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      Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis

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          Abstract

          Background

          Early detection of pneumothorax is critically important. Several studies have shown that chest ultrasonography (CUS) is a highly sensitive and specific tool. The present systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of CUS and chest radiography (CXR) for detection of pneumothorax.

          Materials and Methods

          The literature search was conducted using PubMed, EMBASE, Cochrane, CINAHL, SUMSearch, Trip databases, and review article references. Eligible articles were defined as diagnostic studies on patients suspected for pneumothorax who underwent chest computed tomography (CT) scan and those assessing the screening role of CUS and CXR.

          Results

          The analysis showed the pooled sensitivity and specificity of CUS were 0.87 (95% CI: 0.81-0.92; I2= 88.89, P<0.001) and 0.99 (95% CI: 0.98-0.99; I2= 86.46, P<0.001), respectively. The pooled sensitivity and specificity of CXR were 0.46 (95% CI: 0.36-0.56; I2= 85.34, P<0.001) and 1.0 (95% CI: 0.99-1.0; I2= 79.67, P<0.001), respectively. The Meta regression showed that the sensitivity (0.88; 95% CI: 0.82 - 0.94) and specificity (0.99; 95% CI: 0.98 - 1.00) of ultrasound performed by the emergency physician was higher than by non-emergency physician. Non-trauma setting was associated with higher pooled sensitivity (0.90; 95% CI: 0.83 – 0.98) and lower specificity (0.97; 95% CI: 0.95 – 0.99).

          Conclusion

          The present meta-analysis showed that the diagnostic accuracy of CUS was higher than supine CXR for detection of pneumothorax. It seems that CUS is superior to CXR in detection of pneumothorax, even after adjusting for possible sources of heterogeneity.

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          Most cited references66

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          Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST).

          K Laupland, Rumanasma Hameed, Douglas Brown … (2004)
          Thoracic ultrasound (EFAST) has shown promise in inferring the presence of post-traumatic pneumothoraces (PTXs) and may have a particular value in identifying occult pneumothoraces (OPTXs) missed by the AP supine chest radiograph (CXR). However, the diagnostic utility of hand-held US has not been previously evaluated in this role. Thoracic US examinations were performed during the initial resuscitation of injured patients at a provincial trauma referral center. A high frequency linear transducer and a 2.4 kg US attached to a video-recorder were used. Real-time EFAST examinations for PTXs were blindly compared with the subsequent results of CXRs, a composite standard (CXR, chest and abdominal CT scans, clinical course, and invasive interventions), and a CT gold standard (CT only). Charts were reviewed for in-hospital outcomes and follow-up. There were 225 eligible patients (207 blunt, 18 penetrating); 17 were excluded from the US examination because of battery failure or a lost probe. Sixty-five (65) PTXs were detected in 52 patients (22% of patients), 41 (63%) being occult to CXR in 33 patients (14.2% whole population, 24.6% of those with a CT). The US and CXR agreed in 186 (89.4%) of patients, EFAST was better in 16 (7.7%), and CXR better in 6 (2.9%). Compared with the composite standard, the sensitivity of EFAST was 58.9% with a likelihood ratio of a positive test (LR+) of 69.7 and a specificity of 99.1%. Comparing EFAST directly to CXR, by looking at each of 266 lung fields with the benefit of the CT gold standard, the EFAST showed higher sensitivity over CXR (48.8% versus 20.9%). Both exams had a very high specificity (99.6% and 98.7%), and very predictive LR+ (46.7 and 36.3). EFAST has comparable specificity to CXR but is more sensitive for the detection of OPTXs after trauma. Positive EFAST findings should be addressed either clinically or with CT depending on hemodynamic stability. CT should be used if detection of all PTXs is desired.
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            Lung ultrasound in critically ill patients: comparison with bedside chest radiography.

