51
|
Muniz RT, Mesquita ET, Souza Junior CV, Martins WDA. Pulmonary Ultrasound in Patients with Heart Failure - Systematic Review. Arq Bras Cardiol 2019; 110:577-584. [PMID: 30226917 PMCID: PMC6023636 DOI: 10.5935/abc.20180097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/21/2018] [Indexed: 12/14/2022] Open
Abstract
Pulmonary congestion is an important clinical finding in patients with heart failure (HF). Physical examination and chest X-ray have limited accuracy in detecting congestion. Pulmonary ultrasound (PU) has been incorporated into clinical practice in the evaluation of pulmonary congestion. This paper aimed to perform a systematic review of the use of PU in patients with HF, in different scenarios. A search was performed in the MEDLINE and LILACS databases in February 2017 involving articles published between 2006 and 2016. We found 26 articles in the present review, 11 of which in the emergency setting and 7 in the outpatient setting, with diagnostic and prognosis defined value and poorly studied therapeutic value. PU increased accuracy by 90% as compared to physical examination and chest X-ray for the diagnosis of congestion, being more sensitive and precocious. The skill of the PU performer did not interfere with diagnostic accuracy. The presence of B-lines ≥ 15 correlated with high BNP values (≥ 500) and E/e' ratio ≥ 15, with prognostic impact in IC patients at hospital discharge and those followed up on an outpatient basis. In conclusion, when assessing pulmonary congestion in HF, PU has an incremental value in the diagnostic and prognostic approach in all scenarios studied.
Collapse
Affiliation(s)
- Rafael Tostes Muniz
- Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), Niterói, RJ - Brazil.,Complexo Hospitalar de Niterói, Niterói, RJ - Brazil
| | - Evandro Tinoco Mesquita
- Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), Niterói, RJ - Brazil
| | | | - Wolney de Andrade Martins
- Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), Niterói, RJ - Brazil.,Complexo Hospitalar de Niterói, Niterói, RJ - Brazil
| |
Collapse
|
52
|
The diagnostic accuracy of a point-of-care ultrasound protocol for shock etiology: A systematic review and meta-analysis. CAN J EMERG MED 2019; 21:406-417. [PMID: 30696496 DOI: 10.1017/cem.2018.498] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The aim of this study was to perform a systematic review and meta-analysis of the diagnostic accuracy of a point-of-care ultrasound exam for undifferentiated shock in patients presenting to the emergency department. METHODS Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, and research meeting abstracts were searched from 1966 to June 2018 for relevant studies. QUADAS-2 was used to assess study quality, and meta-analysis was conducted to pool performance data of individual categories of shock. RESULTS A total of 5,097 non-duplicated studies were identified, of which 58 underwent full-text review; 4 were included for analysis. Study quality by QUADAS-2 was considered overall a low risk of bias. Pooled positive likelihood ratio values ranged from 8.25 (95% CI 3.29 to 20.69) for hypovolemic shock to 40.54 (95% CI 12.06 to 136.28) for obstructive shock. Pooled negative likelihood ratio values ranged from 0.13 (95% CI 0.04 to 0.48) for obstructive shock to 0.32 (95% CI 0.16 to 0.62) for mixed-etiology shock. CONCLUSION The rapid ultrasound for shock and hypotension (RUSH) exam performs better when used to rule in causes of shock, rather than to definitively exclude specific etiologies. The negative likelihood ratios of the exam by subtype suggest that it most accurately rules out obstructive shock.
Collapse
|
53
|
Koh Y, Chua MT, Ho WH, Lee C, Chan GWH, Sen Kuan W. Assessment of dyspneic patients in the emergency department using point-of-care lung and cardiac ultrasonography-a prospective observational study. J Thorac Dis 2018; 10:6221-6229. [PMID: 30622794 DOI: 10.21037/jtd.2018.10.30] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Lung ultrasonography is increasingly used in the emergency department (ED) as a standard adjunct in the evaluation of the breathless patient. The study objective was to ascertain the diagnostic accuracy of lung and cardiac ultrasound in undifferentiated dyspneic ED patients. Methods We conducted this prospective observational study on patients presenting with dyspnea in the ED of a tertiary hospital. The sonographers who performed lung and cardiac ultrasound according to a locally-designed protocol were blinded to clinical and radiologic results. Ultrasonographic findings were subsequently compared with the final adjudicated diagnoses. Results Between February and August 2015, 231 patients were recruited. There was male predominance (63.2%) with a mean age of 67.8 years. Overall, lung ultrasonography yielded correct diagnoses in 68.3% of patients. Our protocol had likelihood ratios of 3.63 [95% confidence interval (CI): 2.44-5.40], 3.73 (95% CI: 2.50-5.57) and 6.31 (95% CI: 3.72-10.72) for positive findings; and 0.42 (95% CI: 0.29-0.63), 0.35 (95% CI: 0.25-0.50), and 0.40 (95% CI: 0.28-0.56) for negative findings in the diagnoses of pneumonia, pulmonary edema, and chronic obstructive pulmonary disease or asthma, respectively. Addition of bedside echocardiography was able to differentiate cardiogenic from nephrogenic pulmonary edema in 70% of patients. Conclusions Lung ultrasonography, when complemented with other tools of investigation, aids evaluation, allows for earlier treatment and more accurate disposition of undifferentiated dyspneic patients in the ED. The addition of cardiac ultrasound was not able to reliably differentiate the causes of pulmonary edema.
