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• W4247190968 abstract "In their letter Trovato et al. state that it is, “obvious that in a clinical scenario of severe dyspnea, preliminary diagnosis by history and clinical examination takes precedence, and, in fact, is almost all that the physician and the patient need for effective intervention” and “the reference tool in acute pulmonary edema is auscultation, and the level of wet sounds ….” We agree with the authors that history and physical examination are extremely important, as in most, if not all, clinical scenarios in medicine. However, this does not mean that we need to forgo certain adjuncts that can help in our clinical assessment of patients. The findings of our systematic review and meta-analysis support the use of point-of-care-ultrasonography of the lungs as an adjunct to the clinical assessment of patients with a clinical suspicion of cardiogenic pulmonary edema. Regarding the statement, “the reference tool in acute pulmonary edema is auscultation, and the level of wet sounds,” we believe that this does not reflect the current state of evidence. Prior research has shown that history and physical examination have moderate diagnostic sensitivity and specificity for heart failure.1, 2 Further, older patients with no evidence of comorbid lung disease, normal hearts (on Doppler echocardiography), and normal chest x-ray examinations have been shown to exhibit age-related pulmonary crackles (rales).3 Furthermore in a previous JAMA review, lung auscultation had a positive likelihood ratio (LR) of 2.8 and a negative LR of 0.51 for diagnosing cardiogenic pulmonary edema. This is much lower than our reported LRs for B-lines in diagnosing cardiogenic pulmonary edema.4 In fact, the positive and negative LRs for all of the individual history and physical examination points in the JAMA review were lower than the LR for B-lines. It was the conclusion of the JAMA review that no individual feature in isolation was sufficient to establish a clinical diagnosis of congestive heart failure. Although our systematic review showed a much higher LR for B-lines, our conclusion was still that it should be used to strengthen the clinician's working diagnosis (i.e., integrated as part of the complete clinical assessment of the patient including history and physical examination). Our study provides further evidence that point-of-care lung ultrasonography for the diagnosis of cardiogenic pulmonary edema can be viewed more as an extension to the physical examination rather than a “test” used in isolation. Trovato et al. also state that there is a lack of reliable evidence for ultrasound artifacts as a diagnostic tool. We disagree with this assessment. Lung ultrasound B-lines have been shown to display a strong linear correlation with extravascular lung water when compared with indicator dilution, wedge pressure, and radiographic lung water score,5, 6 and its resolution appears to correlate well with the removal of body fluid.7 In addition, the studies included in our systematic review and meta-analysis consistently demonstrate that the lung ultrasound findings of patients with heart failure and chronic obstructive pulmonary disease differ significantly.8-14 Trovato et al. cite three papers that showed that B-lines did not have significant discriminatory power to differentiate between the various lung pathologies presenting as dyspnea. Two of the citations appear to be the same study published twice (n = 283) but in two different journals. The third is a letter to the editor. While it is known that B-lines are present in certain lung pathologies like pneumonia, ARDS, and pulmonary fibrosis, it was surprising that the study by Trovato et al. showed poor discriminatory power to differentiate between pulmonary edema and COPD. This runs against the conclusion of the seven studies included in our systematic review. While it is unclear why such a difference exists, it might be because of the different patient population studied. In the study by Trovato et al., all patients with severe dyspnea were included, where as in our systematic review we included studies that included patients where there was a clinical suspicion of cardiogenic pulmonary edema. It is our opinion that this does not provide sufficient reason to refute prior work on this topic. We agree with Trovato et al. that in the appropriate clinical setting B-lines need to be “ignored,” but this is also true for almost any physical examination technique in a sense that it could represent another pathology as opposed to the “classic” pathology that the specific physical examination technique or specific lung ultrasound finding may represent. For example, a young immunocompromised patient with no prior history of cardiac disease who presents with fever, productive cough, and bilateral pleuritic chest pain should raise suspicion of bilateral pneumonia. In this situation bilateral B-lines as well as bilateral crackles on lung auscultation need to be ignored as representing cardiogenic pulmonary edema and the clinician should attribute these findings to the pneumonia causing these interstitial findings. However, we disagree that B-lines need to be ignored indefinitely as suggested by Trovato et al., nor is it appropriate to ignore any history or physical examination point indefinitely. All of these data points have their own LRs and combining them will work to strengthen the clinician's working diagnosis. It is at best erratic to ignore the data point that had the strongest LR in diagnosing cardiogenic pulmonary edema while “paying attention” to a physical examination finding with a weaker LR. The main question is: Will adding point-of-care lung ultrasonography in the assessment of patients with a suspicion of cardiogenic pulmonary edema benefit both the patient and the physician? Our answer is “yes,” provided that it is incorporated as part of the clinician's clinical assessment and not used in isolation. In summary, it was not the conclusion of our systematic review and meta-analysis that clinicians should forego a detailed history and physical examination of their patients presenting with acute dyspnea. Lung ultrasound should be used as a complementary adjunct to clinicians’ normal processes to improve diagnostic certainty and aid in clinical decision-making." @default.
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• W4247190968 date "2015-02-01" @default.
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• W4247190968 title "In Reply" @default.
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• W4247190968 doi "https://doi.org/10.1111/acem.12583" @default.
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