Top

The Ultrasound Journal

Published in:

Open Access 01-12-2014 | Original article

Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department

Authors: Concetta Pirozzi, Fabio G Numis, Antonio Pagano, Paolo Melillo, Roberto Copetti, Fernando Schiraldi

Published in: The Ultrasound Journal | Issue 1/2014

Abstract

Background

Dyspnea is one of the most frequent complaints in the Emergency Department. Thoracic ultrasound should help to differentiate cardiogenic from non-cardiogenic causes of dyspnea. We evaluated whether the diagnostic accuracy can be improved by adding a point-of-care-ultrasonography (POC-US) to routine exams and if an early use of this technique produces any advantage.

Methods

One hundred sixty-eight patients were enrolled and randomized in two groups: Group 1 received an immediate POC-US in addition to routine laboratory and instrumental tests; group 2 received an ultrasound scan within 1 h from the admission to the Emergency Department. The concordance between initial and final diagnosis and the percentage of wrong diagnosis in the two groups were evaluated. Mortality, days of hospitalization in Emergency Medicine department and transfers to other wards were compared. Sensitivity and specificity of the routine protocol and the one including ultrasonography for the diagnosis of the causes of dyspnea were also analyzed.

Results

Eighty-eight patients were randomized in group 1 and 80 in group 2. The concordance rate between initial and final diagnoses was significantly different (0.94 in group 1 vs. 0.22 in group 2, p < 0.005). The percentage of wrong initial diagnosis was 5% in group 1 and 50% in group 2 (p < 0.0001).

Conclusions

Adding POC-US to routine exams improves the diagnostic accuracy of dyspnea and reduces errors in the Emergency Department.

Available only for authorised users

Mulrow CD, Lucey CR, Farnett LE: Discriminating causes of dyspnea trough clinical examination. J Gen Intern Med 1993, 8: 383–392. pmid: 8410400 10.1007/BF02600079CrossRefPubMed

Holleman DR Jr, Simel DL: Does the clinical examination predict airflow limitation? JAMA 1995, 273: 313–319. pmid: 7815660 10.1001/jama.1995.03520280059041CrossRefPubMed

Schmitt BP, Kushner MS, Wiener SL: The diagnostic usefulness of the history of the patient with dyspnea. J Gen Intern Med 1986, 1: 386–393. pmid: 3794838 10.1007/BF02596424CrossRefPubMed

Collins SP, Lindsell CJ, Storrow AB, Abraham WT, ADHERE Scientific Advisory Committee, Investigators and Study Group: Prevalence of negative chest radiography results in the emergency department patient with decompensated heart failure. Ann Emerg Med 2006, 47: 13–18. doi: 10.1016/j.annemergmed.2005.04.003 10.1016/j.annemergmed.2005.04.003CrossRefPubMed

Eriksson H, Svärdsudd K, Larsson B, Ohlson LO, Welin L, Tibblin G, Wilhelmsen L: Dyspnoea in a cross-sectional and a longitudinal study of middle-aged men: the study of men born in 1913 and 1923. Eur Heart J 1987, 8: 1015–1023. pmid: 3499319PubMed

Ray P, Birolleau S, Lefort Y, Becquemin MH, Beigelman C, Isnard R, Teixeira A, Arthaud M, Riou B, Boddaert J: Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Crit Care 2006, 10: R82. 10.1186/cc4926PubMedCentralCrossRefPubMed

Lichtenstein D: Ultrasound in the management of thoracic disease. Crit Care Med 2007, 35: S250-S261. doi: 10.1097/01.CCM.0000260674.60761.85 10.1097/01.CCM.0000260674.60761.85CrossRefPubMed

Lichtenstein D, Mézière G, Biderman P, Gepner A, Barré O: The comet tail artifact. an ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997, 156: 1640–1646. doi: 10.1164/ajrccm.156.5.96–07096 10.1164/ajrccm.156.5.96-07096CrossRefPubMed

Barillari A, Fioretti M: Lung ultrasound: a new tool for the emergency physician. Intern Emerg Med 2010, 5: 335–340. doi: 10.1007/s11739–010–0381-x 10.1007/s11739-010-0381-xCrossRefPubMed

10.

