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Comparison of the Accuracy of Nurse-Performed and Physician-Performed Lung Ultrasound in the Diagnosis of Cardiogenic Dyspnea FREE TO VIEW

Josè Vitale, MD; Nicola Mumoli, MD; Matteo Giorgi-Pierfranceschi, MD; Alessandra Cresci, RN; Marco Cei, MD; Valentina Basile, RN; Massimo Cocciolo, MD; Francesco Dentali, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

aDepartment of Internal Medicine, Ospedale Civile di Livorno, Livorno, Italy

bDepartment of Internal Medicine, Ospedale di Circolo, Varese, Italy

cEmergency Department, Ospedale della Val d’Arda, Piacenza, Italy

CORRESPONDENCE TO: Nicola Mumoli, MD, Department of Internal Medicine, Ospedale Civile Livorno, viale Alfieri 36, 57100 Livorno, Italy


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(2):470-471. doi:10.1016/j.chest.2016.04.033
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Dyspnea affects approximately 50% of patients admitted to hospitals. Prompt identification of its correct cause may optimize the management and improve outcomes. Lung ultrasound (LUS) is emerging as a bedside tool that could discriminate different causes of dyspnea even by nonphysicians.

We recently published a prospective study to assess the accuracy of LUS performed by nurses in the diagnosis of congestive heart failure (CHF). In that study, five nurses of Livorno Hospital were trained in LUS (8 h of didactic lectures, 20 h of practice, and 4 h of chest ultrasound image review) to identify typical ultrasound criteria of pulmonary interstitial syndrome of CHF. From April to July 2014, a total of 226 consecutive patients admitted in the Medicine Department with acute dyspnea were included; 107 had a diagnosis of acute cardiogenic dyspnea (ACD). Their mean age was 78.3 ± 11.0 years, and 132 were women. Nurse-performed LUS exhibited good accuracy in the ACD diagnosis, with a sensitivity of 95.3% (95% CI, 92.6-98.1) and a specificity of 88.2% (95% CI, 84.0-92.4) (Table 1). Use of this technique in combination with B-type natriuretic peptide analysis seems to be useful in ruling out ACD, with a negative likelihood ratio of 0.01 (95% CI, 0.0-0.07).

Table Graphic Jump Location
Table 1 Accuracy of Nurse- and Physician-Performed LUS for the Diagnosis of Acute Cardiogenic Dyspnea

LR = likelihood ratio; LUS = lung ultrasound; NPV = negative predictive value; PPV = positive predictive value.

It is still unclear, however, if the accuracy of LUS in diagnosing ACD may be higher when performed by more skilled physicians. All the LUS in our study were performed in duplicate (and blinded) by a trained nurse and by a physician expert in LUS; we thus compared the overall accuracy of these two examinations by using as a reference the overall final diagnosis as assessed by two external independent physicians (J.V. and F.D.) through review of the entire medical record of each patient. In the diagnosis of CHF, physician-performed LUS revealed a similar sensitivity (95.3% vs 95.3%) and a nonsignificantly higher specificity (93.3% vs 88.2%), with a resulting nonsignificantly higher area under the curve (0.94 [95% CI, 0.91-0.98] vs 0.92 [95% CI, 0.88-0.96]) compared with nurse-performed LUS (Table 1). Furthermore, there was a good correlation between ultrasonographic results collected by nurses and physicians (Cohen’s κ = 0.73 [95% CI, 0.67-0.79]). Thus, our results further confirm the good accuracy of nurse-performed LUS, suggesting this technique should be used when a trained physician is not readily available and to reduce the time of diagnosis in overcrowded emergency departments. Nevertheless, nurses should have adequate training in this technique before safely and efficiently applying LUS in clinical practice.

References

Parshall M.B. .Schwartzstein R.M. .Adams L. . on behalf of the ATS Committee on Dsypneaet al An Official American Thoracic Society Statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185:435-452 [PubMed]journal. [CrossRef] [PubMed]
 
Unluer E.E. .Karagoz A. .Oyar O. .Vandenberk N. .Kiyancicek S. .Budak F. . Lung ultrasound by emergency nursing as an aid for rapid triage of dyspneic patients: a pilot study. Int Emerg Nurs. 2014;22:226-231 [PubMed]journal. [CrossRef] [PubMed]
 
Mumoli N. .Vitale J. .Giorgi-Pierfranceschi M. .et al Accuracy of nurse-performed lung ultrasound in patients with acute dyspnea: a prospective observational study. Medicine (Baltimore). 2016;95:e2925- [PubMed]journal. [CrossRef] [PubMed]
 
Volpicelli G. .Elbarbary M. .Blaivas M. . and the International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS)et al International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-591 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 Accuracy of Nurse- and Physician-Performed LUS for the Diagnosis of Acute Cardiogenic Dyspnea

LR = likelihood ratio; LUS = lung ultrasound; NPV = negative predictive value; PPV = positive predictive value.

References

Parshall M.B. .Schwartzstein R.M. .Adams L. . on behalf of the ATS Committee on Dsypneaet al An Official American Thoracic Society Statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185:435-452 [PubMed]journal. [CrossRef] [PubMed]
 
Unluer E.E. .Karagoz A. .Oyar O. .Vandenberk N. .Kiyancicek S. .Budak F. . Lung ultrasound by emergency nursing as an aid for rapid triage of dyspneic patients: a pilot study. Int Emerg Nurs. 2014;22:226-231 [PubMed]journal. [CrossRef] [PubMed]
 
Mumoli N. .Vitale J. .Giorgi-Pierfranceschi M. .et al Accuracy of nurse-performed lung ultrasound in patients with acute dyspnea: a prospective observational study. Medicine (Baltimore). 2016;95:e2925- [PubMed]journal. [CrossRef] [PubMed]
 
Volpicelli G. .Elbarbary M. .Blaivas M. . and the International Liaison Committee on Lung Ultrasound (ILC-LUS) for International Consensus Conference on Lung Ultrasound (ICC-LUS)et al International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577-591 [PubMed]journal. [CrossRef] [PubMed]
 
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