Collapse
Affiliation(s)
- Yiwen Koh
- Duke-NUS Medical School, Singapore.,Ministry of Health Holdings, Singapore
| | - Mui Teng Chua
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weng Hoe Ho
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chengjie Lee
- Emergency Department, Sengkang General Hospital, Singapore
| | - Gene Wai Han Chan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
54
|
Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
Collapse
Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| |
Collapse
|
55
|
Abstract
Over the last decade there has been increasing interest and enthusiasm in point-of-care ultrasound (POCUS) as an aide to traditional examination techniques in assessing acutely unwell adult patients. However, it currently remains the domain of a relatively small handful of physicians within the UK. There are numerous reasons for this, notably a lack of training pathways and supervisors but also a lack of understanding of the evidence base behind this imaging modality. This review article aims to explore some of the evidence base behind POCUS for a number of medical pathologies, and where possible compare it to evidenced traditional examination techniques. We discuss the issues around training in bedside ultrasound and recommend a push to integrate POCUS training into internal medicine curricula and support trainers to comprehensively deliver this.
Collapse
|
56
|
Guttikonda SNR, Vadapalli K. Approach to undifferentiated dyspnea in emergency department: aids in rapid clinical decision-making. Int J Emerg Med 2018; 11:21. [PMID: 29619581 PMCID: PMC5884754 DOI: 10.1186/s12245-018-0181-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 03/23/2018] [Indexed: 01/06/2023] Open
Abstract
Background Diagnosis and management of patients presenting with acute dyspnea is one of the major challenges for physicians in emergency department (ED). A correct diagnosis is frequently delayed and difficult to ascertain, and clinical uncertainty is common, explaining the need for rapid diagnosis and a management plan. The primary aim of our study is to assess a diagnostic strategy using multiorgan point of care ultrasonography (USG) to differentiate patients presenting with acute dyspnea to ED into different diagnostic categories for timely management in a resource-limited setting. Methods This is a prospective cohort study which assessed the diagnostic performance of a strategy in evaluating patients presenting with undifferentiated dyspnea as primary predominant complaint to ED. Focused multiorgan USG which includes cardiac USG for left ventricle systolic function, right ventricle enlargement, and pericardial effusion, inferior vena cava (IVC) diameter and collapsibility, lung USG to identify various patterns (acute interstitial syndrome, pneumothorax, pleural effusion, consolidation, etc.) and renal USG to assess kidney size and echotexture was performed. Later, patients were grouped into one of ten clinical syndromes defined in the study based on USG and clinical patterns. Emergency diagnosis was compared with final hospital diagnosis to assess the accuracy of this strategy. Results Concordance between ED diagnosis of dyspnea using the diagnostic strategy proposed in the study with final hospital diagnosis was high with agreement in 88% of patients (Kappa statistic = .805, p = .000) which is statistically significant. The most common diagnosis was acute decompensated heart failure (ADHF). Sensitivity and specificity of the diagnostic strategy used in this study to identify ADHF was 97.3 and 93.3%, respectively. On multivariate analysis, jugular venous distension, fever and cough, ejection fraction (by eyeball method), dilated IVC, absent to decreased lung sliding showed independent association in predicting cardiac and non-cardiac diagnosis. Conclusions The present study concludes that integrating focused multiorgan USG by lung-cardiac-IVC and renal ultrasound into routine clinical evaluation of patients with dyspnea has a higher accuracy for differentiating causes of dyspnea in emergency department. This strategy can be adopted even in resource limited setting.
Collapse
Affiliation(s)
- Siva Nageswara Rao Guttikonda
- Department of Internal Medicine, Rangaraya Medical College, Government General Hospital, Raja Ram Mohan Rai road, Kakinada, Andhra Pradesh, 533001, India.
| | - Kiran Vadapalli
- Department of Internal Medicine, Rangaraya Medical College, Government General Hospital, Raja Ram Mohan Rai road, Kakinada, Andhra Pradesh, 533001, India
| |
Collapse
|
57
|
Chenkin J, Atzema CL. Contemporary Application of Point-of-Care Echocardiography in the Emergency Department. Can J Cardiol 2018; 34:109-116. [DOI: 10.1016/j.cjca.2017.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 02/06/2023] Open
|
58
|
Alonso JV, Del Pozo FJF, Vaquero M, Islam I. Sepsis, fluid resuscitation and bedside echocardiography. QJM 2018; 111:51-52. [PMID: 29088415 DOI: 10.1093/qjmed/hcx206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- J V Alonso
- Department of Emergency Medicine, Royal Bournemouth Hospital, Bournemouth BH7 7DW, UK
| | - F J F Del Pozo
- Department of Emergency and Critical Care Unit of Montoro, Maimónides Biomedical Research Institute of Córdoba, 14004 Córdoba, Spain
| | - M Vaquero
- Department of Family Medicine, Jean Health Centre, 23003 Jaén, Spain
| | - I Islam
- Department of Emergency Medicine, Royal Bournemouth Hospital, Bournemouth BH7 7DW, UK
| |
Collapse
|
59
|
Saigal S, Joshi R, Sharma JP, Pandey V, Pakhare A. Lung Ultrasound and Blood Gas-Based Classification of Critically Ill Patients with Dyspnea: A Pathophysiologic Approach. Indian J Crit Care Med 2018; 22:789-796. [PMID: 30598565 PMCID: PMC6259439 DOI: 10.4103/ijccm.ijccm_338_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction: The objective of this study was to classify dyspneic patients and to evaluate outcome variables on the basis of lung ultrasound (LUS) and arterial blood gas (ABG) findings. Methods: We performed a retrospective chart-based review in which we included patients with dyspnea admitted to our intensive care unit (ICU) between March 2015 and August 2016. On the basis of LUS (presence of A-lines/B-lines) and ABG (hypoxia/hypercarbia), patients were classified into six groups: (i) metabolic defect (dry lung, no hypoxia); (ii) perfusion defect (dry lung, hypoxia); (iii) ventilation defect (dry lung, hypoxia, and hypercarbia); (iv) ventilation and alveolar defect (wet lung, hypoxia, and hypercarbia); (v) alveolar defect-consolidation ([wet lung] hypoxia, no echocardiographic [ECG] abnormality); (vi) alveolar defect-pulmonary edema (wet lung [usually bilateral], hypoxia, ECG abnormality). The patient's demographic data, sequential organ failure assessment (SOFA) score, need for intubation, vasopressors, form of mechanical ventilation, ICU outcome, and length of stay were noted. Results: A total of 244 out of 435 patients were eligible for inclusion in the study. The median age was 56 years. 132 patients (54.1%) required mechanical ventilation, and median SOFA score was 7. Noninvasive ventilation was required in 87.5% of patients with ventilation defect as compared to 9.2% with alveolar defect-consolidation (P < 0.0001). We had 21.7% mortality in patients with alveolar defect-consolidation, 10.8% mortality in patients with metabolic defect, and 8.7% mortality in patients with alveolar defect-pulmonary edema (P < 0.0001). Conclusion: This classification gives an organized approach in managing patients with dyspnea. It predicts that patients with alveolar defect-consolidation are most sick of all the groups and need immediate intervention.
