Ultrasound in Emergency Medicine| Volume 52, ISSUE 6, P839-845, June 2017

A Modified Lung and Cardiac Ultrasound Protocol Saves Time and Rules in the Diagnosis of Acute Heart Failure

  • Frances M. Russell
    Corresponding Address: Frances M. Russell, md, Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenue, Fifth Third Faculty Office Building, 3rd Floor, Emergency Medicine Office, Indianapolis, IN 46202
    Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois

    Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
    Search for articles by this author
  • Robert R. Ehrman
    Department of Emergency Medicine, Cook County Hospital, Chicago, Illinois

    Department of Emergency Medicine, Wayne State University, Detroit, Michigan
    Search for articles by this author



      Multiorgan ultrasound (US), which includes evaluation of the lungs and heart, is an accurate method that outperforms clinical gestalt for diagnosing acutely decompensated heart failure (ADHF). A known barrier to ultrasound use is the time needed to perform these examinations.


      The primary goal of this study was to determine the test characteristics of a modified lung and cardiac US (LuCUS) protocol for the accurate diagnosis of ADHF.


      This was a secondary analysis of a prospective observational study that enrolled adult patients presenting to the emergency department with undifferentiated dyspnea. Intervention consisted of a modified LuCUS protocol performed by experienced emergency physician sonographers. A positive modified LuCUS protocol was defined as the presence of B+ lines in both the left and right anterosuperior lung zones, plus a left ventricular ejection fraction <45%. If all three of these findings were not present, the modified LuCUS result was interpreted as negative for ADHF. The primary objective was measured by comparing US findings to final diagnosis independently determined by two physicians, both blinded to US findings and each other's final diagnosis.


      We analyzed data on 99 patients; 36% had a final diagnosis of ADHF. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the modified LuCUS protocol are 25% (95% confidence interval [CI] 14–41%), 100% (95% CI 94–100%), undefined, and 0.75 (95% CI 0.62–0.91%), respectively. This modified protocol takes on average 1 min and 32 sec to complete.


