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 "excerpt": "Lung ultrasound is a bedside, artifact-based imaging method detecting pleural effusion, consolidation, pneumothorax, and interstitial syndrome; its BLUE protocol diagnoses acute respiratory failure causes with 90.5% accuracy.",
 "snippet": "Lung ultrasound is a bedside, artifact-based imaging method detecting pleural effusion, consolidation, pneumothorax, and interstitial syndrome; its BLUE protocol diagnoses acute respiratory failure causes with 90.5% accuracy.",
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 "markdown": "# Lung ultrasound\n\nLung ultrasound is a bedside imaging method that applies ultrasound waves at the chest wall to detect pleural effusion, consolidation, pneumothorax, and interstitial syndrome. Unlike most ultrasound examinations, it is predominantly artifact-based: air blocks sound, so the diagnosis rests on interpreting reverberation artifacts and the appearance of the pleural line rather than on direct visualization of the lung itself.<sup>[1](https://pubs.rsna.org/doi/10.1148/ryct.2021200564)</sup> For several acute conditions it outperforms chest radiography; for pleural effusion it is more accurate than supine radiography and as accurate as CT.<sup>[2](https://www.med.upenn.edu/pennultrasound/assets/user-content/documents/internationalevidence-basedrec.pdf)</sup> The structured BLUE protocol takes less than 3 minutes and diagnosed the main causes of acute respiratory failure with 90.5% accuracy in its original 260-patient study.<sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC3895677/)</sup>\n\n| Key fact | Value |\n|---|---|\n| Definition of a B-line | Discrete, laser-like vertical hyperechoic reverberation artifact arising from the pleural line, extending to the bottom of the screen, moving with lung sliding<sup>[2](https://www.med.upenn.edu/pennultrasound/assets/user-content/documents/internationalevidence-basedrec.pdf)</sup> |\n| Pathological B-line threshold | Three or more B-lines in one intercostal space, or confluent B-lines<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> |\n| BLUE protocol | Under 3 minutes; 90.5% overall accuracy for the six main causes of acute respiratory failure<sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC3895677/)</sup> |\n| Pneumonia (pooled, 29 studies, 6702 patients) | Sensitivity 92%, specificity 94%, ROC AUC 0.9712<sup>[5](https://www.mdpi.com/2543-6031/92/3/24)</sup> |\n| Pneumothorax | Lung point sign: 100% specificity<sup>[1](https://pubs.rsna.org/doi/10.1148/ryct.2021200564)</sup> |\n| Pleural effusion | Ultrasound detects 5–20 mL; supine chest X-ray reveals effusions only from 175–525 mL<sup>[6](https://www.ncbi.nlm.nih.gov/books/NBK500013/)</sup> |\n| Pulmonary edema | Sensitivity 97%, specificity 95%; B-lines can precede radiographic abnormalities<sup>[6](https://www.ncbi.nlm.nih.gov/books/NBK500013/)</sup> |\n\n## How it works\n\nThe pleural line appears as a hyperechoic horizontal line that moves with respiration, a movement called lung sliding.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> A-lines are horizontal reverberation artifacts repeated at equidistant intervals equal to the probe-to-pleural-line distance; they indicate air-filled lung.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> B-lines are vertical hyperechoic lines arising from the pleural line and extending to the bottom of the screen; short vertical artifacts that do not reach the bottom are not B-lines.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> The 2012 international consensus defined them as \"discrete laser-like vertical hyperechoic reverberation artifacts\" arising from the pleural line, replacing the older term \"comet tails\".<sup>[2](https://www.med.upenn.edu/pennultrasound/assets/user-content/documents/internationalevidence-basedrec.pdf)</sup>\n\nUp to two or three B-lines per intercostal space can be seen in healthy lung, particularly at the bases; three or more between two ribs, or coalescent B-lines occupying most of the interspace, define pathological interstitial syndrome, and their number correlates with loss of aeration and ground-glass opacities on CT.