الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
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Abstract
The diagnosis of PTE is still a problem especially at emergency units. MSCTPA is considered the gold standard for the diagnosis. Unfortunately MSCTPA is expensive, not widespread enough cannot be reached at the emergency units, and also time factor is important. Furthermore, it has limitations in pregnancy and renal failure. So, PTE remains undiagnosed especially at the emergency units in the majority of patients, suggesting the need for alternative, easy, and widespread bedside diagnostic approaches
TUS is an emerging noninvasive diagnostic technique. It is gaining an increasingly important role in diagnosing many chest diseases including PE.
The aim of this study was to determine the diagnostic role of grayscale and colour Doppler TUS in PTE and also to evaluate if there is additional diagnostic value of colour Doppler over grayscale TUS.
A total of 60 consecutive patients (27 women and 33 men; mean age 50.63 years) admitted at Assiut University Hospital with suspected PE were enrolled in this prospective analytic cross- sectional study at the period from August 2013 to December 2014. These included patients admitted at Chest Department, Medical Emergency Room, Respiratory Intensive Care Unit and those requested for consultation from other departments.
All patients were subjected to the following:
1. Thorough medical history with special attention paid to risk factors and symptoms of PE.
2. Both general and local chest examination.
3. Plain radiographic chest examination.
4. Electrocardiography (ECG).
5. Arterial blood gases (ABGs).
6. Multislice computed tomography with pulmonary angiography (MSCTPA).
7. Grayscale and color Doppler Transthoracic Utrasonography (TUS) at Chest department ultrasonography unit by an expert in TUS.
The following was done in a number of selected cases:
1. Echocardiography was done in all patients with heamodynamic instability and whenever possible in other patients
2. Duplex sonography of lower extremity veins was conducted in all patients with signs or symptoms of DVT and whenever possible in other patients
The following results were observed:
• Out of all patients, 56 (93.3%) had Dyspnea, 38 (63.3%) had pleuritic chest pain, 8 (13.3%) had retrosternal chest pain and 33 (55%) had haemoptysis at the time of admission. Only retrosternal chest pain was significantly higher in pulmonary embolism positive group (p <0.05).
• According to modified Well’s score, 42 (70%) of the cases were defined as moderate risk for PE and 18 (30%) were defined as high risk. The mean score was significantly higher in PE positive group compared to PE negative group (p <0.001).
• The signs of DVT was significantly higher in PE positive group (12% of cases) compared to PE negative group (p <0.05). On the other hand, the presence of cyanosis was significantly higher in PE negative group compared to PE positive group (p <0.05).
• As regarding chest X-ray, the most common findings in PE positive group were pleural effusions (35%) and consolidations (32%) mean while, the most common finding in the PE negative group was free chest x-ray (55%). Raised copula in chest X-ray was significantly higher in PE positive group as it was found in 9 patients (22.5%) and was not found in any patient in PE negative group (p <0.05).
• As regarding ECG, The most common finding were sinus tachycardia (80%) and S1Q3T3 (22.5%) in PE positive group and sinus tachycardia (80%) and normal sinus (20%) in PE negative group. S1Q3T3 in ECG was significantly higher in PE positive group (p <0.05).
• As regarding the presence of pleural effusion as seen by TUS, The presence of pleural effusion was significantly higher in PE positive group (62.5%) than in PE negative group (20%) (p <0.01). The pleura Effusion in the PE positive group was found in 25 out of 40 cases and was in the form of isolated basal effusion in 15 cases and isolated localized effusion at the site of infarctions in 5 cases and both forms was found together in 5 cases.
• MSCTPA established thrombus at right lung in 13 cases and at left lung in 4 cases and bilateral in 23 cases.18 thrombus was detected at right or left main pulmonary arteries, 9 at the lobar branches, 23 at the segmental branches and 16 at the sub-segmental branches.
• As regard the echocardiographic findings, dilated right side of the heart with pulmonary hypertention in a case not known to have decompasetedcor-pulmonale or chronic heart failure was significant for the diagnosis of PE (p <0.05).
• In 33 0f 40 patients finally diagnosed as PE, chest ultrasongraphy demonstrated a total of 66 lesions with a mean ± SD of 2.00 ± 1.20 lesion/patient (range, 1- 6 lesions).
• As regard the shape of the lesions, 47 lesions (71.2%) were wedge shaped, 8 lesions (12.1%) were rounded and 11 lesions (16.7%) were polygonal.
• Concerning the side of the lesions, 34 lesions (51.5%) were found in the right side and 32 lesions (48.5%) in the left side. The majority of the lesions were detected in the lower lobe (53 lesions, 80.3%) followed by the upper lobe (11 lesions, 16.7%) and the middle lobe (2 lesions, 3%).
• Regarding the size of the lesions, most of the lesions showed a depth form 0.5 cm to 2 cm (52 lesions, 78.8%), while 14 lesions (21.2%) show a depth more than 2 cm.
• Central echo indicating the presence of air occupied by the bronchiole affected was found in 3 lesions (4.5% of the total number of lesions) in 3 different patients (9% of the total number of patients with detected hypoechoic lesions).
• When the lesions were examined using colour Doppler imaging 64 out of 66 lesions (97%) showed consolidation with little perfusion sign.
• The presence of pleuritic chest pain and hemoptysis were significantly higher in the presence of positive ultrasonographic findings consistent with PE among PE positive patient (p <0.01 and p <0.05 respectively). On the other hand, the presence of retrosternal chest pain was significantly higher in chest ultrasonography negative cases (p <0.05)
• The free chest x-ray was significantly higher in the chest ultrasonography negative cases among the pulmonary embolism positive group (p <0.05)
• the presence of the thrombus on the right or left main pulmonary artery only as seen by MSCTPA, without the affection of lobar, segmental or subsegmental level, was significantly higher in chest ultrasonography negative cases among PE positive patients (p <0.001). However, the isolated lobar, segmental or subsegmental thrombus was significantly higher in chest ultrasonography positive cases among PE positive patients (p <0.05).
• The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TUS in the diagnosis of PE were presented as 82%, 90%, 94%, 72% and 85% respectively. When chest ultrasonographic scan was considered positive only in cases with positive colour Doppler examination, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TUS were presented as 80%, 95%, 97% and 70.4% respectively