Comparative Performance of Pulmonary

Ultrasound, Chest Radiograph, and CT Among

Patients With Acute Respiratory Failure
David M. Tierney, MD, FACP1; Joshua S. Huelster, MD2; Josh D. Overgaard, MD1;
Michael B. Plunkett, MD3; Lori L. Boland, MPH4; Catherine A. St. Hill, DVM, PhD4;
Vincent K. Agboto, PhD, MS4; Claire S. Smith, MS4; Bryce F. Mikel, MD1; Brynn E. Weise, MD1;
Katelyn E. Madigan, MD5; Ameet P. Doshi, MD1; Roman R. Melamed, MD, FCCP2

Objectives: The study goal was to concurrently evaluate agree-
ment of a 9-point pulmonary ultrasound protocol and portable
chest radiograph with chest CT for localization of pathology to the
correct lung and also to specific anatomic lobes among a diverse
group of intubated patients with acute respiratory failure.
Design: Prospective cohort study.
Setting: Medical, surgical, and neurologic ICUs at a 670-bed
urban teaching hospital.
Patients: Intubated adults with acute respiratory failure having
chest CT and portable chest radiograph performed within 24
hours of intubation.
Interventions: A 9-point pulmonary ultrasound examination per-
formed at the time of intubation.
Measurements and Main Results: Sixty-seven patients had pul-
monary ultrasound, portable chest radiograph, and chest CT
performed within 24 hours of intubation. Overall agreement of
pulmonary ultrasound and portable chest radiograph findings
with correlating lobe (“lobe-specific” agreement) on CT was 87%
1
Department of Graduate Medical Education, Abbott Northwestern Hos-
pital, Minneapolis, MN.
2
Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, MN.
3
Consulting Radiologists, Ltd., Minneapolis, MN.
4
Department of Care Delivery Research, Allina Health, Minneapolis, MN.
5
University of Minnesota Medical School, Minneapolis, MN.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s website (http://journals.lww.com/
ccmjournal).
Dr. Tierney received funding from personally purchased stock options and
versus 62% (p < 0.001), respectively. Relaxing the agreement def-
inition to a matching CT finding being present anywhere within the
correct lung (“lung-specific” agreement), not necessarily the spe-
cific mapped lobe, showed improved agreement for both pulmo-
nary ultrasound and portable chest radiograph respectively (right
lung: 92.5% vs 65.7%; p < 0.001 and left lung: 83.6% vs 71.6%;
p = 0.097). The highest lobe-specific agreement was for the find-
ing of atelectasis/consolidation for both pulmonary ultrasound
and portable chest radiograph (96% and 73%, respectively). The
lowest lobe-specific agreement for pulmonary ultrasound was
normal lung (79%) and interstitial process for portable chest ra-
diograph (29%). Lobe-specific agreement differed most between
pulmonary ultrasound and portable chest radiograph for interstitial
findings (86% vs 29%, respectively). Pulmonary ultrasound had
the lowest agreement with CT for findings in the left lower lobe
(82.1%). Pleural effusion agreement also differed between pul-
monary ultrasound and portable chest radiograph (right: 99% vs
87%; p = 0.009 and left: 99% vs 85%; p = 0.004).
Conclusions: A clinical, 9-point pulmonary ultrasound protocol
strongly agreed with specific CT findings when analyzed by both
lung- and lobe-specific location among a diverse population of
mechanically ventilated patients with acute respiratory failure; in
this regard, pulmonary ultrasound significantly outperformed port-
able chest radiograph. (Crit Care Med 2019; XX:00–00)
Key Words: critical care; lung; point-of-care; radiography;
respiratory insufficiency; ultrasonography

disclosed he is a member of Medical Advisory Boards for Echonous and
Bay Labs. The remaining authors have disclosed that they do not have any
potential conflicts of interest.
This work was performed at Abbott Northwestern Hospital, Minneap-
olis, MN.
For information regarding this article, E-mail: david.tierney@allina.com
Copyright © 2019 by the Society of Critical Care Medicine and Wolters
Kluwer Health, Inc. All Rights Reserved.
DOI: 10.1097/CCM.0000000000004124
A
cute respiratory failure (ARF) requiring mechanical
ventilatory support is the most common reason for
ICU admission and has high mortality (1, 2). Initial
misdiagnosis of ARF etiology is common and increases mor-
tality (3). With the broad differential of diseases causing ARF,
efficiency of diagnosis is not only related to accuracy of the
chest imaging modality, but also its ability to anatomically lo-
calize a process and monitor for change with treatment.

