{"id":1356,"date":"2018-11-09T23:50:36","date_gmt":"2018-11-09T23:50:36","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=1356"},"modified":"2020-07-21T23:54:27","modified_gmt":"2020-07-21T23:54:27","slug":"evaluation-of-acute-dyspnea","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/","title":{"rendered":"Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED"},"content":{"rendered":"<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">Background<\/h2>\n<p style=\"text-align: center;\">Dyspnea is a common presenting symptom in the emergency department, and early diagnosis of underlying disease pathology is crucial in rapid intervention and treatment. Laboratory and radiological tests aid in the diagnosis, but often these results take time.<sup>1-3<\/sup> Additionally, chest radiographs and chest CTs, the most common radiological tests in the evaluation of dyspnea, have several disadvantages including radiation risks and high costs. Unlike these modalities, point-of-care ultrasound (PoCUS) is cheap with no radiation risk, highly accurate, and has better sensitivity in detecting pneumothorax, pneumonia, and pleural effusions than CXR.<sup>4-7<\/sup> In addition to being accurate and reliable, PoCUS can be performed rapidly to aid in early diagnosis and treatment of patients.<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/28212836\">Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED<\/a><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Clinical Question<\/h3><div>\n<p>What is the feasibility and diagnostic accuracy of PoCUS for the management of acute dyspnea in the ED?<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Methods &amp; Study Design<\/h3><div>\n<ul>\n<li><b>Design:<\/b><\/li>\n<\/ul>\n<p>Prospective, blinded, observational study<\/p>\n<ul>\n<li><b>Population:<\/b><\/li>\n<\/ul>\n<p>This study was conducted at Careggi University Hospital, a university-affiliated teaching hospital.<\/p>\n<ul>\n<li><b>Inclusion Criteria:<\/b><\/li>\n<\/ul>\n<p>Patients over the age of 18 with acute dyspnea of any degree.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<ul>\n<li><b>Exclusion Criteria:<\/b><\/li>\n<\/ul>\n<p>Patients with dyspnea of traumatic origin, and those that were discharged from the emergency department after evaluation.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<ul>\n<li><b>Intervention:<\/b><\/li>\n<\/ul>\n<p>All patients were primarily assessed by 2 separate emergency physicians with vital signs, history, physical exam, and EKG.<\/p>\n<p>One physician performed a Lung, Cardiac, and IVC PoCUS.<\/p>\n<p>One physician performed a standard workup using any combination of Chest X-Ray, Chest CT, Echocardiogram, labs, or Arterial Blood Gas.<\/p>\n<p>Both physicians were asked to make up to 2 diagnoses based on their results.<\/p>\n<p>Possible diagnoses: Heart Failure, Acute Coronary Syndrome, Pneumonia, Pleural Effusion, Pericardial Effusion, COPD\/asthma, Pulmonary Embolism, Pneumothorax, ARDS\/ALI, Other.<\/p>\n<ul>\n<li><b>Outcomes<\/b><\/li>\n<\/ul>\n<p>Primary:<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p style=\"padding-left: 30px;\">Accuracy of diagnosis:<\/p>\n<p style=\"padding-left: 60px;\">Follow-up chart review determined the reference diagnosis. Results were compared to the diagnosis obtained from the ultrasound group and the standard workup group.<\/p>\n<p>Secondary:<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p style=\"padding-left: 30px;\">Time to final diagnosis for both groups was recorded.<\/p>\n<p style=\"padding-left: 30px;\">Time for Ultrasound completion was recorded.<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Results<\/h3><div>\n<p>3,487 total patients \u2192 2,683 included in study<\/p>\n<p>Average time to complete US: 7\u00b12 min<\/p>\n<p>Average time to Diagnosis:<\/p>\n<p style=\"padding-left: 30px;\">Ultrasound: 24 \u00b1 10 minutes<\/p>\n<p style=\"padding-left: 30px;\">ED: 186 \u00b1 72 minutes<\/p>\n<table cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">Variable<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">Sensitivity - Ultrasound<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">Sensitivity - Standard<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">Heart Failure<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">88 (85.1-90.6)<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">77.3 (73.7 \u2013 80.6)<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">COPD\/asthma<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">86.6 (84.2-89.2)<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">92.2 (90.1-94)<\/span><\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">Pulmonary Embolism<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">40 (30.1-50.6)<\/span><\/td>\n<td valign=\"top\"><span style=\"color: #000000; font-family: Trebuchet MS; font-size: medium;\">90.5 (82.8-95.6)<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li>Point-of-care ultrasound had an increased sensitivity in detecting heart failure compared to standard workup.<\/li>\n<li>Point-of-care ultrasound had a decreased sensitivity in diagnosing COPD\/asthma and pulmonary embolism compared to standard workup.<\/li>\n<\/ul>\n<p>There were no differences in the sensitivity or specificity of ultrasound vs. standard workup in all other diagnoses.<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Strength &amp; Limitations<\/h3><div>\n<p><b>Strengths<\/b><\/p>\n<p>Adequate sample size obtained for most diagnoses.<\/p>\n<p>Gold standard diagnosis was reviewed by two separate emergency medicine physicians.<\/p>\n<p><b>Limitations<\/b><\/p>\n<p>Ultrasound sonographers focused only on those patients with dyspnea, while the treating physicians were responsible for other patients in the ED.<\/p>\n<p>This likely increased the time to diagnosis for emergency physicians in the standard workup group.<\/p>\n<p>Patients discharged from the hospital were not included in study.<\/p>\n<p>Average age of patient population was 71, but patients 18 and over were accepted.<\/p>\n<p>ARDS patient studies were underpowered.