Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of PhysiciansFREE
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Abstract
Background:
Dyspnea is a common and often debilitating symptom with a complex diagnostic work-up.
Purpose:
To evaluate the benefits, harms, and diagnostic test accuracy of point-of-care ultrasonography (POCUS) in patients with acute dyspnea. (PROSPERO: CRD42019126419)
Data Sources:
Searches of multiple electronic databases without language limitations (January 2004 to August 2020) and reference lists of pertinent articles and reviews.
Study Selection:
Five randomized controlled trials (RCTs) and 44 prospective cohort-type studies in patients with acute dyspnea evaluated POCUS as a diagnostic tool to determine the underlying cause of dyspnea. Two investigators independently screened the literature for inclusion.
Data Extraction:
Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias and determined certainty of evidence.
Data Synthesis:
Point-of-care ultrasonography, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses in patients with dyspnea than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests. Finally, POCUS consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax; specificities increased in most but not all studies.
Limitations:
Most studies assessed diagnostic test accuracy, which has limited utility for clinical decision making. Studies rarely reported on the proportion of indeterminate sonography results, and no evidence is available on adverse health outcomes of false-positive or false-negative POCUS results.
Conclusion:
Point-of-care ultrasonography can improve the correctness of diagnosis in patients with acute dyspnea.
Primary Funding Source:
American College of Physicians.
Dyspnea is a common and often debilitating symptom that is characterized by subjective, distressing breathing discomfort (1). In the United States in 2016, more than 1.2 million people visited emergency departments seeking care for dyspnea and respiratory abnormalities (2).
The diagnostic work-up of acute dyspnea can be challenging. A multitude of potential underlying conditions leads to complex differential diagnoses, particularly in patients with new onset of dyspnea. The basic diagnostic work-up in patients with acute dyspnea includes detailed history taking, physical examination, blood laboratory, electrocardiography, and chest imaging.
The term “point-of-care ultrasonography” (POCUS) refers to ultrasonography that is performed at the bedside by the treating clinician in real time (rather than being recorded by a technician and later interpreted by a specialist) (3). The treating clinician's ability to link the findings of POCUS examinations directly with the patient's signs and symptoms enables immediate patient management. Over the past decade, portable ultrasonography machines and pocket-sized, handheld imaging devices have become more widely available and easier to use, making POCUS a potential tool to enhance bedside physical examination (4). Studies have shown that POCUS can increase clinician diagnostic performance compared with traditional clinical examinations (5–7). In addition, POCUS can be performed without the hazard of ionizing radiation exposure and does not require the transfer of patients to radiology suites.
Several systematic reviews have assessed the use of POCUS for various indications. The largest body of evidence on POCUS is available for central line placement (8, 9) and diagnosis of pneumonia (10, 11). Other reviews have assessed the diagnostic accuracy of POCUS for acute decompensated heart failure (12), pleural effusion (13), pneumothorax (14), pulmonary embolism (15), and exacerbations of chronic obstructive pulmonary disease (16).
To date, however, no systematic review has used a symptom-based approach to assess the benefits, harms, and diagnostic test accuracy of POCUS in patients with acute dyspnea. The objective of this systematic review was to support the American College of Physicians (ACP) in developing clinical practice guidelines on the appropriate use of POCUS in patients with acute dyspnea.
Methods
We registered the protocol in PROSPERO (International Prospective Register of Systematic Reviews): CRD42019126419.
We used methods recommended by the Cochrane Diagnostic Test Accuracy Working Group (17) to conduct our review and followed the reporting guidance of the PRISMA-DTA (Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Test Accuracy) studies statement (18). Our review addressed 2 key questions:
Key Question 1: In patients with acute dyspnea, what is the effectiveness of adding POCUS to clinical examination (that is, physical examination with a standard diagnostic work-up) to improve health outcomes of congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax?
a) What are potentially harmful health effects of POCUS in view of false-positive and false-negative findings?
Key Question 2: What is the diagnostic test accuracy of POCUS in patients with acute dyspnea to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax as the underlying cause of acute dyspnea?
Data Sources and Searches
A professional information specialist searched Ovid MEDLINE, the Cochrane Library (Wiley), and Embase (Elsevier) without language limitations from 2004 to 17 August 2020 and Epistemonikos.org up to October 2019 (Supplement Table 1). A second information specialist peer-reviewed the MEDLINE search strategy, following the PRESS (Peer Review of Electronic Search Strategies) statement (19). In addition, we reviewed reference lists of pertinent review articles and studies meeting our inclusion criteria to minimize retrieval bias. To identify unpublished studies, we searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform.
