Lung Ultrasound

F u n d a m e n t a l s , “ We t Ver s u s
Dry” Lung, Signs of Consolidation
in Dogs and Cats
Gregory R. Lisciandro, DVM, DABVP, DACVECCa,*,
Stephanie C. Lisciandro, DVM, DACVIM (SAIM)a,b

KEYWORDS
 Lung ultrasound  B-lines  Shred sign  B-line scoring system

KEY POINTS
 Vet BLUE is a standardized regional, pattern-based lung ultrasound examination with
exact clarity to its 8 transthoracic views plus the Diaphragmatico-Hepatic View.
 Dry lung artifacts are expected all Vet BLUE acoustic windows with uncommon single
B-lines.
 Wet lung may be scored using the Vet BLUE B-line scoring system of 1, 2, 3 as weak pos-
itives and greater than 3, and infinity (N) as strong positives.
 Dry lung in all views rules out all common wet lung conditions including cardiogenic and
noncardiogenic lung edema, pneumonia, lung hemorrhage, and lung contusions.
 Consolidation is categorized as Shred Sign (air bronchogram), Tissue Sign, (hepatization),
Nodule Sign (nodular diseases), and Wedge Sign (pulmonary thromboembolism).
 8 discreet regional transthoracic views and a pattern-based approach may be used
 to formulate a working diagnosis in patients with suspected respiratory compromise in
less than 2 min
 as a tool to serially track (improvement, deterioration, static) respiratory patients in less
than 2 min
 plus the use of the Diaphragmatico-Hepatic view for lung surface along the pulmonary-
diaphragmatic interface inaccessible from transthoracic views.
 Using its transthoracic views bilaterally, pneumothorax and the location of the lung point is
searched for automatically.

a
Hill Country Veterinary Specialists and FASTVet.com, Spicewood, TX, USA; b Oncura Partners,
Fort Worth, TX, USA
* Corresponding author.
E-mail address: FastSavesLives@gmail.com

Vet Clin Small Anim 51 (2021) 1125–1140

https://doi.org/10.1016/j.cvsm.2021.07.012 vetsmall.theclinics.com
0195-5616/21/ª 2021 Elsevier Inc. All rights reserved.
1126 Lisciandro & Lisciandro

Video content accompanies this article at http://www.vetsmall.theclinics.com

INTRODUCTION

In 2004, the first translational study of focused assessment with sonography for
trauma (FAST) from humans to small animals documented that minimally trained non-
radiologist veterinarians could proficiently recognize ascites, and that hemoperito-
neum was far more common than previously reported.1 Moreover, pleural and
pericardial effusion could be detected via the subxiphoid view by looking cranial to
the diaphragm and lung abnormalities during TFAST at the Chest Tube Site
view.1,2,3,4 As a result, Vet BLUE was created in 2010 as a more comprehensive
screening test and has been evaluated in clinically normal adult dogs, adult cats,
and puppies and kittens aged over 6 weeks.5,6,7,8
Vet BLUE is unique in that its regional views were developed to mimic the manner in
which most veterinarians interpret lung findings on thoracic radiography helping to
rapidly and in real-time develop a working differential list for respiratory small
animals.5,9,10,11,12 Moreover, Vet BLUE has its B-line scoring system and its visual
lung language that are “all or none” ultrasonographic phenomenon, meaning its find-
ings are either present or they are not.5,6,7,8,9,10,11,12 In comparative imaging studies,
Vet BLUE and lung ultrasound have been shown to exceed the sensitivity of thoracic
radiography and fare favorably with computed tomography (CT) for various respiratory
conditions.13,14,15,16,17 The use of lung ultrasound has clear visual advantages over the
subjective nature of lung auscultation and is rapidly becoming the screening test and
monitoring tool of choice for pneumonia and congestive heart failure in human med-
icine and small animals.18,19,20,21,22,23,24,25,26,27,28,29 The time is here—the ultrasound
probe is our new stethoscope!18,19,30,31
Although Vet BLUE may be used as a standalone ultrasound examination, through
the standardized approach of Global FAST, sonographers avoid common imaging
mistakes such as “satisfaction of search error” and “confirmation bias error” through
selective POCUS imaging. As an example, Vet BLUE may show dry lung in all views
with thoracic radiography being unremarkable, and the patient being sent home
with a conservative plan for upper airway disease or occult lower airway disease (ie,
bronchial disease). However, by incorporating the Global FAST approach that in-
cludes TFAST echocardiography, the patient is found to have left ventricular enlarge-
ment and poor contractility with a working diagnosis of dilated cardiomyopathy
confirmed with complete echocardiography thereafter. The thoracic radiograph was
interpreted as unremarkable. This is one of many examples of how integrating Global
FAST information leads to a more accurate diagnosis with similar strategies being
advocated for human medicine.32,33,34

