CHEST Original Research

CRITICAL CARE

Usefulness of Cardiothoracic Chest

Ultrasound in the Management of Acute
Respiratory Failure in Critical Care Practice
Stein Silva, MD, PhD; Caroline Biendel, MD; Jean Ruiz, MD; Michel Olivier, MD;
Benoit Bataille, MD; Thomas Geeraerts, MD, PhD; Arnaud Mari, MD;
Beatrice Riu, MD; Olivier Fourcade, MD, PhD; and Michele Genestal, MD

Background: This study investigated the clinical relevance of early general chest ultrasonography
(ie, heart and lung recordings) in patients in the ICU with acute respiratory failure (ARF).
Methods: We prospectively compared this diagnostic approach (ultrasound) to a routine evaluation
established from clinical, radiologic, and biologic data (standard). Subjects were patients consec-
utively admitted to the ICU of a university teaching hospital during a 1-year period. Inclusion
criteria were age ⱖ 18 years and the presence of severe ARF criteria to justify ICU admission. We
compared the diagnostic approaches and the final diagnosis determined by a panel of experts.
Results: Seventy-eight patients were included (age, 70 ⫾ 18 years; sex ratio, 1). Three patients
given two or more simultaneous diagnoses were subsequently excluded. The ultrasound approach
was more accurate than the standard approach (83% vs 63%, respectively; P , .02). Receiver oper-
ating characteristic curve analysis showed greater diagnostic performance of ultrasound in cases
of pneumonia (standard, 0.74 ⫾ 0.12; ultrasound, 0.87 ⫾ 0.14; P , .02), acute hemodynamic pul-
monary edema (standard, 0.79 ⫾ 0.11; ultrasound, 0.93 ⫾ 0.08; P , .007), decompensated COPD
(standard, 0.8 ⫾ 0.09; ultrasound, 0.92 ⫾ 0.15; P , .05), and pulmonary embolism (standard, 0.65 ⫾ 0.12;
ultrasound, 0.81 ⫾ 0.17; P , .04). Furthermore, we found that the use of ultrasound data could
have significantly improved the initial treatment.
Conclusions: The use of cardiothoracic ultrasound appears to be an attractive complementary
diagnostic tool and seems able to contribute to an early therapeutic decision based on reproducible
physiopathologic data. CHEST 2013; 144(3):859–865

Abbreviations: ARF 5 acute respiratory failure

A cute respiratory failure (ARF) is frequently encoun-

tered in ICUs. ARF cases do not always present
1,2
in conditions that are ideal for early diagnosis, which
sometimes compromises outcomes.3,4 Nevertheless,
immediate diagnosis and suitable treatment seem to
improve prognosis.5,6 Traditionally, a physical exami-
nation and bedside radiography are considered refer-
Manuscript received January 22, 2013; revision accepted April 15,
2013.
Affiliations: From the Réanimation Polyvalente et Médecine
Hyperbare (Drs Silva, Ruiz, Olivier, Mari, Riu, and Genestal) and
Pôle Anesthésie-Réanimation (Drs Silva, Ruiz, Olivier, Bataille,
Geeraerts, Mari, Riu, Fourcade, and Genestal), CHU Purpan; Pôle
Cardiovasculaire et Métabolique (Dr Biendel), CHU Rangueil; and
Equipe d’Accueil (Drs Silva, Geeraerts, and Fourcade), MATN,
IFR 150, Université Paul Sabatier, Toulouse, France.
Funding/Support: This research was supported by institutional
departmental funds from Centre Hospitalier Universitaire de
Toulouse, Toulouse, France.
ence requirements for assessing heart and lung status
in this context, but the flaws of these familiar tools are
becoming increasingly acknowledged. The low accu-
racy of clinical evaluations in the critical care context
has been highlighted frequently.7,8 Additionally, chest
radiography has several technical requirements that
ensure the quality of images obtained, and these cannot
be easily met in the critical care environment.9,10 Con-
sequently, a need for sophisticated tests arises, which
may delay management.11
Correspondence to: Stein Silva, MD, PhD, Critical Care Unit,
CHU Purpan, 31059 Toulouse Cedex 3, France; e-mail: silvastein@
me.com; silva.s@chu-toulouse.fr
© 2013 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.13-0167

