Ultrasound in emergency medicine
Lung Ultrasound in the Evaluation of Patients with Pleuritic Pain in the Emergency Department

https://doi.org/10.1016/j.jemermed.2007.06.024Get rights and content

Abstract

The evaluation of pleuritic pain in the emergency setting is a diagnostic challenge. Most patients are discharged from the Emergency Department (ED) with a diagnosis of chest wall pain not otherwise specified. It is important to rule out possible sources of acute pleuritic pain, like pulmonary embolism, pneumonia, lung cancer, and pneumothorax. Clinical examination, plain film radiography of the chest, and other routine investigations may be inadequate to make the correct diagnosis. In this setting, another bedside test to aid diagnosis would be useful. ED bedside lung ultrasound is a novel technique for the diagnosis of lung diseases. We report on 5 patients who presented to our ED complaining of pleuritic pain, few other symptoms, and negative routine investigations, in whom bedside lung ultrasound aided in making the diagnosis.

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)

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