| PU was useful for the diagnosis in 68% of dyspneic patients in the prehospital setting with no delay in treatment and/or transportation, PE being present in 100% of those with decompensated HF, in 17% of patients with ACS, and in 20% of patients with COPD (p < 0.01), PE thus being a diagnostic marker in patients with decompensated HF.1313 Neesse A, Jerrentrup A, Hoffmann S, Sattler A, Görg C, Kill C, et al. Prehospital chest emergency sonography trial in Germany: a prospective study. Eur J Emerg Med. 2012;19(3):161-6. In the diagnosis of HF on PU, the S = 100% and E = 95% were comparable to those of NT-proBNP (> 1.000 pg/mL), S = 92% and E = 89%, and superior to those of the modified Boston criteria, S = 85% and E = 86%. The combination of PU and NT-proBNP showed S and E of 100%.1818 Prosen G, Klemen P, Štrnad M, Grmec S. Combination of lung ultrasound (a comettail sign) and Nterminal probrain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15(2):R114. Erratum in: Crit Care. 2011;15(6):450.
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Diagnostic assessment of dyspnea in emergency settings (AHF or DCHF)
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Studies reported S ranging from 70% to 96.2% and E from 54% to 75%,2323 Pivetta E, Goffi A, Lupia E, Tizzani M, Porrino G, Ferreri E. Lung ultrasound implemented diagnosis of acute decompensated heart failure in the ED: A SIMEU Multicenter Study. SIMEU Group for Lung Ultrasound in the Emergency Department in Piedmont. Chest. 2015;148(1):202-10.
24 Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E, et al. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) Protocol. Acad Emerg Med. 2015;22(2):182-91.-2525 Gallard E, Redonnet JP, Bourcier JE, Deshaies D, Largeteau N, Amalric JM, et al. Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med. 2015;33(3):352-8.,2727 Anderson KL, Jenq KY, Fields JM, Panebianco NL, Dean AJ. Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med. 2013;31(8):1208-14.,2929 Kajimoto K, Madeen K, Nakayama T, Tsudo H, Kuroda T, Abe T. Rapid evaluation by lung, cardiac and inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting.Cardiovasc Ultrasound. 2012;10(1):49.,3131 Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med. 2009;16(3):201-10. diagnostic reclassification ranging from 19% to 47%,2323 Pivetta E, Goffi A, Lupia E, Tizzani M, Porrino G, Ferreri E. Lung ultrasound implemented diagnosis of acute decompensated heart failure in the ED: A SIMEU Multicenter Study. SIMEU Group for Lung Ultrasound in the Emergency Department in Piedmont. Chest. 2015;148(1):202-10.,2424 Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E, et al. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) Protocol. Acad Emerg Med. 2015;22(2):182-91. with change in treatment in 43% of the cases,2424 Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E, et al. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) Protocol. Acad Emerg Med. 2015;22(2):182-91. figures comparable to those of BNP > 500 (S = 75% and E = 83%).2727 Anderson KL, Jenq KY, Fields JM, Panebianco NL, Dean AJ. Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med. 2013;31(8):1208-14. PU accuracy of 90% versus 67% (p = 0.0001) for clinical examination, and 81% (p = 0.04) for the combination of clinical examination + NT-proBNP + X-ray.2525 Gallard E, Redonnet JP, Bourcier JE, Deshaies D, Largeteau N, Amalric JM, et al. Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med. 2015;33(3):352-8. PU was better for the diagnosis of DCHF (S = 100%) and of PNM (S = 75%) as compared to stethoscope auscultation (S = 89% and S = 73%, respectively).2626 Özkan B, Ünlüer EE, Akyol PY, Karagöz A, Bayata MS, Akoglu H, et al. Stethoscope versus point-of-care ultrasound in the differential diagnosis of dyspnea: a randomized trial. Eur J Emerg Med. 2015;22(6):440-3. Interobserver agreement was better in the anterior/superior thoracic zones for both pairs expert/expert and expert/beginner,1616 Gullett J, Donnelly JP, Sinert R, Hosek B, Fuller D, Hill H, et al. Interobserver agreement in the evaluation of B lines using bedside ultrasound. J Crit Care. 2015;30(6):1395-9. and the PU performed by beginners versus experts had S and E of 79-85% and 84-88%, respectively,1717 Chiem AT, Chan CH, Ander DS, Kobylivker AN, Manson WC. Comparison of expert and novice sonographers' performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome. Acad Emerg Med. 2015;22(5):564-73.,3737 Gustafsson M, Alehagen U, Johansson P. Imaging congestion with a pocket ultrasound device: prognostic implications in patients with chronic heart failure. J Card Fail. 2014;21(7):548-54. and PPV of 64-75% and NPV of 90.9-94%.1717 Chiem AT, Chan CH, Ander DS, Kobylivker AN, Manson WC. Comparison of expert and novice sonographers' performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome. Acad Emerg Med. 2015;22(5):564-73.,2929 Kajimoto K, Madeen K, Nakayama T, Tsudo H, Kuroda T, Abe T. Rapid evaluation by lung, cardiac and inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting.Cardiovasc Ultrasound. 