point of care lung ultrasound

Giovanni VolpicelliMahmoud ElbarbaryMichael BlaivasDaniel A. LichtensteinGebhard MathisAndrew W. KirkpatrickLawrence MelnikerLuna GarganiVicki E. NobleGabriele ViaAnthony DeanJames W. TsungGino SoldatiRoberto CopettiBelaid BouhemadAngelika ReissigEustachio AgricolaJean-Jacques RoubyCharlotte ArbelotAndrew LiteploAshot SargsyanFernando SilvaRichard HoppmannRaoul BreitkreutzArmin SeibelLuca NeriEnrico StortiTomislav PetrovicInternational Liaison Committee on Lung Ultrasound(ILC-LUS) for the InternationalConsensus Conference on Lung Ultrasound (ICC-LUS)

International evidence-basedrecommendations for point-of-carelung ultrasound

Received: 29 October 2011Accepted: 23 January 2012Published online: 6 March 2012� Copyright jointly held by Springer andESICM 2012

Electronic supplementary materialThe online version of this article(doi:10.1007/s00134-012-2513-4) containssupplementary material, which is availableto authorized users.

G. Volpicelli ())Department of Emergency Medicine,San Luigi Gonzaga University Hospital,10043 Orbassano, Torino, Italye-mail: [email protected]

M. ElbarbaryNational & Gulf Center for Evidence BasedHealth Practice, King Saud University forHealth Sciences, Riyadh, Saudi Arabiae-mail: [email protected]

M. BlaivasDepartment of Emergency Medicine,Northside Hospital Forsyth,Atlanta, GA, USAe-mail: [email protected]

D. A. LichtensteinService de Reanimation Medicale, HopitalAmbroise-Pare, Paris-Ouest, Boulogne,Francee-mail: [email protected]

G. MathisInternal Medicine Praxis, Rankweil, Austriae-mail: [email protected]

A. W. KirkpatrickFoothills Medical Centre, Calgary, AB,Canadae-mail: andrew.kirkpatrick@

albertahealthservices.ca

L. MelnikerClinical Epidemiology Unit, Division ofGeneral Internal Medicine, Departmentof Medicine, Weill Medical College ofCornell University, New York, USAe-mail: [email protected]

L. GarganiInstitute of Clinical Physiology,National Research Council, Pisa, Italye-mail: [email protected]

V. E. NobleDivision of Emergency Ultrasound,Department of Emergency Medicine,Massachusetts General Hospital,Boston, MA, USAe-mail: [email protected]

G. Via1st Department of Anesthesia and IntensiveCare Pavia, IRCCS Foundation PoliclinicoSan Matteo, Pavia, Italye-mail: [email protected]

Intensive Care Med (2012) 38:577–591DOI 10.1007/s00134-012-2513-4 CONFERENCE REPORTS AND EXPERT PANEL

http://dx.doi.org/10.1007/s00134-012-2513-4

A. DeanDivision of Emergency Ultrasonography,Department of Emergency Medicine,University of Pennsylvania Medical Center,Philadelphia, PA, USAe-mail: [email protected]

J. W. TsungDepartments of Emergency Medicine andPediatrics, Mount Sinai School of Medicine,New York, NY, USAe-mail: [email protected]

G. SoldatiEmergency Medicine Unit, Valle delSerchio General Hospital, Lucca, Italye-mail: [email protected]

R. CopettiMedical Department, Latisana Hospital,Udine, Italye-mail: [email protected]

B. BouhemadSurgical Intensive Care Unit, Departmentof Anesthesia and Critical Care, GroupeHospitalier Paris Saint-Joseph, Paris, Francee-mail: [email protected]

A. ReissigDepartment of Pneumology andAllergology, Medical University Clinic I,Friedrich-Schiller University,Jena, Germanye-mail: [email protected]

E. AgricolaDivision of Noninvasive Cardiology,San Raffaele Scientific Institute, IRCCS,Milan, Italye-mail: [email protected]

J.-J. Rouby � C. ArbelotMultidisciplinary Intensive Care Unit,Department of Anesthesiology,Pitie-Salpetriere Hospital,University Pierre and Marie Curie (UPMC),Paris 6, Francee-mail: [email protected]

C. Arbelote-mail: [email protected]

A. LiteploEmergency Medicine, MassachusettsGeneral Hospital, Boston, MA, USAe-mail: [email protected]

A. SargsyanWyle/NASA Lyndon B. Johnson SpaceCenter Bioastronautics Contract,Houston, TX, USAe-mail: [email protected]

F. SilvaDepartment of Emergency Medicine,UC Davis Medical Center,Sacramento, CA, USAe-mail: [email protected]

R. HoppmannInternal Medicine, University of SouthCarolina School of Medicine,Columbia, SC, USAe-mail: [email protected]

R. BreitkreutzDepartment of Anaesthesiology, IntensiveCare and Pain Therapy, University Hospitalof the Saarland and Frankfurt Institute ofEmergency Medicine and SimulationTraining (FINEST), Homburg, Germanye-mail: [email protected]

