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Background: Many survivors of severe COVID-19 pneumonia experience lingering respiratory issues. There is limited research on follow-up chest imaging findings in patients with COVID-19 ARDS, particularly in relation to their mMRC dyspnea scores and pulmonary function tests (PFTs). This study addresses this gap by investigating the clinical characteristics, mMRC dyspnea scores, PFTs, and chest CT findings of COVID-19 ARDS patients at the 6 months post-recovery. By analyzing these variables together, we aim to gain a better understanding of the long-term health consequences of COVID-19 ARDS. Methods: This prospective observational study included 56 subjects with COVID-19 ARDS with dyspnea at the six-month follow-up visits. These patients were evaluated by chest CT, mMRC dyspnea scale, and PFT. The CT severity score was calculated individually for each of the four major imaging findings - ground glass opacities (GGOs), parenchymal/atelectatic bands, reticulations/septal thickening, and consolidation - using a modified CT severity scoring system. Statistics were carried out to find any association between individual CT chest findings and the mMRC dyspnea scale and forced vital capacity (FVC). p values < 0.05 were considered statistically significant. Results: Our study population had a mean age of 55.86 ± 9.60 years, with 44 (78.6%) being men. Grades 1, 2, 3, and 4 on the mMRC dyspnea scale were seen in 57.1%, 30.4%, 10.7%, and 1.8% of patients respectively. Common CT findings observed were GGOs (94.6%), reticulations/septal thickening (96.4%), parenchymal/atelectatic bands (92.8%), and consolidation (14.3%). The mean modified CT severity scores for GGOs, reticulations/septal thickening, parenchymal/atelectatic bands, and consolidation were 10.32 ± 5.51 (range: 0-21), 7.66 ± 4.33 (range: 0-19), 4.77 ± 3.03 (range: 0-14) and 0.29 ± 0.91 (range 0-5) respectively. Reticulations/septal thickening (p = 0.0129) and parenchymal/atelectatic bands (p = 0.0453) were associated with an increased mMRC dyspnea scale. Parenchymal/atelectatic bands were also associated with abnormal FVC (<80%) (p = 0.0233). Conclusion: Six-month follow-up chest CTs of COVID-19 ARDS survivors with persistent respiratory problems showed a statistically significant relationship between increased mMRC dyspnea score and imaging patterns of reticulations/septal thickening and parenchymal/atelectatic bands; while parenchymal/atelectatic bands also showed a statistically significant correlation with reduced FVC.
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COVID-19 , Dispneia , Testes de Função Respiratória , Tomografia Computadorizada por Raios X , Humanos , COVID-19/diagnóstico por imagem , COVID-19/complicações , Masculino , Feminino , Dispneia/diagnóstico por imagem , Dispneia/fisiopatologia , Pessoa de Meia-Idade , Estudos Prospectivos , Tomografia Computadorizada por Raios X/métodos , Pulmão/diagnóstico por imagem , Pulmão/fisiopatologia , SARS-CoV-2 , Idoso , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Síndrome do Desconforto Respiratório/fisiopatologia , Adulto , Índice de Gravidade de Doença , Capacidade VitalRESUMO
OBJECTIVES: To study the diagnostic performance of an ultrasound-based algorithm that includes the deceleration time (DT) of early mitral filling to establish a diagnosis of acute heart failure (AHF) in patients who come to an emergency department because of dyspnea. MATERIAL AND METHODS: Prospective analysis in a convenience sample of patients who came to a hospital emergency department with acute dyspnea. The algorithm included ultrasound findings and 4 echocardiographic findings as follows: mitral annular plane systolic excursion, Doppler mitral flow velocity, tissue Doppler imaging measure of the lateral annulus, and the DT of early mitral filling. The definitive diagnosis was made by 2 physicians blinded to each other's diagnosis and the ultrasound findings. RESULTS: A total of 166 adult patients with a mean (SD) age of 76 (13) years were included; 79 (48%) were women. AHF was the definitive diagnosis in 62 patients (37%). Diagnostic agreement was good between the 2 physicians (κ = 0.71). The algorithm classified all the patients, and there were no undetermined diagnoses. Diagnostic performance indicators for the ultrasound-based algorithm integrating early DT findings were as follows: area under the receiver operating characteristic curve, 0.91 (95% CI, 0.86-0.96); sensitivity, 87% (95% CI, 76%-94%); specificity, 95% (95% CI, 89%-98%); positive likelihood ratio, 18.1 (95% CI, 7.7-42.8); and negative likelihood ratio, 0.14 (95% CI, 0.07-0.26). CONCLUSION: The ultrasound-based algorithm integrating the DT of early mitral filling performs well for diagnosing AHF in emergency patients with dyspnea. The inclusion of early DT allows all patients to be diagnosed.
