Online Data Supplement
Diagnostic accuracy, safety and utilisation of respiratory physician
delivered thoracic ultrasound
Najib M Rahman1 MRCP
Authors:
Aran Singanayagam1 MRCP
Helen E Davies1 MRCP
John M Wrightson1 MRCP
Eleanor K Mishra1 MRCP
Y C Gary Lee1, 4 PhD FRACP
Rachel Benamore2 FRCR
Robert J O Davies1,3 DM FRCP*
Fergus V Gleeson2,3 FRCR*
Affiliations:
1Oxford
Centre for Respiratory Medicine and Oxford Pleural Diseases Unit,
Churchill Hospital, Oxford, OX3 7LJ
2Department
of Radiology, Oxford Centre for Respiratory Medicine, Churchill
Hospital, Oxford, OX3 7LJ
3NIHR
Oxford Biomedical Research Centre, University of Oxford, Oxford, U.K.
4University
of Western Australia, Department of Medicine
Correspondence:
Dr Najib Rahman
Oxford Centre for Respiratory Medicine
Churchill Hospital
Oxford, OX3 7LJ
naj_rahman@yahoo,.co.uk
Ph: 0044 1865 225205
Fax: 0044 1865 857209
Funding:
No funding specific to this study
NMR is funded by the UK Medical Research Council
1
EKM is funded by the UK National Cancer Research Institute
RJOD is funded by the NIHR Biomedical Research Centre
Short Title: Safety and efficacy of physician delivered thoracic ultrasound
Conflict of Interest Statement:
The authors have no conflicts of interest to declare on the subject of this
paper
2
1. Details of statistical methods
Linear regression analysis was used to assess the change in activity of
the thoracic ultrasound service over time and the proportion of radiology
referred scans over time. For assessment of activity over time, linear
regression was performed using the number of scans as the outcome variable
and a time factor (3 month period sequentially) as the explanatory variable.
No covariates were used in the model. For assessment of radiology referral
over time, the proportion of scans referred to radiology (number of referred
scans to radiology as a proportion of all scans conducted excepting those prethoracoscopy) was the outcome variable, and a time factor (1 month period
sequentially) was used as the explanatory variable. No covariates were used
in the model.
Sensitivity and specificity of the detection of pleural fluid and technical
feasibility of fluid aspiration was calculated using results of blinded ultrasound
clip assessment by the radiologist. The opinion of the radiologist (i.e. pleural
fluid present or not and fluid technically possible to aspirate or not) was taken
as the reference standard for calculation of sensitivity and specificity.
Chance corrected agreement between radiologist and physician
opinion of the thoracic ultrasound clips (fluid present, fluid technically possible
to aspirate) was conducted using a kappa statistic.
3
2. Literature Review search Strategy
PubMed was searched using the following (including MESH) terms, no
limits:
(("Pleural Effusion"[Mesh]) OR ("Pleura"[Mesh])) AND ((ASPIRATION OR
THORACEN* OR THORACOCE*) OR ("Chest Tubes"[Mesh])) AND
("Ultrasonography"[Mesh] OR "Ultrasonography, Interventional"[Mesh])
A total of 90 citations resulted from this search strategy. Twenty one
citations were discarded immediately due to lack of relevance to the topic
concerned. The remaining 69 abstracts were assessed, and 28 further papers
discarded on the basis of the following criteria:
Reason study discarded
Studies discarded
Lung biopsy / lung aspiration / pleural biopsy
3
Review article
5
Complications not clearly reported
6
Diagnostic ultrasound (no intervention) only
2
Less than 10 patients underwent ultrasound imaging
3
No ultrasound guidance used
5
Combination of CT and ultrasound imaging used
3
Pre-thoracoscopy ultrasound only
1
Total
28
Table E1. Reasons for non-inclusion of studies in comparison of
complications of thoracic ultrasound guided procedures. A total of 69 – 28 =
41 studies were therefore included in the assessment of complications of
ultrasound guided pleural procedures.
4
3. Referenced Literature Review of US guided complications
Formal systematic review and data synthesis of studies was not
attempted. A Medline review of published studies on ultrasound guided
procedures for the diagnosis / treatment of pleural effusion (via Medline
search – see Table E1) identified 69 relevant publications. Of these, 28 were
discounted (3 studies assessing lung / pleural biopsy1-3, 5 review articles4-8, 6
complications not clearly reported9-14, 2 diagnostic only15;16, 3 small (<10
patients undergoing ultrasound) studies17-19, 5 non-ultrasound guided20-24, 3
combined imaging modalities (i.e. ultrasound and CT / fluoroscopy used)25-27
and 1 assessing ultrasound in pre-thoracoscopy patients only28), leaving 41
studies for assessment of complications from US guided pleural fluid
procedures.