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup><sup> • </sup><sup>[7](https://www.mdpi.com/2075-4418/15/6/755)</sup> Two further signs refine diagnosis: the lung point, the location where sliding reappears, is specific to pneumothorax,<sup>[8](https://doi.org/10.1007/s001340000627)</sup> and the lung pulse, transmission of the cardiac pressure wave through non-ventilated lung, indicates complete atelectasis and explains absent sliding without pneumothorax.<sup>[9](https://doi.org/10.1007/s00134-003-1930-9)</sup> Vertical artifact appearance depends strongly on imaging frequency and bandwidth: at the same lung point, several vertical artifacts, or none, may be seen depending on the frequency used.<sup>[10](https://www.ovid.com/journals/jultm/fulltext/10.1002/jum.16088~new-international-guidelines-and-consensus-on-the-use-of)</sup>\n\n## How it is done\n\nProbe choice follows depth: linear high-frequency probes give the best resolution of the pleural line and suit pneumothorax and children, while curvilinear and phased-array lower-frequency probes (roughly 3–5 MHz) reach deeper structures such as consolidation; the curvilinear probe is recommended as the single best probe to elicit all lung ultrasound signs.<sup>[1](https://pubs.rsna.org/doi/10.1148/ryct.2021200564)</sup><sup> • </sup><sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup><sup> • </sup><sup>[7](https://www.mdpi.com/2075-4418/15/6/755)</sup>\n\nThe original BLUE protocol uses three standardized scan points on each side: the upper BLUE-point, the lower BLUE-point, and the PLAPS-point (posterolateral alveolar and/or pleural syndrome point), defined with the patient's hands placed on the anterior chest wall, analogous to ECG electrode placement.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup><sup> • </sup><sup>[11](https://teachim.org/wp-content/uploads/2021/09/Lichtenstein-BLUE-Chest-2008.full_.pdf)</sup><sup> • </sup><sup>[12](https://accjournal.org/upload/pdf/acc-2022-00780.pdf)</sup> The 2012 consensus recommended an eight-region exam (four areas per side) for interstitial syndrome, with a positive region defined by three or more B-lines between two ribs.<sup>[2](https://www.med.upenn.edu/pennultrasound/assets/user-content/documents/internationalevidence-basedrec.pdf)</sup> Findings are combined into profiles: the B profile indicates pulmonary edema; B', A/B, and C profiles indicate pneumonia; an A profile with venous thrombosis indicates pulmonary embolism; and a normal A profile with sliding indicates COPD or asthma.<sup>[11](https://teachim.org/wp-content/uploads/2021/09/Lichtenstein-BLUE-Chest-2008.full_.pdf)</sup>\n\n## Origin\n\nLichtenstein and Mezière reported the comet-tail artifact as a bedside sign distinguishing pulmonary edema from COPD in 1998 in Intensive Care Medicine,<sup>[13](https://doi.org/10.1007/s001340050771)</sup> Daniel Lichtenstein and colleagues reported the lung point as a sign specific to pneumothorax in 2000 in Intensive Care Medicine,<sup>[8](https://doi.org/10.1007/s001340000627)</sup> and Daniel Lichtenstein and colleagues reported the lung pulse as an early sign of complete atelectasis in 2003 in Intensive Care Medicine.<sup>[9](https://doi.org/10.1007/s00134-003-1930-9)</sup> The BLUE protocol itself was reported by Daniel A. Lichtenstein and Gilbert A. Mezière in CHEST Journal in 2008,<sup>[14](https://doi.org/10.1378/chest.07-2800)</sup> and the BLUE-points by the same two authors in The Ultrasound Journal in 2011.<sup>[15](https://doi.org/10.1007/s13089-011-0066-3)</sup> In parallel, Giovanni Volpicelli and colleagues published an eight-zone scanning approach for alveolar-interstitial syndrome in 2006 in The American Journal of Emergency Medicine,<sup>[16](https://doi.org/10.1016/j.ajem.2006.02.013)</sup> and [Eugenio Picano](https://www.edgepedia.org/eugenio-picano) and colleagues introduced the ultrasound lung comets (ULC) score of extravascular lung water in echocardiography the same year in the Journal of the [American Society of Echocardiography](https://www.edgepedia.org/american-society-of-echocardiography).<sup>[17](https://doi.org/10.1016/j.echo.2005.05.019)</sup> The 2012 international evidence-based recommendations, with Giovanni Volpicelli as first author, standardized terminology and technique in Intensive Care Medicine.