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Correspondence |

Diagnosis of Cardiogenic Pulmonary Edema by Sonography Limited to the Anterior Lung FREE TO VIEW

Giovanni Volpicelli, MD; Luciano Cardinale, MD; Alessandro Mussa, MD; Caramello Valeria, MD
Author and Funding Information

San Luigi Gonzaga Hospital Torino, Italy

Correspondence to: Giovanni Volpicelli, MD, San Luigi Gonzaga Hospital, Emergency Medicine, Regione Gonzole 10, Orbassano, Torino 10043, Italy; e-mail: gio.volpicelli@tin.it


The authors have reported to the ACCP that no significant 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/misc/reprints.shtml).


Chest. 2009;135(3):883. doi:10.1378/chest.08-1313
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To the Editor:

We read with interest the article in CHEST (July 2008) by Lichtenstein and Mezière1 on the diagnostic value of lung ultrasound in patients with acute respiratory failure. They examined 64 patients with pulmonary edema in the ICU and observed prevalent B-lines on each side of the anterior chest (the B profile) in 62 cases. Based on these findings, the proposed Bedside Lung Ultrasound in Emergency (BLUE) protocol rules out the diagnosis of cardiogenic pulmonary congestion when the anterior chest scans do not show the B profile.

Our previous two studies2,3 in patients who had been admitted to the emergency department seem to be in disagreement with this view. We performed lung ultrasound in 130 dyspneic patients with confirmed acute decompensated heart failure (ADHF). All had multiple anterolateral B lines, but a retrospective analysis of the distribution of artifacts revealed that 20% of these patients (28.5% of 49 patients in the first study2 and 14.81% of 81 patients in the second study3) did not show the B profile.

Considering that both teams used the same sonographic technique and definition of a positive scan finding, and that the diagnoses were all officially confirmed in the hospitalization report using standardized tests, we suggest two possible explanations to this discrepancy. (1) Lichtenstein and Mezière1 mainly studied patients with severe pulmonary edema in the ICU, and the transudate was probably extended to the whole lung despite gravity and vascularity. The milder forms of ADHF do not necessarily show anterior symmetric B lines, because congestion initially involves the inferior lobes.4 Moreover, comorbidity occurs frequently with a possible asymmetric distribution of edema due to morphologic changes in the lung parenchyma of COPD patients.4 (2) A different timing of the sonographic examinations could be confounding. It has been shown that B lines significantly clear after treatment in patients who have been admitted to the hospital for ADHF.3

Despite this discrepancy, we strongly believe in the high clinical value of the BLUE protocol as validated in critically ill patients. At the same time, we remain convinced that in daily practice in the emergency department sonographic examinations of the lateral chest areas (requiring a few seconds more time) is mandatory to diagnose even asymmetric or mild pulmonary congestion and the conditions modified by initial treatment.

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125. [PubMed] [CrossRef]
 
Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med. 2006;24:689-696. [PubMed]
 
Volpicelli G, Caramello V, Cardinale L, et al. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med. 2008;26:585-591. [PubMed]
 
Gluecker T, Capasso P, Schnyder P, et al. Clinical and radiologic features of pulmonary edema. Radiographics. 1999;19:1507-1531. [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;134:117-125. [PubMed] [CrossRef]
 
Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med. 2006;24:689-696. [PubMed]
 
Volpicelli G, Caramello V, Cardinale L, et al. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med. 2008;26:585-591. [PubMed]
 
Gluecker T, Capasso P, Schnyder P, et al. Clinical and radiologic features of pulmonary edema. Radiographics. 1999;19:1507-1531. [PubMed]
 
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