Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.
TL;DR: In an emergency setting, this new ultraportable echoscope (PUD) was reliable for the real-time detection of focused cardiac abnormalities.
Abstract: Introduction
In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.
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King Abdulaziz Medical City1, University of the Witwatersrand2, University of Minnesota3, King Saud University4, Harvard University5, Icahn School of Medicine at Mount Sinai6, University of Belgrade7, Beth Israel Deaconess Medical Center8, Aarhus University Hospital9, University of South Florida10, Scripps Mercy Hospital11, University Hospital of Wales12, Sydney Adventist Hospital13, Peking Union Medical College Hospital14, Apollo Hospitals15, University of South Carolina16, Cornell University17
TL;DR: For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
Abstract: Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
397 citations
TL;DR: In this article, the anterior and posterior axillary lines are used as anatomical landmarks to locate the diaphragm and the lungs, and three areas per hemithorax (anterior, lateral, and posterior) are iden-tified.
Abstract: LUS is normally performed in supine patients. Operator should firstly locate the diaphragm and the lungs. Lung consolidation or pleural effusion is found predominantly in dependent and dorsal lung regions and can be easily distinguished from liver or spleen once the diaphragm has been identified. By using the anterior and posterior axillary lines as anatomical landmarks, three areas per hemithorax (anterior, lateral, and posterior) can be iden-tified. Each area is divided in two, superior and inferior. In a given region of interest, lung surface of all adjacent inter-costal spaces must be explored by moving the probe trans-versally.
211 citations
TL;DR: The advantages and limits of using continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability are discussed.
Abstract: Over the last decade, the way to monitor hemodynamics at the bedside has evolved considerably in the intensive care unit as well as in the operating room. The most important evolution has been the declining use of the pulmonary artery catheter along with the growing use of echocardiography and of continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques. This article, which is the result of an agreement between authors belonging to the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine, discusses the advantages and limits of using such techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability.
205 citations
Cites background from "Evaluation of a new pocket echoscop..."
..., by electrical impedance tomography, will also increase the amount of information available at the bedside [75, 76]....
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TL;DR: The feasibility of performing sonographer-driven focused echocardiographic studies with long-distance Web-based assessments of recorded images for identifying the burden of structural heart disease in a community is demonstrated.
Abstract: Background Developing countries face the dual burden of high rates of cardiovascular disease and barriers in accessing diagnostic and referral programs. The aim of this study was to test the feasibility of performing focused echocardiographic studies with long-distance Web-based assessments of recorded images for facilitating care of patients with cardiovascular disease. Methods Subjects were recruited using newspaper advertisements and were prescreened by paramedical workers during a community event in rural north India. Focused echocardiographic studies were performed by nine sonographers using pocket-sized or handheld devices; the scans were uploaded on a Web-based viewing system for remote worldwide interpretation by 75 physicians. Results A total of 1,023 studies were interpreted at a median time of 11:44 hours. Of the 1,021 interpretable scans, 207 (20.3%) had minor and 170 (16.7%) had major abnormalities. Left ventricular systolic dysfunction was the most frequent major abnormality (45.9%), followed by valvular (32.9%) and congenital (13.5%) defects. There was excellent agreement in assessing valvular lesions (κ = 0.85), whereas the on-site readings were frequently modified by expert reviewers for left ventricular function and hypertrophy (κ = 0.40 and 0.29, respectively). Six-month telephone follow-up in 71 subjects (41%) with major abnormalities revealed that 57 (80.3%) had improvement in symptoms, 11 (15.5%) experienced worsening symptoms, and three died. Conclusions This study demonstrates the feasibility of performing sonographer-driven focused echocardiographic studies for identifying the burden of structural heart disease in a community. Remote assessment of echocardiograms using a cloud-computing environment may be helpful in expediting care in remote areas.
98 citations
Cites methods from "Evaluation of a new pocket echoscop..."
...However, numerous previous studies have clearly demonstrated that when used by experienced echocardiographers, excellent diagnostic accuracy can be achieved with these pocket-sized devices, comparable with traditional stationary equipment.(27,30,32-34) In addition, we used a visual, qualitative approach for the diagnosis and grading of various echocardiographic abnormalities, which added subjectivity to the interpretations and may have influenced the agreement between the on-site sonographers and the remote expert readers....
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TL;DR: This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users.
Abstract: Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.
81 citations
References
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TL;DR: In this article, the authors investigated the imaging capabilities of recent hand-held ultrasound scanners and compared them with high-end echocardiography (HIGH) to assess the left ventricular (LV) dimensions, regional and global LV function, and grades of valve disease.
Abstract: Background The aim of this study was to investigate the imaging capabilities of recent hand-held ultrasound scanners. Methods Three hundred forty-nine patients were scanned with hand-held ultrasound (HAND) and high-end echocardiography (HIGH). Segmental endocardial border delineation was scored (2 = good, 1=poor, 0=invisible) to describe image quality. Assessments of left ventricular (LV) dimensions, regional and global LV function, and grades of valve disease were compared. Results The mean endocardial visibility grades were 1.6 ± 0.5 with HAND and 1.7 ± 0.4 with HIGH ( P P r = 0.99, P P Conclusions Handheld echocardiography was feasible and missed no relevant findings. Given the future implementation of spectral Doppler capabilities, this handheld scanner can safely be used in clinical routine.