<sup>[18](https://doi.org/10.1007/s00134-012-2513-4)</sup>\n\n## Variants\n\nThe FALLS-protocol (Fluid Administration Limited by Lung Sonography) adapts the BLUE sequence to shock, using the abrupt change from A-lines to lung rockets as the endpoint for fluid therapy; this change appears at a pulmonary artery occlusion pressure threshold of 18 mmHg, providing a bedside marker of volemia.<sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC3895677/)</sup><sup> • </sup><sup>[19](https://journal.chestnet.org/article/S0012-3692%2815%2937223-8/abstract)</sup> For monitoring aeration, the LUS aeration score introduced by Alexis Soummer and colleagues in 2012 grades each region 0 to 3, from normal lung (no more than two B-lines) to complete consolidation.<sup>[20](https://doi.org/10.1097/ccm.0b013e31824e68ae)</sup><sup> • </sup><sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> A widely used LUS Score assesses four stages of aeration loss (N, B1, B2, C) over six areas per side.<sup>[10](https://www.ovid.com/journals/jultm/fulltext/10.1002/jum.16088~new-international-guidelines-and-consensus-on-the-use-of)</sup>\n\nCOVID-19 accelerated scoring systems. The 12-region LUSS allocates 0–3 points per region (normal = 0, well-defined B-lines = 1, coalescent B-lines = 2, consolidation = 3; total 0–36).<sup>[21](https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0236312)</sup> A triage system stratifies admission probability into LowLUS, IntLUS, and HighLUS categories; HighLUS and IntLUS together showed 90.2% sensitivity for positive PCR.<sup>[7](https://www.mdpi.com/2075-4418/15/6/755)</sup> In neonatology, the Brat score divides each half of the chest into three areas scored 0–3 (maximum 18) and predicts the need for surfactant in respiratory distress syndrome.<sup>[7](https://www.mdpi.com/2075-4418/15/6/755)</sup>\n\n## Applications\n\nFor pneumonia in adults, a meta-analysis of 29 studies with 6702 participants found pooled sensitivity 92% (95% CI 91–93%), specificity 94% (94–95%).<sup>[5](https://www.mdpi.com/2543-6031/92/3/24)</sup> Against CT in ICU adults, a [Bayesian network](https://www.edgepedia.org/bayesian-network) meta-analysis found lung ultrasound sensitivity 0.93 and specificity 0.83, versus 0.65 and 0.81 for chest X-ray.<sup>[22](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370%2825%2900486-9/fulltext)</sup>\n\nFor pleural effusion, ultrasound identifies 5–20 mL of fluid with sensitivity 89–100% and specificity 96–100%, whereas supine chest X-ray reveals effusions only from 175–525 mL.<sup>[6](https://www.ncbi.nlm.nih.gov/books/NBK500013/)</sup><sup> • </sup><sup>[23](https://www.acep.org/sonoguide/basic/lung)</sup> Volume can be estimated by measuring the largest distance in centimeters from lung base to diaphragm and multiplying by 200 mL/cm, which supports thoracentesis and drain placement; the [British Thoracic Society](https://www.edgepedia.org/british-thoracic-society) now recommends that pleural procedures only be undertaken with lung ultrasound guidance.<sup>[6](https://www.ncbi.nlm.nih.gov/books/NBK500013/)</sup><sup> • </sup><sup>[7](https://www.mdpi.com/2075-4418/15/6/755)</sup> For pneumothorax, the lung point has 100% specificity,<sup>[1](https://pubs.rsna.org/doi/10.1148/ryct.2021200564)</sup> and a single B-line excludes pneumothorax.<sup>[23](https://www.acep.org/sonoguide/basic/lung)</sup> For pulmonary edema, thoracic ultrasound has sensitivity 97% and specificity 95% and can precede radiographic abnormalities.<sup>[6](https://www.ncbi.nlm.nih.gov/books/NBK500013/)</sup> In COVID-19, a systematic review of 66 studies (4687 patients) found B-lines in 91% of patients (99% in ICU), confluent B-lines in 80%, and pleural abnormalities; higher baseline LUS scores were associated with death, ICU admission, or mechanical ventilation in all 16 prognostic studies.<sup>[24](https://pmc.ncbi.nlm.nih.gov/articles/PMC8783639/)</sup>\n\n## Limitations and alternatives\n\nAir in subcutaneous tissue blocks the beams, so lung sliding is not seen in subcutaneous emphysema; vertical E-lines may appear and mimic B-lines, but E-lines do not arise from the pleural line and do not move with respiration.