COVID-19: The New Ultrasound Alphabet in SARS-CoV-2 Era

 

COVID-19: The New Ultrasound Alphabet in SARS-CoV-2 Era

 To the Editor

We applaud the proposal of Piliego et al1 to use lung ultrasound (US) as a bedside test for triage of coronavirus disease 2019 (COVID-19) patients and for subsequent management of clinical workload and level of care in the scenario of a hospital overloaded with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic patients.2 We describe an expanded role for US. Preliminary reports from the Italian outbreak2 prompted us to adopt some variations on our standard clinical protocols and to implement or upgrade techniques we already use in our critical care practice before SARS-CoV-2 pandemic. We propose the following COVID-US alphabet (Figure).

 C: cardiac evaluation 1. Cardiac chambers diameters and kinesis 2. Pericardium (effusion, tamponade) 3. pulmonary artery pressure 4. ejection fraction% 5. inferior vena cava diameter variations differential 

O: outputs 1. renal resistive index 2. velocity-time integral 

V: ventilation 1. B-lines patterns 2. B-lines spatial distribution 3. Hyperinflation and recruitment response 4. Lung score 5. Search for pneumothorax/effusion

 I: intubation 1. Prediction of difficult laryngoscopy/intubation 2. Endotracheal intubation confirmation 

D: Doppler and deep venous thromboembolism/ pulmonary embolism 

The study of cardiac function, diameters and kinesis, including pericardium, is performed bedside at admission and at times when there are significant hemodynamic changes during the intensive care unit (ICU) stay. Cardiac evaluation includes determination of EF%, PAPs, aortic VTI at apical fifth chamber time/velocity integral at apical fifth chamber at aortic efflux as a more comprehensive parameter than sole stroke volume variation (SVV%),3 ΔIVCD%4 with respiratory cycle and RRI.3 Comparative observation of preload parameters (inferior vena cava diameter variations differential %) with contractile (EF%) and ejective function (VTI) and perfusion indexes such as RRI, allow us to tailor hemodynamic and ventilator therapy based on the specific physiopathological picture of the single patient and to exclude pulmonary embolism. Hemodynamic management of COVID-19 patients is particularly challenging because of cardiopulmonary interactions in mechanically ventilated patients. COVID-19 patients show specific lung abnormality patterns, including lesser effect on pulmonary compliance, increase in pulmonary vascular resistance with consequences to the right ventricle, inferior vena cava and renal function, and on left ventricle and systemic perfusion. In this setting, US is useful in decisions regarding pharmacological choices, fluid administration, ventilator adjustments together with metabolic indexes (ie, blood lactate), and the whole clinical picture. In this perspective, RRI, though not as well established as EF or VTI, is added to US hemodynamic evaluation with emphasis on evaluation of “effective” organ perfusion,4 and as added decisional support for administration of vasoactive drugs, diuretics, or renal vasodilators,5 for renal replacement therapy, including Cyto-Sorb (CytoSorbents Corp, Monmouth Junction, NJ) for cytokine storm control. 

Similarly, the choice of best positive end-expiratory pressure (PEEP) is based not only on arterial oxygen partial pressure/fraction of inspired oxygen ratio and driving pressure evaluation but also on its hemodynamic effects and kidney repercussions. In a 22-patient sample, we observed 9% (2 cases) of exnovo kidney failure, compared with 22.2% in New York6 experience. Ventilation was regularly assessed by US between 3 and 4 times in 24 hours to follow evolutional trends of COVID-19–specific US lung findings,7 to score the amount of B-lines and titrate ventilation accordingly. Response to recruitment maneuver with PEEP escalation was evaluated with US, addressing the need for high (recruiters) or low (nonrecruiters) PEEP settings and the decision for early/late/no prone positioning.2 A potential US application that we have not yet adopted is the assessment of respiratory fatigue through respiratory muscle evaluation, with implications for decision to intubate after the noninvasive ventilation trial2 and extubation readiness assessment. 

In our practice, we also use US for preintubation airway evaluation, given the aerosolization risk associated with the performance of conventional tests (measuring interincisor distance, determining Mallampati score),8 intubation confirmation when end-tidal CO2 is not immediately available,2 diagnosis of intubation-related complications (pneumothorax, pneumomediastinum, airway trauma), and for lung and ventilation assessment.7 Finally, evaluation of right cardiac chamber diameters and lung windows, and eventual integration with lower limbs US, is used to monitor thromboembolic phenomena as part of the routine coagulative evaluation (thromboelastography/thromboelastometry), given the high thrombotic risk associated with COVID-19.7 

We believe that our approach has 2 important novelties.

 First of all, it is not only lung US but integrated US, involving cardiac and pulmonary evaluation, fluid repletion status and perfusion, airway evaluation, and thrombosis screening. 

The second point is that COVID-US approach is not only a diagnostic tool but also an integrated monitoring approach following patient’s evolution and step-by-step clinical and therapeutic decisional support. 

