What are the minimum requirements to establish proficiency in lung ultrasound training for quantifying B-lines?

Frances M. Russell, Robinson Ferre, Robert R. Ehrman, Vicki Noble, Luna Gargani, Sean P. Collins, Phillip D. Levy, Katarina L. Fabre, George J. Eckert, Peter S. Pang

Research output: Contribution to journalArticlepeer-review


Aims: The goal of this study was to determine the number of scans needed for novice learners to attain proficiency in B-line quantification compared with expert interpretation. Methods and results: This was a prospective, multicentre observational study of novice learners, physicians and non-physicians from three academic institutions. Learners received a 2 h lung ultrasound (LUS) training session on B-line assessment, including lecture, video review to practice counting and hands-on patient scanning. Learners quantified B-lines using an eight-zone scanning protocol in patients with suspected acute heart failure. Ultrasound (US) machine settings were standardized to a depth of 18 cm and clip length of 6 s, and tissue harmonics and multibeam former were deactivated. For quantification, the intercostal space with the greatest number of B-lines within each zone was used for scoring. Each zone was given a score of 0–20 based on the maximum number of B-lines counted during one respiratory cycle. The B-line score was determined by multiplying the percentage of the intercostal space filled with B-lines by 20. We compared learner B-line counts with a blinded expert reviewer (five US fellowship-trained faculty with > 5 years of clinical experience) for each lung zone scanned; proficiency was defined as an intraclass correlation of > 0.7. Learning curves for each learner were constructed using cumulative sum method for statistical analysis. The Wilcoxon rank-sum test was used to compare the number of scans required to reach proficiency between different learner types. Twenty-nine learners (21 research associates, 5 residents and 3 non-US-trained emergency medicine faculty) scanned 2629 lung zones with acute pulmonary oedema. After a mean of 10.8 (standard deviation 14.0) LUS zones scanned, learners reached the predefined proficiency standard. The number of scanned zones required to reach proficiency was not significantly different between physicians and non-physicians (P = 0.26), learners with no prior US experience vs. > 25 prior patient scans (P = 0.64) and no prior vs. some prior LUS experience (P = 0.59). The overall intraclass correlation for agreement between learners and experts was 0.74 and 0.80 between experts. Conclusions: Our results show that after a short, structured training, novice learners are able to achieve proficiency for quantifying B-lines on LUS after scanning 11 zones. These findings support the use of LUS for B-line quantification by non-physicians in clinical and research applications.

Original languageEnglish (US)
Pages (from-to)2941-2947
Number of pages7
JournalESC Heart Failure
Issue number5
StatePublished - Oct 1 2020


  • B-lines
  • Heart failure
  • Learning curves
  • Lung ultrasound
  • Proficiency

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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