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European Journal of Heart Failure (2012) 14, 11941196



Ultrasound lung comets: the shape of lung water

Eugenio Picano* and Luna Gargani
CNR, Institute of Clinical Physiology, 56124 Pisa, Italy

This editorial refers to Utility of lung ultrasound in predicting pulmonary and cardiac pressures, by E. Platz
et al., published in this issue on pages 1276 1284.

For a long time, cardiologists thought that the lung was off-limits
for ultrasound, and this is still standard textbook knowledge. In
Harrisons classical textbook Principles of Internal Medicine, it is
clearly stated that because ultrasound energy is rapidly dissipated
in air, ultrasound imaging is not useful for evaluation of the pulmonary parenchyma.1 However, this is not entirely true, and
lung ultrasound can offer surprising clinical dividends in several
challenging conditions, from pulmonary oedema to interstitial
lung fibrosis, from acute respiratory distress syndrome (ARDS)
to pleural effusion and pulmonary embolism.2 In pulmonary
oedema, the presence of water in the lung opens up the previously
locked pulmonary acoustic window and allows cardiologists to gain
spectacular insight into pulmonary congestion, which can be directly imaged and semi-quantified.3 5 The study by Platz et al.6 confirms that B-lines (also called ultrasound lung comets) are a simple,
low-cost, low-technology, practical sign of extravascular lung water
(EVLW). The authors show that correlation with pulmonary pressure is presentbut not strong. This is not surprising, is broadly
consistent with previous studies, and can be better understood if
we consider the heterogeneous nature of B-lines, which can
occur in three different conditions: heart failure, ARDS, and lung
interstitial fibrosis.

Watery B-lines in heart failure

In patients with heart failure, a marked increase in pulmonary pressure and pulmonary capillary wedge pressure can cause ultrastructural changes in the walls of pulmonary capillaries, resulting in
interstitial and alveolar oedema.7 In this model, the presence of
B-lines is a marker of pulmonary congestion (presence of
EVLW), which is somewhat related to increased pulmonary capillary wedge pressure (haemodynamic congestion) and to signs and

Watery B-lines without pulmonary

congestion in acute respiratory
distress syndrome
In the previously described heart failure model, B-lines are usually
accompanied by a rise in E/e , which is a marker of raised left ventricular filling pressures.10 Another interesting and pathophysiologically different model is acute lung injury acute respiratory

The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.

* Corresponding author. Tel: +39 050 3152398, Fax: +39 050 3152374, Email:
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email:

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What shape is water?

Water doesnt have any shape! I said, laughing. It takes the shape you
give it
(Andrea Camilleri, The Shape of Water. Sellerio Editore,
Palermo, 1994)

symptoms of congestion (clinical congestion). However, this relationship is not strict, since the three types of congestion measure
different aspects.8 In patients with impending acute heart failure,
there is a long incubation period of days or weeks characterized
by lung water accumulation, and in the congestion cascade, pulmonary oedema can be detected well before the appearance of
clinical signs of congestion. Detection and treatment of pulmonary
congestion before it is clinically evident may prevent hospitalization
and progression of heart failure.
The correlation between B-lines and invasively assessed pulmonary capillary wedge pressure was moderate (r 0.48, P , 0.001) in
20 patients studied by Agricola et al. before and after cardiac
surgery, in a particularly favourable setting, with each patient
acting as his/her own control.9 In a larger, unselected population
of 340 inpatients admitted to an adult cardiology department,
Frassi et al. observed a significant but weak correlation between
B-lines and pulmonary artery systolic pressure derived from echocardiography (r 0.26, P , 0.0001).10 In 75 haemodialysis patients,
Mallamaci et al. reported a mild association with pulmonary pressure
(r 0.32, P 0.006).11 The two parameters of pulmonary (B-lines)
and haemodynamic (pulmonary artery systolic or wedge pressure)
congestion are therefore associated, but their correlation is very
limited, as also reported by Platz et al.,6 with an r-value of 0.48. In
everyday practice, a patient can show very variable degrees of
B-lines (from absent to severe) for any given level of pulmonary
artery pressure, depending on the duration of history of heart
failure, speed of changes in pulmonary pressure, concomitant
mitral insufficiency, characteristics of the alveolarcapillary membrane, oncotic pressure, lymphatic drainage capacity, and so on.
On the other hand, a patient can have B-lines without haemodynamic congestion, such as in ARDS and in lung interstitial fibrosis.



