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Jean-François Payen, MD, PhD; Christophe Broux, MD; Anne-Claire Hyacinthe, MD; Pierre Bouzat, MD
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From Pôle d’Anesthésie-Réanimation, Hôpital Michallon, et Université Joseph Fourier.

Correspondence to: Jean-François Payen, MD, PhD, Pôle d’Anesthésie-Réanimation, Hôpital Albert Michallon, BP 217, 38043 Grenoble, France; e-mail: jfpayen@ujf-grenoble.fr


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. See online for more details.


Chest. 2013;143(1):269-270. doi:10.1378/chest.12-2246
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To the Editor:

We thank Drs Mackenzie and colleagues for their comments about our recent article in CHEST.1 They expressed concern about the relatively low sensitivities of thoracic ultrasonography in diagnosing pneumothorax, hemothorax, and lung contusion found in the population. This gives us the opportunity to discuss the value of the sensitivity of thoracic ultrasonography.

First, the sensitivity of a diagnostic test can be greatly affected by the context in which it is used. The reader should consider the conditions in which such relatively low sensitivities were obtained (eg, a stressful examination in the ED, the patient immobilized on a vacuum mattress with no possible exploration of the posterior areas, the raised probability of concomitant thoracic lesions in the same patient, and possible subcutaneous emphysema). In addition, the physicians in charge of the patients and the ultrasound operators were asked to write their diagnoses according to a probability diagnostic scale prior to the thoracic CT scan. We then expressed the diagnostic performance of each modality in terms of its area under the receiver operating characteristic curve and not in terms of its sensitivity alone. To our knowledge, our study was the first to estimate and compare the areas under the receiver operating characteristic curves of thoracic ultrasonography after trauma.

Second, we used a thoracic CT scan as the reference. Minor thoracic lesions were missed by thoracic ultrasonography but, in most instances, the consequences were not deleterious. One pneumothorax and one hemothorax were missed that subsequently required a chest tube according to the CT scan, and causes of failure were presented.1 The sensitivity of a diagnostic test should be considered as and when it has clinical relevance.

Third, some ultrasonographic criteria might have appeared conservative; however, they allowed us to reach high specificities for detecting pneumothorax and hemothorax. Ruling out these thoracic lesions by ultrasonography was also important to avoid potentially harmful decisions. For example, we searched for the absence of lung sliding associated with A lines and no lung pulse to define pneumothorax, as suggested previously.2 The lung point was sought systematically but was found in only 15 of 53 pneumothoraces.

In our study, thoracic ultrasonography was better than combined clinical examination and chest radiography. Its diagnostic performance was more enhanced even in the most severely injured patients. Our results strongly argue in favor of the extensive use of thoracic ultrasonography for multiple trauma patients, provided that rigorous criteria are used to diagnose thoracic lesions.

References

Hyacinthe AC, Broux C, Francony G, et al. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012;141(5):1177-1183. [CrossRef] [PubMed]
 
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37(2):224-232. [CrossRef] [PubMed]
 

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References

Hyacinthe AC, Broux C, Francony G, et al. Diagnostic accuracy of ultrasonography in the acute assessment of common thoracic lesions after trauma. Chest. 2012;141(5):1177-1183. [CrossRef] [PubMed]
 
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37(2):224-232. [CrossRef] [PubMed]
 
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