[ Recent Advances in Chest Medicine ]

BLUE-Protocol and FALLS-Protocol

Two Applications of Lung Ultrasound in the Critically Ill
Daniel A. Lichtenstein, MD, FCCP

This review article describes two protocols adapted from lung ultrasound: the bedside lung
ultrasound in emergency (BLUE)-protocol for the immediate diagnosis of acute respiratory
failure and the fluid administration limited by lung sonography (FALLS)-protocol for the man-
agement of acute circulatory failure. These applications require the mastery of 10 signs indi-
cating normal lung surface (bat sign, lung sliding, A-lines), pleural effusions (quad and
sinusoid sign), lung consolidations (fractal and tissue-like sign), interstitial syndrome (lung
rockets), and pneumothorax (stratosphere sign and the lung point). These signs have been
assessed in adults, with diagnostic accuracies ranging from 90% to 100%, allowing consid-
eration of ultrasound as a reasonable bedside gold standard. In the BLUE-protocol, profiles
have been designed for the main diseases (pneumonia, congestive heart failure, COPD,
asthma, pulmonary embolism, pneumothorax), with an accuracy . 90%. In the FALLS-protocol,
the change from A-lines to lung rockets appears at a threshold of 18 mm Hg of pulmonary
artery occlusion pressure, providing a direct biomarker of clinical volemia. The FALLS-protocol
sequentially rules out obstructive, then cardiogenic, then hypovolemic shock for expediting the
diagnosis of distributive (usually septic) shock. These applications can be done using simple
grayscale machines and one microconvex probe suitable for the whole body. Lung ultrasound
is a multifaceted tool also useful for decreasing radiation doses (of interest in neonates where
the lung signatures are similar to those in adults), from ARDS to trauma management, and
from ICUs to points of care. If done in suitable centers, training is the least of the limitations
for making use of this kind of visual medicine. CHEST 2015; 147(6):1659-1670

ABBREVIATIONS: BLUE 5 bedside lung ultrasound in emergency; FALLS 5 fluid administration limited
by lung sonography; LUCI 5 lung ultrasound in the critically ill; LUCIFLR 5 Lung Ultrasound in the
Critically Ill Favoring Limitation of Radiation; PLAPS 5 posterolateral alveolar and/or pleural syndrome

Daily concerns of the intensivist are acute 1982. This article, therefore, could have
respiratory and circulatory failure. The need been written 33 years ago. Echocardiog-
for fast and accurate management calls for a raphy has been used for a long time in the
visual approach, which is what ultrasound ICU and now is currently used inside the
provides. Portable machines suitable for use thorax through the transesophageal route.1,2
at the bedside have been available since Echocardiography is an elegant way to solve

Manuscript received June 1, 2014; revision accepted November 22, 2014. © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
AFFILIATIONS: From the Service de Réanimation Médicale, Hôpital this article is prohibited without written permission from the American
Ambroise-Paré, Boulogne-Billancourt, France. College of Chest Physicians. See online for more details.
CORRESPONDENCE TO: Daniel A. Lichtenstein, MD, FCCP, Service DOI: 10.1378/chest.14-1313
de Réanimation Médicale, Hôpital Ambroise-Paré, 9 Ave Charles-
de-Gaulle, 92100 Boulogne-Billancourt, France; e-mail: [email protected]

