{"id":639,"date":"2017-07-28T19:18:03","date_gmt":"2017-07-28T19:18:03","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=639"},"modified":"2020-07-22T00:11:13","modified_gmt":"2020-07-22T00:11:13","slug":"comparison-of-four-views-to-single-view-ultrasound-protocols-to-identify-clinically-significant-pneumothorax","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/07\/28\/comparison-of-four-views-to-single-view-ultrasound-protocols-to-identify-clinically-significant-pneumothorax\/","title":{"rendered":"Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax"},"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;\">Ultrasound has become a\u00a0key adjunct for the initial evaluation of trauma patients in the emergency department (ED), with the eFAST, or extended focused assessment with sonography in trauma examination, including lung evaluation for the presence of a pneumothorax (PTX) or hemothorax. While prior research has shown ultrasound (US)\u00a0to be very effective at identifying a PTX [1], there is no standardized imaging protocol that has been shown be superior to others. The two most common approaches are a single view of each hemithorax and four views of each hemithorax [2] \u2014this paper sets out to determine if the single view strategy is sufficient to identify\u00a0a clinically significant PTX.<\/p>\n<p style=\"text-align: center;\"><strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27428394\" target=\"_blank\" rel=\"noopener noreferrer\">Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax<\/a><\/strong><\/p>\n<p>&nbsp;<\/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 style=\"text-align: center;\">Does the single-view or four-view lung US technique have a higher diagnostic accuracy for the identification of clinically significant PTX in trauma patients?<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Methods &amp; Study Design <\/h3><div>\n<ul>\n<li class=\"li1\"><span class=\"s2\"><b>Population<\/b><\/span>\n<ul>\n<li>The study was conducted at a single urban academic ED with an annual volume of 130,000 patients and a dedicated Level I trauma service staffed by trauma surgeons and EM physicians. Adult patients with acute traumatic injury who were undergoing a CT scan of the chest as part of their clinical care were eligible for enrollment.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Intervention<\/b><\/span>\n<ul>\n<li>Patients were assigned to one of two imaging protocols, a single view of each hemithorax or four views of each hemithorax prior to any CT imaging being done, with US images obtained by emergency physicians or the attending trauma surgeon using a 7.5-Mhz (5- to 10-MHz) linear array transducer. US exams were performed by both residents and attending physicians who had been credentialed in both US protocols.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Outcomes<\/b><\/span>\n<ul>\n<li>Researchers looked for the ability of US to identify clinically significant PTX requiring chest tube placement; a PTX was considered clinically insignificant if the radiologist, who was blinded to the US interpretation, read the CT scan as a thin collection of air up to 1 cm thick in the greatest slice or seen on fewer than five contiguous slices.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Design<\/b><\/span>\n<ul>\n<li>This was a randomized, prospective trial on trauma patients.<\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s2\"><b>Excluded<\/b><\/span>\n<ul>\n<li>The study excluded any patient who was too unstable and required clinical care that prevented performing a chest wall US, patients with a chest tube in place prior to arrival, children, pregnant women, and prisoners.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Results<\/h3><div>\n<ul>\n<li>\n<ul>\n<li>For clinically significant PTX, CXR showed a sensitivity of 48.0% and specificity of 100%, a single view US showed a sensitivity of 93.0% and a specificity of 99.2%, and four views showed a sensitivity of 93.3% and specificity of 98.0%. There was no statistically significant difference in either sensitivity or specificity when comparing single view and four-view for clinically significant or any PTX.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-641 aligncenter\" src=\"https:\/\/i0.wp.com\/emultrasound.sdsc.edu\/wp-content\/uploads\/2017\/07\/Screen-Shot-2017-07-28-at-11.41.44-AM.png?resize=525%2C266\" alt=\"\" width=\"525\" height=\"266\" \/><\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Strengths &amp; Limitations<\/h3><div>\n<ul>\n<li class=\"li1\"><strong>Strengths<\/strong>\n<ul>\n<li>Randomized, prospective trial<\/li>\n<li>100% agreement between the initial US read by the performing provider and the study author, for a Cohen\u2019s kappa of 1<\/li>\n<\/ul>\n<\/li>\n<li><strong>Limitations<\/strong>\n<ul>\n<li>Study was conducted at a single center with a limited number of US operators<\/li>\n<li>Standard prehospital approach to spinal immobilization that results in