Utility of Dyspnea Discrimination Index and Ultrasonography in discriminating between a Cardiac and Pulmonary Cause for Dyspnea in the Emergency Department

Gina Maryann, Chandy (2015) Utility of Dyspnea Discrimination Index and Ultrasonography in discriminating between a Cardiac and Pulmonary Cause for Dyspnea in the Emergency Department. Masters thesis, Christian Medical College, Vellore.


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INTRODUCTION: Acute breathlessness is one of the main causes for admission into the emergency department of a hospital. Casualty medical officers often need to make rapid and accurate diagnosis so as to devise a treatment plan. This can be challenging as the information available at presentation is usually limited. It is particularly difficult in heart failure syndromes and exacerbation of reactive airway disease as history and examination may not clearly demarcate the actual pathology. The typical example is that of cardiac asthma, where examination findings reveal bilateral wheeze with scattered crepitation‟s. Here the patient is dyspneic and the dilemma is whether it is due to cardiac asthma or reactive airway disease. Often chest X rays take a long time and a silent chest can imply very severe chronic obstructive pulmonary disease or a pneumothorax. The time lag in waiting for a definitive diagnosis can cost a life. In patients with cardiac failure as a cause for breathlessness, chest x ray, ECG and laboratory tests that are available in the emergency department may have variable diagnostic value as cardiac failure syndromes are a heterogeneous set of clinical syndromes. Typically diagnosis is made with history and clinical examination is such cases but studies have proven that this yields very poor sensitivity with good specificity. To improve this, there have been many bed side maneuvers and tests postulated and studied. Bedside tests that deliver rapid and reliable results are a cornerstone of diagnostics in the emergency set up. AIM OF THE STUDY: To assess the utility of the Dyspnea discrimination index along with a multifactorial ultrasound screening tool to differentiate between a cardiac and pulmonary cause for breathlessness in patients who present with acute or acute on chronic breathlessness to the emergency department. OBJECTIVES: 1. To calculate the Dyspnea discrimination Index (DDI) and Percentage Dyspnea Discrimination Index (%DDI) for all patients presenting to the emergency department with dyspnea. 2. To assess the sensitivity, specificity, positive and negative predictive values of Dyspnea Discrimination Index and Percentage Dyspnea Discrimination Index in identifying pulmonary and cardiac causes for dyspnea. 3. To do a discriminate analysis on factors evaluated at admission like PaCO2, PaO2, Peak expiratory flow rate, Percentage peak expiratory flow rate which would help identify the factors with discriminative power between a cardiac and pulmonary etiology. 4. To assess the utility of a screening lung and cardiac plus IVC ultrasound in distinguishing a cardiac and pulmonary etiology for the dyspnea. METHODOLOGY: The study protocol was approved by the Institution Regional Board on 19/3/2013. It was reviewed and approved of by the ethical board. Patient Population: Patients where admitted to the emergency department of our hospital with acute or acute on chronic breathing difficulty, who fit into the inclusion criteria and gave written consent were included. As our hospital has patients from all over the country, consent was taken in the regional language. Inclusion Criteria: 1. Men and women who present to the emergency department with acute onset breathlessness or acute worsening of a chronic breathlessness. 2. Age above 18 years. 3. No other obvious non cardiac or non-pulmonary cause for breathlessness like trauma, organophosphorus poisoning or snake bite induced muscle weakness. Exclusion Criteria: 1. Patients not requiring hospitalization, who get discharged from the emergency department. 2. Those who have an obvious non-cardiac, non-pulmonary cause for dyspnea like trauma induced, poisoning or snake bite induced muscular weakness. 3. Inability to perform peak expiratory flow rate. 4. Patients who refuse consent. CONCLUSION: The bedside tools assessed in this study showed good discriminative power between cardiac and pulmonary causes of breathlessness. As the diagnostic accuracy in our emergency department is good, the dyspnea discrimination index may not help differentiate the cause further. The ultrasound tool on the other hand has a very high sensitivity and specificity and will be ideal in a tertiary care emergency set up where it can be used in the emergency department to identify the exact cause for breathlessness.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Dyspnea Discrimination Index ; Ultrasonography ; Cardiac and Pulmonary Cause ; Dyspnea ; Emergency Department.
Subjects: MEDICAL > General Medicine
Depositing User: Punitha K
Date Deposited: 18 May 2018 18:57
Last Modified: 18 May 2018 18:57
URI: http://repository-tnmgrmu.ac.in/id/eprint/7958

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