<\/p>\n<p><span style=\"font-size: 1rem;\"><\/div><\/div><\/span><\/p>\n<div class=\"motopress-accordion-item\"><h3>Authors Conclusion<\/h3><div>\n<p style=\"text-align: center;\">\u201cIntegrated ultrasound methods could replace the current first diagnostic approach to patients presenting with dyspnea, allowing a drastic reduction in costs and diagnostic times.\u201d<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Our Conclusion<\/h3><div>\n<p style=\"text-align: center;\">Point-of-Care Ultrasound in patients with dyspnea provides us with quick information to begin treatment before other laboratory and radiological tests become available. While this study showed that ultrasound was superior to the standard workup in detecting heart failure, it was slightly inferior to the standard workup in detecting COPD\/asthma, and significantly inferior to standard workup in detecting pulmonary embolism. The authors speculated that with the inclusion of a DVT ultrasound study would improve the sensitivity for detecting PEs greatly. <span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p style=\"text-align: center;\">There have been other studies demonstrating increased sensitivity using ultrasound in patients to diagnose pneumonia and pleural effusions compared to chest x-ray. This study contributed to our knowledge of the accuracy of ultrasound in undifferentiated dyspnea by demonstrating its accuracy in these other important diagnoses. The study shows that PoCUS can guide and the emergency physician\u2019s workup, help risk-stratify, can help us to begin treatment quickly, and improveflow and efficiency in the ED.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-prvt-449-595bfa801309a mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">The Bottom Line<\/h2>\n<p style=\"text-align: center;\">Although PoCUS won\u2019t replace a standard workup in many cases, PoCUS can rapidly and accurately aid in determining the underlying diagnosis in patients presenting to the ED with undifferentiated dyspnea and may lead to quicker treatment times and improved flow in the emergency department.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Authors<\/h3><div>\n<p>This post was written by\u00a0Marissa Wolfe, MS4 at Stony Brook University. Review and further commentary was provided by\u00a0Amir Aminlari, MD,\u00a0Ultrasound Faculty at UCSD.<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>References <\/h3><div>\n<ol>\n<li>Mulrow CD, Lucey CR, Farnett LE. Discriminating causes of dyspnea through clinical examination. J Gen Intern Med. 1993;8(7):383-392.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>Schmitt BP, Kushner MS, Wiener SL. The diagnostic usefulness of the history of the patient with dyspnea. J Gen Intern Med. 1986;1(6):386-393.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>Nielsen LS, Svanegaard J, Wiggers P, Egeblad H. The yield of a diagnostic hospital dyspnoea clinic for the primary health care section. J Intern Med. 2001;250(5):422-428.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>Lichtenstein D, Mezi\u00e8re G. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008;134(1):117-125.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>Reissig A, Copetti R, Mathis G, et al. Lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia: a prospective, multicenter, diagnostic accuracy study. Chest. 2012;142(4): 965-972.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest. 2011;139(5): 1140-1147.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<li>Nazerian P, Volpicelli G, Vanni S, et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med. 2015;33(5):620-625.<span class=\"Apple-converted-space\">\u00a0<\/span><\/li>\n<\/ol>\n<p><span style=\"font-size: 1rem;\"><\/div><\/div><\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Background Dyspnea is a common presenting symptom in the emergency department, and early diagnosis of underlying disease pathology is crucial in rapid intervention and treatment. Laboratory and radiological tests aid in the diagnosis, but often these results take time.1-3 Additionally, chest radiographs and chest CTs, the most common radiological tests in the evaluation of dyspnea, &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[5],"tags":[7,12,15],"class_list":["post-1356","post","type-post","status-publish","format-standard","hentry","category-journal-club","tag-echocardiography","tag-shortness-of-breath","tag-thoracic"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Background Dyspnea is a common presenting symptom in the emergency department, and early diagnosis of underlying disease pathology is crucial in rapid intervention and treatment. 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Laboratory and radiological tests aid in the diagnosis, but often these results take time.1-3 Additionally, chest radiographs and chest CTs, the most common radiological tests in the evaluation of dyspnea, &hellip; Continue reading \"Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED\"","og_url":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/","og_site_name":"UCSD Ultrasound","article_published_time":"2018-11-09T23:50:36+00:00","article_modified_time":"2020-07-21T23:54:27+00:00","author":"UCSD Ultrasound","twitter_card":"summary_large_image","twitter_creator":"@ucsdsono","twitter_site":"@ucsdsono","twitter_misc":{"Written by":"UCSD Ultrasound","Est. reading time":"5 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/#article","isPartOf":{"@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/"},"author":{"name":"UCSD Ultrasound","@id":"https:\/\/emultrasound.ucsd.edu\/#\/schema\/person\/b29066b4104637bc43b8a1c79c2cda34"},"headline":"Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED","datePublished":"2018-11-09T23:50:36+00:00","dateModified":"2020-07-21T23:54:27+00:00","mainEntityOfPage":{"@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/"},"wordCount":944,"commentCount":0,"publisher":{"@id":"https:\/\/emultrasound.ucsd.edu\/#organization"},"keywords":["Echocardiography","Shortness of Breath","Thoracic"],"articleSection":["Journal Club"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/#respond"]}]},{"@type":"WebPage","@id":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/","url":"https:\/\/emultrasound.ucsd.edu\/index.php\/2018\/11\/09\/evaluation-of-acute-dyspnea\/","name":"Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED - 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