Why, when, and how to use lung ultrasound during the COVID-19 pandemic: enthusiasm and caution

Correlation between Serum Biomarkers and Lung Ultrasound in COVID-19: An Observational Study

Serum biomarkers and lung ultrasound are important measures for prognostication and treatment allocation in patients with COVID-19. Currently, there is a paucity of studies investigating relationships between serum biomarkers and ultrasonographic biomarkers derived from lung ultrasound. This study aims to assess correlations between serum biomarkers and lung ultrasound findings. This study is a secondary analysis of four prospective observational studies in adult patients with COVID-19. Serum biomarkers included markers of epithelial injury, endothelial dysfunction and immune activation. The primary outcome was the correlation between biomarker concentrations and lung ultrasound score assessed with Pearson's (r) or Spearman's (rs) correlations. Forty-four patients (67 [41-88] years old, 25% female, 52% ICU patients) were included. GAS6 (rs = 0.39), CRP (rs = 0.42) and SP-D (rs = 0.36) were correlated with lung ultrasound scores. ANG-1 (rs = -0.39) was inversely correlated with lung ultrasound scores. No correlations were found between lung ultrasound score and several other serum biomarkers. In patients with COVID-19, several serum biomarkers of epithelial injury, endothelial dysfunction and immune activation correlated with lung ultrasound findings. The lack of correlations with certain biomarkers could offer opportunities for precise prognostication and targeted therapeutic interventions by integrating these unlinked biomarkers.

Mechanical Ventilation, Past, Present, and Future

Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.

[Ultrasound guided biopsy of lung tumors: evaluation of efficacy and complications]

Introduction

The diagnosis of lung cancer, as well as that of lung nodules, is increasing. Percutaneous biopsy has become a transcendental tool for its diagnosis. Traditionally, computed tomography is used for these procedures because of its ability to clearly demonstrate bone and aerated lung. However, in selected cases it can be performed with ultrasound.

Methods

Retrospective study conducted between January 2020 and December 2021, during the SARS-CoV-2 pandemic. All patients had pleural-based lung lesions or pleural lesions, some with a known history of cancer.

Results

Thirty-six procedures were performed, in 32 (88.9%) the sample obtained presented diagnostic yield and the most used additional test was Immunohistochemistry in 23 (63.9%). Complications were reported in 5 patients (13.9%): 2 with mild pneumothorax, 2 with hemothorax (1 mild and 1 moderate) and 1 patient reported pain.

Conclusion

Ultrasound is a valid method to be used as a guide for biopsies of pleural and peripheral pulmonary lesions. The complications and diagnostic rate has been shown to be in line with the experience of other authors and international guidelines.

Role of cardiac and lung ultrasound in the COVID-19 era

INTRODUCTION

The primary diagnostic method of Coronavirus disease 2019 is reverse transcription polymerase chain reaction of the nucleic acid of severe acute respiratory syndrome coronavirus 2 in nasopharyngeal swabs. There is growing evidence regarding the 2019 coronavirus disease imaging results on chest X-rays and computed tomography but the accessibility to standard diagnostic methods may be limited during the pandemic.

EVIDENCE ACQUISITION

Databases used for the search were MEDLINE (PubMed), Scopus Search, and Cochrane Library. The research took into consideration studies published in English until March 2022 and was conducted using the following research query: ((((sars cov [MeSH Terms])) OR (COVID-19)) OR (Sars-Cov2)) OR (Coronavirus)) AND (((((2d echocardiography [MeSH Terms]) OR (doppler ultrasound imaging [MeSH Terms]))) OR (echography [MeSH Terms])) OR (LUS)) OR ("LUNG ULTRASOUND")).

EVIDENCE SYNTHESIS

Pulmonary and cardiac ultrasound are cost-effective, widely available, and provide information that can influence management.

CONCLUSIONS

Point-of-care ultrasonography is a method that can provide relevant clinical and therapeutic information in patients with COVID-19 where other diagnostic methods may not be easily accessible.

Long-term lung ultrasound follow-up in patients after COVID-19 pneumonia hospitalization: A prospective comparative study with chest computed tomography

During COVID-19 pandemic, lung ultrasound (LUS) proved to be of great value in the diagnosis and monitoring of patients with pneumonia. However, limited data exist regarding its use to assess aeration changes during follow-up (FU). Our study aims to prospectively evaluate 232 subjects who underwent a 3-month-FU program after hospitalization for COVID-19 at the University Hospital of Pisa. The goals were to assess the usefulness of standardized LUS compared with the gold standard chest computed tomography (CT) to evaluate aeration changes and to verify LUS and CT agreement at FU. Patients underwent in the same day a standardized 16-areas LUS and high-resolution chest CT reported by expert radiologists, assigning interpretative codes. Based on observations distribution, LUS score cut-offs of 3 and 7 were selected, corresponding to the 50th and 75th percentile, respectively. Patients with LUS scores above both these thresholds were older and with longer hospital stay. Patients with a LUS score ≥3 had more comorbidities. LUS and chest CT showed a high agreement in identifying residual pathological findings, using both cut-off scores of 3 (OR 14,7; CL 3,6-64,5, Sensitivity 91%, Specificity 49%) and 7 (OR 5,8; CL 2,3-14,3, Sensitivity 65%, Specificity 79%). Our data suggest that LUS is very sensitive in identifying pathological findings at FU after a hospitalization for COVID-19 pneumonia, compared to CT. Given its low cost and safety, LUS could replace CT in selected cases, such as in contexts with limited resources or it could be used as a gate-keeper examination before more advanced techniques.

The value of lung ultrasound in COVID-19 pneumonia, verified by high resolution computed tomography assessed by artificial intelligence

BACKGROUND

Lung ultrasound (LUS) is an increasingly popular imaging method in clinical practice. It became particularly important during the COVID-19 pandemic due to its mobility and ease of use compared to high-resolution computed tomography (HRCT). The objective of this study was to assess the value of LUS in quantifying the degree of lung involvement and in discrimination of lesion types in the course of COVID-19 pneumonia as compared to HRCT analyzed by the artificial intelligence (AI).

METHODS

This was a prospective observational study including adult patients hospitalized due to COVID-19 in whom initial HRCT and LUS were performed with an interval < 72 h. HRCT assessment was performed automatically by AI. We evaluated the correlations between the inflammation volume assessed both in LUS and HRCT, between LUS results and the HRCT structure of inflammation, and between LUS and the laboratory markers of inflammation. Additionally we compared the LUS results in subgroups depending on the respiratory failure throughout the hospitalization.

RESULTS

Study group comprised 65 patients, median 63 years old. For both lungs, the median LUS score was 19 (IQR-interquartile range 11-24) and the median CT score was 22 (IQR 16-26). Strong correlations were found between LUS and CT scores (for both lungs r = 0.75), and between LUS score and percentage inflammation volume (PIV) (r = 0.69). The correlations remained significant, if weakened, for individual lung lobes. The correlations between LUS score and the value of the percentage consolidation volume (PCV) divided by percentage ground glass volume (PGV), were weak or not significant. We found significant correlation between LUS score and C-reactive protein (r = 0.55), and between LUS score and interleukin 6 (r = 0.39). LUS score was significantly higher in subgroups with more severe respiratory failure.

