Financial/nonfinancial disclosures: The authors have reported
4 Then the ultrasonography skills need to
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.
Correspondence to: David J. Krodel, MD, Department of Anes-
thesia, Critical Care and Pain Medicine, Massachusetts General
Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114;
e-mail: dkrodel@partners.org
© 2012 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.11-3316
References
1. Krodel DJ, Bittner EA, Abdulnour RE, Brown RH, Eikermann M.
Negative pressure pulmonary edema following bronchospasm.
Chest. 2011;140(5):1351-1354.
2. Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-
Schafer N. Postoperative complications in patients with obstruc-
tive sleep apnea. Chest. 2012;141(2):436-441.
3. Flum DR, Belle SH, King WC, et al; Longitudinal Assess-
ment of Bariatric Surgery (LABS) Consortium. Perioperative
safety in the longitudinal assessment of bariatric surgery.
N Engl J Med. 2009;361(5):445-454.
4. Hwang D, Shakir N, Limann B, et al. Association of sleep-
disordered breathing with postoperative complications. Chest.
2008;133(5):1128-1134.
5. Bateman BT, Eikermann M. Obstructive sleep apnea predicts
adverse perioperative outcome: evidence for an association
between obstructive sleep apnea and delirium. Anesthesiology.
2012;116(4):753-755.
6. Chaudhary BA, Ferguson DS, Speir WA Jr. Pulmonary edema
as a presenting feature of sleep apnea syndrome. Chest. 1982;
82(1):122-124.
Thoracic Ultrasonography
To The Editor:
We have read with great interest the article by Koenig and
colleagues1 in CHEST (November 2011), in which the authors
describe in a very enthusiastic and detailed manner the current
understanding and the clinical use of thoracic ultrasonography
by pulmonary specialists. In our institution, pulmonary special-
ists have been performing thoracic ultrasonography for a number
of years, using a portable ultrasound machine to perform a large
number of bedside thoracic ultrasonography procedures in respira-
tory outpatient clinic settings as well as for patients who are hospi-
talized.2 We found that the number of thoracic ultrasonography
procedures performed by our radiology department has signifi-
cantly declined as the result of the increase in the number of pro-
cedures being performed by respiratory specialists. We routinely
use thoracic ultrasonography for the investigation of patients with
pleural disorders and, more importantly, to guide pleural proce-
dures such as thoracocentesis, chest drain insertion, or pleural
biopsies.3 The use of thoracic ultrasonography assists in identi-
fying a safe and suitable site for those procedures. It also improves
the tolerability of pleural procedures for the patients and reduces
potential complications.3
We would like to make a number of comments. Respiratory
specialists should be able to perform thoracic ultrasonography as this
improves the investigation and treatment of patients with pleural
disorders and, more importantly, the safety of pleural procedures.
However, there is a requirement for standardized training of
respiratory specialists. A number of guidelines describe the basic
1366
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© 2012 American College of Chest Physicians
competencies required.
be maintained and reinforced by regular practice on patients with a
variety of pleural disorders. Mentoring by an experienced radiol-
ogist can be helpful, someone who can give feedback on patients
with more complex pleural disorders. Respiratory specialists should
be aware of their thoracic ultrasonography skills limitations and
know when to ask for advice from an experienced ultrasonography
specialist. Finally, we would like to highlight the fact that thoracic
ultrasonography should be used in conjunction with the clinical
history, examination, and other imaging modalities (such as chest
radiography or thoracic CT imaging) as thoracic ultrasonography
complements but does not substitute for those procedures and tests.
Jack A. Kastelik, MD
Anthony Arnold, MD
East Yorkshire, England
Affiliations: From the Department of Respiratory Medicine,
Castle Hill Hospital, Hull and East Yorkshire NHS Trust, University
of Hull and Hull York Medical School.
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 dis-
cussed in this article.
Correspondence to: Jack A. Kastelik, MD, Department of
Respiratory Medicine, Castle Hill Hospital, University of Hull
and Hull York Medical School, Cottingham, East Yorkshire, HU16
5JQ, England; e-mail: j.a.kastelik@hull.ac.uk
© 2012 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.11-3067
References
1. Koenig SJ, Narasimhan M, Mayo PH. Thoracic ultraso-
nography for the pulmonary specialist. Chest. 2011;140(5):
1332-1341.
2. Kastelik JA, Alhajji M, Faruqi S, Teoh R, Arnold AG. Tho-
racic ultrasound: an important skill for respiratory physicians.
Thorax. 2009;64(9):825-826.
3. Lee WY, Faruqi S, Kastelik JA, Teoh R. Ultrasound guided
pleural aspiration and chest drain insertion: prospective study.
Eur Respir J. 2011;38(suppl 55):61s.
4. Royal College of Radiologists. Ultrasound training recommen-
dations for medical and surgical specialties. Royal College
of Radiologists website. www.rcr.ac.uk/docs/radiology/pdf/
ultrasound.pdf. Accessed March 1, 2012.
Response
To the Editor:
We thank Drs Kastelik and Arnold for their interest in our recent
article in CHEST.1 They highlight a common and frequently dis-
cussed problem in medicine: competence and quality assurance.
