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Correspondence |

Thoracic Ultrasound Limitations in the Differential Diagnosis of Respiratory Failure CausesThoracic Ultrasound Limitations FREE TO VIEW

Francesca M. Trovato, MD; Giuseppe Musumeci, PhD
Author and Funding Information

From the Department of Clinical and Experimental Medicine (Dr Trovato), The University Hospital of Catania; the Accident and Emergency Department (Dr Trovato), Ospedale Civile, Ragusa, Italy; and the Department of Biomedical and Biotechnological Sciences (Dr Musumeci), Human Anatomy and Histology Section, School of Medicine, University of Catania.

CORRESPONDENCE TO: Francesca M. Trovato, MD, Department of Clinical and Experimental Medicine, The University Hospital of Catania, via Santa Sofia, 79-95123 Catania, Italy; e-mail: trovatofrancesca@gmail.com


CONFLICT OF INTEREST: None declared.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):e186. doi:10.1378/chest.15-1879
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To the Editor:

The article by Sekiguchi et al1 in CHEST (October 2015) is particularly important because they concurrently “evaluated the diagnostic utility of combined cardiac and thoracic critical care ultrasonography” in acute hypoxic respiratory failure. This comprehensive approach is particularly valuable since, by others, lung ultrasound B-line (wrongly referred to as comet) assessment is considered unrealistically to be a very simple procedure, suitable as a stand-alone tool and not as a complementary tool of the other and more contributory clinical and ultrasound signs. Particularly relevant is, in our opinion and experience, that a very practical (and clinical) criterion is used for the assessment of pulmonary artifacts—the “B-line ratio” (proportion of chest zones with positive B-lines of all zones examined).1 This approach should be strongly recommended against the approximate, if not erratic, count or width measurement of B-line artifacts, analyzed in several subsequently checked areas.2

We would respectfully ask if the authors considered, as we do, that these measures may have limited value if intraobserver and interobserver variability information is not provided,2 particularly because the measures are taken off-line, with the possible bias related to the different operators’ recordings (interoperator variability of the actual examination and of the recording time-frame choice). It is particularly significant that in their study they confirm that the B-line criterion is predictive of miscellaneous cause vs cardiogenic pulmonary edema or ARDS. Also in this regard, we would respectfully remark that more B-lines are commonly visible, and reported, in other common conditions, such as pulmonary fibrosis and COPD.2 It is reasonable to conclude, and we wish to respectfully ask the authors if this is also their thought, that these confounding factors and overlap of conditions, so often observed in intensive care, should be considered a major limitation in the practical use of this criterion in elective and emergency medicine. Actually, the measure of B-line artifacts in emergency is still warranted, and we wish to respectfully ask the authors1 if they think that in these conditions the possibility that the inaccuracy of ultrasonography as an imaging and diagnostic tool could increase further.3

References

Sekiguchi H, Schenck LA, Horie R, et al. Critical care ultrasonography differentiates ARDS, pulmonary edema, and other causes in the early course of acute hypoxemic respiratory failure. Chest. 2015;148(4):912-918. [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]
 
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]
 

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References

Sekiguchi H, Schenck LA, Horie R, et al. Critical care ultrasonography differentiates ARDS, pulmonary edema, and other causes in the early course of acute hypoxemic respiratory failure. Chest. 2015;148(4):912-918. [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]
 
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]
 
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