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Sartini S, Ferrari L, Cutuli O, Castellani L, Cristina ML, Arboscello E, Sartini M. The Role of POCUS to Face COVID-19: A Narrative Review. J Clin Med 2024; 13:2756. [PMID: 38792298 PMCID: PMC11121862 DOI: 10.3390/jcm13102756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
COVID-19 has been a challenging outbreak to face, with millions of deaths among the globe. Acute respiratory failure due to interstitial pneumonia was the leading cause of death other than prothrombotic activation and complications. Lung ultrasound (LUS) and point-of-care ultrasound (POCUS) are widely used not only to triage, to identify, and to monitor lungs involvement but also to assess hemodynamic status and thrombotic and hemorrhagic complications, mainly in critically ill patients. POCUS has gained growing consideration due to its bedside utilization, reliability, and reproducibility even in emergency settings especially in unstable patients. In this narrative review, we aim to describe LUS and POCUS utilization in COVID-19 infection based on the literature found on this topic. We reported the LUS patterns of COVID-19 pulmonary infection, the diagnostic accuracy with respect to CT lung scan, its prognostic value, the variety of scores and protocols proposed, and the utilization of POCUS to investigate the extra-lung complications.
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Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Lorenzo Ferrari
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy;
| | - Ombretta Cutuli
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Luca Castellani
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;
- Hospital Hygiene, E.O. Ospedali Galliera, Via Alessandro Volta 8, 16128 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy; (O.C.); (L.C.); (E.A.)
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy;
- Hospital Hygiene, E.O. Ospedali Galliera, Via Alessandro Volta 8, 16128 Genoa, Italy
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2
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Mousa A, Blok SG, Karssen D, Aman J, Annema JT, Bogaard HJ, Bonta PI, Haaksma ME, Heldeweg MLA, Lieveld AWE, Nanayakkara P, Nossent EJ, Smit JM, Smit MR, Vlaar APJ, Schultz MJ, Bos LDJ, Paulus F, Tuinman PR. Correlation between Serum Biomarkers and Lung Ultrasound in COVID-19: An Observational Study. Diagnostics (Basel) 2024; 14:421. [PMID: 38396460 PMCID: PMC10888244 DOI: 10.3390/diagnostics14040421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
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.
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Affiliation(s)
- Amne Mousa
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (M.L.A.H.)
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), 1081 HV Amsterdam, The Netherlands
| | - Siebe G. Blok
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), 1081 HV Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Dian Karssen
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (M.L.A.H.)
| | - Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (E.J.N.)
| | - Jouke T. Annema
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (E.J.N.)
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (E.J.N.)
| | - Peter I. Bonta
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (E.J.N.)
| | - Mark E. Haaksma
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (M.L.A.H.)
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), 1081 HV Amsterdam, The Netherlands
| | - Micah L. A. Heldeweg
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (M.L.A.H.)
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), 1081 HV Amsterdam, The Netherlands
| | - Arthur W. E. Lieveld
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Prabath Nanayakkara
- Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Esther J. Nossent
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (E.J.N.)
| | - Jasper M. Smit
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (M.L.A.H.)
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), 1081 HV Amsterdam, The Netherlands
| | - Marry R. Smit
- Department of Intensive Care Medicine, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care Medicine, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care Medicine, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care Medicine, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care Medicine, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Pieter R. Tuinman
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands (M.L.A.H.)
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), 1081 HV Amsterdam, The Netherlands
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Heldeweg MLA, Lieveld AWE, Mousa A, Pisani L, Tuinman PR. Validation of New Quantitative Lung Ultrasound Protocol and Comparison With Lung Ultrasound Score in Patients With COVID-19. Chest 2023; 164:1512-1515. [PMID: 37516271 PMCID: PMC10716796 DOI: 10.1016/j.chest.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 07/31/2023] Open
Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands.
| | | | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care Medicine, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands; Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands
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Atmowihardjo LN, Schippers JR, Haaksma ME, Smit MR, Bogaard HJ, Heunks L, Juffermans NP, Schultz MJ, Endeman H, van Velzen P, Tuinman PR, Aman J, Bos LDJ. The diagnostic accuracy of lung ultrasound to determine PiCCO-derived extravascular lung water in invasively ventilated patients with COVID-19 ARDS. Ultrasound J 2023; 15:40. [PMID: 37782370 PMCID: PMC10545605 DOI: 10.1186/s13089-023-00340-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Lung ultrasound (LUS) can detect pulmonary edema and it is under consideration to be added to updated acute respiratory distress syndrome (ARDS) criteria. However, it remains uncertain whether different LUS scores can be used to quantify pulmonary edema in patient with ARDS. OBJECTIVES This study examined the diagnostic accuracy of four LUS scores with the extravascular lung water index (EVLWi) assessed by transpulmonary thermodilution in patients with moderate-to-severe COVID-19 ARDS. METHODS In this predefined secondary analysis of a multicenter randomized-controlled trial (InventCOVID), patients were enrolled within 48 hours after intubation and underwent LUS and EVLWi measurement on the first and fourth day after enrolment. EVLWi and ∆EVLWi were used as reference standards. Two 12-region scores (global LUS and LUS-ARDS), an 8-region anterior-lateral score and a 4-region B-line score were used as index tests. Pearson correlation was performed and the area under the receiver operating characteristics curve (AUROCC) for severe pulmonary edema (EVLWi > 15 mL/kg) was calculated. RESULTS 26 out of 30 patients (87%) had complete LUS and EVLWi measurements at time point 1 and 24 out of 29 patients (83%) at time point 2. The global LUS (r = 0.54), LUS-ARDS (r = 0.58) and anterior-lateral score (r = 0.54) correlated significantly with EVLWi, while the B-line score did not (r = 0.32). ∆global LUS (r = 0.49) and ∆anterior-lateral LUS (r = 0.52) correlated significantly with ∆EVLWi. AUROCC for EVLWi > 15 ml/kg was 0.73 for the global LUS, 0.79 for the anterior-lateral and 0.85 for the LUS-ARDS score. CONCLUSIONS Overall, LUS demonstrated an acceptable diagnostic accuracy for detection of pulmonary edema in moderate-to-severe COVID-19 ARDS when compared with PICCO. For identifying patients at risk of severe pulmonary edema, an extended score considering pleural morphology may be of added value. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04794088, registered on 11 March 2021. European Clinical Trials Database number 2020-005447-23.
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Affiliation(s)
- Leila N Atmowihardjo
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands.
| | - Job R Schippers
- Department of Pulmonology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Mark E Haaksma
- Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Marry R Smit
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Harm J Bogaard
- Department of Pulmonology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole P Juffermans
- Intensive Care, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus University, Rotterdam, the Netherlands
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Henrik Endeman
- Intensive Care, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - Patricia van Velzen
- Dijklander Hospital Location Purmerend, Intensive Care, Waterlandlaan 250, Purmerend, The Netherlands
| | - Pieter R Tuinman
- Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands
| | - Jurjan Aman
- Department of Pulmonology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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5
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Chaudhuri S, Ravindra P, Gupta N, Rao S, Kudru CU, Saravu K. Assessment of the Utility of Point-of-Care Testing Incorporating Ultrasound and Arterial Blood Gas in Patients with Acute Febrile Illness in the Emergency Department to Determine Disease Severity, Disposition, Need for Ventilation and Renal Replacement Therapy. J Emerg Trauma Shock 2023; 16:79-85. [PMID: 38025502 PMCID: PMC10661579 DOI: 10.4103/jets.jets_29_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/30/2023] [Accepted: 05/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Acute febrile illness (AFI) patients present to the emergency department (ED), with fever to multi-organ dysfunction. There is a lack of early point-of-care-based disposition criteria in AFI patients regarding the need for intensive care unit (ICU) or high dependency unit (HDU) care. Methods We enrolled 100 patients with AFI presenting to the ED and evaluated using point-of-care ultrasound with two-dimensional echocardiography (ECHO), lung ultrasound score (LUS), renal arterial resistive index (RRI), and arterial blood gas. The need for ICU/HDU admission, ventilation (either noninvasive or invasive), and renal-replacement therapy (RRT) within 48 h of hospitalization was noted. Results Ninety-five patients were included in the analysis. 72 (75.8%) patients required either ICU or HDU admission, 45 (47.4%) required ventilatory support (either noninvasive or invasive), and 32 (33.7%) required RRT. After logistic regression, LUS ≥16, and arterial lactate ≥12 mg/dL were independent predictors of the need for ICU or HDU admission. The respiratory rate (RR) ≥28/minute, LUS ≥16 and RRI ≥61 were the independent predictors of the need for ventilation. The MAP ≤73 mmHg, LUS (≥16), and RRI (≥67) were the predictors of the need for RRT. Conclusion In AFI patients presenting to the ED, the MAP, LUS, and lactate are predictors of the need for ICU/HDU admission. The LUS and RRI were predictors of the need for RRT whereas the RR, LUS, and RRI were the predictors of the need for ventilation.
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Affiliation(s)
- Souvik Chaudhuri
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Prithvishree Ravindra
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Nitin Gupta
- Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Chandrashekar Udyavara Kudru
- Department of Internal Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kavitha Saravu
- Department of Infectious Diseases, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Chrzan R, Polok K, Antczak J, Siwiec-Koźlik A, Jagiełło W, Popiela T. The value of lung ultrasound in COVID-19 pneumonia, verified by high resolution computed tomography assessed by artificial intelligence. BMC Infect Dis 2023; 23:195. [PMID: 37003997 PMCID: PMC10064611 DOI: 10.1186/s12879-023-08173-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/17/2023] [Indexed: 04/03/2023] Open
Abstract
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.
