- Email: [email protected]
About ultrasound in pneumothorax
Correspondence cannot be totally free of floating inside the pleural space. In this case, with the patient lying in the supine position, we could still find regular sliding in the anterior and inferior chest. Moving the probe toward the lateral chest, we will find the limited air layer that will move synchronous with respiration, thus sliding under the probe. For this reason, both edges of the pneumothorax can be scanned and visualized as 2 lung points alternating on the 2 opposite extremities of the probe and moving in opposite directions. One lung point appears on one end of the probe during inspiration, and then the other lung point will come from the opposite end of the probe in expiration. When the air layer is small, we might detect both edges of the bulla in the same scan, by keeping the probe motionless on a particular location on the chest wall. When the air layer is too large to be delimited by a unique scan, we can find the other lung point by moving the probe laterally. Again, an essential feature of this sign is that the second sliding pattern should appear from the opposite end of the probe. The reader could find a clearer explanation by reading a recent review on this topic and watching the related additional file (online resource 1), which is a video clip recorded from a case of double lung point that explains it much better than any word [2]. “Pleural adherences”. The exact term that we used in the text is: “…the visceral and parietal pleural layers for some reason adhere,…” In the case described, the most likely reason of adhesion was that air collection was simply too small to allow complete detachment of the pleural layers, thus rendering it not totally free of floating to the dependent area of the chest. Adherences are not necessarily fibrotic. However, even in the case of tight adherence due to disease, we still are able to detect areas where regular lung sliding alternates with nonsliding. In this case, the problem is the differential diagnosis of conditions that share absence of sliding with the pneumothorax; but this is another question. “Double lung point in the neonate”. The real question is about the meaning of the term lung point and not the double lung point. The “lung point” is traditionally and historically referred to the diagnosis of pneumothorax. Among the 4 signs that allow the correct sonographic diagnosis of pneumothorax, the lung point is the only one showing high accuracy in ruling in the condition (highly specific). For these reasons, it is natural for the community to associate this sign with pneumothorax. The double lung point in the neonate is not a sign of pneumothorax but diagnostic of the transient tachypnea of the newborn. It should always be clarified as the “double lung point of the transient tachypnea of the newborn” to avoid misinterpretation. “Radiographic diagnosis”. The authors of the letter are questioning the radiographic diagnosis of pneumothorax of this case. Since I have done this job I am used to questioning everything, so I have to answer that it is always possible to misdiagnose. However, it is only a matter of probability. I ask the authors: how likely is it that 5 physicians could have misinterpreted the same chest radiography at the same time? Namely, they were the radiologist and the emergency
833 physician of the institution that referred the patient, our attending radiologist, our thoracic surgeon who took charge of the patient for the follow-up, and me. Regarding the location of the pneumothorax, we could discuss this endlessly without confirmation because we lack CT examination. Chest radiography is highly specific, and lung ultrasound is highly sensitive in the diagnosis of pneumothorax. Neither one nor the other, however, is accurate enough in clarifying the exact location and volumetric quantification of pneumothorax. Moreover, it should be considered that difference in the timing and position of the patient between the first radiologic diagnosis (upright) and our ultrasound evaluation (supine) could have justified a change in the condition. “Area of pleuritis”. We studied pleuritic pain in patients with negative chest radiography and showed for the first time that a lung ultrasound can detect many radio-occult pleural and pulmonary conditions, including pleuritis [3,4]. In our daily practice and case studies, we have never seen pleuritis showing motionless lung without visible changes of the parietal pleura, subpleural consolidations, focal interstitial syndrome, and without even the mildest effusion. The ultrasound pattern that we observed in this case cannot be caused by pleuritis, whereas absence of lung pulse was decisive in concluding that the cause could not be referred to as anything but air in the pleural space [2]. Giovanni Volpicelli MD Department of Emergency Medicine San Luigi Gonzaga University Hospital Torino, Italy E-mail address: [email protected] doi:10.1016/j.ajem.2011.04.014
References [1] Lichtenstein D, Meziere G, Biderman P, et al. The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26: 1434-40. [2] Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011;37:224-32. [3] Volpicelli G, Caramello V, Cardinale L, et al. Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain. Ultrasound Med Biol 2008;34:1717-23. [4] 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 2011. doi:10.1016/j.ajem.2010.11.035.
About ultrasound in pneumothorax To the Editor, The interesting case report “the double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax” by Volpicelli and Audino [1] raises several questions.
