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Correspondence |

Comprehensive Clinical Evidence for Pulmonary Embolism Diagnosis and WorkupUltrasound for Pulmonary Embolism FREE TO VIEW

Michele Maggi, MD; Daniela Catalano, MD; Marco Sperandeo, MD; Guglielmo Trovato, MD
Author and Funding Information

From the Department of Emergency Medicine (Dr Maggi) and Medicina Interna (Dr Sperandeo), IRCCS Ospedale Casa Sollievo della Soefferenza; and Department of Medical and Pediatric Sciences (Drs Catalano and Trovato), University of Catania.

Correspondence to: Michele Maggi, MD, Department of Emergency Medicine, IRCCS Ospedale Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy; e-mail: Maggi.css@libero.it


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. 2014;145(5):1173-1174. doi:10.1378/chest.13-2792
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Dear Editor:

The article by Nazerian et al1 in this issue of CHEST (see page 950) strives to demonstrate that “multiorgan ultrasonography sensitivity is significantly superior to that of lung, heart, and leg vein ultrasonography alone,” and aims to establish “a diagnostic algorithm based on multiorgan ultrasonography for patients with suspected pulmonary embolism [PE].”1 We itemize some limitations of this report.

First, thoracic ultrasound (TUS) was performed mainly on supine patients, although most of the lesions described were located posteriorly.1 Only 70% of the subpleural lung is visible by TUS,2 and one-half is posterior; a comprehensive workup cannot be mostly focused on the anterolateral chest surface as, seemingly, the authors suggest.1 Orthopnea is a frequent presentation of PE,3 observed in 45% of patients whom we have seen (57 of 127; years 2010-2012) and is due also to associated conditions. To examine patients in the supine or lateral/supine position has no rationale.

Second, “the detection of pulmonary subpleural infarcts, which consist of pleural-based, well-demarcated echo-poor triangular or rounded consolidations of at least 0.5 cm in size” describes a seemingly semiquantitative and subjective overview evaluation; no actual measurement is reported in the results.1 Triangular or rounded TUS images are nonspecific for PE, even when TUS was adequately performed on sitting patients.4,5

Third, the number of patients, number of lesions for each patient, and the total number, as displayed by Nazerian et al1 in Figure 2 of their article, do not seem concordant. Also, the statement “TUS detected some image suggestive of PE in 77 of the 110 patients” sounds very generic.

Fourth, the diagnostic accuracy of a combination of lung, heart, and leg vein ultrasonography for detecting PE was studied. Can the authors describe in how many patients the findings of two or three ultrasonography procedures were suggestive of PE? Actually, the echocardiography results seem to be suggestive of PE in 60 of 110 patients, and leg veins positive for PE on ultrasonography were observed in 57 of the 110 patients. We wonder about the overlap of these observations; that is, in how many patients was there a double or triple positivity for these criteria?

Last, a positive D-dimer level (≥ 500 ng/mL) was observed in 107 patients with PE (97.3%) and in 187 patients without PE (75.7%). Some information and comment on D-dimer positivity usefulness, if any, is needed. The conclusion implies that diagnostic workup and therapy could be tailored as soon as the patient, although asymptomatic, shows shared US signs. This is speculative and does not improve the reliability and objectivity of the existing best-practice comprehensive approach to PE diagnosis and treatment.

References

Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957.
 
Reissig A, Görg C, Mathis G. Transthoracic sonography in the diagnosis of pulmonary diseases: a systematic approach. Ultraschall Med. 2009;30(5):438-454. [CrossRef] [PubMed]
 
Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871-879. [CrossRef] [PubMed]
 
Mathis G, Blank W, Reissig A, et al. Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005;128(3):1531-1538. [CrossRef] [PubMed]
 
Sperandeo M, Filabozzi P, Varriale A, et al. Role of thoracic ultrasound in the assessment of pleural and pulmonary diseases. J Ultrasound. 2008;11(2):39-46. [CrossRef] [PubMed]
 

Figures

Tables

References

Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957.
 
Reissig A, Görg C, Mathis G. Transthoracic sonography in the diagnosis of pulmonary diseases: a systematic approach. Ultraschall Med. 2009;30(5):438-454. [CrossRef] [PubMed]
 
Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007;120(10):871-879. [CrossRef] [PubMed]
 
Mathis G, Blank W, Reissig A, et al. Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005;128(3):1531-1538. [CrossRef] [PubMed]
 
Sperandeo M, Filabozzi P, Varriale A, et al. Role of thoracic ultrasound in the assessment of pleural and pulmonary diseases. J Ultrasound. 2008;11(2):39-46. [CrossRef] [PubMed]
 
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