Lung, Heart, Vascular, and Diaphragm Ultrasound Examination of COVID-19 Patients: A Comprehensive Approach

Prognostic Value of Diaphragmatic Ultrasound in Patients Admitted for COVID-19 Pneumonia

Introduction

COVID-19 pneumonia results in an impairment of the diaphragmatic musculature that influences the development of respiratory failure during the patient's hospitalization. Diaphragmatic ultrasound is a useful, non-invasive, and accessible tool for measuring the function of this muscle.

Objective

Assessing the morphological and functional ultrasound status of the diaphragm in patients admitted within the first 24 h for COVID-related pneumonia and its association with hospital morbidity and mortality (NCT05805579).

Material and methods

Observational, prospective cohort study that included 68 patients admitted for COVID-19 pneumonia with respiratory failure. Diaphragmatic ultrasound was performed within the first 24 h of admission to the pulmonology ward. Clinical, analytical, and ultrasound variables were collected: excursion, thickness, and diaphragmatic shortening fraction (DSF). DSF < 20% was used to define diaphragmatic dysfunction (DD). Patients who showed favorable progression and were managed on the ward (HCONV) were compared to those who required admission to the respiratory monitoring unit (RMU).

Results

A total of 68 patients were included, of which 22 (32.35%) were admitted to the RMU. Diaphragmatic excursion at maximum volume was higher in the HCONV group compared to the RMU group (58.41 ± 17.83 vs. 50.03 ± 16.23; p = 0.123). Diaphragmatic dysfunction (DD) was observed in 21 (30.88%) patients, with a higher prevalence in the RMU group than in the HCONV group (15 (68.18%) vs. 6 (13.04%); p = 0.0001). In the multivariate analysis, age and DSF at admission were the best predictors of failure to discharge.

Conclusions

Performing diaphragmatic ultrasound to assess mobility and DSF within the first 24 h of admission for COVID-19 pneumonia proves valuable in determining short-term progression and the need for admission to a respiratory monitoring unit.

Ultrasonographic Features of Muscular Weakness and Muscle Wasting in Critically Ill Patients

Muscle wasting begins as soon as in the first week of one's ICU stay and patients with multi-organ failure lose more muscle mass and suffer worse functional impairment as a consequence. Muscle wasting and weakness are mainly characterized by a generalized, bilateral lower limb weakness. However, the impairment of the respiratory and/or oropharyngeal muscles can also be observed with important consequences for one's ability to swallow and cough. Muscle wasting represents the result of the disequilibrium between breakdown and synthesis, with increased protein degradation relative to protein synthesis. It is worth noting that the resulting functional disability can last up to 5 years after discharge, and it has been estimated that up to 50% of patients are not able to return to work during the first year after ICU discharge. In recent years, ultrasound has played an increasing role in the evaluation of muscle. Indeed, ultrasound allows an objective evaluation of the cross-sectional area, the thickness of the muscle, and the echogenicity of the muscle. Furthermore, ultrasound can also estimate the thickening fraction of muscle. The objective of this review is to analyze the current understanding of the pathophysiology of acute skeletal muscle wasting and to describe the ultrasonographic features of normal muscle and muscle weakness.

Echocardiographic parameters in COVID-19 patients and their association with ICU mortality: a prospective multicenter observational study

BACKGROUND

Echocardiography has become an integral part of the management of critically ill patients. It helps to diagnose and treat various conditions. COVID-19 patients can develop cardiac dysfunction. We planned to study the echocardiographic parameters in COVID-19 patients.

METHODS

We conducted a prospective observational multicenter study after institutional ethical committee approval. COVID-19 pneumonia patients admitted to the intensive care unit (ICU) were enrolled. The echocardiographic evaluation was done within 24-48 hours of admission. Assessment of the left and right heart with systolic and left ventricular diastolic function evaluation was done. The primary outcome was ICU mortality. The secondary outcomes were the length of ICU stay and duration of mechanical ventilation.

RESULTS

Among 573 patients mean age was 57.17 (14.67) with 68.60% being males. On day 1 of ICU, invasive mechanical ventilation was used in 257 (45%) patients. One hundred and forty-eight (25.83%) patients were on vasopressors when echocardiography was performed. Severe left ventricle (LV) systolic dysfunction was seen in 8.7% of patients and had higher odds of mortality [2.48(1.058-5.807), p = 0.037] followed by E and e' with odds ratio of [0.984(0.971-0.998), p = 0.021] and 0.897 (0.805-0.998), p = 0.046], respectively. E/e' indicative of filling pressure of the LV was not found to be significant. Troponin I, E/A, and RV dilatation were similar among survivors and non-survivors.

CONCLUSION

Echocardiographic evaluation in COVID-19 patients showed severe LV systolic dysfunction was associated with ICU mortality. E/e' was not found to be significant but lower e' was associated with higher mortality. Trial registration IEC 131/2020, CTRI/2020/06/025858 date 13th June 2020.

Right hemi diaphragmatic eventration - A rare post SARS-COV-2 infection complication

Diaphragm eventration is a rare permanent abnormal elevation of diaphragmatic muscles. They are rare entities with right-sided eventration occurring rarer still. We present a case of a 69-year-old male with right-sided hemidiaphragmatic eventration and post-COVID 19 pulmonary fibrotic changes.

Can Dialysis Patients Identify and Diagnose Pulmonary Congestion Using Self-Lung Ultrasound?

BACKGROUND

With the recent developments in automated tools, smaller and cheaper machines for lung ultrasound (LUS) are leading us toward the potential to conduct POCUS tele-guidance for the early detection of pulmonary congestion. This study aims to evaluate the feasibility and accuracy of a self-lung ultrasound study conducted by hemodialysis (HD) patients to detect pulmonary congestion, with and without artificial intelligence (AI)-based automatic tools.

METHODS

This prospective pilot study was conducted between November 2020 and September 2021. Nineteen chronic HD patients were enrolled in the Soroka University Medical Center (SUMC) Dialysis Clinic. First, we examined the patient's ability to obtain a self-lung US. Then, we used interrater reliability (IRR) to compare the self-detection results reported by the patients to the observation of POCUS experts and an ultrasound (US) machine with an AI-based automatic B-line counting tool. All the videos were reviewed by a specialist blinded to the performer. We examined their agreement degree using the weighted Cohen's kappa (Kw) index.