A. SeibelDiakonie Klinikum jung-stilling,Siegen, Germanye-mail: [email protected]

L. NeriAREU EMS Public Regional Company,Niguarda Ca’ Granda Hospital,Milano, Italye-mail: [email protected]

E. StortiIntensive Care Unit ‘‘G. Bozza,’’, NiguardaCa’ Granda Hospital, Milan, Italye-mail: [email protected]

T. PetrovicSamu 93, University Hospital Avicenne,Bobigny, Francee-mail: [email protected]

Abstract Background: The pur-pose of this study is to provideevidence-based and expert consensusrecommendations for lung ultrasoundwith focus on emergency and criticalcare settings. Methods: A multidis-ciplinary panel of 28 experts fromeight countries was involved. Litera-ture was reviewed from January 1966to June 2011. Consensus memberssearched multiple databases includingPubmed, Medline, OVID, Embase,and others. The process used todevelop these evidence-based recom-mendations involved two phases:determining the level of quality ofevidence and developing the recom-mendation. The quality of evidence is

assessed by the grading of recom-mendation, assessment, development,and evaluation (GRADE) method.However, the GRADE system doesnot enforce a specific method on howthe panel should reach decisionsduring the consensus process. Ourmethodology committee decided toutilize the RAND appropriatenessmethod for panel judgment and deci-sions/consensus. Results: Seventy-three proposed statements wereexamined and discussed in threeconferences held in Bologna, Pisa,and Rome. Each conference includedtwo rounds of face-to-face modifiedDelphi technique. Anonymous panelvoting followed each round. Thepanel did not reach an agreement andtherefore did not adopt any recom-mendations for six statements. Weak/conditional recommendations weremade for 2 statements, and strongrecommendations were made for theremaining 65 statements. The state-ments were then recategorized andgrouped to their current format.Internal and external peer-reviewprocesses took place before submis-sion of the recommendations.Updates will occur at least every4 years or whenever significant majorchanges in evidence appear. Conclu-sions: This document reflects theoverall results of the first consensusconference on ‘‘point-of-care’’ lungultrasound. Statements were dis-cussed and elaborated by experts whopublished the vast majority of paperson clinical use of lung ultrasound inthe last 20 years. Recommendationswere produced to guide implementa-tion, development, andstandardization of lung ultrasound inall relevant settings.

Keywords Lung ultrasound �Chest sonography � Emergencyultrasound � Critical ultrasound �Point-of-care ultrasound � Guideline �RAND � GRADE �Evidence-based medicine

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Introduction

Modern lung ultrasound is mainly applied not only incritical care, emergency medicine, and trauma surgery,but also in pulmonary and internal medicine. Manyinternational authors have produced several studies onthe application of lung ultrasound in various settings.The emergence of differences in approach, techniquesutilized, and nomenclature, however, provided thestimulus to initiate a guideline/consensus process withthe aim of elaborating a unified approach and languagefor six major areas, namely terminology, technology,technique, clinical outcomes, cost effectiveness, andfuture research. This process was conducted following arigorous scientific pathway to produce evidence-basedguidelines containing a list of recommendations forclinical application of lung ultrasound [1]. A literaturesearch was performed, and a multidisciplinary, inter-national panel of experts was identified. The proposedrecommendations represent a framework for ‘‘point-of-care’’ lung ultrasound intended to standardize itsapplication around the globe and in different clinicalsettings.

This report constitutes a concise, shortened version ofthe original document. The electronic version, accessibleonline as supplementary material, provides a full expla-nation of methods and a comprehensive discussion foreach recommendation (see Electronic SupplementaryMaterial 1).

Methods

Grading of recommendation, assessment, development,and evaluation (GRADE) method was used to developthese evidence-based recommendations [2]. The processinvolves two phases: (1) determining the level of qualityof evidence, and (2) developing the recommendation.Relevant articles with clinical outcomes were classifiedinto three levels of quality based on the criteria of theGRADE methodology for developing guidelines andclinical recommendations (Table 1). RAND appropriate-ness method (RAM) was used within the GRADE stepsthat required panel judgment and decisions/consensus [3].RAM was also used in formulating the recommendationsbased purely on expert consensus, such as recommenda-tions related to terminology. Recommendations weregenerated in two classes (strong or weak/conditional)based on the GRADE criteria taking into considerationpreset rules that defined the panel agreement/consensusand its degree. The transformation of evidence into rec-ommendation depends on the evaluation by the panel foroutcome, benefit/cost, and benefit/harm ratios, and cer-tainty about similarity in values/preferences [2].

Panel selection

Experts were eligible for selection if they had publishedas first author a peer-reviewed article on lung ultrasoundduring the past 10 years in more than one main topic oflung ultrasound (pneumothorax, interstitial syndrome,lung consolidation, monitoring, neonatology, pleuraleffusion), taking into consideration the proportionality asdetermined by a MEDLINE literature search from 1966 toOctober 2010. Methodologists with experience in evi-dence-based methodology and guideline developmentwere also included (see ‘‘Appendix’’ for list of partici-pants, affiliations, and assignments).

Literature search strategy

The literature search was done in two tracks. The expertsthemselves, with more than one expert search in eachdomain to avoid selection bias, constituted the first track.An epidemiologist assisted by a professional librarianperformed the second track by conducting literaturesearch of English-language articles from 1966 to October2010. See Table 2 for search databases, terms, and theMeSH headings used. The two bibliographies werecompared for thoroughness and consistency.

