Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of PhysiciansFREE
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Abstract
Description:
The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the appropriate use of point-of-care ultrasonography (POCUS) in patients with acute dyspnea in emergency department (ED) or inpatient settings to improve the diagnostic, treatment, and health outcomes of those with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax.
Methods:
The ACP Clinical Guidelines Committee based this guideline on a systematic review on the benefits, harms, and diagnostic test accuracy of POCUS; patient values and preferences; and costs of POCUS. The systematic review evaluated health outcomes, diagnostic timeliness, treatment decisions, and test accuracy. The critical health, diagnostic, and treatment outcomes evaluated were in-hospital mortality, time to diagnosis, and time to treatment. The important outcomes evaluated were intensive care unit admissions, correctness of diagnosis, disease-specific outcomes, hospital readmissions, length of hospital stay, and quality of life. The critical test accuracy outcomes included false-positive results for suspected pneumonia, pneumothorax, and pulmonary embolism and false-negative results for suspected congestive heart failure, pneumonia, pneumothorax, and pulmonary embolism. Important test accuracy outcomes included false-positive results for suspected congestive heart failure and false-negative and false-positive results for suspected pleural effusion. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.
Target Audience and Patient Population:
The target audience is all clinicians, and the target patient population is adult patients with acute dyspnea in ED or inpatient settings.
Recommendation:
ACP suggests that clinicians may use point-of-care ultrasonography in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings (conditional recommendation; low-certainty evidence).
In recent years, use of point-of-care ultrasonography (POCUS) as a potential diagnostic tool has increased due in part to its increased availability and perceived user-friendliness (1). Physicians trained to use POCUS can do it in real-time at the patient's bedside to possibly improve diagnostic performance compared with standard clinical examinations (2–4). Point-of-care ultrasonography may also facilitate timely and appropriate management of critically ill patients or alleviate the need for ultrasonography or other diagnostic tests.
Point-of-care ultrasonography can be used for various clinical indications. This guideline targets a symptom-based approach to evaluate the effectiveness, test accuracy, and harms of using POCUS in emergency department (ED) or other inpatient settings for patients with acute dyspnea suspected to be due to congestive heart failure, pleural effusion, pneumonia, pneumothorax, or pulmonary embolism but in whom there was diagnostic uncertainty. Dyspnea, defined as a subjective and distressing experience of breathing discomfort, is a common symptom that contributes to more than 1 million ED visits each year (5, 6). Many underlying diseases can cause dyspnea. The diagnostic approach to a patient with acute dyspnea is challenging because of the number of potential causes, several of which are serious and potentially life-threatening.
The standard diagnostic approach to identify the underlying causes of acute dyspnea involves obtaining a patient history, doing a physical examination, and ordering diagnostic testing, such as blood laboratory test, chest or cardiac imaging, and electrocardiography. In relation to the standard diagnostic pathway, POCUS can be used before, after, or in addition to the standard tests or as a replacement for 1 or more standard tests.
Guideline Focus and Target Population
The purpose of this American College of Physicians (ACP) guideline is to provide recommendations on the appropriate use of POCUS in addition to or as a replacement for the standard diagnostic pathway in the approach to patients with acute dyspnea in ED or inpatient settings. The Clinical Guidelines Committee (CGC) developed the recommendations, which are based on the best available evidence on the clinical benefits and harms, test accuracy, patient values and preferences, and consideration of costs.
The target audience for this guideline is all clinicians, and the target patient population is adult patients with acute dyspnea in ED or inpatient settings in whom there is diagnostic uncertainty. These recommendations are based on a systematic review done by Cochrane Austria at Danube University Krems and funded by ACP (7). ACP also did a separate rapid review to assess the costs of POCUS.
Methods
The CGC developed this guideline according to ACP's guideline development process, details of which can be found in ACP's methods articles (8, 9).
Systematic Review of the Evidence
Details and methods for the supporting systematic review are included in the accompanying systematic review (7) and in the Appendix. The CGC identified the key questions and convened a technical expert panel made up of clinical topic experts, clinicians, and epidemiologists to inform the systematic review and assist in refining the scope and key questions (Appendix).
