Point-of-care ultrasound of the heart and lungs in patients with respiratory failure: a pragmatic randomized controlled multicenter trial

Abstract

Background Point-of-care ultrasound is a focus oriented tool for differentiating among cardiopulmonary diseases. Its value in the hands of emergency physicians, with various ultrasound experience, remains uncertain. We tested the hypothesis that, in emergency department patients with signs of respiratory failure, a point-of-care cardiopulmonary ultrasound along with standard clinical examination, performed by emergency physicians with various ultrasound experience would increase the proportion of patients with presumptive diagnoses in agreement with final diagnoses at four hours after admission compared to standard clinical examination alone. Methods In this prospective multicenter superiority trial in Danish emergency departments we randomly assigned patients presenting with acute signs of respiratory failure to intervention or control in a 1:1 ratio by block randomization. Patients received point-of-care cardiopulmonary ultrasound examination within four hours from admission. Ultrasound results were unblinded for the treating emergency physician in the intervention group. Final diagnoses and treatment were determined by blinded review of the medical record after the patients´ discharge. Results From October 9, 2015 to April 5, 2017, we randomized 218 patients and included 211 in the final analyses. At four hours we found; no change in the proportion of patients with presumptive diagnoses in agreement with final diagnoses; intervention 79·25% (95% CI 70·3–86·0), control 77·1% (95% CI 68·0–84·3), an increased proportion of appropriate treatment prescribed; intervention 79·3% (95% CI 70·3–86·0), control 65·7% (95% CI 56·0–74·3) and of patients who spent less than 1 day in hospital; intervention n = 42 (39·6%, 25·8 38·4), control n = 25 (23·8%, 16·5–33·0). No adverse events were reported. Conclusions Focused cardiopulmonary ultrasound added to standard clinical examination in patients with signs of respiratory failure had no impact on the diagnostic accuracy, but significantly increased the proportion of appropriate treatment prescribed and the proportion of patients who spent less than 1 day in hospital. Trial registration https://clinicaltrials.gov/, number NCT 02550184.

Usefulness of Multi-Organ Point-Of-Care Ultrasound as a Complement to the Decision-Making Process in Internal Medicine

“…In a recent systematic review [21] about the usefulness of PoCUS in patients admitted to an internal medicine ward, PoCUS findings allowed a therapeutic adjustment in 20-40% of the patients and provided an unsuspected diagnosis in 34% of patients, similar to our study results. Moreover, some studies suggest that PoCUS can help reduce hospital length of stay [22][23]. Yet, it has not been possible to prove that Po-CUS could reduce mortality.…”

POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence

“…Riishede et al [24] randomized 211 patients between blinding and unblinding of POCUS findings to the treating physicians and examined the impact of POCUS on concordance with final diagnosis. The primary outcome in both groups was comparable but the patients whose POCUS findings were unblinded to the treatment team received appropriate therapy more often with an absolute increase of 13,5%.…”

Valor Do Point-of-Care Ultrasound (Pocus) Em Distintas Situações De Insuficiência Cardíaca E Respiratória

“…Desde então, diversos trabalhos vêm não só interpretando os achados quanto às suas sensibilidade e especificidade, como também protocolando as etapas de análise da anatomia torácica. Como exemplo, Riishede et al (2021) protocolou a análise do tórax instituindo a sua divisão em quadrantes superior e lateral, inferior e superior e, para análise cardíaca, instituiu-se a separação do órgão em 4 câmaras, analisadas pelo apêndice subxifóide ou apical. Dessa maneira, a pesquisa foi capaz de demonstrar a existência de derrame pleural, síndrome intersticial/edema pulmonar e pneumotórax, além de derrame pericárdico, fração de ejeção do ventrículo esquerdo prejudicada e sobrecarga do ventrículo direito.…”

“…O POCUS possui um fácil manuseio. Estudos mostram que profissionais mais inexperientes também conseguem atingir uma alta acurácia diagnóstica, em comparação com outros profissionais especializados em ultrassonografia Contudo, apesar da técnica possuir bastantes vantagens, demonstrando ser uma ferramenta diagnóstica de grande valia, ainda há necessidade de maior validação dos seus achados ultrassonográficos, bem como de protocolização anatômica dos sítios de análise (PIETERSEN, 2018;RIISHEDE et al, 2021).…”

“…terapêutica das situações de IC e IR, Riishede et al, (2021) realizaram uma confrontação entre a conduta de rotina e a conduta com o POCUS. Em um estudo, foram randomizados 211 pacientes (106 no grupo de intervenção e 105 no grupo controle) para comparação entre os diagnósticos presuntivos e os finais (após 4 horas).…”