- Email: [email protected]
Should ultrasound be included in the initial assessment of respiratory patients?
Comment
Little doubt exists about the usefulness of ultrasonography in the identification and correct diagnosis of the many diseases patients present with in the emergency department. For example, abdominal ultrasound is a cornerstone in the diagnosis of acute cholecystitis. In the initial care of patients with multiple injuries, a systematic search for multifocal lesions with ultrasound (focused assessment with sonography for trauma technique) is an established protocol that has been introduced in most emergency services. However, the role of ultrasound in other medical specialties, its exact role in the diagnostic algorithm, and the identification of the professionals responsible for examining and interpreting the findings are still unsolved and even controversial issues. Echocardiography, abdominal sonography, vascular sonography, and transcranial Doppler ultrasound are well established techniques commonly used in the critical-care setting. However, use of lung ultrasonography is less widespread, even though experts have recently established recommendations with the aim of achieving a unified approach to lung sonographic signs.1 There is no doubt about the accuracy of lung ultrasonography in the diagnosis and treatment of pleural effusion, but the management of parenchymal involvement seems to be more complicated. Multiple diffuse bilateral B lines will indicate the presence of an interstitial syndrome and might assist bedside differentiation between a cardiogenic versus a respiratory cause of acute dyspnoea.2,3 Although some authors have shown its usefulness for several respiratory diseases, only lung consolidations involving the pleura seem to be correctly assessed with lung ultrasonography.4 Also, lung ultrasonography is more accurate for the identification of pneumothorax than is supine anterior chest radiography (and on a par with CT) and could be mandatory in some settings such as acute chest pain and cardiac arrest.5 Nevertheless, we should note that the accuracy of lung ultrasonography will be directly affected by the expertise of the clinician using the ultrasonography. In a narrower specialty, such as deep venous thrombosis, www.thelancet.com/respiratory Vol 2 August 2014
good agreement between focused trained clinicians and the radiologist doing a radiology residency has been quoted by some investigators.6 Moreover, an examination for lung diseases done at the patient’s bedside with true contemporaneous interpretation and immediate clinical decision making could not be matched by a scan done by a radiologist with a formal report. To establish education in emergency ultrasound, many scientific societies are including this technology in their training programmes. However, discrepancies exist between emergency medicine programmes in ultrasound curricula and perceived needs for achieving proficiency in emergency ultrasound.7,8 Christian Laursen and colleagues bravely tackle all these controversial aspects about point-of-care ultrasonography in patients with respiratory symptoms treated in the emergency department in their study reported in the Lancet Respiratory Medicine.9 We have the opportunity to see the benefits achieved in terms of appropriate diagnosis when heart, lung, and deep-vein point-of-care ultrasonography is added to the standard diagnostic algorithm in the emergency department. The smart design of this clinical trial proves beyond a doubt that a well trained clinician can improve the diagnostic ability (traditional examination and history) when point-of-care ultrasonography is done systematically in patients with respiratory symptoms. The benefits obtained in the rate of appropriate early diagnosis (<4 h after admission to the emergency department; 88·0% [95% CI 82·8–93·1] in the point-ofcare ultrasonography group versus 63·7% [56·1–71·3] in the control group had correct presumptive diagnoses; absolute effect 24·3% [15·0–33·1] and relative effect 1·38 [1·01–1·31]) cannot be extended to other aspects such as avoiding the application of other diagnostic techniques or improving prognosis. However, as the investigators state, this clinical trial was not designed or powered to achieve such results. A limitation that might affect the conclusions of this clinical trial is its personal nature: results are based on one clinician’s expertise in heart, lung, and deep-vein point-ofcare ultrasonography—a skill that is not necessarily transferable to other professionals. We therefore return
Oto / Chu Bordeaux/Science Photo Library
Should ultrasound be included in the initial assessment of respiratory patients?
Published Online July 4, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70142-0 See Articles page 638
599
Comment
to the need to standardise and certify training and skills in point-of-care ultrasonography for physicians in the emergency department. Hopefully, Laursen will be able to disseminate his knowledge in ultrasound and potentially improve care in the emergency department for patients with respiratory symptoms. Another limitation of the study, inherent to its design, in which only one investigator did the pointof-care ultrasonography, is that the inclusion of patients in the trial was not truly consecutive and this might lead to subsequent bias. The results of Laursen and colleagues’ study show the usefulness of point-of-care ultrasonography in obtaining an early diagnosis in the emergency department in patients with specific respiratory signs and symptoms. Probably, it is now time for specialists in emergency medicine and pulmonologists to learn or improve their knowledge and skills of ultrasonography. Is point-of-care ultrasonography the 21st century stethoscope?
Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Villarroel 170, 08036 Barcelona, Spain (PR) [email protected]
Paula Ramirez, *Antoni Torres
9
Critical Care Department, Hospital Universitario y Politécnico la Fe (PR), and Pneumology Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS (AT), Centro de Investigación
We declare no competing interests. 1
2
3
4
5 6
7
8
Volpicelli G, Elbarbary M, Blaivas M, et al. International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577–91. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134: 117–25. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139: 1140–47. Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med 2009; 27: 379–84. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37: 224–32. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med 2010; 56: 601–10. Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies. West J Emerg Med 2010; 11: 314–18. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG. The status of bedside ultrasonography training in emergency medicine residency programs. Acad Emerg Med 2003; 10: 37–42. Laursen CB, Sloth E, Lassen AT, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014; published online July 4. http://dx.doi.org/10.1016/S2213-2600(14)70135-3.
Happy wheezers, happy parents, and happy doctors? Wheeze is common in young children.1 In this Comment, we summarise a practical approach to three recent papers on the topic.2–4 We also explore the extent to which doctors keep themselves and the families happy by treating a symptom without necessarily considering the scientific evidence. The most frequent picture of wheeze in young children is episodic viral wheeze, characterised by acute episodes of wheeze, cough, and breathlessness in association with a clinically diagnosed viral respiratory tract infection, with few or no interval symptoms. A few children have multiple trigger wheeze, which resembles asthma, with interval symptoms between acute episodes, triggered by cold air, activity, crying, and often with an atopic personal and family history. Overlaps can occur in individual children, which is indicative of the multifactorial nature of wheeze. Rarer specific disorders need to be excluded in the diagnostic approach. 600
Several approaches have been used to categorise wheeze in children less than 5 years of age: epidemiological (transient early wheeze vs persistent wheeze,1 and more sophisticated classifications);5–7 atopic versus non-atopic wheeze;8 and symptom pattern (as described above).9 A cardinal error is to conflate duration and severity of symptoms with temporal pattern. The first two approaches, although of scientific importance, are not useful in guiding of treatment. The European Respiratory Society classification begs the question as to whether multiple trigger wheeze is the same as childhood asthma. The answer depends on the definition of asthma. If it includes airway eosinophilia, the airway pathology in children with at least severe multiple trigger wheeze is similar to that in childhood asthma.10 The correct treatment of a disease should be preceded as far as possible by an accurate diagnosis. www.thelancet.com/respiratory Vol 2 August 2014
Little doubt exists about the usefulness of ultrasonography in the identification and correct diagnosis of the many diseases patients present with in the emergency department. For example, abdominal ultrasound is a cornerstone in the diagnosis of acute cholecystitis. In the initial care of patients with multiple injuries, a systematic search for multifocal lesions with ultrasound (focused assessment with sonography for trauma technique) is an established protocol that has been introduced in most emergency services. However, the role of ultrasound in other medical specialties, its exact role in the diagnostic algorithm, and the identification of the professionals responsible for examining and interpreting the findings are still unsolved and even controversial issues. Echocardiography, abdominal sonography, vascular sonography, and transcranial Doppler ultrasound are well established techniques commonly used in the critical-care setting. However, use of lung ultrasonography is less widespread, even though experts have recently established recommendations with the aim of achieving a unified approach to lung sonographic signs.1 There is no doubt about the accuracy of lung ultrasonography in the diagnosis and treatment of pleural effusion, but the management of parenchymal involvement seems to be more complicated. Multiple diffuse bilateral B lines will indicate the presence of an interstitial syndrome and might assist bedside differentiation between a cardiogenic versus a respiratory cause of acute dyspnoea.2,3 Although some authors have shown its usefulness for several respiratory diseases, only lung consolidations involving the pleura seem to be correctly assessed with lung ultrasonography.4 Also, lung ultrasonography is more accurate for the identification of pneumothorax than is supine anterior chest radiography (and on a par with CT) and could be mandatory in some settings such as acute chest pain and cardiac arrest.5 Nevertheless, we should note that the accuracy of lung ultrasonography will be directly affected by the expertise of the clinician using the ultrasonography. In a narrower specialty, such as deep venous thrombosis, www.thelancet.com/respiratory Vol 2 August 2014
good agreement between focused trained clinicians and the radiologist doing a radiology residency has been quoted by some investigators.6 Moreover, an examination for lung diseases done at the patient’s bedside with true contemporaneous interpretation and immediate clinical decision making could not be matched by a scan done by a radiologist with a formal report. To establish education in emergency ultrasound, many scientific societies are including this technology in their training programmes. However, discrepancies exist between emergency medicine programmes in ultrasound curricula and perceived needs for achieving proficiency in emergency ultrasound.7,8 Christian Laursen and colleagues bravely tackle all these controversial aspects about point-of-care ultrasonography in patients with respiratory symptoms treated in the emergency department in their study reported in the Lancet Respiratory Medicine.9 We have the opportunity to see the benefits achieved in terms of appropriate diagnosis when heart, lung, and deep-vein point-of-care ultrasonography is added to the standard diagnostic algorithm in the emergency department. The smart design of this clinical trial proves beyond a doubt that a well trained clinician can improve the diagnostic ability (traditional examination and history) when point-of-care ultrasonography is done systematically in patients with respiratory symptoms. The benefits obtained in the rate of appropriate early diagnosis (<4 h after admission to the emergency department; 88·0% [95% CI 82·8–93·1] in the point-ofcare ultrasonography group versus 63·7% [56·1–71·3] in the control group had correct presumptive diagnoses; absolute effect 24·3% [15·0–33·1] and relative effect 1·38 [1·01–1·31]) cannot be extended to other aspects such as avoiding the application of other diagnostic techniques or improving prognosis. However, as the investigators state, this clinical trial was not designed or powered to achieve such results. A limitation that might affect the conclusions of this clinical trial is its personal nature: results are based on one clinician’s expertise in heart, lung, and deep-vein point-ofcare ultrasonography—a skill that is not necessarily transferable to other professionals. We therefore return
Oto / Chu Bordeaux/Science Photo Library
Should ultrasound be included in the initial assessment of respiratory patients?
