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Daniel Lichtenstein, MD, FCCP; Gilbert Mezière, MD
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From the Service de Réanimation Médicale (Dr Lichtenstein), Hôpital Ambroise-Paré, and Service de Réanimation Polyvalente (Dr Mezière), Centre Hospitalier.

Correspondence to: Daniel Lichtenstein, MD, FCCP, Service de Réanimation Médicale, Hôpital Ambroise-Paré, F-92100 Boulogne, Faculté 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.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(6):1487-1488. doi:10.1378/chest.10-0582
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To the Editor:

We thank Dr Khosla for his interest in the Bedside Lung Ultrasound in Emergency (BLUE) protocol.1 The phrenic analysis is part of our systematic ultrasound examination that uses our polyvalent microconvex probe, but we have not included it in our decision tree.

Isolated phrenic palsy is not listed as a cause of acute respiratory failure.2 As Dr Khosla admitted, it should be associated with a comorbid condition contributing to respiratory failure. In addition, phrenic palsy is a rare event3 not seen in any patient in the BLUE protocol, as defined in our methodology regarding the final diagnosis. Independent of its rare presence as an associated cause of respiratory failure, and even if the comorbid disorder is seen on ultrasound, this association should be a mixed cause, which by definition is excluded from the BLUE protocol like rare causes (even if easy to diagnose).4

Even if a phrenic palsy was diagnosed in acute respiratory failure, this finding would be of minor relevance because the immediate therapy would depend on the associated disorder; there is no specific routine therapy for phrenic palsy. Additionally, patients with genuine phrenic palsy would be intubated and sedated, making the diagnosis impossible because mechanical ventilation would generate passive phrenic movements.

Phrenic palsy may be more difficult to diagnose than thought. Confusion between phrenic palsy and akinesis is common. Akinetic cupola in severe pneumonia is a common feature seen in 27% of cases.1 In these patients, akinetic cupola is redundant with abolished lung sliding (data included in the decision tree of the BLUE protocol). Akinetic cupola in severe pneumonia may be linked to interpleural inflammatory adherences, not phrenic palsy, when this akinesia persists after mechanical ventilation.

Our phrenic analysis differs from traditional approaches.5 We do not require the presence of pleural effusion or atelectasis nor subcostal approaches. Spleen or liver dynamic, or thorax-abdominal junction behavior (where the diaphragm is inserted), or, again, lung sliding (B-lines excursion) indirectly but efficiently document phrenic function.

This correspondence is an opportunity to specify that the BLUE protocol can be extended to assess additional data (ie, consolidation volume, bronchogram dynamics, ventricle behavior, ultrasound-assisted thoracentesis) for refining diagnoses such as pneumonia. It also can be applied to rare, but ultrasound-accessible diagnoses, including massive pleural effusion (taking volume into account), complete atelectasis, acute gastric dilatation, and others.6 Currently, we prefer to present a simple approach to a community not fully familiar with the potential of lung ultrasound.

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]
 
Offenstadt G. Réanimation Médicale. 2001;2nd ed Paris, France Masson
 
Aldrich TK, Tso R.Mason RJ, Broaddus VC, Murray JF, Nadel JA. The lung and neuromuscular diseases. Murray & Nadel’s Textbook of Respiratory Medicine. 2004;4th ed. New York, NY Elsevier Saunders:2287-2290
 
Khosla R. Utility of lung sonography in acute respiratory failure. Chest. 2009;1353:884. [CrossRef] [PubMed]
 
Lerolle N, Guérot E, Dimassi S, et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest. 2009;1352:401-407. [CrossRef] [PubMed]
 
Lichtenstein D. Whole Body Ultrasonography in the Critically Ill. 2010; Heidelberg, Germany Springer:277-289
 

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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]
 
Offenstadt G. Réanimation Médicale. 2001;2nd ed Paris, France Masson
 
Aldrich TK, Tso R.Mason RJ, Broaddus VC, Murray JF, Nadel JA. The lung and neuromuscular diseases. Murray & Nadel’s Textbook of Respiratory Medicine. 2004;4th ed. New York, NY Elsevier Saunders:2287-2290
 
Khosla R. Utility of lung sonography in acute respiratory failure. Chest. 2009;1353:884. [CrossRef] [PubMed]
 
Lerolle N, Guérot E, Dimassi S, et al. Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery. Chest. 2009;1352:401-407. [CrossRef] [PubMed]
 
Lichtenstein D. Whole Body Ultrasonography in the Critically Ill. 2010; Heidelberg, Germany Springer:277-289
 
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