Collapse
Affiliation(s)
- Saurabh Saigal
- Department of Anesthesia and Critical Care, AIIMS, Bhopal, Madhya Pradesh, India
| | - Rajnish Joshi
- Department of Medicine, AIIMS, Bhopal, Madhya Pradesh, India
| | - Jai Prakash Sharma
- Department of Anesthesia and Critical Care, AIIMS, Bhopal, Madhya Pradesh, India
| | - Vandana Pandey
- Department of Anesthesia, GMC, Bhopal, Madhya Pradesh, India
| | | |
Collapse
|
60
|
Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med 2017; 69:e27-e54. [PMID: 28442101 DOI: 10.1016/j.annemergmed.2016.08.457] [Citation(s) in RCA: 393] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Indexed: 02/06/2023]
|
61
|
Becker TK, Tafoya CA, Osei-Ampofo M, Tafoya MJ, Kessler RA, Theyyunni N, Yakubu HA, Opuni D, Clauw DJ, Cranford JA, Oppong CK, Oteng RA. Cardiopulmonary ultrasound for critically ill adults improves diagnostic accuracy in a resource-limited setting: the AFRICA trial. Trop Med Int Health 2017; 22:1599-1608. [PMID: 29072885 DOI: 10.1111/tmi.12992] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource-limited setting. METHODS Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardised final diagnosis derived from post hoc chart review of the patient's care at 24 h by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-h mortality and use of IV fluids, diuretics, vasopressors and bronchodilators. RESULTS Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a 'cardiac' diagnosis, such as cardiogenic shock, congestive heart failure or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups. CONCLUSIONS In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-h mortality and a number of patient care interventions.
Collapse
Affiliation(s)
- Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, FL, USA
| | - Chelsea A Tafoya
- Department of Emergency Medicine, Highland Hospital, Oakland, CA, USA
| | - Maxwell Osei-Ampofo
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Matthew J Tafoya
- Department of Emergency Medicine, Highland Hospital, Oakland, CA, USA
| | - Ross A Kessler
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nikhil Theyyunni
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hussein A Yakubu
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Daniel Opuni
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Daniel J Clauw
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - James A Cranford
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Chris K Oppong
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Rockefeller A Oteng
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
62
|
Sartini S, Frizzi J, Borselli M, Sarcoli E, Granai C, Gialli V, Cevenini G, Guazzi G, Bruni F, Gonnelli S, Pastorelli M. Which method is best for an early accurate diagnosis of acute heart failure? Comparison between lung ultrasound, chest X-ray and NT pro-BNP performance: a prospective study. Intern Emerg Med 2017; 12:861-869. [PMID: 27401330 DOI: 10.1007/s11739-016-1498-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 06/26/2016] [Indexed: 01/06/2023]
Abstract
Acute heart failure is a common condition among adults presenting with dyspnea in the Emergency Department (ED), still the diagnosis is challenging as objective standardized criteria are lacking. First line work-up, other then clinical findings, is nowadays made with lung ultrasound imaging study, chest X-ray study and brain natriuretic peptide (BNP) level determination; however, it is not clear which is the best diagnostic test to be used and whether there is any real benefit for clinical judgement. We set up this study to compare the performances of these three diagnostic tools; furthermore, we combined them to find the best possible approach to dyspneic patients. This is a prospective observational study based in the ED. We enrolled adults presenting with dyspnea not trauma-related, they underwent lung ultrasound, and chest X-ray studies, and NT pro-BNP level determination. Then we compared the results with the diagnosis of acute heart failure established by an independent panel of experts. 236 patients were enrolled in the study. We find sensitivity and specificity for lung ultrasound of 57.73 and 87.97 %, for chest X-ray 74.49 and 86.26 %, for NT pro-BNP 97.59 and 27.56 %, respectively. Combining together the chest X-ray and lung ultrasound, we find the best overall performance with 84.69 % sensitivity, 77.69 % specificity and 87.07 % negative predictive value. From our results, we could not identify the "best test" to diagnose acute heart failure in an emergency setting, although we could suggest that a stepwise workup combining chest X-ray and lung ultrasound at first, then for those negative, a determination of NT pro-BNP assay would be a reasonable approach to the dyspneic patient.