CONCLUSIONS

LUS can be regarded as an accurate method to evaluate the extent of COVID-19 pneumonia and as a promising tool to estimate its clinical severity. Evaluation of LUS in the assessment of the structure of inflammation, requires further studies in the course of the disease.

TRIAL REGISTRATION

The study has been preregistered 13 Aug 2020 on clinicaltrials.gov with the number NCT04513210.

Echocardiography and Lung Ultrasound in Long COVID and Post-COVID Syndrome, a Review Document of the Austrian Society of Pneumology and the Austrian Society of Ultrasound in Medicine

Lung ultrasound has the potential to enable standardized follow-up without radiation exposure and with lower associated costs in comparison to CT scans. It is a valuable tool to follow up on patients after a COVID-19 infection and evaluate if there is pulmonary fibrosis developing. Echocardiography, including strain imaging, is a proven tool to assess various causes of dyspnea and adds valuable information in the context of long COVID care. Including two-dimensional (2D) strain imaging, a better comprehension of myocardial damage in post-COVID syndrome can be made. Especially 2D strain imaging (left and the right ventricular strain) can provide information about prognosis.

One-Year Follow-Up Lung Ultrasound of Post-COVID Syndrome-A Pilot Study

(1) Background: Millions of people worldwide were infected with COVID-19. After the acute phase of the disease, many suffer from prolonged symptoms, the post-COVID syndrome, especially the phenotype with lung residuals. Many open questions regarding lung ultrasound (LUS) have to be answered. One essential question is the means for optimal following-up of patients with post-COVID-19 residuals with LUS; (2) Methods: A retrospective data analysis of patients after acute COVID-19 infection diagnosed with post-COVID syndrome in the state hospital of Steyr and the rehabilitation center of Hochegg was performed. LUS examinations following a 12-zone scanning protocol were performed, and the LUS score quantified comet tail artifacts. A total of 16 patients were evaluated twice with LUS from May 2020 until June 2021. (3) Results: All patients’ reverberation artifacts were reduced over time. The initial LUS score of 17.75 (SD 4.84) points was decreased over the duration of the second rehabilitation to 8,2 (SD 5.94). The difference in the Wilcoxon test was significant (p < 0.001); (4) Conclusions: Lung ultrasound was a valuable tool in the follow-up of post-COVID-syndrome with lung residuals in the first wave of COVID-19. A reduction in reverberation artifacts was demonstrated. Further studies about the clinical significance have to follow.

Comparative analysis of chest radiography and lung ultrasound to predict intra-hospital prognosis of patients admitted for acute SARS-CoV-2 pneumonia (COVID-19)

Background

Point of care lung ultrasound (POCUS) has been recently used to assess prognosis in COVID-19 patients. However, there are no data comparing POCUS and chest-X ray, a technique widely used.

Patients and methods

Retrospective analysis in stable COVID-19 patients. Schalekamp radiological lung scale and LUZ-Score ultrasound scale were compared. Primary end-point was in-hospital death and/or need for Intensive Care Unit admission.

Results

A total of 138 patients were included. Median Schalekamp scale was 2 (2) and median LUZ-Score scale was 21 (10). No significant correlation was observed between both techniques. Patients with a LUZ-Score ≥ 21 points at admission had worse lung function and higher concentrations of LDH, CRP and Interleuquine-6. Schalekamp scale failed to identify patients at a higher risk at admission for the primary end-point. Addition of POCUS to a previous clinical model, improved risk prediction (AUC 0.805 [95% CI: 0.662-0.948]; P = <0.001).

Conclusions

Chest X-ray and POCUS showed no correlation at admission in this analysis. Only POCUS identified a group of patients with greater clinical and analytical involvement. POCUS improved, previous clinical model, while chest X-ray did not add relevant predictive information for the primary endpoint.

Patient Self-Performed Point-of-Care Ultrasound: Using Communication Technologies to Empower Patient Self-Care

Point-of-Care ultrasound (POCUS) is an invaluable tool permitting the understanding of critical physiologic and anatomic details wherever and whenever a patient has a medical need. Thus the application of POCUS has dramatically expanded beyond hospitals to become a portable user-friendly technology in a variety of prehospital settings. Traditional thinking holds that a trained user is required to obtain images, greatly handicapping the scale of potential improvements in individual health assessments. However, as the interpretation of ultrasound images can be accomplished remotely by experts, the paradigm wherein experts guide novices to obtain meaningful images that facilitate remote care is being embraced worldwide. The ultimate extension of this concept is for experts to guide patients to image themselves, enabling secondary disease prevention, home-focused care, and self-empowerment of the individual to manage their own health. This paradigm of remotely telementored self-performed ultrasound (RTMSPUS) was first described for supporting health care on the International Space Station. The TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group has been investigating the utility of this paradigm for terrestrial use. The technique has particular attractiveness in enabling surveillance of lung health during pandemic scenarios. However, the paradigm has tremendous potential to empower and support nearly any medical question poised in a conscious individual with internet connectivity able to follow the directions of a remote expert. Further studies and development are recommended in all areas of acute and chronic health care.

Reliability and clinical correlations of semi-quantitative lung ultrasound on BLUE points in COVID-19 mechanically ventilated patients: The 'BLUE-LUSS'-A feasibility clinical study

INTRODUCTION

Bedside lung ultrasound has gained a key role in each segment of the treatment chain during the COVID-19 pandemic. During the diagnostic assessment of the critically ill patients in ICUs, it is highly important to maximize the amount and quality of gathered information while minimizing unnecessary interventions (e.g. moving/rotating the patient). Another major factor is to reduce the risk of infection and the workload of the staff.

OBJECTIVES

To serve these significant issues we constructed a feasibility study, in which we used a single-operator technique without moving the patient, only assessing the easily achievable lung regions at conventional BLUE points. We hypothesized that calculating this 'BLUE lung ultrasound score' (BLUE-LUSS) is a reasonable clinical tool. Furthermore, we used both longitudinal and transverse scans to measure their reliability and assessed the interobserver variability as well.

METHODS

University Intensive Care Unit based, single-center, prospective, observational study was performed on 24 consecutive SARS-CoV2 RT-PCR positive, mechanically ventilated critically ill patients. Altogether 400 loops were recorded, rated and assessed off-line by 4 independent intensive care specialists (each 7+ years of LUS experience).

RESULTS

Intraclass correlation values indicated good reliability for transversal and longitudinal qLUSS scores, while we detected excellent interrater agreement of both cLUSS calculation methods. All of our LUS scores correlated inversely and significantly to the P/F values. Best correlation was achieved in the case of longitudinal qLUSS (r = -0.55, p = 0.0119).

