As the amount of effusion increases, the curtain progressively covers less and less of the diaphragm, uncovering it even at inspiration. With massive effusion, the dynamic component is also lost. It has been reported that the positive predictive value of absent lung sliding for the detection of pneumothorax is only 87% in the general population, falls to 56% in the critically ill, and to 27% in patients with respiratory failure ( 3, 5, 17, 18). They gain access to any enclosed space through gaps as small as 20mm and take shelter in lofts, cellars, roofing felts, drain pipes or guttering, between roof tiles, above soffits, under gables or eaves, basically everywhere is warmth and offer protection from elements. If absent, PLAPS is sought - its presence (A profile plus PLAPS) suggests pneumonia; its absence suggests COPD/ asthma Figure 6. The BLUE Protocol. Courtesy Daniel A. Lichtenstein et al. (2008). Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure. This iconic decision tree is quite helpful and uses the A-lines and B-lines in addition to some other lung ultrasound findings to determine the cause of acute respiratory failure.

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In Batman: The Telltale Series, Gordon first uses the Bat Signal in Episode 3, as he needed Batman's help when the cops are stretched thin throughout the city. Lichtenstein D, Mezière G, Biderman P, Gepner A, Barré O: The comet-tail artifact: an ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997, 156: 1640–1646. 10.1164/ajrccm.156.5.96-07096 Figure 4. Lung ultrasound findings of normal, moderate, severe, and critical pleural and lung parenchyma changes in patients with COVID-19. (Courtesy wileylibraryonline.com)

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van der Werf TS, Zijlstra JG: Ultrasound of the lung: just imagine. Intensive Care Med 2004, 30: 183–184. 10.1007/s00134-003-2083-6 The Bat-Signal first appeared in Detective Comics #60 (February 1942). The signal has several different origins in comics featuring post- Crisis continuity. It is introduced as a new tool after Batman's first encounter with the Joker in the 2005 series Batman: The Man Who Laughs, and also during the 1990 " Prey" storyline in Legends of the Dark Knight. A pneumothorax contains air and no fluid, and therefore, will rise to the least dependent area of the chest. In a supine patient this area corresponds to the anterior region of the chest at approximately the second to fourth intercostal spaces in the mid-clavicular line. This location will identify the majority of significant pneumothoraces in the supine patient, which makes it the recommended initial area for investigation in a trauma.[ 17, 18] In contrast, air will accumulate in an apicolateral location in an upright patient.[ 19]

POCUS Lung – Introduction to A-lines and B-lines

Sonography of the lungs is best performed by using a low-frequency curvilinear transducer (3–6 MHz) ( 7). Microconvex transducers (if available) exhibit the additional benefit of having a smaller footprint for better intercostal placement and application in paediatric patients. High-frequency linear transducers (7–12 MHz) are helpful 7 in better visualisation of certain signs including the sliding sign and A-lines (see below); they are also preferred in paediatric patients. It should be noted that the imaging of the lungs relies mostly on the interpretation of artefacts, so various filters like Tissue Harmonic Imaging; Compound Imaging etc., which are designed to reduce these, should be turned off for better visualisation of the artefacts ( 6– 8) (unless mentioned otherwise, all the sonographic images presented in this article were obtained by using a low-frequency curvilinear transducer; 3–6 MHz). If the lung sliding is only observed for a short time during breathing, it may indicate the presence of lung point, which is consistent with pneumothorax. If lung sliding is absent at a level, it may suggest pneumothorax. Prominent A-lines may also be seen in asthma and chronic obstructive pulmonary disease (COPD). Lichtenstein D, Menu Y: A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding. Chest 1995, 108: 1345–1348. 10.1378/chest.108.5.1345

