Pierre Kory, MPA, MDChief, Critical Care Service

Medical Director, Trauma & Life Support CenterAssociate Professor of Medicine

Univ. of Wisconsin School of Medicine and Public Health

September 22, 2015

Diagnostic Errors

Increasing attention in both lay press and medical literature 12 million Americans/year with “wrong diagnosis” (5%)

○ Missed Diagnosis○ Delayed Diagnosis○ Wrong Diagnosis

CHF and Pneumonia most common erroneous diagnoses

Singh H et al. Diagnostic Errors JAMA 2015

DIAGNOSTIC ACCURACY IN DYSPNEA 25% chance of choosing from the “BIG FOUR”.. Pulmonary Edema, Pneumonia, COPD/Asthma, Pulmonary Embolism

ACCURACY INITIAL DIAGNOSIS IN EMERGENCY DEPT Ray P, 2006 – 20% missed diagnosis in elderly a/w dyspnea Bellone M, 2013 – 56.6% accuracy in ED pts with dyspnea Goffi A, 2013 - .26 kappa with final diagnosis in Dyspnea Pirozzi C, 2014 - 50% incorrect initial diagnosis of dyspnea Laursen – 14% of pts had missed life-threatening diagnosis Filopei, 2014 - Clinical diagnosis AUC = .81 (.87 with sono)

ACCURACY OF INITIAL DIAGNOSIS IN INTENSIVE CARE UNIT SILVA - 63% accurate initial diagnosis by 2 expert ICU docs

Ray P, et al. Critical Care, 2006 Pirozzi C, Crit Ultrasound J, 2014 Bellone M, Emerg Care J, 2013 Silva L, Chest 2013Goffi A, Critical Care, 2013 Laursen , Chest 2013

Is a routine CT chest the answer?

319 pts- suspicion of CAP by History and CXR Established probability of CAP pre/post CT scan ***33% of pts with an opacity on CXR:

EXCLUDED by CT scan ***33% of patients without an opacity on CXR:

DEFINITE by CT scan 59% of patients probability of CAP reclassified

Definite, probable, possible, excluded

CT scan excluded CAP in 29% of patients Antibiotics were discontinued in only 9%...?

“CAP presents an extensive clinical and radiographic spectrum – beyond interpretation difficulties and inter observer discordance, CXR seemed, in a large number of cases, to inadequately guide ED physicians, leading toward inappropriate decisions on both diagnosis and antimicrobial therapy for CAP suspected patients..”

Lung Ultrasound: Superior Imaging Modality for the ICU?

Lichtenstein, Anesthesiology, 2004Xirouchaki, Crit Care Med 2011Collins SP, Ann Emerg Med 2006

Chest X-rays LIE Obscure pathology/Reveal non-specific opacities 19% of CHF REGISTRY (ADHERE) with clear

CXR○ 23% received a non-CHF diagnosis

CT Scans – miraculous!! …but impractical LUS – Superior to CXR for PTX, interstitial

syndrome, consolidations, pleural effusion…

This Morning’s News…

• 200 patients, mean age 84, suspected to have pneumonia• Received CXR – clinician documented probability of pneumonia• Underwent CT scan –radiologist documented probability of pneumonia,

clinician incorporated this assessment and made decision to stop/start ABX• Probability changed in 45% of patients (30% downgraded, 15% upgraded• 80% of the “intermediate probability” patients had estimate changed

• Gold standard was diagnosis made by adjudication committee done after discharge, using all data available

• CT correctly ruled out PNA in 29 patients, correctly ruled in 6 patients• CT incorrectly ruled out PNA in 1 patient, incorrectly ruled in 18 patients

• ** Statistician estimated “true” incidence of pneumonia in a patient hospitalized for pneumonia to be 45%

Alternatives to CXR or CT scan?

Is there a “Superman” Diagnostic Test? As fast as a stethoscope.. More accurate than chest x-ray.. Less costly than CT..

IMPROVING DIAGNOSTIC ACCURACY IN ACUTE LUNG DISEASE:

THE ROLE OF LUNG ULTRASOUND

Accuracy of Lung Ultrasound Vs. Chest X-Ray in Diagnosis of Pneumonia

N SensitivityLUS

SensitivityCXR

SpecificityLUS/CXR

Lichtenstein, ‘97 32 97% 75% N/AXirouachki, ‘11 42 100% 38% 78%/89%Boucier’ 13 144 95% 60% 57%/76%Liu, 14 179 95.6% 77.7% 98.5%/94%Reissig’ 12 326 93.4% NA 97.7%/N/AParlamento ‘ 09 49 97% 75% N/ACortellaro ‘ 12 120 98% 67% 95%/85%