Critical Care Medicine www.ccmjournal.org 1

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Tierney et al
Portable chest radiograph (pCXR) lacks the sensitivity and
specificity of CT (4–6), yet may be favored in some settings due
to speed, lower cost and radiation, and risk associated with ICU
patient transport especially with technologically complex support
modes such as extracorporeal membrane oxygenation (ECMO)
(7, 8). Pulmonary ultrasound (PU) has demonstrated the ben-
efits of pCXR’s portability, speed, and lower cost while approach-
ing accuracy of chest CT for pneumonia, interstitial processes,
acute respiratory distress syndrome (ARDS), pleural effusion, and
pneumothorax (9–15). The Society of Critical Care Medicine and
international guidelines support incorporation of point-of-care
ultrasound (POCUS) in diagnosis of these conditions (16, 17). In
addition to its initial diagnostic ability, POCUS offers clinicians a
radiation-free tool to repeatedly reassess for progression or regres-
sion of pulmonary findings in real-time at the bedside which can
further aid in tailoring treatment and differential diagnosis.
The majority of research reporting diagnostic accuracy of
PU has defined agreement as compatible ultrasound findings
anywhere within the correct lung as identified by CT. However,
two small studies (n = 32 and 20) conducted in patients with
ARDS have demonstrated a refined ability of PU to accurately
localize findings beyond the correct lung to distinct lung zones
on CT defined not by anatomic lung lobe (i.e., right lower lobe,
right middle lobe), but by zones corresponding to contempo-
rary protocolized ultrasound examination regions (18, 19).
The goal of this study was to concurrently evaluate the ac-
curacy of both PU and pCXR with CT not only for agreement
of findings within the ipsilateral lung or a correlating CT zone,
but within the specific anatomic lobe using a previously pub-
lished, quick, pragmatic, 9-zone PU protocol (20) among di-
verse medical/surgical, cardiac, and neurologic ICU patient
populations with a wide array of ARF diagnoses.
MATERIALS AND METHODS
Setting and Study Design
This prospective cohort study took place in a 670-bed, 62 ICU
bed, quaternary care, teaching hospital. Patients included in
Figure 1. Ultrasound and chest radiograph zone location. AAx = anterior axillary line, LL = left lower, LU = left upper, MC = mid-clavicular line, PAx =
posterior axillary line, RL = right lower, RU = right upper.
2 www.ccmjournal.org XXX 2019 • Volume XX • Number XXX
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
this study were a subset from a larger (n = 250), previously
published study evaluating a protocolized 9-location PU ex-
amination in patients with ARF requiring mechanical venti-
lation (20). Patients were included in the current study if, in
addition to their PU at the time of intubation, they underwent
pCXR and chest CT within 24 hours of the PU. The protocol
was approved by the institutional review board (Schulman
Associates IRB, number 4080-2E).
Imaging and Classification
Details of the full PU examination protocol have been described
previously (20). Presence of normal lung, quantified B-line cat-
egory (B1–B3), atelectasis/consolidation, and pleural effusion
was registered in nine anatomically chosen (to approximate
lobar anatomy) and clinically applicable PU zones (Fig. 1).
The surface area examined within each zone was limited to
7.5 × 5 cm (the size of our hospital ID badge). A comparison of
this 9-point examination protocol to other frequently used PU
protocols (11, 21, 22) can be found in Supplemental Content
1 (http://links.lww.com/CCM/F166).
All PU examinations were performed by one of four study
physicians with 3+ years of PU experience who participated
in a 1-hour pre-study teaching session to ensure uniformity
of PU classification. They independently scored archived
video clips representing the spectrum of classifications from
64 patients, and inter-rater agreement for pulmonary classifi-
cation was calculated. All examinations were performed with
SonoSite EDGE portable ultrasound systems and a P21 (1–5
MHz) phased-array transducer (FUJIFILM SonoSite, Bothell,
WA) (see additional methods, Pulmonary Ultrasound Exam
Detail, Supplemental Content 2, http://links.lww.com/CCM/
F167).
Ultrasound zones were classified as normal when the region
contained A-lines and lung sliding in the absence of B-lines or
consolidation/atelectasis. Presence of B-lines was subclassified by
B1, B2, or B3 based on quantity (B1 = 1–3 discrete B-lines present
per intercostal space; B3 = confluent B-lines occupying > 50%
of an intercostal space; or B2 = quantity of B-lines between B1