RESULTS

A total of 19 patients were included in our analysis. We found moderate to substantial agreement between the POCUS expert review and the automatic counting both when the patient performed the LUS (Kw = 0.49 [95% CI: 0.05-0.93]) and when the researcher performed it (Kw = 0.67 [95% CI: 0.67-0.67]). Patients were able to place the probe in the correct position and present a lung image well even weeks from the teaching session, but did not show good abilities in correctly saving or counting B-lines compared to an expert or an automatic counting tool.

CONCLUSIONS

Our results suggest that LUS self-monitoring for pulmonary congestion can be a reliable option if the patient's count is combined with an AI application for the B-line count. This study provides insight into the possibility of utilizing home US devices to detect pulmonary congestion, enabling patients to have a more active role in their health care.

Emergency Department Point-Of-Care Echocardiography and Lung Ultrasound in Predicting COVID-19 Severity

OBJECTIVES

We sought to determine if point-of-care ultrasound (POCUS) performed on patients with COVID-19 in the emergency department (ED) can help predict disease course, severity, or identify complications.

METHODS

This was a retrospective cohort study of adult ED patients who tested positive for COVID-19 at hospital admission or within 2 weeks of presentation and received heart or lung POCUS. Clips were reviewed for presence of decreased left ventricular ejection fraction (LVEF), right ventricular dilation, presence of B-lines, and pleural line abnormalities. Patients with worsening hypoxemic respiratory failure or shock requiring higher level of care and patients who expired were considered to have developed severe COVID-19. Regression analysis was performed to determine if there was a correlation between ED POCUS findings and development of severe COVID-19.

RESULTS

A total of 155 patients met study criteria; 148 patients had documented cardiac views and 116 patients had documented lung views (113 with both). Mean age was 66.5 years old (±18.6) and 53% of subjects were female. Subjects with decreased LVEF that was not previously documented had increased odds of having severe COVID during their hospitalization compared to those with old or no dysfunction (OR 5.66, 95% CI: 1.55-19.95, P = .08). The presence of pleural line abnormalities was also predictive for development of severe COVID (OR 2.68, 95% CI: 1.04-6.92, P = .04).

CONCLUSION

POCUS findings of previously unidentified decreased LVEF and pleural line abnormalities in patients with COVID-19 evaluated in the ED were correlated to a more severe clinical course and worse prognosis.

Ultrasound imaging assessment of the diaphragm and abdominal muscles in people with a recent history of moderate Covid-19 infection and healthy participants: A cross-sectional pilot study

Coronavirus disease (Covid-19) is a highly infectious disease caused by the SARS-CoV-2 virus and is associated with a decrease of respiratory, physical, and psychological function, subsequently affecting quality of life. The aim of the present pilot study was to use ultrasound imaging (USI) to evaluate and compare the thickness of the diaphragm and abdominal muscles between individuals recently diagnosed with moderate Covid-19 infection and healthy individuals.

METHODS

A cross-sectional observational pilot study was performed. A total sample of 24 participants were recruited from a private medical center (Madrid, Spain): Covid-19 (n = 12) and healthy controls (n = 12). The external oblique (EO), internal oblique (IO), transversus abdominis (TrA), rectus abdominis (RA), interrecti distance (IRD) and diaphragm thickness were assessed using USI during inspiration, expiration and during contraction.

RESULTS

USI measurements of the thickness of EO, IO, TrA, RA, IRD and the diaphragm did not differ significantly between groups during inspiration, expiration or during contraction (all P > 0.05).

CONCLUSIONS

These preliminary results suggest that the morphology of the abdominal muscles and diaphragm is not altered in people with a recent history of moderate Covid-19 infection.

Infectious Pneumonia and Lung Ultrasound: A Review

The application of thoracic ultrasound examination has not long been developed because ultrasound's interaction with the lung does not generate an anatomical image but an artifactual one. Subsequently, the evaluation of pulmonary artifacts and their correlation to specific diseases allowed the development of ultrasound semantics. Currently, pneumonia still represents one of the main causes of hospitalization and mortality. Several studies in the literature have demonstrated the ultrasound features of pneumonia. Although ultrasound cannot be considered the diagnostic gold standard for the study of all lung diseases, it has experienced an extraordinary development and growth of interest due to the SARS-CoV-2 pandemic. This review aims to provide essential information on the application of lung ultrasound to the study of infectious pneumonia and to discuss the differential diagnosis.

Severe COVID-19-associated myocarditis with cardiogenic shock - management with assist devices - a case report & review

BACKGROUND

Primary viral myocarditis associated with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection is a rare diagnosis.

CASE PRESENTATION

We report the case of an unvaccinated, healthy patient with cardiogenic shock in the context of a COVID-19-associated myocarditis and therapy with simultaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous left ventricular decompression therapy with an Impella. The aim of this review is to provide an overview of therapeutic options for patients with COVID-19-associated myocarditis.

CONCLUSIONS

The majority of patients required a combination of two assist devices to achieve sufficient cardiac output until recovery of left ventricular ejection fraction. Due to the rapid onset of this fulminant cardiogenic shock immediate invasive bridging therapy in a specialized center was lifesaving.

Post-COVID-19 Myositis Based on Magnetic Resonance Imaging: A Case Report

The severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) causes COVID-19, which is known to cause fever, dry cough, exhaustion, headache, and loss of taste and smell. Although fever, sore throat, and cough have historically been the utmost characteristic symptoms of the illness, published case reports have recently started to emphasize additional uncommon and unusual presentations of infection with the coronavirus. In COVID, the musculoskeletal system is seldomly involved. In addition to reviewing the causes and imaging characteristics of COVID-19-related illnesses of the musculoskeletal system, we elaborate on a case of a middle-aged man who developed myositis as sequelae to the COVID-19 infection.

Feasibility of Self-Performed Lung Ultrasound with Remote Teleguidance for Monitoring at Home COVID-19 Patients

During the COVID-19 pandemic, use of telemedicine with the aim of reducing the rate of viral transmission increased. This proof-of-concept observational study was planned to test the feasibility of a home-based lung ultrasound (LUS) follow-up performed by patients with mild COVID-19 infection on themselves. We enrolled patients presenting to the emergency department with SARS-CoV-2 infection without signs of pneumonia and indication to discharge. Each patient received a brief training on how to perform LUS and a handheld ultrasound probe. Then, patients were contacted on a daily basis, and LUS images were acquired by the patients themselves under “teleguidance” by the investigator. Twenty-one patients were enrolled with a median age of 44 years. All evaluations were of sufficient quality for a follow up. Probability of a better LUS quality was related to higher degree (odds ratio, OR, 1.42, 95% CI 0.5–3.99) and a lower quality to evaluation time (from 0.71, 95% CI 0.55–0.92 for less than 7 min, to 0.52, 95% CI 0.38–0.7, between 7 and 10 min, and to 0.29, 95% CI 0.2–0.43, for evaluations longer than 10 min). No effect related to gender or age was detected. LUS performed by patients and remotely overseen by expert providers seems to be a feasible and reliable telemedicine tool.

