An ultrasound couplant is a material that propagates acoustical waves. The couplant eliminates air from the interface and adapts the contours of the transducer to the skin. The used material is an ultrasound gel that mimics the acoustic characteristics of biological tissue.

(ESWL) Extracorporeal shock wave lithotripsy is a special use of kidney ultrasound, where high intensity focused ultrasound pulses are used to break up calcified stones in the kidney, bladder, or urethra. Pulses of sonic waves pulverize dense renal stones, which are then more easily passed through the ureter and out of the body in the urine. The ultrasound energy at high acoustic power levels is focused to a point exactly on the stone requiring an ultrasound scanning gel for maximum acoustic transmission.
Air bubbles in the ultrasound couplant, regardless of their size, degrade the performance of Lithotripsy and have the following effect:
Air bubbles smaller that 1/4 wavelength cause scattering of the sound waves as omni directional scatterers and less acoustic energy reaches the focal point. The result is less acoustic power at the focal point to disintegrate the kidney stone.
Air bubbles larger than 1/4 wavelength act as reflectors and deflects the acoustic energy off in a different direction. These results in less acoustic energy at the focal point.
Microbubbles dispersed throughout the ultrasound couplant layer change the average acoustic impedance of the gel layer (which reduces the total transmitted energy) and, due to refraction, change the focal point.

The acoustic lens is placed at the time the transducer is manufactured and cannot be changed. The acoustic lens is generally focused in the mid field rather than the near or far fields. The exact focal length varies with transducer frequency, but is generally in the range of 4-6 cm for a 5 MHz curved linear probe and 7-9 cm for a 3.5 MHz curved transducer.
Placing the elevation plane (z-plane) focal zone of the acoustic lens in the very near or far field would improve the beam width at precisely those depths. However, this would degrade the beam width to a much greater and unacceptable degree at all other depths.
There are some chemicals in ultrasound couplants that can degrade the acoustic lens, destroy bonding, or change the acoustic properties of the lens. Problematic chemicals include mineral oil, silicone oil, alcohol, surfactants, and fragrances. Fragrance can affect the transducer's acoustic lens or face material by absorption over time into elastomer and plastic materials, thus changing the material's weight, size, density, and acoustic impedance. Surfactants can degrade the bond between the lens and the piezoelectric elements and contribute to the accelerated degeneration of the lens.

See also Retrolenticular Afterglow.

Reflection of the sound beam occurs when it hits a boundary between materials having different acoustic impedance. The reflection (echo) is the portion of a sound that is returned from the boundary. The reflection time (the time taken for the wave to return to the probe) can be used to determine the depth of the object.
The reflection within the body produces the ultrasound image, but should be minimized at an ultrasound couplant to skin boundary where the couplant acts as an acoustic window through which the image is seen. The amount of sound waves, which are reflected back at the interface between two tissues is depend on the angle of incidence and the difference between the acoustic impedance values of the two tissues.
If the difference is great, a large part of the sound waves will be reflected back. If too much sound is reflected back and not enough waves are remaining to be able to penetrate the tissue, the imaging will be poor.
If the difference is small, a small amount will be reflected back. Enough sound signal remains to continue with ultrasound imaging.
If the ultrasound beam meets a rough surface or small object, the beam is scattered in all directions and only a small amount will be received by the probe.

See also False Distance Artifact, Target Strength, and Snells Law.

(TTE) Transthoracic echocardiography is a common type of cardiac ultrasound and is used to evaluate the size and function of the heart.

Indications:
TTE requires no sedation or special patient preparation. After the application of ECG electrodes and ultrasound couplant, the probe is maneuvered over the chest in the area adjacent to the breast bone and under the left breast, to provide the different views of the heart. Usually the images will be obtained lying relaxed on the left side. Other views can be sampled lying on the back with the knees bent, or sitting in an upright position.

See also Bicycle Stress Echocardiography and Transesophageal Echocardiography.