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Nielsen AB, Dragsbæk J, Jacobsen N, Laursen CB, Farr A, Slavicky M, Konge L, Pietersen PI. Assessment of Basic Thoracic Ultrasound Skills in Immersive Virtual Reality: Gathering Validity Evidence. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:467-473. [PMID: 38185537 DOI: 10.1016/j.ultrasmedbio.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Operator skills are essential for thoracic ultrasound (TUS) to ensure diagnostic accuracy. Immersive virtual reality (IVR) has shown potential within medical education but never for assessment of TUS skills. This study was aimed at developing an IVR test for assessing TUS skills, gathering validity evidence and establishing a pass/fail score. METHODS An expert panel developed a test based on the TUS protocol by the European Respiratory Society (ERS), including a tutorial and two clinical cases (pleural effusion and interstitial syndrome), using an IVR platform (VitaSim, Odense, Denmark). Four anterior, four lateral and six posterior zones were available for examination and decision of diagnosis. Each correct examination equaled one point. The contrasting groups' method was used to set a pass/fail score. RESULTS Data were collected during the 2022 ERS Congress. We included 13 novices (N, experience: 0 TUS), 22 intermediates (I, 1-50 TUS) and 11 experienced clinicians (E, >50 TUS). Cronbach's α was 0.86. The total mean point scores in case 1 (C1) were (N) 5.0 ± 2.7, (I) 7.3 ± 2.4 and (E) 8.7 ± 1.3, and the scores in case 2 (C2) were (N) 4.5 ± 1.8, (I) 6.7 ± 2.3 and (E) 8.5 ± 2.1. Significant differences were found between N and I for C1 (p = 0.007) and C2 (p = 0.02), I and E for C1 (p = 0.04) and C2 (p = 0.019) and N and E for C1 (p < 0.001) and C2 (p < 0.001). The pass/fail score was 7 points in each case. CONCLUSION We established an IVR test that can distinguish between operators with different TUS skills. This enables a standardized, objective and evidence-based approach to assessment of TUS skills.
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Affiliation(s)
- Anders Bo Nielsen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Svendborg, Denmark; SimC Simulation Centre, Odense University Hospital, Odense, Denmark
| | - Jonas Dragsbæk
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Niels Jacobsen
- Department of Respiratory Medicine, Sygehus Lillebælt-Vejle, Vejle, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark; Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Amy Farr
- Educational Activities, European Respiratory Society, Lausanne, Switzerland
| | - Marek Slavicky
- Educational Activities, European Respiratory Society, Lausanne, Switzerland
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Pia Iben Pietersen
- Department of Radiology, Odense University Hospital, Svendborg, Denmark; UNIFY-Research and Innovation Unit of Radiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Sartini S, Ferrari L, Cutuli O, Castellani L, Bagnasco M, Moisio Corsello L, Bracco C, Cristina ML, Arboscello E, Sartini M. The Role of Pocus in Acute Respiratory Failure: A Narrative Review on Airway and Breathing Assessment. J Clin Med 2024; 13:750. [PMID: 38337444 PMCID: PMC10856192 DOI: 10.3390/jcm13030750] [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: 12/13/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Acute respiratory failure (ARF) is a challenging condition that clinicians, especially in emergency settings, have to face frequently. Especially in emergency settings, many underlying diseases can lead to ARF and life-threatening conditions have to be promptly assessed and correctly treated to avoid unfavorable outcomes. In recent years, point-of-care ultrasound (POCUS) gained growing consideration due to its bedside utilization, reliability and reproducibility even in emergency settings especially in unstable patients. Research on POCUS application to assess ARF has been largely reported mainly with observational studies showing heterogeneous results from many different applications. This narrative review describes the wide potentiality of POCUS to face airways and breathing life-threatening conditions such as upper airway management, pulmonary and pleural pathologies and diaphragm impairment. We conducted extensive research of the literature to report from major studies to case reports deemed useful in practical clinical utilization of POCUS in ARF. Due to the huge amount of the literature found, we focused on airways and breathing assessment trying to systematize the evidence according to clinical care of ARF in emergency settings. Further studies, possibly trials, should determine how POCUS is crucial in clinical practice in terms of standard of care improvements, patient safety and cost-benefit analysis.