TABLE 1. Anatomical Correspondence and Definition of Finding Agreement Across CT,
Pulmonary Ultrasound, and Portable Single-View Chest Radiograph
Properties CT
Anatomical correspondence Right upper lobe
Right middle lobe
Right lower lobe
Left upper lobe
Left lower lobe
Definition of agreement Normal
Interstitial
Ground glass
Atl/Cons
Effusion
Atl/Cons = atelectasis/consolidation.
and B3). An isolated B1 area in the postero-caudal tip of the lung
was classified as normal. Areas of nonaerated lung greater than
3 cm in its axis perpendicular to pleura with dynamic air bron-
chograms and lack of compressive reason for aeration loss (e.g.,
pleural effusion, elevated diaphragm) were classified as non-
atelectatic consolidation. Zones with small, focal, less than 3 cm
areas, of peripheral consolidation were subclassified as “small”
consolidations. Areas of nonaerated lung greater than 3 cm in
its axis perpendicular to pleura with distinct features suggest-
ing volume loss atelectasis such as presence of a pleural effusion
size consistent with volume of nonaerated lung, lack of dynamic
air bronchograms, typical atelectatic distribution in the inferior
or lateral tip of lung with a smooth re-aeration interface, were
classified as atelectasis. A combined classification of atelectasis/
consolidation was assigned when the area examined consisted of
tissue-like density and the physician was unable to see discrim-
inating features indicative of either specific entity. Pleural effu-
sion was classified as fluid in the pleural space whether simple or
complicated with a minimum visceral-parietal pleural dimen-
sion greater than or equal to 0.5 cm at any location. Individual
classifications were also grouped into the categories of paren-
chymal abnormality (normal, interstitial, ground glass, atelec-
tasis/consolidation) or pleural effusion for subanalyses.
A single, expert chest radiologist without PU training,
blinded to PU results and clinical information, reviewed all
pCXR and chest CT studies to classify each anatomical zone
(pCXR) and lobe (CT) as normal, interstitial, ground glass (CT
only), atelectasis, consolidation, or pleural effusion. CXR zones
were defined as shown in Figure 1. CT regions were defined by
anatomical lobe.
Agreement for lung findings and zones/lobes across modal-
ities are presented in Table 1. “Lobe-specific” agreement was
defined as identification of an agreeing PU/pCXR finding in an
agreeing PU/pCXR zone with the CT finding and specific ana-
tomic lobe. “Lung-specific” agreement was defined as identifi-
cation of a PU/pCXR finding to an agreeing finding anywhere
Critical Care Medicine www.ccmjournal.org 3
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Clinical Investigation
Portable Chest
Ultrasound Radiograph
Zone 1 Right upper zone
Zones 2 and 4 Right lower zone
Zones 3 and 5 Right lower zone
Zones 6 and 7 Left upper zone
Zones 8 and 9 Left lower zone
A-lines + lung sliding Normal
B1, B2, or B3 profile Interstitial
B2, B3, Atl/Cons Atl/Cons
Atl/Cons Atl/Cons
Effusion Effusion
in the ipsilateral lung on CT (not restricted to the specific
anatomic lobe mapping in Table 1) (see additional methods,
Pulmonary Ultrasound Agreement Details and Rationale,
Supplemental Content 2, http://links.lww.com/CCM/F167).
Final clinical diagnoses for ARF were adjudicated by two
study physicians blinded to, and not having performed, the PU
examination (see additional methods, Final Clinical Diagnosis
Assignment, Supplemental Content 2, http://links.lww.com/
CCM/F167). They then reviewed the PU examination collec-
tively and determined whether it was consistent with the clin-
ical diagnosis.
Data Analysis
Descriptive statistics were used to describe study sample charac-
teristics. With CT findings considered gold standard, the propor-
tion of patients with agreement between PU and CT, and pCXR
and CT was compared using two-sample tests of proportions.
Level of agreement was examined for both the combination
of correct finding in the correct lobar correlate (lobe-specific
agreement) and for the correct finding anywhere in the ipsilat-
eral lung (lung-specific agreement). The sensitivity of PU and
pCXR to detect CT findings was evaluated overall, by body mass
index (BMI), and duration of time between CT and PU/pCXR
(dichotomized at sample medians) using z tests for difference in
proportions. Fleiss’s kappa coefficient was used to assess inter-
rater agreement in the pre-study training set. A sample size of 67
patients achieved 83% power to detect an overall difference of
22% between the agreement of ultrasound and pCXR, using the
two-sided z test with pooled variance. Statistical analyses were
conducted at 5% significance level. Analyses were conducted
using Stata 14.1 (StataCorp, LP, College Station, TX).
RESULTS
From the broader 250 patient cohort (20), 67 patients (Table 2)
met inclusion criteria. The most common ARF diagnosis was
Tierney et al

