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Physics of Ultrasound
Daquan Xu

INTRODUCTION
Ultrasound application allows for noninvasive visualization of tissue structures. Real-time
ultrasound images are integrated images resulting from reflection of organ surfaces and
scattering within heterogeneous tissues. Ultrasound scanning is an interactive procedure
involving the operator, patient, and ultrasound instruments. Although the physics behind
ultrasound generation, propagation, detection, and transformation into practical
information is rather complex, its clinical application is much simpler. Because ultrasound
imaging has improved tremendously over the last decade, it can provide anesthesiologists
opportunity to directly visualize target nerve and relevant anatomical structures. An
ultrasound-guided nerve block is a critical growth area for new applications of ultrasound
technology and has become an essential part of regional anesthesia. Understanding the
basic ultrasound physics presented in this section will be helpful for anesthesiologists to
appropriately select the transducer, set the ultrasound system, and then obtain
satisfactory imaging.

HISTORY OF ULTRASOUND
In 1880, French physicists Pierre Curie and his elder brother, Paul-Jacques Curie,
discovered the piezoelectric e"ect in certain crystals. Paul Langevin, a student of Pierre
Curie, developed piezoelectric materials, which can generate and receive mechanical
vibrations with high frequency (therefore ultrasound). During World War I, ultrasound was
introduced in the navy as a means to detect enemy submarines. In the medical field,
however, ultrasound was initially used for therapeutic rather than diagnostic purposes. In
the late 1920s, Paul Langevin discovered that high-power ultrasound could generate heat
in bone and disrupt animal tissues. As a result, throughout the early 1950s ultrasound was
used to treat patients with Ménière disease, Parkinson disease, and rheumatic
arthritis. Diagnostic applications of ultrasound began through the collaboration of
physicians and sonar (sound navigation ranging) engineers. In 1942, Karl Dussik, a
neuropsychiatrist, and his brother, Friederich Dussik, a physicist, described ultrasound as
a medical diagnostic tool to visualize neoplastic tissues in the brain and the cerebral
ventricles. However, limitations of ultrasound instrumentation at the time prevented
further development of clinical applications until the mid-1960s. The real-time B-scanner
was developed in 1965 and was first introduced in obstetrics. In 1976, the first ultrasound
machines coupled with Doppler measurements were commercially available. With regard
to regional anesthesia, as early as 1978, La Grange and his colleagues were the first
anesthesiologists to publish a case series report of ultrasound application for peripheral
nerve block. They simply used a Doppler transducer to locate the subclavian artery and
performed supraclavicular brachial plexus block in 61 patients (Figures 1A and 1B).
Reportedly, Doppler guidance led to a high block success rate (98%) and absence of
complications such as pneumothorax, phrenic nerve palsy, hematoma, convulsion,
recurrent laryngeal nerve block, and spinal anesthesia. In 1989, Ting and Sivagnanaratnam
reported the use of B-mode ultrasonography to demonstrate the anatomy of the axilla
and to observe the spread of local anesthetics during axillary brachial plexus block.
Figure 1. A: Early application of Doppler ultrasound by LaGrange to perform
a supraclavicular brachial block. B: Relationship of the brachial plexus of nerves and the
subclavian artery.

In 1994, Stephan Kapral and colleagues systematically explored brachial plexus with B-
mode ultrasound. Since that time, multiple teams worldwide have worked tirelessly to
define and improve the application of ultrasound imaging in regional anesthesia.
Ultrasound-guided nerve block is currently used routinely in the practice of regional
anesthesia in many centers worldwide.

