To the Editor: We read with interest the article of Reissig et al (December 2001) (1) The main finding described was a small alveolar consolidation touching the lung surface and considered as a lung infarct.

To the Editor:

We read with interest the article of Reissig et al (December 2001) (1) The main finding described was a small alveolar consolidation touching the lung surface and considered as a lung infarct. Our personal observations are contradictory at first sight, as we have not ever detected such lesions in pulmonary embolism. sum of two units explanations are possible. First, the standing of severity of pulmonary embolism in the series of Reissig et al (1) is not specified. Thus, patients listed in that study probably had nonsevere pulmonary embolism (ie, small emboli, which are known to cause more distal disorders than the bitter forms). Another possibility is that our screening missed small lesions.

We report briefly 33 cases of patients admitted to our ICU for rigid pulmonary embolism. None of these patients had the anterolateral pattern described by dint of Reissig et al. (1) We had previously set up this pattern in ICU patients with censorious infectious disorders, a pattern we called C lines (2); however, we can describe a pattern that is 91% sensitive to pulmonary embolism--a regular repetition of the lung-wall interface, a pattern we called A lines. This sign has no specificity, as it is the normal signal (2); however, in a patient with respiratory distress, the normality of the lung ultrasound signal is a crucial finding, as pneumothorax or pulmonary edema, for instance, give totally different patterns. (3-6)

We largely agree with Reissig et al (1) that there is a mighty correlation between ultrasound and CT patterns, however we are still investigating the relationship of this ultrasound pattern to particular infectious or embolic processes

Another point of agreement with Reissig et al (1) is that lung ultrasonography in respiratory disorders should become routine, as it yields crucial bedside information that will be directly useful for the immediate management of the patient. (7) We are confident this use will help ultrasound to the status of a genuine stethoscope (8)

Daniel A. Lichtenstein, MD

Hopital Ambroise-Pare

Boulogne France

Yann Loubieres, MD

midmost point Hospitalier Intercommunal

Saint-Germain-en-Laye, France

Reproduction of this article is prohibited without written permission from the American body of Chest Physicians (e-mail: permissions@chestnet.org).

Correspondence to: Daniel A. Lichtenstein, MD Service de Reanimation Mddicale, Hopital Ambroise-Pard, 1;-92100 Boulogne (Paris-Quest), France

REFERENCES

(1) Reissig A, Heynes JP Kroegel C Sonography of lung and pleura in pulmonary embolism: sonomorphologic characterization and comparison with spiral CT scanning. Chest 2001; 120:1977-1983

(2) Lichtenstein D Lung ultrasound in the intensive care unit. Re Devel Respir Crit Care M 2001; 1:83-93

(3) Lichtenstein D Menu Y A bedside ultrasound sign ruling gone out pneumothorax in the critically ill: lung sliding. Chest 1995; 108:1345-1348

(4) Lichtenstein D Meziere G Biderman P et al. The "lung point": an ultrasound sign specific to pneumothorax. Intensive Care M 2000; 26:1434-1440

(5) Lichtenstein D Meziere G Biderman P et al. The comet-tail artifact, an ultrasound sign of alveolar-interstitial syndrome Am J Respir Crit Care M 1997; 156:1640-1646

(6) Lichtenstein D Meziere G A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care M 1998; 24:1331-1334

(7) Lichtenstein D General ultrasound in the critically ill. 2nd ed Paris, France: Springer-Verlag, 2002; 209-213

(8) Filly RA. Ultrasound: the stethoscope of the futurity alas. Radiology 1988; 167:400

To the Editor:

We would like to thank Dr Lichtenstein and Loubieres for their interesting annotates on our article in CHEST (December 2001) (1) forward the diagnostic significance of transthoracic parenchymal sonography of the lung in patients with pulmonary embolism (PE) We full support their view regarding the part of comet tail artifacts in diagnosing pulmonary diseases. (23) We also agree with Dr Lichtenstein and Loubieres that sonography of the lung should be performed as a routine investigation. Although the performance of transthoracic sonography requires near experience, this approach is extremely attractive since the technique is inexpensive, widely available, and immediately accessible to the physician at bedside, facilitating a swift diagnosis and attack of therapy.

Dr Lichtenstein (4) and Loubieres failed to lay open the characteristic multiple, hypoechoic, pleural-based, wedge-shaped or sphericaled parenchymal lesions, which generally are well-demarcated from the surrounding tissue that are observ in cases of PE and reported by dint of us and others. (5) The reasons for the discrepancy are not immediately apparent unless are likely to be befitting to the patient selection within an ICU setting, the sonographic proceeding applied, and the inherent characteristics of the PE

First, Dr Lichtenstein examined patients with PE in an intensive care setting, whereas the patients enlisted in our study had their conditions diagnosed while upon a pulmonary ward. The majority of our patients (1) experienced isolated dyspnea and pleuritic pain. Circulatory collapse of no other apparent cause was observ in approximately 15% of all patients who experienced PE (67) and was no other than evident in four patients in our studious mood As suggested by Drs. Lichtenstein and Loubieres, the explanation for the failure to ascertain characteristic parenchymal lesions may lie in the differences in the severity of disease. However, several studies (15) have demonstrated that in PE peripheral lesions and the central obstruction of pulmonary artery branches offer simultaneously. After lodging at the bifurcation of the main pulmonary artery or the lobar branches, at least a certain thrombi disintegrate mechanically or in subordination to the influence of intrinsic fibrinolytic activity into smaller fragments and continue traveling distally, resulting in peripheral PEs

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