Ultrasound in emergency medicineLung Ultrasound in the Evaluation of Patients with Pleuritic Pain in the Emergency Department
Introduction
Diagnostic evaluation of patients presenting with pleuritic pain in the emergency setting creates the problem of excluding important lung diseases such as pulmonary embolism, pneumonia, cancer, and pneumothorax. Most patients are discharged with a diagnosis of chest wall pain not otherwise specified (1). Clinical examination and routine investigation such as electrocardiography, chest X-ray study, and blood gas analysis very often provide inconclusive information (2, 3, 4). In cases of an otherwise healthy patient presenting with pleuritic pain but normal respiratory function, clinical examination, and routine investigations, the physician has to decide whether to exclude a lung disease by further image testing. This is not always an easy choice, especially in cases of overcrowded or poorly equipped institutions and night or weekend referral. In this setting, lung ultrasound could be a useful, sometimes decisive clinical adjunct. This non-invasive bedside approach is easily performed in a few minutes by the emergency physician with a minimum of training. Despite a large number of articles about the usefulness of lung sonography in the diagnosis of pulmonary embolism, alveolar consolidation, and pneumothorax, we did not find any reference about the sonographic approach to distinguish different sources of pleuritic pain (5, 6, 7, 8, 9, 10, 11, 12). Moreover, we found no reports on the means for incorporating lung sonography into a diagnostic algorithm that combines pre-test probability, D-dimer, and imaging results by Bayesian reasoning in outpatients complaining of pleuritic pain who are selected to be tested for pulmonary embolism (4).
We report on 5 patients who presented to our Emergency Department (ED) complaining of pleuritic thoracic pain without any signs of respiratory failure or hemodynamic instability. Bedside lung ultrasound in the ED added clinically useful data to the decision-making process. Performing it as a routine investigation in the ED may be useful to reduce the probability of incorrect diagnosis of lung disease.
A 5-MHz convex and 7.5-MHz linear scanner were employed (Sonoline G50, Siemens; Malvern, PA). The patient was either seated (dorsal application; Figure 1, left panel) or in a supine position (ventral application; Figure 1, right panel). The scanner was first applied to the intercostal areas where the patient localized the pain, and this was followed by a systematic evaluation of the remaining intercostal spaces. Maximal inspiration and exhalation were utilized to gain access to areas covered by solid structures of the thoracic cage. Breath-holding by the patient was useful to exclude breath motion-related artifacts. Time needed to perform the examination was never longer than 5 min. In all five cases, the first examination of the painful area was enough to make a diagnosis of pathology, and this never took more than 1–2 min.
The emergency physicians who performed sonographic examinations had specific training focusing on lung ultrasound. Moreover, they had spent at least 200 h performing bedside ultrasonography in the ED for general applications.
Section snippets
Case 1
A previously fit and healthy young woman aged 22 years was admitted to our ED with severe right-sided pleuritic chest pain for 2 days, without fever, dyspnea, or cough. The day before, she had been discharged from another institution with a diagnosis of chest wall pain of unknown origin. She located the pain at the fifth–sixth rib in the posterior axillary line. She had been taking contraceptive estro-progestinic tablets for 2 years. At presentation she was breathing comfortably, had a normal
Discussion
Differentiating sources of pleuritic pain in the ED is often difficult. When an otherwise young and healthy patient presents to the ED complaining of isolated pleuritic pain and normal respiratory function and hemodynamic status, and all the first-level diagnostic tests are unremarkable, the emergency physician has to decide whether to discharge the patient with a diagnosis of chest wall pain or to perform second-level imaging to rule out lung and pleural disease. Underestimating such patients
References (14)
- et al.
Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease
Chest
(1991) - et al.
Sonography of lung and pleura in pulmonary embolismSonomorphologic characterization and comparison with spiral CT scanning
Chest
(2001) Thoraxsonography—Part II: Peripheral pulmonary consolidation
Ultrasound Med Biol
(1997)- et al.
Ultrasonographic approach to diagnosing hydropneumothorax
Chest
(1992) - et al.
A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding
Chest
(1995) - et al.
Suspicion of pulmonary embolism in outpatients: nonspecific chest pain is the most frequent alternative diagnosis
J Intern Med
(2004) - et al.
Investigation and management of patients with pleuritic chest pain presenting to the accident and emergency department
J Accid Emerg Med
(1999)
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2015, American Journal of Emergency MedicineThe role of lung ultrasound in the diagnosis and follow-up of community-acquired pneumonia
2012, European Journal of Internal MedicineCitation Excerpt :Moreover, auscultation and bedside chest X-ray are often inappropriate for diagnosing pneumonia, especially in the Emergency Department. In conclusion, LUS helps to differentiate causes of acute respiratory failure in the majority of patients, showing good sensitivity and specificity in diagnosing pneumonia and reducing the need for CT, as well as time to diagnosis [15,38–41]. Although current guidelines recommend chest X-ray as the primary imaging technique, LUS can be the method of choice for the diagnosis and follow-up of lung and pleural diseases in the emergency setting.
A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED
2012, American Journal of Emergency MedicineCitation Excerpt :These patients are at high risk of misdiagnosis, and the decision to ask for an additional second-level imaging test is not always easy for the attending EP, especially in the case of overcrowded or poorly equipped institutions and when referral takes place at night or during the weekend. Lung ultrasound can reduce both the amount of negative diagnostic image testing in the ED and the number of patients symptomatic for a lung disease who are discharged without the proper diagnosis [18]. Our data show that LUS is highly accurate in visualizing radio-occult pleural and pulmonary lesions in patients with pleuritic pain, successfully screening cases with pulmonary conditions from those with parietal chest pain.
Sonographic detection of radio-occult interstitial lung involvement in measles pneumonitis
2009, American Journal of Emergency MedicineCitation Excerpt :Adult patients with measles may present to the emergency department (ED) with significant hypoxemia even if they have both normal pulmonary auscultation and chest radiography. Bedside lung ultrasound is a relatively new approach that provides information that is not obtained on chest radiography and has no auscultatory equivalent when using the stethoscope [3]. Detection of the sonographic interstitial syndrome in the ED is useful to the diagnosis of some pulmonary conditions, such as diffuse interstitial pneumonia [4].