Panel meetings and voting

The panel of experts met on three occasions: Bologna(28–30 November 2009), Pisa (11–12 May 2010), andRome (7–9 October 2010). The panelists formulated draft

Table 1 Levels of quality of evidence

Level Pointsb Quality Interpretation

A C4 High Further research is very unlikely tochange our confidence in the estimateof effect or accuracy

B 3 Moderate Further research is likely to have animportant impact on our confidence inthe estimate of effect or accuracy andmay change the estimate

Ca B2 Lowa Further research is very likely to havean important impact on ourconfidence in the estimate of effect oraccuracy and is likely to change theestimate. Any estimate of effect oraccuracy is very uncertain (very low)

This table was modified from Guyatt et al. [2]a Level C can be divided into low (points = 2) and very low(points = 1 or less)b Points are calculated based on the nine GRADE quality factors[2]

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recommendations before the conferences, which laid thefoundation to work together and critique the recommen-dations during the conferences. At each plenaryconference, a representative of each domain presentedpotentially controversial issues in the recommendations. Aface-to-face debate took place in two rounds of modifiedDelphi technique; after each round, anonymous voting wasconducted. A standardized method for determining theagreement/disagreement and the degree of agreement andhence for deciding about the grade of recommendation(weak versus strong) was then applied [3, 4].

Results

Literature search results

A total of 209 articles and two books were retrieved bythe first track search. An additional 110 articles wereadded from the second track over a 1-year period. These320 references (see Electronic Supplementary Material 1)were individually appraised based on methodologicalcriteria to determine the initial quality level. The final

judgment about the quality of evidence-based recom-mendations was only done after assigning the articles toeach statement/question.

General results

A total number of 73 proposed statements were examinedby 28 experts and discussed in the three conferences.Each statement was coded with an alphanumeric code,which includes the following in order of appearance: thelocation of the conference (Bologna, B; Pisa, P; Rome,RL), the number assigned to the domain, and the numberassigned to the statement. Table 3 presents each statementcode with its grade of recommendation, degree of con-sensus, and level of quality of evidence.

Statements and discussion

Pneumothorax

Technique

Statement code B-D1-S1 (strong recommendation:level A of evidence)

• The sonographic signs of pneumothorax include thefollowing:

– Presence of lung point(s)– Absence of lung sliding– Absence of B-lines– Absence of lung pulse

B-D1-S2 (strong: level A)

• In the supine patient, the sonographic techniqueconsists of exploration of the least gravitationallydependent areas progressing more laterally.

• Adjunct techniques such as M-mode and colorDoppler may be used.

B-D1-S3 (weak: level C)

• Ultrasound scanning for pneumothorax may be a basicultrasound technique with a steep learning curve.

P-D1-S2 (strong: level B)

• During assessment for pneumothorax in adults, amicroconvex probe is preferred. However, othertransducer (e.g., linear array, phased array, convex)may be chosen based on physician preference andclinical setting.

Clinical implications


• Lung ultrasound should be used in clinical settingswhen pneumothorax is in the differential diagnosis.

Table 2 Search terms used

MeSHheadings

Terms

Sonography (echographic OR echography OR sonographic ORsonography OR ultrasonic OR ultrasonographicOR ultrasonography OR ultrasound).ti

EM/CCM (bedside OR critical OR intensive OR emergency ORemergent OR urgency OR urgent OR critical ORcritically OR shock OR unstable OR hypotensiveOR hypoperfusion OR sepsis).ti

ECHO (cardiac OR cardiologic OR cardiologicalechocardiography OR echocardiographic OR heartOR pacing OR chest OR lung OR congestive heartfailure OR CHF OR ADHF OR pressure).ti

LUNG (lung OR chest OR thoracic OR transthoracic ORcardiothoracic OR pleural OR pulmonary ORpulmonic OR pneumology OR pneumonic ORalveolar OR interstitial OR pneumothorax ORhemothorax OR consolidation).ti

OTHER (accuracy OR accurate OR sensitivity OR sensitiveOR specificity OR specific OR predictive ORpredict).ti

COST (cost OR effective OR effectiveness OR efficacy ORefficacious OR efficient OR efficiency OR benefitOR value).ti

Search databases: Books@Ovid June 02, 2011; Journals@Ovid FullText June 2003, 2011; Your Journals@Ovid; AMED (Allied andComp Medicine) 1985 to May 2011; CAB Abstracts Archive1910–1972; Embase 1980–2011 week 22; ERIC 1965 to May2011; Health and Psychosocial Instruments 1985 to April 2011;Ovid MEDLINE(R) In-Process and Other Non-Indexed Citationsand Ovid MEDLINE(R) 1948 to present; Ovid MEDLINE(R) 1948to May week 4 2011; Social Work Abstracts 1968 to June 2011;NASW Clinical Register 14th Edition

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Imaging strategies and outcomes

B-D1-S5 (strong: level B)

• Lung ultrasound more accurately rules in the diagno-sis of pneumothorax than supine anterior chestradiography (CXR).


• Lung ultrasound more accurately rules out the diag-nosis of pneumothorax than supine anterior chestradiography.

B-D1-S7 (strong: level C)

• Lung ultrasound when compared with supine chestradiography may be a better diagnostic strategy as aninitial diagnostic study in critically ill patients with

suspected pneumothorax, and may lead to betterpatient outcome.

B-D1-S8 (no consensus: level C)

• Lung ultrasound compares well with computer-ized tomography in assessment of pneumothoraxextension.

P-D1-S1 (no consensus: level C)

• Bedside lung ultrasound is a useful tool to differen-tiate between small and large pneumothorax, usingdetection of the lung point.

