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CHEST publishes select peer-reviewed, accepted manuscripts Online First each week. The media embargo is lifted on the date of Online First publication. Final, edited versions will appear in a numbered issue of CHEST and may contain substantive changes. We encourage readers to check back for the final article. Online First papers are indexed in PubMed and by search engines, but the information, including the final title and author list, may be updated on final publication.

contemporary reviews in critical care medicine 
Carlos L. Rodriguez, MD; Nattapong Jaimchariyatam, MD, MS, FCCP; Kumar Budur, MD, MS
No abstract is available for this article
topics in practice management 
Yiwey Shieh, MD; Martin Bohnenkamp, MD
Topics: ,

Lung cancer screening with low-dose computed tomography (LDCT) was shown to reduce lung cancer mortality in the National Lung Screening Trial, a large randomized-controlled trial of high-risk current and former smokers. Despite ongoing uncertainty over the effectiveness of LDCT in the real-world setting, the Centers for Medicare and Medicaid Services (CMS) decided to cover LDCT as a preventive service. As part of its national coverage determination, CMS set forth a series of requirements for reimbursement of LDCT, including a counseling and shared decision-making visit prior to a LDCT being ordered. During this visit, providers must determine patient eligibility, engage in shared decision-making around LDCT, discuss the importance of adherence to screening, and provide smoking cessation counseling (if applicable). Two new billing codes were introduced for the counseling and shared decision-making visit and subsequent LDCT scan. In this review, we summarize the evidence around lung cancer screening and describe practical aspects of the counseling and shared decision-making, including billing considerations. We conclude with a discussion of the greater implications of the CMS national coverage determination, especially as it pertains to quality assurance around new screening tests.

translating basic research into clinical practice 
Y.S. Prakash, MD, PhD; Christina M. Pabelick, MD; Gary C. Sieck, PhD
Topics: ,

There is increasing appreciation that mitochondria serve cellular functions beyond oxygen sensing and energy production. Accordingly, it has become important to explore non-canonical roles of mitochondria in normal and pathophysiological processes that influence airway structure and function in the context of diseases such as asthma and COPD. Mitochondria can sense upstream processes such as inflammation, infection, tobacco smoke and environmental insults important in these diseases, and in turn can respond to such stimuli via altered mitochondrial protein expression, structure, and resultant dysfunction. Conversely, mitochondrial dysfunction has downstream influences on cytosolic and mitochondrial calcium regulation, airway contractility, gene and protein housekeeping, responses to oxidative stress, proliferation, apoptosis, fibrosis, and certainly metabolism: all key aspects of airway disease pathophysiology. Indeed, mitochondrial dysfunction is thought to play a role even in normal processes such as aging and senescence, and conditions such as obesity that impact on airway diseases. Thus understanding how mitochondrial structure and function play central roles in airway disease may be critical for development of novel therapeutic avenues targeting dysfunctional mitochondria. Here, it is likely that mitochondria of airway epithelium, smooth muscle and fibroblasts play differential roles, consistent with their contributions to disease biology, underlining the challenge of targeting a ubiquitous cellular element of existential importance. This translational review summarizes current state of understanding of mitochondrial processes that play a role in airway disease pathophysiology, identifying areas of unmet research need, and opportunities for novel therapeutic strategies.

original research 
Federica De Giacomi, M.D; Paul A. Decker, M.S; Robert Vassallo, M.D; Jay H. Ryu, M.D

Background  Acute eosinophilic pneumonia (AEP) is an uncommon disease, often indistinguishable from acute respiratory distress syndrome or community-acquired pneumonia at initial presentation. AEP can be idiopathic but identifiable causes include medications and inhalational exposures including cigarette smoke.

Methods  Using a computer-assisted search, we retrospectively identified and reviewed the medical records of all patients diagnosed with AEP between January 1, 1998 and June 30, 2016 at our institution. We extracted demographic and clinical data including exposures (occupational, environmental, recreational, pharmacologic and smoking), laboratory and radiological findings, treatments, hospitalization including intensive care unit stay, and subsequent clinical course.