TABLE 2. Patient Characteristics TABLE 3. Agreement of Pulmonary

Variable n = 67 Ultrasound and Portable Chest Radiograph
Findings With CT
Age, yr, mean ± sd 65.2 ± 13
Portable
Males, n (%) 30 (45) Chest
Ultrasound, Radiograph,
Body mass index, kg/m2, median (IQR) 29 (23–36) Variable % % pa
Partial pressure of arterial oxygen/ 214 (135–336)
percentage of inspired oxygen ratio, Lobe-specific agreement by location
median (IQR)  Overall 86.6 61.6 < 0.001
Ventilator days, median (IQR) 4.1 (2.6–7.0)    Right lung overall 86.6 61.9 < 0.001
In-hospital mortality, % 28    Right upper lobe 83.6 64.2 0.011
Elapsed time between ultrasound and CT, 12.2 (6.2–18.4)    Right middle lobe 86.6 59.7 b
< 0.001
hr, median (IQR)
   Right lower lobe 89.6 59.7 b
< 0.001
Elapsed time between portable chest 8.8 (4.2–15.3)
radiograph and CT, hr, median (IQR)    Left lung overall 86.6 61.2 < 0.001

Clinical diagnosis, n (%)    Left upper lobe 91.0 59.7 < 0.001

 Pneumonia 20 (30)    Left lower lobe 82.1 62.7 0.012

 Aspiration 10 (15) Lobe-specific agreement by finding

  Cardiac arrest 9 (13)  Normal 78.8 59.5 0.005

 Sepsis 6 (9)  Interstitial 86.2 28.6 < 0.001

  Congestive heart failure 5 (8)   Ground glass 89.9 72.5 < 0.001

  Chronic obstructive pulmonary disease 4 (6)  Atelectasis/ 95.6 72.5 < 0.001
exacerbation consolidation

  Acute lung injury/acute respiratory 4 (6)  Effusion 100.0 74.5 < 0.001
distress syndrome  Overall 88.9 66.3 < 0.001
  Acute myocardial infarction 3 (5) Lung-specific agreement by category
  Neuromuscular weakness 2 (3)   Right lung parenchymalc 92.5 65.7 < 0.001
  Pulmonary embolism 1 (2)   Right pleural effusion 98.5 86.6 0.009
 Pneumothorax 1 (2)   Left lung parenchymalc 83.6 71.6 0.097
  Cryptogenic organizing pneumonia 1 (2)   Left pleural effusion 98.5 85.1 0.005
  Allergic bronchopulmonary 1 (2) Two-sample proportion z test.
a

aspergillosis b
Agreement for the right lower zone on single-view portable chest radiograph
was with findings in either the right lower or middle lobe on CT.
Left ventricular systolic function, n (%) Normal, interstitial, ground glass, atelectasis/consolidation classifications
c

included in this analysis and pleural effusion was analyzed separately.

