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Correspondence |

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Daniel A. Lichtenstein, MD, FCCP; Gilbert A. Mezière, MD
Author and Funding Information

From the Medical ICU (Dr Lichtenstein), Hospital Ambroise-Paré and the Medicosurgical ICU (Dr Mezière), Centre Hospitalier de Meulan-les Mureaux.

Correspondence to: Daniel Lichtenstein, MD, FCCP, Service de Réanimation Médicale, Hôpital Ambroise-Paré. F-92100 Boulogne (Paris-Ouest), France; e-mail: dlicht@free.fr


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):233-234. doi:10.1378/chest.09-2551
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To the Editor:

We appreciate Dr Mathis’s interest regarding the BLUE protocol in our article published in CHEST (July 2008).1 We would like to make a few comments in return. Dr Mathis writes that modern systems suppress artifacts. In fact, artifacts are generally considered of little value because physicians do not find them of interest, which we, however, have demonstrated. Suppressing artifacts would deprive lung ultrasound of half its potential. Dr Mathis states that artifacts allow physicians to determine the presence of pneumothorax. Note that the number of horizontal artifacts is not considered in our criteria.

Dr Mathis states that comet-tails are found in (many) interstitial processes. In acute respiratory failure, lung-rockets indicate pulmonary edema 22 times more frequently than chronic interstitial diseases. We no longer use the term “comet-tail artifact,” because it involves not only the B-line but also many meaningless artifacts (E-line, Z-line, and so forth).

He asks, why anterior access alone? Because the anterior access is sufficient in > 50% of cases for immediate diagnosis, and also because the consideration of posterior elements alone would have decreased the BLUE protocol’s accuracy (see our response to Drs Reissig and Kroegel in CHEST [December 2009].1

Why look for artifacts alone when the original is visible? If Dr Mathis understands anatomic images (pleural-based consolidations) to be original, we answer: because the original is not so original. These lesions are usual in most cases of acute respiratory failure (see our response to Drs Reissig and Kroegel). In addition, in the case of an A-profile, typically there is no original. Dr Mathis’s remark is untrue. We use both artifacts and anatomic data, according to the profiles. For pulmonary edema, only anterior artifacts are necessary. For certain pneumoniae, the diagnosis is based on anterior artifacts plus posterior lesions. Regarding their comment that further abbreviations would make decision trees complex, for nearly 20 years the main artifacts have been A-lines and B-lines, so it is unlikely that new signs, merging from observation, decrease lung ultrasound simplicity.

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;1341:117-125. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Response. Chest. 2009;1366:1706-1707. [CrossRef] [PubMed]
 

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References

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;1341:117-125. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière GA. Response. Chest. 2009;1366:1706-1707. [CrossRef] [PubMed]
 
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