journal.publications.chestnet.org CHEST / 144 / 3 / SEPTEMBER 2013 859

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 Cardiac and lung ultrasonography have been inde-
pendently proposed as useful approaches to patients
with acute illness, guiding management and care.12,13
For example, the accuracy of lung ultrasound has been
established for the diagnoses of pneumothorax,14 lung
consolidation,15 alveolar-interstitial syndrome,16 and
pleural effusion.17 In parallel, several studies have dem-
onstrated that cardiac ultrasound can provide accu-
rate information with diagnostic relevance in patients
in the ICU. For example, echocardiography may accu-
rately distinguish ARF caused by left-sided heart dys-
function from that resulting from noncardiac causes.12,18
The aim of the current study was to prospectively
investigate the clinical relevance of early general chest
ultrasonography (ie, heart and lung recordings) in
patients with ARF in the ICU. We used the routine
evaluation of clinical, radiologic, and biologic data as
the standard diagnostic approach against which to test
an original integrative ultrasound procedure. The
hypothesis was that a significant improvement would
be seen in the diagnostic accuracy of this paraclinical
tool when both lung and cardiac ultrasonographic data
are analyzed together. Finally, we evaluated the extent
to which this cardiothoracic ultrasonographic approach
could improve therapeutic decision-making during the
early management of critically ill patients with ARF.
Materials and Methods
Patients
We prospectively recruited patients consecutively admitted
for ARF to the ICU of a university teaching hospital between
September 2010 and September 2011. Inclusion criteria were
age ⱖ 18 years and the presence of one of the following objec-
tive criteria of ARF: a respiratory rate of at least 25/min, a Pao2
of ⱕ 60 mm Hg, an oxygen saturation as measured by pulse oxim-
etry of ⱕ 90% while breathing room air, and a Paco2 of ⱖ 45 mm Hg
with an arterial pH ⱕ 7.35. The ethics committee of the University
Hospital of Toulouse, France (Comite Consultatif pour la Protec-
tion des Personnes, CHU Toulouse, France; Ref 2010-A01225-48),
approved the therapeutic and investigational procedures and waived
the requirement for written informed consent. To simplify this
study, patients given several final diagnoses were subsequently
excluded.19
Experimental Design
Routine Clinical Assessment: For every patient, standard medical
care provided by the senior ICU physician in charge (A. M., J. R.)
included the following: medical history; physical examination find-
ings, including signs of ARF (use of accessory respiratory muscles,
paradoxical abdominal respiration); arterial blood gas analysis while
breathing room air; 12-lead ECG; chest radiograph; and routine
blood tests, including plasma levels of cardiac troponin I and B-type
natriuretic peptide. Experts were blinded to the ultrasound results.
As usual, after the initial presentation in the ICU, all patients were
reviewed by a second senior staff member (M. O.). Thus, depend-
ing on the suspected diagnosis, initial treatment was decided by
these members of the medical staff in accordance with normal
practice and recommendations.20,21
860
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Cardiothoracic Ultrasound: All patients underwent a cardio-
thoracic ultrasound test by investigators who did not participate in
the patient’s management (S. S., B. R.). The ultrasound test was
performed without interrupting management at the time of ICU
admission (ie, within 20 ⫾ 6 min) and lasted 12 ⫾ 4 min. Investiga-
tors used standardized criteria (Table 1) and followed a strict pattern
analysis. Data were recorded for further interobserver variability
assessment and then discussed to obtain an ultrasound diagnosis
based on consensus of the two scanners. Transthoracic echocardi-
ography and lung ultrasound assessment were performed with an
HP Sonos 5500 (Hewlett-Packard Development Company, LP)
and 2- to 4-MHz probes. All patients were studied in the semire-
cumbent position.
The echocardiographic examination included left ventricular
systolic function (visual estimation of the left ventricular ejection
fraction at , 30%, 30%-50%, and . 50%),23 left ventricular end-
diastolic pressure estimation (pulsed Doppler echocardiography-
recorded mitral inflow and Doppler tissue imaging with the sample
cursor placed in the lateral mitral annulus to record the following:
E-wave velocity, A-wave velocity, Ea velocity, and E/A and E/Ea
