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Daniel Lichtenstein, MD, FCCP; Gilbert A. Mezière, MD
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Affiliations: Hôpital Ambroise-Paré Boulogne, Paris-Ouest, France,  Centre Hospitalier Saint-Cloud, Paris-Ouest, France

Correspondence to: Daniel A. Lichtenstein, MD, FCCP, Hospital Ambroise-Paré, Medical ICU, Rue Charles-de-Gaulle, Boulogne, Paris-West, F-92100 France; e-mail: dlicht@free.fr


The authors have no conflicts of interest to disclose.

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):883-884. doi:10.1378/chest.08-2733
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To the Editor:

We are pleased to see the interest of Volpicelli and colleagues1,2 in lung ultrasound and the BLUE protocol.3 Our observations (July 2008)3 stressed a correlation between pulmonary edema and the B profile. Volpicelli and colleagues1,2 pointed out cases of pulmonary edema without the B profile. In actual fact, we believe there is no discordance between their results and ours; rather, they are complementary. As Volpicelli and colleagues1,2 say, the severity of their patients' illness was different (patients were able to keep the supine position, and most did not require instrumental therapy1). The time at which these results were recorded, up to 48 h after hospital admission,1 is important since B lines vanish during therapy. Most of their patients had the B profile, however. Those patients with no B profile (14.8%, considering only patients examined at hospital admission2) should indeed be referred to as having the mildest cases. This hypothesis is explained by the physiopathology of pulmonary edema since fluids flow against gravity. On the other hand, in the BLUE protocol, all patients had acute respiratory failure, and pulmonary edema nearly always correlated with the B profile. Errors in the final diagnosis, which can never be fully excluded, may explain the few cases (3%) in this study and a previous one4 in which the B profile did not show. Exceptional cases of giant bullous dystrophy may alter the location of B lines.

Lateral B lines were always sought in our series, but this information appeared to be redundant. Associated with the B profile, lateral B lines were redundant for diagnosing pulmonary edema. Associated with B, C, or A/B profiles, lateral B lines were redundant for diagnosing pneumonia. Associated with the A profile, lateral B lines were redundant with posterolateral alveolar/ pleural syndrome (or PLAPS) for demonstrating pneumonia (seven cases). An A profile associated with lateral B lines should therefore be interpreted cautiously.

It should be specified that the B lines are not a sign of “alveolar-interstitial” syndrome.1 Our 1997 princeps study compared ultrasound mostly with radiologic alveolar-interstitial syndrome, but using CT scanning as the “gold standard” clearly demonstrated that B lines indicate interstitial syndrome, distinct from alveolar syndrome.

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] [CrossRef]
 
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]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125. [PubMed]
 
Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24:1331-1334. [PubMed]
 

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References

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] [CrossRef]
 
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]
 
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125. [PubMed]
 
Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24:1331-1334. [PubMed]
 
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