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Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
| | - Lorenzo Ferrari
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy;
| | - Ombretta Cutuli
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
| | - Luca Castellani
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
| | - Maddalena Bagnasco
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy;
| | - Luca Moisio Corsello
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
| | - Cristina Bracco
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;
- Hospital Hygiene, E.O. Ospedali Galliera, Via Alessandro Volta 8, 16128 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (M.B.); (L.M.C.); (C.B.); (E.A.)
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;
- Hospital Hygiene, E.O. Ospedali Galliera, Via Alessandro Volta 8, 16128 Genoa, Italy
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Arvig MD, Lassen AT, Gæde PH, Gärtner SW, Falster C, Skov IR, Petersen HØ, Posth S, Laursen CB. Impact of serial cardiopulmonary point-of-care ultrasound exams in patients with acute dyspnoea: a randomised, controlled trial. Emerg Med J 2023; 40:700-707. [PMID: 37595984 PMCID: PMC10579498 DOI: 10.1136/emermed-2022-212694] [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: 06/29/2022] [Accepted: 07/23/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Serial point-of-care ultrasound (PoCUS) can potentially improve acute patient care through treatment adjusted to the dynamic ultrasound findings. The objective was to investigate if treatment guided by monitoring patients with acute dyspnoea with serial cardiopulmonary PoCUS and usual care could reduce the severity of dyspnoea compared with usual care alone. METHODS This was a randomised, controlled, blinded-outcome trial conducted in three EDs in Denmark between 9 October 2019 and 26 May 2021. Patients aged ≥18 years admitted with a primary complaint of dyspnoea were allocated 1:1 with block randomisation to usual care, which included a single cardiopulmonary PoCUS within 1 hour of arrival (control group) or usual care (including a PoCUS within 1 hour of arrival) plus two additional PoCUS performed at 2 hours interval from the initial PoCUS (serial ultrasound group). The primary outcome was a reduction of dyspnoea measured on a verbal dyspnoea scale (VDS) from 0 to 10 recorded at inclusion and after 2, 4 and 5 hours. RESULTS There were 206 patients recruited, 102 in the serial ultrasound group and 104 in the control group, all of whom had complete follow-up. The mean difference in VDS between patients in the serial ultrasound and the control group was -1.09 (95% CI -1.51 to -0.66) and -1.66 (95% CI -2.09 to -1.23) after 4 and 5 hours, respectively. The effect was more pronounced in patients with a presumptive diagnosis of acute heart failure (AHF). A larger proportion of patients received diuretics in the serial ultrasound group. CONCLUSION Therapy guided by serial cardiopulmonary PoCUS may, together with usual care, facilitate greater improvement in the severity of dyspnoea, especially in patients with AHF compared with usual care with a single PoCUS in the ED. Serial PoCUS should therefore be considered for routine use to aid the physician in stabilising the patient faster. TRIAL REGISTRATION NUMBER NCT04091334.
