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Angelika Reissig, MD
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From Pneumology and Allergology, Clinic for Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University.

Correspondence to: Angelika Reissig, MD, Pneumology and Allergology, Clinic for Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, Erlanger Allee 101, D-07740 Jena, Germany; e-mail: angelika.reissig@med.uni-jena.de


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. See online for more details.


Chest. 2013;143(3):878-879. doi:10.1378/chest.12-2780
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To the Editor:

I thank Dr Medford for his interesting comments on our recent article in CHEST1 on lung ultrasound (LUS) in the diagnosis and follow-up of community-acquired pneumonia (CAP). I agree that the lack of radiation makes LUS an attractive modality in children, women who are pregnant, and young female patients. Furthermore, sonography may help stem the increasing levels of iatrogenic radiation exposure due to the increasing availability and use of CT scanning.2 Although LUS seems to be especially useful in situations in which chest radiography is not available (eg, home visits, emergency situations), not immediately available (eg, ED), or of limited use (eg, in bedridden patients not able to undergo radiographs in two planes), our study,1 as well as that of Parlamento et al,3 has demonstrated that LUS is an excellent diagnostic tool in the evaluation of all patients with suspected CAP.

I agree that LUS is operator dependent. Proper training in LUS is essential, just as it is for interpretation of radiographs4 and CT scans. In the United States5 and Germany, ultrasound training is increasingly a part of the education of medical students.

With respect to the question of the usefulness of chest radiography for identifying underlying malignancy, I would like to point out that the primary goal of our study was to establish the usefulness of LUS in diagnosing CAP. A study found a low incidence of new lung cancer after pneumonia: approximately 1% within 90 days and 2% over 5 years.6 The authors concluded that routine chest radiographs after pneumonia for detecting lung cancer are not warranted.6 However, the use of radiography may be questionable in light of recent studies showing a low sensitivity of radiography in identifying lung cancer, in comparison with CT scanning.7

In our study, fluid bronchograms, a possible sign of an occult obstructive process such as cancer, were identified in only 17 patients. In only one of these patients, lung carcinoma was diagnosed 3 months later. In another patient whose fluid bronchograms prompted the suspicion of lung carcinoma, no cancer was identified despite an extensive workup, including CT scanning and bronchoscopy. In a third patient, the incidental finding of liver metastases during LUS performed for suspected CAP diagnosed occult cancer that had not been identified by chest radiograph, resulting in immediate modification of the patient’s management.

However, in all cases with incomplete or delayed recovery from CAP, persistent symptoms, especially in patients with evidence of fluid bronchogram and/or risk factors for lung cancer, further diagnostic procedures are indicated, especially CT scanning. Therefore, as we mentioned in our conclusions, a chest radiograph or CT scan is necessary in cases with a negative ultrasound, if other differential diagnoses are taken into account or if complications occur.1

Acknowledgments

Other contributions: I thank Anthony J. Dean, MD, University of Pennsylvania Medical Center, for his assistance in drafting the manuscript.

Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective multicentre diagnostic accuracy study. Chest. 2012;142(4):965-972. [CrossRef] [PubMed]
 
Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. [CrossRef] [PubMed]
 
Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med. 2009;27(4):379-384. [CrossRef] [PubMed]
 
Novack V, Avnon LS, Smolyakov A, Barnea R, Jotkowitz A, Schlaeffer F. Disagreement in the interpretation of chest radiographs among specialists and clinical outcomes of patients hospitalized with suspected pneumonia. Eur J Intern Med. 2006;17(1):43-47. [CrossRef] [PubMed]
 
Hoppmann RA, Rao VV, Poston MB, et al. An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound J. 2011;3(1):1-12. [CrossRef] [PubMed]
 
Tang KL, Eurich DT, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med. 2011;171(13):1193-1198. [CrossRef] [PubMed]
 
Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia [published online ahead of print October 18, 2012].Am J Emerg Med. doi: 10.1016/j.ajem.2012.08.041.
 

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References

Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective multicentre diagnostic accuracy study. Chest. 2012;142(4):965-972. [CrossRef] [PubMed]
 
Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277-2284. [CrossRef] [PubMed]
 
Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med. 2009;27(4):379-384. [CrossRef] [PubMed]
 
Novack V, Avnon LS, Smolyakov A, Barnea R, Jotkowitz A, Schlaeffer F. Disagreement in the interpretation of chest radiographs among specialists and clinical outcomes of patients hospitalized with suspected pneumonia. Eur J Intern Med. 2006;17(1):43-47. [CrossRef] [PubMed]
 
Hoppmann RA, Rao VV, Poston MB, et al. An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound J. 2011;3(1):1-12. [CrossRef] [PubMed]
 
Tang KL, Eurich DT, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med. 2011;171(13):1193-1198. [CrossRef] [PubMed]
 
Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia [published online ahead of print October 18, 2012].Am J Emerg Med. doi: 10.1016/j.ajem.2012.08.041.
 
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