placement of patients supine on a long board - in areas where this approach may differ (e.g., patients arrive semirecumbent or upright), the positioning of a PTX in the chest may be altered, rendering a single view of the anterior chest wall less accurate<\/li>\n<li>As this study was a convenience sample that required the treating physician to remember to enroll the patient and randomize them prior to performing the US, there is a possibility of selection bias<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Author's Conclusions <\/h3><div>\n<p style=\"text-align: center;\">\"The sensitivities are equivalent for both a single view and four views of each hemithorax when using point-of-care ultrasound to evaluate for a clinically significant pneumothorax in the trauma population.\u00a0 The additional time required for additional views should be weighed against the lack of additional diagnostic accuracy when evaluating critically ill and time-sensitive trauma patients in the ED.\"<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Our Conclusions<\/h3><div>\n<p style=\"text-align: center;\">Although not all PTXs are located anteriorly and multiple views of each hemithorax may be thought to maximize sensitivity and\/or allow the physician to be able to attempt to quantify the size of the PTX, performing eight views instead of two views during the eFAST requires extra time\u00a0while adding no diagnostic value.\u00a0 From this study, it appears that a single view on each side of the thorax is sufficient to detect clinically significant PTXs on trauma patients.<\/p>\n<p style=\"text-align: center;\">As with any diagnostic tool, it is important to remember its limitations. Specifically, the US exams in this study were done in supine patients, who were brought in by EMS in a supine position, allowing the pneumothorax to move to the most anterior portion of the chest. Caution should be taken when applying the test characteristics of this study to patients that are not in the supine position. There was also one patient who had a significant PTX that was missed by US and required a chest tube. This patient had received a needle decompression by prehospital providers and was randomized to a single anterior US chest view that was performed just lateral to the needle insertion site which may have led to false negative US exam. It appears this specific group of patients may benefit from a more comprehensive four-view lung examination.<\/p>\n<p>&nbsp;<\/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<h3 style=\"text-align: center;\">A\u00a0single anterior view on each side of the chest in a supine patient is sufficient to detect clinically significant pneumothoraces.<\/h3>\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 Ben Foorman, MS4 at UCSF. It was edited by Michael Macias, MD.<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>References <\/h3><div>\n<ol>\n<li>\n<ol>\n<li>Lichtenstein DA, e. (2017).\u00a0Ultrasound diagnosis of occult pneumothorax. - PubMed - NCBI\u00a0.\u00a0Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/15942336<\/li>\n<li>Blaivas M, e. (2017).\u00a0A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. - PubMed - NCBI\u00a0.\u00a0Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/16141018<\/li>\n<li>Helland G, e. (2017).\u00a0Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax. - PubMed - NCBI\u00a0.\u00a0Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/27428394<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Background Ultrasound has become a\u00a0key adjunct for the initial evaluation of trauma patients in the emergency department (ED), with the eFAST, or extended focused assessment with sonography in trauma examination, including lung evaluation for the presence of a pneumothorax (PTX) or hemothorax. While prior research has shown ultrasound (US)\u00a0to be very effective at identifying a &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2017\/07\/28\/comparison-of-four-views-to-single-view-ultrasound-protocols-to-identify-clinically-significant-pneumothorax\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax\"<\/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":[16,15,8],"class_list":["post-639","post","type-post","status-publish","format-standard","hentry","category-journal-club","tag-pneumothorax","tag-thoracic","tag-trauma"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax - 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\/2017\/07\/28\/comparison-of-four-views-to-single-view-ultrasound-protocols-to-identify-clinically-significant-pneumothorax\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Background Ultrasound has become a\u00a0key adjunct for the initial evaluation of trauma patients in the emergency department (ED), with the eFAST, or extended focused assessment with sonography in trauma examination, including lung evaluation for the presence of a pneumothorax (PTX) or hemothorax. 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