OBJETIVO: Analizar el rendimiento diagnóstico de un algoritmo ecográfico que incluye el tiempo de desaceleración precoz del flujo mitral (TD) para establecer el diagnóstico de insuficiencia cardiaca aguda (ICA) en pacientes que consultan en un servicio de urgencias hospitalario (SUH) por disnea. METODO: Análisis prospectivo de una muestra de conveniencia de pacientes que consultan por disnea aguda en un SUH. El algoritmo ecográfico incluyó la ecografía pulmonar y cuatro parámetros ecocardiográficos, se midió MAPSE (desplazamiento sistólico del plano del anillo mitral), medidas doppler de flujo mitral, medidas doppler tisular en el anillo mitral lateral y TD. El diagnóstico final fue asignado por 2 médicos ciegos entre sí y a los hallazgos ecográficos. RESULTADOS: Se incluyeron 166 pacientes adultos, la edad media fue de 76 años (DE 13) y 79 eran mujeres (48%). Hubo 62 pacientes (37%) con un diagnóstico final de ICA. La concordancia entre asignadores fue buena para el diagnóstico de ICA (κ = 0,71). El algoritmo clasificó a todos los pacientes, no hubo ningún diagnóstico indeterminado. El rendimiento diagnóstico del algoritmo mostró un área bajo la curva de 0,91 (IC 95%: 0,86-0,96), sensibilidad del 87% (IC 95%: 76%-94%), especificidad del 95% (IC 95%: 89%-98%), razón de verosimilitud positiva del 18,1 (IC 95%: 7,7-42,8), razón de verosimilitud negativa del 0,14 (IC 95%: 0,07-0,26). CONCLUSIONES: Un algoritmo ecográfico que incluye el TD tiene un buen rendimiento para el diagnóstico de ICA en pacientes que acuden a SUH por disnea. Además, el uso de TD permite clasificar a todos los pacientes.
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Serviço Hospitalar de Emergência , Insuficiência Cardíaca , Adulto , Humanos , Feminino , Idoso , Masculino , Ultrassonografia , Algoritmos , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Insuficiência Cardíaca/diagnóstico por imagemRESUMO
BACKGROUND: Differentiating cardiovascular causes of dyspnea in resource-limited healthcare settings can be challenging. The use of easy-to-train, point-of-care, focused cardiac ultrasound (FoCUS) protocols may potentially alleviate this challenge. RESEARCH QUESTION: Can novices attain competency in FoCUS use after training using the cardiac ultrasound for resource-limited settings (CURLS) protocol? METHODS: A quasi-experimental study was conducted at the Kenyatta National Hospital in Nairobi, Kenya. Forty-five graduate medical pre-interns, novices in cardiac ultrasound, received simulated didactic and hands-on FoCUS skills training using the CURLS protocol and 2018 European Association of Cardiovascular Imaging (EACVI) FoCUS training and competence assessment recommendations. Competency was assessed in image interpretation, image acquisition, and image quality. RESULTS: Aggregate image interpretation competency was attained by n = 38 (84%) of trainees with a median score of 80%. The proportion of trainees attaining category-specific image interpretation competency was as follows: pericardial effusion n = 44 (98%), left atrial enlargement n = 40 (89%), cardiomyopathy n = 38 (84%), left ventricular hypertrophy n = 37 (82%), and right ventricular enlargement n = 29 (64%). Image acquisition skills competency was attained by n = 36 (80%) of trainees. Three-quarters of trainee-obtained images were of good quality. CONCLUSION: Majority of the trainees attained competency. Training constraints limit the generalizability of our findings.