Study Selection
To screen the literature, we developed and pilot tested abstract and full-text review forms. Two reviewers independently screened abstracts and full-text articles by using DistillerSR. They resolved discrepancies by discussion or by the involvement of a third, senior investigator. Supplement Table 2 shows the prespecified inclusion and exclusion criteria. Our population of interest was adult patients with acute dyspnea. For study populations to be eligible, at least 85% of study participants had to report acute dyspnea. The target diseases of interest were congestive heart failure (including pulmonary edema), pneumonia, pulmonary embolism, pleural effusion, or pneumothorax. Eligible study designs included randomized controlled trials (RCTs) and prospective, cohort-type studies that assessed health outcomes or test accuracy measures (such as sensitivities and specificities) in hospital settings. Only studies from countries with a very high Human Development Index were eligible for this review (Supplement Table 2).
Outcome Selection
Members of the ACP Clinical Guideline Committee, a technical expert panel, and a panel of patient representatives nominated a pool of patient-relevant health outcomes in patients with acute dyspnea. Of these, they rated the relative importance for decision making of each outcome by using a 9-point Likert scale via a web-based survey and a modified Delphi approach (20). The rationale was that any potential benefits of POCUS needed to be reflected in improvements of relevant health outcomes. Following guidance of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group (21), we focused on the 7 top-ranked outcomes: mortality, time to initiate therapy, time to accurate diagnosis, unnecessary use of antibiotics, need to use breathing support, hospital length of stay, and quality of life. In addition, the ACP Clinical Guideline Committee was interested in diagnostic test accuracy measures and any harmful consequences of the use of POCUS.
Data Extraction and Quality Assessment
We designed and pilot tested a structured data extraction form. A single investigator extracted data from each study; a second investigator checked for completeness and accuracy. In cases of ambiguous or missing data, we contacted the study authors by email or telephone to ask for clarification or additional data. Two reviewers independently assessed the risk of bias of each study with respect to each relevant outcome. For RCTs, we used the Cochrane Risk of Bias Tool (22), and for the diagnostic test accuracy studies, we used the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool (23). Investigators resolved disagreements by discussion or by consulting a third reviewer. Two reviewers independently rated the certainty of evidence with GRADEpro (https://gradepro.org), following guidance of the GRADE Working Group for diagnostic test accuracy studies (24).
Data Synthesis and Analysis
In general, we synthesized the data narratively. We applied a commonly used classification for new tests when compared with existing diagnostic pathways (25). On the basis of the available studies, we classified the use of POCUS as parallel use or replacement. “Parallel use” describes a situation where POCUS is added to the standard diagnostic pathway to increase the accuracy of the diagnostic work-up. “Replacement” characterizes a situation where POCUS entirely replaces 1 or more diagnostic tests.
If 5 or more diagnostic test accuracy studies were similar with regard to the population, index test, and reference test, we considered meta-analyses. We limited meta-analyses to studies that had low or unclear risk of bias and had enrolled participants with unspecified dyspnea who had been assessed with a standard portable device by clinicians with experience using POCUS. We calculated meta-analyses of sensitivity and specificity pairs with 95% CIs by using the bivariate normal model (26). We determined the variability by visually inspecting the CIs for sensitivity and, separately, for specificity in the paired forest plots. To explore variability, we conducted sensitivity analyses adding studies with high risk of bias, studies with handheld devices, and studies with clinicians who had little prior POCUS experience. In addition, we explored the influence of studies on the model variables by using Cook distance. To check for outliers, we calculated standardized residuals (standardized predicted random effects).
For pairwise meta-analyses, we used a random-effects model (Hartung–Knapp–Sidik–Jonkman) (27) if 3 or more similar studies were available. We used the I 2 statistic to assess heterogeneity. The number of studies was insufficient to determine publication bias statistically.
We conducted all meta-analyses with Stata 15 by using the metandi and midas commands for diagnostic test accuracy meta-analyses and the admetan command for pairwise meta-analyses.
Role of the Funding Source
This review was funded by a contract with ACP. The ACP Clinical Guidelines Committee assisted in the development of key questions, study inclusion criteria, and outcome measures of interest but was not involved in data collection, analysis, or manuscript preparation.
