藉由在病床邊使用超音波 研究醫師可以指出肺栓塞位置


  【24drs.com】根據一篇單一中心研究的結果,對於懷疑患有肺栓塞的患者,肺部與重症照護研究醫師與專責主治醫師可以使用具有可接受之精準度的快速照護現場超音波。
  
  領銜研究者、紐約市西奈山貝斯以色列醫院的Jason Filopei醫師表示,坦白地說,透過最少的培訓,研究醫師就可以做得相當不錯。
  
  同樣來自西奈山貝斯以色列醫院的資深研究者Samuel Acquah醫師表示,通常,是由心臟科醫師完成這項檢查,但是不一定找得到心臟科醫師執行;那麼,你要如何能夠安全、快速地執行它,且隨時都可以操作呢?這就是需要訓練精於這些操作的學員之處。
  
  他報告指出,藉由一些基本訓練,研究醫師可以準確地執行檢測。
  
  但是,並非所有人都同意。義大利Varese Insubria大學血栓栓塞性疾病和抗栓塞治療研究中心的Alessandro Squizzato博士表示,我不同意這些結論;在這篇研究中,充分訓練之肺部與重症照護研究醫師的準確度仍未臻理想。
  
  研究結果以壁報方式發表於「CHEST 2016:美國胸腔科醫師學院年會」。
  
  在這篇研究中,由完成3天現場超音波介紹課程的肺部與重症照護研究醫師進行病床邊超音波。
  
  Filopei醫師解釋,研究醫師在病床邊評估了60名患者的右心室大小與功能。
  
  為了比較,所有患者也進行了經胸壁心超—由超音波專家執行,並由委員會認證的心臟科醫師分析。
  
  另外,44例病床邊超音波檢查由有5年以上超音波經驗的肺部與重症照護主治醫師進行。
  
  與由超音波專家進行的經胸壁心超進行準確度比較時,Filopei醫師報告指出,肺部與重症照護研究醫師的診斷準確度是可接受的,合併敏感度與專一度時,他們的整體正確診斷率約為80%。
  
  他指出,專責主治醫師做得更好,在許多案例,準確度大於90%。
  
  但是,根據Squizzato醫師指出—參與了最近一篇照護現場超音波用於肺栓塞之研究(Crit Ultrasound J. 2015;7:7) —敏感度93%意謂著7%的偽陰性比率,專一度86%意謂著14%的偽陽性比率。
  
  他表示,這是過高的偽陽性與偽陰性,就我的觀點,對於肺栓塞這個潛在致命的疾病,這是不可接受的。
  
  Filopei醫師指出,但是,時機是其中一個重要的考慮因素。
  
  他解釋,對於急性肺栓塞患者,最初24小時的死亡風險最高;平均而言,現場超音波可以比經胸壁心超提早一天進行,平均時間差達25小時31分鐘。
  
  Filopei醫師表示,這是一個可行的選擇,當你週遭沒有超音波專家可以適當地進行風險分類,但是你現場有受過充分訓練、足以執行的一些人力時,專責主治醫師與肺部研究醫師可以安全地執行它且有高度準確度。
  
  資料來源:http://www.24drs.com/
  
  Native link:With Bedside Ultrasound, Fellows Can Spot Pulmonary Embolism

With Bedside Ultrasound, Fellows Can Spot Pulmonary Embolism

By Kate Johnson
Medscape Medical News

LOS ANGELES — For patients suspected of having pulmonary embolism, pulmonary and critical care fellows and intensivists can use rapid point-of-care ultrasound with acceptable accuracy, according to results from a single-center study.

"In all honesty, with minimal training, fellows can do a pretty good job," said lead investigator Jason Filopei, MD, from Mount Sinai Beth Israel Hospital in New York City.

"Normally, the exam is done by cardiologists, who are not routinely available. So how can you do it safely and quickly and have it available all the time? That's where having trainees who are adept at doing the procedure comes in," said senior investigator Samuel Acquah, MD, also from Mount Sinai Beth Israel Hospital.

"With some basic training, fellows are able to perform the test appropriately," he reported.

But not everyone agrees. "I would definitely downgrade these conclusions," said Alessandro Squizzato, MD, PhD, from the Research Center on Thromboembolic Disorders and Antithrombotic Therapies at the University of Insubria in Varese, Italy.

"The accuracy of well-trained pulmonary and critical care fellows in this study is still suboptimal," he told Medscape Medical News.

The findings were presented as a poster here at CHEST 2016: American College of Chest Physicians Annual Meeting.

In the study, bedside ultrasound was performed by pulmonary and critical care fellows who had attended a 3-day introductory course on point-of-care ultrasound.

The fellows evaluated right ventricular size and function at the bedsides of 60 patients, explained Dr Filopei.

For comparison, all patients also underwent a transthoracic echocardiogram performed by an expert sonographer, which was analyzed by a board-certified cardiologist.

In addition, 44 of the bedside ultrasound examinations were available for overread by a pulmonary and critical care attending physician who had more than 5 years of ultrasound experience.

In comparison with the accuracy of transthoracic echocardiography performed by an expert sonographer, "the diagnostic accuracy of pulmonary and critical care fellows was acceptable," Dr Filopei reported. "They're hitting diagnostic accuracies of about 80% overall, when you combine sensitivity and specificity."

"And intensivists did much better," he added, with accuracies of "greater than 90% in many cases."

For pulmonary embolism, a potentially fatal disease, this is not acceptable. Dr Alessandro Squizzato

But according to Dr Squizzato — who was involved in a recent study of point-of-care ultrasound for the diagnosis of pulmonary embolism (Crit Ultrasound J. 2015;7:7) — "a sensitivity of 93% means a 7% false-negative rate, and a specificity of 86% means a 14% false-positive rate."

That is "too many false positives and false negatives," he said. "For pulmonary embolism, a potentially fatal disease, this is not acceptable from my point of view."

But timing is an important consideration in the equation, Dr Filopei pointed out.

"For acute pulmonary embolism patients, risk of death is greatest in the first 24 hours. On average, point-of-care ultrasound was performed 1 day earlier than transthoracic echocardiogram, with an average time difference of 25 hours and 31 minutes," he explained.

This is a viable option "when you don't have a sonographer accessible to appropriately risk-stratify but you do have boots on the ground that are capable of doing it with some level of training," Dr Filopei said. "Intensivists and pulmonary fellows can do it safely with a high degree of accuracy."

Dr Filopei, Dr Acquah, and Dr Squizzato have disclosed no relevant financial relationships.

CHEST 2016: American College of Chest Physicians Annual Meeting. Presented October 26, 2016.

    
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