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Daniel A. Lichtenstein Lung Ultrasound in the Critically Ill The BLUE Protocol 123 Lung Ultrasound in the Critically Ill Daniel A. Lichtenstein Lung Ultrasound in the Critically Ill The BLUE Protocol Daniel A. Lichtenstein Hôpital Ambroise Paré Service de Réanimation Médicale Boulogne (Paris-West University) France ISBN 978-3-319-15370-4 ISBN 978-3-319-15371-1 DOI 10.1007/978-3-319-15371-1 (eBook) Library of Congress Control Number: 2015941278 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com) “The lung: a major hindrance for the use of ultrasound at the thoracic level.” TR Harrison Principles of Internal Medicine, 1992, p. 1043 “Ultrasound imaging: not useful for evaluation of the pulmonary parenchyma.” TR Harrison Principles of Internal Medicine, 2011, p. 2098 “Most of the essential ideas in sciences are fundamentally simple and can, in general, be explained in a language which can be understood by everybody.” Albert Einstein The evolution of physics, 1937 “Le poumon…, vous dis-je !” (The lung… I tell you!) Molière, 1637 (continued) These extracts were introducing the Chapter on lung ultrasound of our 2005 Edition. The present textbook is fully devoted to this application. A ma famille, mes enfants, le temps que je leur ai consacré était en concurrence avec ces livres qui ont aussi été ma vie. Trouver l’équilibre entre une vie de famille idéale et la productivité scientifique a été un défi permanent. Les défauts qu’on pourra trouver dans le présent ouvrage ne seront dûs qu’à une faiblesse dans la délicate gestion de cet équilibre. Mon père n’aurait pas cru, en 1992, époque de la première édition, qu’il verrait celle-ci; cet ouvrage lui est dédié. Ma mère sera heureuse de voir d’en haut cet achèvement d’une vie. A Joëlle Our life is a gift from God; what we do with that life is our gift to God. Contents Part I The Tools of the BLUE-Protocol 1 Basic Knobology Useful for the BLUE-Protocol (Lung and Venous Assessment) and Derived Protocols . . . . . . . . . . . . . . . . . . . . . . 3 Preliminary Note on Knobology. Which Setting for the BLUE-Protocol? Which Setting for the Other Protocols (FALLS, SESAME, etc.) and Whole Body Critical Ultrasound? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Step 1: The Image Acquisition. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Step 2: Understanding the Composition of the Image . . . . . . . . . . 6 Step 3: Image Interpretation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2 Which Equipment for the BLUE-Protocol? (And for Whole-Body Critical Ultrasound). 1 – The Unit . . . . . . . . . . . . The Seven Requirements We Ask of an Ultrasound Machine Devoted to Critical Care – A Short Version for the Hurried Reader . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A Longer Version: The Seven Requirements We Ask of an Ultrasound Machine Devoted to Critical Care . . . . . . . . . . . The Coupling System: A Detail? . . . . . . . . . . . . . . . . . . . . . . . . . . Data Recording . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . How to Practically Afford a Machine in One’s ICU . . . . . . . . . . . What Solutions Are There for Institutions Already Equipped with Laptop Technologies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Which Machines for Those Who Work Outside the Hospital and in Confined Space? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Solution for the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some Basic Points and Reminders . . . . . . . . . . . . . . . . . . . . . . . . Appendix 1: The PUMA, Our Answer to the Traditional Laptops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Which Equipment for the BLUE-Protocol 2. The Probe . . . . . The Critical Point to Understand for Defining the “Universal Probe” in Critical Care: The Concept of the Providential (Optimal) Compromise . . . . . . . . . . . . . . . . . . 11 12 12 17 18 18 19 19 20 21 21 22 23 23 vii Contents viii How to Scientifically Assess This Notion of “Domain of Interpretability”? Our High-Level Compromise Probe . . . . . . . Why Is Our Microconvex Probe Universal . . . . . . . . . . . . . . . . . . The Strong Points of Having One Unique Probe. . . . . . . . . . . . . . The Usual Probes of the Laptop Machines . . . . . . . . . . . . . . . . . . Some Doctors Prefer to Swap the Probes for Each Application, and Not Use the Universal Probe. Why? . . . . . Pericardial Tamponade: Time for a Nice Paradox, Just One Illustration of What is “Holistic Ultrasound” . . . . . . . . . What to Say to Those Who Still Have Only the Three Usual Probes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . An Unexpected (Temporary) Solution? . . . . . . . . . . . . . . . . . . . . . Important Notes Used as Conclusion. . . . . . . . . . . . . . . . . . . . . . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5 6 How We Conduct a BLUE-Protocol (And Any Critical Ultrasound): Practical Aspects . . . . . . . . . . Disinfection of the Unit: Not a Futile Step . . . . . . . . . . . . . . . . . . When Is It Time to Perform an Ultrasound Examination . . . . . . . Since When Do We Perform These Whole-Body Ultrasound Examinations: Some Historical Perspectives. . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Seven Principles of Lung Ultrasound . . . . . . . . . . . . . . . . . Development of the First Principle: A Simple Method . . . . . . . . . Development of the Second Principle: Understanding the Air-Fluid Ratio and Respecting the Sky-Earth Axis . . . . . . . . The Third Principle: Locating the Lung and Defining Areas of Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Fourth Principle: Defining the Pleural Line . . . . . . . . . . . . . . The Fifth Principle: Dealing with the Artifact Which Defines the Normal Lung, the A-Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Sixth Principle: Defining the Dynamic Characteristic of the Normal Lung, Lung Sliding. . . . . . . . . . . . . . . . . . . . . . . . . Development of the Seventh Principle: Acute Disorders Have Superficial, and Extensive, Location . . . . . . . . . . . . . . . . . . . . . . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The BLUE-Points: Three Points Allowing Standardization of a BLUE-Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Concept of the BLUE-Hands . . . . . . . . . . . . . . . . . . . . . . . . . Lung Zones, Their Relevance in the BLUE-Protocol, Their Combination with the Sky-Earth Axis for Defining Stages of Investigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some Technical Points for Making Lung Ultrasound an Easier Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standardization of a Lung Examination: The BLUE-Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standardization of a Lung Examination: The Upper BLUE-Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 28 29 31 33 33 34 34 35 35 37 38 42 42 42 45 45 46 47 47 47 47 47 49 51 51 52 53 53 54 Contents ix Standardization of a Lung Examination: The Lower BLUE-Point. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The PLAPS-Point. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Location of the Lung in Challenging Patients . . . . . . . . . . . . . . . . Other Points? The Case of the Patient in the Prone Position . . . . . BLUE-Points and Clinical Information . . . . . . . . . . . . . . . . . . . . . Aside Note More Devoted to Pulmonologists . . . . . . . . . . . . . . . . Philosophy of the BLUE-Points: Can the Users Do Without?. . . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 54 54 56 56 56 57 57 58 An Introduction to the Signatures of Lung Ultrasound . . . . . . 1. The pleural line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. The A-line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Lung sliding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4–7. The quad sign, sinusoid sign, shred sign, and tissue-like sign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Lung rockets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Abolished lung sliding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. The lung point. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Signs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 59 59 59 8 The Pleural Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Pleural Line: The Basis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standardizing Lung Ultrasound: Merlin’s Space. . . . . . . . . . . . . . Standardizing Lung Ultrasound: Keye’s Space . . . . . . . . . . . . . . . Standardizing Lung Ultrasound: The M-Mode-Merlin’s Space . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 61 63 63 64 64 9 The A-Profile (Normal Lung Surface): 1) The A-Line . . . . . . . The Artifact Which Defines the Normal Lung Surface: The A-line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Some History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 The A-Profile (Normal Lung Surface): 2) Lung Sliding . . . . . Lung Sliding: A New Sign, a New Entity in the Respiratory Semiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Normal Lung Sliding in the Healthy Subject, a Relative Dynamic: The Seashore Sign . . . . . . . . . . . . . . . . . . . . Lung Sliding, Also a Subtle Sign Which Can Be Destroyed by Inappropriate Filters or So-Called Facilities. The Importance of Mastering Dynamics and Bypassing These Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . The Various Degrees of Lung Sliding, Considering Caricaturally Opposed States . . . . . . . . . . . . . . . . . . Lung Sliding in the Dyspneic Patient. The Maximal Type. Critical Notions Regarding the Mastery of the B/M-Mode . . . . . . 67 10 59 59 59 59 60 60 65 66 66 66 66 67 68 69 69 70