Frequency of Abnormalities Detected by Point-of-Care Lung Ultrasound in Symptomatic COVID-19 Patients: Systematic Review and Meta-Analysis

The use of lung ultrasound in COVID-19

This review article addresses the role of lung ultrasound in patients with coronavirus disease 2019 (COVID-19) for diagnosis and disease management. As a simple imaging procedure, lung ultrasound contributes to the early identification of patients with clinical conditions suggestive of COVID-19, supports decisions about hospital admission and informs therapeutic strategy. It can be performed in various clinical settings (primary care facilities, emergency departments, hospital wards, intensive care units), but also in outpatient settings using portable devices. The article describes typical lung ultrasound findings for COVID-19 pneumonia (interstitial pattern, pleural abnormalities and consolidations), as one component of COVID-19 diagnostic workup that otherwise includes clinical and laboratory evaluation. Advantages and limitations of lung ultrasound use in COVID-19 are described, along with equipment requirements and training needs. To infer on the use of lung ultrasound in different regions, a literature search was performed using key words "COVID-19", "lung ultrasound" and "imaging". Lung ultrasound is a noninvasive, rapid and reproducible procedure; can be performed at the point of care; requires simple sterilisation; and involves non-ionising radiation, allowing repeated exams on the same patient, with special benefit in children and pregnant women. However, physical proximity between the patient and the ultrasound operator is a limitation in the current pandemic context, emphasising the need to implement specific infection prevention and control measures. Availability of qualified staff adequately trained to perform lung ultrasound remains a major barrier to lung ultrasound utilisation. Training, advocacy and awareness rising can help build up capacities of local providers to facilitate lung ultrasound use for COVID-19 management, in particular in low- and middle-income countries.

Gastrointestinal microbiota: A predictor of COVID-19 severity?

Coronavirus disease 2019 (COVID-19), caused by a severe acute respiratory syndrome coronavirus 2 infection, has raised serious concerns worldwide over the past 3 years. The severity and clinical course of COVID-19 depends on many factors (e.g., associated comorbidities, age, etc) and may have various clinical and imaging findings, which raises management concerns. Gut microbiota composition is known to influence respiratory disease, and respiratory viral infection can also influence gut microbiota. Gut and lung microbiota and their relationship (gut-lung axis) can act as modulators of inflammation. Modulating the intestinal microbiota, by improving its composition and diversity through nutraceutical agents, can have a positive impact in the prophylaxis/treatment of COVID-19.

Early Lung Ultrasound Findings in Patients With COVID-19 Pneumonia: A Retrospective Multicenter Study of 479 Patients

OBJECTIVES

Lung ultrasound (LUS) holds the promise of an accurate, radiation-free, and affordable diagnostic and monitoring tool in coronavirus disease 2019 (COVID-19) pneumonia. We sought to evaluate the usefulness of LUS in the diagnosis of patients with respiratory distress and suspicion of interstitial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, in comparison to other imaging modalities.

METHODS

This was a multicenter, retrospective study. LUS was performed, on Emergency Department (ED) arrival of patients presenting for possible COVID-19 evaluation, by trained emergency physicians, before undergoing conventional radiologic examination or while waiting for the report. Scans were performed using longitudinal transducer orientation of the lung regions. CXR was interpreted by radiologists staffing ED radiology. Subjects were divided into two group based on molecular test results. LUS findings were compared to COVID test results, nonlaboratory data, and other imaging for each patient. Categorical variables were expressed as percentages and continuous variables as median ± standard error.

RESULTS

A total of 479 patients were enrolled, 87% diagnosed with SARS-CoV-2 by molecular testing. COVID positive and COVID negative patients differed with respect to sex, presence of fever, and white blood cells count. Most common findings on lung point of care ultrasound (POCUS) for COVID-positive patients were B-lines, irregular pleural lines, and small consolidation. Normal chest X-ray was found in 17.89% of cases.

CONCLUSIONS

This 479 patient cohort, with COVID-19, found LUS to be noninferior to chest X-ray (CXR) for diagnostic accuracy. In this study, COVID-positive patients are most likely to show B lines and sub-pleural consolidations on LUS examination.

Diagnostic accuracy and prognostic value of lung ultrasound in coronavirus disease (COVID-19)

Purpose

This study aimed to assess the correlation between lung ultrasound (LUS) and computed tomography (CT) findings and the predictability of LUS scores to anticipate disease characteristics, lab data, clinical severity, and mortality in patients with COVID-19.

