Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis
Point-of-care Ultrasonography for the Diagnosis of Acute Cardiogenic Pulmonary Edema in Patients Presenting With Acute Dyspnea: A Systematic Review and Meta-analysis
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DOI：
10.1111/acem.12435
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发表时间：
2014-08-01
影响因子：
4.4
通讯作者：
Barbic, David
中科院分区：
文献类型：
--
作者：
Al Deeb, Mohammad;Barbic, Skye;Barbic, David
目标 急性呼吸困难是急诊科 (ED) 的常见主诉，护理点 (POC) 肺部超声 (US) 已显示出作为这种情况下的诊断工具的前景。本系统评价的主要目的是确定使用 B 线超声诊断急性呼吸困难患者的急性心源性肺水肿 (ACPE) 的敏感性和特异性。方法 创建遵循 Cochrane 手册指南的系统评价方案来指导检索和分析，我们检索了以下数据库：PubMed、EMBASE、Ovid MEDLINE、Ovid MEDLINE 处理中和其他非索引引文以及 Cochrane 系统评价数据库。手动检索审阅文章的参考文献，并对主要急诊医学、心脏病学和重症监护会议的会议摘要进行电子检索。作者纳入了前瞻性队列研究和前瞻性病例对照研究，招募了因症状、急性呼吸困难或临床怀疑患有充血性心力衰竭而入院的患者，并报告了 B 线诊断 ACPE 的敏感性和特异性。对无症状个体或不怀疑患有 ACPE 的患者的研究被排除在外。令人感兴趣的结果是使用 US B 线诊断 ACPE。临床随访的最终诊断被接受作为参考标准。两名评审员独立评审了所有引文以评估纳入情况、提取数据，并使用 QUADAS-2 工具评估纳入研究的方法学质量。使用列联表来计算敏感性和特异性。预先计划了三个亚组分析，以检查研究类型、患者群体和所采用的肺部超声方案的影响。结果 7 篇文章 (n=1,075) 被确定符合纳入标准（两项研究在急诊室完成，两项研究在重症监护病房 [ICU] 完成，两项研究在住院病房完成，一项在院前环境中完成）。这七项研究的方法学质量被评为平均至优秀。使用 B 线超声诊断 ACPE 的敏感性为 94.1%（95% 置信区间 [CI]=81.3% 至 98.3%），特异性为 92.4%（95% CI=84.2% 至 96.4%）。预先计划的亚组分析并没有揭示总体总结估计的统计显着变化，也没有排除三项潜在的异常研究。结论 这项研究表明，对于 ACPE 预检概率为中度至高的患者，美国的一项研究显示 B 线可用于加强急诊医生对 ACPE 的工作诊断。对于 ACPE 预检概率较低的患者，美国研究阴性几乎可以排除 ACPE 的可能性。需要对大量出现未分化呼吸困难的 ED 患者进行进一步研究，以获得对 ED 患者测试准确性的更有效和可靠的估计。
Objectives Acute dyspnea is a common presenting complaint to the emergency department (ED), and point-of-care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea. Methods A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand-searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case-control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B-lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B-lines. A final diagnosis from clinical follow-up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS-2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed. Results Seven articles (n=1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B-lines to diagnosis ACPE is 94.1% (95% confidence interval [CI]=81.3% to 98.3%) and the specificity is 92.4% (95% CI=84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies. Conclusions This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B-lines can be used to strengthen an emergency physician's working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.