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Affiliation(s)
- Robert Chrzan
- Department of Radiology, Jagiellonian University Medical College, Kopernika 19, 31-501, Krakow, Poland.
| | - Kamil Polok
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Antczak
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Andżelika Siwiec-Koźlik
- Department of Rheumatology and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Jagiełło
- Second Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Tadeusz Popiela
- Department of Radiology, Jagiellonian University Medical College, Kopernika 19, 31-501, Krakow, Poland
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Heldeweg MLA, Lieveld AW, Walburgh-Schmidt RS, Smit JM, Haaksma ME, Veldhuis L, de Grooth HJ, Girbes AR, Heunks LM, Tuinman PR. Concise Versus Extended Lung Ultrasound Score to Monitor Critically Ill Patients With COVID-19. Respir Care 2023; 68:400-407. [PMID: 36649978 PMCID: PMC10027145 DOI: 10.4187/respcare.10406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lung ultrasound (LUS) can be used to monitor critically ill patients with COVID-19, but the optimal number of examined lung zones is disputed. METHODS This was a prospective observational study. The objective was to investigate whether concise (6 zones) and extended (12 zones) LUS scoring protocols are clinically equivalent in critically ill ICU subjects with COVID-19. The primary outcome of this study was (statistical) agreement between concise and extended LUS score index evaluated in both supine and prone position. Agreement was determined using correlation coefficients and Bland-Altman plots to detect systematic differences between protocols. Secondary outcomes were difference between LUS score index in supine and prone position using similar methods. RESULTS We included 130 LUS examinations in 40 subjects (mean age 69.0 ± 8.5y, 75% male). Agreement between concise and extended LUS score index had no clinically relevant constant or proportional bias and limits of agreement were below the smallest detectable change. Across position changes, supine LUS score index was 8% higher than prone LUS score index and had limits above the smallest detectable change, indicating true LUS score index differences between protocols may occur due to the position change itself. Lastly, inter-rater and intra-rater agreement were very good. CONCLUSIONS Concise LUS was equally informative as extended LUS for monitoring critically ill subjects with COVID-19 in supine or prone position. Clinicians can monitor patients undergoing position changes but must be wary that LUS score index alterations may result from the position change itself rather than disease progression or clinical improvement.
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Affiliation(s)
- Micah LA Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Leiden IC Focused Echography, Amsterdam, the Netherlands.
| | - Arthur We Lieveld
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Robin S Walburgh-Schmidt
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Leiden IC Focused Echography, Amsterdam, the Netherlands
| | - Lars Veldhuis
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Armand Rj Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Leo Ma Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Leiden IC Focused Echography, Amsterdam, the Netherlands
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8
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Lieveld AWE, Heldeweg MLA, Schouwenburg J, Veldhuis L, Haaksma ME, van Haaften RM, Teunissen BP, Smit JM, Twisk J, Heunks L, Nanayakkara PWB, Tuinman PR. Monitoring of pulmonary involvement in critically ill COVID-19 patients - should lung ultrasound be preferred over CT? Ultrasound J 2023; 15:11. [PMID: 36842163 PMCID: PMC9968403 DOI: 10.1186/s13089-022-00299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/27/2022] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND It is unclear if relevant changes in pulmonary involvement in critically ill COVID-19 patients can be reliably detected by the CT severity score (CTSS) and lung ultrasound score (LUSS), or if these changes have prognostic implications. In addition, it has been argued that adding pleural abnormalities to the LUSS could improve its prognostic value. The objective of this study was to compare LUSS and CTSS for the monitoring of COVID-19 pulmonary involvement through: first, establishing the correlation of LUSS (± pleural abnormalities) and CTSS throughout admission; second, assessing agreement and measurement error between raters for LUSS, pleural abnormalities, and CTSS; third, evaluating the association of the LUSS (± pleural abnormalities) and CTSS with mortality at different timepoints. METHODS This is a prospective, observational study, conducted during the second COVID-19 wave at the AmsterdamUMC, location VUmc. Adult COVID-19 ICU patients were prospectively included when a CT or a 12-zone LUS was performed at admission or at weekly intervals according to local protocol. Patients were followed 90 days or until death. We calculated the: (1) Correlation of the LUSS (± pleural abnormalities) and CTSS throughout admission with mixed models; (2) Intra-class correlation coefficients (ICCs) and smallest detectable changes (SDCs) between raters; (3) Association between the LUSS (± pleural abnormalities) and CTSS with mixed models. RESULTS 82 consecutive patients were included. Correlation between LUSS and CTSS was 0.45 (95% CI 0.31-0.59). ICCs for LUSS, pleural abnormalities, and CTSS were 0.88 (95% CI 0.73-0.95), 0.94 (95% CI 0.90-0.96), and 0.84 (95% CI 0.65-0.93), with SDCs of 4.8, 1.4, and 3.9. The LUSS was associated with mortality in week 2, with a score difference between patients who survived or died greater than its SDC. Addition of pleural abnormalities was not beneficial. The CTSS was associated with mortality only in week 1, but with a score difference less than its SDC. CONCLUSIONS LUSS correlated with CTSS throughout ICU admission but performed similar or better at agreement between raters and mortality prognostication. Given the benefits of LUS over CT, it should be preferred as initial monitoring tool.