            Eumorfia Kondili, Alexandros Patrianakos, N Xirouchaki … (2011)
            To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard. Forty-two mechanically ventilated patients scheduled for CT were prospectively studied with a modified lung ultrasound protocol. Four pathologic entities were evaluated: consolidation, interstitial syndrome, pneumothorax, and pleural effusion. Each hemithorax was evaluated for the presence or absence of each abnormality. Eighty-four hemithoraces were evaluated by the three imaging techniques. The sensitivity, specificity, and diagnostic accuracy of CXR were 38, 89, and 49% for consolidation, 46, 80, and 58% for interstitial syndrome, 0, 99, and 89% for pneumothorax, and 65, 81, and 69% for pleural effusion, respectively. The corresponding values for lung ultrasound were 100, 78, and 95% for consolidation, 94, 93, and 94% for interstitial syndrome, 75, 93, and 92% for pneumothorax, and 100, 100, and 100% for pleural effusion, respectively. The relatively low sensitivity of lung ultrasound for pneumothorax could be due to small number of cases (n = 8) and/or suboptimal methodology. In our unselected general ICU population lung ultrasound has a considerably better diagnostic performance than CXR for the diagnosis of common pathologic conditions and may be used as an alternative to thoracic CT.
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              Ultrasound diagnosis of occult pneumothorax.

              G Mezière, Daniel Lichtenstein, Nathalie Lascols … (2005)
              Pneumothorax can be missed by bedside radiography, and computed tomography is the current alternative. We asked whether lung ultrasound could be of any help in this situation. Retrospective study. The medical intensive care unit of a university-affiliated teaching hospital. All patients admitted to the intensive care unit are routinely scanned with whole-body ultrasound (including screening for pneumothorax) and chest radiography. The study population included 200 consecutive undifferentiated intensive care unit patients who received a chest computed tomography scan in addition to ultrasound and chest radiograph. Forty-seven consecutive cases of radioccult pneumothorax were compared with 310 consecutive hemithoraces free from pneumothorax in the intensive care unit. None. Three signs were investigated at the anterolateral chest wall in supine patients: lung sliding, the A line sign, and the lung point. A total of 357 hemithoraces were analyzed in this study, 47 with occult pneumothorax and 310 controls. Four of the 47 cases of pneumothorax were excluded from the final analysis (parietal emphysema) as well as eight of the 310 controls (large dressings), leaving a final study population of 345 hemithoraces in 197 patients. Feasibility was 98%. Ultrasound scans in all 43 examinable patients with pneumothorax showed absent lung sliding, 41 of 43 patients had the A line sign, and 34 exhibited a lung point. Among 302 analyzable controls, 65 had absent lung sliding, 16 of them showed an A line sign, and none showed a lung point. For the diagnosis of occult pneumothorax, the abolition of lung sliding alone had a sensitivity of 100% and a specificity of 78%. Absent lung sliding plus the A line sign had a sensitivity of 95% and a specificity of 94%. The lung point had a sensitivity of 79% and a specificity of 100%. For the diagnosis of occult pneumothorax, ultrasound can decrease the need for computed tomography.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Tanaffos
                Journal ID (iso-abbrev): Tanaffos
                Journal ID (publisher-id): Tanaffos
                Title: Tanaffos
                Publisher: National Research Institute of Tuberculosis and Lung Disease
                ISSN (Print): 1735-0344
                ISSN (Electronic): 2345-3729
                Publication date (Print): 2014
                Volume: 13
                Issue: 4
                Pages: 29-40
                Affiliations
                [1 ]Trauma Research Center, Baqiyatallah University of Medial Sciences, Tehran, Iran
                [2 ]Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
                [3 ]Department of Occupational Health Engineering, Faculty of Public Health, Tehran University of Medical Sciences, Tehran, Iran
                [4 ]Department of Emergency Medicine, School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
                [5 ]Department of Epidemiology and Biostatistics, Faculty of Public Health, Tehran University of Medical Sciences, Tehran, Iran
                Author notes
                Correspondence to: Yousefifard M, Address: Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Email address: usefifard@ 123456razi.tums.ac.ir
                Article
                Publisher ID: Tanaffos-13-029
                PMC ID: 4386013
                PubMed ID: 25852759
                SO-VID: 36bd2b9b-f786-48d2-b699-e7ec15e5e48e
                Copyright © Copyright © 2014 National Research Institute of Tuberculosis and Lung Disease
                License:

                This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.

                History
                Date received : 03 September 2014
                Date accepted : 31 October 2014
                Categories
                Subject: Original Article

                Keywords: pneumothorax,ultrasonography,radiography,diagnostic tests,routine
                Data availability:
                Keywords: pneumothorax, ultrasonography, radiography, diagnostic tests, routine

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