Clinical Concepts and Commentary

Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M., Editor

I-AIM (Indication, Acquisition, Interpretation, Medical

Decision-making) Framework for Point of Care Lung
Ultrasound
Richelle Kruisselbrink, M.D., Vincent Chan, M.D., Gian Alfonso Cibinel, M.D., Simon Abrahamson, M.D.,
Alberto Goffi, M.D.

Three Patients with Dyspnea Is there any role for lung ultrasound in the management
of these patients? How should we perform the ultrasound
Case 1
and what findings should we look for?
You are on call for anesthesia. The neurosurgeon on call has
booked an emergency decompression of a subdural hema-
toma for an elderly man who fell at home during a syncopal Introduction
episode. A chest radiograph on admission showed fractures Over the past decade, lung ultrasound has emerged as a
of the sixth to eighth ribs with no evidence of a pneumotho- point of care diagnostic tool that can be applied at the
rax. Cardiac workup and blood work were noncontributory. bedside to answer specific clinical questions and guide
On assessment, the man is desaturating on room air despite management. Lung ultrasound is easy to learn, quickly per-
no previous respiratory history. He is uncooperative and will formed, goal-oriented, and has definite, easily recognized
require general anesthesia and mechanical ventilation. findings.1–3 One of the primary limitations of point of
care ultrasound is operator dependency.4 Practicing point
Case 2 of care ultrasound applications in an organized, protocol-
You are working in the intensive care unit (ICU). A patient based fashion is crucial to its clinical effectiveness and to
with heart failure related to severe systolic dysfunction has prevent harm.4
steadily increasing work of breathing and oxygen require- Several protocols for point of care ultrasound have been
ments despite noninvasive mechanical ventilation. On phys- described in the literature (e.g., Focused Assessment with
ical exam, there is decreased air entry on the right side. A Sonography for Trauma [FAST], Bedside Lung Ultrasound
right-sided central line is in place. in Emergency [BLUE], Focused Assessed Transthoracic
Echocardiography [FATE]).5–7 However, they have been
Case 3 developed to address specific clinical situations or organ sys-
You are called to the postanesthesia care unit to see a 60-yr- tems and are not applicable across the spectrum of point of
old patient with a history of asthma who just underwent lap- care applications. In contrast, the I-AIM (Indication, Acqui-
aroscopic cholecystectomy. He has persistent wheezing and sition, Interpretation, Medical decision-making) model,
respiratory distress that has been unresponsive to initial treat- described by Bahner et al.,8 presents an intuitive framework
ment with nebulized beta agonists and intravenous steroids. and cognitive aid designed to standardize the approach to

This article is featured in “This Month in Anesthesiology,” page 1A. Supplemental Digital Content is available for this article. Direct URL
citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided
in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). Figure 2 was enhanced by Annemarie B. Johnson, C.M.I.,
Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina.
Submitted for publication December 5, 2016. Accepted for publication May 16, 2017. From the Department of Anesthesia, University Health
Network, Toronto, Ontario, Canada (R.K., V.C.); Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada (R.K., V.C., S.A.);
Department of Emergency Medicine, “E. Agnelli” General Hospital, Pinerolo, Turin, Italy (G.A.C.); Department of Critical Care Medicine, Trauma
and Neurosurgical Intensive Care Unit and Medical Surgical Intensive Care Unit, St. Michael’s Hospital, Toronto, Ontario, Canada (S.A.); Depart-
ment of Anesthesia, St. Michael’s Hospital – University of Toronto, Toronto, Ontario, Canada (S.A.); Interdepartmental Division of Critical Care
Medicine, University of Toronto, Toronto, Ontario, Canada (S.A., A.G.); Department of Medicine, Division of Respirology (Critical Care), Uni-
versity Health Network, Toronto, Ontario, Canada (A.G.); and Department of Medicine, University of Toronto, Toronto, Ontario, Canada (A.G.)
Copyright © 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2017; 127:568–82

Anesthesiology, V 127 • No 3 568 September 2017

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<zdoi;10.1097/ALN.0000000000001779>
 EDUCATION

