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Hiroshi Sekiguchi, MD; Ognjen Gajic, MD, FCCP
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic.

CORRESPONDENCE TO: Hiroshi Sekiguchi, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: sekiguchi.hiroshi@mayo.edu


CONFLICT OF INTEREST: None declared.

FUNDING/SUPPORT: This work was supported by a Mayo Clinic Department of Medicine Write-up and Publish (WRAP) grant.

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-e187. doi:10.1378/chest.15-2034
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To the Editor:

We appreciate the insightful comments made by Drs Trovato and Musumeci about our article in CHEST.1 In our study, each patient was examined once by a trained sonographer; therefore, no intraoperator or interoperator variability was measured on critical care ultrasonography image acquisition.1 Stored cardiac and thoracic images were independently reviewed by two cardiologists and two radiologists, and thoracic images were reviewed by an intensivist. The weighted κ on agreement of the number of chest zones with positive B-lines per patient was 0.97 (95% CI, 0.96-0.99). Previously, studies reported excellent intraoperator and interoperator agreement on both image acquisition and image interpretation of B-lines.2

It has been described that COPD or asthma manifests as a low number of total B-lines or few chest zones with positive B-lines.2-4 On the other hand, multiple B-lines or many chest zones with positive B-lines are often observed in interstitial syndrome (IS), such as pulmonary edema of various causes (cardiogenic or noncardiogenic), pneumonia, and diffuse parenchymal lung disease.5 Interestingly, the majority of studies that evaluated a role of positive B-lines for the diagnosis of cardiogenic pulmonary edema (CPE) did not enroll patients with exacerbation of diffuse parenchymal lung disease or ARDS.2 Diagnostic accuracy of positive B-lines for CPE may still remain high in a population where the prevalence of ARDS or noncardiogenic IS is low. However, the assessment of B-lines alone for the diagnosis of CPE may have a limited value in the ICU not because of the accuracy of B-lines for detecting IS but because of a high prevalence of ARDS or noncardiogenic IS, as seen in our study.1

It is important to clarify that in our study, patients with bilateral noncardiogenic IS were categorized into the ARDS group as were those with concurrent noncardiogenic IS with COPD exacerbation.1 Patients with concurrent CPE and ARDS were categorized into the CPE group.1 This diagnostic categorization was created with a goal to guide intensivists to recognize patients who either require aggressive diuretic therapy for CPE or more targeted therapy for ARDS or noncardiogenic IS, such as low tidal volume ventilation, corticosteroids, prone positioning, and paralytics. The same categorical approach may not be applicable in the care of patients with mild or chronic hypoxemia in the outpatient clinic or on the regular hospital ward where a specific diagnostic etiology must be identified and treated accordingly.

Acknowledgments

Role of sponsors: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

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]
 
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]
 
Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15(2):R114. [CrossRef] [PubMed]
 
Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24(12):1331-1334. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [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]
 
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]
 
Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15(2):R114. [CrossRef] [PubMed]
 
Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24(12):1331-1334. [CrossRef] [PubMed]
 
Volpicelli G, Elbarbary M, Blaivas M, et al; International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. [CrossRef] [PubMed]
 
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