12 breathless algorithm

1

The breathless patient

Adapted from Lichtenstein's BLUE protocol

(with permission)

2

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

4

1. Formulate the question

Why is the patient breathless?

5

Why is the patient breathless?

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

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

2. The BLUE protocol

7

Curved probe, abdominal preset

• Machine settings: as for arrest screen

8

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

9

The BLUE protocol scan

9

The BLUE protocol scan

10

Step 1: anterior chest: upper & lower BLUE points

11

Step 1: anterior chest: upper & lower BLUE points

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

12

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

15

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.

19

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

27

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

29

BLUE protocol: important notes

30

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

31

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

34

Modified BLUE protocol scan

34

Modified BLUE protocol scan

35

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

36

Summary: the modified BLUE protocol

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