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 these respiratory and circulatory concerns. This article like its resolution; 32-cm width in settings where each
describes a complementary tool: lung ultrasound. lateral centimeter counts; 7-s start-up time; flat, easy-
to-clean, fluid-proof design; 5-MHz microconvex probe
History
allowing whole-body analysis from 0.6 to 17 cm; simple
Lung ultrasound originally was not meant to be used
technology based on three clearly identified buttons,
in emergent care. Except for echocardiography used
instant response, respect of artifacts, and ease of mainte-
in cardiology and sonography used in obstetrics,
nance; intelligent narrow cart (preventing any drop);
ultrasound in general was a tool for radiologists, and
and low cost. These reasons make up the first of seven
the lung in particular was not considered suitable for
principles: The simplest equipment is suitable for lung
this imaging technology.3 Since 1989, François Jardin’s
imaging.43 Any modern machine can be used, however.
ICU explored, applied, and made lung ultrasound with
We believe that redesigns of the same machine for use
a portable unit a standard of care in critically ill patients.
in modern facilities (using wireless transmission, Doppler
Based on our 25 years of experience using lung ultra-
and transesophageal echocardiography, etc) are appro-
sound in the critically ill (LUCI), the American College
priate as long as these do not interfere with the critical
of Chest Physicians and La Société de Réanimation de
properties of small size, cost-effectiveness, and immediate
Langue Française jointly proposed LUCI as a standard
start-up time. The alternative, which we have been
of care.4
using for 25 years, is to have one simple, cost-effective
Since 1991, intensivists have been using whole-body unit and one comprehensive echocardiographic unit
ultrasound, including vascular access, search for free on hand.
blood, and so forth, and lung ultrasound.5 Gradually, the
The second principle is to use gravity rules (gas toward
ICU community understood the relevance of lung ultra-
the sky, fluids toward the earth) to locate disorders. The
sound in critical care. Publications began to emerge and
third principle is to define standardized thoracic points,
are now quite prevalent in the literature; thus, only a few
called BLUE-points, to allow for reproducible analyses44
regarding the lung are quoted in the present article.6-42
(Fig 1), and the fourth is to precisely define the pleural
Tools Used for the BLUE-Protocol line, the first of 10 basic signatures. The fifth principle in
One application of lung ultrasound is the onsite explo- lung ultrasound focuses specifically on artifacts. The
ration of acute respiratory failure: the bedside lung A-line is a repetition of the pleural line, indicating gas
ultrasound in emergency (BLUE)-protocol. Although (Fig 2). The sixth principle analyzes lung sliding, which
the new generation of intensivists benefits from a variety is a twinkling visible at the pleural line that spreads
of excellent machines, we keep using our 1992 tech- homogeneously below it (generating the seashore sign
nology (last updated in 2008) for several reasons: We in M-mode). Lung sliding and A-lines define a normal

Figure 1 – A, B, The bedside lung ultrasound in emergency (BLUE)-points. This figure shows the standardized points used in the BLUE-protocol. Two
hands (from roughly the patient’s size) are applied as follows: upper little finger just below clavicle, fingertips at middle line, and lower hand just below
upper hand (thumbs excluded). The point coined “upper BLUE-point” is at the middle of the upper hand. The “lower BLUE-point” is at the middle of the
lower palm. These four points roughly follow the anatomy of the lung, and avoid the heart as much as possible. The posterolateral alveolar and/or pleural
syndrome (PLAPS)-point is built from the horizontal line continuing the lower BLUE-point and the vertical line continuing the posterior axillary line.
The intersection, rigorously, is the PLAPS-point, but the user can move the probe in two directions: (1) as posteriorly as possible in order to get more
posterior information in these supine, sedated patients or (2) downward when no PLAPS is detected at first sight. Usually, after two intercostal spaces,
the probe scans the abdomen. Like the six spots of ECG, the six BLUE-points help in reproducible analysis. They were sufficient for providing the 90.5%
accuracy of the BLUE-protocol. (Adapted with permission from Lichtenstein.45)

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 Figure 2 – Pleural line and A-line. The bat sign: The ribs (vertical arrows) Figure 3 – Lung sliding. The left image shows the bat sign (arrowheads
and the pleural line (upper horizontal arrows) outline a silhouette indicate the pleural line). In the Merlin space, there is a partial A-line
reminiscent of a bat. This allows confident recognition of the pleural line (arrows), meaning that there is gas below the pleural line. A partial
in all circumstances, even in challenging examinations (patients with A-line (or even not visible, a pattern then coined “O-line,” for non-A
dyspnea, patients who are agitated, bariatric patients). The pleural line non-B) is a common finding, with unchanged pathophysiologic meaning.
always corresponds to the parietal pleura (and to the visceral pleural Note that a comet-tail artifact is seen arising from the pleural line (*); it
only if joined). The Merlin space encompasses the pleural line, the shadow is ill defined, not erasing A-lines (arrows); less echoic than the pleural
of both ribs, and the lower border of the image. The A-line: Inside the line; short; and standstill (in real time), allowing easy distinction with
Merlin space, a repetition of the pleural line is seen (lower horizontal the B-line (see Fig 7). This artifact, devoid of meaning, is coined “Z-line.”
arrows), occurring at a standardized distance from skin to pleural line. It The right image shows the seashore sign of lung sliding. Lung sliding is
indicates gas below the pleural line. A-lines can be complete, as here, or visible in real-time but not in a frozen image (left image). It can, how-
partial (as in Figs 3 and 8). ever, be demonstrated using the M-mode. Above the pleural line, the
pattern is stratified (motionless soft tissues). Exactly from and below the
pleural line (arrowheads), the pattern is sandy, hence, the seashore sign.
This indicates that the gas pattern indicated by the A-line in the left
lung surface46 (Figs 2, 3). The seventh principle is based image is alveolar gas (ruling out pneumothorax).