The accompanying systematic review (7) searched several databases for studies published in English from January 2004 to August 2020. Included studies compared bedside POCUS (trolley- or cart-based, compact–handheld, or application-based) done by students, residents, general internists, or intensivists as an intervention of interest in hospitalized or ED patients with acute dyspnea to assess health outcomes or treatment decisions or as an index test to assess test accuracy in detecting congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax. Further details can be found in the accompanying systematic review (7).
Main Outcomes
The systematic review (7) evaluated health outcomes, diagnostic timeliness, treatment decisions, and test accuracy. Members of the CGC (clinicians and nonclinician public members) and the CGC Public Panel were asked a priori to independently rate the importance of evaluated outcomes (Appendix Table). A separate outcome, correctness of diagnosis, which is the proportion of patients receiving a correct diagnosis with or without the use of POCUS, was not listed in the original protocol as an outcome but was derived from the included studies and considered important by the CGC. The systematic review graded the 7 highest-rated outcomes, and all critical and important outcomes were considered in developing recommendations.
The CGC and technical expert panel members also estimated the typical prevalence of each specific disease in patients with acute dyspnea and low, medium, or high pretest probability for the disease, as informed by the prevalence reported in the included studies. This information was used to calculate the number of false-positive and false-negative test results from POCUS for each indication of interest.
Values and Preferences and Public Panel Review
The evidence review team searched several databases (MEDLINE, the Cochrane Library, EMBASE, and Epistemonikos) to identify literature on patient values and preferences about the use of POCUS. The development of this guideline also included perspectives, values, and preferences of 2 CGC members who represent the public and a 7-member CGC Public Panel, who rated outcomes, provided input on preferences among the intervention options via a direct-choice exercise, and provided comments on the draft guideline and recommendations.
Costs
To identify literature on the costs of the interventions, ACP staff searched PubMed (MEDLINE) from inception through February 2020 and several additional databases (National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and Health Technology Assessment database) from inception through 2015 (the last year that the additional databases were updated). ACP staff also used the Medicare Fee Schedules to identify Medicare reimbursements fees for POCUS and other tests included in the standard diagnostic work-up for the included conditions.
Evidence to Recommendations
The CGC used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tables in the accompanying systematic review (7) when reporting the evidence and graded the evidence and recommendations using the GRADE method (10, 11) (Figure 1). The GRADE evidence-to-decision tables illustrate the evidence framework supporting the recommendation (Tables 1 and 2 of Supplement 1).
Figure 1. Grading the certainty of evidence and strength of recommendations of ACP clinical guidelines using GRADE.
ACP = American College of Physicians; GRADE = Grading of Recommendations Assessment, Development and Evaluation.
Peer Review
The guideline underwent a peer review process through the journal and was posted online for comments from ACP Regents and ACP Governors who represent internal medicine and its subspecialty physician members at the national and international levels. The CGC considered any comments before finalizing the guideline.
Summary of the Evidence
Tables 1 and 2 of Supplement 1 provide a detailed summary of findings, and the full findings of the systematic review are published in the accompanying systematic review (7), but main points are highlighted here. No studies were identified that used POCUS before or after the standard diagnostic pathway. The reference standards for test accuracy studies varied. Most (n = 42) of the studies were done in the ED; the remaining were done in inpatient hospital wards or the intensive care unit. Most (n = 44) studies used standard portable POCUS devices (any device that could be moved to a patient's bed but was not a handheld), and 5 used handheld devices (12–16).
Key Findings From the Systematic Review on Critical and Important Outcomes: POCUS in Addition to the Standard Diagnostic Pathway
Health, Diagnostic, and Treatment Outcomes
Evidence was very uncertain (insufficient) on the following critical outcomes for using POCUS in addition the standard diagnostic pathway (7): mortality (17–19), time to diagnosis (13), and time to treatment (13). Among important outcomes, moderate-certainty evidence showed that POCUS probably increases the proportion of correct diagnoses from 59% to 91% (absolute risk difference, 31.9% [95% CI, 22.4% to 53.8%) (7, 17, 20, 21) and probably does not reduce the length of hospital stay (data could not be pooled) (7, 13, 17, 18, 20).
Test Accuracy
Depending on indication and protocol, low-certainty evidence showed that sensitivities of POCUS in addition to the standard diagnostic pathway ranged from 79% to 100% and specificities ranged from 63% to 100%, compared with sensitivities of standard diagnostic pathway alone ranging from 0% to 83% and specificities ranging from 68% to 100%. Table 1 and Figure 2 present test accuracy of POCUS in addition to the standard diagnostic pathway, reporting numbers of false-positive and false-negative findings across various suspected underlying conditions and according to pretest probabilities of suspected underlying conditions.
