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Correspondence |

Chest Ultrasonography as a Replacement for Chest Radiography in the EDChest Ultrasonography in the ED FREE TO VIEW

Andrew R. L. Medford, MBChB, MD, FCCP
Author and Funding Information

From the North Bristol Lung Centre, Southmead Hospital.

Correspondence to: Andrew R. L. Medford, MBChB, MD, FCCP, North Bristol Lung Centre, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, England; e-mail: andrewmedford@hotmail.com


Financial/nonfinancial disclosures: The author has 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 (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(5):1386-1387. doi:10.1378/chest.11-1403
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To the Editor:

The study by Zanobetti et al1 in a recent issue of CHEST (May 2011) proposes chest ultrasonography as a replacement for chest radiography as the initial imaging modality in the ED. Although the superior sensitivity of ultrasonography over chest radiography for assessment of effusion is acknowledged and in keeping with previous studies,2 there are a number of caveats to using ultrasonography in favor of chest radiography as a first-line imaging test.

First, the training required for detecting the sonographic features of pneumothorax, localized atelectasis, and pulmonary fibrosis is extensive, and probably requires at least level 2 Royal College of Radiology training in chest ultrasonography in the United Kingdom (if not level 3, which would be equivalent to a radiologist).3 In addition, acquisition and interpretation of sonographic images is notoriously operator dependent, unlike interpretation of chest radiographs or CT images. This also presents issues with how a critical mass of operators who are adequately trained can be generated for the ED environment.

Second, acquisition of ultrasound equipment has cost implications for financially rationed health-care systems. This usually requires the demonstration of cost utility, which may be demonstrable for effusions4 but not the other conditions encountered in the study, on the basis of its performance against chest radiography.

Third, in the detection of pneumothorax, the chest radiograph (unlike ultrasonography) provides useful ancillary information as to the anatomic extent and location of most pneumothoraces (unless too small to be visible, in which case CT scan is needed). Many guidelines use the chest radiograph appearance in pneumothorax to guide further management.5

Finally, the chest radiograph may also give useful ancillary information not available from the ultrasonograph (eg, a more central lung neoplasm, mediastinal adenopathy, or a dilated right interlobar pulmonary artery suggesting pulmonary hypertension). In summary, chest ultrasonography has many applications,6 especially in the assessment of pleural effusion, but it should not replace the chest radiograph as a first-line imaging test in the assessment of acutely dyspneic patients presenting to the ED.

Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;1395:1140-1147 [CrossRef] [PubMed]
 
Eibenberger KL, Dock WI, Ammann ME, Dorffner R, Hörmann MF, Grabenwöger F. Quantification of pleural effusions: sonography versus radiography. Radiology. 1994;1913:681-684 [PubMed]
 
Royal College of RadiologistsRoyal College of Radiologists Ultrasound training recommendations for medical and surgical specialties. Ref No: BFCR (05)2. Royal College of Radiologists Web site.http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf. Published 2005. Accessed May 6, 2011.
 
Medford AR. Additional cost benefits of chest physician-operated thoracic ultrasound (TUS) prior to medical thoracoscopy (MT). Respir Med. 2010;1047:1077-1078 [CrossRef] [PubMed]
 
MacDuff A, Arnold A, Harvey J. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65suppl 2:ii18-ii31 [CrossRef] [PubMed]
 
Medford AR, Entwisle JJ. Indications for thoracic ultrasound in chest medicine: an observational study. Postgrad Med J. 2010;861011:8-11 [CrossRef] [PubMed]
 

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References

Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;1395:1140-1147 [CrossRef] [PubMed]
 
Eibenberger KL, Dock WI, Ammann ME, Dorffner R, Hörmann MF, Grabenwöger F. Quantification of pleural effusions: sonography versus radiography. Radiology. 1994;1913:681-684 [PubMed]
 
Royal College of RadiologistsRoyal College of Radiologists Ultrasound training recommendations for medical and surgical specialties. Ref No: BFCR (05)2. Royal College of Radiologists Web site.http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf. Published 2005. Accessed May 6, 2011.
 
Medford AR. Additional cost benefits of chest physician-operated thoracic ultrasound (TUS) prior to medical thoracoscopy (MT). Respir Med. 2010;1047:1077-1078 [CrossRef] [PubMed]
 
MacDuff A, Arnold A, Harvey J. BTS Pleural Disease Guideline Group BTS Pleural Disease Guideline Group Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65suppl 2:ii18-ii31 [CrossRef] [PubMed]
 
Medford AR, Entwisle JJ. Indications for thoracic ultrasound in chest medicine: an observational study. Postgrad Med J. 2010;861011:8-11 [CrossRef] [PubMed]
 
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