on the fact that all acute, life-threatening disorders

are superficial. This allows to standardize the field Patients, Diseases, and Profiles in the
(Table 1). BLUE-Protocol
Diagnosis of pleural effusion is an old application of The BLUE-protocol was developed based on the study
lung ultrasound51,52 and basically yields two standard of 300 consecutive adults with acute respiratory failure
signs: the quad sign and the sinusoid sign (Figs 4, 5).47 who were admitted to our ICU and given a diagnosis.
Alveolar syndrome (lung consolidation) is also an old The most frequent cause of respiratory failure was
diagnostic application of lung ultrasound.53 This fluid pneumonia (32%) followed by acute hemodynamic
disorder usually is superficial48 and, thus, accessible to pulmonary edema (24%); exacerbated COPD (18%);
ultrasound, particularly in the diagnosis of nontranslobar severe asthma (13%); pulmonary embolism (8%);
consolidations, which yield the fractal (or shred) sign pneumothorax (4%); and countless rare causes, including
(Fig 5), and translobar forms, which yield the tissue-like easy-to-diagnose ones, such as massive pleural effusion
sign (Fig 6).48 Interstitial syndrome generates lung rockets (3%). We excluded rare, unknown, and multiple diagnoses
on lung ultrasound (Fig 7).49 This application is a main because they generate methodologic issues. The
point of discussion in this article.
Pneumothorax was first approached in lung ultraso- TABLE 1 ] Published Performances of Lung Ultrasound
nography using the sole abolition of lung sliding.54-56 in Critically Ill Patients Compared With
CT Scanning
This sign had a poor specificity until it was associated
with the A-line sign (Fig 8).46,57 Abolished lung sliding Ultrasound Sensitivity, % Specificity, %
generates the stratosphere sign in M-mode. Lung Pleural effusion 47 94 97
sliding (or its equivalent, the lung pulse)58 or B-lines Alveolar consolidation48 90 98
rule out pneumothorax. The lung point (Fig 9) is a Interstitial syndrome49 100 100
pathognomonic sign.59 Pneumothorax occurring in Complete pneumothorax46 100 96
patients with severe dyspnea or adherences is beyond Occult pneumothorax 50 79 100
the scope of this article.

