Abstract
Computed tomography pulmonary angiography (CTPA) is the diagnostic standard for pulmonary embolism (PE), but is unavailable in many low resource settings. We evaluated the evidence for point of care ultrasound as an alternative diagnostic. Using a PROSPERO-registered, protocol-driven strategy (https://www.crd.york.ac.uk/PROSPERO, ID = CRD42018099925), we searched MEDLINE, EMBASE, and CINHAL for observational and clinical trials of cardiopulmonary ultrasound (CPUS) for PE. We included English-language studies of adult patients with acute breathlessness, reported according to PRISMA guidelines published in the last two decades (January 2000 to February 2020). The primary outcome was diagnostic accuracy of CPUS compared to reference standard CTPA for detection of PE in acutely breathless adults. We identified 260 unique publications of which twelve met all inclusion criteria. Of these, seven studies (N = 3872) were suitable for inclusion in our meta-analysis for diagnostic accuracy (two using CTPA and five using clinically derived diagnosis criterion). Meta-analysis of data demonstrated that using cardiopulmonary ultrasound (CPUS) was 91% sensitive and 81% specific for pulmonary embolism diagnosis compared to diagnostic standard CTPA. When compared to clinically derived diagnosis criterion, CPUS was 52% sensitive and 92% specific for PE diagnosis. We observed substantial heterogeneity across studies meeting inclusion criteria (I2 = 73.5%). Cardiopulmonary ultrasound may be useful in areas where CTPA is unavailable or unsuitable. Interpretation is limited by study heterogeneity. Further methodologically rigorous studies comparing CPUS and CTPA are important to inform clinical practice.
Highlights
Pulmonary embolism (PE) is a significant public health problem with an estimated 10 million cases per year worldwide [1]
Meta-analysis of data demonstrated that using cardiopulmonary ultrasound (CPUS) was 91% sensitive and 81% specific for pulmonary embolism diagnosis compared to diagnostic standard Computed tomography pulmonary angiography (CTPA)
In this meta-analysis we found that cardiopulmonary ultrasound (CPUS) is 91% sensitive and 81% specific for a diagnosis of PE when compared to the diagnostic standard CTPA
Summary
Pulmonary embolism (PE) is a significant public health problem with an estimated 10 million cases per year worldwide [1]. Despite advances in diagnosis and therapy, PE is frequently undiagnosed and untreated; especially in low resource settings [2]. Computed tomography pulmonary angiography (CTPA) is currently considered the diagnostic standard for the diagnosis of PE [3, 4]. CTPA is not always available, affordable or feasible, in LMIC settings. A combination of lung ultrasound (LUS) and cardiac echocardiography has been advocated in patients with suspected pulmonary embolism [4, 6]. Ultrasound techniques may be relevant in low-resource settings as this modality is more accessible and less expensive than CTPA. The use of ultrasound has been shown to promote patient safety [8]. Important barriers to the widespread uptake of ultrasonography include lack of training and a limited evidence base [9]
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