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35 Point-of-Care Ultrasound fortheDiagnosis ofPneumothorax
431
• Chest radiography, while very specic for the
diagnosis, is poorly sensitive and should not
be relied upon to exclude PTx.
• Lung POCUS is both sensitive and specic for
the diagnosis of pneumothorax, approaching
that of computer tomography (when proper
and careful technique is be used).
• Using s stepwise approach, assessing for the
presence or absence of lung sliding, B-lines,
lung pulse, and lung point can provide a diagnosis rapidly, accurately, and safely.
• Two sagittal scans (parasternal and midclavicular line) should be performed on both
sides to maximize your accuracy.
• While POCUS is excellent for the diagnosis of
pneumothorax, it should not be used to determine its size.
Evolving Evidence
There are reports of missed pneumothorax based on
atypical locations of lung collapse [23]. These case
reports underline the importance of careful and
complete assessment of each lung using a step-wise
approach and a two-two sagittal scan approach.
Pro-Tips (Call-Out)
While the absence of lung sliding strongly suggests the possibility of a pneumothorax, there is
an important differential of other pathologies that
can result in an absence of lung sliding.
The absence of both lung sliding and B-lines
provides enough information for the safe diagnosis of pneumothorax, without the need to spend
valuable time identifying a lung point.
Both lungs should be scanned along two
sagittal planes, parasternal and midclavicular,
from the angle of Louie to the liver lung point (on
the right) and to the cardiac lung point (on the
left).
Questions
1. Which two ndings on POCUS effectively
rule out pneumothorax on POCUS?
A. Presence of Lung Pulse and Lung Point
B. Absence of lung sliding and B-lines
C. Absence of lung sliding and presence of
Lung Point
D. Presence of B-lines and lung pulse
E. Absence of Lung sliding and Liver lung
point
Answer: A
2. All of the following can cause an absence of
lung sliding in the right lung, except,
A. Right main stem intubation
B. Massive atelectasis
C. Cardiac arrest
D. Pleurodesis
E. ARDS
3. Which of the following is correct regarding
lung POCUS for the diagnosis of PTx?
A. In an urgent situation, you should still
identify the lung point in order to determine the size of the PTx
B. Presence of lung sliding in one view is
adequate to rule out PTx on that side?
C. Absence of B-lines is diagnostic for PTx
D. Identifying a lung point denitively rules
in a PTx
E. The liver lung point is a surrogate for a
lung point on the right lung, and therefore,
diagnostic of a PTx
References
1. Dotson K, Timm N, Gittelman M. Is spontaneous
pneumothorax really a pediatric problem? A National
Perspective. Pediatr Emerg Care. 2012;28(4):340–4.
2. Huang Y, Chang P, Wong K, Chang C, Lai J, Chen
J. An age-stratied longitudinal study of primary
spontaneous pneumothorax. J Adolesc Health.
2017;61(4):527–32.
3. Noppen M, De Keukeleire T. Pneumothorax.
Respiration. 2008;76(2):121–7.
4. Hallifax R, Goldacre R, Landray M, Rahman N,
Goldacre M.Trends in the incidence and recurrence
of inpatient-treated spontaneous pneumothorax,
1968–2016. JAMA. 2018;320(14):1471.
5. Lee G.UpToDate. 2022 [online] Uptodate.
com. https://www.uptodate.com/contents/
pneumothorax- in- adults- epidemiology- and- etiology
6. John J, Sei A.Incidence of iatrogenic pneumothorax
in the United States in teaching vs. non-teaching hospitals from 2000 to 2012. J Crit Care. 2016;34:66–8.
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7. Çelik B, Sahin E, Nadir A, Kaptanoglu
M. Iatrogenic pneumothorax: etiology, incidence and risk factors. Thorac Cardiovasc Surg.
2009;57(05):286–90.
8. Loiselle A, Parish J, Wilkens J, Jaroszewski
D. Managing iatrogenic pneumothorax and chest
tubes. J Hosp Med. 2013;8(7):402–8.
9. Gulati M, Levy P, Mukherjee D, Amsterdam E, Bhatt
D, Birtcher K, Blankstein R, Boyd J, Bullock-Palmer
R, Conejo T, Diercks D, Gentile F, Greenwood J,
Hess E, Hollenberg S, Jaber W, Jneid H, Joglar J,
Morrow D, O’Connor R, Ross M, Shaw L. 2021
AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR
Guideline for the Evaluation and Diagnosis of Chest
Pain: Executive Summary: A Report of the American
College of Cardiology/American Heart Association
Joint Committee on Clinical Practice Guidelines.