Results  Among 36 consecutive patients with AEP, 11 were smoking-related, 6 medication-related, and 19 idiopathic. Smoking-related AEP included 6 first-time smokers and 5 ex-smokers who had resumed smoking after a period of abstinence. Patients with smoking-related AEP were younger compared to both medication-related and idiopathic AEP (median age 22 vs. 47.5 vs. 55 years, respectively, p=0.004). Smoking-related AEP was less likely to be associated with peripheral eosinophilia at presentation (36% vs. 50% vs. 58%, p=0.52) but more likely to be hospitalized (100% vs. 50% vs. 63%, p=0.039), including a longer intensive care unit stay, when compared to medication-related and idiopathic cases.

Conclusion  AEP is associated with a good prognosis when recognized and treated promptly. In comparison to medication-related and idiopathic AEP, smoking-related AEP was less likely to be associated with peripheral eosinophilia at presentation but was characterized by more severe disease manifestations.

original research 
Khalid Alansari, MD, FRCPC, FAAP(PEM); Rafah Sayyed, MD; Bruce L. Davidson, MD, MPH; Shahaza Al Jawala, MD; Mohamed Ghadier, MD
Topics: ,

Background  To determine if intravenous magnesium, useful for severe pediatric asthma, reduces time to medical readiness for discharge in bronchiolitis patients when added to supportive care

Methods  We compared a single dose of 100 mg/kg intravenous magnesium sulfate versus placebo for acute bronchiolitis. Patients received bronchodilator therapy, nebulized hypertonic saline, and 5 days of dexamethasone if there was eczema and/or a family history of asthma. Time to medical readiness for discharge was the primary efficacy outcome. Bronchiolitis severity scores and need for infirmary or hospital admission and for clinic revisits within 2 wk were secondary outcomes. Cardiorespiratory instability onset was the safety outcome.

Results  162 previously healthy infants diagnosed with bronchiolitis aged 22 days to 17.6 months, median 3.7 months, were enrolled. About half had eczema and/or a family history of asthma. 86.4% had positive nasopharyngeal virus swabs. Geometric mean time until medical readiness for discharge was 24.1h (95% CI, 20.0-29.1) for the 78 magnesium patients and 25.3h (95% CI, 20.3-31.5) for the 82 placebo patients (ratio 0.95; 95% CI,0.52-1.80, p=0.91). Mean bronchiolitis severity scores over time were similar for the two groups. The frequency of clinic visits in the subsequent 2 wk, 33.8% and 27.2%, respectively, was also similar. Fifteen (19.5%) magnesium versus 5 (6.2%) placebo patients were readmitted to infirmary or hospital within 2 wk (p= 0.016). No acute cardiorespiratory side effects were reported.

Conclusions  Intravenous magnesium did not provide benefit for patients with acute bronchiolitis and may be harmful.

original research 
Christopher L. Carroll, MD, MS; Kristi Bruno, MA; Pradeep Ramachandran, MBBS
Topics: , , , ,

Background  Social media sites such as Twitter can significantly enhance education and advocacy efforts. In 2013, the American College of Chest Physicians (CHEST) launched a Twitter chat series using the hashtag #pulmcc to educate and advocate for topics related to pulmonary, critical care and sleep medicine.

Method  To assess the reach of these chats, we analyzed the metrics using Symplur analytics, and compared data from each chat, as well as participant data.

Results  Since 12/19/13, there have been twelve Twitter chats; six have been on Critical Care related topics, four on Pulmonary/Sleep related topics, and two conducted during the CHEST annual meeting on more general topics. During these one-hour Twitter chats there were a total of 4,212 tweets by 418 participants resulting in 9,361,519 impressions (i.e. views). There were similar numbers of participants and tweets in the three categories of Twitter chats, but there was a significantly greater reach during the more general Twitter chats conducted at the CHEST annual meeting with 1,596,013 + 126,472 impressions per chat session at these chats, compared to 739,203 + 73,109 impressions per chat session during the Critical Care Twitter chats and 621,965+ 123,933 impressions per chat session in the Pulmonary/Sleep chats. Seventy-five of the participants participated in 2 or more #pulmcc Twitter chats and the average percent of return participants in each chat was 30% + 7%. The large majority of the return participants were healthcare providers.

Conclusion  Twitter chats can be a powerful tool for the widespread engagement of a medical audience.

original research 
Bridget F. Collins, MD; Charles F. Spiekerman, PhD; Megan A. Shaw, MD; Lawrence A. Ho, MD; Jennifer Hayes, RN; Carolyn A. Spada, RN; Caroline M. Stamato, MPH; Ganesh Raghu, MD
Topics: ,

Background  Some patients with autoimmune characteristics and idiopathic interstitial pneumonia (IIP), particularly usual interstitial pneumonia (UIP), do not fit neatly into the category of connective tissue disease associated interstitial lung disease (CTD-ILD), idiopathic pulmonary fibrosis (IPF) or recently proposed yet to be validated criteria for interstitial pneumonia with autoimmune features (IPAF). Outcomes of these patients are unknown.