CONCLUSION

Summarized score of BLUE-LUSS can be an important, easy-to-perform adjunct tool for assessing and quantifying lung pathology in critically ill ventilated patients at bedside, especially for the P/F ratio. The best agreement for the P/F ratio can be achieved with the longitudinal scans. Regarding these findings, assessing BLUE-points can be extended with the BLUE-LUSS for daily routine using both transverse and longitudinal views.

A direct comparison between five lung-US and chest-CT-scans in a patient infected by SARS-CoV-2

The gold standard for SARS-CoV-2 pneumonia diagnosis is chest Computed Tomography (CT), but Lung Ultrasound (LUS) is also useful in differential diagnosis and in-hospital monitoring of patients with infection by new Coronavirus 2019 disease (COVID- 19). We present a case of a young man who was infected with SARS-CoV-2 pneumoniae and underwent five steps of chest imaging, including LUS aeration scorings and chest CT scans. Each decrease or increase in LUS scoring could accurately predict CT scan changes.

Optical Monitoring of Breathing Patterns and Tissue Oxygenation: A Potential Application in COVID-19 Screening and Monitoring

The worldwide outbreak of the novel Coronavirus (COVID-19) has highlighted the need for a screening and monitoring system for infectious respiratory diseases in the acute and chronic phase. The purpose of this study was to examine the feasibility of using a wearable near-infrared spectroscopy (NIRS) sensor to collect respiratory signals and distinguish between normal and simulated pathological breathing. Twenty-one healthy adults participated in an experiment that examined five separate breathing conditions. Respiratory signals were collected with a continuous-wave NIRS sensor (PortaLite, Artinis Medical Systems) affixed over the sternal manubrium. Following a three-minute baseline, participants began five minutes of imposed difficult breathing using a respiratory trainer. After a five minute recovery period, participants began five minutes of imposed rapid and shallow breathing. The study concluded with five additional minutes of regular breathing. NIRS signals were analyzed using a machine learning model to distinguish between normal and simulated pathological breathing. Three features: breathing interval, breathing depth, and O₂Hb signal amplitude were extracted from the NIRS data and, when used together, resulted in a weighted average accuracy of 0.87. This study demonstrated that a wearable NIRS sensor can monitor respiratory patterns continuously and non-invasively and we identified three respiratory features that can distinguish between normal and simulated pathological breathing.

Cardiovascular disease and COVID-19, a deadly combination: A review about direct and indirect impact of a pandemic

Coronavirus disease 2019 (COVID-19) is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular manifestations. The cardiovascular manifestations reported comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. There is also an indirect impact of the pandemic on the management of cardiovascular care that has been shown clearly in multiple publications. In this review, we summarize the deadly relation of COVID-19 with cardiovascular events and the wider impact on several cardiovascular care areas by the pandemic situation

Association Between Lung Ultrasound Patterns and Pneumonia

ABSTRACT

Pneumonia is a common respiratory infection that affects the lungs. Lung ultrasound (LUS) is a portable, cost-effective imaging method, which is free of ionizing radiation and has been shown to be useful for evaluating pneumonia. The aim of this retrospective analytical study was to determine the association between lung ultrasound patterns and pneumonia. For the purpose of performing the required analysis, LUS patterns including consolidations, pleural line irregularities, A lines and B lines from 90 subjects (44 patients with confirmed pneumonia and 46 controls) were retrieved from a published open-access data set, which was reviewed and approved by medical experts. A χ 2 test was used for the comparison of categorical variables to determine the association between each LUS pattern and the presence of pneumonia. There is a significant association between LUS consolidation and the presence of pneumonia ( P < 0.0001). Lung ultrasound A lines are significantly associated with the absence of pneumonia ( P < 0.0001), whereas there are no associations between B lines or pleural line irregularities with pneumonia. Lung ultrasound consolidation is found to be associated with the presence of pneumonia. A lines are associated with healthy lungs, and there is no association of B lines and pleural irregularities with the presence of pneumonia. Further studies investigating LUS patterns with clinical information and symptoms of patients with pneumonia are required.

Current Advances in Lung Ultrasound in COVID-19 Critically Ill Patients: A Narrative Review

Lung ultrasound (LUS) has a relatively recent democratization due to the better availability and training of physicians, especially in intensive care units. LUS is a relatively cheap and easy-to-learn and -use bedside technique that evaluates pulmonary morphology when using simple algorithms. During the global COVID-19 pandemic, LUS was found to be an accurate tool to quickly diagnose, triage and monitor patients with COVID-19 pneumonia. This paper aims to provide a comprehensive review of LUS use during the COVID-19 pandemic. The first section of our work defines the technique, the practical approach and the semeiotic signs of LUS examination. The second section exposed the COVID-19 pattern in LUS examination and the difference between the differential diagnosis patterns and the well-correlation found with computer tomography scan findings. In the third section, we described the utility of LUS in the management of COVID-19 patients, allowing an early diagnosis and triage in the emergency department, as the monitoring of pneumonia course (pneumonia progression, alveolar recruitment, mechanical ventilation weaning) and detection of secondary complications (pneumothorax, superinfection). Moreover, we describe the usefulness of LUS as a marker of the prognosis of COVID-19 pneumonia in the fourth section. Finally, the 5th part is focused on describing the interest of the LUS, as a non-ionized technique, in the management of pregnant COVID-19 women.

Design and calibration of a Tonpilz transducer for low frequency medical ultrasound tomography

The design and performance of a transducer for low frequency ultrasound tomography is presented, motivated by recent research demonstrating that acoustic waves transmitting at frequencies between 10 kHz and 750 kHz penetrate the lungs and may be useful for thoracic imaging. An adaptation of the traditional Tonpilz design was developed, vibrational amplitude and electrical impedance were measured, and an optimal frequency was determined. The design is found to meet the desired mechanical, electrical, and safety specifications. Thus, it was considered a promising option for the target application of pulmonary imaging with ultrasound computed tomography between 50 and 200 kHz; highest efficiency achieved around 125 kHz and 156 kHz, and beam divergence of 40°.

The Value of Lung Ultrasound to Detect the Early Pleural and Pulmonary Pathologies in Nonhospitalized COVID-19-Suspected Cases in a Population With a Low Prevalence of COVID-19 Infection: A Prospective Study in 297 Subjects

OBJECTIVES

This prospective study aimed to evaluate the value of B-mode lung ultrasound (LUS) for the early diagnosis of coronavirus disease 2019 (COVID-19) infection in nonhospitalized COVID-19 suspected cases in a population with a low prevalence of disease.

METHODS

From April 2020 to June 2020, in an ambulatory testing center for COVID-19-suspected cases, 297 subjects were examined by LUS before a nasopharyngeal swab was taken for a reverse transcription polymerase chain reaction (RT-PCR) test. The following LUS findings were defined as pathological ultrasound findings and were analyzed: the presence of 1) pleural effusion, 2) B-lines, 3) fragmented visceral pleura, 4) consolidation, and 5) air bronchogram in the consolidation. The LUS findings were compared with the RT-PCR test results.