Figure 2. Frequencies of false test results when using POCUS in addition to the standard diagnostic pathway according to low, medium, and high pretest probabilities in patients with acute dyspnea across common underlying conditions.
No evidence was available to assess the test accuracy of using POCUS in addition to the standard diagnostic pathway for suspected pneumothorax. No studies reported data on inconclusive test results or test complications. CGC = Clinical Guideline Committee; POCUS = point-of-care ultrasonography; RCT = randomized controlled trial; TEP = technical expert panel.
* The CGC and TEP estimated typical prevalence of specific underlying conditions in patients with acute dyspnea and low, medium, and high pretest probabilities, and estimates were informed by prevalence reported in the studies. Table 3 of Supplement 1 provides clinical descriptions of low, medium, and high pretest probabilities according to specific condition.
† Table 4 of Supplement 1 provides descriptions of clinical consequences of false-positive and false-negative test results according to specific condition.
‡ Small sample size; downgraded 2 steps for serious imprecision.
§ Same value across studies.
Congestive Heart Failure. Low-certainty evidence showed that POCUS (lung alone or in combination with heart, inferior vena cava, and deep veins) in addition to the standard diagnostic pathway correctly identified 79% to 100% of patients with unspecified dyspnea who had congestive heart failure and 95% to 99% of patients who did not congestive heart failure (7, 17, 18, 20).
Pleural Effusion. Low-certainty evidence showed that POCUS (lung, heart, and deep veins; lung, heart, and inferior vena cava) in addition to the standard diagnostic pathway correctly identified 89% to 100% of patients with unspecified dyspnea who had pleural effusion and 98% to 100% of patients who did not have pleural effusion (7, 17, 20).
Pneumonia. Low-certainty evidence showed that POCUS (lung, heart, inferior vena cava, and deep veins) in addition to the standard diagnostic pathway correctly identified 92% of patients with unspecified dyspnea who had pneumonia and 63% to 98% of patients who did not have pneumonia (7, 17, 20).
Pneumothorax. No studies assessed the test accuracy of POCUS in addition to the standard diagnostic pathway for detecting pneumothorax.
Pulmonary Embolism. Low-certainty evidence showed that POCUS (lung, heart, inferior vena cava, and deep veins) in addition to the standard diagnostic pathway correctly identified 89% to 100% of patients with unspecified dyspnea who had pulmonary embolism and 95% to 100% of patients who did not have pulmonary embolism (7, 17, 20).
Key Findings From the Systematic Review on Critical and Important Outcomes: POCUS as a Replacement Diagnostic Test
Health, Diagnostic, and Treatment Outcomes
No studies reported on general health outcomes for POCUS as a replacement to the standard diagnostic pathway in patients with acute dyspnea. Three prospective cohort studies reported on diagnostic and treatment outcomes (22–24) in patients with unspecified dyspnea. Evidence was insufficient to assess correctness of diagnosis with POCUS as a replacement test compared with the standard diagnostic pathway, and no other outcomes were reported (7).
Test Accuracy
Most studies did not report the test accuracy of the standard diagnostic pathway without POCUS, and comparative data are limited for specific conditions. Two studies (low-certainty evidence) reported sensitivity and specificity for POCUS as a replacement to the standard diagnostic pathway and the standard diagnostic pathway alone across various potential underlying conditions in patients with unspecified dyspnea (Table 2) (17, 19). The systematic review did not meta-analyze studies with high risk of bias; across all other included studies (regardless of whether comparative data were reported), sensitivities for POCUS as a replacement to the standard diagnostic pathway ranged from 40% to 100%, and specificities ranged from 58% to 100%, depending on indication and protocol (17, 19, 25–30). These findings are summarized here and reported in more detail in the systematic review (7) and Table 2 of Supplement 1.
Congestive Heart Failure. Moderate-certainty evidence showed that POCUS (lung) as a replacement test correctly identified 76% of patients with unspecified dyspnea who had congestive heart failure (CI, 48% to 91%) and 96% who did not have congestive heart failure (CI, 90% to 98%) (7, 17, 19, 25, 27, 29). Low-certainty evidence showed that POCUS (lung, heart, and inferior vena cava) correctly identified 88% of patients with unspecified dyspnea who had congestive heart failure (CI, 85% to 91%) and 96% of patients who did not have congestive heart failure (CI, 95% to 97%) (7, 30).
