This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (48)  • Contact me when this article is cited  Related Content  • Related letter  • Related article  • Similar articles in JAMA  Topic Collections  • Venous Thromboembolism  • Cardiovascular System  • Emergency Medicine  • Alert me on articles by topic  Social Bookmarking   What's this?

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.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

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.
EXTRACT | FULL TEXT  

RELATED ARTICLE

Pulmonary Embolism
JAMA. 2001;285(6):836.
PDF  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Systematic errors and susceptibility to noise of four methods for calculating anatomical dead space from the CO2 expirogram
Tang et al.
Br J Anaesth 2007;98:828-834.
ABSTRACT | FULL TEXT  

The Bedside Investigation of Pulmonary Embolism Diagnosis Study: A Double-blind Randomized Controlled Trial Comparing Combinations of 3 Bedside Tests vs Ventilation-Perfusion Scan for the Initial Investigation of Suspected Pulmonary Embolism
Rodger et al.
Arch Intern Med 2006;166:181-187.
ABSTRACT | FULL TEXT  

Respiratory Dead Space Measurement in the Investigation of Pulmonary Embolism in Outpatients With Pleuritic Chest Pain
Hogg et al.
Chest 2005;128:2195-2202.
ABSTRACT | FULL TEXT  

Effects of alveolar dead-space, shunt and V/Q distribution on respiratory dead-space measurements
Tang et al.
Br J Anaesth 2005;95:538-548.
ABSTRACT | FULL TEXT  

Evaluation of Capnography Using a Genetic Algorithm To Predict PaCO2
Engoren et al.
Chest 2005;127:579-584.
ABSTRACT | FULL TEXT  

Improving access to diagnostics: an evaluation of a satellite laboratory service in the emergency department
Leman et al.
Emerg. Med. J. 2004;21:452-456.
ABSTRACT | FULL TEXT  

D-Dimer for the Exclusion of Acute Venous Thrombosis and Pulmonary Embolism: A Systematic Review
Stein et al.
ANN INTERN MED 2004;140:589-602.
ABSTRACT | FULL TEXT  

Volumetric Capnography as a Screening Test for Pulmonary Embolism in the Emergency Department
Verschuren et al.
Chest 2004;125:841-850.
ABSTRACT | FULL TEXT  

Diagnostic Strategies for Excluding Pulmonary Embolism in Clinical Outcome Studies: A Systematic Review
Kruip et al.
ANN INTERN MED 2003;138:941-951.
ABSTRACT | FULL TEXT  

Diagnosis of pulmonary embolism
Kearon
CMAJ 2003;168:183-194.
ABSTRACT | FULL TEXT  

The STARD Statement for Reporting Studies of Diagnostic Accuracy: Explanation and Elaboration
Bossuyt et al.
ANN INTERN MED 2003;138:W1-W12.
ABSTRACT | FULL TEXT  

The STARD Statement for Reporting Studies of Diagnostic Accuracy: Explanation and Elaboration
Bossuyt et al.
Clin. Chem. 2003;49:7-18.
ABSTRACT | FULL TEXT  

Normal D-dimer levels in emergency department patients suspected of acute pulmonary embolism
Dunn et al.
J Am Coll Cardiol 2002;40:1475-1478.
ABSTRACT | FULL TEXT  

Plasma D-Dimers in the Diagnosis of Venous Thromboembolism
Kelly et al.
Arch Intern Med 2002;162:747-756.
ABSTRACT | FULL TEXT  

Steady-State End-Tidal Alveolar Dead Space Measure and D-dimer
Verschuren et al.
Chest 2002;121:1373-1373.
FULL TEXT  

A normal alveolar dead space fraction plus D-dimer assay ruled out suspected pulmonary embolism in the emergency department
Kearon
Evid. Based Med. 2001;6:158-158.
FULL TEXT  

Bedside Diagnostic Tests for Pulmonary Embolism
Schuur et al.
JAMA 2001;285:2326-2327.
FULL TEXT  

Pair of Bedside Tests Excludes Pulmonary Embolism
JWatch Emergency Med. 2001;2001:1-1.
FULL TEXT  

New Way to Rule Out Pulmonary Embolism
JWatch General 2001;2001:6-6.
FULL TEXT  

New Way to Rule Out Pulmonary Embolism?
JWatch General 2001;2001:1-1.
FULL TEXT