Lichtenstein, Anesthesiology, 2004Xirouchaki, Int Care Med, 2011Boucier, 2013Liu, Lung 2014Reissig, Chest, 2012Parlamento, Crit Care Med 2009Cortellaro, 2012

Chavez MA, Respiratory Research, 2014-Meta-Analysis, 10 studies in AdultsPooled Sens/Spec – 94%/96%Area under ROC= .99

LUS in ICU: Comparison with CXR Xirouachki, Int Care Med, 2011 37:1488-93)

Prospective comparison study of LUS vs. CXR N = 42 pts (84 hemithorax) on MV ordered for CT chest All received simultaneous CXR and LUS

Study results

Xirouachki, Int Care Med, 2011 37:1488-93

Sensitivity(LUS/CXR)

Specificity(LUS/CXR)

Diagnostic Accuracy(LUS/CXR)

Interstitial Syndrome

94/46 93/80 94/58

Consolidation 100/38 78/89 95/49

Pleural Effusion 100/65 100/81 100/69

Pneumothorax 75/0 93/99 92/89

Learning Objectives/Agenda

Recognize Challenges in Diagnosis of Dyspnea/ARF Consider Diagnostic Accuracy as a Core QI Measure?

Overview of Lung Ultrasound (LUS) – 5 Main Lung Ultrasound Patterns Evaluate Evidence Supporting LUS in Improving Diagnostic Accuracy

Diagnostic Capability of LUS vs. CXR vs. CT scan Role of LUS in Diagnosing:

○ PNA PTX APE PULM EMBOLISM DYSPNEA Review Evidence for Heart/Lung Ultrasound in Acute Respiratory Failure Propose Method of Integrating Training/Use of Thoracic Ultrasound in

Management of Cardiopulmonary Failure

DIAGNOSIS OF ACUTE DYSPNEA/ACUTE RESPIRATORY FAILURE (ARF) Challenging diagnostic problem

Life-threatening vs. worried well Poor discriminatory tests in adults (esp. elderly) Co-existing signs/symptoms overlap

○ “Cardiac” wheeze, CXR opacities, common RF’s Causes often treatable – why tests are important

Diagnostic uncertainty common - pts often given multiple and rapidly changing treatments Value of H&P, CXR, lab tests? “SLIRPP” syndromic approach??

○ Steroid/ Imipenem/ Lasix Responsive Pneumonic Process

Schmitt, BP et al. J Gen Int Med, 1986Pearson, SB et al. Lancet 1980

IMPACT OF INACCURATE INITIAL THERAPY FOR DYSPNEIC PATIENTS Study Design

Retrospective - 493 pts treated by 3 paramedic units Compared pts treated with CHF medicines vs. those not

treated for CHF (all got 02 ) Study Results

“Final Diagnosis” CHF Pts: Decreased mortality!○ 6.7% vs 15.4%, despite more “critical pts” among treated

“Final Diagnosis” COPD Pts: worse outcomes if Rx for CHF vs. no-Rx○ 13.8% vs 3.8% (if treated with bronchodilators instead) ○ 8.3% mortality for COPD pts not treated for CHF (p<.01)

Wuerz, RC. Ann Emerg Med, 1992

HARMS OF INACCURATE DIAGNOSIS AND THERAPY

Ray P et al. Critical Care, 2006 Assessed accuracy of diagnosis in elderly patients with dyspnea Found inappropriate treatment in 32%

○ Worsened mortality if inappropriately treated: 25% vs 11%

Singer AJ. Ann Emerg Med, 2008 ADHERE Registry – 10,978 pts with confirmed diagnosis of CHF 7,299 patients with no history of COPD 2,317 of these patients received bronchodilators in ED

○ Required mechanical ventilation more often (6% vs. 2%)○ Admitted to ICU more often (17% vs 11%)○ Required IV vasodilators more often (28% vs. 16%)

COPD/CHF pts who got bronchodilators – no difference in outcome

HARMS OF INAPPROPRIATE PNA TREATMENT IN CHF PATIENTS

Maisel AS, J Am Coll Card, 2010

Maisel AS, J Am Coll Card, 2010

HARMS OF INAPPROPRIATE PNA TREATMENT IN CHF PATIENTS

“Improving” Diagnostic Accuracy On Back Burner of Safety Agenda?

