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Nils Petter Oveland, MD
Author and Funding Information

From the Department of Research and Development, Norwegian Air Ambulance Foundation, and Department of Anesthesiology and Intensive Care, Stavanger University Hospital.

Correspondence to: Nils Petter Oveland, MD, Department of Research and Development, Norwegian Air Ambulance Foundation, Mailbox 94, 1441 Droebak, Norway; e-mail: nils.petter.oveland@norskluftambulanse.no


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(6):1838-1839. doi:10.1378/chest.13-0467
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Published online
To the Editor:

I thank Drs Alappan and Marak for their interest in our recently published article.1 The study demonstrated a linear relationship between pneumothorax volume and the lateral position of the lung point on the chest during mechanical ventilation and that ultrasound imaging is as accurate as CT scanning for localizing lung points. We consider these findings to be clinically relevant and may enable physicians to use ultrasonography to monitor the size of a pneumothorax. Furthermore, we believe that the concept of measuring the sternum-lung point distance is a reproducible standard that can be used in future research in the assessment of pneumothorax progression (Fig 1).

Figure Jump LinkFigure 1. The lung point is where the lung detaches from the inside of the chest wall. The pen-marked cross projects the position of the lung point on the patient’s chest and maps the extension of the pneumothorax. The distance from the sternum to the lung point correlates with the volume of the intrapleural air.Grahic Jump Location

The demonstration of the lung point is 100% specific to pneumothorax, but unfortunately, not all patients present this ultrasound sign. One explanation in large pneumothoraxes is the complete retraction of the lung with obliteration of lung sliding in the anterior, lateral, and posterior locations on the chest, where no lung point can then be visualized.2 Furthermore, several conditions such as atelectasis, pulmonary contusions, ARDS, and pleural adhesions may cause motionless pleura and thereby limit the chance of obtaining the lung point,2 as shown in mixed ICU patients (sensitivity range, 66%-79%).3,4 This is in contrast to the results from a prospective study of 109 spontaneously breathing patients with trauma, where 23 of 25 pneumothoraxes were diagnosed based on identification of the lung point (sensitivity, 92%).5 In our experimental study, 131 lung points were readily identified in mechanically ventilated porcine models. The discrepancy in numbers of lung points found in the anterior and posterior locations is merely due to differences in measurements between the two readers who analyzed the CT images and assigned the position of the lung point (marked by needles) to the costal levels.1 Subcutaneous emphysema, pleural calcifications, thoracic dressings, and obesity are general limitations not specific to ultrasound identification of lung points. We believe that lung ultrasonography is for everyone with the appropriate training but agree that the sensitivity of lung point depends on the setting where this diagnostic tool is applied.

References

Oveland NP, Lossius HM, Wemmelund K, Stokkeland PJ, Knudsen L, Sloth E. Using thoracic ultrasound to accurately assess pneumothorax progression during positive pressure ventilation: A comparison with computed tomography. Chest. 2013;143(2):415-422. [PubMed]
 
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37(2):224-232. [CrossRef] [PubMed]
 
Lichtenstein D, Mezière G, Biderman P, Gepner A. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med. 2000;26(10):1434-1440. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231-1238. [CrossRef] [PubMed]
 
Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133(1):204-211. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. The lung point is where the lung detaches from the inside of the chest wall. The pen-marked cross projects the position of the lung point on the patient’s chest and maps the extension of the pneumothorax. The distance from the sternum to the lung point correlates with the volume of the intrapleural air.Grahic Jump Location

Tables

References

Oveland NP, Lossius HM, Wemmelund K, Stokkeland PJ, Knudsen L, Sloth E. Using thoracic ultrasound to accurately assess pneumothorax progression during positive pressure ventilation: A comparison with computed tomography. Chest. 2013;143(2):415-422. [PubMed]
 
Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37(2):224-232. [CrossRef] [PubMed]
 
Lichtenstein D, Mezière G, Biderman P, Gepner A. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med. 2000;26(10):1434-1440. [CrossRef] [PubMed]
 
Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231-1238. [CrossRef] [PubMed]
 
Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133(1):204-211. [CrossRef] [PubMed]
 
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