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 Figure 4 – PLAPS and pleural effusion. This image at the PLAPS-point Figure 5 – PLAPS and lung consolidation: nontranslobar consolidation.
shows the quad sign, which is an image outlined by the pleural line The shred sign: At the PLAPS-point, a disorder can be described between
(upper horizontal arrows), the rib shadows (vertical arrows), and a a lung line (because there is an associated anechoic pleural effusion)
clearly defined line (lower horizontal arrows) called the lung line, regular (lower horizontal arrows) and a shredded deep border, where this
and roughly parallel to the pleural line ( 15°-20°). The lung line indi- pattern is replaced by gas barriers (all vertical arrows). This shredded
cates the visceral pleura. Note the long comet-tail artifact (*) arising from line instantaneously demonstrates a lung consolidation. The whole makes
the lung line but not from the pleural line, hence coined “sub-B-line.” This another example of PLAPS, here combining free pleural fluid with alveolar
sub-B-line indicates that the lung in contact is aerated, not consolidated fluid, an extremely frequent pattern in critically ill patients. At the step a
(ie, one more piece of information). This effusion is roughly anechoic. PLAPS is found (ie, after detection of an A-profile, then of a free venous
Even if echoic, the quad sign is a universal sign of pleural effusion regard- network), pneumonia is a likely cause of the respiratory failure. The
less of its echogenicity. In free pleural effusions, the lung line moves distance between the pleural and lung lines in this standardized view
toward the pleural line on inspiration, shaping the sinusoid sign, a basic taken on expiration is 25 mm. One can assume that there is more fluid
sign that indicates unloculated pleural effusion, and mostly low viscosity than shown in Figure 4 (between roughly 350 and 700 mL or slightly
of the fluid, indicating that a small needle is suitable if thoracentesis is more, according to our index). The upper horizontal arrows indicate the
envisioned. The distance between the pleural and lung lines is roughly pleural line. See Figure 1 legend for expansion of abbreviation.
10 mm (the present view taken on expiration). We consider an effusion
volume of roughly 75 to 150 mL in adults. In the BLUE-protocol, this
pattern of isolated, minute pleural effusion is, sensu stricto, a PLAPS. the reverberation of the pleural line. The A-profile
See Figure 1 legend for expansion of abbreviations.
indicates a normal anterior lung surface. Associated
with a DVT, it is connected with pulmonary embolism.
BLUE-protocol is integrated within the control of acute
The venous step is the longest part of the BLUE-protocol.
respiratory failure, which requires an understanding of
The anterior lung analysis takes 0.5 min, negative
anatomy, physiology, pathophysiology, clinical signs,
venous scanning 2 min, and posterior lung step 0.5 min
traditional imaging, and the biology of dyspnea. The
by an experienced operator using the standardized
BLUE-protocol is fully based on pathophysiology.
BLUE-points.
One feature of the BLUE-protocol is the established
Lung sliding with lung rockets define the B-profile
profiles, that is, signs associated with locations. These
and usually indicate hemodynamic pulmonary edema.
profiles are labeled simply to indicate abridged
When interlobular septa are enlarged by edema, the
concepts. The A-profile is shorthand for “anterior lung
ultrasound flow penetrates the lung, but the major
sliding with A-lines profile.” The remaining eight
impedance gradient between gas and fluids traps the
profiles follow the same labeling convention: B-profile
ultrasound flow, hence showing a persistent to-and-fro
(hemodynamic pulmonary edema), B9-profile, A/B-profile,
dynamic, generating the B-line. Three B-lines between
C-profile, A-profile without DVT but with posterolateral
two ribs, a pattern called lung rockets, correspond to
alveolar and/or pleural syndrome (A-no-V-PLAPS-
the anatomic number of subpleural interlobular septa.
profile) (pneumonia), A-profile plus DVT (pulmonary
Hemodynamic pulmonary edema creates a transudative,
embolism), A9-profile (pneumothorax), and nude profile
pressurized pulmonary edema, therefore associating
(COPD/asthma).
lung sliding with a culminant (anterior) location of lung
At the anterior chest wall, lung sliding with predominant rockets. Anterior lung rockets associated with abolished
A-lines define the A-profile. Lung sliding is explained by lung sliding define the B9-profile. In inflammatory
the respiratory movements of the visceral pleura against interstitial syndrome (ie, pneumonia), each subpleural
the parietal pleura. The A-line is displayed when normal interlobular septum should exudate fibrin, behaving like
subpleural interlobular septa are too thin for disturbing glue, resulting in abolishing lung sliding. Unilateral lung

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 hemodynamic pulmonary edema or pulmonary embolism
are posterior.60
Anterior A-lines associated with abolished lung
sliding define the A9-profile. The A9-profile suggests
pneumothorax—the lung point is mandatory. In pneu-
mothorax, the abolished lung sliding is explained by the
absence of visceral pleura and the A-line by the absence
of any fluid structure abutting the parietal pleura. The
lung point is explained by the slight inspiratory increase
of volume of the collapsed lung and, therefore, an increased
parietal contact making an abrupt ultrasound change.
At the posterior chest wall, lung consolidations and
pleural effusions are assessed together for simplicity
Figure 6 – PLAPS and lung consolidation: translobar consolidation. The
tissue-like sign: This huge tissue-like image (similar to the spleen [S]) at because both disorders usually come together, hence the
the PLAPS-point touches the pleural line (arrowheads); there is no (or practical term “PLAPS” (Fig 5). The A-no-V-PLAPS-
almost no) pleural effusion. The deep limit is the mediastinal line, which
is not sharply defined in this image, but another sign can be used here:
profile is connected with pneumonia. The A-profile with
The interpleural distance in this image is 10 to 11 cm, a size not compat- no DVT and no PLAPS (ie, nude profile) is linked with
ible with a pleural effusion. This image definitely indicates a consolida- asthma and COPD (two bronchial diseases with similar
tion. Note the other features. The location is the left lower lobe, totally
hepatized. The tissue-like sign is homogeneous; necrotic areas are therapy combined for simplification).
unlikely (they would appear as hypoechoic, rounded areas). There is no
air bronchogram and no loss of volume (as an atelectasis would cause). In developing the BLUE-protocol, all study patients,
There are some drops of subpulmonary effusion. Real time would have including the excluded ones, benefited from receiving a
shown an abolished lung sliding (this patient had a pneumonia). See
Figure 1 legend for expansion of abbreviation. profile. The A-profile was seen in 53.8%, the B-profile in
27.3%, the A9-profile in 3.4%, the B9-profile in 3.4%, the
rockets define the A/B-profile. This asymmetry of inter- C-profile in 7.6%, and the A/B-profile in 4.6%.
stitial signs is also linked to pneumonia. The BLUE-Protocol: When and How
Anterior lung consolidation, regardless of number and Is it Used, What Occurs Practically,
size (up to simply a thick, irregular pleural line), defines With How Much Accuracy?
the C-profile. In the BLUE-protocol, the C-profile is The BLUE-protocol is done each time the physician
associated with pneumonia. Following the second has clinical doubts after the physical examination. The
principle of lung ultrasound, consolidations seen in machine is brought to the bedside, the probe applied at

