Improving recognition of heart failure using lung ultrasound

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This project aims to improve patient care by putting evidence into practice. Secondary gains include improving ultrasound practices, establishing robust predictive values,and eventually reducing certain unnecessary xrays. This technique, once validated, will be of particular use in regional Australia. Many older persons present to the emergency department complaining of breathlessness. This can be an important forewarning of heart failure, but is present in many conditions. In most cases, several tests are carried out to identify those patients with heart failure. Despite these investigations, heart failure is initially misdiagnosed in up to one quarter of patients. The interpretation of chest xray by treating physicians is notoriously fallible. Many European hospitals use bedside lung ultrasound(LUS) to improve their recognition of heart failure, but as the European practice model is significantly different from the Australian, the practice is not common here. The method is cheap, rapid, safe, readily available and causes trivial interference to current management. Our pilot study has already tested the lung ultrasound method in parallel with conventional investigation, without allowing it to influence management. Now we aim to incorporate it within the testing paradigm, by unblinding the treating doctor. We wish to see if the augmented assessment paradigm has a superior diagnostic accuracy to the conventional assessment paradigm. We will start by teaching a cohort of emergency trainee doctors to perform the test. Older patient who present with breathlessness to the ED will be randomised to either conventional or augmented investigation paradigm, track the emergency doctor's diagnosis after lung scan and again after full workup, and then compare the accuracy of these diagnosed in each group against a reference standard of delayed expert chart audit (which includes all prior and subsequent tests and course of disease). The primary endpoint is the difference in diagnostic accuracy between the LUS augmented investigation and the conventional investigation of breathlessness in the emergency department. Secondary endpoints are the sensitivity and specificity of LUS for differentiation of breathlessness. Exploratory endpoints will be the difference in length of stay in hospital between the groups, and the proportion of cases where chest xray contributed extra informationabove that contributed by the LUS.