every point of care exam within a user’s scope of practice, Patient

thereby improving the performance of the instrument and Patient positioning is critical to the accuracy of lung imag-
avoiding potential harm. The I-AIM framework already has ing. The optimal patient position depends on the suspected
been clinically applied to the FAST8 and gastric ultrasound pathology. For example, if the question regards a pneumo-
exams.9 thorax, patients should be positioned supine because pleural
In this article, we present a systematic approach to lung air collects in the least dependent part of the thorax, or the
ultrasound, based on the I-AIM framework. We provide a anterior chest wall, which is highly accessible to ultrasound
imaging. The semisitting position places the apical regions
summary of the key terms and patterns associated with lung
of the thorax in the least dependent position, which is much
ultrasound and highlight potential pitfalls to avoid at each
less accessible for imaging due to the presence of the clavicles
stage of the I-AIM protocol. We also present a practical algo- and may result in missing small pneumothoraces.15,36
rithm to structure the interpretation of findings and direct By contrast, if the primary question pertains to a pleu-
clinical decision-making. ral effusion, the most dependent region of the thoracic cav-
ity is the area of interest. This corresponds to the posterior
Indication ­costophrenic angle provided the patient is in a supine or
There is a growing body of evidence for the use of lung ultra- semisitting position. In rare circumstances, when the patient
sound as a diagnostic and monitoring tool (table 1, I-AIM is placed in prone position or is not subjected to gravita-
framework for lung ultrasound: Indication). tional forces, the findings change dramatically: in the prone
position, nonloculated fluid redistributes ventrally whereas
As a diagnostic tool, the primary clinical indication is the
in microgravity, it redistributes throughout the thoracic cav-
presence of respiratory symptoms (e.g., dyspnea, pleuritic
ity and is visualized in both anterior and posterior windows
chest pain), or signs (e.g., tachypnea, oxygen desaturation, simultaneously. It also has been shown that the transition
abnormal findings on respiratory physical examination) from supine to prone position is associated with redistribu-
where the etiology has not been established.2,10–13 Another tion of aeration, with improved aeration in the posterior
indication is an unclear chest radiography finding, when areas and increased loss of aeration in the anterior areas.28,37
other imaging modalities (e.g., computed tomography scan) For lung consolidation and interstitial syndrome, patient
are not practical or available. In these situations, the pres- position is less crucial and any position allowing complete
ence or absence of key sonographic findings may provide examination of the lung fields can be used. In situations
objective information with which to focus or revise the dif- where serial ultrasounds are performed, it is essential that
ferential diagnosis. Lung ultrasound is highly sensitive and the scanning position remains consistent to facilitate reli-
specific for the identification of pneumothorax14,15; intersti- able comparisons and thus patient position should be docu-
tial syndrome (associated with cardiogenic and noncardio- mented in the report.
genic pulmonary edema, pneumonia and pneumonitis, lung To insonate the posterior lung zones, the patient’s torso
contusion, interstitial lung diseases and other pulmonary may be slightly rotated to the contralateral side and the ipsi-
lateral arm abducted. The upper thorax should be exposed
conditions that cause increased lung density)2,13,16–22; pleu-
and draped, with monitors and dressings repositioned as
ral effusions23; and lung consolidation bordering the pleu-
necessary.
ral line.24–26 However, it does not necessarily discriminate
between the various etiologies that may create these sono- Probe
graphic patterns. Prospective studies using a variety of ultrasound probes
As a monitoring tool, lung ultrasound can be used to have demonstrated that performance and interpretation of
assess the response to recruitment strategies (positive end- lung sonography is not probe specific.2 Nevertheless, certain
expiratory pressure changes or prone positioning),27,28 elu- probes may be preferred depending on the lung region of
cidate causes for weaning failure,29 and evaluate response to interest.36 For instance, visualization of the pleural line is
therapy in patients with pneumothorax, pleural effusions, best accomplished with a high frequency (10 to 12 MHz)
and interstitial syndrome.30–32 Lung ultrasound also may linear probe, whereas imaging of the supradiaphragmatic
play a role in assessing fluid tolerance33 and have prognostic region (pleural space and lung) requires a lower frequency
capabilities in heart failure and end-stage renal disease.34,35 (1 to 5 MHz) probe for adequate depth penetration. Either
curvilinear, microconvex or phased-array probes may be
used.
Acquisition
With respect to probe orientation, either radiology con-
According to the I-AIM model,8 image acquisition is sub- vention (i.e., reference marker to the left of the screen), or
divided into patient, probe, picture, and protocol consid- cardiology convention (i.e., reference marker to the right
erations (table 1, I-AIM framework for lung ultrasound: of the screen), can be used. Because the probe orientation
Acquisition). marker is placed cephalad or toward the right with respect to

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 I-AIM Framework for Lung Ultrasound

Table 1. I-AIM Framework for Lung Ultrasound

(I) Indication
Diagnostic Tool
• Unexplained respiratory symptoms (dyspnea, pleuritic chest pain) or signs (tachypnea, desaturation, abnormal finding on respiratory
physical examination)
• Unclear chest radiograph finding
• Suspicion of:
o Pneumothorax
o Pleural effusion
o Airspace disease (increased lung density)
  ◼ Increased lung weight
   ◻ Extra Vascular Lung Water (e.g., cardiogenic or nonhydrostatic pulmonary edema—ARDS, idiopathic interstitial pneumonias,
lung consolidation, pneumonitis, pulmonary infarct)
   ◻ Pus (e.g., infection, pneumonitis, lung consolidation)
   ◻ Blood (e.g., alveolar hemorrhage)
   ◻ Protein/Collagen (e.g., idiopathic interstitial pneumonias, alveolar proteinosis, lung consolidation, pulmonary infarct)
   ◻ Cells (e.g., primary or metastatic lung cancer)
   ◻ Lipids (e.g., lipoid pneumonia)
  ◼ Decreased lung aeration with no increased lung weight (i.e., atelectasis)
Monitoring and Prognostic tool
• Mechanical ventilation:
o Recruitment strategies
o Weaning failure
• Disease progression:
o Effusion: progression, resolution, changes in characteristics
o Interstitial syndrome/consolidation: progression or resolution of lung deaeration/increased density
o Pneumothorax: lung reexpansion or increase in size
• Fluid tolerance
• Identification of patients with worse prognosis (heart failure and end-stage renal disease)
(A) Acquisition
PATIENT • Position
o Pneumothorax: supine
o Effusion: supine or semisitting
o Interstitial syndrome/consolidation: supine or semisitting
o Posterior lung zones: torso rotation and ipsilateral arm abduction
• Adjust ambient light
• Expose and drape hemithorax
• Surface preparation (adjust monitoring cables/leads and dressings, if possible)
PROBE • Probe selection
o Pleural line: consider higher frequency probe (≥ 5 MHz)
o Posterior/Supradiaphragmatic lung: curvilinear, microconvex, or phased array probe
o Lung parenchyma: consider curvilinear, microconvex, or phased array probe
• Probe orientation: marker placed cephalad or toward patient’s right
PICTURE Knobology • Primary: adjust depth (initiate with ~12 to 15 cm when using a low frequency probe and ~5 to 6 cm when
using a high frequency linear probe; if need to focus on sliding and pulse, minimize depth to clearly visual-
ize pleural line) and optimize gain to maximize visualization of pleural line, artifacts, or lung parenchyma
• Secondary: disable artifact filters, postprocessing functions (if available, choose lung preset); focal zone
• Tertiary: M-mode for the assessment of lung sliding/pulse; zoom; Power Doppler imaging
Scan Antero-Lateral Lung:
• STEP 1: Sagittal scanning plane with visualization of
minimum two ribs; identify pleura
• STEP 2: Tilt the probe to achieve probe angulation
­perpendicular to pleural line; confirm perpendicular angle
by the presence of A-line pattern (in absence of B-lines)
and/or best definition of pleural line appearance
• STEP 3: Hold transducer still to identify pleural move-
ment with respiration (M-mode if required)
• STEP 4: Adjust depth to identify vertical artifacts/B-lines,
sliding/pulse and pleural line characteristics

