Appropriate Use of Point-of-Care Ultrasonography in Acute Dyspnea

Authors:
Qaseem A, Etxeandia-Ikobaltzeta I, Mustafa RA, et al.
Citation:
Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med 2021;Apr 27:[Epub ahead of print].

The following are key points to remember from this American College of Physicians (ACP) clinical guideline on appropriate use of point-of-care ultrasonography (POCUS) in patients with acute dyspnea in emergency department (ED) or inpatient settings:

  1. This ACP guideline was based on a systematic literature review regarding use of POCUS to evaluate adults with acute dyspnea in ED or inpatient settings. In included studies, POCUS was performed by general internists, intensivists, residents, or students. Diagnoses of interest included heart failure (HF), pneumonia, pulmonary embolism (PE), and pleural effusion.
  2. Moderate-certainty evidence showed that POCUS probably increases the proportion of correct diagnoses from 59% to 91% (absolute risk difference, 31.9%; 95% confidence interval [CI], 22.4-53.8%), as compared with the standard diagnostic pathway (history, physical examination, laboratory work, chest imaging, and electrocardiogram). There were insufficient data to draw conclusions about POCUS’ impact on time to diagnosis, time to treatment, and mortality.
  3. POCUS evaluation for HF included assessment of the lungs alone or in combination with the heart, inferior vena cava (IVC), and deep veins. Low-certainty evidence showed that POCUS correctly identified 79-100% of patients with unspecified dyspnea who had HF and 95-99% of patients who did not have HF.
  4. POCUS evaluation for PE included assessment of the lungs, heart, IVC, and deep veins. Low-certainty evidence showed that POCUS, in addition to the standard diagnostic pathway, correctly identified 89-100% of patients with PE and 95-100% of patients without PE.
  5. As a replacement test for the standard diagnostic pathway, POCUS (lungs alone) correctly identified 76% of patients with HF (95% CI, 48-91%), based on moderate-certainty evidence. More extensive POCUS evaluation (lungs, heart, and IVC) correctly identified 88% of patients with HF (95% CI, 8-91%), based on low-certainty evidence.
  6. As a replacement test for the standard diagnostic pathway, POCUS (lungs, heart, IVC, deep veins) correctly identified 40-100% of patients with PE, based on moderate-certainty evidence.
  7. The ACP recommends that clinicians may use POCUS in addition to the standard diagnostic pathway when diagnostic uncertainty exists for patients with acute dyspnea in ED or inpatient settings (conditional recommendation; low-certainty evidence).
  8. To place all this in perspective, POCUS may be a useful tool for triage but should not be considered a substitute for comprehensive transthoracic echocardiography (TTE). POCUS can provide a general idea of ventricular size and function and identify some hallmarks of right heart strain and tamponade. Most often, it does not include assessment of valves. Wall motion abnormalities may not be identified, particularly if they are subtle. If a significant abnormality is detected on POCUS, a follow-up TTE can often provide clarification and context.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Vascular Medicine, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Diagnostic Imaging, Dyspnea, Echocardiography, Electrocardiography, Emergency Service, Hospital, Heart Failure, Inpatients, Physical Examination, Pleural Effusion, Pneumonia, Point-of-Care Systems, Pulmonary Embolism, Time-to-Treatment, Triage, Ultrasonography, Vena Cava, Inferior


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