834
Correspondence
The lung point as defined by Lichtenstein et al [2] is a dynamic sign at a specific location on the chest where lung sliding alternates with absent lung sliding during the respiratory cycle; but at any particular point in time, only one of them is present. It is not clear from the report that this sign was detected; and without it, the ultrasound diagnosis of an incomplete pneumothorax is not secure. The authors postulated that the air forms a “bulla surrounded by adherent pleural layers,” producing the double lung point. However, if the pleura is adherent, it should not be possible to detect a lung point sign but only an area of absent lung sliding. Of note, the term double lung point has already been used to describe a completely different lung ultrasound sign in the neonate useful in the diagnosis of transient tachypnea of the newborn [3]. In addition, if the air bulla is fixed, it seems unlikely that the apical pneumothorax seen on the initial chest radiograph would spread as far as the fourth interspace in the anterolateral and midaxillary areas. Could the initial radiograph have been misinterpreted? Anterior lung sliding in the supine patient has been claimed to rule out a pneumothorax [4], and it is interesting to note that, in the series of Lichtenstein et al [2] of 47 radio-occult pneumothoraces, all had absent anterior lung sliding in the supine position irrespective of whether a lung point was detected [5]. In the area of absent lung sliding, B lines or a lung pulse sign would rule out a pneumothorax at that location. It is not clear whether B lines were present or the lung pulse assessed. Is it possible that the localized area of absent lung sliding represented an area of pleuritis causing the pleuritic chest pain and absent lung sliding due to adhesions, which resolved over the next week? Andrew Verniquet MD Department of Anesthesia Central Health-James Paton Memorial Hospital Gander, Newfoundland and Labrador Canada A1V 2K1 E-mail address: [email protected] Rafid Kakel MD Department of Orthopedic Surgery Central Health-James Paton Memorial Hospital Gander, Newfoundland and Labrador Canada A1V 2K1 doi:10.1016/j.ajem.2011.04.015
References [1] Volpicelli G, Audino B. The double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax. Am J Emerg Med 2011;29: 355e1-355e2. [2] Lichtenstein D, Meziere G, Biderman P, et al. The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26: 1434-40.
[3] Copetti R, Catarossi L. The “double lung point”: an ultrasound sign diagnostic of transient tachypnea of the newborn. Neonatology 2007;91: 203-9. [4] Lichtenstein D, Menu YA. Bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 1995;108:1345-8. [5] Lichtenstein D, Meziere G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33:1231-8.
Gang members in the ED: what you believe may not be true To the Editor, Gang membership has been associated with a variety of high-risk behaviors: drug use and sales, violence both as perpetrator and as victim, and dropping out of high school [1,2]. Many of these risky behaviors increase the likelihood that gang members will land in an emergency department (ED) [3]. We do not yet know the types of health concerns that bring gang members to the ED, the ways in which their visits differ from those of nongang members, and we lack prevalence information that might lead to the development of interventions addressing gang issues or risky behaviors. In addition, the opinions of ED staff toward gang members are not well documented. Recent studies have found that health care provider biases and prejudices exist, even among physicians who claim to have none, and can have a negative effect on treatment of patients [4,5]. We assessed ED staff beliefs regarding young adult ED patients and gang membership and then asked urbandwelling, noncritical ED patients aged 18 to 25 years about gang membership and risky behaviors. This project was approved by the Office of Human Research, The George Washington University. In the ED at George Washington University Hospital (Level I Trauma Center with 62,000 adult patients per year), ED staff, including technicians, nurses, and physicians, who had been employed in the study ED for longer than 1 year participated in a descriptive survey to assess ED staff beliefs regarding young adult (ages 18-25 years) patients and gang membership. Fifty-six ED staff members participated (approximately 78 persons were approached; some on multiple occasions, estimated response rate 71%). The mean estimate of gang membership among young ED patients by the staff was 23.4% (range, 2%-100%; SD, 22.6). Of the staff, 59.6% believed that patients would not reveal gang membership to providers if asked. Sex, age, length of practice, and staff position were not associated with any trends in the prediction of gang membership. We next surveyed a convenience sample of non-critically ill, English-speaking, DC-residing ED patients aged 18 to 25 years between March and September 2008. Patients with critical illness or injury, those undergoing procedures, and those receiving sedating medications were not eligible. Of 380 eligible patients, 235 agreed to participate (61.8% response). The respondents were 64.3% women, 58.1%
833 physician of the institution that referred the patient, our attending radiologist, our thoracic surgeon who took charge of the patient for the follow-up, and me. Regarding the location of the pneumothorax, we could discuss this endlessly without confirmation because we lack CT examination. Chest radiography is highly specific, and lung ultrasound is highly sensitive in the diagnosis of pneumothorax. Neither one nor the other, however, is accurate enough in clarifying the exact location and volumetric quantification of pneumothorax. Moreover, it should be considered that difference in the timing and position of the patient between the first radiologic diagnosis (upright) and our ultrasound evaluation (supine) could have justified a change in the condition. “Area of pleuritis”. We studied pleuritic pain in patients with negative chest radiography and showed for the first time that a lung ultrasound can detect many radio-occult pleural and pulmonary conditions, including pleuritis [3,4]. In our daily practice and case studies, we have never seen pleuritis showing motionless lung without visible changes of the parietal pleura, subpleural consolidations, focal interstitial syndrome, and without even the mildest effusion. The ultrasound pattern that we observed in this case cannot be caused by pleuritis, whereas absence of lung pulse was decisive in concluding that the cause could not be referred to as anything but air in the pleural space [2]. Giovanni Volpicelli MD Department of Emergency Medicine San Luigi Gonzaga University Hospital Torino, Italy E-mail address: [email protected] doi:10.1016/j.ajem.2011.04.014
References [1] Lichtenstein D, Meziere G, Biderman P, et al. The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26: 1434-40. [2] Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011;37:224-32. [3] Volpicelli G, Caramello V, Cardinale L, et al. Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain. Ultrasound Med Biol 2008;34:1717-23. [4] 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 2011. doi:10.1016/j.ajem.2010.11.035.
