Diagnosing Lung Abnormalities Related to Heart Failure in Chest Radiogram, Lung Ultrasound and Thoracic Computed Tomography

Round 1

Reviewer 1 Report

My recommendation to the authors is to add a short paragraph about the difference in the right ventricular failure and the left ventricular failure and comment dilemmas and challenges for radiologist according to this difference.

A list of abbreviations should be added after the key words. 

Author Response

Thank you very much for reviewing our manuscript. Below, we enclose the specific responses to your comments.

Comment 1
Add a short paragraph about the difference in the right ventricular failure and the left ventricular failure and comment on dilemmas and challenges for radiologists according to this difference.

Reply 1 
Thank you for this comment. Following your remark, we added information about right ventricular failure (page 3, lines 111-119).

Comment 2
A list of abbreviations should be added after the keywords. 

Reply 2 
Thank you for this suggestion. We added a list of abbreviations after the keywords (page 2).

Reviewer 2 Report

I would like to commend the authors on a thorough review of the common lung imaging modalities in the setting of heart failure. 

For the section focusing on chest Xray , it would be great for the readers to understand why the sensitivity for pulm edema is so low in chest Xrays for example  discuss the impact of retrocardiac opacities , how the lymphatic system in the lung , especially in the setting of chronic heart failure, can lead to falsely normal Xrays. I would recommend expanding their search to include more meta-analyses regarding Xray in heart failure. I would also discuss the differences in AP and PA lateral Xrays would be of great interest as well.

Figure 1

With regards to  vascular pedicle width it would help the reader to have an image to show how this is measured

To differentiate the “pseudo-exudates” from true exudates it would be helpful to mention the role of pleural fluid LDH.

Unclear as to the need to discuss the pericardial effusions in chest Xray as the manuscript’s focus is lung pathology.

In the lung ultrasound section I believe it is important for the reader to be informed that B lines reflect total lung water volume and clarify the two main ways this occurs : Via hydrostatic pressures ( as seen in Heart Failure)  versus capillary leak syndrome which is seen in inflammatory lung pathology (for example ARDS and or Pneumonia). Looking at the distribution of of B lines can help distinguish these two main categories as well as lung sliding. No lung ultrasound is complete without pleural evaluation which includes presence/absence and degree of lung sliding as well as pleural regularity, I believe this should be included in this section of the manuscript.

I would love to see a summary table including the main findings of Xrays/LUS and CT along with their individual test characteristics and mini-description

Author Response

Thank you very much for reviewing our manuscript. Below, we enclose the specific responses to your comments.

Comment 1 
For the section focusing on chest Xray , it would be great for the readers to understand why the sensitivity for pulm edema is so low in chest Xrays for example  discuss the impact of retrocardiac opacities , how the lymphatic system in the lung , especially in the setting of chronic heart failure, can lead to falsely normal X-rays. I would recommend expanding their search to include more meta-analyses regarding Xray in heart failure. 

Reply 1
Thank you for your relevant comment. We added arguments for low sensitivity in a paragraph on Chest X-ray (page 3, lines 126-134). We also added some references on this topic.

 

Comment 2 
Discuss the differences in AP and PA lateral X-rays would be of great interest as well. 

Reply 2
Thank you for this suggestion. We added information on the differences in PA and AP CXR in the subsection Cardiac abnormalities related to HF in CXR  (page 7, lines 255-260)

 

Comment 3
Figure 1 : With regards to vascular pedicle width it would help the reader to have an image to show how this is measured 

Reply 3
Thank you for pointing this out. We certainly agree with the Reviewer that it would be beneficial, an image presenting the measurement method was added (Figure 2).

 

Comment 4 
To differentiate the “pseudo-exudates” from true exudates it would be helpful to mention the role of pleural fluid LDH.  