Results
Of 5231 unique records, we included 49 studies with data on 9782 participants (28 –76). Figure 1 shows the literature search and selection. Forty-four studies were prospective cohort-type studies, (20–30, 32–55, 56–62, 64–73, 75, 76) and 5 studies were RCTs (31, 43, 56, 63, 74). We rated 13 studies as low risk of bias, 9 as unclear, and 27 as high risk of bias. Sample sizes of studies ranged from 25 to 2683 participants, mean age from 54 to 86 years, and proportion of females from 38% to 62%. Most studies were conducted in emergency department settings with clinicians using standard portable POCUS devices; 5 studies used handheld devices (43, 46, 48, 64, 68).
Eligible studies addressed 2 situations of how clinicians can use POCUS in daily practice. The first situation is the use of POCUS as an additional diagnostic tool to augment the standard diagnostic pathway (that is, parallel use). The second situation is the use of POCUS as a replacement of the standard diagnostic pathway.
Supplement Tables 3 and 4 present detailed characteristics of individual studies, Supplement Table 5 summarizes certainty of evidence ratings, and Supplement Figure 1 shows risk of bias ratings for each study.
Beneficial and Harmful Health Effects of the Use of POCUS
Five RCTs with data on 1483 participants reported health outcomes of the use of POCUS in addition to standard diagnostic pathways (parallel use) compared with the standard diagnostic pathways only (31, 43, 56, 63, 74). Outcomes were limited to in-hospital mortality, length of hospital stay, and readmission. We rated 3 RCTs as low risk of bias (31, 63, 74), 1 as unclear (56), and 1 as high risk of bias (43). Four trials used standard portable POCUS devices in emergency department settings (31, 43, 56, 63, 74); the study with high risk of bias used a handheld device (42). Most participants in the trials had multiple chronic conditions and visited the emergency department because of unspecified acute dyspnea. Their mean ages ranged from 65 to 79 years. In 3 trials, emergency department physicians who were experienced in ultrasonography conducted POCUS examinations; 1 trial included clinicians without prior experience in lung ultrasonography who received a 4-hour training program (74). The trial with high risk of bias did not report details on training of clinicians and the reference standard (43). The Table summarizes characteristics and results of studies assessing health outcomes.
In-Hospital Mortality
Three RCTs with low risk of bias and data on 1275 participants reported no statistically significant differences for in-hospital mortality (very low-certainty evidence) (31, 63, 74). Overall, 5.1% (33 of 634) of participants who had POCUS plus the standard diagnostic pathway died, compared with 6.6% (42 of 641) in the groups that received a standard diagnostic pathway only. A random-effects meta-analysis yielded a relative risk of 0.78 (95% CI, 0.12 to 5.09) (Supplement Figure 2).
Length of Hospital Stay and Readmissions
Four RCTs with data on 965 patients reported a similar length of hospital stay between participants in the POCUS and control groups (moderate-certainty evidence) (43, 56, 63, 74). In the 2 larger trials with low risk of bias, Baker and colleagues (74) reported median length of hospital stay of 2.9 days for patients who received POCUS plus the standard diagnostic pathway versus 3.1 days for those who received the standard diagnostic pathway only, and Laursen and associates (63) reported median length of stay of 3.0 days in both groups. On the basis of 1 trial, the proportions of readmission within 30 days were also similar (23% in group that had the POCUS plus the standard diagnostic pathway vs. 26% in the group that had the standard diagnostic pathway alone;P = 0.93) (63).
Harmful Health Effects of POCUS
None of the studies reported on harmful health effects of POCUS, such as consequences of false-positive or false-negative findings or additional diagnostic interventions because of incidental findings.
Diagnostic Outcomes of POCUS When Added to a Standard Diagnostic Pathway
Three RCTs (56, 63, 74) of low and unclear risk of bias and a prospective cohort-type study with high risk of bias (28) compared the correctness of diagnoses and the diagnostic test accuracy of standard diagnostic pathways with and without the use of POCUS (parallel use).
