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PubMed1990

Accuracy of four indirect methods of blood pressure measurement, with hemodynamic correlations.

In 38 adults undergoing cardiac surgery, 4 indirect blood pressure techniques were compared with brachial arterial blood pressure at predetermined intervals before and after cardiopulmonary bypass. Indirect blood pressure measurement techniques included automated oscillometry, manual auscultation, visual onset of oscillation (flicker) and return-to-flow methods. Hemodynamic measurements or calculations included heart rate, cardiac index, stroke volume index, and systemic vascular resistance index. Indirect and intraarterial blood pressure values were compared by simple linear regression by patient and measurement period. Measurement errors (arterial minus indirect blood pressure) were calculated, and stepwise regression assessed the relationship between measurement error and heart rate, cardiac index, stroke volume index, and systemic vascular resistance index. Indirect to intraarterial blood pressure correlation coefficients varied over time, with the strongest correlations often occurring at the first and last measurement periods (preinduction and 60 minutes after cardiopulmonary bypass), particularly for systolic blood pressure. Within-patient correlations between indirect and arterial blood pressure varied widely--they were consistently high or low in some patients. In other patients, correlations were especially weak with a particular indirect blood pressure method for systolic, mean, or diastolic blood pressure; in some cases indirect blood pressure was inadequate for clinical diagnosis of acute blood pressure changes or trends. The mean correlations between indirect and direct blood pressure values were, for systolic blood pressure: 0.69 for oscillometry, 0.77 for auscultation, 0.73 for flicker, and 0.74 for return-to-flow; for mean blood pressure: 0.70 for oscillometry and 0.73 for auscultation; and for diastolic blood pressure: 0.73 for oscillometry and 0.69 for auscultation. The mean measurement errors (arterial minus indirect values) for the individual indirect blood pressure methods were, for systolic: 0 mm Hg for oscillometry, 9 mm Hg for auscultation, -5 mm Hg for flicker, 7 mm Hg for return-to-flow; for mean: -6 mm Hg for oscillometry, and -3 mm Hg for auscultation; and for diastolic: -9 mm Hg for oscillometry and -8 mm Hg for auscultation. Mean measurement error for systolic blood pressure was thus least with automated oscillometry and greatest with manual auscultation, while standard deviations ranging from 9 to 15 mm Hg confirmed the highly variable nature of single indirect blood pressure measurements. Except for oscillometric diastolic blood pressure, a combination of systemic hemodynamics (heart rate, stroke volume index, systemic vascular resistance index, and cardiac index) correlated with each indirect blood pressure measurement error, which suggests that particular numeric ranges of these variables minimize measurement error.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed2003

A comparison of five techniques for detecting cardiac activity in infants.

BACKGROUND: The new guidelines for cardiopulmonary resuscitation recommend that laypersons should begin chest compressions without checking for a pulse because the pulse check has serious limitations in accuracy. We determined the efficacy of the most suitable method to search for cardiac activity in infants. METHODS: Twenty-eight nurses tried to detect infants' cardiac activity and determined their heart rates with five different techniques: palpation of brachial pulse, carotid pulse, femoral pulse, apical impulse and auscultation of apical impulse with the naked ear (direct auscultation technique). RESULTS: The mean time interval required to find the pulse within 30 s in the auscultation, the apical, the brachial, the carotid and the femoral were 2.4 +/- 1.2, 3.5 +/- 2.7, 4.0 +/- 2.7, 9.9 +/- 7.0 and 9.1 +/- 5.9 s, respectively. The required time was significantly shorter in the auscultation method than in the palpation of carotid and femoral pulses. The percentage and 95% confidence intervals (95% CI) of pulses identified within 10 s (= the number of the correct identified within 10 s/the number of all cases) in auscultation, apical, brachial, carotid and femoral palpations were 100.0% (95% CI 51.8, 100), 75.0% (95% CI 28.9, 89.3), 73.1% (95% CI 52.2, 88.4), 50.0% (95% CI 30.6, 69.4) and 42.9% (95% CI 24.5, 62.8), respectively. These values were greater in the auscultation method than in all the palpation methods. CONCLUSIONS: The direct auscultation technique was more rapid and accurate than any other techniques to determine cardiac activity without instruments. It is suggested that direct a auscultation technique is also superior to the palpation of brachial artery in cardiopulmonary resuscitation in infants.

