Day 3 :
Ambroise-Paré Hospital, France
Daniel Lichtenstein is medical intensivist working at Ambroise-Paré Hospital (Paris-West, France) since 1989, visiting Professor. Main developments: use of critical ultrasound since 1985, defined in 1991 (Intensive Care Med 19:353-355) as a discipline associating ultrasound diagnoses and immediate therapies, with adjunct uses (venous canulation, thoracentesis...). Main publications: textbooks (1992, 2002, 2005, 2010, 2011 & 2015 editions, Springer), two dozens of original articles, mostly focused on lung and venous ultrasound, including: BLUE-protocol (acute respiratory failure), FALLS-protocol (lung ultrasound for management of acute circulatory failure), SESAME-protocol (cardiac arrest), lung ultrasound in critically ill neonates. President of CEURF, personnalized training center at the bedside in the I.C.U. , where critical ultrasound is taught as a holistic approach, favoring simple equipment (without Doppler), one universal probe for whole body, emphasis on lung, adapted venous ultrasound, simple cardiac sonography (and others), extrapolable to multiple disciplines (pediatry, pulmonology...), settings (ICU, austere areas...), patients (from bariatric to neonates).
The diagnosis of hemodynamic pulmonary edema, sometimes difficult, usually requires irradiating techniques or indirect approaches (echocardiography, BNP), which are time-consuming. The BLUE-protocol proposes lung ultrasound as a direct diagnosis. What is required is a simple, gray-scale unit; a wide range (up to 17 cm) microconvex probe, the best for scanning together lungs and veins (and heart plus whole body). The B-line is the basis for the diagnosis, a certain kind of comet-tail artifact strictly defined for avoiding confusions. The B-profile is defined, in a supine or semirecumbent patient, by anterior, bilateral and multiple B-lines, associated with a conserved lung sliding. This profile is called the B-profile. For the diagnosis of hemodynamic pulmonary edema, regardless any echocardiographic data, regardless the quality of a cardiac window, the B-profile has a sensitivity of 97%, and a specificity of 95%. The BLUE-protocol should be used first in a dyspneic patient, in order to see the reality of the pulmonary edema. Then the patient can be treated accordingly. A test showing the origin of this edema is asked in a second step, calling an expert echocardiographist. The BLUE-protocol also allows, by an exclusive scanning of the lung and (when required) the veins, an accurate diagnosis of the other most frequent acute lung diseases : pneumonia, pulmonary embolism, exacerbated COPD, severe asthma and pneumothorax, using 7 other profiles (called A-profile, A’-profile, B’-profile, A/B-profile, C-profile). These profiles allow fresquently or confidently differential diagnoses of hemodynamic pulmonary edema, such as pneumonia, pulmonary embolism, COPD. All in all, when using the BLUE-protocol wisely, i.e., surrounded by the clinical informations and a few, basic tests, the diagnosis, positive or negative, of hemodynamic pulmonary edema is usually done confidently. Many subtleties (associated lung diseases, difficulties of diagnoses using too modern equipments (which destroy artifacts) are not dealt ith in this volume.