Methods  Retrospective single center study; ANOVA analyses compared differences in mean change in forced vital capacity (FVC) and diffusion capacity (DLCO) over 1-year among 124 well defined patients (20 AI-ILD [positive autoantibodies with or without symptoms of CTD], 15 IPAF, 36 CTD-ILD, 53 “Lone-IPF” [patients with IPF without any autoantibodies])

Results  75% of patients with AI-ILD, 33% IPAF, and 33% CTD-ILD had UIP. Initial FVC and DLCO were similarly moderately reduced across groups. Mean change in FVC: -60 mL IPAF, -110 mL AI-ILD, -10 mL CTD-ILD, -90 mL Lone-IPF (p=0.52); Mean change in DLCO (mL/mmHg/min): 2.39 IPAF, -1.15 AI-ILD, -0.27 CTD-ILD, -1.05 Lone-IPF (p < 0.001) over 12 months. By pattern of disease mean change in FVC: -140 mL UIP, 10 mL NSIP, 12 mL unclassifiable/other (p=0.001).

Conclusion  No clinically significant differences in pulmonary function to distinguish between patients with AI-ILD, IPAF, CTD-ILD and Lone-IPF were observed after 1 year. Longer periods of follow up are needed to understand the outcomes of these patients. It is not yet clear whether AI-ILD is a distinct phenotype or a variant of the newly proposed entity IPAF.

original research 
Eoin B. Hunt, MD; Chris Ward, PhD; Stephen Power, MD; Ashley Sullivan, Bsc; Jeffrey Pearson, PhD; Susan Lapthorne, PhD; Paul M. O’Byrne, MD FCCP; Joseph Eustace, MD; Barry J. Plant, MD; Michael M. Maher, MD; John MacSharry, PhD; Desmond M. Murphy, MD FCCP
Topics: , , , , , ,

Background  Many asthmatics remain sub-optimally controlled despite current treatments. Reasons include comorbidities that could aggravate asthma, including gastro-esophageal reflux (GER). We aimed to investigate whether aspiration occurs in asthmatic patients and if so does it correlate with asthma control.

Methods  Patients had ACQ-7, FeNO, and spirometry performed to characterize their level of asthma control. Barium swallow with provocation was performed to assess for predisposition to aspiration. Patients underwent bronchoscopic investigation, with bronchoalveolar lavage (BAL) pepsin measured as a marker of aspiration.

Results  Seventy-eight patients stratified by disease severity (GINA) into mild (35.8%), moderate (21.7%) and severe (42.3%) were studied. Pepsin was detectable in BAL in 46/78 (58.9%). There were no differences between pepsin levels in patients with different disease severity. Furthermore, no significant associations were seen between pepsin level and measures of asthma control, FEV1, ACQ or exacerbation frequency. Similarly no associations were found with adjustments for smoking history, BMI, proton pump inhibitor use, eosinophil count or IgE. When stratified into eosinophilic or neutrophilic asthmatic populations based on BAL there was no relationship to detected pepsin concentrations. A positive barium swallow (seen in 33/60 patients) did not correlate with BAL pepsin level and we found no significant association between barium swallow result and ACQ, GINA, exacerbation frequency or FEV1 using either univariate or multivariate analyses.

Conclusion  Our study suggests that the importance of aspiration on current asthma symptom control and exacerbation rate may be over-stated. However, our study did not address the role of aspiration and future risk of exacerbation.

original research 
Roop Kaw, MD; Samer El Zarif, MD; Lu Wang, MS; James Bena, MS; Eugene Blackstone, PhD; Reena Mehra, MD, MS
Topics: , , , , ,

Introduction  As the inter-relationships of objectively-ascertained sleep disordered breathing (SDB), post-cardiac surgery atrial fibrillation (PCSAF) and obesity remain unclear; we aimed to further investigate in a clinic-based cohort.

