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Omar M, Jabir AR, Khan I, Novelli EM, Xu JZ. Diagnostic Test Accuracy of Lung Ultrasound for Acute Chest Syndrome in Sickle Cell Disease: A Systematic Review and Meta-analysis. Chest 2023; 163:1506-1518. [PMID: 36509124 PMCID: PMC10258441 DOI: 10.1016/j.chest.2022.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute chest syndrome (ACS) is a leading cause of death in patients with sickle cell disease. Lung ultrasound (LUS) is emerging as a point-of-care method to diagnose ACS, allowing for more rapid diagnosis in the ED setting and sparing patients from ionizing radiation exposure. RESEARCH QUESTION What is the diagnostic accuracy of LUS for ACS diagnosis, using the current reference standard of chest radiography? STUDY DESIGN AND METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed for this systematic review and meta-analysis. Embase, MEDLINE, Web of Science, and Google Scholar were used to compile all relevant studies. Two reviewers screened the studies for inclusion in this review. Cases of discrepancy were resolved by a third reviewer. Meta-analyses were conducted using both metadta and midas STATA software packages to retrieve summary receiver operating characteristic curves, sensitivities, and specificities. Three reviewers scored the studies with QUADAS-2 for risk of bias assessment. RESULTS From a total of 713 unique studies retrieved, six studies were included in the final quantitative synthesis. Of these, five studies were in pediatric EDs. Two studies were conference abstracts and not published manuscripts. Data were available for 625 possible ACS cases (97% of cases in patients aged ≤ 21 years) and 95 confirmed ACS diagnoses (pretest probability of 15.2%). The summary sensitivity was 0.92 (95% CI, 0.68-0.98) and the summary specificity was 0.89 (95% CI, 0.69-0.97) with an area under the curve of the summary receiver operating characteristic curve of 0.96 (95% CI, 0.94-0.97). INTERPRETATION LUS has excellent sensitivity and very good specificity for ACS diagnosis and may serve as an initial point-of-care test to facilitate rapid treatment of ACS and spare pediatric patients from ionizing radiation; however, further research is warranted to improve the generalizability to the adult sickle cell disease population.
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Affiliation(s)
- Mahmoud Omar
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Imadh Khan
- Southern Illinois University School of Medicine, Springfield, IL
| | - Enrico M Novelli
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julia Z Xu
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Koehl JL, Koyfman A, Hayes BD, Long B. High risk and low prevalence diseases: Acute chest syndrome in sickle cell disease. Am J Emerg Med 2022; 58:235-244. [PMID: 35717760 DOI: 10.1016/j.ajem.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 05/31/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Acute chest syndrome (ACS) in sickle cell disease (SCD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ACS in SCD, including diagnosis and management in the emergency department (ED) based on current evidence. DISCUSSION ACS is defined by respiratory symptoms and/or fever and a new radiodensity on chest imaging in a patient with SCD. There are a variety of inciting causes, including infectious and non-infectious etiologies. Although ACS is more common in those with homozygous SCD, clinicians should consider ACS in all SCD patients, as ACS is a leading cause of death in SCD. Patients typically present with or develop respiratory symptoms including fever, cough, chest pain, and shortness of breath, which can progress to respiratory failure requiring mechanical ventilation in 20% of adult patients. However, the initial presentation can vary. While the first line imaging modality is classically chest radiograph, lung ultrasound has demonstrated promise. Further imaging to include computed tomography may be necessary. Management focuses on analgesia, oxygen supplementation, incentive spirometry, bronchodilators, rehydration, antibiotics, consideration for transfusion, and specialist consultation. Empiric antibiotics that cover atypical pathogens are necessary along with measures to increase oxygen-carrying capacity in those with hypoxemia such as simple transfusion or exchange transfusion. CONCLUSIONS An understanding of ACS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Bryan D Hayes
