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Correspondence |

Time for a New Consensus on Lung Ultrasonography FREE TO VIEW

Martin Girard, MD; Gabrielle Migner-Laurin, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: M. G. has consulted for GE Healthcare and was awarded an equipment grant from GE Healthcare in July 2015. None declared (G. M.-L.).

FUNDING/SUPPORT: This work was supported by grants from the Fondation 2013, Fondation d’Anesthésiologie et Réanimation du Québec (bourse de la Fondation 2013) and the Fonds de Développement (bourse 2014), Département d’Anesthésiologie, Université de Montréal.

aDepartment of Anesthesiology, Critical Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada

bDepartment of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada

CORRESPONDENCE TO: Martin Girard, MD, Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, 1560 Sherbrooke est, Montréal, QC, H2L 4M1, Canada


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(4):986-987. doi:10.1016/j.chest.2015.10.029
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Published online

We read with great interest the recent article by Bataille et al in CHEST (December 2014) exploring the added diagnostic value of combined lung and cardiac ultrasonographic examinations compared with lung ultrasonography alone. While we also believe that an integrated cardiopulmonary approach is needed, we were rather surprised by the poor diagnostic performance of lung ultrasonography for the diagnosis of pneumonia and cardiogenic pulmonary edema.

Prior to reading the article, we expected lung ultrasonography to be a specific, but poorly sensitive examination for the diagnosis of community-acquired pneumonia. The nonspecific nature of both B lines and lung consolidations render an echographic diagnosis of pneumonia complex. To make a firm diagnosis, more detailed characterization of B lines, consolidations, and other associated echographic features (eg, pleural line) must be taken into account. An example of this issue is the Bedside Lung Ultrasound in Emergency protocol’s echographic diagnostic criteria for pneumonia, which were used by Bataille et al in their article. One of these criteria states that all lung consolidations (C profile) are pneumonia. Applying this criterion, a patient with congestive heart failure presenting with bilateral pleural effusions and resulting atelectasis would be misdiagnosed as having pneumonia. The dynamic air bronchogram sign, which represents pus and air intermingled in a bronchus moving with a patient’s ventilation, allows differentiation between atelectasis and pneumonia with good specificity but poor sensitivity. Recognizing the problem of differentiating these two common causes of consolidation, others have studied the state of pulmonary hypoxic vasoconstriction using various Doppler indices with good discriminatory power. Finally, the differential diagnosis of lung consolidations also includes lung tumors, pulmonary infarcts, and lung contusions. Using more specific contemporary lung echographic criteria for the diagnosis of pneumonia might have influenced the results of Bataille et al.

Second, Bataille et al observed that the B profile was not present in 37% of patients with cardiogenic pulmonary edema. While B lines are not specific for increased extravascular lung water, most agree they are very sensitive. Although others have already commented on this very issue, the matter of imaging settings deserves to be raised. Given their artifactual nature, improper focus setting, use of second harmonic imaging, and any automatic postprocessing can lead to dramatic changes in the appearance of B lines (Fig 1, Videos 1, 2). We could find no mention of precise imaging settings in the Materials and Methods section of the study by Bataille et al. Given that usual presets for cardiac examinations include the above-mentioned suboptimal imaging settings for lung ultrasonography, were different settings used for the cardiac and lung examinations?

Figure Jump LinkFigure 1 Influence of imaging settings on B-line visualization in the same patient using a GE Vivid q echograph and a phased array 1.5 to 4.6 MHz transducer (GE Healthcare/General Electric Co). A, Poorly visible B lines (*) when using standard cardiac ultrasound examination settings (focus 9.5 cm and use of second harmonic imaging) (Video 1). B, Highly visible B lines when using specific lung ultrasound examination settings (focus set on the pleural line, no second harmonic imaging) (Video 2).Grahic Jump Location
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;146:1586-1593 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D. .Mezière G. .Seitz J. . The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest. 2009;135:1421-1425 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D.A. .Mezière G.A. . Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125 [PubMed]journal. [CrossRef] [PubMed]
 
Yuan A. .Yang P.C. .Lee L. .et al Reactive pulmonary artery vasoconstriction in pulmonary consolidation evaluated by color Doppler ultrasonography. Ultrasound Med Biol. 2000;26:49-56 [PubMed]journal. [CrossRef] [PubMed]
 
Zanforlin A. .Smargiassi A. .Inchingolo R. .et al B-lines: to count or not to count? JACC Cardiovasc Imaging. 2014;7:635-636 [PubMed]journal
 

Figures

Figure Jump LinkFigure 1 Influence of imaging settings on B-line visualization in the same patient using a GE Vivid q echograph and a phased array 1.5 to 4.6 MHz transducer (GE Healthcare/General Electric Co). A, Poorly visible B lines (*) when using standard cardiac ultrasound examination settings (focus 9.5 cm and use of second harmonic imaging) (Video 1). B, Highly visible B lines when using specific lung ultrasound examination settings (focus set on the pleural line, no second harmonic imaging) (Video 2).Grahic Jump Location

Tables

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;146:1586-1593 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D. .Mezière G. .Seitz J. . The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest. 2009;135:1421-1425 [PubMed]journal. [CrossRef] [PubMed]
 
Lichtenstein D.A. .Mezière G.A. . Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134:117-125 [PubMed]journal. [CrossRef] [PubMed]
 
Yuan A. .Yang P.C. .Lee L. .et al Reactive pulmonary artery vasoconstriction in pulmonary consolidation evaluated by color Doppler ultrasonography. Ultrasound Med Biol. 2000;26:49-56 [PubMed]journal. [CrossRef] [PubMed]
 
Zanforlin A. .Smargiassi A. .Inchingolo R. .et al B-lines: to count or not to count? JACC Cardiovasc Imaging. 2014;7:635-636 [PubMed]journal
 
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