CRP and Thoracic Emergency Ultrasound in Pneumonia

Community-acquired Pneumonia Clinical Trial

— TUS-STRAT  

Official title:

CRP (C-Reactive-Protein) and Pneumonia Biomarkers Stratification for Selectively Addressing Priorities in Thoracic Emergency Ultrasound in Pneumonia

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03212248
• Other study ID #: TUS-STRAT
• Status: Completed
• Phase: N/A
• First received: July 6, 2017
• Last updated: July 8, 2017
• Start date: January 2, 2016
• Est. completion date: June 30, 2017

Study information

• Verified date: July 2017
• Source: Azienda Ospedaliera, Universitaria Policlinico Vittorio Emanuele
• Contact: n/a
• Is FDA regulated: No
• Study type: Observational

Clinical Trial Summary

This preliminary study investigates in patients with possible clinical diagnosis of pneumonia, clues and biomarker assessed at Emergency Department (ED) triage, potentially predicting detection of lung consolidation by Thoracic-ultrasound (TUS) and/or by Chest-X-Rays. Cough and high admission CRP levels will be defined according to the cutoff defined by ROC analysis, will be challenged if independently associated with TUS lung consolidation detection High level of the chosen biomarker, and any of the considered symptoms, in otherwise not extremely critical patients (CURB65≤3), should prompt to immediate confirm by TUS, during the physical examination. This may limit the need of further radiological investigations allowing targeted workup.

Description:

Chest-X-Rays (CXR), Computerized Tomography (CT) or Thoracic Ultrasound (TUS) provide images deemed consistent with acute lung consolidation and suitable to confirm the diagnosis of community acquired pneumonia (CAP). Patients which may be affected by CAP are many , but diagnosis is not straightforward because we are managing "a disease characterized by educated guesswork" . Comprehensive imaging workup may be not regularly affordable in busy emergency rooms. Point-of-care TUS allows reliable diagnosis of lung consolidation and of pleural effusion. Regretfully, adequate TUS expertise is more warranted than actually available in most medical departments. Even not specifically investigated, a delay or even an impairment of appropriate TUS or CXR evaluation for several patients may occur due to time- or resource-limiting factors.

Clinical clues of lung consolidation are many. Key symptoms are cough, fever, chest pain and dyspnea with tachypnea, while the major physical signs are chest crackles and dullness. Surrogate biomarkers more easily obtainable in emergency facilities are C-reactive-protein (CRP), peripheral non-invasive pulse-oxymetry and neutrophil-to-lymphocyte ratio (NLR) which is an index of systemic inflammation associated also with pneumonia and subsequent outcome.

The aim of this preliminary study is to evaluate if any clue and which biomarker, including NLR, assessed at Emergency Department (ED) triage, is predictive of the subsequent detection of lung consolidation by TUS and/or by CXR.

The minimal groups' size, with and without TUS or CXR lung consolidation, was calculated according to the difference of the averages of neutrophil-to-lymphocyte ratio (NLR) in the reference the study of Yoon et al. Accepting alpha 0.01, for the probability of type 1 error, and power 80% for probability of type 2 error, a minimum sample size of 19 participants in each group (total 38) was required. Student's t-tests assessed the differences of CRP, WBC - white blood cells count - (TLC), neutrophil count (TNC) and NLR, between the groups with TUS and, separately, with CXR lung consolidation.Thereafter, by ROC (receiver operating curve) analysis, a cutoff of NLR, total leucocytes count (TLC), total Neutrophil count (TNC) and of CRP was calculated vs. the optimal reliability for the detection of TUS consolidation; sensitivity, specificity and accuracy (The proportion of all tests that are correct), and relative Odds Ratio (OR) and confidence intervals (CI) of the individual symptoms, and ORs of so defined laboratory assay cut-offs were calculated separately vs. TUS and CXR consolidation.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 70
• Est. completion date: June 30, 2017
• Est. primary completion date: April 30, 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 19 Years to 75 Years

Eligibility

Inclusion Criteria:

presence of history and symptoms, signs at physical examination and early laboratory clues of CAP According to the preliminary triage, in all patients, as a routine assessment, breath frequency, blood pressure and heart rate, pulse oxymetry, serum and blood analysis including creatinine and urea, CRP, blood cell counts and hemoglobin assay, were performed, also for CURB65 staging. ECG was preliminary done in all patients with chest pain, dyspnea and/or fever.

Exclusion Criteria:

Related Conditions & MeSH terms

• Community-acquired Pneumonia
• Difference, Individual
• Emergencies
• Pneumonia
• Ultrasound

Intervention

Diagnostic Test:
• Thoracic Ultrasound (TUS)

Locations

Country	Name	City	State
Italy	MCAU	Catania	Please select an option below

Sponsors (2)

Lead Sponsor	Collaborator
Azienda Ospedaliera, Universitaria Policlinico Vittorio Emanuele	Ospedale Civile di Ragusa, Italy

Country where clinical trial is conducted

Italy, 

References & Publications (7)

Cataudella E, Giraffa CM, Di Marca S, Pulvirenti A, Alaimo S, Pisano M, Terranova V, Corriere T, Ronsisvalle ML, Di Quattro R, Stancanelli B, Giordano M, Vancheri C, Malatino L. Neutrophil-To-Lymphocyte Ratio: An Emerging Marker Predicting Prognosis in Elderly Adults with Community-Acquired Pneumonia. J Am Geriatr Soc. 2017 Apr 13. doi: 10.1111/jgs.14894. [Epub ahead of print] — View Citation

Interrigi MC, Trovato FM, Catalano D, Trovato GM. Emergency thoracic ultrasound and clinical risk management. Ther Clin Risk Manag. 2017 Feb 9;13:151-160. doi: 10.2147/TCRM.S126770. eCollection 2017. — View Citation

Sperandeo M, Rea G, Grimaldi MA, Trovato F, Dimitri LM, Carnevale V. Contrast-enhanced ultrasound does not discriminate between community acquired pneumonia and lung cancer. Thorax. 2017 Feb;72(2):178-180. doi: 10.1136/thoraxjnl-2016-208913. Epub 2016 Oct 14. — View Citation

Trovato FM, Catalano D, Trovato GM. Thoracic ultrasound: An adjunctive and valuable imaging tool in emergency, resource-limited settings and for a sustainable monitoring of patients. World J Radiol. 2016 Sep 28;8(9):775-784. Review. — View Citation

Trovato FM, Catalano D. Diagnosis of Pneumonia by Lung Ultrasound in Children and Limited Resources Subsets: A Valuable Medical Breakthrough. Chest. 2016 Jul;150(1):258-60. doi: 10.1016/j.chest.2016.04.032. — View Citation

Waterer GW. The Diagnosis of Community-acquired Pneumonia. Do We Need to Take a Big Step Backward? Am J Respir Crit Care Med. 2015 Oct 15;192(8):912-3. doi: 10.1164/rccm.201507-1460ED. — View Citation

Yoon NB, Son C, Um SJ. Role of the neutrophil-lymphocyte count ratio in the differential diagnosis between pulmonary tuberculosis and bacterial community-acquired pneumonia. Ann Lab Med. 2013 Mar;33(2):105-10. doi: 10.3343/alm.2013.33.2.105. Epub 2013 Feb 21. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Odds of detecting lung consolidation by TUS according to symptoms or biomarkers' cutoffs	ultrasound	ten minutes
Secondary	Odds of detecting lung consolidation by Chest X Rays (CXR) according to symptoms or biomarkers' cutoffs	radiology	ten minutes