Diagnostic Accuracy of Lung Ultrasonography Compared to Chest
Radiography, BNP and Physical Examination in Patients with Dyspnea
Suggestive of Pulmonary Edema: A Systematic Review and Meta-Analysis

Dev   H.   Desai; Abeer   A.   Bahattab; Eman   S.   Barhoom; Maria   E.   Malafi; Ahmed   H.   Mujamammi; Khulood   S.   Basalem; Khalid   M.   Sumaily; Essa   M.   Sabi; Tayba   A.   Mugibel; Nouf   O.   AlAfaleq; Lotfi   S.   Bin Dahman

Abstract

Background: Pulmonary edema (PE) is the result of an abrupt increase in hydrostatic pressure in the pulmonary capillaries that leads to leakage of fluid through microvascular endothelial cells. This leads to a disruption of gas exchange in the lungs.

Aims: This meta-analysis aimed to determine the diagnostic accuracy of lung ultrasonography (LUS) in pulmonary edema.

Methods: A systematic search was conducted using a strategy based on these search terms (Lung ultrasonography, pulmonary edema, diagnostic accuracy); we searched PubMed, Google Scholar, and the Cochrane Library. Out of 1029, 14 prospective cross-sectional and observational studies with 2239 patients who reported the sensitivity and specificity of lung ultrasonography in diagnosing pulmonary edema were selected. For inclusion and data extraction, an independent review of citations was carried out. The data obtained were analyzed using SPSS, RevMan 5.3, and Stata 14.0 software. A quality assessment was conducted using the QUADAS-2 tool. The reference gold standard was the final clinical diagnosis according to chest radiography, B-type natriuretic peptide, and/or physical examination in dyspneic patients.

Results: The overall sensitivity and specificity of lung ultrasonography in the diagnosis of pulmonary edema were 0.86 (95% CI, 0.81-0.90) and 0.91 (95% CI, 0.90-0.93), respectively, with a Younden index of 77.8%. The area under the receiver operating characteristic (ROC) curve was 0.889.

Conclusion: The overall diagnostic odds ratio was 68.86. The results of this meta-analysis suggest that lung ultrasonography is an effective non-invasive technique in the diagnosis of acute pulmonary edema with rapid bedside examination and immediate interpretation.

[1]
Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med  2005; 353(26): 2788-96.
 [http://dx.doi.org/10.1056/NEJMcp052699] [PMID: 16382065]

[2]
Sciscione AC, Ivester T, Largoza M, Manley J, Shlossman P, Colmorgen GHC. Acute pulmonary edema in pregnancy. Obstet Gynecol  2003; 101(3): 511-5.
 [http://dx.doi.org/10.1097/00006250-200303000-00016] [PMID: 12636955]

[3]
Baker K, Mitchell G, Thompson AG, Stieler G. Comparison of a basic lung scanning protocol against formally reported chest x-ray in the diagnosis of pulmonary oedema. Australas J Ultrasound Med  2013; 16(4): 183-9.
 [http://dx.doi.org/10.1002/j.2205-0140.2013.tb00245.x] [PMID: 28191195]

[4]
Nielsen LS, Svanegaard J, Wiggers P, Egeblad H. The yield of a diagnostic hospital dyspnoea clinic for the primary health care section. J Intern Med  2001; 250(5): 422-8.
 [http://dx.doi.org/10.1046/j.1365-2796.2001.00901.x] [PMID: 11887977]

[5]
Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis. Acad Emerg Med  2014; 21(8): 843-52.
 [http://dx.doi.org/10.1111/acem.12435] [PMID: 25176151]

[6]
Maw AM, Hassanin A, Ho PM, et al. Diagnostic accuracy of point-of-care lung ultrasonography and chest radiography in adults with symptoms suggestive of acute decompensated heart failure: A systematic review and meta-analysis. JAMA Netw Open  2019; 2(3): e190703.
 [http://dx.doi.org/10.1001/jamanetworkopen.2019.0703] [PMID: 30874784]

[7]
Perrone T, Maggi A, Sgarlata C, et al. Lung ultrasound in internal medicine: A bedside help to increase accuracy in the diagnosis of dyspnea. Eur J Intern Med  2017; 46: 61-5.
 [http://dx.doi.org/10.1016/j.ejim.2017.07.034] [PMID: 28793969]