RESULTS

The result of the RT-PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive in 11 and negative in 286 subjects, and the prevalence of COVID-19 infection in the study participants was 3.7%. On LUS, a pathological finding could be detected in 56/297 (18.9%) study participants. The LUS revealed a sensitivity of 27.3%, a specificity of 81.5%, a positive predictive value of 5.4%, a negative predictive value of 96.7%, and a diagnostic accuracy of 79.9% for the identification of COVID-19 infection.

CONCLUSIONS

For the identification of COVID-19 infection, LUS is highly sensitive to the patient spectrum and to the prevalence of the disease. Due to the low diagnostic performance in nonhospitalized COVID-19 cases in low-prevalence areas, LUS cannot be considered to be an adequate method for making a diagnosis in this group.

Lung Ultrasound in Patients With SARS-COV-2 Pneumonia: Correlations With Chest Computed Tomography, Respiratory Impairment, and Inflammatory Cascade

OBJECTIVES

Lung ultrasound (LUS) might be comparable to chest computed tomography (CT) in detecting parenchymal and pleural pathology, and in monitoring interstitial lung disease. We aimed to describe LUS characteristics of patients during the hospitalization for COVID-19 pneumonia, and to compare the extent of lung involvement at LUS and chest-CT with inflammatory response and the severity of respiration impairment.

METHODS

During a 2-week period, we performed LUS and chest CT in hospitalized patients affected by COVID-19 pneumonia. Dosages of high sensitivity C-reactive protein (HS-CRP), d-dimer, and interleukin-6 (IL-6) were also obtained. The index of lung function (P/F ratio) was calculated from the blood gas test. LUS and CT scoring were assessed using previously validated scores.

RESULTS

Twenty-six consecutive patients (3 women) underwent LUS 34 ± 14 days from the early symptoms. Among them, 21 underwent CT on the same day of LUS. A fair association was found between LUS and CT scores (R = 0.45, P = .049), which became stronger if the B-lines score on LUS was not considered (R = 0.57, P = .024). LUS B-lines score correlated with IL-6 levels (R = 0.75, P = .011), and the number of involved lung segments detected by LUS correlated with the P/F ratio (R = 0.60, P = .019) but not with HS-CRP and d-Dimer levels. No correlations were found between CT scores and inflammations markers or P/F.

CONCLUSION

In patients with COVID-19 pneumonia, LUS was correlated with both the extent of the inflammatory response and the P/F ratio.

What is the Hidden Biological Mechanism Underlying the Possible SARS-CoV-2 Vertical Transmission? A Mini Review

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2) represents an emerging infection that is spreading around the world. Among susceptible patients, pregnant women are more likely to develop serious complications and negative obstetric outcomes. Vertical transmission constitutes a debating issue which has not been completely understood. This review aims at describing the currently available evidence on SARS-CoV2 vertical transmission. We carried out a computerized literature search in the Cochrane Library, PubMed, Scopus and Web of Science, selecting the most relevant studies on vertical transmission from the outbreak onset until February 2022. The analysis of the available literature identifies the presence of SARS-CoV2 genome in different biological specimens, confirming the hypothesis that a transplacental infection can occur. In spite of the high number of infected people around the world, mother-to-child infections have been infrequently reported but it can be observed under certain biologic conditions. A deep knowledge of the underlying mechanisms of SARS-CoV2 vertical transmission is of paramount importance for planning an adequate management for the affected mothers and newborns.

Pulmonary Function and Psychological Burden Three Months after COVID-19: Proposal of a Comprehensive Multidimensional Assessment Protocol

Persisting limitations in respiratory function and gas exchange, cognitive impairment, and mental health deterioration have been observed weeks and months after acute SARS-CoV-2 (COVID-19). The present study aims at assessing the impairment at three-months in patients who successfully recovered from acute COVID-19. We collected data from May to July 2020. Patients underwent a multidimensional extensive assessment including pulmonary function test, psychological tests, thoracic echo scan, and functional exercise capacity. A total of 21 patients (M:13; Age 57.05 ± 11.02) completed the global assessment. A considerable proportion of patients showed symptoms of post-traumatic stress disorder (28.6%), moderate depressive symptoms (9.5%), and clinical insomnia (9.5%); 14.3% of patients exhibited moderate anxiety. A total of eleven patients (52.4%) showed impaired respiratory gas exchange capacity (P-DLCO, DLCO ≤ 79% pred). Compared to patients with normal gas exchange, the P-DLCO subgroup perceived a significant worsening in quality of life (QoL) after COVID-19 (p = 0.024), higher fatigue (p = 0.005), and higher impact of lung disease (p = 0.013). In P-DLCO subgroup, higher echo score was positively associated with hospitalization length of stay (p = 0.047), depressive symptoms (p = 0.042), fatigue (p = 0.035), impairment in mental health (p = 0.035), and impact of lung disease in health status (p = 0.020). Pulmonary function and echo scan lung changes were associated to worsened QoL, fatigue, and psychological distress symptoms.

Review of Machine Learning in Lung Ultrasound in COVID-19 Pandemic

Ultrasound imaging of the lung has played an important role in managing patients with COVID-19–associated pneumonia and acute respiratory distress syndrome (ARDS). During the COVID-19 pandemic, lung ultrasound (LUS) or point-of-care ultrasound (POCUS) has been a popular diagnostic tool due to its unique imaging capability and logistical advantages over chest X-ray and CT. Pneumonia/ARDS is associated with the sonographic appearances of pleural line irregularities and B-line artefacts, which are caused by interstitial thickening and inflammation, and increase in number with severity. Artificial intelligence (AI), particularly machine learning, is increasingly used as a critical tool that assists clinicians in LUS image reading and COVID-19 decision making. We conducted a systematic review from academic databases (PubMed and Google Scholar) and preprints on arXiv or TechRxiv of the state-of-the-art machine learning technologies for LUS images in COVID-19 diagnosis. Openly accessible LUS datasets are listed. Various machine learning architectures have been employed to evaluate LUS and showed high performance. This paper will summarize the current development of AI for COVID-19 management and the outlook for emerging trends of combining AI-based LUS with robotics, telehealth, and other techniques.

Análisis comparativo de la radiografía de tórax y la ecografía pulmonar para predecir el pronóstico intra-hospitalario de pacientes ingresados por neumonía secundaria a SARS-COV2 (COVID-19)

Antecedentes

La ecografía torácica es una técnica novedosa para estratificar el riesgo de los pacientes COVID-19. Sin embargo, no existen datos que comparen dicha técnica con la radiografía de tórax, una técnica ampliamente utilizada en esta enfermedad.

Pacientes y métodos

Análisis retrospectivo en pacientes estables COVID-19. Se compararon la escala de daño pulmonar radiológica de Schalekamp y ecográfica de LUZ-Score. El objetivo primario fue la muerte intrahospitalaria o la necesidad de ingreso en la UCI para tratamiento con ventilación mecánica.

