American Journal of Emergency Medicine xxx (2015) xxx–xxx

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American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem

Correspondence

Lung ultrasound and pulmonary consolidations To the Editor, Here again, for the umpteenth time, we receive a letter submitted from the same group of readers commenting a lung ultrasound study. We must confess that most of the points raised in this new letter are not fully comprehensible, but perhaps it is our limit. However, it is the time to reply in general to the whole fervent activity of correspondence submitted to this and other journals by these readers. In their correspondences, they always mistake conventional consultative ultrasound and point-of-care ultrasound. As their belonging institutions show, they do not practice emergency or intensive care medicine. Although they certainly have a very advanced ultrasound skill, we respectfully think that they do not realize the contingency of the practice in emergency setting [1]. Understanding point-of-care ultrasound is crucial and also clear to the most. We daily use lung ultrasound for the diagnosis of pneumonia in the emergency department and intensive care, but we would never rely only on a thoracic imaging technique, from lung ultrasound to computed tomographic (CT) scan, to differentiate a consolidated lung because of pneumonia or cancer in a nonacute situation. Is this crucial difference so difficult to understand? Indeed, chest radiography (CXR), the standard imaging technique for pneumonia in the emergency department, has great limitations. One large study, among many others, showed the high interoperator variability reading of chest film [2]. This stands in contrast with the high accuracy and low variability showed in lung ultrasound studies [3]. Do these readers feel the necessity to investigate alternative methods to CXR and auscultation for the bedside diagnostic workup of pneumonia? This necessity is strongly felt by the whole community from the moment clinicians started to handle ultrasound themselves, with the intuitive high potential that point-of-care ultrasound is bringing to the clinical scenario. Our approach as clinicians who daily care for patients is purely investigative. We all are clearly trying to understand power and limitations of the technique in the interest of our patients. Many groups from around the world, using different machines, having different skill and professional background, are showing similar results in their studies on lung ultrasound. On the other hand, the attitude of these isolated readers insistently addressing insignificance of these studies without any constructive purpose, and without considering the significant data and statistics, appears to be scarcely motivated by a spirit of scientific investigation. This is what we recognize as prejudice, to the best because of incomprehension, to the worst because of inability to be protagonists in the significant world literature on the topic. However, writing so many letters cannot represent a valid scientific curriculum. Artifacts in ultrasound are significant not only for lung examination. The range of signs that are used in lung ultrasound goes from the visualization of the consolidation, which is a real anatomic image, to the B-lines, which are pure artifacts [4,5]. The readers should resign themselves to the fact that artifacts in ultrasonography sometimes correspond to specific clinical conditions. This correlation was largely shown for many lung ultrasound artifacts, from the B-lines to the air bronchograms

[6,7]. In a single view, the shape of air bronchograms, not only in lung ultrasound but also in CXR and CT scan, depends on the axis of the 2-dimensional image, varying from lentil-sized spots to a branch form sign. Multiple B-lines around the consolidation are indicated as “focal interstitial syndrome,” which may have a different interpretation depending on the clinical situation [8]. For instance, in acute pleuritic pain or in thoracic blunt trauma, this sign has a strong diagnostic predictive power [9,10]. The “diffuse interstitial syndrome” has a different clinical and ultrasound meaning [6,8]. However, in our study, we investigated signs of consolidation and only annotated artifacts as possible accompanying signs, never sufficient alone, without exploring the possibility of differential diagnosis with cancer [11]. Thus, the comments and speculation about B-lines and air bronchograms in the letter are misplaced. However, both lung ultrasound and CT scan have limitations in differentiating consolidations, and quite often, only a clinical follow-up with serial examinations or histology may conclude the diagnosis. Regarding the fervid correspondence activity of this group of readers, they always claim a reply to their letters, but some of them rejected our correspondence when, on the contrary, they authored a review article strongly criticized for inconsistency, published in the local journal of the Italian radiology society [12]. We still are waiting someone’s response to our strongly motivated concerns, which were not considered and replied not only by the authors but also by the editor of the journal. The American Journal of Emergency Medicine, which always hosts their letters and our replies, certainly shows a totally different style and scientific profile. Finally, the readers claim that our study will “not contribute to the current knowledge on clinical usefulness of thoracic ultrasound.” It is a personal opinion not supported by shareable concerns and scientific data, but perhaps they are right. We will see. What we can say is that many studies on lung ultrasound changed deeply not only our knowledge but also our daily practice in many settings [1]. The first historical article introducing for the very first time the tight correlation between lung ultrasound artifacts and real clinical and radiologic conditions is cited 292 times in the significant literature (source: Scopus) [6]. The document of the first international consensus conference on point-ofcare lung ultrasound published only 2 and a half years ago is already cited 205 times (source: Scopus) [8]. We encourage the readers to produce their own studies that maybe will change the current knowledge and, as such, will be extensively cited by other groups. It is the only way to resolve, or possibly support, their concerns on lung ultrasound. Giovanni Volpicelli, MD Department of Emergency Medicine, San Luigi Gonzaga University Hospital Torino, Italy S.C.D.O. Medicina d’Urgenza, Ospedale San Luigi Gonzaga, Regione Gonzole 10, Orbassano TO, Italy Tel.: +39 11 9026603 9026827 E-mail address: [email protected]

0735-6757/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Volpicelli G, Zanobetti M, Lung ultrasound and pulmonary consolidations, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.020

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Correspondence / American Journal of Emergency Medicine xxx (2015) xxx–xxx

Maurizio Zanobetti, MD Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy http://dx.doi.org/10.1016/j.ajem.2015.04.020 References [1] Volpicelli G. Usefulness of emergency ultrasound in nontraumatic cardiac arrest. Am J Emerg Med 2011;29:216–23. [2] Campbell SG, Murray DD, Hawass A, et al. Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia. Emerg Radiol 2005;11:242–6. [3] Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest 2012;142:965–72. [4] Volpicelli G. Lung sonography. J Ultrasound Med 2013;32:165–71.

[5] Volpicelli G, Melniker LA, Cardinale L, et al. Lung ultrasound in diagnosing and monitoring pulmonary interstitial fluid. Radiol Med 2013;118:196–205. [6] Lichtenstein D, Meziere G, Biderman P, et al. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156:1640–6. [7] Lichtenstein D, Meziere GSeitz J. The dynamic air bronchogram. A lung ultrasound sign of alveolar consolidation ruling out atelectasis. Chest 2009;135:1421–5. [8] Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012;38:577–91. [9] Soldati G, Testa A, Silva FR, et al. Chest ultrasonography in lung contusion. Chest 2006;130:533–8. [10] Volpicelli G, Cardinale L, Berchialla P, et al. A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED. Am J Emerg Med 2012;30:317–24. [11] Nazerian P, Volpicelli G, Vanni S, et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med 2015. http://dx.doi.org/10.1016/j.ajem.2015.01.035. [12] Sperandeo M, Rotondo A, Guglielmi G, et al. Transthoracic ultrasound in the assessment of pleural and pulmonary diseases: use and limitations. Radiol Med 2014;119: 729–40.

Please cite this article as: Volpicelli G, Zanobetti M, Lung ultrasound and pulmonary consolidations, Am J Emerg Med (2015), http://dx.doi.org/ 10.1016/j.ajem.2015.04.020

Lung ultrasound and pulmonary consolidations.

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