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Affiliation(s)
- Michael Dan Arvig
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Annmarie Touborg Lassen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Peter Haulund Gæde
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Stefan Wernblad Gärtner
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark
- Department of Anaesthesiology, Herlev Hospital, Herlev, Denmark
| | - Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Inge Raadal Skov
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Ømark Petersen
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
- Department of Emergency Medicine, Regional Hospital Horsens, Horsens, Denmark
| | - Stefan Posth
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Alonso-Ojembarrena A, Morales-Navarro A, Rodriguez-Medina J, Correro-Almagro A, Martínez-García R, López-de-Francisco R, González-Haba-Martínez B. The increase in diaphragm thickness in preterm infants is related to birth weight: a pilot study. Eur J Pediatr 2023; 182:3723-3732. [PMID: 37289234 DOI: 10.1007/s00431-023-05052-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/17/2023] [Accepted: 06/02/2023] [Indexed: 06/09/2023]
Abstract
Diaphragm ultrasound (DU) has been used in adult and pediatric critical patients in relation to prediction of extubation success or to detect diaphragm dysfunction, but there is a lack of evidence in neonates. Our aim is to study the evolution of diaphragm thickness in preterm infants, as well as related variables. This prospective monocentric observational study included preterm infants born before 32 weeks (PT32). We performed DU to measure right and left inspiratory and expiratory thickness (RIT, LIT, RET, and LET) and calculated the diaphragm-thickening fraction (DTF) in the first 24 h of life and then weekly until 36 weeks postmenstrual age, death, or discharge. Using multilevel mixed-effect regression, we evaluated the influence of time since birth on diaphragm measurements, as well as bronchopulmonary dysplasia (BPD), birth weight (BW), and days of invasive mechanical ventilation (IMV). We included 107 infants, and we performed 519 DUs. All diaphragm thickness increased with time since birth, but the only additional variable that influenced this growth was BW: beta coefficients RIT = 0.00006; RET = 0.00005; LIT = 0.00005; and LET = 0.00004, p < 0.001. Right DTF values remained stable since birth but left DTF increased with time only in infants with BPD. Conclusion: In our population we found that the higher the BW, the higher diaphragm thicknesses at birth and follow-up. Contrary to the previously published findings in adult and pediatric settings, we were unable to describe a relationship between days of IMV and diaphragm thickness in PT32. The final diagnosis of BPD does not influence this increase either, but it does increase left DTF. What is Known: • Diaphragm thickness and diaphragm thickening fraction have been related to the time on invasive mechanical ventilation in adults and pediatric patients, as well as with extubation failure. • Very few evidence is yet available on the use of diaphragmatic ultrasound in preterm infants. What is New: • Birth weight is the only variable related to diaphragm thickness in preterm infants born before 32 weeks postmenstrual age. • Days of invasive mechanical ventilation do not influence diaphragm increase in thickness in preterm infants.
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Affiliation(s)
- Almudena Alonso-Ojembarrena
- Neonatal Intensive Care Unit, Puerta del Mar University Hospital, Avenida Ana de Viya 11, 11010, Cádiz, Spain.
- Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, Cádiz, Spain.
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Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
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Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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Vasudeva R, Challa A, Chaaban N, Shah H, Brumfield E, Duran B, Vindhyal M. Cardiac POCUS: Another Tool in the Armory. Kans J Med 2023; 16:172-175. [PMID: 37539370 PMCID: PMC10395770 DOI: 10.17161/kjm.vol16.19802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/05/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction This study assessed the educational impact of hybrid cardiac Point of Care Ultrasonography (POCUS) training in a community-based academic setting. Methods Internal Medicine and Medicine/Pediatrics residents across all post-graduate years (PGY) at a midwestern medical school under-took a structured hybrid (online and hands-on teaching) model of POCUS training. Anonymous surveys with Likert-type scale responses were administered before and after the curriculum. Questions were categorized into domains to assess the residents' interest in learning POCUS, their understanding of fundamental cardiac ultrasound (US) concepts, and their confidence in its application. The authors used Fisher's Exact and t-test, and estimated odds ratios to gauge the impact of the training to achieve net scores above 0 on each domain. Results A total of 27 and 26 residents completed the pre-and post-training surveys, respectively. Experience with previous cardiac US use showed a positive skew. The training resulted in a significant increase in both, the understanding of the principles, and the residents' confidence in its application. These findings were most significant amongst PGY 2 and 3 residents. Post-training mean scores were similar across all domains for subgroups of PGY level and previous ultrasound experience. Conclusions Residents displayed greater understanding of the fundamental cardiac ultrasound concepts with improved confidence levels after implementing a structured hybrid teaching model for POCUS. Future studies with objective assessment tools are needed to gauge the clinical impact of POCUS and its adoption rate in clinical practice to guide a recommendation for its incorporation into the residency curriculum.
