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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 10
| Issue : 3 | Page : 105-109 |
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Accuracy of PoCUS in diagnosing acute dyspnea in ED
Ponnankandy Salfi1, Adithya Venkataram Bharadwaj1, Afza Tasneem1, Delma D’Cunha2
1 Department of Emergency Medicine, Indiana Hospital and Heart Institute, Mangalore, Karnataka, India
2 Department of Anaesthesiology and Critical Care, Yenepoya Medical College, Mangalore, Karnataka, India
| Date of Submission | 15-Apr-2022 |
| Date of Decision | 06-Jun-2022 |
| Date of Acceptance | 09-Jun-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Delma D’Cunha
Department of Anaesthesiology and Critical Care, Yenepoya Medical College, Mangalore, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/DYPJ.DYPJ_31_22
Introduction: Acute dyspnea is a common symptom in the emergency department (ED). Diagnosis and management of patients presenting with acute dyspnea is one of the major challenges for physicians in the ED. A correct diagnosis is frequently delayed and difficult to ascertain, and clinical uncertainty is common, explaining the need for rapid diagnosis and a management plan. The standard approach to dyspnea often relies on radiologic and laboratory results, causing an excessive delay before adequate therapy is started. The use of an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile. Materials and Methods: This was a prospective study on 88 patients aged above 18 years who came with a complaint of acute dyspnea to emergency room of a tertiary care center in Mangalore, Karnataka, over a period of 1 year from September 2017 to September 2018. Results: The accuracy of PoCUS in diagnosing acute dyspneic patients was found to be 93.8% in our study. Conclusion: PoCUS is a great tool in all emergency settings to deliver a better care. Keywords: Dyspnea, emergency medicine, PoCUS
How to cite this article:
Salfi P, Bharadwaj AV, Tasneem A, D’Cunha D. Accuracy of PoCUS in diagnosing acute dyspnea in ED. D Y Patil J Health Sci 2022;10:105-9 |
| Introduction | |  |
Acute dyspnea is a frequent presenting symptom in the emergency department (ED), and emergency physicians need to rapidly and accurately formulate a diagnosis to guide an early and appropriate therapeutic intervention. Dyspnea is the leading symptom of many diseases, and a rapid discrimination of the underlying pathologic condition is often difficult for the emergency physician. A careful and thorough physical examination can direct diagnostic suspicion, but these methods need to be integrated with laboratory and radiologic testing (using chest radiograph [CXR] or chest computed tomography [CCT]), whose results are often delayed.[1],[2],[3]
Moreover, it can be difficult to perform CXR in critically ill patients, and results may be misinterpreted.[4],[5] Conversely, CCT scanning, which is considered the gold standard for the differential diagnosis of dyspnea,[6] has high costs, is not feasible in patients in unstable condition, and is not available 24 h a day in all ED settings.[7] Point-of-care ultrasonography (PoCUS) has become a widely used diagnostic tool in the ED. Because it can be rapidly performed at the bedside by the emergency physician, it should be considered an extension of the physical examination, adding anatomic and functional information to the clinical data.[8],[9],[10],[11] This approach allows the identification of the most likely diagnosis and the prompt initiation of urgent therapies. Many studies have confirmed the high accuracy of lung ultrasonography (LUS) in the differential diagnosis of acute respiratory failure,[4] and emergency echocardiography (ECHO) performed by emergency physicians can also add some important information regarding patients with acute dyspnea (i.e., dilation of heart chambers, visual estimation of the left ventricular ejection fraction, the presence of pericardial fluid, regional wall motion abnormality [RWMA]).[12],[13],[14] Integrating LUS and ECHO helps differentiate cardiogenic from noncardiogenic dyspnea.[15],[16],[17]
Finally, the inferior vena cava (IVC) diameter and its variations during respiratory activity allow an indirect estimation of right atrial pressure and an assessment of volume status, providing useful information to guide fluid therapy.[18],[19]
Based on this information, the integration of lung, heart, and IVC ultrasound with PoCUS could lead to a rapid diagnosis and therefore to targeted, early treatment of patients with acute dyspnea in the ED.
The primary aim of our study was to assess the accuracy of PoCUS to differentiate patients presenting with acute dyspnea to ED into different diagnostic categories for timely management in a resource-limited setting.
Studies by Sforza et al.[16] and Lichtenstein[17] have shown that PoCUS represents a feasible and reliable diagnostic approach to the dyspneic patient, allowing a reduction of the diagnostic time and helping to stratify patients who should undergo a more detailed evaluation.