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Competência Clínica , Dispneia , Ecocardiografia , Humanos , Competência Clínica/estatística & dados numéricos , Dispneia/diagnóstico por imagem , Masculino , Feminino , Ecocardiografia/métodos , Quênia , Adulto , Cardiopatias/diagnóstico por imagem , Cardiopatias/complicações , Internato e Residência , Sistemas Automatizados de Assistência Junto ao LeitoAssuntos
Dispneia , Átrios do Coração , Humanos , Dispneia/etiologia , Dispneia/diagnóstico por imagem , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/fisiopatologia , Masculino , Tomografia Computadorizada por Raios X , Feminino , Dilatação Patológica , Cardiomegalia/diagnóstico por imagem , Cardiomegalia/etiologia , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/etiologiaRESUMO
This methodological study aimed to validate the cardiac output (CO) measured by exercise-stress real-time phase-contrast cardiovascular magnetic resonance imaging (CMR) in patients with heart failure and preserved ejection fraction (HFpEF). 68 patients with dyspnea on exertion (NYHA ≥ II) and echocardiographic signs of diastolic dysfunction underwent rest and exercise stress right heart catheterization (RHC) and CMR within 24 h. Patients were diagnosed as overt HFpEF (pulmonary capillary wedge pressure (PCWP) ≥ 15mmHg at rest), masked HFpEF (PCWP ≥ 25mmHg during exercise stress but < 15mmHg at rest) and non-cardiac dyspnea. CO was calculated using RHC as the reference standard, and in CMR by the volumetric stroke volume, conventional phase-contrast and rest and stress real-time phase-contrast imaging. At rest, the CMR based CO showed good agreement with RHC with an ICC of 0.772 for conventional phase-contrast, and 0.872 for real-time phase-contrast measurements. During exercise stress, the agreement of real-time CMR and RHC was good with an ICC of 0.805. Real-time measurements underestimated the CO at rest (Bias:0.71 L/min) and during exercise stress (Bias:1.4 L/min). Patients with overt HFpEF had a significantly lower cardiac index compared to patients with masked HFpEF and with non-cardiac dyspnea during exercise stress, but not at rest. Real-time phase-contrast CO can be assessed with good agreement with the invasive reference standard at rest and during exercise stress. While moderate underestimation of the CO needs to be considered with non-invasive testing, the CO using real-time CMR provides useful clinical information and could help to avoid unnecessary invasive procedures in HFpEF patients.
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Débito Cardíaco , Teste de Esforço , Insuficiência Cardíaca , Valor Preditivo dos Testes , Volume Sistólico , Função Ventricular Esquerda , Humanos , Feminino , Masculino , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/diagnóstico por imagem , Idoso , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Cateterismo Cardíaco , Imagem Cinética por Ressonância Magnética , Fatores de Tempo , Dispneia/fisiopatologia , Dispneia/etiologia , Dispneia/diagnóstico por imagem , Função Ventricular DireitaRESUMO
BACKGROUND: Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation. METHODS: We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status. RESULTS: In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97). Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%). CONCLUSION: The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis.