VET BLUE OVERVIEW

Gator Sign Orientation
The fundamental orientation for all lung ultrasound is the Gator Sign.5,6 The Gator Sign
is composed of 2 ribs with its interposing intercostal space (ICS) much like a partially
submerged alligator peering at the sonographer (Fig. 1) (Videos 1–3). The interposing
ICS is where the lung surface is expected to be immediately against the thoracic wall.
We refer to this as the “Lung Line” over the parietal and visceral pleura interface
because when pleural space abnormalities exist, the “Lung Line” better describes
the location of the lung surface.9 Without the Gator Sign orientation, it becomes
easy to mistake fascial planes, flat bones, air reverberation artifact for the “Lung
Line,” and thus errors in interpretation will occur.9 In instances where the probe is
 Lung Ultrasound Fundamentals 1127

Fig. 1. The gator sign orientation is the fundamental orientation for all lung ultrasounds.
Without it, the sonographer cannot be certain they are identifying the correct bright white
line (hyperechoic line) representing the lung surface, which we refer to as the lung line. In
(A), the scanning plane is perpendicular to the long axis of the ribs to create the gator sign
appearance of rib, intercostal space, and rib, like an eye, bridge of the nose or forehead,
and eye. In (B) is the schematic showing that lung sliding (arrows) is created by visceral
and parietal pleural on a micro level sliding over one another or on a macro level the
lung sliding over the intercostal space compared to C) with the correlative B-mode ultra-
sound still image. This is a real-time phenomenon and cannot be shown on still images.
A-lines are maximized when the angle of insonation is at 90 to the aerated and thus reflec-
tive lung line. (ª 2021 Gregory R. Lisciandro.)

rotated from longitudinal to transverse orientation along the lung surface, the Gator
Sign should be periodically checked, making sure that the “Lung Line” is being prop-
erly followed.9

Curtain Sign
Air reflects ultrasound and borders of aerated structures cast a linear border at mar-
gins of the respective aerated structure. This linear air-associated border is likened to
a curtain covering and uncovering the structures in that immediate area (Video 4 and
5). “Curtain Sign” was first used to describe the curtain sign of pleural effusion.35 How-
ever, with lung ultrasound, the “Curtain Sign” similarly covers and uncovers the tran-
sition zone between the pleural and abdominal cavities (Fig. 2).9,36

Vet BLUE Standardized Methodology—Names, Views, Order, and Probe

Maneuvering
Vet BLUE has bilaterally applied transthoracic views named Caudodorsal, Perihilar,
Middle, and Cranial Lung Regions plus the Diaphragmatico-Hepatic (DH) view,
providing a deeper acoustic window along the pulmonary-diaphragmatic interface
inaccessible from transthoracic views with the updated methodology described
here (Fig. 3).9,37 The Caudodorsal view is located by identifying the “Curtain Sign”,
the “Transition Zone” between the pleural and abdominal cavities, and then sliding
3 ICSs cranially away from the abdominal cavity. This is the starting point for the Cau-
dodorsal view and referred to as its “primary” ICS. From this primary ICS, slide
1128 Lisciandro & Lisciandro

Fig. 2. The curtain sign is a term originally applied to the curtain sign of pleural effusion.
However, it is a basic principle. When air moves over any structures, it has a linear border.
In the thorax, the curtain sign created by air-filled lung, covers and uncovers the adjacent
regions because of the movement during phases of respiration. In (A), (B), and (D), that
linear border is shown with overlays and shows the curtain sign transition zone of the
pleural and abdominal cavities. The arrows in (D) represent the sliding to and fro of the cur-
tain sign with phases of respiration. In (C) is a picture of window curtain to emphasize the
curtain sign. The importance in recognizing this area during Vet BLUE is to not mistake
abdominal structures for pulmonary or other intrathoracic pathology. Note that the head
is to the left of the screen and the tail to the right so that abdominal structures are always
expected to enter the view from the right. (ª 2021 Gregory R. Lisciandro.)

caudally one ICS, return to the primary ICS, and then slide cranially for a third ICS
(Video 6). Each Vet BLUE regional view surveys a minimum of 3 ICSs at that respective
regional view. Sliding caudally first from the primary ICS should be made a habit
because the question is asked, “where is the abdominal cavity?” In haste and with
improper training, the stomach, liver, and gallbladder are easily mistaken for lung pa-
thology such as pseudo B-lines, pseudo shred sign, and pseudo tissue sign (Video 4
and 5).9 By understanding the “Curtain Sign” of the “Transition Zone,” the sonogra-
pher is better able to differentiate the pleural from abdominal cavities at the Caudodor-
sal, Perihilar, and Middle Lung Regional views.
The Perihilar view is next imaged by drawing a line, called “the Vet BLUE Line,” with
acoustic coupling medium from the primary ICS of the Caudodorsal view to the pa-
tient’s elbow. Approximately halfway to the elbow is the Perihilar Lung Region view.
The same methodology of evaluating an ICS cranial and caudal to this site is repeated.
Slide caudally first and ask, “where is the abdominal cavity (and is the curtain sign
identified)?” Then, return to the primary ICS, and then slide cranially for the minimum
 Lung Ultrasound Fundamentals 1129

