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doi:10.1093/eurjhf/hfs157
EDITORIAL
This editorial refers to Utility of lung ultrasound in predicting pulmonary and cardiac pressures, by E. Platz
et al., published in this issue on pages 1276 1284.
For a long time, cardiologists thought that the lung was off-limits
for ultrasound, and this is still standard textbook knowledge. In
Harrisons classical textbook Principles of Internal Medicine, it is
clearly stated that because ultrasound energy is rapidly dissipated
in air, ultrasound imaging is not useful for evaluation of the pulmonary parenchyma.1 However, this is not entirely true, and
lung ultrasound can offer surprising clinical dividends in several
challenging conditions, from pulmonary oedema to interstitial
lung fibrosis, from acute respiratory distress syndrome (ARDS)
to pleural effusion and pulmonary embolism.2 In pulmonary
oedema, the presence of water in the lung opens up the previously
locked pulmonary acoustic window and allows cardiologists to gain
spectacular insight into pulmonary congestion, which can be directly imaged and semi-quantified.3 5 The study by Platz et al.6 confirms that B-lines (also called ultrasound lung comets) are a simple,
low-cost, low-technology, practical sign of extravascular lung water
(EVLW). The authors show that correlation with pulmonary pressure is presentbut not strong. This is not surprising, is broadly
consistent with previous studies, and can be better understood if
we consider the heterogeneous nature of B-lines, which can
occur in three different conditions: heart failure, ARDS, and lung
interstitial fibrosis.
The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.
* Corresponding author. Tel: +39 050 3152398, Fax: +39 050 3152374, Email: picano@ifc.cnr.it
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email: journals.permissions@oup.com.
symptoms of congestion (clinical congestion). However, this relationship is not strict, since the three types of congestion measure
different aspects.8 In patients with impending acute heart failure,
there is a long incubation period of days or weeks characterized
by lung water accumulation, and in the congestion cascade, pulmonary oedema can be detected well before the appearance of
clinical signs of congestion. Detection and treatment of pulmonary
congestion before it is clinically evident may prevent hospitalization
and progression of heart failure.
The correlation between B-lines and invasively assessed pulmonary capillary wedge pressure was moderate (r 0.48, P , 0.001) in
20 patients studied by Agricola et al. before and after cardiac
surgery, in a particularly favourable setting, with each patient
acting as his/her own control.9 In a larger, unselected population
of 340 inpatients admitted to an adult cardiology department,
Frassi et al. observed a significant but weak correlation between
B-lines and pulmonary artery systolic pressure derived from echocardiography (r 0.26, P , 0.0001).10 In 75 haemodialysis patients,
Mallamaci et al. reported a mild association with pulmonary pressure
(r 0.32, P 0.006).11 The two parameters of pulmonary (B-lines)
and haemodynamic (pulmonary artery systolic or wedge pressure)
congestion are therefore associated, but their correlation is very
limited, as also reported by Platz et al.,6 with an r-value of 0.48. In
everyday practice, a patient can show very variable degrees of
B-lines (from absent to severe) for any given level of pulmonary
artery pressure, depending on the duration of history of heart
failure, speed of changes in pulmonary pressure, concomitant
mitral insufficiency, characteristics of the alveolarcapillary membrane, oncotic pressure, lymphatic drainage capacity, and so on.
On the other hand, a patient can have B-lines without haemodynamic congestion, such as in ARDS and in lung interstitial fibrosis.
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Editorial
Table 1 The three B-lines scenarios: heart failure, acute lung injury-acute respiratory distress syndrome, and interstitial
lung disease
Clinical examples
Heart failure
ALI-ARDS
EF
PASP
Abnormal (decreased)
Abnormal (increased)
Normal
Normal
Normal
Normal
No effect
No effect
Pleural effusion
ER/cardiology/nephrology
Subpleural alterations
Intensive care
Pleural thickening
Internal medicine
...............................................................................................................................................................................
ALI, acute lung injury; ARDS, acute respiratory distress syndrome; EF, ejection fraction; ER, Emergency Room; LUS, lung ultrasound; PASP, pulmonary artery systolic pressure.
Conclusion
B-lines are the shape of lung waterbut they can also be the shape
of interstitial fibrosis. They are not mere meteors in the ultrasound
diagnostic sky, but are here to stay as part of the standard armamentarium of cardiologists as well as intensivists, nephrologists,
rheumatologists, and sports physicians. They are associated with
pulmonary hypertension in heart failure, but identify a different
variable from haemodynamic congestion: it is water, not pressure.
It is also an appealingly simple sign to learn and to teach. From a
technical viewpoint, in the echocardiographic cursus studiorum
where 2D echo represents elementary school, Doppler-echo secondary school, and stress echo university, B-lines correspond to
References
1. Longo D, Fauci AS, Kasper DL, Hauser S, Jameson JL, Loscalzo J. Harrisons Principles
of Internal Medicine. 18th ed. New York: McGraw-Hill; 2011. Part 11, Section 1,
Chapter 253.
2. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW,
Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R,
Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A,
Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T; International
Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012;38:577591.
3. Lichtenstein D, Meziere G, Biderman P, Gepner A. The comet-tail artifact. An
ultrasound sign of alveolarinterstitial syndrome. Am J Respir Crit Care Med
1997;156:1640 1646.
4. Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G. Ultrasound lung
comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr
2006;19:356 363.
5. Gargani L. Lung ultrasound: a new tool for the cardiologist. Cardiovasc Ultrasound
2011;9:6.
6. Platz E, Lattanzi AM, Agbo C, Takeuchi M, Resnic FS, Solomon SD, Desai AS.
Utility of lung ultrasound in predicting pulmonary and cardiac pressures. Eur J
Heart Fail 2012;14:1276 1284.
7. Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG,
Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL,
Mebazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van
Veldhuisen DJ, Zannad F, Anker SD, Rhodes A, McMurray JJ, Filippatos G; European Society of Cardiology; European Society of Intensive Care Medicine. Assessing and grading congestion in acute heart failure: a scientific statement from the
Acute Heart Failure Committee of the Heart Failure Association of the European
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8.
9.
10.
11.
Editorial