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Hemoptise , Neoplasias Pulmonares , Humanos , Hemoptise/diagnóstico por imagem , Hemoptise/etiologia , Estudos Retrospectivos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/diagnóstico por imagem , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Atenção Primária à SaúdeRESUMO
PURPOSE: This study aimed to determine the association between functional impairment in small airways and symptoms of dyspnea in patients with Long-coronavirus disease (COVID), using imaging and computational modeling analysis. PATIENTS AND METHODS: Thirty-four patients with Long-COVID underwent thoracic computed tomography and hyperpolarized Xenon-129 magnetic resonance imaging (HP Xe MRI) scans. Twenty-two answered dyspnea-12 questionnaires. We used a computed tomography-based full-scale airway network (FAN) flow model to simulate pulmonary ventilation. The ventilation distribution projected on a coronal plane and the percentage lobar ventilation modeled in the FAN model were compared with the HP Xe MRI data. To assess the ventilation heterogeneity in small airways, we calculated the fractal dimensions of the impaired ventilation regions in the HP Xe MRI and FAN models. RESULTS: The ventilation distribution projected on a coronal plane showed an excellent resemblance between HP Xe MRI scans and FAN models (structure similarity index: 0.87 ± 0.04). In both the image and the model, the existence of large clustered ventilation defects was not identifiable regardless of dyspnea severity. The percentage lobar ventilation of the HP Xe MRI and FAN model showed a strong correlation (ρ = 0.63, P < 0.001). The difference in the fractal dimension of impaired ventilation zones between the low and high dyspnea-12 score groups was significant (HP Xe MRI: 1.97 [1.89 to 2.04] and 2.08 [2.06 to 2.14], P = 0.005; FAN: 2.60 [2.59 to 2.64] and 2.64 [2.63 to 2.65], P = 0.056). CONCLUSIONS: This study has identified a potential association of small airway functional impairment with breathlessness in Long-COVID, using fractal analysis of HP Xe MRI scans and FAN models.
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Síndrome de COVID-19 Pós-Aguda , Isótopos de Xenônio , Humanos , Pulmão/diagnóstico por imagem , Pulmão/patologia , Respiração , Imageamento por Ressonância Magnética/métodos , Dispneia/diagnóstico por imagemRESUMO
BACKGROUND: Persistent dyspnea is frequent in post-COVID patients, even in the absence of pulmonary embolism (PE). In this scenario, the role of lung perfusion scintigraphy is unclear. The present study correlated scintigraphy-based semiquantitative perfusion parameters with chest high-resolution computed tomography (hrCT) volumetric indexes and clinical data in post-COVID patients with persistent dyspnea. RESEARCH DESIGN AND METHODS: Sixty patients (30 post-COVID and 30 not previously affected by COVID-19) with persistent dyspnea submitted to lung perfusion scintigraphy and hrCT were retrospectively recruited. Perfusion rates of the pulmonary fields and hrCT-based normalized inflated, emphysematous, infiltrated, collapsed, and vascular lung volumes were calculated. Inflammatory and coagulation biomarkers were collected. PE at imaging was an exclusion criterion. RESULTS: Compared to controls, reduced perfusion rates of the lower pulmonary fields and higher perfusion rates of the middle ones were observed in post-COVID patients, while hrCT findings were superimposable between the two groups. Perfusion rates of lower pulmonary fields were significantly associated only with abnormal lung volumes at hrCT. CONCLUSIONS: In post-COVID dyspnea without PE, lung perfusion scintigraphy may reveal a pulmonary involvement not detectable by hrCT. Post-COVID patients may show decreased perfusion rates of lower pulmonary fields in the presence of normal vascular density and markers of inflammation/coagulation.
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COVID-19 , Embolia Pulmonar , Humanos , Estudos Retrospectivos , COVID-19/complicações , COVID-19/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem , Imagem de Perfusão/métodos , Dispneia/diagnóstico por imagem , Dispneia/etiologia , PerfusãoRESUMO
BACKGROUND: A proportion of coronavirus disease 2019 (COVID-19) survivors experience persistent dyspnoea without measurable impairments in lung function. We performed a systematic review and meta-analysis to determine relationships between dyspnoea and imaging abnormalities over time in post-COVID-19 patients. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we analysed studies published prior to 15 September 2022 and indexed by Google Scholar, PubMed and LitCOVID which assessed chest imaging in adults ≥3â months after COVID-19. Demographic, chest imaging, spirometric and post-COVID-19 symptom data were extracted. The relationships between imaging abnormalities and dyspnoea, sex and age were determined using a random effects model and meta-regression. RESULTS: 47 studies were included in the meta-analysis (n=3557). The most prevalent computed tomography (CT) imaging abnormality was ground-glass opacities (GGOs) (44.9% (95% CI 37.0-52.9%) at any follow-up time-point). Occurrence of reticulations significantly decreased between early and late follow-up (p=0.01). The prevalence of imaging abnormalities was related to the proportion of patients with dyspnoea (p=0.012). The proportion of females was negatively correlated with the presence of reticulations (p=0.001), bronchiectasis (p=0.001) and consolidations (p=0.025). Age was positively correlated with imaging abnormalities across all modalities (p=0.002) and imaging abnormalities present only on CT (p=0.001) (GGOs (p=0.004) and reticulations (p=0.001)). Spirometric values improved during follow-up but remained within the normal range at all time-points. CONCLUSIONS: Imaging abnormalities were common 3â months after COVID-19 and their occurrence was significantly related to the presence of dyspnoea. This suggests that CT imaging is a sensitive tool for detecting pulmonary abnormalities in patients with dyspnoea, even in the presence of normal spirometric measurements.
