- Email: [email protected]
or chest pain
264 Journal of Cardiac Failure Vol. 14 No. 3 April 2008 4. Lichtenstein D, Mezie`re G, Biderman P, Gepner A, Barre´ O. The comet tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156:1640e6. 5. Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 2006;24:689e96. 6. Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF. Detection of sonographic B lines in patients with normal lungs or radiographic alveolar consolidation. Med Sci Monit 2008;14:CR122e8. 7. Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest 2006;130:533e8. 8. Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco M. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008; In press. doi:10.1016/j.cardfail.2008.01.007
Prognostic value of extravascular lung water assessed with ultrasound lung comets by chest sonography in patients with dyspnea and/or chest pain
The Reply: We thank Dr Volpicelli for his interest in our article. The letter raises several interesting issues deserving clarification. 1. The semantics. It is true that other names have been proposed over the years, such as ‘‘comet-tail artifacts’’ or ‘‘B-lines’’ in the seminal work of Lichtenstein et al.1 We prefer ultrasound lung comets (ULCs) because the acronym puts together several key information necessary to establish a clear ‘‘relation between signs and the things they refer to’’ (Wikipedia definition of semantics). The term ‘‘ultrasound lung comet’’ implies ultrasound-based technique, lung sonography, and comet-like appearance.2 The term ‘‘artifact’’ may be misleading, because the first echo of the comet reverberation is indeed generated by a real biological interface in the water-thickened subpleural interlobular septa. The term ‘‘B-line’’ is also unsatisfactory because ULCs can be present before Kerley B-lines and can be made of water but also of connective tissue. 2. The diagnostic ambiguity. ULCs can be present for accumulation of lung water (eg, in heart failure) or lung fibrosis (eg, in diffuse sclerodermia). Dr Volpicelli points out that in patients with acute dyspnea, no ULCs are usually detected in pneumogenic dyspnea. We agree on that, and indeed we have shown that ULCs can help the cardiologist in identifying cardiogenic dyspnea.3 3. The prognostic meaning. We agree that ULCs can help the physician to monitor the diuretic efficacy in patients with pulmonary congestion at the bedside, but in our opinion it seems unlikely that the worse prognosis is only linked to the resistance and delay in the clearing up of ULCs by treatment. Both watery and fibrotic ULCs probably have an unfavorable prognostic meaning, and it is entirely possible that ‘‘fixed’’
(fibrotic, diuretic-resistant) ULCs are prognostically different from ‘‘reversible’’ (watery) ULCs. Neverthless, it is well known that in patients with heart failure or acutely ill patients, lung water accumulation is associated with a worse prognostic outcome.4 4. The quantification. The ULC score adopted in our laboratory2 integrates the number of ULCs in any intercostal space (the severity) with the number of intercostal spaces showing an abnormal signal (the extent). This method served us well in clinical3 and experimental studies5 over the years, and it seems to be an acceptable trade-off between need of accuracy and priority of simplicity.2 This approach is easy to do and fast to learn.6 We count ULCs on-line during the examination, on moving images, and the image freeze is rarely used. Several other approaches are obviously possible. 5. The pragmatics. Pragmatics is an important part of semeiotics and describes the relation of signs to their impact on those who use them (Wikipedia). We need quantification for accuracy, but we also need simplicity for a clinically driven assessment in a theatre often characterized by intense time pressure. In this context, the separation of ‘‘black,’’ ‘‘black and white,’’ and ‘‘white’’ lung is an attempt to broadly simplify the main, clinically relevant patterns of chest sonography for the cardiologist. In the lungs, the normal signal is no signal, and the abnormal signal represents ‘‘the shape of water’’ and can be semiquantitatively titrated by eyeballing analysis. Dr Volpicelli himself seems to be vulnerable to the appeal of this straightforward approach because he elegantly describes ‘‘shining’’ or ‘‘white’’ lung comets a few lines before warning against the use of this terminology ‘‘disconcerting for the sonographer.’’ When a ‘‘white lung’’ pattern is observed in a given intercostal space, we assign the arbitrary ‘‘plateau’’ value of 10 ULCs for quantification purposes. In conclusion, we agree that the ULCs are a key sign of chest sonography and offer a novel opportunity for the detection of extravascular lung water and lung fibrosis with a practical, radiation-free method. The ULCs may appear somewhat different to astronomers-sonographers looking at them from different angles of view and disparate clinical perspectives (intensive care, emergency care, pneumology, cardiology).7,8 However, all agree on the key issue.1,2,6,8,9 Because the current technology for measuring lung edema can be inaccurate (chest x-ray), cumbersome (nuclear medicine and radiology techniques), or invasive (indicator dilution), there is great diagnostic and prognostic potential for ultrasound technology that can quantify lung edema noninvasively in real time. Francesca Frassi, MD Luna Gargani, MD Eugenio Picano, MD, PhD
MMPs as Markers of Post-MI Remodeling
Cardiology Division, CNR Institute of Clinical Physiology Pisa, Italy References 1. Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156:1640e6. 2. Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 2006;19:356e63. 3. Gargani L, Frassi F, Soldati G, Tesorio P, Gheorghiade M, Picano E. Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: a comparison with natriuretic peptides. Eur J Heart Fail 2008;10:70e7. 4. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP,
5.