(Continued)

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 EDUCATION

Table 1. (Continued)
Posterior/Supradiaphragmatic Lung:
• STEP 1: Longitudinal scanning plane in midaxillary line
with beam directed posteriorly
• STEP 2: Rotate probe counterclockwise to eliminate the
rib shadows
• STEP 3: Visualization of diaphragm, liver/spleen
and spine (confirmation for posterior costophrenic
angle—most dependent pleural cavity zone in patient
­semisitting)
• STEP 4: Deep inspiration/expiration to assess for
­effusion (and diaphragmatic displacement)
• STEP 5: If pleural effusion or consolidation identified,
sweep transducer in a posterior to anterior direction
and move cranially to assess full extent.
Findings (see Normal LUS Findings – “SPAA” Abnormal Findings
Table 2) • Lung Sliding • Pneumothorax – “3A-2P”
• Lung Pulse o Absence of Lung Sliding
• A-Lines o Absence of Lung Pulse
• Short Vertical Artifacts o Absence of Comet Tail/Vertical Artifacts
o Presence of Lung Point
o Presence of A lines
• Increased Lung Density – “ABC”
o Absence of A-Lines
o B-Lines
o Consolidation
• Pleural Effusion – “CSF”
o Negative Curtain Sign
o Positive Spine Sign
o Presence of Fluid
PROTOCOL • Complete lung assessment examining anterior, lateral, and posterior surfaces of the lung bilaterally
(8-zone or 12-zone protocols) or abbreviated protocol for emergency situations
• Interventions to enhance exam accuracy: breath-hold; deep inspiration-expiration; changes in patient’s
position (e.g., from supine to semisitting); use of M-mode or Power Doppler imaging
• Capture video inclusive of minimum of one to two respiratory cycles in duration
• Complete written report (Supplemental Digital Content 5, http://links.lww.com/ALN/B513)
(I) Interpretation
• Assessment of image quality/adequacy
o Correct ultrasound settings (preset, depth, gain, focal zone)
o Inclusion of relevant anatomical structures
• Pattern recognition (fig. 2)
• Ultrasonographic differential diagnosis
• Consider further integrative system ultrasonography (e.g., cardiac, vascular, abdominal, diaphragmatic)
(M) Medical Decision-making
• Integration with clinical context (pretest probability)
o History and physical examination
o Imaging
o Laboratory tests
o Electrocardiogram
• Consistency or inconsistency of ultrasound findings with pretest diagnostic hypothesis
• LUS diagnostic or nondiagnostic
• Changes in diagnostic and therapeutic approach

Images adapted with permission from the Department of Anesthesia, University Health Network, Toronto, Canada (http://pie.med.utoronto.ca/POCUS).
ARDS = acute respiratory distress syndrome; LUS = lung ultrasound.

the patient, the cranial-caudal orientation of the image will have been well described2,6 and a detailed description is given in
be reversed depending on the convention used. table 2, Supplemental Digital Content videos, and at the web-
site http://pie.med.utoronto.ca/POCUS/POCUS_content/
Picture lungUS.html. Both the distribution of the abnormalities within
Sonographic examination of the lungs is unique in that it the lung zones, and the timing of the findings with respect to
requires systematic analysis of both nonanatomical images (e.g., symptom onset are significant for later interpretation.
artifacts as A-lines, B-lines) generated by reflection and reverber- When performing artifact analysis, any machine features
ation of the ultrasound waves at the interface between aerated designed to decrease artifact production, including com-
lung tissues and fluid-rich structures (e.g., thickened interlobular pound imaging, speckle reduction, and tissue harmonic imag-
septa, fluid-filled alveoli, soft tissues), and anatomical visualiza- ing need to be deactivated. Some ultrasound machines have a
tion of the pleural space and lung parenchyma in the presence lung exam preset mode that will automatically deactivate these
of consolidation and effusion. Such lung ultrasound findings image filters.

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 I-AIM Framework for Lung Ultrasound