Collapse
Affiliation(s)
- Stefano Sartini
- IRCCS AOU San Martino, Genoa, Italy.
- , Via Marco Perennio 24/c, 52100, Arezzo, AR, Italy.
| | - Jacopo Frizzi
- Emergency Department, Hospital of Lucca, Lucca, Italy
| | - Matteo Borselli
- Emergency Department, San Bortolo Hospital of Vicenza, Vicenza, Italy
| | | | - Carolina Granai
- Emergency Department, University Hospital of Siena, Siena, Italy
| | - Veronica Gialli
- Emergency Department, University Hospital of Siena, Siena, Italy
| | | | - Gianni Guazzi
- Department of Emergency Radiology, University Hospital of Siena, Siena, Italy
| | - Fulvio Bruni
- Emergency Department, University Hospital of Siena, Siena, Italy
| | - Stefano Gonnelli
- Internal Medicine Department, University Hospital of Siena, Siena, Italy
| | | |
Collapse
|
63
|
Rutz MA, Clary JM, Kline JA, Russell FM. Emergency Physicians Are Able to Detect Right Ventricular Dilation With Good Agreement Compared to Cardiology. Acad Emerg Med 2017; 24:867-874. [PMID: 28453186 DOI: 10.1111/acem.13210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/07/2017] [Accepted: 04/22/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Focused cardiac ultrasound (FOCUS) is a useful tool in evaluating patients presenting to the emergency department (ED) with acute dyspnea. Prior work has shown that right ventricular (RV) dilation is associated with repeat hospitalizations and shorter life expectancy. Traditionally, RV assessment has been evaluated by cardiologist-interpreted comprehensive echocardiography. The primary goal of this study was to determine the inter-rater reliability between emergency physicians (EPs) and a cardiologist for determining RV dilation on FOCUS performed on ED patients with acute dyspnea. METHODS This was a prospective, observational study at two urban academic EDs; patients were enrolled if they had acute dyspnea and a computed tomographic pulmonary angiogram without acute disease. All patients had an EP-performed FOCUS to assess for RV dilation. RV dilation was defined as an RV to left ventricular ratio greater than 1. FOCUS interpretations were compared to a blinded cardiologist FOCUS interpretation using agreement and kappa statistics. RESULTS Of 84 FOCUS examinations performed on 83 patients, 17% had RV dilation. Agreement and kappa, for EP-performed FOCUS for RV dilation were 89% (95% confidence interval [CI] 80-95%) and 0.68 (95% CI 0.48-0.88), respectively. CONCLUSIONS Emergency physician sonographers are able to detect RV dilation with good agreement when compared to cardiology. These results support the wider use of EP-performed FOCUS to evaluate for RV dilation in ED patients with dyspnea.
Collapse
Affiliation(s)
- Matt A. Rutz
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Julie M. Clary
- Department of Medicine; Division of Cardiology; Indiana University School of Medicine; Indianapolis IN
| | - Jeffrey A. Kline
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Frances M. Russell
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| |
Collapse
|
64
|
Ringgård VK, Sørensen AH, Wemmelund KB, Sloth E, Juhl-Olsen P. Effects of Progressive Hypoventilation on Left Ventricular Appearance: An Alternative Etiology of Acute Sonographic Short-Axis D-Shaping. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1321-1328. [PMID: 28295522 DOI: 10.7863/ultra.16.07019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 09/06/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate the effects of progressive hypoventilation on echocardiographic measures of the left ventricular (LV) appearance in a porcine model. METHODS Ten piglets were included in the experimental group, and 5 served as controls. The experimental group underwent 3 interventions of progressive hypoventilation (baseline: tidal volume, 240 mL; respiratory frequency, 16 minutes-1 ; first intervention: tidal volume, 240 mL; respiratory frequency, 8 minutes-1; second intervention: tidal volume, 240 mL; respiratory frequency, 4 minutes-1 ; and third intervention: tidal volume, 120 mL; respiratory frequency, 4 minutes-1 ). Respiratory resuscitation was initiated if the MAP decreased to 50% of the baseline level or at the end of the third intervention. Transthoracic sonography and invasive measurements were obtained throughout. The primary end point was the LV end-diastolic eccentricity index, a measure of LV D-shaping. RESULTS The median LV end-diastolic eccentricity index increased from 1.1 (interquartile range, 1.0-1.1) at baseline to 1.4 (1.3-1.4) 3 minutes after the third intervention (P < .001) and returned to baseline after resuscitation (P = .093). The MAP declined from 87 mm Hg (81-92 mm Hg) to 50 mmHg (33-66 mm Hg) after initiation of the third intervention (P < .001). The mean pulmonary arterial pressure increased from 20 mm Hg (15-21 mm Hg) to 39 mm Hg (38-40 mm Hg) during the second intervention (P < .001). CONCLUSIONS Progressive hypoventilation led to a marked D-configuration of the LV and a sharp decrease in systemic blood pressure. After respiratory resuscitation, sonographic measures normalized. These findings were explainable by the pressure changes observed within the left and right ventricles.