6.
7.
8.
9.
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265
Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564e75. Gargani L, Lionetti V, Di Cristofano C, Bevilacqua G, Recchia FA, Picano E. Early detection of acute lung injury uncoupled to hypoxemia in pigs using ultrasound lung comets. Crit Care Med 2007;35:2769e74. Bedetti G, Gargani L, Corbisiero A, Frassi F, Poggianti E, Mottola G. Evaluation of ultrasound lung comets by hand-held echocardiography. Cardiovasc Ultrasound 2006;4:34. Rajan GR. Ultrasound lung comets: a clinically useful sign in acute respiratory distress syndrome/acute lung injury. Crit Care Med 2007; 35:2869e70. Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008;133:204e11. Copetti R, Cattarossi L, Macagno F, Violino M, Furlan R. Lung ultrasound in respiratory distress syndrome: a useful tool for early diagnosis. Neonatology 2008;94:52e9. doi:10.1016/j.cardfail.2008.01.016
Prognostic value of extravascular lung water assessed with ultrasound lung comets by chest sonography in patients with dyspnea and/or chest pain
The Reply: We thank Dr Volpicelli for his interest in our article. The letter raises several interesting issues deserving clarification. 1. The semantics. It is true that other names have been proposed over the years, such as ‘‘comet-tail artifacts’’ or ‘‘B-lines’’ in the seminal work of Lichtenstein et al.1 We prefer ultrasound lung comets (ULCs) because the acronym puts together several key information necessary to establish a clear ‘‘relation between signs and the things they refer to’’ (Wikipedia definition of semantics). The term ‘‘ultrasound lung comet’’ implies ultrasound-based technique, lung sonography, and comet-like appearance.2 The term ‘‘artifact’’ may be misleading, because the first echo of the comet reverberation is indeed generated by a real biological interface in the water-thickened subpleural interlobular septa. The term ‘‘B-line’’ is also unsatisfactory because ULCs can be present before Kerley B-lines and can be made of water but also of connective tissue. 2. The diagnostic ambiguity. ULCs can be present for accumulation of lung water (eg, in heart failure) or lung fibrosis (eg, in diffuse sclerodermia). Dr Volpicelli points out that in patients with acute dyspnea, no ULCs are usually detected in pneumogenic dyspnea. We agree on that, and indeed we have shown that ULCs can help the cardiologist in identifying cardiogenic dyspnea.3 3. The prognostic meaning. We agree that ULCs can help the physician to monitor the diuretic efficacy in patients with pulmonary congestion at the bedside, but in our opinion it seems unlikely that the worse prognosis is only linked to the resistance and delay in the clearing up of ULCs by treatment. Both watery and fibrotic ULCs probably have an unfavorable prognostic meaning, and it is entirely possible that ‘‘fixed’’
(fibrotic, diuretic-resistant) ULCs are prognostically different from ‘‘reversible’’ (watery) ULCs. Neverthless, it is well known that in patients with heart failure or acutely ill patients, lung water accumulation is associated with a worse prognostic outcome.4 4. The quantification. The ULC score adopted in our laboratory2 integrates the number of ULCs in any intercostal space (the severity) with the number of intercostal spaces showing an abnormal signal (the extent). This method served us well in clinical3 and experimental studies5 over the years, and it seems to be an acceptable trade-off between need of accuracy and priority of simplicity.2 This approach is easy to do and fast to learn.6 We count ULCs on-line during the examination, on moving images, and the image freeze is rarely used. Several other approaches are obviously possible. 