Resultados

Se reclutaron 138 pacientes. La mediana de la escala de Schalekamp fue de 2 (2) y la del LUZ-Score de 21 (10). No se objetivó una correlación significativa entre ambas escalas. Los pacientes con un LUZ-Score ≥ 21 puntos al ingreso presentaron peor función pulmonar y mayores concentraciones de LDH, PCR e interleucina-6. La escala radiológica de Schalekamp no logró identificar a una población de mayor riesgo. Únicamente la adición de la ecografía pulmonar a un modelo de valoración clínica mejoró de manera significativa el área bajo la curva para el objetivo primario (ABC 0,805 [IC 95%: 0,662-0,948]; p ≤ 0,001).

Conclusiones

No se objetivó una correlación entre la afectación radiológica y la ecográfica. Únicamente la ecografía pulmonar identificó un subgrupo de pacientes con una mayor afectación clínico-analítica. La ecografía pulmonar mejoró el modelo de predicción clínico, mientras que la radiografía de tórax no añadió información relevante.

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.

A New Scoring Model to Diagnose COVID-19 Using Lung Ultrasound in the Emergency Department

Background

Several studies have reported the predictors of the prognosis in COVID-19 patients; however, smoking, X-ray findings of pulmonary congestion, and A-profile and areas of consolidation in LUS are independent predictors for COVID-19 infection. The new score had a sensitivity of 93.8% and a specificity of 58% for the prediction of COVID-19. Mortality in COVID-19 patients is significantly correlated with age, fever duration, cardiac history, and B-profile and areas of consolidation in LUS. However, it is negatively correlated with initial O2 saturation and ejection fraction. This study aimed to design a new scoring model to diagnose COVID-19 using bedside lung ultrasound (LUS) in the emergency department (ED).

Results

Eighty-two patients were recruited. Fifty patients (61%) were negative for COVID-19, and 32 (39%) were positive. Sixty-four patients (78%) recovered while 18 patients (22%) died. COVID-19 patients had more AB-profile and more areas of consolidation than the non-COVID-19 group (p<0.001). Smoking, congestion in X-ray, A-profile, and abnormal A line in LUS are independent predictors for COVID-19 infection. The score had a sensitivity of 93.8% and a specificity of 58% for the prediction of COVID-19. Mortality in COVID-19 patients is significantly correlated with age, fever duration, cardiac history, and B-profile and areas of consolidation in LUS. However, it is negatively correlated with initial O2 saturation and ejection fraction.

Conclusions

In conclusion, the application of our new score can stratify patients presented to ED with suspected COVID-19 pneumonia, considering that it is a good negative test. Moreover, this score may have a good impact on the safety of medical personnel.

Trial registration

ClinicalTrials.gov Identifier: NCT05077202. Registered October 14, 2021 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05077202

Lung Ultrasonography for COVID-19 Patients in Out of Hospital Settings

PURPOSE

The portability of a hand-held ultrasound allows the health care worker to conduct lung ultrasound in out-of-hospital setting. It is used as a tool to conduct staging and triaging for COVID-19 patients. This study evaluated the utilization of lung ultrasound in an out-of-hospital setting versus chest x-rays in detecting and staging of COVID-19 patients with pneumonia.

METHODS

The study was conducted among COVID-19 subjects at an out-of-hospital setting whereby lung ultrasound was done and subsequently chest x-rays were taken after being admitted to the health care facilities. Lung ultrasound findings were reviewed by emergency physicians, while the chest x-rays were reviewed by radiologists. Radiologists were blinded by the patients' lung ultrasound findings and clinical conditions. The analysis of the agreement between the lung ultrasound findings and chest x-rays was conducted.

RESULTS

A total of 261 subjects were recruited. LUS detected pulmonary infiltrative changes in more stage 3 COVID-19 subjects in comparison to chest x-rays. Multiple B-lines were the predominant findings at the right lower anterior, posterior and lateral zones. Interstitial consolidations and ground glass opacities were the predominant descriptive findings in chest x-rays. However, there was no agreement between lung ultrasound and chest x-ray findings in detecting COVID-19 pneumonia as the Cohen's Kappa coefficient was 0.08 (95% CI 0.06-0.22, p = 0.16).

CONCLUSION

The diagnostic imaging and staging of COVID-19 patients using lung ultrasound in out-of-hospital settings showed LUS detected lung pleural disease more often than CXR for stage 3 COVID-19 patients.

COVID-19 findings in chest computed tomography

OBJECTIVE

The aim of this study was to describe chest computed tomography image findings in patients with COVID-19.

METHODS

The chest computed tomography scans of 453 hospitalized patients with confirmed COVID-19 were collected at two tertiary care Brazilian hospitals. Demographics and clinical data were extracted from the electronic record medical system.

RESULTS

The main chest computed tomography findings were ground-glass opacities (92.5%), consolidation (79.2%), crazy-paving pattern (23.9%), parenchymal bands (50%), septal thickening (43.5%), and inverted halo sign (3.5%). Of the 453 hospitalized patients, 136 (30%) died. In this group, ground-glass opacities (94.1%), consolidation (89.7%), septal thickening (58.1%), crazy-paving pattern (52.2%), and parenchymal bands (39.7%) were the most common imaging findings.

CONCLUSIONS

In a dynamic disease with a broad clinical spectrum such as COVID-19, radiologists can cooperate in a better patient management. On wisely indicated chest computed tomography scans, the fast identification of poor prognosis findings could advise patient management through hospital care facilities and clinical team decisions.

Empowering the willing: the feasibility of tele-mentored self-performed pleural ultrasound assessment for the surveillance of lung health

Background

SARS-CoV-2 infection, manifesting as COVID-19 pneumonia, constitutes a global pandemic that is disrupting health-care systems. Most patients who are infected are asymptomatic/pauci-symptomatic can safely self-isolate at home. However, even previously healthy individuals can deteriorate rapidly with life-threatening respiratory failure characterized by disproportionate hypoxemic failure compared to symptoms. Ultrasound findings have been proposed as an early indicator of progression to severe disease. Furthermore, ultrasound is a safe imaging modality that can be performed by novice users remotely guided by experts. We thus examined the feasibility of utilizing common household informatic-technologies to facilitate self-performed lung ultrasound.

Methods

A lung ultrasound expert remotely mentored and guided participants to image their own chests with a hand-held ultrasound transducer. The results were evaluated in real time by the mentor, and independently scored by three independent experts [planned a priori]. The primary outcomes were feasibility in obtaining good-quality interpretable images from each anatomic location recommended for COVID-19 diagnosis.

Results

Twenty-seven adults volunteered. All could be guided to obtain images of the pleura of the 8 anterior and lateral lung zones (216/216 attempts). These images were rated as interpretable by the 3 experts in 99.8% (647/648) of reviews. Fully imaging one’s posterior region was harder; only 108/162 (66%) of image acquisitions was possible. Of these, 99.3% of images were interpretable in blinded evaluations. However, 52/54 (96%) of participants could image their lower posterior lung bases, where COVID-19 is most common, with 99.3% rated as interpretable.