Material and methods

Fifty consecutive hospitalized PCR-confirmed COVID-19 patients who underwent chest CT scan and LUS on the first day of admission were enrolled. The LUS score was calculated based on the presence, severity, and distribution of parenchymal abnormalities in 14 regions.

Results

The participants’ mean age was 54.60 ± 19.93 years, and 26 (52%) were female. All patients had CT and LUS findings typical of COVID-19. The mean value of CT and LUS severity scores were 11.80 ± 3.89 (ranging from 2 to 20) and 13.74 ± 6.43 (ranging from 1 to 29), respectively. The LUS score was significantly higher in females (p = 0.016), and patients with dyspnoea (p = 0.048), HTN (p = 0.034), immunodeficiency (p = 0.034), room air SpO₂ ≤ 93 (p = 0.02), and pleural effusion (p = 0.036). LUS findings were strongly correlated with CT scan results regarding lesion type, distribution, and severity in a region-by-region fashion (92-100% agreement). An LUS score of 14 or higher was predictive of room air SpO₂ ≤ 93 and ICU admission, while an LUS score ≥ 12 was predictive of death (p = 0.011, 0.023, and 0.003, respectively).

Conclusions

Our results suggested that LUS can be used as a valuable tool for detecting COVID-19 pneumonia and determining high-risk hospitalized patients, helping to triage and stratify high-risk patients, which waives the need to undertake irradiating chest CT and reduces the burden of overworked CT department staff.

Lung ultrasound in ruling out COVID-19 pneumonia in the ED: a multicentre prospective sensitivity study

PURPOSE

Early diagnosis of COVID-19 has a crucial role in confining the spread among the population. Lung ultrasound (LUS) was included in the diagnostic pathway for its high sensitivity, low costs, non-invasiveness and safety. We aimed to test the sensitivity of LUS to rule out COVID-19 pneumonia (COVIDp) in a population of patients with suggestive symptoms.

METHODS

Multicentre prospective observational study in three EDs in Northeastern Italy during the first COVID-19 outbreak. A convenience sample of 235 patients admitted to the ED for symptoms suggestive COVIDp (fever, cough or shortness of breath) from 17 March 2020 to 26 April 2020 was enrolled. All patients underwent a sequential assessment involving: clinical examination, LUS, CXR and arterial blood gas. The index test under investigation was a standardised protocol of LUS compared with a pragmatic composite reference standard constituted by: clinical gestalt, real-time PCR test, radiological and blood gas results. Of the 235 enrolled patients, 90 were diagnosed with COVIDp according to the reference standard.

RESULTS

Among the patients with suspected COVIDp, the prevalence of SARS-CoV-2 was 38.3%. The sensitivity of LUS for diagnosing COVIDp was 85.6% (95% CI 76.6% to 92.1%); the specificity was 91.7% (95% CI 86.0% to 95.7%). The positive predictive value and the negative predictive value were 86.5% (95%CI 78.8% to 91.7%) and 91.1% (95% CI 86.1% to 94.4%) respectively. The diagnostic accuracy of LUS for COVIDp was 89.4% (95% CI 84.7% to 93.0%). The positive likelihood ratio was 10.3 (95% CI 6.0 to 17.9), and the negative likelihood ratio was 0.16 (95% CI 0.1 to 0.3).

CONCLUSION

In a population with high SARS-CoV-2 prevalence, LUS has a high sensitivity (and negative predictive value) enough to rule out COVIDp in patients with suggestive symptoms. The role of LUS in diagnosing patients with COVIDp is perhaps even more promising. Nevertheless, further research with adequately powered studies is needed.

TRIAL REGISTRATION NUMBER

NCT04370275.

A Review of Deep Learning Applications in Lung Ultrasound Imaging of COVID-19 Patients

The massive and continuous spread of COVID-19 has motivated researchers around the world to intensely explore, understand, and develop new techniques for diagnosis and treatment. Although lung ultrasound imaging is a less established approach when compared to other medical imaging modalities such as X-ray and CT, multiple studies have demonstrated its promise to diagnose COVID-19 patients. At the same time, many deep learning models have been built to improve the diagnostic efficiency of medical imaging. The integration of these initially parallel efforts has led multiple researchers to report deep learning applications in medical imaging of COVID-19 patients, most of which demonstrate the outstanding potential of deep learning to aid in the diagnosis of COVID-19. This invited review is focused on deep learning applications in lung ultrasound imaging of COVID-19 and provides a comprehensive overview of ultrasound systems utilized for data acquisition, associated datasets, deep learning models, and comparative performance.