Sports Imaging of COVID-19: A Multi-Organ System Review of Indications and Imaging Findings

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in December 2019 in Wuhan, China. Although coronavirus disease-19 (COVID-19) affects every population group, the sports community and athletes require special consideration of the effects on cardiovascular, musculoskeletal, neurologic, and respiratory systems. A comprehensive understanding of imaging indications, findings, and features of COVID-19 supports appropriate imaging utilization and effective patient management and treatment.

PURPOSE

To review the spectrum of sports imaging in COVID-19 infection, organ system manifestations, vaccine effects, and complications in recreational and competitive athletes.

STUDY DESIGN

Narrative review.

LEVEL OF EVIDENCE

Levels 4 and 5.

METHODS

Based on a PubMed database search, studies describing the imaging findings of COVID-19 infection, organ system manifestations, vaccine effects, and complications in recreational and competitive athletes were included.

RESULTS

On March 11, 2020, World Health Organization officially declared COVID-19 a global pandemic. As of May 9, 2022, more than 515 million confirmed cases of COVID-19 were reported globally. While the multisystem effects of COVID-19 are incompletely understood, the role of imaging in diagnosing, monitoring, and prognosticating active disease, long-term effects, and complications is evolving. In the respiratory system, imaging plays an important role in diagnosing, characterizing, and monitoring pulmonary COVID-19 infections, barotrauma, and COVID-19-associated chronic pulmonary opacities and fibrotic-like lung changes. Ultrasonography, computed tomography, and magnetic resonance imaging aid in the timely diagnosis of ischemic, embolic, and thrombotic peripheral and central cardiovascular events, including deep venous thrombosis, pulmonary embolism, myocarditis, and stroke. COVID-19-associated musculoskeletal and peripheral nervous system manifestations include rhabdomyolysis and myonecrosis, plexus and peripheral neuropathies, Guillain-Barré syndrome, and shoulder injury related to vaccine administration.

CONCLUSION

In athletes, COVID-19 infections and associated effects on cardiovascular, musculoskeletal, neurologic, and respiratory systems require special consideration. With the increasing understanding of the multisystem effects of COVID-19, the role of imaging in diagnosing, monitoring, and prognosticating active disease, long-term effects, and complications is evolving. A comprehensive understanding of imaging indications, COVID-19 imaging features, and organ system effects aids in appropriate imaging utilization and effective patient management and treatments.

Association of diaphragm thickness and density measured on chest CT with disease severity in COVID-19 patients

Introduction

A decrease in muscle mass of the diaphragm could be a significant risk factor for pneumonia. The aim of our study was to evaluate whether diaphragm thickness (DT) and density measured on chest computed tomography (CT) were associated with clinical course and mortality in adult patients with coronavirus disease 2019 (COVID-19) in emergency department admission.

Methods

We retrospectively analyzed 404 patients with a positive polymerase chain reaction test for COVID-19 and pneumonia findings on chest CT between September 1 and November 1, 2020. Bilateral DT measurements were performed at the level of the celiac artery origin, and the total mean diaphragm thickness (TMDT) was estimated. Hemidiaphragm density was measured at the level of the celiac artery origin. The relationship between demographic characteristics, comorbidities, TMDT, mean hemidiaphragm density (MHD) and clinical outcomes was investigated using the logistic regression analyses. The reliability of the measurement of the two observers was evaluated by intraclass correlation analyses.

Results

Intraclass correlation analyses demonstrated almost perfect inter-observer agreement for TMDT and substantial agreement for MHD. There was a statistically significant relationship between the presence of a thinner diaphragm and mortality (p < 0.001). Bilateral diaphragm densities were lower in the patients with severe disease and mortality (p < 0.001). The threshold values of TMDT were 3.67 mm and 3.47 mm for the prediction of ICU admission and mortality, respectively. TMDT (odds ratio [OR]: 0.634, 95% confidence interval [CI]: 0.447–0.901), age (OR: 1.053, 95% CI: 1.027–1.081) and MHD (OR: 0.920, 95% CI: 0.883–0.959) were found to be independent predictors for severe disease in the multivariable model. In addition, MHD (OR: 0.883, 95% CI: 0.827–0.942) and age (OR: 1.040, 95% CI: 1.003–1.078) were independent risk factors for mortality.

Conclusion

Our study demonstrated that a low diaphragm thickness and density measured on chest CT were associated with severe disease in patients with COVID-19 and could be evaluated as poor prognostic markers.

Efficacy of a rehabilitation protocol on pulmonary and respiratory muscle function and ultrasound evaluation of diaphragm and quadriceps femoris in patients with post-COVID-19 syndrome: a series of cases

This study assessed the efficacy of a pulmonary rehabilitation (PR) on pulmonary and respiratory muscle function and thickness of quadriceps femoris and diaphragm of patients with post-COVID-19 syndrome. This series of cases followed nine patients who performed PR twice a week for six weeks. Patients received the following PR program: lung expansion therapy; respiratory muscle training; upper limb strength exercises; aerobic exercises on a treadmill. After the program, we observed increased peak expiratory flow (26.03%), forced vital capacity (FVC) (7.14%), forced expiratory volume in the first second (FEV1) (9.55%), and ratio between FEV1/FVC (6.19%). All parameters of respiratory muscle strength and endurance were improved. Diaphragmatic thickening fraction and thickness of quadriceps femoris also improved, whereas echo intensity of quadriceps reduced. Thus, RP protocol improved pulmonary function, respiratory muscle strength and endurance, and thickness of diaphragm and quadriceps femoris, and reduced echo intensity of quadriceps in patients with post-COVID-19 syndrome.

The Possible Impact of COVID-19 on Respiratory Muscles Structure and Functions: A Literature Review

The impact of SARS-CoV-2 infection on respiratory muscle functions is an important area of recent enquiry. COVID-19 has effects on the respiratory muscles. The diaphragm muscle is perturbed indirectly due to the mechanical-ventilation-induced-disuse, but also by direct mechanisms linked with SARS-CoV-2 viral infection. In this sense, a deeper understanding of the possible links between COVID-19 and alterations in structure and functions of the respiratory muscles may increase the success rate of preventive and supportive strategies. Ultrasound imaging alongside respiratory muscle strength tests and pulmonary function assessment are valid approaches to the screening and monitoring of disease, for mild to severe patients. The aim of the present review is to highlight the current literature regarding the links between COVID-19 and respiratory muscle functions. We examine from the pathophysiological aspects of disease, up to approaches taken to monitor and rehabilitate diseased muscle. We hope this work will add to a greater understanding of the pathophysiology and disease management of respiratory muscle pathology subsequent to SARS-CoV-2 infection.

