How to utilize the basic buttons on a duplex ultrasound machine

26th Feb 2021

The duplex ultrasound machine may look complex, but only a few buttons are used for a basic lower extremity arterial study:

  • Power and sleep
  • Probe and preset
  • Trackball, freeze, and save (e.g., acquire 1)
  • Caliper and depth
  • Doppler gain, two-dimensional gain, and color gain 
  • Color scale
  • Steering
  • Pulsed-wave

Let’s get familiarized with each of these buttons so that you can feel confident using a Doppler probe. 

 

Power and sleep functions on duplex ultrasound

As is true for all the buttons covered in this article, the power button will be located in different places depending on the machine. We’ll demonstrate examples of where each button may be found on the keyboard. But, keep in mind that their locations vary.  

There is usually a sleep button next to the power button that can be used when the machine needs to be transported. Sleep mode decreases battery use, and the power usually lasts about 20–30 minutes for off-outlet scanning time. 

Duplex ultrasound machine keyboard with power and sleep buttons highlighted. Illustration.

 

Picking a probe and preset on duplex ultrasound

As you get started, you will be prompted to pick a probe and a preset. Choose the 12 MHz linear transducer and the arterial lower extremity preset.

Duplex ultrasound machine display with 12 MHz linear transducer and arterial lower extremity preset highlighted. Illustration.

Figure 1. To perform a duplex ultrasound of the lower extremities, choose the 12 MHz linear transducer and the arterial lower extremity preset.​

 

Trackball, freeze, and save (e.g., acquire 1) functions on duplex ultrasound

Most machines have a trackball in the middle of the keyboard with freeze and save buttons around it. Save is labeled as the acquire 1 button.

The freeze button is used to freeze images, which are then scrolled back with the trackball to get an optimal image, and then saved with the acquire 1 button. 

Duplex ultrasound machine keyboard with trackball, freeze, and save (acquire 1) buttons highlighted. Illustration.

Pro tip: the acquire 1 and acquire 2 buttons can be programmed to capture a few seconds of cine clip. If this function is used, the freeze button is not required. Medmastery note.

 

Caliper and depth functions on duplex ultrasound

Once an image is frozen, you can use the caliper button on the main keyboard to measure the distance between the arterial walls to diagnose an aneurysm, or to measure the peak systolic velocity (e.g., the highest peak on the waveform) to diagnose an obstruction.  

The depth button will allow you to increase the image depth to see deeper vessels and decrease the image depth to more clearly see superficial vessels. 

Duplex ultrasound machine keyboard illustration with caliper and depth buttons highlighted. Ultrasound image showing a color flow duplex with waveforms.

Figure 2. Use the caliper button to measure the distance between arterial walls or measure the peak systolic velocity during a lower extremity arterial ultrasound. Use the depth button to increase or decrease the image depth.

 

Doppler gain, two-dimensional gain, and color gain functions on duplex ultrasound

An additional set of buttons frequently used during a lower extremity examination are the gain buttons. These consist of two-dimensional (2D) gain, color gain, and Doppler gain (pulsed-wave or PW button). Gain buttons control the brightness of an image and can be adjusted throughout the exam. 

Duplex ultrasound machine keyboard with two-dimensional gain, color gain, and Doppler gain (pulsed-wave) buttons highlighted. Illustration.

Adjusting the Doppler gain will affect the brightness of the ultrasound. Changing the Doppler gain can affect the brightness so much that, at some levels, the waveforms can completely disappear. A slight adjustment will bring it into view again—but too much of an adjustment will create background changes!

Arterial ultrasound Doppler waveforms with too little, too much, and optimal Doppler gain. Ultrasound images.

Figure 3. When adjusting the Doppler gain, too much will cause the waveforms to disappear; too little will cause background distortion. 

Check out this short video snippet from our Ultrasound Masterclass: Arteries of the Legs Course to see an example of Doppler gain adjustments:

 

Two-dimensional gain adjusts the visual volume of the black-and-white screen. Keep in mind that if the gain is too high, you can sometimes get artifacts that can affect the image quality.