Figure 7 – A, B, Lung rockets. An elementary signature of interstitial syndrome, the B-line, can be described by seven criteria. This is always a comet-tail
artifact and always arises from the pleural line. It always moves in concert with lung sliding. Almost always (roughly 95% for each of these last four
features), it is long and up to the edge of the screen (in the left image, some do not reach the 17-cm depth); is well defined, like a laser; obliterates the
A-lines; and is hyperechoic like the pleural line. Usually, all seven criteria are present (always the first three ones) and define the B-lines with a precision
that avoids confusion with other comet-tail artifacts, such as Z-lines and E-lines. (E-lines are comet-tail artifacts with most criteria of B-lines but arising
above the pleural line, indicating subcutaneous emphysema.) Lung rockets, defined as three B-lines or more between two ribs, demonstrate interstitial
syndrome. The left image shows septal rockets. Three or four B-lines can be counted between two ribs (ie, roughly 6 or 7 mm apart, the anatomic
distance between two subpleural interlobular septa in adults). Septal rockets indicate the thickening (usually edematous) of these septa. The right image
shows ground glass rockets. One can count here twice as many B-lines than on the left image. Ground glass rockets are correlated with scanographic
ground glass areas. Lung rockets are used in daily routine to assess acute respiratory or circulatory failure, among other uses.

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 Figure 8 – Pneumothorax and A9-profile. The diagnosis of pneumo- Figure 9 – Pneumothorax and lung point. The lung point: Each time an
thorax requires a two-step approach. The first step is to detect the A9-profile is detected (at the anterior wall, by definition), the search for
A9-profile, associating the A-line sign with the abolition of lung sliding. the lung point is the second mandatory step, time permitting. At a
The left image shows the A-line sign. The Merlin space always displays certain location of the thorax (lateral, posterior), probe standstill, lung
A-lines (arrowheads), meaning gas below the pleural line (arrows). The patterns such as lung sliding and lung rockets replace the A9-profile. The
A-line shown here is ill defined, again more like an O-line, but there is change in rhythm with respiration is abrupt (arrow in right image). The
definitely no B-line. The dots delineate the M-mode shooting line. The lung point is pathognomonic for pneumothorax, indicating its volume.
right image shows the stratosphere sign. This homogeneous, stratified (In this patient, the lung point was roughly located at the PLAPS point,
pattern demonstrates what is seen on real-time imaging (ie, the constant corresponding to a radiovisible pneumothorax.) It indicates that the
and complete abolition of lung sliding). The arrows indicate the pleural equipment is suitable (real-time instant-response acquisition, suitable
line. The A9-profile is very sensitive but not specific to pneumothorax. resolution, mastery of filters). Arrows in the left image indicate the
Note that the two images are not only side by side but also exactly side by pleural line. See Figure 1 legend for expansion of abbreviation.
side (take a ruler at the pleural line) without any lag that may generate,
in acute conditions, one element of confusion. This case is of a eupneic
pneumothorax and represents a first step for learning (the signs of dys-
pneic pneumothorax are standardized too but add one more degree of Frequently asked questions are answered in Lichtenstein.45
complexity because they obey the rules of shooting at a mobile target).
For example, a frequent question is, “Why is the heart
not included?” Looking at the heart to solve a pulmonary
the anterior standardized points, and the BLUE-protocol failure is a legitimate, yet indirect approach. The
begun (Fig 10), first searching for lung sliding. If lung suffering organ is the lung, so lung ultrasound provides
sliding is present, the association with predominant a direct approach. Echocardiography is associated but
A-lines defines the A-profile, and a venous scan is not included (searching for left-sided heart anomalies
done following a sequential order.62 An A-profile in the absence of lung rockets makes less sense because
associated with a DVT is 99% specific to pulmonary pulmonary edema has been ruled out as a cause of
embolism. For this reason, the veins are analyzed respiratory failure). Small anterior lung consolidations
before the rest of the lung. PLAPS are common to (C-lines) suggest pneumonia 18 times more frequently
several causes, the veins must preferably be assessed than pulmonary embolism.61
before searching for PLAPS. Finding a DVT after Of importance, the BLUE-protocol is only designed
detecting an A-profile makes sense. If no DVT is to be piloted by the physician’s common sense and
found, PLAPS are sought for the PLAPS point. If present, integrated with other basic data. A nude profile will
the A-no-V-PLAPS-profile is defined, suggesting sometimes require confident elimination of pulmonary
pneumonia. If absent, the nude profile (all items normal) embolism (CT scan, scintigraphy); an anterior small
is defined, suggesting COPD or asthma. The A9-profile consolidation will, rarely, be one sign of pulmonary
requires the search for a lung point, which if positive, embolism. Used this way, the BLUE-protocol shows
rules in pneumothorax. The B-profile makes hemody- maximal efficiency.
namic pulmonary edema the priority diagnosis. The
B9-profile, A/B-profile, C-profile (anterior consolida- A Development of the BLUE-Protocol:
tions) highly suggest pneumonia. Eighty-six percent of Lung Ultrasound for Diagnosing Acute
ARDS cases have one of the four profiles of pneumonia.61 Circulatory Failure—the FALLS-Protocol
All in all, the BLUE-protocol provides a 90.5% accuracy,61 For this major concern, successive tools have been
with detailed accuracies ranging from 81% to 100% used, with echocardiography currently being one of
(Table 2). the most popular.1,2 Many others are competing,