2012;10(1):49. Global agreement with the gold-standard method for pulmonary edema interpretation on PU was 74%, higher than that with X-ray (58%, p< 0.0001).2828 Martindale JL, Noble VE, Liteplo A. Diagnosing pulmonary edema: lung ultrasound versus chest radiography. Eur J Emerg Med. 2013;20(5):356-60. A combination of PU and US of IVC had S = 94.3%, E = 91.9%, NPV = 91.9% and PPV = 94.3% to differentiate AHF from pulmonary disease,2929 Kajimoto K, Madeen K, Nakayama T, Tsudo H, Kuroda T, Abe T. Rapid evaluation by lung, cardiac and inferior vena cava (LCI) integrated ultrasound for differentiating heart failure from pulmonary disease as the cause of acute dyspnea in the emergency setting.Cardiovasc Ultrasound. 2012;10(1):49. and JVD-US is a sensitive test (S = 98.2%) to identify pulmonary edema in dyspneic patients with suspicion of congestive AHF.3030 Jang T, Aubin C, Naunheim R, Lewis LM, Kaji AH. Jugular vein ultrasound and pulmonary oedema in patients with suspected congestive heart failure. Eur J Emerg Med. 2011;18(1):41-5. Studies have shown an LR(+) of PU of 3.88-4.8% and an LR(-) of PU of 0.20-0.50%2424 Russell FM, Ehrman RR, Cosby K, Ansari A, Tseeng S, Christain E, et al. Diagnosing acute heart failure in patients with undifferentiated dyspnea: a lung and cardiac ultrasound (LuCUS) Protocol. Acad Emerg Med. 2015;22(2):182-91.,3131 Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med. 2009;16(3):201-10. for the diagnosis of AHF or DCHF, being higher than the LR(+) of NT‑proBNP [= 2.3] and similar to the LR(-) of NT-proBNP [= 0.24].3131 Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med. 2009;16(3):201-10.
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Diagnostic assessment in intensive care settings (AHF or DCHF)
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| Agreement of PU with the final diagnosis was 84%, with S = 86% and E = 87% for cardiac pulmonary edema,3232 Dexheimer Neto FL, Andrade JM, Raupp AC, Townsend RS, Beltrami FG, Brisson H, et al. Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients. J Bras Pneumol. 2015;41(1):58-64. and IVC values > 9 mm on B mode had S = 84.4% and E = 92.9% [LR(+) = 11.8, LR(-) = 0.16] for the diagnosis of cardiac dyspnea.3333 Yamanoglu A, Çelebi Yamanoglu NG, Parlak I, Pinar P, Tosun A, Erkuran B, et al. The role of inferior vena cava diameter in the differential diagnosis of dyspneic patients, best sonographic measurement method? Am J Emerg Med. 2015;33(3):396-401.
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Diagnostic assessment in outpatient settings
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| Primary outcome (hospitalization due to DCHF and all-cause death) was 4x more frequent in patients of the third tertile than in patients of the first tertile with B-lines ≥ 3 (p < 0.001), whose time alive or outside the hospital was shorter (p< 0.001).3636 Platz E, Lewis EF, Uno H, Peck J, Pivetta E, Merz AA, et al. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. Eur Heart J. 2016:37(15):1244-51. The finding of B-lines or PE or both increased the risk of death or hospitalization (p< 0.05)1919 Gustafsson M, Alehagen U, Johansson P. Pocketsized ultrasound examination of fluid imbalance in patients with heart failure: a pilot and feasibility study of heart failure nurses without prior experience of ultrasonography. Eur J Cardiovasc Nurs. 2015;14(4):294-302. and correlated in a paired way with the estimates of PCWP (p < 0.001) and with the fluid impedance index (p < 0.001); the impedance monitoring alert detected clinical deterioration of HF with S = 92%, while B-lines ≥ 5 showed S = 83%.3535 Maines M, Catanzariti D, Angheben C, Valsecchi S, Comisso J, Vergara G. Intrathoracic impedance and ultrasound lung comets in heart failure deterioration monitoring. Pacing Clin Electrophysiol. 2011;34(8):968-74. HF decompensation was present in 68% of the patients when the number of B-lines ≥ 15, and correlated with NT-proBNP > 1000 (p < 0.0001) and with an E/e’ ratio > 15 (p < 0.0001).3434 Miglioranza MH, Gargani L, Sant'Anna RT, Rover MM, Martins VM, Mantovani A. Lung ultrasound for the evaluation of pulmonary congestion in outpatients: a comparison with clinical assessment, natriuretic peptides, and echocardiography. JACC Cardiovasc Imaging. 2013;6(11):1141-51.