Reply 4
Thank you for your valuable suggestion. Indeed, precise diagnosis of pleural effusion in patients with HF may be misleading, especially in those treated with diuretics. In such cases the exact biochemical analysis of the fluid based on Light’s criteria, NT-proBNP, and finally serum-effusion albumin gradient (SEAG) are decisive. However, the detailed discussion about the diagnosis of pleural effusion is somewhat beyond the scope of this review. Therefore, we have decided to mention only the significance of NT-proBNP assessment, which seems most useful in clinical practice ( page 6, line 221-229). 

 

Comment 5 
Unclear as to the need to discuss the pericardial effusions in chest Xray as the manuscript’s focus is lung pathology. 

Reply 5
Thank you for your accurate comment. Indeed, this review focuses on lung abnormalities. Although pericardial effusion is a relatively rare symptom found in patients with HF, it may coexist with other, more common symptoms – particularly in congestive HF. Therefore, we have decided to mention it and compare it with pleural effusion, which is a more typical sign of HF. We tried to emphasise the differences in the  pathomechanism of fluid  accumulation in the pericardium compared to the pleura. We hope that leaving this paragraph in a slightly changed version in the manuscript is satisfactory ( page 6, lines 230-241). 

 

Comment 6 
In the lung ultrasound section I believe it is important for the reader to be informed that B lines reflect total lung water volume and clarify the two main ways this occurs : Via hydrostatic pressures (as seen in Heart Failure) versus capillary leak syndrome which is seen in inflammatory lung pathology (for example ARDS and or Pneumonia). Looking at the distribution of B lines can help distinguish these two main categories as well as lung sliding. No lung ultrasound is complete without pleural evaluation which includes presence/absence and degree of lung sliding as well as pleural regularity, I believe this should be included in this section of the manuscript. 

Reply 6
Thank you very much for this valuable insight. The section on lung ultrasound has been considerably expanded, shedding more light on this modality’s application in HF. We have briefly addressed the topic of differentiating B-lines of cardiogenic and non-cardiogenic origin, but we belive that describing the enormous topic of the B-lines in detail misses the aim of this paper.

 

Comment 7 
I would love to see a summary table including the main findings of Xrays/LUS and CT along with their individual test characteristics and mini-description.

Reply 7
Thank you for this valuable suggestion. We have, accordingly, created an appropriate  table summarising the main findings in all three imaging tests with their comparison (Table 2). 

Reviewer 3 Report

Dominika et al. present a review about diagnosing heart failure (HF) with CXR, LUS, and CT based criteria. The authors note the large incidence of HF, with or without normal ejection fraction, and the poor prognosis associated with the conditions. Thus, the ability to detect and mitigate the immediate and long term trajectories of the disease with timely diagnosis is important.

The authors then proceed to present in detail these three diagnostic modalities, with basic findings and more sophisticated nuances mentioned with appropriate illustrations. The consequent clinical course based on findings are discussed, with relevant physiology and hormonal changes noted.

 

In general, the article is a good read and provides clinical information that would be of use to the readership that cares for these patients. However, I have a number of comments.

 

The authors state (lines 96-98): “When this space is filled and lymphatics become congested, the excess is becoming gathered in the alveoli thus becoming the second stage - alveolar oedema (phase 3) [20].” It is confusing to tell the reader that the second stage is phase 3. Please find a way to improve this passage.

 

The section concerning LUS has far less detail than the other sections. The brief text focuses on lung parenchyma. Figures 4&5. Please indicate the B lines with arrows, etc. The visualization of pleural effusion is not even presented or discussed.

 

CT section. The labeling of the CT scans (figures 9 and 10) is quite poor. Please improve the symbols and arrows explanation of them in the figure legends. The labels within the picture of figure 11 also should be enlarged.

 

Lastly, the concluding paragraph is too brief. It should at least summarize the basic strengths and weaknesses between the three diagnostic modalities, with one noted as the golden standard with some sort of hierarchy of power noted.

 

 

Author Response

Thank you very much for reviewing our manuscript. Below, we enclose the specific responses to your comments.

Comment 1
The authors state (lines 96-98): “When this space is filled and lymphatics become congested, the excess is becoming gathered in the alveoli thus becoming the second stage - alveolar oedema (phase 3) [20].” It is confusing to tell the reader that the second stage is phase 3. Please find a way to improve this passage.