Changing resuscitation strategies during a pandemic: lessons from the consecutive surges in New York and global challenges

PURPOSE OF REVIEW

To provide a framework for resuscitation of COVID-19 critical illness for emergency and intensive care clinicians with the most up to date evidence and recommendations in the care of COVID-19 patients in cardiac arrest or in extremis.

RECENT FINDINGS

Performing cardiopulmonary resuscitation (CPR) on COVID-19 patients requires the clinicians to adopt infection mitigation strategies such as full personal protective equipment, mechanical chest compression devices, and restricting the number of people present during the resuscitation. The time of intubation is a subject of ongoing research and clinicians should use their best judgment for each patient. Clinicians should prepare for CPR in prone position. Particular attention should be given to the psychological well-being of the staff. Point of care ultrasound has proved to be an invaluable diagnostic tool in assessing ventricular dysfunction and parenchymal lung disease. Although novel therapies to supplant the function of diseased lungs have shown promise in select patients the evidence is still being collected. The end-of-life discussions have been negatively impacted by prognostic uncertainty as well as barriers to in person meetings with families.

SUMMARY

The resuscitation of critically ill COVID-19 patients poses new challenges, but the principles remain largely unchanged.

Variability in Point-of-Care Lung Ultrasound Findings in Pediatric COVID-19 Patients: A Multicenter Case Series

ABSTRACT

Point-of-care ultrasound (POCUS) has been described as a useful tool for identification of coronavirus disease 2019 (COVID-19) in adults and children. Although several case reports describe POCUS findings in children with COVID-19, to our knowledge, there have been no published multicenter case series describing the large heterogeneity in lung POCUS findings in pediatric COVID-19. This series includes 7 symptomatic patients with COVID-19 who had a lung POCUS performed at 6 institutions by pediatric emergency attendings and fellows. The findings were variable, ranging from no findings to the appearance of B-lines, pleural abnormalities, consolidations, and a pleural effusion. Further studies are needed to improve our understanding, characterization, and prognostic correlation of POCUS findings in this novel disease in children.

Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care expert consensus statement on the use of lung ultrasound in critically ill patients with coronavirus disease 2019 (ITACO)

BACKGROUND

To produce statements based on the available evidence and an expert consensus (as members of the Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care, SIAARTI) on the use of lung ultrasound for the management of patients with COVID-19 admitted to the intensive care unit.

METHODS

A modified Delphi method was applied by a panel of anesthesiologists and intensive care physicians expert in the use of lung ultrasound in COVID-19 intensive critically ill patients to reach a consensus on ten clinical questions concerning the role of lung ultrasound in the following: COVID-19 diagnosis and monitoring (with and without invasive mechanical ventilation), positive end expiratory pressure titration, the use of prone position, the early diagnosis of pneumothorax- or ventilator-associated pneumonia, the process of weaning from invasive mechanical ventilation, and the need for radiologic chest imaging.

RESULTS

A total of 20 statements were produced by the panel. Agreement was reached on 18 out of 20 statements (scoring 7-9; "appropriate") in the first round of voting, while 2 statements required a second round for agreement to be reached. At the end of the two Delphi rounds, the median score for the 20 statements was 8.5 [IQR 8.9], and the agreement percentage was 100%.

CONCLUSION

The Lung Ultrasound Working Group of the Italian Society of Analgesia, Anesthesia, Resuscitation, and Intensive Care produced 20 consensus statements on the use of lung ultrasound in COVID-19 patients admitted to the ICU. This expert consensus strongly suggests integrating lung ultrasound findings in the clinical management of critically ill COVID-19 patients.

The Use of POCUS to Manage ICU Patients With COVID-19

Since the advent of SARS-CoV-2, the virus that causes COVID-19, clinicians have had to modify how they provide high-value care while mitigating the risk of viral spread. Routine imaging studies have been discouraged due to elevated transmission risk. Patients who have been diagnosed with COVID-19 often have a protracted hospital course with progression of disease. Given the need for close follow-up of patients, we recommend the use of ultrasonography, particularly point-of-care ultrasound (POCUS), to manage patients with COVID-19 through their entire ICU course. POCUS will allow a clinician to evaluate and monitor cardiac and pulmonary function, as well as evaluate for thromboembolic disease, place an endotracheal tube, confirm central venous catheter placement, and rule out a pneumothorax. If a patient improves sufficiently to perform weaning trials, POCUS can also help evaluate readiness for ventilator liberation.

