Top

Critical Care

Published in:

Open Access 01-04-2011 | Research

Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting

Authors: Gregor Prosen, Petra Klemen, Matej Strnad, Štefek Grmec

Published in: Critical Care | Issue 2/2011

Abstract

Introduction

We studied the diagnostic accuracy of bedside lung ultrasound (the presence of a comet-tail sign), N-terminal pro-brain natriuretic peptide (NT-proBNP) and clinical assessment (according to the modified Boston criteria) in differentiating heart failure (HF)-related acute dyspnea from pulmonary (chronic obstructive pulmonary disease (COPD)/asthma)-related acute dyspnea in the prehospital setting.

Methods

Our prospective study was performed at the Center for Emergency Medicine, Maribor, Slovenia, between July 2007 and April 2010. Two groups of patients were compared: a HF-related acute dyspnea group (n = 129) and a pulmonary (asthma/COPD)-related acute dyspnea group (n = 89). All patients underwent lung ultrasound examinations, along with basic laboratory testing, rapid NT-proBNP testing and chest X-rays.

Results

The ultrasound comet-tail sign has 100% sensitivity, 95% specificity, 100% negative predictive value (NPV) and 96% positive predictive value (PPV) for the diagnosis of HF. NT-proBNP (cutoff point 1,000 pg/mL) has 92% sensitivity, 89% specificity, 86% NPV and 90% PPV. The Boston modified criteria have 85% sensitivity, 86% specificity, 80% NPV and 90% PPV. In comparing the three methods, we found significant differences between ultrasound sign and (1) NT-proBNP (P < 0.05) and (2) Boston modified criteria (P < 0.05). The combination of ultrasound sign and NT-proBNP has 100% sensitivity, 100% specificity, 100% NPV and 100% PPV. With the use of ultrasound, we can exclude HF in patients with pulmonary-related dyspnea who have positive NT-proBNP (> 1,000 pg/mL) and a history of HF.

Conclusions

An ultrasound comet-tail sign alone or in combination with NT-proBNP has high diagnostic accuracy in differentiating acute HF-related from COPD/asthma-related causes of acute dyspnea in the prehospital emergency setting.

Trial registration

ClinicalTrials.gov NCT01235182.

Available only for authorised users

Ray P, Delerme S, Jourdain P, Chenevier-Gobeaux C: Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department. QJM 2008, 101: 831-843. 10.1093/qjmed/hcn080CrossRefPubMed

Klemen P, Golub M, Grmec S: Combination of quantitative capnometry, N-terminal pro-brain natriuretic peptide, and clinical assessment in differentiating acute heart filure from pulmonary disease as cause of acute dyspnea in prehospital emergency setting: study of diagnostic accuracy. Croat Med J 2009, 50: 133-142. 10.3325/cmj.2009.50.133PubMedCentralCrossRefPubMed

Steinhart B, Thorpe KE, Bayoumi AM, Moe G, Januzzi JL Jr, Mazer CD: Improving the diagnosis heart failure using a validated prediction model. J Am Coll Cardiol 2009, 54: 1515-1521. 10.1016/j.jacc.2009.05.065CrossRefPubMed

Michota FA Jr, Amin A: Bridging the gap between evidence and practice in acute decompensated heart failure management. J Hosp Med 2008,3(6 Suppl):S7-S15.CrossRefPubMed

Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK: Prehospital therapy for acute congestive heart failure:state of the rat. Prehosp Emerg Care 2003, 7: 13-23. 10.1080/10903120390937049CrossRefPubMed

Remes J, Miettinen H, Reunanen A, Pyörälä K: Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 1991, 12: 315-321.CrossRefPubMed

Teboul A, Gaffinel A, Meune C, Greffet A, Sauval P, Carli P: Management of caute dyspnea:use and feasibility of brain natriuretic peptide (BNP) assay in the prehospital setting. Resuscitation 2004, 61: 91-96. 10.1016/j.resuscitation.2003.12.005CrossRefPubMed

Cardinale L, Volpicelli G, Binello F, Garofalo G, Priola SM, Veltri A, Fava C: Clinical application on lung ultrasound in patients with acute dyspnea:differential diagnosis between cardiogenic and pulmonary causes. Radiol Med 2009, 114: 1053-1064. 10.1007/s11547-009-0451-1CrossRefPubMed

Lichtenstein D, Mezière GA, Biderman P, Gepner A, Barre O: The comet-tail artifact: an ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med 1997, 156: 1640-1646.CrossRefPubMed

10.

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

11.

Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, Fava C, Francisco M: Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 2006, 24: 689-696. 10.1016/j.ajem.2006.02.013CrossRefPubMed

12.

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: 201-210. 10.1111/j.1553-2712.2008.00347.xCrossRefPubMed

13.

