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Correspondence |

Lung Ultrasound in the Emergency SettingAccuracy of LUS in the Emergency Setting: Accuracy Cannot Exclude Expertise FREE TO VIEW

Cristiana Cipriani, MD; Giorgia Ghittoni, MD
Author and Funding Information

From the Department of Internal Medicine and Medical Disciplines (Dr Cipriani), Università degli Studi di Roma “La Sapienza”; and Interventional Ultrasound (Dr Ghittoni), Fondazione IRCCS Policlinico San Matteo.

CORRESPONDENCE TO: Cristiana Cipriani, MD, Department of Internal Medicine and Medical Disciplines, Università degli Studi di Roma “La Sapienza”, Viale del Policlinico 155, 00161, Rome, Italy; e-mail: cristiana.cipriani@gmail.com


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;148(3):e96. doi:10.1378/chest.15-1089
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To the Editor:

The article in CHEST (July 2015) by Pivetta et al1 reported data on the role of lung ultrasonography (LUS) in the clinical assessment of acute decompensated heart failure (ADHF), raising several concerns regarding study design and clinical implications of the results. The main conclusion from this report is that chest radiograph showed moderate accuracy in the identification of ADHF. We believe that this point needs to be clarified, and roles of different diagnostic modalities should be better defined. LUS and chest radiography can help define factors associated with dyspnea, mainly of pulmonary origin, while ECG and echocardiography are widely used to identify subclinical heart disease.

Patient’s clinical assessment, past medical history, physical examination, ECG, and blood gas analysis were performed in the study as the standard workup and followed by LUS. Those standardized methods have been defined as “heavily undermined by several factors, such as the poor sensitivity of the physical examination, ECG inaccuracy, and unreliability of chest radiography (CXR) findings.”1 This statement has to be defined in the clinical context: We believe that such a low value of the standard workup could, in selected cases, possibly be related to poor professional accuracy of the operator in charge of performing the workup, interpreting results, or both. In this scenario, chest radiography, as well as any diagnostic workup (including ultrasound, an operator-dependent procedure, by definition) could conceivably be useless for exploring the cause of dyspnea.

Additionally, Pivetta et al1 did not provide comprehensive details on LUS images a posteriori revision. Were image frames or videos evaluated? B-line artifacts are not real images and are not easily quantifiable.2-5 Are the three B lines used for identifying interstitial syndrome referring to the numbers in an image frame or during a video evaluation? If the latter, what was the duration of those videos? This is a methodologic drawback that alone could influence validity and interpretation of results, particularly considering that, “The accuracy of LUS alone was determined by reanalyzing, a posteriori, the sonographic images; the presence of diffuse IS [interstitial syndrome] was considered diagnostic for ADHF.”1

With these concerns in mind, we believe that the “pragmatic real world” should focus on the actual role of LUS as a complementary but not superior imaging technology in the emergency setting. Attempts at encouraging inexperienced medical doctors to use LUS artifacts in the definition of the differential diagnosis of acute heart disease should definitely be avoided.

References

Pivetta E, Goffi A, Lupia E, et al; for the SIMEU Group for Lung Ultrasound in the Emergency Department in Piedmont. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210. [CrossRef] [PubMed]
 
Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med. 2014;21(8):843-852. [CrossRef] [PubMed]
 
Trovato GM, Sperandeo M, Catalano D. Ultrasound diagnosis of acute pulmonary edema: the oblivion of a great future behind us. Acad Emerg Med. 2015;22(2):244-245. [CrossRef] [PubMed]
 
Trovato GM, Sperandeo M. The resistible rise of B-line lung ultrasound artefacts. Respiration. 2015;89(2):175-176. [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]
 

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References

Pivetta E, Goffi A, Lupia E, et al; for the SIMEU Group for Lung Ultrasound in the Emergency Department in Piedmont. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210. [CrossRef] [PubMed]
 
Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med. 2014;21(8):843-852. [CrossRef] [PubMed]
 
Trovato GM, Sperandeo M, Catalano D. Ultrasound diagnosis of acute pulmonary edema: the oblivion of a great future behind us. Acad Emerg Med. 2015;22(2):244-245. [CrossRef] [PubMed]
 
Trovato GM, Sperandeo M. The resistible rise of B-line lung ultrasound artefacts. Respiration. 2015;89(2):175-176. [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]
 
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