Table 1 The three B-lines scenarios: heart failure, acute lung injury-acute respiratory distress syndrome, and interstitial
lung disease
Clinical examples

Heart failure


Interstitial lung disease


Abnormal (decreased)
Abnormal (increased)



Effect of diuresis/dialysis on B-lines

Reduction in minutes to hours

No effect

No effect

Other LUS sign


Pleural effusion

Subpleural alterations
Intensive care

Pleural thickening
Internal medicine


ALI, acute lung injury; ARDS, acute respiratory distress syndrome; EF, ejection fraction; ER, Emergency Room; LUS, lung ultrasound; PASP, pulmonary artery systolic pressure.

B-lines as a sign of lung interstitial

B-lines may arise not only from water-thickened but also from
fibrosis-thickened subpleural septa, which are an important sign
of the pulmonary interstitial syndrome, for instance in interstitial
lung disease of systemic sclerosis.14 Fibrotic B-lines are diuresis resistant, whereas watery B-lines of pulmonary oedema are reduced
by diuretics and/or dialysis within minutes or hours.4,11 They may
be detected in patients with very early systemic sclerosis, and correlate very nicely with interstitial lung disease observed with highresolution computed tomography (CT) scan of the chest. It is an
attractive biomarker for the frequent evaluation of pulmonary involvement in patients at high risk of developing pulmonary fibrosis,
since it is radiation free and inexpensive, compared with CT.15

B-lines are the shape of lung waterbut they can also be the shape
of interstitial fibrosis. They are not mere meteors in the ultrasound
diagnostic sky, but are here to stay as part of the standard armamentarium of cardiologists as well as intensivists, nephrologists,
rheumatologists, and sports physicians. They are associated with
pulmonary hypertension in heart failure, but identify a different
variable from haemodynamic congestion: it is water, not pressure.
It is also an appealingly simple sign to learn and to teach. From a
technical viewpoint, in the echocardiographic cursus studiorum
where 2D echo represents elementary school, Doppler-echo secondary school, and stress echo university, B-lines correspond to

kindergarten. Still, much remains to be done for a full translation

of this sign from echo lab to bedside. At present, we need a
better understanding of the underlying physics, more standardized
methodology and analysis, clear definition of the prognostic impact
in different subsets, and outcome studies with B-line-driven
therapy compared with a standard approach. At least one
large-scale, prospective, randomized trial is already in progress in
high-risk chronic kidney disease patients with heart failure and
renal insufficiency and on dialysisthe LUST Trial (Lung water
by UltraSound guided Treatment to prevent death and cardiovascular complications in high-risk end-stage renal disease patients
with cardiomyopathy), coordinated by eminent nephrologist
Carmine Zoccali from Reggio Calabria, Italy, funded by the European Renal Association-European Dialysis and Transplant Association for 1 million Euros and involving .30 nephrology
cardiology centres across Europe. The results of this study will
be crucial eventually to incorporate B-lines into our clinically
oriented diagnostic algorithms.
Conflict of interest: none declared.

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distress syndrome (ALI-ARDS), which is characterized by normal

left ventricular filling pressures and normal left ventricular ejection
fraction (Table 1). Recently, lung ultrasound has been applied to a
pig model of oleic acid-induced lung injury, which mimics human
ARDS.12 B-lines unmasked accumulation of histologically verified
EVLW very early in the course of lung injury in pigs, even at a
stage when no changes in haemogasanalytical parameters could
be observed. In humans, B-lines can identify clinically silent pulmonary oedema in elite apnoea divers, triathlon athletes after a
race, and in recreational climbers,13 suggesting again that clinical
symptoms are only the tip of the iceberg of pulmonary oedema,
even outside the acute heart failure syndrome.






Society of Cardiology and endorsed by the European Society of Intensive Care

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