Circulation. 2021;144(22)
10. Tschopp J, Bintcliffe O, Astoul P, Canalis E, Driesen
P, Janssen J, Krasnik M, Maskell N, Van Schil P,
Tonia T, Waller D, Marquette C, Cardillo G. ERS
task force statement: diagnosis and treatment of
primary spontaneous pneumothorax. Eur Respir J.
2015;46(2):321–35.
11. Ding W, Shen Y, Yang J, He X, Zhang M.Diagnosis of
pneumothorax by radiography and ultrasonography.
Chest. 2011;140(4):859–66.
12. Alrajhi K, Woo M, Vaillancourt C.Test characteristics
of ultrasonography for the detection of pneumothorax. Chest. 2012;141(3):703–8.
13. Ron E, Alattar Z, Hoebee S, Kang P, van Sonnenberg
E. Current trends in the use of ultrasound over
chest X-ray to identify pneumothoraces in ICU,
trauma, and ARDS patients. J Intensive Care Med.
2021;37(1):5–11.
14. Chan K, Joo D, McRae A, Takwoingi Y, Premji Z,
Lang E, Wakai A. Chest ultrasonography versus
supine chest radiography for diagnosis of pneumotho-
rax in trauma patients in the emergency department.
Cochrane Database Syst Rev. 2020;2020(8)
15. Lichtenstein D, Mezière G.Relevance of lung ultrasound in the diagnosis of acute respiratory failure*:
the BLUE protocol. Chest. 2008;134(1):117–25.
16. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2010;37(2):224–32.
17. Gargani L, Volpicelli G.How I do it: lung ultrasound.
Cardiovasc Ultrasound. 2014;12(1):1–10.
18. Socransky S, Wiss R, Hall G, Ho B, Skinner A, Turner
J, Woo M, Chen R.Essentials of point-of-care ultrasound. 1st ed. Sudbury: The EDE 2 Course Inc.; 2014.
19. Turner J, Dankoff J.Thoracic ultrasound. Emerg Med
Clin North Am. 2012;30(2):451–73.
20. Helland G, Gaspari R, Licciardo S, Sanseverino A,
Torres U, Emhoff T, Blehar D. Comparison of four
views to single-view ultrasound protocols to identify
clinically signicant pneumothorax. Acad Emerg
Med. 2016;23(10):1170–5.
21. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein
D, Mathis G, Kirkpatrick A, Melniker L, Gargani L,
Noble V, Via G, Dean A, Tsung J, Soldati G, Copetti R,
Bouhemad B, Reissig A, Agricola E, Rouby J, Arbelot C,
Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz
R, Seibel A, Neri L, Storti E, Petrovic T.International
evidence-based recommendations for point-of-care lung
ultrasound. Intensive Care Med. 2012;38(4):577–91.
22. Bignucolo A, Acton C, Ohle R, Socransky
S. Traumatic pneumothorax mapping using computed tomography to assess optimal area to scan with
POCUS.CJEM. 2020;22(5):708–11.
23. Retief J, Chopra M. Pitfalls in the ultrasonographic
diagnosis of pneumothorax. J Intensive Care Soc.
2016;18(2):143–5.
24. Blanco P, Volpicelli G. Common pitfalls in pointof- care ultrasound: a practical guide for emergency
and critical care physicians. Crit Ultrasound J.
2016;8(1):1–12.
Pulmonary Edema
DanielGerber andPaulK.Mohabir
36
Learning Objectives
1. Explore how an A-line pattern strongly correlates with dry pulmonary interstitium, low
pulmonary capillary wedge pressure, and
therefore, low likelihood of cardiogenic pulmonary edema.
2. Examine how B-line artifacts are nonspecic
markers of subpleural interstitial thickening
with a broad differential.
3. Demonstrate how a B-line predominance is
characteristic of pulmonary edema, acute
respiratory distress syndrome, interstitial lung
diseases, pneumonia, pneumonitis, pulmonary infarcts, and pulmonary contusions.
4. Review protocols, algorithms, and scoring
systems have been proposed to qualitatively
determine the underlying etiology of respiratory failure.