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 Figure 10 – BLUE-protocol decision
tree showing the practical steps of the
BLUE-protocol. See Figure 1 legend
for expansion of abbreviations.
(Adapted from Lichtenstein and
Mezière.61)

providing an impressive list of parameters when A-lines and B-lines, indicating that B-lines appear
combined, suggesting that no gold standard is cur- (and vanish) all of a sudden, making septal thick-
rently available. The fluid administration limited by ening an on-off parameter. The use of lung artifacts
lung sonography (FALLS)-protocol is not yet sup- allows for a direct assessment of lung water, more
ported by clinical studies but should be considered as specifically interstitial lung water (what no bedside
a potential source of help in difficult situations. It is tool can do). The FALLS-protocol assumes that pul-
based on sequential concepts: Pulmonary edema gen- monary edema is the most harmful consequence of
erates a thickening of the interlobular septa of which fluid overload in an extreme emergency (see limita-
their subpleural end is accessible using lung ultra- tions presented later in this section).
sound63,64; A-lines transform into B-lines at a pulmo- The FALLS-protocol follows the Weil classification of
nary artery occlusion pressure threshold of 18 mm Hg shock.66 The best of simple cardiac sonography and some
at the anterior chest wall in critically ill patients65; BLUE-protocol are used. With the same unit and the
and no artifact has ever been described between same probe, we first search for a substantial pericardial

TABLE 2 ] Accuracy of the BLUE-Protocol

Mechanism of Dyspnea Profiles of BLUE-Protocol Sensitivity, % Specificity, % PPV, % NPV, %
Acute hemodynamic B-profile 97 95 87 99
pulmonary edema
Exacerbated COPD or Nude profile (A-profile with no DVT 89 97 93 95
severe acute asthma and no PLAPS)
Pulmonary embolism A-profile with DVT 81 99 94 98
Pneumothorax A9-profile (with lung point) 88 100 100 99
Pneumonia The four profiles 89 94 88 95
B9-profile 11 100 100 70
A/B profile 14.5 100 100 71.5
C-profile 21.5 99 90 73
A-no-V-PLAPS-profile 42 96 83 78

BLUE 5 bedside lung ultrasound in emergency; NPV 5 negative predictive value; PLAPS 5 posterolateral alveolar and/or pleural syndrome; PPV 5 positive
predictive value. (Adapted from Lichtenstein and Mezière.61)