Correctness of Diagnosis and Time to Diagnosis
Two RCTs (56, 63) and a prospective cohort-type study (28) with data on 572 participants assessed whether adding POCUS to a standard diagnostic pathway improves the correctness of diagnoses in patients with acute dyspnea. In all 3 studies, participants had unspecified, acute dyspnea and multiple chronic conditions. Emergency department clinicians in Denmark (63), France (28), and Italy (56) with extensive experience in emergency ultrasonography conducted all POCUS examinations. All 3 studies used standard portable devices. Results showed higher percentages of correct diagnoses when patients received POCUS in addition to standard diagnostic tests (moderate certainty of evidence). In the larger RCT (n = 315) with low risk of bias (63), 88% of participants who received POCUS in addition to the standard diagnostic pathway had a correct diagnosis at 4 hours, compared with 64% of participants in the control group with the standard diagnostic pathway only (P < 0.001). More participants in the POCUS group than the control group received appropriate treatment after 4 hours (78% vs. 57%; P < 0.001) (63). Likewise, in the smaller RCT (n = 168) (56), statistically significantly more participants who received POCUS had a correct initial diagnosis compared with the control group with a standard diagnostic work-up only (95% vs. 50%; P < 0.001). The prospective cohort study reported similar results (28).
A small RCT with high risk of bias reported a shorter time to diagnosis when POCUS was added to the standard diagnostic pathway (40 vs. 60 minutes; very low certainty of evidence) (43).
Diagnostic Test Accuracy
Three RCTs with low (63, 74) and unclear risk of bias (56), with data on 544 participants, and a cohort-type study (28) with high risk of bias assessed the diagnostic test accuracy of POCUS to detect congestive heart failure, pneumonia, pulmonary embolism, or pleural effusion when added to a standard diagnostic pathway (56, 63, 74). None of the studies addressed pneumothorax. Figure 2 shows sensitivities and specificities of POCUS for the different target diseases, based on findings of the individual RCTs. Sensitivities ranged from 79% to 100%, and specificities ranged from 63% to 100% (low certainty of evidence). By comparison, sensitivities of the standard diagnostic pathway without POCUS ranged from 0% to 83% and specificities from 68% to 100%. Supplement Figure 3 shows the number of false-positive and false-negative findings of POCUS for target conditions at different pretest probabilities. Supplement Table 6 compares sensitivities and specificities of standard diagnostic pathways with and without POCUS.
Figure 2. Sensitivities and specificities of point-of-care ultrasonography when added to the standard diagnostic pathway.
IVC = inferior vena cava.
Diagnostic Outcomes of POCUS When Used as a Replacement for a Standard Diagnostic Pathway
Diagnostic Test Accuracy
Forty-three prospective cohort-type studies (29, 30, 32–42, 44–55, 57–62, 64–73, 75, 76) and 2 RCTs (31, 63), mostly of unclear and high risk of bias (Supplement Figure 1), assessed the diagnostic test accuracy of POCUS when used as a replacement for the standard diagnostic pathway. These studies provided data on 8626 participants, most of whom visited an emergency department because of unspecified acute dyspnea. Eleven studies enrolled patients with suspected disease (for example, suspected pneumonia based on the clinical presentation) (35–37, 39, 41, 42, 44, 55, 66, 72, 76). Most studies used standard portable ultrasonography devices, but few studies provided detailed information on training and experience of the clinicians who used POCUS; 4 studies used handheld devices (46, 48, 64, 68). Thirty-seven studies were conducted in emergency departments (29–42, 44, 45, 47, 57–63, 65–67, 69–73, 75, 76), 5 in regular hospital wards (40, 47, 49, 57, 64), and 1 in an intensive care unit (67).
Because of the heterogeneity of studies, we were unable to conduct meta-analyses for most indications of interest, with the exception of congestive heart failure (Supplement Figure 4). For congestive heart failure, our meta-analysis included 5 studies that used POCUS of the lung for patients who visited emergency departments because of unspecified dyspnea (31, 52, 63, 65, 75). In all trials, standard portable POCUS devices were used and independent chart review by experts was the reference standard. The expertise of clinicians using POCUS was poorly reported, but they were generally described as experienced internists or emergency department clinicians. Figure 3 shows a paired forest plot of the sensitivities and specificities of POCUS of the lung to detect congestive heart failure on the basis of studies with low or unclear risk of bias. The pooled sensitivity was 76% (CI, 48% to 91%), and the pooled specificity was 96% (CI, 90% to 98%). Sensitivity analyses involving studies with high risk of bias, studies that used handheld devices, or studies with clinicians who had little experience with POCUS reported similar results as the main meta-analysis (Supplement Table 7).
Figure 3. Meta-analyses of sensitivities and specificities of POCUS of the lung when used as a replacement of the standard diagnostic pathway to detect congestive heart failure.
POCUS = point-of-care ultrasonography; ROB = risk of bias.