Pleural Effusion. Low-certainty evidence showed that POCUS (lung, heart, and deep veins; lung, heart, and inferior vena cava) as a replacement test correctly identified 78% to 89% of patients with unspecified dyspnea who had pleural effusion and 88% to 99% of patients who did not have pleural effusion (7, 17, 30).
Pneumonia. Moderate-certainty evidence showed that POCUS (lung; lung, heart, and deep veins; lung, heart, and inferior vena cava; lung, heart, deep veins, and inferior vena cava) as a replacement test correctly identified 52% to 88% of patients with mainly unspecified dyspnea who had pneumonia and correctly identified 58% to 92% of patients who did not have pneumonia (7, 17, 27, 28, 30).
Pneumothorax. Evidence is very uncertain (insufficient) about the test accuracy of POCUS as a replacement test for detecting pneumothorax in patients with unspecified dyspnea (7, 24, 30).
Pulmonary Embolism. Moderate-certainty evidence showed that POCUS (heart; lung, heart, and deep veins; lung, heart, and inferior vena cava; lung, heart, inferior vena cava, and deep veins) as a replacement test correctly identified 40% to 100% of patients with unspecified dyspnea who had pulmonary embolism and 97% to 100% of patients who did not have pulmonary embolism (7, 17, 26, 27, 30).
Harms of POCUS in Addition to the Standard Diagnostic Pathway or as a Replacement Diagnostic Test
No studies reported direct complications due to POCUS or the downstream consequences of false-positive or false-negative results from POCUS or additional diagnostic interventions because of incidental findings. Few studies reported on indeterminate sonography results.
Values and Preferences
No relevant literature was identified that assessed the values and preferences of patients with dyspnea for the selected outcomes.
Feedback from the CGC Public Panel showed preferences trending in favor of adding POCUS to the standard diagnostic pathway, mostly because of the findings for correctness of diagnosis. For POCUS as a replacement test, most CGC Public Panel members responded that they would not be willing to undergo POCUS.
Costs
No studies were identified that reported on the costs of POCUS compared with standard diagnostic pathways in the United States. Table 3 presents the Medicare national average reimbursement rates by condition.
Multiple Chronic Conditions: Clinical Considerations
Many (n = 34) of the studies evaluated for this guideline included patients with 2 or more chronic conditions; thus, these recommendations likely apply to those with multiple chronic conditions. There may be differences in pretest probability depending on the individual clinical situation that would affect the test accuracy of POCUS in addition to or as a replacement for the standard diagnostic pathway.
Areas of Inconclusive Evidence
Overall, evidence to make a recommendation for or against the use of POCUS as a replacement test in patients with acute dyspnea is inconclusive, given the absence of any direct evidence on health outcomes.
On the basis of the data included in this guideline and the accompanying systematic review (7), the effect of the amount and type of physician training and type of device used on the outcomes remained unclear. More research is needed to understand the linkage among physician training, device type, and health outcomes.
Areas of No Evidence
No studies provided information for the following outcomes when POCUS was used in addition to the standard diagnostic pathway or as a replacement test in patients with acute dyspnea: quality of life, admissions to intensive care units, and disease-specific health outcomes (unnecessary use of antibiotics, need to use breathing support, time to referral, and lung computed tomography [proportion of patients]). No studies reported the consequences of false-positive or false-negative findings from POCUS in addition to the standard diagnostic pathway or as a replacement test, including additional or downstream testing.
Recommendation
Supplement 2 presents a graphic summary of the recommendation, evidence and rationale, and clinical considerations.
Recommendation: ACP suggests that clinicians may use point-of-care ultrasonography in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings (conditional recommendation; low-certainty evidence).
