Fig. 1

The sonographic pattern with multiple echogenic vertical artifacts named B-lines. They generate from the pleural line, reach the edge of the screen without fading, and move synchronous with lung sliding. Visualization of this sign in the painful chest area was decisive for ruling in a pleural origin of the pain.

Fig. 2

Disruption of the pleural line (white arrow) with a wedge-shaped, pleural-based hypoechoic image with sharp margins and some B-lines in the surrounding area (asterisks). This image is typical of a small lung consolidation due to a peripheral infarction. Final diagnosis was pulmonary embolism.

Fig. 3

A, Upright CXR study of a 28-year-old man admitted to the hospital because of severe left dorsal pleuritic pain and cough. B, Corresponding sonogram of the painful dorsal chest area showing irregular pleural line, coalescent B-lines (B+ pattern), and subpleural irregular shape consolidation. C, Corresponding sCT scan. One basal dorsal soft consolidated area of the lung is visible. The final diagnosis was radio-occult pneumonia.

Fig. 4

Negative and positive likelihood ratio is numerically equivalent to the slopes of the solid lines. The solid line passing through (0.0) is the likelihood ratio positive line, and the solid line passing through (1.1) is the likelihood ratio negative line. The solid lines split the graph in 4 areas. Tests falling in area 1 are overall superior to LUS, those falling in area 2 are superior for confirming absence of disease, tests in area 3 are superior for confirming presence of disease, and, finally, tests in area 4 are overall inferior. The dashed lines represent the sensitivity and specificity of LUS.

Fig. 5

Flowchart that explains our proposal of evaluation of pleuritic pain in the ED in patients without signs of respiratory distress or hemodynamic instability, when LUS is available. Basic LUS is based on the assessment of 4 simple signs: (1) absence of sliding, (2) B+ pattern on more than 1 intercostal scan, (3) peripheral alveolar consolidation, and (4) disruption with irregularity of the pleural line with or without effusion. MDCT indicates multidetector computer tomography; US, ultrasound; PNX, pneumothorax; PE, pulmonary embolism.

Fig. 6

Evaluation of pleuritic pain in the ED when LUS is not available. We start from the CXR study and discharge the patient with diagnosis of chest wall pain only when both radiography and blood tests are negative. In case of visualization of radiographic lesions, we can make the diagnosis or require blood tests and second-level imaging. MDCT, multidetector computer tomography; US, ultrasound; PNX, pneumothorax; PE, pulmonary embolism.