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Seth Koenig, MD, FCCP; Paul H. Mayo, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Department of Medicine (Drs Koenig and Mayo), Hofstra-North Shore Long Island Jewish Medical Center.

CORRESPONDENCE TO: Seth Koenig, MD, FCCP, Department of Medicine, Hofstra-North Shore Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040; e-mail: skoenig@nshs.edu


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;146(3):e109-e110. doi:10.1378/chest.14-1126
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To the Editor:

We thank Drs Nobre and Thomas for their insightful comments regarding our article.1 They call attention to the fact that the rate of CT pulmonary angiography (CTPA) results that were positive for pulmonary embolism in the study was only 12.5%. This reflects the difficulty that nonpulmonary specialists may have in deciding when to perform CTPA and is not a problem unique to our hospital. Schissler et al2 reported a 4.5% rate of positive CTPA findings at another large hospital in New York City. We agree completely that combining clinical judgment, a formal scoring system, and an alternative imaging study could substantially reduce the number of unnecessary CTPAs. We focused on the utility of ultrasonography as an imaging tool that could be useful in avoiding CTPA and did not include other factors that are useful in determining the need for a CTPA. We believe that in combination with clinical assessment and formal scoring, ultrasonography would have even greater utility. The results, although limited, are supported in a recent article by Nazerian et al.3 Although chest radiography is useful in identifying alternative diagnoses, thoracic ultrasonography has operating characteristics that are superior to chest radiography.4-6 Additionally, it may be used to assess cardiac function and to examine for DVT.

There is no doubt that the low rate of positive CTPA findings is problematic. A key question is how to convince our nonspecialist colleagues to be more thoughtful about their decisions to perform CTPA. The combination of clinical gestalt, formal scoring, and ultrasonography (or chest radiography) would likely greatly reduce the use of unnecessary CTPA.

References

Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145(4):818-823. [CrossRef] [PubMed]
 
Schissler AJ, Rozenshtein A, Kulon ME, et al. CT pulmonary angiography: increasingly diagnosing less severe pulmonary emboli. PLoS One. 2013;8(6):e65669. [CrossRef] [PubMed]
 
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. [CrossRef] [PubMed]
 
Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9-15. [CrossRef] [PubMed]
 
Xirouchaki N, Magkanas E, Vaporidi K, et al. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011;37(9):1488-1493. [CrossRef] [PubMed]
 
Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;139(5):1140-1147. [CrossRef] [PubMed]
 

Figures

Tables

References

Koenig S, Chandra S, Alaverdian A, Dibello C, Mayo PH, Narasimhan M. Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145(4):818-823. [CrossRef] [PubMed]
 
Schissler AJ, Rozenshtein A, Kulon ME, et al. CT pulmonary angiography: increasingly diagnosing less severe pulmonary emboli. PLoS One. 2013;8(6):e65669. [CrossRef] [PubMed]
 
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. [CrossRef] [PubMed]
 
Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology. 2004;100(1):9-15. [CrossRef] [PubMed]
 
Xirouchaki N, Magkanas E, Vaporidi K, et al. Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med. 2011;37(9):1488-1493. [CrossRef] [PubMed]
 
Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;139(5):1140-1147. [CrossRef] [PubMed]
 
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