Fig. 3. The Vet BLUE shown on a standing dog with external anatomy in (A) and (B) and
then overlays in (C) and (D). The lung regions are named as caudodorsal, perihilar, middle,
and cranial. The caudodorsal view is located by finding the transition zone, curtain sign, and
sliding 3 intercostal spaces cranially away from the abdominal structures. At each respective
view, a minimum of 3 intercostals spaces are surveyed by sliding first caudally and then
cranially (numbers and arrows). The cranial lung region is found by flexing and abducting
the foreleg so that the probe may be placed in the axillary area over the thoracic inlet
and then the first 3 ribs. The DH view is part of Vet BLUE because it provides a window
of the lung along its pulmonary-diaphragmatic interface that is not accessible via transtho-
racic views. (ª 2021 Gregory R. Lisciandro.)

of 3 ICSs (Video 6). Moving on to the Middle Lung Region, slide ventral over heart
along “the Vet BLUE Line” to the elbow. Slide dorsally to eliminate the heart from
view and identify the Gator Sign orientation. Then slide caudally from the primary
ICS, back to the primary Middle Lung Region ICS, and then cranially as the previous
2 regional views. In many small animals and exotic companion mammals, you may be
at the “Curtain Sign” of the “Transition Zone” at the start of the Middle Lung Region. In
these cases, slide over the first 3 ICSs as you move cranially away from the “Curtain
Sign” and count those IVCs as the middle lung region. Even though the sonographer
slides 3 ICSs from the caudodorsal “Transition Zone” and follows “the Vet BLUE Line,”
the respirophasic dynamics of the Caudodorsal, Perihilar, and Middle lung regions
often still bring the abdominal structures into the field of view.
The final transthoracic view is the Cranial Lung Region performed by gently flexing
the foreleg and working the probe dorsal and cranially into the patient’s axilla heading
for the middle of the first rib. The “Transition Zone” is now to the left of the screen and
is the transition between the lung within the pleural cavity and the thoracic inlet. The
1130 Lisciandro & Lisciandro

thoracic inlet is best recognized by the pulsating of the Costocervical trunk and carotid
arteries. The probe is then slid caudally over Gator Sign orientations of the first rib, first
ICS, second rib, second ICS, and third rib, third ICS (Video 7). Of note, the cupula of
the lung in some small animals extends cranially to the first rib and in the author’s
experience, the first ICS is much smaller than the subsequent ICSs. The author prefers
to start with the left Vet BLUE and then move to the DH view, before completing the
Vet BLUE examination on the right side.
The advantages here are that the TFAST right Pericardial Site echocardiography
views, generally the most time-consuming and most challenging for many sonogra-
phers, are left for last when doing TFAST and Vet BLUE simultaneously. Moreover,
much information has been already gained with this recommended order of Vet
BLUE and Global FAST. The Global FAST Fallback Views of Vet BLUE/lung, the
AFAST-TFAST DH view, and the characterization of the caudal vena cava and he-
patic veins have already been assessed. Thus, the sonographer advantageously
knows if there is wet versus dry lung, if there are abnormalities with the caudal
vena cava and hepatic veins, and if there is pericardial and pleural effusion (or
pneumothorax) before performing the TFAST echocardiography views. Further-
more, the sonographer has a better idea of safe degrees of physical and chemical
restraint.

Pitfalls and Limitations

Vet BLUE B-line scoring system
The Vet BLUE B-line scoring system takes the highest number over a single ICS at
each of its 9 regional acoustic windows (views), a scoring system published with
our original studies.6,7,10,38 The B-lines scoring is as follows: 0 (no B-lines), 1 (single
B-line), 2 (2 B-lines), 3 (3 B-lines), greater than 3 (more than 3 B-lines, however, not
confluent over an entire ICS), and infinity (confluent over an entire ICS) (Videos 8

Fig. 4. The Vet BLUE B-line scoring system is performed by taking the highest number of
B-lines over a single intercostal space at each respective Vet BLUE view. The scoring is
0 for no B-lines (dry lung). The wet lung scores are 1, single B-line, 2, 2 B-lines, 3, 3 B-lines,
greater than 3, more than 3 B-lines but not confluent, and infinite, B-lines that are
confluent over the entire intercostal space. Scores of 1 to 3 are considered weak positives
and those of greater than 3 and infinite as strong positives. (ª 2021 Gregory R. Lisciandro.)
 Lung Ultrasound Fundamentals 1131

and 9).6,7,10,38 These may be further broken down into weak (1–3) and strong (>3 and
infinity) positives, which helps with placing a severity score on each patient through
B-line scoring combined with positive regions (Fig. 4).38
B-lines and pseudo B-lines
B-lines are primarily created by the cuffing of aerated alveoli around fluid or soft tissue.
The echoes enter this reflective chamber and then exit back to the transducer and are
cast through the far field as a tight band of reverberation.38,39 Most commonly B-lines
represent types of alveolar-interstitial edema and when doing so are referred to as
alveolar-interstitial syndrome. The cuffed fluid is most commonly water (cardiogenic
and noncardiogenic pulmonary edema), blood (hemorrhage and contusions), or
exudate pus (pneumonia). However, we have described “pseudo B-lines” created
by aerated alveoli cuffing nodules and air surrounding gastric ingesta (Video 10).38
Lung fibrosis also may be placed in this category because the term “pseudo B-lines”
differentiates “true B-lines” caused by alveolar-interstitial syndrome from these non–
fluid-related causes.38
Vet BLUE Sign of Consolidation
When enough air has been displaced by pulmonary parenchymal disease, the echoes
can penetrate past the pleural margin imaging deep to the lung surface (Lung Line).

