Reply: Getting the Full Diagnostic Picture in Intensive Care Medicine: A Plea for “Physiological Examination”

From the Authors:

We thank Dr. Saugel and colleagues for their thoughtful response and for their interest in our article reviewing the evidence and proposing a framework for bedside assessment in the intensive care unit. They recommend that the traditional bedside physical examination be formally augmented by the “PhysioEx,” a physiologic assessment of the qualitative and quantitative data available from bedside monitors such as intravascular pressure tracings, ventilator waveforms, and plethysmography signals. Dr. Saugel and colleagues point out that these data and the response to maneuvers such as passive leg raise can provide a wealth of data supporting diagnoses of valvular and pericardial pathology, preload responsiveness, vascular tone, and patient–ventilator interaction. All these insights have direct implications for therapy, and the PhysioEx has the additional advantage of easy repeatability.

We agree: The physical examination and the PhysioEx are both important facets of intensive care unit bedside assessment. Similar to physical examination, in which training in and practice of correct technique are paramount, training in and deep understanding of components of the PhysioEx is necessary to use these tools correctly. Current training paradigms, however, may not provide this knowledge. For example, in one study, the ability of intensivists to correctly interpret pulmonary artery occlusion pressure waveforms was no better than random guess (1). Similarly poor performance has been observed for the identification of patient–ventilator dyssynchrony by evaluation of the ventilator waveforms (2). Even with a given set of data, the clinical response to PhysioEx data may be variable across clinicians. For example, there was significant heterogeneity in management among intensivists given a set of pulmonary artery catheterization data and echocardiographic data (3).

We agree that the PhysioEx and the traditional physical examination are complimentary in the care of critically ill patients and have the potential to improve patient care in the intensive care unit. Future studies should address the optimal manner to teach these techniques and continue to address both the diagnostic accuracy and clinical outcomes of patients cared for by expert clinicians using these data. We believe that both components of bedside assessment enable engaged clinicians to provide accurate diagnoses and appropriate treatment. Finally, we, as a critical care community, should enable the sharing and dissemination of our best practices for rounding, bedside assessment, and teaching these techniques to trainees and peers, both between institutions and within the same institution.