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Mao Zhang, MD; Wu Ding, MM
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From the Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine and Research Institute of Emergency Medicine, Zhejiang University.

Correspondence to: Mao Zhang, MD, Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University, School of Medicine and Research Institute of Emergency Medicine, Zhejiang University, NO.88 JieFang Rd, Hangzhou 310009, China; e-mail: znhz@hotmail.com


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).


© 2012 American College of Chest Physicians


Chest. 2012;141(3):828. doi:10.1378/chest.11-2820
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To the Editor:

We thank Dr Alrajab and colleagues for their comments on our recent article in CHEST.1 Their suggestions and opinions on the key points relating to the diagnosis of pneumothorax (PNX) by ultrasonography will also benefit our research. Our responses to their comments are as follows.

First, the extent to which a Cochrane review can draw conclusions about the effects of an intervention depends on whether the data and results from the included studies are valid. For our analysis, the most valid studies would have been prospective, double-blind studies with a large sample, which would have had the same gold standard for comparison. However, there were only a few studies which complied with these criteria. All of the 20 studies we included in our analysis complied with at least seven of 10 quality of diagnostic accuracy studies tool items (shown in e-Table 1 of our article1), and the study published in 1995 complied with nine of 10 quality of diagnostic accuracy studies tool items. The possible sources of heterogeneity across the studies were explored using metaregression analysis, which implied that heterogeneity resulted from factors other than the way in which a study was designed.

Second, in our experience and in the opinion of other experts,2 the accuracy of pleural ultrasonography (PUS) in diagnosing PNX depends on the operator’s skill. The lung point is a specific sign that allows PNX to be confirmed and the PNX volume to be determined. Furthermore, not all of the PNX diagnosed by PUS requires an invasive procedure. Only a large PNX needs emergency treatment. In these circumstances, a well-trained operator can evaluate PNX precisely with PUS. For mild to moderate PNX, clinicians can wait for the results of CT scans or chest radiographs (CXRs) before performing an invasive procedure.

Third, we indicated that PUS complements CXR rather than replaces it. Both PUS and CXR have advantages and limitations in detecting PNX. There is no conflict between these two modalities. The choice should be made depending on the specific conditions, including available equipment, clinician ability, and patient circumstances. PUS and CXR each have a role in detecting PNX.

Sufficient training and certification of the operator are essential before performing PUS. Despite the limitations of PUS, from our analysis we believe that it is a promising alternative for the diagnosis of PNX, especially when performed by clinicians in critically ill patients.3

Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 2011;1404:859-866. [PubMed] [CrossRef]
 
Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol. 2005;155:930-935. [PubMed]
 
Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma. 2004;572:288-295. [PubMed]
 

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References

Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 2011;1404:859-866. [PubMed] [CrossRef]
 
Chung MJ, Goo JM, Im JG, Cho JM, Cho SB, Kim SJ. Value of high-resolution ultrasound in detecting a pneumothorax. Eur Radiol. 2005;155:930-935. [PubMed]
 
Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma. 2004;572:288-295. [PubMed]
 
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