Of the 41 studies, 9 were conducted by non-radiologists29-37
(respiratory or intensive care physicians) and 32 conducted by radiologists3869.
Complications reported in these studies were recorded if considered major
on the same criteria as listed above (intrapleural bleed or pneumothorax
requiring any form of intervention, pleural infection, visceral pleura or viscus
perforation). Combing the results of these studies, the overall major
complication rate was 137 complications in 6836 procedures (2.0%, 95% CI
1.7 to 2.3). The major complication rate of radiology studies (121/5530 =
2.2%, 95% CI 1.8 to 2.6) was comparable to that of the physician conducted
studies (16/1306 = 1.2%, 95% CI 0.7 to 2.0) (2 1df = 5.0, p=0.03). The
proportion of complications seen in this study was significantly lower than the
proportion in published studies (this study 3/558, 0.5% versus 137/6836,
5
2.0%; 2 1df = 6.0, p=0.01, difference 1.5%, 95% confidence interval for the
difference = 0.8 to 2.2%) (Figure 3). (Figure E1).
Figure 3. Major complication rates of studies using ultrasound for pleural fluid
procedures, assessing studies by size and whether conducted by a radiologist
or non-radiologist, in comparison to the current study. Individual studies are
shown with filled triangles, and summary complication rates (non-weighted)
and 95% CI (confidence intervals) are shown with dots and bars (see legend,
* = current study)
6
Reference List
1. Cinti, D. and H. B. Hawkins. 1984. Aspiration biopsy of peripheral
pulmonary masses using real-time sonographic guidance. AJR
Am.J.Roentgenol. 142:1115-1116.
2. Das, D. K., C. S. Pant, J. N. Pant, and P. Sodhani. 1995. Transthoracic
(percutaneous) fine needle aspiration cytology diagnosis of pulmonary
tuberculosis. Tuber.Lung Dis. 76:84-89.
3. Diacon, A. H., M. M. Schuurmans, J. Theron, P. T. Schubert, C. A. Wright,
and C. T. Bolliger. 2004. Safety and yield of ultrasound-assisted transthoracic
biopsy performed by pulmonologists. Respiration 71:519-522.
4. Keske, U. 1999. Ultrasound-aided thoracentesis in intensive care patients.
Intensive Care Med. 25:896-897.
5. Klein, J. S., S. Schultz, and J. E. Heffner. 1995. Interventional radiology of
the chest: image-guided percutaneous drainage of pleural effusions, lung
abscess, and pneumothorax. AJR Am.J.Roentgenol. 164:581-588.
6. Nicolaou, S., A. Talsky, K. Khashoggi, and V. Venu. 2007. Ultrasoundguided interventional radiology in critical care. Crit Care Med. 35:S186-S197.
7. Yang, P. C. 2000. Ultrasound-guided transthoracic biopsy of the chest.
Radiol.Clin.North Am. 38:323-343.
7
8. Stavas, J., E. vanSonnenberg, G. Casola, and G. R. Wittich. 1987.
Percutaneous drainage of infected and noninfected thoracic fluid collections.
J.Thorac.Imaging 2:80-87.
9. Diacon, A. H., M. H. Brutsche, and M. Soler. 2003. Accuracy of pleural
puncture sites: a prospective comparison of clinical examination with
ultrasound. Chest 123:436-441.
10. Gryminski, J., P. Krakowka, and G. Lypacewicz. 1976. The diagnosis of
pleural effusion by ultrasonic and radiologic techniques. Chest 70:33-37.
11. Kohlberger, E. and D. Waldmann. 1987. [Real-time controlled pleural
puncture in surgical intensive care patients]. Chirurg 58:261-264.
12. Levinson, G. M. and D. W. Pennington. 2007. Intrapleural fibrinolytics
combined with image-guided chest tube drainage for pleural infection. Mayo
Clin.Proc. 82:407-413.
13. Kohan, J. M., R. H. Poe, R. H. Israel, J. D. Kennedy, R. B. Benazzi, M. C.
Kallay, and D. W. Greenblatt. 1986. Value of chest ultrasonography versus
decubitus roentgenography for thoracentesis. Am.Rev.Respir.Dis. 133:11241126.
