Ultrasonography of diaphragm in chronic obstructive pulmonary disease: Unanswered questions.

Sir,

We read with great interest the article published by Jain et al. in the July–August issue of Lung India.[1] Chronic obstructive pulmonary disease (COPD) is primarily an airway disease management of which mainly focused on relief of symptoms. Dyspnea is one of the disabling symptoms among these patients. Although airway involvement is the central mechanism leading to dyspnea, diaphragm dysfunction also plays an important role.[23] Therefore, assessment of diaphragm functions is a crucial step for any prophylactic or therapeutic intervention. Diaphragm is a hidden and constantly moving structure; hence, assessment of its functions is challenging. Ultrasonography (USG) has been proposed and used by various researchers as a tool to assess diaphragm functions. USG can capture both thickness during various phases of respiration (end-expiration, end-inspiration, during sniff, etc.) and movement (excursion) of diaphragm.[4]

In the study published by Jain et al., the study objective was of clinical importance and interesting.[1] They aimed to demonstrate the diaphragm characteristics and their relationship with various clinical parameters among patients with COPD. Importance of the subject may be understood with the fact that an accompanying editorial was also published for this study.[5] However, it was surprising that the study published by Jain et al. did not report methodology.[1] Therefore, readers did not get answers to many important questions if they wish to repeat this study. Some of the important unanswered questions are – (1) Who performed ultrasonography of the diaphragm – a radiologist or respiratory physician? (2) How experienced was the operator? (3) What was posture of the patient while ultrasonography was performed? (4) Which machine was used? (5) How the zone of apposition measured? (6) How many readings were taken – single or multiple? (7) What was the reliability of the measurements taken? (8) How patients were recruited? (9) Was ethical clearance obtained for the conducted of study?

One of the major purposes of any scientific research is to disseminate the knowledge acquired with that research so that a larger group can get the benefit out of it. Publication in a good journal is one way of communication of the findings of the research to the peer group working in that field. We understand that publishing a manuscript in a good journal including Lung India requires efforts. Before publication of the manuscript, multiple people including authors, reviewers, and editors who are involved in the process have important roles to play. From authors, it is expected that study is reported in an acceptable format and no major aspect of the study is missing. To guide authors, there are guidelines existing for each journal separately. Furthermore, there are guidelines for how to report randomized control trial, observation studies, case– control studies, etc., For observational study such as by Jain et al., following checklist provided in the STROBE guidelines[6] would minimize chances of missing any important aspect of the study.

Peer review is a process where authors' scholarly work, research, or ideas are scrutinized by others who are experts of that field. The purpose of the peer review is to maintain a high standard of reporting and control of dissemination of unwarranted or uncertain claims/views by authors.[7] There is no uniform format of peer review, and it varies from journal to journal as well as reviewer to reviewer. However, it seems developing a standard format of assessment of manuscript in which reviewers may be asked to evaluate each aspect of the manuscript separately is the need of time for a reputed journal such as Lung India. That could have avoided publication of the manuscript by Jain et al. without methodology.

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Conflicts of interest

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