Fig. 5. The Vet BLUE Visual Lung Language consists of the following from most normal to
most abnormal lung ultrasound signs as follows: (A) dry lung (A-lines with lung sliding),
(B) B-lines most commonly representing forms of alveolar-interstitial edema, (C) shred
sign representing air bronchograms, (D) tissue sign representing hepatization of lung, (E)
nodule sign, and (F) wedge sign representing pulmonary thromboembolism. (ª 2021 Greg-
ory R. Lisciandro.)
1132 Lisciandro & Lisciandro

Signs of lung consolidation sonographically include the Shred Sign (air bronchogram)
and Tissue Sign (hepatization of lung), terms used in human medicine (Videos 11 and
12).5,38,40 We have added the Nodule Sign and Wedge Sign (Fig. 5).5,15,38,41
The Shred Sign is hallmarked by hyperechoic foci (bright white) within the consoli-
dation with generally irregular borders along its far field. These hyperechoic foci repre-
sent air bronchograms that may be dynamic or static. In dynamic air bronchograms,
air can be seen wisping through the hyperechoic foci (bronchi).42 However, these 2
forms of air bronchograms are often difficult to differentiate in spontaneously breath-
ing patients. As a general rule, static air bronchograms represent atelectasis and dy-
namic air bronchograms represent types of pneumonia.42
The Tissue Sign represents a complete lack of aeration within the consolidated lung.
Thus, the tissue sign appears ultrasonographically hepatized or like the liver.5,35,38 In
fact, it can be difficult to tell the difference between the Tissue Sign of the lung and the
actual liver. This is why we have Vet BLUE sonographers understand and be able to
recognize the “Curtain Sign” at the transitions zones of the Caudodorsal, Perihilar,
and Middle Lung Regions.9,38

Box 1
Differentials for the finding of dry lung all views during Vet BLUE

Differentials for Dry Lung All Views on Vet BLUE

Respiratory
Pneumothorax
Dynamic Upper Airway Conditions (eg, Collapsing Trachea, Laryngeal Paralysis)
Intrathoracic Airway Collapse (eg, Tracheal Collapse, Mainstem Bronchial Collapse, Lobar
Bronchial Collapse, Bronchomalacia)
Upper Airway Obstruction (eg, Mass, Foreign Body, Oropharyngeal Swelling, Inflammation,
Nasopharyngeal Polyp [cats], Granulomatous Laryngitis [cats])
Tracheobronchitis (eg, Infectious, Inflammatory, Irritant)
Inflammatory Lower Airway Disease (Chronic Bronchitis, Asthma [cats], Eosinophilic
Bronchitis [dogs], Bronchiectasis)
Lung Pathology not Located at the Lung Surface at any Vet BLUE view
Cardiac
Pericardial Effusion/Cardiac Tamponade
Cardiac Arrhythmia
Dilated Cardiomyopathy (DCM)
Right-sided Congestive Heart Failure
Pulmonary Vascular Disease
Pulmonary Thromboembolism (PTE)
Pulmonary Hypertension
Undifferentiated Hypotension
Canine Anaphylaxis
Cavitary or Spatial Bleeding (eg, Hemoabdomen, Hemothorax, Hemoretroperitoneum,
Hemopericardium, Fracture Site)
Gastric Dilatation-Volvulus/Bloat
Sepsis
Other Nonrespiratory
Pyrexia/Heat Stroke/High Fever
Severe Metabolic Acidosis
Severe Anemia
Neurologic Disease
Pain

ª 2021 Gregory R. Lisciandro.

 Lung Ultrasound Fundamentals 1133

Fig. 6. Vet BLUE may be used as a monitoring tool dependent on the type of respiratory dis-
ease. However, the concept is that dry lung progresses to wet lung and B-lines that may be
further differentiated by weak vs strong positives followed by signs of consolidation
including shred sign which is less severe than a tissue sign. Nodule sign and wedge sign
represent additional categories of consolidation. By understanding the basic gist of this
schematic, the clinician performing Vet BLUE has a monitoring tool for tracking in a low
impact manner, point-of-care that fares well with other imaging modalities of thoracic radi-
ography and computed tomography. (ª 2021 Gregory R. Lisciandro.)

