PHYSICS

Physics of ultrasound Learning objectives

David J Martin
After reading this article you should be able to:
Irving TP Wells C describe the characteristics of sound waves
Christopher R Goodwin C explain how ultrasound waves are produced and how they
interact with the tissues they encounter to produce echoes
which are then interpreted to form a two-dimensional image
Abstract C identify common ultrasound imaging artefacts
Ultrasound is a form of non-ionizing radiation that uses high-frequency C explain the Doppler effect and its use in ultrasound imaging
sound waves to image the body. It is a real-time investigation which
allows assessment of moving structures and also facilitates measurement
of velocity and direction of blood flow within a vessel.
It can be used for a variety of purposes in the intensive care setting, for
wavelengths produce higher resolution images but less penetra-
example to aid central venous catheter insertion and pleural drain inser-
tion into the soft tissues. In medical imaging therefore higher
tion. When using this imaging modality it is vital to understand the rele-
frequency probes (5e10 MHz) are used for superficial structures,
vant physical principles and how the images are created.
for example peripheral vessel visualisation, and lower frequency
This article will explain these principles, including the use of Doppler
probes (2e5 MHz) for deeper structures such as abdominal
ultrasound and the interpretation of common artefacts.
organs.

Keywords Doppler effect; echoes; imaging artefacts; sound attenuation;

Ultrasound image production
ultrasound safety; ultrasound waves
Production of echoes
Royal College of Anaesthetists CPD matrix: 1A03 Ultrasound waves are produced by briefly passing an electrical
current through a piezoelectric crystal within the ultrasound
probe. The resulting pulse of ultrasound waves is delivered to the
Wave characteristics tissues. The crystal then waits for the rebounding echoes to be
received before transmitting the next pulse. The pulse duration is
Sound is a mechanical wave that causes disturbance in a me-
typically 1 ms and repeated at 1 ms intervals. Each crystal
dium, transferring energy from one point to another. As the
therefore emits ultrasound waves 1% of the time and receives the
sound wave travels through a medium the energy is propagated
returning echoes for the remaining 99% of the time. In practice,
through collisions of adjacent particles which oscillate around
the probe contains a phased array of many piezoelectric crystals
their resting position without net displacement. Sound waves can
which are stimulated sequentially by electronic pulses which
be longitudinal or transverse depending on the direction of their
sweep from one side of the probe to the other.
oscillations in relation to the direction of the energy travelling
As the ultrasound wave passes through the patient it en-
through the medium. Only solids can propagate sound waves
counters interfaces between different tissues. At these interfaces
transversely, whereas all materials can support a longitudinal
a proportion of the wave’s energy is reflected and the remainder
wave, and this is therefore how ultrasound is transmitted
is transmitted. If the angle between the interface and transducer
through the soft tissues (including liquids) within the body
is greater than 60 degrees then the reflected echoes will return to
(Figure 1).
the transducer. The piezoelectric crystal converts the reflected
The frequency of a sound wave (hertz, Hz) is the number of
oscillations (or cycles) per second. If a particle completes one full
oscillation per second, its frequency is 1 Hz. Ultrasound refers to
any sound waves that have a frequency that is too high for the
human ear to detect (i.e. >20 kHz), however the frequencies At rest
used in medical imaging are far greater: typically 2e18 MHz.
Wavelength is the distance travelled by sound in one cycle. It
is inversely proportional to the frequency, that is, the shorter the
wavelength the higher the frequency (Figure 2). Shorter Transverse
propagation

David J Martin MBBCh MRCP FRCR is a Specialty Registrar in Radiology at

the University Hospital of Wales, UK. Conflict of interest: none declared.

Irving T P Wells MBBS MRCP FRCR is a Consultant Radiologist at Morriston Longitudinal

propagation
and Singleton Hospitals, Swansea, Wales, UK. Conflict of interest: none
declared.