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Affiliation(s)
- Arthur W. E. Lieveld
- grid.509540.d0000 0004 6880 3010Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location VU Medical Center, Postbox 7507, 1007MB Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Micah L. A. Heldeweg
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jasper Schouwenburg
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Lars Veldhuis
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Mark E. Haaksma
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Rutger M. van Haaften
- grid.509540.d0000 0004 6880 3010Section Emergency Radiology, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Berend P. Teunissen
- grid.509540.d0000 0004 6880 3010Section Emergency Radiology, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Jasper M. Smit
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jos Twisk
- grid.509540.d0000 0004 6880 3010Department of Epidemiology and Data Science, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Leo Heunks
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Prabath W. B. Nanayakkara
- grid.509540.d0000 0004 6880 3010Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location VU Medical Center, Postbox 7507, 1007MB Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
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9
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Li H, Bihari S, Weister T, LeMahieu A, Kashyap R, Chalmers S, Lal A, Bersten A, Gajic O. Admission serum sodium and osmolarity are not associated with the occurrence or outcomes of acute respiratory distress syndrome in critically ill. J Crit Care 2023; 73:154179. [PMID: 36368178 PMCID: PMC9616514 DOI: 10.1016/j.jcrc.2022.154179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/03/2022] [Accepted: 10/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Previous studies suggested that hypernatremia or hyperosmolarity may have protective effects in lung injury. We hypothesized that hypernatremia and/or hyperosmolarity would prevent ARDS. DESIGN Retrospective cohort study of all admissions at medical, surgical, and multidisciplinary intensive care units in Mayo Clinic, Rochester from the year of 2009 to 2019. The occurrence of ARDS was identified using a validated computerized search strategy. The association between serum sodium/osmolarity and the occurrence of ARDS was analyzed using a multivariable logistic regression model. The relationship between serum sodium/osmolarity and outcomes of ARDS was analyzed using linear and logistic regression models. RESULTS Among 50,498 patients, the serum sodium level on admission did not have a significant association with the occurrence of ARDS, with an adjusted odds ratio of 0.95 [95% CI (0.86, 1.05)]. There was no significant association between calculated serum osmolarity and the occurrence of ARDS, with an adjusted odds ratio of 1.03 [95% CI (1.00, 1.07)]. 1560 patients developed ARDS during the ICU stay. Their serum sodium level and osmolarity level did not have a significant association with their outcomes. CONCLUSIONS Admission serum sodium or serum osmolarity were not associated with the occurrence or outcomes of ARDS in ICU.
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Affiliation(s)
- Heyi Li
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Shailesh Bihari
- Intensive Care Unit, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia 5042, Australia
| | - Timothy Weister
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN 55905, USA
| | - Allison LeMahieu
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Rochester, MN 55905, USA
| | - Rahul Kashyap
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Sarah Chalmers
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Andrew Bersten
- Intensive Care Unit, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia,College of Medicine and Public Health, Flinders University, Bedford Park, South Australia 5042, Australia
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA
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10
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Heldeweg M, Mousa A, van Ekeren J, Lieveld A, Walburgh-Schmidt R, Smit J, Haaksma M, de Grooth H, Heunks L, Tuinman P. Lung ultrasound to predict gas-exchange response to prone positioning in COVID-19 patients: A prospective study in pilot and confirmation cohorts. J Crit Care 2023; 73:154173. [PMID: 36265246 PMCID: PMC9576547 DOI: 10.1016/j.jcrc.2022.154173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/18/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To examine whether lung ultrasound prior to prone positioning can predict the resulting gas-exchange response. MATERIALS AND METHODS This is a prospective observational study on critically-ill COVID-19 patients with a pilot and confirmation cohort. Lung ultrasound examinations were performed before prone positioning and gas-exchange parameters were recorded before and after position change. RESULTS A total of 79 patients, 36 in the pilot cohort and 43 in the confirmation cohort, were included. In the pilot cohort, a moderate correlation between pre-turn lung ultrasound score index (LUSI) and change in PaO2/FiO2 after prone positioning was found. These findings were corroborated and extended upon in the confirmation cohort. The confirmation cohort found that anterior LUSI had the strongest correlation with follow-up time-points 1, 6, 12, and 24 h after prone positioning, with strength of correlation gradually increasing up to 24 h. In a multivariate model anterior aeration loss (odds ratio 0.035; 95%CI 0.003-0.319 for anterior LUSI >50%) and higher pre-turn PaCO2 (odds ratio 0.479 95% CI 0.235-0.979) were negatively predictive of a PaO2/FiO2 increase ≥20 mmHg. CONCLUSIONS Anterior LUSI, in addition to other clinical parameters, may be used to aid COVID-19 respiratory strategy and a clinician's decision to prone.