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Affiliation(s)
- Rhythm Vasudeva
- Internal Medicine/Pediatrics Residency Program, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Abhiram Challa
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Nourhan Chaaban
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Hamna Shah
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Elisha Brumfield
- Department of Internal Medicine, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Brent Duran
- Internal Medicine/Pediatrics Residency Program, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Mohinder Vindhyal
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS
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Szabó GV, Szigetváry C, Szabó L, Dembrovszky F, Rottler M, Ocskay K, Madzsar S, Hegyi P, Molnár Z. Point-of-care ultrasound improves clinical outcomes in patients with acute onset dyspnea: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:639-653. [PMID: 36310302 PMCID: PMC10017566 DOI: 10.1007/s11739-022-03126-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
The early, appropriate management of acute onset dyspnea is important but often challenging. The aim of this study was to investigate the effects of the use of Point-of-Care Ultrasound (PoCUS) versus conventional management on clinical outcomes in patients with acute onset dyspnea. The Cochrane Library, MEDLINE, EMBASE and reference lists were searched to identify eligible trials (inception to October 14, 2021). There were no language restrictions. Randomized controlled trials (RCTs), and prospective and retrospective cohort studies that compared PoCUS with conventional diagnostic modalities (controls) in patients with acute onset dyspnea were included. Two independent reviewers extracted data and assessed the risk of bias. Disagreements were resolved by consensus. The primary study outcomes were time to diagnosis, time to treatment, and length of stay (LOS). Secondary outcomes included rate of appropriate treatment, 30-day re-admission rate, and mortality. We included eight RCTs and six observational studies with a total of 5393 participants. Heterogeneity across studies was variable (from low to considerable), with overall low or moderate study quality and low or moderate risk of bias (except one article with serious risk of bias). Time to diagnosis (mean difference [MD], - 63 min; 95% CI, - 115 to - 11 min] and time to treatment (MD, - 27 min; 95% CI - 43 to - 11 min) were significantly shorter in the PoCUS group. In-hospital LOS showed no differences between the two groups, but LOS in the Intensive Care Unit (MD, - 1.27 days; - 1.94 to - 0.61 days) was significantly shorter in the PoCUS group. Patients in the PoCUS group showed significantly higher odds of receiving appropriate therapy compared to controls (odds ratio [OR], 2.31; 95% CI, 1.61-3.32), but there was no significant effect on 30-day re-admission rate and in-hospital or 30-day mortality. Our results indicate that PoCUS use contributes to early diagnosis and better outcomes compared to conventional methods in patients admitted with acute onset dyspnea.
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Affiliation(s)
- Gergő Vilmos Szabó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Emergency Department, Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
- National Ambulance Service, Budapest, Hungary
- Hungarian Air Ambulance Nonprofit Ltd., Budaörs, Hungary
| | - Csenge Szigetváry
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - László Szabó
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Fanni Dembrovszky
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Máté Rottler
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Department of Anesthesiology and Intensive Therapy, Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Klemetina Ocskay
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Stefanie Madzsar
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
- Department of Anesthesiology and Intensive Therapy, Poznan University, Poznan, Poland.
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Gundersen EA, Juhl-Olsen P, Bach A, Rostgaard-Knudsen M, Nielsen BRR, Skaarup SH, Petersen HØ, Fjølner J, Poulsen MGG, Bøtker MT. PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study. Scand J Trauma Resusc Emerg Med 2023; 31:6. [PMID: 36740691 PMCID: PMC9899351 DOI: 10.1186/s13049-023-01070-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/25/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy. METHODS Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea. RESULTS In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%). CONCLUSION Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure. TRIAL REGISTRATION Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 .