Duplex ultrasound with too little, too much, and optimal two-dimensional gain. Ultrasound images.

Figure 4. When adjusting two-dimensional gain, too little will cause the image to disappear and too much will cause artifacts that can affect the image quality.

Here’s a video example from our Ultrasound Masterclass: Arteries of the Legs Course showing the results of 2D gain adjustments:

 

As color gain is adjusted, the color appearance changes. It can fade away so that no color flow is seen or becomes so bright that it overwhelms the image, which makes the duplex difficult to evaluate. Fine adjustments to the color gain will affect how well you see the color flow.

Color flow duplex ultrasound with too little, too much, and optimal color gain. Ultrasound images.

Figure 5. When adjusting color gain on a duplex ultrasound, too little causes the color to disappear, and too much causes color to overwhelm the image. 

Check out this example of color gain adjustments from our Ultrasound Masterclass: Arteries of the Legs Course:

 

 

Color scale function on duplex ultrasound

Another color gain function is color scale, which can also be adjusted as you examine a vessel. Initially, it should be set around 30–40 cm / s. Color scale controls the color sensitivity, meaning that it allows a specific range of blood flow velocities to be translated into color. The gain helps amplify this data. 

Duplex ultrasound machine keyboard with color scale dial highlighted. Illustration.

A lower color scale reads slower blood flow and must be adjusted. It can be adjusted along with gain throughout the examination. You can turn the color scale up or, if you are not seeing color very well in what seems like a patent artery, you can turn it down and increase your color gain. This is especially helpful if the area of concern is distal to significant stenosis and only has a trickle of blood flow. 

If the scale is appropriately low but the gain is also too low, you still won’t see the blood flow. Thus, gain and scale are often adjusted depending on the need at each particular vessel.

In contrast, you can turn the color scale up to exclude low velocities and focus on high velocities, such as velocities that create aliasing and bruits. Turning the color scale up should make the color less sensitive to stenotic vibrations, decrease artifacts, and give better color fill. 

 

Steering function on duplex ultrasound

The Doppler angle should be set at 60° with the angle parallel to the vessel wall. The steering button is used to make this adjustment.

Duplex ultrasound machine keyboard with steering button highlighted. Illustration.

If the vessel is at a slant where the Doppler angle cannot be parallel to the walls at 60°, then the angle can be adjusted to less than 60° for an accurate measurement. But, you ideally want to keep a 45–60° angle. If the Doppler angle is over 60°, the machine overestimates the velocity and thus the degree of stenosis.

As you measure the velocities, turn the direction of the color box so that it follows the slant of the vessel. The steering button controls the slant of the color box and the sample volume. Knowing how to maneuver these controls is helpful when measuring velocities.

Duplex ultrasound cursor showing the ideal angle 60° and a less than 60° angle. Illustration.

Figure 6. An ideal Doppler angle on a duplex ultrasound is 60°, but if the vessel is at an increased slant, the steering function can be adjusted to keep the angle parallel with the vessel walls as long as it does not exceed a 60° angle. 

 

Pulsed-wave function on duplex ultrasound

When measuring velocities, press the PW button. This is the same PW button as mentioned under Doppler gain. 

In addition to controlling gain (e.g., darkness or brightness), the PW button controls the waveform scale (e.g., size of the waveforms) on the velocity graph. This is extremely helpful for more accurate measurements of velocity. Keep in mind that you may have to increase your PW scale to accommodate high velocities in stenosis. 

Color flow duplex ultrasound with pulsed-wave adjustments resulting in waveforms that are too small, too large, and optimal. Ultrasound image.

Figure 7. Use the pulsed-wave button to adjust the size of the waveforms. This is especially helpful when examining stenosis since it allows you to accommodate for high velocities. 

Check out another short video snippet from our Ultrasound Masterclass: Arteries of the Legs Course to see how pulsed-wave adjustments change the size of the waveforms: 

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