Adding lung views to resuscitative TOE named more causes of shock

Design

multicentre observational cohort using prospectively collected registry data

Population

379 resuscitative TOE examinations in ventilated adults with shock across 23 hospitals; 96 included lung ultrasound

Primary outcome

operator-reported identification of shock aetiology, with management change, duration and complications

Effect

aetiology identified 86.5% vs 75.3% (OR 1.95, 95% CI 1.02–3.72, p = 0.04); duration 21.5 vs 19.0 minutes

Resuscitative transoesophageal echocardiography is increasingly used in ventilated patients with shock, where transthoracic windows are poor and the probe can stay in place through a resuscitation. This registry study across 23 hospitals asked what happens when lung views are added to the same examination.

Of 1,213 registry examinations, 379 met criteria for shock evaluation or haemodynamic monitoring in ventilated adults, and 96 (25.3%) included transoesophageal lung ultrasound. Operators reported identifying a cause of shock in 86.5% of examinations that included lung views against 75.3% of those that did not (odds ratio 1.95, 95% CI 1.02 to 3.72, p = 0.04). Reported changes in management were more frequent but not significantly so (78.1% vs 71.7%; OR 1.40, 0.82 to 2.41). The added views cost a median 2.5 minutes (21.5 vs 19.0, p = 0.01), and complications were rare and similar.

The weakness is in the outcome, and the authors say so. 'Operator-reported identification of shock aetiology' is the operator's own judgement, recorded by the person who chose to do the extra views, with no independent adjudication. That is close to asking whether clinicians found their own additional imaging useful. The finding is worth having as a feasibility result — the views can be obtained quickly and safely as part of an examination already being done — and not as evidence that patients do better.

• Treat this as a feasibility finding: the views add about 2.5 minutes to an examination already under way
• Do not let a diagnostic impression from unadjudicated imaging substitute for the usual shock workup
• Restrict to operators already credentialed in resuscitative transoesophageal echocardiography
• Record what the lung findings changed, so a local answer accumulates

Why it matters

It reframes lung views as a routine part of an examination already being performed rather than a separate decision.

Don't overread it

The outcome is the operator's own impression, unadjudicated and unblinded — this is not evidence of diagnostic accuracy or patient benefit.

The statistics, in plain English

An odds ratio of 1.95 with an interval of 1.02 to 3.72 only just excludes 1.0, so the association is fragile. More importantly, the outcome is self-reported by unblinded operators who selected which patients got the extra views — a design that reliably produces a positive result regardless of true value. The management-change outcome, which is nearer to something that matters, was not significant.

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