Tag: Pneumothorax

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Does adding M-mode to B-mode improve accuracy in diagnosing pneumothorax?

Background

Ultrasound has been shown to be superior to supine chest x-ray in the diagnosis of pneumothorax, with one recent systematic review demonstrating 91% sensitivity using ultrasound compared to 50% using chest x-ray.1 CT scan remains the gold standard in diagnosis but is often not feasible in unstable trauma patients. Ultrasound is recommended by ATLS guidelines for use in trauma patients as part of the eFAST protocol. There are three main described ultrasound findings in pneumothorax: lung sliding, B-lines, and the lung point. While B-mode (2D mode) is commonly described, many resources also suggest the use of M-mode (motion mode).

 

This study evaluates whether the addition of M-mode to B-mode impacts the sensitivity, specificity, and accuracy of bedside ultrasound in the diagnosis of lung sliding. Previous studies have evaluated the accuracy of M-mode on cadaveric subjects2, but no previous studies have investigated the accuracy of M-mode + B-mode compared to B-mode alone in live human subjects.

Does adding M-mode to B-mode improve accuracy in diagnosing pneumothorax?

Avila, J et al. Does the Addition of M-Mode to B-Mode Ultrasound Increase the Accuracy of Identification of Lung Sliding in Traumatic Pneumothoraces?. J Ultrasound Med, 37: 2681-2687   

Clinical Question

Does the addition of M-mode to B-mode improve accuracy in identifying lung sliding? Does this vary by ultrasound experience and level of training?

Methods & Study Design

Design:
Survey

Population:
Emergency Physicians including residents, fellows, and attending physicians

Intervention:
Hemithorax anterior lung field ultrasound scans were performed on 15 patients who had a unilateral pneumothorax confirmed by CT scan. B-mode and corresponding M-mode images were obtained for each patient, with one scan on each side, producing scans of 30 lungs. These images were incorporated into a 30-question quiz in which respondents were asked to identify the presence or absence of lung sliding. One version of the quiz contained B-mode clips alone and one version contained B-mode and M-mode clips for each lung. Respondents were randomized to one of the two quizzes. The quiz was sent to EM residency directors for distribution. One hundred forty physicians responded and were randomized.

Outcomes:
Sensitivity, specificity, and accuracy of the diagnosis of lung sliding, and association with respondent ultrasound experience and level of training.

Results

Overall, the addition of M-Mode to B-Mode resulted in unchanged sensitivity, 93.1% vs 93.2%, improved specificity from 89.8% to 96% (P < 0.0001), and improved accuracy from 91.5% to 94.5% (p=0.0091).

In subgroup analysis, there was no significant difference in accuracy, sensitivity, or specificity when adding M-mode for physicians with more than 250 ultrasound scans previously performed. For physicians with less than 250 total scans previously performed, use of B-mode + M-mode increased accuracy from 88.2% to 94.4% (P = 0.001) and increased specificity from 87.0% to 97.2% (P < 0.0001) compared with B-mode alone. For resident physicians, the addition of M-mode to B-mode significantly improved accuracy from 89.6% to 94.6% (P = 0.0016) and specificity from 87.9% to 95.9% (P < 0.001) for resident physicians. There was no significant improvement for fellows and attending physicians.

Strengths and Limitations

Strengths:

The authors describe methods in detail, including how the ultrasound scans were performed, number of sites scaned, and the type of machine, probe, and settings used. They also collected detailed information on level of ultrasound experience which helps generalize results among emergency physicians with varying levels of ultrasound experience. Ultrasound results were compared to the gold standard of CT scan.

Limitations:

The survey was sent out to residency program directors to distribute to residents, fellows, and attendings, which excludes the large number of practicing emergency physicians in the community. Community physicians may have different levels of experience and formal training with ultrasound and would be an important group to include in terms of study generalizability. Additionally, the sample size was relatively small (140 total participants) and included many more residents (92) than fellows/attendings (48). The images used also did not capture the absence or presence of B-lines, which could also impact interpretation and management. This study evaluated interpretation only and did not evaluate image acquisition, which could impact the outcomes measured and would be more helpful for practical application. Finally, there may be a difference in clinical significance between pneumothorax diagnosed with x-ray or bedside ultrasound versus CT scan– CT may identify more smaller and less clinically relevant pneumothoraces which may be missed on ultrasound.

Author's Conclusions

“The addition of M-mode images to B-mode clips aids in the accurate diagnosis of lung sliding by emergency physicians. The subgroup analysis showed that the benefit of M-mode US disappears after emergency physicians have performed more than 250 US examinations.”

Our Conclusions

The addition of M-mode to B-mode can improve accuracy in identifying lung sliding when evaluating for pneumothorax when performed by emergency physicians with less training or ultrasound experience. Given this benefit, more junior physicians could be encouraged to add M-mode to their evaluation for pneumothorax, especially as the additional image acquisition required is relatively quick.

The Bottom Line 

Adding M-mode to B-mode when using ultrasound to evaluate for pneumothorax improved accuracy amongst emergency physicians with less US experience.

Authors

This post was written by Julie Westover, MS4 at UCSD School of Medicine, with editing by Ben Liotta, MD and Amir Aminlari, MD. 

