Breathless Algorithm

1. The breathless patient
Adapted from Lichtenstein's BLUE
protocol
(with permission)
1

2. Summary
1 (Ongoing resus) Clinical assessment:
formulate the question
2 Rapid screen
3 Form a working diagnosis
4 Continue resuscitation
5 Re-scan / monitor progress / further
investigations
2

3. 1. Formulate the question

4. 1. Formulate the question
Why is the patient breathless?
4

5. Why is the patient breathless?
• Pneumothorax (PTX)
• Pneumonia
• Acute cardiogenic pulmonary oedema
(APO)
• Pulmonary embolism (PE)
• Asthma / COPD
• (Other: rare)
5

6. 2. The BLUE protocol

7. Curved probe, abdominal preset
• Machine settings: as for arrest screen
7

8. A 3-step scan
1. Anterior lung fields: 2 points
2. If A profile: scan the upper & lower limb
veins for DVT
3. If no DVT: PLAPS points
8

9. The BLUE protocol scan
9

10. The BLUE protocol scan
9

11. Step 1: anterior chest: upper & lower
BLUE points
10

12. Step 1: anterior chest: upper & lower
BLUE points
• Probe sagittal, midclavicular line
• 2 spots on each side
• i.e. upper chest & lower chest
11

13. Recall: upper & lower BLUE points
1 1
2 2
12

14. Step 1 findings
One lung not Both lungs sliding
sliding
A’ profile B’ profile A profile B profile A/B or C
profile

15. Step 1 findings
One lung not Both lungs slidng
sliding
A’ profile: B’ profile: A profile B profile: A/B or C
PTX? Pneumonia Pulmonary profile:
Look for Treat. Oedema Pneumonia
lung point, Treat. Treat.
consider
DDX. Step 2
Treat

16. Step 2: the veins
15

17. Step 2 (if dry lungs)
Compression scans UL & LL veins
Upper limb: IJV, SCV
Lower limb: femoral confluence, lower SFV,
calf veins!

18. Step 2: scan the veins
Scan the veins DVT seen = PE
Treat.
DVT not seen:
Proceed to step 3

19. 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.

20. Step 3: the PLAPS points
19

21. What are the PLAPS points?
= the most dependent part of the lungs
As far behind & as low as you can scan
without hitting the diaphragm
‘The Morison’s Pouch of the lung’ [thanks Dr
Chris Wong]

22. Recall: PLAPS
Posterolateral alveolar &/or pleural syndrome
Not as bad as it sounds!

23. Posterolateral alveolar &/or pleural
syndrome
If you see effusion or If you see anything
consolidation at else (A lines, B
PLAPS points it's lines), it's 'PLAPS-
'PLAPS positive’ negative'

24. PLAPS-positive?

25. PLAPS-positive?

26. PLAPS-positive?

27. PLAPS-positive?

28. PLAPS-positive?

29. Step 3: the PLAPS points
PLAPS points PLAPS seen:
Pneumonia
(PE still possible but
much less likely)
PLAPS not seen: Treat.
COPD
Asthma
PE is still possible
Reassess patient;
consider other
tests.

30. Now what?
You’ve reached the end of the scan
Patient still breathless
You’ve ruled out APO, PTX, pneumonia
…but not PE.
If it’s still on your list, you need a different
test.
27

31. The BLUE protocol
One lung not sliding Both lungs slidng
A’ profile: B’ profile: A profile B profile: A/B or C
PTX? Pneumonia Pulmonary profile:
Look for Oedema Pneumonia
lung point, Step 2
consider DDX. Scan the
Veins
DVT not seen DVT seen: PE
PLAPS seen: Step 3 PLAPS not seen:
Pneumonia PLAPS points COPD / asthma / PE

32. BLUE protocol: important notes
29

33. 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
30

34. 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 discretion
3. Perform validation studies & review this advice
31

35. Step 4: heart / IVC
Dry lungs, no DVT,
no PLAPS:
High pressure RV Heart / IVC Grossly normal:
+ distended IVC: COPD
Massive PE Asthma
PE is still possible
Inadequate view:
Reassess patient;
Get help, or finish consider other
the scan & tests.
arrange other
tests

36. Modified BLUE protocol
Step 1
One lung not sliding The lungs Both lungs sliding
A’ profile: B’ profile: A profile B profile: A/B or C
PTX? Pneumonia Pulmonary profile:
Look for Oedema Pneumonia
lung point, Step 2
consider DDX.
The veins
DVT not seen DVT seen: PE
PLAPS seen: Step 3 PLAPS not seen:
Pneumonia PLAPS points Step 4 heart /IVC
Grossly normal: COPD / Asthma High pressure RV
PE is still possible + distended IVC:
Reassess patient; consider other tests. Massive PE

37. Modified BLUE protocol scan
34

38. Modified BLUE protocol scan
34

39. 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
35

40. Summary: the modified BLUE protocol
Step 1: anterior lungs
Step 2: the veins
Step 3: the PLAPS points
Step 4: heart & IVC
36