A Comparison of Lung Ultrasound and Computed Tomography in the Diagnosis of Patients with COVID-19: A Systematic Review and Meta-Analysis

Background Lung ultrasound (LUS) and computed tomography (CT) can both be used for diagnosis of interstitial pneumonia caused by coronavirus disease 2019 (COVID-19), but the agreement between LUS and CT is unknown. Purpose to compare the agreement of LUS and CT in the diagnosis of interstitial pneumonia caused by COVID-19. Materials and Methods We searched PubMed, Cochrane library, Embase, Chinese Biomedicine Literature, and WHO COVID-19 databases to identify studies that compared LUS with CT in the diagnosis of interstitial pneumonia caused by COVID-19. We calculated the pooled overall, positive and negative percent agreements, diagnostic odds ratio (DOR) and the area under the standard receiver operating curve (SROC) for LUS in the diagnosis of COVID-19 compared with CT. Results We identified 1896 records, of which nine studies involving 531 patients were finally included. The pooled overall, positive and negative percentage agreements of LUS for the diagnosis of interstitial pneumonia caused by COVID-19 compared with CT were 81% (95% confidence interval [CI] 43–99%), 96% (95% CI, 80–99%, I² = 92.15%) and 80% (95%CI, 60–92%, I² = 92.85%), respectively. DOR was 37.41 (95% CI, 9.43–148.49, I² = 63.9%), and the area under the SROC curve was 0.94 (95% CI, 0.92–0.96). The quality of evidence for both specificity and sensitivity was low because of heterogeneity and risk of bias. Conclusion The level of diagnostic agreement between LUS and CT in the diagnosis of interstitial pneumonia caused by COVID-19 is high. LUS can be therefore considered as an equally accurate alternative for CT in situations where molecular tests are not available.

Covid-19 imaging: A narrative review

Background

The 2019 novel coronavirus disease (COVID-19) imaging data is dispersed in numerous publications. A cohesive literature review is to be assembled.

Objective

To summarize the existing literature on Covid-19 pneumonia imaging including precautionary measures for radiology departments, Chest CT's role in diagnosis and management, imaging findings of Covid-19 patients including children and pregnant women, artificial intelligence applications and practical recommendations.

Methods

A systematic literature search of PubMed/med line electronic databases.

Results

The radiology department's staff is on the front line of the novel coronavirus outbreak. Strict adherence to precautionary measures is the main defense against infection's spread. Although nucleic acid testing is Covid-19's pneumonia diagnosis gold standard; kits shortage and low sensitivity led to the implementation of the highly sensitive chest computed tomography amidst initial diagnostic tools. Initial Covid-19 CT features comprise bilateral, peripheral or posterior, multilobar ground-glass opacities, predominantly in the lower lobes. Consolidations superimposed on ground-glass opacifications are found in few cases, preponderantly in the elderly. In later disease stages, GGO transformation into multifocal consolidations, thickened interlobular and intralobular lines, crazy paving, traction bronchiectasis, pleural thickening, and subpleural bands are reported. Standardized CT reporting is recommended to guide radiologists. While lung ultrasound, pulmonary MRI, and PET CT are not Covid-19 pneumonia's first-line investigative diagnostic modalities, their characteristic findings and clinical value are outlined. Artificial intelligence's role in strengthening available imaging tools is discussed.

Conclusion

This review offers an exhaustive analysis of the current literature on imaging role and findings in COVID-19 pneumonia.

•

Chest computed tomography is a highly sensitive Covid −19 pneumonia's diagnostic tool.

•

Initial Covid-19 CT features are bilateral, multifocal, peripheral or posterior ground-glass opacities, mainly in the lower lobes.

•

Multifocal consolidations, bronchiectasis, pleural thickening, and subpleural bands are late disease stages features.

•

Standardized CT reporting is recommended to guide radiologists.

•

Artificial intelligence could strengthen available imaging tools.

The Risk of Hospitalization in COVID-19 Patients Can Be Predicted by Lung Ultrasound in Primary Care

BACKGROUND

The usefulness of Lung Ultrasound (LUS) for the diagnosis of interstitial syndrome caused by COVID-19 has been broadly described. The aim of this study was to evaluate if LUS may predict the complications (hospital admission) of COVID-19 pneumonia in primary care patients.

METHODS

This observational study collects data from a cohort of 279 patients with clinical symptoms of COVID-19 pneumonia who attended the Balaguer Primary Health Care Area between 16 March 2020 and 30 September 2020. We collected the results of LUS scans reported by one general practitioner. We created a database and analysed the absolute and relative frequencies of LUS findings and their association with hospital admission. We found that different LUS patterns (diffuse, attenuated diffuse, and predominantly unilateral) were risk factors for hospital admission (p < 0.05). Additionally, an evolutionary pattern during the acute phase represented a risk factor (p = 0.0019). On the contrary, a normal ultrasound pattern was a protective factor (p = 0.0037). Finally, the presence of focal interstitial pattern was not associated with hospital admission (p = 0.4918).

