Novel aspects in diagnostic approach to respiratory patients: is it the time for a new semiotics?

Abstract

Medical approach to patients is a fundamental step to get the correct diagnosis. The aim of this paper is to analyze some aspects of the reasoning process inherent in medical diagnosis in our era. Pathologic signs (anamnestic data, symptoms, semiotics, laboratory and strumental findings) represent informative phenomena to be integrated for inferring a diagnosis. Thus, diagnosis begins with “signs” and finishes in a probability of disease. The abductive reasoning process is the generation of a hypothesis to explain one or more observations (signs) in order to decide between alternative explanations searching the best one. This process is iterative during the diagnostic activity while collecting further observations and it could be creative generating new knowledge about what has not been experienced before. In the clinical setting the abductive process is not only theoretical, conversely the physical exploitation of the patient (palpation, percussion, auscultation) is always crucial. Through this manipulative abduction, new and still unexpressed information is discovered and evaluated and physicians are able “to think through doing” to get the correct diagnosis. Abductive inferential path originates with an emotional reaction (discovery of the signs), step by step explanations are formed and it ends with another emotional reaction (diagnosis). Few bedside instruments are allowed to physicians to amplify their ability to search for signs. Stethoscope is an example. Similarities between ultrasound exploration and percussion can be found. Bedside ultrasonography can be considered an external amplifier of signs, a particular kind of percussion and represents a valid example of abductive manipulation. In this searching for signs doctors act like detectives and sometimes the discovering of a strategic, unsuspected sign during abductive manipulation could represent the key point for the correct diagnosis. This condition is called serendipity. Ultrasound is a powerful tool for detecting soft, hidden, unexpected and strategic signs.

Possible Role of Chest Ultrasonography for the Evaluation of Peripheral Fibrotic Pulmonary Changes in Patients Affected by Idiopathic Pulmonary Fibrosis—Pilot Case Series

“…Ultrasound technology in medicine uses acoustic energy to assess internal body parts. Physicians interpret interactions between ultrasonic waves and body tissues to get signs leading to diagnostic hypothesis [9].…”

Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID‐19

“…A decade of clinical [1][2][3][4] and physical studies [5][6][7][8][9] clearly showed that lung ultrasound (LUS) is able to detect interstitial lung disease, subpleural consolidations, and acute respiratory distress syndrome from any etiologic cause. New evidence from published studies, [10][11][12] national and international organization statements, and informal case discussions with internationally recognized experts are showing the usefulness of LUS for the management of patients with 2019 new coronavirus disease (COVID-19) pneumonia, from diagnosis to monitoring and follow-up.…”

Ultrasonography of the Lung

“…If a "lung pulse" is already present before intubation, ultrasound cannot predict atelectasis after selective intubation [26,27]. Besides X-ray, ultrasound imaging serves as a fast and easily available bedside test for the assessment of lung aeration during mechanical ventilation [28,29]. Alternatively, only electrobioimpedancy (EIT) provides real-time monitoring of chest impedance correlating with air content or fluid accumulation, but unlike X-ray and ultrasound, ventilation maps of the lung generated with EIT do not contribute information about the morphology of the affected tissue [30].…”

“…Standardized procedures are focused on the relevant anatomical regions in the chest and well defined criteria with known sensitivity and specificity for the underlying condition allow for a fast and efficient application of the technique [10]. In the current literature, broader application and more comprehensive use of lung imaging with ultrasound is advocated [10,11]. It is therefore the aim of this review article to make potential users more familiar with the technical and diagnostic aspects and to encourage the more widespread application of this frequently underestimated lung imaging modality.…”