ratios),24 right ventricular function (assessment of the interven-
tricular septal configuration and dynamic M-mode measurement
of the inferior vena cava diameter, including paradoxical septal
motion, right ventricular dilatation, and central venous pressure
estimation),25 and pericardial evaluation (detection of pericardial
effusion as either present or absent).12 For the lung ultrasound
examination, the anterior chest wall was delineated from the clav-
icles to the diaphragm and from the sternum to the anterior axil-
lary line. The lateral chest was delineated from the axillary zone to
the diaphragm and from the anterior to the posterior axillary line.
The anterior and lateral chest walls were divided into three lung
regions. Lung ultrasonograms were contemporaneously classified
in a few categories according to previously described criteria.17
The pleural line was defined as a horizontal hyperechoic line vis-
ible 0.5 cm below the rib line. A normal pattern was defined as
the presence, in every lung region, of lung sliding with A lines
(A profile).26 Pleural effusion was defined as a dependent collec-
tion limited by the diaphragm and the pleura with an inspiratory
movement of the visceral pleura from depth to superficial.27 With
the use of TM mode, pneumothorax was defined by the loss of
pleural sliding (A9 profile).28 Alveolar consolidation was defined as
the presence of poorly defined, wedge-shaped hypoechoic tissue
structures (C profile).29 Within the consolidation, hyperechoic punc-
tiform images can be seen that correspond to air-filled bronchi (ie,
bronchograms).15 Pleural effusion can also be associated with the
patterns of alveolar consolidation (ie, posterolateral alveolar con-
solidation and/or pleural effusion syndrome).19 Alveolar-interstitial
syndrome was defined as the presence of more than two B lines in
a given lung region (B profile).30 Each of the 12 lung regions exam-
ined per patient was classified in one or more of these profiles and
Table 1—Ultrasound Profiles Used in the Bedside
General Chest Ultrasound Evaluation
Condition Lung Heart
Pulmonary embolism A profile with DVT RV failure (acute)
Acute hemodynamic B profile High end-diastolic
pulmonary edema LV pressure
Decompensated COPD A profile RV failure (chronic)
Pneumothorax A9 profile Nonspecific
Pneumonia C profile Nonspecific
A profile plus PLAPS
A/B profile
LV 5 left ventricular; PLAPS 5 posterolateral alveolar and/or pleural
syndrome22; RV 5 right ventricular.
Original Research
 associated with cardiac ultrasonographic data to establish a diag-
nosis (Table 1). Finally, a simplified DVT study was performed on
all patients with the same probe.19
Final Diagnosis: The final diagnosis of ARF was determined
by two independent senior experts (T. G, O. F.) from an exami-
nation of the complete medical chart, including all initial clinical
findings; emergency laboratory tests, including plasma levels of
cardiac troponin I and B-type natriuretic peptide; chest radiograph
data; and the results of thoracic high-resolution CT scans (per-
formed in 75% of the patients). Additionally, transthoracic Dopp-
ler echocardiography was performed in 68% of the patients by a
senior cardiologist (C. B.) who was blinded to the ultrasound data
to allow an independent comparison between the different diag-
nostic methods. In a few cases (5% of the patients), a pulmonary
function test (peak expiratory flow or bedside spirometry) was con-
ducted to assess the severity of a suspected airflow obstruction in
accordance with current recommendations.31 In case of disagree-
ment between the two experts, a consensus was reached with the
help of a third expert (M. G.). The main diagnoses finally proposed
were cardiogenic pulmonary edema, including left-sided heart
failure; community-acquired pneumonia; acute exacerbation of
chronic respiratory disease; acute asthma; pulmonary embolism;
and pneumothorax. Validated criteria were used (ie, response to
diuretic or vasodilator, results of cardiac troponin I32 and B-type
natriuretic peptide tests performed at admission to the ED), and
other cardiac tests were specifically analyzed for cardiogenic pul-
monary edema.33 Response to bronchodilators, steroids, or anti-
biotics; results from the pulmonary function test; and thoracic
high-resolution CT scans were analyzed specifically for respiratory
disorders.34 Results of echocardiography and a contrast-enhanced
helical CT scan were analyzed specifically for pulmonary embolism,35
as recommended.
Initial Treatment: The initial treatment of ARF was decided