Conclusions

Ultrasound-novice adults at risk for COVID-19 deterioration can be successfully mentored using freely available software and low-cost ultrasound devices to provide meaningful lung ultrasound surveillance of themselves that could potentially stratify asymptomatic/paucisymptomatic patients with early risk factors for serious disease. Further studies examining practical logistics should be conducted.

Trial Registration: ID ISRCTN/77929274 on 07/03/2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-021-00250-6.

SARS-CoV-2 management in Emergency Department: risk stratification and care setting identification proposal based on first pandemic wave in Pisa University Hospital

SARS-CoV-2 management in Emergency Department: risk stratification and care setting identification proposal based on first pandemic wave in Pisa University Hospital Background: COVID-19 patients require early treatment and admission to an appropriate care setting, considering possible rapid and unpredictable to Severe Acute Respiratory Syndrome. Objective: A flow-chart was developed by a multidisciplinary team of Emergency Department (ED) clinicians, intensivists and radiologists aiming to provide tools for disease severity stratification, appropriate ventilation strategy and hospitalization setting identification. Methods: We conducted a retrospective application of our model on 313 hospitalized patients at Pisa University Hospital including 222 patients admitted to ED for respiratory failure between March and April 2020. Risk stratification score was based on respiratory and chest imaging parameters, while management strategy on comorbidities and age.  Results: Age, comorbidities, clinical respiratory and arterial blood gas parameters, semi-quantitative chest computed tomography score were significant predictors of mortality (p<0,05). Mortality rate was higher in patients treated in intensive care units (26,5%) and undergoing endo-tracheal intubation (32,7%), compared to medical area (21,3%). We verified a good concordance (81,7%) between the proposed model and actual evaluation in ED. Outcomes analysis of subgroups of patients homogeneous for baseline features allowed to verify safety of our model: in non-elderly and/or non-comorbid patients (15% mortality) our scheme overestimates the risk in 30% of cases, but it suggests non-intensive management in patients with reduced functional reserve, elderly and with comorbidities (50% mortality). Conclusion: Correct management of respiratory failure COVID-19 patients is crucial in this unexpected pandemic. Our flow-chart, despite retrospectively application in small sample, could represents a valid and safe proposal for evaluation in ED.

The Impact of Different Lung Ultrasound Protocols in the Assessment of Lung Lesions in COVID-19 Patients: Is There an Ideal Lung Ultrasound Protocol?

Background

In the past months, several lung ultrasonography (LUS) protocols have been proposed, mainly on previously validated schemes independent of coronavirus disease 2019 (COVID-19).

Objectives

The main purpose of this study was to determine the impact and accuracy of different LUS protocols proposed in COVID-19.

Methods

Patients were evaluated with a standard sequence of LUS scans in 72 intercostal spaces along 14 anatomic lines in the chest. A scoring system of LUS findings was reported and then analyzed separately according to each proposed LUS protocol zones. This score was then correlated to a validated Pulmonary Inflammation Index (PII) on chest Computed Tomography (CT).

Results

Thirty-two patients were enrolled. The most frequent pattern was ground-glass opacities in the chest X-ray (53.1%), chest CT (59.1%) and subpleural or lobar consolidations (40.8%) in the posteroinferior areas (p < 0.001) on LUS. The Interclass Correlation Coefficient (ICC) was significantly correlated with almost every protocol analyzed except the 8-zone (p = 0.119) and the 10-zone protocol that only included one posterior point (p = 0.052). The highest ICC was obtained with a 12-zone protocol (ICC 0.500; p = 0.027) and decreased as more points were included.

Conclusions

In conclusion, our study results suggest that performing an ultrasound protocol with 12-zone scanning, including the superior and inferior areas of the anterior, lateral and posterior regions of the chest was consistent with higher ICC and higher degree of concordance with CT. We emphasize the need of a more standardization technique to further implement and develop this imaging modality in COVID-19.

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.

Correlation Between Low-Dose Chest Computed Tomography and RT-PCR Results for the Diagnosis of COVID-19: A Report of 27,824 Cases in Tehran, Iran

RATIONALE AND OBJECTIVES

Real-time polymerase chain reaction (RT-PCR) remains the gold standard for confirmation of Coronavirus Disease 2019 (COVID-19) despite having many disadvantages. Here, we investigated the diagnostic performance of chest computed tomography (CT) as an alternative to RT-PCR in patients with clinical suspicion of COVID-19 infection.

METHODS

In this descriptive cross-sectional study, 27,824 patients with clinical suspicion of COVID-19 infection who underwent unenhanced low-dose chest CT from 20 February, 2020 to 21 May, 2020 were evaluated. Patients were recruited from seven specifically designated hospitals for patients with COVID-19 infection affiliated to Shahid Beheshti University of Medical Sciences. In each hospital, images were interpreted by two independent radiologists. CT findings were considered as positive/negative for COVID-19 infection based on RSNA diagnostic criteria. Then, the correlation between the number of daily positive chest CT scans and number of daily PCR-confirmed cases and COVID-19-related deaths in Tehran province during this three-month period was assessed. The trends of admission rate and patients with positive CT scans were also evaluated.

RESULTS

A strong positive correlation between the numbers of daily positive CT scans and daily PCR-confirmed COVID-19 cases (r = 0.913, p < 0.001) was observed. Furthermore, in hospitals located in regions with a lower socioeconomic status, the admission rate and number of positive cases within this three-month period was higher as compared to other hospitals.

CONCLUSION

Low-dose chest CT is a safe, rapid and reliable alternative to RT-PCR for the diagnosis of COVID-19 in high-prevalence regions. In addition, our study provides further evidence for considering patients' socioeconomic status as an important risk factor for COVID-19.

Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making

In the last years, new trends on patient diagnosis for admission in cardiac intensive care unit (CICU) have been observed, shifting from acute myocardial infarction or acute heart failure to non-cardiac diseases such as sepsis, acute respiratory failure or acute kidney injury. Moreover, thanks to the advances in scientific knowledge and higher availability, there has been increasing use of positive pressure mechanical ventilation which has its implications on the heart. Therefore, there is a growing need for Cardiac intensivists to quickly, noninvasively and repeatedly evaluate various hemodynamic conditions and the response to therapy. Transthoracic critical care echocardiography (CCE) currently represents an essential tool in CICU, as it is used to evaluate biventricular function and complications following acute coronary syndromes, identify the mechanisms of circulatory failure, acute valvular pathologies, tailoring and titrating intravenous treatment or mechanical circulatory support. This could be completed with trans-esophageal echocardiography (TOE), advanced echocardiography and lung ultrasound to provide a thorough evaluation and monitoring of CICU patients. However, CCE could sometimes be challenging as the acquisition of good-quality images is limited by mechanical ventilation, suboptimal patient position or recent surgery with drains on the chest. Moreover, there are some technical caveats that one should bear in mind while performing CCE in order to optimize its use and avoid misleading findings. The aim of this review is to highlight the key role of CCE, providing an updated overview of its main applications and possible pitfalls in order to facilitate its use in CICU for clinical decision-making.