CONCLUSION

The lung ultrasound was useful to predict complications in COVID-19 pneumonia and to diagnose other lung diseases such as cancer, tuberculosis, pulmonary embolism, chronic interstitial pneumopathy, pleuropericarditis, pneumonia or heart failure.

Pulmonary Ultrasound in the Diagnosis and Monitoring of Coronavirus Disease (COVID-19): A Systematic Review

The goal of this review was to systematize the evidence on pulmonary ultrasound (PU) use in diagnosis, monitorization or hospital discharge criteria for patients with coronavirus disease 2019 (COVID-19). Evidence on the use of PU for diagnosis and monitorization of or as hospital discharge criteria for COVID-19 patients confirmed to have COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) between December 1, 2019 and July 5, 2020 was compared with evidence obtained with thoracic radiography (TR), chest computed tomography (CT) and RT-PCR. The type of study, motives for use of PU, population, type of transducer and protocol, results of PU and quantitative or qualitative correlation with TR and/or chest CT and/or RT-PCR were evaluated. A total of 28 articles comprising 418 patients were involved. The average age was 50 y (standard deviation: 25.1 y), and there were 395 adults and 23 children. One hundred forty-three were women, 13 of whom were pregnant. The most frequent result was diffuse, coalescent and confluent B-lines. The plural line was irregular, interrupted or thickened. The presence of subpleural consolidation was noduliform, lobar or multilobar. There was good qualitative correlation between TR and chest CT and a quantitative correlation with chest CT of r = 0.65 (p < 0.001). Forty-four patients were evaluated only with PU. PU is a useful tool for diagnosis and monitorization and as criteria for hospital discharge for patients with COVID-19.

Lung Assessment with Point-of-Care Ultrasound in Respiratory Coronavirus Disease (COVID-19): A Prospective Cohort Study

Lung ultrasound (LUS) has shown promising diagnostic potential in different pulmonary conditions. We evaluated the diagnostic accuracy of LUS for pulmonary COVID-19. In this prospective cohort study at a Swiss tertiary care center, patients hospitalized with suspected COVID-19 were scanned using a 12-zone protocol. Association of a summation score (0-36 points) with the final diagnosis was tested using the area under the receiver operating characteristic curve and sensitivity and specificity at different cutoff points. Of the 49 participants, 11 (22%) were later diagnosed with COVID-19. LUS score showed excellent diagnostic performance, with an odds ratio of 1.30 per point (95% confidence interval [CI], 1.09-1.54, p = 0.003) and an area under the curve of 0.85 (95% CI, 0.71-0.99). At a cutoff of 8/36 points, 10 of 11 participants later diagnosed with COVID-19 were correctly predicted (sensitivity 91%, 95% CI, 59%-100%), and 29 of the 38 who were not diagnosed with COVID-19 were correctly ruled out (specificity 76%, 95% CI, 60%-89%). LUS demonstrated promising discriminatory potential in people hospitalized with suspected COVID-19.

Diagnostic accuracy of lung ultrasound for SARS-CoV-2: a retrospective cohort study

Background

As medical infrastructures are strained by SARS-CoV-2, rapid and accurate screening tools are essential. In portions of the world, reverse transcription polymerase chain reaction (RT-PCR) testing remains slow and in limited supply, and computed tomography is expensive, inefficient, and involves exposure to ionizing radiation. Multiple studies evaluating the efficiency of lung point-of-care ultrasound (POCUS) have been published recently, but include relatively small cohorts and often focus on characteristics associated with severe illness rather than screening efficacy. This study utilizes a retrospective cohort to evaluate the test characteristics (sensitivity, specificity, likelihood ratios, predictive values) of lung POCUS in the diagnosis of SARS-CoV-2, and to determine lung score cutoffs that maximize performance for use as a screening tool.

Results

Lung POCUS examinations had sensitivity 86%, specificity 71.6%, NPV 81.7%, and PPV 77.7%. The Lung Ultrasound Score had an area under the curve of 0.84 (95% CI 0.78, 0.90). When including only complete examinations visualizing 12 lung fields, lung POCUS had sensitivity 90.9% and specificity 75.6%, with NPV 87.2% and PPV 82.0% and an area under the curve of 0.89 (95% CI 0.83, 0.96). Lung POCUS was less accurate in patients with a history of interstitial lung disease, severe emphysema, and heart failure.