[8]
Mumoli N, Vitale J, Giorgi-Pierfranceschi M, et al. Accuracy of nurse-performed lung ultrasound in patients with acute dyspnea: A prospective observational study. Medicine  2016; 95(9): e2925.
 [http://dx.doi.org/10.1097/MD.0000000000002925] [PMID: 26945396]

[9]
Vitturi N, Soattin M, Allemand E, Simoni F, Realdi G. Thoracic ultrasonography: A new method for the work-up of patients with dyspnea. J Ultrasound  2011; 14(3): 147-51.
 [http://dx.doi.org/10.1016/j.jus.2011.06.009] [PMID: 23396858]

[10]
Cibinel GA, Casoli G, Elia F, et al. Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department. Intern Emerg Med  2012; 7(1): 65-70.
 [http://dx.doi.org/10.1007/s11739-011-0709-1] [PMID: 22033792]

[11]
Wang Y, Shen Z, Lu X, Zhen Y, Li H. Sensitivity and specificity of ultrasound for the diagnosis of acute pulmonary edema: a systematic review and meta-analysis. Med Ultrason  2018; 1(1): 32-6.
 [http://dx.doi.org/10.11152/mu-1223] [PMID: 29400365]

[12]
Yang W, Wang Y, Qiu Z, et al. Lung ultrasound is accurate for the diagnosis of high-altitude pulmonary edema: A prospective study. Can Respir J  2018; 2018: 1-9.
 [http://dx.doi.org/10.1155/2018/5804942] [PMID: 30364105]

[13]
Macaskill P, Gatsonis P, Deeks JJ, Harbord R, Takwoingi Y. Analysing and presenting results. Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. The Cochrane Collaboration 2010.

[14]
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int J Surg  2010; 8(5): 336-41.
 [http://dx.doi.org/10.1016/j.ijsu.2010.02.007] [PMID: 20171303]

[15]
Desai D. Dev’s formulae for diagnostic test accuracy meta-analysis. medRxiv202303 2023.
 [http://dx.doi.org/10.1101/2023.03.27.23287186]

[16]
Prosen G, Klemen P, Štrnad M, Grmec Š. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care  2011; 15(2): R114.
 [http://dx.doi.org/10.1186/cc10140] [PMID: 21492424]

[17]
Gargani L, Frassi F, Soldati G, Tesorio P, Gheorghiade M, Picano E. Ultrasound lung comets for the differential diagnosis of acute cardiogenic dyspnoea: A comparison with natriuretic peptides. Eur J Heart Fail  2008; 10(1): 70-7.
 [http://dx.doi.org/10.1016/j.ejheart.2007.10.009] [PMID: 18077210]

[18]
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(12): 1331-4.
 [http://dx.doi.org/10.1007/s001340050771] [PMID: 9885889]

[19]
Öhman J, Harjola VP, Karjalainen P, Lassus J. Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department. Eur J Emerg Med  2019; 26(2): 112-7.
 [http://dx.doi.org/10.1097/MEJ.0000000000000499] [PMID: 28984662]

[20]
Pivetta E, Goffi A, Lupia E, et al. Lung ultrasound-implemented diagnosis of acute decompensated heart failure in the ED. Chest  2015; 148(1): 202-10.
 [http://dx.doi.org/10.1378/chest.14-2608] [PMID: 25654562]

[21]
Sartini S, Frizzi J, Borselli M, et al. Which method is best for an early accurate diagnosis of acute heart failure? Comparison between lung ultrasound, chest X-ray and NT pro-BNP performance: A prospective study. Intern Emerg Med  2017; 12(6): 861-9.
 [http://dx.doi.org/10.1007/s11739-016-1498-3] [PMID: 27401330]

[22]
Bekgoz B, Kilicaslan I, Bildik F, et al. BLUE protocol ultrasonography in Emergency Department patients presenting with acute dyspnea. Am J Emerg Med  2019; 37(11): 2020-7.
 [http://dx.doi.org/10.1016/j.ajem.2019.02.028] [PMID: 30819579]

[23]
Goradia E, Secko M, Cheng Y, et al. Comprehensive physical exam versus lung ultrasound for dyspneic patients in the emergency department. medRxiv 2022.
 [http://dx.doi.org/10.1101/2022.10.08.22280828]

