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Correspondence |

Pulmonary UltrasonographyLung Ultrasound and Echocardiography: Staying Within the Lines Prevents Us Finding Something Better on the Other Side FREE TO VIEW

Guglielmo M. Trovato, MD; Marco Sperandeo, MD
Author and Funding Information

From the Department of Medical and Pediatric Sciences, University of Catania (Dr Trovato); and the Interventional and Diagnostic Ultrasound Unit, Department of Internal Medicine, IRCCS Casa Sollievo della Sofferenza (Dr Sperandeo).

CORRESPONDENCE TO: Guglielmo M. Trovato, MD, School of Medicine and Policlinico University Hospital, Department Medical and Pediatric Sciences, University of Catania, Catania, Italy; e-mail: Guglielmotrovato@unict.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. 2015;147(6):e236-e237. doi:10.1378/chest.14-3118
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To the Editor:

The article by Bataille et al1 in CHEST (December 2014) represents a significant advancement in the field, not least because it demonstrates that lung ultrasonography (LUS) has serious limitations in patients with acute respiratory failure and that thoracic ultrasonography (TUS), which includes echocardiography, is preferable. Nevertheless, even if we consider Descartes’ observation that perfect numbers, like perfect men, are very rare, we wonder what numerical grounds there are for claiming that TUS could disambiguate cases of hemodynamic pulmonary edema and pneumonia.1 Is this conundrum solved with the aid of careful physical examination?

Although we agree that “the bedside use of artificial intelligence methods in this setting could pave the way for the development of new clinically relevant integrative diagnostic models,”1 we respectfully emphasize that overreliance on such tools could undermine quick clinical decisions in emergency scenarios. Indeed, artificial intelligence feedback, yielded by software programmed using information from very human, and therefore potentially fallacious, subjects, is no substitute for easy-to-use and reliable diagnostic tools in the hands of comprehensively trained experts.

Likewise, we agree that the statistical approach adopted, partial least-squares regression, was appropriate, particularly because 7% of pulmonary and 10% of cardiac ultrasonographic data were missing at the recording time. However, focusing more on the core of the study, we would like to highlight some of the authors’ statements and make a few respectful remarks and queries of our own:

  1. First and foremost, we strongly agree with the authors’ statement emphasizing the weakness/unreliability of using an increase in LUS B-lines2,3 for diagnostic purposes: “Of note, the exclusive use of LUS patterns to detect cardiac edema (B profile) was highly unreliable because B lines were also detected in 33% of pneumonia cases (ie, false-positive diagnosis) and absent in 37% of cardiogenic edema cases (ie, false-negative diagnosis).”1

  2. The finding that fewer patients with cardiogenic edema (22 of 34, 65%) were correctly diagnosed by LUS than by TUS (32 of 34, 94%) is to be expected, as the latter technique includes echocardiography, undoubtedly the most appropriate option for a cardiologic diagnosis.4,5 However, the authors’ finding that 51 of 77 patients with pneumonia (66%) were correctly diagnosed by LUS and 64 of 77 (83%) by TUS is not so intuitive, and we wonder whether the authors can explain why this should be so.

  3. We would also be interested to learn whether there were any comorbidities present in this series, and what effect this would have on the findings (aside from complicating the statistical analysis, of course).

We hope that the authors of this excellent study, steadfastly aimed at improving best clinical practice, will enlighten us. After all, “In questions of science the authority of a thousand is not worth the humble reasoning of a single individual” (Galileo Galilei).

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. [CrossRef] [PubMed]
 
Trovato GM, Sperandeo M. Sounds, ultrasounds, and artifacts: which clinical role for lung imaging? Am J Respir Crit Care Med. 2013;187(7):780-781. [CrossRef] [PubMed]
 
Catalano D, Trovato GM, Sperandeo M. Acute heart failure diagnosis by ultrasound: new achievements and persisting limitations. Am J Emerg Med. 2014;32(4):384-385. [CrossRef] [PubMed]
 
Trovato GM, Catalano D, Sperandeo M. Assessment of lung ultrasound artifacts (B-lines): incremental contribution to echocardiography in heart failure? JACC Cardiovasc Imaging. 2014;7(6):635. [CrossRef] [PubMed]
 
Trovato GM, Catalano D, Sperandeo M. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(3):406-407. [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. [CrossRef] [PubMed]
 
Trovato GM, Sperandeo M. Sounds, ultrasounds, and artifacts: which clinical role for lung imaging? Am J Respir Crit Care Med. 2013;187(7):780-781. [CrossRef] [PubMed]
 
Catalano D, Trovato GM, Sperandeo M. Acute heart failure diagnosis by ultrasound: new achievements and persisting limitations. Am J Emerg Med. 2014;32(4):384-385. [CrossRef] [PubMed]
 
Trovato GM, Catalano D, Sperandeo M. Assessment of lung ultrasound artifacts (B-lines): incremental contribution to echocardiography in heart failure? JACC Cardiovasc Imaging. 2014;7(6):635. [CrossRef] [PubMed]
 
Trovato GM, Catalano D, Sperandeo M. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(3):406-407. [CrossRef] [PubMed]
 
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