Original ContributionA comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED
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)
- et al.
Diagnosis of radio-occult pulmonary conditions by real-time chest ultrasonography in patients with pleuritic pain
Ultrasound Med Biol
(2008) - et al.
Bedside diagnosis and follow-up of patients with pleural effusion by a hand-carried ultrasound device early after cardiac surgery
Chest
(2005) - et al.
Sonography of lung and pleura in pulmonary embolism: sonomorphologic characterization and comparison with spiral CT scanning
Chest
(2001) - et al.
Thoracic ultrasound for diagnosing pulmonary embolism: a prospective multicenter study of 352 patients
Chest
(2005) - et al.
Occult traumatic pneumotshorax. Diagnostic accuracy of ultrasonography in the emergency department
Chest
(2008) - et al.
Lung ultrasound in the evaluation of patients with pleuritic pain in the emergency department
J Emerg Med
(2008) - et al.
Investigation and management of patients with pleuritic chest pain presenting to the accident and emergency department
J Accid Emerg Med
(1999) - et al.
Agreement between emergency physician diagnosis and radiologist reports in patients discharged from an emergency department with community-acquired pneumonia
Emerg Radiol
(2005) - et al.
Suspicion of pulmonary embolism in outpatients: nonspecific chest pain is the most frequent alternative diagnosis
J Intern Med
(2004)
Cited by (39)
Continuing Medical Education guideline on lung ultrasound
2022, FMC Formacion Medica Continuada en Atencion PrimariaClinical ultrasonography in venous thromboembolism disease
2020, Revista Clinica EspanolaUltrasound of the Lungs: More than a Room with a View
2019, Heart Failure ClinicsCitation Excerpt :If the chest pain is not of ischemic origin, LUS can visualize a small pleural effusion or a consolidation. In particular, if the pain has pleuritic characteristics and no LUS abnormalities are visualized in the area of the chest pain, a consolidation as the cause of pleuritic pain is practically excluded.28 Pneumothorax is another cause of acute chest pain or hemodynamic instability and is detected by LUS as an absence of lung sliding and absence of any other LUS signs (even one small B-line or consolidation) below the area of pneumothorax.29
Lung ultrasound and pulmonary consolidations
2015, American Journal of Emergency MedicineAccuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography
2015, American Journal of Emergency MedicineCitation Excerpt :Pleuritic pain may even increase the ability of LUS in the detection of pulmonary conditions, because this symptom allows to focus the initial ultrasound examination to a limited chest area [10]. Previous studies showed that LUS might detect radio-occult pulmonary lesions when the examination is guided by localized pain [8,35,36]. In our study, sensitivity of LUS increased in the subgroup of patients complaining of pleuritic chest pain at presentation, thus confirming the peculiarity of this diagnostic model that may increase the potential of LUS for the diagnosis of pulmonary consolidations.