Diagnostic errors/faults in reasoning – few studies in literature Leading type of malpractice claim High on list of patient reported failures in health care

Diagnostic Reasoning Highly Error Prone Relies on human memory Idiosyncratic - widespread practice variations

○ 2 NYC hospitals with 4.5% and 12.5% (+) CTPA No guidelines on how to best diagnose dyspnea

○ ”Dyspnea Panel”? - BNP, Trop, D-dimer, Procalcitonin, PF/EtC02, FeNO

Lack of systematic feedback systems on our diagnostic reasoning/accuracy

Schiff GD. Acad Med, 2012Mueller C, NEJM, 2004Zwann L, Acad Med, 2012Oks M, Chest, 2014Schissler, AJ PLoS One, 2013

BENEFITS OF IMPROVED TESTING STRATEGY - LANDMARK BNP TRIAL Study Design

Prospective RCT of 452 pts a/w dyspnea to ED Compared group diagnosed using BNP vs. group

diagnosed using traditional approach/tests

Study Results Hospitalization – 74% vs 85% (p<.01) Intensive care – 15% vs 24% (p<.01) LOS – 8 days vs. 11 days (p<.001) Cost - $5410 vs. $7254 (p<.01) Mortality - 10% vs 12% (NS)

Mueller C, NEJM, 2004

Hardeep Singh, 2015

“But, as of now, we don’t have well developed mechanisms for doctors to get feedback on the accuracy of their diagnosis and information about the ones they get wrong..”

DIAGNOSTIC ACCURACY – A “CORE” QUALITY MEASURE?

Quality Health Care/Quality Improvement Degree that a health service increases the likelihood of

a desired outcome

Current Quality Measures for Doctors? Complications/Billing? Malpractice Claims? Referrals?

Funding? Publications?

Quality Measures In Other Professions….?

MEASURING THE QUALITY OF A DOCTOR

Current Quality Measures? Grant funding/publications/Rvu’s Health grades/avatar Complication rates Billing? Malpractice Claims?

Referrals? Top Doctors Ranking?

DIAGNOSTIC ACCURACY – A “CORE” QUALITY MEASURE?

QUARTERBACK RATING (QBR) = QBR = Comp/Att + Yds/Att + TD/Att – INT/Att

___________________________________ICU Attending Rating (IAR) IAR= IDA/(TTO*NDTI)

○ IDA = Initial Diagnostic Accuracy○ TTO = Total Tests Ordered ○ NDTI= Number of Discrete Therapies Initiated

CRITICAL CARE SERVICE – UW

CRITICAL CARE SERVICE MD’s - UW

Learning Objectives/Agenda

Recognize Challenges and Harms in Diagnosis of Dyspnea/ARF Consider Diagnostic Accuracy as a Core QI Measure?

Overview of Lung Ultrasound (LUS) – 5 Main Lung Ultrasound Patterns Evaluate Evidence Supporting LUS in Improving Diagnostic Accuracy

Diagnostic Capability of LUS vs. CXR Role of LUS in Diagnosing:

○ PNA PTX APE PULM EMBOLISM DYSPNEA Review Evidence for Heart/Lung Ultrasound in Acute Respiratory Failure Propose Method of Integrating Training/Use of Thoracic Ultrasound in

Management of Cardiopulmonary Failure

LUNG ULTRASONOGRAPHY “Discovered” by Dr. Daniel Lichtenstein, Parisian intensivist

“Pleural Line” Ultrasonography?

Traditional Insights by Radiologists: Air scatter reflects ultrasound waves

○ Cannot “see” past an air barrier ○ Lungs are filled with air○ Lungs not amenable to ultrasound imaging!

Novel Insights by Dr. Lichtenstein Can “see” the pleural line in everyone Pleural line changes with underlying pathology

○ >90% of causes of ARF involve the pleural surface Can “see” lung that is sick (filled with fluid or devoid of air)

The Lung Signatures: Air-Fluid ratios

Lichtenstein, Crit Care Med, 2007

Miracle of lung ultrasound is founded upon:• NORMAL Intralobular septal width (4 microns) is “just” below resolution of ultrasound• Intralobular septa widens in many pathologic conditions – then “seen” as B lines

Lung Ultrasound Signs• Sliding Lung – visceral and parietal pleura sliding against each other• A Lines – reverberation artifact caused by air beyond pleural surface• B lines –artifact caused by widened interlobular septa • Alveolar Consolidation Pattern – airless/fluid filled lung• Pleural Effusion – anechoic space above diaphragm, surrouns lung

Pleural line

A line

Rib leaves an acoustic shadow

•Hyperechoic•Reflects interface between soft tissues & lung tissue

•An artifact parallel to the pleural line

STANDARD LUNG VIEW

Rib

Sliding Lung

2 layers of pleuraSeen as 1 layer

The Pleural Line and Lung Sliding: Explained

Pneumothorax: what will we see?

