Emergency Ultrasound (EUS)教學(18)

急診超音波在呼吸急症之應用
BLUE protocol
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
 Principles of Lung Ultrasound
1. Dependent v.s. Nondependent disorders
2. Lung surface is extensive
3. All lung signs arise from the pleural line
4. Analyze artifacts
5. Dynamic signs
6. Acute disorders contact the thorax surface
7. A simple & 2-D device meets this task
 Ultrasound areas

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

© 2008 by American College of Chest Physicians

 Batlung
Normal Sign
surface
Seashore Sign/ Lung sliding

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

© 2008 by American College of Chest Physicians

 Barcode sign
Pneumothorax
Stratosphere sign

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

© 2008 by American College of Chest Physicians

 Lung rockets
Interstitial syndrome
Comet-tail artifacts

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

© 2008 by American College of Chest Physicians

 Pleural effusion and alveolar consolidation;
typical example of PLAPS

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

PLAPS: PosteroLateral Alveolar and/or Pleural Syndrome

© 2008 by American College of Chest Physicians

 Ultrasound profiles

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

© 2008 by American College of Chest Physicians

 A decision tree utilizing lung ultrasonography to guide diagnosis of severe dyspnea.

Lichtenstein D. A., Mezière G. A. Chest 2008;134:117-125

BLUE: Bedside Lung Ultrasound in Emergency

© 2008 by American College of Chest Physicians

Normal PV demo
Deep Vein Thrombosis
Pulmonary embolism
 Combined Results

Normal
Profile,
and A’
A Profile Profile
Plus Without A/B Lung
Diagnoses PLAPS PLAPS B Profile B’ Profile C Profile Profile Point
Pulmonary
edema 2 0 621 0 0 0 0
COPD or
asthma 4 751 3 0 1 0 0
Pulmonary
embolism 108 109 0 0 10 0 0
Pneumotho
rax 0 1 0 0 0 0 8
Pneumonia 35 3 6 9 18 12 0
 Accuracy of the Ultrasound
Disease
Profiles
Ultrasound Signs Used Sensitivity, % Specificity, % Positive Predictive Value, % Negative Predictive Value, %
Diffuse bilateral
Cardiogenic anterior B+ lines
pulmonary associated with lung
edema sliding (B profile) 97 (62/64) 95 (187/196) 87 (62/71) 99 (187/189)
Predominant anterior A
lines without PLAPS
and with lung sliding
(normal profile), or with
COPD or absent lung sliding
asthma without lung point 89 (74/83) 97 (172/177) 93 (74/79) 95 (172/181)
Predominant anterior
Pulmonary bilateral A lines plus
embolism venous thrombosis 81 (17/21) 99 (238/239) 94 (17/18) 98 (238/242)
Absent anterior lung
sliding, absent anterior
B lines and present lung
Pneumothorax point 88 (8/9) 100 (251/251) 100 (8/8) 99 (251/252)
Pneumonia Diffuse bilateral
anterior B+ lines
associated with
abolished lung sliding
(B’ profile) 11 (9/83) 100 (177/177) 100 (9/9) 70 (177/251)
Predominant anterior
B+ lines on one side,
predominant anterior
A lines on the other
(A/B profile) 14.5 (12/83) 100 (177/177) 100 (12/12) 71.5 (177/248)
Anterior alveolar
consolidation (C profile) 21.5 (18/83) 99 (175/177) 90 (18/20)

A profile plus PLAPS 42 (35/83) 96 (170/177) 83 (35/42)

A profile plus PLAPS, B’,
A/B or C profile 89 (74/83) 94 (167/177) 88 (74/84)
 52M, Esophageal cancer,
c/o dyspnea, SpO2 80%
970816 990114

Diagnosis ? Next step?

55M, AMS with right side paralysis
and respiratory failure

Diagnosis ? Next step?

33M with dyspnea and orthopnea +
low grade fever 38℃

Diagnosis ? Next step?

40M with left chest pain and
dyspnea + cold sweating

Diagnosis ? Next step?

43M c/o left chest pain, fever &
dyspnea

Diagnosis ? Next step?

71M with dyspnea and fever

Diagnosis ? Next step?

28F c/o dyspnea

Diagnosis ? Next step?

28M c/o fever, left chest pain and dyspnea

Diagnosis ? Next step?

81M c/o dyspnea and fever

Diagnosis ? Next step?

81M with respiratory failure

Dynamic air bronchogram

93M c/o right chest pain and
dyspea after falling down

Diagnosis ? Next step?

48F, MVA victim with shock and dyspnea

Diagnosis ? Next step?

53F, MVA victim with chest pain and dyspnea

Diagnosis ? Next step?

39F, fell off bridge with dyspnea and hypothermia

Diagnosis ? Next step?

81F, SOB w/ desaturation

Diagnosis ? Next step?

46F, fever, dyspnea & shock
47M, right chest pain w/ sweating,
dyspnea and shock
47F, anemia, SOB with low grade
fever; got worse after transfusion
39M, ESRD, fever and dyspnea
990602 990816
 Take Home Message
• Remember 7 principles of lung ultrasound
• Consider BLUE protocol for acute dyspneic patients
– Check anterior lung sliding
– Check A/B/C profiles
– A (+)  venous analysis
– A (-)  PLAPS
• BLUE protocol help diagnosis for
– Pulmonary edema
– Pulmonary embolism
– Pneumonia
– COPD or asthma
– Pneumothorax
Test: 4 Signs + Diagnosis
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