Explanation ofB-Lines
B-lines are vertical ring-down artifacts that form
when there is an increase in subpleural alveolar or
interstitial lung density disrupting normal pleural
reection. Aerated lung creates a signicant shift
in acoustic impedance at the pleural-air interface
acting as a near total reector. Reection between
the transducer and the pleural line generates artifactual horizontal A-lines. By contrast, interstitial
thickening by uid, inammation, or brosis
forms acoustic windows and surrounds alveolar
air bubbles. Rather than reecting, ultrasound
waves resonate within these air- interstitium complexes creating B-lines. Characteristically, they
are hyperechoic vertical artifacts that originate
from the pleural line, extend the entire depth of
the visual eld without fading, obliterate A-lines,
and move with lung sliding.
While occasional B-lines are physiologic,
especially in dependent lung zones, 3 or more
within a single eld-of-view are considered pathological. B-lines are characteristic of pulmonary
edema, yet are nonspecic and encompass a
broad differential, including acute respiratory
distress syndrome (ARDS), pneumonia, pneumonitis, interstitial lung diseases (ILD), pulmonary infarcts, and pulmonary contusions.
Image
B/A/Z lines
Call Out Pro-Tip
B-lines
D. Gerber · P. K. Mohabir (*)
Stanford University School of Medicine,
Stanford, CA, USA
e-mail: dgerber@stanford.edu;
mohabir@stanford.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_36
433
434
D. Gerber and P. K. Mohabir
• Hyperechoic vertical artifacts
• Originate from the pleural line
• Extend the depth of the visual eld without
fading
• Obliterate horizontal A-lines
• Move with lung sliding
Call Out Pro-Tip
≥3 B-lines in a single eld of view is
pathological.
Cardiogenic Vs. Noncardiogenic
Pulmonary edema represents the accumulation of
extravascular uid in the pulmonary interstitium
and alveolar air spaces. Any mechanism that
causes pulmonary edema via increased pulmonary venous and capillary hydrostatic pressures
is considered cardiogenic. Common etiologies
include left ventricular systolic or diastolic dysfunction, aortic or mitral valvular disease, and
atrial or ventricular arrhythmias. By contrast,
noncardiogenic pulmonary edema is the result of
decreased oncotic pressure or increased pulmonary capillary permeability. This broad differential includes ARDS, pneumonitis, pulmonary
infarcts and contusions, transfusion-related acute
lung injury (TRALI), high altitude pulmonary
edema (HAPE), opiate and salicylate overdose,
re-expansion pulmonary edema, and many others
[1, 2].
Call Out
Pulmonary Edema
• Cardiogenic: increased pulmonary capillary
hydrostatic pressure
• Noncardiogenic: increased pulmonary capillary permeability or decreased oncotic
pressure
Diagnostically, the gold standard for conrm-
ing cardiogenic pulmonary edema is invasive cardiac catheterization demonstrating elevated left
atrial or pulmonary capillary wedge pressure
(PCWP). While lung ultrasonography to assess
PCWP is an area of evolving evidence, it provides a promising method of rapidly and nonin-
vasively identifying pulmonary edema, assessing
its distribution and severity, and determining
etiology.
Soldati and colleagues have outlined a succinct approach to the ultrasonographic evaluation
of parenchymal lung pathology [1]. Their algorithm focuses on (1) conrming the presence of a
B-line pattern, (2) determining focal versus diffuse involvement, and (3) assessing for heterogeneity. Cardiogenic pulmonary edema causes a
diffuse and homogenous increase in interstitial
edema with B-line predominance, yet without
evidence of parenchymal lung injury [1]. While
B-lines are nonspecic and correlate poorly with
PCWP, their absence, A-line predominance, is
highly specic for a low PCWP and essentially
rules out cardiogenic edema [3]. Pathological
B-lines limited to a specic lung region unilaterally imply focality, as is seen in pneumonia, atelectasis, pulmonary contusion, pulmonary infarct,
or malignancy. Finally, diffuse B-line patterns are
further categorized as homogenous, suggestive of
cardiogenic pulmonary edema, or heterogenous
with features of parenchymal lung injury. Areas
of patchy lung sparing, pleural irregularities,
altered lung sliding, and subpleural consolidations all suggest underlying parenchymal damage
with atelectasis or brosis consistent with noncardiogenic pulmonary edema, ARDS, or diffuse
interstitial brosis [4].
Quantitative andSemi-Quantitative
Scores
As discussed above, lung ultrasonography is a
powerful noninvasive tool to estimate pulmonary
edema, or extravascular lung water (EVLW).
