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  1. A Jaffe1,
  2. A D Calder2,
  3. C M Owens2,
  4. S Stanojevic3,
  5. S Sonnappa3,4
  1. 1
    Sydney Children's Hospital, Randwick and University of New South Wales, Sydney, Australia
  2. 2
    Department of Radiology, Great Ormond Streat Hospital for Children NHS Trust, London, UK
  3. 3
    Portex Anaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health, London, UK
  4. 4
    Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Trust, London, UK
  1. Dr A Jaffe, Department of Respiratory Medicine, Sydney Children's Hospital, High Street, Randwick, Sydney, NSW 2031, Australia; adam.jaffe{at}

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We thank Massie et al for correctly questioning the clinical need for routine chest CT scanning before performing video-assisted thoracoscopic surgery (VATS). Our study was pragmatically designed to reflect clinical practice in our institute, where thoracic surgeons routinely request a preoperative CT scan for use as a “road map” when performing minimally invasive endoscopic surgery where direct visual access is limited. This helps to plan and assist in placement of the ports and instruments in order to decrease risk and avoid potential complications such as bronchopleural fistula which would result as a consequence of puncturing the lung parenchyma in close proximity to the pleura. We agree with them that there is no evidence base to support this practice in terms of risk, and our study was not designed to answer this question.

The principle of providing surgical “road maps” (which cross-sectional imaging now provides) is prevalent in many areas of cardiothoracic imaging where CT and MRI are added as an adjunct to echocardiography and ultrasound scans in order to enhance anatomical (and, indeed, sometimes functional) information to enhance quality and provide a safer more informed patient journey.

We are surprised that Massie et al advocate the use of a lateral decubitus chest radiograph in place of an ultrasound scan which is not, in fact, a recommendation of the BTS guidelines. Indeed, this would be a retrograde step in terms of the quality of information and the radiation burden, and should only be advocated where there is no access to ultrasound.

As discussed in our paper, ultrasound is an invaluable tool as it is cheap, mobile, easy to use, can differentiate transonic from purulent fluid, solid lung from fluid and enables the radiologist to mark the spot for chest drain insertion. Although it has been used to stage the disease, we agree that it is not useful in predicting the clinical outcome as was evident in our study. Importantly, ultrasound does not carry a radiation burden.

One of the key messages we had hoped to emphasise in our study is the critical need to reduce exposure of children to unnecessary radiation. With this in mind, we disagree with Massie et al and continue to advocate the use of ultrasound as the most important imaging modality in managing children with empyema. The BTS guidelines also support this view.

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  • Competing interests: None.

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