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Correspondence |

Pretest Probability in the Assessment of Acute Dyspnea in the ED FREE TO VIEW

Sami Alsolamy, MD, MPH; Khaled Alrajhi, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Emergency Medicine and Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

CORRESPONDENCE TO: Sami Alsolamy, MD, MPH, Emergency Medicine and Intensive Care Department, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, PO Box 22490, Riyadh 11426, Saudi Arabia


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(6):1407-1408. doi:10.1016/j.chest.2017.03.044
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Published online

It is with great interest that we read the article by Zanobetti et al published in this issue of CHEST regarding point-of-care ultrasonography (PoCUS) and its implications in the diagnosis of acute dyspnea in the ED. In this study, the authors found that the average time needed to formulate a diagnosis by using PoCUS was significantly shorter than that of a typical ED diagnosis.

Although we believe that PoCUS adds significant value to the clinical assessment of many patients presenting to the ED with dyspnea, we would like to highlight an important point regarding shortening the diagnostic timeline by using PoCUS. Overall, after the initial assessment when managing a patient in the ED, using pretest probabilities for a suspected disease generates individualized suspected diagnoses for a given patient. The pretest probability is often either high enough to guarantee the diagnosis and warrant treatment or low enough to disprove the suspected diagnosis.

Various resources aid emergency physicians in determining the initial probability of any diagnosis, particularly what the authors described as the primary assessment, which consists of medical history, physical examination, and the use of rapid diagnostic methods such as electrocardiography, chest radiography, or arterial blood gas measurements (or a combination), as needed. In the study, emergency physicians were not asked about their impressions or possible diagnoses at the time of the primary assessment, which was also at the time of the PoCUS examination. A diagnosis is often made clinically during the initial assessment and may not be influenced by laboratory test results to determine the diagnosis. For example, a patient with congestive heart failure may present with a typical exacerbation, or pneumonia is suggested in a patient presenting with a typical history, physical examination, and chest radiographic findings. In both scenarios, the pretest probability should be high enough to suspect the diagnosis and initiate treatment. Thus the difference in time for formulating a diagnosis could be attributed to the design of the study rather than the use of PoCUS.

Finally, providing a decision tree or algorithm either in the main article or as a supplement would also have been helpful, especially for cases with conflicting PoCUS findings (eg, low ejection fraction and no B-lines on PoCUS).

References

Zanobetti M. .Scorpiniti M. .Gigli C. .et al Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151:1295-1301 [PubMed]journal
 
Safari S. .Baratloo A. .Elfil M. .Negida A. . Evidence based emergency medicine; part 4: pre-test and post-test probabilities and Fagan’s nomogram. Emergency. 2016;4:48-51 [PubMed]journal. [PubMed]
 
Wang C.S. .FitzGerald J.M. .Schulzer M. .Mak E. .Ayas N.T. . Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294:1944-1956 [PubMed]journal. [CrossRef] [PubMed]
 
Metlay J.P. .Kapoor W.N. .Fine M.J. . Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278:1440-1445 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Zanobetti M. .Scorpiniti M. .Gigli C. .et al Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151:1295-1301 [PubMed]journal
 
Safari S. .Baratloo A. .Elfil M. .Negida A. . Evidence based emergency medicine; part 4: pre-test and post-test probabilities and Fagan’s nomogram. Emergency. 2016;4:48-51 [PubMed]journal. [PubMed]
 
Wang C.S. .FitzGerald J.M. .Schulzer M. .Mak E. .Ayas N.T. . Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005;294:1944-1956 [PubMed]journal. [CrossRef] [PubMed]
 
Metlay J.P. .Kapoor W.N. .Fine M.J. . Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997;278:1440-1445 [PubMed]journal. [CrossRef] [PubMed]
 
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