POCUS Improves Diagnostic Certainty for Dyspnea Patients, ACP Says

Emergency department or inpatient clinicians can use point-of-care ultrasonography (POCUS) as a complement to the standard diagnostic pathway when working with patients with acute shortness-of-breath for whom a diagnosis is uncertain, according to a new American College of Physicians (ACP) recommendation.

ACP officials published their new guidance in the April 27 issue of Annals of Internal Medicine.

Shortness-of-breath affects more than 1 million patients in the emergency department each year, making evaluation and diagnosis critical.

“Many underlying diseases can cause dyspnea,” said the team led by Amir Qaseem, M.D., Ph.D., vice president of clinical policy and the Center for Evidence Reviews at the ACP. “The diagnostic approach to a patient with acute dyspnea is challenging because of the number of potential causes, several of which are serious and potentially life-threatening.”

The intent, the ACP said, is to improve diagnosis, treatment, and outcomes for patients who might have congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax. POCUS can be used before, after, or alongside standard diagnostic approaches, including collecting a patient history, conducting a physical, or ordering diagnostic tests (blood laboratory tests, chest or cardiac imaging, and electrocardiography) to provide greater diagnostic certainty.

To draft this recommendation, the ACP team examined data from January 2004 to August 2020 on POCUS tests conducted by students, residents, general internists, and intensivists. Their evaluation determined that POCUS probably increases the proportion of correct diagnoses from 59 percent to 91 percent, but it likely does not reduce the length of a patient’s hospital stay.

In addition, the team determined that using POCUS with standard diagnostic pathways for patients with dyspnea can lead to a correct diagnosis 79 percent-to-100 percent of the time for patients with congestive heart failure (CHF), and it rules out the condition for 95 percent-to-99 percent of unaffected patients. When used alone, POCUS can correctly identify 76 percent of CHF patients and rule it out for 96 percent.

For patients with dyspnea suspected of pleural effusion (PE), POCUS plus the standard diagnostic pathway can led to a correct diagnosis for 89 percent-to-100 percent of patients, and it can rule PE out for 98 percent-to-100 percent of individuals. When used alone, POCUS can identify 78 percent-to-89 percent of cases and eliminate the possibility for 88 percent-to-99 percent of unaffected patients.

In addition, for cases of suspected pneumonia, the paired tests can correctly pinpoint 92 percent of cases and rule out between 63 percent-to-98 percent. As a replacement test, POCUS correctly identifies 52 percent-to-88 percent of instances and rules out 58 percent-to-92 percent.

Lastly, POCUS and the standard diagnostic pathways can also correctly identify 89 percent-to-100 percent of patients with shortness-of-breath who might also have a pulmonary embolism, as well as rule it out for 95 percent-to-100 percent of patients. As a stand-alone test, though, it correctly identifies between 40 percent-to-100 percent of cases and can rule it out for between 97 percent-to-100 percent of unaffected patients.

These findings are important, said ACP leadership, because the tool can amplify the clinicians’ capabilities.

“The appropriate use of POCUS in treating patients in these settings is an important topic for physicians,” said Jacqueline W. Fincher, M.D., MACP, ACP president. “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.”

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