Conclusions

When applied in the appropriate patient population, lung POCUS is an inexpensive and reliable tool for rapid screening and diagnosis of SARS-CoV-2 in symptomatic patients with influenza-like illness. Adoption of lung POCUS screening for SARS-CoV-2 may identify patients who do not require additional testing and reduce the need for RT-PCR testing in resource-limited environments and during surge periods.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00217-7.

Lung ultrasonography: A prognostic tool in non-ICU hospitalized patients with COVID-19 pneumonia

BACKGROUND

High diagnostic accuracy for pneumonia, absence of radiation exposure and repeatability are intrinsic features of lung ultrasonography making it an attractive tool in the assessment of patients with COVID-19 pneumonia. The aim of our prospective, observational study was to detect COVID-19-associated sonographic features and assess the potential value of LUS in predicting adverse events.

METHODS

From March 12th to April 20th 2020 patients admitted to two medium-intensive wards with a discharge diagnosis of COVID-19 pneumonia were enrolled and underwent lung ultrasonography. The prognostic value of several ultrasonographic scores at admission and after 72 hours from the first examination (the total score, the anterolateral score, the number of positive region and the presence of consolidation) were analysed with logistic regression along with other potential prognostic factors. The primary outcome was a composite of death and transfer to Intensive Care Unit (ICU), while the secondary was continuous positive airways pressure (CPAP) support.

RESULTS

190 patients were enrolled in the study. The primary outcome was seen in 25 patients (13%), the secondary outcome in 36 (22%). At multivariate regression no sonographic score at admission was independently correlated with the primary outcome while the total score, the anterolateral score, the number of positive regions were associated with CPAP support. When considering the subgroup of patients undergoing lung ultrasonography after 72 hours (128 patients) the total score was independently associated with both the primary and secondary outcome.

CONCLUSION

Lung ultrasonography can be a promising prognostic tool in patients admitted to non-ICU units for COVID-19 pneumonia.

Respiratory Care in Children with COVID-19

The novel coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is causing significant morbidity and mortality worldwide. The common presentations in children include involvement of respiratory system leading to pneumonia and acute respiratory distress syndrome, as well as multiorgan dysfunction syndrome and multisystem inflammatory syndrome in children (MIS-C). Pediatric COVID-19 is a milder disease as compared with the adults. Also, there is rise in MIS-C cases which is a hyperinflammatory condition temporally associated with SARS-CoV-2. Since respiratory system is predominantly involved, few of these critically ill children often require respiratory support which can range from simple oxygen delivery devices, high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), invasive mechanical ventilation, and extracorporeal membrane oxygenation (ECMO). Most of the oxygen delivery devices and respiratory interventions generate aerosols and pose risk of transmission of virus to health care providers (HCPs). The use of HFNC and NIV should be limited to children with mild respiratory distress preferably in negative pressure rooms and with adequate personnel protective equipments (PPEs). However, there should be low thresholds for intubation and invasive mechanical ventilation in the event of clinical deterioration while on any respiratory support. The principle of providing respiratory support requires special droplet and air-borne precautions to limit exposure or transmission of virus to HCPs and at the same time ensuring safety of the patient.

Point-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission (POCUSCO): a study protocol of an international study

INTRODUCTION

In the context of the COVID-19 pandemic, early identification of patients who are likely to get worse is a major concern. Severity mainly depends on the development of acute respiratory distress syndrome (ARDS) with a predominance of subpleural lesions. Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may be appropriate for examining patients with COVID-19. We suggest that L-POCUS performed during the initial examination may identify patients with COVID-19 who are at a high risk of complicated treatment or unfavourable evolution.

METHODS AND ANALYSIS

Point-of-care ultrasonography for risk stratification of non-critical COVID-19 patients on admission is a prospective, multicentre study. Adult patients visiting the emergency department (ED) of participating centres for suspected or confirmed COVID-19 are assessed for inclusion. Included patients have L-POCUS performed within 48 hours following ED admission. The severity of lung damage is assessed using the L-POCUS score based on 36 points for ARDS. Apart from the L-POCUS score assessment, patients are treated as recommended by the WHO. For hospitalised patients, a second L-POCUS is performed at day 5±3. A follow-up is carried out on day 14, and the patient's status according to the Ordinal Scale for Clinical Improvement for COVID-19 from the WHO is recorded.The primary outcome is the rate of patients requiring intubation or who are dead from any cause during the 14 days following inclusion. We will determine the area under the ROC curve of L-POCUS.

ETHICS AND DISSEMINATION

The protocol has been approved by the French and Belgian Ethics Committees and is carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The study is funding by a grant from the French Health Ministry, and its findings will be disseminated in peer-reviewed journals and at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04338100.