Comments The four sonographic signs useful todiagnose pneumothorax and their usefulness in ruling inand ruling out the condition are reported in Fig. 1 [5].Lung sliding is the depiction of a regular rhythmic

Table 3 Summary table for the 73 statements with their level of evidence

SN Statementcode

Recommendationstrength

Degree ofconsensus

Level of qualityof evidence

SN Statementcode

Recommendationstrength

Degree ofconsensus

Level of qualityof evidence

1 B-D1-S1 Strong Very good A 38 P-D2-S1 Strong Very good N/A2 B-D1-S2 Strong Very good A 39 P-D2-S2 Strong Very good B3 B-D1-S3 Weak Some C 40 P-D2-S3 Strong Very good B4 B-D1-S4 Strong Very good A 41 P-D2-S4 No = disagreement No C5 B-D1-S5 Strong Very good B 42 P-D3-S1 Strong Very good A6 B-D1-S6 Strong Good A 43 P-D3-S2 Strong Very good A7 B-D1-S7 Strong Good C 44 P-D3-S3 Strong Very good B8 B-D1-S8 No = disagreement No C 45 P-D3-S4 Strong Very good B9 B-D2-S1 Strong Very good A 46 P-D3-S5 Strong Very good B10 B-D2-S2 Strong Very good A 47 P-D3-S6 Strong Very good B11 B-D2-S3 Strong Very good B 48 P-D3-S7 Strong Very good A12 B-D2-S4 Strong Good B 49 P-D4-S1 Strong Very good B13 B-D2-S5 Strong Very good B 50 P-D4-S2 Strong Very good B14 B-D2-S6 Strong Very good B 51 P-D4-S3 Strong Very good B15 B-D2-S7 No = disagreement No C 52 P-D4-S4 Strong Very good B16 B-D2-S8 Strong Very good C 53 P-D4-S5 Strong Very good B17 B-D2-S9 Strong Very good N/A 54 P-D4-S6 Strong Very good B18 B-D2-S10 Strong Very good N/A 55 P-D4-S7 Strong Very good B19 B-D3-S1 Strong Very good C 56 P-D4-S8 Strong Very good A20 B-D3-S2 Weak Some C 57 P-D4-S9 Strong Very good A21 B-D3-S3 Strong Good N/A 58 P-D5-S1 Strong Very good B22 B-D3-S4 Strong Very good A 59 RL-D2-S1 Strong Very good A23 B-D3-S5 Strong Very good A 60 RL-D2-S2 Strong Very good A24 B-D3-S6 Strong Good B 61 RL-D3-S1 Strong Very good B25 B-D3-S7 No = disagreement No C 62 RL-D3-S2 Strong Very good B26 B-D3-S8 Strong Very good A 63 RL-D3-S3 Strong Very good B27 B-D4-S1 Strong Good A 64 RL-D3-S4 Strong Very good B28 B-D4-S2 Strong Very good A 65 RL-D3-S5 Strong Very good B29 B-D4-S3 Strong Very good A 66 RL-D4-S1 Strong Very good B30 B-D4-S4 Strong Very good A 67 RL-D4-S2 Strong Very good B31 B-D4-S5 Strong Very good B 68 RL-D4-S3 Strong Very good A32 B-D4-S6 Strong Very good B 69 RL-D4-S4 Strong Very good A33 B-D4-S7 Strong Very good A 70 RL-D4-S5 Strong Very good A34 B-D4-S8 Strong Good C 71 RL-D5-S1 Strong Very good N/A35 B-D4-S9 No = disagreement No N/A 72 RL-D5-S2 Strong Very good N/A36 P-D1-S1 No = disagreement No C 73 RL-D6-S1 Strong Good B37 P-D1-S2 Strong Very good B

No statement for D1 in Rome (removed for duplication); RL-D6-S1 was a revision of P-D2-S4 due to new evidence presented; statementB-D3-S1 covers information given by statements P-D3-S4 and P-D3-S5; these latter two are not presented in the documentB Bologna, P Pisa, RL Rome-Lung, D domain, S statement, SN statement number, N/A not applicable

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movement synchronized with respiration that occursbetween the parietal and visceral pleura that are either indirect apposition or separated by a thin layer of intra-pleural fluid [6–9]. The lung pulse refers to the subtlerhythmic movement of the visceral upon the parietalpleura with cardiac oscillations [6, 8, 10]. As B-lines(well defined elsewhere) originate from the visceralpleura, their simple presence proves that the visceralpleura is opposing the parietal, thus excluding pneumo-thorax at that point. The lung point refers to the depictionof the typical pattern of pneumothorax, which is simplythe absence of any sliding or moving B-lines at a physicallocation where this pattern consistently transitions into anarea of sliding, which represents the physical limit ofpneumothorax as mapped on the chest wall [7, 11, 12].

In extreme emergency, absence of any movement ofthe pleural line, either horizontal (sliding) or vertical(pulse), coupled with absence of B-lines allows promptand safe diagnosis of pneumothorax without the need forsearching the lung point.

Lung ultrasound is more accurate than CXR particu-larly in ruling out pneumothorax [1, 6, 13–17]. There aresome settings where lung ultrasound for pneumothorax isnot only recommended but also essential: cardiac arrest/unstable patient, radio-occult pneumothorax, and limited-resource areas.

Disagreement on the steep learning curve of thetechnique is based on the fact that the positive predictivevalue of ultrasound and its specificity have tended to beslightly lower than the sensitivity in the studies onpneumothorax. Consideration has been made that diag-nosis of pneumothorax can require more nuanced

interpretation of the combination of findings as lungbullae, contusions, adhesions, and others that can result infalse positives.

