Impact of Noninvasive Studies to Distinguish Volume Overload From ARDS in Acutely Ill Patients With Pulmonary Edema : Analysis of the Medical Literature From 1966 to 1998

摘要

Study objective: To assess the impact of substituting noninvasive diagnostic studies for Swan-Ganzncatheter (SGC) placement in the evaluation of acutely ill patients.nDesign: Modified decision analysis.nMethods: Using published studies that define effectiveness of clinical examination, echocardiography,nand SGC placement to diagnose pulmonary edema, an analysis of the impact ofnsubstituting three diagnostic approaches using (1) clinical assessment (CA), (2) M-mode twodimensionalntransthoracic echocardiography (EC), or (3) CA then EC if necessary for SGCnplacement was considered.nStudy population: Patients with acute respiratory distress and radiographic findings of pulmonarynedema, and ICU patients with hypotension and/or pulmonary edema without acute cardiac ischemia.nInterventions: Three approaches using noninvasive studies were substituted for placement of SGC innthe initial evaluation of pulmonary edema.nMeasurements and results: The number of SGCs placed, the number of tests needed to diagnosen(NTND) all cases of volume overload, and the total number of procedure-related adverse events werencalculated for each diagnostic approach and compared to SGC placement. EC, and CA then ECnapproaches produced fewer procedure-related serious complications and deaths, compared to thenSGC approach; however, these approaches also produced a higher NTND and total proceduresnperformed than did the SGC or CA approaches. The CA approach led to reduced NTND andnprocedure-related adverse events.nConclusions: Substituting noninvasive studies for SGC placement in the initial evaluation of acutely illnpatients may slightly reduce procedure-related adverse events, but it may also increase the numbernof procedures performed. Studies of SGC use are warranted and need to include a clinical assessmentncontrol group and an analysis of resource utilization.