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Michael H. Baumann, MD, FCCP
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From the Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center.

Correspondence to: Michael H. Baumann, MD, FCCP, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216; e-mail: mbaumann@umc.edu


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).


© 2012 American College of Chest Physicians


Chest. 2012;141(4):1128. doi:10.1378/chest.11-3328
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To the Editor:

Thank you to Dr Chan and colleagues for their comments regarding my editorial about chest ultrasonography.1 As they aptly note, ultrasound may not have a role in the discovery of an occult pneumothorax (one not seen on a chest radiograph but seen on a chest CT scan), especially in the setting of blunt chest trauma. Given the now-frequent incorporation of a chest CT scan in this clinical setting, ultrasound may be obviated as a pneumothorax diagnostic tool. Also, the discovery of an occult pneumothorax in the blunt chest trauma setting may not require specific intervention, further marginalizing the need for its discovery by CT imaging or ultrasonography.

The meta-analysis by Ding et al1 includes 11 studies out of 20 with the patient type being listed as “trauma,” with four of these 11 being performed by emergency medicine physicians. How often were occult pneumothoraces specifically and systematically searched for and/or an issue in these studies? Were any occult pneumothoraces diagnosed independent of an accompanying CT imaging? What was the sequence and timing of the diagnostic examinations, and where was an ultrasound positioned in this sequence? These and other questions need to be systematically answered to effectively position (or not) ultrasonography as a diagnostic tool for occult pneumothorax. Dr Chan and colleagues show a particular interest in the emergency and trauma settings, as reflected in their comments and in the related publication regarding occult pneumothoraces.3 They and their similarly situated colleagues are ideally located to assist in answering these and other incompletely answered questions regarding the role of ultrasound in pneumothorax diagnosis.

We should not lose, in this specific discussion about occult traumatic pneumothoraces, the fact that ultrasonography, despite potential study flaws to date, has a role in pneumothorax diagnosis. The analysis by Ding et al,1 at a minimum, indicates that ultrasonography is as accurate as a chest radiograph for the detection of a pneumothorax.1,2 But, understanding the limits of chest ultrasonography (including for occult pneumothorax and other clinical settings), the need for adequate training and the need for appropriate patient selection and timing for its implementation are fundamental to its safe and most effective use. Meantime, the comments by Dr Chan and colleagues point to a universal issue with any evolving technology: Extending applications of any technology beyond areas of its known efficacy must be done very carefully. Stated differently, just because you own a hammer does not mean the whole world is a nail!

Baumann MH. Chest ultrasonography: where’s the beef? Chest. 2011;1404:837-839 [CrossRef] [PubMed]
 
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 [CrossRef] [PubMed]
 
Lee KL, Graham CA, Yeung JH, Ahuja AT, Rainer TH. Occult pneumothorax in Chinese patients with significant blunt chest trauma: incidence and management. Injury. 2010;415:492-494 [CrossRef] [PubMed]
 

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References

Baumann MH. Chest ultrasonography: where’s the beef? Chest. 2011;1404:837-839 [CrossRef] [PubMed]
 
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 [CrossRef] [PubMed]
 
Lee KL, Graham CA, Yeung JH, Ahuja AT, Rainer TH. Occult pneumothorax in Chinese patients with significant blunt chest trauma: incidence and management. Injury. 2010;415:492-494 [CrossRef] [PubMed]
 
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