 Normal 34 (51)
  Mildly/moderately reduced 14 (21) PU had significantly better overall lobe-specific agreement
with CT than pCXR, when agreement was examined by right
  Severely reduced 8 (12)
versus left lung, and within each zone/lobe individually. Lung-
 Hyperdynamic 11 (16) specific agreement of PU with CT for parenchymal findings
IQR = interquartile range. (excludes pleural effusion) was lower in the left lung compared
pneumonia (30%), followed by aspiration, cardiac arrest, with right (83.6% vs 92.5%; p = 0.109), and PU performed
sepsis, congestive heart failure (CHF), and ARDS. Median par- worst (82.1%) in the left lower lobe (LLL) (Table 3).
tial pressure of arterial oxygen/percentage of inspired oxygen Analysis by specific CT finding (Table 3) demonstrated that
(P/F) ratio was 214 (interquartile range [IQR], 135–336) and PU consistently had better agreement with CT than pCXR,
overall mortality was 28%. with the greatest difference for interstitial findings (86.2%
Inter-rater agreement was “very good” overall (kappa vs 28.6%; p < 0.001). Patient BMI and time between PU and
= 0.83), “almost perfect” for assignment of normal lung CT did not significantly affect agreement of PU overall (BMI
(kappa = 0.96), “very good” for atelectasis/consolidation < 29 = 88.5% vs BMI ≥ 29 = 89.4%, p = 0.734; < 12.2 hr =
(kappa = 0.84), and “substantial” for specific B1, B2, and B3 90.3% vs ≥ 12.2 hr = 87.6%, p = 0.295) or for any individual
classifications (kappa = 0.77, 0.61, 0.74, respectively). finding (e.g., interstitial, consolidation).
4 www.ccmjournal.org XXX 2019 • Volume XX • Number XXX

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
 Clinical Investigation

The overall PU examination was determined to be consistent DISCUSSION

with final diagnosis in 62 of 67 patients. Four cases where PU
did not agree are described below with corresponding images
(Fig. 2) as illustrations of potential PU pitfalls.
1) A patient with metastatic pleural nodules from breast cancer
and LLL pneumonia/empyema. CT showed diffuse pleural
nodules in the right thorax and consolidation/effusion in the
LLL (Fig. 2, A and B). Classification by PU showed interstitial
findings in the right middle and upper lobes and consolida-
tion in the right lower lobe. These interstitial and consolida-
tive findings on PU were likely the pleural-based nodules. The
PU correctly identified LLL pneumonia and pleural effusion.
2) A patient with bullous emphysema and bilateral scarring
on CT (Fig. 2C) was classified by PU as diffuse interstitial
process. Without knowledge of the patient’s prior bilat-
eral scarring, this scenario could result in an obstructive
lung disease exacerbation being interpreted as hydrostatic
pulmonary edema or influenza pneumonia if PU findings
are not integrated with other clinical and POCUS data.
Although PU findings are consistent with the diagnosis, it
demonstrates the low specificity of B-lines in isolation.
3) A patient with a superior/anterior right upper lobe mass on
CT, not visualized on pCXR (Fig. 2, D and E), had a normal
PU examination due to the superior and nonpleural-based
location of the mass.
4) In addition to a right lower lobe pneumonia visualized with
PU, the posteromedial LLL consolidation on CT scan was
missed with PU of left thorax. The large, superiorly dis-
placed stomach bubble/diaphragm impeded visualization
in this recumbent patient because the transducer was not
far enough posterior (Fig. 2F).
This study adds to the literature on the agreement of PU with
CT and provides new evidence that a clinically feasible 9-point
PU protocol can accurately localize findings not only to a spe-
cific lung or region but to anatomic lobe. The lobe-specific
agreement in this study adds further nuance to the lung zone
localizing ability of PU demonstrated in the prior smaller stud-
ies of ARDS patients by Lichtenstein et al (19) and Chiumello
et al (18). By prospectively and concurrently evaluating both
lung- and lobe-specific agreement for pCXR and PU across a
broad set of ARF diagnoses, a wide range of illness severity (P/F
IQR, 135–336), and within medical/surgical, neurologic, and
cardiac ICUs, our study provides more generalizable evidence
regarding the accuracy of PU for localization of specific find-
ings and adds support for the clinical and diagnostic value of
the 9-point PU protocol and scoring system previously shown
to correlate with mortality, length of stay, and P/F ratio (20).
Localization of findings to the correct lung with PU is often
clinically adequate, and the higher “lung-specific” (compared
to “lobe-specific”) agreement found in our study (overall right
lung parenchymal and pleural effusion agreement = 92.5% and
98.5%, respectively; left lung = 83.6% and 98.5%, respectively)
is consistent with the majority of existing PU literature evalu-
ating agreement by lung and is indicative of the accuracy of PU
as a diagnostic tool. However, “lobe-specific” localization also
has clinical utility. It can support diagnoses such as aspiration
by localizing findings to commonly involved lobes such as the
superior segments of the lower lobe or posterior segment of
the upper lobe (23), or assist in differentiating acute findings
in patients with previously known fibrosis/scarring in a spe-
cific lobe. It can guide bronchoscopic intervention, especially
in patients difficult to transport for CT (e.g., ECMO patients),