Interstitial syndrome

Artifacts and physics

P-D2-S1 [strong: level not applicable (N/A)]

• B-lines are defined as discrete laser-like verticalhyperechoic reverberation artifacts that arise fromthe pleural line (previously described as ‘‘comettails’’), extend to the bottom of the screen withoutfading, and move synchronously with lung sliding.

RL-D5-S1 (strong: level N/A)

• B-lines are artifacts.

RL-D5-S2 (strong: level N/A)

• The anatomic and physical basis of B-lines is notknown with certainty at this time.

B-D2-S9 (strong: level N/A)

• The term ‘‘sliding’’ (rather than ‘‘gliding’’) should beused in the description of pleural movement.

Scanning and training methodology


• Multiple B-lines are the sonographic sign of lunginterstitial syndrome.


• In the evaluation of interstitial syndrome, the sono-graphic technique ideally consists of scanningeight regions, but two other methods have beendescribed:

– A more rapid anterior two-region scan may besufficient in some cases.

– The evaluation of 28 rib interspaces is analternative.

• A positive region is defined by the presence of three ormore B-lines in a longitudinal plane between two ribs.


• In the evaluation of interstitial syndrome, the follow-ing suggest a positive exam:

– Two or more positive regions (see B-D2-S2)bilaterally.

– The 28 rib space technique may semiquantify theinterstitial syndrome: in each rib space, count the

Fig. 1 Flow chart on diagnosing pneumothorax. This flow chartsuggests the correct sequence and combination of the foursonographic signs useful to rule out or rule in pneumothorax

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number of B-lines from zero to ten, or if confluent,assess the percentage of the rib space occupied byB-lines and divide it by ten.


• The term ‘‘B-pattern’’ should be used (rather than‘‘lung rockets’’ or ‘‘B-PLUS’’) in the description ofmultiple B-lines in patients with interstitial syndrome.


• In the evaluation of interstitial syndrome, lungultrasound should be considered as a basic techniquewith a steep learning curve.

Clinical implications


• The presence of multiple diffuse bilateral B-linesindicates interstitial syndrome. Causes of interstitialsyndrome include the following conditions:

– Pulmonary edema of various causes– Interstitial pneumonia or pneumonitis– Diffuse parenchymal lung disease (pulmonary

fibrosis)


• Regarding B-lines, focal multiple B-lines may bepresent in a normal lung, and a focal (localized)sonographic pattern of interstitial syndrome may beseen in the presence of any of the following:

– Pneumonia and pneumonitis– Atelectasis– Pulmonary contusion– Pulmonary infarction– Pleural disease– Neoplasia

RL-D3-S1 (strong: level B)

• Lung ultrasound is a reliable tool to evaluate diffuseparenchymal lung disease (pulmonary fibrosis).

• The primary sonographic sign to be identified is thepresence of multiple B-lines in a diffuse and nonho-mogeneous distribution.

• Pleural line abnormalities are often present.


• In patients with diffuse parenchymal lung disease(pulmonary fibrosis), the distribution of B-lines corre-lates with computed tomography (CT) signs of fibrosis.


• In contrast to cardiogenic pulmonary edema, thesonographic findings that are indicative of diffuse

parenchymal lung disease (pulmonary fibrosis)include the following:

– Pleural line abnormalities (irregular, fragmentedpleural line)

– Subpleural abnormalities (small echo-poor areas)– B-lines in a nonhomogeneous distribution


• In contrast to cardiogenic pulmonary edema, thesonographic findings that are indicative of acuterespiratory distress syndrome (ARDS) include thefollowing:

– Anterior subpleural consolidations– Absence or reduction of lung sliding– ‘‘Spared areas’’ of normal parenchyma– Pleural line abnormalities (irregular thickened

fragmented pleural line)– Nonhomogeneous distribution of B-lines

Imaging strategies


• Lung ultrasound is superior to conventional chestradiography for ruling in significant interstitialsyndrome.


• In patients with suspected interstitial syndrome, anegative lung ultrasound examination is superior to

Fig. 2 The four chest areas per side considered for complete eight-zone lung ultrasound examination. These areas are used to evaluatefor the presence of interstitial syndrome. Areas 1 and 2 denote theupper anterior and lower anterior chest areas, respectively. Areas 3and 4 denote the upper lateral and basal lateral chest areas,respectively. PSL parasternal line, AAL anterior axillary line, PALposterior axillary line (modified from Volpicelli et al. [19])

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conventional chest radiography in ruling out signifi-cant interstitial syndrome.


• Lung ultrasound used as a first-line diagnosticapproach in the evaluation of suspected interstitialsyndrome, when compared with chest radiography,may lead to better patient outcomes.


• In resource-limited settings, lung ultrasound should beconsidered as a particularly useful diagnostic modalityin the evaluation of interstitial syndrome.

Outcomes


• Use of sonography in diagnosis of interstitial syn-drome is likely to improve the care of patients inwhom this diagnosis is a consideration.


• In suspected decompensated left-sided heart failure,lung ultrasound should be considered because, withother bedside tests, it provides additional diagnosticinformation about this condition.