Why pneumothorax results in loss of lung sliding parietal pleura

visceral pleuraintrapleural air

ABSENCE LUNG SLIDING

Sliding Lung

Lung Point

A lines

B Lines

Alveolar Consolidation

Pleural Effusion

“3 POINT” LUNG ULTRASOUND EXAM

POINT1

POINT 2

POINT 3

THE BLUE PROTOCOL 2008

Lung Ultrasound Profiles

Lung Ultrasound Patterns –Differentiating the “Big 4”

Learning Objectives/Agenda

Recognize Challenges and Harms in Diagnosis of Dyspnea/ARF Consider Diagnostic Accuracy as a Core QI Measure?

Overview of Lung Ultrasound (LUS) – 5 Main Lung Ultrasound Patterns Evaluate Evidence Supporting LUS in Improving Diagnostic Accuracy

Diagnostic Capability of LUS vs. CXR Role of LUS in Diagnosing:

○ PNA PTX APE PULM EMBOLISM DYSPNEA Review Evidence for Heart/Lung Ultrasound in Acute Respiratory Failure Propose Method of Integrating Training/Use of Thoracic Ultrasound in

Management of Cardiopulmonary Failure

Lung Ultrasound: Superior Imaging Modality for the ICU?

Lichtenstein, Anesthesiology, 2004Xirouchaki, Crit Care Med 2011Collins SP, Ann Emerg Med 2006

Chest X-rays LIE Obscure pathology/Reveal non-specific opacities 19% of CHF REGISTRY (ADHERE) with clear

CXR○ 23% received a non-CHF diagnosis

CT Scans – miraculous!! …but impractical LUS – Superior to CXR for PTX, interstitial

syndrome, consolidations, pleural effusion…

LUS in ICU: Comparison with CXR Xirouachki, Int Care Med, 2011 37:1488-93)

Prospective comparison study of LUS vs. CXR N = 42 pts (84 hemithorax) on MV ordered for CT chest All received simultaneous CXR and LUS

Study results

Xirouachki, Int Care Med, 2011 37:1488-93

Sensitivity(LUS/CXR)

Specificity(LUS/CXR)

Diagnostic Accuracy(LUS/CXR)

Interstitial Syndrome

94/46 93/80 94/58

Consolidation 100/38 78/89 95/49

Pleural Effusion 100/65 100/81 100/69

Pneumothorax 75/0 93/99 92/89

LUS vs CXR in ARDS: Lichtenstein D, Anesthesiology, 2004

Prospective comparison study of auscultation vs LUS vs. CXR

N = 42 pts (384 lung regions) – healthy and ARDS All received Chest CT Study results

Sensitivity(LUS/CXR/Aus)

Specificity(LUS/CXR/Aus)

Diagnostic Accuracy(LUS/CXR/Aus)

Interstitial Syndrome

98/60/34 88/100/90 95/72/55

Consolidation 93/68/8 100/95/100 97/75/36

Pleural Effusion 92/39/42 93/85/90 93/47/61

Accuracy of Lung Ultrasound Vs. Chest X-Ray in Diagnosis of Pneumonia

N SensitivityLUS

SensitivityCXR

SpecificityLUS/CXR

Lichtenstein, ‘97 32 97% 75% N/AXirouachki, ‘11 42 100% 38% 78%/89%Boucier’ 13 144 95% 60% 57%/76%Liu, 14 179 95.6% 77.7% 98.5%/94%Reissig’ 12 326 93.4% NA 97.7%/N/AParlamento ‘ 09 49 97% 75% N/ACortellaro ‘ 12 120 98% 67% 95%/85%

Lichtenstein, Anesthesiology, 2004Xirouchaki, Int Care Med, 2011Boucier, 2013Liu, Lung 2014Reissig, Chest, 2012Parlamento, Crit Care Med 2009Cortellaro, 2012

Chavez MA, Respiratory Research, 2014-Meta-Analysis, 10 studies in AdultsPooled Sens/Spec – 94%/96%Area under ROC= .99

LUS vs. CXR for Diagnosis of PTX– 4 Meta-Analyses

N # of Studies

SensitivityLUS

SensitivityCXR

Specificity LUS/CXR

Wilkerson, 2010 606 4 86-98% 28-75% 97-100/100Ding, 2011 7569 20 89% 52% 99/100Alrajhi, 2012 1048 8 90.9% 50.2% 98.4/99.4Alrajab, 2013 1548 13 78.6% 39.8% 98.4/99.2