Reissig A, Kroegel C: Transthoracic sonography of diffuse parenchymal lung disease: the role of comet tail artifacts. J Ultrasound Med 2003, 22: 173–180. pmid: 12562122PubMed

11.

Volpicelli G, Cardinale L, Garofalo G, Veltri A: Usefulness of lung ultrasound in the bedside distinction between pulmonary edema and exacerbation of COPD. Emerg Radiol 2008, 15: 145–151. doi: 10.1007/s10140–008–0701-x 10.1007/s10140-008-0701-xCrossRefPubMed

12.

Copetti R, Soldati G, Copetti P: Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008, 6: 16–21. doi: 10.1186/1476–7120–6-16 10.1186/1476-7120-6-16PubMedCentralCrossRefPubMed

13.

Cibinel GA, Casoli G, Elia F, Padoan M, Pivetta E, Lupia E, Goffi A: Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in Emergency Department. Intern Emerg Med 2012, 7: 65–70. doi: 10.1007/s11739–011–0709–1CrossRefPubMed

14.

Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, Capp R, Noble VE: Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med 2009,16(3):201–210. doi: 10.1111/j.1553–2712.2008.00347.x 10.1111/j.1553-2712.2008.00347.xCrossRefPubMed

15.

McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Køber L, Lip GY, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, ESC Committee for Practice Guidelines: ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012,14(8):803–869. doi: 10.1093/eurheartj/ehs104CrossRefPubMed

16.

Vestbo J, Hurd SS, Agustí AG, Jones PW, Vogelmeier C, Anzueto A, Barnes PJ, Fabbri LM, Martinez FJ, Nishimura M, Stockley RA, Sin DD, Rodriguez-Roisin R: Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease, GOLD executive summary. Am J Respir Crit Care Med 2012,187(4):347–365. doi: 10.1164/rccm.201204–0596PPCrossRefPubMed

17.

Expert Panel Report 3 (EPR-3) (2007) Guidelines for the Diagnosis and Management of Asthma-Summary Report: National Asthma Education and Prevention Program. J Allergy Clin Immunol 2007,120(Suppl 5):S94-S138. doi: 10.1016/j.jaci.2007.09.029

18.

Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG: Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007,44(Suppl 2):S27-S72. doi: 10.1086/511159CrossRefPubMed

19.

Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM: The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012,38(10):1573–1582. doi: 10.1007/s00134–012–2682–1 10.1007/s00134-012-2682-1CrossRefPubMed

20.

Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP, ESC Committee for Practice Guidelines (CPG): Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008, 18: 2276–2315. doi: 10.1093/eurheartj/ehn310

21.

Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G, Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A, Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti E, Petrovic T, International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS): International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012,38(4):577–591. 10.1007/s00134-012-2513-4CrossRefPubMed

22.

Volpicelli G, Lamorte A, Tullio M, Cardinale L, Giraudo M, Stefanone V, Boero E, Nazerian P, Pozzi R, Frascisco MF: Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med 2013, 39: 1290–1298. doi: 10.1007/s00134–013–2919–7 10.1007/s00134-013-2919-7CrossRefPubMed

23.

Brennan JM, Blair JE, Goonewardena S, Ronan A, Shah D, Vasaiwala S, Kirkpatrick JN, Spencer KT: Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr 2007, 20: 857–861. doi: 10.1016/j.echo.2007.01.005 10.1016/j.echo.2007.01.005CrossRefPubMed

24.

Kircher BJ, Himelman RB, Schiller NB: Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava. Am J Cardiol 1990, 66: 493–496. doi: 10.1016/0002–9149(90)90711–9 10.1016/0002-9149(90)90711-9CrossRefPubMed

25.

Mueller X, Stauffer J, Jaussi A, Goy JJ, Kappenberger L: Subjective visual echocardiographic estimate of left ventricle ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast angiography. Clin Cardiol 1991, 14: 127–134. pmid: 1764826CrossRef

26.

Narasimhan M, Koenig SJ, Mayo PH: Advanced echocardiography for the critical care physician part 2. Chest 2014,145(1):135–142. doi: 10.1378/chest.12–2442 10.1378/chest.12-2442CrossRefPubMed

27.

Gargani L: Lung ultrasound: a new tool for the cardiologist. Cardiovasc Ultrasound 2011, 9: 6–13. doi: 10.1186/1476–7120–9-6 10.1186/1476-7120-9-6PubMedCentralCrossRefPubMed

28.