by two physicians on the ICU staff (A. M., J. R., M. O.) and was
established from the standard data. It must be pointed out that
an inaccurate initial treatment was recorded when (1) pulmonary
embolism was diagnosed by the experts (ie, final diagnosis) with-
out initial anticoagulation, (2) cardiogenic pulmonary edema was
diagnosed without initial administration of vasodilators or diuretics,
(3) community-acquired pneumonia was diagnosed without initial
antibiotics, (4) asthma was diagnosed without initial b2-agonist
administration, and (5) pneumothorax/pleural effusion was diag-
nosed without initial thoracentesis.
Statistical Analysis
Continuous data are expressed as mean ⫾ SD and categorical
variables as numbers and percentages. McNemar test was used to
compare the diagnostic approaches (standard vs ultrasound) and
the final diagnosis determined by the panel of experts. Two means
were compared with a Student test and two proportions with Fisher
exact method. The diagnostic performance of each approach was
assessed by calculating the sensitivity, specificity, and diagnostic
accuracy with standard formulas.36 A receiver operating charac-
teristic curve depicting the relationship between the proportion
of true-positive findings and the proportion of false-positive find-
ings was drawn.37 The level of agreement among observers for the
ultrasound finding was evaluated by means of the 900 lung regions
analyzed (12 per patient) and the 300 echocardiographic data an-
alyzed (four criteria per patient) with the k reliability test38;
k values , 0.40 indicated low agreement, values between 0.40 and
0.75 indicated medium agreement, and values . 0.75 indicated
high agreement between the two raters. All statistical tests were
two-sided, and P , .05 was required to reject the null hypothesis.
Statistical analysis was performed with Statistica 7.0 (StatSoft, Inc)
software.
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Results
Patients
Seventy-eight patients with ARF admitted to the
ICU were prospectively included in the study. The
mean age of the patients was 70 ⫾ 18 years, and the sex
ratio was 1. At inclusion in the study, patients had a
mean Pao2 of 58 ⫾ 19 mm Hg (spontaneous ventilation
and Fio2 of 0.21), and mean Paco2 was 44 ⫾ 9 mm Hg.
Within the first 8 h of initial treatment, 26 patients
(34.6%) were intubated, and 34 patients (45.3%) were
treated with noninvasive mechanical ventilation. The
mortality rate was 18%. The final diagnoses established
by the panel of experts were pneumonia (n 5 33), acute
hemodynamic pulmonary edema (n 5 19), decompen-
sated COPD (n 5 12), pulmonary embolism (n 5 8),
and pneumothorax (n 5 3). It must be highlighted that
CT scan was used as the reference criterion to con-
firm a suspected pneumothorax. In the absence of a
clinical and standard chest radiographic sign of com-
pressive pneumothorax, CT scan and thoracic ultra-
sonography were performed before pleural exsufflation
in all three cases. All the pneumothoraces identified
by the gold standard procedure were also diagnosed
with use of the ultrasound approach. Three patients
had several final diagnoses. To simplify the analysis,
these patients were subsequently excluded.
Comparative Diagnostic Accuracy
With respect to the final diagnosis, the ultrasound
diagnostic approach was more accurate than the stan-
dard approach (83% vs 63%, respectively, P , .02)
(Fig 1). Furthermore, receiver operating characteris-
tic analysis showed a significantly greater area under
the curves when the diagnosis was made with the
ultrasound rather than with the standard approach
(Fig 2) in cases of pneumonia (standard, 0.74 ⫾ 0.12;
ultrasound, 0.87 ⫾ 0.14; P , .02), acute hemodynamic
pulmonary edema (standard, 0.79 ⫾ 0.11; ultrasound,
0.93 ⫾ 0.08; P , .007), decompensated COPD (stan-
dard, 0.8 ⫾ 0.09; ultrasound, 0.92 ⫾ 0.15; P , .05), and
pulmonary embolism (standard, 0.65 ⫾ 0.12; ultra-
sound, 0.81 ⫾ 0.17; P , .04).
Interobserver Variability
For the 900 lung regions analyzed by two indepen-
dent investigators, k values for assessing normal lung
ultrasonography pattern (Table 1), B profile, A profile,
A profile with DVT, A9 profile, C profile, and A pro-
file plus posterolateral alveolar and/or pleural syndrome
were 0.81, 0.78, 0.69, 0.78, 0.72, 0.79, and 0.88 respec-
tively. For the 300 echocardiography data, k values for
assessing normal cardiac patterns, left ventricular sys-
tolic failure, left ventricular diastolic failure, right ven-
tricular failure, and the presence of pericardial effusion
CHEST / 144 / 3 / SEPTEMBER 2013 861