Here is a summary of ultrasound quick facts:

1880: Pierre and Jacques Curie discovered the piezoelectric e"ect in crystals.
1915: Ultrasound was used by the navy for detecting submarines.
1920s: Paul Langevin discovered that high-power ultrasound can generate heat in
osseous tissues and disrupt animal tissues.
1942: The Dussik brothers described ultrasound use as a diagnostic tool.
1950s: Ultrasound was used to treat patients with Ménière disease, Parkinson disease,
and rheumatic arthritis.
1965: The real-time B-scan was developed and was introduced in obstetrics.
1978: La Grange published the first case series of ultrasound application for
placement of needles for nerve blocks.
 1989: Ting and Sivagnanaratnam used ultrasonography to demonstrate the anatomy
of the axilla and to observe the spread of local anesthetics during an axillary block.
1994: Steven Kapral and colleagues explored brachial plexus block using B-mode
ultrasound.

Definition of Ultrasound

Sound travels as a mechanical longitudinal wave in which back-and-forth particle motion is

parallel to the direction of wave travel. Ultrasound is high-frequency sound and refers to
mechanical vibrations above 20 kHz. Human ears can hear sounds with frequencies
between 20 Hz and 20 kHz. Elephants can generate and detect sound with frequencies
less than 20 Hz for long-distance communication; bats and dolphins produce sounds in
the range of 20 to 100 kHz for precise navigation (Figures 2A and 2B). Ultrasound
frequencies commonly used for medical diagnosis are between 2 and 15 MHz. However,
sounds with frequencies above 100 kHz do not occur naturally; only human-developed
devices can both generate and detect these frequencies, or ultrasounds.

Figure 2. A: Elephants can generate and detect the sound of frequencies less than 20 Hz
for long-distance communication. B: Bats and dolphins produce sounds in the range of
20–100 kHz for navigation and spatial orientation.

Piezoelectric E"ect

Ultrasound waves can be generated by material with a piezoelectric e"ect. The

piezoelectric e"ect is a phenomenon exhibited by the generation of an electric charge in
response to a mechanical force (squeeze or stretch) applied on certain materials.
Conversely, mechanical deformation can be produced when an electric field is applied to
such material, also known as the piezoelectric e"ect (Figure 3). Both natural and human-
made materials, including quartz crystals and ceramic materials, can demonstrate
piezoelectric properties. Recently, lead zirconate titanate has been used as piezoelectric
material for medical imaging. Lead-free piezoelectric materials are also under
development. Individual piezoelectric materials produce a small amount of energy.
However, by stacking piezoelectric elements into layers in a transducer, the transducer
can convert electric energy into mechanical oscillations more e"ciently. These mechanical
oscillations are then converted into electric energy.

Figure 3. The piezoelectric e#ect. Mechanical deformation and consequent oscillation

caused by an electrical field applied to certain material can produce a sound of high
frequency.

Ultrasound Terminology

Period is the time for a sound wave to complete one cycle; the period unit of measure is
the microsecond (µs). Wavelength is the length of space over which one cycle occurs; it is
equal to the travel distance from the beginning to the end of one cycle. Frequency is the
number of cycles repeated per second and measured in hertz (Hz). Acoustic velocity is the
speed at which a sound wave travels through a medium. It is equal to the frequency times
the wavelength. Speed c is determined by the density ρ and sti#ness κ of the medium (c =
(κ/ρ)1/2). Density is the concentration of a medium. Sti!ness is the resistance of a material
to compression. Propagation speed increases if the sti#ness is increased or the density is
decreased.

The average propagation speed in soft tissues is 1540 m/s (ranges from 1400 to 1640 m/s).
However, ultrasound cannot penetrate lung or bone tissues. Acoustic impedance z is the
degree of di"culty demonstrated by a sound wave being transmitted through a medium;
it is equal to density ρ multiplied by acoustic velocity c (z = ρc). It increases if the
propagation speed or the density of the medium is increased. Attenuation coe"cient is
the parameter used to estimate the decrement of ultrasound amplitude in certain media
as a function of ultrasound frequency. The attenuation coe"cient increases with
increasing frequency; therefore, a practical consequence of attenuation is that the
penetration decreases as frequency increases (Figure 4).
Ultrasound waves have a self-focusing e#ect, which refers to the natural narrowing of the
ultrasound beam at a certain travel distance in the ultrasonic field. It is a transition level
between near field and far field. The beam width at the transition level is equal to half the
diameter of the transducer. At the distance of two times the near-field length, the beam
width reaches the transducer diameter. The self-focusing e#ect amplifies ultrasound
signals by increasing acoustic pressure.