Pragmatic Recommendations for the Use of Diagnostic Testing and Prognostic Models in Hospitalized Patients with Severe COVID-19 in Low- and Middle-Income Countries

Management of patients with severe or critical COVID-19 is mainly modeled after care of patients with severe pneumonia or acute respiratory distress syndrome from other causes. These models are based on evidence that primarily originates from investigations in high-income countries, but it may be impractical to apply these recommendations to resource-restricted settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for microbiology and laboratory testing, imaging, and the use of diagnostic and prognostic models in patients with severe COVID-19 in LMICs. For diagnostic testing, where reverse transcription-PCR (RT-PCR) testing is available and affordable, we recommend using RT-PCR of the upper or lower respiratory specimens and suggest using lower respiratory samples for patients suspected of having COVID-19 but have negative RT-PCR results for upper respiratory tract samples. We recommend that a positive RT-PCR from any anatomical source be considered confirmatory for SARS-CoV-2 infection, but, because false-negative testing can occur, recommend that a negative RT-PCR does not definitively rule out active infection if the patient has high suspicion for COVID-19. We suggest against using serologic assays for the detection of active or past SARS-CoV-2 infection, until there is better evidence for its usefulness. Where available, we recommend the use of point-of-care antigen-detecting rapid diagnostic testing for SARS-CoV-2 infection as an alternative to RT-PCR, only if strict quality control measures are guaranteed. For laboratory testing, we recommend a baseline white blood cell differential platelet count and hemoglobin, creatinine, and liver function tests and suggest a baseline C-reactive protein, lactate dehydrogenase, troponin, prothrombin time (or other coagulation test), and D-dimer, where such testing capabilities are available. For imaging, where availability of standard thoracic imaging is limited, we suggest using lung ultrasound to identify patients with possible COVID-19, but recommend against its use to exclude COVID-19. We suggest using lung ultrasound in combination with clinical parameters to monitor progress of the disease and responses to therapy in COVID-19 patients. We currently suggest against using diagnostic and prognostic models as these models require extensive laboratory testing and imaging, which often are limited in LMICs.

Point-of-care lung ultrasound for the assessment of pneumonia: a narrative review in the COVID-19 era

In the coronavirus disease-2019 (COVID-19) era, point-of-care lung ultrasound (LUS) has attracted increased attention. Prospective studies on LUS for the assessment of pneumonia in adult patients were extensively carried out for more than 10 years before this era. None of these prospective studies attempted to differentiate bacterial and viral pneumonia in adult patients using LUS. The majority of studies considered the LUS examination to be positive if sonographic consolidations or multiple B-lines were observed. Significant differences existed in the accuracy of these studies. Some studies revealed that LUS showed superior sensitivity to chest X-ray. These results indicate that point-of-care LUS has the potential to be an initial imaging modality for the diagnosis of pneumonia. The LUS diagnosis of ventilator-associated pneumonia in intensive care units is more challenging in comparison with the diagnosis of community-acquired pneumonia in emergency departments due to the limited access to the mechanically ventilated patients and the high prevalence of atelectasis. However, several studies have demonstrated that the combination of LUS findings with other clinical markers improved the diagnostic accuracy. In the COVID-19 era, many case reports and small observational studies on COVID-19 pneumonia have been published in a short period. Multiple B-lines were the most common and consistent finding in COVID-19 pneumonia. Serial LUS showed the deterioration of the disease. The knowledge and ideas on the application of LUS in the management of pneumonia that are expected to accumulate in the COVID-19 era may provide us with clues regarding more appropriate management.

Point-of-care ultrasound in the COVID-19 era: A scoping review

In the midst of the COVID-19 pandemic, unprecedented pressure has been added to healthcare systems around the globe. Imaging is a crucial component in the management of COVID-19 patients. Point-of-care ultrasound (POCUS) such as hand-carried ultrasound emerges in the COVID-19 era as a tool that can simplify the imaging process of COVID-19 patients, and potentially reduce the strain on healthcare providers and healthcare resources. The preliminary evidence available suggests an increasing role of POCUS in diagnosing, monitoring, and risk-stratifying COVID-19 patients. This scoping review aims to delineate the challenges in imaging COVID-19 patients, discuss the cardiopulmonary complications of COVID-19 and their respective sonographic findings, and summarize the current data and recommendations available. There is currently a critical gap in knowledge in the role of POCUS in the COVID-19 era. Nonetheless, it is crucial to summarize the current preliminary data available in order to help fill this gap in knowledge for future studies.