Integrated lung ultrasound score for early clinical decision-making in patients with COVID-19: results and implications

Background and objectives

Lung Ultrasound Score (LUS) identifies and monitors pneumonia by assigning increasing scores. However, it does not include parameters, such as inferior vena cava (IVC) diameter and index of collapse, diaphragmatic excursions and search for pleural and pericardial effusions. Therefore, we propose a new improved scoring system, termed “integrated” lung ultrasound score (i-LUS) which incorporates previously mentioned parameters that can help in prediction of disease severity and survival, choice of oxygenation mode/ventilation and assignment to subsequent areas of care in patients with COVID-19 pneumonia.

Methods

Upon admission at the sub-intensive section of the emergency medical department (SEMD), 143 consecutively examined COVID-19 patients underwent i-LUS together with all other routine analysis. A database for anamnestic information, laboratory data, gas analysis and i-LUS parameters was created and analyzed.

Results

Of 143 enrolled patients, 59.4% were male (mean age 71 years) and 40.6% female. (mean age 79 years: p = 0.005). Patients that survived at 1 month had i-LUS score of 16, which was lower than that of non-survivors (median 20; p = 0.005). Survivors had a higher PaO2/FiO2 (median 321.5) compared to non-survivors (median 229, p < 0.001). There was a correlation between i-LUS and PaO2/FiO2 ratio (rho:-0.4452; p < 0.001), PaO2/FiO2 and survival status (rho:-0.3452; p < 0.001), as well as i-LUS score and disease outcome (rho:0.24; p = 0.005). In non-survivors, the serum values of different significant COVID indicators were severely expressed. The i-LUS score was higher (median 20) in patients who required non-invasive ventilation (NIV) than in those treated only by oxygen therapy (median 15.42; p = 0.003). The odds ratio for death outcome was 1.08 (confidence interval 1.02–1.15) for each point increased. At 1-month follow-up, 65 patients (45.5%) died and 78 (54.5%) survived. Patients admitted to the high critical ward had higher i-LUS score than those admitted to the low critical one (p < 0.003).

Conclusions

i-LUS could be used as a helpful clinical tool for early decision-making in patients with COVID-19 pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00264-8.

Paradoxical venous air embolism detected with point-of-care ultrasound: a case report

Venous air embolism (VAE) is an uncommon event consistent in the entrainment of air from any communication between the environment and the venous vasculature that could occur during central venous catheter (CVC) manipulation, and might trigger circulatory shock within minutes depending on the amount of air embolized. We present a case of a critical care patient who presented sudden clinical hemodynamic deterioration after the removal of central venous catheter. Hemodynamic evaluation with point-of-care ultrasound (POCUS) showed bubbles in both right and left heart cavities wherewith air embolism facilitated by heart septal defect was suspected. Therefore, the patient was reintubated, supported with vasopressors and a new CVC was inserted to proceed with air aspiration. Shortly after, the patient’s hemodynamic status improved in terms of vital signs stabilization. 6 h after the event with optimal perfusion markers and diminished sedation, the patient showed left hemiparesis therefore a cerebral magnetic resonance (MRI) was also performed showing hyperintensity in the right precentral gyrus, so ischemic stroke without hemorrhagic transformation diagnosis was made, because of paradoxical embolism. This case report demonstrates the value of POCUS application as a diagnostic tool in the hemodynamically unstable patient.

Role of Lung Ultrasound in the Management of Patients with Suspected SARS-CoV-2 Infection in the Emergency Department

Background: The lung ultrasound (LUS) score has been proposed as an optimal scheme for the ultrasound study of patients with suspected/confirmed COVID-19 pneumonia. The aims of our study were to evaluate the use of lung ultrasound as a diagnostic tool for diagnosing SARS-CoV-2 pneumonia, to examine the validity of the LUS score for the diagnosis of COVID-19 pneumonia, and to correlate this score with hospitalization rate and 30-day mortality. Materials and Methods: A retrospective analysis was performed on 1460 patients who were referred to the General Emergency Department of the S. Orsola-Malpighi Hospital from April 2020 to May 2020 for symptoms suspected to indicate SARS-CoV-2 infection. The ultrasound examination was based on a common execution scheme called the LUS score, as previously described. Results and Conclusions: The LUS score was found to correlate with the degree of clinical severity and respiratory failure (paO2/FiO2 ratio and the alveolar−arterial gradient increase than expected for age). It was shown that COVID-19 patients with an LUS score of >7 require the use of oxygen support, and a value of >10 is associated with an increased risk of oro-tracheal intubation. The LUS score was found to present higher values in hospitalized patients, increasing according to the degree of care intensity. Patients who died from COVID-19 were characterized by a mean LUS score of 11 at presentation to the emergency department. An LUS score of >7.5 was found to indicate a sensitivity of 83% and a specificity of 89% for 30-day mortality in COVID-19 patients. The use of LUS seems to be an optimal first level method for pneumonia detection and risk stratification in patients with suspected SARS-CoV-2 infection.

COVID-19 pathophysiology and ultrasound imaging: A multiorgan review

COVID-19 is a dynamic disease and may affect different tissues and organs as it progresses. Therefore, the impact generated by the disease in all its stages and organs requires a functional and versatile imaging technique able to detect particularities or artifacts dynamically. Ultrasonography fulfills all these requirements and exhibit several advantages relative to other imaging modalities, including portability, lower cost and biosafety. Throughout the COVID-19 pandemic, ultrasonography displayed a crucial role in the triage, monitoring, indicating organ damages and enabling individualized therapeutical decisions in COVID-19 patients. This review is dedicated to highlight the main pathological effects correlated with ultrasound changes caused by COVID-19 in the lungs, heart and liver.

Ten conditions where lung ultrasonography may fail: limits, pitfalls and lessons learned from a computer-aided algorithmic approach

Lung ultrasonography provides relevant information on morphological and functional changes occurring in the lungs. However, it correlates weakly with pulmonary congestion and extra vascular lung water. Moreover, there is lack of consensus on scoring systems and acquisition protocols. The automation of this technique may provide promising easy-to-use clinical tools to reduce inter- and intra-observer variability and to standardize scores, allowing faster data collection without increased costs and patients risks.