Figure 4. The ultrasound amplitude decreases in certain media as a function of ultrasound

frequency, a phenomenon known as the attenuation coe"cient. (Adapted with permission
from Hadzic A: Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided
Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc; 2011.)

In ultrasound imaging, there are two aspects of spatial resolution: axial and lateral. Axial
resolution is the minimum separation of above-below planes along the beam axis. It is
determined by spatial pulse length, which is equal to the product of wavelength and the
number of cycles within a pulse. It can be presented in the following formula:

Axial resolution = Wavelength λ × Number of cycles per pulse n ÷ 2

The number of cycles within a pulse is determined by the damping characteristics of the
transducer. The number of cycles within a pulse is usually set between 2 and 4 by the
manufacturer of the ultrasound machines. As an example, if a 2-MHz ultrasound
transducer is theoretically used to do the scanning, the axial resolution would be between
0.8 and 1.6 mm, making it impossible to visualize a 21-gauge needle. For constant acoustic
velocity, higher-frequency ultrasound can detect smaller objects and provide an image
with better resolution. The axial resolution of current ultrasound systems is between 0.05
and 0.5 mm. Figure 5 shows images at di#erent resolutions when a 0.5-mm diameter
object is visualized with three di#erent frequency settings.
Figure 5. Ultrasound frequency a#ects the resolution of the imaged object. Resolution can
be improved by increasing frequency and reducing the beam width by focusing.
(Reproduced with permission from Hadzic A: Hadzic’s Peripheral Nerve Blocks and
Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc;
2011.)

Lateral resolution is another parameter of sharpness to describe the minimum side-

by-side distance between two objects. It is determined by both ultrasound frequency
and beam width. The higher frequencies have a narrower focus and provide better
axial and lateral resolution. Lateral resolution can also be improved by adjusting focus
to reduce the beam width.

Temporal resolution is also important for observing a moving object such as blood
vessels and heart. Like a movie or cartoon video, the human eye requires that the
image is updated at a rate of approximately 25 times a second or higher for an
ultrasound image to appear continuous. However, imaging resolution will be
compromised by increasing the frame rate. Optimizing the ratio of resolution to the
frame rate is essential for providing the best possible image.

INTERACTIONS OF ULTRASOUND WITH TISSUES

As the ultrasound wave travels through tissues, it is subject to a number of interactions.
The most important features are as follows:

Reflection
 Scatter
Absorption

When ultrasound encounters boundaries between di#erent media, part of the ultrasound
is reflected and the other part is transmitted. The reflected and transmitted directions are
given by the reflection angle θr and transmission angle θt, respectively (Figure 6).

Figure 6. The interaction of ultrasound waves through the media in which they travel is
complex. When ultrasound encounters boundaries between di#erent media, part of the
ultrasound is reflected and part is transmitted. The reflected and transmitted directions
depend on the respective angles of reflection and transmission. (Adapted with permission
from Hadzic A: Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided
Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc; 2011.)

Refection of sound waves is similar to optical reflection. Some of its energy is sent back
into the medium from which it came. In a true reflection, the reflection angle θr must
equal the incidence angle θi. The strength of the reflection from an interface is variable
and depends on the di#erence of impedances between two a"nitive media and the
incident angle at the boundary. If the media impedances are equal, there is no reflection
(no echo). If there is a significant di#erence between media impedances, there will be
nearly complete reflection. For example, an interface between soft tissues and either lung
or bone involves a considerable change in acoustic impedance and creates strong echoes.
This reflection intensity is also highly angle dependent. In practical terms, it means that
the ultrasound transducer must be placed perpendicular to the target nerve to visualize it
clearly. A change in sound direction when crossing the boundary between two media is
called refraction. If the propagation speed through the second medium is slower than that
through the first medium, the refraction angle is smaller than the incident angle.
Refraction can cause the artifact that occurs beneath large vessels on the image.

