Emergency Department Accuracy of Point-of-Care Ultrasound in Identifying Clinically Significant Pneumothorax in...

Thoracic point-of-care ultrasound (POCUS) is an improved modality for detecting pneumothorax (PTX) with high accuracy compared with supine chest x-ray (CXR) study. However, recent research has questioned the sensitivity of POCUS for diagnosis of PTX in trauma patients.

The authors determined the accuracy of emergency physician (EP) POCUS in identifying clinically significant PTX in high-severity trauma patients based on the red criteria of the 2021 National Expert Panel on Field Triage.

The authors conducted a retrospective review of high-severity trauma patients over a 3-year period at a level I trauma center. The presence or absence of PTX was determined by means of computed tomography or a clinician's description of a "rush of air" on tube thoracostomy placement. PTX was defined as clinically significant if the patient required tube thoracostomy within 2.5 h of triage. Diagnostic test characteristics of CXR study and POCUS performed by emergency providers were calculated.

Forty of 924 patients had clinically significant PTX. POCUS identified 26 of 38 patients who survived before computed tomography, for a sensitivity of 68% (95% CI 52-80%), specificity of 100% (95% CI 19.8-100%), positive predictive value of 100% (95% CI 84-100%), and negative predictive value of 14.3% (95% CI 2.5-43.9%). Review of POCUS by fellowship-trained EPs improved sensitivity to 32 of 38 (84%; 95% CI 70-93%), specificity remained the same, PPV was 100% (95% CI 87-100%), and NPV was 25% (95% CI 4.5-64%). Plain CXR study had an overall sensitivity of 48.1% (95% CI 34.2-62.2%) and specificity of 99% (95% CI 97.5-99.6%).

Our results suggest that POCUS is accurate in identifying clinically significant PTX, especially when supervised by fellowship-trained EPs. Less experienced EPs should exercise proper technique in image acquisition and interpretation and may require more supervision by trained EPs. These results highlight the necessity for ongoing real-time quality improvement.