Application of POCUS in patients with COVID-19 for acute respiratory distress syndrome management: a narrative review

COVID-19 has inflicted the world for over two years. The recent mutant virus strains pose greater challenges to disease prevention and treatment. COVID-19 can cause acute respiratory distress syndrome (ARDS) and extrapulmonary injury. Dynamic monitoring of each patient's condition is necessary to timely tailor treatments, improve prognosis and reduce mortality. Point-of-care ultrasound (POCUS) is broadly used in patients with ARDS. POCUS is recommended to be performed regularly in COVID-19 patients for respiratory failure management. In this review, we summarized the ultrasound characteristics of COVID-19 patients, mainly focusing on lung ultrasound and echocardiography. Furthermore, we also provided the experience of using POCUS to manage COVID-19-related ARDS.

Diaphragm and Phrenic Nerve Ultrasound in COVID-19 Patients and Beyond: Imaging Technique, Findings, and Clinical Applications

The diaphragm, the principle muscle of inspiration, is an under-recognized contributor to respiratory disease. Dysfunction of the diaphragm can occur secondary to lung disease, prolonged ventilation, phrenic nerve injury, neuromuscular disease, and central nervous system pathology. In light of the global pandemic of coronavirus disease 2019 (COVID-19), there has been growing interest in the utility of ultrasound for evaluation of respiratory symptoms including lung and diaphragm sonography. Diaphragm ultrasound can be utilized to diagnose diaphragm dysfunction, assess severity of dysfunction, and monitor disease progression. This article reviews diaphragm and phrenic nerve ultrasound and describes clinical applications in the context of COVID-19.

Lung Ultrasound: A Diagnostic Leading Tool for SARS-CoV-2 Pneumonia: A Narrative Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide causing a global pandemic. In this context, lung ultrasound (LUS) has played an important role due to its high diagnostic sensitivity, low costs, simplicity of execution and radiation safeness. Despite computed tomography (CT) being the imaging gold standard, lung ultrasound point of care exam is essential in every situation where CT is not readily available nor applicable. The aim of our review is to highlight the considerable versatility of LUS in diagnosis, framing the therapeutic route and follow-up for SARS-CoV-2 interstitial syndrome.

Research on SARS-COV-2 pandemic: a narrative review focused on the Italian contribution

Background

Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection.

Main body

We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives.

Conclusions

Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.

Diagnostic imaging in COVID-19 pneumonia: a literature review

In December 2019 in Wuhan (China), a bat-origin coronavirus (2019-nCoV), also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was identified, and the World Health Organization named the related disease COVID-19. Its most severe manifestations are pneumonia, systemic and pulmonary thromboembolism, acute respiratory distress syndrome (ARDS), and respiratory failure. A swab test is considered the gold standard for the diagnosis of COVID-19 despite the high number of false negatives. Radiologists play a crucial role in the rapid identification and early diagnosis of pulmonary involvement. Lung ultrasound (LUS) and computed tomography (CT) have a high sensitivity in detecting pulmonary interstitial involvement. LUS is a low-cost and radiation-free method, which allows a bedside approach and needs disinfection of only a small contact area, so it could be particularly useful during triage and in intensive care units (ICUs). High-resolution computed tomography (HRCT) is particularly useful in evaluating disease progression or resolution, being able to identify even the smallest changes.

Diaphragmatic Point-of-Care Ultrasound in COVID-19 Patients in the Emergency Department-A Proof-of-Concept Study

Background: Lung Ultrasound Evaluation (LUS) is usefully applied in the Emergency Department (ED) to patients with suspected or confirmed COVID-19. Diaphragmatic Ultrasound (DUS) may provide additional insight into ventilatory function. This proof-of-concept study aimed to evaluate the feasibility of LUS and DUS in a third level ED during the COVID-19 pandemic. Methods: Adult patients presenting with COVID-19 symptoms were eligible. After the physical examination, both LUS and DUS (i.e., diaphragmatic motion and thickness) were performed. All patients were followed after 30 days to determine their need for ventilation, admission, and/or a new ED evaluation after discharge. The diagnostic accuracies of diaphragm measurements in assessing the risk of the 30-day outcome were calculated as well as the measurements’ usefulness. Bland–Altman plots were used for comparing bedside and off-line diaphragm measurements. Results: 118 patients were enrolled. Median thickness and motion were 1.7 mm (iqr 0.4) and 1.8 cm (iqr 0.7), respectively, with a mean difference of 0.009 mm (95% CI −0.037–0.056 mm) and −0.051 cm (95% CI −0.108–0.006 cm), respectively. The 30-day outcome was associated with an increase in thickness (OR 5.84, 95% CI 0.96–35.4), and a lower motion (OR 0.49, 95% CI 0.2–1.21). Conclusion: DUS seemed to be feasible and reliable in the ED in a population of patients presenting with symptoms related to COVID-19 infection.

Musculoskeletal involvement of COVID-19: review of imaging

The global pandemic of coronavirus disease 2019 (COVID-19) has revealed a surprising number of extra-pulmonary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While myalgia is a common clinical feature of COVID-19, other musculoskeletal manifestations of COVID-19 were infrequently described early during the pandemic. There have been emerging reports, however, of an array of neuromuscular and rheumatologic complications related to COVID-19 infection and disease course including myositis, neuropathy, arthropathy, and soft tissue abnormalities. Multimodality imaging supports diagnosis and evaluation of musculoskeletal disorders in COVID-19 patients. This article aims to provide a first comprehensive summary of musculoskeletal manifestations of COVID-19 with review of imaging.

Imaging Evaluation of Pulmonary and Non-Ischaemic Cardiovascular Manifestations of COVID-19

Coronavirus Disease 2019 (COVID-19) has been a pandemic challenge for the last year. Cardiovascular disease is the most described comorbidity in COVID-19 patients, and it is related to the disease severity and progression. COVID-19 induces direct damage on cardiovascular system, leading to arrhythmias and myocarditis, and indirect damage due to endothelial dysfunction and systemic inflammation with a high inflammatory burden. Indirect damage leads to myocarditis, coagulation abnormalities and venous thromboembolism, Takotsubo cardiomyopathy, Kawasaki-like disease and multisystem inflammatory syndrome in children. Imaging can support the management, assessment and prognostic evaluation of these patients. Ultrasound is the most reliable and easy to use in emergency setting and in the ICU as a first approach. The focused approach is useful in management of these patients due its ability to obtain quick and focused results. This tool is useful to evaluate cardiovascular disease and its interplay with lungs. However, a detailed echocardiography evaluation is necessary in a complete assessment of cardiovascular involvement. Computerized tomography is highly sensitive, but it might not always be available. Cardiovascular magnetic resonance and nuclear imaging may be helpful to evaluate COVID-19-related myocardial injury, but further studies are needed. This review deals with different modalities of imaging evaluation in the management of cardiovascular non-ischaemic manifestations of COVID-19, comparing their use in emergency and in intensive care.