Christopher R Goodwin MB ChB MRCS (Eng) FRCR is a Consultant Radiologist Figure 1 Diagrammatic representation of the propagation of a mechanical
at Princess of Wales Hospital, Bridgend, Wales, UK. Conflict of interest: force transversely as can occur only in solids or longitudinally as occurs
none declared. with sound in the tissues of the body.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 132 Ó 2015 Elsevier Ltd. All rights reserved.
 PHYSICS

friction between oscillating tissue particles and is lost in the form

High-frequency wave
Time
Wavelength
Low-frequency wave
Time
Wavelength
Figure 2 The relationship between wavelength and frequency.
sound waves into electrical pulses, and these are interpreted into
a two-dimensional (2D) image. The more energy in the returning
echoes, the brighter the image displayed.
The amount of energy reflected at the interface between tis-
sues depends on the difference in acoustic impedance of those
tissues. The acoustic impedance of a tissue is mainly determined
by its density. Air has a much lower density than water or soft
tissue, which in turn have a much lower density than bone. The
larger the difference in acoustic impedance, the more energy will
be reflected, and the brighter the resulting image. At the interface
of tissues of similar densities, such as liver and kidney, less than
1% of the wave’s energy is reflected. However at the interface
between soft tissue and air or bone, nearly all of the wave’s
energy is reflected. No energy is transmitted, and hence no in-
formation can be gained about tissues which lie deep to this
point. This explains why ultrasound is generally not useful for
assessment of bone, bowel, or lung. It also explains why a
coupling gel is required between the probe and patient’s skin to
eliminate air.
To create a 2D image, the depth (d) of the tissue interface
must be calculated. Ultrasound travels at an average speed (c) of
1540 m/second through soft tissue. The time (t) taken for the
ultrasound pulse to travel distance (d) to the interface, and for
the reflected wave to return to the transducer, is therefore:
of heat.
The combination of attenuation, and the fact that only a small
proportion of the wave’s energy is reflected at many of the tissue
interfaces (and is then attenuated further as it travels back to-
wards the probe), means that the ultrasound transducer will only
receive a very small amount of energy from the returning echoes,
particularly from deeper structures. To compensate for this loss
of energy the ultrasound machine uses a process called time gain
compensation. This gives greater amplification to those echoes
which take longer to return to the transducer, producing an even
image.
Image resolution
Axial resolution is the ability to distinguish between structures
lying perpendicular to the beam. A structure can only be
visualized if it is larger than the wavelength of the emitted ul-
trasound. As wavelength is inversely proportional to frequency,
a high-frequency probe is required to view small structures.
However, higher frequency waves are attenuated more rapidly,
and therefore will only be able to visualize superficial
structures.
Lateral resolution is the ability to distinguish two structures
lying side by side. Diffraction causes divergence of the original
beam soon after it leaves the probe, as well as of reflected echoes
from a tissue interface. If two structures are lying closely adja-
cent, the reflected waves can interact and appear to the trans-
ducer as if they originate from the same structure, and will
appear so on the image created.
a b
e
c d

d ¼ ct=2

Sound attenuation and compensation

As a sound wave passes through the body it gradually loses its
energy in a process called attenuation. The causes of this are:
absorption, reflection, diffraction and refraction (Figure 3).
Reflection and refraction occur at the interface between tissues.
Reflection as already described is responsible for the production
of echoes. Refraction causes a transmitted wave to be deflected
from its original course. Diffraction is scattering of the wave
which occurs particularly when a wave interacts with small
Figure 3 Causes of attenuation: (a) absorption, (b) reflection, (c) diffrac-
structures. The majority of attenuation however occurs due to tion and (d) refraction all contribute to the overall attenuation of the ul-
absorption. The energy of the sound wave is converted into trasound wave seen in (e).

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 133 Ó 2015 Elsevier Ltd. All rights reserved.
 PHYSICS

Artefacts
Imaging artefacts can lead to misinterpretation but can also aid
the operator in certain circumstances.

Reverberation artefact (Figure 4a) occurs when sound waves

bounce back and forth between two reflective surfaces before
returning to the transducer. These returning echoes will arrive
later than the original echo in a sequential manner creating
numerous evenly spaced lines, as the processor believes these
echoes to be returning from deeper structures.

Ring down artefact (Figure 4b) occurs when sound waves hit a
small structure, such as air, that then resonates at the same
frequency as ultrasound and emits sound. The sound is produced
after the original wave has been reflected back to the transducer
and it will therefore be interpreted as a second echo originating
from a deeper structure; and is displayed as bright line deep to
the original target. It may used to identify air within the biliary
tree.

Mirror artefact (Figure 4c) occurs at highly reflective surfaces.

The original beam is reflected from a surface and then encoun-
ters an adjacent structure, at which point the original echo is
reflected back towards the highly reflective surface, before being
reflected back again to the transducer. This is interpreted as
returning from a deeper structure which appears to be on the
opposite side of the reflective surface. This is classically seen at
the diaphragm.

