Lung Ultrasound Profiles From the BLUE Protocol – “BLUE-Protocol and FALLS-Protocol: Two Applications of Lung Ultrasound in the Critically Ill”

This post discusses the Lung Ultrasound Profiles of the BLUE protocol from BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Chest. 2015 Jun;147(6):1659-70. doi: 10.1378/chest.14-1313.

The Lung Ultrasound Profiles are used in the decision tree from the article:

The interpretation of lung ultrasound in acute respiratory failure requires the mastery of ten lung ultrasound signs [See post Lung Ultrasound Signs]:

1. Normal lung surface
   1. bat sign
   2. lung sliding
   3. A-lines
2. Pleural effusion
   1. Quad sign
   2. Sinusoid sign
3. Lung consolidation
   1. Fractal sign (also called the shred sign)
   2. Tissue-like sign
4. Interstitial syndrome
   1. Lung rockets
5. Pneumothorax
   1. Stratosphere sign
   2. lung point sign

These lung signs are determined at standard points on the chest (Ref 4 below):

There are eight lung profiles discussed in the article:

1. A-profile
   1. Anterior A-lines present with lung sliding
2. A’-profile
   1. Anterior A lines present with absent lung sliding
3. B-profile
   1. Lung sliding with lung rockets
4. B’-profile
   1. Absent lung sliding with lung rockets
5. A/B-profile
   1. Unilateral lung rockets
6. C-profile – See fig 4 below from Reference 4
   1. “Anterior lung consolidation regardless of number and size up to simply a thick irregular pleural line”
7. Posterior consolidations are seen in hemodynamic pulmonary edema or pulmonary embolism
8. “PLAPS” profiles*: “At the posterior chest wall, lung consolidations and pleural effusions are assessed together for simplicity because both disorders usually come together, hence the practical term “PLAPS”
   1. “The A-no-V-PLAPS-profile is connected with pneumonia.”
   2. “The A-profile with no DVT and no PLAPS (ie, nude profile) is linked with asthma and COPD (two bronchial diseases with similar therapy combined for simplification.”

Lung Consolidation from Reference 4:

The following are excerpts from the above article:

. . .  all acute, life-threatening [lung] disorders are superficial. This allows to standardize the field ( Table 1 ).

The BLUE-protocol was developed based on the study of 300 consecutive adults with acute respiratory failure who were admitted to our ICU and given a diagnosis. The most frequent cause of respiratory failure was:

• pneumonia (32%)
• followed by acute hemodynamic pulmonary edema (24%);
• exacerbated COPD (18%);
• severe asthma (13%);
• pulmonary embolism (8%);
• pneumothorax (4%);
• and countless rare causes, including easy-to-diagnose ones, such as massive pleural eff usion (3%).
• We excluded rare, unknown, and multiple diagnoses because they generate methodologic issues.

The BLUE-protocol is integrated within the control of acute respiratory failure, which requires an understanding of anatomy, physiology, pathophysiology, clinical signs, traditional imaging, and the biology of dyspnea. Th e BLUE-protocol is fully based on pathophysiology.

Additional Resources:

(1) BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Chest. 2015 Jun;147(6):1659-70. doi: 10.1378/chest.14-1313.

(2) Lung Ultrasound in the Critically Ill Neonate [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Curr Pediatr Rev. 2012 Aug;8(3):217-223.

(3) Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review  ([PubMed Abstract] [Full Text HTML] [Full Text PDF]. J Intensive Care. 2016 Aug 15;4:54. doi: 10.1186/s40560-016-0172-1. eCollection 2016.)

(4) Lung ultrasound in the critically ill. Ann Intensive Care. 2014 Jan 9;4(1):1. doi: 10.1186/2110-5820-4-1. [PubMed Abstract] [Full Text HTML] [Full Text PDF]