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Emanuele Pivetta, MD; Alberto Goffi, MD; Enrico Lupia, MD, PhD; Maria Tizzani, MD; Giulio Porrino, MD; Enrico Ferreri, MD; Giovanni Volpicelli, MD, FCCP; Paolo Balzaretti, MD; Alessandra Banderali, MD; Antonello Iacobucci, MD; Stefania Locatelli, MD; Giovanna Casoli, MD; Michael B. Stone, MD; Milena M. Maule, PhD; Ileana Baldi, PhD; Franco Merletti, MD; Gian Alfonso Cibinel, MD; for the SIMEU Group for Lung Ultrasound in the Emergency Department in Piedmont
Author and Funding Information

From the Cancer Epidemiology Unit (Drs Pivetta, Maule, Baldi, and Merletti), Department of Medical Sciences, CeRMS and University of Turin; Department of Emergency Medicine (Drs Pivetta and Cibinel), “E. Agnelli” General Hospital, Pinerolo; Department of Emergency Medicine (Drs Pivetta and Stone), Brigham and Women’s Hospital; Department of Emergency Medicine (Drs Pivetta, Lupia, Tizzani, Porrino, Ferreri, and Locatelli), A.O.U. Città della Salute e della Scienza di Torino and University of Turin; Interdepartmental Division of Critical Care Medicine (Dr Goffi), University of Toronto; Toronto Western Hospital (Dr Goffi ), University Health Network; Department of Medical Sciences (Dr Lupia), University of Turin; Department of Emergency Medicine (Dr Volpicelli), “San Luigi Gonzaga” University Hospital, Orbassano; Department of Emergency Medicine (Dr Balzaretti), “Ordine Mauriziano” Hospital; Department of Emergency Medicine (Dr Banderali), “Cardinal Massaia” Hospital; Department of Emergency Medicine (Dr Iacobucci), “Santa Croce e Carle” Hospital; Department of Emergency Medicine (Dr Casoli), “Martini” Hospital; and Department of Cardiac, Thoracic, and Vascular Sciences (Dr Baldi), University of Padova.

CORRESPONDENCE TO: Emanuele Pivetta, MD, Department of Medical Sciences, Division of Emergency Medicine and High Dependency Unit, Cancer Epidemiology Unit, A.O.U. Città della Salute e della Scienza di Torino, Via Santena 7, 10126, Torino, Italy; e-mail: emanuele.pivetta@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-e98. doi:10.1378/chest.15-1225
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To the Editor:

We appreciate the comments of Drs Cipriani and Ghittoni, which give us the opportunity to further clarify the message of our study.1 We believe our study demonstrates that an integrated approach combining lung ultrasonography (LUS) and the standard clinical assessment significantly improves the accuracy of the diagnostic process for acute decompensated heart failure (ADHF). We do not believe that the study outcome can be summarized as “chest radiography (CXR) showed moderate accuracy in the identification of ADHF.” The poor diagnostic performance of CXR for identifying ADHF is not a new finding.2,3 Although very specific, detection of pulmonary venous congestion, interstitial edema, or alveolar edema on CXR has unacceptably low sensitivity.3 Current guidelines, indeed, caution physicians from using CXR in the diagnosis of ADHF, instead highlighting the value of CXR in the identification of alternative pulmonary causes of a given patient’s dyspnea.4

In their letter, Drs Cipriani and Ghittoni suggest that the “low value of the standard workup could, in selected cases, possibly be related to poor professional accuracy of operator in charge of performing the workup, interpreting the results, or both.” This statement is unsubstantiated. In our study, the sensitivity and specificity of the standard evaluation were as high as 85.3% and 90%, and LUS implementation was able to further increase them to 97% and 97.4%.1 Although our study included ED physicians with varying levels of expertise, we believe this is part of real-world practice and should have equally affected both clinical and LUS-implemented approaches. In addition, LUS is highly reproducible and easy to learn as compared with CXR interpretation, even when performed by physicians with minimal training.1,5 Finally, we remind Drs Cipriani and Ghittoni that our study was conducted in seven EDs from academic, university-affiliated, and community1 hospitals, providing a level of external validity not previously available in similar studies.

Drs Cipriani and Ghittoni also question the methodology used to compare the performance of CXR and LUS. In our study, the CXR reports completed by staff radiologists were compared with the original LUS findings obtained by ED physicians. No new a posteriori revision of LUS loops was performed; we simply categorized the presence of diffuse interstitial syndrome as ADHF on the basis of case report forms completed at the time of the examination.

In conclusion, we believe that our study, rather than encouraging indiscriminate LUS use, suggests a sound and prudent use of LUS integrated in the diagnostic evaluation of patients presenting to the ED with acute dyspnea. LUS implementation should not raise unjustified alarms but rather be evaluated, as with all novel medical technologies, using a scientific and unbiased approach.

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 ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210. [CrossRef] [PubMed]
 
Collins SP, Lindsell CJ, Storrow AB, Abraham WT; ADHERE Scientific Advisory Committee, Investigators and Study Group. Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med. 2006;47(1):13-18. [CrossRef] [PubMed]
 
Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294(15):1944-1956. [CrossRef] [PubMed]
 
McMurray JJ, Adamopoulos S, Anker SD, et al; ESC Committee for Practice Guidelines. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33(14):1787-1847. [CrossRef] [PubMed]
 
Martindale JL, Noble VE, Liteplo A. Diagnosing pulmonary edema: lung ultrasound versus chest radiography. Eur J Emerg Med. 2013;20(5):356-360. [CrossRef] [PubMed]
 

Figures

Tables

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 ED: a SIMEU multicenter study. Chest. 2015;148(1):202-210. [CrossRef] [PubMed]
 
Collins SP, Lindsell CJ, Storrow AB, Abraham WT; ADHERE Scientific Advisory Committee, Investigators and Study Group. Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med. 2006;47(1):13-18. [CrossRef] [PubMed]
 
Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294(15):1944-1956. [CrossRef] [PubMed]
 
McMurray JJ, Adamopoulos S, Anker SD, et al; ESC Committee for Practice Guidelines. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33(14):1787-1847. [CrossRef] [PubMed]
 
Martindale JL, Noble VE, Liteplo A. Diagnosing pulmonary edema: lung ultrasound versus chest radiography. Eur J Emerg Med. 2013;20(5):356-360. [CrossRef] [PubMed]
 
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