To B-line or Not to B-line

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Matthew Tyler
Critical Care and Emergency doc in Chicagoland. Minimalist Intensivist. Advanced echo ultrasonographer. Proceduralist. ChoosingWisely advocate. Health policy wonk. I make damn good pasta. Urban gardener

Pre-brief

Lung ultrasound (LUS) has become an invaluable component of assessing patients in respiratory distress. B-lines have become one of the more useful findings in lung ultrasonography allowing for rapid detection of interstitial edema and initiation of appropriate therapies before a chest X-ray is even obtained. Is it that simple? Do B-lines equal pulmonary edema? No, of course not, and clinicians need to be aware of the limitations of lung ultrasound and B-line patterns.

Definitions:

  • B-line: Vertical hyperechoic line emanating from the pleura extending to the bottom of the screen and moving with the pleura during lung sliding. Variable clinical significance.
  • Z-line: An echogenic vertical line emanating from the pleural line, not moving with lung sliding, not erasing A-lines, and ending after 2-4 cm. No clinical significance.

The Brief

A 2019 meta-analysis comparing LUS and CXR in the diagnosis of pulmonary edema found LUS had a sensitivity of 0.88 and a specificity of 0.90, which was superior to CXR. LUS is therefore a ‘good’ tool in the detection of pulmonary edema, but there will certainly be false positives and false negatives, and clinicians need to incorporate clinical context when using LUS to diagnose pulmonary edema. The detection of B-lines can be affected by transducer size, shape, and frequency, pre-and post-processing parameters, gain and depth, focus setting, examiner expertise, etc.. B-lines could be missed if not enough lung zones are examined thoroughly. Z-lines could be misinterpreted as B-lines. Multiple other acute and chronic conditions can cause diffuse B-line patterns (pneumonitis, interstitial pneumonia, pulmonary fibrosis) or focal B-line patterns (pneumonia, atelectasis, pulmonary contusion, pulmonary infarction, malignancy, pleural disease).  B-lines can be found in the last intercostal space above the diaphragm in up to 28% of healthy subjects. Lastly, patients with signs and symptoms of pulmonary edema may not display the characteristic B-line pattern.

The point of this post is not to demonstrate how to detect B-lines, which can be easily referenced in some of the articles below. The point is to caution providers in interpreting B-lines as equivalent to pulmonary edema. 

Key Steps to Diagnose Pulmonary Edema with LUS

  1. The International Liaison Committee on Lung Ultrasound recommends that each hemithorax should be split into four regions. A LUS scan positive for interstitial edema must have three or more B-lines in an intercostal space in at least two regions bilaterally. Utilizing a low-frequency abdominal or micro convex probe is preferred and setting the probe depth to at least 4-8 cm is recommended, with some experts recommending a depth of 16 cm.
  2. Identify the B-line pattern as diffuse or focal. This narrows the diagnosis to disease patterns that cause relatively diffuse lung disease (pulmonary edema, ARDS, lung fibrosis, pneumonitis, interstitial pneumonia).
  3. Identify lung sliding and ensure the B-lines move with the pleura. Lung sliding may be absent in ARDS lungs but is present in pulmonary edema.
  4. Identify homogeneous distribution of B-lines. The B-lines may not be as evenly distributed in ARDS and pulmonary fibrosis, while they are in pulmonary edema
  5. Switch to the superficial transducer to examine the pleura. ARDS and fibrosis will likely have a thick and irregular pleural line.
  6. Incorporate the patient’s clinical presentation, exam findings, labs, and echocardiogram.

Video 1: LUS with hyperechoic vertical lines emanating from a thin pleural line. Vertical lines move with pleural line movement and extend to the bottom of the screen. If present in two ‘zones’ bilaterally, this ultrasound suggests the presence of interstitial edema, likely pulmonary edema.

Video 2: LUS revealing hyperechoic vertical lines that do not move with the pleural line. They also are sporadic and not uniform across the intercostal space. Ultrasound is more consistent with atelectasis in this patient receiving very low tidal volumes while on veno-venous extracorporeal membrane oxygenation support.

Video 3: LUS with sporadic hyperechoic vertical lines and a thick, irregular pleura. Ultrasound is more consistent with ARDS or fibrosis. 

The Debrief

LUS is an essential tool for diagnosing lung pathology. Pulmonary edema can be better identified using ultrasound than with CXR. When a B-line pattern is detected be aware that there are multiple disease processes that can cause interstitial edema/inflammation. Incorporate clinical context.

References

  1. Maw AM, Hassanin A, Ho PM, McInnes MD, Moss A, Juarez-Colunga E, Soni NJ, Miglioranza MH, Platz E, DeSanto K, Sertich AP. Diagnostic accuracy of point-of-care lung ultrasonography and chest radiography in adults with symptoms suggestive of acute decompensated heart failure: a systematic review and meta-analysis. JAMA network open. 2019 Mar 1;2(3):e190703-.
  2. Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, Cui XW, Fan M, Yi D. Lung B-line artefacts and their use. Journal of thoracic disease. 2016 Jun;8(6):1356.
  3. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A. International evidence-based recommendations for point-of-care lung ultrasound. Intensive care medicine. 2012 Apr;38(4):577-91.
  4. Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O. The comet-tail artifact: an ultrasound sign of alveolar-interstitial syndrome. American journal of respiratory and critical care medicine. 1997 Nov 1;156(5):1640-6.
  5. Lichtenstein DA. Current misconceptions in lung ultrasound: a short guide for experts. Chest. 2019 Jul 1;156(1):21-5.
  6. Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure*: the BLUE protocol. Chest. 2008 Jul 1;134(1):117-25.
  7. Chao A, Gharahbaghian L. Emergency Ultrasound Tips and Tricks: LUNG LINES!
  8. Hendin A, Koenig S, Millington SJ. Better with ultrasound: thoracic ultrasound. Chest. 2020 Nov 1;158(5):2082-9.

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