Brachial Artery↗
PubMed2000

Bedside cardiac examination: constancy in a sea of change.

The general trend in the recent literature has been to highlight the difficulties and shortcomings of the physical examination and to attribute these difficulties to deficiencies in training rather than to intrinsic weaknesses in auscultation itself. The call is for better training. Given the advice of the authors mentioned above, individual training may be warranted at the postgraduate level and in the large community of practicing internists and cardiologists. Although not proven, it is likely that individual training with computer technology, audiotape instruction, or simulator technology such as described in the following paragraphs would be effective at improving bedside clinical diagnosis and cost-effective patient care in the postgraduate, continuing medical education setting. The advances in auscultation during the last few years have been more incremental than fundamental. There is ongoing research into the mechanism of production of S3 and S4, and mathematical modeling techniques have recently been used with some success in evaluating the vibrations of S3 and S4 as forced, damped oscillations of a viscoelastic system. Analysis of sound energy with the technique of spectral waveform analysis, which investigates the frequency content of sound signals, has been used for many years in the study of cardiovascular sound. By the use of various methods of mathematical analysis, investigators have found potentially useful information in spectral sound patterns of prosthetic valves, murmur characteristics, and even potentially hemodynamic information from heart sounds. Despite the mathematical advances, there are still disturbing drawbacks to some of the analytic techniques, such as the production of mathematical terms containing "negative energy." Although the potential of obtaining significant clinical information from spectral analysis of heart sound recordings is attractive, the clinical usefulness of such techniques remains virtually nonexistent. Similar to the recent advances in auscultation, the technical advances in the design of the stethoscope have also been more incremental than fundamental. There are at least 3 recently introduced electronic stethoscopes that have the capability of amplification and filtration and that claim noise reduction. Because their introduction is recent, no information is available in the peer-review literature regarding their clinical performance; therefore their place in the clinical arena remains to be elucidated--perhaps a boon for patient care providers with specific hearing defects and perhaps useful in noisy clinical environments. Peer-review literature has not shown clear superiority of one type of acoustic stethoscope over another. The teaching of auscultation has been an area of recognized importance in patient care since the inception of auscultation as a medical art. Attempts to facilitate practitioner learning in the performance and interpretation of auscultation have advanced through the decades limited only by the technical infrastructure of the day. The availability of recorded heart sounds and murmurs appeared shortly after the availability of recording and playback devices, with first vinyl and later tape recordings. In 1974, technology was employed to create a virtual patient named "Harvey," an engineered cardiology patient simulator that reproduces many of the physical findings of the cardiology examination. Later, with the advent of commercially available CD-ROM devices, newer, better-integrated teaching devices have been developed, some of them outstanding in their clarity and quality. Despite the obvious value of such instructional aids that are best used in the individual setting, there is evidence that the classroom is still of significant value in teaching auscultation. However, nowhere else in the practice of medicine is a mentor approach more valuable than in learning auscultation. (ABSTRACT TRUNCATED)

Cardiology↗
PubMed2002

Teaching and testing physical examination skills without the use of patients.