About ultrasound in pneumothorax To the Editor, The interesting case report “the double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax” by Volpicelli and Audino [1] raises several questions.
834
Correspondence
The lung point as defined by Lichtenstein et al [2] is a dynamic sign at a specific location on the chest where lung sliding alternates with absent lung sliding during the respiratory cycle; but at any particular point in time, only one of them is present. It is not clear from the report that this sign was detected; and without it, the ultrasound diagnosis of an incomplete pneumothorax is not secure. The authors postulated that the air forms a “bulla surrounded by adherent pleural layers,” producing the double lung point. However, if the pleura is adherent, it should not be possible to detect a lung point sign but only an area of absent lung sliding. Of note, the term double lung point has already been used to describe a completely different lung ultrasound sign in the neonate useful in the diagnosis of transient tachypnea of the newborn [3]. In addition, if the air bulla is fixed, it seems unlikely that the apical pneumothorax seen on the initial chest radiograph would spread as far as the fourth interspace in the anterolateral and midaxillary areas. Could the initial radiograph have been misinterpreted? Anterior lung sliding in the supine patient has been claimed to rule out a pneumothorax [4], and it is interesting to note that, in the series of Lichtenstein et al [2] of 47 radio-occult pneumothoraces, all had absent anterior lung sliding in the supine position irrespective of whether a lung point was detected [5]. In the area of absent lung sliding, B lines or a lung pulse sign would rule out a pneumothorax at that location. It is not clear whether B lines were present or the lung pulse assessed. Is it possible that the localized area of absent lung sliding represented an area of pleuritis causing the pleuritic chest pain and absent lung sliding due to adhesions, which resolved over the next week? Andrew Verniquet MD Department of Anesthesia Central Health-James Paton Memorial Hospital Gander, Newfoundland and Labrador Canada A1V 2K1 E-mail address: [email protected] Rafid Kakel MD Department of Orthopedic Surgery Central Health-James Paton Memorial Hospital Gander, Newfoundland and Labrador Canada A1V 2K1 doi:10.1016/j.ajem.2011.04.015
References [1] Volpicelli G, Audino B. The double lung point: an unusual sonographic sign of juvenile spontaneous pneumothorax. Am J Emerg Med 2011;29: 355e1-355e2. [2] Lichtenstein D, Meziere G, Biderman P, et al. The lung point: an ultrasound sign specific to pneumothorax. Intensive Care Med 2000;26: 1434-40.
[3] Copetti R, Catarossi L. The “double lung point”: an ultrasound sign diagnostic of transient tachypnea of the newborn. Neonatology 2007;91: 203-9. [4] Lichtenstein D, Menu YA. Bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 1995;108:1345-8. [5] Lichtenstein D, Meziere G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med 2005;33:1231-8.
Gang members in the ED: what you believe may not be true To the Editor, Gang membership has been associated with a variety of high-risk behaviors: drug use and sales, violence both as perpetrator and as victim, and dropping out of high school [1,2]. Many of these risky behaviors increase the likelihood that gang members will land in an emergency department (ED) [3]. We do not yet know the types of health concerns that bring gang members to the ED, the ways in which their visits differ from those of nongang members, and we lack prevalence information that might lead to the development of interventions addressing gang issues or risky behaviors. In addition, the opinions of ED staff toward gang members are not well documented. Recent studies have found that health care provider biases and prejudices exist, even among physicians who claim to have none, and can have a negative effect on treatment of patients [4,5]. We assessed ED staff beliefs regarding young adult ED patients and gang membership and then asked urbandwelling, noncritical ED patients aged 18 to 25 years about gang membership and risky behaviors. This project was approved by the Office of Human Research, The George Washington University. In the ED at George Washington University Hospital (Level I Trauma Center with 62,000 adult patients per year), ED staff, including technicians, nurses, and physicians, who had been employed in the study ED for longer than 1 year participated in a descriptive survey to assess ED staff beliefs regarding young adult (ages 18-25 years) patients and gang membership. Fifty-six ED staff members participated (approximately 78 persons were approached; some on multiple occasions, estimated response rate 71%). The mean estimate of gang membership among young ED patients by the staff was 23.4% (range, 2%-100%; SD, 22.6). Of the staff, 59.6% believed that patients would not reveal gang membership to providers if asked. Sex, age, length of practice, and staff position were not associated with any trends in the prediction of gang membership. We next surveyed a convenience sample of non-critically ill, English-speaking, DC-residing ED patients aged 18 to 25 years between March and September 2008. Patients with critical illness or injury, those undergoing procedures, and those receiving sedating medications were not eligible. Of 380 eligible patients, 235 agreed to participate (61.8% response). The respondents were 64.3% women, 58.1%