Chest Ultrasonography as a Replacement for Chest Radiography in the ED: Response

Abstract

We thank Dr Medford for his thoughtful comments on our article regarding the use of chest ultrasonography (CUS) in the ED.1Zanobetti M Poggioni C Pini R Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED?.Chest. 2011; 139: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar In his letter, Dr Medford expressed some concerns for the use of CUS before chest radiography as a first-line imaging test. In general, we would agree with Dr Medford's concerns if we had proposed the use of CUS in general clinical practice, but we limited the use of this diagnostic tool as a first-line screening modality in the ED. As a consequence, we never proposed the replacement of chest radiography with CUS in the clinical management of all chest/lung diseases. Instead, we presented data supporting the advantages of ultrasonography (eg, less time consuming, absence of ionizing radiations) in the initial evaluation of patients presenting in the ED with acute dyspnea. Due to this limited and focused use of CUS, the training required to achieve clinical competence is probably shorter than the training suggested by Dr Medford. In effect, the American College of Emergency Physicians Emergency Ultrasound Guidelines2American College of Emergency Physicians Emergency ultrasound guidelines.Ann Emerg Med. 2009; 53: 550-570Abstract Full Text Full Text PDF PubMed Scopus (468) Google Scholar propose a 1-day introductory course and a minimum 2-week rotation; a minimum of 150 ultrasound examinations must be performed to acquire a sufficient level of competency.2American College of Emergency Physicians Emergency ultrasound guidelines.Ann Emerg Med. 2009; 53: 550-570Abstract Full Text Full Text PDF PubMed Scopus (468) Google Scholar This training duration seems to be significantly shorter than the training duration proposed by the Royal College of Radiology. If, as suggested by the American College of Emergency Physicians, emergency ultrasonography education is incorporated into the core educational program for all emergency medicine residency programs, in a few years all new emergency physicians will have the required competency, and a critical mass of operators will be available in the ED. Obviously, as for all novel developments, a delay is inevitable before a widespread diffusion of the new methodology is realized. Regarding the costs associated with the use of ultrasonography in the ED, at least in our experience, almost all EDs had ultrasound equipment. However, as suggested by Dr Medford, further studies must be performed to demonstrate the cost/effectiveness of CUS vs chest radiography. Regarding the detection of pneumothorax, several data demonstrated that small pneumothorax can be missed by bedside radiography but detected by CUS and subsequently confirmed by chest CT scan.3Lichtenstein DA Mezière G Lascols N et al.Ultrasound diagnosis of occult pneumothorax.Crit Care Med. 2005; 33: 1231-1238Crossref PubMed Scopus (434) Google Scholar, 4Volpicelli G Sonographic diagnosis of pneumothorax.Intensive Care Med. 2011; 37: 224-232Crossref PubMed Scopus (197) Google Scholar In conclusion, we never stated that chest radiography can be eliminated from the workout of a patient with dypsnea, but our data support the hypothesis that CUS can be a reliable modality for the initial clinical evaluation of these patients in the ED. Chest Ultrasonography as a Replacement for Chest Radiography in the EDCHESTVol. 140Issue 5PreviewThe study by Zanobetti et al1 in a recent issue of CHEST (May 2011) proposes chest ultrasonography as a replacement for chest radiography as the initial imaging modality in the ED. Although the superior sensitivity of ultrasonography over chest radiography for assessment of effusion is acknowledged and in keeping with previous studies,2 there are a number of caveats to using ultrasonography in favor of chest radiography as a first-line imaging test. Full-Text PDF