14. Adams, F. V. and V. Galati. 1978. M-mode ultrasonic localization of
pleural effusion. Use in patients with nondiagnostic physical and
roentgenographic examinations. JAMA 239:1761-1764.
15. Lipscomb, D. J., C. D. Flower, and J. W. Hadfield. 1981. Ultrasound of the
pleura: an assessment of its clinical value. Clin.Radiol. 32:289-290.
8
16. Rozycki, G. S., S. D. Pennington, and D. V. Feliciano. 2001. Surgeonperformed ultrasound in the critical care setting: its use as an extension of the
physical examination to detect pleural effusion. J.Trauma 50:636-642.
17. Crouch, J. D., B. A. Keagy, and D. J. Delany. 1987. "Pigtail" catheter
drainage in thoracic surgery. Am.Rev.Respir.Dis. 136:174-175.
18. Merriam, M. A., J. J. Cronan, G. S. Dorfman, R. E. Lambiase, and R. A.
Haas. 1988. Radiographically guided percutaneous catheter drainage of
pleural fluid collections. AJR Am.J.Roentgenol. 151:1113-1116.
19. Ravin, C. E. 1977. Thoracocentesis of loculated pleural effusions using
grey scale ultrasonic guidance. Chest 71:666-668.
20. Collop, N. A., S. Kim, and S. A. Sahn. 1997. Analysis of tube
thoracostomy performed by pulmonologists at a teaching hospital. Chest
112:709-713.
21. Colt, H. G., N. Brewer, and E. Barbur. 1999. Evaluation of patient-related
and procedure-related factors contributing to pneumothorax following
thoracentesis. Chest 116:134-138.
22. Davies, H. E., S. Merchant, and A. McGown. 2008. A study of the
complications of small bore 'Seldinger' intercostal chest drains. Respirology.
13:603-607.
23. Horsley, A., L. Jones, J. White, and M. Henry. 2006. Efficacy and
complications of small-bore, wire-guided chest drains. Chest 130:1857-1863.
9
24. Collins, T. R. and S. A. Sahn. 1987. Thoracocentesis. Clinical value,
complications, technical problems, and patient experience. Chest 91:817-822.
25. Hunnam, G. R. and C. D. Flower. 1988. Radiologically-guided
percutaneous catheter drainage of empyemas. Clin.Radiol. 39:121-126.
26. vanSonnenberg, E., S. K. Nakamoto, P. R. Mueller, G. Casola, C. C. Neff,
P. J. Friedman, J. T. Ferrucci, Jr., and J. F. Simeone. 1984. CT- and
ultrasound-guided catheter drainage of empyemas after chest-tube failure.
Radiology 151:349-353.
27. Westcott, J. L. 1985. Percutaneous catheter drainage of pleural effusion
and empyema. AJR Am.J.Roentgenol. 144:1189-1193.
28. Hersh, C. P., D. Feller-Kopman, M. Wahidi, R. Garland, F. Herth, and A.
Ernst. 2003. Ultrasound guidance for medical thoracoscopy: a novel
approach. Respiration 70:299-301.
29. Feller-Kopman, D., D. Berkowitz, P. Boiselle, and A. Ernst. 2007. Largevolume thoracentesis and the risk of reexpansion pulmonary edema.
Ann.Thorac.Surg. 84:1656-1661.
30. Grogan, D. R., R. S. Irwin, R. Channick, V. Raptopoulos, F. J. Curley, T.
Bartter, and R. W. Corwin. 1990. Complications associated with
thoracentesis. A prospective, randomized study comparing three different
methods. Arch.Intern.Med. 150:873-877.
10
31. Heidecker, J., J. T. Huggins, S. A. Sahn, and P. Doelken. 2006.
Pathophysiology of pneumothorax following ultrasound-guided thoracentesis.
Chest 130:1173-1184.
32. Lichtenstein, D., J. S. Hulot, A. Rabiller, I. Tostivint, and G. Meziere. 1999.
Feasibility and safety of ultrasound-aided thoracentesis in mechanically
ventilated patients. Intensive Care Med. 25:955-958.
33. Mayo, P. H., H. R. Goltz, M. Tafreshi, and P. Doelken. 2004. Safety of
ultrasound-guided thoracentesis in patients receiving mechanical ventilation.