Usefulness of lung ultrasound for selecting asymptomatic older patients with COVID 19 pneumonia

Clinical and prognostic differences between symptomatic and asymptomatic older patients with COVID-19 are of great interest since frail patients often show atypical presentation of illness. Lung Ultrasound (LUS) has been proven to be a reliable tool for detecting early-phase COVID-19 pneumonic alterations. The current prospective bicentric study aimed to compare LUS score and 3-month overall mortality between asymptomatic and symptomatic older patients with COVID-19, according to frailty status. Patients were stratified according to LUS score tertiles and Clinical Frailty Scale categories. Survival rate was assessed by telephone interviews 3 months after discharge. 64 symptomatic (24 women, aged 80.0 ± 10.8 years) and 46 asymptomatic (31 women, aged 84.3 ± 8.8 years) were consecutively enrolled. LUS score resulted an independent predictor of 3-month mortality [OR 2.27 (CI95% 1.09–4.8), p = 0.03], and the highest mortality rate was observed in symptomatic and asymptomatic pre-frail and frail patients (70.6% and 66.7%, respectively) with greater LUS abnormalities (3rd tertile). In conclusion, LUS identified an acute interstitial lung involvement in most of the older asymptomatic patients. Mortality rate progressively increased according to clinical frailty and LUS score degree, resulting a reliable prognostic tool in both symptomatic and asymptomatic patients.

Lung Ultrasound for Identification of Patients Requiring Invasive Mechanical Ventilation in COVID-19

OBJECTIVES

Indication for invasive mechanical ventilation in COVID-19 pneumonia has been a major challenge. This study aimed to evaluate if lung ultrasound (LUS) can assist identification of requirement of invasive mechanical ventilation in moderate to severe COVID-19 pneumonia.

MATERIALS AND METHODS

Between April 23 and November 12, 2020, hospitalized patients with moderate to severe COVID-19 (oxygen demand ≥4 L/min) were included consecutively. Lung ultrasound was performed daily until invasive mechanical ventilation (IMV-group) or spontaneous recovery (non-IMV-group). Clinical parameters and lung ultrasound findings were compared between groups, at intubation (IMV-group) and highest oxygen demand (non-IMV-group). A reference group with oxygen demand <4 L/min was examined at hospital admission.

RESULTS

Altogether 72 patients were included: 50 study patients (IMV-group, n = 23; non-IMV-group, n = 27) and 22 reference patients. LUS-score correlated to oxygen demand (SpO₂ /FiO₂ -ratio) (r = 0.728; p < .0001) and was higher in the IMV-group compared to the non-IMV-group (20.0 versus 18.0; p = .026). Based on receiver operating characteristic analysis, a LUS-score of 19.5 was identified as cut-off for requirement of invasive mechanical ventilation (area under the curve 0.68; sensitivity 56%, specificity 74%). In 6 patients, LUS identified critical coexisting conditions. Respiratory rate and oxygenation index ((SpO₂ /FiO₂ )/respiratory rate) ≥4.88 identified no requirement of invasive mechanical ventilation with a positive predictive value of 87% and negative predictive value of 100%.

CONCLUSIONS

LUS-score had only a moderate diagnostic value for requirement of invasive mechanical ventilation in moderate to severe COVID-19. However, LUS proved valuable as complement to respiratory parameters in guidance of disease severity and identifying critical coexisting conditions.

Point of care echocardiography and lung ultrasound in critically ill patients with COVID-19

Hundreds of millions got infected, and millions have died worldwide and still the number of cases is rising.

Chest radiographs and computed tomography (CT) are useful for imaging the lung but their use in infectious diseases is limited due to hygiene and availability.

Lung ultrasound has been shown to be useful in the context of the pandemic, providing clinicians with valuable insights and helping identify complications such as pleural effusion in heart failure or bacterial superinfections. Moreover, lung ultrasound is useful for identifying possible complications of procedures, in particular, pneumothorax.

Associations between coronavirus disease 2019 (COVID-19) and cardiac complications, such as acute myocardial infarction and myocarditis, have been reported. As such, point of care echocardiography as well as a comprehensive approach in later stages of the disease provide important information for optimally diagnosing and treating complications of COVID-19.

In our experience, lung ultrasound in combination with echocardiography, has a great impact on treatment decisions. In the acute state as well as in the follow-up setting after a severe or critical state of COVID-19, ultrasound can be of great impact to monitor the progression and regression of disease.

The year 2020 in the European Heart Journal-Cardiovascular Imaging: part II

The European Heart Journal-Cardiovascular Imaging was launched in 2012 and has during these years become one of the leading multimodality cardiovascular imaging journal. The journal is now established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal from 2020 will be highlighted in two reports. Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease. While Part I of the review has focused on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging.

Prediction Accuracy of Serial Lung Ultrasound in COVID-19 Hospitalized Patients (Pred-Echovid Study)

The value of serial lung ultrasound (LUS) in patients with COVID-19 is not well defined. In this multicenter prospective observational study, we aimed to assess the prognostic accuracy of serial LUS in patients admitted to hospital due to COVID-19. The serial LUS protocol included two examinations (0–48 h and 72–96 h after admission) using a 10-zones sequence, and a 0 to 5 severity score. Primary combined endpoint was death or the need for invasive mechanical ventilation. Calibration (Hosmer–Lemeshow test and calibration curves), and discrimination power (area under the ROC curve) of both ultrasound exams (SCORE1 and 2), and their difference (DIFFERENTIAL-SCORE) were performed. A total of 469 patients (54.2% women, median age 60 years) were included. The primary endpoint occurred in 51 patients (10.9%). Probability risk tertiles of SCORE1 and SCORE2 (0–11 points, 12–24 points, and ≥25 points) obtained a high calibration. SCORE-2 showed a higher discrimination power than SCORE-1 (AUC 0.72 (0.58–0.85) vs. 0.61 (0.52–0.7)). The DIFFERENTIAL-SCORE showed a higher discrimination power than SCORE-1 and SCORE-2 (AUC 0.78 (0.66–0.9)). An algorithm for clinical decision-making is proposed. Serial lung ultrasound performing two examinations during the first days of hospitalization is an accurate strategy for predicting clinical deterioration of patients with COVID-19.

The year 2020 in the European Heart Journal - Cardiovascular Imaging: part I

The European Heart Journal - Cardiovascular Imaging was launched in 2012 and has during these 9 years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as number 20 among all cardiovascular journals. Our journal is well established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal in 2020 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

A new standard scoring for interstitial pneumonia based on quantitative analysis of ultrasonographic data: A study on COVID-19 patients

OBJECTIVE

To assess the effectiveness of 3 novel lung ultrasound (LUS)-based parameters: Pneumonia Score and Lung Staging for pneumonia staging and COVID Index, indicating the probability of SARS-CoV-2 infection.