      The point estimate for the specificity of the modified LuCUS protocol in this pilot study, accomplished by a reanalysis of data collected for a previously reported investigation of the full LuCUS protocol, was 100% for the diagnosis of ADHF.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Pitts S.R.
        • Niska R.W.
        • Xu J.
        • Burt C.W.
        National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary.
        Natl Health Stat Rep. 2008; 7: 1-38
        • Blehar D.J.
        • Dickman E.
        • Gaspari R.
        Identification of congestive heart failure via respiratory variation of inferior vena cava diameter.
        Am J Emerg Med. 2009; 27: 71-75
        • Singer A.J.
        • Emerman C.
        • Char D.M.
        • et al.
        Bronchodilator therapy in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease.
        Ann Emerg Med. 2008; 51: 25-34
        • Martindale J.L.
        • Wakai A.
        • Collins S.
        • et al.
        Diagnosing acute heart failure in the emergency department: a systematic review and meta analysis.
        Acad Emerg Med. 2016; 23: 223-242
        • Volpicelli G.
        • Caramello V.
        • Cardinale L.
        • Mussa A.
        • Bar F.
        • Frascisco M.F.
        Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure.
        Am J Emerg Med. 2008; 26: 585-591
        • Volpicelli G.
        • Silva F.
        • Radeos M.
        Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department.
        Eur J Emerg Med. 2010; 17: 63-72
        • Xirouchaki N.
        • Magkanas E.
        • Vaporidi K.
        • et al.
        Lung ultrasound in critically ill patients: comparison with bedside chest radiography.
        Intensive Care Med. 2011; 37: 1488-1493
        • Agricola E.
        • Bove T.
        • Oppizzi M.
        • et al.
        “Ultrasound comet-tail images”: a marker of pulmonary edema: a comparative study with wedge pressure and extravascular lung water.
        Chest. 2005; 127: 1690-1695
        • Collins S.P.
        • Lindsell C.J.
        • Storrow A.B.
        • Abraham W.T.
        Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure.
        Ann Emerg Med. 2006; 47: 13-18
        • Russell F.M.
        • Ehrman R.R.
        • Cosby K.
        • et al.
        Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol.
        Acad Emerg Med. 2015; 22: 182-191
        • Kajimoto K.
        • Madeen K.
        • Nakayama T.
        • Tsudo H.
        • Kuroda T.
        • Abe T.
        Rapid evaluation by lung-cardiac-inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting.
        Cardiovasc Ultrasound. 2012; 10: 49
        • Anderson K.L.
        • Jenq K.Y.
        • Fields J.M.
        • Panebianco N.L.
        • Dean A.J.
        Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography.
        Am J Emerg Med. 2013; 31: 1208-1214
        • Moore C.
        • Molina A.
        • Lin H.
        Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography.
        Ann Emerg Med. 2006; 47: 147-153
        • Bedetti G.
        • Gargani L.
        • Corbisiero A.
        • Frassi F.
        • Poggianti E.
        • Mottola G.
        Evaluation of ultrasound lung comets by hand-held echocardiography.
        Cardiovasc Ultrasound. 2006; 4: 34
        • Andersen G.N.
        • Haugen B.O.
        • Graven T.
        • Salvesen O.
        • Mjølstad O.C.
        • Dalen H.
        Feasibility and reliability of point-of-care pocket-sized echocardiography.
        Eur J Echocardiogr. 2011; 12: 665-670
        • Lichtenstein D.
        • Meziere G.
        A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact.
        Intensive Care Med. 1998; 24: 1331-1334
        • Lichtenstein D.
        Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol.
        Minerva Anestesiol. 2009; 75: 313-317
        • Cibinel G.A.
        • Casoli G.
        • Elia F.
        • et al.
        Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department.
        Intern Emerg Med. 2012; 7: 65-70
        • Volpicelli G.
        • Mussa A.
        • Garofalo G.
        • et al.
        Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome.
        Am J Emerg Med. 2006; 24: 689-696
        • Moore C.L.
        • Rose G.A.
        • Tayal V.S.
        • Sullivan D.M.
        • Arrowood J.A.
        • Kline J.A.
        Determination of left ventricular function by emergency physician echocardiography of hypotensive patients.
        Acad Emerg Med. 2002; 9: 186-193
        • Nazerian P.
        • Vanni S.
        • Zanobetti M.
        • et al.
        Diagnostic accuracy of emergency Doppler echocardiography for identification of acute left ventricular heart failure in patients with acute dyspnea: comparison with Boston criteria and N-terminal prohormone brain natriuretic peptide.
        Acad Emerg Med. 2010; 17: 18-26
        • Gilbert E.H.
        • Lowenstein S.R.
        • Koziol-McLain J.
        • Barta D.C.
        • Steiner J.
        Chart reviews in emergency medicine research: where are the methods?.
        Ann Emerg Med. 1996; 27: 305-308
        • Gheorghiade M.
        • Filippatos G.
        • De Luca L.
        • Burnett J.
        Congestion in acute heart failure syndromes: an essential target of evaluation and treatment.
        Am J Med. 2006; 119: S3-S10
        • Gheorghiade M.
        • Follath F.
        • Ponikowski P.
        • et al.
        Assessing and grading congestion in acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine.
        Eur J Heart Fail. 2010; 12: 423-433
        • Wang C.S.
        • FitzGerald J.M.
        • Schulzer M.
        • Mak E.
        • Ayas N.T.
        Does this dyspneic patient in the emergency department have congestive heart failure?.
        JAMA. 2005; 294: 1944-1956
        • Pivetta E.
        • Goffi A.
        • Lupia E.
        • et al.
        Lung ultrasound implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study.
        Chest. 2015; 148: 202-210
        • Liteplo A.S.
        • Marill K.A.
        • Villen T.
        • et al.
        Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure.
        Acad Emerg Med. 2009; 16: 201-210
        • Chiem A.T.
        • Chan C.H.
        • Ander D.S.
        • Kobylivker A.N.
        • Manson W.C.
        Comparison of expert and novice sonographers’ performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome.
        Acad Emerg Med. 2015; 22: 564-573
        • Al Deeb M.
        • Barbic S.
        • Featherstone R.
        • Dankoff J.
        • Barbic D.
        Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis.
        Acad Emerg Med. 2014; 21: 843-852
        • Vitturi N.
        • Soattin M.
        • Allemand E.
        • Simoni F.
        • Realdi G.
        Thoracic ultrasonography: a new method for the work-up of patients with dyspnea.
        J Ultrasound. 2011; 14: 147-151
        • Martindale J.L.
        • Noble V.E.
        • Liteplo A.
        Diagnosing pulmonary edema: lung ultrasound versus chest radiography.
        Eur J Emerg Med. 2013; 20: 356-360
        • Noble V.E.
        • Lamhaut L.
        • Capp R.
        • et al.
        Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers.
        BMC Med Educ. 2009; 9: 3
      1. American College of Emergency Physicians website. Emergency ultrasound guidelines. Available at: Accessed February 15, 2017.

        • Bustam A.
        • Noor Azhar M.
        • Singh Veriah R.
        • et al.
        Performance of emergency physicians in point-of-care echocardiography following limited training.
        Emerg Med J. 2014; 31: 369-373
        • Chisholm C.
        • Dodge W.
        • Balise R.
        • et al.
        Focused cardiac ultrasound training: how much is enough?.
        J Emerg Med. 2013; 44: 818-822
        • Johnson T.
        • Hickey R.
        • Switzer G.
        • et al.
        The impact of cognitive stressors in the emergency department on physician implicit racial bias.
        Acad Emerg Med. 2016; 23: 297-305