Published Online July 4, 2014 http://dx.doi.org/10.1016/ S2213-2600(14)70142-0 See Articles page 638
599
Comment
to the need to standardise and certify training and skills in point-of-care ultrasonography for physicians in the emergency department. Hopefully, Laursen will be able to disseminate his knowledge in ultrasound and potentially improve care in the emergency department for patients with respiratory symptoms. Another limitation of the study, inherent to its design, in which only one investigator did the pointof-care ultrasonography, is that the inclusion of patients in the trial was not truly consecutive and this might lead to subsequent bias. The results of Laursen and colleagues’ study show the usefulness of point-of-care ultrasonography in obtaining an early diagnosis in the emergency department in patients with specific respiratory signs and symptoms. Probably, it is now time for specialists in emergency medicine and pulmonologists to learn or improve their knowledge and skills of ultrasonography. Is point-of-care ultrasonography the 21st century stethoscope?
Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Instituto de Salud Carlos III, Villarroel 170, 08036 Barcelona, Spain (PR) [email protected]
Paula Ramirez, *Antoni Torres
9
Critical Care Department, Hospital Universitario y Politécnico la Fe (PR), and Pneumology Department, Hospital Clinic, Universitat de Barcelona, IDIBAPS (AT), Centro de Investigación
We declare no competing interests. 1
2
3
4
5 6
7
8
Volpicelli G, Elbarbary M, Blaivas M, et al. International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS). International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38: 577–91. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008; 134: 117–25. Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011; 139: 1140–47. Parlamento S, Copetti R, Di Bartolomeo S. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. Am J Emerg Med 2009; 27: 379–84. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med 2011; 37: 224–32. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med 2010; 56: 601–10. Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies. West J Emerg Med 2010; 11: 314–18. Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG. The status of bedside ultrasonography training in emergency medicine residency programs. Acad Emerg Med 2003; 10: 37–42. Laursen CB, Sloth E, Lassen AT, et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind, randomised controlled trial. Lancet Respir Med 2014; published online July 4. http://dx.doi.org/10.1016/S2213-2600(14)70135-3.
Happy wheezers, happy parents, and happy doctors? Wheeze is common in young children.1 In this Comment, we summarise a practical approach to three recent papers on the topic.2–4 We also explore the extent to which doctors keep themselves and the families happy by treating a symptom without necessarily considering the scientific evidence. The most frequent picture of wheeze in young children is episodic viral wheeze, characterised by acute episodes of wheeze, cough, and breathlessness in association with a clinically diagnosed viral respiratory tract infection, with few or no interval symptoms. A few children have multiple trigger wheeze, which resembles asthma, with interval symptoms between acute episodes, triggered by cold air, activity, crying, and often with an atopic personal and family history. Overlaps can occur in individual children, which is indicative of the multifactorial nature of wheeze. Rarer specific disorders need to be excluded in the diagnostic approach. 600
Several approaches have been used to categorise wheeze in children less than 5 years of age: epidemiological (transient early wheeze vs persistent wheeze,1 and more sophisticated classifications);5–7 atopic versus non-atopic wheeze;8 and symptom pattern (as described above).9 A cardinal error is to conflate duration and severity of symptoms with temporal pattern. The first two approaches, although of scientific importance, are not useful in guiding of treatment. The European Respiratory Society classification begs the question as to whether multiple trigger wheeze is the same as childhood asthma. The answer depends on the definition of asthma. If it includes airway eosinophilia, the airway pathology in children with at least severe multiple trigger wheeze is similar to that in childhood asthma.10 The correct treatment of a disease should be preceded as far as possible by an accurate diagnosis. www.thelancet.com/respiratory Vol 2 August 2014