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COVID-19 , Pneumopatias , Adulto , Feminino , Humanos , SARS-CoV-2 , Pulmão/diagnóstico por imagem , Dispneia/diagnóstico por imagem , Dispneia/etiologiaRESUMO
Following the COVID-19 pandemic, a growing percentage of COVID-19 survivors exhibit post-COVID symptoms. This cross-sectional study aimed to assess radiological findings in individuals having post-COVID respiratory problems. This study was conducted in the Departments of Radiology and Imaging and Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from November 2021 to June 2022 and included 30 COVID survivors aged 40 to 65 years. We employed a pre-tested semi-structured questionnaire including socio-demographic information, clinical data and CT chest imaging parameters. Pearson's correlation coefficient was calculated, as well as multiple linear regressions. Among 30 participants, 56.0% were male. The mean age of the respondents was 51.20 years (standard deviation of 7.09), ranging from 40 to 65 years. Approximately one-third of the participants had at least one co-morbid condition where hypertension (26.67%), diabetes (26.67%), chronic interstitial lung disease (16.67%) and obesity (16.67%) were most commonly recorded. Approximately 20.0% of participants were smokers. The incident of at least one post-COVID symptom was 100.0%. Approximately 73.0% presented with post-COVID lethargy, 16.67% with SoB (Shortness of Breath), and 90.0% of participants complaint of self-reported anxiety. We have found a positive correlation between age and overall lung involvement. The most common lung tomographic findings were fibrosis (93.0%) and diffuse ground glass opacity (70.0%). Interstitial lung thickening was found in 50.0% of cases and bronchiectasis accounted for 16.67%. In 6.6% of cases, there was no pulmonary lesion. It was notifiable that, with time, the feature of DGGO (diffuse ground glass opacity) became subtle and the total lung involvement decreased from 75.0% to about 25.0% during the post-COVID period. Timely assessment for post-COVID pulmonary sequelae by high-resolution CT chest scan might play an important role in modulating a treatment plan for patients suffering from the post-COVID syndrome.
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COVID-19 , Radiologia , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Bangladesh/epidemiologia , Estudos Transversais , Pandemias , COVID-19/complicações , COVID-19/diagnóstico por imagem , Dispneia/diagnóstico por imagem , Dispneia/epidemiologia , Dispneia/etiologiaRESUMO
BACKGROUND: HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the incremental prognostic value of CPET for the HFA-PEFF score among patients with unexplained dyspnea with preserved ejection fraction (EF). METHODS: Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography in the left ventricle, left atrium and right ventricle. The primary outcome was defined as a composite cardiovascular event including cardiovascular-related mortality, acute recurrent heart failure hospitalization, urgent repeat revascularization/myocardial infarction or any hospitalization due to cardiovascular events. RESULTS: The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2-4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO2 slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure were independently associated with composite cardiovascular events. Furthermore, the addition of VE/VCO2 and HFA-PEFF to the base model showed incremental prognostic value for predicting composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement 0.129, p = 0.032; net reclassification improvement 1.043, p ≤ 0.001). CONCLUSIONS: CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic value and diagnosis among patients with unexplained dyspnea with preserved EF.