179 citations
TL;DR: HCU will extend the concept of the "complete physical examination," allowing more rapid assessment of cardiovascular anatomy, function, and physiology, but appropriate user-specific training and assumption of responsibility are essential to ensure the most accurate acquisition, interpretation, and use of the data.
Abstract: The newest introduction to echocardiography is a hand-carried ultrasound (HCU) device It is a small echocardiographic machine that typically weighs less than 6 lb and can obtain echocardiographic images and data However, neither the device nor the context of the examination fulfills the criteria for a comprehensive or complete echocardiographic examination The American Society of Echocardiography believes that HCU will extend the concept of the "complete physical examination," allowing more rapid assessment of cardiovascular anatomy, function, and physiology However, appropriate user-specific training (Level 1 at a minimum) and assumption of responsibility are essential to ensure the most accurate acquisition, interpretation, and use of the data
174 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...However, confusion between focused and comprehensive US among the many types of hand-carried US devices must be avoided [9-11]....
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TL;DR: In conclusion, pocket size device showed a relevant additional diagnostic value in comparison with physical examination and its appropriateness of use in compared with standard echo machine in a non-cardiologic population.
Abstract: Miniaturization has evolved in the creation of a pocket-size imaging device which can be utilized as an ultrasound stethoscope. This study assessed the additional diagnostic power of pocket size device by both experts operators and trainees in comparison with physical examination and its appropriateness of use in comparison with standard echo machine in a non-cardiologic population. Three hundred four consecutive non cardiologic outpatients underwent a sequential assessment including physical examination, pocket size imaging device and standard Doppler-echo exam. Pocket size device was used by both expert operators and trainees (who received specific training before the beginning of the study). All the operators were requested to give only visual, qualitative insights on specific issues. All standard Doppler-echo exams were performed by expert operators. One hundred two pocket size device exams were performed by experts and two hundred two by trainees. The time duration of the pocket size device exam was 304 ± 117 sec. Diagnosis of cardiac abnormalities was made in 38.2% of cases by physical examination and in 69.7% of cases by physical examination + pocket size device (additional diagnostic power = 31.5%, p < 0.0001). The overall K between pocket size device and standard Doppler-echo was 0.67 in the pooled population (0.84 by experts and 0.58 by trainees). K was suboptimal for trainees in the eyeball evaluation of ejection fraction, left atrial dilation and right ventricular dilation. Overall sensitivity was 91% and specificity 76%. Sensitivity and specificity were lower in trainees than in experts. In conclusion, pocket size device showed a relevant additional diagnostic value in comparison with physical examination. Sensitivity and specificity were good in experts and suboptimal in trainees. Specificity was particularly influenced by the level of experience. Training programs are needed for pocket size device users.
129 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...In fact, it embodies the concept of the visual stethoscope by Galderisi and colleagues [33], who demonstrated the relevant additional diagnostic power of pocket-size devices in addition to the physical examination....
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TL;DR: The new miniaturized echocardiographic system showed additive clinical value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine e chocardiography, increasingThe number of adequate echOCardiographic studies, and determining a large number of releases from the outpatient clinic.
Abstract: Background The aim of this study was to assess the usefulness of a new miniaturized echocardiographic system (MS) to perform bedside echocardiography in initial outpatient cardiology consultations, in addition to physical examination. Methods One hundred eighty-nine patients referred for initial cardiology outpatient consultations at two tertiary hospitals in two countries were studied. Each patient was submitted to physical examination followed by MS assessment. Scanning time, the number of examinations with abnormal results after physical examination and the MS, and the information obtained by physical examination alone and followed by the MS (in terms of its importance in reaching a diagnosis, in the necessity of performing routine echocardiography, and in the decision to release the patient from the outpatient clinic) were assessed. Results The scanning time with the MS was 180 ± 86 seconds. Its use after physical examination led to diagnoses in 141 patients (74.6%) and to an additional 37 patients (19.6%) being released from the outpatient clinic. After physical examination followed by MS assessment, only 64 patients (33.9%) were sent to the echocardiography lab. The MS modified the decision of whether to send a patient to the echocardiography lab, with referral determined by the MS in 27 patients (14.3%) and no referral determined by the MS in 58 patients (30.7%). Conclusions The new MS caused a negligible increase in the duration of consultations. It showed additive clinical value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine echocardiography, increasing the number of adequate echocardiographic studies, and determining a large number of releases from the outpatient clinic.
119 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...By increasing the number of clinical diagnoses, PUD could prove costeffective by decreasing the number of medical errors, providing a more efficient real-time diagnosis, and reducing the use of unnecessary routine US examinations [17,30]....
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...At present, only a few studies evaluating its feasibility and clinical usefulness have been published [16-20]....
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TL;DR: HHE appears to have a narrower diagnostic field when compared with conventional TTE, but promises to accurately identify diagnoses based on two-dimensional imaging in ventilated critically ill patients.
Abstract: Study objectives
To compare the diagnostic capability of recently available hand-held echocardiography (HHE) and of conventional transthoracic echocardiography (TTE) used as a gold standard in critically ill patients under mechanical ventilation.
101 citations
"Evaluation of a new pocket echoscop..." refers background or methods in this paper
...Moreover, limited TTE not only provides new information on cardiac function but also may change the initial management of intensive care patients with a similar therapeutic impact thanks to the use of a portable US system compared with a standard US, despite its lower overall diagnostic capacity [13,15]....
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...have been shown to directly guide and alter clinical management and have a therapeutic impact equivalent to that of standard echocardiography [12-15]....
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