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Affiliation(s)
- Elise Arem Gundersen
- grid.425869.40000 0004 0626 6125Department for Research and Development, Prehospital Emergency Medical Services, Brendstrupgårdsvej 7, 2. th, 8200 Aarhus N, Central Denmark Region Denmark ,grid.416838.00000 0004 0646 9184Department of Anesthesiology, Viborg Regional Hospital, 8800 Viborg, Denmark
| | - Peter Juhl-Olsen
- grid.425869.40000 0004 0626 6125Department for Research and Development, Prehospital Emergency Medical Services, Brendstrupgårdsvej 7, 2. th, 8200 Aarhus N, Central Denmark Region Denmark ,grid.154185.c0000 0004 0512 597XDepartment of Cardiothoracic and Vascular Surgery, Anesthesia Section, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Allan Bach
- grid.425869.40000 0004 0626 6125Department for Research and Development, Prehospital Emergency Medical Services, Brendstrupgårdsvej 7, 2. th, 8200 Aarhus N, Central Denmark Region Denmark ,grid.425869.40000 0004 0626 6125Department of Prehospital Emergency Medical Services, Central Denmark Region, Olof Palmes Allé 32, 1, 8200 Aarhus N, Denmark
| | | | - Bent Roni Ranghøj Nielsen
- grid.154185.c0000 0004 0512 597XDepartment of Cardiology B, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Søren Helbo Skaarup
- grid.154185.c0000 0004 0512 597XDepartment of Respiratory Medicine and Allergy, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Henrik Ømark Petersen
- grid.414334.50000 0004 0646 9002Department of Emergency Medicine, Horsens Regional Hospital, 8700 Horsens, Denmark
| | - Jesper Fjølner
- grid.416838.00000 0004 0646 9184Department of Anesthesiology, Viborg Regional Hospital, 8800 Viborg, Denmark ,grid.425869.40000 0004 0626 6125Department of Prehospital Emergency Medical Services, Central Denmark Region, Olof Palmes Allé 32, 1, 8200 Aarhus N, Denmark
| | - Morten Gustav Gerstrøm Poulsen
- grid.425869.40000 0004 0626 6125Department of Prehospital Emergency Medical Services, Central Denmark Region, Olof Palmes Allé 32, 1, 8200 Aarhus N, Denmark
| | - Morten Thingemann Bøtker
- grid.425869.40000 0004 0626 6125Department for Research and Development, Prehospital Emergency Medical Services, Brendstrupgårdsvej 7, 2. th, 8200 Aarhus N, Central Denmark Region Denmark ,grid.415677.60000 0004 0646 8878Department of Anesthesiology, Randers Regional Hospital, 8930 Randers NØ, Denmark
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Raco J, Peterson B, Muallem S. Assessment of Volume Status in Hospitalized Patients With Chronic Heart Failure. Cardiol Res 2023; 14:2-11. [PMID: 36896231 PMCID: PMC9990539 DOI: 10.14740/cr1434] [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: 10/15/2022] [Accepted: 11/26/2022] [Indexed: 02/27/2023] Open
Abstract
Assessment of volume status in hospitalized patients with heart failure is a critically important diagnostic skill that clinicians utilize frequently. However, accurate assessment is challenging and there is often significant inter-provider disagreement. This review serves as an appraisal of current methods of volume assessment amongst different categories of evaluation including patient history, physical exam, laboratory analysis, imaging, and invasive procedures. Within each category, this review highlights methods that are particularly sensitive or specific, or those that carry impactful positive or negative likelihood ratios. Utilization of the information that this review provides will allow clinicians to determine volume status of hospitalized heart failure patients more accurately and more precisely in order to provide appropriate and effective therapies.
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Affiliation(s)
- Joseph Raco
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Brandon Peterson
- Department of Cardiology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Samer Muallem
- Department of Cardiology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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10
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Kok B, Wolthuis D, Bosch F, van der Hoeven H, Blans M. POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence. Eur J Intern Med 2022; 106:9-38. [PMID: 35927185 DOI: 10.1016/j.ejim.2022.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration. METHODS Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test. CONCLUSION We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment. TRIAL REGISTRY INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/.