During ultrasound scanning, a coupling medium must be used between the transducer
and the skin to displace air from the transducer-skin interface. A variety of gels and oils
are applied for this purpose. Moreover, they can act as lubricants, making a smooth
scanning performance possible. Most scanned interfaces are somewhat irregular and
curved. If the boundary dimensions are significantly less than the wavelength or not
smooth, the reflected waves will be di#used.

Scattering is the redirection of sound in any directions by rough surfaces or by

heterogeneous media (Figure 7).
Figure 7. Scattering is the redirection of ultrasound in any direction caused by rough
surfaces or by heterogeneous media. (Adapted with permission from Hadzic A: Hadzic’s
Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed.
New York: McGraw-Hill, Inc; 2011.)

Normally, scattering intensity is much less than mirror-like reflection intensities and is
relatively independent of the direction of the incident sound wave; therefore, the
visualization of the target nerve is not significantly influenced by another nearby
scattering.

Absorption is defined as the direct conversion of the sound energy into heat. In other
words, ultrasound scanning generates heat in the tissue. Higher frequencies are absorbed
in a greater rate than lower frequencies. However, a higher scanning frequency gives a
better axial resolution. If the ultrasound penetration is not su"cient to visualize the
structures of interest, a lower frequency is selected to increase the penetration. The use of
longer wavelengths (lower frequency) results in lower resolution because the resolution of
ultrasound imaging is proportional to the wavelength of the imaging wave. Frequencies
between 6 and 12 MHz typically yield adequate resolution for imaging in peripheral nerve
block, whereas frequencies between 2 and 5 MHz are usually needed for imaging of
neuraxial structures. Frequencies of less than 2 MHz or higher than 15 MHz are rarely
used because of insu"cient resolution or the insu"cient penetration depth in most
clinical applications.

ULTRASOUND IMAGE MODES

A-Mode

The A-mode is the oldest ultrasound technique and was invented in 1930. The transducer
sends a single pulse of ultrasound into the medium. Consequently, a one-dimensional
simplest ultrasound image is created on which a series of vertical peaks is generated after
ultrasound beams encounter the boundary of the di#erent tissue. The distance between
the echoed spikes (Figure 8) can be calculated by dividing the speed of ultrasound in the
tissue (1540 m/s) by half the elapsed time, but it provides little information on the spatial
relationship of imaged structures. Therefore, A-mode ultrasound is not applicable to
regional anesthesia.
Figure 8. The A-mode of ultrasound consists of a one-dimensional ultrasound image
displayed as a series of vertical peaks corresponding to the depth of structures the
ultrasound encounters in di#erent tissues. (Reproduced with permission from Hadzic A:
Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional
Anesthesia, 2nd ed. New York: McGrawHill, Inc; 2011.)

B-mode

The B-mode is a two-dimensional (2D) image of the area that is simultaneously scanned by
a linear array of 100–300 piezoelectric elements rather than a single one as in A-mode
(Figure 9). The amplitude of the echo from a series of A-scans is converted into dots of
di#erent brightness in B-mode imaging. The horizontal and vertical directions represent
real distances in tissue, whereas the intensity of the grayscale indicates echo strength
(Figure 10). B-mode can provide an image of a cross section through the area of interest,
and it is the primary mode currently used in regional anesthesia.
Figure 9. The B-mode transducer incorporates numeric piezoelectric elements that are
electrically connected in parallel.
Figure 10. An example of B-mode imaging. The horizontal and vertical directions
represent distances and tissues, whereas the intensity of the grayscale indicates echo
strength. (Adapted with permission from Hadzic A: Hadzic’s Peripheral Nerve Blocks and
Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc;
2011.)

