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Can echocardiographic assessment of interatrial septum shape and motion improve the accuracy of the BLUE protocol?


1Department of Cardiology, University Medical Centre, Ljubljana, Slovenia

2 Department of Vascular Neurology and Intensive Care, Neurological Clinic, University Medical Centre, Ljubljana, Slovenia

3 Institute of Physiology, Faculty of Medicine, University of Ljubljana, Slovenia

4 Department of Intensive care, General Hospital Celje, Celje, Slovenia

5 Institute for Pathophysiology, Faculty of Medicine, University of Ljubljana, Slovenia

DOI: 10.22514/SV152.102019.2 Vol.15,Issue 2,September 2019 pp.18-22

Published: 20 September 2019

*Corresponding Author(s): MATEJ PODBREGAR E-mail:


Acute respiratory failure is one of the most challenging critical conditions due to a wide variety of differential diagnosis. Bedside lung ultrasound in emergency (BLUE) protocol allows accurate differen-tiation between the most common under-lying causes of acute respiratory failure in up to 90% of the cases. The assessment of left atrial pressure affecting left ventricular filling is essential in critically ill patients guiding volume substitution, optimization of left ventricular function and prevention of pulmonary congestion, thus ensuing haemodynamic stability. A simple, non-in-vasive method of left atrial pressure evalu-ation is the echocardiographic assessment of interatrial septum shape and motion, which is affected by interatrial pressure gradient. Aiming to improve the accura-cy of the BLUE protocol, we propose the simple, non-invasive echocardiographic assessment of interatrial septum shape and motion as an upgrade, providing ad-ditional information of the loading of left and right atrium thus distinguishing the most common causes of acute respiratory failure.


lung ultrasound, BLUE protocol, interatrial septum, echocardiography

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ANA OVSENIK,ANDREJ FABJAN,MOJCA BERVAR,MATEJ PODBREGAR. Can echocardiographic assessment of interatrial septum shape and motion improve the accuracy of the BLUE protocol?. Signa Vitae. 2019. 15(2);18-22.


1. Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med 2011;183(3):341-7.

2. Patel CJ, Bhatt HB, Parikh SN, Jhaveri BN, Puranik JH. Bedside Lung Ultrasound in Emergency Protocol as a Diagnostic Tool in Patients of Acute Respiratory Distress Presenting to Emergency Department. J Emerg Trauma Shock 2018;11(2):125-9.

3. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al. International evidence-based recommenda-tions for point-of-care lung ultrasound. Intensive Care Med 2012;38(4):577-91.

4. Wooten WM, Shaffer LET, Hamilton LA. Bedside Ultrasound Versus Chest Radiography for Detection of Pulmonary Edema: A Prospective Cohort Study. J Ultrasound Med 2019;38(4):967-73.

5. Strnad M., Zadel S., Klemenc-Ketis Z., Prosen G. Identification of lung sliding: a basic ultrasound technique with a steep learning curve. Signa vitae. 2013;(8)1:31-35.

6. Dexheimer Neto FL, Andrade JM, Raupp AC, Townsend Rda S, Beltrami FG, Brisson H, et al. Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients. J Bras Pneumol 2015;41(1):58-64.

7. Koh Y, Chua MT, Ho WH, Lee C, Chan GWH, Sen Kuan W. Assessment of dyspneic patients in the emergency department using point-of-care lung and cardiac ultrasonography-a prospective observational study. J Thorac Dis 2018;10(11):6221-9.

8. Lichtenstein DA, Meziere GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134(1):117-25.

9. Lichtenstein D, van Hooland S, Elbers P, Malbrain ML. Ten good reasons to practice ultrasound in critical care. Anaesthesiol Inten-sive Ther 2014;46(5):323-35.

10. Mojoli F, Bouhemad B, Mongodi S, Lichtenstein D. Lung Ultrasound for Critically Ill Patients. Am J Respir Crit Care Med 2019;199(6):701-14.

11. Lichtenstein D. Novel approaches to ultrasonography of the lung and pleural space: where are we now? Breathe 2017;13(2):100-11.

12. Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care 2014;4(1):1.

13. Rudas M, Orde S, Nalos M. Bedside lung ultrasound in the care of the critically ill. Crit Care Resusc 2017;19(4):327-36.

14. Goffi A, Kruisselbrink R, Volpicelli G. The sound of air: point-of-care lung ultrasound in perioperative medicine. Can J Anaesth 2018;65(4):399-416.

15. Lichtenstein DA. BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Chest 2015;147(6):1659-70.

16. Volpicelli G, Skurzak S, Boero E, Carpinteri G, Tengattini M, Stefanone V, et al. Lung ultrasound predicts well extravascular lung water but is of limited usefulness in the prediction of wedge pressure. Anesthesiology 2014;121(2):320-7.

17. Peverill RE. "Left ventricular filling pressure(s)" - Ambiguous and misleading terminology, best abandoned. Int J Cardiol 2015;191:110-3.

18. Royse CF, Royse AG, Soeding PF, Blake DW. Shape and movement of the interatrial septum predicts change in pulmonary capillary wedge pressure. Ann Thorac Cardiovasc Surg2001;7(2):79-83.

19. Haji DL, Ali MM, Royse A, Canty DJ, Clarke S, Royse CF. Interatrial septum motion but not Doppler assessment predicts elevated pulmonary capillary wedge pressure in patients undergoing cardiac surgery. Anesthesiology 2014;121(4):719-29.

20. Tei C, Tanaka H, Kashima T, Nakao S, Tahara M, Kanehisa T. Echocardiographic analysis of interatrial septal motion. Am J Cardiol 1979;44(3):472-7.

21. Kusumoto FM, Muhiudeen IA, Kuecherer HF, Cahalan MK, Schiller NB. Response of the interatrial septum to transatrial pressure gradients and its potential for predicting pulmonary capillary wedge pressure: an intraoperative study using transesophageal echo-cardiography in patients during mechanical ventilation. J Am Coll Cardiol 1993;21(3):721-8.

22. Masai K, Kishima H, Takahashi S, Ashida K, Goda A, Mine T, et al. Interatrial septal motion as a novel index to predict left atrial pressure. Heart Vessels 2018;33(7):762-9.

23. Russell FM, Ehrman RR. A Modified Lung and Cardiac Ultrasound Protocol Saves Time and Rules in the Diagnosis of Acute Heart Failure. J Emerg Med 2017;52(6):839-45.

24. Khosla R. Bedside lung ultrasound in emergency (BLUE) protocol: a suggestion to modify. Chest 2010;137(6):1487; author reply -8.

25. Lichtenstein D., Meziere G. Bedside Lung Ultrasound in Emergency (BLUE) Protocol: Response. Chest 2010;137 (6), 1487–1488.

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