Evaluation of the Diagnostic Role of Bedside Lung Ultrasonography in Patients with Suspected Pulmonary Embolism in the Emergency Department

Abstract

_Despite the existence of detailed consensus guidelines, challenges remain regarding efficient, appropriate, and safe imaging methods for the diagnosis of suspected pulmonary embolism. Aims_ To investigate the role of the wedge sign, B-lines, and pleural effusion seen on bedside lung ultrasound in the diagnosis of pulmonary embolism. Study Design_ Diagnostic accuracy study. Methods_ During the first evaluation of patients with suspected pulmonary embolism, bedside lung ultrasound was performed, and the B-lines, wedge sign, and pleural effusion were investigated. Computed tomography angiography was used as a confirmatory test and was compared with the lung ultrasound findings. Results_ Pulmonary embolism was detected in 38 (38%) patients. In the comparison of bedside lung ultrasound results, statistically significant differences were found between the groups in terms of the B-lines and wedge sign (p=0.005 and p_0.001, respectively). There were no significant differences in terms of effusion (p=0.234). Comparison of these findings with computed tomography angiography of the chest showed weak negative correlations between the groups in terms of B-lines (r=-0297) and a moderately positive correlation in terms of the wedge sign (r=0.523). The sensitivity, specificity, and positive and negative predictive values of lung ultrasound findings alone were low. In the logistic regression analysis, the wedge sign (p_0.01, OR=69.45, 95% CI=6.94-695.17) and B-line (p=0.033, OR=1.96, 95% CI=0.41-8.40) were found to be effective in the diagnosis of pulmonary embolism. Conclusion_ Although the role of lung ultrasound has been increasing in the management of critically ill patients, its value is limited and cannot replace the gold standard tests in the diagnosis of pulmonary embolism_

Keywords

• Pulmonary embolism, ultrasonography, diagnostic ultrasound, emergency departments, bedside testing

References

1. 1. Reissig A, Kroegel C. Transthoracic ultrasound of lung and pleura in the diagnosis of pulmonary embolism: a novel non-invasive bedside approach. Respiration 2003;70:441-52.
2. 2. Jiang L, Ma Y, Zhao C, Shen W, Feng X, Xu Y, et al. Role of Transthoracic Lung Ultrasonography in the Diagnosis of Pulmonary Embolism: A Systematic Review and Meta-Analysis. PLoS One 2015;10:e0129909.
3. 3. Barillari A, Fioretti M. Lung ultrasound: a new tool for the emergency physician. Intern Emerg Med 2010;5:335-40.
4. 4. Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134:117-25.
5. 5. Joyner CR Jr, Miller LD, Dudrick SJ, Eskin DJ, Knight DH. Reflected ultrasound in the detection of pulmonary embolism. Trans Assoc Am Physicians 1966;79:262-77.
6. 6. Miller LD, Joyner CR Jr, Dudrick SJ, Eskin DJ. Clinical use of ultrasound in the early diagnosis of pulmonary embolism. Ann Surg 1967;166:381-93.
7. 7. Mathis G, Blank W, Reissig A, Lechleitner P, Reuss J, Schuler A, et al. Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest 2005;128:1531-8.
8. 8. Geersing GJ, Erkens PM, Lucassen WA, Büller HR, Cate HT, Hoes AW, et al. Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study. BMJ 2012;345:e6564.

9. 9. Lichtenstein D, van Hooland S, Elbers P, Malbrain ML. Ten good reasons to practice ultrasound in critical care. Anaesthesiol Intensive Ther 2014;46:323-35.
10. 10. Lichtenstein DA. Introduction to lung ultrasound. In: Lichtenstein DA, editor. Whole Body Ultrasonography in the Critically Ill. 1st ed. Paris: Springer Science & Business Media; 2010:117-27.
11. 11. Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276-315.
12. 12. Flahault A, Cadilhac M, Thomas G. Sample size calculation should be performed for design accuracy in diagnostic test studies. J Clin Epidemiol 2005;58:859-62.
13. 13. Hasan AA, Makhlouf HA. B-lines: transthoracic chest ultrasound signs useful in assessment of interstitial lung diseases. Ann Thorac Med 2014;9:99-103.
14. 14. Volpicelli G, Mussa A, Garofalo G, Cardinale L, Casoli G, Perotto F, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med 2006;24:689-96.
15. 15. Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med 1998;24:1331-4.
16. 16. Kline JP, Dionisio D, Sullivan K, Early T, Wolf J, Kline D. Detection of pneumothorax with ultrasound. AANA J 2013;81:265-71.
17. 17. Reissig A, Gramegna A, Aliberti S. The role of lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia. Eur J Intern Med 2012;23:391-7.