Chest 125:1059-1062.
34. Seneff, M. G., R. W. Corwin, L. H. Gold, and R. S. Irwin. 1986.
Complications associated with thoracocentesis. Chest 90:97-100.
35. Yu, C. J., P. C. Yang, D. B. Chang, and K. T. Luh. 1992. Diagnostic and
therapeutic use of chest sonography: value in critically ill patients. AJR
Am.J.Roentgenol. 159:695-701.
36. Hsu, W. H., C. D. Chiang, C. Y. Chen, P. C. Kwan, and J. Y. Hsu. 1998.
Ultrasound-guided small-bore Elecath tube insertion for the rapid
sclerotherapy of malignant pleural effusion. Jpn.J.Clin.Oncol. 28:187-191.
37. Duncan, D. R., T. I. Morgenthaler, J. H. Ryu, and C. E. Daniels. 2009.
Reducing iatrogenic risk in thoracentesis: establishing best practice via
experiential training in a zero-risk environment. Chest 135:1315-1320.
11
38. Afschrift, M., P. Nachtegaele, D. Voet, L. Noens, W. Van Hove, S. M. van
der, and G. Verdonk. 1982. Puncture of thoracic lesions under sonographic
guidance. Thorax 37:503-506.
39. Akhan, O., O. Ozkan, D. Akinci, A. Hassan, and M. Ozmen. 2007. Imageguided catheter drainage of infected pleural effusions. Diagn.Interv.Radiol.
13:204-209.
40. Atar, E., Z. Heyman, A. Coret, and Y. Itzchak. 1996. [Ultrasound-guided
aspiration of pleural fluid]. Harefuah 130:16-7, 71.
41. Barnes, T. W., T. I. Morgenthaler, E. J. Olson, G. K. Hesley, P. A. Decker,
and J. H. Ryu. 2005. Sonographically guided thoracentesis and rate of
pneumothorax. J.Clin.Ultrasound 33:442-446.
42. Cantin, L., C. Chartrand-Lefebvre, L. Lepanto, D. Gianfelice, A. Rabbat,
B. Aubin, P. Perreault, R. Dery, and M. Lafortune. 2005. Chest tube drainage
under radiological guidance for pleural effusion and pneumothorax in a tertiary
care university teaching hospital: Review of 51 cases. Can.Respir.J. 12:29-33.
43. Elyaderani, M. K. and O. F. Gabriele. 1982. Aspiration of thoracic masses
and fluid collections under guidance of ultrasonography. South.Med.J. 75:536539.
44. Gervais, D. A., A. Petersein, M. J. Lee, P. F. Hahn, S. Saini, and P. R.
Mueller. 1997. US-guided thoracentesis: requirement for postprocedure chest
radiography in patients who receive mechanical ventilation versus patients
who breathe spontaneously. Radiology 204:503-506.
12
45. Harnsberger, H. R., T. G. Lee, and D. H. Mukuno. 1983. Rapid,
inexpensive real-time directed thoracentesis. Radiology 146:545-546.
46. Hirsch, J. H., J. V. Rogers, and L. A. Mack. 1981. Real-time sonography
of pleural opacities. AJR Am.J.Roentgenol. 136:297-301.
47. Jones, P. W., J. P. Moyers, J. T. Rogers, R. M. Rodriguez, Y. C. Lee, and
R. W. Light. 2003. Ultrasound-guided thoracentesis: is it a safer method?
Chest 123:418-423.
48. Josephson, T., C. A. Nordenskjold, J. Larsson, L. U. Rosenberg, and M.
Kaijser. 2009. Amount drained at ultrasound-guided thoracentesis and risk of
pneumothorax. Acta Radiol. 50:42-47.
49. Keeling, A. N., S. Leong, P. M. Logan, and M. J. Lee. 2008. Empyema
and effusion: outcome of image-guided small-bore catheter drainage.
Cardiovasc.Intervent.Radiol. 31:135-141.
50. Lipscomb, D. J. and C. D. Flower. 1980. Ultrasound in the diagnosis and
management of pleural disease. Br.J.Dis.Chest 74:353-361.
51. Marom, E. M., S. M. Palmer, J. J. Erasmus, J. E. Herndon, C. Zhang, and
H. P. McAdams. 2003. Pleural effusions in lung transplant recipients: imageguided small-bore catheter drainage. Radiology 228:241-245.
