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Interpreting Lung Ultrasound B-Lines in Acute Respiratory FailureB-Lines in Respiratory Failure FREE TO VIEW

Giovanni Volpicelli, MD, FCCP
Author and Funding Information

From the Department of Emergency Medicine, San Luigi Gonzaga University Hospital.

CORRESPONDENCE TO: Giovanni Volpicelli, MD, FCCP, Department of Emergency Medicine, San Luigi Gonzaga University Hospital, 10043 Orbassano, Torino, Italy; e-mail: gio.volpicelli@tin.it


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. 2014;146(6):e230. doi:10.1378/chest.14-2098
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Published online
To the Editor:

The article in this issue of CHEST (see page 1586) by Bataille et al1 on thoracic and lung ultrasonography (LUS) is of high interest. This study has the great merit of going in the right direction. To date, scientists explored the potential of LUS alone because it represents a new paradigm. Now, it is time to move on and explore how LUS may further improve diagnostic workup by combining it with other ultrasound modalities and, even more, with other diagnostic tools.

Regarding the interpretation of B-lines, there are two points of this study that need to be addressed. The first is the high number of false-positive diagnoses of pneumonia (33%). I imagine that the typical consolidations were not visualized by LUS. It is well known that pneumonia and other consolidative conditions of the lung are surrounded by interstitial involvement.2 Sometimes, the early phase of pneumonia is only visible by interstitial patterns, which often are radiooccult.3 Moreover, deep consolidative lesions not abutting the pleural surface may be visualized as surrounding interstitial pattern. All these situations are known as focal interstitial syndromes, which cannot be misdiagnosed for congestion because of the different distribution and, as said, the focal limited extension.2 Did the authors consider these aspects?

The second point is the high percentage of false-negative findings of cardiogenic edema (37%). The interstitial syndrome is nothing more than the ultrasound effect of a partial loss of aeration and increase in density, which involves the periphery of the lung. The sensitivity was very high in previous studies. If congestion occurs, B-lines should be bilateral, homogeneously distributed, and multiple in the anterior and lateral chest. In my opinion, there are only three possible explanations for false-negative findings. The first explanation is the effect of early treatment preceding LUS. B-lines have been shown to be very fast to appear but just as quick to resolve following medical and ventilator treatment.4 A second explanation is that congestion may spare the lung periphery. In this case, normally aerated lung interposes between the probe and the congested lung, thus giving a false-negative pattern. This would be contrary to physiology and the anatomic distribution of the secondary pulmonary lobules.5 The third explanation is respiratory distress not due to congestion in acute heart failure, which is a novelty worth consideration and full discussion.

References

Bataille B, Riu B, Ferre F, et al. Integrated use of bedside lung ultrasound and echocardiography in acute respiratory failure: a prospective observational study in ICU. Chest. 2014;146(6):1586-1593.
 
Volpicelli G. Lung sonography. J Ultrasound Med. 2013;32(1):165-171. [PubMed]
 
Volpicelli G, Cardinale L, Berchialla P, Mussa A, Bar F, Frascisco MF. A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED. Am J Emerg Med. 2012;30(2):317-324. [CrossRef] [PubMed]
 
Volpicelli G, Silva F, Radeos M. Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emerg Med. 2010;17(2):63-72. [CrossRef] [PubMed]
 
Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the image—the 2004 Fleischner lecture. Radiology. 2006;239(2):322-338. [CrossRef] [PubMed]
 

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References

Bataille B, Riu B, Ferre F, et al. Integrated use of bedside lung ultrasound and echocardiography in acute respiratory failure: a prospective observational study in ICU. Chest. 2014;146(6):1586-1593.
 
Volpicelli G. Lung sonography. J Ultrasound Med. 2013;32(1):165-171. [PubMed]
 
Volpicelli G, Cardinale L, Berchialla P, Mussa A, Bar F, Frascisco MF. A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED. Am J Emerg Med. 2012;30(2):317-324. [CrossRef] [PubMed]
 
Volpicelli G, Silva F, Radeos M. Real-time lung ultrasound for the diagnosis of alveolar consolidation and interstitial syndrome in the emergency department. Eur J Emerg Med. 2010;17(2):63-72. [CrossRef] [PubMed]
 
Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the image—the 2004 Fleischner lecture. Radiology. 2006;239(2):322-338. [CrossRef] [PubMed]
 
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