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Meta-Analysis
. 2020 Jul 23;7(7):CD013031.
doi: 10.1002/14651858.CD013031.pub2.

Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department

Kenneth K Chan  1 , Daniel A Joo  1 , Andrew D McRae  1 , Yemisi Takwoingi  2 , Zahra A Premji  3 , Eddy Lang  1 , Abel Wakai  4
Affiliations
Meta-Analysis

Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department

Kenneth K Chan et al. Cochrane Database Syst Rev. .

Abstract

Background: Chest X-ray (CXR) is a longstanding method for the diagnosis of pneumothorax but chest ultrasonography (CUS) may be a safer, more rapid, and more accurate modality in trauma patients at the bedside that does not expose the patient to ionizing radiation. This may lead to improved and expedited management of traumatic pneumothorax and improved patient safety and clinical outcomes.

Objectives: To compare the diagnostic accuracy of chest ultrasonography (CUS) by frontline non-radiologist physicians versus chest X-ray (CXR) for diagnosis of pneumothorax in trauma patients in the emergency department (ED). To investigate the effects of potential sources of heterogeneity such as type of CUS operator (frontline non-radiologist physicians), type of trauma (blunt vs penetrating), and type of US probe on test accuracy.

Search methods: We conducted a comprehensive search of the following electronic databases from database inception to 10 April 2020: Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection and Clinicaltrials.gov. We handsearched reference lists of included articles and reviews retrieved via electronic searching; and we carried out forward citation searching of relevant articles in Google Scholar and looked at the "Related articles" on PubMed.

Selection criteria: We included prospective, paired comparative accuracy studies comparing CUS performed by frontline non-radiologist physicians to supine CXR in trauma patients in the emergency department (ED) suspected of having pneumothorax, and with computed tomography (CT) of the chest or tube thoracostomy as the reference standard.

Data collection and analysis: Two review authors independently extracted data from each included study using a data extraction form. We included studies using patients as the unit of analysis in the main analysis and we included those using lung fields in the secondary analysis. We performed meta-analyses by using a bivariate model to estimate and compare summary sensitivities and specificities.

Main results: We included 13 studies of which nine (410 traumatic pneumothorax patients out of 1271 patients) used patients as the unit of analysis; we thus included them in the primary analysis. The remaining four studies used lung field as the unit of analysis and we included them in the secondary analysis. We judged all studies to be at high or unclear risk of bias in one or more domains, with most studies (11/13, 85%) being judged at high or unclear risk of bias in the patient selection domain. There was substantial heterogeneity in the sensitivity of supine CXR amongst the included studies. In the primary analysis, the summary sensitivity and specificity of CUS were 0.91 (95% confidence interval (CI) 0.85 to 0.94) and 0.99 (95% CI 0.97 to 1.00); and the summary sensitivity and specificity of supine CXR were 0.47 (95% CI 0.31 to 0.63) and 1.00 (95% CI 0.97 to 1.00). There was a significant difference in the sensitivity of CUS compared to CXR with an absolute difference in sensitivity of 0.44 (95% CI 0.27 to 0.61; P < 0.001). In contrast, CUS and CXR had similar specificities: comparing CUS to CXR, the absolute difference in specificity was -0.007 (95% CI -0.018 to 0.005, P = 0.35). The findings imply that in a hypothetical cohort of 100 patients if 30 patients have traumatic pneumothorax (i.e. prevalence of 30%), CUS would miss 3 (95% CI 2 to 4) cases (false negatives) and overdiagnose 1 (95% CI 0 to 2) of those without pneumothorax (false positives); while CXR would miss 16 (95% CI 11 to 21) cases with 0 (95% CI 0 to 2) overdiagnosis of those who do not have pneumothorax.

Authors' conclusions: The diagnostic accuracy of CUS performed by frontline non-radiologist physicians for the diagnosis of pneumothorax in ED trauma patients is superior to supine CXR, independent of the type of trauma, type of CUS operator, or type of CUS probe used. These findings suggest that CUS for the diagnosis of traumatic pneumothorax should be incorporated into trauma protocols and algorithms in future medical training programmes; and that CUS may beneficially change routine management of trauma.

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Conflict of interest statement

Kenneth K Chan is an Attending Emergency Physician with the University of Calgary and Alberta Health Services. He is also an Attending Emergency Physician with the University of British Columbia and Fraser Health Authority. He has no conflicts of interest to declare.

Daniel A Joo is an Attending Emergency Physician with the University of Calgary and Alberta Health Services. He has no conflicts of interest to declare.

Andrew D McRae is an Assistant Professor of Emergency Medicine and Community Health Sciences at the University of Calgary. His institution has been awarded research grants and consulting fees on cardiac biomarkers from Roche Diagnostics Canada.

Yemisi Takwoingi is a Professor of Test Evaluation and Evidence Synthesis, University of Birmingham, UK. She has no conflicts of interest to declare.

Zahra A Premji is a Research and Learning Librarian with the University of Calgary. She has no conflicts of interest to declare.

Eddy Lang is the Department Head of Emergency Medicine and a Clinician Scientist with the University of Calgary and Alberta Health Services. He has no conflicts of interest to declare.

Abel Wakai is the Director of Emergency Care Research Unit, Division of Population Health Sciences, Royal College of Surgeons, in Ireland. He has no conflicts of interest to declare.

Figures

1
1
Current and proposed clinical pathway ‐ CUS may provide a faster and more accurate diagnosis of traumatic pneumothorax, leading to immediate tube thoracostomy in an unstable trauma patient. Supine CXR is a useful diagnostic tool for identification of other traumatic pathologies, such as rib fractures, mediastinal injuries, etc.
2
2
Study flow diagram
3
3
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study. Studies included in the secondary analysis: Abdulrahman 2015, Hyacinthe 2012, Kirkpatrick 2004, Soldati 2008. CUS = chest ultrasonography; CXR = chest radiography.
4
4
Forest plot of sensitivity and specificity of chest ultrasonography and supine chest radiography for diagnosis of pneumothorax. For each test, studies are sorted by trauma type and study identifier. CUS = chest ultrasonography; CXR = chest radiography; FN = false negative; FP = false positive; TN = true negative; TP = true positive.
5
5
Summary ROC plot of chest ultrasonography and supine chest radiography for diagnosis of pneumothorax CUS = chest ultrasonography; CXR = chest radiography. Each study point was scaled according to the precision of sensitivity and specificity in the study. This means that the greater the height of a study point relative to other study points, the greater the precision of the estimated sensitivity in that study. Similarly, for specificity, the greater the width of a study point relative to other study points, the greater the precision of the estimated specificity in that study. The solid circles (summary points) represent the summary estimates of sensitivity and specificity for CUS (black circle) and CXR (red circle). Each summary point is surrounded by a dotted line representing the 95% confidence region and a dashed line representing the 95% prediction region (the region within which one is 95% certain the results of a new study will lie).
6
6
Hypothetical cohort of 100 ED patients assessed for traumatic pneumothorax. tp: true positive – test is positive (indicates pneumothorax) and patient has pneumothorax; fp: false positive – test is positive (indicates pneumothorax) but patient does not have pneumothorax tn: true negative – test is negative (indicates pneumothorax not present) and patient does not have pneumothorax; fn: false negative – test is negative (indicates pneumothorax not present) but patient has pneumothorax
1
1. Test
CUS
2
2. Test
CXR
3
3. Test
CUS (lung field level analysis)
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4. Test
CXR (lung field level analysis)
See this image and copyright information in PMC

Comment in

References

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