Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the Emergency Department
Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the Emergency Department
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DOI：
10.1007/s11739-011-0709-1
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发表时间：
2012-02-01
影响因子：
4.6
通讯作者：
Goffi, Alberto
中科院分区：
文献类型：
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作者：
Cibinel, Gian Alfonso;Casoli, Giovanna;Goffi, Alberto
呼吸困难是急诊室 (ED) 患者的常见症状，区分心源性和非心源性呼吸困难通常是临床难题。最初的诊断检查在定义病因和潜在的病理生理学方面可能不准确。本研究的目的是评估胸膜和肺部超声 (PLUS) 的诊断准确性和可重复性，该超声检查由急诊医生在急诊室对患者进行初步评估时进行，以确定急性呼吸困难的心脏原因。 2007 年 2 月至 7 月期间，56 名因急性呼吸困难而到急诊室就诊的患者前瞻性地参加了这项研究。急诊医生对所有患者进行了 PLUS 检查，目的是确定是否存在弥漫性肺泡间质综合征 (AIS) 或胸腔积液。所有扫描结果随后由另外两名急诊医生（PLUS 专家）进行审查，他们对临床参数不知情，他们是弥漫性 AIS 和胸腔积液阳性的最终判断者。两名经验不足的观察者还对一组随机的 80 个记录的扫描进行了审查，以评估观察者之间的变异性。整个病历由两名对超声（美国）结果不知情的专家医生（一名急诊科医生和一名心脏病专家）独立审查，以确定每位患者的呼吸困难是否是由于心力衰竭所致。获得敏感性、特异性和阳性/阴性预测值；使用似然比（LR）检验。 Cohen 的 kappa 用于评估观察者间的一致性。弥漫性 AIS 的存在高度预测心源性呼吸困难（敏感性 93.6%，特异性 84%，阳性预测值 87.9%，阴性预测值 91.3%）。相反，超声检测胸腔积液对鉴别诊断没有帮助（敏感性83.9%，特异性52%，阳性预测值68.4%，阴性预测值72.2%）。最后，弥漫性AIS和胸腔积液共存对于心源性呼吸困难的准确度低于单独弥漫性AIS（敏感性81.5％，特异性82.8％，阳性预测值81.5％，阴性预测值82.8％）。 AIS 的阳性 LR 为 5.8 [95% CI 4.8-7.1]，胸腔积液的 LR 为 1.7 (95% CI 1.2-2.6)，AIS 的阴性 LR 为 0.1 (95% CI 0.0-0.4)，胸腔积液的 LR 为 0.3 (95% CI 0.1-0.8)。对于 AIS 和胸腔积液的诊断，经验丰富和缺乏经验的操作员之间的一致性分别为 92.2% (p < 0.01) 和 95% (p < 0.01)。在对因呼吸困难而到急诊室就诊的患者进行早期评估时，以识别弥漫性 AIS 为目的进行的 PLUS 可能是区分心源性和非心源性呼吸困难的准确且可重复的床边工具。相反，超声检测胸腔积液并不能可靠地区分未经选择的 ED 患者急性呼吸困难的不同原因。
Dyspnea is a common symptom in patients admitted to the Emergency Department (ED), and discriminating between cardiogenic and non-cardiogenic dyspnea is often a clinical dilemma. The initial diagnostic work-up may be inaccurate in defining the etiology and the underlying pathophysiology. The aim of this study was to evaluate the diagnostic accuracy and reproducibility of pleural and lung ultrasound (PLUS), performed by emergency physicians at the time of a patient's initial evaluation in the ED, in identifying cardiac causes of acute dyspnea. Between February and July 2007, 56 patients presenting to the ED with acute dyspnea were prospectively enrolled in this study. In all patients, PLUS was performed by emergency physicians with the purpose of identifying the presence of diffuse alveolar-interstitial syndrome (AIS) or pleural effusion. All scans were later reviewed by two other emergency physicians, expert in PLUS and blinded to clinical parameters, who were the ultimate judges of positivity for diffuse AIS and pleural effusion. A random set of 80 recorded scannings were also reviewed by two inexperienced observers to assess inter-observer variability. The entire medical record was independently reviewed by two expert physicians (an emergency medicine physician and a cardiologist) blinded to the ultrasound (US) results, in order to determine whether, for each patient, dyspnea was due to heart failure, or not. Sensitivity, specificity, and positive/negative predictive values were obtained; likelihood ratio (LR) test was used. Cohen's kappa was used to assess inter-observer agreement. The presence of diffuse AIS was highly predictive for cardiogenic dyspnea (sensitivity 93.6%, specificity 84%, positive predictive value 87.9%, negative predictive value 91.3%). On the contrary, US detection of pleural effusion was not helpful in the differential diagnosis (sensitivity 83.9%, specificity 52%, positive predictive value 68.4%, negative predictive value 72.2%). Finally, the coexistence of diffuse AIS and pleural effusion is less accurate than diffuse AIS alone for cardiogenic dyspnea (sensitivity 81.5%, specificity 82.8%, positive predictive value 81.5%, negative predictive value 82.8%). The positive LR was 5.8 for AIS [95% confidence interval (CI) 4.8-7.1] and 1.7 (95% CI 1.2-2.6) for pleural effusion, negative LR resulted 0.1 (95% CI 0.0-0.4) for AIS and 0.3 (95% CI 0.1-0.8) for pleural effusion. Agreement between experienced and inexperienced operators was 92.2% (p < 0.01) and 95% (p < 0.01) for diagnosis of AIS and pleural effusion, respectively. In early evaluation of patients presenting to the ED with dyspnea, PLUS, performed with the purpose of identifying diffuse AIS, may represent an accurate and reproducible bedside tool in discriminating between cardiogenic and non-cardiogenic dyspnea. On the contrary, US detection of pleural effusions does not allow reliable discrimination between different causes of acute dyspnea in unselected ED patients.