Table 2. Lung Ultrasound Findings

Sonographic Findings Definition Clinical Significance

Lung sliding Shimmering movement synchronous with respira- • Present in normal lung or in pathologic conditions that
tion at the pleural line indicating sliding of the do not affect ventilation
visceral pleura against the parietal pleura (Sup- • Absent or reduced when visceral pleura does not slide
plemental Digital Content 2, http://links.lww.com/ against parietal pleura: apnea, inflammatory adherences,
ALN/B514) loss of lung expansion (overinflation/distension or severe
bullous disease), decrease in lung compliance, airway
obstruction/atelectasis, pleural symphysis, endobronchial
intubation
• Absent when visceral and parietal pleura are separated
(i.e., pneumothorax; Supplemental Digital Content 1,
http://links.lww.com/ALN/B515)
Lung pulse Subtle, rhythmic movement of the lung paren- • Present in normal lung and conditions with minimal
chyma at the cardiac frequency from transmission effect on lung aeration (e.g., pulmonary embolism)
of heartbeat vibrations through the lung tissue • Absent or reduced when lung aeration is significantly
(Supplemental Digital Content 2, http://links.lww. increased (e.g., bullous disease, overinflation/disten-
com/ALN/B514) sion)
• Absent when visceral and parietal pleura are separated
(i.e., pneumothorax; Supplemental Digital Content 1,
http://links.lww.com/ALN/B515)
• Increased in conditions associated with increased lung
density (see B-lines and interstitial syndrome)
Note: Identification of lung pulse in the context of absent
lung sliding is considered a sign of lack of ventilation as
seen in apnea, selective intubation, airway obstruction
(foreign body, mucous plugging, etc.)
A-lines Hyperechoic horizontal lines at increasing depth • Present when air is homogenously distributed below the
separated by same distance as that between the pleural line:
probe and the pleural line o Normally aerated lung
Considered reverberation artifacts arising from o Pneumothorax
the strongly reflective interfaces of the probe and o Pathologic conditions with minimal effect on lung
pleural line (Supplemental Digital Content 2, http:// aeration (e.g., acute pulmonary embolism, asthma/
links.lww.com/ALN/B514) acute COPD exacerbation, early phases of airway
obstruction/atelectasis)
• Absent or reduced when:
o Increased lung density and nonhomogeneous distri-
bution of air
o Nonperpendicular angulation of the ultrasound beam
with the pleural line (Supplemental Digital Content 2,
http://links.lww.com/ALN/B514)
B-lines and Discrete laser-like, vertical, hyperechoic artifacts • Present in conditions associated with increased lung
interstitial that arise from the pleural line, extend to the density and involvement of alveolar units in close rela-
syndrome bottom of the screen without fading, and move tionship with visceral pleura such as:
synchronously with lung sliding (Supplemental o Lung deflation (i.e., atelectasis)
Digital Content 6, http://links.lww.com/ALN/B516   ◼ Normal pattern (if isolated at lung bases)
and Supplemental Digital Content 8, http://links. • Increased lung weight:
lww.com/ALN/B520)2 o Extra vascular lung water (e.g., cardiogenic or non-
Three or more B-lines/intercostal space (sagittal hydrostatic pulmonary edema—ARDS, idiopathic
scan) represent a positive region of increased lung interstitial pneumonias, lung consolidation, pneumo-
density2: nitis, pulmonary infarct)
• Normal aeration: fewer than two isolated o Pus (e.g., infection, pneumonitis, lung consolidation)
B-lines/intercostal space o Blood (e.g., alveolar hemorrhage)
• Moderate loss of lung aeration (B1 pattern): o Protein/Collagen (e.g., idiopathic interstitial pneu-
presence of ≥ 3 well-defined spaced B-lines/ monias, alveolar proteinosis, lung consolidation,
intercostal space pulmonary infarct)
• Severe loss of lung aeration (B2 pattern): mul- o Cells (e.g., primary or metastatic lung cancer)
tiple coalescent B-lines/intercostal space 27, 29
o Lipids (e.g., lipoid pneumonia)
Vertical artifacts at the transition from consolidated
to normally aerated lung (“shred sign”) represent the • Absent when visceral and parietal pleura are separated (i.e.,
same physical and pathophysiologic phenomenon pneumothorax; Supplemental Digital Content 1, http://links.
as B lines, although not defined as such.2 lww.com/ALN/B515) and in normally aerated lung
Short vertical artifacts Vertical artifacts that originate from and move with • Present in normal lungs
(also known as the pleural line but fade quickly; do not obscure • Absent when visceral and parietal pleura are separated
Z-lines or comet A-lines (Supplemental Digital Content 2, http:// (i.e., pneumothorax; Supplemental Digital Content 1,
tails) links.lww.com/ALN/B514) http://links.lww.com/ALN/B515)

(Continued)

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 EDUCATION

Table 2. (Continued)

Sonographic Findings Definition Clinical Significance

Lung point Presence of lung sliding, pulse and/or vertical arti- • Present and very specific in pneumothorax, repre-
facts on one side of an image with the absence of senting transition point at which partially collapsed
these findings on the other side lung contacts the parietal pleura during respiration
(Supplemental Digital Content 1, http://links.lww.
com/ALN/B515).
• Absent in presence of large pneumothorax causing
complete lung collapse (not a highly sensitive finding)
Pleural line Any deviation from the normally appearing • Present in association with several inflammatory
abnormalities thin, smooth, and continuous hyperechoic line conditions (e.g., ARDS, infection, pneumonitis, idi-
including thickening, coarse irregularities, and opathic interstitial pneumonia, and other interstitial
the presence of small subpleural consolidations lung diseases)
(Supplemental Digital Content 6, http://links.lww. Note: False positive pleural line abnormalities when ultra-
com/ALN/B516 and Supplemental Digital Content sound beam not perpendicular to the pleural line
7, http://links.lww.com/ALN/B517)
Lung Anechoic or tissue-like image (hepatization) aris- • Present in same conditions associated with B-lines
consolidation ing from the pleural line that is limited in depth by and interstitial syndrome, as the extreme spectrum of
an irregular border (shred sign) increased lung density
Represents severely increased lung density with
(almost) complete loss of aeration (Supplemen-
tal Digital Content 7, http://links.lww.com/ALN/
B517).
Air bronchogram Hyperechoic spots or branch-like structures seen • Present within areas of lung consolidation (dynamic air
within consolidated lung: bronchograms) or atelectasis (if obstruction atelectasis,
• Static air bronchograms static air bronchograms)
• Dynamic air bronchograms (moving with
the respiratory cycle; Supplemental Digital
Content 7, http://links.lww.com/ALN/B517).
Spine sign Discontinuation of the transverse processes of • Negative spine sign: Present in normally aerated supra-
the spine above the diaphragm from the presence diaphragmatic lung
of normally aerated lung tissue preventing their • Positive spine sign: visualization of the transverse
visualization (negative spine sign; Supplemental processes of the spine above the diaphragm; Present
Digital Content 2, http://links.lww.com/ALN/B514 in pleural effusion and/or supradiaphragmatic lung con-
solidation (Supplemental Digital Content 3, http://links.
lww.com/ALN/B518 and Supplemental Digital Content
4, http://links.lww.com/ALN/B519)
Curtain sign Phenomenon at the lung base, where diaphragm, • Present in normally aerated supradiaphragmatic lung
liver/spleen, and spine disappear on inspiration • Absent in the presence of pleural effusion and/or
due to lung descent and reappear on expiration supradiaphragmatic lung consolidation (Supplemen-
as the lung ascends tal Digital Content 2, http://links.lww.com/ALN/B514
and Supplemental Digital Content 3, http://links.lww.
com/ALN/B518)
Pleural effusion Anechoic (fluid) collection between the parietal • Present most often in supradiaphragmatic regions;
and visceral pleura (Supplemental Digital complex or loculated collections may be elsewhere
Content 2, http://links.lww.com/ALN/B514 and Note: Ultrasound cannot differentiate the nature of the
Supplemental Digital Content 3, http://links. pleural effusion (e.g., hemothorax, transudate, exudate)
lww.com/ALN/B518). Associated with positive although visualization of mobile echoic particles or septa
spine sign and absent curtain sign (Supple- is highly suggestive of complex effusion (e.g., empyema;
mental Digital Content 3, http://links.lww.com/ Supplemental Digital Content 3, http://links.lww.com/ALN/
ALN/B518 and Supplemental Digital Content 4, B518)
http://links.lww.com/ALN/B519)
ARDS = acute respiratory distress syndrome; COPD = chronic obstructive pulmonary disease

