Nefes Darlığı için Acil Serviste FOCUS: Pulmoner Emboli için Yatak Başı Teşhis Artık Mümkün

Year 2020, Volume: 3 Issue: 4, 99 - 104, 31.12.2020

Halil İbrahim Atalay Serhad Ömercikoğlu Murat Doğanay Çiğdem Özpolat Erkman Sanrı Özge Ecmel Onur Arzu Denizbaşı

Abstract

Amaç: Pulmoner Emboli(PE)’de altın standart görüntüleme yöntemi Pulmoner Anjiyografik Bilgisayarlı Tomografi (PABT) olarak bilinmektedir. Anstabil hastalarda yatak başı ekokardiyografi ve odaklanmış kardiyak ultrasonografi (FOCUS) en yararlı tanı araçlarındandır. Amacımız FOCUS’un akut PE tanı algoritmasındaki değerliliğini saptamak olacaktır.

Gereç ve Yöntemler: Bu çalışma 3.basamak bir acil servis kliniğinde prospektif olarak dizayn edilmiştir. Acil Servise solunum sıkıntısı ile başvuran hastalar ESI triaj kriterlerine göre (kriter 1-2) triaj yapılmıştır ve bundan sonra ayırıcı tanısında PE varsa ve Well’s Skoru orta ve yüksek risk grubunda olanlara randomizasyon yapılarak yatak başı FOCUS yapılıp yapılmayacağına karar verilmiştir. PABT görüntülemesi yapılmış olan hastalar çalışmaya dâhil edilmiştir. FOCUS protokolü parasternal uzun aks penceresini, parasternal kısa aks penceresini, subksifoid pencereyi ve apikal 4 odacıktan penceresini içermiştir. Bu pencerelerden sol ventrikül fonksiyonu, sağ/sol ventrikül oranları, sağ ventrikülün dilatasyonu, septal düzleşme, septal paradoksal hareket, sağ atrial and ventriküler trombüs varlığı ve inferior vena kavayla ejeksiyon fraksiyonunun ölçümü değerlendirilmiştir. Hastaların son tanıları ve FOCUS’ta bulunan parametrelerin pulmoner emboli tanısında istatistiksel olarak anlamlılıkları incelenmiştir.

Bulgular: Çalışmaya 102 hasta dâhil edilmiş olup, bunların 45 tanesi (%44,1) kadındır. Hastaların ortalama yaşı 63,8-+15 yıldır. PABT çekilen 102 hastanın 60(%58,8)’ında son tanı olarak PE saptanmıştır. FOCUS parametrelerinden; sağ ventrikülün sol ventriküle oranı [duyarlılığı %45(%32,12-%58,39) ve özgüllüğü %80,95(%65,88-%91,40) (p=0,0069)], septal paradoksal hareket [duyarlılığı %21,67(%12,07-%34,20) ve özgüllüğü %95,24(%83,84-%99,42) (p=0,0182)], dolu VCI(>21 mm, <%50 kollabilite) ve hiperdinamik EF(>%70) ilişkisi [duyarlılığı %28.33(%17.45, %41.44) and özgüllüğü %97.62(%87.43, %99.94) (p=0,0004)], en değerli olarak görülmüştür.

Sonuç: FOCUS erken tanıyı mümkün kılabilerek anstabil hastada hayat kurtaran değerli bir tanı aracıdır.

Keywords

Pulmoner emboli, Ekokardiyografi, FOCUS

Thanks

Prof. Dr. Haldun Akoğlu'na destekleri ve katkıları için teşekkür ediyoruz.

FOCUS In Emergency Room For Dyspnea: Bedside Diagnosis Is Now Possible For Pulmonary Embolism

Abstract

Aim: It’s known that computed tomographic pulmonary anjiography (CTPA) is the gold standard in imaging techniques for pulmonary embolism (PE). Echocardiography and focused cardiac ultrasonography (FOCUS) are the most beneficial bedside diagnostic tools. Our aim was to determine the value of FOCUS in the diagnostic algoritm of pulmonary embolism.