Cardiac manifestations of the coronavirus disease-19: a review of pathogenesis, clinical manifestations, diagnosis, and treatment

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

COVID-19 pandemic in an Italian obstetric department: sharing our experience

BACKGROUND AND AIM OF THE WORK

The outbreak of the novel coronavirus (or SARS-CoV 2) has significantly struck the healthcare system worldwide. Over the course of a few weeks, hospitals reorganized their internal structure entirely at any level of care, from the Emergency rooms to Departments, including all the medical specialties.

METHODS

In order to cope with the contingent state of emergency, the Gynecology and Obstetrics Unit of the University Hospital in Udine introduced new protocols and guidance for the usual standard of care, ensuring a safe environment for both healthcare providers and patients.

RESULTS

By a continuous update of scientific evidence, the department was able to increase capacity as well as maintain flexibility when a higher number of admissions was required.

CONCLUSION

We aimed to share our experience, which provided a relevant lesson about what to expect and how to prepare a referral center for high-risk pregnancy in response to a pandemic such as COVID-19.

Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of Cardiorespiratory System in COVID-19

BACKGROUND

Coronavirus disease-2019 (COVID-19) causes various cardiopulmonary manifestations. Bedside ultrasound helps in the rapid diagnosis of these manifestations. Vscan Extend™ (GE, Wauwatosa, WI, USA) is a handheld ultrasound device with a dual probe and an artificial intelligence application to detect ejection fraction. It can help in reducing the time for diagnosis, duration, and the number of healthcare workers exposed to COVID-19. This is a prospective observational study comparing the cardiorespiratory parameters and time duration for assessment between Vscan Extend™ and the conventional ultrasound machine.

MATERIALS AND METHODS

Paired observations were made in 96 COVID-19 patients admitted to the intensive care unit by two intensivists. Intensivist A used the Vscan Extend™ device to assess the cardiac function, lung fields, diaphragm, deep veins, and abdomen. Intensivist B used clinical examination, X-ray chest, ECG, and conventional echocardiogram for assessment. The agreement between the findings and the time duration required in both the methods was compared.

RESULTS

The use of handheld ultrasound has significantly decreased the duration of bedside examination of patients than the conventional method. The median duration of examination using handheld ultrasound was 9 (8.0-11.0) minutes, compared to 20 (17-22) minutes with the conventional method (P < 0.001). The Cohen's kappa coefficient was 1.0 for left ventricular systolic function, most of the lung fields, and diaphragmatic movement.

CONCLUSION

Vscan Extend™ helps in the rapid identification and diagnosis of cardiopulmonary manifestations in COVID-19 patients. The agreement between the handheld device and the conventional method proves its efficacy and safety.

CTRI NUMBER

CTRI/2020/07/026701.

HOW TO CITE THIS ARTICLE

Maheshwarappa HM, Mishra S, Kulkarni AV, Gunaseelan V, Kanchi M. Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of Cardiorespiratory System in COVID-19. J Crit Care Med 2021;25(5):524-527.

A research update: Significance of cytokine storm and diaphragm in COVID-19

Emerging research on severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) shows that it is spreading to multiple organs in addition to the respiratory system. Though the SARS-CoV2 enters the human body by binding to ACE2 receptors on pulmonary alveolar cells, recent studies indicate that it is spreading to the central nervous system, cardiac and skeletal muscles leading to various pathological conditions in these organs. In particular, the effects of SARS-CoV-2 on triggering the cytokine storm and its consequential effects on skeletal muscles has generated a lot of discussion. The effects of this virus on muscular function especially in susceptible elderly populations is still being explored. However, its effects on diaphragm, a respiratory muscle which plays an important role in determining lung capacity are not completely explored. Currently, as new evidence on using lung ultrasounds to confirm COVID-19 diagnosis is gaining traction, it is necessary to explore the role of diaphragm in treating COVID-19 patients. This article will review the effects of cytokine storm triggered by the SARS-CoV-2 and its resultant effects on skeletal muscle with a specific focus on the diaphragm in order to identify knowledge gaps in effectively treating COVID-19 patients, especially those who are on a mechanical ventilator.

One year of SARS-CoV-2 and lung ultrasound: what has been learned and future perspectives

A first screening by ultrasound can be relevant to set a specific diagnostic and therapeutic route for a patient with a COVID-19 infection. The finding of bilateral B-lines and white lung areas with patchy peripheral distribution and sparing areas is the most suggestive ultrasound picture of COVID-19 pneumonia. Failure to detect bilateral interstitial syndrome (A pattern) on ultrasound excludes COVID-19 pneumonia with good diagnostic accuracy, but does not exclude current infection. The use of shared semiotic and reporting schemes allows the comparison and monitoring of the COVID-19 pulmonary involvement over time. This review aims to summarise the main data on pulmonary ultrasound and COVID-19 to provide accurate and relevant information for clinical practice.

Patients in intensive care unit for COVID-19 pneumonia: the lung ultrasound patterns at admission and discharge. An observational pilot study

Background

During COVID-19 pandemic, optimization of the diagnostic resources is essential. Lung Ultrasound (LUS) is a rapid, easy-to-perform, low cost tool which allows bedside investigation of patients with COVID-19 pneumonia. We aimed to investigate the typical ultrasound patterns of COVID-19 pneumonia and their evolution at different stages of the disease.

Methods

We performed LUS in twenty-eight consecutive COVID-19 patients at both admission to and discharge from one of the Padua University Hospital Intensive Care Units (ICU). LUS was performed using a low frequency probe on six different areas per each hemithorax. A specific pattern for each area was assigned, depending on the prevalence of A-lines (A), non-coalescent B-lines (B1), coalescent B-lines (B2), consolidations (C). A LUS score (LUSS) was calculated after assigning to each area a defined pattern.