Use of lung ultrasound for diagnosis and monitoring of coronavirus disease 2019 pneumonia: A case report

Knowledge of lung ultrasound characteristics of coronavirus disease 2019 pneumonia might be useful for early diagnosis and clinical monitoring of patients, and lung ultrasound can help to control the spread of infection in healthcare settings. In this case report, a 36-year-old man with severe acute respiratory syndrome coronavirus 2 infection was diagnosed by reverse transcription-polymerase chain reaction testing of a nasopharyngeal swab. The lung ultrasound findings for this patient were the interstitial-alveolar damage showing bilateral, diffuse pleural line abnormalities, subpleural consolidations, white lung areas and thick, irregular vertical artifacts. When the patient recovered from the severe acute respiratory syndrome coronavirus 2 infection, lung ultrasound images showed a normal pleural line with A-lines regularly reverberating. Performing lung ultrasound at the bedside minimizes the need to move the patient, thus reducing the risk of spreading infection among healthcare staff. Lung ultrasound is useful for early diagnosis and evaluation of the severity of coronavirus disease 2019 pneumonia and for monitoring its progress over the course of the disease.

Lung Ultrasound Findings in Patients with COVID-19

The current SARS-CoV-2 outbreak leads to a growing need of point-of-care thoracic imaging that is compatible with isolation settings and infection prevention precautions. We retrospectively reviewed 17 COVID-19 patients who received point-of-care lung ultrasound imaging in our isolation unit. Lung ultrasound was able to detect interstitial lung disease effectively; severe cases showed bilaterally distributed B-Lines with or without consolidations; one case showed bilateral pleural plaques. Corresponding to CT scans, interstitial involvement is accurately depicted as B-Lines on lung ultrasound. Lung ultrasound might be suitable for detecting interstitial involvement in a bedside setting under high security isolation precautions.

COVID-19 Control by Computer Vision Approaches: A Survey

The COVID-19 pandemic has triggered an urgent call to contribute to the fight against an immense threat to the human population. Computer Vision, as a subfield of artificial intelligence, has enjoyed recent success in solving various complex problems in health care and has the potential to contribute to the fight of controlling COVID-19. In response to this call, computer vision researchers are putting their knowledge base at test to devise effective ways to counter COVID-19 challenge and serve the global community. New contributions are being shared with every passing day. It motivated us to review the recent work, collect information about available research resources, and an indication of future research directions. We want to make it possible for computer vision researchers to find existing and future research directions. This survey article presents a preliminary review of the literature on research community efforts against COVID-19 pandemic.

Lung ultrasonography for risk stratification in patients with COVID-19: a prospective observational cohort study

Background

Point-of-care lung ultrasound (LUS) is a promising pragmatic risk stratification tool in COVID-19. This study describes and compares LUS characteristics between patients with different clinical outcomes

Methods

Prospective observational study of PCR-confirmed COVID-19 adults with symptoms of lower respiratory tract infection in the emergency department (ED) of Lausanne University Hospital. A trained physician recorded LUS images using a standardized protocol. Two experts reviewed images blinded to patient outcome. We describe and compare early LUS findings (acquired within 24hours of presentation to the ED) between patient groups based on their outcome at 7 days after inclusion: 1) outpatients, 2) hospitalised and 3) intubated/death. Normalized LUS score was used to discriminate between groups

Results

Between March 6 and April 3 2020, we included 80 patients (17 outpatients, 42 hospitalized and 21 intubated/dead). 73 patients (91%) had abnormal LUS (70% outpatients, 95% hospitalised and 100% intubated/death; p=0.003). The proportion of involved zones was lower in outpatients compared with other groups (median 30% [IQR 0-40%], 44% [31-70%] and 70% [50-88%], p<0.001). Predominant abnormal patterns were bilateral and multifocal spread thickening of the pleura with pleural line irregularities (70%), confluent B lines (60%) and pathologic B lines (50%). Posterior inferior zones were more often affected. Median normalized LUS score had a good level of discrimination between outpatients and others with area under the ROC of 0.80 (95% CI 0.68-0.92)

Conclusions

Systematic LUS has potential as a reliable, cheap and easy-to-use triage tool for the early risk stratification in COVID-19 patients presenting in EDs

Case Report: COVID-19-Related Pneumothorax-Case Series Highlighting a Significant Complication

COVID-19 is a recent outbreak in China and rapidly spread worldwide. Lung consolidation is the most common radiologic finding of COVID-19 pneumonia. Pneumothorax has been rarely reported as a complication of severe COVID-19 pneumonia. Early recognition and management are detrimental to the outcome. We here report three cases of SARS-CoV-2 infection complicated by pneumothorax. In addition, we present a brief literature review.