Reply 1
Thank you very much for your apt remark. Indeed, this phrase was misleading. We have corrected it according to your suggestion (page 4, line 151).

 

Comment 2
The section concerning LUS has far less detail than the other sections. The brief text focuses on lung parenchyma. Figures 4&5. Please indicate the B lines with arrows, etc. The visualisation of pleural effusion is not even presented or discussed.

Reply 2
Thank you for this valuable input. Section on LUS and on pleural effusion has been considerably expanded. We have updated Figures 5 and 6 with arrows. We also added Figures of pleural effusion (Fig  7 and 8). The text has been modified accordingly (page 11, line 386-421)

 

Comment 3
CT section. The labelling of the CT scans (figures 9 and 10) is quite poor. Please improve the symbols and arrows explanation of them in the figure legends. The labels within the picture of figure 11 also should be enlarged.

Reply 3
Thank you for pointing this out. According to your suggestion, we have improved the labelling of the CT scans in figures (these are now fig. 12,13,14). We have also applied it to figures 10 and 11. 

Comment 4
Lastly, the concluding paragraph is too brief. It should at least summarise the basic strengths and weaknesses between the three diagnostic modalities, with one noted as the golden standard with some sort of hierarchy of power noted.

 

Reply 4
Thank you for your valuable remark. Following your suggestions, we tried to improve the conclusion paragraph. Additionally, we summarised the advantages and disadvantages of all three imaging techniques in table (Table 2).

Reviewer 4 Report

Comments for author File: Comments.pdf

Author Response

Thank you very much for reviewing our manuscript. Below, we enclose the specific responses to your comments.

Comment 1
A good description as far as the diagnosis of heart failure (HF) was done, but some details are lacking about differential diagnosis with other interstitial diseases, such as, for example, interstitial pneumonia associated with autoimmune features (Sambataro G. et al., Clin Exp Rheumatol. 2022 Jul;40(7):1324-1329; Sambataro D. et al., Clin Exp Rheumatol 2022 Oct;40(10):1970-1976; Sambataro G. et al., Clin Exp Rheumatol 2022, Oct 3;).

Reply 1
Thank you for this relevant comment and suggestion of very interesting papers. We added a paragraph on difficulties in differential diagnosis between pulmonary congestion and interstitial lung diseases (page 13, line 471-477)

 

Comment 2
The comparison of imaging patterns of lung and cardiac origin should be discussed to distinguish pulmonary component characterising radiological abnormalities in pathophysiological states different from HF.

Reply 2
Thank you for pointing this out. According to your suggestion, we have added Table 1 to summarize differences between lung abnormalities due to HF and ILD (Table 1). 

Reviewer 5 Report

I read with pleasure the work review: Diagnosing lung abnormalities related to heart failure in chest 2 radiogram, lung ultrasound and thoracic computed tomography.

 

My comments are below:  

 

Abstract: The abstract is to short and do not give the message of what the reader should found insight.

 

Introduction: Line 35 Echocardiography is not the only tools to reach the diagnosis but should be match with Lung ultrasound. Please move the text as for your line 55-56.

 

Better explain the way at the end of the intro: This is just an example: Thus, this narrative review aimed at the following points: 1) to report xxxxxxxxxxxx, 2) to analyzed the xxxxxxxxxxxxx, and 3) to find xxxxxxx 4) finally, to do xxxxxxxxxxxxx.

 

 

 

CHEST X-ray: line 77 -78 I disagree about this sentence.

 

 

 

Please try to improve the color of figure 1

 

 

 

Line 176: The prognostic value of pericardial effusion is not yet confirmed, 176 as the evidence is inconclusive [36],[37]. Please serch more literature and possible metanalisis about pleural effusion drainage in ICU benefit and risk.

 

 

 

3. Lung Ultrasound (LUS): line 219-220 please explain lung ultrasound score or how to count B-lines and in how many time: Please serch a reference about the time needed to do a lung ultrasound score.

