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Maurizio Zanobetti, MD; Chiara Gigli, MD; Riccardo Pini, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

Emergency Department, Azienda Ospedaliero Universitaria Careggi Ringgold standard institution, Firenze, Italy

CORRESPONDENCE TO: Maurizio Zanobetti, MD, Largo Brambilla 3, Firenze 50134, Italy


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(6):1408-1409. doi:10.1016/j.chest.2017.03.046
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We thank Drs Alsolamy and Alrajhi for their thoughtful comments on our article regarding the use of point-of-care ultrasonography (PoCUS) for patients presenting with dyspnea in the ED. In their letter, the colleagues expressed some concerns regarding the effective capability of PoCUS in shortening the diagnostic process, claiming that is often possible to clinically establish a diagnosis during the initial assessment of the patient independent of other test results.

In our opinion, and according to previous literature,,, a careful history taking and a thorough physical examination can only direct diagnostic suspicion but are unreliable and need to be integrated with laboratory and radiologic testing. In their letter, Drs Alsolamy and Alrajhi themselves argue that in some patients it is possible to establish a diagnosis with a suggestive medical history and typical findings at physical examination associated with chest radiography.

Moreover, as demonstrated by Ray et al, the diagnostic performance of emergency physicians in evaluating patients with dyspnea, even when chest radiography results are considered, is low, with 20% missed diagnoses, especially in patients > 65 years, as in our population.

However, the main aim of our study was to demonstrate that the use of PoCUS shortens the diagnostic process exactly by avoiding the delay brought about by radiologic testing such as chest radiography, CT imaging, or echocardiography performed by a cardiologist. For this reason, as specified in the Methods section of our article, we included in the primary assessment of enrolled patients only vital signs, medical history, physical examination, and 12-lead electrocardiogram.

Regarding the suggestion of providing a decision tree or algorithm, we think that PoCUS with absence of diffuse interstitial syndrome and presence of reduced ejection fraction cannot be considered a “conflicting” result, because a patient with a stable low ejection fraction can present with a purely pulmonary cause of acute dyspnea such as pneumonia, COPD exacerbation, pneumothorax, or pleural effusion, all findings that we can discover by lung ultrasonography.

In conclusion, we believe that PoCUS can add significant value to the clinical assessment of many patients presenting to the ED with dyspnea and may represent the first feasible and accurate diagnostic approach to help stratify patients who should undergo a second-level diagnostic test.

References

Zanobetti M. .Scorpiniti M. .Gigli C. .et al Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151:1295-1301 [PubMed]journal
 
Mulrow C.D. .Lucey C.R. .Farnett L.E. . Discriminating causes of dyspnea through clinical examination. J Gen Intern Med. 1993;8:383-392 [PubMed]journal. [CrossRef] [PubMed]
 
Schmitt B.P. .Kushner M.S. .Wiener S.L. . The diagnostic usefulness of the history of the patient with dyspnea. J Gen Intern Med. 1986;1:386-393 [PubMed]journal. [CrossRef] [PubMed]
 
Nielsen L.S. .Svanegaard J. .Wiggers P. .Egeblad H. . The yield of a diagnostic hospital dyspnoea clinic for the primary health care section. J Intern Med. 2001;250:422-428 [PubMed]journal. [CrossRef] [PubMed]
 
Ray P. .Birolleau S. .Lefort Y. .et al Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Crit Care. 2006;10:R82- [PubMed]journal. [CrossRef] [PubMed]
 

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Tables

References

Zanobetti M. .Scorpiniti M. .Gigli C. .et al Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151:1295-1301 [PubMed]journal
 
Mulrow C.D. .Lucey C.R. .Farnett L.E. . Discriminating causes of dyspnea through clinical examination. J Gen Intern Med. 1993;8:383-392 [PubMed]journal. [CrossRef] [PubMed]
 
Schmitt B.P. .Kushner M.S. .Wiener S.L. . The diagnostic usefulness of the history of the patient with dyspnea. J Gen Intern Med. 1986;1:386-393 [PubMed]journal. [CrossRef] [PubMed]
 
Nielsen L.S. .Svanegaard J. .Wiggers P. .Egeblad H. . The yield of a diagnostic hospital dyspnoea clinic for the primary health care section. J Intern Med. 2001;250:422-428 [PubMed]journal. [CrossRef] [PubMed]
 
Ray P. .Birolleau S. .Lefort Y. .et al Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Crit Care. 2006;10:R82- [PubMed]journal. [CrossRef] [PubMed]
 
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