POCUS Lung – Introduction to A-lines and B-lines

To celebrate Batman's 80th anniversary, DC Comics and Warner Bros. lit the Bat-Signal in thirteen cities on September 21, 2019, starting in Melbourne and ending in Los Angeles. [3] [4] [5] Origins [ edit ] The Bat-Signal's debut in Detective Comics #60 (February 1942). Data for using the FALLS-protocol (Fluid Administration Limited by Lung Sonography) have been published, showing the correlation between an A-profile or equivalents (A/B-profile) and a low pulmonary artery occlusion pressure (PAOP), with a 18-mmHg value occurring when B-lines appear [ 46]. Caval vein analysis is associated to the FALLS-protocol, especially in the case of initial B-profile. Volpicelli G, Caramello V, Cardinale L, et al.: Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008, 26: 585–591. 10.1016/j.ajem.2007.09.014 Regarding rare, double, absent causes, read [ 42]. False-positives and false-negatives are of interest, because ultrasound provided data that questioned a posteriori the value of the “gold standard” [ 36]. Let us remind that, more than simple CT (which isolated does not have a perfect discriminatory power for a given disease), the “gold standard” was the final diagnosis of the hospitalization report. Hemodynamic assessment of circulatory failure using lung ultrasound: FALLS-protocol

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Lichtenstein D: Cardiac arrest. In Whole Body Ultrasonography in the Critically Ill. Heidelberg, Berlin, New York: Springer-Verlag; 2010:279–291.Tocino IM, Miller MH, Fairfax WR: Distribution of pneumothorax in the supine and semi-recumbent critically ill adult. Am J Roentgenol 1985, 144: 901–905. 10.2214/ajr.144.5.901 In the 1999 miniseries Batman: Dark Victory, after Batman asks for The Riddler to offer his insight into the riddles of the new villain the Hangman, the Riddler uses the Signal to summon Batman after he's finished his analysis. [7] Later in the series, the Hangman sneaks onto the roof of Police Headquarters and turns the Bat-Signal on to lure then-recently appointed Commissioner Gordon to the roof and try to kill him, but is thwarted when Two-Face cuts Gordon down. [8] There are many advantages of using Lung Ultrasound (LUS), namely it is a fast, easily repeatable, widely available, cheap, and portable method. Most importantly, it is safe and does not use harmful ionising radiation, and avoids potentially dangerous transfers within the hospital. The diagnostic accuracy of LUS is superior to that of physical examination and chest radiography combined ( 3, 4). The normal aerated lung ultrasound image obtained with the probe marker pointing cephalad shows a classic finding known as the “Bat sign.” The outer periosteum of the ribs represents the bat’s wings, and the pleural line between two adjacent ribs represents the bat’s body. This sign helps confirm that we are visualizing the correct space. The “Bat sign” is more helpful in obese patients to identify an intercostal space and confirm the correct placement of the ultrasound transducer because we may not be able to confirm the intercostal space by palpation alone. Lerolle N, Guérot E, Dimassi S, Zegdi R, Faisy C, Fagon JY, Diehl JL: Ultrasonographic diagnosis criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest 2009, 135: 401–407. 10.1378/chest.08-1531

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Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris NS: Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest 2007, 131: 1013–1018. 10.1378/chest.06-1864 In the CW series The Flash, a 'Flash signal' is created by Cisco, who claimed to have gotten the idea from "some comic book", which implies Batman does not exist in on Arrowverse Earth One. However, Earth 38, the universe Supergirl takes place in makes several references to him, solely as "Clark's (kind of) friend", and Oliver later refers to Bruce Wayne on Earth One.

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In the 2022 film The Batman, directed by Matt Reeves who co-wrote the screenplay with Peter Craig, the Bat-Signal is featured prominently. Robert Pattinson, in his opening narration as Bruce Wayne/Batman, states that the signal is a recent development for the city, and serves as a means for Jim Gordon to call Batman when needed. But its main purpose is to create fear for Gotham's criminal element, by reminding them (to great effect) that while Batman may not be hiding in every shadow, he could be there, waiting to strike. Or, as Batman says, this does not translate into a fear that he is lurking in every shadow, but rather that he is the shadows. As a result, the lone, opportunistic, and petty criminals second-guess their actions and run away when the Bat-Signal appears; as the superhero states: “Fear is a tool. When that light hits the sky, it's not just a call. It's a warning.”