Collapse
Affiliation(s)
- Viktor Kromann Ringgård
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Høyer Sørensen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kristian Borup Wemmelund
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Erik Sloth
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Juhl-Olsen
- Department of Anesthesiology, Randers Regional Hospital, Randers, Denmark
| |
Collapse
|
65
|
A Modified Lung and Cardiac Ultrasound Protocol Saves Time and Rules in the Diagnosis of Acute Heart Failure. J Emerg Med 2017; 52:839-845. [DOI: 10.1016/j.jemermed.2017.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 11/23/2022]
|
66
|
Price S, Platz E, Cullen L, Tavazzi G, Christ M, Cowie MR, Maisel AS, Masip J, Miro O, McMurray JJ, Peacock WF, Martin-Sanchez FJ, Di Somma S, Bueno H, Zeymer U, Mueller C. Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure. Nat Rev Cardiol 2017; 14:427-440. [PMID: 28447662 PMCID: PMC5767080 DOI: 10.1038/nrcardio.2017.56] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.
Collapse
Affiliation(s)
- Susanna Price
- Royal Brompton &Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Butterfield St &Bowen Bridge Road, Herston, Queensland 4029, Australia
| | - Guido Tavazzi
- University of Pavia Intensive Care Unit 1st Department, Fondazione Policlinico IRCCS San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Michael Christ
- Department of Emergency and Critical Care Medicine, Klinikum Nürnberg, Prof.-Ernst-Nathan-Straße 1, 90419 Nürnberg, Germany
| | - Martin R Cowie
- Department of Cardiology, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Alan S Maisel
- Coronary Care Unit and Heart Failure Program, Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, California 92161, USA
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral, Hospital Sant Joan Despí Moisès Broggi and Hospital General de l'Hospitalet, University of Barcelona, Grand Via de las Corts Catalanes 585, 08007 Barcelona, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic de Barcelona, Carrer de Villarroel 170, 08036 Barcelona, Spain
| | - John J McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Scurlock Tower, 1 Baylor Plaza, Houston, Texas 77030, USA
| | - F Javier Martin-Sanchez
- Emergency Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, Calle del Prof Martín Lagos, 28040 Madrid, Spain
| | - Salvatore Di Somma
- Emergency Department, Sant'Andrea Hospital, Faculty of Medicine and Psychology, LaSapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares and Department of Cardiology, Hospital 12 de Octubre, Avenida de Córdoba, 28041 Madrid, Spain
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen, Bremserstraße 79, 67063 Ludwigshafen am Rhein, Germany
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | | |
Collapse
|
67
|
Vezzosi T, Mannucci T, Pistoresi A, Toma F, Tognetti R, Zini E, Domenech O, Auriemma E, Citi S. Assessment of Lung Ultrasound B-Lines in Dogs with Different Stages of Chronic Valvular Heart Disease. J Vet Intern Med 2017; 31:700-704. [PMID: 28370336 PMCID: PMC5435052 DOI: 10.1111/jvim.14692] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/10/2017] [Accepted: 02/15/2017] [Indexed: 01/26/2023] Open
Abstract
Background In dogs with chronic valvular heart disease (CVHD), early recognition of pulmonary edema (PE) is of paramount importance. Recent studies in dogs showed that lung ultrasound examination (LUS) is a useful technique to diagnose cardiogenic PE. Objectives To describe LUS features in dogs with different stages of CVHD, and to determine its diagnostic accuracy in detecting PE using thoracic radiography as the reference standard. Animals Sixty‐three dogs with CVHD. Methods Prospective, multicenter, cross‐sectional study. Each dog underwent physical examination, echocardiography, thoracic radiography, and LUS. The LUS findings were classified as absent, rare, numerous, or confluent B‐lines. Sensitivity, specificity, and positive and negative predictive values of LUS B‐lines to identify PE were calculated using thoracic radiography as the reference standard. Results Dogs in stage B1 had absent or rare B‐lines in 14 of 15 cases (93.3%). Dogs in stage B2 had absent or rare B‐lines in 16 of 18 cases (88.9%). All dogs in stage C, without radiographic signs of PE, had absent or rare B‐lines. Dogs in stage C, with radiographic signs of PE, had numerous or confluent B‐lines in 18 of 20 cases (90%). Lung ultrasound examination detected PE with a sensitivity of 90%, specificity of 93%, and with positive and negative predictive values of 85.7 and 95.2%, respectively. Conclusions and Clinical Importance Lung ultrasound examination showed good diagnostic accuracy to identify cardiogenic PE and might be helpful in staging dogs with CVHD. Lung ultrasound examination should be considered as a new, noninvasive diagnostic tool for clinicians managing CVHD in dogs.