Figure 2. Discrepant case images. A and B, Case 1 chest CT; arrows = pleural-based nodules. C, Case 2 chest CT; arrows = bullae. D, Case 3 chest
CT; arrow = right upper lobe mass. E, Case 3 portable chest radiograph without visible right upper lobe mass. F, Case 4 chest CT; arrow = posterior left
lower lobe consolidation missed by ultrasound; *stomach. L = left, R = right. See high resolution image versions of the figures (Supplemental Content
3, http://links.lww.com/CCM/F168).

Critical Care Medicine www.ccmjournal.org 5

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Tierney et al
to a lobe with presumed airway obstruction for suctioning or
to a lobar parenchymal consolidation for culture. Evaluation
of lobe-specific agreement also allows for examination of dif-
ferences in PU agreement within specific lobes such as the LLL
which can be difficult to visualize due to recumbent patient
positioning and positioning of the heart in the left hemithorax.
Lower agreement of PU in the LLL (82.1%) reveals a poten-
tial pitfall of PU in mechanically ventilated patients that would
likely improve with examination of posterior zones. Basal re-
gions, especially the left retrocardiac region can also be difficult
to evaluate with pCXR and is a potential shortcoming of both
modalities (24).
The PU lobe-specific agreement in our study (87%) is sim-
ilar to that reported by Lichtenstein et al (19) where overall
concordance of PU with CT regions (not anatomic lobes)
among a cohort of 32 ARDS patients was 83%. Both studies
report very good inter-rater agreement across categories and
show significantly greater accuracy of PU compared with CXR.
The main differences between our study and the study by
Lichtenstein et al (19) include as follows: 1) size of study (67 vs
32 patients, respectively), 2) a wide spectrum of ARF diagnoses
versus ARDS alone, 3) a 9-point examination protocol limited
to a 7.5 × 5 cm area at each point versus a 12 zone examina-
tion with full exploration of each zone, and 4) PU examina-
tion point agreement with CT anatomic lobes versus CT zones
chosen to approximate the PU examination areas.
PU had better agreement with CT than pCXR across a va-
riety of findings but outperformed pCXR most strongly for in-
terstitial process identification (Table 3). The lower agreement
of PU for the normal CT classification (78.8%) may in fact re-
flect superior sensitivity of PU compared with CT for subtle
interstitial processes seen as 1–3 B-lines in an interspace. One
might argue 1–3 B-lines (B1 classification) is a normal find-
ing, especially in dependent lung locations. However, in our
protocol, the B1 classification was assigned to agree with the
“interstitial” rather than “normal” (except when isolated to the
postero-caudal tip of the lung). Our decision to map the B1
PU classification in this manner reflects the clinical experience
that occasional B-lines in a nondependent location often rep-
resents pulmonary pathology but when isolated to the postero-
caudal lung tip are often insignificant. Prior studies evaluating
a greater surface area of the chest have used similar approaches
to grouping B-line quantity but have categorized 1–2 B-lines
or an “isolated B-line” as “normal” (25, 26). A comparatively
smaller chest surface area was examined in our study, increas-
ing the chance that 1–3 B-lines in the examined area represent
the penumbra of a more significant process and was a factor in
our decision to not map the B1 classification to normal lung on
CT. Due to the divergence from previous classification schemes,