Figure 1. Comparative diagnostic accuracy. Each diagnostic
approach (standard and ultrasound) was compared against the
final diagnosis determined by a panel of experts (*P , .05).
were 0.82, 0.77, 0.82, 0.69, and 0.77, respectively.
Finally, when the 200 echocardiographic data pro-
vided by a senior cardiologist (C. B.) were compared
with that obtained by intensivists, k values for assess-
ing normal cardiac patterns, left ventricular systolic
failure, left ventricular diastolic failure, right ventric-
ular failure, and the presence of pericardial effusion
were 0.88, 0.81, 0.82, 0.72, and 0.79, respectively, for
to the first investigator (B. R.) and 0.79, 0.88, 0.79, 0.80,
and 0.81, respectively, for the second (S.S.).
Potential Therapeutic Improvement
The accuracy of the initial treatment, established
with use of the standard approach, was compared with
the therapeutic decisions that could have been made
from the ultrasound data. The use of general ultra-
sound chest data, already available at the time of the
first therapeutic decisions, could have significantly
improved the initial treatment (Fig 3) in cases of pneu-
monia (P , .05), acute hemodynamic pulmonary edema
(P , .04), decompensated COPD (P , .009), and pul-
monary embolism (P , .05).
Discussion
Lung and heart ultrasound generates standardized
patterns, which have been independently proposed to
help bedside diagnosis in patients admitted to the ICU.
Previous studies have focused on assessing the sensi-
tivity and specificity of these profiles, comparing ultra-
sonography data to gold standard methods, such as
thoracic CT scan39 or pulmonary artery catheter.40 To
our knowledge, this study is the first to evaluate the
diagnostic value and potential therapeutic impact of
an approach that combines lung and heart ultrasound
scans in the early management of critically ill patients

