The American College of Physicians (ACP) today released a new Clinical Guideline regarding the appropriate use of point-of-care ultrasound (POCUS) for patients with acute dyspnea in emergency departments or in-patient settings. The guidelines will help improve the diagnostic, treatment, and health outcomes of those with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax.
The Clinical Guidelines Committee (CGC) developed the recommendations, which are based on the best available evidence on the clinical benefits and harms, test accuracy, patient values and preferences, and consideration of costs. The guideline and recommendations also include input from 2 CGC public members and a 7-member CGC Public Panel, who provide layperson perspectives on values and preferences.
The new, evidence-based guideline was published in Annals of Internal Medicine.
Main recommendations include-
Congestive heart failure: POCUS of the lungs alone or with the heart, inferior vena cava, and deep veins correctly identified 79%–100% of patients who had congestive heart failure and 95%–99% who did not.
Pleural effusion: POCUS of the lungs, heart, inferior vena cava, and deep veins correctly identified 89%–100% of patients who had pleural effusion and 98%–100% of those who did not.
Pneumonia: POCUS correctly identified 92% of patients who had pneumonia and 63%-98% who did not.
Pulmonary embolism: POCUS correctly identified 89%–100% of patients who had pulmonary embolism and 95%–100% who did not
The new was developed by ACP to provide clinical recommendations to improve the diagnostic, treatment, and health outcomes of patients with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax. Acute dyspnea is a common symptom that contributes to more than 1 million emergency room visits each year and is defined as a subjective and distressing experience of breathing discomfort.
ACP's new guideline suggests that clinicians may use POCUS in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings. The standard diagnostic approach to identify the underlying causes of acute dyspnea involves taking a patient history, conducting a physical examination, and ordering diagnostic testing such as blood laboratory, chest or cardiac imaging, and electrocardiogram. Evidence was inconclusive to make a recommendation for or against using POCUS as a replacement for the standard diagnostic approach in patients with acute dyspnea
In recent years, the use of POCUS as a potential diagnostic tool has increased due its increased availability. Physicians trained to use POCUS can perform it in real-time at the patient bedside to possibly improve diagnostic performance when used in addition to standard clinical examinations.
"The appropriate use of POCUS in treating patients in these settings is an important topic for physicians," said Jacqueline W. Fincher, MD, MACP, President, ACP. "As the use of this diagnostic tool continues to see more widespread use, it's critical to understand the benefits, potential harms and best use as an accurate diagnostic tool."
The rationale to add POCUS to the standard diagnostic pathway is largely based on diagnostic accuracy studies and encompasses several considerations. POCUS increased the proportion of correct diagnoses by 32% when used in addition to the standard diagnostic pathway and the test accuracy of standard diagnostic testing with the addition of POCUS is better than with the standard diagnostic alone. Additionally, it is unlikely that POCUS is directly associated with serious harms and it is not a high-cost test. However, the test accuracy varied according to the likelihood of underlying diseases.
The guideline identified many areas of uncertainty in the clinical use of POCUS including how accuracy and outcomes compare for handheld devices, for different amounts of training, and by user experience. Additionally, the guideline found insufficient evidence on the effect of POCUS when used in addition to the standard diagnostic pathway on in-hospital mortality, time to diagnosis or treatment.
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