The majority of the lung exam utilizes two-dimensional, links.lww.com/ALN/B515). Some authors also have sug-
also called B-mode, imaging. Depth, gain, and focus should gested Power Doppler imaging to help identify lung sliding.39
be adjusted to optimize the image as needed. Decreasing the To examine the anterolateral surface of the lung, the
gain is particularly important for artifact visualization. In probe is placed sagittally on the anterior chest and angu-
some circumstances, the zoom function may be required to lated until the beam is directed perpendicular to the pleural
optimize visualization of sonographic air bronchograms. line. An optimal view contains two adjacent ribs with the
For the diagnosis of pneumothorax, M-mode imaging may pleural line visualized between. The presence of an A-line
help confirm the presence or absence of pleural movement, artifact pattern confirms appropriate probe angulation
especially in situations where it may be reduced (e.g., elderly perpendicular to the pleural line. Once the optimal view
patients, lung overdistension, severe chronic obstructive pul- is identified, the probe must be held completely still to
monary disease 38; Supplemental Digital Content 1, http:// reliably identify the subtle movements of the pleura with

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 I-AIM Framework for Lung Ultrasound

respiration (Supplemental Digital Content 2, http://links. Image storage is essential for comparison with future
lww.com/ALN/B514). images, quality assurance, education, and medico-legal
For examination of the posterior and supradiaphragmatic purposes. In addition, a written report should be generated
regions of the lung, the probe is placed longitudinally in the (Supplemental Digital Content 5, http://links.lww.com/
midaxillary line with the beam directed posteriorly. A slight ALN/B513).
counterclockwise rotation allows the probe footprint to lie
obliquely over an intercostal space and eliminate the rib Interpretation
shadows from the image. An optimal image contains the dia- Image interpretation should follow a logical stepwise
phragm and the liver or spleen to the right of the display with approach including: (1) assessment of image quality and
the spine and kidney visualized in the far field. Visualization adequacy for interpretation, with correct ultrasound set-
of the spine confirms that the posterior costophrenic angle tings and inclusion of relevant anatomical structures; (2)
has been imaged; if more anterior structures are visualized, establishment of the presence or absence of suspected
such as the colon or inferior vena cava, the probe should be findings; (3) generation of an ultrasonographic differential
angled more posteriorly to ensure that a small pleural effu- diagnosis; (4) progression to further scanning if needed,
sion has not been missed.40 The probe is held still while the including utilization of other point of care applications
patient performs a deep inspiration-expiration to assess for (e.g., focused cardiac ultrasound, vascular ultrasound, dia-
descent of the lung. If a pleural effusion or consolidation is phragmatic and abdominal ultrasound) (table 1, I-AIM
identified, the probe is swept in a posterior to anterior direc- framework for lung ultrasound: Interpretation; fig. 2).
tion and moved cranially to assess its full extent (Supple- Image quality should be maximized by attention to
mental Digital Content 3, http://links.lww.com/ALN/B518 machine settings, probe location and angulation, inclusion
and Supplemental Digital Content 4, http://links.lww.com/ of appropriate anatomical structures, and recording of an
ALN/B519). A detailed stepwise approach to scanning the optimal video length. Images of inadequate quality may
lung at the anterior chest wall and posterior and supradia- not be amenable to interpretation. For instance, nonper-
phragmatic regions of the lung is given in table 1. pendicular probe orientation may artificially display the
pleural line as fragmented and nonhomogenous and/or fail
Protocol to demonstrate the expected artifact pattern (Supplemental
A complete lung exam will insonate the anterior, lateral, Digital Content 2, http://links.lww.com/ALN/B514).
and posterior surfaces of the lung bilaterally from the Confirmation that relevant anatomical structures are
anterior and lateral chest walls. The most commonly used present is also essential for accurate image interpretation. For
protocols are an eight-zone protocol (four chest areas per instance, imaging the lower posterior lung without includ-
side based on a division of each hemithorax into anterior/ ing the spine may miss a small pleural effusion because the
lateral and upper/lower zones) and a twelve-zone proto- beam has not reached the most dependent region of the
col (six chest areas per side, based on a division of each lung40 (Supplemental Digital Content 4, http://links.lww.
hemithorax into anterior/lateral/posterior and upper/lower com/ALN/B519). Likewise, an image at the anterior chest
zones—anterior chest identified by anterior axillary line; wall that does not include two ribs flanking the pleural line
lateral chest by anterior axillary line and posterior axillary may result in mistaking the hyperechoic line of the rib as
line; posterior chest by posterior axillary line and spine— the pleural line and falsely diagnosing a pneumothorax due
not including scapular area).2,27 In emergency situations, to the absence of movement (table 1, I-AIM framework for
however, the lung exam may be abbreviated to rapidly diag- lung ultrasound: Acquisition).
nose or exclude life-threatening acutely intervenable causes Regardless of the likelihood of the diagnostic hypothesis,
of respiratory failure (one anterior chest zone to evaluate interpretation of lung ultrasound findings should proceed in
for pneumothorax and interstitial syndrome, a lateral zone an organized fashion. Our approach begins with an assess-
for interstitial syndrome, and one lower posterior site to ment of the pleural line interface (fig. 2). This interface repre-
evaluate for hemothorax and massive effusion; fig. 1).2,6 sents the boundary between the intercostal muscles/parietal
The lung is a dynamic organ; therefore, images ideally are pleura and the visceral pleura/most superficial alveolar units
captured as videos of at least one to two respiratory and several and is a key branch point in the discovery of the most likely
cardiac cycles in length. Occasionally a breath-hold (e.g., to diagnoses (Supplemental Digital Content 2, http://links.
assess lung pulse) or a deep breathing maneuver (e.g., to assess lww.com/ALN/B514). It appears on lung ultrasound as: (1)
the curtain sign), would aid the accuracy of the exam (table 2). fluid interface between parietal and visceral pleura; (2) A-line
Attention to the respiratory and cardiac cycles as opposed to artifact pattern (aerated lung or air in the pleural space); (3)
absolute duration ensures that severely bradypneic/apneic or increased lung density, ranging from a B-line artifact pattern
bradycardic patients will not be misdiagnosed with a pneumo- to a solid interface (increased lung weight or decreased lung
thorax. In bradypnea/apnea there may be little, or complete aeration due to deflation or collapse).
lack of, lung sliding while in bradycardia the lung pulse may be The finding at the pleural line interface provides
missed, thereby falsely raising suspicion for a pneumothorax. immediate feedback on the accuracy of the pretest