The initial ultrasound examination with point of care ultrasonography is a useful extension of the clinical examination, can be readily available at the bedside or in ambulance, requires few minutes, and has a reliable diagnostic discriminant ability in the setting of acute dyspnea.[20],[21]
| Materials and Methods | | |
This was a prospective, observational study of adult patients, which used multiorgan PoCUS in evaluating patients presenting with acute dyspnea in the emergency care. The study was approved by ethics committee. The study was performed between September 2017 and September 2018 in the ED of Indiana Hospital and Heart Institute, Mangalore. Written informed consent was taken from all patients. Adult patients aged 18 years and above who presented with acute dyspnea were included in the study. Patients with the traumatic origin of dyspnea and age < 18 years were excluded from the study. The primary assessment of enrolled patients consisted of a routine evaluation with the detection of vital signs, a medical history, physical examination, 12-lead electrocardiography (ECG), chest X ray, and labs. The demographic details are as shown in [Table 1][Table 2][Table 3][Table 4].
After an initial evaluation, all patients were subjected to a focused multiorgan ultrasonography (USG) at bedside using a standard medium-frequency curved array probe.
LUS was performed using a linear probe with patients in erect or semi-recumbent positions depending on their severity of breathlessness.
- A. Using only the bilateral anterior lung windows (representing four lung zones),[22] we assessed whether there was predominantly an A-line or B-line (indicating abnormal pulmonary fluid) pattern, as described by Lichtenstein and Menu.[23]
- B. We also scanned the lateral chest superior to the hemidiaphragms for the presence or absence of pleural effusions, but were not evaluated for the presence of A or B lines.[22]
- C. We assessed pleural sliding on 2D and M-mode as needed over the anterior lung fields to exclude pneumothorax.
LUS was performed on each hemithorax divided into five zones (two anterior, two lateral, and one posterior) with patients in a seated or lying-down position. Several signs were explored to conclude on typical patterns as per the international evidence-based recommendations on a point-of-care LUS,[24] which includes:
- A. Lung sliding
- B. Pleural effusion (anechoic space between parietal and visceral pleura with sinusoid sign)
- C. Pneumothorax (the loss of lung sliding with positive lung point)
- D. Acute interstitial syndrome, defined as B-pattern with at least three B-lines in two lung zones bilaterally
- E. Lung consolidation signs (focal B-lines with tissue-like echotexture and dynamic air bronchograms).[24],[25]
Cardiac ultrasound
Cardiac ultrasonography was performed with the following views: parasternal long axis, parasternal short axis, and apical four chambers. The contractility, RWMA, chambers, and pericardial effusion were assessed.[22]
The left ventricular systolic function was typically graded as normal dysfunction (ejection fraction [EF] > 50%), moderate dysfunction (EF = 30%–50%), or severe dysfunction (EF < 30%) basing on eyeball visual estimate and mitral valve E-point to septal separation (EPSS) measurement.[23],[25]
A qualitative evaluation of the right ventricle dimension was made for right atrium/right ventricle dilatation.25
IVC ultrasound
IVC USG was performed in a subxiphoid view for diameter and collapsibility. An IVC with a maximal diameter of ≥2 cm and <50% collapse was considered plethoric. An IVC with a maximal diameter of ≤2 cm and >50% collapse was considered collapsible.[25]
Statistical analysis
Continuous data were expressed as mean ± 1 standard deviation (SD) and categorical variables as percentages. Quantitative variables were compared by using Student’s t-test.
A P value < 0.05 was regarded as statistically significant.
The performance of different diagnostic tools was analyzed using sensitivity, specificity, positive predictive value, and negative predictive value analysis. The level of agreement between ED diagnosis and final hospital diagnosis was assessed using the kappa statistic.
| Results | | |
Patient characteristics
Age
In our study, 28 out of 88 patients (31.8%) were between the age 61 and 70, and 21 out of 88 patients with 23.9% were above 70 years of age.
Sex
Eighty-eight patients were included in this analysis. Out of which 33 were females and 55 were males.
Comorbidities
Forty patients had a past history of coronary artery disease (CAD) with 45.5%, 25 patients had a past history of chronic kidney disease with 28.4, 28 patients had a past history of chronic obstructive pulmonary disease (COPD) with 31.8%, 43 patients had a past history of diabetes mellitus with 48.9%, 49 patients had a past history of hypertension with 55.7%, six patients had a past history of cerebrovascular accident with 6.8%, two patients had a past history of seizure disorder with 2.3%, eight patients had a past history of carcinoma lung with 9.1%, and six patients had other past history such as chronic liver disease, rheumatic heart disease, hypothyroidism, and aortic aneurysm.
