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| COMMENTARY |
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| Year : 2018 | Volume
: 4
| Issue : 3 | Page : 113-116 |
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The digital handheld ultrasound device: A new portable diagnostic tool for healthcare. Will it replace the stethoscope?
Joseph S Alpert1, Rajesh Janardhanan2
1 Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
2 Department of Medicine and Medical Imaging, University of Arizona College of Medicine, Tucson, Arizona, USA
| Date of Web Publication | 18-Oct-2018 |
Correspondence Address:
Joseph S Alpert
Department of Medicine, University of Arizona College of Medicine, Tucson, Arizona
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/digm.digm_27_18
How to cite this article:
Alpert JS, Janardhanan R. The digital handheld ultrasound device: A new portable diagnostic tool for healthcare. Will it replace the stethoscope?. Digit Med 2018;4:113-6 |
How to cite this URL:
Alpert JS, Janardhanan R. The digital handheld ultrasound device: A new portable diagnostic tool for healthcare. Will it replace the stethoscope?. Digit Med [serial online] 2018 [cited 2023 Jun 8];4:113-6. Available from: http://www.digitmedicine.com/text.asp?2018/4/3/113/243642 |
Equipment used daily by hundreds of thousands of physicians throughout the world has not changed for many decades. The stethoscope, the neurological hammer, the blood pressure cuff, and the ophthalmoscope have undergone modest innovations over the years, but remain basically similar in design to how they were in the early 20th century. Recently, however, there has been a flurry of interest and a number of investigations involving a new digital diagnostic tool with substantial potential for everyday use in medical practice: the portable, handheld, and ultrasound device.[1],[2]
Unfortunately, many aspects of the traditional physical examination have been shown to be neither sensitive nor specific. A good example of that is the abdominal examination seeking the presence of ascites. Other aspects of the physical examination can be confusing, particularly to young physicians, thus leading to a missed or incorrect diagnoses as well as faulty understanding.[1],[2],[3],[4] Noninvasive diagnostic technology such as ultrasound imaging has greatly enhanced the ability of physicians to detect occult, less obvious, or unapparent pathological conditions at the bedside. Similar to many other digital devices, technical advances have progressively miniaturized ultrasound imaging equipment to the point where the device can be comfortably carried in a laboratory coat pocket and used by a physician or other health-care provider making daily hospital rounds or working in the office. A number of studies have firmly established that the use of such portable ultrasound devices markedly increases a physician's ability to detect a variety of disease states compared with physical examination alone.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]
The cost for such portable, handheld ultrasound devices has declined substantially over recent years, and the use of these systems has become increasingly more common. A full-sized office and hospital ultrasound machines such as those used by internists and radiologists in-hospital are approximately $250,000. A basic, miniaturized, and portable ultrasound device can be purchased from Amazon.com for as little as $1500, which is substantially less expensive compared to 10 years ago. The basic device only shows anatomy. Doppler flow patterns cannot be determined using the basic devices, but this technology is available in more expensive handheld echo instruments. As the use of these devices becomes increasingly common, it is likely that prices will decline even further.
A number of studies have compared the accuracy of handheld echo results with those obtained during an expert or novice physical examination. As noted in the review by Thomas et al., as well as a substantial number of other investigations, handheld echo was substantially more accurate compared with the physical examination. Thomas et al. reported that expert physical examinations detected moderate-to-severe mitral stenosis in 33%–90% of patients (mean 62%) and 71%–100% of patients with moderate-to-severe aortic stenosis (mean 84%). Sensitivity for detecting valvular regurgitation by physical examination ranged from 60% to 91% (mean 73%) for mitral regurgitation and 40%–88% (mean 63%) for aortic insufficiency. Detection of tricuspid regurgitation by physical examination ranged from 17% to 69% (mean 48%). The accuracy of handheld echo, on the other hand, was substantially better when compared with physical examination: mitral stenosis = 92%–100% (mean 97%); aortic stenosis = 63%–100% (mean 86%); mitral regurgitation = 90% mean; aortic regurgitation = 86% mean; and tricuspid regurgitation = 83% mean. Thus, handheld echocardiographic study substantially increased the sensitivity for detecting valvular lesions compared with physical examination.[1] Because of the above results, Narula et al. suggest that handheld echo use should become more widespread in clinical situations and that the echo findings might even increase auscultation skills by providing a “gold standard” for comparison with stethoscope findings.[2]
A number of studies have demonstrated that even in the hands of noncardiologists, handheld echo increases diagnostic yield.[6],[7],[8],[9],[10],[11],[12],[13],[14] The use of handheld echo has also been shown to improve the diagnostic ability of less experienced physicians and even medical students.[5],[15] Medical students at the University of South Carolina in the United States are given a handheld echo device as well as instruction in its use early in their 1st year curriculum. The faculty at this institution is convinced that this intervention has increased the diagnostic ability of their graduates.
