Clinician-Performed Bedside Ultrasound in Improving Diagnostic Accuracy in Patients Presenting to the ED with Acute Dyspnea

Abstract

IntroductionDiagnosing acute dyspnea is a critical action performed by emergency physicians (EP). It has been shown that ultrasound (US) can be incorporated into the work-up of the dyspneic patient; but there is little data demonstrating its effect on decision-making. We sought to examine the impact of a bedside, clinician-performed cardiopulmonary US protocol on the clinical impression of EPs evaluating dyspneic patients, and to measure the change in physician confidence with the leading diagnosis before and after US.MethodsWe conducted a prospective observational study of EPs treating adult patients with undifferentiated dyspnea in an urban academic center, excluding those with a known cause of dyspnea after evaluation. Outcomes: 1) percentage of post-US diagnosis matching final diagnosis; 2) percentage of time US changed providers’ leading diagnosis; and 3) change in physicians’ confidence with the leading diagnosis before and after US. An US protocol was developed and standardized prior to the study. Providers (senior residents, fellows, attendings) were trained on US (didactics, hands on) prior to enrollment, and were supervised by an US faculty member. After patient evaluation, providers listed likely diagnoses, documenting their confidence level with their leading diagnosis (scale of 1–10). After US, providers revised their lists and their reported confidence level with their leading diagnosis. Proportions are reported as percentages with 95% confidence interval (CI) and continuous variables as medians with quartiles. We used the Wilcoxon signed-rank test and Cohen’s kappa statistics to analyze data.ResultsA total of 115 patients were enrolled (median age: 61 [51, 73], 59% female). The most common diagnosis before US was congestive heart failure (CHF) (41%, 95%CI, 32–50%), followed by chronic obstructive pulmonary disease (COPD) and asthma. CHF remained the most common diagnosis after US (46%, 95%CI, 38–55); COPD became less common (pre-US, 22%, 95%CI, 15–30%; post-US, 17%, 95%CI, 11–24%). Post-US clinical diagnosis matched the final diagnosis 63% of the time (95%CI, 53–70%), compared to 69% pre-US (95%CI, 60–76%). Fifty percent of providers changed their leading diagnosis after US (95%CI, 41–59%). Overall confidence of providers’ leading diagnosis increased after US (7 [6, 8]) vs. 9 [8, 9], p: 0.001).ConclusionBedside US did not improve the diagnostic accuracy in physicians treating patients presenting with acute undifferentiated dyspnea. US, however, did improve providers’ confidence with their leading diagnosis.

Diagnostic accuracy and temporal impact of ultrasound in patients with dyspnea admitted to the emergency department

“…We found that our standardized ultrasound strategy did not significantly change the physician’s diagnosis, although we observed a modest increase in their diagnostic confidence. This finding is in contrast to that of Papanagnou et al [20] who reported a moderate increase in diagnostic confidence and some changes in management. Consistent with the lack of a change in diagnosis, we found that un-blinding the ultrasound data did not change therapy or disposition decisions.…”

“…They reported similar mean±standard deviation times of 24± 10 and 186±72 minutes for ultrasound and standard of care diagnostic time, respectively. Finally, both Mantuani et al [19] and Papanagnou et al [20] found that the most common final diagnoses in patients presenting to the ED with acute dyspnea were heart failure, airway disease, and pneumonia, which is similar to our findings.…”

Recommendations for Lung Ultrasound in Internal Medicine

“…Experts’ comments [ 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 , 145 , 146 , 147 , 148 , 149 , 150 , 151 , 152 , 153 ] Inflammatory lesions are categorized as parenchymatous (consolidation with an irregular marginal contour, dynamic air bronchogram visible within the consolidation and/or the air trapping sign), vascular (normal flow pattern in CD and PD options) and pleural (pleural effusion). This description of lesions does not apply to bronchopneumonia.…”

Implementation study reporting diagnostic accuracy, outcomes and costs in a multicentre randomised controlled trial of non‐expert lung ultrasound to detect pulmonary oedema

“…Despite evidence that the B line artefact is strongly associated with pulmonary oedema, quantification of B lines appears to be more nuanced than originally proposed . Studies are limited by convenience sampling and the lack of an accessible clinical gold standard with most studies resorting to post hoc expert opinion.…”

“…With two important exceptions, most are prospective observational trials. LUS performs less well when performed by non‐expert sonologists on a broad cohort …”