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All content in this area was uploaded by Abdulrahman M. Alfuraih on Sep 09, 2020
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BJR|Open
© 2020 The Authors. Published by the British Institute of Radiology. This is an open access article distributed under the terms of the Creative Commons
Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source
are credited.
Cite this article as:
Alfuraih AM. Point of care lung ultrasound in COVID-19: hype or hope?. BJR Open 2020; 2: 20200027.
Received:
29 May 2020
Accepted:
30 July 2020
Revised:
17 July 2020
OPINION
Point of care lung ultrasound in COVID-19: hype
orhope?
ABDULRAHMAN M. ALFURAIH,BSc, MSc, PhD
Department of Radiology and Medical Imaging, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Kharj, Saudi
Arabia
Address correspondence to: Dr Abdulrahman M. Alfuraih
E-mail: a. alfuraih@ psau. edu. sa
Aer the initial outbreak of the SARS- CoV-2 virus in Wu-
han, the world got into a state of turmoil with total cases
exceeding 15 million as of July 2020. It is an extremely con-
tagious virus, which could potentially cause acute respirato-
ry distress and potentially organ failure in advanced stages.1
COVID-19 is diagnosed by reverse- transcription poly-
merase chain reaction (RT- PCR), which was criticized aer
reports of poor diagnostic sensitivity.2,3 In contrast, alterna-
tive diagnostic tests such as chest CT has not been recom-
mended by international and local guidelines due to several
reasons, including poor specicity and radiation risks.4
Lung ultrasonography (LU) is an established technique for
evaluating lung pathologies. It is sensitive to abnormalities
in the pleura and subpleural spaces. e initial evidence on
COVID-19 suggesting peripheral lung involvement at the
terminal alveoli, which alludes a signicant role for LU in
diagnosis and management. is paper presents an up- to-
date review of the LU evidence in COVID-19 and discusses
the pitfalls and future perspectives.
LUNG ULTRASOUND IN COVID-19
ere have been several publications describing the role
of LU in COVID-19.5–16 e publications were divided
between simple case- studies, letters of opinion and
commentaries discussing the potential usefulness of LU.
Despite a few useful descriptions of how LU can be included
in the COVID-19 diagnostic workup and management, they
present inconclusive results and apparent lack of thorough-
ness. e paragraphs below discuss the overall ndings.
e rst case report was of a 57- year- old male presenting to
the ER with fever, cough, general weakness, and headache.
e LU ndings showed bilateral irregular pleural line
with minimal consolidations and thick multiple B- lines in
the anterior and posterior hemithorax. As a control case,
a suspected patient (later conrmed negative) with typical
COVID-19 symptoms exhibited normal lung pleura with
A- lines on LU. Notably, the scan was performed by two
operators using a handheld device, one scanning and the
other holding the tablet (freezing and storing images). is
practice was recommended by them to mitigate the risks
of infection. e second case study6 was of a female heath
practitioner in her sixties with conrmed COVID-19 that
developed a cough and sore throat followed by dyspnea.
LU demonstrated multiple B- lines, consolidation and
thickened pleural line. Both of these cases can be consid-
ered moderate in terms of severity (both febrile with low
oxygen saturation). e third, and most interesting, case
study14 was of pregnant females with positive lung ultra-
sound ndings suggesting COVID-19 which had an early
negative PCR result. e ndings included bilateral thick
https:// doi. org/ 10. 1259/ bjro. 20200027
ABSTRACT
The COVID-19 coronavirus pandemic has critically struck the world economy and healthcare systems. The highly
contagious virus spreads rapidly and can result in potentially life- threatening acute respiratory distress. The current
established test for diagnosing COVID-19 is using the RT- PCR laboratory test. However, the test requires specialized
laboratories and testing kits. Recent reports also showed high false- negative rates. Experts recognize the urgent need
to develop a rapid point of care diagnostic tests. Ultrasonography is a widely established safe diagnostic imaging test
for detecting various lung abnormalities. Recent publications from China and Italy provided limited evidence on its
usefulness for diagnosing COVID-19 in emergency departments earlier than RT- PCR. Ultrasound is sensitive to pleural
and subpleural abnormalities, which suggests a great potential diagnostic role given the predilection for COVID-19 in
peripheral subpleural regions.This paper reviews the current evidence and discusses the problems with specificity and
scoring.
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B- lines in posterior lung regions, which correlated perfectly with
the CT results. She later tested positive on RT- PCR. is report
demonstrates the early detection capability of LU in cases with
false- negative RT- PCR results. It also further supports Ai et al.3
recommendations regarding the importance of lung imaging
considering the high sensitivity prior to positive RT- PCR results.
Several publications included descriptive case series. Huang et al
were the rst to publish a case series on 20 patients of non- critical
patients in the emergency department.11 Despite not being peer-
reviewed, their report described lesions located bilaterally in the
posterior inferior lung regions. ey were characterized by xed
conuent B- lines (waterfall sign), diused B- lines (white lung
sign), irregular and thickened pleural line, and consolidation
with air bronchograms. Additionally, they reported localized
pleural eusion in a few cases (exact number not mentioned),
which is seldom found in viral pneumonia. ey highlighted that
these are characteristic ndings dierent from bacterial pneu-
monia or pulmonary edema, where B- lines are mobile and focal.
We argue otherwise as explained below.
In the emergency settings, Peng et al published a brief letter
explaining the ultrasonographic features of COVID-19 in 20
cases.9 ey reported the same ndings of Huang et al except for
nding focal B- lines. An Italian group of researchers published
a letter on 12 patients presenting to the ER.10 In agreement with
the above reports, they found diused B- lines in all patients
and posterior consolidation in three patients only. ey also
mentioned a good correlation between CT and LU.