Lichtenstein DA, Meziere GA: Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008, 134: 117–125. doi: 10.1378/chest.07–2800 10.1378/chest.07-2800PubMedCentralCrossRefPubMed

29.

Kajimoto K, Madeen K, Nakayama T, Tsudo H, Kuroda T, Abe T: Rapid evaluation by lung-cardiac-inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting. Cardiovasc Ultrasound 2012,10(1):49. doi: 10.1186/1476–7120–10–49 10.1186/1476-7120-10-49PubMedCentralCrossRefPubMed

30.

Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ: Comparative diagnostic performances of auscultation, chest radiography and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 2004, 100: 9–15. doi: 10.3109/03009734.2011.643510 10.1097/00000542-200401000-00006CrossRefPubMed

31.

Greenbaum DM, Marschall KE: The value of routine daily chest X-rays in intubated patients in the medical intensive care unit. Crit Care Med 1982, 10: 29–30. pmid: 7056051 10.1097/00003246-198201000-00007CrossRefPubMed

32.

Zanobetti M, Poggioni C, Pini R: Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011,139(5):1140–1147. doi: 10.1378/chest.10–0435 10.1378/chest.10-0435CrossRefPubMed

33.

Xirouchaki N, Magkanas E, Vaporidi K, Kondili E, Plataki M, Patrianakos A, Akoumianaki E, Georgopoulos D: Lung ultrasound in critically ill patients: comparison with bedside chest radiography. Intensive Care Med 2011, 37: 1488–1493. doi: 10.1007/s00134–011–2317-y 10.1007/s00134-011-2317-yCrossRefPubMed

34.

Lakhal K, Serveaux-Delous M, Lefrant JY, Capdevila X, Jaber S, AzuRéa Network for the RadioDay Study Group: Chest radiographs in 104 French ICUs: current prescription strategies and clinical value (the RadioDay study). Intensive Care Med 2012, 38: 1787–1799. doi: 10.1007/s00134–012–2650–9 10.1007/s00134-012-2650-9CrossRefPubMed

35.

Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF: Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med 2008, 26: 585–591. doi: 10.1016/j.ajem.2007.09.014 10.1016/j.ajem.2007.09.014CrossRefPubMed

36.

Liteplo AS, Murray AF, Kimberly HH, Noble VE: Real-time resolution of sonographic B-lines in a patient with pulmonary edema on continuous positive airway pressure. Am J Emerg Med 2010, 541: e5-e8. doi: 10.1016/j.ajem.2009.08.013

37.

Atkinson PR, McAuley DJ, Kendall RJ, Abeyakoon O, Reid CG, Connolly J, Lewis D: Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension. Emerg Med J 2009, 26: 87–91. doi: 10.1136/emj.2007.056242 10.1136/emj.2007.056242CrossRefPubMed

38.

Jones AE, Tayal VS, Kline JA: Focused training of emergency medicine residents in goal directed echocardiography: a prospective study. Acad Emerg Med 2003, 10: 1054–1058. doi: 10.1197/s1069–6563(03)00346–4 10.1111/j.1553-2712.2003.tb00574.xCrossRefPubMed

Title: Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department
Authors: Concetta Pirozzi
Fabio G Numis
Antonio Pagano
Paolo Melillo
Roberto Copetti
Fernando Schiraldi
Publication date: 01-12-2014
Publisher: Springer Milan
Published in: The Ultrasound Journal / Issue 1/2014
Electronic ISSN: 2524-8987
DOI: https://doi.org/10.1186/2036-7902-6-5

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department

Abstract

Background

Methods

Results

Conclusions

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2014

Is B-mode ultrasound alone a sufficient screening tool for carotid stenosis? A pilot study

Analysis of trainees' memory after classroom presentations of didactical ultrasound courses

Current practice of lung ultrasonography (LUS) in the diagnosis of pneumothorax: a survey of physician sonographers in Germany

The BUDDY (Bedside Ultrasound to Detect Dehydration in Youth) study

The importance of dynamic ultrasound in the diagnosis of tibialis anterior muscle herniation

Personalized peer-comparison feedback and its effect on emergency medicine resident ultrasound scan numbers

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page