Results

Out of 28 patients, 18 survived, were stabilized and then referred to other units. The prevalence of C pattern was 58.9% on admission and 61.3% at discharge. Type B2 (19.3%) and B1 (6.5%) patterns were found in 25.8% of the videos recorded on admission and 27.1% (17.3% B2; 9.8% B1) on discharge. The A pattern was prevalent in the anterosuperior regions and was present in 15.2% of videos on admission and 11.6% at discharge. The median LUSS on admission was 27.5 [21–32.25], while on discharge was 31 [17.5–32.75] and 30.5 [27–32.75] in respectively survived and non-survived patients. On admission the median LUSS was equally distributed on the right hemithorax (13; 10.75–16) and the left hemithorax (15; 10.75–17).

Conclusions

LUS collected in COVID-19 patients with acute respiratory failure at ICU admission and discharge appears to be characterized by predominantly lateral and posterior non-translobar C pattern and B2 pattern. The calculated LUSS remained elevated at discharge without significant difference from admission in both groups of survived and non-survived patients.

The comprehensive clinic, laboratory, and instrumental evaluation of children with COVID-19: A 6-months prospective study

Objectives

To perform a comprehensive clinic, laboratory, and instrumental evaluation of children affected by coronavirus disease (COVID‐19).

Methods

Children with a positive result of nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) underwent laboratory tests, anal and conjunctival swab, electrocardiography, lung, abdomen, and cardiac ultrasound. Twenty‐four‐hour ambulatory blood pressure monitoring was performed if abnormal basal blood pressure. Patients were followed‐up for 6 months.

Results

Three hundred and sixteen children were evaluated; 15 were finally included. Confirmed family member SARS‐CoV‐2 infection was present in all. Twenty‐seven percent were asymptomatic. Anal and conjunctival swabs tests resulted negative in all. Patients with lower body mass index (BMI) presented significantly higher viral loads. Main laboratory abnormalities were: lactate dehydrogenase increasing (73%), low vitamin D levels (87%), hematuria (33%), proteinuria (26%), renal hyperfiltration (33%), and hypofiltration (13%). Two of the patients with hyperfiltration exhibited high blood pressure levels at diagnosis, and persistence of prehypertension at 6‐month follow‐up. No abnormalities were seen at ultrasound, excepting for one patient who exhibited B‐lines at lung sonography. Immunoglobulin G seroconversion was observed in all at 1‐month.

Conclusions

Our study confirm that intra‐family transmission is important. The significant higher viral loads recorded among patients with lower BMI, together with low vitamin D levels, support the impact of nutritional status on immune system. Renal involvement is frequent even among children with mild COVID‐19, therefore prompt evaluation and identification of patients with reduced renal function reserve would allow a better stratification and management of patients. Seroconversion occurs also in asymptomatic children, with no differences in antibodies titer according to age, sex and clinical manifestations.

Neurological involvement in the respiratory manifestations of COVID-19 patients

The peculiar features of coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), are challenging the current biological knowledge. Early in Feb, 2020, we suggested that SARS-CoV-2 may possess neuroinvasive potential similar to that of many other coronaviruses. Since then, a variety of neurological manifestations have been associated with SARS-CoV-2 infection, which was supported in some patients with neuroimaging and/or cerebrospinal fluid tests. To date, at least 27 autopsy studies on the brains of COVID-19 patients can be retrieved through PubMed/MEDLINE, among which neuropathological alterations were observed in the brainstem in 78 of 134 examined patients, and SARS-CoV-2 nucleic acid and viral proteins were detected in the brainstem in 16/49 (32.7%) and 18/71 (25.3%) cases, respectively. To shed some light on the peculiar respiratory manifestations of COVID-19 patients, this review assessed the existing evidence about the neurogenic mechanism underlying the respiratory failure induced by SARS-CoV-2 infection. Acknowledging the neurological involvement has important guiding significance for the prevention, treatment, and prognosis of SARS-CoV-2 infection.

Ultrasound assessment of pulmonary fibroproliferative changes in severe COVID-19: a quantitative correlation study with histopathological findings

PURPOSE

This study was designed to evaluate the usefulness of lung ultrasound (LUS) imaging to characterize the progression and severity of lung damage in cases of COVID-19.

METHODS

We employed a set of combined ultrasound parameters and histopathological images obtained simultaneously in 28 patients (15 women, 0.6-83 years) with fatal COVID-19 submitted to minimally invasive autopsies, with different times of disease evolution from initial symptoms to death (3-37 days, median 18 days). For each patient, we analysed eight post-mortem LUS parameters and the proportion of three histological patterns (normal lung, exudative diffuse alveolar damage [DAD] and fibroproliferative DAD) in eight different lung regions. The relationship between histopathological and post-mortem ultrasonographic findings was assessed using various statistical approaches.

RESULTS

Statistically significant positive correlations were observed between fibroproliferative DAD and peripheral consolidation (coefficient 0.43, p = 0.02) and pulmonary consolidation (coefficient 0.51, p = 0.005). A model combining age, time of evolution, sex and ultrasound score predicted reasonably well (r = 0.66) the proportion of pulmonary parenchyma with fibroproliferative DAD.

CONCLUSION

The present study adds information to previous studies related to the use of LUS as a tool to assess the severity of acute pulmonary damage. We provide a histological background that supports the concept that LUS can be used to characterize the progression and severity of lung damage in severe COVID-19.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study

BACKGROUND

Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported.

OBJECTIVES

Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt.

METHODS

A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer.

RESULTS

After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17-22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected.

CONCLUSION

Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.

Multimodality imaging in COVID-19 patients: A key role from diagnosis to prognosis

The integrated clinical, laboratory and ultrasound approach is essential for the diagnosis, evaluation and monitoring of the patient's therapy in coronavirus disease 2019 pneumonia. The ideal imaging approach in this context is not yet well defined. Chest X-ray is characterized by low sensitivity in identifying earlier lung changes. The "bedside" pulmonary ultrasound has an undeniable series of advantages in the patient at high infectious risk and can provide incremental data in the respiratory intensive care for the serial control of the individual patient as well as for the home delivery of the stabilized subjects. Pulmonary computed tomography shows high sensitivity but should not be routinely performed in all patients, because in the first 48 h it can be absolutely negative and in the late phase the imaging findings may not change the therapeutic approach. Echocardiography should be limited to patients with hemodynamic instability to assess ventricular function and pulmonary pressures.

Diaphragmatic thickening fraction as a potential predictor of response to continuous positive airway pressure ventilation in Covid-19 pneumonia: A single-center pilot study

BACKGROUND

In a variable number of Covid-19 patients with acute respiratory failure, non-invasive breathing support strategies cannot provide adequate oxygenation, thus making invasive mechanical ventilation necessary. Factors predicting this unfavorable outcome are unknown, but we hypothesized that diaphragmatic weakness may contribute.

