Protocol and the diagnosis of pneumonia

1. The BLUE Bedside Lung Ultrasound in Emergency-Protocol and the Diagnosis of Pneumonia

THE BLUE
B E D S I D E L U N G U LT R A S O U N D
IN EMERGENCY-
PROTOCOL AND THE
DIAGNOSIS OF
PNEUMONIA

2.

The BLUE-protocol is an ultrasound approach of the lung, and of the venous network in appropriate
cases, allowing the rapid etiological diagnosis of an acute respiratory failure. It combines signs with
localizations,
The approach to acute respiratory failure: the BLUE-protocol
Acute respiratory failure is a life-threatening condition whose cause is sometimes difficult to recognize
immediately.
Initial mistakes have deleterious consequences. BLUE-protocol, performed on dyspneic patients who will
be admitted to the ICU, is a fast protocol: 3 minutes are required using suitable machines and the
standardized points of analysis. Otherwise it can take longer (this time depends on the simplicity and
adequacy of their equipment, of the standardization of their training).
Based on pathophysiology, it provides a step-by-step diagnosis of the main causes of acute respiratory
failure, i.e., six diseases seen in 97% of patients in the emergency room, offering an overall 90.5% accuracy

3. Which device, which probe?

WHICH DEVICE, WHICH PROBE?
We recommend a gray scale device (we do not use the Doppler), with simple
settings. Pulmonary ultrasound is best studied on a natural image. A Japanese
microconvex probe has the best ergonomics, resolution, and the best field of penetration
(from 1 to 17 cm deep). It also allows immediate analysis of the veins, heart, abdomen

4.

Note: Lung sliding has been described as a shimmering
appearance of the pleura, or like tiny ants marching on a string.
The pleura will seem to slide back and forth as the patient

5. Describe the main pathological profile (profile B)

DESCRIBE THE MAIN PATHOLOGICAL
• This aspect of multiple B lines and
PROFILE (PROFILE B)
accompanied by a pleural slip, when
it is visible on the 4 BLUE-points
(thus anterior) is called "Profile B".
At this point, the main diagnosis is
Hemodynamic Pulmonary Acute
Edema.
• The B-profile suggests acute
hemodynamic pulmonary
• edema with 97% sensitivity and 95%
specificity

6.

Pleural effusion. Left and middle: minute pleural effusion at the PLAPS-point. Below 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 kind of quad: the
quad sign. Right: M-mode shows a movement of the lung line (white arrows) toward the pleural line (black
arrows) on inspiration—the sinusoid sign, indicating also a free pleural effusion, and a viscosity enabling
the use of small caliper needle if thoracentesis is envisaged. E, expiration. Quantitative data: this effusion
found at the PLAPS-point has an expiratory thickness of roughly 13 mm, i.e., an expectedly small volume
(study in progress). A 15-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

7. Basic identification

BASIC IDENTIFICATION
. The A-line indicates gas below the pleural line
ULCs (or B-lines) associated with a fringed and
irregular pleural line indicative of pulmonary
fibrosis pattern.

8.

• Merlin's space defines the area located
between the pleural line, the shadow of the
ribs and the bottom of the image. The Aline (lower white arrows) is the repetition of
the pleural line at a standardised distance,
the skin–pleural line distance.

9. Describe profile A (normal pulmonary surface

DESCRIBE PROFILE A (NORMAL
PULMONARY SURFACE
• image obtained in the normal subject
when the probe is placed longitudinally on
the lower BLUE-point: three points are
identified successively.
1. The pleural line, by the
sign of the bat (hyperechogenic line slightly
lower than the line of the ribs).
2. The pleural slip.
3. Artefacts visible in Merlin's space:
exclusive A lines here.

10. Describe Profile B' (main pathological profile)

DESCRIBE PROFILE B' (MAIN
PATHOLOGICAL PROFILE)
• This video shows an interstitial
syndrome close to the B profile, with
the difference that pleural slippage is
here abolished. This profile is called
Profile B'. The priority diagnosis is lung
disease
Lung Rockets: The Ultrasound Sign of
Interstitial Syndrome

11. Describe profile A' (pneumothorax)

DESCRIBE PROFILE A'
(PNEUMOTHORAX)
• This video shows a totally abolished pleural slip
(with the stratosphere sign on the right, in TM
mode). No B-lines are visible. This profile called
A' profile is the characteristic aspect of a
pneumothorax, which, if time permits, will need
to be confirmed by the detection of a lung point.

12.

• Lung point
This video shows a characteristic appearance of
frontal lung point, an all-or-nothing law where
an A' profile is replaced transiently, fleetingly
and synchronously with breathing, in here a B
profile. In the patient, the lung point was
located in the PLAPS-point region, reflecting a
significant volume pneumothorax.
PLAPS = Postero Lateral Alveolar &/or Pleural Syndrome.)

13. Describe profile C (pneumopathy

DESCRIBE PROFILE C (PNEUMOPATHY
• The detection of alveolar disorders
(regardless of number and size) on the
anterior wall defines the C profile (for
Consolidation), and prioritizes the diagnosis
of pulmonary infection that causes acute
respiratory failure.

14. Describe a/B profile (pneumopathy)

DESCRIBE A/B PROFILE
(PNEUMOPATHY)
• An anterior asymmetry, with a profile A on
one side and profile B on the other, is a true
sign of infectious damage. This is the A/B
profile, rare but almost specific.

15. Describe a/PLAPS profile (pneumopathy)

DESCRIBE A/PLAPS PROFILE
(PNEUMOPATHY)
• It is defined by the association of a profile A
(thus anterior) and a PLAPS (so later). Later
consolidation and/or posterior pleural
effusion, if not associated with a B-profile
(transudative reaction in hemodynamic
pulmonary edema), an A' profile (possible
hemothorax in pneumothorax), or venous
thrombosis (pulmonary infarction or pleural
reaction during pulmonary embolism), are
correlated in the BLUE-protocol to the
diagnosis of pneumopathy.
PLAPS = Posterio Lateral Alveolar &/or
Pleural Syndrome.)

16. Describe the Nude Profile /Non plap/copd/asthma

DESCRIBE THE NUDE PROFILE /NON
PLAP/COPD/ASTHMA
• Everything is normal in the nude profile, the appearance of profile A (by definition
earlier) broadcast. The slip may be small, but it is present. Later rockets, possible,
are not considered, as long as there is no PLAPS. The nude profile implies that no
venous thrombosis has been detected. This is the usual profile of COPD and
acute asthma.

17. Thanks for your attention

THANKS FOR YOUR ATTENTION