Impact of Noninvasive Studies to Distinguish Volume Overload From ARDS in Acutely Ill Patients With Pulmonary Edema

To assess the impact of substitutingnoninvasive diagnostic studies for Swan-Ganz catheter (SGC) placementin the evaluation of acutely ill patients. Modified decision analysis. Using publishedstudies that define effectiveness of clinical examination, echocardiography, and SGC placement to diagnose pulmonary edema, ananalysis of the impact of substituting three diagnostic approachesusing (1) clinical assessment (CA), (2) M-mode two-dimensionaltransthoracic echocardiography (EC), or (3) CA then EC if necessary for, SGC placement was considered. Patients with acute respiratory distress and radiographic findings ofpulmonary edema, and ICU patients with hypotension and/or pulmonaryedema without acute cardiac ischemia. Three approaches using noninvasive studies were substituted forplacement of SGC in the initial evaluation of pulmonary edema. The number of SGCs placed, thenumber of tests needed to diagnose (NTND) all cases of volume overload, and the total number of procedure-related adverse events werecalculated for each diagnostic approach and compared to SGC placement. EC, and CA then EC approaches produced fewer procedure-related seriouscomplications and deaths, compared to the SGC approach; however, theseapproaches also produced a higher NTND and total procedures performedthan did the SGC or CA approaches. The CA approach led to reduced NTNDand procedure-related adverse events. Substituting noninvasive studies for SGC placement in the initialevaluation of acutely ill patients may slightly reduceprocedure-related adverse events, but it may also increase the numberof procedures performed. Studies of SGC use are warranted and need toinclude a clinical assessment control group and an analysis of resourceutilization.