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Lung POCUS: The Hospitalist’s New Stethoscope

In the time it takes to order, perform, and upload a stat chest X-ray, a skilled clinician with an ultrasound probe can diagnose an early pneumothorax, confirm pulmonary edema, or eyeball a pneumonia1—all at the bedside with zero radiation exposure to the patient and the doctor.2 Welcome to an era where sound waves, with an expert hand, can sometimes perform better than other imaging and even physical exams.3

Lung point-of-care ultrasound (POCUS) has become an essential tool in hospital medicine, offering rapid bedside assessment of respiratory pathologies, often outperforming chest radiography.4

Lung POCUS enables early detection of conditions such as pneumothorax, pleural effusion, pulmonary edema, and pneumonia, thereby enhancing clinical decision making in real time, guiding targeted interventions, and reducing delays in care.4

Furthermore, its portability and repeatability make it particularly valuable in critically ill or immobile patients.5

As a result, lung POCUS is increasingly recognized as a core competency for hospital-based clinicians.

Hospital medicine is inherently dynamic. Patients can decompensate fast. Imaging can lag. But lung POCUS always rises to deliver answers in seconds. Below, we explore five brief clinical vignettes that reveal how this tool is transforming inpatient care and can perform as the clinician’s third hand. Each scenario ends with a clinical pearl.

Invisible pneumothorax

Case: A 62-year-old man, post-renal transplant, is admitted for pneumonia, for which he is being treated with levofloxacin. While on the regular nursing floor, he suddenly develops dyspnea and chest discomfort. Chest auscultation is unrevealing. Chest X-ray is pending.

Bedside lung POCUS: No lung sliding in the upper lobes, no B-lines, but a positive barcode sign on M-mode—classic signs of a pneumothorax.

Action: Chest tube placed at bedside. Patient stabilizes before radiology even pages back.

Clinical Pearl: In the right clinical setting, absent lung sliding and a barcode sign on M-mode point towards a diagnosis of pneumothorax. POCUS was found to be superior to chest X-ray for early detection of this potentially fatal diagnosis.6

It is important to note that absent lung sliding is sensitive but not 100% specific to pneumothorax, as it may also be observed in conditions like severe emphysema, pleural effusion, main bronchial intubation, pleurodesis, and apnea.7

Quiet pneumonia

Case: An 80-year-old woman with dementia presents for shortness of breath. She is found to be in sepsis with fever and acute respiratory failure with hypoxia. Labs noted an elevated white blood cell count on the complete blood count. Some crackles are heard in the right lower lobe, with a portable X-ray showing low lung volumes with right lower lobe haziness. Urinalysis is suggestive of possible infection.

Bedside lung POCUS: Subpleural consolidation with dynamic air bronchograms, indicating lobar pneumonia.

Action: Antibiotics are started, and the patient is made nil per os pending a swallow study. The swallow study is completed the next day and shows active liquid penetration, indicating pharyngeal-phase aspiration.

Clinical Pearl: POCUS can help in the early identification of pneumonia.8

Dynamic air bronchograms are the sonographic signature of pneumonia—they appear like “moving shadows” where consolidation lives, and they help differentiate pneumonia from atelectasis, where consolidation can still be seen, but dynamic air bronchograms are absent.9

Lake of B-lines

Case: A 59-year-old man with morbid obesity, ischemic cardiomyopathy, and chronic systolic heart failure presents with worsening shortness of breath and orthopnea. He also notes a 10-pound weight gain. B-type natriuretic peptide (BNP) and initial troponin are mildly elevated.

POCUS: Bilateral, diffuse B-lines are seen in all lung fields, especially the lower lobes. B-lines appear like laser-like rays from the pleura to the screen edge, suggesting pulmonary edema in the right clinical setting.

Action: High-dose IV diuretics are started confidently. Chest X-ray arrives later with “vague interstitial markings.”

Clinical Pearl: Bilateral, diffuse B-lines indicate pulmonary edema in the right clinical setting.10 Can be a helpful finding when labs are borderline (underestimated BNP in obese patients).