Methods  Patients with polysomnography (PSG) and cardiac surgery (coronary artery bypass surgery and/or valvular surgery) within 3 years, from January 2009 to January 2014 were identified excluding those with pre-existing AF. Logistic models were used to determine the association of SDB (apnea hypopnea index (AHI) per 5 unit increase) and secondary predictors [central sleep apnea (CSA) (central apnea index>5) and oxygen desaturation index (ODI)] with PCSAF. Models were adjusted for age, sex, race, body mass index (BMI) and hypertension. Statistical interaction and stratification by median BMI was performed. Odds ratios and 95% confidence intervals are presented.

Results  190 patients comprised the analytic sample; age: 60.6±11.4 years, 36.1% females, 80% white, BMI:33.3±7.5 kg/m2, 93.2% had AHI >5 and 30% with PCSAF. Unlike unadjusted analyses (OR=1.06, 1.01-1.1), in the adjusted model, increasing AHI was not significantly associated with increased odds of PCSAF: OR=1.04 (0.98, 1.1). Neither CSA nor ODI was associated with PCSAF. A significant interaction with median BMI was noted (p=0.015). Effect modification by median BMI was observed; those with a higher BMI>32 kg/m2 had 15% increased odds of PCSAF: OR=1.15 (1.05, 1.26; P<0.003).

Conclusion  SDB was significantly associated with PCSAF in unadjusted analyses, but not after taking into account obesity; those with both SDB and obesity may represent a vulnerable subgroup to target in order to reduce PCSAF and its associated morbidity.

original research 
Catia Cillóniz, PhD; Antoni Torres, MD; Christian Manzardo, MD; Albert Gabarrús, MSc; Juan Ambrosioni, MD; Adriana Salazar, MD; Felipe García, MD; Adrián Ceccato, MD; Josep Mensa, MD; Jorge Puig de la Bella Casa, MD; Asunción Moreno, MD; Jose M. Miró, MD
Topics: , ,

Background  The study aimed to investigate whether the clinical presentations and outcomes (length-of-stay (LOS), intensive care unit (ICU) admission and 30-day mortality) of pneumococcal pneumonia in virologically suppressed HIV-infected patients on ART with a CD4+ T cell count >350 cells/mm3 are comparable to those seen in non-HIV-infected patients, using a case-control design.

Methods  A case-control study was carried out in Hospital Clinic, Barcelona, Spain (2001-2016). Controls were matched by age (±10 years), gender, co-morbidities and pneumonia diagnosis in the same calendar period. Clinical presentation and outcomes of pneumococcal pneumonia in HIV-infected patients and non-HIV-infected patients were compared.

Results  Pneumococcal pneumonia was studied in 50 cases (HIV-infection) and 100 controls (non-HIV-infection). Compared with the control patients, case patients had higher rates of influenza (14% vs. 2%, p=0·007) and pneumococcal vaccination (10% vs. 1%, p=0·016). The group of cases also presented a higher rate of co-infection with HBV (6% vs. 0%, p=0·036). Both groups presented similar ICU admission (18% vs. 27%, p=0·22), need for mechanical ventilation (12% vs. 8%; p=0·43), length of stay (7 days vs. 7 days, p<0·76) and 0% of 30-day mortality. No evidence was found of a more severe presentation or a worse clinical outcome in cases than in controls.

Conclusions  Pneumococcal pneumonia episodes requiring hospitalization in virologically suppressed HIV-infected patients with >350 CD4+ T cell count/mm3 were neither more severe nor had worse prognosis compared with uninfected patients. These results support the fact that such patients do not need treatment, admission or care sites different to the general population.

original research 
Irene Cano-Pumarega, MD; Ferrán Barbé, MD, PhD; Andrés Esteban, MD, PhD; Montserrat Martínez-Alonso, PhD; Carlos Egea, MD, PhD; Joaquín Durán-Cantolla, MD, PhD
Topics: , , , ,

Background  Evidence from longitudinal studies has reported contradictory results regarding the association between obstructive sleep apnea (OSA) and hypertension. In a previous analysis of the Vitoria Sleep Cohort, we evaluated the relationship between OSA and the risk of developing hypertension and we did not find an independent association after adjustment for confounding factors. In the present study, we perform a post hoc analysis to assess the association between OSA and incident stage 2 hypertension (systolic blood pressure ≥ 160 mmHg and/or diastolic blood pressure ≥ 100 mmHg) based on gender differences.

