Links To And Slides From Dr. Lichtenstein’s YouTube Video 2015 Lung The Blue Protocol and Advanced Issues

Today, I link to and excerpt from the outstanding YouTube video, 2015 Lung The Blue Protocol and Advanced issues By D. Daniel Lichtenstein. 55:09, Apr 27, 2019.

To quickly review the video, you can read the auto-generated transcript on YouTube. But the lecture is so good and so complete, it is worth reviewing more than once.

I went ahead and excerpted some (most) of the slides as this exercise seems to be a good memory aid for me. I’ve put the time stamps on the slides so that I can read Dr. Lichtenstein’s  comments about each slide from the YouTube transcript.


Slide 1 1:31


Slide 2 1:36


Slide 3 1:57

Slide 4 2:27

Slide 5 2:57

Slide 6 3:00

Slide 7 3:14

Slide 8 3:55 The SESAME Protocol For Cardiac Arrest

Slide 9 4:00 We see lung sliding on the left side [as, of course, the patient is being ventilated with BVM or an advanced airway device]

Slide 10 4:06 But on the right side we do NOT see lung sliding.

Slide 11 4:39 So we enlarge the B mode and add M mode and we see A-lines on B-scan and Stratosphere sign on M-mode: Thus pneumothorax most likely

Slide 12 4:55 The presence of the lung point sign allows us to say that pneumothorax is definitely present.

And here is a link to a 2 minute YouTube video on the lung point in pneumothorax for a brief fast review.

Slide 13 5:08 The patient below is in shock (acute circulatory failure)

Slide 14 5:44 The parasternal long axis of the heart shows vigorous contraction despite the severe hypotension. The lung ultrasound shows a normal A profile (lung sliding and A lines meaning repetitions of the pleural line). Therefore Dr. Lichtenstein concludes:

The Blue Protocol

Slide 15  6:26 What we need to perform  the Blue Protocol. Dr. Lichtenstein uses a microconvex probe at 5 MHz for the lungs. For the cardiac part of the exam it needs to set at  a lower frequency (2 to 2.5 MHz) for greater penetration.

Slide 16 6:33

So from 6:33 to 12:30 Dr. Lichtenstein gives us great examples of the ten signs and this portion of the YouTube video is best reviewed as a whole. The ten signs are:

  1.  6:46 The pleural line and the bat sign. The pleural line indicates the parietal pleura and the bat sign (the wings) are the rib shadows.
  2. 6:55 The A line indicates gas below the pleura and is the repetition of the pleural line.
  3. 7:38 Lung sliding and the seashore sign on M-mode indicates there is no pneumothorax.
  4. 8:02 Pleural effusion is indicated by the lung line, a line that is parallel to the pleural line. The lung line is, of course, the visceral pleura
  5. 8:02 Dr. L shows a picture of the sinusoidal sign, which is # 5 but doesn’t discuss it. It is basically an M-mode through the pleural effusion.
  6. 8:32 The shred sign
  7. 8:32 The tissue like sign
  8. 8:36 The interstitial syndrome-basic sign: the B-line (Sign 8)
  9. 11:10 Pneumothorax and the abolished lung sliding. And the on M-mode the stratosphere sign
  10. 12:01 Pneumothorax and the lung point sign

Slide 17 12:38

Slide 18 13:39

Slide 19 13:51 Lung rockets are a critical part of the Blue Protocol

Slide 20 17:05

Slide 21 18:04 These examples below are four examples of the eight BLUE protocol.

Slide 22 18:49 Below – We are at the anterior chest wall. This is the A-profile.

Slide 23 19:21 Again we are at the anterior wall and this is the B-profile

Slide 24 19:54 Below-No lung sliding but lung rockets.

Slide 25 20:14 The patient below likely has pneumothorax as the cause of the respiratory failure.

Slide 26 20:25 Below

This is one sign that is a posterior sign and is called the PLAPS sign or syndrome.

PLAPS stands for Postero-Lateral Alveolar and/or Pleural syndrome.

The above means that that is it can be completely alveolar
or completely pleural or it can have elements of both. It is so frequent that we wanted to give a name to that.

Slide 27 20:57

Slide 28 21:33 Below are the findings of the B profile.

Slide 29 22:30

Slide 30 25:53 Below-So in the slide above we have ruled in pulmonary edema. But we can also use the Blue protocol to rule out diagnoses.

Slide 31 26:00 Below-So maybe you want to rule out, say pneumothorax. Well, you have lung rockets and lung sliding so you have ruled out pneumothorax.

Slide 32 26:21 Below-And because we have interstitial signs (lung rockets), it is not consistent with COPD or simple asthma. But it could be a cardiac asthma. It could be a pulmonary embolus because in four percent of pulmonary embolus cases you can have interstitial signs.

Slide 33 26:40 Below-Pulmonary Embolism rule out? Well, we see the B profile  in four percent of pulmonary embolus cases. So we need to be cautious in this rule out. “It is [pulmonary embolus] unlikely, just unlikely.”

Slide 34 26:56 Below-So we look at the anterior chest wall. And what we see is a normal A profile in most cases of massive PE.

Slide 35 27:22 Below-So we see the A profile. So the next step is to rapidly examine the lower extremities venous system with ultrasound.

Slide 36 27:37 Below-So next you do Dr. Lichtenstein’s lower extremity venous exam. And if you see clot then in the patient with the appropriate clinical findings (and clinically unstable), you have made the diagnosis (99% specificity) of pulmonary embolus and can possibly treat the patient.

Slide 37 27:56 Below-Dr. Lichtenstein gives advice on the venous exam.


Slide 38


Slide 39


Slide 40


Slide 41

Additional Resources:

(1) A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. [PubMed Abstract] [Download PDF]. Chest. 2009 Oct;136(4):1014-1020

(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.

The above article has been cited by 7 PubMed Central articles.

(3) Critical care ultrasound in cardiac arrest. Technological requirements for performing the SESAME-protocol–a holistic approach. [PubMed Abstract] [Full Text PDF]. Anaesthesiol Intensive Ther. 2015;47(5):471-81

(4) Point of Care Ultrasound: DVT–Another Great YouTube Video from Critical Care Specialist Dr. Liz Turner
Posted on January 14, 2015 by Tom Wade MD



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