All reports above omitted reporting the severity of the cases.
is is vital information as it can be postulated that LU features
vary depending on the disease development. Additionally, none
of the case series examined the usefulness of handheld ultra-
sound devices. With regard to LU scanning techniques, there
is a clear discrepancy in the number of regions screened. Some
studies opted for the limited four- zone testing, while others
employed the 12- and 14- zone protocols. Soldati et al12 proposed
an unvalidated protocol to perform LU in COVID-19 patients.
ey recommended scanning patients in a sitting position
(when possible) using convex or linear transducers operating
low mechanical index settings with a single focus point on the
pleura. However, their recommended 14- zone scanning protocol
is cumbersome and has not been described before. It extends
the 12- zone protocol by adding two extra zones at the back of
the chest. In our experience, the lung is mostly obscured at the
back by the scapula, and the 12- zone is a sucient protocol to
thoroughly scan the lung even in ICU settings where the scan-
ning time should be short. It was also the employed protocol in
multiple publications5,9,11,13 and endorsed by multiple societies.17
Vetrugno et al described quite positively their Italian experi-
ence with LU in COVID-19.13 ey noted the application of
LU helped in decreasing the rates of chest x- rays and CT scans,
which contributed to making care delivery and management
more ecient. ey also described a total scanning time of less
than 5 min, which we believe underestimates the actual whole
time especially with dressing, positioning and documentation.
Despite the promising results of accuracy, eciency, safety, repro-
ducibility, and point of care use of LU, it has several drawbacks.
For example, LU is limited to visualizing the pleural surface and
cannot detect deep lung lesions. However, this may not be an
issue considering the predilection of COVID-19 in peripheral
subpleural regions. A second limitation is a need for experienced
users to operate the ultrasound device. Practitioners should
also be aware that LU, like CT, does not exclude COVID-19 in
subjects with no pulmonary complications.
THE SPECIFICITY PROBLEM
The LU features of COVID-19 include irregular pleural line,
confluent B- lines, and consolidations in more severe cases.
Two studies described pleural effusion, which is seldom
found in viral pneumonia. The problem is that none of these
signs are pathognomonic for COVID-19 as they merely
describe the density state of the lung surface. We should
be cautious when calling these signs characteristics amidst
hospitals flooding with COVID-19 as the pre- test likelihood
for positive findings in suspected COVID-19 is currently
high.
Few researchers argue the presence of a typical LU sign
coined as the ‘light beam artifact’ characterized by a vertical
echoic broadband- like artifact, similar to the white lung sign,
which comes in and out of the frame with respiration.18,19
This feature corresponds to acute ground glass alteration
which are prevalent in COVID-19 pneumonia. It may be a
specific sign especially when imaged in young patients with
no history of lung diseases. Nevertheless, the described
features bring some hope. They can be considered signifi-
cantly different to signs of pulmonary fibrosis and interstitial
pneumonia caused by other viruses where a diffused B- lines
with no spared areas.
IMAGE SCORING
ere is currently no validated image scoring system for diag-
nosing COVID-19 on LU. Soldati et al12 proposed a scoring
criterion for LU images. It scores each zone in the 12- zone
LU protocol from 0 (normal) to 3 (severe) based on the LU
lung involvement patterns relating to pleural lines, vertical
artifacts and consolidations. is scoring system was also
recently proposed by Manivel et al20 but with minor modica-
tions in each category denition. is semiquantitative scoring
system is a promising attempt to standardize the reporting of
COVID-19 scans. However, it was developed based on the sole
observations of the research team of Soldati et al.12 Hence, the
criterion and content validity must be established as well as the
inter- and intra- reader reproducibility.
It can be dicult to appreciate or count the number of B- lines
especially as minute changes can signicantly inuence the
image. Hence, we recommend obtaining the best possible
image for each zone then ‘freezing’ to count the lines for
scoring. A best practice approach is to acquire a clip and still
images of each zone for post scanning documentation, inter-
reader deliberation and medicolegal purposes.
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Opinion: Lung ultrasound in COVID-19
FUTURE PERSPECTIVES
To date, all results provided positive outcomes on the useful-
ness of LU in COVID-19. However, the presented evidence
thus far is considered weak. None of the studies included a
control group or reported their ndings longitudinally. More-
over, the sample sizes were extremely small, impeding results
generalization. Several international societies, such as the
British Medical Ultrasound Society, the intensive care society,
and the WFUMB are calling for more research on LU in
COVID 19. Future research should focus on validating the LU
signs and patterns based on the proposed scoring system to
suggest optimum cut- o scores.
In our opinion, LU in COVID-19 can have elevated rates of
false- positives due to the overlapping features with other viral
pneumonia. LU ndings should never be interpreted without
consideration of the clinical context (e.g., symptoms, decision
to supplement oxygen). For instance, it can be used to check
lung aeration before and aer non- invasive ventilation. is
may indicate that there is more hope for LU in COVID-19
as a bed- side- management tool for conrmed cases, poten-
tially saving them from re- exposure to ionizing radiation.
However, in screening tests, it is better to have a high sensi-
tivity than high specicity. As a false- negative case infected
with COVID-19 can be discharged and mingle back in society,
eventually infecting numerous new cases.
e novel coronavirus unprecedented healthcare crisis indis-
putably calls for point of care screening solutions that can
deliver rapid and sensitive results. e previous and recent
evidence suggests that LU could be the called- for solution to
diagnose positive cases and grade their severity. Modern hand-
held ultrasound devices can be particularly useful considering
their relatively cheap prices and ease of disinfection without
signicant compromises on quality. e future potential for a
radiation- free and relatively cheap bed- side- tool carries hope.
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