OBJECTIVE: To design a cardiopulmonary physical exam curriculum that does not involve the use of patients. Bedside teaching is becoming a lost art, and the use of alternative methods of instruction such as simulation has become increasingly important. Simulators have been shown to enhance physical examination skills of students and physicians in training.(1) DESCRIPTION: In 1995, a program was started to improve cardiopulmonary physical diagnosis and the teaching of auscultation at the University of Texas Medical Branch at Galveston (UTMB). The teaching manikin "Harvey" played a vital role in the development of the new curriculum. In 1997, UTMB adopted an organ-based approach to the basic science curriculum. The cardiopulmonary module in the basic science curriculum was a ten-week course taught in the second year of medical school. The physical diagnosis section of that course involved six instructional hours; four of the six hours were dedicated to cardiac auscultation and two hours to pulmonary auscultation. Only simulators and CD-ROMs were used for instruction. The 184 second-year medical students at UTMB were formed into small groups for instruction and practice. Although "Harvey" was an effective teaching tool, other simulators had to be developed for testing students' skills after instruction. It would be very difficult to administer a skills OSCE for 184 students without the development of several smaller transportable simulators. A commercially available blood pressure simulator from the Medical Plastics Laboratory, Inc., Gatesville, TX, was used to test the accuracy of students' blood pressure readings. Small auscultation transducers combined with a palpable pulse simulator, developed by one of the authors (WT) in collaboration with Andries Acoustics, Spicewood, TX, were used to efficiently test students' proficiency in cardiopulmonary auscultation. Digital simulated cardiopulmonary sounds were recorded onto a standard CD-ROM mini-disc and transmitted to the small transducers. Students used their own stethoscopes for auscultation. The targeted skills were efficiently tested in one hour of testing time per student. DISCUSSION: This cardiopulmonary instructional module was well received by the second-year medical students. In the skills OSCE, 80% of the students accurately measured systolic and diastolic blood pressure to within 5 mm Hg. Cardiopulmonary auscultation proficiency results showed average recognition of 60% for cardiac abnormalities and 88% for pulmonary sounds. Developing auscultation transducers with pulse simulation capability ensured that students could identify systole. Therefore, heart murmurs and sounds could be timed with the cardiac cycle. We found the results from the skills OSCE encouraging. Most students demonstrated reasonable competency in the skills taught, and the new transportable simulators performed well. The six-hour instructional module was meant to prepare students for their bedside teaching during the third year of medical school. The significant cost of the "Harvey" simulator may be a barrier to its widespread use for teaching. Therefore, continued development of smaller transportable simulators for teaching and testing purposes is important.

Clinical Competence↗
PubMed2006

[Heart murmur and echocardiographic findings in 2,907 non-selected patients admitted to hospital].

INTRODUCTION: Since the introduction and increased availability of echocardiography, the importance of heart auscultation in diagnosing valvular heart disease has been reduced. Nevertheless, auscultation is still important when deciding whether to refer a patient for further examination. MATERIALS AND METHODS: A retrospective analysis was done of 2,907 consecutive patients admitted to a hospital in Copenhagen from 1 April 1998 to 31 March 1999. Auscultation, clinical history and echocardiography were performed within 24 hours of admittance. RESULTS: The prevalence of heart murmurs was 20.5%. The sensitivity and specificity of murmur found by auscultation and echocardiographic findings were 0.52 and 0.93, respectively. We found a positive predictive value of auscultation of 0.76 and a negative predictive value of 0.82. CONCLUSION: The relationship between auscultation and echocardiography in diagnosing heart murmurs in non-selected patients admitted to hospital has not previously been described. Auscultation has a high specificity, indicating that such patients should be referred for echocardiography. Its sensitivity, however, is low, indicating that it is insufficient as a means of screening for valvular heart disease.

Adult↗
PubMed1999

The assessment of four different methods to verify tracheal tube placement in the critical care setting.

