Papanagnou Dimitrios, Secko Michael, Gullett John, Stone Michael, Zehtabchi Shahriar
Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania.
The State University of New York, Downstate Medical Center, Department of Emergency Medicine, Brooklyn, New York.
West J Emerg Med. 2017 Apr;18(3):382-389. doi: 10.5811/westjem.2017.1.31223. Epub 2017 Mar 3.
Diagnosing acute dyspnea is a critical action performed by emergency physicians (EP). It has been shown that ultrasound (US) can be incorporated into the work-up of the dyspneic patient; but there is little data demonstrating its effect on decision-making. We sought to examine the impact of a bedside, clinician-performed cardiopulmonary US protocol on the clinical impression of EPs evaluating dyspneic patients, and to measure the change in physician confidence with the leading diagnosis before and after US.
We conducted a prospective observational study of EPs treating adult patients with undifferentiated dyspnea in an urban academic center, excluding those with a known cause of dyspnea after evaluation. Outcomes: 1) percentage of post-US diagnosis matching final diagnosis; 2) percentage of time US changed providers' leading diagnosis; and 3) change in physicians' confidence with the leading diagnosis before and after US. An US protocol was developed and standardized prior to the study. Providers (senior residents, fellows, attendings) were trained on US (didactics, hands on) prior to enrollment, and were supervised by an US faculty member. After patient evaluation, providers listed likely diagnoses, documenting their confidence level with their leading diagnosis (scale of 1-10). After US, providers revised their lists and their reported confidence level with their leading diagnosis. Proportions are reported as percentages with 95% confidence interval (CI) and continuous variables as medians with quartiles. We used the Wilcoxon signed-rank test and Cohen's kappa statistics to analyze data.
A total of 115 patients were enrolled (median age: 61 [51, 73], 59% female). The most common diagnosis before US was congestive heart failure (CHF) (41%, 95%CI, 32-50%), followed by chronic obstructive pulmonary disease (COPD) and asthma. CHF remained the most common diagnosis after US (46%, 95%CI, 38-55); COPD became less common (pre-US, 22%, 95%CI, 15-30%; post-US, 17%, 95%CI, 11-24%). Post-US clinical diagnosis matched the final diagnosis 63% of the time (95%CI, 53-70%), compared to 69% pre-US (95%CI, 60-76%). Fifty percent of providers changed their leading diagnosis after US (95%CI, 41-59%). Overall confidence of providers' leading diagnosis increased after US (7 [6, 8]) vs. 9 [8, 9], p: 0.001).
Bedside US did not improve the diagnostic accuracy in physicians treating patients presenting with acute undifferentiated dyspnea. US, however, did improve providers' confidence with their leading diagnosis.
诊断急性呼吸困难是急诊医生（EP）的一项关键工作。已有研究表明，超声（US）可用于呼吸困难患者的检查；但几乎没有数据表明其对决策的影响。我们旨在研究床边临床医生实施的心肺超声方案对评估呼吸困难患者的急诊医生临床印象的影响，并测量超声检查前后医生对主要诊断的信心变化。
我们在一家城市学术中心对治疗未分化型成人呼吸困难患者的急诊医生进行了一项前瞻性观察研究，排除评估后已知呼吸困难原因的患者。结果：1）超声检查后诊断与最终诊断相符的百分比；2）超声改变医生主要诊断的时间百分比；3）超声检查前后医生对主要诊断信心的变化。在研究前制定并标准化了超声方案。在入组前，对医疗人员（高级住院医师、研究员、主治医生）进行了超声培训（理论教学、实践操作），并由一名超声教员进行监督。在对患者进行评估后，医疗人员列出可能的诊断，并记录他们对主要诊断的信心水平（1 - 10分制）。超声检查后，医疗人员修改他们的诊断列表以及报告的对主要诊断的信心水平。比例以百分比及95%置信区间（CI）报告，连续变量以中位数及四分位数报告。我们使用Wilcoxon符号秩检验和Cohen's kappa统计量来分析数据。
共纳入115例患者（中位年龄：61岁[51, 73]，59%为女性）。超声检查前最常见的诊断是充血性心力衰竭（CHF）（41%，95%CI，32 - 50%），其次是慢性阻塞性肺疾病（COPD）和哮喘。超声检查后CHF仍然是最常见的诊断（46%，95%CI，38 - 55%）；COPD变得不那么常见（超声检查前，22%，95%CI，15 - 30%；超声检查后，17%，95%CI，11 - 24%）。超声检查后的临床诊断与最终诊断在63%的时间内相符（95%CI，53 - 70%），而超声检查前为69%（95%CI，60 - 76%）。50%的医疗人员在超声检查后改变了他们的主要诊断（95%CI，41 - 59%）。超声检查后医疗人员对主要诊断的总体信心增加（7[6, 8]）与9[8, 9]，p：0.001）。
床边超声并未提高治疗急性未分化型呼吸困难患者的医生的诊断准确性。然而，超声确实提高了医疗人员对其主要诊断的信心。