Multiple scoring systems and protocols have
been proposed to standardize this assessment,
though this remains an area of evolving evidence.
Semiquantitative scores rely on visual estimation
of B-line predominance. Each intercostal space is
scored based on the total number of B-lines present, percentage of occupied intercostal space, or
presence and extent of coalescence, which occurs
when numerous B-lines fuse and become indistinguishable [5, 6]. While semiquantitative scores
36 Pulmonary Edema
435
correlate with gold-standard invasive metrics of
EVLW, they are prone to operator interpretation
and error. Quantitative methods employ
computer- assisted analysis, reducing error and
providing superior accuracy [7, 8].
Dierentiating Z-Lines
Similar in appearance to B-lines, Z-lines are vertical hyperechoic artifacts that originate from the
pleural line. These reverberation artifacts are
thought to be generated by reection between
pleura and extra-pulmonary fascia [9, 10]. Unlike
B-lines, they fade 2–4cm beyond the pleural line,
do not move in synchrony with lung sliding, and
do not obliterate A-lines. Z-lines are of no apparent clinical signicance and are considered
artifactual.
CALL OUT
Z-lines evolving evidence:
• Hyperechoic vertical artifacts
• Originate from the pleural line
• Fade after 2–4cm
• Do not obliterate horizontal A-lines
• Do not move with lung sliding
Committee on Lung Ultrasound [11]. The
Bedside Lung Ultrasound in Emergency (BLUE)
protocol further simplies this to three standardized “BLUE-points” on each hemithorax to
improve speed and reproducibility [12].
Summary Points
• Coupled with focused echocardiography, lung
ultrasonography is an invaluable tool in identi-
fying and differentiating the etiology of pulmo-
nary edema by quantitative and semiquantitative
measures of B-line predominance.
• B-lines are hyperechoic vertical artifacts that
originate from the pleural line, extend the
depth of the visual eld without fading, oblit-
erate horizontal A-lines, and move with lung
sliding. These are nonspecic markers of
increased interstitial lung density most com-
monly seen in the setting of pulmonary edema,
ARDS, pneumonia or pneumonitis, pulmo-
nary infarcts or contusions, and interstitial
lung diseases.
• Cardiogenic pulmonary edema is the result of
increased pulmonary capillary hydrostatic
pressure, whereas noncardiogenic edema is
the result of decreased oncotic pressure or
increased vascular permeability.
Lung Zones/Locations
A standard lung ultrasound examination is performed with the patient in the reclined or supine
position. The transducer is placed perpendicular
to the chest wall in the vertical or cranial-caudal
plane with the indicator, and by convention the
left side of the image, oriented toward the
patient’s head. Each hemithorax is divided based
on anatomical landmarks and imaged according
to a variety of protocols. A standard bilateral
exam consists of 12 lung zones: anterior, lateral,
and posterior zones demarcated by the sternum,
anterior and posterior axillary lines, and thoracic
spine subdivided into upper and lower halves by
the clavicle, fourth rib, and diaphragm. In the
critical care setting, an eight-zone approach omitting the posterior lung elds is often preferred,
and is recommended by the International Liaison
Questions
1. A 65-year-old man with a history of hyperten-
sion, hyperlipidemia, aortic stenosis, and
transfusion-dependent myelodysplastic syndrome presents to the emergency department
with dyspnea 12h after scheduled transfusion
of two packed red blood cells. Vitals are notable for a heart rate of 85bpm, BP 120/80mmHg,
and oxygen saturation 92% on 2L O
by nasal
2
cannula. Exam is notable for a systolic murmur and bibasilar crackles. ECG shows sinus
rhythm. While awaiting the results of his labs
and chest X-ray, you perform bedside lung
ultrasonography which shows >3 B-lines in
each lung zone. Which of the following additional sonographic ndings would support a
diagnosis of cardiogenic pulmonary edema?
A. Pleural effusions
B. Subpleural consolidations
436
D. Gerber and P. K. Mohabir
C. Areas of lung sparing
D. Impaired pleural sliding
E. Pleural irregularities
Answer: A.
2. A previously heathy 19-year-old man presents
to the emergency department with palpitations and dyspnea 2h after smoking methamphetamines. Heart rate is 110 bpm, BP
150/90 mmHg, and oxygen saturation is
100% on room air. Exam shows an anxious
young man with clear lungs, no murmurs, and
no other focal ndings. ECG shows sinus
tachycardia. Labs, toxicology, and chest
X-ray are pending. Lung ultrasonography
shows hyperechoic vertical artifacts that originate from the pleural line. Which of the following additional ndings conrm that these
artifacts are Z-lines rather than B-lines?
