, for routine, daily tas!s ((enous line insertion7). 3ome manufacturers begin to build machines inspired by this ,))8 technology. -ne#pected limitations (dealt with in our te#tboo!, some apparently futile) can suddenly appear at any step of the management of e#treme emergencies, potentiali ed by the e#treme stress. An issue is the permanent ris! to

face unsuitable cardiac windows. If the user wishes to follow the 3.3AC.-protocol, i.e., assessing here the (eins (especially calf areas), the cardiac probe should be urgently replaced by a (ascular probe. $ime is necessary at each probe change (heart, abdomen, lungs7), setting change, not to forget probeMcable disinfection (here theoretical, usually a critical point). %omple# !eyboards turn into hindrances to no(ices. 3e(eral probes ma!e cables ine#tricably mi#ed. %ables lying on the floor fa(or the ris! of a machine tipo(er when suddenly mobili ed. 1roblems occur when each of these small difficulties is added to each other. 2or e#pediting the mastery of lung ultrasound, we ad(ise to bypass all filters (a setting one may call &lung'). .ach probe pro(ides fractional data (abdominal probe for pleural-al(eolar characteri ation, cardiac probe for posterior analysis in challenging patients, (ascular probe if others cannot show lung-sliding, abdominal again for assessment of artifacts length, etc.). Cost microcon(e# probes found in laptop machines do not ha(e the resolution or range of ours. Cachines with lag between real-time and C-mode can confuse young or stressed users. 1hysicians also should chec! that their cardiac probes are able to document lung sliding in all conditions (s!inny patients, dyspnea, etc.). $his section was an opportunity to emphasi e the interest of our uni(ersal probe among others A=EB. 9e thin! each user, e(en e#pert, should try similar systems, at least once.
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Lung ultrasound: a holistic discipline

A perspecti(e is holistic when the rele(ance of each of its multiple element can be understood only if integrated with the others. Lung ultrasound ma!es ultrasound a holistic discipline, as partially seen in the pre(ious section.
"ultifaceted tool

Lung ultrasound can be used without comple# adaptation from the intensi(ist to anesthesiologists, pediatricians, neonatal intensi(ists, emergency physicians, and others (cardiologists, pulmonologists, nephrologists, etc.), e(en out-of-hospital doctors A=FB. $he lung is a common target in these disciplines. $he signs assessed using %$ in adults are found without difference in critically ill neonates A=:,=)B. $he unit is easily affordable, generating huge cost-cutting A0)B. $hese potentials are applicable from sophisticated I%-s to more basic settings on .arth. Lung ultrasound complements poor cardiac windows: "-profile shows pulmonary edema, A-profile hypo(olemia, schematically. Its feasibility is nearly ,**+: this (ital organ is superficial and e#tensi(e, including bariatric patients, where the anterior approach pro(ides basic data. 1ainful blood gas analyses become less rele(ant.
Attractive tool

Lung ultrasound is not really ultrasound (i.e., this e#pert, operator-dependent tool) for se(eral reasons. ?ust two signs are sufficient to define the normality (lung-sliding, A-lines). $his potential allows us to reconsider usual priorities. 4nce the physicians operational for life-sa(ing protocols ("L-.-protocol, 2ALL3-protocol), they can quietly learn comprehensi(e echocardiography during as long time as necessary.
Solution to the issue of gro#ing irradiation

All intensi(ists prefer the least in(asi(e tool, all else being equal. -ltrasound is an answer to the longstanding dilemma: &5adiography or %$ in the I%-K' 5adiography is a familiar tool that lac!s sensiti(ity AE*B: E*-F*+, all fields considered AE,-E0B. %$ has a high accuracy but se(ere drawbac!s: cost (a real problem for most patients on .arth), transportation of critically ill patients, delay between %$ and the resulting therapy, renal issues, anaphylactic shoc!, mainly high irradiation AE@,E=B. -ltrasound has quite similar performances to %$

