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Potential for Point-of-Care Ultrasonography to Improve Patient Care in Diagnosis of Dyspnea

The introduction of point-of-care ultrasonography (POCUS) to the health system continues to affect patient care in evolvingways and has beendescribed as a disruptive innovation (1). Point-of-care ultrasonography is not intended to replace conventional diagnostic pathways but rather to complement the diagnostic evaluation with a bedside test that addresses clinical uncertainty in real time. In their article, Qaseem and colleagues (2) offers recommendations on the use of POCUS in patients with acute dyspnea that is based on a comprehensive reviewof available evidence (3).Most of the recommendations are based on low-certainty evidence, but the guideline provides a rationale for the use of POCUS for dyspnea in the emergency department and inpatient setting while we await stronger evidence that the use of POCUS improves patient outcomes. We need additional high-quality research toguide theuseof POCUS in the evaluation of dyspnea both in acute andother patient care settings. Understanding the limitations of POCUS for evaluating patients with dyspnea is important to its appropriate use. Because direct evidence on the effect of POCUS for clinical outcomes when used to diagnose congestive heart failure, pleural effusions, pneumonia, and pulmonary embolism is lacking, the American College of Physicians (ACP) guideline considers the performance characteristics of POCUS, including false-negative and false-positive results, when used with or without a conventional diagnostic pathway (3). The guideline also notes the need to consider the potential harms associated with inappropriate treatment with anticoagulation or antibiotics or a delayed diagnosis when POCUS incorrectly suggests pulmonary embolism or pneumonia. Although there may be clinical scenarios in which POCUS may be considered as a replacement test, such as in unstable patients who cannot travel to radiology for definitive imaging, the ACP guideline suggests that POCUS may be used in addition to the standard diagnostic pathway to improve diagnosis, particularly for congestive heart failure. Being well versed in the existing evidence about the performance characteristics of POCUS and its limitations for different conditions will enable clinicians to better incorporate it into their patient care. Achieving the accuracy and benefits of POCUS found in the studies requires its use by trained providers. As more specialties consider integrating POCUS into care for patients, they must consider the need for investments in training to assure competency among all users, reorganization to standardize workflows, and the appropriate technology needed to maintain the highest standard. Some institutions have coordinated this effort among departments by establishing a system-wide clinical ultrasound program to provide quality assurance oversight and controls costs (4). Within these programs, each specialty is tasked with the development of their own training and credentialing guidelines that best represent the standard of care within that specialty. Emergency, hospital, and critical care medicine were the first specialties to release POCUS guidelines and training recommendations (5–7). Most of the research involving POCUS has been done in the emergency department with highly trained providers doing the scans. This poses a challenge to interpreting and applying POCUS to other clinical settings, such as lowacuity urgent care settings or even different inpatient settings. The outpatient population is less likely to have preexisting health conditions and potentially a lower pretest probability for the disease, whereas the inpatient setting may have a higher pretest probability of some diseases than others. The ACP recommendations demonstrate how different pretest probabilities will affect the accuracy of POCUS diagnoses. Further research is needed to determine the actual accuracy of POCUS in different acuity settings and resulting harms (3). Equally important is research to identify clinical situations in which conventional diagnostics administered by specialists are more appropriate than POCUS. Although the ACP guideline focused only on the emergency department or inpatient settings, POCUS has potential for value in the outpatient setting. Currently, use of POCUS in specialties outside of emergency medicine and critical care is lagging, likely because of less investment in training and clinical integration. Cost of training is a barrier, but there are opportunities to collaborate with established training pathways to train new POCUS experts and align costs with departmental budgets (8). Once POCUS experts exist within a specialty, they can train their colleagues who can then train others, making the model sustainable. Expanding POCUS use to new clinical settings and for well-supported indications could theoretically decrease transfers to emergency departments and unnecessary referrals to specialists. More selective use of conventional imaging that may take days to weeks to obtain by using POCUS in outpatient settings could improve efficiency and decrease costs. However, research is needed to document these potential benefits. Handheld ultrasound devices are a potential disruptive innovation within the field of POCUS. They offer the potential benefits of portability and affordability, but the evidence supporting the accuracy of handheld devices versus standard cart-based devices is lacking. Only a minority of studies considered by the ACP guideline used handheld devices—most used standard cart-based portable devices. The American College of Emergency Physicians has addressed appropriate use of handheld ultrasound devices (9). A concern among the POCUS leadership is the lack of oversight of individual providers purchasing and using the handheld devices within various clinical settings. Handheld devices should comply with the same administrative, environmental, and competency standards as cart-based devices. The image quality of most handheld devices is good, but their diagnostic performance depends on user training. As with any study of POCUS, the