Point-of-care ultrasound: Coming soon to primary care?

,; ,; ,; ,; ,

Applied Evidence

Point-of-care ultrasound: Coming soon to primary care?

J Fam Pract. 2018 February;67(2):70-74,76-80

PDF Download

References

1. Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract. 1988;5:129-135.

2. Deutchman ME, Hahn RG, Rodney WMM. Diagnostic ultrasound imaging by physicians of first contact: extending the family medicine experience into emergency medicine. Ann Emerg Med. 1993;22:594-596.

3. Bornemann P, Bornemann G. Military family physicians’ perceptions of a pocket point-of-care ultrasound device in clinical practice. Mil Med. 2014;179:1474-1477.

4. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014;371:1100-1110.

5. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5:182-188.

6. Gordon CE, Feller-Kopman D, Balk EM, et al. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170:332-339.

7. Calvert N, Hind D, McWilliams RG, et al. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review and economic evaluation. Health Technol Assess. 2003;7:1-84.

8. Hoppmann RA, Rao VV, Bell F, et al. The evolution of an integrated ultrasound curriculum (iUSC) for medical students: 9-year experience. Crit Ultrasound J. 2015;7:18.

9. Clinical procedures performed by physicians at their practice. American Academy of Family Physicians Member Census, December 31, 2016. Available at: http://www.aafp.org/about/the-aafp/family-medicine-facts/table-12(rev).html. Accessed June 26, 2017.

10. Hall JW, Holman H, Bornemann P, et al. Point of care ultrasound in family medicine residency programs: a CERA study. Fam Med. 2015;47:706-711.

11. Bornemann P. Assessment of a novel point-of-care ultrasound curriculum’s effect on competency measures in family medicine graduate medical education. J Ultrasound Med. 2017;36:1205-1211.

12. Steinmetz P, Oleskevich S. The benefits of doing ultrasound exams in your office. J Fam Pract. 2016;65:517-523.

13. Flick D. Bedside ultrasound education in family medicine. J Ultrasound Med. 2016;35:1369-1371.

14. Dresang LT, Rodney WM, Rodney KM. Prenatal ultrasound: a tale of two cities. J Natl Med Assoc. 2006;98:167-171.

15. Dresang LT, Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med. 2004;36:98-107.

16. Rodney WM, Deutchman ME, Hartman KJ, et al. Obstetric ultrasound by family physicians. J Fam Pract. 1992;34:186-194.

17. Broadhurst NA, Simmons N. Musculoskeletal ultrasound - used to best advantage. Aust Fam Physician. 2007;36:430-432.

18. Spencer KT, Kimura BJ, Korcarz CE, et al. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567-581.

19. Panoulas VF, Daigeler AL, Malaweera AS, et al. Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Heart J Cardiovasc Imaging. 2013;14:323-330.

20. Razi R, Estrada JR, Doll J, et al. Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. J Am Soc Echocardiogr. 2011;24:1319-1324.

21. Mjølstad OC, Snare SR, Folkvord L, et al. Assessment of left ventricular function by GPs using pocket-sized ultrasound. Fam Pract. 2012;29:534-540.

22. Evangelista A, Galuppo V, Méndez J, et al. Hand-held cardiac ultrasound screening performed by family doctors with remote expert support interpretation. Heart. 2016;102:376-382.

23. Kimura BJ, Yogo N, O’Connell CW, et al. Cardiopulmonary limited ultrasound examination for “quick-look” bedside application. Am J Cardiol. 2011;108:586-590.

24. Kimura BJ, Amundson SA, Phan JN, et al. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med. 2012;7:537-542.

25. Kimura BJ, Shaw DJ, Amundson SA, et al. Cardiac limited ultrasound examination techniques to augment the bedside cardiac physical examination. J Ultrasound Med. 2015;34:1683-1690.

26. Brennan JM, Ronan A, Goonewardena S, et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol. 2006;1:749-753.

27. Goonewardena SN, Gemignani A, Ronan A, et al. Comparison of hand-carried ultrasound assessment of the inferior vena cava and N-terminal pro-brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure. JACC Cardiovasc Imaging. 2008;1:595-601.

28. Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA. 2009;301:309-317.

29. Blackmore CC, Black WC, Dallas RV, et al. Pleural fluid volume estimation: a chest radiograph prediction rule. Acad Radiol. 1996;3:103-109.

30. Kitazono MT, Lau CT, Parada AN, et al. Differentiation of pleural effusions from parenchymal opacities: accuracy of bedside chest radiography. Am J Roentgenol. 2010;194:407-412.

31. Kalokairinou-Motogna M, Maratou K, Paianid I, et al. Application of color Doppler ultrasound in the study of small pleural effusion. Med Ultrason. 2010;12:12-16.

32. Yousefifard M, Baikpour M, Ghelichkhani P, et al. Screening performance characteristic of ultrasonography and radiography in detection of pleural effusion; a meta-analysis. Emerg (Tehran, Iran). 2016;4:1-10.

33. Begot E, Grumann A, Duvoid T, et al. Ultrasonographic identification and semiquantitative assessment of unloculated pleural effusions in critically ill patients by residents after a focused training. Intensive Care Med. 2014;40:1475-1480.

34. World Health Organization. Pneumonia. Fact Sheet No. 331. Available at: http://www.who.int/mediacentre/factsheets/fs331/en/. Accessed June 26, 2017.

35. Gereige RS, Laufer PM. Pneumonia. Pediatr Rev. 2013;34:438-456.

36. National Center for Health Statistics. Leading causes of death. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed July 2, 2017.

37. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-S72.

38. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics. 2015;135:714-722.

39. Xia Y, Ying Y, Wang S, et al. Effectiveness of lung ultrasonography for diagnosis of pneumonia in adults: a systematic review and meta-analysis. J Thorac Dis. 2016;8:2822-2831.

40. Nazerian P, Volpicelli G, Vanni S, et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med. 2015;33:620-625.

41. Filopei J, Siedenburg H, Rattner P, et al. Impact of pocket ultrasound use by internal medicine housestaff in the diagnosis of dyspnea. J Hosp Med. 2014;9:594-597.

42. Lichtenstein D, Mezière G. A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact. Intensive Care Med. 1998;24:1331-1334.

43. Gargani L, Volpicelli G. How I do it: lung ultrasound. Cardiovasc Ultrasound. 2014;12:25.

44. Martindale JL, Wakai A, Collins SP, et al. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2016;23:223-242.

45. Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med. 2006;24:689-696.

46. Picano E, Frassi F, Agricola E, et al. Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiogr. 2006;19:356-363.

47. Noble VE, Murray AF, Capp R, et al. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis: time course for resolution. Chest. 2009;135:1433-1439.

48. Gullett J, Donnelly JP, Sinert R, et al. Interobserver agreement in the evaluation of B-lines using bedside ultrasound. J Crit Care. 2015;30:1395-1399.

49. Guirguis-Blake JM, Beil TL, Sun X, et al. Primary Care Screening for Abdominal Aortic Aneurysm: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Syntheses No. 109. Rockville, MD; 2014.

50. Metcalfe D, Holt PJE, Thompson MM. The management of abdominal aortic aneurysms. BMJ. 2011;342:d1384.

51. Thompson SG, Ashton HA, Gao L, et al. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Brit J Surg. 2012;99:1649-1656.

52. LeFevre ML. Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161:281-290.

53. Lindholt JS, Vammen S, Juul S, et al. The validity of ultrasonographic scanning as screening method for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 1999;17:472-475.

54. Rubano E, Mehta N, Caputo W, et al. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013;20:128-138.

55. Blois B. Office-based ultrasound screening for abdominal aortic aneurysm. Can Fam Physician. 2012;58:e172-e178.

56. Sisó-Almirall A, Gilabert Solé R, Bru Saumell C, et al. Feasibility of hand-held-ultrasonography in the screening of abdominal aortic aneurysms and abdominal aortic atherosclerosis. Med Clin (Barc). 2013;141:417-422.

57. Sisó-Almirall A, Kostov B, Navarro González M, et al. Abdominal aortic aneurysm screening program using hand-held ultrasound in primary healthcare. PLoS One. 2017;12:e0176877.