ACCURACY OF LUS IN ACUTE RESPIRATORY FAILURE – THE “BLUE” PROTOCOL Study Design

260 patients newly admitted to ICU LUS/DVT exam by “clinically blinded” sonographer Exam performed within 20 min (lasted <3min)

Study Result LUS/DVT exam correct in 90.5% of cases

○ SENSITIVITY/SPECIFICITY COPD/ASTHMA – 87%/97% PULMONARY EDEMA – 97%/95% PULMONARY EMBOLISM – 81%/99% (added a DVT study) PNEUMONIA - 89%/94%

Lichtenstein, D, Chest, 2008

Accuracy of LUS for Diagnosis of Acute Pulmonary Edema Study Design

Trained 2 ED nurses in LUS (3 hours theoretical, hands-on with 60 patients)

Nurses triaged 96 consecutive patients with dyspnea into cardiac (B profile) vs. non-cardiac causes

Final Diagnosis established by blinded ED physicians Study Results

47 patients deemed “cardiac”, 49 “non-cardiac”○ Nurse 1 sens/spec = 95%/96%○ Nurse 2 sens/spec = 100%/100%

Unluer E, Int Emerg Nursing, 2014

LUS and BNP for CHF – ETUDES STUDY

STUDY DESIGN Prospective, observational, convenience sample 101 ED patients presenting with dyspnea 8 Point LUS and a BNP level were done “Positive” LUS for CHF if Inf-Lat B lines bilaterally

STUDY RESULTS +LR for LUS = 4.73 -LR for LUS = 0.3 +LR for BNP = 2.3 -LR for BNP = .24 +LR for both = 8.04 -LR for both = .11

Liteplo AS et al. Acad Emerg Med, 2009

LUNG ULTRASOUND IN DIAGNOSIS AND MANAGEMENT OF ACUTE PULMONARY EDEMA

STUDY DESIGN Prospective RCT – 128 ED pts with signs APE Standard Group – CXR, biomarkers, diuretics Ultrasound Group – assessed LVEF, IVC, LUS

STUDY RESULTS Ultrasound Group

○ Shorter time to diagnosis, less fluid infusions, shorter ICU stay, faster return to normal biomarkers

○ Same LOS and mortality

Wang XT, J Ultrasound Med 2014

LUNG ULTRASOUND IN THE DIAGNOSIS OF DYSPNEA

Study Design 50 adult patients to ED with undifferentiated dyspnea Compared clinical (pre-LUS) with post-LUS diagnosis

○ Clinical: History and Physical, CXR, Blood Tests Reference Diagnosis by expert “blinded” chart review

Study Results Diagnostic Agreement with Reference Diagnosis

○ Clinical Approach: kappa = .26 (“poor-fair”)○ LUS Approach: kappa = .81 (“excellent”) LUS changed management in 58% cases

Goffi A. Critical Care , 2013

LUNG/HEART/DVT ULTRASOUND IN DIAGNOSIS OF ACUTE RESPIRATORY FAILURE

Study Design Prospective, randomized trial in 186 ED pts with severe dyspnea Group 1 – Immediate lung/heart/DVT exam with CXR, labs, EKG Group 2 – Delayed lung/heart/DVT exam (one hour later) Initial diagnoses in each group compared with final diagnoses

Study Results Group 1 - .94 kappa (5% wrong diagnosis) Group 2- .22 (50% wrong diagnosis)

○ Accuracy increased to .95 after LUS

Pirozzi C, Critical Ultrasound Journal, 2014

STUDY DESIGN Prospective study of 78 ICU pts with ARF “Standard” Diagnostic Approach: 2 Senior Academics used

H&P, CXR, ABG, ECG, Troponin, BNP “Ultrasound” Approach – 2 sono-intensivists without any

clinical info, performed “Heart/Lung/DVT” U/S exam STUDY RESULTS

Accuracy of standard approach was 63% Accuracy of ultrasound-only approach was 83% (p<.02)

Silva S, Chest, 2013

HEART/LUNG ULTRASOUND IN ACUTE RESPIRATORY FAILURE

Study Design Retrospective, controlled study of 228 pts with ARF

○ U/S GROUP: 108 pts w/ heart/lung u/s on admission○ CONTROL: 120 pts without ultrasound exam on admit (no machine or sonographer available)

Study Results Initial diagnosis correct in 90.7% ultrasound group Initial diagnosis correct in 56.6% control group Mortality difference!!!