Methods  A prospective study was performed over 7.5 ± 0.8 years on a middle-aged general population, which included 1,155 normotensive subjects (43.7% men) who completed the follow-up. Blood pressure measurements (at baseline and follow up) and polygraphy at baseline were performed. Logistic regression models were used to determine the association between the respiratory disturbance index (RDI) and stage 2 hypertension and a recursive partitioning method was used to determine the variables related to the incidence of stage 2 hypertension. The RDI was divided into subgroups (0-2.9, 3-6.9, 7-13.9 and ≥14), using the first subgroup as reference.

Results  For men, an RDI ≥ 14 was associated with a significantly increased odds ratio (OR) for stage 2 hypertension [OR = 2.54 (95% CI 1.09-5.95), p = 0.032]. This association was not statistically significant among women (p = 0.371).

Conclusions  Our results suggest an association between moderate to severe OSA and the incidence of more severe forms of hypertension in men but not in women. However, as this is a community-based study, our women’s population characteristics may differ from women usually seen in sleep-disorders clinics.

original research 
Shiro Mizuno, MD, PhD; Takeshi Ishizaki, MD, PhD; Maiko Kadowaki, MD, PhD; Masaya Akai, MD, PhD; Kohei Shiozaki, MD, PhD; Masaharu Iguchi, MD, PhD; Taku Oikawa, MD, PhD; Ken Nakagawa, MD, PhD; Kazuhiro Osanai, MD, PhD; Hirohisa Toga, MD, PhD; Jose Gomez-Arroyo, MD, PhD; Donatas Kraskauskas, DVM; Carlyne D. Cool, MD; Herman J. Bogaard, MD, PhD; Norbert F. Voelkel, MD
Topics: , , ,

Background  The p53 signaling pathway may be important for the pathogenesis of emphysematous changes in the lungs of smokers. Polymorphism of p53 at codon 72 is known to affect apoptotic effector proteins, and the polymorphism of mouse double minute 2 homolog (MDM2) SNP309 is known to increase MDM2 expression. The aim of this study was to assess polymorphisms of the p53 and MDM2 genes in smokers and confirm the role of SNPs in these genes in the pathogenesis of pulmonary emphysema.

Methods  365 patients with a smoking history were included in this study, and the polymorphisms of p53 and MDM2 genes were identified. The degree of pulmonary emphysema was determined by computed tomography scanning. SNPs, MDM2 mRNA and p53 protein levels were assessed in human lung tissues from smokers. Plasmids encoding p53 and MDM2 SNPs were used to transfect human lung fibroblasts (HLFs) with or without cigarette smoke extract (CSE), and effect on cell proliferation and MDM2 promoter activity were measured.

Results  The polymorphisms of p53 and MDM2 genes were associated with emphysematous changes in the lung, and were also associated with p53 protein and MDM2 mRNA expression in the lung tissue samples. Transfection with a p53 gene-coding plasmid regulated HLFs proliferation, and the analysis of P2 promoter activity in MDM2 SNP309-coding HLFs showed the promoter activity was altered by CSE.

Conclusions  Our data demonstrate that p53 and MDM2 gene polymorphisms are associated with apoptotic signaling and smoking-related emphysematous changes in the lungs from smokers.

original research 
Akira Kuriyama, MD, MPH; Noriyuki Umakoshi, MD; Rao Sun, MD

Background  Corticosteroid administration before elective extubation has been employed to prevent post-extubation stridor and reintubation. We updated a systematic review to identify which patients would benefit from prophylactic corticosteroids before elective extubation.

Methods  We searched PubMed, EMBASE, the Wanfang Database, the China Academic Journal Network Publishing Database, and the Cochrane Central Register of Controlled Trials for eligible trials from inception through February 29, 2016. All randomized controlled trials were eligible if they examined the efficacy and safety of systemic corticosteroids given prior to elective extubation in mechanically ventilated adults. We pooled data using the DerSimonian and Laird random effects model.

Results  We identified 11 trials involving 2472 participants for analysis. Use of prophylactic corticosteroids was associated with a reduced incidence of post-extubation airway events [risk ratio (RR) 0.43, 95% CI 0.29–0.66] and reintubation (RR 0.42, 95% CI 0.25–0.71) compared with placebo or no treatment. This association was prominent in participants at high risk for developing post-extubation airway complications, defined using cuff-leak test, with a reduced incidence of post-extubation airway events (RR 0.34, 95% CI 0.24–0.48) and reintubation (RR 0.35, 95% CI 0.20– 0.64). This association was not found in trials with unselected participants. Adverse events were rare.