Collapse
Affiliation(s)
- T Vezzosi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - T Mannucci
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - A Pistoresi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - F Toma
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - R Tognetti
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| | - E Zini
- Istituto Veterinario di Novara, Novara, Italy.,Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland.,Department of Animal Medicine, Production and Health, University of Padova, Padova, Italy
| | - O Domenech
- Istituto Veterinario di Novara, Novara, Italy
| | - E Auriemma
- Istituto Veterinario di Novara, Novara, Italy
| | - S Citi
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
| |
Collapse
|
68
|
Carnell J, Wu E. Echocardiography for ED Dyspnea Evaluation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0119-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
69
|
Riishede M, Laursen CB, Teglbjærg LS, Lassen AT, Baatrup G. Focused ultrasound examination of the chest on patients admitted with acute signs of respiratory problems: a study protocol for a pragmatic randomised controlled multicentre trial. BMJ Open 2016; 6:e012367. [PMID: 27742624 PMCID: PMC5073536 DOI: 10.1136/bmjopen-2016-012367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Patients with acute respiratory problems poses a diagnostic challenge because similar symptoms can be caused by various pathological conditions. Focused ultrasound examination (f-US) of the heart and lungs has proven to increase the diagnostic accuracy in these patients. In this protocol of a randomised multicentre trial, we study the effect of f-US of the heart and lungs in patients with respiratory problems performed by emergency physicians (EP) as soon as the patient arrives to the emergency department (ED). The primary outcome is the number of patients with a correct presumptive diagnosis at 4 hours from admission. METHODS AND ANALYSIS This is a semiblinded randomised prospective study. 288 patients will be included and randomised into the control or intervention group. All patients receive a standard diagnostic evaluation by the EP to assess the primary presumptive diagnosis. Investigators are EP, with varying degrees of experience in f-US, who perform an f-US of the heart and lungs in patients in both treatment arms. f-US results in the intervention group are non-blinded to the treating EP to be included in the assessment of the 4-hour presumptive diagnosis. As standard for correct diagnosis, we perform a blinded journal audit after discharge. As primary analysis, we use the intention-to-treat analysis. CONCLUSIONS This study is the first multicentre trial in EDs to investigate whether f-US, in the hands of the EP, increases the proportion of correct diagnosis at 4 hours after arrival when performed on patients with respiratory problems. ETHICS AND DISSEMINATION This trial is conducted in accordance with the Helsinki II Declaration and approved by the Danish Data Protection Agency and the Committee on Biomedical Research Ethics for the Region of Southern Denmark. Results will be published in accordance with the CONSORT statement in a peer-reviewed scientific journal regardless of the outcome. TRIAL REGISTRATION NUMBER NCT02550184; Pre-results.
Collapse
Affiliation(s)
- M Riishede
- Department of Surgery (A), Odense University Hospital, Svendborg, Denmark Institute of Clinical Research, University of Southern Denmark, SDU-Odense, Denmark Department of Internal Medicine & Emergency Medicine (M/FAM), Odense University Hospital, Svendborg, Denmark
| | - C B Laursen
- Institute of Clinical Research, University of Southern Denmark, SDU-Odense, Denmark Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - L S Teglbjærg
- Department of Internal Medicine & Emergency Medicine (M/FAM), Odense University Hospital, Svendborg, Denmark
| | - A T Lassen
- Institute of Clinical Research, University of Southern Denmark, SDU-Odense, Denmark Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - G Baatrup
- Department of Surgery (A), Odense University Hospital, Svendborg, Denmark Institute of Clinical Research, University of Southern Denmark, SDU-Odense, Denmark
| |
Collapse
|
70
|
Aslaner MA, Boz M, Çelik A, Ahmedali A, Eroğlu S, Metin Aksu N, Eroğlu SE. Etiologies and delirium rates of elderly ED patients with acutely altered mental status: a multicenter prospective study. Am J Emerg Med 2016; 35:71-76. [PMID: 27765479 DOI: 10.1016/j.ajem.2016.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 09/28/2016] [Accepted: 10/03/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Altered mental status (AMS) is a challenging diagnosis in older patients and has a large range of etiologies. The aim of this study was to investigate the nature of such etiologies for physicians to be better aware of AMS backgrounds and hence improve outcomes and mortality rates. METHODS This prospective observational study was conducted at 4 emergency departments. Patients 65 years and older who presented to the emergency department with acute AMS (≤1 week), with symptoms ranging from comas and combativeness, were eligible for inclusion in this study. The outcomes, etiologies, Richmond Agitation and Sedation Scale scores, and the presence of delirium were recorded. RESULTS Among 822 older patients with AMS, infection (39.5%) and neurological diseases (36.5%) were the most common etiologies. The hospital admission and mortality rates were 73.7% (n = 606) and 24.7% (n = 203), respectively. The mortality rate rose if AMS persisted for more than 3 days. Delirium was observed in 55.7% of the patients; these individuals had higher durations of AMS than those without delirium (median, 24 hours; interquartile range, 3-48 hours; median 6 hours, interquartile range, 3-48 hours, respectively; P = .010). Notably, delirium was observed in more than two-thirds of neurological patients. CONCLUSIONS The most common causes of AMS were infection and neurological diseases. Delirium was associated with AMS in nearly half the patients. Moreover, the rates of hospitalization and mortality remained high.
Collapse
Affiliation(s)
| | - Mustafa Boz
- Hacettepe University Faculty of Medicine, Emergency Medicine, Ankara, Turkey
| | - Ali Çelik
- Marmara University Pendik Research and Training Hospital, Emergency Medicine, İstanbul, Turkey
| | | | - Sercan Eroğlu
- Ahi Evran University Training and Research Hospital, Emergency Department, Kırsehir, Turkey
| | - Nalan Metin Aksu
- Hacettepe University Faculty of Medicine, Emergency Medicine, Ankara, Turkey
| | - Serkan Emre Eroğlu
- Marmara University Pendik Research and Training Hospital, Emergency Medicine, İstanbul, Turkey
| |
Collapse
|
71
|
Ha YR, Toh HC. Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review. J Intensive Care 2016; 4:54. [PMID: 27529030 PMCID: PMC4983789 DOI: 10.1186/s40560-016-0172-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/12/2016] [Indexed: 12/16/2022] Open
Abstract
Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review the role and utility of symptom-based and sign-oriented MOPOCUS in patients with undifferentiated respiratory difficulty, chest pain, or shock and how it can be performed in a timely, effective, and efficient manner.
Collapse
Affiliation(s)
- Young-Rock Ha
- Emergency Department, Bundang Jesaeng Hospital, 20 Seohyeon-ro 180beongil, Bundang-gu, Seongnam-si, Gyeonggi-do South Korea
| | - Hong-Chuen Toh
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, 90 Yishun Central, S768828 Singapore, Singapore
| |
Collapse
|
72
|
Abstract
Undifferentiated patients in respiratory distress require immediate attention in the emergency department. Using a thorough history and clinical examination, clinicians can determine the most likely causes of dyspnea. Understanding the pathophysiology of the most common diseases contributing to dyspnea guides rational testing and informed, expedited treatment decisions.