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Affiliation(s)
- M.L.A. Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands,Corresponding author at: VU University Medical Center Amsterdam, Postbox 7507, 11081HV Amsterdam, the Netherlands
| | - A. Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands
| | - J. van Ekeren
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - A.W.E. Lieveld
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location, VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands
| | - R.S. Walburgh-Schmidt
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - J.M. Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location, VUmc, Amsterdam, the Netherlands
| | - M.E. Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Amsterdam Leiden IC Focused Echography (ALIFE, http://www.alifeofpocus.com), the Netherlands
| | - H.J. de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - L.M.A. Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - P.R. Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands,Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location, VUmc, Amsterdam, the Netherlands
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11
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Bardakci O, Daş M, Akdur G, Akman C, Siddikoğlu D, Şimşek G, Kaya F, Atalay Ü, Topal MT, Beyazit F, Ünal Çetin E, Akdur O, Beyazit Y. Point-of-care Lung Ultrasound, Lung CT and NEWS to Predict Adverse Outcomes and Mortality in COVID-19 Associated Pneumonia. J Intensive Care Med 2022; 37:1614-1624. [PMID: 36317355 PMCID: PMC9623409 DOI: 10.1177/08850666221111731] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: The appraisal of disease severity and prediction of
adverse outcomes using risk stratification tools at early disease stages is
crucial to diminish mortality from coronavirus disease 2019 (COVID-19). While
lung ultrasound (LUS) as an imaging technique for the diagnosis of lung diseases
has recently gained a leading position, data demonstrating that it can predict
adverse outcomes related to COVID-19 is scarce. The main aim of this study is
therefore to assess the clinical significance of bedside LUS in COVID-19
patients who presented to the emergency department (ED). Methods:
Patients with a confirmed diagnosis of SARS-CoV-2 pneumonia admitted to the ED
of our hospital between March 2021 and May 2021 and who underwent a 12-zone LUS
and a lung computed tomography scan were included prospectively. Logistic
regression and Cox proportional hazard models were used to predict adverse
events, which was our primary outcome. The secondary outcome was to discover the
association of LUS score and computed tomography severity score (CT-SS) with the
composite endpoints. Results: We assessed 234 patients [median age
59.0 (46.8-68.0) years; 59.4% M), including 38 (16.2%) in-hospital deaths for
any cause related to COVID-19. Higher LUS score and CT-SS was found to be
associated with ICU admission, intubation, and mortality. The LUS score
predicted mortality risk within each stratum of NEWS. Pairwise analysis
demonstrated that after adjusting a base prediction model with LUS score,
significantly higher accuracy was observed in predicting both ICU admission (DBA
−0.067, P = .011) and in-hospital mortality (DBA −0.086,
P = .017). Conclusion: Lung ultrasound can be
a practical prediction tool during the course of COVID-19 and can quantify
pulmonary involvement in ED settings. It is a powerful predictor of ICU
admission, intubation, and mortality and can be used as an alternative for chest
computed tomography while monitoring COVID-19-related adverse outcomes.
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Affiliation(s)
- Okan Bardakci
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Murat Daş
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey,Murat Daş, Department of Emergency
Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University,
TerzioğluYerleşkesi, Barbaros Mh, Canakkale 17100, Turkey.
| | - Gökhan Akdur
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Canan Akman
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Duygu Siddikoğlu
- Department of Biostatistics, Faculty of
Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Güven Şimşek
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Feyyaz Kaya
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Ünzile Atalay
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - M. Taha Topal
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Fatma Beyazit
- Department of Obstetrics and
Gynecology, Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Ece Ünal Çetin
- Department of Internal Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Okhan Akdur
- Department of Emergency Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
| | - Yavuz Beyazit
- Department of Internal Medicine,
Faculty of Medicine, Çanakkale Onsekiz Mart
University, Çanakkale, Turkey
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12
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Valk CM, Zimatore C, Mazzinari G, Pierrakos C, Sivakorn C, Dechsanga J, Grasso S, Beenen L, Bos LDJ, Paulus F, Schultz MJ, Pisani L. The RALE Score Versus the CT Severity Score in Invasively Ventilated COVID-19 Patients—A Retrospective Study Comparing Their Prognostic Capacities. Diagnostics (Basel) 2022; 12:diagnostics12092072. [PMID: 36140474 PMCID: PMC9497927 DOI: 10.3390/diagnostics12092072] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Quantitative radiological scores for the extent and severity of pulmonary infiltrates based on chest radiography (CXR) and computed tomography (CT) scan are increasingly used in critically ill invasively ventilated patients. This study aimed to determine and compare the prognostic capacity of the Radiographic Assessment of Lung Edema (RALE) score and the chest CT Severity Score (CTSS) in a cohort of invasively ventilated patients with acute respiratory distress syndrome (ARDS) due to COVID-19. Methods: Two-center retrospective observational study, including consecutive invasively ventilated COVID-19 patients. Trained scorers calculated the RALE score of first available CXR and the CTSS of the first available CT scan. The primary outcome was ICU mortality; secondary outcomes were duration of ventilation in survivors, length of stay in ICU, and hospital-, 28-, and 90-day mortality. Prognostic accuracy for ICU death was expressed using odds ratios and Area Under the Receiver Operating Characteristic curves (AUROC). Results: A total of 82 patients were enrolled. The median RALE score (22 [15–37] vs. 26 [20–39]; p = 0.34) and the median CTSS (18 [16–21] vs. 21 [18–23]; p = 0.022) were both lower in ICU survivors compared to ICU non-survivors, although only the difference in CTSS reached statistical significance. While no association was observed between ICU mortality and RALE score (OR 1.35 [95%CI 0.64–2.84]; p = 0.417; AUC 0.50 [0.44–0.56], this was noticed with the CTSS (OR, 2.31 [1.22–4.38]; p = 0.010) although with poor prognostic capacity (AUC 0.64 [0.57–0.69]). The correlation between the RALE score and CTSS was weak (r2 = 0.075; p = 0.012). Conclusions: Despite poor prognostic capacity, only CTSS was associated with ICU mortality in our cohort of COVID-19 patients.