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> Loss of lung sliding is sensitive but not specific for pneumothorax, since pleural adhesions, pleurodesis, atelectasis, mainstem intubation, apnea, and COPD give similar appearances; the lung pulse helps separate these.<sup>[6](https://www.ncbi.nlm.nih.gov/books/NBK500013/)</sup><sup> • </sup><sup>[9](https://doi.org/10.1007/s00134-003-1930-9)</sup> Anterior-only scans miss posterior disease, and assessing dorsal zones improves pneumonia detection.<sup>[22](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370%2825%2900486-9/fulltext)</sup> For many algorithms, findings overlap between conditions, making dichotomous categorization hard, for example distinguishing cardiogenic pulmonary edema from ARDS.<sup>[4](https://link.springer.com/article/10.1186/s13054-024-05102-y)</sup> A complete lung ultrasound can take 20 minutes, whereas chest radiography takes a few minutes, and quality varies by practitioner.<sup>[1](https://pubs.rsna.org/doi/10.1148/ryct.2021200564)</sup>\n\nQuantification is moving toward automation. Laura J. Brattain and colleagues reported automated B-line scoring on thoracic sonography in 2013,<sup>[25](https://doi.org/10.7863/ultra.32.12.2185)</sup> and Claudia Brusasco and colleagues an automatic B-line detection and quantification algorithm in 2019.<sup>[26](https://doi.org/10.1186/s13054-019-2569-4)</sup> A systematic review covering January 2015 to November 2025 identified 24 articles applying AI to lung ultrasound; segmentation models allow a B-line Artifact Score quantifying the exact percentage of each intercostal space occupied by B-lines.<sup>[27](https://www.frontiersin.org/journals/radiology/articles/10.3389/fradi.2026.1899103/full)</sup> A 2025 focused update of the international recommendations, produced by 21 experts through a Delphi review of 1775 new publications, achieved consensus on 83 statements.<sup>[28](https://pure.amsterdamumc.nl/en/publications/international-evidence-based-recommendations-for-point-of-care-lu/)</sup>\n\n## References\n\n1. [Lung Ultrasound: The Essentials (Radiology: Cardiothoracic Imaging)](https://pubs.rsna.org/doi/10.1148/ryct.2021200564)\n2. [International evidence-based recommendations for point-of-care lung ultrasound (ILC-LUS, Intensive Care Med 2012)](https://www.med.upenn.edu/pennultrasound/assets/user-content/documents/internationalevidence-basedrec.pdf)\n3. [Lung ultrasound in the critically ill (Lichtenstein, Annals of Intensive Care 2014)](https://pmc.ncbi.nlm.nih.gov/articles/PMC3895677/)\n4. [Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies (Critical Care, 2024)](https://link.springer.com/article/10.1186/s13054-024-05102-y)\n5. [Lung Ultrasonography Accuracy for Diagnosis of Adult Pneumonia: Systematic Review and Meta-Analysis (Advances in Respiratory Medicine, 2024)](https://www.mdpi.com/2543-6031/92/3/24)\n6. [Thoracic and Lung Ultrasound - StatPearls (NCBI Bookshelf)](https://www.ncbi.nlm.nih.gov/books/NBK500013/)\n7. [Lung Ultrasound in Critical Care: A Narrative Review (Diagnostics, 2025)](https://www.mdpi.com/2075-4418/15/6/755)\n8. [Daniel Lichtenstein and colleagues (2000). The \"lung point\": an ultrasound sign specific to pneumothorax. Intensive Care Medicine.](https://doi.org/10.1007/s001340000627)\n9. [Daniel A. Lichtenstein and colleagues (2003). The “lung pulse”: an early ultrasound sign of complete atelectasis. Intensive Care Medicine.](https://doi.org/10.1007/s00134-003-1930-9)\n10. [New International Guidelines and Consensus on the Use of Lung Ultrasound (Journal of Ultrasound in Medicine)](https://www.ovid.com/journals/jultm/fulltext/10.1002/jum.16088~new-international-guidelines-and-consensus-on-the-use-of)\n11. [Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure: The BLUE Protocol (Chest 2008)](https://teachim.org/wp-content/uploads/2021/09/Lichtenstein-BLUE-Chest-2008.full_.pdf)\n12. [Lung ultrasound for evaluation of dyspnea: a pictorial review (Applied Radiology, 2022)](https://accjournal.org/upload/pdf/acc-2022-00780.pdf)\n13. [D. Lichtenstein, G. Mezière (1998). A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Medicine.](https://doi.org/10.1007/s001340050771)\n14. [Daniel A. Lichtenstein, Gilbert A. Mezière (2008). Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure*: The BLUE Protocol. CHEST Journal.](https://doi.org/10.1378/chest.07-2800)\n15. [Daniel A. Lichtenstein, Gilbert A. Mezière (2011). The BLUE-points: three standardized points used in the BLUE-protocol for ultrasound assessment of the lung in acute respiratory failure. The Ultrasound Journal.](https://doi.org/10.1007/s13089-011-0066-3)\n16. [Giovanni Volpicelli and colleagues (2006). Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. The American Journal of Emergency Medicine.](https://doi.org/10.1016/j.ajem.2006.02.013)\n17. [Eugenio Picano and colleagues (2006). Ultrasound Lung Comets: A Clinically Useful Sign of Extravascular Lung Water. Journal of the American Society of Echocardiography.](https://doi.org/10.1016/j.echo.2005.05.019)\n18. [Giovanni Volpicelli and colleagues (2012). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Medicine.](https://doi.org/10.1007/s00134-012-2513-4)\n19. [abstract (journal.chestnet.org)](https://journal.chestnet.org/article/S0012-3692%2815%2937223-8/abstract)\n20. [Alexis Soummer and colleagues (2012). Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress*. Critical Care Medicine.](https://doi.org/10.1097/ccm.0b013e31824e68ae)\n21. [Lung ultrasound score to monitor COVID-19 pneumonia progression in patients with ARDS (PLOS One, 2020)](https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0236312)\n22. [fulltext (thelancet.com)](https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370%2825%2900486-9/fulltext)\n23. [Lung | Sonoguide (ACEP)](https://www.acep.org/sonoguide/basic/lung)\n24. [Ultrasound findings of lung ultrasonography in COVID-19: A systematic review (2021)](https://pmc.ncbi.nlm.nih.gov/articles/PMC8783639/)\n25. [Laura J. Brattain and colleagues (2013). Automated B‐Line Scoring on Thoracic Sonography. Journal of Ultrasound in Medicine.](https://doi.org/10.7863/ultra.32.12.2185)\n26. [Claudia Brusasco and colleagues (2019). Quantitative lung ultrasonography: a putative new algorithm for automatic detection and quantification of B-lines. Critical Care.](https://doi.org/10.1186/s13054-019-2569-4)\n27. [Artificial intelligence for lung ultrasound interpretation: a systematic review (Frontiers in Radiology, 2026)](https://www.frontiersin.org/journals/radiology/articles/10.3389/fradi.2026.1899103/full)\n28. [International evidence-based recommendations for point-of-care lung ultrasound: 2025 focused update of the 2012 recommendations (Intensive Care Medicine, 2026)](https://pure.amsterdamumc.nl/en/publications/international-evidence-based-recommendations-for-point-of-care-lu/)\n\n---\n*Topic: Encyclopedia › Life and health › Human health and medicine › Clinical assessment and procedures › Medical imaging and radiography › Ultrasound and echocardiography*\n\n*Initially written Sep 29, 2026 · Edited: Oct 15, 2026; Oct 21, 2026*\n\n*Copyright 2026 EdgeChat AI, a subsidiary of Biostate AI.*\n\nLicense: Edgepedia Community License 1.0, https://www.edgepedia.org/edgepedia/license\n",
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 "credit": "\"Lung ultrasound\", Edgepedia (EdgeChat), https://www.edgepedia.org/lung-ultrasound. Edgepedia Community License 1.0.",
 "credit_md": "\"[Lung ultrasound](https://www.edgepedia.org/lung-ultrasound)\", Edgepedia (EdgeChat), [https://www.edgepedia.org/lung-ultrasound](https://www.edgepedia.org/lung-ultrasound). [Edgepedia Community License 1.0](https://www.edgepedia.org/edgepedia/license).",
 "credit_html": "\"<a href=\"https://www.edgepedia.org/lung-ultrasound\">Lung ultrasound</a>\", Edgepedia (EdgeChat), <a href=\"https://www.edgepedia.org/lung-ultrasound\">https://www.edgepedia.org/lung-ultrasound</a>. <a href=\"https://www.edgepedia.org/edgepedia/license\">Edgepedia Community License 1.0</a>.",
 "speakable": "Lung ultrasound is a bedside, artifact-based imaging method detecting pleural effusion, consolidation, pneumothorax, and interstitial syndrome; its BLUE protocol diagnoses acute respiratory failure causes with 90.5% accuracy."
}
