Contribution of point-of-care ultrasound in the prehospital management of patients with non-trauma acute dyspnea: a systematic review and meta-analysis

Abstract

Acute dyspnea is a common symptom whose management is challenging in prehospital settings. Point-of-care ultrasound (POCUS) is increasingly accessible because of device miniaturization. To assess the contribution of POCUS in the prehospital management of patients with acute nontraumatic dyspnea, we performed a systematic review on nontrauma patients of any age managed in the prehospital setting for acute dyspnea and receiving a POCUS examination. We searched seven databases and gray literature for English-language studies published from January 1995 to November 2023. Two independent reviewers completed the study selection, data extraction, and risk of bias assessment. The primary outcome was the assessment of the contribution of POCUS to feasibility, diagnostic, therapeutic, prognosis, patient referral, and transport vector modification. Twenty-three studies were included. The risk of bias assessment identified 3 intermediate-risk, 18 serious-risk, and 2 critical-risk studies. Three studies reported moderate to excellent feasibility for lung POCUS, and three studies reported poor to mediocre feasibility for cardiac POCUS. The median duration of the POCUS examination was less than 5 minutes (six studies). POCUS improved diagnostic identification (seven studies). The diagnostic accuracy of POCUS was excellent for pneumothorax (sensitivity = 100%, specificity = 100%, two studies), very good for acute heart failure (sensitivity = 71-100%, specificity = 72-95%, eight studies), good for pneumonia (sensitivity = 88%, specificity = 59%, one study), and moderate for pleural effusion (sensitivity = 26-53%, specificity = 83-92%, two studies). Treatment was modified in 11 to 54% of the patients (seven studies). POCUS had no significant effect on patient prognosis (two studies). POCUS contributed to patient referrals and transport vectors in 51% (four studies) and 25% (three studies) of patients, respectively. The evidence supports the use of POCUS for managing acute nontraumatic dyspnea in the prehospital setting in terms of feasibility, overall diagnostic contribution, and, particularly, lung ultrasound for acute heart failure diagnosis. Moreover, POCUS seems to have a therapeutic contribution. There is not enough evidence supporting the use of POCUS for pneumonia, pleural effusion, pneumothorax, chronic obstructive pulmonary disease, or asthma exacerbation diagnosis, nor does it support prognostic, patient referral, and transport vector contribution. A high level of evidence is lacking and needed.

Fig. 1

PRISMA 2020 flow diagram of the POCUS-PH-DYSPNEA Study.

Fig. 2

Cochrane risk of bias In nonrandomized studies—of interventions (a) and Cochrane Risk of Bias Tool for randomized controlled trials (b) assessment results.

Fig. 3

Point-of-care ultrasound contribution for management of patients with acute dyspnea in the prehospital setting: meta-analysis for diagnostic accuracy of lung ultrasound in acute heart failure. Forest plots of specificity (a) and sensitivity (b) for studies, and summary receiver operating characteristic curve for studies included in meta-analysis (c). (a) and (b): Study point estimates presented proportional to size. CI, confidence interval; FN, false negatives; FP, false positives; ROC, receiver operating characteristic; SROC, summary receiving operator characteristics; TN, true negatives; TP, true positives.