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Lung Ultrasound in the Critically Ill: The BLUE Protocol

Ramsingh, Davinder MD

doi: 10.1213/ANE.0000000000002350
Books, Multimedia, and Meeting Reviews

Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California,

Conflicts of Interest: Dr Ramsingh is a consultant for FUJIFILM SonoSite, Inc (Bothell, WA), is a consultant for Edwards Lifesciences (Irvine, CA), and has received grant funding from General Electric Ultrasound (Fairfield, CT).

Until recently, the majority of acute care specialties viewed medical ultrasound (US) as a formal diagnostic image modality with little utility for the assessment of the pulmonary system. Over the past decade, both of these points have been discredited in a multitude of patient care environments, including the perioperative setting.1 The concept of point-of-care US as a real-time patient evaluation tool has been supported to facilitate acute care, with a recent call to action to embrace this modality in the perioperative setting.2 Moreover, the concept of lung US, once thought to be a misnomer given the common understanding of US interaction with air, has also been refuted thanks in large part to the works of Dr Lichtenstein. However, the concept of pulmonary US is still in its infancy with regard to its understanding and routine use. More literature is needed on the education and clinical application of lung US. The following review discusses Dr Lichtenstein’s book that seeks to address these matters.

The introduction to Lung Ultrasound in the Critically Ill: The BLUE Protocol highlights the development of lung US for the critically ill and the hurdles encountered. Dr Lichtenstein highlights the fundamental concept of critical care US and offers this book as a compilation of years of work on the topic. The 41 chapters of this book exploring various lung US topics are broken into 4 parts: (1) The Tools of the BLUE Protocol (Bedside Lung Ultrasound in Emergency); (2) The BLUE Protocol in Clinical Use; (3) The Main Products Derived from the BLUE Protocol; and (4) Extension of Lung Ultrasound to Specific Disciplines, Wider Settings, Various Considerations.

The first part of the book provides an excellent introduction to the application of lung US. The author provides a thorough review of US equipment, knobology, and the principles that allow for the clinical utility of lung US. Fundamental to this is the concept that the majority of lung US relies on the appreciation of artifacts that develop at the level of the pleural line. Review of this section teaches the reader how to detect various pathologies by learning the sonographic differences that occur at this level. Ultimately, the reader is able to grasp the concept that what was once thought to be a hindrance (the air–fluid interface of the lung) is actually a tremendous benefit that allows lung US to be used for the detection of a wide variety of pathologies. The remainder of this section provides an excellent introduction to the various lung US artifacts and describes their profiles at this interface. Careful detail is included for readers to appreciate the differences in these profiles along with frequent “clinical pearls” and summary points. Importantly, reviews of cardiac and vascular US, as they pertain to the BLUE protocol, are also included in this section.

The second part of this text discusses the clinical uses of the BLUE protocol applications. The author delves deeper into the specifics of the BLUE protocol and how it integrates the analysis of the various lung profiles discussed in the first section. The utility of BLUE protocol for the diagnosis of pneumonia, hemodynamic pulmonary edema, asthma, pulmonary embolism, and pneumothorax is also highlighted.

The third part of the book explores additional US protocols that can serve as extensions of the BLUE protocol. The section focuses on the utility of various US protocols for the evaluation and management of patients experiencing acute respiratory distress syndrome. In addition, the use of lung US to facilitate the diagnosis and management of acute circulatory failure is highlighted with the discussion of the FALLS protocol (Fluid Administration Limited by Lung Sonography). Finally, this section reviews the utility of lung US in the management of cardiac arrest with a review of the SESAME-protocol (Sequential Emergency Sonographic Assessment of Mechanism Or Origin of Shock of Indistinct Cause).

The book concludes with a section on the extension of lung US. The author discusses neonatal lung US, the utility of lung US outside of the intensive care unit, and highlights other noncardiopulmonary US modalities. This section consolidates the topics discussed throughout the book in a comprehensive description of an extended BLUE protocol. Finally, the author provides a very interesting discussion on the methods of education of the topics examined.

Overall, this book serves as an excellent reference for the topic of lung US from a comprehensive approach that has not previously been available. The author provides thorough background and has structured the concepts so as to appeal to any acute care specialty. As with all books published by Springer, this book is available in either paper or digital format.

Davinder Ramsingh, MDDepartment of AnesthesiologyLoma Linda University Medical CenterLoma Linda,

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1. Ramsingh D, Rinehart J, Kain Z, et al. Impact assessment of perioperative point-of-care ultrasound training on anesthesiology residents. Anesthesiology. 2015;123:670–682.
2. Mahmood F, Matyal R, Skubas N, et al. Perioperative ultrasound training in anesthesiology: a call to action. Anesth Analg. 2016;122:1794–1804.
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