 

Line 229: ref to these works: Lung ultrasound to evaluate aeration changes in response to recruitment maneuver and prone positioning in intubated patients with COVID‑19 pneumonia: preliminary study. January 2023 DOI: 10.1186/s13089-023-00306-9

 

 

 

Lung ultrasound monitoring: impact on economics and outcomes Current Opinion in Anaesthesiology. DOI: 10.1097/ACO.0000000000001231

Author Response

Thank you very much for reviewing our manuscript. Below, we enclose the specific responses to your comments.

Comment 1
Abstract: The abstract is to short and do not give the message of what the reader should found insight.

Reply 1
Thank you for such a valuable remark. According to your suggestion we modified and included a description of the main points, which can be found in the full text (page 1).

 

Comment 2
Introduction: Line 35 Echocardiography is not the only tools to reach the diagnosis but should be match with Lung ultrasound. Please move the text as for your line 55-56.

Reply 2
Thank you for your suggestion. Following your remark we modified the paragraph concerning diagnostic tools  to stress the significance of lung ultrasound (page 2, line 68-71)

 

Comment 3
Better explain the way at the end of the intro: This is just an example: Thus, this narrative review aimed at the following points: 1) to report xxxxxxxxxxxx, 2) to analyzed the xxxxxxxxxxxxx, and 3) to find xxxxxxx 4) finally, to do xxxxxxxxxxxxx.

Reply 3
Thank you for this relevant comment. Following your advice we have added a similar sentence at the end of the introduction section, which better explains the aims of the review (page 3, line 94-99).

 

Comment 4
CHEST X-ray: line 77 -78 I disagree about this sentence.

Reply 4
Thank you for your valuable opinion. After analysing this sentence we changed this paragraph to emphasise the present use of LUS and ECHO as the most important diagnostic tools (page 3, line 120-137).

 

Comment 5
Please try to improve the color of figure 1

Reply 5
Thank you for pointing this out. Indeed, it was illegible. Therefore we have changed the colour of figure 1 hoping that now it becomes much clearer (page 4). 

 

Comment 6
Line 176: The prognostic value of pericardial effusion is not yet confirmed, 176 as the evidence is inconclusive [36],[37]. Please serch more literature and possible metanalisis about pleural effusion drainage in ICU benefit and risk.

Reply 6
Thank you for this valuable remark. Indeed, this paragraph was not complete. Therefore we enriched it and added two meta-analyses and modified the conclusions. (page 6, line 230-241)

 

Comment 7
3. Lung Ultrasound (LUS): line 219-220 please explain lung ultrasound score or how to count B-lines and in how many time: Please search a reference about the time needed to do a lung ultrasound score.

Reply 7
Thank you for drawing our attention to this shortcoming. Part concerning quantifying B-lines has been expanded. We would deliberately like to avoid presenting any method of counting B-lines as preferable as to our knowledge no single consensus has been reached in this matter. We share experiences from our everyday practice.

 

Comment 8
Line 229: ref to these works: Lung ultrasound to evaluate aeration changes in response to recruitment maneuver and prone positioning in intubated patients with COVID-19 pneumonia: preliminary study. January 2023 DOI: 10.1186/s13089-023-00306-9

Reply 8
Thank you very much for your suggestion, we have added this paper to the references concerning LUS (page 10, line 360). 

 

Comment 9
Lung ultrasound monitoring: impact on economics and outcomes Current Opinion in Anaesthesiology. DOI: 10.1097/ACO.0000000000001231

Reply 9
Thank you very much for your suggestion, we have added this paper to the references concerning LUS (page 12, line 437) 

Round 2

Reviewer 1 Report

Thank you very much for inclusion of my suggestions. I am completely satisfied with the amended version of the manuscript.

Reviewer 2 Report

Thank you for your revisions on this excellent paper ! 

Reviewer 3 Report

Hugely improved. No further comments.

Reviewer 4 Report

No further concern.

Reviewer 5 Report

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