* Refers to the overall study population.
Compared with POCUS in patients with unspecified dyspnea, POCUS in patients with suspected disease rendered higher sensitivities (Supplement Tables 3 and 4). In studies with low and unclear risk of bias involving participants with unspecified dyspnea, sensitivities of standard portable devices ranged from 52% to 88% for pneumonia, 40% to 100% for pulmonary embolism, 78% to 89% for pleural effusion, and 88% for pneumothorax. Likewise, specificities ranged from 58% to 92% for pneumonia, 97% to 100% for pulmonary embolism, 88% to 99% for pleural effusion, and 100% for pneumothorax. Supplement Figure 5 shows the number of false-positive and false-negative findings of POCUS for target conditions at different pretest probabilities.
Data were insufficient to compare the diagnostic test accuracy of standard portable devices with that of handheld devices.
Discussion
Over the past years, POCUS has become an emerging diagnostic tool for the bedside examination of patients. Our systematic review took a symptom-based approach and assessed the effectiveness and diagnostic accuracy of POCUS in patients with acute dyspnea. It included 49 studies with data on more than 9700 participants. Results based on 5 RCTs (31, 43, 56, 63, 74) with data on 1483 participants show that POCUS, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly. None of the studies reported on harmful health effects of POCUS, such as consequences of false-positive or false-negative findings or additional diagnostic interventions because of incidental findings. On the basis of our data, it remains unclear whether standard portable devices and handheld devices differ in diagnostic test accuracy.
Most studies in our review, however, did not assess health outcomes but rather diagnostic test accuracy outcomes to detect a target disease. Across studies, adding POCUS to a standard diagnostic pathway consistently improved sensitivities to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax compared with the standard diagnostic pathway alone; specificities increased in most but not all studies. Diagnostic test accuracy studies, however, have limited utility for clinical decision making. Clinically, the expected downstream health effects of positive and negative test results (including false-positive and false-negative findings) must be considered when selecting a test. This is a complex task because downstream health effects depend on not only the benefits and harms of the available treatments but also the clinical context and the prevalence of the disease. A diagnostic test that has acceptable accuracy for a given condition in a specific population might cause an unacceptably high proportion of false-positive or false-negative results in a population with a different prevalence of the same condition. For example, on the basis of numbers in our systematic review, in a population with dyspnea and a high pretest probability (70%) of having pneumonia, 1 of 10 pneumonia diagnoses based on POCUS will be false-positive. Consequently, about 6 of 100 patients undergoing POCUS might receive unnecessary treatment with antibiotics. By comparison, in a population with dyspnea and a low pretest probability (10%) of having pneumonia, 7 of 10 pneumonia diagnoses will be false-positive and about 19 of 100 patients undergoing POCUS might receive unnecessary treatment with antibiotics.
Eligible studies in our review addressed 2 situations of how clinicians can use POCUS in daily practice: parallel use and replacement. With parallel use, clinicians apply POCUS as an additional diagnostic tool to augment the standard diagnostic pathway. In such a scenario, POCUS can increase the sensitivity of the diagnostic work-up and therefore can reduce the proportion of cases that would be missed by the standard diagnostic pathway alone (false-negative findings). Our technical expert panel deemed this situation as the most likely clinical use of POCUS. Most studies, however, assessed POCUS as a replacement of the standard diagnostic pathway. In this situation, POCUS replaces other diagnostic tests, such as chest radiography. Theoretical reasons for replacement include that a new test is less invasive, easier to do, more accurate, or less risky (77).
To the best of our knowledge, our review is the first to take a symptom-based approach by focusing on dyspnea rather than on a specific condition. We excluded studies in which fewer than 85% of participants reported dyspnea. Other systematic reviews focused on specific conditions and included a higher proportion of studies with participants who had high pretest probabilities of having a specific condition. Consequently, these reviews reported higher sensitivities and specificities than our findings (12, 16, 78–81).
Our review has limitations. First, the included studies had considerable heterogeneity. Studies enrolled populations with substantially different pretest probabilities of target conditions; POCUS devices and POCUS protocols also varied across studies. For example, the prevalence of congestive heart failure in included studies ranged from 4% to 82%, and the prevalence of pneumonia ranged from 21% to 91%. Naturally, studies that enrolled populations with unspecified dyspnea had a lower prevalence of each target condition than studies that enrolled patients with dyspnea and a suspected underlying cause. Such variations can lead to spectrum effects when determining the diagnostic test accuracy (82). When we explored diagnostic test accuracy for different prevalences, however, we could not detect a discernible pattern. Different POCUS protocols had little effect on sensitivity, but protocols that were more complex increased specificity. The experience of the clinicians who used POCUS, when reported, also varied, from expert sonographers in some studies to clinicians with a few hours of training in others.
