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Dyspnea is a common symptom in patients admitted to the Emergency Department (ED), and discriminating between cardiogenic and non-cardiogenic dyspnea is often a clinical dilemma. The initial diagnostic work-up may be inaccurate in defining the etiology and the underlying pathophysiology. The aim of this study was to evaluate the diagnostic accuracy and reproducibility of pleural and lung ultrasound (PLUS), performed by emergency physicians at the time of a patient's initial evaluation in the ED, in identifying cardiac causes of acute dyspnea. Between February and July 2007, 56 patients presenting to the ED with acute dyspnea were prospectively enrolled in this study. In all patients, PLUS was performed by emergency physicians with the purpose of identifying the presence of diffuse alveolar-interstitial syndrome (AIS) or pleural effusion. All scans were later reviewed by two other emergency physicians, expert in PLUS and blinded to clinical parameters, who were the ultimate judges of positivity for diffuse AIS and pleural effusion. A random set of 80 recorded scannings were also reviewed by two inexperienced observers to assess inter-observer variability. The entire medical record was independently reviewed by two expert physicians (an emergency medicine physician and a cardiologist) blinded to the ultrasound (US) results, in order to determine whether, for each patient, dyspnea was due to heart failure, or not. Sensitivity, specificity, and positive/negative predictive values were obtained; likelihood ratio (LR) test was used. Cohen's kappa was used to assess inter-observer agreement. The presence of diffuse AIS was highly predictive for cardiogenic dyspnea (sensitivity 93.6%, specificity 84%, positive predictive value 87.9%, negative predictive value 91.3%). On the contrary, US detection of pleural effusion was not helpful in the differential diagnosis (sensitivity 83.9%, specificity 52%, positive predictive value 68.4%, negative predictive value 72.2%). Finally, the coexistence of diffuse AIS and pleural effusion is less accurate than diffuse AIS alone for cardiogenic dyspnea (sensitivity 81.5%, specificity 82.8%, positive predictive value 81.5%, negative predictive value 82.8%). The positive LR was 5.8 for AIS [95% confidence interval (CI) 4.8-7.1] and 1.7 (95% CI 1.2-2.6) for pleural effusion, negative LR resulted 0.1 (95% CI 0.0-0.4) for AIS and 0.3 (95% CI 0.1-0.8) for pleural effusion. Agreement between experienced and inexperienced operators was 92.2% (p < 0.01) and 95% (p < 0.01) for diagnosis of AIS and pleural effusion, respectively. In early evaluation of patients presenting to the ED with dyspnea, PLUS, performed with the purpose of identifying diffuse AIS, may represent an accurate and reproducible bedside tool in discriminating between cardiogenic and non-cardiogenic dyspnea. On the contrary, US detection of pleural effusions does not allow reliable discrimination between different causes of acute dyspnea in unselected ED patients.

We appreciate the comments of Drs Cipriani and Ghittoni, which give us the opportunity to further clarify the message of our study. 1 We believe our study demonstrates that an integrated approach combining lung ultrasonography (LUS) and the standard clinical assessment significantly improves the accuracy of the diagnostic process for acute decompensated heart failure (ADHF). We do not believe that the study outcome can be summarized as "chest radiography (CXR) showed moderate accuracy in the identification of ADHF." The poor diagnostic performance of CXR for identifying ADHF is not a new finding. 2,3 Although very specific, detection of pulmonary venous congestion, interstitial edema, or alveolar edema on CXR has unacceptably low sensitivity. 3 Current guidelines, indeed, caution physicians from using CXR in the diagnosis of ADHF, instead highlighting the value of CXR in the identification of alternative pulmonary causes of a given patient's dyspnea. 4

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Lung ultrasound (LUS) has emerged as a rapid, immediately available, non-invasive bedside tool for detection of several pulmonary and/or pleural diseases [1,2]. However, no data are available for its impact on patient management in the emergency department.We studied 50 adult patients (25 women, median age 80.5 years, interquartile range 12.3 years) presenting with acute undifferentiated dyspnea to the emergency department of 'Edoardo Agnelli' Hospital (Pinerolo, Turin), and evaluated the LUS diagnostic impact by comparing the main diagnosis (cardiac, respiratory, or combined dyspnea), the most likely pathophysiologic dysfunction, and the etiological diagnosis, as indicated by the emergency physician caring for the patient, before and after LUS. Reference diagnosis was established by two expert emergency physicians, blinded to LUS results, who independently reviewed the entire medical record. Moreover, we asked the emergency physician how LUS findings changed patient management.We used a previously described eight-region scanning protocol [3] and assessed five major syndromes (see Figure 1) [1]. Diffuse interstitial syndrome (IS) was the most common finding (58%), followed by pleural effusion (52%), focal IS (18%), alveolar consolidation (14%), and pneumothorax (8%). Twenty-seven patients had two or more LUS pathological findings (for example, 17 patients showed pleural effusion and IS), while in six patients LUS detected no alterations.The agreement between clinical assessment and reference diagnoses was fair (Cohen's kappa coefficient = 0.25, 0.32, and 0.26 for main, pathophysiologic, and etiological diagnosis, respectively; P <0.01), while agreement was excellent between LUS-implemented and reference diagnoses (kappa coefficient = 0.94, 0.84, and 0.81, respectively; P <0.01). Overall, LUS changed the main clinical diagnosis in 44% of cases. The agreement for the different main diagnosis is reported in Figure 2.Therapeutic management was changed, because of LUS findings, in 58% of patients. LUS led to prescribing a new drug in 19 cases, and to holding a drug previously considered for treatment in 10 cases; moreover, LUS results led to a new procedure (for example, thoracentesis) being performed in six cases, and to a change of the disposition plan in five cases.Our study is the first to address the issue of how LUS affects patient management in real-world practice. We found a high diagnostic and therapeutic impact, mainly related to the sequential approach used integrating clinical assessment and LUS, that paired the detection of IS, a very sensitive but poorly specific ultrasound sign [1], with the pretest probability of clinical assessment. These data need to be confirmed in larger cohort and multicenter studies. Figure 1 Lung ultrasound major syndromes. (A) Diffuse B-lines representing interstitial syndrome. (B) Alveolar consolidation. (C) M-mode findings of a pneumothorax (stratosphere sign or bar code sign; left), and a normal lung (seashore sign). (D) Pleural effusion.Figure 2 Agreement for the main diagn...

Diffuse comet-tail artifacts at lung ultrasound are due to thickened interlobular septa and extravascular lung water. This condition is typical of the alveolar-interstitial syndrome due to pulmonary edema, diffuse parenchymal lung disease or ARDS. Aim of our study is to assess the potential of bedside lung ultrasound to diagnose the alveolar-interstitial syndrome in patients admitted to our emergency medicine unit. The ultrasonic feature of multiple and diffuse comet-tail artifacts was investigated during 5 months, in 121 consecutive patients admitted to our unit. Each patient was studied bedside in a supine position, by 8 antero-lateral pulmonary intercostal scans. Ultrasonic results were compared with chest radiograph and clinical outcome. Lung ultrasound showed a sensitivity of 84% and a specificity of 98% in diagnosing the radiologic alveolar-interstitial syndrome. Corresponding figures in the identification of a disease involving lung interstitium were 83% and 96%. These preliminary data show that the study of comet-tail artifacts at lung ultrasound is a method reasonably accurate for diagnosing the alveolar-interstitial syndrome at bedside. This conclusion opens the hypothesis of the usefullness of bedside lung ultrasound in the evaluation of dyspnoeic patients in the emergency setting

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