A,8,,F,8*,0*,0FB, being on occasion superior: better detection of pleural septations, necrotic areas AEEB, realtime measurement allowing assessment of dynamic signs: lung-sliding, air bronchogram AEFB, diaphragm AE:,E)B. -ltrasound should be considered as reasonable, bedside &gold standard.' 2or all assessed disorders, it pro(ides quantitati(e data (2igures 0, ,@,@, and andF).F). 1leural effusions can be quantified A,@,F*-F8B. Lung consolidation can be monitored, which is useful for those who want to increase end-e#piratory pressure AF0B. $he (olume and progression of a pneumothora# are monitored using the lung-point location A0@,0F,0:B. Lung ultrasound will fa(or programs allowing decrease in bedside radiographs and %$s in the ne#t decades.
Li itations

6ressings and subcutaneous emphysema ma!e unsuperable limitations. .#ceptional cases pro(ide difficult interpretation, e(en for e#perts. Is lung ultrasound easyK 3ome e#periences show high interobser(er agreement A,0B. A burgeoning literature, up to a consensus conference AF@-::B, seems to confirm this accessibility. A scientific assessment of the learning cur(e remains to be done, not in (olunteers (creating a selection bias), but in unselected physicians. %are should be ta!en to confide training to e#perts choosing simplicity, although one can practice lung ultrasound with any machine, any probe, any teaching approach. 4ur wor! was mainly to pro(ide standardi ed signs, a maDor ad(antage of lung ultrasound, because the ris! of wrong interpretations is highly decreased.
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$evie#% conclusions
Lung ultrasound allows fast, accurate, bedside e#aminations of most acute respiratory disorders. It enables a pathophysiological approach to circulatory failure. 3implicity is pro(identially found at this (ital organ. $he (ersatility of lung ultrasound heralds a !ind of (isual medicine, a priority in intensi(e care as well as many other disciplines and settings A:)B.
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Iideos are a(ailable at http:MMwww.%.-52.net, section "L-.-protocol.

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Co peting interest
$he author declares that he has no competing interests.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3895677/

Figure !

"reas o# investigation an$ the %&'()points. Two hands placed this way (size equivalent to the patients hands, upper hand touching the clavicle, thumbs excluded) correspond to the location of the lung, and allow three standardized points to be defined. The upper !"#$ point is at the middle of the upper hand. The lower !"#$ point is at the middle of the lower palm. The %"&%' point is defined by the intersection of( a horizontal line at the level of the lower !"#$ point) a vertical line at the posterior axillary line. 'mall probes, such as this *apanese microconvex one (+,,-), allow positioning posterior to this line as far as possible in supine patients, providing more sensitive detection of posterolateral alveolar or pleural syndromes (%"&%'). The diaphragm is usually at the lower end of the lower hand. $xtract from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +3), with 4ind permission of 'pringer 'cience.

Figure *

+ormal lung sur#ace. "eft( 'can of the intercostal space. The ribs (vertical arrows). 5ib shadows are displayed below. The pleural line (upper, horizontal arrows), a horizontal hyperechoic line, half a centimeter below the rib line in adults. The proportions are the same in neonates. The association of ribs and pleural line ma4e a solid landmar4 called the bat sign. The pleural line indicates the parietal pleura in all cases. !elow the pleural line, this horizontal repetition artifact of the pleural line has been called the & line (lower, small horizontal arrows). The & line indicates that air (gas more precisely) is the component visible below the pleural line. 5ight( 6 mode reveals the seashore sign, which indicates that the lung moves at the chest wall. The seashore sign therefore indicates that the pleural line also is the visceral pleura. &bove the pleural line, the motionless chest wall displays a stratified pattern. !elow the pleural line, the dynamics of lung sliding show this sandy pattern. 7ote that both images are strictly aligned, of importance in critical settings. !oth images, i.e., lung sliding plus & lines ma4e the & profile (when found at the anterior chest wall). They give basic information on the level of capillary pressure. $xtract from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +3), with 4ind permission of 'pringer 'cience.

