UP foi útil para o diagnóstico em 68% dos pacientes dispneicos pré-hospitalar sem atraso no tratamento e/ou transporte, onde a presença de DP em pacientes com IC descompensada foi de 100%, em pacientes com SCA (17%) e em pacientes com DPOC (20%; p < 0,01), sendo o DP marcador diagnóstico em pacientes com IC descompensada.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. Sensibilidade de 100% e especificidade de 95% para o diagnóstico de IC pela UP foram comparáveis às do NT-próBNP (> 1,000 pg/mL), S = 92% e E = 89%, e superior às dos critérios de Boston modificado: S = 85% e E = 86%. A combinação de UP e NT-próBNP teve S e E de 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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Avaliação diagnóstica de dispneia na emergência (ICA ou ICCD)
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Estudos apresentaram S variando de 70% a 96,2% e E de 54% a 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. sendo que a reclassificação diagnóstica variou de 19% a 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. havendo mudança de tratamento em 43%,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. com valores comparáveis aos do BNP > 500 (S = 75% e 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. Acurácia de 90% da UP versus 67% (p = 0,0001) para exame clínico, e acurácia de 81% (p = 0,04) para a combinação de exame clínico, NT-próBNP e raioX.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. A UP foi superior para o diagnóstico de ICCD com S = 100% e de PNM com S = 75% comparada ao estetoscópio (S = 89% e S = 73%, respectivamente).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. A concordância interobservador foi melhor nas zonas torácicas anterior/superior, por ambos os pares perito/perito e perito/iniciante,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. sendo que a UP feita por iniciantes versus especialista teve S e E de 79-85% e 84-88%, respectivamente,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. VPP de 64-75% e VPN de 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. A concordância global com o padrão-ouro na interpretação de edema pulmonar na UP foi 74%, superior à do raioX (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. UP e US de VCI integradas apresentou S= 94,3%, E= 91,9%, VPN= 91,9% e VPP= 94,3% para diferenciar ICA de doença pulmonar,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. e a DVJ-US é teste sensível (S = 98,2%) para identificar edema pulmonar em pacientes dispneicos com suspeita de ICA congestiva.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. Estudos revelaram LR(+) da UP de 3,88-4,8% e LR(-) da UP de 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. para um diagnóstico de ICA ou ICCD, sendo superior à LR(+) do NT-próBNP [= 2,3] e semelhante à LR(-) do NT-próBNP [= 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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Avaliação diagnóstica na terapia intensiva (ICA ou ICCD)
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Concordância da UP com diagnóstico final foi de 84%, tendo o edema pulmonar cardiogênico S = 86% e E = 87%,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. e valores de VCI > 9 mm, no modo-B, tiveram S = 84,4% e E = 92,9% [LR(+) = 11,8, LR(-) = 0,16] para diagnóstico de dispneia cardiogênica.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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Avaliação diagnóstica ambulatorial
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O desfecho primário (internação por ICCD e morte por todas as causas) ocorreu 4x mais nos pacientes no terceiro tercil do que nos pacientes no primeiro tercil com ≥ 3 linhas B (p < 0,001), que ficaram menos tempo vivos e menos dias fora do hospital (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. O achado de linhas B ou DP ou ambos aumentou o risco de morte ou hospitalização (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. e correlacionou-se de forma pareada com as estimativas de PCAP (p < 0,001) e com o índice de impedância de fluidos (p < 0,001); o alerta de impedância detectou deterioração clínica de IC com S = 92% e ≥ 5 linhas B mostrou 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. A descompensação da IC esteve presente em 68% dos pacientes quando o número de linhas B foi ≥ 15, tendo correlação com o NT-próBNP > 1000 (p< 0,0001) e a relação E/e’ > 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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Avaliação prognóstica
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A sobrevida livre de eventos (morte por todas as causas ou reinternação) em pacientes com IC e com ≥ 30 linhas B foi menor que em pacientes com < 30 linhas B (p < 0,0001) em 3 meses1010 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. e em pacientes com ≥ 15 linhas B em 6 meses,1111 Gargani L. Lung ultrasound: a new tool for the cardiologist. Cardiovascular Ultrasound. 2011 Feb 27;9:6. sendo que um número ≥ 30 linhas B foi preditor de morte juntamente com 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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Avaliação terapêutica
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Houve redução do número de linhas B com o tratamento (p < 0,05), havendo correlação linear do escore da UP com o escore radiológico (p < 0,05), o escore clínico (p < 0,05) e o nível de BNP (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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Avaliação da UP em comparação com outros métodos diagnósticos
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Achado de aumento de linhas B correlacionou-se com VDFVE (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. diâmetro sistólico final VE (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. PP (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.; índice massa VE (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. índice volume AE (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. velocidade da RT (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. medida de AD, PDAP, PAPM, RVP, todos 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. e PSAP (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. e, para cada linha B, houve aumento de 1 mmHg na PSAP e 0,1 ui Woods na 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. Não houve diferença estatística na análise de número de linhas B entre os tipos de aparelhos de US usados, seja 4 ou 8 zonas avaliadas (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. mas houve diferença na duração do clip 4 versus 2 segundos (p < 0,001 para 4 e 8 zonas) e clip 6 versus 4 segundos (p = 0,057 para 4 zonas e p = 0,018 para 8 zonas).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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