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 EDUCATION

Fig. 1. Eight-zone and twelve-zone lung ultrasound protocol. AL = anterior left; AR = anterior right; LL = lateral left; LR = lateral
right; PBL = postero-basal left; PBR = postero-basal right. Images adapted with permission from the Department of Anesthesia,
University Health Network, Toronto, Canada (http://pie.med.utoronto.ca/POCUS).

hypothesis and refines the differential diagnosis depend- or absence of vertical artifacts. In the absence of both
ing on the specific pattern (fig. 2). Fluid beneath the movements and artifacts, pneumothorax is highly likely,
pleural line usually represents a pleural effusion. Ultra- with the caveat that certain lung conditions (e.g., severe
sound is limited in further differentiating the type of chronic obstructive pulmonary disease, bullous disease,
fluid (except when mobile echoic particles or septa are lung overdistension) can create a similar sonographic
identified),2 but it can provide an estimate of effusion pattern (Supplemental Digital Content 1, http://links.
size41(Supplemental Digital Content 3, http://links. lww.com/ALN/B515). When lung motion is present at
lww.com/ALN/B518; Supplemental Digital Content 4, the pleural line, an A-line pattern represents normal lung
http://links.lww.com/ALN/B519). An A-line pattern is density and the differential is focused on pathologies
further categorized by the presence or absence of lung not necessarily visible on lung ultrasound (e.g., patholo-
movements (lung sliding and/or pulse) and the presence gies not reaching the pleural line, pulmonary vascular

Anesthesiology 2017; 127:568-82 575 Kruisselbrink et al.

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 I-AIM Framework for Lung Ultrasound

Fig. 2. Clinical application of the I-AIM framework for lung ultrasound. ABG = arterial blood gas; ARDS = acute respiratory dis-
tress syndrome; COPD = chronic obstructive pulmonary disease; ECG = electrocardiogram; ILDs = interstitial lung diseases;
LUS = lung ultrasound; PEEP = positive end-expiratory pressure; PTX = pneumothorax.

diseases, effect of high positive end-expiratory pressure). line abnormalities)2,17,43 and by the clinical context
Increased lung density on lung ultrasound can be con- (table 3; Supplemental Digital Content 6, http://links.
sidered as a continuum of sonographic findings, from a lww.com/ALN/B516; Supplemental Digital Content 7,
progressively more severe interstitial syndrome (B-line http://links.lww.com/ALN/B517).44
patterns, see table 2) to a consolidated appearance of the Before proceeding, two caveats should be mentioned.
lung parenchyma.42 The extensive differential diagnosis Complete lung ultrasound requires images at multiple
can be narrowed by specific sonographic findings (e.g., locations on the chest wall. A given image is reflective
diffuse vs. focal pattern, B-lines distribution—gravity of the pathology at that specific location and is not
dependent or independent, changes in characteristics of necessarily representative of the entire organ. Further,
lung sliding and pulse, presence of pleural and subpleural multiple pleural line interface patterns may be observed

Anesthesiology 2017; 127:568-82 576 Kruisselbrink et al.

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 Table 3. Lung Pathologies and Associated Sonographic Findings

Lung A-Lines B-Lines / Vertical Pattern of Pleural Line

Condition Sliding Lung Pulse Pattern Artifacts Consolidation(s) ­Distribution ­Characteristics Other(s) Videos
EDUCATION

Normal lung Present Present Present Absent Absent Bilateral and homog- Thin, homogenous - Supplemental Digital
(Rare B-lines pos- enous appearance Content 2, http://links.
sible in dependent lww.com/ALN/B514
areas)
Bullous diseases Reduced/ Reduced/ Present Possible in the Focal or diffuse May appear thick and - Supplemental Digital
Absent Absent con­text of focal irregular Content 2, http://links.
increased lung lww.com/ALN/B514

Anesthesiology 2017; 127:568-82

density
Lung hyper- Reduced/ Reduced/ Present More prominent in Thin, homogenous - -
inflation (Absent)* (Absent) nondependent zones appearance
Pneumothorax Absent Absent Present Absent Absent Unilateral (bilateral Visceral pleural not Lung point Supplemental Digital
rare) visible Content 1, http://links.
lww.com/ALN/B515
Asthma/COPD Present Present Present Absent, unless Absent, unless associ- Bilateral Thin, homogenous - -
Exacerbation (Reduced) (Reduced) associated infec- ated infection/atelec- appearance
tion/atelectasis tasis
Pulmonary Present Present Present Absent, unless Absent, unless pulmo- Bilateral or unilateral Pleural line may be - Supplemental Digital
embolism (± evolving pulmonary nary infarct(s) present “interrupted” by small Content 7, http://links.
­pulmonary infarct(s) (small, peripheral peripheral consolida- lww.com/ALN/B517
infarcts) consolidations) tions
Cardiogenic Present Present/ Usually Present Possible in depend- Bilateral and Thin, homogenous - Supplemental Digital