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Affiliation(s)
- Christel M. Valk
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Claudio Zimatore
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, 70124 Bari, Italy
- Correspondence:
| | - Guido Mazzinari
- Department of Anaesthesiology and Critical Care, Hospital Universitario y Politecnico la Fe, 46026 Valencia, Spain
- Perioperative Medicine Research Group, Instituto de Investigación Sanitaria la Fe, 46026 Valencia, Spain
| | - Charalampos Pierrakos
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Intensive Care, Centre Hospitalier Universitaire Brussels, 1020 Brussels, Belgium
| | - Chaisith Sivakorn
- Intensive Care Unit, NHS Foundation Trust, University College London Hospitals, London NW1 2BU, UK
| | - Jutamas Dechsanga
- Division of Pulmonary and Critical Care, Department of Medicine, Chonburi Hospital, Chonburi 20000, Thailand
| | - Salvatore Grasso
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, 70124 Bari, Italy
| | - Ludo Beenen
- Department of Radiology, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Department of Pulmonology, Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 2JD, UK
| | - Luigi Pisani
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Anaesthesia and Intensive Care Unit, Miulli Regional Hospital, 70021 Acquaviva Delle Fonti, Italy
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13
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The Role of Lung Ultrasound Monitoring in Early Detection of Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Observational Study. J Clin Med 2022; 11:jcm11113001. [PMID: 35683392 PMCID: PMC9181291 DOI: 10.3390/jcm11113001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/11/2022] [Accepted: 05/21/2022] [Indexed: 02/08/2023] Open
Abstract
Specific lung ultrasound signs combined with clinical parameters allow for early diagnosis of ventilator-associated pneumonia in the general ICU population. This retrospective cohort study aimed to determine the accuracy of lung ultrasound monitoring for ventilator-associated pneumonia diagnosis in COVID-19 patients. Clinical (i.e., clinical pulmonary infection score) and ultrasound (i.e., presence of consolidation and a dynamic linear−arborescent air bronchogram, lung ultrasound score, ventilator-associated lung ultrasound score) data were collected on the day of the microbiological sample (pneumonia-day) and 48 h before (baseline) on 55 bronchoalveolar lavages of 33 mechanically-ventilated COVID-19 patients who were monitored daily with lung ultrasounds. A total of 26 samples in 23 patients were positive for ventilator-associated pneumonia (pneumonia cases). The onset of a dynamic linear−arborescent air bronchogram was 100% specific for ventilator-associated pneumonia. The ventilator-associated lung ultrasound score was higher in pneumonia-cases (2.5 (IQR 1.0 to 4.0) vs. 1.0 (IQR 1.0 to 1.0); p < 0.001); the lung ultrasound score increased from baseline in pneumonia-cases only (3.5 (IQR 2.0 to 6.0) vs. −1.0 (IQR −2.0 to 1.0); p = 0.0001). The area under the curve for clinical parameters, ventilator-associated pneumonia lung ultrasound score, and lung ultrasound score variations were 0.472, 0.716, and 0.800, respectively. A newly appeared dynamic linear−arborescent air bronchogram is highly specific for ventilator-associated pneumonia in COVID-19 patients. A high ventilator-associated pneumonia lung ultrasound score (or an increase in the lung ultrasound score) orients to ventilator-associated pneumonia.
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14
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Gil-Rodríguez J, Pérez de Rojas J, Aranda-Laserna P, Benavente-Fernández A, Martos-Ruiz M, Peregrina-Rivas JA, Guirao-Arrabal E. Ultrasound findings of lung ultrasonography in COVID-19: A systematic review. Eur J Radiol 2022; 148:110156. [PMID: 35078136 PMCID: PMC8783639 DOI: 10.1016/j.ejrad.2022.110156] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify the defining lung ultrasound (LUS) findings of COVID-19, and establish its association to the initial severity of the disease and prognostic outcomes. METHOD Systematic review was conducted according to the PRISMA guidelines. We queried PubMed, Embase, Web of Science, Cochrane Database and Scopus using the terms ((coronavirus) OR (covid-19) OR (sars AND cov AND 2) OR (2019-nCoV)) AND (("lung ultrasound") OR (LUS)), from 31st of December 2019 to 31st of January 2021. PCR-confirmed cases of SARS-CoV-2 infection, obtained from original studies with at least 10 participants 18 years old or older, were included. Risk of bias and applicability was evaluated with QUADAS-2. RESULTS We found 1333 articles, from which 66 articles were included, with a pooled population of 4687 patients. The most examined findings were at least 3 B-lines, confluent B-lines, subpleural consolidation, pleural effusion and bilateral or unilateral distribution. B-lines, its confluent presentation and pleural abnormalities are the most frequent findings. LUS score was higher in intensive care unit (ICU) patients and emergency department (ED), and it was associated with a higher risk of developing unfavorable outcomes (death, ICU admission or need for mechanical ventilation). LUS findings and/or the LUS score had a good negative predictive value in the diagnosis of COVID-19 compared to RT-PCR. CONCLUSIONS The most frequent ultrasound findings of COVID-19 are B-lines and pleural abnormalities. High LUS score is associated with developing unfavorable outcomes. The inclusion of pleural effusion in the LUS score and the standardisation of the imaging protocol in COVID-19 LUS remains to be defined.