[24]
Liteplo AS, Marill KA, Villen T, et al. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): Sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med  2009; 16(3): 201-10.
 [http://dx.doi.org/10.1111/j.1553-2712.2008.00347.x] [PMID: 19183402]

[25]
Volpicelli G, Mussa A, Garofalo G, et al. Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. Am J Emerg Med  2006; 24(6): 689-96.
 [http://dx.doi.org/10.1016/j.ajem.2006.02.013] [PMID: 16984837]

[26]
Torres-Macho J, Aro T, Bruckner I, et al. Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine. Eur J Intern Med  2020; 73: 67-71.
 [http://dx.doi.org/10.1016/j.ejim.2019.11.016] [PMID: 31836177]

[27]
Kimura BJ, Sliman SM, Waalen J, Amundson SA, Shaw DJ. Retention of ultrasound skills and training in “point-of-care” cardiac ultrasound. J Am Soc Echocardiogr  2016; 29(10): 992-7.
 [http://dx.doi.org/10.1016/j.echo.2016.05.013] [PMID: 27372559]

[28]
Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med  2012; 38(4): 577-91.
 [http://dx.doi.org/10.1007/s00134-012-2513-4] [PMID: 22392031]

[29]
Testa A, Soldati G, Copetti R, Giannuzzi R, Portale G, Gentiloni-Silveri N. Early recognition of the 2009 pandemic influenza A (H1N1) pneumonia by chest ultrasound. Crit Care  2009; 16(1): 1-30.
 [http://dx.doi.org/10.1186/cc11201]

[30]
Lichtenstein D, Mezière G, Biderman P, Gepner A. The comet-tail artifact: An ultrasound sign ruling out pneumothorax. Intensive Care Med  1999; 25(4): 383-8.
 [http://dx.doi.org/10.1007/s001340050862] [PMID: 10342512]

[31]
Mozzini C, Fratta Pasini AM, Garbin U, Cominacini L. Lung ultrasound in internal medicine: Training and clinical practice. Crit Ultrasound J  2016; 8(1): 10.
 [http://dx.doi.org/10.1186/s13089-016-0048-6] [PMID: 27501700]

[32]
Noble VE, Lamhaut L, Capp R, et al. Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. BMC Med Educ  2009; 9(1): 3.
 [http://dx.doi.org/10.1186/1472-6920-9-3] [PMID: 19138397]

[33]
Touw HR, Parlevliet KL, Beerepoot M, et al. Lung ultrasound compared with chest X-ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study. Anaesthesia  2018; 73(8): 946-54.
 [http://dx.doi.org/10.1111/anae.14243] [PMID: 29529332]

[34]
Yousefifard M, Baikpour M, Ghelichkhani P, et al. Screening performance characteristic of ultrasonography and radiography in detection of pleural effusion a meta-analysis. Emerg  2016; 4(1): 1-10.https://pubmed.ncbi.nlm.nih.gov/26862542

[35]
Chavez MA, Shams N, Ellington LE, et al. Lung ultrasound for the diagnosis of pneumonia in adults: A systematic review and meta-analysis. Respir Res  2014; 15(1): 50.
 [http://dx.doi.org/10.1186/1465-9921-15-50] [PMID: 24758612]

[36]
Alrajab S, Youssef AM, Akkus NI, Caldito G. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Crit Care  2013; 17(5): R208.
 [http://dx.doi.org/10.1186/cc13016] [PMID: 24060427]

[37]
Xia Y, Ying Y, Wang S, Li W, Shen H. Effectiveness of lung ultrasonography for diagnosis of pneumonia in adults: A systematic review and meta-analysis. J Thorac Dis  2016; 8(10): 2822-31.
 [http://dx.doi.org/10.21037/jtd.2016.09.38] [PMID: 27867558]

[38]
Sabuwala NM, Raval D, Parikh H, Saiyed F, Desai D. Diagnostic accuracy of MRI in diagnosing cardiac sarcoidosis: A meta-analysis. MedRXIV 2023.
 [http://dx.doi.org/10.1101/2023.04.29.23289313]

Cite As

Current Respiratory Medicine Reviews

Diagnostic Accuracy of Lung Ultrasonography Compared to Chest Radiography, BNP and Physical Examination in Patients with Dyspnea Suggestive of Pulmonary Edema: A Systematic Review and Meta-Analysis

Abstract