58. Philbrick JT, Becker DM. Calf deep venous thrombosis: a wolf in sheep’s clothing? Arch Intern Med. 1988;148:2131-2138.

59. Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e351S-418S.

60. Cushman M, Tsai AW, White RH, et al. Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. Am J Med. 2004;117:19-25.

61. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349:1227-1235.

62. Lensing AW, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med. 1989;320:342-345.

63. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010;56:601-610.

64. Blaivas M, Lambert MJ, Harwood RA, et al. Lower-extremity doppler for deep venous thrombosis—can emergency physicians be accurate and fast? Acad Emerg Med. 2000;7:120-126.

65. Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008;15:493-498.

66. Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350:1795-1798.

67. Birdwell BG, Raskob GE, Whitsett TL, et al. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep venous thrombosis. Ann Intern Med. 1998;128:1-7.

68. Cogo A, Lensing AW, Koopman MM, et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ. 1998;316:17-20.

69. Tick LW, Ton E, Van Voorthuizen T, et al. Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test. Am J Med. 2002;113:630-635.

70. Stevens SM, Woller SC, Graves KK, et al. Withholding anticoagulation following a single negative whole-leg ultrasound in patients at high pretest probability for deep vein thrombosis. Clin Appl Thromb Hemost. 2013;19:79-85.

Just 2 hours of cardio POCUS training enhanced Dx accuracy

The American Society of Echocardiography (ASE) issued an expert consensus statement for focused cardiac ultrasound in 2013.¹⁸ The guideline supports non-cardiologists utilizing POCUS to assess for pericardial effusion and right and left ventricular enlargement, as well as to review global cardiac systolic function and intravascular volume status. Cardiovascular POCUS protocols are relatively easy to learn; even small amounts of training and practice can yield competency.

Point-of-care ultrasound is safe, accurate, and beneficial and can be performed with a relatively small amount of training by family physicians.

For example, a 2013 study showed that after 2 hours of training with a pocket ultrasound device, medical students and junior physicians inexperienced with POCUS were able to improve their diagnostic accuracy for heart failure from 50% to 75%.¹⁹ In another study, internal medicine residents with limited cardiac ultrasound training (ie, 20 practice exams) were able to detect decreased left ventricular ejection fraction using a handheld ultrasound device with 94% sensitivity and specificity in patients admitted to the hospital with acute decompensated heart failure.²⁰ Similarly, after only 8 hours of training, a group of Norwegian general practitioners were able to obtain measurements of systolic function with a pocket ultrasound device that were not statistically different from a cardiologist’s measurements.²¹

In another study, rural FPs attended a 4-day course and then performed focused cardiac ultrasounds on primary care patients with a clinical indication for an echocardiogram.²² The scans were uploaded to a Web-based program for remote interpretation by a cardiologist. There was high concordance between the FPs’ interpretations of the focused cardiac ultrasounds and the cardiologist’s interpretations. Only 32% of the patients in the study group required a formal follow-up echocardiogram.

Kimura et al published a POCUS protocol for the rapid assessment of patients with heart failure, called the Cardiopulmonary Limited Ultrasound Exam (CLUE).²³ The CLUE protocol utilizes 4 views to assess left ventricular systolic and diastolic function along with signs of pulmonary edema or systemic volume overload (TABLE 3²³). The presence of pulmonary edema or a plethoric inferior vena cava (IVC) was highly prognostic of in-hospital mortality. The CLUE protocol has been successfully used by novices including internal medicine residents after brief training (ie, up to 60 supervised scans) and can be performed in less than 5 minutes.^24,25

Inpatient use. In addition to its use as an outpatient diagnostic tool, POCUS may be able to help guide therapy in patients admitted to the hospital with heart failure. Increasing collapse of the IVC directly correlates with the amount of fluid volume removed during hemodialysis.²⁶ Goonewardena et al showed that IVC collapsibility was an independent predictor of 30-day hospital readmission even when demographics, signs and symptoms, and volume of diuresis were otherwise equal.²⁷ However, whether the use of IVC collapsibility to guide management improves outcomes in heart failure remains to be validated in a prospective trial.