5. The pragmatics. Pragmatics is an important part of semeiotics and describes the relation of signs to their impact on those who use them (Wikipedia). We need quantification for accuracy, but we also need simplicity for a clinically driven assessment in a theatre often characterized by intense time pressure. In this context, the separation of ‘‘black,’’ ‘‘black and white,’’ and ‘‘white’’ lung is an attempt to broadly simplify the main, clinically relevant patterns of chest sonography for the cardiologist. In the lungs, the normal signal is no signal, and the abnormal signal represents ‘‘the shape of water’’ and can be semiquantitatively titrated by eyeballing analysis. Dr Volpicelli himself seems to be vulnerable to the appeal of this straightforward approach because he elegantly describes ‘‘shining’’ or ‘‘white’’ lung comets a few lines before warning against the use of this terminology ‘‘disconcerting for the sonographer.’’ When a ‘‘white lung’’ pattern is observed in a given intercostal space, we assign the arbitrary ‘‘plateau’’ value of 10 ULCs for quantification purposes. In conclusion, we agree that the ULCs are a key sign of chest sonography and offer a novel opportunity for the detection of extravascular lung water and lung fibrosis with a practical, radiation-free method. The ULCs may appear somewhat different to astronomers-sonographers looking at them from different angles of view and disparate clinical perspectives (intensive care, emergency care, pneumology, cardiology).7,8 However, all agree on the key issue.1,2,6,8,9 Because the current technology for measuring lung edema can be inaccurate (chest x-ray), cumbersome (nuclear medicine and radiology techniques), or invasive (indicator dilution), there is great diagnostic and prognostic potential for ultrasound technology that can quantify lung edema noninvasively in real time. Francesca Frassi, MD Luna Gargani, MD Eugenio Picano, MD, PhD
MMPs as Markers of Post-MI Remodeling
Cardiology Division, CNR Institute of Clinical Physiology Pisa, Italy References 1. Lichtenstein D, Meziere G, Biderman P, Gepner A, Barre O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997;156:1640e6. 2. Picano E, Frassi F, Agricola E, Gligorova S, Gargani L, Mottola G. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr 2006;19:356e63. 3. Gargani L, Frassi F, Soldati G, Tesorio P, Gheorghiade M, Picano E. Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: a comparison with natriuretic peptides. Eur J Heart Fail 2008;10:70e7. 4. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP,
5.
6.
7.
8.
9.
Jugdutt
265
Bernard GR, Thompson BT, Hayden D, deBoisblanc B, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564e75. Gargani L, Lionetti V, Di Cristofano C, Bevilacqua G, Recchia FA, Picano E. Early detection of acute lung injury uncoupled to hypoxemia in pigs using ultrasound lung comets. Crit Care Med 2007;35:2769e74. Bedetti G, Gargani L, Corbisiero A, Frassi F, Poggianti E, Mottola G. Evaluation of ultrasound lung comets by hand-held echocardiography. Cardiovasc Ultrasound 2006;4:34. Rajan GR. Ultrasound lung comets: a clinically useful sign in acute respiratory distress syndrome/acute lung injury. Crit Care Med 2007; 35:2869e70. Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008;133:204e11. Copetti R, Cattarossi L, Macagno F, Violino M, Furlan R. Lung ultrasound in respiratory distress syndrome: a useful tool for early diagnosis. Neonatology 2008;94:52e9. doi:10.1016/j.cardfail.2008.01.016