Ultrasound of extravascular lung water: a new standard for pulmonary congestion

Eugenio Picano, Patricia A Pellikka, Eugenio Picano, Patricia A Pellikka

Abstract

Extravascular lung water (EVLW) is a key variable in heart failure management and prognosis, but its objective assessment remains elusive. Lung imaging has been traditionally considered off-limits for ultrasound techniques due to the acoustic barrier of high-impedance air wall. In pulmonary congestion however, the presence of both air and water creates a peculiar echo fingerprint. Lung ultrasound shows B-lines, comet-like signals arising from a hyper-echoic pleural line with a to-and-fro movement synchronized with respiration. Increasing EVLW accumulation changes the normal, no-echo signal (black lung, no EVLW) into a black-and-white pattern (interstitial sub-pleural oedema with multiple B-lines) or a white lung pattern (alveolar pulmonary oedema) with coalescing B-lines. The number and spatial extent of B-lines on the antero-lateral chest allows a semi-quantitative estimation of EVLW (from absent, ≤5, to severe pulmonary oedema, >30 B-lines). Wet B-lines are made by water and decreased by diuretics, which cannot modify dry B-lines made by connective tissue. B-lines can be evaluated anywhere (including extreme environmental conditions with pocket size instruments to detect high-altitude pulmonary oedema), anytime (during dialysis to titrate intervention), by anyone (even a novice sonographer after 1 h training), and on anybody (since the chest acoustic window usually remains patent when echocardiography is not feasible). Cardiologists can achieve much diagnostic gain with little investment of technology, training, and time. B-lines represent 'the shape of lung water'. They allow non-invasive detection, in real time, of even sub-clinical forms of pulmonary oedema with a low cost, radiation-free approach.

Keywords: Lung; Oedema; Ultrasound; Water.

© The Author 2016. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1
Figure 1
The recommended protocol for evaluating B-lines is performed by scanning 28-region protocol on the anterior chest with the patient in the supine position.,,
Figure 2
Figure 2
From left to right panels, the normal lung, then increasing severity of pulmonary oedema. From top to bottom, the corresponding pathology (first row), schematic ultrasound pattern (second row), and in vivo ultrasound texture (bottom). The increase in relative content of water, and decrease of content of air in the lung (middle panel), reshapes the texture of clinical image (last row) from normal, A-lines to abnormal B-lines (water and air mix).,
Figure 3
Figure 3
A very good correlation (R = 0.91 in both cases) is shown between B-lines and extravascular lung water evaluated experimentally by gravimetry in pigs with acute lung injury induced by oleic acid (left panel) and clinically by thermodilution in patients with acute lung injury-acute respiratory distress syndrome (right panel).,
Figure 4
Figure 4
Sequence of events in a pig model of acute respiratory distress syndrome. B-lines occur early (already significantly increased at 15 min); only at a later stage (at 90 min) were changes in haemogasanalytic parameters significant. ALI, acute lung injury; ARDS, acute respiratory distress syndrome.
Figure 5
Figure 5
Lung ultrasound (third right intercostal space) at rest (upper panel) and immediately after exercise (lower panel). The exercise-induced appearance of B-lines eclipses the normal pattern of A-lines present at rest.
Figure 6
Figure 6
Outdoor stress echo with lung ultrasound for the diagnosis of subclinical pulmonary oedema. A typical image of lung ultrasound before (left panel, normal) and soon after (right panel, B-lines) apnoea diving. Scan is made by a sonographer on the boat supporting divers in Red Sea.

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