577
(hydrostatic) Increased abolished (B1 or B2 pattern) ent areas (especially homogenous: appearance Content 6, http://links.
­pulmonary Regularly spaced if associated pleural gravity-dependent lww.com/ALN/B516
edema effusion) gradient pattern

Non-hydrostatic Present Present/ Preserved Present Present (mostly in Bilateral and hetero- Pleural line abnormal- - Supplemental Digital
pulmonary (often Increased in some (B1 or B2 pattern) dependent areas) geneous (“spared” ities (thick, fragmented Content 6-8, http://
edema (e.g., reduced) areas Irregularly spaced areas) with small peripheral links.lww.com/ALN/
ARDS) Non-gravity-­ consolidations) B516, http://links.
dependent pattern lww.com/ALN/B517,
http://links.lww.com/
ALN/B520
Idiopathic Present Present/ Preserved Present Not typically present Bilateral but not nec- Pleural line abnormali- - Supplemental Digital
­interstitial (Reduced) Increased in some Irregularly spaced essarily homogenous ties (thick, fragmented Content 6, http://links.
pneumonias and areas distribution (disease- with small peripheral lww.com/ALN/B516
other interstitial specific) consolidations)
lung diseases
(ILDs)
Alveolar hemor- Present Present/ Preserved Usually present Can be present Bilateral, more homo- In inflammatory - Supplemental Digital
rhage/alveolar (Reduced) Increased in some (B1 or B2 pattern) geneous than ARDS processes, pleural line Content 6, http://links.
proteinosis/dif- areas (if not abnormalities (thick, lww.com/ALN/B516
fuse pneumonitis diffuse) fragmented with small
peripheral consolida-
tions)

Kruisselbrink et al.
(Continued)

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 Table 3. (Continued)

Lung A-Lines B-Lines / Vertical Pattern of Pleural Line

Condition Sliding Lung Pulse Pattern Artifacts Consolidation(s) ­Distribution ­Characteristics Other(s) Videos
Focal infection/ Reduced/ Present/ Absent in It can present as irregularly spaced B-lines Focal (or multifocal) If vertical artifacts Often presence Supplemental Digital
inflammation (Absent) Increased affected pattern (initial or resolution phase, or inter- present, usually asso- of dynamic Content 6 and 7,

Anesthesiology 2017; 127:568-82

(e.g., pneumonia, area stitial pneumonia) or as large consolidation ciated with pleural line air broncho- http://links.
aspiration pneu- (with irregular margins) abnormalities (thick, grams or fluid lww.com/ALN/B516,
monitis) fragmented with small bronchograms http://links.
peripheral consolida- Sonographic lww.com/ALN/B517
tions) findings only
evident if lesion
reaching pleural
line
Atelectasis Reduced/ Present/ Present Initially absent, Initially absent, then Usually focal (often Thin, homogenous Absence of Supplemental Digital
(absorption or Absent (if Increased in initial then present with present with increased dependent areas) appearance dynamic air Content 7, http://links.
compression) obstruction phases, increased lung lung density (more bronchograms lww.com/ALN/B517
present) then density regular borders com- (in absorption
absent with pared to pneumonia) atelectasis)
increased

578
lung density
Pulmonary con- Present Present/ Absent in It can present as irregularly spaced Focal (or multifocal) If vertical artifacts - Supplemental Digital
tusion (Reduced) Increased affected B-lines pattern (initial or resolution phase) present, usually asso- Content 7, http://links.
area or as consolidation (peak evolution) ciated with pleural line lww.com/ALN/B517
abnormalities (thick,
fragmented with small
peripheral consolida-
tions)
Primary Present Present/ Absent in Vertical artifacts If peripheral lesion, Focal If vertical artifacts Sonographic Supplemental Digital
lung cancer/ Increased affected often present at detection of consoli- present, usually asso- findings only Content 7, http://links.
tumor or metas- area the periphery of dation-like area ciated with pleural line evident if lesion lww.com/ALN/B517
tasis the lesion abnormalities, (thick reaching pleural
and fragmented) line
*The terms in parentheses in columns 2 and 3 indicate that the finding described can be observed but occurs less often.
I-AIM Framework for Lung Ultrasound

Kruisselbrink et al.

