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We would like to thank J A Kastelik et al for their letter in response to our recent Thorax publication.1 As the letter describes, we entirely agree that thoracic ultrasound is a technique which is becoming more commonly practised by chest physicians, and there is good and increasing data in support of this technique as a sensitive diagnostic test for pleural effusion, and as the safest mode of guiding pleural intervention. We further agree with the data presented from their local audit that this chest physician-based activity may result in a decrease in radiology department activity for pleural procedures and thoracic ultrasound. This does have training implications, not only for chest physicians hoping to accrue the necessary skills to perform thoracic ultrasound as part of routine practice, but also for trainees in radiology who may no longer have the opportunity to conduct pleural procedures under ultrasound guidance.
The findings of our study suggest that thoracic ultrasound is a sensitive and specific diagnostic test in a population of patients with suspected malignant pleural effusion. It is important to note that these scans were conducted by radiologists (NQ and FVG). We believe that conducting an extensive thoracic ultrasound scan for the diagnosis of malignant pleural disease is likely to be beyond the remit of level 1-trained thoracic ultrasound practitioners.2 Most chest physicians will use thoracic ultrasound for detection of pleural effusion and guided procedures (level 1). The features we described in our article (assessment of parietal pleural thickening, visceral thickening, nodularity and diaphragm anatomy abnormalities) may be subtle and require some experience to recognise. It is therefore likely that only radiologists and chest physicians with a high degree of experience will be in the position to assess similar criteria in the clinical situation. It is also likely that the majority of chest physicians will train to level 1 competence in thoracic ultrasound, with a fewer number (eg, those with an interest in pleural disease in specialist centres) training to level 2 competence.2
Although Kastelik et al have suggested that higher frequency ultrasound probes may be necessary to detect these abnormalities, in our study all features were visible using a 3–5 Hz curvilinear abdominal probe.1 We initially used a higher frequency probe to assess for subtle thickening and nodularity, but in fact abandoned its use for the study as it led to no increase in diagnostic yield and substantially increased scanning time.
Once again, we would like to thank the authors of the letter for their interest in our study.
Competing interests None.
Provenance and Peer review Not commissioned; not externally peer reviewed.
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