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Maurizio Zanobetti, MD; Claudio Poggioni, MD; Riccardo Pini, MD
Author and Funding Information

From the Intensive Observation Unit, Careggi University Hospital, and Department of Critical Care Medicine and Surgery, University of Florence.

Correspondence to: Maurizio Zanobetti, MD, Intensive Observation Unit, Careggi University Hospital, and Department of Critical Care Medicine and Surgery, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy; e-mail: zanomau@libero.it


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 (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(5):1387. doi:10.1378/chest.11-1649
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To the Editor:

We thank Dr Medford for his thoughtful comments on our article regarding the use of chest ultrasonography (CUS) in the ED.1 In his letter, Dr Medford expressed some concerns for the use of CUS before chest radiography as a first-line imaging test.

In general, we would agree with Dr Medford’s concerns if we had proposed the use of CUS in general clinical practice, but we limited the use of this diagnostic tool as a first-line screening modality in the ED. As a consequence, we never proposed the replacement of chest radiography with CUS in the clinical management of all chest/lung diseases. Instead, we presented data supporting the advantages of ultrasonography (eg, less time consuming, absence of ionizing radiations) in the initial evaluation of patients presenting in the ED with acute dyspnea.

Due to this limited and focused use of CUS, the training required to achieve clinical competence is probably shorter than the training suggested by Dr Medford. In effect, the American College of Emergency Physicians Emergency Ultrasound Guidelines2 propose a 1-day introductory course and a minimum 2-week rotation; a minimum of 150 ultrasound examinations must be performed to acquire a sufficient level of competency.2 This training duration seems to be significantly shorter than the training duration proposed by the Royal College of Radiology.

If, as suggested by the American College of Emergency Physicians, emergency ultrasonography education is incorporated into the core educational program for all emergency medicine residency programs, in a few years all new emergency physicians will have the required competency, and a critical mass of operators will be available in the ED. Obviously, as for all novel developments, a delay is inevitable before a widespread diffusion of the new methodology is realized.

Regarding the costs associated with the use of ultrasonography in the ED, at least in our experience, almost all EDs had ultrasound equipment. However, as suggested by Dr Medford, further studies must be performed to demonstrate the cost/effectiveness of CUS vs chest radiography. Regarding the detection of pneumothorax, several data demonstrated that small pneumothorax can be missed by bedside radiography but detected by CUS and subsequently confirmed by chest CT scan.34 In conclusion, we never stated that chest radiography can be eliminated from the workout of a patient with dypsnea, but our data support the hypothesis that CUS can be a reliable modality for the initial clinical evaluation of these patients in 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]
 
American College of Emergency PhysiciansAmerican College of Emergency Physicians Emergency ultrasound guidelines. Ann Emerg Med. 2009;534:550-570 [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;336:1231-1238 [CrossRef] [PubMed]
 
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;372:224-232 [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]
 
American College of Emergency PhysiciansAmerican College of Emergency Physicians Emergency ultrasound guidelines. Ann Emerg Med. 2009;534:550-570 [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;336:1231-1238 [CrossRef] [PubMed]
 
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;372:224-232 [CrossRef] [PubMed]
 
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