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Affiliation(s)
- Bram Kok
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands.
| | - David Wolthuis
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands
| | - Frank Bosch
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands; Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands
| | | | - Michiel Blans
- Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands; Intensive Care Unit, Rijnstate, Arnhem, the Netherlands
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11
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Choi YA, Jung JY, Park JW, Lee MS, Kim TK, Lee SGW, Lee YH, Kim KH. Association between focused cardiac ultrasound and time to furosemide administration in acute heart failure. Am J Emerg Med 2022; 59:156-161. [PMID: 35870373 DOI: 10.1016/j.ajem.2022.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heart failure (HF) is a global health burden, and its management in the emergency department (ED) is important. This study aimed to evaluate the association between focused cardiac ultrasound (FoCUS) and early administration of diuretics in patients with acute HF admitted to the ED. METHODS This retrospective observational study was conducted at a tertiary academic hospital. Patients with acute HF patients who were admitted to the ED and receiving intravenous medication between January 2018 and December 2019 were enrolled. The main exposure was a FoCUS examination performed within 2 h of ED triage. The primary outcome was the time to furosemide administration. RESULTS Of 1154 patients with acute HF, 787 were included in the study, with 116 of them having undergone FoCUS. The time to furosemide was significantly shorter in the FoCUS group (median time (q1-q3), 112 min; range, 65-163 min) compared to the non-FoCUS group (median time, 131 min; range, 71-229 min). In the multivariable logistic regression analysis adjusting for age, sex, chief complaint, mode of arrival, triage level, shock status, and desaturation at triage, early administration of furosemide within 2 h from triage was significantly higher in the FoCUS group (adjusted odds ratio, 1.63; 95% confidence intervals, 1.04-2.55) than in the non-FoCUS group. CONCLUSIONS Early administration of intravenous furosemide was associated with FoCUS examination in patients with acute HF admitted to the ED. An early screening protocol could be useful for improving levels in clinical practice at EDs.
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Affiliation(s)
- Yun Ang Choi
- Department of Emergency Medicine, Pediatric Emergency, Seoul National University Hospital, Republic of Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Pediatric Emergency, Seoul National University Hospital, Republic of Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Pediatric Emergency, Seoul National University Hospital, Republic of Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Tae Kwon Kim
- Department of Emergency Medicine, Keimyung University School of Medicine, Republic of Korea
| | - Stephen Gyung Won Lee
- Department of Emergency Medicine, Keimyung University School of Medicine 1095, Dalgubeol-daero, Dalseo-gu, Daegu 42601, Republic of Korea
| | - Yong Hee Lee
- Department of Emergency Medicine, Seoul National University Hospital, Republic of Korea
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
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12
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Casado-López I, Tung-Chen Y, Torres-Arrese M, Luordo-Tedesco D, Mata-Martínez A, Casas-Rojo JM, Montero-Hernández E, García De Casasola-Sánchez G. Usefulness of Multi-Organ Point-of-Care Ultrasound as a Complement to the Decision-Making Process in Internal Medicine. J Clin Med 2022; 11:2256. [PMID: 35456356 PMCID: PMC9032971 DOI: 10.3390/jcm11082256] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/16/2022] [Accepted: 04/17/2022] [Indexed: 02/04/2023] Open
Abstract
Accumulated data show the utility of diagnostic multi-organ point-of-care ultrasound (PoCUS) in the assessment of patients admitted to an internal medicine ward. We assessed whether multi-organ PoCUS (lung, cardiac, and abdomen) provides relevant diagnostic and/or therapeutic information in patients admitted for any reason to an internal medicine ward. We conducted a prospective, observational, and single-center study, at a secondary hospital. Multi-organ PoCUS was performed during the first 24 h of admission. The sonographer had access to the patients’ medical history, physical examination, and basic complementary tests performed in the Emergency Department (laboratory, X-ray, electrocardiogram). We considered a relevant ultrasound finding if it implied a significant diagnostic and/or therapeutic change. In the second semester of 2019, we enrolled 310 patients, 48.7% were male and the mean age was 70.5 years. Relevant ultrasound findings were detected in 86 patients (27.7%) and in 60 (19.3%) triggered a therapeutic change. These findings were associated with an older age (Mantel−Haenszel χ2 = 25.6; p < 0.001) and higher degree of dependency (Mantel−Haenszel χ2 = 5.7; p = 0.017). Multi-organ PoCUS provides relevant diagnostic information, complementing traditional physical examination, and facilitates therapy adjustment, regardless of the cause of admission. Multi-organ PoCUS to be useful need to be systematically integrated into the decision-making process in internal medicine.
