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Thromboembolism in UltrasoundThromboembolism in Ultrasound: Killing Three Birds With One Stone FREE TO VIEW

Gebhard Mathis, MD
Author and Funding Information

Dr Mathis is an internist in private practice.

Correspondence to: Gebhard Mathis, MD, Bahnhofstrasse 16, 6830 Rankweil, Austria; e-mail: gebhard.mathis@cable.vol.at


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):931-932. doi:10.1378/chest.13-2607
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Pulmonary thromboembolism (PTE) is a common clinical problem that is associated with substantial morbidity and mortality. The incidence of PTE in the United States is estimated at one case per 1,000 people per year.

Pulmonary embolism still represents the most common cause of death that is not clinically diagnosed before death. In the 1990s, clinical diagnosis of PTE was only made in one-third of all cases. Even in times of multislice computed angiography (MSCT), clinical accuracy before death is just about 59%.1 Mortality has slightly decreased during the last decades, probably due to the use of CT imaging.2 On the other hand, it has also been shown that the application of MSCT could not substantially reduce PTE mortality and that increased diagnoses may lead to overtreatment accompanied by undesirable side effects.3 Do our current diagnostic procedures include patients who are threatened by a lethal course of this disease? Obviously, we are on the horns of both a diagnostic and a therapeutic dilemma resulting from several reasons.

The first problem lies in the fact that PTE is often ignored, because the clinical symptoms, such as dyspnea or chest pain, are nonspecific and frequently suggest a known underlying disease, such as COPD or heart failure, although these two underlying diseases are also associated with an increased risk for PTE. In most cases, physical examination by means of a stethoscope is not efficient, whereas clinical probability scores, such as the Wells probability score or the pulmonary embolism severity index, constitute helpful tools for further diagnostic and therapeutic steps.4

In different algorithms, the quantitative D-dimer test is recommended in outpatients for excluding PTE. And still, with this test method applied at the time of the symptoms, 8% to 12% false-negative results can occur.5 Other biomarkers, such as troponin and Na-brain natriuretic peptide, may be interesting, but finally they are nonspecific. Thromboembolism is a dynamic event. We do not know what will happen during the next hours or the next day. Each diagnostic measure is but a snapshot in time that must be called in question along with the clinical progress. Besides, we do not sufficiently know if minor emboli are harmless or rather forerunners of a fatal event.

In patients with unstable hemodynamics, diagnosis is often made by echocardiography in EDs. Although the sensitivity of echocardiography in patients with shock proving right-sided heart strain is very high (90%), it is only 41% to 50% for PTE.6 Patients in stable condition will sooner or later undergo MSCT to provide evidence for or to exclude a PTE. This method proves to be very accurate; however, the dynamics of the disease also make it inappropriate for definitely excluding a PTE.

In case of a suspected PTE, compression sonography of the leg veins is recommended. It can be performed within 2 min but, on average, yields a positive result in only one-half of the cases of PTE.

During the last years, pulmonary sonography took root as a complementary method to MSCT either when the latter is not available or when it is contraindicated because of contrast agent allergy, renal insufficiency, or pregnancy.5 This method was able to provide evidence of subpleural pulmonary consolidations due to embolism in at least three-fourths of patients having a PTE.5 In current meta-analyses, sensitivity is 80% to 87% and specificity 82% to 93% when PTE was diagnosed by pulmonary sonography alone.7,8

In this issue of CHEST (see page 950), Nazerian and colleagues9 presented a new concept: the point-of-care multiorgan ultrasonography for diagnosis of pulmonary embolism. In patients with unstable hemodynamics, echocardiography is performed first; then patients in stable condition undergo pulmonary sonography and, as the case may be, compression sonography of the leg veins. Although, according to this study, accuracy of pulmonary sonography is the best, it remains below the values that have been determined in previous studies. This could be because 7% of the patients were exclusively examined in supine position and the time factor plays an important role in EDs.

For anatomic and hemodynamic reasons, the majority of embolic pulmonary consolidations can be found in the dorsobasal segments of the lung. Therefore, emergency patients undergoing sonography should be in an oblique position to improve the accuracy of the diagnosis.5 Another remarkable point identified in this study is that, notwithstanding a missing definitive diagnosis of PTE, alternative diagnoses, such as pneumonia, interstitial syndrome, or pleural effusion, could immediately be made in 106 patients (47%). Consequently, it pays off to thoroughly sound the lung of patients with stable hemodynamics.

The multiorgan ultrasound is special and novel when PTE is suspected, performed in one session immediately when such suspicion arises. Lung ultrasound on lung consolidations is relatively new. It is scientifically well documented but not really accepted, although it is recommended in guidelines and consensus conferences. This concept is fast, effective, and reduces radiation exposure and costs. The source (leg vein sonography), transmission and hemodynamics (echocardiography), and arrival (lung ultrasound) of thromboembolic disease can be detected with a single ultrasound system in one procedure, thus, “killing three birds with one stone.”

Portable ultrasound systems have led to a paradigm shift, especially in emergency sonography. Instead of using a stethoscope, we can take our ultrasound probe to the patient and make a point-of-care examination. This allows precise diagnoses in many cases, such as pneumothorax or acute abdomen. From a diagnostic and therapeutic point of view, further strategic decisions may be made more easily and more precisely. Now then: Use your ultrasound stethoscope!

References

Mathis G. Pulmonary embolism.. In:Mathis G., ed. Chest Sonography.3rd ed. Heidelberg, Germany: Springer; 2011:76-92.
 
Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med. 2003;163(14):1711-1717. [CrossRef] [PubMed]
 
Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol. 2008;63(4):381-386. [CrossRef] [PubMed]
 
Jiménez D, Aujesky D, Moores L, et al; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-1389. [CrossRef] [PubMed]
 
Mathis G, Blank W, Reissig A, et al. Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005;128(3):1531-1538. [CrossRef] [PubMed]
 
Dresden S, Mtchell 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. [CrossRef] [PubMed]
 
Niemann T, Egelhof T, Bongartz G. Transthoracic sonography for the detection diagnosis of pulmonary embolism–a meta-analysis. Ultraschall Med. 2009;30(2):150-156. [CrossRef] [PubMed]
 
Squizzato A, Rancan E, Dentali F, et al. Diagnostic accuracy of lung ultrasound for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2013;11(7):1269-1278. [CrossRef] [PubMed]
 
Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957.
 

Figures

Tables

References

Mathis G. Pulmonary embolism.. In:Mathis G., ed. Chest Sonography.3rd ed. Heidelberg, Germany: Springer; 2011:76-92.
 
Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data. Arch Intern Med. 2003;163(14):1711-1717. [CrossRef] [PubMed]
 
Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol. 2008;63(4):381-386. [CrossRef] [PubMed]
 
Jiménez D, Aujesky D, Moores L, et al; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-1389. [CrossRef] [PubMed]
 
Mathis G, Blank W, Reissig A, et al. Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients. Chest. 2005;128(3):1531-1538. [CrossRef] [PubMed]
 
Dresden S, Mtchell 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. [CrossRef] [PubMed]
 
Niemann T, Egelhof T, Bongartz G. Transthoracic sonography for the detection diagnosis of pulmonary embolism–a meta-analysis. Ultraschall Med. 2009;30(2):150-156. [CrossRef] [PubMed]
 
Squizzato A, Rancan E, Dentali F, et al. Diagnostic accuracy of lung ultrasound for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost. 2013;11(7):1269-1278. [CrossRef] [PubMed]
 
Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957.
 
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