METHODS

We prospectively analyzed the data of 27 consecutive patients admitted to the general Intensive Care Unit (ICU) from March 19, 2020, to April 20, 2020 and submitted to continuous positive airway pressure (CPAP) before considering invasive ventilation. Diaphragmatic thickening fraction (DTF) inferred by ultrasound was determined before applying CPAP.

RESULTS

Eighteen patients recovered with CPAP, whereas nine required invasive mechanical ventilation with longer stay in ICU (p < 0.001) and hospital (p = 0.003). At univariate logistic regression analysis, CPAP failure was significantly associated with low DTF [β: -0.396; OR: 0.673; p < 0.001] and high respiratory rate [β: 0.452; OR: 1.572; p < 0.001] but only DTF reached statistical significance at multivariate analysis [β: -0.384; OR: 0.681; p < 0.001]. The DTF best threshold predicting CPAP failure was 21.4 % (AUC: 0.944; sensitivity: 94.4 %, specificity: 88.9 %).

CONCLUSIONS

In critically ill patients with Covid-19 respiratory failure admitted to ICU, a reduced DTF could be a potential predictor of CPAP failure and requirement of invasive ventilation.

Chest physiotherapy: An important adjuvant in critically ill mechanically ventilated patients with COVID-19

In late 2019, an outbreak of a novel human coronavirus causing respiratory disease was identified in Wuhan, China. The virus spread rapidly worldwide, reaching pandemic status. Chest computed tomography scans of patients with coronavirus disease-2019 (COVID-19) have revealed different stages of respiratory involvement, with extremely variable lung presentations, which require individualized ventilatory strategies in those who become critically ill. Chest physiotherapy has proven to be effective for improving long-term respiratory physical function among ICU survivors. The ARIR recently reported the role of chest physiotherapy in the acute phase of COVID-19, pointing out limitation of some procedures due to the limited experience with this disease in the ICU setting. Evidence on the efficacy of chest physiotherapy in COVID-19 is still lacking. In this line, the current review discusses the important role of chest physiotherapy in critically ill mechanically ventilated patients with COVID-19, around the weaning process, and how it can be safely applied with careful organization, including the training of healthcare staff and the appropriate use of personal protective equipment to minimize the risk of viral exposure.

SARS-CoV-2/Renin-Angiotensin System: Deciphering the Clues for a Couple with Potentially Harmful Effects on Skeletal Muscle

Severe acute respiratory syndrome coronavirus (SARS-CoV-2) has produced significant health emergencies worldwide, resulting in the declaration by the World Health Organization of the coronavirus disease 2019 (COVID-19) pandemic. Acute respiratory syndrome seems to be the most common manifestation of COVID-19. A high proportion of patients require intensive care unit admission and mechanical ventilation (MV) to survive. It has been well established that angiotensin-converting enzyme type 2 (ACE2) is the primary cellular receptor for SARS-CoV-2. ACE2 belongs to the renin–angiotensin system (RAS), composed of several peptides, such as angiotensin II (Ang II) and angiotensin (1-7) (Ang-(1-7)). Both peptides regulate muscle mass and function. It has been described that SARS-CoV-2 infection, by direct and indirect mechanisms, affects a broad range of organ systems. In the skeletal muscle, through unbalanced RAS activity, SARS-CoV-2 could induce severe consequences such as loss of muscle mass, strength, and physical function, which will delay and interfere with the recovery process of patients with COVID-19. This article discusses the relationship between RAS, SARS-CoV-2, skeletal muscle, and the potentially harmful consequences for skeletal muscle in patients currently infected with and recovering from COVID-19.

Transthoracic echocardiographic findings in patients admitted with SARS-CoV-2 infection

Introduction

Severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2)–infected patients commonly have elevated troponin and D‐dimer levels, but limited imaging exists to support most likely etiologies in efforts to avoid staff exposure. The purpose of this study was to report transthoracic echocardiographic (TTE) findings in SARS‐CoV‐2 patients with correlating troponin and D‐dimer levels.

Methods

We identified 66 SARS‐CoV‐2 patients (mean age 60 ± 15.7 years) admitted within a large, eight‐hospital healthcare system over a 6‐week period with a TTE performed. TTE readers were blinded to laboratory data with intra‐observer and inter‐observer analysis assessed.

Results

Sixty‐six of 1780 SARS‐CoV‐2 patients were included and represented a high‐risk population as 38 (57.6%) were ICU‐admitted, 47 (71.2%) had elevated D‐dimer, 41 (62.1%) had elevated troponin, and 25 (37.9%) died. Right ventricular (RV) dilation was present in 49 (74.2%) patients. The incidence and average D‐dimer elevation was similar between moderate/severe vs. mild/no RV dilation (69.6% vs 67.6%, P = 1.0; 3736 ± 2986 vs 4141 ± 3351 ng/mL, P = .679). Increased left ventricular (LV) wall thickness was present in 46 (69.7%) with similar incidence of elevated troponin and average troponin levels compared to normal wall thickness (66.7% vs 52.4%, P = .231; 0.88 ± 1.9 vs 1.36 ± 2.4 ng/mL, P = .772). LV dilation was rare (n = 6, 9.1%), as was newly reduced LV ejection fraction (n = 2, 3.0%).

Conclusion

TTE in SARS‐CoV‐2 patients is scarce, technically difficult, and reserved for high‐risk patients. RV dilation is common in SARS‐CoV‐2 but does not correlate with elevated D‐dimer levels. Increased LV wall thickness is common, while newly reduced LV ejection fraction is rare, and neither correlates with troponin levels.

Electrical Impedance Tomography and Prone Position During Ventilation in COVID-19 Pneumonia: Case Reports and a Brief Literature Review

At the end of 2019, a novel coronavirus (COVID-19) was identified as the cause of a cluster of pneumonia cases, with high needs of mechanical ventilation in critically ill patients. It is still unclear whether different types of COVID-19 pneumonia require different ventilator strategies. With electrical impedance tomography (EIT) we evaluated, in real time and bedside, the distribution of ventilation in the different pulmonary regions before, during, and after pronation in COVID-19 respiratory failure. We present a brief literature review of EIT in non-COVID-19 patients and a report of 2 COVID-19 patients: one that did not respond well and another one that improved during and after pronation. EIT might be a useful tool to decide whether prone positioning should or should not be used in COVID-19 pneumonia.