Collapse
Affiliation(s)
- Elizabeth DeVos
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Lisa Jacobson
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.
| |
Collapse
|
73
|
Martindale JL, Wakai A, Collins SP, Levy PD, Diercks D, Hiestand BC, Fermann GJ, deSouza I, Sinert R. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med 2016; 23:223-42. [PMID: 26910112 DOI: 10.1111/acem.12878] [Citation(s) in RCA: 200] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/31/2015] [Accepted: 09/16/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging. OBJECTIVES The primary objective of this study was to perform a systematic review and meta-analysis of the operating characteristics of diagnostic elements available to the emergency physician for diagnosing AHF. Secondary objectives were to develop a test-treatment threshold model and to calculate interval likelihood ratios (LRs) for natriuretic peptides (NPs) by pooling patient-level results. METHODS PubMed, EMBASE, and selected bibliographies were searched from January 1965 to March 2015 using MeSH terms to address the ability of the following index tests to predict AHF as a cause of dyspnea in adult patients in the ED: history and physical examination, electrocardiogram, chest radiograph (CXR), B-type natriuretic peptide (BNP), N-terminal proB-type natriuretic peptide (NT-proBNP), lung ultrasound (US), bedside echocardiography, and bioimpedance. A diagnosis of AHF based on clinical data combined with objective test results served as the criterion standard diagnosis. Data were analyzed using Meta-DiSc software. Authors of all NP studies were contacted to obtain patient-level data. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was utilized to evaluate the quality and applicability of the studies included. RESULTS Based on the included studies, the prevalence of AHF ranged from 29% to 79%. Index tests with pooled positive LRs ≥ 4 were the auscultation of S3 on physical examination (4.0, 95% confidence interval [CI] = 2.7 to 5.9), pulmonary edema on both CXR (4.8, 95% CI = 3.6 to 6.4) and lung US (7.4, 95% CI = 4.2 to 12.8), and reduced ejection fraction observed on bedside echocardiogram (4.1, 95% CI = 2.4 to 7.2). Tests with low negative LRs were BNP < 100 pg/mL (0.11, 95% CI = 0.07 to 0.16), NT-proBNP < 300 pg/mL (0.09, 95% CI = 0.03 to 0.34), and B-line pattern on lung US LR (0.16, 95% CI = 0.05 to 0.51). Interval LRs of BNP concentrations at the low end of "positive" results as defined by a cutoff of 100 pg/mL were substantially lower (100 to 200 pg/mL; 0.29, 95% CI = 0.23 to 0.38) than those associated with higher BNP concentrations (1000 to 1500 pg/mL; 7.12, 95% CI = 4.53 to 11.18). The interval LR of NT-proBNP concentrations even at very high values (30,000 to 200,000 pg/mL) was 3.30 (95% CI = 2.05 to 5.31). CONCLUSIONS Bedside lung US and echocardiography appear to the most useful tests for affirming the presence of AHF while NPs are valuable in excluding the diagnosis.
Collapse
Affiliation(s)
| | - Abel Wakai
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University School of Medicine; Detroit MI
| | - Deborah Diercks
- The Department of Emergency Medicine; University of Texas Southwestern; Dallas TX
| | - Brian C. Hiestand
- The Department of Emergency Medicine; Wake Forest University School of Medicine; Winston-Salem NC
| | - Gregory J. Fermann
- The Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Ian deSouza
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
| | - Richard Sinert
- The Department of Emergency Medicine; SUNY Downstate Medical Center; New York NY
- The Emergency Care Research Unit; Royal College of Surgeons in Ireland; Dublin Ireland
| |
Collapse
|
74
|
Mantuani D, Frazee BW, Fahimi J, Nagdev A. Point-of-Care Multi-Organ Ultrasound Improves Diagnostic Accuracy in Adults Presenting to the Emergency Department with Acute Dyspnea. West J Emerg Med 2016; 17:46-53. [PMID: 26823930 PMCID: PMC4729418 DOI: 10.5811/westjem.2015.11.28525] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/12/2015] [Accepted: 11/13/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction Determining the etiology of acute dyspnea in emregency department (ED) patients is often difficult. Point-of-care ultrasound (POCUS) holds promise for improving immediate diagnostic accuracy (after history and physical), thus improving use of focused therapies. We evaluate the impact of a three-part POCUS exam, or “triple scan” (TS) – composed of abbreviated echocardiography, lung ultrasound and inferior vena cava (IVC) collapsibility assessment – on the treating physician’s immediate diagnostic impression. Methods A convenience sample of adults presenting to our urban academic ED with acute dyspnea (Emergency Severity Index 1, 2) were prospectively enrolled when investigator sonographers were available. The method for performing components of the TS has been previously described in detail. Treating physicians rated the most likely diagnosis after history and physical but before other studies (except electrocardiogram) returned. An investigator then performed TS and disclosed the results, after which most likely diagnosis was reassessed. Final diagnosis (criterion standard) was based on medical record review by expert emergency medicine faculty blinded to TS result. We compared accuracy of pre-TS and post-TS impression (primary outcome) with McNemar’s test. Test characteristics for treating physician impression were also calculated by dichotomizing acute decompensated heart failure (ADHF), chronic obstructive pulmonary disease (COPD) and pneumonia as present or absent. Results 57 patients were enrolled with the leading final diagnoses being ADHF (26%), COPD/asthma (30%), and pneumonia (28%). Overall accuracy of the treating physician’s impression increased from 53% before TS to 77% after TS (p=0.003). The post-TS impression was 100% sensitive and 84% specific for ADHF. Conclusion In this small study, POCUS evaluation of the heart, lungs and IVC improved the treating physician’s immediate overall diagnostic accuracy for ADHF, COPD/asthma and pneumonia and was particularly useful to immediately exclude ADHF as the cause of acute dyspnea.
