title: Comparison of expert and novice sonographers' performance in focused lung ultrasonography in dyspnea (FLUID) to diagnose patients with acute heart failure syndrome.
abstract: OBJECTIVE
  The goal of this study was to examine the ability of emergency physicians who are not experts in emergency ultrasound (US) to perform lung ultrasonography and to identify B-lines. The hypothesis was that novice sonographers are able to perform lung US and identify B-lines after a brief intervention. In addition, the authors examined the diagnostic accuracy of B-lines in undifferentiated dyspneic patients for the diagnosis of acute heart failure syndrome (AHFS), using an eight-lung-zone technique as well as an abbreviated two-lung-zone technique.
  
  
  METHODS
  This was a prospective, cross-sectional study of patients who presented to the emergency department (ED) with acute dyspnea from May 2009 to June 2010. Emergency medicine (EM) resident physicians, who received a 30-minute training course in thoracic US examinations, performed lung ultrasonography on patients presenting to the ED with undifferentiated dyspnea. They attempted to identify the presence or absence of sonographic B-lines in eight lung fields based on their bedside US examinations. An emergency US expert blinded to the diagnosis and patient presentation, as well as to the residents' interpretations of presence of B-lines, served as the criterion standard. A secondary outcome determined the accuracy of B-lines, using both an eight-lung-zone and a two-lung-zone technique, for predicting pulmonary edema from AHFS in patients presenting with undifferentiated dyspnea. Two expert reviewers who were blinded to the US results determined the clinical diagnosis of AHFS.
  
  
  RESULTS
  A cohort of 66 EM resident physicians performed lung US on 380 patients with a range of 1 to 28 examinations, a mean of 5.8 examinations, and a median of three examinations performed per resident. Compared to expert interpretation, lung US to detect B-lines by inexperienced sonographers achieved the following test characteristics: sensitivity 85%, specificity 84%, positive likelihood ratio (+LR) 5.2, negative likelihood ratio (-LR) 0.2, positive predictive value (PPV) 64%, and negative predictive value (NPV) 94%. Regarding the secondary outcome, the final diagnosis was AHFS in 35% of patients (134 of 380). For novice sonographers, one positive lung zone (i.e., anything positive) had a sensitivity of 87%, a specificity of 49%, a +LR of 1.7, a -LR of 0.3, a PPV of 50%, and an NPV of 88% for predicting AHFS. When all eight lung zones were determined positive (i.e., totally positive) by novice sonographers, the sensitivity was 19%, specificity was 97%, +LR was 5.7, -LR was 0.8, PPV was 76%, and NPV was 68% for predicting AHFS. The areas under the curve for novice and expert sonographers were 0.77 (95% CI = 0.72 to 0.82) and 0.76 (95% CI = 0.71 to 0.82), respectively.
  
  
  CONCLUSIONS
  Novice sonographers can identify sonographic B-lines with similar accuracy compared to an expert sonographer. Lung US has fair predictive value for pulmonary edema from acute heart failure in the hands of both novice and expert sonographers.
authors.affiliation: Department of Emergency Medicine, Olive View-University of California, Los Angeles, Sylmar, CA.
authors.forename: Alan T
authors.initials: AT
authors.lastname: Chiem
authors.affiliation: Department of Emergency Medicine, Kaiser Permanente Honolulu Medical Center, Honolulu, HI.
authors.forename: Connie H
authors.initials: CH
authors.lastname: Chan
authors.affiliation: Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Ander
authors.affiliation: Department of Cardiology, The Southeast Permanente Medical Group, Atlanta, GA.
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Kobylivker
authors.affiliation: Department of Anesthesiology, The University of Texas, Southwestern, Dallas, TX.
authors.forename: William C
authors.initials: WC
authors.lastname: Manson
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D002983:Clinical Competence; D003430:Cross-Sectional Studies; D004418:Dyspnea, Paroxysmal / Q000000981:diagnostic imaging*; D004489:Edema, Cardiac / Q000000981:diagnostic imaging*; D004635:Emergency Medicine / Q000193:education; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging*; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013577:Syndrome; D014463:Ultrasonography