Pocket-sized ultrasound – A new tool for heart-failure nurses in daily clinical practice?

Heart-failure management programmes are advised in several professional guidelines and in a lot of countries, these programmes are considered as a standard of care and considered to impact patient reported outcomes and costs. ¹ One of the important components of these programmes is follow-up to assess heart-failure status, optimize treatment and support self-care. This can be done through face-to-face meetings and telemonitoring. ² One of the reasons for regular follow up of patients with chronic heart failure is to prevent deterioration by assessing early signs of decompensation. However, detection of fluid overload in patients with heart failure in the outpatient clinic setting can be difficult. Lung-auscultation is the method often used by nurses and physicians in heart-failure clinics, but there may be difficulties in detecting and interpreting lung sounds and the relation to the amount of fluid in the lungs. Further, the monitoring of natriuretic peptides to detect fluid overload may also be challenging to interpret.

The development of miniature, low cost ultrasound scanners has opened up the possibilities for specialized nurses and GPs to perform ultrasound outside specialized units. Monitoring of pleural cavities and inferior vena cava is related to right atrial pressure and fluid overload and has been found to predict outcomes in patient with heart failure.

In this issue of the European Journal of Cardiovascular Nursing there are two articles^3,4 published on the feasibility and reliability of pocket-sized ultrasound examinations of the pleural cavities and vena cava inferior performed by nurses in heart-failure clinics. Both studies were performed in Scandinavia, a part of Europe where heart-failure clinics have been initiated and nurses play an active role in the care and follow-up of patients with heart failure. ⁵ In a lot of these clinics there is a constant striving to improve care, and there is an openness to changing roles and responsibilities for nurses and other healthcare workers. One of these developments is the use of new technologies, such as, for example telemonitoring to improve follow-up or the use of pocket-sized ultrasound examinations to improve assessment of the early signs of decompensation.

Two studies in this issue conclude that the use of pocket-sized ultrasound examinations is feasible, fairly reliable regarding the detection of pleural cavities, but less reliable with regard to assessing the vena cava inferior. The nurses in the studies could – after a short training programme – perform protocolized examinations of pleural cavities and the vena cava inferior, ³ and the investigation took on average 5 minutes. ⁴ There was a good agreement between the cardiologist and the heart-failure nurses when using pocket-sized ultrasound, with regard to the number of comet tail artifacts, a sign of interstitial fluid. ³ Similarly, the nurses found almost the same number of pleural cavities as found by reference echocardiography. ⁴ More extensive supervised training and feed-back may improve quality of the nurses pocket-sized ultrasound assessments.

Based on the findings so far with regard to feasibility and reliability we need to question if we are ready for a wider implementation of this tool in heart-failure clinics and maybe also for hospitalized heart-failure patients. Should this tool be used for all patients or for selected groups? To what extent will it change practice and help guiding treatment and management? Further larger studies are needed to verify the impact on cost-effectiveness and quality of life based on clinical significance in terms of improving detection of early signs of deterioration. However, with the current data available, this tool already seems promising. Routine assessment of volume state using pocket-size ultrasound may improve diagnostics in nurse-led outpatient heart-failure clinics, and improve quality and increase safety of treatment and care. Dalen et al. ⁴ conclude that since the assessment only takes a few minutes it could be part of every routine visit to an outpatient heart-failure clinic. Heart-failure nurses may probably be able to use pocket-sized ultrasound for detecting pleural cavities after sufficient training. Therefore, it will be interesting to follow how this new tool is used in daily clinical practice in the future.