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CCF

In CCF, the pleural line is thin and B lines are bilateral. Oedema begins at the lung bases and progresses superiorly and anteriorly. Initially B lines are separated in space and A lines may be seen; however, as B lines become more confluent you may see a white out of that lung field. Bilateral anechoic effusions are also commonly associated.

Confluent B lines in pulmonary oedema are described as homogenous: that it, there will be no areas of normal lung seen in the insonated field of view. The number of B lines correlates closely with the degree of pulmonary oedema on CXR and the BNP level in acute heart failure (1). 

The beauty of B lines in heart failure is their dynamic appearance and disappearance. Agricola et al (2) showed that new B lines appear within 6 minutes of stress induced diastolic heart failure. Noble et al (3) showed B line resolution within one hour of dialysis in renal failure patients. Further, they showed that B line resolution correlated with the volume of fluid removed. Thus, in the emergency department, quantification of B lines at the start of treatment and during the ED stay will help determine the effectiveness of diuretic therapy. 

In acute pulmonary oedema, patients will have confluent B lines throughout their lung fields and bilateral anechoic effusions. Confluent B lines at L1 and R1 and thin pleura in a patient with respiratory distress is classically due to APO (4).

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REFERENCES

1.Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med. 2008 Jun;26(5):585-91.

2. Agricola E, Picano E, Oppizzi M, Pisani M, Meris A, Fragasso G, Margonato A. Assessment of stress-induced pulmonary interstitial edema by chest ultrasound during exercise echocardiography and its correlation with left ventricular function. J Am Soc Echocardiogr 2006, 1:457-63.

3. Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJ, Liteplo A: Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest 2009, 135:1433-9.

4. D. A. Lichtenstein and G. A. Mezière, "Relevance of lung ultrasound in the diagnosis of acute respiratory failure the BLUE protocol," CHEST, vol. 134, no. 1, pp. 117-125, 2008.