We agree that although a competency statement outlines what
constitutes an acceptable thoracic ultrasound examination, it does
not ensure adequate training on an individual basis, nor does it
provide the means for ongoing quality assurance. Our fellows
gain competence through experiential training and regular over-
sight by pulmonary/critical care attending physicians experienced
in thoracic ultrasonography, but this may reflect local expertise
and not general practice. The challenge remains to train pulmo-
nary and critical care specialists in the important skill of thoracic
ultrasonography.1
Correspondence
 The American College of Chest Physicians (ACCP) has taken factor for acute hypersensitivity reactions to contrast agents.2,3
concrete steps to provide training in thoracic ultrasonography Additional data and evaluations are required to reach definitive
in the United States. Training in thoracic ultrasonography is a conclusions. This study aims to evaluate the risk of hypersensi-
key component in the numerous courses that the college has tivity reactions to contrast agents in patients with asthma by the
given to . 2,000 clinicians over the past 7 years. The ACCP has severity of asthma.
developed a comprehensive critical care ultrasonography train- A retrospective cohort study of all adult patients who under-
ing program that includes lung and pleural ultrasonography. This went contrast-enhanced CT imaging tests with IV contrast agents
Certificate of Completion program requires 7 days of course from 2004 through 2011 was conducted at St. Luke’s Interna-
work, a 20-h Internet training component, and a mandatory tional Hospital. All parameters that are potentially related to
250 image portfolio collection, followed by a hands-on and image- acute hypersensitivity to contrast agents, including asthma his-
based examination that includes thoracic ultrasonography. The tory, were collected before testing. The patients with asthma
image portfolio, which is reviewed by the faculty, allows an expe- were divided into five groups by severity, according to the GINA
rienced ultrasonographer to provide meaningful feedback to the (Global Initiative for Asthma) guidelines.4 According to the guide-
learner, thereby increasing skill level. line, patients in step 1 were treated without steroids. Patients in
In addition to the national ACCP program, we have developed steps 2 through 4 were prescribed inhaled steroids. Patients in step 5
a local ultrasound training course for fellows. Each summer, were mostly treated with oral steroids. Acute hypersensitivity
80 first-year pulmonary/critical care fellows from New York City reactions to contrast agents were defined according to the anaphy-
receive an intensive 3-day course in general critical care ultrasonog- laxis criteria as occurring within 24 h.5 This study was approved
raphy, including thoracic ultrasonography. Standardized training by Research Ethics Committee of St. Luke’s International Hos-
early in fellowship training ensures that, moving forward, these pital (11-R133).
fellows will disseminate this valuable skill. According to the result of univariate analyses and clinical impor-
Finally, we could not agree more that point-of-care bedside tho- tance, variables were included in the logistic regression model.
racic ultrasonography performed by the treating pulmonologist The acute hypersensitivity reactions of patients with asthma
must be integrated with the clinical history and physical examina- in each GINA step were compared with the patients without
tion. In this regard, thoracic ultrasonography is a powerful exten- asthma. Analyses were conducted using SPSS (SPSS Inc) and
sion of the physical examination, providing immediate diagnostic Stata (Statview).
and therapeutic benefit. CT imaging with contrast was performed on 36,472 patients.
Four hundred eighty of these patients (1.3%, 95% CI: 1.2-1.4)
Seth J. Koenig, MD had an acute hypersensitivity reaction. A total of 10 patients
Mangala Narasimhan, DO, FCCP (2.1%, 95% CI: 1.0-3.8) had asthma (step 1: eight; step 2: one;
Paul H. Mayo, MD, FCCP step 3: one; step 4: 0; and step 5: 0) in the hypersensitivity reaction
New Hyde Park, NY group; a total of 266 patients (0.7%, 95% CI: 0.7-0.8) had asthma
(step 1: 151; step 2: 25; step 3: 33; step 4: 20; and step 5: 37) in the
no-reaction group. In the hypersensitivity reaction group, there
Affiliations: From the Department of Medicine, Long Island were only a few patients in steps 2 to 5; therefore, we combined
Jewish Medical Center.
Financial/nonfinancial disclosures: The authors have reported steps 2 to 5 in logistic regression. As compared with patients who
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis- Table 1—The Results From the Multivariable Logistic
cussed in this article. Regression
Correspondence to: Seth J. Koenig, MD, Department of Med-
icine, Long Island Jewish Medical Center, 270-05 76th Ave, New
Hyde Park, NY 11040; e-mail: Skoenig@nshs.edu OR 95% CI P Value
© 2012 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the Age, y 0.98 0.98-0.99 , .01
American College of Chest Physicians (http://www.chestpubs.org/ Male sex 1.03 0.85-0.24 .77
site/misc/reprints.xhtml). Total iodine compound 1.01 1.00-1.02 , .01
DOI: 10.1378/chest.12-0019 amount, g
Allergic history to contrast 6.13 4.60-8.17 , .01
agents
References Allergic history to any drugs 1.73 1.32-2.27 , .01
1. Koenig SJ, Narasimhan M, Mayo PH. Thoracic ultraso- Medical history
nography for the pulmonary specialist. Chest. 2011;140(5): Asthma … … .01
1332-1341. No asthma Reference Reference
GINA step 1 3.28 1.50-7.15 , .01
GINA steps 2-5 0.98 0.22-4.43 .98
Urticaria 2.52 1.90-3.34 , .01
Asthma Severity Is a Risk Factor Atopic dermatitis 0.51 0.22-1.20 .12
for Acute Hypersensitivity Reactions Medication
Oral steroid users 0.58 0.25-1.31 .19
to Contrast Agents without asthma
Inhaled steroid users 0.91 0.48-1.73 .78
A Large-scale Cohort Study without asthma
NSAID users 0.91 0.75-1.11 .36
To the Editor: b-Blocker users 1.25 0.82-1.92 .30
ACE inhibitor users 0.69 0.38-1.26 .23
CT imaging has become a common diagnostic tool because Antihistamine users 1.37 0.96-1.95 .08
of its utility. However, adverse events from contrast agents have ACE 5 angiotensin-converting enzyme; GINA 5 Global Initiative for
also increased.1 Controversy exists as to whether asthma is a risk Asthma; NSAID 5 nonsteroidal antiinflammatory drug.

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