Comments Many studies showed a tight correlationbetween interstitial involvement of lung diseases andB-lines [10, 18–20]. The consensus process defined thebasic eight-region sonographic technique (Fig. 2) and thecriteria for positive scan and positive examination [19–21]. In the critically ill, a more rapid anterior two-regionscan may be sufficient to rule out interstitial syndrome incardiogenic acute pulmonary edema [12]. A positiveexamination for sonographic diffuse interstitial syndromeallows bedside distinction between a cardiogenic versus arespiratory cause of acute dyspnea [22–24]. For moreprecise quantification of interstitial syndrome, the28-scanning-site technique can be useful, especially incardiology and nephrology settings [25]. In acutedecompensated heart failure, semiquantification of theseverity of congestion can be calculated by counting thetotal number of B-lines (28-scanning-site technique) orthe number of positive scans (eight-region technique) [26,27]. A focal sonographic pattern of interstitial syndromeshould be differentiated from a diffuse interstitial syn-drome [21]. Similar B-patterns are observed in manyacute and chronic conditions with diffuse interstitialinvolvement [1, 19, 20, 25, 28, 29]. However, some so-nographic signs other than B-lines are useful todifferentiate the B-pattern of cardiogenic pulmonaryedema, ARDS, and pulmonary fibrosis [10]. The sono-graphic technique for diagnosis of interstitial syndrome isa basic technique [30–32] with superiority over conven-tional CXR [33].

Lung consolidation

Signs and clinical implications

B-D3-S1 (strong: level C) (this statement combinesstatements P-D3-S4 and P-D3-S5)

• The sonographic sign of lung consolidation is asubpleural echo-poor region or one with tissue-likeechotexture.

• Lung consolidations may have a variety of causesincluding infection, pulmonary embolism, lung cancerand metastasis, compression atelectasis, obstructiveatelectasis, and lung contusion. Additional sonograph-ic signs that may help to determine the cause of lungconsolidation include the following:

– The quality of the deep margins of the consolidation– The presence of comet-tail reverberation artifacts at

the far-field margin– The presence of air bronchogram(s)– The presence of fluid bronchogram(s)– The vascular pattern within the consolidation.


• Lung ultrasound for detection of lung consolidationcan be used in any clinical setting including point-of-care examination.


• Lung ultrasound should be used in the evaluation oflung consolidation because it can differentiate con-solidations due to pulmonary embolism, pneumonia,or atelectasis.


• Lung ultrasound is a clinically useful diagnostic toolin patients with suspected pulmonary embolism.

P-D3-S7 (strong: level A)

• Lung ultrasound is an alternative diagnostic tool tocomputerized tomography in diagnosis of pulmonaryembolism when CT is contraindicated or unavailable.


• Lung ultrasound is a clinically useful tool to rule inpneumonia; however, lung ultrasound does not ruleout consolidations that do not reach the pleura.


• Lower-frequency ultrasound scanning may allow forbetter evaluation of the extent of a consolidation.

Imaging strategies and learning curve


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• Lung ultrasound should be considered as an accuratetool in ruling in lung consolidation when comparedwith chest radiography.


• Lung ultrasound may be considered as an accuratetool in ruling out lung consolidation in comparisonwith chest radiography.


• Use of lung ultrasound as an initial diagnostic strategyin the evaluation of lung consolidation improvesoutcomes in comparison with chest radiography.


• Ultrasound diagnosis of lung consolidation may beconsidered as a basic sonographic technique with asteep learning curve.


• Lung ultrasound should be considered in the detectionof radio-occult pulmonary conditions in patients withpleuritic pain.

B-D3-S2 (weak: level C)

• In the evaluation of lung consolidation, the sono-graphic technique should commence with theexamination of areas of interest (if present, e.g., areaof pain) then progress to the entire lung, as needed.


• In mechanically ventilated patients, lung ultrasoundshould be considered because it is more accurate thanchest radiography in distinguishing various types ofconsolidations.


• In mechanically ventilated patients lung ultrasoundshould be considered as it is more accurate thanportable chest radiography in the detection ofconsolidation.

B-D4-S9 (no consensus: level N/A)

• Lung ultrasound is accurate in distinguishing varioustypes of consolidations in comparison with CT scan inmechanically ventilated patients.

Comments The consolidated region of the lung isvisualized at lung ultrasound as an echo-poor or tissue-like image, depending on the extent of air loss and fluidpredominance, which is clearly different from the normalpattern [34–38]. The cause of lung consolidation can bediagnosed by analyzing the sonographic features of thelesion [39, 40]. Accuracy of lung ultrasound in the diag-nosis and differential diagnosis of lung consolidation hasbeen tested in different settings [36, 41–44] and showed

good accuracy compared with CXR [43, 45–48]. Inpleuritic pain, lung ultrasound is superior to CXR andmay allow visualization of radio-occult pulmonary con-ditions [47, 48]. In mechanically ventilated patients,lung ultrasound is more accurate than CXR in detectingand distinguishing various types of consolidations[49, 50].

Monitoring lung diseases


• In patients with cardiogenic pulmonary edema, semi-quantification of disease severity may be obtained byevaluating the number of B-lines as this is directlyproportional to the severity of congestion.


• In patients with cardiogenic pulmonary edema,B-lines should be evaluated because it allows moni-toring of response to therapy.


• In patients with increased extravascular lung water,assessment of lung reaeration can be assessed bydemonstrating a change (decrease) in the number ofB-lines.


• In the majority of cases of acute lung injury or ARDS,ultrasound quantification of lung reaeration may beassessed by tracking changes in sonographic findings.

• Sonographic findings should include assessment oflung consolidation and B-lines.