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Affiliation(s)
- Irene Casado-López
- Department of Internal Medicine, Hospital Infanta Cristina, Parla, 28981 Madrid, Spain; (I.C.-L.); (D.L.-T.); (J.M.C.-R.)
| | - Yale Tung-Chen
- Department of Internal Medicine, Hospital Universitario La Paz, 28046 Madrid, Spain
- Department of Medicine, Universidad Alfonso X, Villanueva de la Cañada, 28691 Madrid, Spain
| | - Marta Torres-Arrese
- Department of Emergency Medicine, Hospital Universtario Fundación de Alcorcón, Alcorcón, 28922 Madrid, Spain; (M.T.-A.); (A.M.-M.); (G.G.D.C.-S.)
| | - Davide Luordo-Tedesco
- Department of Internal Medicine, Hospital Infanta Cristina, Parla, 28981 Madrid, Spain; (I.C.-L.); (D.L.-T.); (J.M.C.-R.)
| | - Arantzazu Mata-Martínez
- Department of Emergency Medicine, Hospital Universtario Fundación de Alcorcón, Alcorcón, 28922 Madrid, Spain; (M.T.-A.); (A.M.-M.); (G.G.D.C.-S.)
| | - Jose Manuel Casas-Rojo
- Department of Internal Medicine, Hospital Infanta Cristina, Parla, 28981 Madrid, Spain; (I.C.-L.); (D.L.-T.); (J.M.C.-R.)
| | - Esther Montero-Hernández
- Department of Internal Medicine, Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, 28222 Madrid, Spain;
| | - Gonzalo García De Casasola-Sánchez
- Department of Emergency Medicine, Hospital Universtario Fundación de Alcorcón, Alcorcón, 28922 Madrid, Spain; (M.T.-A.); (A.M.-M.); (G.G.D.C.-S.)
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13
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Cao J, Sun J, Wang Y, Wang L. Diagnostic accuracy of cardiopulmonary ultrasound for pulmonary embolism: A systematic review and meta-analysis. Echocardiography 2022; 39:185-193. [PMID: 35026045 DOI: 10.1111/echo.15280] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/26/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cardiopulmonary ultrasound has shown varying results in the diagnosis of pulmonary embolism patients around the world. Hence, the current review was done to assess the diagnostic accuracy of cardiopulmonary ultrasound for diagnosis of pulmonary embolism among suspected patients. METHODS We conducted a systematic search for all studies reporting the diagnostic accuracy of cardiopulmonary ultrasound for pulmonary embolism in the databases of MEDLINE, EMBASE, MEDLINE, SCOPUS, and Cochrane library from inception till May 2021. Meta-analysis was performed using STATA software "midas" package. RESULTS Ten studies with 4216 patients were included. The pooled sensitivity was 77% (95% CI, 50-92%) and specificity was 99% (95% CI, 97-100%), respectively. The pooled DOR was 382 (95% CI, 77-1883). Pooled LRP was 90 (95% CI, 24-326) and pooled LRN was .23 (.09-.58). There was significant heterogeneity found with the outcome with significant chi-square test and I2 statistic > 75%. CONCLUSION Cardiopulmonary ultrasound has the ability to be used as an adjunct to CTPA especially in resource constrained settings. Further reviews comparing multiple non-invasive imaging modalities are required to pick the best tool for diagnosis of pulmonary embolism.
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Affiliation(s)
- Jingli Cao
- Department of Cardiac Intensive Care Unit, RiZhao International Heart Hospital, RiZhao, Shandong, China
| | - Junjie Sun
- Department of Ultrasound, Shandong Province Yantai YuhuangDing Hospital, Yantai, Shandong, China
| | - Yuanyuan Wang
- Cardiac Rehabilitation Center, Rizhao International Heart Hospital, Rrizhao, Shandong, China
| | - Lihong Wang
- Department of Ultrasound, Shandong Province Yantai YuhuangDing Hospital, Yantai, Shandong, China
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