○ 5% vs 2.7% (p<.01)

Bellone A, Emergency Care, 2013

OUTCOMES OF CRITICAL CARE ULTRASOUND – REDUCTION IN IMAGING TESTS

Peris A et al, Anaesth Analg, 2010 Introduced LUS to a group of intensivists. Measured CXR

and CT scans use 3 months before and after LUS training○ CT’s: 274 to 135 ( 50% decrease)○ CXR’s: 803 to 589 (40% decrease)○ *trend to a lower LOS, lower days on ventilator”

Oks M et al, Chest, 2014 Compared radiology tests between North Shore ICU (no

diagnostic U/S) and Long Island Jewish (heavy U/S use)○ 3.75 CXR/pt vs. 0.82 CXR/pt ( p<.05) ○ .1 CT/pt vs.04 CT/pt (p<.05) ○ .17 CT abdo/pt vs. .05 CT Abdo/pt (p<.05)

First Textbook covering all aspects of POCUS – print and electronic/IPAD version….

SUMMARY Point-of-Care Ultrasound in Cardiopulmonary failure

SHOCK: Current standard of practice for differentiating shock states (the Swan died)○ Image acquisition: steep learning curve for obtaining

interpretable images○ Image Interpretation: Clinicians can achieve high accuracy in

qualitative chamber function assessments○ Clinical Application of findings: core of medical practice

ACUTE RESPIRATORY FAILURE:○ Highly accurate test for diagnosis– approaches accuracy of CT

scan in this condition “poor man’s CT scan”○ Highly underutilized in my opinion

There are Endless Uses for Ultrasound in Both Critical Care and Pulmonary Practice

Differentiating Cardiogenic vs. Non-Cardiogenic Pulmonary Edema Ruling out out Pulmonary Embolism as cause of shock/hypoxemia/dyspnea Evaluation of full stomach pre-intubation Evaluation for ischemic bowel – absence/presence of peristalsis Rule out of obstructive uropathy Evaluation for free fluid in abdomen Transthoracic needle biopsies of ANY pleural or peripheral lung based mass Chest tube placement into loculated pleural effusions ECMO catheter placement Hemidiaphragm function assessments Extubation planning and quantification of lung water Screening for elevated intracranial pressure

And the list grows..

LUNG AND HEART ULTRASOUND FOR EVALUATION OF PULMONARY EMBOLUS

Grifoni, Chest 2013 357 consecutive pts in 3 ED’s, Wells>4 or + D-dimer Heart, Lung, DVT study BEFORE CTPA PE diagnosis: Subpleural consolidation, DVT, RV

dilation PE not diagnosed if alternative explanation found Sono: 90% sensitive, 86% specific If no PE on sono, + alt dx, - Ddimer:

○ No patient had a PE Studies done by 13 MD’s – 4 residents 50% of CTPA’s could have been avoidedby focused DVT study alone

“SPEED” Study – Sonographic Assessment for Pulmonary Embolism in Patients with Dyspnea

Koenig S et al. Chest 2014 Sono-intensivists went down to ED and did a blinded

U/S exam on consecutive ED pts going for CTPA IF: alternative diagnosis, normal RV, or DVT found:

CTPA not recommended IF: no alternative diagnosis nor DVT found – CTPA

indicated 96 total patients: 12% had PE 56% deemed “alternative” diagnosis (NONE HAD PE) 58% of CTPA’s could have been avoided 100% of “alternative” diagnoses were concordant with

CT scan… ○ All relied solely on lung ultrasound and not echo!!

Learning Objectives/Agenda

Recognize Challenges and Harms in Diagnosis of Dyspnea/ARF Consider Diagnostic Accuracy as a Core QI Measure?

Overview of Lung Ultrasound (LUS) – 5 Main Lung Ultrasound Patterns Evaluate Evidence Supporting LUS in Improving Diagnostic Accuracy

Diagnostic Capability of LUS vs. CXR Role of LUS in Diagnosing:

○ PNA PTX APE DYSPNEA/ ARF Review Evidence for Heart/Lung Ultrasound in Acute Respiratory Failure A Method for Integrating Training/Use of Ultrasound in Management of

Cardiopulmonary Failure

INTEGRATION OF CRITICAL CARE ULTRASONOGRAPHY SKILLS TRAINING INTO PCCM CURRICULUM USING WIRELESS ARCHIVED, CLOUD BASED TRAINING PROGRAM Program Components:

3 Day Intensive Course for all 1st Yr Fellows - July Mandated saving of protocolized exam image sets

by fellows (attendings?) Mandated Point-of-Care Interpretation Report Form

Completion Automatic Wireless Upload to Qpath database

management system Regular Over-Reading of CCUS exams by Trained

faculty ○ Detailed feedback on image acquisition,

interpretation, and clinical application

Mandated saving of protocolized image sets by fellows during exams of critically ill patients

Fellows immediately record their exam interpretation using a structured GCCUS report form

Regular over-reading and feedback on uploaded studies by an attending trained in GCCUS

Feedback reviewed by Pulmonary & Critical Care Fellows

FUTURE OF LUNG IMAGING?