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Insuficiência Cardíaca , Função Ventricular Esquerda , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Feminino , Volume Sistólico/fisiologia , Insuficiência Cardíaca/diagnóstico , Prognóstico , Teste de Esforço/métodos , Dispneia/diagnóstico por imagem , Dispneia/complicaçõesRESUMO
Reduced lung diffusing capacity for carbon monoxide (DLCO) at rest and increased ventilation (â©E)-carbon dioxide output (â©CO2) during exercise are frequent findings in dyspneic smokers with largely preserved FEV1. It remains unclear whether low DLCO and high â©E-â©CO2 are mere reflections of alveolar destruction (i.e. emphysema) or impaired pulmonary perfusion in non-emphysematous tissue contributes to these functional abnormalities. Sixty-four smokers (41 males, FEV1= 84 ± 13%predicted) underwent pulmonary function tests, an incremental exercise test, and quantitative chest computed tomography. Total pulmonary vascular volume (TPVV) was calculated for the entire segmented vascular tree (VIDA Vision™). Using the median % low attenuation area (-950 HU), participants were dichotomized into "Trace" or "Mild" emphysema (E), each group classified into preserved versus reduced DLCO. Within each emphysema subgroup, participants with abnormally low DLCO showed lower TPVV, higher â©E-â©CO2, and exertional dyspnea than those with preserved DLCO (p < 0.05). TPVV (r = 0.34; p = 0.01), but not emphysema (r = -0.05; p = 0.67), correlated with lower DLCO after adjusting for age and height. Despite lower emphysema burden, Trace-E participants with reduced DLCO had lower TPVV, higher dyspnea, and lower peak work rate than the Mild-E with preserved DLCO (p < 0.05). Interestingly, TPVV (but not emphysema) correlated inversely with both dyspnea-work rate (r = -0.36, p = 0.004) and dyspnea-â©E slopes (r = -0.40, p = 0.001). Reduced pulmonary vascular volume adjusted by emphysema extent is associated with low DLCO and heightened exertional ventilation in dyspneic smokers with minor emphysema. Impaired perfusion of non-emphysematous regions of the lungs has greater functional and clinical consequences than hitherto assumed in these subjects.
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Doença Pulmonar Obstrutiva Crônica , Enfisema Pulmonar , Masculino , Humanos , Fumantes , Capacidade de Difusão Pulmonar , Enfisema Pulmonar/complicações , Enfisema Pulmonar/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy. METHODS: Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea. RESULTS: In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%). CONCLUSION: Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure. TRIAL REGISTRATION: Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 .
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Asma , Insuficiência Cardíaca , Doença Pulmonar Obstrutiva Crônica , Adulto , Humanos , Estudos Prospectivos , Serviço Hospitalar de Emergência , Sistemas Automatizados de Assistência Junto ao Leito , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Ultrassonografia , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Asma/complicações , Asma/diagnóstico , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico por imagemRESUMO
HISTORY: A 45-year-old woman presented to the emergency department of an outside hospital with shortness of breath and cough. Five days after initial presentation, the patient presented again to the same emergency department with worsening headache and progressive left arm and left leg weakness. She was transferred to the neuroscience intensive care unit of our hospital with concern for an intracranial abnormality based on her work-up at the outside hospital. Her past medical history was notable only for a large uterine fibroid. In our hospital, CT of the brain and chest (Figs 1, 2) and MRI of the brain, including perfusion studies (Figs 3, 4), were performed. Additionally, CT venography of the brain was performed (Fig 5).
