Cardiopulmonary ultrasound for critically ill adults improves diagnostic accuracy in a resource-limited setting: the AFRICA trial

Trop Med Int Health. 2017 Dec;22(12):1599-1608. doi: 10.1111/tmi.12992. Epub 2017 Nov 9.

Abstract

Objective: To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource-limited setting.

Methods: Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardised final diagnosis derived from post hoc chart review of the patient's care at 24 h by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-h mortality and use of IV fluids, diuretics, vasopressors and bronchodilators.

Results: Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a 'cardiac' diagnosis, such as cardiogenic shock, congestive heart failure or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups.

Conclusions: In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-h mortality and a number of patient care interventions.

Keywords: Africa; Afrique; choc; critical illness; dyspnoea; dyspnée; global health; maladie grave; santé mondiale; shock; sonography; échographie.

Publication types

  • Controlled Clinical Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Clinical Protocols
  • Critical Illness*
  • Developing Countries
  • Emergency Service, Hospital*
  • Female
  • Ghana
  • Health Resources*
  • Heart Diseases / complications
  • Heart Diseases / diagnosis
  • Heart Diseases / diagnostic imaging
  • Hospitals, Teaching
  • Humans
  • Income
  • Male
  • Middle Aged
  • Respiratory Distress Syndrome, Adult / diagnosis
  • Respiratory Distress Syndrome, Adult / diagnostic imaging*
  • Respiratory Distress Syndrome, Adult / etiology
  • Shock / diagnosis
  • Shock / diagnostic imaging*
  • Shock / etiology
  • Ultrasonography / methods*