Collapse
Affiliation(s)
- Daniel Mantuani
- Alameda Health System Highland Campus, Department of Emergency Medicine, Oakland, California
| | - Bradley W Frazee
- Alameda Health System Highland Campus, Department of Emergency Medicine, Oakland, California
| | - Jahan Fahimi
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Arun Nagdev
- Alameda Health System Highland Campus, Department of Emergency Medicine, Oakland, California
| |
Collapse
|
75
|
Favot M, Courage C, Ehrman R, Khait L, Levy P. Strain Echocardiography in Acute Cardiovascular Diseases. West J Emerg Med 2016; 17:54-60. [PMID: 26823931 PMCID: PMC4729419 DOI: 10.5811/westjem.2015.12.28521] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/02/2015] [Accepted: 12/02/2015] [Indexed: 01/19/2023] Open
Abstract
Echocardiography has become a critical tool in the evaluation of patients presenting to the emergency department (ED) with acute cardiovascular diseases and undifferentiated cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of echocardiographic assessment. This article discusses the application of LV longitudinal strain in the ED and reviews how it has been used in various disease states including acute heart failure, acute coronary syndromes (ACS) and pulmonary embolism. It is important for EPs to understand the utility of technological and software advances in ultrasound and how new methods can build on traditional two-dimensional and Doppler techniques of standard echocardiography. The next step in competency development for EP-performed focused echocardiography is to adopt novel approaches such as strain using speckle-tracking software in the management of patients with acute cardiovascular disease. With the advent of speckle tracking, strain image acquisition and interpretation has become semi-automated making it something that could be routinely added to the sonographic evaluation of patients presenting to the ED with cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a variety of conditions including heart failure, ACS and shock.
Collapse
Affiliation(s)
- Mark Favot
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| | - Cheryl Courage
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| | - Robert Ehrman
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| | - Lyudmila Khait
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| | - Phillip Levy
- Wayne State University School of Medicine, Department of Emergency Medicine, Detroit, Michigan
| |
Collapse
|
76
|
Russell FM, Rutz M, Pang PS. Focused Ultrasound in the Emergency Department for Patients with Acute Heart Failure. Card Fail Rev 2015; 1:83-86. [PMID: 28785437 DOI: 10.15420/cfr.2015.1.2.83] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The emergency department (ED) plays a key role in the initial diagnosis and management of acute heart failure (AHF). Despite the advent of novel biomarkers and traditional methods of assessment, such as history, examination, and chest X-ray, diagnosis of the dyspnoeic ED patient is, at times, very challenging. Focused cardiac and pulmonary ultrasound has emerged as a valid, facile and efficient method to aid in the initial diagnosis and management of AHF.
Collapse
Affiliation(s)
- Frances M Russell
- Department of Emergency Medicine, Indiana University School of Medicine,Indianapolis, USA
| | - Matt Rutz
- Department of Emergency Medicine, Indiana University School of Medicine,Indianapolis, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine,Indianapolis, USA.,Regenstrief Institute,Indianapolis, USA
| |
Collapse
|
77
|
Platz E, Jhund PS, Campbell RT, McMurray JJ. Assessment and prevalence of pulmonary oedema in contemporary acute heart failure trials: a systematic review. Eur J Heart Fail 2015; 17:906-16. [PMID: 26230356 DOI: 10.1002/ejhf.321] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/06/2015] [Accepted: 06/12/2015] [Indexed: 01/01/2023] Open
Abstract
AIMS Pulmonary oedema is a common and important finding in acute heart failure (AHF). We conducted a systematic review to describe the methods used to assess pulmonary oedema in recent randomized AHF trials and report its prevalence in these trials. METHODS AND RESULTS Of 23 AHF trials published between 2002 and 2013, six were excluded because they were very small or not randomized, or missing full-length publications. Of the remaining 17 (n = 200-7141) trials, six enrolled patients with HF and reduced ejection fraction (HF-REF) and 11, patients with both HF-REF and HF with preserved ejection fraction (HF-PEF). Pulmonary oedema was an essential inclusion criterion, in most trials, based upon findings on physical examination ('rales'), radiographic criteria ('signs of congestion'), or both. The prevalence of pulmonary oedema in HF-REF trials ranged from 75% to 83% and in combined HF-REF and HF-PEF trials from 51% to 100%. Five trials did not report the prevalence or extent of pulmonary oedema assessed by either clinical examination or chest x-ray. Improvement of pulmonary congestion with treatment was inconsistently reported and commonly grouped with other signs of congestion into a score. One trial suggested that patients with rales over >2/3 of the lung fields on admission were at higher risk of adverse outcomes than those without. CONCLUSION Although pulmonary oedema is a common finding in AHF, represents a therapeutic target, and may be of prognostic importance, recent trials used inconsistent criteria to define it, and did not consistently report its severity at baseline or its response to treatment. Consistent and ideally quantitative, methods for the assessment of pulmonary oedema in AHF trials are needed.
Collapse
Affiliation(s)
- Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ross T Campbell
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John J McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|