Note that diffuse B-lines can also be seen in interstitial lung disease. Focal B-lines can be a sign of pneumonia.

Parapneumonic complicated effusion versus simple pleural effusion

Case: A 44-year-old man undergoing chemotherapy for acute myeloid leukemia, and with nonischemic cardiomyopathy, presents for shortness of breath and cough. He is admitted for hypoxic respiratory failure requiring 2 L/min of O2 support. Labs show a high normal white cell count. Chest X-ray shows right-sided pleural effusion with right diaphragm elevation. BNP is slightly elevated on labs. The initial thought is acute decompensated heart failure. Diuretics are being considered.

Bedside lung POCUS: Anechoic, loculated pleural effusion with septations and adjacent consolidation and air bronchogram seen. Findings are concerning for a complicated parapneumonic effusion.

Action: Interventional radiology thoracentesis is ordered, with fluid analysis indicating an exudative process. Early infection is successfully detected, furosemide is held, and antibiotics are started, preventing progression to sepsis in an immunocompromised patient.

Clinical Pearl: Complex pleural fluids with septations and adjacent lung dynamic air bronchogram should raise alarm for complicated pleural effusion11—especially when X-ray is unable to differentiate complicated from simple pleural effusion.

Summary

Lung POCUS isn’t just an imaging modality; it’s a bedside extension of the physical exam for perfect clinical reasoning. It’s a democratized diagnosis—immediate, repeatable, and free of radiation. For hospitalists navigating diagnostic uncertainty, lung POCUS can be the difference between delayed and decisive care. 

Dr. Abou Asala is a hospitalist and associate staff physician in the department of hospital medicine of the Cleveland Clinic Foundation, and clinical assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine, both in Cleveland.

 

References

  1. Llamas-Álvarez AM, et al. Accuracy of lung ultrasonography in the diagnosis of pneumonia in adults: systematic review and meta-analysis. Chest. 2017;151(2):374-382. doi:10.1016/j.chest.2016.10.039.
  2. Chelikam N, et al. Past and present of point-of-care ultrasound (PoCUS): a narrative review. Cureus. 2023;15(12):e50155. doi:10.7759/cureus.50155.
  3. Argaiz ER, et al. Comprehensive assessment of fluid status by point-of-care ultrasonography. Kidney360. 2021;2(8):1326-1338. doi:10.34067/KID.0006482020.
  4. Taylor A, et al. Thoracic and lung ultrasound. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available at https://www.ncbi.nlm.nih.gov/sites/books/NBK500013/.
  5. Fröhlich E, et al. Point of care ultrasound in geriatric patients: prospective evaluation of a portable handheld ultrasound device. Ultraschall Med. [English]. 2020;41(3):308-316. doi:10.1055/a-0889-8070.
  6. Pereira ROL, et al. Point-of-care lung ultrasound in adults: image acquisition. J Vis Exp. 2023;(193). doi:10.3791/64722.
  7. Markota A, et al. Absence of lung sliding is not a reliable sign of pneumothorax in patients with high positive end-expiratory pressure. Am J Emerg Med. 2016;34(10):2034-2036. doi:10.1016/j.ajem.2016.07.032.
  8. Abid I, et al. Point-of-care lung ultrasound in detecting pneumonia: A systematic review. Can J Respir Ther. 2024;60:37-48. doi:10.29390/001c.92182.
  9. Lichtenstein D, et al. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest. 2009;135(6):1421-1425. doi:10.1378/chest.08-2281.
  10. Naddaf N, et al. Point of care ultrasound (POCUS) in the management of heart failure: a narrative review. J Pers Med. 2024;14(7):766. doi:10.3390/jpm14070766.
  11. Sandoz E, et al. POCUS : diagnostiquer la pneumonie par l’échographie pleuropulmonaire [POCUS : diagnosis of pneumonia by lung ultrasonography]. Rev Med Suisse. [French]. 2023;19(847):2008-2013. doi:10.53738/REVMED.2023.19.847.2008.
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