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 effusion (assimilated to tamponade), then an enlarged
right ventricle (assimilated to pulmonary embolism)
(if poor cardiac windows, the BLUE-protocol can be used
instead), and then an A9-profile (suggesting a tension
pneumothorax). At this step, obstructive shock can
reasonably be ruled out.
The B-profile is sought next. In its absence, a cardiogenic
shock from left origin (ie, the far majority) can be ruled
out by definition.
The next step is performed in patients with neither the
A9-profile nor the B-profile. The A-profile or equivalent
(A/B-profile mainly) usually is seen, indicating that the
patient is a FALLS-responder. Only hypovolemic and
distributive shock are remaining causes, and the thera-
peutic part begins, which is fluid resuscitation. The
A-profile shows that fluids can be administrated, a
notion of interest for intensivists who use volume resus-
citation in distributive shock. Intensivists who would
rather use vasopressors may appreciate that the FALLS-
protocol allows them to avoid giving these drugs in Figure 11 – FALLS-protocol decision tree. This is a schematic, simplified
decision tree of the FALLS-protocol, an approach to an acute circulatory
underestimated hypovolemia (ie, a safety factor useful at failure without strong diagnostic orientation. (1) In the absence of cardiac
the initial step). The improvement of clinical/biologic window, the section “pulmonary embolism” of the BLUE-protocol can
be used. (2) It is assumed that cardiogenic shock is of left origin. For the
signs of circulatory failure with an unchanged A-profile rare cases of cardiogenic shock of right origin (ie, with a low pulmonary
under fluid therapy reasonably defines hypovolemic artery occlusion pressure [right-sided myocardial infarction usually]), an
ECG is routinely done, solving most issues, and fluid therapy is an other-
shock. The FALLS-protocol as a new tool for diagnosing wise familiar therapeutic option. If lung rockets are present on admission
hypovolemia should be appreciated in these complex and the diagnosis of cardiogenic shock not clinically satisfying, echocar-
diography and caval veins analysis, among other tools, can be used.
settings (prolonged surgery, prolonged intensive care) FALLS 5 fluid administration limited by lung sonography. See Figure 1
occurring in complex, challenging, and bariatric legend for expansion of other abbreviation.
patients.
If no clinical improvement occurs, fluid therapy continues. Previous guidelines recommended early and massive
The apparition of anterior B-lines (one can search more fluid therapy in sepsis.69 The FALLS-protocol allows
laterally) means that an iatrogenic interstitial syndrome an earlier fluid therapy (on admission) hours before
likely has been generated by the fluid administration. the sepsis is confirmed and provides the fluid volume
Interstitial edema is an early step, preceding alveolar just necessary to generate an infraclinical, infrabiologic
edema.67,68 This step is clinically and biologically silent23 step of interstitial edema (ie, likely an appropriate
and is the FALLS-end point (ie, the time to discontinue volume). Fluid administration is discontinued once
fluid therapy). Schematically, the FALLS-protocol the last tolerable drop has been given. The FALLS-
rules out obstructive, then cardiogenic, then hypovolemic protocol aims at decreasing high mortality from septic
shock to expedite the diagnosis of the last remaining shock.
cause, distributive shock (ie, usually septic shock)
The main limitation of the FALLS-protocol is the pres-
(Fig 11).
ence of diffuse lung rockets (B-profile, B9-profile) on
At this step, one must acknowledge that the fluid admission because no transformation from A-lines
therapy has positioned the (left-side) heart at the inflec- to B-lines can occur. To simplify this preliminary approach,
tion point of the Frank-Starling curve. Blood tests are conventional tools are used. Similarly, each time
performed, including blood cultures (fully indicated isolated, fully asymmetric right-sided heart failure is
here), as well as other maneuvers to withdraw this slight suspected, one is free to associate right ventricle and
fluid excess (reversal of initial passive leg raising [a var- caval veins assessment.1,2,70 Bear in mind that pulmonary
iant labeled FALLS-PLR-protocol], diuretics, or other embolism has been discounted at this step. It should
options). also be understood that the FALLS-protocol is not

