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US in the Detection of Pneumothorax [letter]

Department of Radiology, University of Florida, PO Box 110374, Gainesville, FL 32610. e-mail: sistrc@radiology.ufl.edu

Editor:

In a recent article about ultrasonographic (US) detection of traumatic pneumothorax in the October 2002 issue of Radiology (1), the authors cited an article from 1996 that I worked on, in which we described a study to determine receiver operating characteristics of real-time US for pneumothorax detection. In that experiment, blinded observers viewed videotapes of thoracic US performed after lung biopsy. Their reading was compared with upright inspiratory and/or expiratory chest radiographs as the standard of reference (2). We found that the sensitivity of the five readers for pneumothorax ranged from 54% to 85%, with the average being 73%.

I am writing because of the way our results were summarized in the recent article. The authors stated, "We did not attempt to estimate the size of the pneumothoraces ultrasonographically, because previous research has shown that although US is highly sensitive for pneumothorax detection, it does not enable a reliable estimation of the volume of a pneumothorax [citation for our article]." I disagree that an average of 73% qualifies as "highly sensitive." In fact, the conclusion of our article was that US is useful for localization of pneumothoraces for planned chest tube placement, but it cannot be used to exclude a diagnosis (ie, US is not sensitive for pneumothorax).

I have no reason to doubt the authors’ excellent results (11/11 = 100% of pneumothoraces detected with US). Differences in patients (ours were mostly older smokers), readers (ours were general body imagers), and better equipment can easily explain the discrepancy in sensitivity between our two studies. In fact, this is likely an example of the phenomenon of spectrum composition influencing diagnostic test performance metrics.

REFERENCES

1. Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT—initial experience. Radiology 2002; 225:210-214.[Abstract/Free Full Text]
2. Sistrom CL, Reiheld CT, Gay SB, Wallace KK. Detection and estimation of the volume of pneumothorax using real-time sonography: efficacy determined by receiver operating characteristic analysis. AJR Am J Roentgenol 1996; 166:317-321.[Abstract/Free Full Text]

Dr Rowan and colleagues respond:

Kevin R. Rowan, MD,*, Andrew W. Kirkpatrick, MD, FRCSC, David Liu, MD,*, Kevin E. Forkheim, MD,*, John R. Mayo, MD,* and Savvas Nicolaou, MD, FRCPC*

Department of Radiology* and Section of Trauma Services, Vancouver Hospital and Health Sciences Centre, 899 West 12th Avenue, Vancouver, British Columbia, Canada V5Z 1M9. e-mail: snicolao@vanhosp.bc.ca

We thank Dr Sistrom for commenting on our article (1). He took issue with our reference to his research on pneumothorax detection with US, with regard to the following statement: "We did not attempt to estimate the size of the pneumothoraces ultrasonographically, because previous research has shown that although US is highly sensitive for pneumothorax detection, it does not enable a reliable estimation of the volume of a pneumothorax [citation for the article of Dr Sistrom and colleagues]."

Dr Sistrom correctly commented that, although their research showed that US is useful for the localization of pneumothorax, US could not be used to determine the size of pneumothorax, and they did not find that US was "highly sensitive" for pneumothorax detection. They reported an average sensitivity of 73%, which, we agree, does not qualify as highly sensitive. Elsewhere in our article, however, we cited several other studies (3–5) that showed between 95% and 100% sensitivity for US in the detection of pneumothorax, which would certainly be considered highly sensitive. We erroneously neglected to add these citations to the statement concerning estimation of pneumothorax volume. Indeed, the intent of the statement in question was to discuss reasons why assessment of pneumothorax volume should not be attempted, not to discuss sensitivity and accuracy of US, which had been addressed elsewhere in our article.

We apologize for any misrepresentation of the research of Dr Sistrom and colleagues.

REFERENCES

1. Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT–initial experience. Radiology 2002; 225:210-214.[Abstract/Free Full Text]
2. Sistrom CL, Reiheld CT, Gay SB, Wallace KK. Detection and estimation of the volume of pneumothorax using real-time sonography: efficacy determined by receiver operating characteristic analysis. AJR Am J Roentgenol 1996; 166:317-321.[Abstract/Free Full Text]
3. Lichtenstein D, Meziere G, Biderman P, Gepner A. The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med 1999; 25:383-388.[CrossRef][Medline]
4. Wernecke K, Galanski M, Peters PE, Hansen J. Pneumothorax: evaluation by ultrasound–preliminary results. J Thorac Imaging 1987; 2:76-78.[Medline]
5. Lichenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding. Chest 1995; 108:1345-1348.[Abstract/Free Full Text]

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