Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill

Abstract

Background: In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Methods: This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. Results: The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in nonventilated than in ventilated patients. Conclusion: The agreement between lung ultrasound and auscultation is poor.

Routine use of Point-of-Care lung ultrasound during the COVID-19 pandemic

“…Ultrasound is considered to be the fifth pillar of physical examinations, 2 and there is an open debate on whether ultrasound should replace stethoscopes in certain scenarios. 3 This same scenario has been shown to happen in echocardiography, where medical students who have trained to recognize cardiovascular disease showed a greater accuracy in their diagnoses using pocket ultra-sounds than a trained cardiologist using a traditional physical examination. 4 We would like to strongly encourage the medical community to not rely solely on auscultation in patients with dyspnea, reduce their use of X-rays and do selective CT scans in this pandemic.…”

Daily Evaluation of COVID-19 Patients Primarily Based on Lung Ultrasound: In Times of Emergency, It's Time to Change Some Paradigms

“…Several studies have demonstrated that LUS has comparable or superior accuracy compared with chest radiography for many of the most common causes of dyspnea. 3 However, few studies have compared LUS with pulmonary auscultation 4 in the follow-up of patients.…”

Need for Objective Assessment of Volume Status in Critically Ill Patients with COVID-19: The Tri-POCUS Approach

“…Conventional physical examination has limited diagnostic utility to predict the fluid status and to guide vasoactive therapy in hemodynamically unstable patients [11]. Of particular note, the diagnostic accuracy of auscultation for detection of alveolar-pulmonary edema is only about 55-67% [12], which is likely to be even lower when using disposable stethoscopes in the noisy ICU environment. Adding to this, several of our clinical assumptions are either inaccurate or have limited value in the case of critically ill patients.…”

“…POCUS is a bedside ultrasound examination performed by the clinician to answer focused question(s) and guide management. Studies have consistently confirmed that it can improve the diagnostic accuracy of physical examination in various clinical backdrops [12,16]. However, isolated use of lung or inferior vena cava (IVC) ultrasound is subject to limitations in this context.…”