A. Fade after 2–4cm
B. Erase A-lines
C. Move with lung sliding
D. Extend the entire depth of the visual eld
Answer: A.
References
1. Soldati G, Demi M, Demi L.Ultrasound patterns of
pulmonary edema. Ann Transl Med. 2019;7(Suppl
1):S16. https://doi.org/10.21037/atm.2019.01.49.
2. Soldati G, Demi M. The use of lung ultrasound images
for the differential diagnosis of pulmonary and cardiac
interstitial pathology. J Ultrasound. 2017;20:91–6.
https://doi.org/10.1007/s40477-017-0244-7.
3. Sekiguchi H, Schenck LA, Horie R, etal. Critical care
ultrasonography differentiates ARDS, pulmonary
edema, and other causes in the early course of acute
hypoxemic respiratory failure. Chest. 2015;148:912–8.
https://doi.org/10.1378/chest.15- 0341.
4. Copetti R, Soldati G, Copetti P.Chest sonography: a
useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome.
Cardiovasc Ultrasound. 2008;29(6):16.
5. Gargani L.Lung ultrasound: a new tool for the cardiologist. Cardiovasc Ultrasound. 2011;9:6.
6. Mongodi S, Bouhemad B, Orlando A, Stella A,
Tavazzi G, Via G, Iotti GA, Braschi A, Mojoli
F. Modied lung ultrasound score for assessing and
monitoring pulmonary aeration. Ultraschall Med.
2017;38(5):530–7.
7. Corradi F, Ball L, Brusasco C, Riccio AM, Barofo
M, Bovio G, Pelosi P, Brusasco V. Assessment of
extravascular lung water by quantitative ultrasound
and CT in isolated bovine lung. Respir Physiol
Neurobiol. 2013;187(3):244–9.
8. Corradi F, Brusasco C, Vezzani A, Santori G, Manca
T, Ball L, Nicolini F, Gherli T, Brusasco V.Computeraided quantitative ultrasonography for detection of
pulmonary edema in mechanically ventilated cardiac
surgery patients. Chest. 2016;150(3):640–51.
9. Francisco MJN, et al. Advances in lung ultrasound.
Einstein (Sao Paulo, Brazil). 2016;14(3):443–8.
https://doi.org/10.1590/S1679- 45082016MD3557.
10. Lee FCY. Lung ultrasound-a primary survey of the acutely dyspneic patient. J Intensive
Care. 2016;4(1):57. https://doi.org/10.1186/
s40560- 016- 0180- 1.
11. Volpicelli G, Elbarbary M, Blaivas M, et al.
International evidence-based recommendations
for point-of-care lung ultrasound. Intensive Care
Med. 2012;38:577–91. https://doi.org/10.1007/
s00134- 012- 2513- 4.
12. Lichtenstein DA, Mezière GA. Relevance of lung
ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117–25.
Pneumonia andConsolidation
AndrewFoderaro andAndrewT.Levinson
37
Learning Objectives
1. Compare lung ultrasound (LUS) to other
imaging modalities for diagnosing
pneumonia
2. Describe various ultrasound features seen in
patients with pneumonia
3. Examine LUS for the diagnosis of pneumonia
in the Covid-19 era
Lung ultrasound has a long history of clinical
application for lung pathologies with good evidence especially in evaluating pleural effusions,
pulmonary edema, and pneumothoracies [1–3].
More recently the use of point-of-care ultrasound
for the investigation of pneumonia has become
more common in practice. During the coronavirus disease-2019 (COVID-19) pandemic there
has been opportunity for some advancement of
the understanding of lung ultrasound especially
in viral pneumonia. Point-of-care ultrasound for
pneumonia has been especially useful clinically.
It has shown improved capabilities compared to
the chest x-ray which is often the preferred rst
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 80038- 2_37.
A. Foderaro · A. T. Levinson (*)
Division of Pulmonary, Critical Care, and Sleep
Medicine, The Warren Alpert Medical School,
Brown University, Providence, RI, USA
e-mail: andrew_levinson@brown.edu
imaging modality. When compared to computed
tomography (CT) scan, the use of lung ultrasound
(LUS) can reduce patient risk by eliminating the
need for transport across the hospital to access a
CT scanner, which is especially pertinent in a
critically ill patient [4, 5]. Over this chapter, the
focus will be on the use of lung ultrasound in the
evaluation of lung consultation/pneumonia with
some focus on the pandemic as a novel source of
experience in this area of point-of-care
ultrasound.