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Dispneia , Feminino , Humanos , Pessoa de Meia-Idade , Dispneia/diagnóstico por imagemRESUMO
The objective of this study was to determine whether echocardiographic views adapted for lung evaluation may aid in diagnosis of dyspnea in dogs. Fifteen chronic valvular heart disease (CVHD) dogs without cardiac remodeling, 30 CVHD dogs with cardiac remodeling, 15 CVHD dogs with cardiogenic pulmonary edema and 15 dogs with pulmonary disease were prospectively enrolled. Loop recordings of pericardial-lung ultrasound were gathered during echocardiographic evaluation, and four videos of 4 different adapted views were recorded for each dog. Chest X-rays were used as reference-standard for pulmonary edema and/or disease. The videos were classified based on the number of B- lines as NEGATIVE (0, 1, 2 or 3) or POSITIVE (> 3 or confluent). Accuracy of a POSITIVE classification in identifying pulmonary edema and/or disease was calculated. Multivariate analyses were performed using echocardiographic variables that reflect increased left ventricular filling pressure (LVFP) to distinguish pulmonary edema from disease. Results showed that a POSITIVE classification distinguished dogs with pulmonary edema or disease from asymptomatic CVHD dogs in all four views. The best views were right parasternal short axis at papillary muscle level and long axis 4- chamber view, both with the same sensitivity (86.7%) and a specificity of 95.6% and 82.2%, respectively. Multivariate analyses showed that adding cutoff values of peak E wave > 130, E/IVRT > 2.5 or LA/Ao > 2.0 distinguished pulmonary edema from disease with 100% specificity. In conclusion, echocardiographic views adapted for lung evaluation, in addition to conventional echocardiography, may help identify the cause of dyspnea in dogs.
Assuntos
Doenças do Cão , Dispneia , Edema Pulmonar , Cães , Animais , Edema Pulmonar/diagnóstico por imagem , Edema Pulmonar/veterinária , Remodelação Ventricular , Ecocardiografia/veterinária , Ecocardiografia/métodos , Pulmão/diagnóstico por imagem , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Dispneia/veterinária , Doenças do Cão/diagnóstico por imagemRESUMO
AIM: To assess the performance of a "triple-low" free-breathing protocol for computed tomography pulmonary angiography (CTPA) evaluated on patients with dyspnoea and suspected pulmonary embolism and discuss its application in routine clinical practice for the study of the pulmonary parenchyma and vasculature. MATERIAL AND METHODS: This study was conducted on a selected group of dyspnoeic patients referred for CTPA. The protocol was designed using fast free-breathing acquisition and a small, fixed volume (35 ml) of contrast agent in order to achieve a low-exposure dose. For each examination, radiodensity of the pulmonary trunk and ascending aorta, and the dose-length product (DLP) were recorded. A qualitative analysis was performed of pulmonary arterial enhancement and the pulmonary parenchyma. RESULTS: This study included 134 patients. Contrast enhancement of the pulmonary arteries (409 ± 159 HU) was systematically >250 HU. The duration of acquisition ranged from 0.9 to 1.3 seconds for free-breathing imaging. The mean DLP was in the range of low-dose chest CT acquisitions (145 ± 73 mGy·cm). The analysis was deemed optimal in 90% (120/134) of cases for the pulmonary parenchyma. Sixty-nine per cent (92/134) of cases demonstrated homogeneous enhancement of the pulmonary arteries to the subsegmental level. Only 6% (8/134) of examinations were considered uninterpretable. CONCLUSION: The present "triple-low" CTPA protocol allows convenient analysis of the pulmonary parenchyma and arteries without hindrance by respiratory motion artefacts in dyspnoeic patients.
Assuntos
Embolia Pulmonar , Humanos , Angiografia/métodos , Meios de Contraste , Dispneia/diagnóstico por imagem , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodosRESUMO
AN APPRECIATION of the utility of echocardiographic Doppler spectral profile analysis in diagnosing cardiac pathology and guiding surgical intervention more than justifies an investment in obtaining proficiency in these skills. Given the relatively low incidence of significant complications associated with transesophageal echocardiographic examination, the facile use of both spectral and color Doppler principles to diagnose unusual pathology is essential. Doppler modalities are used to characterize blood flow, pressure gradients, chamber dimensions, and other anatomic and physiological parameters. The authors present a case in which several Doppler principles were used to evaluate and diagnose the etiology of dyspnea and a high aortic valve gradient.
Assuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Ecocardiografia Doppler/métodos , Ecocardiografia Transesofagiana/métodos , Coração , HumanosRESUMO
Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.