This meta-analysis demonstrates that chest radiograph has a low sensitivity and reasonable specificity compared with CT for detecting lung pathology in critically ill patients. The studies also investigating lung ultrasound, showed lung ultrasound to be clearly superior to chest radiograph in terms of sensitivity with similar specificity, thereby opting to be the first-line diagnostic tool in these patients.
SummaryPostoperative pulmonary complications are common after cardiothoracic surgery and are associated with adverse outcomes. The ability to detect postoperative pulmonary complications using chest X‐rays is limited, and this technique requires radiation exposure. Little is known about the diagnostic accuracy of lung ultrasound for the detection of postoperative pulmonary complications after cardiothoracic surgery, and we therefore aimed to compare lung ultrasound with chest X‐ray to detect postoperative pulmonary complications in this group of patients. We performed this prospective, observational, single‐centre study in a tertiary intensive care unit treating adult patients who had undergone cardiothoracic surgery. We recorded chest X‐ray findings upon admission and on postoperative days 2 and 3, as well as rates of postoperative pulmonary complications and clinically‐relevant postoperative pulmonary complications that required therapy according to the treating physician as part of their standard clinical practice. Lung ultrasound was performed by an independent researcher at the time of chest X‐ray. We compared lung ultrasound with chest X‐ray for the detection of postoperative pulmonary complications and clinically‐relevant postoperative pulmonary complications. We also assessed inter‐observer agreement for lung ultrasound, and the time to perform both imaging techniques. Subgroup analyses were performed to compare the time to detection of clinically‐relevant postoperative pulmonary complications by both modalities. We recruited a total of 177 patients in whom both lung ultrasound and chest X‐ray imaging were performed. Lung ultrasound identified 159 (90%) postoperative pulmonary complications on the day of admission compared with 107 (61%) identified with chest X‐ray (p < 0.001). Lung ultrasound identified 11 out of 17 patients (65%) and chest X‐ray 7 out of 17 patients (41%) with clinically‐relevant postoperative pulmonary complications (p < 0.001). The clinically‐relevant postoperative pulmonary complications were detected earlier using lung ultrasound compared with chest X‐ray (p = 0.024). Overall inter‐observer agreement for lung ultrasound was excellent (κ = 0.907, p < 0.001). Following cardiothoracic surgery, lung ultrasound detected more postoperative pulmonary complications and clinically‐relevant postoperative pulmonary complications than chest X‐ray, and at an earlier time‐point. Our results suggest lung ultrasound may be used as the primary imaging technique to search for postoperative pulmonary complications after cardiothoracic surgery, and will enhance bedside decision making.
Background Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect pneumothorax, chest x-ray film has been the reference standard, while ultrasound might be an accurate alternative. The aim of this study was to evaluate diagnostic accuracy of ultrasound to detect central venous catheter malposition and pneumothorax. Methods This was a prospective, multicenter, diagnostic accuracy study conducted at the intensive care unit and postanesthesia care unit. Adult patients who underwent central venous catheterization of the internal jugular vein or subclavian vein were included. Index test consisted of venous, cardiac, and lung ultrasound. Standard reference test was chest x-ray film. Primary outcome was diagnostic accuracy of ultrasound to detect malposition and pneumothorax; for malposition, sensitivity, specificity, and other accuracy parameters were estimated. For pneumothorax, because chest x-ray film is an inaccurate reference standard to diagnose it, agreement and Cohen’s κ-coefficient were determined. Secondary outcomes were accuracy of ultrasound to detect clinically relevant complications and feasibility of ultrasound. Results In total, 758 central venous catheterizations were included. Malposition occurred in 23 (3.3%) out of 688 cases included in the analysis. Ultrasound sensitivity was 0.70 (95% CI, 0.49 to 0.86) and specificity 0.99 (95% CI, 0.98 to 1.00). Pneumothorax occurred in 5 (0.7%) to 11 (1.5%) out of 756 cases according to chest x-ray film and ultrasound, respectively. In 748 out of 756 cases (98.9%), there was agreement between ultrasound and chest x-ray film with a Cohen’s κ-coefficient of 0.50 (95% CI, 0.19 to 0.80). Conclusions This multicenter study shows that the complication rate of central venous catheterization is low and that ultrasound produces a moderate sensitivity and high specificity to detect malposition. There is moderate agreement with chest x-ray film for pneumothorax. In conclusion, ultrasound is an accurate diagnostic modality to detect malposition and pneumothorax. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New
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