US applications in COVID-19 patients are promising, though they deserve larger studies and robust data to be validated and adopted in clinical practice. We propose a simple, patient-tailored, bedside approach to COVID-19 patients that reflects the multiorgan involvement of SARS-CoV-2.

Antonio Anile, MD Giacomo Castiglione, MD Anesthesia and Intensive Care Policlinico San Marco University Hospital Catania, Italy 

Chiara Zangara, MD Chiara Calabrò, MD Postgraduate School Anesthesia and Intensive Care University of Catania Catania, Italy

 Mauro Vaccaro, MD Postgraduate School Emergency Medicine University of Catania Catania, Italy 

Massimiliano Sorbello, MD Anesthesia and Intensive Care Policlinico San Marco University Hospital Catania, Italy maxsorbello@gmail.com

 

PoCUS LUNG in ASSESSMENT for RISK STRATIFICATION and THERAPY in COVID-19 PATIENTS

 

ABSTRACT

Background: Lung ultrasound (LUS) is feasible for assessing lung injury caused by COVID19. However, the prognostic meaning and time-line changes of lung injury assessed by LUS in COVID-19 hospitalized patients, is unknown. 

Methods: Prospective cohort study designed to analyze prognostic value of LUS in COVID-19 patients by using a quantitative scale (LUZ-score) during the first 72 hours after admission. Primary endpoint was in-hospital death and / or admission to the intensive care unit. Total length of hospital stay, increase of oxygen flow or escalate medical treatment during the first 72 hours, were secondary endpoints.

  Results: 130 patients were included in the final analysis; mean age was 56.7 ± 13.5 years. Time since the beginning of symptoms until admission was 6 days (4 - 9). Lung injury assessed by LUZ-score did not differ during the first 72 hours (21 points [16-26] at admission vs 20 points [16-27] at 72 hours; p = 0.183). In univariable logistic regression analysis estimated PaO2/FiO2 (HR 0.99 [0.98 – 0.99]; p=0.027) and LUZ-score > 22 points (5.45 (1.42 – 20.90); p=0.013) were predictors for the primary endpoint. 

Conclusions: LUZ-score is an easy, simple and fast point of care ultrasound tool to identify patients with severe lung injury due to COVID-19, upon admission. Baseline score is predictive of severity along the whole period of hospitalization. The score facilitates early implementation or intensification of treatment for COVID-19 infection. LUZ-score may be combined with clinical variables (as estimated PAFI) to further refine risk stratification. 

Lung ultrasound 

Lung US examinations were performed with the UPROBE-C5PL wireless ultrasound device (Leleman ©), convex probe of 3.5 to 5 MHz, with a gain between 80-100 dB, and a maximum depth of between 160 and 220 mm. Images and videos were stored (Ipad 10.2. Apple ©). Researchers responsible for LUS were Internal Medicine specialists, with extensive experience in clinical ultrasound (more than two years and more than 180 thoracic LUS explorations)[11– 13]. 

In each examination, 12 areas were analyzed according to previous studies[14] (2 anterior, 2 lateral and 2 posterior for each lung). 

Given the progressive nature of ultrasound changes in COVID-19, a score between 0 and 4 points was assigned to each quadrant according to the pattern of observed findings, resulting in a total score between 0 and 48 points

(0 point: A lines and normal pleural line; 

1 point: A lines coexist with isolated and small "B "lines; 

2 points: A lines disappear and multiple "B" lines are seen alternating with preserved lung parenchymal spaces. Pleural line thickens and small "bites" may be seen; 

3 points: "B" lines merge and form a giant "B" line that fills the entire intercostal space. Pleural line is blurred, "bites" appear more frequently; 

4 points: Pleural line is broken and subpleural consolidations (1 to 1,5 cm deep) are observed. ―Sun rays and ―Waterfall‖ patterns coexists.) 

(Figure 1,supplementary figure 5 and supplementary multimedia)

 -we called this protocol ―Lung Ultrasound Zaragoza Score‖ (LUZScore).

 In case of multiple patterns coexisting in the same lung quadrant (according to the intercostal space analyzed), the finding with highest score was annotated. Number of affected areas, presence of sub-pleural consolidations and presence of pleural effusion were also recorded.

Limitations The study was carried out in a single center, so their results cannot be generalizable. We did not analyzed correlations between LUS and CT due to the study design. The sample size was designed based on the collection of samples for biomarkers analysis, which could have underestimated power of multivariable logistic regression analysis. Finally, although all physicians who took LUS images had a large previous experience in LUS, this technique is operator-dependent, and could have influenced final results. 

Lung ultrasound and LUZ-Score allow quantifying degree of pulmonary involvement in patients with COVID-19. There are no changes in the score during the first 72 hours of admission, which reinforces the importance of the very first ultrasound assessment, which should be performed soon after admission. 

A baseline admission LUZ-Score > 22 is a predictor of ICU admission or in-hospital death. Despite the improvement in clinical condition, ultrasound lung artifacts remain at discharge in a proportion of patients. This particular finding has not been previously reported and its significance is not clear.