What are the various areas of medicine besides cardiology where the daily use of a handheld, portable ultrasound device might be valuable? Investigation of a number of organ systems has demonstrated substantial diagnostic value including musculoskeletal, cardiac, vascular, endocrine, renal, gastrointestinal, pulmonary, and cutaneous systems.[4],[5],[10],[11],[13] For example, central venous intravascular cannulation is made considerably easier and safer when performed under handheld ultrasound guidance.[10] The same is true for a number of other procedures such as thoracentesis, paracentesis, and pericardiocentesis.[9] These devices offer a dual benefit of shortening the procedural times as well as making them safer. Joint aspiration and administration of steroids are also simpler, easier, and more accurately performed when ultrasound needle guidance is employed.
Early carotid artery atherosclerosis, a marker for systemic atherosclerosis, can also be detected with handheld echocardiography leading to the initiation of appropriate medical and lifestyle therapy. Thyroid nodules can be identified and either followed serially or biopsied safely with portable ultrasound guidance. In addition, biopsies of a number of other organs (e.g., kidney and liver) can also be performed with greater safety with this technique. Intravascular volume status can also be assessed with an ultrasound examination of the hepatic veins.[11] If the hepatic veins are wholly or partially collapsed, the implication is that this patient's blood volume is low and should be augmented by ingestion of additional fluids or administration of intravenous fluids.
As noted above, important diagnostic information concerning a variety of cardiac conditions can be obtained with the portable ultrasound device. Dyspnea can be the result of pulmonary disease or heart failure. An ultrasound examination can often be of assistance in determining the etiology of dyspnea: If the left ventricular function is abnormal or left atrial size is substantially increased, heart failure is likely to be the cause of the patient's shortness of breath. [Table 1] summarizes the many current indications where the portable, handheld ultrasound device can be a useful diagnostic adjunct.
Despite the excellent images obtained and the relative ease and efficiency of training, studies so far have tended to include only relatively small numbers of patients.[14],[16] Consequently, recommendations concerning the routine use of handheld echo in many areas of internal medicine have been tentative, awaiting the results of larger more definitive studies. It is expected that larger trials to examine the utility of these devices will be forthcoming in the near future. Nevertheless, many individual physicians and group practices have already purchased these devices resulting in routine daily use in many healthcare settings. It has been estimated that as many as one-third of the US rheumatologists are already using these machines in their daily practice to assess joint effusions and erosions, fasciitis, and tendon injuries. Procedures such as central venous cannulation and aspiration of fluid from the chest and abdomen are now routinely guided by ultrasound as are many biopsy procedures performed on internal organs.
Since these handheld echo devices are now readily available, increasingly reasonable in cost, and highly accurate when employed properly, how quickly, accurately, and easily can the average internal medicine trainee or physician learn to use these instruments? A number of studies have addressed this question. The simple answer is: Most medical students, trainees, as well as experienced clinicians can rapidly acquire the skills required to use the device efficiently and accurately.[13],[14],[15],[16] Consequently, a number of the US medical schools have already begun integrating training in the uses and indications of ultrasound into their undergraduate and postgraduate medical curricula (see the above comment on the University of South Carolina School of Medicine). It is anticipated that many more medical schools will soon follow this pattern. However, it is essential to point out that the handheld echo device can lead to erroneous diagnostic conclusions if the echo examination is not performed correctly. Physicians, trainees, and medical students must undergo extensive, careful training so that the ultrasound information obtained is accurate. Suboptimal studies may result in increased need for a standard, traditional echo, which means increased resource utilization. Incorrect use and/or interpretation can result in harm to patients, a perfect example of “garbage in/garbage out” in clinical medicine.