GE Advertisement in Magazine

SUMMARYROLE OF ULTRASOUND IN DIAGNOSING ARF Strengths

Superior test performance compared to clinical/ CXR ○ **When performed by “highly trained/expert” A MAJOR LIMITATION OF THE EVIDENCE

Improves INITIAL diagnostic accuracy (thus outcome?) ○ A “Poor Man’s” CT scan?

Weaknesses MD/RN must acquire - time/equipment constraints

○ Acquisition challenges in obese/supine Should we train sonographers (RDMS) to do it for us? Critical Care Ultrasonographer Covering All Units?

Do better diagnostic tests change outcomes??

SUMMARY/FUTURE Initial Diagnostic Accuracy (IDA) impacts outcomes Measurement of Diagnostic Accuracy and underlying

processes underemphasized in QI/Patient Safety Diagnostic Strengths of LUS published >10 years ago

Still-growing body of evidence showing patient care improved when LUS included in diagnostic work up

Knowledge/use of LUS still limited?○ Integration into Medical Schools/Training Programs

Add sonoscope skills along with stethoscope skills?

CASE 1 – UW ED

A DIAGNOSTIC ALGORITHM/TIMELINE

WHAT WOULD I DO NEXT??

YAY!!!!

A few clips…

DATA SUMMARY BEFORE CT

History – infectious sounding ( rigors, sore throat, lymph nodes)…. PNA?

CXR – PNA PNA PNA POCUS –

Lungs – could not review images Heart – RV normal size, normal function

SO, WHAT WOULD I NOT DO NEXT??

POST CXR and POST CT diagnosis of multifocal pneumonia

CASE 2

DIAGNOSTIC ALGORITHM AND TIMELINE

WBC = 8.6 Procalcitonin = .21 (was not back in ED, came later, lets pretend it is back)BNP = 93 D-dimer =.57 Troponin .06

DATA BEFORE CT CHEST: History – most s/o infection? vs. chronic

decompensation/overload – OSA/RHF -non-specific)

WBC = 8.6 Procalcitonin = .21 CXR – Pulmonary edema BNP = 93 –NOT pulmonary edema? D-dimer =.57 – who knows

LETS DO A HEART LUNG SONO TO DIFFERENTIATE….?

RIGHT LUNG LEFT LUNG

HEART

SUMMARY OF CASE Diagnosis of dyspnea in obesity a challenge – all

imaging studies have some limitations This pt had multiple non-specific findings or had strong

evidence for diagnosis of pulm edema Problem is that actual diagnosis was PNA This case, it you think about it, and JUST WENT WITH

YOUR LUS FINIDNGS would have led you to diagnosis of PNA, which was supported by CT and was the correct diagnosis –he was not appreciably overloaded – the CXR lied!!! ( no interstitial syndrome on right on LUS but did have some unilaterallerally on CT….)

CXR in obese patients are tough to read LUS in obese patients are hard to do

LUNG ULTRASOUND Simply scanning the surface tells you a lot

about the underlying lung Wet, consolidated, collapsed, pleffed “Poor Man’s CT scan” “LUS has never lied to me… “Has not always given me the answer, but it has

never lied!

KEEP IN MIND, VERY FEW STUDIES HAVE BEEN DESIGNED SHOWING IMPACT OF “COMBINED” CLINCIAL AND ULTRASOUND DIAGNOSTIC APPROACHES

EVOLUTION OF POINT OF CAREULTRASONOGRAPHY (CCUS)

Soni, Arntfield, Kory, POCUS, 2014

SPECTRUM OF MAIN CRITICAL CARE ULTRASONOGRAPHY APPLICATIONS CARDIAC

Differentiation of Shock States Assessment of Fluid Responsiveness

LUNG and PLEURA Diagnosis of Causes of Acute Respiratory Failure Characterization/drainage of pleural pathology

ABDOMINAL Free Fluid, Obstructive Uropathy, Ischemic Colitis

VASCULAR Catheter Insertion Guidance Diagnosis of Deep Venous Thrombosis

B Line Spectrum: normal to abnormal

B3 linesB7 linesNormal

Lichtenstein A-lines and B-lines: lung ultrasound as a bedside tool for predicting pulmonary artery occlusion pressure in the critically ill. Crit Care Med. 2007 May;35(5 Suppl):S250-61

What About This B line?