Ultrasound Features ofPneumonia
As discussed in more detail elsewhere, the image
acquisition for LUS uses a high frequency linear
probe which is placed between the ribs and is
often the preferred choice for pleural or subpleural imaging. For patients with a thick chest wall,
or with obesity, a lower-frequency probe can be
used. As with other lung protocols, such as the
BLUE-protocol, a comprehensive assessment of
the lung includes the evaluation of multiple lung
zones [5, 6]. This evaluation can lead to a diagnosis of lung consolidation and thus pneumonia by
identifying various ultrasound ndings such as
lung hepatization, shred sign, and air bronchograms. Set apart from the normal pattern of
healthy lung, which demonstrate an A-line pattern (Fig.37.1; Video 37.3), and lung sliding, the
identication of these ndings added to the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_37
437
438
Fig. 37.1 A line pattern
with lung sliding
A. Foderaro and A. T. Levinson
clinical evaluation of respiratory failure help produce a more specic diagnosis of lung consolidative processes. In addition to differentiating from
normal lung, the various ndings aid in differentiating between causes of consolidation, including pneumonia, non-cardiogenic pulmonary
edema, or acute respiratory distress syndrome
(ARDS), and cardiogenic pulmonary edema
(CPE).
When obtaining imaging within each lung
zone, the ultrasound ndings can also be used to
differentiate translobar versus nontranslobar lung
consolidation. Translobar alveolar consolida-
tion on ultrasound is seen as sonographic lung
hepatization. In a severe translobar pneumonia,
the alveoli are lled with exudative inammation, increasing acoustic impedance, which
causes the image to resemble that of the liver
(Fig.37.2; Video 37.2) as opposed to the lower
impedance image produced with air-lled alveoli
in normal lung [7].
Nontranslobar pneumonia is signied by a
differentiation of the area of consolidation and
the air-lled lung within the same lobe. The ultrasound nding is an irregular line between the
area of consolidated lung and the aerated lung at
the pleural surface, which has some resemblance
to a torn piece of paper, and thus, is referred to as
the shred sign (Fig.37.3) [8].
Air bronchograms, both dynamic and static,
can be seen on lung ultrasound and are helpful in
determining processes such as pneumonia and
atelectasis. Sonographic air bronchograms appear
as hyperechoic lines within a hypoechoic area of
lung (Fig.37.4; Video 37.5). This nding is produced as the air within the airway is highlighted
by the dense and less echogenic consolidation. If
the air bronchograms are moving within the
image, this is referred to as dynamic air bron-
chograms and have been shown to be specic for
pneumonia as compared to atelectasis [9].
Conversely, a static air bronchogram can be
seen in both pneumonia and atelectasis.
Lung pulse is a sonographic observation of
pleural line movement corresponding to heart
beats. This nding is seen transmitted through
consolidated lung and, in addition to dynamic air
bronchograms, can be helpful in differentiating
pneumonia from atelectasis [10] (Video 37.4
Lung pulse).
B-lines are vertical lines arising from the
pleura and are sharply dened (Fig.37.5; Video
37 Pneumonia andConsolidation
Fig. 37.2 Translobar
pneumonia with lung
hepatization
Fig. 37.3 Shred sign
439
37.1). This nding can be seen in numerous
lung pathologies and thus needs to be interpreted with other clinical parameters. Typically,
B-lines associated with pneumonia are often
more focal and unilateral whereas a more diffuse identication of B-lines is more specic for
CPE [11].
Pleural effusions can be easily identied
using point-of-care ultrasound [12]. Light etal.
in 1980 showed that 44% of patients in their
cohort of 203 patients developed a parapneumonic effusion [13]. When evaluating a parapneumonic effusion associated with an infectious
inammatory pneumonia, generally they will be
unilateral and demonstrate other ndings such as
septations [14]. Evaluation demonstrating bilateral free owing effusions can again be helpful in
differentiating pneumonia from a process such as
CPE (Fig.37.6; Videos 37.2 and 37.5).
440
Fig. 37.4 Sonographic
air bronchograms
Fig. 37.5 B Lines
A. Foderaro and A. T. Levinson