The study by Zanobetti et al 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, there are a number of caveats to using ultrasonography in favor of chest radiography as a first-line 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). 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.
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