12 breathless algorithm
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Transcript of 12 breathless algorithm
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The breathless patient
Adapted from Lichtenstein's BLUE protocol
(with permission)
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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
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1. Formulate the question
Why is the patient breathless?
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Why is the patient breathless?
• Pneumothorax (PTX)• Pneumonia • Acute cardiogenic pulmonary oedema
(APO)• Pulmonary embolism (PE)• Asthma / COPD• (Other: rare)
2. The BLUE protocol
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Curved probe, abdominal preset
• Machine settings: as for arrest screen
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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
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The BLUE protocol scan
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The BLUE protocol scan
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Step 1: anterior chest: upper & lower BLUE points
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Step 1: anterior chest: upper & lower BLUE points
• Probe sagittal, midclavicular line• 2 spots on each side• i.e. upper chest & lower chest
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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
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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.
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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
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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
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BLUE protocol: important notes
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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
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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
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Modified BLUE protocol scan
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Modified BLUE protocol scan
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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
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Summary: the modified BLUE protocol
Step 1: anterior lungsStep 2: the veinsStep 3: the PLAPS pointsStep 4: heart & IVC