The Nodule Sign is created by aerated alveoli cuffing soft tissue and is characterized
by a hypoechoic or anechoic oval or circle with a hyperechoic far border and a pseudo
B-lines extending from the far border through the far field (Video 13).5,15,38 Lastly, the
Wedge Sign is an amalgam of the Shred and Tissue Signs and represents lung infarc-
tion.41,43–45 When the Wedge Sign is found in non–gravity-dependent Vet BLUE re-
gions (Caudodorsal and Perihilar), its finding supports the presence of pulmonary
thromboembolism (lung infarction) (Video 14).41 In gravity-dependent regions, the
wedge sign is difficult to differentiate from a Shred Sign and pneumonia.38,41 Note
all the Vet BLUE lung findings may be recognized along the pulmonary-
diaphragmatic interface at the DH view (Video 15).

Vet BLUE Rules Out Wet Lung Conditions

The major strength of Vet BLUE is the finding of dry lung, A-lines with lung sliding, in all
views. Dry lung in all Vet BLUE views effectively rules out in less than 60 seconds all
wet lung conditions (those with B-lines) including cardiogenic and noncardiogenic
pulmonary edema, pneumonia, pulmonary hemorrhage, and contusions
(Box 1).6,7,11,12,14,16,17 In veterinary studies, Vet BLUE has shown its superiority over
1134 Lisciandro & Lisciandro

TXR with favorable comparison to CT for wet lung conditions.13,14,16,17 Vet BLUE pro-
vides evidence-based information of a negative test (dry lung in all views) for the absence
of any clinically relevant wet lung conditions. This is hugely impactful for patient care.
Think about it. In less than 60 seconds, one can rule out acute respiratory distress syn-
drome, transfusion-related lung injury, neurogenic pulmonary edema, pulmonary hemor-
rhage in coagulopathic patients, left-sided congestive heart failure and volume overload,
and aspiration pneumonia; traditionally challenging or time-consuming diagnoses.

Vet BLUE Patient Monitoring

The echelon of lung ultrasound findings ranges from normal lung surface to most
abnormal loosely follows dry lung (A-lungs with lung sliding), wet lung (B-lines), Shred
Sign (air bronchogram), Tissue Sign (hepatization of lung), Nodule Sign, and Wedge
Sign (supportive of PTE) (see Fig. 5). By understanding this, echelon Vet BLUE may
be used for patient monitoring and answering the clinical question in real-time, cage-
side (at the patient’s side)—“Is the patient’s problem static, worsening, or resolving?”
dependent on what respiratory disease the patient has (Fig. 6).

Vet BLUE Lung Metastasis Check

Vet BLUE is hugely impactful as a quick lung metastasis check because by ruling out
obvious pulmonary metastasis makes the client presentation more positive than

Fig. 7. Some examples of Vet BLUE illustrating its regional, pattern-based approach showing
B-lines. Its greatest power may be the finding of dry lung all views as in (A) because all clin-
ically relevant dry lung conditions are ruled out in a matter of 1 to 2 minutes. In (B) and (C),
patterns that are gravity dependent and asymmetrical commonly represent types of pneu-
monia. In (B), you would expect wet lung in the right middle lung region in a dog for classic
aspiration pneumonia. Wet lung in pneumonia could be replaced with signs of consolida-
tion like shred sign and tissue sign. In (D) and (E), patterns are more non–gravity-dependent
or generalized and symmetric commonly supporting the presence of cardiogenic and non-
cardiogenic pulmonary edema. (ª 2021 Gregory R. Lisciandro.)
 Lung Ultrasound Fundamentals 1135

when nodules are found.15,37 Care should be taken to not over-interpret abnormalities
along the lung surface. A true nodule should have a pseudo B-line extending through
the far field (see Fig. 4).9,37,38 From our preliminary studies, true sensitivity and speci-
ficity for Vet BLUE in detecting metastatic nodules is unclear. In one study comparing
Vet BLUE, TXR, and CT, Vet BLUE was found to be similar in sensitivity and specificity
of TXR with CT outperforming Vet BLUE.37 The study design, however, did not have
consistency in imaging order and Vet BLUE was often performed after anesthesia
and CT, confounding interpretation. Moreover, the time interval between imaging mo-
dalities was up to 2 weeks. In a pilot study published as an abstract, Vet BLUE clearly
outperformed TXR.15 At this time, the author’s conclusion would be that Vet BLUE
should be used as a rapid pulmonary metastasis check as part of the initial patient eval-
uation. A negative Vet BLUE examination for nodules should help move the client to a
continued work-up including 3-view TXR and CT when indicated for a more comprehen-
sive evaluation.