McKee PA, Castelli WP, McNamara PM, Kannel WB: The natural history of congestive heart failure: the Framingham study. N Engl J Med 1971, 285: 1441-1446. 10.1056/NEJM197112232852601CrossRefPubMed

14.

Papiris S, Kotanidou A, Malagari K, Roussos C: Clinical review: severe asthma. Crit Care 2002, 6: 30-44. 10.1186/cc1451PubMedCentralCrossRefPubMed

15.

Chung KF, Godard P, Adelroth E, Ayres J, Barnes N, Barnes P, Bel E, Burney P, Chanez P, Connett G, Corrigan C, de Blic J, Fabbri L, Holgate ST, Ind P, Joos G, Kerstjens H, Leuenberger P, Lofdahl CG, McKenzie S, Magnussen H, Postma D, Saetta M, Salmeron S, Sterk P: Difficult/therapy-resistant asthma: the need for an integrated approach to define clinical phenotypes, evaluate risk factors, understand patophysiology and find novel therapies. ERS Task Force on Difficult/Therpy-Resistant Asthma. European Respiratory Society. Eur Respir J 1999, 13: 1198-1208.PubMed

16.

Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS, GOLD Scientific Committee: Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLB/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Summary. Am J Respir Crit Care Med 2001, 163: 1256-1276.CrossRefPubMed

17.

McGee SR: Physical examination of venous pressure:a critical review. Am Heart J 1998, 136: 10-18. 10.1016/S0002-8703(98)70175-9CrossRefPubMed

18.

Baggish AL, Siebert U, Lainchbury JG, Cameron R, Anwaruddin S, Chen AA, Krauser DG, Tung R, Brown DF, Richards AM, Januzzi JL: A validated clinical and biochemical score for the diagnosis of acute heart failure:the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Acute Heart Failure Score. Am Heart J 2006, 151: 48-54. 10.1016/j.ahj.2005.02.031CrossRefPubMed

19.

Hanley JA, McNeil BJ: A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983, 148: 839-843.CrossRefPubMed

20.

Januzzi JL Jr, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser DG, Tung R, Cameron R, Nagurney JT, Chae CU, Lloyd-Jones DM, Brown DF, Foran-Melanson S, Sluss PM, Lee-Lewandrowski E, Lewandrowski KB: The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol 2005, 95: 948-954. 10.1016/j.amjcard.2004.12.032CrossRefPubMed

21.

Januzzi JL Jr, Chen-Tournoux AA, Moe G: Amino-terminal pro-B-type natriuretic peptide testing for the diagnosis or exclusion of heart failure in patients with acute symptoms. Am J Cardiol 2008, 101: 29-38. 10.1016/j.amjcard.2007.11.017CrossRefPubMed

22.

Jambrik Z, Monti S, Coppola V, Agricola E, Mottola G, Miniati M, Picano E: Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water. Am J Cardiol 2005, 96: 322-323.

23.

Agricola E, Bove T, Oppizzi M, Marino G, Zangrillo A, Margonato A, Picano E: "Ultrasound comet-tail images": a marker of pulmonary edema: a marker of pulmonary edema:a comparative study with wedge pressure and extravascular lung water. Chest 2005, 127: 1690-1695. 10.1378/chest.127.5.1690CrossRefPubMed

24.

Zechner PM, Aichinger G, Rigaud M, Wildner G, Prause G: Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med 2010, 28: 389.e1-389.e2. 10.1016/j.ajem.2009.07.021CrossRef

25.

Brooke M, Walton J, Scutt D: Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature. Emerg Med J 2010, 27: 702-707. 10.1136/emj.2010.094219CrossRefPubMed

26.

Heegaard W, Hildebrandt D, Spear D, Chason K, Nelson B, Ho J: Prehospital ultrasound by paramedics: results of field trial. Acad Emerg Med 2010, 17: 624-630. 10.1111/j.1553-2712.2010.00755.xCrossRefPubMed

27.

Lichtenstein DA, Mezière GA: Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Am J Emerg Med 2006, 24: 689-696. 10.1016/j.ajem.2006.02.013CrossRef

Title: Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting
Authors: Gregor Prosen
Petra Klemen
Matej Strnad
Štefek Grmec
Publication date: 01-04-2011
Publisher: BioMed Central
Published in: Critical Care / Issue 2/2011
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/cc10140

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting

Abstract

Introduction

Methods

Results

Conclusions

Trial registration

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

Trial registration

Please log in to get access to this content

Other articles of this Issue 2/2011

Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study

Multinational, observational study of procalcitonin in ICU patients with pneumonia requiring mechanical ventilation: a multicenter observational study

Inspiratory muscle training in difficult to wean patients: work it harder, make it better, do it faster, makes us stronger

Beyond volutrauma in ARDS: the critical role of lung tissue deformation

Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy

Virus-associated hemophagocytic syndrome as a major contributor to death in patients with 2009 influenza A (H1N1) infection