Background: Lung Ultrasound Evaluation (LUS) is usefully applied in the Emergency Department (ED) to patients with suspected or confirmed COVID-19. Diaphragmatic Ultrasound (DUS) may provide ...additional insight into ventilatory function. This proof-of-concept study aimed to evaluate the feasibility of LUS and DUS in a third level ED during the COVID-19 pandemic. Methods: Adult patients presenting with COVID-19 symptoms were eligible. After the physical examination, both LUS and DUS (i.e., diaphragmatic motion and thickness) were performed. All patients were followed after 30 days to determine their need for ventilation, admission, and/or a new ED evaluation after discharge. The diagnostic accuracies of diaphragm measurements in assessing the risk of the 30-day outcome were calculated as well as the measurements’ usefulness. Bland–Altman plots were used for comparing bedside and off-line diaphragm measurements. Results: 118 patients were enrolled. Median thickness and motion were 1.7 mm (iqr 0.4) and 1.8 cm (iqr 0.7), respectively, with a mean difference of 0.009 mm (95% CI −0.037–0.056 mm) and −0.051 cm (95% CI −0.108–0.006 cm), respectively. The 30-day outcome was associated with an increase in thickness (OR 5.84, 95% CI 0.96–35.4), and a lower motion (OR 0.49, 95% CI 0.2–1.21). Conclusion: DUS seemed to be feasible and reliable in the ED in a population of patients presenting with symptoms related to COVID-19 infection.
Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still ...raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.
We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.
The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% 95% CI, 95%-98.3%; specificity, 97.4% 95% CI, 95.7%-98.6%) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% 95% CI, 81.8%-88.4%; specificity, 90% 95% CI, 87.2%-92.4%), chest radiography alone (sensitivity, 69.5% 95% CI, 65.1%-73.7%; specificity, 82.1% 95% CI, 78.6%-85.2%), and natriuretic peptides (sensitivity, 85% 95% CI, 80.3%-89%; specificity, 61.7% 95% CI, 54.6%-68.3%; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.
The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.
Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.
Aims
Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point‐of‐care diagnostic tool, ...but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in conjunction with clinical evaluation.
Methods and results
This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non‐ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT‐proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT‐proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy area under the receiver operating characteristic curve (AUC) 0.95 than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT‐proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS‐integrated approach was higher then that of the CXR/Nt‐proBNP‐integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt‐proBNP group.
Conclusion
Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT‐proBNP.
Accurate diagnostic testing to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is critical. Although highly specific, SARS-CoV-2 reverse transcriptase–polymerase chain ...reaction (RT-PCR) has been shown in clinical practice to be affected by a noninsignificant proportion of false-negative results. This study seeks to explore whether the integration of lung ultrasonography with clinical evaluation is associated with increased sensitivity for the diagnosis of coronavirus disease 2019 pneumonia, and therefore may facilitate the identification of false-negative SARS-CoV-2 RT-PCR results.
This prospective cohort study enrolled consecutive adult patients with symptoms potentially related to SARS-CoV-2 infection who were admitted to the emergency department (ED) of an Italian academic hospital. Immediately after the initial assessment, a lung ultrasonographic evaluation was performed and the likelihood of SARS-CoV-2 infection, based on both clinical and lung ultrasonographic findings (“integrated” assessment), was recorded. RT-PCR SARS-CoV-2 detection was subsequently performed.
We enrolled 228 patients; 107 (46.9%) had SARS-CoV-2 infection. Sensitivity and negative predictive value of the clinical–lung ultrasonographic integrated assessment were higher than first RT-PCR result (94.4% 95% confidence interval {CI} 88.2% to 97.9% versus 80.4% 95% CI 71.6% to 87.4% and 95% 95% CI 89.5% to 98.2% versus 85.2% 95% CI 78.3% to 90.6%, respectively). Among the 142 patients who initially had negative RT-PCR results, 21 tested positive at a subsequent molecular test performed within 72 hours. All these false-negative cases were correctly identified by the integrated assessment.
This study suggests that, in patients presenting to the ED with symptoms commonly associated with SARS-CoV-2 infection, the integration of lung ultrasonography with clinical evaluation has high sensitivity and specificity for coronavirus disease 2019 pneumonia and it may help to identify false-negative results occurring with RT-PCR.
ABSTRACT
Objectives
Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID‐19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study ...was to estimate the diagnostic test characteristics of physician's gestalt for COVID‐19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results.
Methods
From April 1 to April 30, 2020, patients with suspected COVID‐19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID‐19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt CG) and after evaluation of clinical features and results of lung ultrasound or chest x‐ray (clinical and bedside imaging–integrated gestalt CBIIG). The final diagnosis was adjudicated after independent review of 30‐day follow‐up data.
Results
Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID‐19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID‐19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT‐PCR had a sensitivity of 98.4% for COVID‐19 (p < 0.01 vs. RT‐PCR alone) compared to 95.9% for CG plus RT‐PCR (p = 0.05).
Conclusions
In suspected COVID‐19, CG and CBIIG have fair diagnostic accuracy, in line with physicians’ gestalt for other acute conditions. Negative RT‐PCR plus low probability based on CBIIG can rule out COVID‐19 with a relatively low number of false‐negative cases.
BACKGROUND Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure ...(ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED. METHODS We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS (“LUS-implemented” diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared. RESULTS The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% 95% CI, 95%-98.3%; specificity, 97.4% 95% CI, 95.7%-98.6%) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% 95% CI, 81.8%-88.4%; specificity, 90% 95% CI, 87.2%-92.4%), chest radiography alone (sensitivity, 69.5% 95% CI, 65.1%-73.7%; specificity, 82.1% 95% CI, 78.6%-85.2%), and natriuretic peptides (sensitivity, 85% 95% CI, 80.3%-89%; specificity, 61.7% 95% CI, 54.6%-68.3%; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%. CONCLUSIONS The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED. TRIAL REGISTRY Clinicaltrials.gov ; No.: NCT01287429; URL: www.clinicaltrials.gov
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