POCUS Atlas: Pleural Effusion

Positive Findings (Patient Has This)

Finding	Increased Disease Probability (Positive Likelihood Ratio)
Anechoic fluid above diaphragm	47
Note: accuracy of ultrasound is operator-dependent. Reported LRs may not be reproducible by an inexperienced sonographer.

Negative Findings (Patient Doesn't Have This)

Finding	Decreased Disease Probability (Negative Likelihood Ratio)
Anechoic fluid above diaphragm	0.06
Note: accuracy of ultrasound is operator-dependent. Reported LRs may not be reproducible by an inexperienced sonographer.

Source

Yousefifard M, Baikpour M, Ghelichkhani P, et al. Screening Performance Characteristic of Ultrasonography and Radiography in Detection of Pleural Effusion; a Meta-Analysis. Emerg (Tehran). 2016;4(1):1-10.

Narrative

This was a meta-analysis including 12 retrospective and prospective studies (n=1554) of adults and pediatric patients. Ultrasound was used to diagnose pleural effusion, with the reference standard either CT, surgery, or a more formal “high quality ultrasound in conjunction with expert end diagnosis.” Ultrasound examinations were performed by a variety of operators including emergency physicians, intensivists, radiologists, and nurses. Exact criteria for diagnosis of a pleural effusion by ultrasound was not defined.

Caveats

Note: accuracy of ultrasound is operator-dependent. Reported LRs may not be reproducible by an inexperienced sonographer.

Published in collaboration with The POCUS Atlas

Author

Kyle Kelson, MD; Matthew Riscinti

Published/Updated

September 13, 2018

What are Likelihood Ratios?

LR, pretest probability and posttest (or posterior) probability are daunting terms that describe simple concepts that we all intuitively understand.

Let's start with pretest probability: that's just a fancy term for my initial impression, before we perform whatever test it is that we're going to use.

For example, a patient with prior stents comes in sweating and clutching his chest in agony, I have a pretty high suspicion that he's having an MI – let's say, 60%. That is my pretest probability.

He immediately gets an ECG (known here as the "test") showing an obvious STEMI.

Now, I know there are some STEMI mimics, so I'm not quite 100%, but based on my experience I'm 99.5% sure that he's having an MI right now. This is my posttest probability - the new impression I have that the patient has the disease after we did our test.

And likelihood ration? That's just the name for the statistical tool that converted the pretest probability to the posttest probability - it's just a mathematical description of the strength of that test.

Using an online calculator, that means the LR+ that got me from 60% to 99.5% is 145, which is about as high an LR you can get (and the actual LR for an emergency physician who thinks an ECG shows an obvious STEMI).

(Thank you to Seth Trueger, MD for this explanation!)