RL-D2-S1 (strong: level A)

• In critically ill patients with acute lung injury orARDS, ultrasound changes in lung aeration can besemiquantitatively assessed (at a given location on thechest) using the following four sonographic findings,often in progression:

– Normal pattern– Multiple spaced B-lines– Coalescent B-lines– Consolidation


• Lung ultrasound is able to monitor aeration changesand the effects of therapy in a number of acute lungdiseases, including the following:

– Acute pulmonary edema– Acute respiratory distress syndrome– Acute lung injury– Community-acquired pneumonia– Ventilator-associated pneumonia

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– Recovery from lavage of alveolar proteinosis


• Serial evaluation of B-lines allows monitoring ofpulmonary congestion in patients on hemodialysis, butis of undetermined clinical utility.

P-D2-S4 (no consensus: level C)

• The semiquantitative techniques of B-line evaluation(see B-D2-S2 and B-D2-S4) are useful as a prognosticindicator of outcomes or mortality in patients withleft-sided heart failure.


• Semiquantitative B-line assessment is a prognosticindicator of adverse outcomes and mortality inpatients with acute decompensated heart failure.

Comments The concept of using lung ultrasound formonitoring the patient is one of the major innovations thatemerged from recent studies. Pulmonary congestion maybe semiquantified using lung ultrasound [22, 25, 27, 51–55]. In the clinical arena, lung ultrasound can therefore beemployed as a bedside, easy-to-use, alternative tool formonitoring pulmonary congestion changes in heart failurepatients, as they disappear or clear upon adequate medicaltreatment [27, 56–60]. More generally, any significantchange in lung aeration resulting from any therapy aimedat reversing aeration loss might be detected by corre-sponding changes in lung ultrasound patterns [61, 62].

Neonatology and pediatrics


• Lung ultrasound is a clinically useful diagnostic toolin neonates with suspected respiratory distress syn-drome (RDS).


• All the following sonographic signs are likely to bepresent in neonates with respiratory distress syndrome:

– Pleural line abnormalities– Absence of spared areas– Bilateral confluent B-lines


• Lung ultrasound is as accurate as chest radiography inthe diagnosis of respiratory distress syndrome inneonates.


• Lung ultrasound is a clinically useful diagnostic toolin suspected transient tachypnea of the newborn(TTN).


• The sonographic signs for transient tachypnea of thenewborn are bilateral confluent B-lines in the depen-dent areas of the lung (‘‘white lung’’) and normal ornear-normal appearance of the lung in the superiorfields.


• Lung ultrasound is as accurate as chest radiography indiagnosis of TTN.


• Lung ultrasound is a clinically useful diagnostic toolin pediatric patients with suspected pneumonia.


• The ultrasound signs of lung and pleural diseasesdescribed in adults are also found in pediatric patients.


• Lung ultrasound is as accurate as chest radiography indiagnosis of pneumonia in pediatric patients.

Comments In newborns, lung ultrasound signs aresimilar to those previously described in adults, althoughthese signs will be context specific. Lung ultrasoundallows diagnosis of RDS with accuracy similar to CXReven if there is no correlation between the differentradiographic stages of RDS and ultrasound findings [63].Lung ultrasound demonstrates very unique findings in thediagnosis of TTN, whereas CXR is nonspecific [64].

Many studies showed that the ultrasound signs of lungand pleural diseases described in adults are also found inpediatric patients [45, 65–68]. In suspected pneumonia,lung ultrasound has demonstrated to be no less accuratethan CXR. These data suggest that, when there is clinicalsuspicion of pneumonia, a positive lung ultrasoundexcludes the need to perform CXR.

Pleural effusion


• Both of the following signs are present in almost allfree effusions:

– A space (usually anechoic) between the parietal andvisceral pleura

– Respiratory movement of the lung within theeffusion (‘‘sinusoid sign’’)


• A pleural effusion with internal echoes suggests that itis an exudate or hemorrhage. While most transudatesare anechoic, some exudates are also anechoic. Tho-racentesis may be needed for further characterization.

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• In the evaluation of pleural effusion in adults, themicroconvex transducer is preferable. If not available, aphased array or a convex transducer can be used.


• The optimal site to detect a nonloculated pleuraleffusion is at the posterior axillary line above thediaphragm.


• For the detection of effusion, lung ultrasound is moreaccurate than supine radiography and is as accurate asCT.


• In opacities identified by chest radiography, lungultrasound should be used because it is more accuratethan chest radiography in distinguishing betweeneffusion and consolidation.

Comments Pleural effusion is usually visualized as ananechoic space between the parietal and visceral pleura.This condition can be obvious in patients with substantialeffusion. In other conditions, such as complex effusionand in patients where pleural effusion is suspected, thesonographic technique can benefit from standardizedcriteria to improve diagnostic accuracy. The sinusoid signis a dynamic sign showing the variation of the interpleuraldistance during the respiratory cycles [69, 70]. This var-iation is easily visualized on M-mode as a sinusoidmovement of the visceral pleura [70].

Lung ultrasound has the potential also for diagnosingthe nature of the effusion [71]. Visualization of internalechoes, either of mobile particles or septa, is highlysuggestive of exudate or hemothorax [72–76]. However,when faced with an anechoic effusion, the only way todifferentiate between transudate and exudate is to usethoracentesis or alternatively to evaluate effusion in theclinical context [71, 77–79].

Lung ultrasound accuracy is proved to be higher thanCXR, particularly when anterior–posterior view in thesupine patient is considered [49, 69, 70]. Lung ultrasoundperformance is nearly as good as CT scan [49, 80].