Second, about 30% of studies used reference standards other than blinded, independent chart review, such as diagnosis at hospital discharge, chest radiography, computed tomography, or mixed standards. Differences in reference standards can make it difficult to compare test accuracy results of individual studies. In addition, it is unclear which reference standard for dyspnea best corresponds to the true target disease status.
Third, the methodological quality of many studies was low. We rated 55% (27 of 49) of included studies as high risk of bias. Common reasons for the high risk of bias ratings included lack of consecutive participant enrollment, exclusion of participants with unsatisfactory visibility on ultrasound, or varying reference standards for diagnostic test accuracy studies within the same study.
Fourth, very few studies reported on indeterminate results. Like any imaging test, POCUS can produce uninterpretable images, which should not be removed from the analyses because this might lead to biased test characteristics. Because of a lack of reporting, the average proportion of uninterpretable images during POCUS exams remains unclear. Fifth, the generalizability of results to outpatient practice settings is unclear. All included studies were conducted in hospital settings with presumably higher pretest probabilities of the underlying conditions than those in outpatient practice settings.
Finally, despite comprehensive literature searches, publication bias is always a concern for any systematic review. Particularly for diagnostic test accuracy studies, it is difficult to determine the extent of nonpublication of studies (83).
In conclusion, evidence from RCTs indicates that POCUS can improve the correctness of diagnosis in patients with acute dyspnea. Adequate and standardized training for clinicians who use POCUS will be paramount to utilize the benefits of this new technology.
Supplemental Material
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Published In
Annals of Internal Medicine
Volume 174 • Number 7 • July 2021
Pages: 967 - 976
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Published online: 27 April 2021
Published in issue: July 2021
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© 2021 American College of Physicians.
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Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med.2021;174:967-976. [Epub 27 April 2021]. doi:10.7326/M20-5504
Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Ann Intern Med.2021;174:967-976. [Epub 27 April 2021]. doi:10.7326/M20-5504
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Comments on “Point-of-Care Ultrasonography in Patients with Acute Dyspnea”
The publication of guidelines by the American College of Physicians (ACP) on appropriate use of point of care ultrasonography (POCUS) is an exciting and long anticipated development for champions of POCUS. In the first of hopefully many such clinical guidelines, the April 27, 2021 work by Qaseem et al. laid out recommendations for use of POCUS as an adjunct to standard testing in the evaluation of acute dyspnea, based on a systematic review of available evidence by Gartlehner et al. (1,2) The review of 44 cohort studies found that POCUS increased the proportion of correct diagnoses for unexplained acute dyspnea by 32% when used in addition to standard diagnostic pathways.(2) Although evidence for patient-centered outcomes is still insufficient to support a strong GRADE-based recommendation, the guideline connects improved diagnostic accuracy to potentially improved outcomes without high cost or serious risk of harm.(1) While on the surface this is a subtle victory for practitioners of POCUS, the deeper significance of the guideline cannot be overstated. Widespread adoption of the technology by internists over the past decade has been limited, despite the anecdotal upsides of POCUS, because of difficult-to-quantify benefits in cost and outcomes, training time to learn and practice new applications, uncertainty related to demonstration of competency, and variable institutional support. This guideline and its accompanying articles confront these challenges, (1-3) and pave the way forward to broader application of POCUS by internists in two very significant ways. First, it provides much needed direction from ACP on the need for additional high-quality, methodologically sound, outcomes-based research. ACP endorsement for research in this area is a beacon for enthusiasts of POCUS in Internal Medicine who are eager to add to a growing body of evidence. Second, the guideline promotes institutional investment in training, technology, and infrastructure as a call to action to support the best practice use of POCUS by internists, making an educational argument to support commitment of resources. As an extension of this argument, we advocate for the commitment of resources to residency training programs who seek to incorporate POCUS training into their curricula, promoting a future of POCUS-capable internists. Owing to this guideline and the accompanying articles, use of POCUS is more likely than ever to find its place into residency programs and the broader practice of Internal Medicine, as it has in Emergency Medicine and Critical Care. The authors are to be commended.