Posterior acoustic shadowing (Figure 4d) occurs when the ul-

trasound beam encounters a strongly attenuating or highly
reflective structure or surface. There is little or no through
transmission and this creates a dark area beyond the surface.
Visualization of any structure deep to this point is therefore
diminished. This artefact can be used to identify dense or calci-
fied structures such as gallstones.

Posterior acoustic enhancement (Figure 4e) occurs when the

ultrasound beam passes through a weakly attenuating structure,
such as simple fluid in a cyst. The structures posterior to the cyst
will appear brighter, as more energy of the original beam will
reach them, and hence an echo of greater energy will be reflected
back to the probe.

Doppler
The Doppler effect describes the change in frequency of the
incident wave that occurs when it is reflected at a moving
interface. Doppler shift frequency is measured as the difference
between the transmitted and observed frequency (f e f1). If the
object(s) being imaged (e.g. blood cells) are moving towards the
transducer, their motion will cause the reflected waves to be
Figure 4 Ultrasound artefacts: (a) Reverberation artefact e evenly spaced
compressed and return back to the transducer more rapidly,
lines in the bladder, (b) Ringdown artefact e bright white line caused by
shortening the wavelength and increasing the frequency. The air within the biliary tree, (c) Mirror artefact e liver ‘reflected’ on the other
opposite occurs when the blood cells are moving away from the side of the diaphragm, (d) Post-acoustic shadowing e caused by two
transducer, resulting in a decrease in frequency of the reflected gallstones in the gallbladder, (e) Post-acoustic enhancement e due to
wave. The change in frequency is proportional to the velocity of simple liver cyst.
the moving interface:

ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3 134 Ó 2015 Elsevier Ltd. All rights reserved.
 PHYSICS
change of frequency ðf  f1 Þ velocity of the interface ðvÞ
¼2
original frequency ðfÞ velocity of sound ðcÞ
The Doppler shift frequency is also related to the cosine of the
angle between the probe and the vessel being imaged:


f  f1 =ðfÞ ¼ 2  ðv=cÞcosq
The cosine of 90 degrees is 0, therefore no Doppler signal will be
present when the probe is perpendicular to the vessel. Ideally the
probe should be positioned such that the flow of the vessel is
directly toward it. In practice this is difficult, and if measurement
of velocity is required an angle less than 60 degrees can be used
in conjunction with the angle correction function on the ultra-
sound machine.
Doppler imaging can provide information about flow direction
which is typically displayed using colour mapping, with red
conventionally representing flow towards the probe and blue
away from it. Alternatively it can be displayed as a graph of
velocity against time, which allows the operator to obtain mea-
surements of flow velocity.
Safety
Ultrasound is safe and does not use ionizing radiation. Known
bio-effects fall into two categories: mechanical and thermal.
Mechanical effects are related to tiny bubbles which are
ANAESTHESIA AND INTENSIVE CARE MEDICINE 16:3
produced within tissues as ultrasound propagates through them.
If these bubbles collapse rapidly (microcavitation), energy is
released which can damage tissues.
Thermal effects occur from the heat produced from the fric-
tion of oscillating particles.
In routine medical imaging neither of these bio-effects causes
any significant or lasting damage but it is good practice to keep
the examination time to a minimum and use appropriate settings
to minimize the power, particularly during fetal scanning. A
FURTHER READING
Aldrich JE. Basic physics of ultrasound imaging. Crit Care Med 2007;
35(suppl 5): S131e7, http://ovidsp.uk.ovid.com.abc.cardiff.ac.uk/sp-3.
12.0b/ovidweb.cgi?&S¼MDEAPDMAJKHFMDMLFNMKACDGGHAMAA00&
LinkþSet¼jb.search.32%7c2%7csl_10.
Feldman MK, Katyal S, Blackwood MS. US artifacts. Radiographics 2009;
29: 1179e89.
Hangiandreou NJ. AAPM/RSNA physics tutorial for residents. Topics in US:
B-mode US: basic concepts and new technology. Radiographics 2003;
23: 1019e33.
Hopkins R, Peden C, Gandhi S. Ultrasound. In: Radiology for anaesthesia
and intensive care. 2nd edn. Cambridge: Cambridge University Press,
2009.
Middleton B, Phillips J, Thomas R, Stacey S. Ultrasound. In: Physics in
anaesthesia. 1st edn. Scion Publishing, 2012.
Ziskin MC. Fundamental physics of ultrasound and its propagation in
tissue. Radiographics 1993; 13: 705e9.
135 Ó 2015 Elsevier Ltd. All rights reserved.