Conclusions  Administration of prophylactic corticosteroids before elective extubation was associated with significant reductions in the incidence of post-extubation airway events and reintubation, with few adverse events. It is reasonable to select patients at high risk for airway obstruction who may benefit from prophylactic corticosteroids.

ahead of the curve 
Shinya Tane, MD PhD; Kentaro Noda, PhD; Norihisa Shigemura, MD PhD

Ex vivo lung perfusion (EVLP) promises to be a comprehensive platform for assessment, re-conditioning, and preservation for donor lungs and has been dramatically changing the face of clinical lung transplantation. Besides its increasing role in lung transplantation, EVLP has also been recognized as a useful tool for translational research involving the lungs. Based on recent remarkable evidence and experience using EVLP in lung transplantation, there is growing interest in and expectations for the use of EVLP beyond the field of lung transplantation. By combining EVLP with advances in regenerative medicine, stem cell biology, and oncology, the evolving technology of EVLP has a tremendous potential to advance pulmonary medicine and science. In this review, we revisit recent advances in EVLP technology and research and discuss the future translation of EVLP applications into life-changing medicine.

special features 
Shine Raju, MD; Subha Ghosh, MD; Atul C. Mehta, MD, FACP, FCCP
Topics: ,

Computed tomography (CT) of the chest is one of the most important imaging modalities available to a pulmonologist. The advent of high-resolution CT of the chest has led to its increasing use. While chest radiographs are still useful as an initial test, their utility is limited in the diagnosis of lung diseases which depend on higher resolution images such as interstitial lung diseases and pulmonary vascular diseases. Several metaphorical chest CT signs have been described linking abnormal imaging patterns to lung diseases. Some of these are specific to a disease, while others help narrow the differential diagnosis. Recognizing these imaging patterns and CT signs are thus of vital importance. In the following article, the authors attempt to describe a comprehensive list of the commonly encountered metaphorical chest CT signs and their clinical relevance.

point and counterpoint 
Vivek N. Ahya, M.D., MBA
No abstract is available for this article
point and counterpoint 
Marie Budev, DO, MPH FCCP
No abstract is available for this article
point and counterpoint 
Vivek N. Ahya, M.D., MBA
Topics: , , , ,
No abstract is available for this article
point and counterpoint 
Marie Budev, DO, MPH FCCP
Topics: , , , , , , , ,
No abstract is available for this article
original research 
Maurizio Zanobetti, M.D; Margherita Scorpiniti, M.D.; Chiara Gigli, M.D.; Peiman Nazerian, M.D.; Simone Vanni, M.D.; Francesca Innocenti, M.D.; Valerio T. Stefanone, M.D.; Caterina Savinelli, M.D.; Alessandro Coppa, M.D.; Sofia Bigiarini, M.D.; Francesca Caldi, M.D.; Irene Tassinari, M.D.; Alberto Conti, M.D.; Stefano Grifoni, M.D.; Riccardo Pini, M.D.
Topics: , ,

Background  Acute dyspnea is a common symptom in the emergency department (ED). Standard approach to dyspnea often relies on radiologic and laboratoristic results, causing excessive delay before adequate therapy is started; an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis maintaining an acceptable safety profile.

Methods  Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient: sonographer performed ultrasonography (US) evaluation of lung, heart and inferior vena cava, while treating physician requested traditional tests as needed. Time needed to formulate US and ED diagnosis was recorded and compared. Accuracy and concordance of US and ED diagnosis were calculated.

Results  2683 patients were enrolled. Average time needed to formulate US diagnosis was significantly lower than that required for ED diagnosis (24±10 min vs 186±72 min, p 0.025). US and ED diagnosis showed a good overall concordance (k=0.71). There were no statistically significant differences in the accuracy of PoCUS and standard ED workup for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax and dyspnea from other causes; PoCUS was significantly more sensitive for the diagnosis of heart failure, while standard ED workup performed better in the diagnosis of chronic obstructive pulmonary disease/asthma and pulmonary embolism.

Conclusions  PoCUS represents a feasible and reliable diagnostic approach to the dyspnoic patient, allowing a reduction of the diagnostic time. This protocol could help to stratify patients who should undergo a more detailed evaluation.

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  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543