a sensitivity analysis was performed evaluating agreement if
all B1 zones were reclassified as normal and showed a 5–10%
reduction in lobe-specific and overall agreement between PU
and CT (Supplemental Table 1, Supplemental Digital Content
4, http://links.lww.com/CCM/F169). This supports that the B1
classification (except when isolated to the postero-caudal tip
of the lung) correlates better with an interstitial process on CT
6 www.ccmjournal.org XXX 2019 • Volume XX • Number XXX
Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
than with normal lung using this 9-point protocol among this
patient population.
Our study has limitations, some inherent to clinical POCUS
workflow. First, study physicians did not discuss patients with
caregivers prior to or during the examination. However, clin-
ical clues in the room, such as antibiotic or diuretic infusions,
may have influenced zone interpretation. Second, the inclu-
sion requirement of CT and pCXR within 24 hours of PU ex-
amination may have introduced a bias for more severe illness
in this subgroup. Although not detracting from the findings,
this may impact generalizability. However, comparison of the
original 250 patient cohort (20) and the 67 patient subgroup
showed strong similarities in clinical markers (mortality: 24%
vs 28%, median ventilator days: 4.1 vs 4.1, mean P/F ratio: 223
vs 234, respectively) and diagnoses (pneumonia: 30% vs 30%,
aspiration: 14% vs 15%, sepsis: 12% vs 9%, CHF 11% vs 8%,
ARDS and chronic obstructive pulmonary disease/asthma: 7%
vs 6%, respectively), thus supporting greater generalizability
of our subgroup results. Third, to preserve PU protocol effi-
ciency, each zone’s examination area was restricted to the size
of our hospital ID badge potentially resulting in a lower sen-
sitivity for processes just outside the scanned area. In clinical
use when suspicion is high and a limited PU examination is
normal, a more detailed examination would occur and likely
improve sensitivity. Fourth, duration of time between imaging
modalities may have positively or negatively impacted agree-
ment, but we did not observe any meaningful impact on agree-
ment with increasing elapsed time. This may be in part due
to the severity of illness and predominance of slowly resolving
radiographic processes (pneumonia and aspiration) compris-
ing 45% of diagnoses. We conjecture that in healthier patients
with more rapidly changing ARF etiologies, time between im-
aging studies may have greater impact on agreement. Finally,
examination of whether PU examination summaries matched
adjudicated clinical diagnoses had the potential for significant
bias. Therefore, these data are included only to illustrate po-
tential pitfalls of the PU examination, and to use available, cor-
related CT data to better understand the limitations of our PU
protocol in certain scenarios.
CONCLUSIONS
The results of this study, conducted within a clinical ICU
workflow and in a population with diverse ARF diagnoses and
severity, demonstrate strong support for the role of PU in not
only pulmonary pathology identification but also its lobar lo-
calization; in this regard, PU significantly outperformed pCXR.
The study also illustrates potential scenarios where PU has
limitations as compared with CT. In the hands of well-trained
providers with an appreciation for its limitations, PU can be an
invaluable, cost-saving, risk-reducing imaging modality as an
adjunct or replacement for pCXR and CT in patients with ARF.
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