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Affiliation(s)
- Jaime Gil-Rodríguez
- Internal Medicine Unit, San Cecilio University Hospital, Avenida del Conocimiento s/n, 18016 Granada, Spain,Corresponding author
| | - Javier Pérez de Rojas
- Preventive Medicine and Public Health Unit, San Cecilio University Hospital, Avenida del Conocimiento s/n, 18016 Granada, Spain
| | - Pablo Aranda-Laserna
- Internal Medicine Unit, San Cecilio University Hospital, Avenida del Conocimiento s/n, 18016 Granada, Spain
| | | | - Michel Martos-Ruiz
- Internal Medicine Unit, San Cecilio University Hospital, Avenida del Conocimiento s/n, 18016 Granada, Spain
| | | | - Emilio Guirao-Arrabal
- Infectious Diseases Unit, San Cecilio University Hospital, Avenida del Conocimiento s/n, 18016 Granada, Spain
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15
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Smit JM, Haaksma ME, Winkler MH, Heldeweg MLA, Arts L, Lust EJ, Elbers PWG, Meijboom LJ, Girbes ARJ, Heunks LMA, Tuinman PR. Lung ultrasound in a tertiary intensive care unit population: a diagnostic accuracy study. Crit Care 2021; 25:339. [PMID: 34535169 PMCID: PMC8447620 DOI: 10.1186/s13054-021-03759-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Evidence from previous studies comparing lung ultrasound to thoracic computed tomography (CT) in intensive care unit (ICU) patients is limited due to multiple methodologic weaknesses. While addressing methodologic weaknesses of previous studies, the primary aim of this study is to investigate the diagnostic accuracy of lung ultrasound in a tertiary ICU population. METHODS This is a single-center, prospective diagnostic accuracy study conducted at a tertiary ICU in the Netherlands. Critically ill patients undergoing thoracic CT for any clinical indication were included. Patients were excluded if time between the index and reference test was over eight hours. Index test and reference test consisted of 6-zone lung ultrasound and thoracic CT, respectively. Hemithoraces were classified by the index and reference test as follows: consolidation, interstitial syndrome, pneumothorax and pleural effusion. Sensitivity, specificity, positive and negative likelihood ratio were estimated. RESULTS In total, 87 patients were included of which eight exceeded the time limit and were subsequently excluded. In total, there were 147 respiratory conditions in 79 patients. The estimated sensitivity and specificity to detect consolidation were 0.76 (95%CI: 0.68 to 0.82) and 0.92 (0.87 to 0.96), respectively. For interstitial syndrome they were 0.60 (95%CI: 0.48 to 0.71) and 0.69 (95%CI: 0.58 to 0.79). For pneumothorax they were 0.59 (95%CI: 0.33 to 0.82) and 0.97 (95%CI: 0.93 to 0.99). For pleural effusion they were 0.85 (95%CI: 0.77 to 0.91) and 0.77 (95%CI: 0.62 to 0.88). CONCLUSIONS In conclusion, lung ultrasound is an adequate diagnostic modality in a tertiary ICU population to detect consolidations, interstitial syndrome, pneumothorax and pleural effusion. Moreover, one should be careful not to interpret lung ultrasound results in deterministic fashion as multiple respiratory conditions can be present in one patient. Trial registration This study was retrospectively registered at Netherlands Trial Register on March 17, 2021, with registration number NL9344.
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Affiliation(s)
- Jasper M Smit
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands.
