1. health and fitness
2. disease

Table 1—Patients With COPD in Each Cardiovascular Risk Category Prescribed an Antiplatelet Drug,
Statin, or Other Anticoagulant
No Established CVD
Drug
Antiplatelet
Statin
Other anticoagulant
Established CVD (n 5 32)
Estimated 10-y CV
Risk . 20% (n 5 32)
Estimated 10-y CV
Risk 10%-20% (n 5 26)
Estimated 10-y CV
Risk , 10% (n 5 27)
22 (69)
17 (53)
8 (25)
19 (59)
7 (22)
6 (19)
3 (12)
12 (46)
4 (15)
8 (30)
3 (11)
1 (7)
Data presented as No. (%). CV 5 cardiovascular; CVD 5 cardiovascular disease.
Low rates of statin and aspirin prescribing in patients
with both COPD and increased cardiovascular risk imply that
CVD is considered too infrequently in this group. Because
COPD itself may well be an additional risk factor for CVD, it
follows that statin therapy, along with other interventions to
modify cardiovascular risk, is especially important in this complex group.1
Richard D. Turner, MBChB
Charles M. Gwavava, MBChB
Stephen M. Bianchi, PhD
Sheffield, England
Affiliations: From the Department of Respiratory Medicine,
Sheffield Teaching Hospitals NHS Trust.
Financial/nonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be discussed in this article.
Correspondence to: Richard D. Turner, MBChB, Sheffield
Teaching Hospitals NHS Trust, Department of Respiratory
Medicine, Herries Rd, Sheffield, S5 7AU, England; e-mail:
richturner77@yahoo.com
© 2011 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (http://www.chestpubs.org/
site/misc/reprints.xhtml).
DOI: 10.1378/chest.11-0887
References
1. Nussbaumer-Ochsner Y, Rabe KF. Systemic manifestations
of COPD. Chest. 2011;139(1):165-173.
2. British Cardiac Society; British Hypertension Society;
Diabetes UK; HEART UK; Primary Care Cardiovascular
Society; Stroke Association. JBS 2: Joint British Societies’
guidelines on prevention of cardiovascular disease in clinical
practice. Heart. 2005;91(suppl 5):v1-v52.
3. Pearson TA, Blair SN, Daniels SR, et al; American Heart
Association Science Advisory and Coordinating Committee.
AHA guidelines for primary prevention of cardiovascular
disease and stroke: 2002 update: consensus panel guide to
comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation.
2002;106(3):388-391.
4. Baigent C, Blackwell L, Collins R, et al; Antithrombotic
Trialists’ (ATT) Collaboration. Aspirin in the primary and
secondary prevention of vascular disease: collaborative metaanalysis of individual participant data from randomised trials.
Lancet. 2009;373(9678):1849-1860.
5. Taylor F, Ward K, Moore TH, et al. Statins for the primary
prevention of cardiovascular disease. Cochrane Database
Syst Rev. 2011;(1):CD004816.
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Chest Ultrasonography as a
Replacement for Chest
Radiography in the ED
To the Editor:
The 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 firstline imaging test.
First, the training required for detecting the sonographic features
of pneumothorax, localized atelectasis, and pulmonary fibrosis is
extensive, and probably requires at least level 2 Royal College of
Radiology training in chest ultrasonography in the United Kingdom
(if not level 3, which would be equivalent to a radiologist).3 In
addition, acquisition and interpretation of sonographic images is
notoriously operator dependent, unlike interpretation of chest
radiographs or CT images. This also presents issues with how a
critical mass of operators who are adequately trained can be generated for the ED environment.
Second, acquisition of ultrasound equipment has cost implications for financially rationed health-care systems. This usually requires the demonstration of cost utility, which may be
demonstrable for effusions4 but not the other conditions encountered in the study, on the basis of its performance against chest
radiography.
Third, in the detection of pneumothorax, the chest radiograph
(unlike ultrasonography) provides useful ancillary information
as to the anatomic extent and location of most pneumothoraces
(unless too small to be visible, in which case CT scan is needed).
