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Am J Emerg Med. 2019 Feb 20. pii: S0735-6757(19)30112-3. doi: 10.1016/j.ajem.2019.02.028. [Epub ahead of print]

BLUE protocol ultrasonography in Emergency Department patients presenting with acute dyspnea.

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Etimesgut State Hospital, Emergency Service, Ankara, Turkey.
Gazi University School of Medicine, Department of Emergency Medicine, Ankara, Turkey. Electronic address:
Gazi University School of Medicine, Department of Emergency Medicine, Ankara, Turkey.
Izmir Health Science University, Tepecik Training and Research Hospital, Emergency Medicine Clinic, Izmir, Turkey.
Kastamonu State Hospital, Emergency Service, Kastamonu, Turkey.
Sanlıurfa Health Science University, Mehmet Akif Inan Training and Research Hospital, Emergency Service, Sanliurfa, Turkey.



Dyspnea is a common Emergency Department (ED) symptom requiring prompt diagnosis and treatment. The bedside lung ultrasonography in emergency (BLUE) protocol is defined as a bedside diagnostic tool in intensive care units. The aim of this study was to investigate the test performance characteristics of the BLUE-protocol ultrasonography in ED patients presenting with acute dyspnea.


This study was performed as a prospective observational study at the ED of a tertiary care university hospital over a 3-month period. The BLUE-protocol was applied to all consecutive dyspneic patients admitted to the ED by 5 emergency physicians who were certified for advanced ultrasonography. In addition to the BLUE-protocol, the patients were also evaluated for pleural and pericardial effusion.


A total of 383 patients were included in this study (mean age, 65.5 ± 15.5 years, 183 (47.8%) female and 200 (52.2%) male). According to the BLUE-protocol algorithm, the sensitivities and specificities of the BLUE-protocol are, respectively, 87.6% and 96.2% for pulmonary edema, 85.7% and 99.0% for pneumonia, 98.2% and 67.3% for asthma/COPD, 46.2% and 100% for pulmonary embolism, and 71.4% and 100% for pneumothorax. Although not included in the BLUE-protocol algorithm, pleural or pericardial effusion was detected in 82 (21.4%) of the patients.


The BLUE-protocol can be used confidently in acute dyspneic ED patients. For better diagnostic utility of the BLUE-protocol in EDs, it is recommended that the BLUE-protocol be modified for the assessment of pleural and pericardial effusion. Further diagnostic evaluations are needed in asthma/COPD groups in terms of the BLUE-protocol.


BLUE protocol; Bedside lung ultrasonography; Dyspnea; Emergency Department


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