ABC | Volume 110, Nº6, June 2018

Review Article Pulmonary Ultrasound in Patients with Heart Failure - Systematic Review Rafael Tostes Muniz, 1,2 Evandro Tinoco Mesquita, 1 Celso Vale Souza Junior, 2 Wolney de Andrade Martins 1,2 Programa de Pós-graduação em Ciências Cardiovasculares da Universidade Federal Fluminense (UFF), 1 Niterói, RJ - Brazil Complexo Hospitalar de Niterói, 2 Niterói, RJ – Brazil Keywords Heart Failure; Pulmonary Congestion, Extravascular Lung Water / diagnostic imaging; Lung / diagnostic imaging; Ultrassonography; Lung / radiography. Mailing Address: Rafael Tostes Muniz • Hospital Universitário Antônio Pedro - Rua Marques de Paraná, 330, 4º andar - prédio anexo. Postal Code 24240-670, Niterói, RJ - Brazil E-mail: dr.rtmuniz@gmail.com Manuscript received November 14, 2017, revised manuscript March 13, 2018, accepted March 21, 2018 DOI: 10.5935/abc.20180097 Abstract Pulmonary congestion is an important clinical finding in patients with heart failure (HF). Physical examination and chest X-ray have limited accuracy in detecting congestion. Pulmonary ultrasound (PU) has been incorporated into clinical practice in the evaluation of pulmonary congestion. This paper aimed to perform a systematic review of the use of PU in patients with HF, in different scenarios. A search was performed in the MEDLINE and LILACS databases in February 2017 involving articles published between 2006 and 2016. We found 26 articles in the present review, 11 of which in the emergency setting and 7 in the outpatient setting, with diagnostic and prognosis defined value and poorly studied therapeutic value. PU increased accuracy by 90% as compared to physical examination and chest X-ray for the diagnosis of congestion, being more sensitive and precocious. The skill of the PU performer did not interfere with diagnostic accuracy. The presence of B-lines ≥ 15 correlated with high BNP values (≥ 500) and E/e' ratio ≥ 15, with prognostic impact in IC patients at hospital discharge and those followed up on an outpatient basis. In conclusion, when assessing pulmonary congestion in HF, PU has an incremental value in the diagnostic and prognostic approach in all scenarios studied. Introduction Heart failure (HF) is one of themajor causes of hospitalization of adults in Brazil. The BREATHE Registry is the first to include a large sample of hospitalized patients with decompensated HF of different regions from Brazil, 1 that being the first cause of hospitalization of patients older than 65 years, 2 one fourth of whom are readmitted to the hospital within 30 days. 3 In Europe, 44% of the patients with HF are readmitted at least once every 12 months. 4 Acute or progressive dyspnea due to pulmonary congestion is the major reason why patients seek care in emergency units. 5 Subclinical congestion is associated with a worse clinical outcome. 3,4 Physical examination and chest X-ray are widely used by emergency doctors; however, they have low accuracy to diagnose pulmonary congestion. In addition, chest X-ray often depends on the radiologist’s assessment, which delays decision-making. 6 Pulmonary ultrasound (PU) was previously considered of little clinical usefulness in classic cardiology textbooks. 5 However, since the study by Daniel Lichtenstein in 1997, 6 PU has become widely used to assess alveolar-interstitial syndrome, which encompasses pulmonary congestion of cardiac origin, 6 in intensive care and emergency settings, for hospitalized patients before hospital discharge, and for patients with HF undergoing outpatient follow-up. The major use of PU for the cardiologist is to assess B-lines. 7-9 The analysis of B-lines (ultrasound lung comets) allows the detection of alveolar-interstitial syndrome and the access to extravascular lung water. 6,7 The B-lines are laser‑like vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen without fading and move synchronously with lung sliding. 10 Several B-lines are present in pulmonary congestion and can aid the detection, semiquantification and monitoring of extravascular lung water, the differential diagnosis of dyspnea and the prognostic stratification of chronic and acute HF. 6,11 When three or more B-lines are identified, the zone or field is considered positive. 7,10,12 Different methodologies have been applied to PU to analyze B-lines, from the prehospital setting, where only 2 lung fields are assessed, 13,14 to more detailed assessments with 28 fields, as described by Jambrik 12,15 (Figure 1). Most studies, however, have used the 8-field methodology as shown in Figure 2. Pulmonary ultrasound has shown better accuracy than physical examination and lung X-ray for the diagnosis of pulmonary congestion, even when performed by physicians lacking training in the method or physicians other than radiologists. 16,17 This method adds value to neuropeptides [brain natriuretic peptide (BNP) and NTpro-BNP] for the diagnosis, 18 prognosis and treatment of patients with decompensated HF. This study was aimed at conducting a systematic review about the use of PU for patients with HF in different clinical scenarios, to identify its role in the diagnosis, prognosis and treatment of the condition. We hypothesized that PU applied to the analysis of pulmonary congestion in different clinical scenarios for patients with HF can contribute to clinical practice. Methods Bibliographic search The search was conducted in the MEDLINE (accessed via PubMed) and LILACS databases. The descriptors used were “heart failure”, “pulmonary ultrasound”, “thoracic ultrasound”. The search in the databases used the following 577