Doppler Mode

The Doppler e#ect is based on the work of Austrian physicist Johann Christian
Doppler. The term describes a change in the frequency or wavelength of a sound wave
resulting from relative motion between the sound source and the sound receiver. In other
words, at a stationary position, the sound frequency is constant. If the sound source
moves toward the sound receiver, the sound waves have to be squeezed, and a higher-
pitch sound occurs (positive Doppler shift); if the sound source moves away from the
receiver, the sound waves have to be stretched, and the received sound has a lower pitch
(negative Doppler shift) (Figure 11). The magnitude of Doppler shift depends on the
incident angle between the directions of emitted ultrasound beam and moving reflectors.
With a 90° angle there is no Doppler shift. If the angle is 0° or 180°, the largest Doppler
shift can be detected. In medical settings, the Doppler shifts usually fall in the audible
range.

Figure 11. The Doppler e#ect. When a sound source moves away from the receiver, the
received sound has a lower pitch and vice versa. (Adapted with permission from Hadzic A:
Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional
Anesthesia, 2nd ed. New York: McGraw-Hill, Inc; 2011.)

Color Doppler produces a color-coded map of Doppler shifts superimposed onto a B-

mode ultrasound image. Blood flow direction depends on whether the motion is toward or
away from the transducer. Selected by convention, red and blue colors provide
information about the direction and velocity of the blood flow. According to the color map
(color bar) in the upper left-hand corner of the figure (Figure 12), the red color on the top
of the bar denotes the flow coming toward the ultrasound probe, and the blue color on
the bottom of the bar indicates the flow away from the probe.

Figure 12 Color Doppler produces a color-coded map of Doppler shapes superimposed

onto a B-mode ultrasound image. Selected by convention, red and blue colors provide
information about the direction and velocity of the blood flow. (Adapted with permission
from Hadzic A: Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided
Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc; 2011.)
Figure 13. Color Doppler mode is used to detect the direction of the blood vessel.

In ultrasound-guided peripheral nerve blocks, color Doppler mode is used to detect the
presence and nature of the blood vessels (artery vs. vein) in the area of interest. When the
direction of the ultrasound beam changes, the color of the arterial flow switches from blue
to red, or vice versa, depending on the convention used (Figures 13, 14A, 14B, and 14C).
Power Doppler is up to five times more sensitive in detecting blood flow than color
Doppler, and it is less dependent on the scanning angle. Thus, power Doppler can be used
to identify the smaller blood vessels more reliably. The drawback is that power Doppler
does not provide any information on the direction and speed of blood flow (Figure 15).

Figure 14. A: Carotid artery displays a red color when the blood flows toward the
transducer. B: Carotid artery displays ambiguous color at a 90° Doppler angle; the equal
waveform can be seen on both sides of the baseline. C: Carotid artery displays blue color
when the blood flows away from the transducer.

Figure 15. Although the power Doppler may be useful in identifying smaller blood vessels,
the drawback is that it does not provide information on the direction and speed of blood
flow. (Adapted with permission from Hadzic A: Hadzic’s Peripheral Nerve Blocks and
Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc;
2011.)
M-Mode

A single beam in an ultrasound scan can be used to produce a picture with a motion
signal, where movement of a structure such as a heart valve can be depicted in a wave-like
manner. M-mode is used extensively in cardiac and fetal cardiac imaging; however, its
present use in regional anesthesia is negligible (Figure 16).

Figure 16. M-mode consists of a single beam used to produce an image with a motion
signal. Movement of a structure can be depicted in a wavelike matter. (Reproduced with
permission from Hadzic A: Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-
Guided Regional Anesthesia, 2nd ed. New York: McGraw-Hill, Inc; 2011.)

ULTRASOUND INSTRUMENTS
Ultrasound machines convert the echoes received by the transducer into visible dots,
which form the anatomic image on an ultrasound screen. The brightness of each dot
corresponds to the echo strength, producing what is known as a grayscale image. Two
types of scan transducers are used in regional anesthesia: linear and curved. A linear
transducer can produce parallel scan lines and a rectangular display, called a linear scan,
whereas a curved transducer yields a curvilinear scan and an arc-shaped image (Figures
17A and 17B). In clinical scanning, even a very thin layer of air between the transducer and
skin may reflect virtually all the ultrasound, hindering any penetration into the tissue.
Therefore, a coupling medium, usually an aqueous gel, is applied between surfaces of the
transducer and skin to eliminate the air layer.

