Original Contribution
A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED

https://doi.org/10.1016/j.ajem.2010.11.035Get rights and content

Abstract

Purposes

Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR).

Methods

Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS.

Results

In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis.

Conclusions

Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.

Introduction

Pleuritic pain is felt as a sharp pain, usually well localized by the patient to a precise chest area, that worsens by forceful breathing movements, such as taking a deep breath, talking, coughing, or sneezing. It represents a common presenting symptom in the emergency department (ED). Ancillary testing is frequently relied upon to aid in sorting out the differential diagnosis between a parietal muscoloskeletal condition, very often with spontaneous recovery, or an irritation of the parietal pleura due to a pleural-pulmonary disease, requiring precise differential diagnosis, specific treatment, and follow-up. Conventionally, the diagnostic process relies mainly on the visualization of pleural and pulmonary lesions, corresponding to the painful chest area, by plain film chest radiography (CXR). However, in a significant number of cases, pleuritic pain may be caused by radio-occult lesions occurring as a presenting complaint for pneumonia, pulmonary embolism, cancer, or pneumothorax [1], [2], [3]. Hence, very often, when CXR is silent, the diagnostic process in the ED is inconclusive. Most patients presenting with isolated pleuritic pain are discharged from the ED with a diagnosis of “chest wall pain,” not otherwise specified [4]. In a previous study, we have demonstrated that bedside lung ultrasound (LUS), a noninvasive approach easily performed in a few minutes, is highly accurate in detecting radio-occult conditions, being of value even in the differential diagnosis of lesions due to pneumonia, pulmonary embolism, or cancer [3]. Without great sonographic skill, the attending emergency physician (EP) may easily identify those patients who need further imaging by detection of any abnormal sonographic pattern at LUS, whereas negative examination allows safe discharge with a diagnosis of chest wall pain [3]. In the daily practice, other clinical parameters, such as symptoms, physical signs, and blood examinations, are commonly used in the decision-making process in the ED, and the exact role of LUS has not yet been explored.

This study was designed to compare the value of LUS with other conventional diagnostic tools commonly applied at bedside in the ED evaluation of patients complaining of pleuritic pain and showing nondiagnostic CXR.

Section snippets

Materials and methods

The study took place in the ED of the San Luigi Gonzaga Hospital, Turin, Italy. The latter is a university hospital, whose ED performs approximately 45 000 visits per year. Consecutive patients who presented with acute pleuritic chest pain, normal respiratory function, hemodynamic stability, and low-risk profile for thromboembolism were enrolled. All patients were submitted to history recording, physical examination, electrocardiogram, blood sampling, CXR in 2 views, and LUS. Only patients

Results

Fifty-seven patients (63%) had a final diagnosis of parietal chest pain. In this group, pulmonary disease was finally ruled out at follow-up in 42 patients, by a combination of sCT (n = 2), venous compression ultrasonography (n = 15), and lung scintigraphy (n = 1) in the remaining 15 patients. Thirty-three (37%) patients had a final diagnosis of radio-occult pleural-pulmonary disease with the lesion topographically corresponding to the painful thoracic area. Twenty-four patients (27%) had a

Discussion

Lung ultrasound has been successfully applied in the diagnosis of pneumonia and pleural effusion [11], [12], [13], [14], pulmonary embolism [14], [15], and pneumothorax [5], [16], [17]. Many articles have shown that LUS is at least equal if not superior to CXR. In a previous study, we showed the usefulness of LUS in visualizing radio-occult pulmonary conditions on a series of patients with pleuritic pain and no symptoms of respiratory distress [3]. These patients are at high risk of

Limitations

A major limitation of our study is the lack of a systematic comparison between ultrasound and sCT. Most diagnoses were confirmed by CXR control within a few days and/or follow-up by repeated clinical examination, blood assay, and LUS up to 1 month. Our intention was to avoid useless irradiation of the patients. Moreover, this is a clinical study, which evaluates the accuracy of diagnostic methods to be used in the ED to predict pulmonary conditions. For these reasons, we chose to use the

Conclusions

This study provides further evidence that bedside LUS is superior to conventional CXR in many situations. Bedside sonographic evaluation of the lung by the attending EP in the ED is a reliable easy-to-use method and accurate enough to be routinely used in patients presenting with pleuritic pain. Lung ultrasound has shown to be of value to rule out radio-occult pulmonary conditions and to identify patients who need a second-level image testing. No other routine laboratory test or accompanying

References (19)

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