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 devoted to defining the need for fluid in a given critically pneumonia, pulmonary edema, COPD, asthma, and
ill patient but to expediting a diagnosis. pneumothorax. In the case of small pulmonary embo-
lisms, infarctions may be more frequent. The respirolo-
The FALLS-protocol does not appear to have any draw-
gist can assess for pleural effusions, safe thoracentesis,47
backs relative to other hemodynamic tools,71 but any
an early diagnosis of chronic interstitial diseases, and
criticism is welcome. Based on pathophysiology, and
lung consolidations in oncology. Expert approaches are
above all pragmatism, the FALLS-protocol can be used
available in Mathis75 and Reissig and Kroegel.9
when the usual tools fail (eg, limited cardiac windows).
Furthermore, the FALLS-protocol cannot be compared Disciplines including pediatrics, cardiology, nephrology,
directly with these tools because it does not monitor neurology, and internal medicine, will find interest in
cardiac output changes, yet both approaches have a lung ultrasound. The use of lung ultrasound by these
common bond: providing therapeutic orientations. Like disciplines is made without complex adaptation because
traditional tools, the FALLS-protocol suggests who of the simplicity of the equipment and the same signs
should receive fluids and when to discontinue fluids used for diagnosis. To define a normal lung, only two
based on pathophysiology. Many questions are answered signs are necessary, regardless of where the probe is
in Lichtenstein.45 applied, which is not the case in cardiac, fetal, and
abdominal ultrasound. For this reason, lung ultrasound
The FALLS-protocol requires a simple unit without
is probably far less operator dependent. This means that
Doppler and has a steep learning curve. It can be of priorities can be reconsidered. One may, for instance,
interest to not only those who have not yet mastered initiate a curriculum with the normal lung and become
expert echocardiography but also those who do not yet rapidly operational for basic applications (pneumothorax,
(or will never) have echocardiographic units. pulmonary edema) and then learn expert echocardiog-
How Can These Protocols Affect the raphy, taking as long a time as necessary. The feasibility
Routine of Several Disciplines? of ultrasound of this superficial organ is . 98%76; even
Lung ultrasound in critical care is a holistic tool. A con- in bariatric patients the anterior approach provides
cept is holistic when the understanding of each of its basic data.
multiple components is necessary to fully understand Medical irradiation (and costs) can be drastically
the whole.45 The result generates a whole-body approach reduced, which is of critical interest in neonates and
in addition to the main vital organ. This allows for sim- young women. The Lung Ultrasound in the Critically Ill
plification of expert domains such as echocardiography, Favoring Limitation of Radiation (LUCIFLR) project
if associated with lung ultrasound. In the case of subop- aims to limit, not eradicate, one-third of urgent bedside
timal cardiac windows, the B-profile suggests pulmonary radiographs and two-thirds of urgent CT scans in the
edema and the A-profile hypovolemia, schematically. next three decades,77 which can be considered a reason-
Using simple equipment and appropriate training, lung able target. The LUCIFLR project does not require inde-
ultrasound is an accessible discipline for physicians. pendent confirmatory studies. Bedside radiography has
demonstrated an inaccurate sensitivity for most life-
These fast protocols can help in cases of cardiac arrest
threatening disorders. With a roughly 60% to 70% sen-
where each second is precious for sequentially pinpointing
sitivity, it appears to be a suboptimal tool in critical
reversible causes, including pneumothorax, pulmonary
care.78,79 Urgent CT imaging offers a strong overview yet
embolism, bleeding, pericardial tamponade, and
at the cost of severe drawbacks (need for transportation,
others.72 This application does not require urgent valida-
anaphylaxis, etc).80,81 Lung ultrasound has proven to be a
tion because it uses already-validated fields; simply, all
quite similar diagnostic tool in most cases47-50,57 and
elements optimizing the speed (narrow units, a 7-s start-
sometimes superior, particularly with better detection of
ing time, the universal probe, etc) as well as a logical
pleural septations,77 necrosis within consolidations,82
sequence (ie, first scanning the lungs, a 4-s step) are
real-time assessment of lung sliding with no bedside
adopted in determining the diagnosis.
equivalent,57 dynamic air bronchograms,83 and dia-
Apart from critical care, lung ultrasound will affect several phragmatic analysis.29,41 Ultrasound provides quantita-
disciplines. In the critically ill neonate, the 10 to 12 signs tive data for all disorders (as shown in the figure legends
assessed in adults are found, with no difference.73,74 In in this article) and helps to quantify pleural effusions,15,19,61
anesthesiology and emergency medicine, where mod- and monitor lung consolidation, which are of interest
erate dyspnea is managed, we see similar profiles for for intensivists who use positive end-expiratory pressure

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Financial/nonfinancial disclosures: The author has reported to CHEST
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lung ultrasound in critical care practice. Crit Care. 2007;11(1):205.
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