Rationale
The rationale to add POCUS to the standard diagnostic pathway is largely based on diagnostic accuracy studies and encompasses several considerations. First, POCUS increased the proportion of correct diagnoses by 32% when used in addition to the standard diagnostic pathway (moderate-certainty evidence). Second, the test accuracy, particularly sensitivity, of standard diagnostic testing with the addition of POCUS is better than the test accuracy of standard diagnostic pathway alone without a substantial tradeoff in specificity (low-certainty evidence) (Table 1). The test accuracy of POCUS is generally acceptable, particularly for diagnosis of congestive heart failure or pleural effusion, although the usefulness of POCUS varies somewhat according to the underlying disease (Table 1 and Figure 2; see Clinical Considerations). Third, it is unlikely that POCUS is directly associated with serious harms. Finally, POCUS is not a high-cost test (Table 3). Of note, although correctness of diagnosis was not a prespecified outcome of importance, the CGC believed it was likely of value to patients and clinicians and was likely to correlate with the delivery of appropriate care and improved health outcomes.
The CGC graded this as a conditional recommendation because there was limited evidence examining the effect of POCUS on health outcomes, and there are many uncertainties related to variation in testing protocols, training, clinician experience, clinical setting, and equipment. Limited evidence on health outcomes showed that POCUS did not reduce hospital length of stay or readmissions (moderate-certainty evidence). However, there was no increase in length of stay with the addition of POCUS. The CGC determined that the lack of demonstrated effects on other health outcomes was either of low certainty or insufficient and thus does not preclude clinically meaningful benefits, especially given the supporting evidence on correctness of diagnosis and test accuracy as well as the lack of evidence of serious harms or high costs.
Clinical Considerations
•
The included studies enrolled adult patients presenting in EDs and inpatient settings with dyspnea as a primary symptom (unspecified acute dyspnea) and who were later confirmed to have 1 of the conditions of interest (congestive heart failure [including pulmonary edema], pleural effusion, pneumonia, pneumothorax, or pulmonary embolism).
•
Findings may differ in outpatient settings. Thus, our recommendation applies to EDs and inpatient settings.
•
The systematic review excluded studies that included patients with other medical conditions that can cause dyspnea (for example, chronic obstructive pulmonary disease, asthma, acute coronary symptoms, and trauma) if the patients were not also confirmed to have 1 of the conditions of interest.
•
This recommendation does not apply to handheld devices; evidence from 1 high risk of bias study is very uncertain (insufficient) about the effect of handheld POCUS devices in addition to the standard pathway on health, diagnostic, and treatment outcomes. Future research is needed to assess the effectiveness, harms, and diagnostic accuracy characteristics of handheld devices.
•
Clinicians who use POCUS should be trained in the use and interpretation of findings and ongoing care quality assessment. This is an important area for future research: In the included studies, the experience and training of POCUS operators varied and reporting was limited.
•
As with any diagnostic test, this recommendation applies to clinical scenarios where there is diagnostic uncertainty. Clinicians should understand and consider that the test accuracy of POCUS varies according to the likelihood of underlying diseases.
•
Figure 2 shows that, using the prevalence estimates of various conditions reported in the studies, the rate of false-positive test results for pneumonia and pulmonary embolism may be higher than what many clinicians and patients are comfortable with, especially because false-positive results for these conditions may lead to unnecessary use of anticoagulation and antibiotics.
•
Clinicians can also review Figure 2 and consider that the severity of consequences of false-negative or false-positive test results may differ according to condition. Table 4 of Supplement 1 provides clinical descriptions of potential consequences according to specific conditions: It may be more “serious” to miss a diagnosis of pneumonia or pulmonary embolism than to miss a diagnosis of heart failure or pleural effusion.
•
However, we do not have direct evidence about the health outcome effect of false-negative or false-positive testing in POCUS.
•
In patients who are clinically unstable, the use of POCUS should not delay management actions derived from results of other diagnostic tests in the pathway.
•
The extent of organs and anatomical sites imaged varied across included studies, with some confined to the lungs, whereas others included more comprehensive assessment of the inferior vena cava, deep veins, and heart. Clinicians should focus POCUS on anatomical sites consistent with their diagnostic and treatment uncertainties.
Appendix: Detailed Methods of the Systematic Review and Guideline
Cochrane Austria at Danube University Krems conducted the supporting systematic review. Details of the ACP guideline development process can be found in ACP's methods articles (8, 9). Disclosure of interests and management of any conflicts can be found at https://www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Key Questions Addressed
Key question 1: In patients with acute dyspnea, what are the beneficial and harmful health effects of POCUS plus clinical examination compared with clinical examination alone?
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?
Search Strategy of Systematic Review
Reviewers searched several databases for studies and systematic reviews published in English from 2004 to August 2020.
