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

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.

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“…While cardiac and thoracic applications routinely get the lion's share of the POCUS spotlight, our first 2 articles highlight examples of utility for other body parts. As ultrasound is used more and more frequently in the search for reversible causes of cardiac arrest, and in determining the presence or absence of cardiac activity 1 during cardiac arrest, it can perhaps also be used to help with other important resuscitative tasks. All healthcare providers (HCPs) can attest to the difficulties associated with palpating pulses during a crisis, and since the ultrasound machine is most likely already at the bedside, perhaps POCUS can make things easier here too.…”

A retrospective study on parapneumonic effusion in 130 dogs with a clinical diagnosis of pneumonia

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Metastatic testicular cancer presenting with dyspnoea: A case report on the utility of lung ultrasound in the emergency department

“…Recently, a study carried out in 237 subjects, who presented with dyspnea in the emergency department, showed that LUS under the POCUS concept had good concordance with the final diagnosis (k = 0.668) in a mean time of 16 versus 170 min required with traditional methods ( p < .001). 6 To our knowledge, there are no validated protocols for dyspnea evaluation in cancer patients. We suggest that this known protocol, an extended BLUE protocol of proven validity and usefulness may explain with high degree of certainty the causes of dyspnea in cancer patients.…”

“…The protocol was also validated in an observational and prospective study 5 that recruited 260 patients with acute respiratory failure, demonstrating the power to identify the correct cause among the most common diagnoses (bronchial asthma, COPD, pneumonia, pneumothorax, acute pulmonary edema, and pulmonary thromboembolism) of respiratory failure in 90.5% of cases. Recently, a study carried out in 237 subjects, who presented with dyspnea in the emergency department, showed that LUS under the POCUS concept had good concordance with the final diagnosis (k = 0.668) in a mean time of 16 versus 170 min required with traditional methods ( p < .001) 6 …”