Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study

Himanshi Baid, Nagasubramanyam Vempalli, Subodh Kumar, Poonam Arora, Rohit Walia, Udit Chauhan, Krishna Shukla, Aakash Verma, Hannah Chawang, Disha Agarwal, Himanshi Baid, Nagasubramanyam Vempalli, Subodh Kumar, Poonam Arora, Rohit Walia, Udit Chauhan, Krishna Shukla, Aakash Verma, Hannah Chawang, Disha Agarwal

Abstract

Background: Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings.

Methodology: The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared.

Results: Two hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5-264) min compared to the 170 (8-1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001).

Conclusion: By combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients' prompt management and disposition with reliable accuracy.

Keywords: Bedside ultrasound; Diagnostic accuracy; Dyspnea; Emergency department; PoCUS; Point of care ultrasound.

Conflict of interest statement

The authors declared no conflicts of interest with respect to the research, authorship, and/or publication of this article.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
The study flow

References

    1. Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, et al. An Official American Thoracic Society Statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435–452. doi: 10.1164/rccm.201111-2042ST.
    1. Kelly AM, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, et al. An Observational study of dyspnea in emergency departments: the Asia, Australia, and New Zealand Dyspnea in Emergency Departments Study (AANZDEM) Acad Emerg Med. 2017;24(3):328–336. doi: 10.1111/acem.13118.
    1. Mockel M, Searle J, Muller R, Slagman A, Storchmann H, Oestereich P, et al. Chief complaints in medical emergencies. Eur J Emerg Med. 2013;20(2):103–108. doi: 10.1097/MEJ.0b013e328351e609.
    1. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010;26:1–31.
    1. Ray P, Birolleau S, Lefort Y, Becquemin MH, Beigelman C, Isnard R, et al. Acute respiratory failure in the elderly: Etiology, emergency diagnosis and prognosis. Crit Care. 2006;10(3):1–12. doi: 10.1186/cc4926.
    1. Berliner D, Schneider N, Welte T, Bauersachs J. The differential diagnosis of dyspnoea. Dtsch Arztebl Int. 2016;113(49):834–845. doi: 10.3238/arztebl.2016.0834.
    1. Goldberg BB, Gramiak R, Freimanis AK. Early history of diagnostic ultrasound: the role of American radiologists. AJR Am J Roentgenol. 1993;160(1):189–194. doi: 10.2214/ajr.160.1.8416623.
    1. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117–125. doi: 10.1378/chest.07-2800.
    1. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically lll. Emerg Med Clin North Am. 2010;28(1):29–56.vii. doi: 10.1016/j.emc.2009.09.010.
    1. Lichtenstein D. FALLS-protocol: lung ultrasound in hemodynamic assessment of shock. Hear Lung Vessel. 2013;5(3):142–147.
    1. Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001;38(4):377–382. doi: 10.1067/mem.2001.118224.
    1. Kajimoto K, Madeen K, Nakayama T, et al. Rapid evaluation by lung-cardiac-inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting. Cardiovasc Ultrasound. 2012;10(1):49. doi: 10.1186/1476-7120-10-49.
    1. Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E, et al. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol. Acad Emerg Med. 2015;22(2):182–191. doi: 10.1111/acem.12570.
    1. Zanobetti M, Scorpiniti M, Gigli C, Nazerian P, Vanni S, Innocenti F, et al. Point-of-Care Ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151(6):1295–1301. doi: 10.1016/j.chest.2017.02.003.
    1. Buhumaid RE, St-Cyr Bourque J, Shokoohi H, Ma IWY, Longacre M, Liteplo AS. Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath. Am J Emerg Med. 2019;37(2):298–303. doi: 10.1016/j.ajem.2018.10.059.
    1. Stewart VM, Bjornsson HM, Clinton M, Byars DV. BRIPPED scan for evaluation of ED patients with shortness of breath. Am J Emerg Med. 2016;34(3):386–391. doi: 10.1016/j.ajem.2015.11.006.
    1. Ahn JH, Jeon J, Toh HC, Noble VE, Kim JS, Kim YS, et al. SEARCH 8Es: A novel point of care ultrasound protocol for patients with chest pain, dyspnea or symptomatic hypotension in the emergency department. PLoS One. 2017;12(3):e0174581. doi: 10.1371/journal.pone.0174581.
    1. Guttikonda SNR, Vadapalli K. Approach to undifferentiated dyspnea in emergency department: aids in rapid clinical decision-making. Int J Emerg Med. 2018;11(1):21. doi: 10.1186/s12245-018-0181-z.
    1. Long L, Zhao H-T, Zhang Z-Y, Wang G-Y, Zhao H-L. Lung ultrasound for the diagnosis of pneumonia in adults. Medicine (Baltimore) 2017;96(3):e5713. doi: 10.1097/MD.0000000000005713.
    1. Wang Y, Shen Z, Lu X, Zhen Y, Li H. Sensitivity and specificity of ultrasound for the diagnosis of acute pulmonary edema: a systematic review and meta-analysis. Med Ultrason. 2018;1(1):32–36. doi: 10.11152/mu-1223.
    1. Hansell L, Milross M, Delaney A, Tian DH, Ntoumenopoulos G. Lung ultrasound has greater accuracy than conventional respiratory assessment tools for the diagnosis of pleural effusion, lung consolidation and collapse: a systematic review. J Physiother. 2021;67(1):41–48. doi: 10.1016/j.jphys.2020.12.002.
    1. See KC, Ong V, Tan YL, Sahagun J, Taculod J. Chest radiography versus lung ultrasound for identification of acute respiratory distress syndrome: a retrospective observational study. Crit Care. 2018;22(1):203. doi: 10.1186/s13054-018-2105-y.
    1. Sanjan A, Krishnan SV, Abraham SV, Palatty BU. Utility of point-of-care lung ultrasound for initial assessment of acute respiratory distress syndrome patients in the emergency department. J Emerg Trauma Shock. 2019;12(4):248–253. doi: 10.4103/JETS.JETS_47_19.
    1. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med. 2003;10(9):973–977. doi: 10.1111/j.1553-2712.2003.tb00654.x.
    1. Farsi D, Hajsadeghi S, Hajighanbari MJ, Mofidi M, Hafezimoghadam P, Rezai M, et al. Focused cardiac ultrasound (FOCUS) by emergency medicine residents in patients with suspected cardiovascular diseases. J Ultrasound. 2017;20(2):133–138. doi: 10.1007/s40477-017-0246-5.
    1. Gaber HR, Mahmoud MI, Carnell J, Rohra A, Wuhantu J, Williams S, et al. Diagnostic accuracy and temporal impact of ultrasound in patients with dyspnea admitted to the emergency department. Clin Exp Emerg Med. 2019;6(3):226–234. doi: 10.15441/ceem.18.072.

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