Figure 3

Pleural e##usion. "eft and middle( minute pleural effusion at the %"&%' point. !elow the pleural line, a line regular and roughly parallel to the pleural line can be seen( the lung line, indicating the visceral pleura (arrows). This line, together with the pleural line and the shadow of the ribs, display a 4ind of quad( the quad sign. 5ight( 6 mode shows a movement of the lung line (white arrows) toward the pleural line (blac4 arrows) on inspiration8the sinusoid sign, indicating also a free pleural effusion, and a viscosity enabling the use of small caliper needle if thoracentesis is envisaged. $, expiration. 9uantitative data( this effusion found at the %"&%' point has an expiratory thic4ness of roughly +: mm, i.e., an expectedly small volume (study in progress). & +; mm distance is our minimum required for safe diagnostic or therapeutic puncture, allowing to simplify the problem of modeling the real volume of an effusion (5ef. +3). $xtract from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +;), with 4ind permission of 'pringer 'cience.

Figure ,

&ung consoli$ation. Two signs of lung consolidation. "eft( a massive consolidation (probe at the %"&%' point) invades the whole left lower lobe. 7o aerated lung tissue is present, and no fractal sign can be generated. The deep border is at the mediastinal line (arrows). The pattern is tissue li4e, similar to the spleen ('). The thic4ness of this image is roughly +1 cm, a value incompatible with a pleural effusion. <mage acquired using an &=5 3111 and a sectorial probe (+,>- mobile technology) 5ight( a middle lobe consolidation, which does not invade the whole lobe. This generates a shredded, fractal boundary between the consolidation and the underlying aerated lung (arrows)( the quite specific shred (or fractal) sign. 'uch an anterior consolidation generates the 2 profile in the !"#$ protocol. 2ompare with the regular lung line of ?igure :. 7ote the blurred letters due to multiple transfers of this image. 9uantitative data( a reasonable thic4ness at the right image is ;.; cm, giving an index of ;.; corresponding to a +@; m" consolidation, roughly. <n the left image, the +1 cm depth would correspond to a volume of roughly + ". &dapted from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +@), with 4ind permission of 'pringer 'cience.

Figure 5

-nterstitial s.n$rome an$ the lung roc/ets. Two examples of interstitial syndrome. "eft( four or five ! lines (see precise description in the text) are visible, called lung roc4ets (here septal roc4ets correlating with thic4ened subpleural interlobular septa). 6iddle( twice as many ! lines, called ground glass roc4ets. Two examples of pulmonary edema (with ground glass areas on 2T on the middle figure). 5ight( A lines for comparison. These parasites are ill defined, short, and do not erase & lines (arrows), among several criteria. $xtract from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +B), with 4ind permission of 'pringer 'cience.

Figure 6

Pneumothora0 an$ the stratosphere sign. "eft( same pattern as in ?igure -, i.e., pleural line with & lines, indicating gas below the pleural line. 7ot visible on the left image, lung sliding is totally absent. 5ight( here on 6 mode, the abolition of lung sliding is visible through the stratosphere sign (which replaces the seashore sign) and indicates total absence of motion. This suggests pneumothorax as a possible cause (see others in text). &rrows( location of the pleural line. The combination of abolished lung sliding with & lines, at the anterior chest wall, is the & profile of the !"#$ protocol (as opposed to the & profile, where lung sliding is present, ruling out pneumothorax). $xtract from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +>), with 4ind permission of 'pringer 'cience.

Figure 7

Pneumothora0 an$ the lung point. & specific sign of pneumothorax. 5eal time mode allows detection of the inspiratory increase in volume of the collapsed lung. /hen reaching the chest wall where the probe is laid, it ma4es a sudden change in the ultrasound image, from an & profile to an & or ! profile usually. The change is sudden because (using an appropriate equipment, without average filters or time lag mainly) ultrasound is a highly sensitive method, able to detect subtle changes, such as the difference between free gas and alveolar gas. The left image shows the pleural line Cust before the visceral pleura appears. The right image shows (arrow) the very moment the visceral pleura has touched the parietal pleural. This sign has been called lung point (it can be seen along a line, but one point is sufficient for the diagnosis). Dideo visible at 2$#5?.net. $xtract from ./hole body ultrasonography in the critically ill0 (-1+1 $d, 2hapter +>), with 4ind permission of 'pringer 'cience.

Figure 8

1he %&'()protocol $ecision tree. This decision tree, slightly modified from the original article (2hest -11>)+:3(++BE +-;), with the permission of Chest, indicates a way proposed for immediate diagnosis of the main causes of acute respiratory failure, using a lung and venous ultrasound approach.

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