They come from the pleural surface (the P-Visceral surface must be together)

They move with respiration They reach the bottom of the screen They efface the A-lines

They are very helpful to determine the clinical problem

LUNG AND HEART ULTRASOUND FOR EVALUATION OF PULMONARY EMBOLUS

Grifoni, Chest 2013 357 consecutive pts in 3 ED’s, Wells>4 or + D-dimer Heart, Lung, DVT study BEFORE CTPA PE diagnosis: Subpleural consolidation, DVT, RV

dilation PE not diagnosed if alternative explanation found Sono: 90% sensitive, 86% specific If no PE on sono, + alt dx, - Ddimer:

○ No patient had a PE Studies done by 13 MD’s – 4 residents 50% of CTPA’s could have been avoidedby focused DVT study alone

“SPEED” Study – Sonographic Assessment for Pulmonary Embolism in Patients with Dyspnea

Koenig S et al. Chest 2014 Sono-intensivists went down to ED and did a blinded

U/S exam on consecutive ED pts going for CTPA IF: alternative diagnosis, normal RV, or DVT found:

CTPA not recommended IF: no alternative diagnosis nor DVT found – CTPA

indicated 96 total patients: 12% had PE 56% alternative diagnosis (NONE HAD PE) 58% of CTPA’s could have been avoided 100% of alternative LUS diagnoses were concordant

with CT scan

LUNG ULTRASOUND IMPACT IN MANAGEMENT OF ICU PATIENTS STUDY DESIGN

Enrolled 189 patients - LUS ordered to investigate a deterioration or confirm a suspected diagnosis

12 Point LUS performed STUDY RESULTS

119 cases led to a management change (47%○ 81 cases involved invasive changes chest tube, bornchoscopy, thoracentesis, dialysis, trach,

abdominal decompression○ 38 cases non-invasive changes Diuretic, abx initiation/change, PEEP, recruitment

Xirouachki, Int Care Med, 2014

LUNG ULTRASOUND IMPACT IN ICU

STUDY DESIGN Enrolled 41 ICU patients with CXR’s that were:

○ “difficult to interpret” or “failed to explain clinical findings” ○ Initial diagnosis made on CXR/clinical findings○ Final diagnosis made on thora, biopsy, surgery, follow-up○ Sonographer blinded to clinical case

STUDY RESULTS Confirmed diagnosis in 12 cases (29%) Changed diagnosis correctly in 8 cases (20%) Added information in 7 cases (17%) Management changed in 41% cases

Yu CJ, Am J Roentgenol, 1992

Study Design Academic ED enrolled 101 pts suspected CHF

○ Only Performed LUS, IVC, LVEF assessment Final diagnosis by blinded ED docs

Study Results B lines >10 sens/spec = 70%/75% BNP sens/spec = 75%/83% Using echo (EF<45%) and IVC (non-collapse increased

specificity to 100% but decreased sensitivity

Accuracy of LUS for Diagnosis of Acute Pulmonary Edema

Anderson KL, Am J Emerg Med 2013

Requirements to realize benefits of LUS (and CCUS in general) Dedicated machines in ICU “Frontline” intensivists skilled at CCUS Team decision to rely on U/S as primary imaging tool Deployment of U/S as primary tool on rounds Decision that confirmatory imaging not required for U/S

exams performed by ICU team

DIFFERENTIATING ARDS FROM CARDIOGENIC PULMONARY EDEMA

“B” Profile (B/L “B” Lines) Most often represents cardiogenic pulmonary edema Can also be seen in ARDS/Multi-focal PNA

Can Discriminate using LUS: 1) Areas of sparing in ARDS (100% vs 0%) 2) Diminished sliding in ARDS (100% vs 0%) 3) Subpleural consolidations in ARDS (83% vs 0%) 3) Thickened, irregular pleura in ARDS (100% vs 25%)

Copetti R, Cardiovasc Ultrasound, 2008

Accuracy of Lung Ultrasound for Diagnosis of Pneumonia – Meta-Analysis Study Design

Meta-Analysis of studies comparing LUS vs. CXR in Adults with CT chest or Clinical Dx as standard

Study Results 10 Studies – 6 ED, 4 ICU

○ 1172 Patients○ Sonographers: “Highly skilled” – 7 “Trained”- 3○ Pooled Sens/Spec – 94%/96%○ Area under ROC= .99

Conclusion – excellent test when performed by highly trained sonographer

Chavez MA, Respiratory Research, 2014

PLEURAL LINE IN CHF vs . ARDS

“SUB PLEURAL” CONSOLIDATIONS IN ARDS vs. CHF

“AREAS OF SPARING” IN ARDS