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The breathless patient

Adapted from Lichtenstein's BLUE protocol

(with permission)

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Summary

1 (Ongoing resus) Clinical assessment: formulate the question

2 Rapid screen3 Form a working diagnosis4 Continue resuscitation 5 Re-scan / monitor progress / further

investigations

1. Formulate the question

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1. Formulate the question

Why is the patient breathless?

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Why is the patient breathless?

• Pneumothorax (PTX)• Pneumonia • Acute cardiogenic pulmonary oedema

(APO)• Pulmonary embolism (PE)• Asthma / COPD• (Other: rare)

2. The BLUE protocol

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Curved probe, abdominal preset

• Machine settings: as for arrest screen

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A 3-step scan

1. Anterior lung fields: 2 points2. If A profile: scan the upper & lower limb

veins for DVT 3. If no DVT: PLAPS points

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The BLUE protocol scan

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The BLUE protocol scan

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Step 1: anterior chest: upper & lower BLUE points

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Step 1: anterior chest: upper & lower BLUE points

• Probe sagittal, midclavicular line• 2 spots on each side• i.e. upper chest & lower chest

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Recall: upper & lower BLUE points

1 1

2 2

Step 1 findings

One lung not sliding

Both lungs sliding

A’ profile B’ profile A profile B profile A/B or C profile

Step 1 findings

One lung not sliding

Both lungs slidng

A profile B profile:Pulmonary

OedemaTreat.

A/B or C profile:

PneumoniaTreat.

A’ profile:PTX?

Look for lung point,consider DDX. Treat

B’ profile:Pneumonia

Treat.

Step 2

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Step 2: the veins

Step 2 (if dry lungs)

Compression scans UL & LL veins

Upper limb: IJV, SCV

Lower limb: femoral confluence, lower SFV, calf veins!

Step 2: scan the veins

DVT not seen:Proceed to step 3

DVT seen = PETreat.

Scan the veins

Step 2 note

This is rule-in, not rule-out. Even with 81% sensitivity in the hands of an expert, you’ll

still miss 19% of patients with PE.

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Step 3: the PLAPS points

What are the PLAPS points?

= the most dependent part of the lungsAs far behind & as low as you can scan

without hitting the diaphragm‘The Morison’s Pouch of the lung’ [thanks Dr

Chris Wong]

Recall: PLAPS

Posterolateral alveolar &/or pleural syndromeNot as bad as it sounds!

Posterolateral alveolar &/or pleural syndrome

If you see effusion or consolidation at PLAPS points it's 'PLAPS positive’

If you see anything else (A lines, B lines), it's 'PLAPS-negative'

PLAPS-positive?

PLAPS-positive?

PLAPS-positive?

PLAPS-positive?

PLAPS-positive?

Step 3: the PLAPS points

PLAPS not seen:COPDAsthma

PE is still possibleReassess patient;

consider other tests.

PLAPS seen:Pneumonia

(PE still possible but much less likely)

Treat.

PLAPS points

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Now what?

You’ve reached the end of the scanPatient still breathless

You’ve ruled out APO, PTX, pneumonia…but not PE.

If it’s still on your list, you need a different test.

The BLUE protocolOne lung not sliding Both lungs slidng

A profile B profile:Pulmonary

Oedema

A/B or C profile:

Pneumonia

A’ profile:PTX?

Look for lung point,

consider DDX.

B’ profile:Pneumonia

Step 2Scan the

Veins

DVT seen: PEDVT not seen

Step 3PLAPS points

PLAPS seen:Pneumonia

PLAPS not seen:COPD / asthma / PE

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BLUE protocol: important notes

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BLUE protocol: notes

• Controversial eg for DVT:• Scans below the knee• Scans the upper limbs (increases sensitivity for PE by 4%)

• Does not make use of cardiac / IVC windows (and misses 19% PE in the hands of an expert)

• Accurate in hands of expert lung sonologist. Not yet validated in multicentre trials of all comers with breathlessness, by non-experts

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Suggestions

1. Add cardiac/IVC scan to the protocol to increase sensitivity for PE (Rule-in, not rule –out: if cardiac/IVC scan negative, could still be PE)• E.G. as step 4 (PTO)• Or as step 3 (before veins)2. Include upper limb & below knee in your DVT

scan? Leave to operator discretion3. Perform validation studies & review this advice

Step 4: heart / IVCDry lungs, no DVT,

no PLAPS:

Heart / IVCHigh pressure RV+ distended IVC:

Massive PE

Grossly normal:COPDAsthma

PE is still possibleReassess patient;

consider other tests.

Inadequate view:Get help, or finish

the scan & arrange other

tests

Modified BLUE protocol

One lung not sliding Both lungs sliding

A profile B profile:Pulmonary

Oedema

A/B or C profile:

Pneumonia

A’ profile:PTX?

Look for lung point,

consider DDX.

B’ profile:Pneumonia

Step 2The veins

DVT seen: PEDVT not seen

Step 3PLAPS points

PLAPS seen:Pneumonia

PLAPS not seen:Step 4 heart /IVC

High pressure RV+ distended IVC:

Massive PE

Grossly normal: COPD / AsthmaPE is still possible

Reassess patient; consider other tests.

Step 1The lungs

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Modified BLUE protocol scan

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Modified BLUE protocol scan

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Oustanding issues

• Does RV/IVC distension occur in status asthmaticus / severe COPD? If so, this could limit its use as a discriminator for massive PE (and is the reason Lichtenstein does not include it on the BLUE protocol)

• BUT realistically a sensible dr can pick asthma/COPD clinically, so this should not be an issue

• Scanning for DVT• Include upper limb? Only adds 4% sensitivity• Include below knee? This will be controversial for many• Details less important than the understanding that this is ‘rule-

in’, not ‘rule-out’• Validation studies by non-experts are needed

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Summary: the modified BLUE protocol

Step 1: anterior lungsStep 2: the veinsStep 3: the PLAPS pointsStep 4: heart & IVC