ABC | Volume 110, Nº6, June 2018

Review Article Muniz et al Pulmonary ultrasound in patients with heart failure Arq Bras Cardiol. 2018; 110(6):577-584 Outpatient AU ICU Emergency Prehospital 0 2 2 4 4 6 8 10 12 3 7 11 Figure 5 – Distribution of the number of publications about pulmonary ultrasound in heart failure according to the assessment setting. AU: admission unit; ICU: intensive care unit. applicability. 8 A recent systematic review has shown that the PU findings can rapidly change with therapy for HF, and that the identification of residual congestion in patients with acute HF at hospital discharge or in patients with chronic HF followed up on an outpatient basis can indicate those at higher risk for adverse events. 45 Gullet et al. 16 and Bedetti et al. 46 have reported the excellent correlation between two observers with different specific expertise regarding PU for the analysis of B-lines at the bedside of patients with known or presumed HF. In a study on stable patients undergoing dialysis, the identification of B-lines on PU correlated with pre-dialysis diastolic blood pressure (p = 0.015) and with the combination of reduced ejection fraction and reduced blood volume percentage at the end of hemodialysis (p = 0.028). 47 We trained two non-specialized physicians on PU to assess congestion. We concluded that 4 hours of theoretical training and performing 15 tests were sufficient for them to develop similar accuracy in quantifying pulmonary congestion. Our tests are validated by a specialist radiologist (AMB), emphasizing our commitment with performance areas and need for proficiency-training. In addition, in our medical practice, we identified the superiority of PU over stethoscope auscultation to assess pulmonary congestion. Furthermore, the presence of B-lines (mean value of 12.2±7.3) was a marker of re-admission for one fourth of the patients in 90 days, and the presence of moderate congestion was a predictor of re-admission in 100% of the cases. Pulmonary ultrasound and evidence-based recommendations Volpicelli et al. 12 have proposed the first document to provide evidence-based recommendations for clinical use of point-of-care PU. In that document, those authors have determined the levels of evidence for each applicability, establishing that, when assessing interstitial syndrome, the ultrasonographic technique consists ideally of the assessment of 8 regions (range: from 2 to 28). A positive region is defined by the presence of at least three B-lines on a longitudinal plane between two ribs. The ultrasonographic definition of B-line and the positive zone criterion (presence of ≥ 3 B-lines per field analyzed) were criteria used by all the authors of the present review. In addition, the criterion to define alveolar-interstitial syndrome (≥ 3 B-lines per field analyzed bilaterally) was common among the authors. Limitations The present systematic review had as limitation the small sample size. The lack of standardization of the scores used for semiquantitative analysis was also a limiting factor. Conclusion The use of PU to assess dyspneic patients and those with HF in different clinical settings increases the sensitivity, specificity and accuracy of the diagnosis and prognosis of pulmonary congestion in patients with HF. Pulmonary ultrasound adds value to the diagnosis, facilitating decision-making in the assessment of acutely dyspneic patients, to whom HF is one of the differential diagnoses, minimizing treatment errors and improving the clinical outcome of this patient model. Author contributions Conception and design of the research: Muniz RT, Mesquita ET; Acquisition of data and analysis and interpretation 582