Figure 2. A-D, Receiver operating characteristic curves depicting the relationship between the proportion of true-positive findings and
the proportion of false-positive findings. The standard and ultrasound approaches are represented for each diagnosis as follows: hemody-
namic pulmonary edema (A), pneumonia (B), decompensated COPD (C), and pulmonary embolism (D).

862 Original Research

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Figure 3. Potential therapeutic improvement related to the use
of the ultrasound approach. The accuracy of the initial treatment,
established with standard data, was compared with the therapeutic
decisions that could have been made with the ultrasound approach.
The use of general ultrasound chest data could have significantly
improved the initial treatment in cases of pneumonia (P , .05),
acute HPE (P , .04), decompensated COPD (P , .009), and pul-
monary embolism (P , .05). *P , .05. HPE 5 hemodynamic pul-
monary edema.
with ARF. The main result was a significant improve-
ment in the initial diagnostic accuracy with general
chest ultrasound compared with a standard approach
that encompassed clinical, radiologic, and biologic data.
Furthermore, greater diagnostic ability of the ultra-
sound approach was identified when each main etio-
logic entity was analyzed independently.
It must be highlighted that we observed similar levels
of sensitivity and specificity to those described in pre-
vious studies that used lung ultrasonography alone.19,27,39
We believe that combining echocardiography with
lung ultrasonography in this context probably does
not improve the diagnostic value of lung ultrasound
alone but could have fundamental importance in ther-
apeutic decisions. Actually, the present data suggest
that general chest ultrasonography provide accurate
online assessment of lung and heart status and dynamic
interactions, which are specifically disrupted in path-
ologic states. For example, it has been shown that the
diagnosis of acute pulmonary edema is accurate with
lung ultrasound (sensitivity near 100%),27 but with
heart ultrasound, we can obtain crucial information
about the etiology and underlying mechanism (acute
lung injury vs cardiogenic edema). Further investiga-
tions are needed to evaluate the impact of such inte-
grative ultrasound procedures for the correct initial
treatment of ARF in this context.41-43 Furthermore,
we describe how the use of general chest ultrasonog-
raphy, easily performed at the patient’s bedside, could
have improved initial treatment in cases of pneumonia,
decompensated COPD, and pulmonary embolism.
Altogether, these results confirm the present hypo-
thesis of a direct diagnostic and potential therapeutic
impact when general chest ultrasonography is used in
critically ill patients with ARF.
It is worth noting that we observed highly satisfac-
tory interobserver agreement in the experts’ findings
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for both heart and lung ultrasounds. This important
point might be related to the fact that general chest
ultrasound generates standardized and reproducible
patterns, even in the ICU environment. For example,
despite the difficult acquisition conditions, an accept-
able cardiac Doppler echocardiography examination
was possible in all cases. We believe that the data we
obtained had a significant added value and contributed
to accurately disambiguating ARF caused by left-sided
heart dysfunction from that resulting from noncar-
diac causes.40,44
In agreement with previous studies,11,39 we observed
a high concordance between chest ultrasonography
and CT scan data. We speculate that in the present
cohort, where 75% of patients underwent thoracic
CT scanning, these tests could have been avoided by
thoughtful use of ultrasound in more than one-half of
the cases. Future studies are needed to assess the
time savings and cost-effectiveness of combined car-
diothoracic ultrasonography compared with CT scan
in this context.
This study has several limitations. First, the inten-
sivists who performed the ultrasonography could not
be blinded to obvious clues of diagnosis that might be
readily apparent to an experienced observer while per-
forming an ultrasound examination. Second, in a few
cases, the echocardiography performed by the senior
cardiologist was probably recorded past the initial man-
agement of the patient, so it had limited value in deter-
mining the diagnosis at the time of presentation. For
the purposes of this study, a general chest ultrasound
team was set up and comprised two noncardiologist
intensivists (B. R., S. S.) with advanced-level training
and competence in lung, pleural, and cardiac ultraso-
nography according to La Société de Réanimation
de Langue Française and American College of Chest
Physicians criteria.45 These investigators followed a
training tailored to critical care practice (2 years) and
have . 3 years of experience in using and teaching
ultrasonography in their daily practice. In the pre-
sent work, we concentrated on comparing a standard
approach and an independent general chest ultrasound
analysis because we wanted to assess the diagnostic
and therapeutic impact of this novel procedure against
a gold standard approach. Finally, patients who were
given several final diagnoses were subsequently excluded
from this study. Future studies will need to focus on
evaluating the utility of combining standard and ultra-
sound data to obtain better diagnostic accuracy, par-
ticularly when several simultaneous causes contribute
to the ARF.
Conclusions
Cardiothoracic ultrasonography appears to be an
attractive complementary diagnostic tool and one of
CHEST / 144 / 3 / SEPTEMBER 2013 863
 the most promising techniques for the management
of critically ill patients with ARF. Ultrasound is non-
invasive, easily repeatable at the bedside, and provides
an accurate online assessment of lung and heart status
and dynamic interactions, which are specifically dis-
rupted in pathologic states. Furthermore, this new tool
seems to contribute to an early ICU therapeutic deci-
sion based on more accurate and reproducible data.
Benefits to be evaluated in future studies include a
reduced need for CT scans and, thus, shorter delays;
lower irradiation levels and cost; and above all, improved
prognosis for the patient.
Acknowledgments
Author contributions: Dr Silva had full access to all of the data
in the study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
Dr Silva: contributed to the study design; data acquisition, analysis,
and interpretation; critical revision of the manuscript for impor-
tant intellectual content; and approval of the final version of the
manuscript.
Dr Biendel: contributed to the data acquisition, critical revision of
the manuscript for important intellectual content, and approval of
the final version of the manuscript.
Dr Ruiz: contributed to the study design, data acquisition, critical
revision of the manuscript for important intellectual content, and
approval of the final version of the manuscript.
Dr Olivier: contributed to the data acquisition, critical revision of
the manuscript for important intellectual content, and approval of
the final version of the manuscript.
Dr Bataille: contributed to the study conception, data analysis,
critical revision of the manuscript for important intellectual con-
tent, and approval of the final version of the manuscript.
Dr Geeraerts: contributed to the data acquisition, critical revision
of the manuscript for important intellectual content, and approval
of the final version of the manuscript.
Dr Mari: contributed to the data acquisition, critical revision of
the manuscript for important intellectual content, and approval of
the final version of the manuscript.
Dr Riu: contributed to the study design, data acquisition, critical
revision of the manuscript for important intellectual content, and
approval of the final version of the manuscript.
Dr Fourcade: contributed to the data acquisition, critical revision
of the manuscript for important intellectual content, and approval
of the final version of the manuscript.
Dr Genestal: contributed to the data acquisition, critical revision
of the manuscript for important intellectual content, and approval
of the final version of the manuscript.
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.
Role of sponsors: The sponsor had no role in the design of the
study, the collection and analysis of the data, or the preparation of
the manuscript.
Other contributions: The authors thank Marie Dao, MD; Elodie
Brunel, MD; and Andree Villaceque, MD, for their help in col-
lecting data.
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