References

Avila, J., Smith, B., Mead, T., Jurma, D., Dawson, M., Mallin, M. and Dugan, A. (2018), Does the Addition of M-Mode to B-Mode Ultrasound Increase the Accuracy of Identification of Lung Sliding in Traumatic Pneumothoraces?. J Ultrasound Med, 37: 2681-2687. https://doi.org/10.1002/jum.14629

1. Alrajhi K, Woo MY, Vaillancourt C. Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and analysis. Chest 2012; 141:703–708.
2. Adhikari S, Zeger W, Wadman M, Walker R, Lomneth C. Assessment of a human cadaver model for training emergency medicine res- idents in the ultrasound diagnosis of pneumothorax. Biomed Res Int 2014; 2014:724050

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Comparison of Four Views to Single-View Ultrasound Protocols to Identify Clinically Significant Pneumothorax

Background

Ultrasound has become a key adjunct for the initial evaluation of trauma patients in the emergency department (ED), with the eFAST, or extended focused assessment with sonography in trauma examination, including lung evaluation for the presence of a pneumothorax (PTX) or hemothorax. While prior research has shown ultrasound (US) to be very effective at identifying a PTX [1], there is no standardized imaging protocol that has been shown be superior to others. The two most common approaches are a single view of each hemithorax and four views of each hemithorax [2] —this paper sets out to determine if the single view strategy is sufficient to identify a clinically significant PTX.

Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax

 

Clinical Question

Does the single-view or four-view lung US technique have a higher diagnostic accuracy for the identification of clinically significant PTX in trauma patients?

Methods & Study Design

  • Population
    • The study was conducted at a single urban academic ED with an annual volume of 130,000 patients and a dedicated Level I trauma service staffed by trauma surgeons and EM physicians. Adult patients with acute traumatic injury who were undergoing a CT scan of the chest as part of their clinical care were eligible for enrollment.
  • Intervention
    • Patients were assigned to one of two imaging protocols, a single view of each hemithorax or four views of each hemithorax prior to any CT imaging being done, with US images obtained by emergency physicians or the attending trauma surgeon using a 7.5-Mhz (5- to 10-MHz) linear array transducer. US exams were performed by both residents and attending physicians who had been credentialed in both US protocols.
  • Outcomes
    • Researchers looked for the ability of US to identify clinically significant PTX requiring chest tube placement; a PTX was considered clinically insignificant if the radiologist, who was blinded to the US interpretation, read the CT scan as a thin collection of air up to 1 cm thick in the greatest slice or seen on fewer than five contiguous slices.
  • Design
    • This was a randomized, prospective trial on trauma patients.
  • Excluded
    • The study excluded any patient who was too unstable and required clinical care that prevented performing a chest wall US, patients with a chest tube in place prior to arrival, children, pregnant women, and prisoners.

Results

    • For clinically significant PTX, CXR showed a sensitivity of 48.0% and specificity of 100%, a single view US showed a sensitivity of 93.0% and a specificity of 99.2%, and four views showed a sensitivity of 93.3% and specificity of 98.0%. There was no statistically significant difference in either sensitivity or specificity when comparing single view and four-view for clinically significant or any PTX.

Strengths & Limitations

  • Strengths
    • Randomized, prospective trial
    • 100% agreement between the initial US read by the performing provider and the study author, for a Cohen’s kappa of 1
  • Limitations
    • Study was conducted at a single center with a limited number of US operators
    • Standard prehospital approach to spinal immobilization that results in placement of patients supine on a long board - in areas where this approach may differ (e.g., patients arrive semirecumbent or upright), the positioning of a PTX in the chest may be altered, rendering a single view of the anterior chest wall less accurate
    • As this study was a convenience sample that required the treating physician to remember to enroll the patient and randomize them prior to performing the US, there is a possibility of selection bias

Author's Conclusions

"The sensitivities are equivalent for both a single view and four views of each hemithorax when using point-of-care ultrasound to evaluate for a clinically significant pneumothorax in the trauma population.  The additional time required for additional views should be weighed against the lack of additional diagnostic accuracy when evaluating critically ill and time-sensitive trauma patients in the ED."

Our Conclusions

Although not all PTXs are located anteriorly and multiple views of each hemithorax may be thought to maximize sensitivity and/or allow the physician to be able to attempt to quantify the size of the PTX, performing eight views instead of two views during the eFAST requires extra time while adding no diagnostic value.  From this study, it appears that a single view on each side of the thorax is sufficient to detect clinically significant PTXs on trauma patients.

As with any diagnostic tool, it is important to remember its limitations. Specifically, the US exams in this study were done in supine patients, who were brought in by EMS in a supine position, allowing the pneumothorax to move to the most anterior portion of the chest. Caution should be taken when applying the test characteristics of this study to patients that are not in the supine position. There was also one patient who had a significant PTX that was missed by US and required a chest tube. This patient had received a needle decompression by prehospital providers and was randomized to a single anterior US chest view that was performed just lateral to the needle insertion site which may have led to false negative US exam. It appears this specific group of patients may benefit from a more comprehensive four-view lung examination.

 

The Bottom Line

A single anterior view on each side of the chest in a supine patient is sufficient to detect clinically significant pneumothoraces.

Authors

This post was written by Ben Foorman, MS4 at UCSF. It was edited by Michael Macias, MD.

References

    1. Lichtenstein DA, e. (2017). Ultrasound diagnosis of occult pneumothorax. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/15942336
    2. Blaivas M, e. (2017). A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/16141018
    3. Helland G, e. (2017). Comparison of Four Views to Single-view Ultrasound Protocols to Identify Clinically Significant Pneumothorax. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 28 July 2017, from https://www.ncbi.nlm.nih.gov/pubmed/27428394
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