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Diagnostic Accuracy of a Bedside D-dimer Assay and Alveolar Dead-Space Measurement for Rapid Exclusion of Pulmonary Embolism
A Multicenter Study
Jeffrey A. Kline, MD;
Elizabeth G. Israel, MD, DVM, MS;
Edward A. Michelson, MD;
Brian J. O'Neil, MD;
Michael C. Plewa, MD;
David C. Portelli, MD
JAMA. 2001;285:761-768.
Context A previous study suggested that the combination of a normal D-dimer assay and normal alveolar dead-space fraction is a highly sensitive screening test for pulmonary embolism (PE).
Objective To determine if the combination of a normal alveolar dead-space fraction (volume of alveolar dead space/tidal volume  20%) and a normal whole-blood agglutination D-dimer assay can exclude PE in emergency department (ED) patients.
Design Prospective, noninterventional study conducted in 1998-1999. Study data were obtained prior to standard testing for PE, consisting of radionuclide lung scanning or contrast-enhanced computed tomography and 6-month follow-up plus selective use of venous ultrasonography and pulmonary angiography. Imaging studies were interpreted by blinded observers.
Setting Six urban teaching hospitals in the United States.
Patients A total of 380 hemodynamically stable ED patients aged 18 years or older with suspected acute PE.
Main Outcome Measures Sensitivity and specificity for PE with a positive test defined as having either alveolar dead-space fraction or D-dimer assay results abnormal. Alveolar dead-space fraction was determined by subtracting airway dead space from physiological dead space (determined using the modified Bohr equation) and D-dimer assay, assayed at bedside using 20 µL of arterial blood.
Results Pulmonary embolism was diagnosed in 64 patients (16.8%), of those 20 had an abnormal D-dimer assay result, 3 had an abnormal alveolar dead-space fraction, 40 had abnormal results in both, and 1 had normal results for both tests. The sensitivity for diagnosis of PE was 98.4% (95% confidence interval [CI], 91.6%-100.0%). Among the 316 patients without PE, both D-dimer and dead-space results were normal in 163, for a specificity of 51.6% (95% CI, 46.1%-57.1%). Posterior probability of PE with normal results on both tests was 0.75% (95% CI, 0%-3.4%).
Conclusion In this multicenter study of ED patients, a normal D-dimer assay result plus a normal alveolar dead-space fraction was associated with a low prevalence of PE.
Author Affiliations: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (Dr Kline); Division of Emergency Medicine, Barnes Hospital, Washington University School of Medicine, St Louis, Mo (Dr Israel); Division of Emergency Medicine, Department of Medicine, Northwestern University Medical School, Chicago, Ill (Dr Michelson); Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Mich (Dr O'Neil); Department of Emergency Medicine, St Vincent Mercy Medical Center, Toledo, Ohio (Dr Plewa); and Department of Emergency Medicine, Henry Ford Hospital, Detroit (Dr Portelli). Dr Israel is now with United States Public Health Service, Indian Health Services, Cortez, Colo, and Dr O'Neil is now with St John Hospital and Medical Center, Wayne State University School of Medicine, Detroit.
RELATED LETTER
Bedside Diagnostic Tests for Pulmonary Embolism
Jeremiah Schuur, Kenneth S. Fink, William C. Miller, Jeffrey A. Kline, Edward A. Michelson, and Brian J. O'Neil
JAMA. 2001;285(18):2326-2327.
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JAMA. 2001;285(6):836.
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