METHODS

Adult patients admitted to the emergency department with symptoms potentially related to pneumonia, healthy volunteers and clinical cases from online accessible databases were evaluated. The patients underwent a clinical-epidemiological questionnaire and a LUS acquisition, following a 14-zone protocol. For each zone, a Pneumonia score from 0 to 4 was assigned by the algorithm and by an expert operator (kept blind with respect to the algorithm results) on the basis of the identified imaging signs and the patient Lung Staging was derived as the highest observed score. The output of the operator was considered as the ground truth. The algorithm calculated also the COVID Index by combining the automatically identified LUS markers with the questionnaire answers and compared with the nasopharyngeal swab results.

RESULTS

Overall, 556 patients were analysed. A high agreement between the algorithm assignments and the expert operator evaluations was observed, both for Pneumonia Score and Lung Staging, with the latter having sensitivity and specificity over 92% both in the discrimination between healthy/sick patients and between sick patients with mild/severe pneumonia. Regarding the COVID Index, an area under the curve of 0.826 was observed for the classification of patients with/without SARS-CoV-2.

CONCLUSION

The proposed methodology allowed the identification and staging of patients suffering from pneumonia with high accuracy. Moreover, it provided the probability of being infected by SARS-CoV-2.

Late phase of COVID-19 pandemic in General Cardiology. A position paper of the ESC Council for Cardiology Practice

Cardiovascular (CV) engagement in coronavirus disease 2019 (COVID-19) is a huge determinant of prognosis during the acute phase of the disease. However, little is known about the potential chronic implications of the late phase of COVID-19 and about the appropriate approach to these patients. Heart failure, type 1 and type 2 myocardial infarction, arrhythmias, myocarditis, pulmonary fibrosis, and thrombosis have been shown to be related to severe acute respiratory syndrome coronavirus 2 infection, and a 'long COVID-19' illness has been recognized with fatigue, chest pain, and dyspnoea among the most frequent symptoms reported after discharge from hospital. This paper focuses on some open questions that cardiologists are going to face during the next months in a general cardiology outpatient clinic, in particular how to evaluate a 'post-COVID' patient during follow-up of CV complications of the acute phase and how to manage new CV symptoms that could be the consequence, at least in part, of heart/vessels and/or lung involvement of the previous virus infection. Present symptoms and signs, history of previous CV disease (both preceding COVID-19 and occurring during viral infection), and specific laboratory and imaging measurements during the acute phase may be of interest in focusing on how to approach the clinical evaluation of a post-COVID patient and how to integrate in our standard of care the new information on COVID-19, possibly in a multidisciplinary view. Dealing with the increased COVID-associated CV risk burden and becoming acquainted with potential new e-cardiology approaches aimed at integrating the cardiology practice are relevant new challenges brought by severe acute respiratory syndrome coronavirus 2 infection and its sequelae.

Management of COVID-19 Patients in the Emergency Department

COVID-19 is an emerging disease of global public health concern. As the pandemic overwhelmed emergency departments (EDs), a restructuring of emergency care delivery became necessary in many hospitals. Furthermore, with more than 2000 papers being published each week, keeping up with ever-changing information has proven to be difficult for emergency physicians. The aim of the present review is to provide emergency physician with a summary of the current literature regarding the management of COVID-19 patients in the emergency department.

Home-Based Physiological Monitoring of Patients with COVID-19

The COVID-19 pandemic has necessitated the rise of telehealth modalities to relieve the incredible stress the pandemic has placed on the healthcare system. This rise has seen the emergence of new software, applications, and hardware for home-based physiological monitoring, leading to the promise of innovative predictive and therapeutic practices. This article is a literature-based review of the most promising technologies and advances regarding home-based physiological monitoring of patients with COVID-19. We conclude that the applications currently on the market, while helping stem the flow of patients to the hospital during the pandemic, require additional evidence related to improvement in patient outcomes. However, new devices and technology are a promising and successful venture into home-based monitoring with clinical implications reaching far into the future.

Canadian Internal Medicine Ultrasound (CIMUS) Expert Consensus Statement on the Use of Lung Ultrasound for the Assessment of Medical Inpatients With Known or Suspected Coronavirus Disease 2019

OBJECTIVES

To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19).

METHODS

Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered.

RESULTS

Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus.

CONCLUSIONS

In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Lungensonographie bei COVID‑19

Die medizinische Versorgung von Patienten, die im Zusammenhang mit der pandemischen Coronaviruserkrankung 2019 („coronavirus disease 2019“, COVID-19) erkrankt sind, stellt für die staatlichen Gesundheitssysteme weltweit eine große Herausforderung dar. Das Virus mit dem Namen „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) zeigt eine hohe Organspezifität zu den unteren Atemwegen. Da bislang weder eine wirksame Therapie noch Impfung gegen das Virus existieren, kommt der diagnostischen Früherkennung eine große Bedeutung zu. Durch den spezifischen Aspekt der überwiegend im peripheren Lungenparenchym beginnenden Infektion ist die Lungensonographie als bildgebende Diagnostikmethode geeignet, Verdachtsfälle bereits im Frühstadium der Erkrankung als solche zu identifizieren. Serielle Ultraschalluntersuchungen an Patienten mit bestätigter Infektion können bettseitig und zeitnah Veränderungen im betroffenen Lungengewebe nachweisen. Dieser Artikel fasst das diagnostische Potenzial der Lungensonographie im Hinblick auf Screening und therapeutische Entscheidungsfindung bei Patienten mit vermuteter oder bestätigter SARS-CoV-2-Pneumonie zusammen.

Diagnostic performance of lung ultrasound compared to CT scan in the diagnosis of pulmonary lesions of COVID-19 induced pneumonia: a preliminary study

Chest CT scan is currently used to assess the extent of lung involvement in patients with the coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the diagnostic performance of lung ultrasound in the diagnosis of COVID-19 pulmonary manifestations in comparison to CT scan. Thirty-three symptomatic patients with suspected COVID-19 pneumonia were evaluated by lung ultrasound and then, at a short interval, chest CT scan. In the anterior chest, each hemithorax was divided into four areas. In the posterior chest, eight zones similar to the anterior part were examined. The axillary areas were also divided into upper and lower zones (20 zones were determined per patient). Mean age of the patients was 58.66 years. The sensitivity (95% CI) and specificity (95% CI) of lung ultrasound for the diagnosis of parenchymal lesions were 90.5% (69.6–98.8%) and 50% (21.1–78.9%), respectively. In the evaluation of pleural lesions, the sensitivity (95% CI) and specificity (95% CI) of lung ultrasound were 100% (71.5–100%) and 22.7% (7.8–45.4%), respectively. Owing to the high sensitivity of ultrasound in identifying lung lesions in patients with COVID-19 pneumonia, it can be recommended to use lung ultrasound as a tool for initial screening of patients with high clinical suspicion for SARS-CoV-2 infection during the pandemic.