Update plan

New research and knowledge will give impetus to updatethese guidelines by renewing the development process atleast every 4 years or whenever a significant major changein evidence appears. A professional librarian will reviewliterature on a regular basis and send any updates to thecorresponding author. The panel is open to new inputs, andthe position of new researchers and experts will be con-sidered in the future before the next revision.

Conclusions

This is the first document reporting evidence-based rec-ommendations on clinical use of point-of-care lungultrasound. Experts who published the vast majority ofpapers on clinical use of lung ultrasound in the last20 years elaborated these specific 73 recommendations. Anumber of these recommendations will potentiallyreshape the future practice and knowledge of this rapidlyexpanding field. These applications will benefit patientsworldwide as rigorous assessment, classification, andpublication efforts continue to make this critical infor-mation available to all clinicians. The advantages ofcorrect use of bedside lung ultrasound in the emergencysetting are striking, particularly in terms of saving fromradiation exposure, delaying or even avoiding transpor-tation to the radiology suite, and guiding life-savingtherapies in extreme emergency. This document waselaborated to guide implementation, development, andtraining on use of lung ultrasound in all relevant settings;it will also serve as the basis for further research and toinfluence and enhance the associated standards of care.

Appendix

Organizing society

World Interactive Network Focused on Critical Ultra-sound (WINFOCUS)

Consensus conference participants and affiliations

Working subgroup leaders

Writing committee: G Volpicelli (Emergency Medicine,San Luigi Gonzaga University Hospital, Torino, Italy)

Document reviewers: M Blaivas (Department ofEmergency Medicine, Northside Hospital Forsyth, Atlanta,GA, USA)

Methodology committee: M Elbarbary (National & GulfCenter for Evidence Based Health Practice, King SaudUniversity for Health Sciences, Riyadh, Saudi Arabia)

Organizing committee: L Neri (AREU EMS PublicRegional Company, Niguarda Ca’ Granda Hospital, Mi-lano, Italy)

Working committees

Writing committee:

• DA Lichtenstein (Service de Reanimation Medicale,Hopital Ambroise-Pare, Boulogne, Paris-Ouest,France)

587

• G Mathis (Internal Medicine Praxis, Rankweil, Austria)• A Kirkpatrick (Foothills Medical Centre, Calgary, AB,

Canada)• L Gargani (Institute of Clinical Physiology, National

Research Council, Pisa, Italy)• VE Noble (Division of Emergency Ultrasound, Depart-

ment of Emergency Medicine, Massachusetts GeneralHospital, Boston, MA, USA)

• R Copetti (Medical Department, Latisana Hospital,Udine, Italy)

• G Soldati (Emergency Medicine Unit, Valle delSerchio General Hospital, Lucca, Italy)

• B Bouhemad (Surgical Intensive Care Unit, Depart-ment of Anesthesia and Critical Care, GroupeHospitalier Paris Saint-Joseph, Paris, France)

• A Reissig (Department of Pneumology and Allergol-ogy, Medical University Clinic I, Friedrich-SchillerUniversity, Jena, Germany)

• JJ Rouby (Multidisciplinary Intensive Care Unit,Department of Anesthesiology, Pitie-Salpetriere Hos-pital, University Pierre and Marie Curie, Paris, France)

Document reviewers:

• G Via (IRCCS Foundation Policlinico San Matteo,Pavia, Italy)

• E Agricola (Division of Noninvasive Cardiology, SanRaffaele Scientific Institute, IRCCS, Milan, Italy)

• JW Tsung (Mount Sinai School of Medicine, Depart-ments of Emergency Medicine and Pediatrics, NewYork, NY, USA)

Methodology committee:

• L Melniker (Department of Emergency Medicine, NewYork Methodist Hospital and Clinical EpidemiologyUnit, Division of General Internal Medicine, Depart-ment of Medicine, Weill Medical College of CornellUniversity, NY, USA)

• A Dean (Division of Emergency Ultrasonography,Department of Emergency Medicine, University ofPennsylvania Medical Center, Philadelphia, PA, USA)

• R Breitkreutz [Department of Anaesthesiology, Inten-sive Care and Pain therapy, University Hospital of theSaarland and Frankfurt Institute of Emergency Medi-cine and Simulation Training (FINEST), Germany]

• A Seibel (Diakonie Klinikum jung-stilling, Siegen,Germany)

Organizing committee:

• E Storti (Intensive Care Unit ‘‘G. Bozza,’’ NiguardaCa’ Granda Hospital, Milan, Italy)

• T Petrovic (Samu 93, University Hospital Avicenne,Bobigny, France)

Other consensus conference members:

• C Arbelot (Multidisciplinary Intensive Care Unit,Department of Anesthesiology, Pitie-Salpetriere Hos-pital, University Pierre and Marie Curie, Paris, France)

• A Liteplo (Emergency Medicine, Massachusetts Gen-eral Hospital, Boston, MA, USA)

• A Sargsyan (Wyle/NASA Lyndon B. Johnson SpaceCenter Bioastronautics Contract, Houston, TX, USA)

• F Silva (UC Davis Medical Center, Emergency Med-icine, Sacramento, CA, USA)

• R Hoppmann (Internal Medicine, University of SouthCarolina School of Medicine)

Acknowledgments Special thanks to the Cornell library staff forconducting the literature search, to Ms. Maddalena Bracchetti forher outstanding organizational and administrative support, and toall the secretariat staff. This study was endorsed by the WorldInteractive Network Focused on Critical Ultrasound (WINFOCUS).

Conflicts of interest The authors declare that they have nocompeting interests.

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