Case Examples
Vet BLUE’s unique regional, pattern-based approach helps rapidly develop a working
diagnosis in respiratory suspects and patients. For example, cardiogenic and noncar-
diogenic lung edema will involve upper regional views and generally is symmetric in
contrast to pneumonia that would be more gravity-dependent and asymmetrical. A
dog with classic aspiration pneumonia would be wet or consolidated in the right mid-
dle lung region. Examples are shown (Fig. 7). Differentiating wet lung due to cardio-
genic or noncardiogenic pulmonary edema requires incorporating TFAST
echocardiography views and Global FAST findings. Algorithms may be used for the

Fig. 8. Algorithm for the differential diagnoses of B-lines during Vet BLUE. (ª 2021 Gregory
R. Lisciandro.)
1136 Lisciandro & Lisciandro

Fig. 9. Algorithm for Respiratory Patients Using Vet BLUE Lung Ultrasound Signs. aStep Sign
is a deviation from the linear expectation of the pulmonary-pleural interface and the “Lung
Line.” bIn trauma the Step Sign’s rule out list includes thoracic wall injury (intercostal tear,
rib fracture(s), subcostal hematoma/mass), pleural space disease (diaphragmatic hernia,
mass, heart enlargement). (ª 2021 Gregory R. Lisciandro.)

presence and distribution of B-lines (Fig. 8) and considering all Vet BLUE lung ultra-
sound signs (Fig. 9).38

Vet BLUE as Part of Global FAST for Monitoring Patients and Staging Disease
The Global FAST approach obtains a large amount of clinical information gained by
combining AFAST, TFAST, and Vet BLUE to help better define disease as being local-
ized or disseminated. The assimilation of this information is important for the initial dis-
cussion with clients being that localized staging lends support for a more optimistic
approach with the possibility of patient cure.46 In both localized and disseminated dis-
ease, regions for fluid and tissue sampling may be better defined through Global FAST
over plain radiography. Furthermore, Global FAST serves as a rapid, cost-effective,
monitoring tool providing real-time clinical information for decision-making and guid-
ing therapy.

SUMMARY

Vet BLUE is minimally invasive, low impact, cost-effective, real-time information, that
is rapidly gained point-of-care while being radiation-sparing and goal-directed. The ul-
trasound probe has clear advantages over lung auscultation, allowing the sonogra-
pher to “see” with evidence-based information and record lung pathology specific
to the described Vet BLUE lung regions. The standardized regional, pattern-based
Vet BLUE approach allows clinicians to better direct diagnostic plan and serves as
 Lung Ultrasound Fundamentals 1137

an effective monitoring tool. Vet BLUE’s greatest strength may prove to be in ruling out
wet lung conditions with the finding of dry lung all views, use as a monitoring tool, and
its ability to detect the smallest of lung surface pathologies that are sometimes unclear
on TXR and perhaps not temporally evident on CT. Its major limitation is the require-
ment for lung pathology to be present at the lung surface at one of its acoustic win-
dows and the cranial dorsal thorax is limited by the foreleg and its associated
musculature. Global FAST, which includes Vet BLUE, should be used as an extension
of the physical examination on a daily basis for nearly all patients in the clinical setting
and should preempt add-on POCUS examinations to optimize a correct patient
assessment and prevent imaging interpretation errors.

CLINICS CARE POINTS (VET BLUE)

 Vet BLUE serves as a regional, pattern-based approach to lung ultrasound that
allows for the development of a working diagnosis for respiratory conditions.
 The sonographer should expect absent to rare single B-lines in normalcy in adult
dogs and cats, and puppies and kittens over 6-weeks of age.
 Vet BLUE dry all views effectively rules all out all clinically relevant wet lung con-
ditions in minutes including cardiogenic and non-cardiogenic edema, pneu-
monia, lung hemorrhage, and lung contusions.
 The combination of Vet BLUE and its B-line scoring system and numbers of pos-
itive regional views allows for a severity score for wet lung conditions.
 Vet BLUE serves as a real-time, point-of-care, radiation-sparing and low risk
(minimal restraint) tracking tool for congestive heart failure and all other respira-
tory conditions.

DISCLOSURE

The authors are the owners of FASTVet.com, a private corporation that provides vet-
erinary ultrasound training to practicing veterinarians. Ultrasound companies sponsor
Global FAST Courses and include Oncura Partners, Universal Imaging, EI Medical,
and Sound; and EI Medical and the Veterinary Medical Network have licensed Global
FAST education materials. Stephanie Lisciandro, is a veterinarian and Medical Direc-
tor at Oncura Partners, Fort Worth, Texas. The authors have no funding sources to
declare for this article.

SUPPLEMENTARY DATA

Supplementary data to this article can be found online at https://doi.org/10.1016/j.

cvsm.2021.07.012

REFERENCES

1. Boysen SR, Rozanski EA, Tidwell AS, et al. Evaluation of a focused assessment
with sonography for trauma protocol to detect free abdominal fluid in dogs
involved in motor vehicle accidents. J Am Vet Med Assoc 2004;225(8):1198–204.
2. Lisciandro GR. The use of the diaphragmatico-hepatic (DH) views of the abdom-
inal and thoracic focused assessment with sonography for triage (AFAST/TFAST)
examinations for the detection of pericardial effusion in 24 dogs (2011-2012).
J Vet Emerg Crit Care 2016;26(1):125–31.
3. Lisciandro GR, Lagutchik MS, Mann KA, et al. Evaluation of a thoracic focused
assessment with sonography for trauma (TFAST) protocol to detect
1138 Lisciandro & Lisciandro