The ultrasound machines currently used in regional anesthesia provide a 2D image, or

“slice.” Machines capable of producing three-dimensional (3D) images have recently been
developed. Theoretically, 3D imaging should help in understanding the relationship of
anatomic structures and the spread of local anesthetics. There are three major types of 3D
ultrasound imaging: (1) Freehand 3D is based on a set of 2D cross-sectional ultrasound
images acquired from a sonographer sweeping the transducer over a region of interest
(Figures 18A and 18B). (2) Volume 3D provides 3D volumetric images using a dedicated
3D transducer. The transducer elements automatically sweep through the region of
interest during the scanning; the sonographer is not required to perform hand motions
(Figure 18C). (3) Real-time 3D takes multiple images at di#erent angles, allowing the
sonographer to see the 3D model moving in real time. However, typical spatial resolution
of 3D imaging is about 0.34–0.5 mm. At present, 3D imaging systems still lack the
resolution and simplicity of 2D images, so their practical use in regional anesthesia is
limited.
Figure 17. A: Rectangular scan field given by linear transducer. B: Arc-shaped scan field
given by curved transducer. (Adapted with permission from Hadzic A: Hadzic’s Peripheral
Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed. New York:
McGraw-Hill, Inc; 2011.)

Figure 18. A: Freehand 3D imaging. A linear transducer produces parallel scan lines and a
rectangular display; linear scan. B: Freehand 3D imaging. A curved “phase array”
transducer results in a curvilinear scan and an arch-shaped image. C: Fetal face viewed by
volume 3D imaging. (Reproduced with permission from Hadzic A: Hadzic’s Peripheral
Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed. New York:
McGraw-Hill, Inc; 2011.)
TIME-GAIN COMPENSATION
The echoes exhibit a steady decline in amplitude with increasing depth. This occurs for two
reasons: First, each successive reflection removes a certain amount of energy from the
pulse, decreasing the generation of later echoes. Second, tissue absorbs ultrasound, so
there is a steady loss of energy as the ultrasound pulse travels through the tissues. This
can be corrected by manipulating time-gain compensation (TGC) and compression
functions. Gain is the ratio of output to input electric power; it controls the brightness of
the image. The gain is usually measured in decibels (dB). Increasing the gain amplifies not
only the returning signals, but also the background noise within the system in the same
manner. TGC is a time-dependent amplification. TGC function can be used to increase the
amplitude of incoming signals from various tissue depths.

The layout of the TGC controls varies from one machine to another. A popular design is a
set of slider knobs. Each knob in the slider set controls the gain for a specific depth, which
allows for a well-balanced gain scale on the image (Figures 19A, 19B, and 19C).

Figure 19: A, B, and C: The e#ect of the time-gain compensation settings. Time-gain
compensation is a function that allows time- (depth) dependent amplification of signals
returning from di#erent depths. (Adapted with permission from Hadzic A: Hadzic’s
Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed.
New York: McGraw-Hill, Inc; 2011.)

Amplification is the conversion of the small voltages received from the transducer into
larger ones that are suitable for further processing and storage. There are two
amplification processes considered to increase the magnitude of ultrasound echoes: linear
and nonlinear amplification. Currently, the ultrasonic imaging system with linear amplifiers
is commonly used in medical diagnostic applications. However, the strength of
echoes attenuates exponentially as the distance between the transducer and the reflector
increases. Ultrasonic imaging instruments equipped with logarithmic amplifiers can
display echo signals with a wider dynamic range than a linear amplifier and remarkably
improve the sensitivity for a small magnitude of echoes on the screen.