52. McGahan, J. P. 1985. Aspiration and drainage procedures in the intensive
care unit: percutaneous sonographic guidance. Radiology 154:531-532.
53. Morrison, M. C., P. R. Mueller, M. J. Lee, S. Saini, J. A. Brink, S. L.
Dawson, E. D. Cortell, and P. F. Hahn. 1992. Sclerotherapy of malignant
13
pleural effusion through sonographically placed small-bore catheters. AJR
Am.J.Roentgenol. 158:41-43.
54. Moulton, J. S., R. E. Benkert, K. H. Weisiger, and J. A. Chambers. 1995.
Treatment of complicated pleural fluid collections with image-guided drainage
and intracavitary urokinase. Chest 108:1252-1259.
55. Mynarek, G., K. Brabrand, J. A. Jakobsen, and A. Kolbenstvedt. 2004.
Complications following ultrasound-guided thoracocentesis. Acta Radiol.
45:519-522.
56. O'Moore, P. V., P. R. Mueller, J. F. Simeone, S. Saini, R. J. Butch, P. F.
Hahn, E. Steiner, D. D. Stark, and J. T. Ferrucci, Jr. 1987. Sonographic
guidance in diagnostic and therapeutic interventions in the pleural space. AJR
Am.J.Roentgenol. 149:1-5.
57. Parker, L. A., G. C. Charnock, and D. J. Delany. 1989. Small bore
catheter drainage and sclerotherapy for malignant pleural effusions. Cancer
64:1218-1221.
58. Parulekar, W., G. Di Primio, F. Matzinger, C. Dennie, and G. Bociek.
2001. Use of small-bore vs large-bore chest tubes for treatment of malignant
pleural effusions. Chest 120:19-25.
59. Patz, E. F., Jr., P. C. Goodman, and J. J. Erasmus. 1998. Percutaneous
drainage of pleural collections. J.Thorac.Imaging 13:83-92.
14
60. Petersen, S., M. Freitag, W. Albert, S. Tempel, and K. Ludwig. 1999.
Ultrasound-guided thoracentesis in surgical intensive care patients. Intensive
Care Med. 25:1029.
61. Pihlajamaa, K., M. K. Bode, T. Puumalainen, A. Lehtimaki, S. Marjelund,
and T. Tikkakoski. 2004. Pneumothorax and the value of chest radiography
after ultrasound-guided thoracocentesis. Acta Radiol. 45:828-832.
62. Raptopoulos, V., L. M. Davis, G. Lee, C. Umali, R. Lew, and R. S. Irwin.
1991. Factors affecting the development of pneumothorax associated with
thoracentesis. AJR Am.J.Roentgenol. 156:917-920.
63. Rasmussen, O. S. and P. Boris. 1989. Ultrasound guided puncture of
pleural fluid collections and superficial thoracic masses. Eur.J.Radiol. 9:91-92.
64. Reinhold, C., F. F. Illescas, M. Atri, and P. M. Bret. 1989. Treatment of
pleural effusions and pneumothorax with catheters placed percutaneously
under imaging guidance. AJR Am.J.Roentgenol. 152:1189-1191.
65. Sartori, S., P. Tombesi, D. Tassinari, P. Ceccotti, I. Nielsen, L. Trevisani,
and V. Abbasciano. 2004. Sonographically guided small-bore chest tubes and
sonographic monitoring for rapid sclerotherapy of recurrent malignant pleural
effusions. J.Ultrasound Med. 23:1171-1176.
66. Shankar, S., M. Gulati, M. Kang, S. Gupta, and S. Suri. 2000. Imageguided percutaneous drainage of thoracic empyema: can sonography predict
the outcome? Eur.Radiol. 10:495-499.
15
67. Silverman, S. G., P. R. Mueller, S. Saini, P. F. Hahn, J. F. Simeone, B. H.
Forman, E. Steiner, and J. T. Ferrucci. 1988. Thoracic empyema:
management with image-guided catheter drainage. Radiology 169:5-9.
68. Weingardt, J. P., R. R. Guico, A. A. Nemcek, Jr., Y. P. Li, and S. T. Chiu.
1994. Ultrasound findings following failed, clinically directed thoracenteses.
J.Clin.Ultrasound 22:419-426.
69. Ng, A. W., K. W. Chan, and S. K. Lee. 1994. Simple aspiration of
pneumothorax. Singapore Med.J. 35:50-52.
16