Lung ultrasound by emergency nursing as an aid for rapid triage of dyspneic patients: a pilot study
Introduction
Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity (Zimmermann et al., 1994). Patients suffering from dyspnea or shortness of breath commonly seek care in the emergency department (ED) (West, 1985). Anticipating the dangerous diagnoses that cause this complaint and preventing the associated morbidity and mortality from such conditions has been the primary focus of emergency medicine. Differential diagnosis of dyspnea is an important issue for emergency physicians (EPs) to guide the appropriate treatment of patients. Treatment decisions and evaluation of the dyspneic patients must be conducted at the same time. The indiscriminate use of bronchodilatator treatment in patients who do not have a history of chronic obstructive pulmonary disease (COPD) is associated with a greater need for ‘aggressive interventions’, including mechanical ventilation and the need for intravenous vasodilators (Singer et al., 2008). Bedside lung ultrasonography (BLUS) has become an increasingly valuable diagnostic tool in various pulmonary and cardiac diseases, especially in emergency conditions (Copetti, 2008, Kirkpatrick, 2004, Lichtenstein, Mezière, 2008, Ünlüer, Kara, 2013, Ünlüer, 2012, Ünlüer, 2013a, Ünlüer, 2013b). There is a growing body of evidence that shows that patient care is improved when BLUS is included in the diagnostic workup of such patients. Use of ultrasonography (USG) in pre-hospital care and in EDs could potentially provide critical information about dyspneic patients and could thereby optimize the early treatment of patients with dyspnea. The portability, accuracy, and non-invasiveness of the USG give it potential as an effective imaging modality to provide diagnostic information in an emergency setting. In addition, the traditional physical examination often has significant limitations in the diagnosis of cardiopulmonary pathology (Johnson, Carpenter, 1986, Liang, Schnittger, 2003, Mangione, Nieman, 1997).
Our objective was to evaluate the accuracy of emergency nurse (EN)-performed BLUS for diagnosing dyspnea as having a cardiac or a non-cardiac cause in patients admitted to the ED.
Section snippets
Setting
This study was a prospective, cross-sectional cohort study that was conducted from 1 to 30 May 2013 at an academic, adult tertiary care center ED of a university hospital in Turkey. In our ED, at least two emergency medicine specialists with eight residents of emergency medicine work in each shift. No patients have been discharged from the ED without establishing a final diagnosis by eight emergency medicine specialists or ten consultant physicians. The local Ethics Committee approved the study
Results
Patients were enrolled in the study from 1 to 30 may 2013. During the study period, 106 patients with dyspnea were admitted to the ED. Ten of them were excluded from the study: two were aged under 18, four had acute chest pain, two were pregnant, one was hypotensive, and one had had previous thoracic surgery. The remaining 96 patients, who gave informed consent, were included in the study. Six of them were excluded from the final statistical analysis: three patients had severe anemia and three
Discussion
ENs have started to perform various procedures in the emergency care setting, including fluorescein staining, the removal of foreign bodies from the eye, the interpretation of radiographic images, the simple closure of lacerations, splinting extremities, and microscopy of blood, urine, and other tissue samples (Cole and Ramirez, 2000). In addition, several studies have found that the overall patient comfort and satisfaction was comparable when they were treated by either a physician or
Limitations
One of the limitations of our study was only two operators were included in the study. The other limitation was that the ENs were not blinded to the study. Since the ENs knew that they were being evaluated, they were more motivated to enhance their performance in the criteria being studied. As no standards exist for training nurses in USG, we cannot assume that our training program was adequate. However, it was designed on the basis of the training program used to train our emergency residents
Conclusion
Emergency USG has the promising ability to assist in making appropriate triage decisions for dyspneic patients. Our study shows that ENs can perform BLUS in hospital EDs with a high degree of accuracy to dyspneic patients.
References (33)
- et al.
Validation of nurse-performed FAST ultrasound
Injury
(2010) - et al.
Safety of dobutamine stress echocardiography supervised by registered nurse sonographers
Journal of the American Society of Echocardiography
(1998) - et al.
Activities and procedures performed by nurse practitioners in emergency care settings
Journal of Emergency Nursing
(2000) - et al.
Visually estimated left ventricular ejection fraction by echocardiography is closely correlated with formal quantitative methods
International Journal of Cardiology
(2005) - et al.
Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea
The American Journal of Medicine
(2004) - et al.
Relevance of lung ultrasound in the diagnosis of acute respiratory failure. The BLUE protocol
Chest
(2008) - et al.
Bronchodilator therapy in acute decompensated heart failure patients without a history of chronic obstructive pulmonary disease
Annals of Emergency Medicine
(2008) - et al.
Limited obstetric ultrasound examinations. Competency and cost
Journal of Obstetric, Gynecologic, and Neonatal Nursing
(2003) - et al.
Ultrasonography of jugular vein as a marker of hypovolemia in healthy volunteers
The American Journal of Emergency Medicine
(2013) - et al.
Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome
The American Journal of Emergency Medicine
(2006)
Effects of prehospital medications on mortality and lenght of stay in congestive heart failure
Annals of Emergency Medicine
How well can the chest radiograph diagnose left ventricular dysfunction?
Journal of General Internal Medicine
Can the clinical examination diagnose left-sided heart failure in adults?
JAMA: The Journal of the American Medical Association
A nurse led central line insertion service
EDTNA/ERCA Journal (English Ed.)
Chest sonography. A useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome
Cardiovascular Ultrasound
Outcome analysis and patient satisfaction following octant transrectal ultrasound-guided prostate biopsy. A prospective study comparing consultant urologist, specialist registrar and nurse practitioner in urology
Prostate Cancer and Prostatic Diseases
Cited by (14)
Training, Competency, and Interdisciplinary Collaboration in Point-of-Care Ultrasound
2024, Seminars in Ultrasound, CT and MRILung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis
2019, Journal of Emergency MedicineCitation Excerpt :Pneumonia had prevalence ranging from 30% to 85% in patients with respiratory symptoms indicative of this disease, from 21% to 39% in patients with acute dyspnea, and from 32% to 49% in patients with respiratory failure (16–29). Prevalence of acute heart failure varied from 35% to 88% in patients with acute dyspnea and from 24% to 40% in patients with respiratory failure (19–21,30–40). Exacerbation of COPD/asthma had prevalence ranging from 11% to 32% in patients with respiratory failure, and was 11% in the study that assessed patients with acute dyspnea (18–21).
Role of Ultrasound Lung Comets in the Diagnosis of Acute Heart Failure in Emergency Department: A Systematic Review and Meta-analysis
2018, Biomedical and Environmental SciencesDiagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea
2015, American Journal of Emergency MedicineCitation Excerpt :Its feasibility of 100% was a real advantage to distinguish dyspnea by left ventricular dysfunction from other causes of dyspnea, by highlighting a bilateral interstitial syndrome (B profile) [9,10,20,36-38]. A recent study has even shown that bedside lung ultrasonography performed by an emergency nurse can identify with a high degree of accuracy the patients with dyspnea as having a cardiac or a noncardiac cause according to the presence of a B or A profile [39]. However, interstitial pneumonitis, pulmonary fibrosis, and acute respiratory distress syndrome have the same echographic aspect and can report false positives as seen in 6 of our 130 patients.