Dynamic range is the range of amplitudes from largest to the smallest echo signals that an
ultrasound system can detect. The wider/higher dynamic range presents a larger number
of grayscale levels, and it creates a softer image; the image with a narrower/lower dynamic
range appears with more contrast (Figures 20A and 20B). Dynamic range less than 50 dB
or greater than 100 dB is probably too low or too high in terms of visualization of
peripheral nerve. Compression is the process of decreasing the di#erences between the
smallest and largest echo-voltage amplitudes; the optimal compression is between 2 and 4
for a maximal scale equal to 6.

Figure 20.: A: A softer image provided by a higher dynamic range. B: An image with more
contrast provided by a lower dynamic range.

FOCUSING
As previously discussed, it is common to use electronic means to narrow the width of the
beam at some depth and achieve a focusing e#ect similar to that obtained using a convex
lens (Figure 21). There are two types of focusing: annular and linear. These are illustrated
in Figures 22A and 22B, respectively.

Adjusting focus improves the spatial resolution on the plane of interest because the beam
width is converged. However, the reduction in beam width at the selected depth is
achieved at the expense of degradation in beam width at other depths, resulting in poorer
images below the focal zone.
Figure 21: A demonstration of focusing e#ect. An electronic means can be used to narrow
the width of the beam at a specific depth, resulting in the focusing e#ect and greater
resolution at a chosen depth. (Adapted with permission from Hadzic A: Hadzic’s Peripheral
Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia, 2nd ed. New York:
McGraw-Hill, Inc; 2011.)
Figure 22: A: Annular focusing is electronic focusing from all directions in the scan plane
given by an annular transducer that contains several ring elements arranged
concentrically. B: Linear focusing is electronic focusing applied along both lateral sides in
the scan plane.

BIOEFFECT AND SAFETY

The mechanisms of action by which an ultrasound application could produce a biologic
e#ect can be conceptually categorized into two aspects: heating and mechanical. In reality,
these two e#ects are rarely separable except for extracorporeal lithotripsy, the
therapeutic application of mechanical bioe#ects alone. The generation of heat increases
as ultrasound intensity or frequency is increased. For similar exposure conditions, the
expected temperature increase in bone is significantly greater than in soft tissues. In in
vivo experiments, high-intensity ultrasound (usually > 2 W/cm2) is used to evaluate
harmful biological e#ect; it is 5 to 20 times larger than therapeutic intensities (0.08–0.5
W/cm2) and 8 to 100 times larger than diagnostic intensities (color flow mode 0.25 W/cm2,
B-mode scan 0.02 W/cm2). Reports in animal models (mice and rats) suggest that
application of ultrasound may result in a number of undesired e#ects, such as fetal weight
reduction, postpartum mortality, fetal abnormalities, tissue lesions, hind limb paralysis,
blood flow stasis, and tumor regression. Other reported undesired e#ects in mice are
abnormalities in B-cell development and ovulatory response and teratogenicity.

In general, adult tissues are more tolerant of rising temperature than fetal and neonatal
tissues. A modern ultrasound machine displays two standard indices: thermal and
mechanical. The thermal index (TI) is defined as the transducer acoustic output power
divided by the estimated power required to raise tissue temperature by 1°C. The
mechanical index (MI) is equal to the peak rarefactional pressure divided by the square
root of the center frequency of the pulse bandwidth. TI and MI indicate the relative
likelihood of thermal and mechanical hazard in vivo, respectively. Either TI or MI greater
than 1.0 is hazardous.

The biologic e#ect due to ultrasound also depends on tissue exposure time. The
researchers usually use pregnant mice to expose to ultrasound with a minimum intensity
of 1 W/cm2 for 60 to 420 minutes to evaluate the time-dependent adverse events that
happen in rodent fetuses. Fortunately, ultrasound-guided nerve block requires the use of
only low TI and MI values on the patient for a short period of time. Based on in vitro and in
vivo experimental study results to date, there is no evidence that the use of diagnostic
ultrasound in routine clinical practice is associated with any biologic risks.

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