UNLABELLED: One of the most serious complications of conventional endotracheal intubation is unidentified placement of the tube in the esophagus. The aim of our study was to evaluate four different methods for immediate detection of the tube position: auscultation, capnographic determination of ETCO2, esophageal detection method (EDM) using a self-inflating bulb, and the transillumination method using a lighted stylet (Trachlight; Laerdal, Armonk, NY). Thirty-eight endotracheally intubated patients admitted to our medical intensive care unit were enrolled in the study. A second identical tube was inserted into the esophagus under laryngoscopic control. The endotracheal tube was then disconnected from the ventilator. Two blinded examiners, one experienced, the other inexperienced, determined the tube position within 30 s using one of the four methods. The order of the tubes tested and the methods used were randomized. In 130 of 152 examinations, both examiners correctly diagnosed the position of the tube. The wrong result was obtained by both examiners 4 times; only the experienced examiner was wrong 4 times, and only the inexperienced examiner was wrong 14 times. Using ETCO2, both examiners were correct in all cases. Auscultation showed an obvious relation to the examiner's experience: the experienced examiner was correct in all cases, the inexperienced examiner was correct in only 68% of cases. Using the self-inflating bulb, there were two wrong results of the experienced examiner and one wrong result of the inexperienced examiner. The transillumination technique was associated with a high error rate by both examiners (16% and 13%, respectively). Comparing all four methods showed that capnography is superior to auscultation (P = 0.0005) and to the Trachlight detection method (P = 0.0078). EDM was not statistically superior to auscultation and transillumination. Capnography was the most reliable method for rapid evaluation of tube position, followed by EDM, whereas auscultation and Trachlight did not seem to be of comparable value. Experience was a determining factor for auscultation. IMPLICATIONS: To prevent unidentified esophageal intubation, a serious complication in the critical care setting, four methods for detecting tube position were tested by two examiners (one experienced, the other inexperienced) in endotracheally intubated patients after insertion of a second tube into the esophagus.

Adult↗
PubMed2000

Effect of age and training on murmurs of atrioventricular valvular regurgitation in young thoroughbreds.

Cardiac auscultation was carried out on 111 Thoroughbred horses age 2-5 years to test the hypothesis that athletic training might influence the development of atrioventricular (AV) valve regurgitation in young Thoroughbreds. Murmurs of valvular regurgitation were identified and graded on a 1-6 scale. There were 2 sources of auscultation data: 1) 55 2-year-old horses that were examined by auscultation before training commenced and 9 months later when at race fitness; 2) 56 horses age 2-5 years that were examined on one occasion only (25 2-year-olds, 23 3-year-olds, five 4-year-olds and five 5-year olds). All horses in the second data set were in full training and racing regularly at the time of the examination. To conclude the study, 35 horses were selected randomly from both groups of horses and examined with colour-flow Doppler echocardiography. The aim of the final part of the study was to check specificity and sensitivity of auscultation for detection of AV valve murmurs and therefore validate the auscultation findings. Prior to training, the prevalence in 2-year-old racehorses of murmurs of mitral regurgitation and tricuspid regurgitation was 7.3% (4/55) and 12.7% (7/55), respectively. After training, the prevalence proportions increased to 21.8% (12/55) and 25.5% (14/55). After training, one horse developed a murmur characteristic of aortic regurgitation. The differences in murmur prevalence were statistically significant for mitral and tricuspid regurgitation (paired t test results: mitral regurgitation, P = 0.019; tricuspid regurgitation, P = 0.007), as were the differences in mean murmur grade (P = 0.018 and P = 0.0006, respectively). There were no significant effects of age on the prevalence of valvular regurgitation in 56 horses examined at race fitness. Auscultation was a specific (specificity 100%) and reasonably sensitive method for detection of murmurs of mitral and tricuspid regurgitation (mitral regurgitation: positive predictive value 100%, negative predictive value 84%, tricuspid regurgitation: positive predictive value 100%, negative predictive value 65%). These data suggest that the prevalence and grade of murmurs of mitral and tricuspid valvular regurgitation increase in 2-year-old Thoroughbreds after 9 months of athletic training. Whereas the effects of age and growth on the prevalence of murmurs cannot be ruled out from these data, this study suggests that there is an influence of athletic training on the development of atrioventricular valvular regurgitation in flat-racing Thoroughbreds.

Age Factors↗