pneumothorax and concurrent thoracic injury in 145 traumatized dogs. J Vet

Emerg Crit Care 2008;18(3):258–69.
4. Lisciandro GR. Abdominal and thoracic focused assessment with sonography for
trauma, triage and monitoring in small animals. J Vet Emerg Crit Care 2011;21(2):
104–22.
5. Lisciandro GR. Chapter 10: The Vet BLUE Lung Scan. In: Lisciandro GR, editor.
Focused ultrasound techniques for the small animal practitioner. Ames IA: Wiley
Blackwell; 2014.
6. Lisciandro GR, Fulton RM, Fosgate GT, et al. Frequency of B-lines using a
regionally-based lung ultrasound examination (the Vet BLUE proto Lisciandro
GR, Fosgate GT, Fulton RM. Frequency of ultrasound lung rockets using a
regionally-based lung ultrasound examination named veterinary bedside lung ul-
trasound exam (Vet BLUE) in 98 dogs with normal thoracic radiographic lung
findings. Vet Radiol Ultrasound 2014;55(3):315–22.
7. Lisciandro GR, Fulton RM, Fosgate GT, et al. Frequency of B-lines using a
regionally-based lung ultrasound examination (the Vet BLUE protocol) in 49
cats with normal thoracic radiographical lung findings. J Vet Emerg Crit Care
2017;27(3):267–77.
8. Lisciandro GR, Romero L, Fosgate GT. The frequency of B-lines and other lung
ultrasound artifacts during Vet BLUE in 91 healthy puppies and kittens. Abstract.
J Vet Emerg Crit Care 2018;28(S1):S16.
9. Lisciandro GR, Lisciandro SC. Chapter 22: POCUS: Vet BLUE-introduction and
image acquisition. In: Lisciandro GR, editor. Point-of-care ultrasound techniques
for the small animal practitioner. 2nd edition. Ames IA: Wiley Blackwell; 2021.
p. 425–58.
10. Ward JL, Lisciandro GR, Keene BW, et al. Accuracy of point-of-care lung ultraso-
nography for the diagnosis of cardiogenic pulmonary edema in dogs and cats
with acute dyspnea. J Am Vet Med Assoc 2017;250:666–75.
11. Ward JL, Lisciandro GR, Ware WA, et al. Lung ultrasound findings in 100 dogs
with various etiologies of cough. J Am Vet Med Assoc 2019;255(5):574–83.
12. Lisciandro GR, Ward JL, DeFrancesco TC, et al. Absence of B-lines on lung ul-
trasound (Vet BLUE protocol) to rule out left-sided congestive heart failure in
368 cats and dogs. Abstract. J Vet Emerg Crit Care 2016;26(S1):S8.
13. Ward JL, Lisciandro GR, DeFrancesco TD. Distribution of alveolar-interstitial syn-
drome in dogs and cats with respiratory distress assessed with lung ultrasound
versus thoracic radiographs. J Vet Emerg Crit Care 2018;28(5):415–28.
14. Dicker SA, Lisciandro GR, Newell SM, et al. Diagnosis of pulmonary contusions
with point-of-care lung ultrasonography and thoracic radiography compared to
thoracic computed tomography in dogs with motor vehicle trauma: 29 cases
(2017-2018). J Vet Emerg Crit Care 2020;30(6):638–46.
15. Kulhavy DA, Lisciandro GR. Use of a lung ultrasound examination called Vet
BLUE to screen for metastatic lung nodules in the emergency room. Abstract.
J Vet Emerg Crit Care 2015;25(S1):S14.
16. Vezzosi T, Mannucci A, Pistoresi F, et al. Assessment of lung ultrasound B-lines in
dogs with different stages of chronic valvular heart disease. J Vet Intern Med
2017;31(3):700–4.
17. Rademacher N, Pariaut R, Pate J, et al. Transthoracic lung ultrasound in normal
dogs and dogs with cardiogenic pulmonary edema: a pilot study. Vet Radiol Ul-
trasound 2014;55(4):447–52.
18. Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of
acute respiratory failure: the BLUE protocol. Chest 2008;134(1):117–25.
 Lung Ultrasound Fundamentals 1139

19. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recom-

mendations for point-of-care lung ultrasound. Intensive Care Med 2012;38:
577–91.
20. Balk DS, Lee C, SchaferJ, et al. Kung ultrasound compared to chest X-ray for
diagnosis of pediatric pneumonia: a meta-analysis. Pediatr Pulmonol 2018;
53(8):1130–9.
21. Nouvenne A, Zani MD, Milanese G, et al. Lung ultrasound in COVID-19 pneu-
monia: correlations with chest CT on hospital admissions. Respiration 2020;
99(7):617–24.
22. Vetrugno L, Bove T, Orso D, et al. Our Italian experience using lung ultrasound for
identification, grading and serial follow-up of severity of lung involvement for
management of patients with COVID-19. Echocardiography 2020;37(4):625–7.
23. Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of
pneumonia in adults: a systematic review and meta-analysis. Respir Res 2014;
15(1):50.
24. Stadler J, Andronikou S, Zar HJ. Lung ultrasound for the diagnosis of community-
acquired pneumonia in children. Pedriatr Radiol 2017;47(11):1412–9.
25. Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standard-
ization of the use of lung ultrasound for patients with COVID-19: A simple, quan-
titive, reproducible method. Ultrasound Med 2020;39(7):1413–9.
26. Cardinale L, Priola AM, Moretti F, et al. Effectiveness of chest radiography, lung
ultrasound and thoracic computed tomography in the diagnosis of congestive
heart failure. World J Radiol 2014;6(6):230–7.
27. Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ul-
trasound in the critically ill. Chest 2015;147(6):1659–70.
28. Gargani L, Pang PS, Frassi F, et al. Persistent pulmonary congestion before
discharge predicts rehospitalization in heart failure: a lung ultrasound study. Car-
diovasc Ultrasound 2015;4(13):40.
29. Murphy SD, Ward JL, Viall AK, et al. Utility of point-of-care ultrasound for moni-
toring cardiogenic pulmonary edema in dogs. J Vet Intern Med 2021;35(1):68–77.
30. Filly RA. Ultrasound: the stethoscope of the future, alas. Radiology 1988;167:400.
31. Moore CL, Copel JA. Point of care ultrasonography. N Eng J Med 2011;364:
749–57.
32. Tavares J, Ivo R, Gonzales F, et al. Global ultrasound check for the critically ill
(GUCCI) – a new systematized protcol unifying point-of-care ultrasound in crit-
cally ill patinets based on clinical presentation. Emerg Med 2019;10(11):133–45.
33. Narasimhan M, Koenig SJ, Mayo PH. A whole body approach to point of care ul-
trasound. Chest 2016;150(4):772–6.
34. Lichtenstein DA. Chapter 19: Basic applications of lung ultrasound in the critically
ill -A bedside alternative to CT and other irradiating techniques. In:
Lichtenstein DA, editor. Whole body ultrasonography in the critically ill. Verlag
Berlin Heidelberg: Springer; 2010. p. 181–8.
35. Neelis DA, Mattoon JS, Nyland TG. Chapter 7: Thorax. In: Small animal diagnostic
ultrasound 2014. Mattoon JS and Nyland TG, editors. Elsevier Saunders: Phila-
delphia PA, pp. 188–216.
36. Boysen S, McMurray J, Gommeren K. Abnormal curatin signs identified with a
novel lung ultrasound protocol in 6 dogs with pneumothorax. Front Vet Sci
2019;6:291.
37. Pacholec C, Lisciandro GR, Masseau I, et al. Lung ultrasound nodule sign for
detection of nodule pulmonary lesions in dogs: comparison to thoracic
1140 Lisciandro & Lisciandro

radiography using computed tomography as the criterion standard. Vet J, in

press 2021.
38. Lisciandro GR, Lisciandro SC. Chapter 23: POCUS: Vet BLUE-Clinical Integra-
tion. In: Lisciandro GR, editor. Point-of-care ultrasound Techniques for the small
animal practitioner. 2nd edition. Ames IA: Wiley Blackwell; 2021. p. 459–508.
39. Demi M, Prediletto R, Soldati G, et al. Physical mechanisms providing clinical in-
formation from ultrasound lung images: Hypotheses and early confirmations.
IEEE Trans Ultrason Ferroelectr Freq Control 2020;67(3):612–23.
40. Lichtenstein DA. Should lung ultrasonography be more widely used in the
assessment of acute respiratory disease? Expert Rev Resp Med 2010;4(5):
533–8.
41. Lisciandro GR, Puchot ML, Gambino JM, et al. The wedge sign: a possible lung
ultrasound sign for pulmonary thromboembolism. J Vet Emerg Crit Care, in press
2021.
42. Lichtenstein DA, Meziere G, Seitz J. The dynamic air bronchogram. A lung ultra-
sound signs of alveolar consolidation in ruling out atelectasis. Chest 2019;135(6):
1421–5.
43. Copetti R, Cominotto F, Meduri S, et al. The “survived lung”: an ultrasound sign of
“Bubbly Consolidation” pulmonary infarction. Ultrasound Med Biol 2020. https://
doi.org/10.1016/j.ultrasmedbio.2020.04.036.
44. Reissig A, Heyne J, Kroegel C. Sonography of lung and pleura in pulmonary em-
bolism: sonomorphologic characterization and comparison with spiral CT scan-
ning. Chest 2001;120(6):1977–83.
45. Reissig A, Kroegel C. Transthoracic ultrasound of lung and pleura in the diag-
nosis of pulmonary embolism: a novel non-invasive bedside approach. Respira-
tion 2003;70:441–52.
46. Lisciandro GR, Lisciandro GR. Chapter 36: POCUS: Global FAST-patient moni-
toring and staging. In: Point-of-care ultrasound Techniques for the small animal
practitioner. 2nd edition. Ames IA: Wiley Blackwell; 2021. p. 685–728.