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 EDUCATION

within the same lung. A patient in respiratory distress confirmed in another view or ordering a different test,
following chest trauma, for example, may have an A-line if appropriate) while negative results do not necessarily
pattern in the anterior lung zones (normal lung or pneu- definitively exclude the diagnosis in question.25 Further,
mothorax), a B-line pattern in the lateral zones (area of when a sonographic diagnosis is made in a patient with a
contused lung), and fluid in the lower posterior zones low pretest probability of that disease, a more advanced
(hemothorax). test should be considered for confirmation.
Finally, the clinical context should remain the primary
Medical Decision-making determinant of patient management. A small pneumo-
Point of care lung ultrasound must be performed and thorax may require intervention if the patient requires
interpreted within a clinical context, defined by the general anesthesia and mechanical ventilation for a surgi-
cal procedure, whereas a large pleural effusion may not
history, physical exam, and other standard radiologic
require drainage in a patient requiring minimal respiratory
and laboratory testing. The clinical context informs
support.
physicians’ initial hypothesis regarding the diagnosis,
which determines the pretest probability of a finding16
(table 1, I-AIM framework for lung ultrasound: Medical Three Patients with Dyspnea
Decision-making). Now, you can return to the three patients with dyspnea and
Lung ultrasound is only one piece of the diagnostic puz- use lung ultrasound as part of their clinical work-up, apply-
zle and will have one of four possible effects on the pretest ing the I-AIM framework.
diagnostic hypothesis: Case 1: Lung ultrasound revealed the absence of lung
sliding, lung pulse, and vertical artifacts on the anterior left
(1) Lung ultrasound findings may corroborate and sup- hemithorax. A lung point also was identified more laterally.
port (e.g., patient with chest trauma; pretest hypoth- Left pneumothorax was therefore diagnosed and a chest tube
esis is pneumothorax; lung ultrasound reveals no inserted preoperatively (fig. 3, A and B; Supplemental Digi-
sliding, no pulse and presence of a lung point. Lung tal Content 1, http://links.lww.com/ALN/B515).
ultrasound supports the high pretest probability of Case 2: Lung ultrasound revealed a large right pleu-
pneumothorax); ral effusion that was drained under ultrasound guidance;
(2) Lung ultrasound findings may mislead (e.g., elderly no pneumothorax was detected. Intubation was averted
patient with fever and dyspnea; pretest hypothesis (fig. 3C; Supplemental Digital Content 3, http://links.lww.
is pneumonia; lung ultrasound findings are consis- com/ALN/B518; Supplemental Digital Content 4, http://
tent with the appearance of normal lungs. In reality, links.lww.com/ALN/B519).
the computed tomography scan of the chest shows Case 3: Lung ultrasound revealed multiple bilateral
a large consolidation. Lung ultrasound is misleading B-lines. A subsequent focused cardiac ultrasound showed
due to its inability to detect consolidation that has hypertrophic cardiomyopathy and the diagnosis of cardiac
not reached the pleural line, giving the false impres- asthma secondary to heart failure with preserved ejection
sion that respiratory pathology is absent)25,26; fraction was made (fig. 3D; Supplemental Digital Content
(3) Lung ultrasound findings may be inconsequential, 6, http://links.lww.com/ALN/B516).
not supporting but not changing the hypothesis/
plan (e.g., ICU patient; pretest hypothesis of acute Conclusions
respiratory distress syndrome; lung ultrasound In conclusion, we present the application of the I-AIM
reveals diffuse B-line pattern and mild to mod- framework to a specific point of care ultrasound exam. As
erate pleural effusion. Lung ultrasound findings has been demonstrated in other applications, the I-AIM
not completely specific for acute respiratory dis- framework is intuitive, structured, and generalizable. There
tress syndrome but also unlikely to change clinical are some limitations to the model with respect to adequate
management); validation of the design, identification of benefits and risks,
(4) Lung ultrasound findings may completely change and its dependency on the English language. Nevertheless,
the pretest diagnosis (e.g., patient in the emergency we believe it has practical bedside potential as the adoption
department with wheezing; pretest hypothesis is of point of care ultrasound becomes more widespread.
asthma exacerbation; lung ultrasound reveals diffuse
B-line pattern bilaterally suggesting alternative diag- Acknowledgments
nosis of pulmonary edema). The authors acknowledge Jean YiChun Lin, M.Sc.B.M.C.,
It is apparent from the above examples that lung ultra- Gordon Tait, Ph.D., and Massimiliano Meineri, M.D., from
the Toronto General Hospital Department of Anesthe-
sound, like other diagnostic tests, can lead to false sia Perioperative Interactive Education (http://pie.med.­
positive or false negative results. Therefore, positive utoronto.ca/index.htm), Department of Anesthesia, Uni-
results should always be confirmed before reacting (e.g., versity Health Network and University of Toronto, Toronto,

Anesthesiology 2017; 127:568-82 579 Kruisselbrink et al.

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 I-AIM Framework for Lung Ultrasound

Fig. 3. Still images of lung ultrasound findings in the context of case 1, pneumothorax: (A) normal pleural line, presence of A lines, ab-
sence of vertical artifacts; (B) lung point (red arrow; see also Supplemental Digital Content 1, http://links.lww.com/ALN/B515); case 2,
pleural effusion: (C) anechoic fluid collection between parietal and visceral pleural, positive spine sign present (see also Supplemen-
tal Digital Content 3, http://links.lww.com/ALN/B518, and 4, http://links.lww.com/ALN/B519); case 3, interstitial syndrome: (D) more
than three B lines present in a single intercostal space (see also Supplemental Digital Content 6, http://links.lww.com/ALN/B516).

Canada, and Emanuele Pivetta, M.D., M.Sc., from the Cancer anesthesiology.org or on the masthead page at the begin-
Epidemiology Unit, Department of Medical Sciences, Uni- ning of this issue. ANESTHESIOLOGY’s articles are made freely
versity of Turin, and the Division of Emergency Medicine accessible to all readers, for personal use only, 6 months
and High Dependency Unit, AOU Cittá della Salute e della from the cover date of the issue.
Scienza, Turin, Italy, for the generous sharing of their edu-
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ANESTHESIOLOGY REFLECTIONS FROM THE WOOD LIBRARY-MUSEUM

George J. Brett, D.D.S., Copyrights His Brettometer Index of

Analgesia and Anesthesia

In January of 1928, George J. Brett, D.D.S. (1896 to 1969), received a copyright for his “Brettometer Index” from
the U.S. Copyright Office. Mounted on his namesake Brettometer anesthesia machine, the index was designed
to assist dentists and physicians in delivering nitrous oxide and oxygen through “Stages I–IV” of anesthetic depth.
According to Dr. Brett’s index, increasing the ratio of nitrous oxide to oxygen generally led to breathing changes:
respirations increased slightly (stage I), quickened (II), regularized progressively toward a mechanical rhythm (III)
and, if carried too far, became dangerously “spasmatic” (IV). On his unpremedicated patients, the Brettometer
Index suggested that patient’s pupils dilated in stages I and II, constricted (III) and, if carried too far, finally dilated
again (IV). Notice that Brett’s index presumed that men would need to be carried under greater inspired nitrous
oxide concentration (hence lower oxygen) than would women and children! (Copyright © the American Society of
Anesthesiologists’ Wood Library-Museum of Anesthesiology.)
George S. Bause, M.D., M.P.H., Honorary Curator and Laureate of the History of Anesthesia, Wood Library-
Museum of Anesthesiology, Schaumburg, Illinois, and Clinical Associate Professor, Case Western Reserve
­University, Cleveland, Ohio. UJYC@aol.com.

Anesthesiology 2017; 127:568-82 582 Kruisselbrink et al.

Copyright © 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.