Quality Assessment, Synthesis, and Overall Certainty of Evidence
Population Studied
Adult patients with unspecified acute dyspnea or acute dyspnea due to a suspected diagnosis of congestive heart failure (including pulmonary edema), pneumonia, pulmonary embolism, pleural effusion, or pneumothorax.
Interventions Evaluated
Bedside POCUS (trolley- or cart-based, compact–handheld, or application-based) in addition to clinical examination with or without a standard diagnostic pathway.
Comparators
Standard diagnostic pathway without POCUS; reference tests: chest radiography, echocardiography, laboratory values for congestive heart failure, chest radiography and computed tomography scan for pleural effusion and pneumonia, chest radiography for pneumothorax, and computed tomography pulmonary angiography and ventilation perfusion scanning for pulmonary embolism.
Outcomes
Members of the CGC (clinicians and nonclinician public members) and the CGC Public Panel members were asked a priori to independently rate the importance of evaluated outcomes.
Setting
Hospital settings (ED, intensive care units, and nonintensive care settings) in countries with a “very high” Human Development Index.
Target Audience
The target audience is all clinicians.
Target Patient Population
The target patient population is adult patients with acute dyspnea in ED or inpatient settings.
Public or Patient Involvement
The development of this guideline also included perspectives, values, and preferences of 2 nonphysician CGC members who represent the public and a 7-member CGC Public Panel. In addition, the CGC Public Panel was also surveyed to assess their preferences with regards of the intervention options.
Cost Search
ACP staff searched PubMed (MEDLINE) from inception to February 2020. ACP staff searched several other databases (National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and the Health Technology Assessment database) from inception through 2015, at which point the databases stopped adding records. The search used a modified search string strategy from the clinical effectiveness review that added cost, resource use, and economic search terms as identified by the Canadian Agency for Drugs and Technologies in Health Information Services Filters Working Group.
ACP staff used the Medicare Fee Schedules to identify Medicare reimbursements fees for POCUS and other tests included in the standard diagnostic work-up for the included conditions. The search yielded 779 citations, of which 6 were selected for full-text review.
Peer Review
The supporting systematic review and guideline each had a peer review process through the journal. The guideline was posted online for comments from ACP Regents and ACP Governors, who represent internal medicine and its subspecialty physician members at the national and international levels.
Supplemental Material
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Published In
Annals of Internal Medicine
Volume 174 • Number 7 • July 2021
Pages: 985 - 993
History
Published online: 27 April 2021
Published in issue: July 2021
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© 2021 American College of Physicians.
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Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med.2021;174:985-993. [Epub 27 April 2021]. doi:10.7326/M20-7844
Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med.2021;174:985-993. [Epub 27 April 2021]. doi:10.7326/M20-7844
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One step towards the right direction!
I'm an academic hospitalist and I use POCUS almost on daily basis when I'm on wards with residents. I found it most useful in patients with respiratory symptoms, so I'm excited that this is what the recommendations tackle (acute dyspnea). I use a handheld device and I'm able to share de-identified images with residents. Many of them got convinced about its diagnostic usefulness so that they purchased their own devices! I'm happy that generally no harm was revealed as I expected. I still believe false positive results are the main concern in the hands of those with limited use and experience, but this is something that can be improved with practice, and it also emphasizes that POCUS should be utilized IN ADDITION TO (not as a replacement of) accurate history and physical exam.
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.
Conflicts of interest: none
The views expressed in this article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the United States Government.
We are military service members or federal/contracted employees of the United States government. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that `copyright protection under this title is not available for any work of the United States Government.' Title 17 U.S.C. 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person's official duties.
References
1. Qaseem A, Etxeandia-Ikobaltezeta I, Mustafa RA, Kansagara D, Fitterman N, Wilt TJ. Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2021 Apr 27. [Epub ahead of print] doi:10.7326/M20-7844.
2. Gartlehner G, Wagner G, Affengruber L, Chapman A, Dobrescu A, Klerings I, et l. 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 Apr 27. [Epub ahead of print]. doi:10.7326/M20-5504.
3. Leo, M. Potential for Point-of-Care Ultrasonography to Improve Patient Care in Diagnosis of Dyspnea. Ann Intern Med. 2021 Apr 27. [Epub ahead of print]. doi:10.7326/M21-1773