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Michiel H Winkler
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
| | - Micah L A Heldeweg
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Luca Arts
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
| | - Erik J Lust
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE) and Amsterdam Cardiovascular Sciences (ACS), Amsterdam UMC, Location VU University Medical Center, de Boelelaan 11171007MB, Postbox 7505, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
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16
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Sosa FA, Matarrese A, Saavedra S, Osatnik J, Roberti J, Oribe BT, Ivulich D, Durán AL, Caputo C, Benay C. Lung ultrasound as a predictor of mortality of patients with COVID-19. J Bras Pneumol 2021; 47:e20210092. [PMID: 34495211 PMCID: PMC8647154 DOI: 10.36416/1806-3756/e20210092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/04/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the performance of lung ultrasound to determine short-term outcomes of patients with COVID-19 admitted to the intensive care unit. METHODS This is a Prospective, observational study. Between July and November 2020, 59 patients were included and underwent at least two LUS assessments using LUS score (range 0-42) on day of admission, day 5th, and 10th of admission. RESULTS Age was 66.5±15 years, APACHE II was 8.3±3.9, 12 (20%) patients had malignancy, 46 (78%) patients had a non-invasive ventilation/high-flow nasal cannula and 38 (64%) patients required mechanical ventilation. The median stay in ICU was 12 days (IQR 8.5-20.5 days). ICU or hospital mortality was 54%. On admission, the LUS score was 20.8±6.1; on day 5th and day 10th of admission, scores were 27.6±5.5 and 29.4±5.3, respectively (P=0.007). As clinical condition deteriorated the LUS score increased, with a positive correlation of 0.52, P <0.001. Patients with worse LUS on day 5th versus better score had a mortality of 76% versus 33% (OR 6.29, 95%CI 2.01-19.65, p. 0.003); a similar difference was observed on day 10. LUS score of 5th day of admission had an area under the curve of 0.80, best cut-point of 27, sensitivity and specificity of 0.75 and 0.78 respectively. CONCLUSION These findings position LUS as a simple and reproducible method to predict the course of COVID-19 patients.
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Affiliation(s)
| | | | | | | | - Javier Roberti
- Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
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17
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Meroi F, Orso D, Vetrugno L, Bove T. Lung Ultrasound Score in Critically Ill COVID-19 Patients: A Waste of Time or a Time-Saving Tool? Acad Radiol 2021; 28:1323-1324. [PMID: 34275738 PMCID: PMC8275841 DOI: 10.1016/j.acra.2021.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Francesco Meroi
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, P.le S. Maria della Misericordia n° 15, 33100 Udine, Italy; Department of Medicine, University of Udine, Anesthesia and Intensive Care Clinic, Via Colugna n° 50, 33100 Udine, Italy.
| | - Daniele Orso
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, P.le S. Maria della Misericordia n° 15, 33100 Udine, Italy; Department of Medicine, University of Udine, Anesthesia and Intensive Care Clinic, Via Colugna n° 50, 33100 Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, P.le S. Maria della Misericordia n° 15, 33100 Udine, Italy; Department of Medicine, University of Udine, Anesthesia and Intensive Care Clinic, Via Colugna n° 50, 33100 Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, P.le S. Maria della Misericordia n° 15, 33100 Udine, Italy; Department of Medicine, University of Udine, Anesthesia and Intensive Care Clinic, Via Colugna n° 50, 33100 Udine, Italy
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18
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Ökmen K, Yildiz DK, Soyaslan E, Ceylan İ, Sayan HE, Aytünür CS. Comparison of two different lung ultrasound imaging protocols in COVID-19 pneumonia. Ultrasonography 2021; 41:212-221. [PMID: 34711019 PMCID: PMC8696151 DOI: 10.14366/usg.21095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/13/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose The aim of this study was to determine the effectiveness of two different lung ultrasonography (LUS) methods that can be used in the diagnosis of coronavirus disease 2019 (COVID-19) and to investigate their correlations with computed tomography (CT). Methods In this prospective, randomized, and single-blind study, 60 patients with COVID-19 were included. The patients were randomized to either the 12-zone LUS group (n=30) or the 14-zone LUS group (n=30). The correlation between LUS and thoracic CT scores was evaluated. As a secondary outcome measure, the characteristic features of the findings of thoracic CT and LUS were examined. Results The study was completed with a total of 59 patients. Moderate and high correlations were found between the total CT and LUS scores in the 12-zone and 14-zone study groups. There were no statistically significant differences in the lesion types detected in patients using LUS and CT (P>0.05). The left lung lower lobe CT scores were statistically significantly lower in the 14-zone study group than in the 12-zone group (P=0.019). The left lower lobe CT and LUS scores were highly correlated in the 14-zone group (P<0.001, r=0.902). Conclusion The results of our study indicated that the two different LUS examination methods performed in different patients had similar findings in terms of the diagnosis and their correlations with CT results.
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Affiliation(s)
- Korgün Ökmen
- Department of Anesthesiology and Reanimation, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Durdu Kahraman Yildiz
- Department of Anesthesiology and Reanimation, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Emel Soyaslan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - İlkay Ceylan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Halil Erkan Sayan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Cihan Sedat Aytünür
- Department of Anesthesiology and Reanimation, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
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19
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Heldeweg MLA, Lieveld AWE, de Grooth HJ, Heunks LMA, Tuinman PR. Determining the optimal number of lung ultrasound zones to monitor COVID-19 patients: can we keep it ultra-short and ultra-simple? Intensive Care Med 2021; 47:1041-1043. [PMID: 34173859 PMCID: PMC8233591 DOI: 10.1007/s00134-021-06463-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/18/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Postbox 7507, 1081HV, Amsterdam, The Netherlands.
- Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands.
| | - Arthur W E Lieveld
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Postbox 7507, 1081HV, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands
- Department of Internal Medicine, Amsterdam UMC, Section Acute Medicine, Location VUmc, Amsterdam, The Netherlands
| | - Harm J de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Postbox 7507, 1081HV, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Postbox 7507, 1081HV, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Postbox 7507, 1081HV, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands
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