Evaluation of respiratory system
Fifty-five out of 88 patients in our study were detected with bilateral crepitations on respiratory examination, 15 out of 88 patients had crepitations and rhonchi, five out of 88 patients had rhonchi, four out of 88 patients with decreased breath sounds, and nine out of 88 patients had normal breath sounds as tabulated in [Table 5].
ECG
ECG changes out of 88 patients: 32 patients had sinus tachycardia, 21 patients had arrhythmias such as atrial fibrillation, left bundle branch block, right bundle branch block, 19 patients had normal sinus rhythm, 13 patients had ST/T changes such as ST elevation and ST depression, and others were tachycardia with bigeminy, sinus rhythm with ectopics, and tachycardia with pacemaker rhythm as shown in [Table 6].
ED diagnosis
The most common cause of dyspnea in this study was found to be acute pulmonary edema with 45.5%, followed by pleural effusion with 34.1%, acute exacerbation of COPD with 11.4%, pneumothorax with 3.4%, CAD-ACS with 3.4%, and postpartum cardiomyopathy with 1.1% as shown in [Table 7].
Final diagnosis
According to our study, the most common cause of acute dyspnea presenting to ED was found to be acute pulmonary edema followed by pleural effusion, acute exacerbation of COPD, pneumothorax, postpartum cardiomyopathy, and CAD-ACS as shown in [Table 8].
The accuracy of the diagnosis is as shown in [Table 9].
The overall accuracy in diagnosing a dyspneic patient in emergency using PoCUS was thus found to be 93.2% in our study.
| Discussion | | |
Out of 88 patients presenting with acute dyspnea, 45 patients were diagnosed to be in acute pulmonary edema, which accounted for 51.1% of total dyspneic patients that presented to our ED. The final diagnosis with pulmonary edema was established in 40 out of 88 patients, which accounted for 45.5%. The accuracy of diagnosing pulmonary edema in ED using PoCUS was thus found to be 94.8%.
Similarly, the final diagnosis of pleural effusion was established in 30 out of 88 patients, which accounts to 34.1%. Thus, the accuracy of diagnosing pleural effusion in ED using PoCUS was found to be 94.32%. The acute exacerbation of COPD was established in 10 out of 88 patients, which accounts to 11.4%. Thus, the accuracy of diagnosing acute exacerbation of COPD in ED using PoCUS was found to be 96.59% in our study.
Out of the 88 patients who presented to the emergency room with acute dyspnea, three patients were diagnosed to have pneumothorax, which accounted for 3.4% of total dyspneic patients. The accuracy of diagnosing pneumothorax in ED using PoCUS was thus found to be 100%.
One patient had been diagnosed with postpartum cardiomyopathy, which accounted for 1.1% of total dyspneic patients. The accuracy of diagnosing postpartum cardiomyopathy in ED using PoCUS was also found to be 100%.
Out of 88 patients presenting with acute dyspnea, three patients were diagnosed to be CAD-ACS, which accounts to 3.4% of total dyspneic patients. Thus the accuracy of diagnosing CAD-ACS in ED using PoCUS was found to be 100%.
Our study shows that out of 88 patients, 82 patients received correct disease-specific treatment using the above diagnostic strategy with an agreement to ED diagnosis and final discharge diagnosis. The measure of agreement Kappa is 0.805 (P = 0.000), where the level of agreement is statistically significant.
The concordance between initial diagnosis at admission and final hospital diagnosis at discharge was analyzed by Kappa. There is an agreement in diagnosis in 82 of the patients. The measure of agreement Kappa = 0.805 (P = 0.000). The level of agreement between emergency diagnosis using PoCUS and final diagnosis is 93.2%.
| Conclusion | | |
From these results, we can affirm that PoCUS is a reliable and accurate tool that can be used in an initial approach to patients in ED with acute dyspnea. It allows fast, accurate, bedside examination of the patients presenting with dyspnea. Adding PoCUS to routine examination can improve diagnostic accuracy in patients complaining of dyspnea.
From these results, we can affirm that PoCUS is a reliable and accurate tool that could be used in the initial approach to patients in the ED. From these results, we can affirm that PoCUS is a reliable and accurate tool that could be used in the initial approach to patients in the ED.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Authors’ contribution
AB = concept, framing, data collection, SPK = data collection, article proofreading, AT = concept, framing, data collection, article writing, DD = data compilation and analysis, article proofreading.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
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