- Department of Emergency Medicine, Division of Medical Toxicology, Harvard Medical School, Boston, MA, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Preto-Zamperlini M, Giorno EPC, Bou Ghosn DSN, Sá FVM, Suzuki AS, Suzuki L, Farhat SC, Weerdenburg K, Schvartsman C. Point-of-care lung ultrasound is more reliable than chest X-ray for ruling out acute chest syndrome in sickle cell pediatric patients: A prospective study. Pediatr Blood Cancer 2022; 69:e29283. [PMID: 34931750 DOI: 10.1002/pbc.29283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute chest syndrome (ACS) is a leading cause of morbidity and mortality in sickle cell patients, and it is often challenging to establish its diagnosis. PROCEDURE This was a prospective observational study conducted in a pediatric emergency (PEM) department. We aimed to investigate the performance characteristics of point-of-care lung ultrasound (LUS) for diagnosing ACS in sickle cell children. LUS by trained PEM physicians was performed and interpreted as either positive or negative for consolidation. LUS results were compared to chest X-ray (CXR) and discharge diagnosis as reference standards. RESULTS Four PEM physicians performed the LUS studies in 79 suspected ACS cases. The median age was 8 years (range 1-17 years). Fourteen cases (18%) received a diagnosis of ACS based on CXR and 21 (26.5%) had ACS discharge diagnosis. Comparing to CXR interpretation as the reference standard, LUS had a sensitivity of 100% (95% CI: 77%-100%), specificity of 68% (95% CI: 56%-79%), positive predictive value of 40% (95% CI: 24%-56%), and negative predictive value of 100% (95% CI: 92%-100%). Overall LUS accuracy was 73.42% (95% CI: 62%-83%). Using discharge diagnosis as the endpoint for both CXR and LUS, LUS had significantly higher sensitivity (100% vs. 62%, p = .0047) and lower specificity (76% vs.100%, p = .0002). LUS also had lower positive (60% vs.100%, p < .0001) and higher negative (100% vs.77%, p = .0025) predictive values. The overall accuracy was similar for both tests (82% vs. 88%, p = .2593). CONCLUSION The high negative predictive value, with narrow CIs, makes LUS an excellent ruling-out tool for ACS.
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Affiliation(s)
- Marcela Preto-Zamperlini
- Emergency Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Eliana P C Giorno
- Emergency Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Danielle S N Bou Ghosn
- Emergency Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Fernanda V M Sá
- Emergency Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Adriana S Suzuki
- Intensive Care Unit, Hematology-Oncology Division, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Lisa Suzuki
- Radiology Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Sylvia C Farhat
- Emergency Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Kirstin Weerdenburg
- Department of Emergency Medicine IWK Health Center and Dalhousie University, Halifax, Nova Scotia, Canada.,IWK Health Center, Halifax, Nova Scotia, Canada
| | - Claudio Schvartsman
- Emergency Department, Children's Institute, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.,Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, Brazil
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Klings ES, Steinberg MH. Acute chest syndrome of sickle cell disease: genetics, risk factors, prognosis and management. Expert Rev Hematol 2022; 15:117-125. [PMID: 35143368 DOI: 10.1080/17474086.2022.2041410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IntroductionSickle cell disease, one of the world's most prevalent Mendelian disorders, is a chronic hemolytic anemia punctuated by acute vasoocclusive events. Both hemolysis and vasoocclusion lead to irreversible organ damage and failure. Among the many sub-phenotypes of sickle cell disease is the acute chest syndrome (ACS) characterized by combinations of chest pain, cough, dyspnea, fever, abnormal lung exam, leukocytosis, hypoxia, and new radiographic opacities. ACS is a major cause of morbidity and mortality.Area coveredWe briefly review the diagnosis, epidemiology, etiology, and current treatments for ACS and focus on understanding and estimating the risks for developing this complication, how prognosis and outcomes might be improved and the genetic elements that might impact the risk of ACS.Expert opinionThe clinical heterogeneity of ACS has hindered our understanding of risk stratification. Lacking controlled clinical trials most treatment is based on expert opinion. Fetal hemoglobin levels and coexistent α thalassemia affect the incidence of ACS; other genetic associations are tenuous. Transfusions, whose use not innocuous, should be targeted to the severity and likelihood of ACS progression. Stable, non-hypoxic patients with favorable hematologic and radiographic findings usually do not need transfusion; severe progressive ACS is best managed with exchange transfusion.
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Affiliation(s)
- Elizabeth S Klings
- Sections of Pulmonary, Allergy, Sleep and Critical Care Medicine, Boston University School of Medicine, Boston, USA
| | - Martin H Steinberg
- Hematology and Medical Oncology, Center of Excellence for Sickle Cell Disease, Boston University School of Medicine and Boston Medical Center, Boston, USA
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