In conclusion, hand-carried ultrasound devices are rapidly becoming part of the daily practice of internal medicine in the United States and throughout the world. These devices are becoming reasonable in cost and highly efficient, but their use requires careful training in order for a physician to obtain accurate and clinically important information at the bedside or in the ambulatory setting. These devices have already increased the safety for many procedures being done under ultrasound guidance. As in any field with rapid growth, standards for performance and outcomes, cost analyses, and quality issues must be carefully studied, and the results of such studies disseminated throughout the health-care population. We are personally convinced of the utility of handheld ultrasound devices and anxiously await their widespread use in hospitals, clinics, and medical offices throughout the United States.
| References | |  |
| 1. | Thomas F, Flint N, Setareh-Shenas S, Rader F, Kobal SL, Siegel RJ. Accuracy and efficacy of hand-held echocardiography in diagnosing valve disease: A systematic review. Am J Med 2018. pii: S0002-9343 (18) 30493-5.  |
| 2. | Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside physical examination: Inspection, palpation, percussion, auscultation, and insonation. JAMA Cardiol 2018;3:346-50. |
| 3. | Vukanovic-Criley JM, Criley S, Warde CM, Boker JR, Guevara-Matheus L, Churchill WH, et al. Competency in cardiac examination skills in medical students, trainees, physicians, and faculty: A multicenter study. Arch Intern Med 2006;166:610-6. |
| 4. | Fitzgerald FT. Physical diagnosis versus modern technology. A review. West J Med 1990;152:377-82. |
| 5. | Kimura BJ, Fowler SJ, Nguyen DT, Amundson SA, DeMaria AN. Detection of early carotid arterial atherosclerosis by briefly trained physicians using a hand-held ultrasound device. Am J Cardiol 2003;92:239-40. |
| 6. | Kimura BJ, Shaw DJ, Agan DL, Amundson SA, Ping AC, DeMaria AN, et al. Value of a cardiovascular limited ultrasound examination using a hand-carried ultrasound device on clinical management in an outpatient medical clinic. Am J Cardiol 2007;100:321-5. |
| 7. | Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 2005;96:1002-6. |
| 8. | Kobal SL, Atar S, Siegel RJ. Hand-carried ultrasound improves the bedside cardiovascular examination. Chest 2004;126:693-701. |
| 9. | Piccoli M, Trambaiolo P, Salustri A, Cerquetani E, Posteraro A, Pastena G, et al. Bedside diagnosis and follow-up of patients with pleural effusion by a hand-carried ultrasound device early after cardiac surgery. Chest 2005;128:3413-20. |
| 10. | Abboud PA, Kendall JL. Ultrasound guidance for vascular access. Emerg Med Clin North Am 2004;22:749-73. |
| 11. | Brennan JM, Ronan A, Goonewardena S, Blair JE, Hammes M, Shah D, et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol 2006;1:749-53. |
| 12. | Galasko G, Lahiri R, Senior R. Portable echocardiography: An innovative tool for community based heart failure screening programmes. Circulation 2001;104:334-5. |
| 13. | Brennan JM, Blair JE, Goonewardena S, Ronan A, Shah D, Vasaiwala S, et al. A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure. Am J Cardiol 2007;99:1614-6. |
| 14. | Fedson S, Neithardt G, Thomas P, Lickerman A, Radzienda M, DeCara JM, et al. Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr 2003;16:901-5. |
| 15. | Hellmann DB, Whiting-O'Keefe Q, Shapiro EP, Martin LD, Martire C, Ziegelstein RC, et al. The rate at which residents learn to use hand-held echocardiography at the bedside. Am J Med 2005;118:1010-8. |
| 16. | Martin LD, Howell EE, Ziegelstein RC, Martire C, Shapiro EP, Hellmann DB, et al. Hospitalist performance of cardiac hand-carried ultrasound after focused training. Am J Med 2007;120:1000-4. |
[Table 1]
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