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Prognostic assessment
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| Event-free survival (all-cause death and re-hospitalization) of patients with HF and B-lines ≥ 30 was shorter than that of patients with B-lines < 30 (p < 0.0001) in 3 months1010 Coiro S, Rossignol P, Ambrosio G, Carluccio E, Alunni G, Murrone A, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail. 2015;17(11):1172-81. and of patients with B-lines ≥ 15 in 6 months,1111 Gargani L. Lung ultrasound: a new tool for the cardiologist. Cardiovascular Ultrasound. 2011 Feb 27;9:6. and the presence of B-lines ≥ 30 was a predictor of death with BNP > 700 (p = 0.002).1010 Coiro S, Rossignol P, Ambrosio G, Carluccio E, Alunni G, Murrone A, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail. 2015;17(11):1172-81.
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Therapeutic assessment
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| The number of B-lines reduced with treatment (p < 0.05), and the PU score showed a linear correlation with the radiologic (p < 0.05) and clinical scores (p < 0.05) and with BNP levels (p < 0.05).88 Volpicelli G, Caramello V, Cardinale L, Mussa A, Bar F, Frascisco MF. Bedside ultrasound of the lung for the monitoring of acute decompensated heart failure. Am J Emerg Med. 2008;26(5):585-91.
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Assessment of PU as compared to other diagnostic methods
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| An increase in the number of B-lines correlated with LVEDV (p = 0.036);2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9. LV end-systolic diameter (p = 0.026);2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9. PW (p = 0.009);2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9. LV mass index (p = 0.001);2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9. RA volume index (p = 0.005);2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9. TR velocity (p = 0.005);2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9. measures of RA, DPAP, MPAP, PVR, all p < 0,005,2121 Platz E, Lattanzi A, Agbo C, Takeuchi M, Resnic FS, Solomon SD, et al. Utility of lung ultrasound in predicting pulmonary and cardiac pressures. Eur J Heart Fail. 2012;14(11):1276-84. and SPAP (p = 0.003-0,005),2020 Platz E, Hempel D, Pivetta E, Rivero J, Solomon SD. Echocardiographic and lung ultrasound characteristics in ambulatory patients with dyspnea or prior heart failure. Echocardiography. 2014;31(2):133-9.-2121 Platz E, Lattanzi A, Agbo C, Takeuchi M, Resnic FS, Solomon SD, et al. Utility of lung ultrasound in predicting pulmonary and cardiac pressures. Eur J Heart Fail. 2012;14(11):1276-84. and, for each B-line, there was an increase of 1 mm Hg in SPAP and of 0.1 Woods units in RVP.2121 Platz E, Lattanzi A, Agbo C, Takeuchi M, Resnic FS, Solomon SD, et al. Utility of lung ultrasound in predicting pulmonary and cardiac pressures. Eur J Heart Fail. 2012;14(11):1276-84. In the analysis of the number of B-lines, the US device types used did not statistically differ (4 or 8 zones assessed; p= 0.67),2222 Platz E, Pivetta E, Merz AA, Peck J, Rivero J, Cheng S. Impact of device selection and clip duration on lung ultrasound assessment in patients with heart failure. Am J Emerg Med. 2015;33(11):1552-6. but the clip duration did differ: 4 versus 2 seconds (p < 0.001 for 4 and 8 zones) and 6 versus 4 seconds (p = 0.057 for 4 zones; and p = 0.018 for 8 zones).2222 Platz E, Pivetta E, Merz AA, Peck J, Rivero J, Cheng S. Impact of device selection and clip duration on lung ultrasound assessment in patients with heart failure. Am J Emerg Med. 2015;33(11):1552-6.
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