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: Cardiac ultrasound imaging continues to evolve rapidly and further miniaturisation of digital technologies has recently led to the construction of marvels of modern electronic bioengineering: real time, three dimensional echocardiography and, at the other end of the spectrum, small hand carried imaging devices.
Abstract: The availability and versatility of echo/Doppler has made it the most widely used test to diagnose and quantify heart disease in many different health care environments. What impact will hand held ultrasound imaging devices have on our future diagnostic capabilities?
This year marks the 50th anniversary of echocardiography. The evolution of this non-invasive imaging modality has been impressive and has paralleled the rapid developments in microprocessor technology. Together with Doppler assessment of intracardiac haemodynamics, a comprehensive and diagnostic evaluation of most patients suspected of having heart disease is now possible. The method introduced new pathophysiologic concepts and has made unique contributions to the management of cardiac patients. Because of its availability and versatility in application, echo/Doppler has become the most widely used test to diagnose and quantify heart disease in many different health care environments. Cardiac ultrasound imaging continues to evolve rapidly and further miniaturisation of digital technologies has recently led to the construction of marvels of modern electronic bioengineering: real time, three dimensional echocardiography and, at the other end of the spectrum, small hand carried imaging devices.
The basic physical examination as we practice it today was introduced by Pharaonic doctors and included history taking, inspection, palpation, and direct auscultation. In later times, doctors did not examine their patients. Renewed interest in the physical examination was stimulated by the pioneering work of GB Morgagni (1682–1771) who showed for the first time the pathologic changes induced in the organs by disease and how these cause signs and symptoms. Clinicians wanted to diagnose hidden pathology by detecting these signs at the bedside. It was the beginning of the “golden era” of physical diagnosis, with the great contributions of Auenbrugger, Corvisart, and Laennec. RTH Laennec (1781–1826) revolutionised the physical examination by the introduction of the stethoscope, the first technological aid in clinical …
38 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...The capability and simplicity of this new PUD make it ideally suited for bedside use in emergency settings, providing time-sensitive assessment to assist physicians in the diagnosis of cardiovascular diseases in addition to the physical examination [31,32]....
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TL;DR: Preliminary experiences show the possibility to improve and anticipate diagnosis of several cardiovascular diseases but also the need to plan specific ultrasound training to avoid incorrect use of HHE.
36 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: Left ventricular EF is underestimated by visual estimation compared with the quantitative assessment, and the visual approach for EF assessment may be used for rapid assessment of left ventricular function in clinical practice where accuracy is of less concern.
36 citations
"Evaluation of a new pocket echoscop..." refers methods in this paper
...However, the systematic measures using the reference diagnostic method were necessary to confirm that a visual approach alone may be sufficient [35]....
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TL;DR: A new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.
Abstract: We hypothesized that, based on greyscale imaging and color Doppler capabilities, a new pocket ultrasound device (PUD) could accurately record cardiologic diagnostic findings. One hundred patients referred for conventional clinical indications underwent a standard echocardiography. Subsequently, a second physician blinded to the results performed an evaluation using the PUD on the same patients. Study end-points were echocardiographic window quality; left ventricular (LV) morphology; function; hypertrophy; right ventricular, atrial and vena caval morphologies; aortic and mitral valvulopathies; and pericardial structure. Using a scale of three grades, concordance in image quality proved good with a kappa coefficient (κ) of 0.71. Concordances between systems were excellent for LV function and morphology (κ = 0.91 and 0.96). Concordance for LV hypertrophy was good (κ = 0.74). Concordances for mitral regurgitation grades were 0.90, 0.95 and 1.00, respectively. In conclusion, a new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.
36 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...At present, only a few studies evaluating its feasibility and clinical usefulness have been published [16-20]....
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...In 100 cardiologic patients in a cardiological setting, Lafitte and colleagues [19] demonstrated that PUD showed good concordance of diagnostic capability with that of standard full-feature echocardiographic instruments....
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TL;DR: In ICU patients, the extension of physical examination using an US improves the ability of trained intensivists to determine left ventricular ejection fraction at bedside, and with trained operators, the semi-quantitative assessment of LVEF using the US is accurate when compared to standard TTE.
Abstract: Introduction: Assessment of cardiac function is key in the management of intensive care unit (ICU) patients and frequently relies on the use of standard transthoracic echocardiography (TTE). A commercially available new generation ultrasound system with two-dimensional imaging capability, which has roughly the size of a mobile phone, is adequately suited to extend the physical examination. The primary endpoint of this study was to evaluate the additional value of this new miniaturized device used as an ultrasonic stethoscope (US) for the determination of left ventricular (LV) systolic function, when compared to conventional clinical assessment by experienced intensivists. The secondary endpoint was to validate the US against TTE for the semi-quantitative assessment of left ventricular ejection fraction (LVEF) in ICU patients. Methods: In this single-center prospective descriptive study, LVEF was independently assessed clinically by the attending physician and echocardiographically by two experienced intensivists trained in critical care echocardiography who used the US (size: 135 × 73 × 28 mm; weight: 390 g) and TTE. LVEF was visually estimated semi-quantitatively and classified in one of the following categories: increased (LVEF > 75%), normal (LVEF: 50 to 75%), moderately reduced (LVEF: 30 to 49%), or severely reduced (LVEF < 30%). Biplane LVEF measured using the Simpson’s rule on TTE loops by an independent investigator was used as reference. Results: A total of 94 consecutive patients were studied (age: 60 ± 17 years; simplified acute physiologic score 2: 41 ± 15), 63 being mechanically ventilated and 36 receiving vasopressors and/or inotropes. Diagnostic concordance between the clinically estimated LVEF and biplane LVEF was poor (Kappa: 0.33; 95% CI: 0.16 to 0.49) and only slightly improved by the knowledge of a previously determined LVEF value (Kappa: 0.44; 95% CI: 0.22 to 0.66). In contrast, the diagnostic agreement was good between visually assessed LVEF using the US and TTE (Kappa: 0.75; CI 95%: 0.63 to 0.87) and between LVEF assessed on-line and biplane LVEF, regardless of the system used (Kappa: 0.75; CI 95%: 0.64 to 0.87 and Kappa: 0.70; CI 95%: 0.59 to 0.82, respectively).
35 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...More recently, Amiel and colleagues [16] demonstrated that PUD was able to assess LVEF with a good agreement in 94 critically ill patients....
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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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