Materials and Methods: This study was designed prospectively in a tertiary medical center’s emergency medicine department. All the patients which were presented with dyspnea triaged with Emergency Severity Index triage criteria 1-2, after that if PE was involved in differential diagnosis and the patients whose had Wells score as moderate or high risk randomized for whether to carry out FOCUS or not. The patients who underwent CTPA were included to study. FOCUS protocol consisted of the views of parasternal long axis, parasternal short axis, subxiphoid and apical four chamber views. The ratio of Right ventricle to the left ventricle, right ventricular dilatation, septal flattening, septal paradoxal movement, right atrial and ventricular thrombus, vena cava inferior (VCI) and ejection fraction (EF) were evaluated from these views. Final diagnoses of patients and the statistical significance of FOCUS parameters in the diagnosis of pulmonary embolism was examined.

Results: 102 patients were included in the study, of which 45 (44,1%) were women. Patients mean age was 63,8 -+ 15. PE was found as final diagnosis at the 60(%58,8) patients. The FOCUS parameters which were the ratio of right ventricle to the left ventricle over 0,9 [sensitivity %45(%32,12-%58,39) and specificity %80,95(%65,88-%91,40) (p=0,0069)], septal paradoxal movement [sensitivity %21,67(%12,07-%34,20) and specificity %95,24(%83,84-%99,42) (p=0,0182)], full VCI(>21 mm, <%50 collapsibility) and hyperdynamic EF(>%70) relation [sensitivity %28.33(%17.45, %41.44) and specificity %97.62(%87.43, %99.94) (p=0,0004)] were found as the most valuable.

Conclusion: FOCUS could be a valuable diagnostic tool that saves lifes in unstable patients by making early diagnosis.

Keywords

FOCUS, Pulmonary embolism, Echocardiography

References

• Ray P, Birolleau S, Lefort Y, et al. Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Crit Care. 2006;10(3):R82.
• Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129(12):997-1005.
• Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med. 2006;144(3):165-71.
• Kim KI, Muller NL, Mayo JR. Clinically suspected pulmonary embolism: utility of spiral CT. Radiology. 1999;210(3):693-7.
• Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23(12):1225-30.
• Yamanoglu A, Celebi Yamanoglu NG, Parlak I, et al. The role of inferior vena cava diameter in the differential diagnosis of dyspneic patients; best sonographic measurement method? Am J Emerg Med. 2015;33(3):396-401.
• Moore CL, Rose GA, Tayal VS, et al. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med. 2002;9(3):186-93.
• Bova C, Greco F, Misuraca G, et al. Diagnostic utility of echocardiography in patients with suspected pulmonary embolism. Am J Emerg Med. 2003;21(3):180-3.
• Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med. 2015;49(1):104-17.
• Fremont B, Pacouret G, Jacobi D, et al. Prognostic value of echocardiographic right/left ventricular end-diastolic diameter ratio in patients with acute pulmonary embolism: results from a monocenter registry of 1,416 patients. Chest. 2008;133(2):358-62.
• Grifoni S, Olivotto I, Cecchini P, et al. Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism. Am J Cardiol. 1998;82(10):1230-5.
• Ryan T, Petrovic O, Dillon JC, et al. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol. 1985;5(4):918-27.
• Franchi F, Cameli M, Taccone FS, et al. Assessment of left ventricular ejection fraction in critically ill patients at the time of speckle tracking echocardiography: intensivists in training for echocardiography versus experienced operators. Minerva Anestesiol. 2018;84(11):1270-8.
• Konstantinides SV, Torbicki A, Agnelli G, et al. Corrigendum to: 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2015;36(39):2642.
• Russell FM, Ehrman RR, Cosby K, et al. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) protocol. Acad Emerg Med. 2015;22(2):182-91.
• Anderson KL, Jenq KY, Fields JM, et al. Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med. 2013;31(8):1208-14.
• Rutz MA, Clary JM, Kline JA, et al. Emergency Physicians Are Able to Detect Right Ventricular Dilation With Good Agreement Compared to Cardiology. Acad Emerg Med. 2017;24(7):867-74.
• Taylor RA, Davis J, Liu R, et al. Point-of-care focused cardiac ultrasound for prediction of pulmonary embolism adverse outcomes. J Emerg Med. 2013;45(3):392-9.
• Dresden S, Mitchell P, Rahimi L, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63(1):16-24.