Many guidelines use the chest radiograph appearance in pneumothorax to guide further management.5
Finally, the chest radiograph may also give useful ancillary
information not available from the ultrasonograph (eg, a more
central lung neoplasm, mediastinal adenopathy, or a dilated
right interlobar pulmonary artery suggesting pulmonary hypertension). In summary, chest ultrasonography has many applications,6
especially in the assessment of pleural effusion, but it should
not replace the chest radiograph as a first-line imaging test
in the assessment of acutely dyspneic patients presenting to
the ED.
Andrew R. L. Medford, MBChB, MD, FCCP
Bristol, England
Affiliations: From the North Bristol Lung Centre, Southmead
Hospital.
Correspondence
Financial/nonfinancial disclosures: The author has reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be discussed in this article.
Correspondence to: Andrew R. L. Medford, MBChB, MD, FCCP,
North Bristol Lung Centre, Southmead Hospital, Westbury-onTrym, Bristol, BS10 5NB, England; e-mail: andrewmedford@
hotmail.com
© 2011 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (http://www.chestpubs.org/
site/misc/reprints.xhtml).
DOI: 10.1378/chest.11-1403
References
1. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography
replace standard chest radiography for evaluation of acute
dyspnea in the ED? Chest. 2011;139(5):1140-1147.
2. Eibenberger KL, Dock WI, Ammann ME, Dorffner R,
Hörmann MF, Grabenwöger F. Quantification of pleural
effusions: sonography versus radiography. Radiology. 1994;
191(3):681-684.
3. Royal College of Radiologists. Ultrasound training recommendations for medical and surgical specialties. Ref No: BFCR (05)2.
Royal College of Radiologists Web site. http://www.rcr.ac.uk/
docs/radiology/pdf/ultrasound.pdf. Published 2005. Accessed
May 6, 2011.
4. Medford AR. Additional cost benefits of chest physicianoperated thoracic ultrasound (TUS) prior to medical thoracoscopy (MT). Respir Med. 2010;104(7):1077-1078.
5. MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline
Group. Management of spontaneous pneumothorax: British
Thoracic Society Pleural Disease Guideline 2010. Thorax.
2010;65(suppl 2):ii18-ii31.
6. Medford AR, Entwisle JJ. Indications for thoracic ultrasound
in chest medicine: an observational study. Postgrad Med J.
2010;86(1011):8-11.
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.3,4 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.
Maurizio Zanobetti, MD
Claudio Poggioni, MD
Riccardo Pini, MD
Florence, Italy
Affiliations: From the Intensive Observation Unit, Careggi
University Hospital, and Department of Critical Care Medicine
and Surgery, University of Florence.
Financial/nonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be discussed in this article.
Correspondence to: Maurizio Zanobetti, MD, Intensive Observation Unit, Careggi University Hospital, and Department of
Critical Care Medicine and Surgery, University of Florence, Largo
Brambilla, 3, 50134 Florence, Italy; e-mail: zanomau@libero.it
© 2011 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (http://www.chestpubs.org/
site/misc/reprints.xhtml).
DOI: 10.1378/chest.11-1649
Response
References
To the Editor:
We thank Dr Medford for his thoughtful comments on our
article regarding the use of chest ultrasonography (CUS) in
the ED.1 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 Guidelines2 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. 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
www.chestpubs.org
Downloaded From: http://journal.publications.chestnet.org/ on 10/21/2014
1. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography
replace standard chest radiography for evaluation of acute
dyspnea in the ED? Chest. 2011;139(5):1140-1147.
2. American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med. 2009;53(4):550-570.
3. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound
diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):
1231-1238.
4. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive
Care Med. 2011;37(2):224-232.
Lung Transplantation in Coal Workers
Pneumoconiosis
To the Editor:
We read with great interest the article by Wade et al1 in a recent
issue of CHEST (June 2011). The authors reviewed the records of
138 coal miners who were diagnosed with coal workers pneumoconiosis (CWP) and developed evidence of progressive massive
fibrosis (PMF). The authors reported that several patients had
a rapid progression of the disease (5-12 years) and reported
21 deaths (15%) in the cohort during the study period.
CHEST / 140 / 5 / NOVEMBER, 2011
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