Lung ultrasound findings in a 64-year-old woman with COVID-19

Adam Thomas; Greg Haljan; Anish Mitra

doi:10.1503/cmaj.200414

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Clarifying the role of lung ultrasound in COVID-19 respiratory disease [RE: Lung ultrasound findings in a 64-year-old woman with COVID-19]
Cameron W Pierce [B.Sc, M.A., MD, FRCPC internal medicine & respirology]

Posted on: 02 April 2020
RE: Lung ultrasound findings in a 64-year-old woman with Covid-19: This examination could be remote!
Andrew W Kirkpatrick [MD MHSc FRCSC] and Jessica L Mckee [BA MSc]

Posted on: 31 March 2020

Posted on: (2 April 2020)

Clarifying the role of lung ultrasound in COVID-19 respiratory disease [RE: Lung ultrasound findings in a 64-year-old woman with COVID-19]
Cameron W Pierce [B.Sc, M.A., MD, FRCPC internal medicine & respirology], respirologist, Vancouver Coastal Health
Thomas et al(1) describe a patient with COVID-19 pneumonia, in whom lung ultrasound demonstrated "multifocal B-lines, pleural thickening and subpleural consolidation." On the basis of these findings, they propose "that lung ultrasonography may be useful in the workup of patients with suspected COVID-19, even though differentiating between different causes of viral pneumonia is not possible." These comments require further clarification.

First, the sonographic findings described here are highly nonspecific, being found not only in other viral pneumonias, but also in non-viral pneumonias, as well as a wide spectrum of noninfectious processes, including interstitial lung disease and ARDS.(2)

Secondly and consequently, the nature of this patient's sonographic findings must be further qualified, particularly her 'multifocal' B-lines. If by this term three or more B-lines per acoustic window is designated, an 'interstitial' (or 'alveolar-interstitial') pattern is identified (whereas occasional B-lines, especially dependently, can be normal).(3) However, if by this term a certain global distribution of interstitial pattern is designated, diagnostic implications follow: whereas a homogeneous interstitial pattern favours cardiogenic edema, a heterogeneous interstitial pattern, particularly combined with subpleural consolidation, pleural thickening, and reduced lung sliding, is consistent with pneumonia and/or AR...
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Thomas et al(1) describe a patient with COVID-19 pneumonia, in whom lung ultrasound demonstrated "multifocal B-lines, pleural thickening and subpleural consolidation." On the basis of these findings, they propose "that lung ultrasonography may be useful in the workup of patients with suspected COVID-19, even though differentiating between different causes of viral pneumonia is not possible." These comments require further clarification.

First, the sonographic findings described here are highly nonspecific, being found not only in other viral pneumonias, but also in non-viral pneumonias, as well as a wide spectrum of noninfectious processes, including interstitial lung disease and ARDS.(2)

Secondly and consequently, the nature of this patient's sonographic findings must be further qualified, particularly her 'multifocal' B-lines. If by this term three or more B-lines per acoustic window is designated, an 'interstitial' (or 'alveolar-interstitial') pattern is identified (whereas occasional B-lines, especially dependently, can be normal).(3) However, if by this term a certain global distribution of interstitial pattern is designated, diagnostic implications follow: whereas a homogeneous interstitial pattern favours cardiogenic edema, a heterogeneous interstitial pattern, particularly combined with subpleural consolidation, pleural thickening, and reduced lung sliding, is consistent with pneumonia and/or ARDS.(4) Presuming a heterogeneous interstitial pattern, this patient's overall presentation suggests concomitant COVID-19 pneumonia and ARDS.

In sum, the findings on lung ultrasound of COVID-19 respiratory disease appear to be nonspecific, and likely on par with similar non-COVID respiratory diseases; the need for microbiological confirmation remains. In general, lung ultrasound in critical illness provides data that are probably best regarded as complementary to chest radiography; its unique benefit in the current context includes bedside feasibility, particularly when advanced chest imaging is unavailable or contraindicated for infection control.(5)
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Competing Interests: None declared.
References
(1). Clarifying the role of lung ultrasound in COVID-19 respiratory disease [RE: Lung ultrasound findings in a 64-year-old woman with COVID-19]. 2020;:-.
(2) Mojoli F, Bouhemad B, Mongodi S, Lichtenstein D. Lung ultrasound for critically ill patients. Am J Respir Crit Care Med 2019;199:701-714.
(3) Doerschug KC, Schmidt GA. Intensive Care Ultrasound: III. Lung and pleural ultrasound for the intensivist. Ann Am Thorac Soc 2013;10:708-712.
(4) Copetti R, Soldati G, Copetti P. Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome. Cardiovasc Ultrasound 2008:6:16.
(5) See KC, Ong V, Tan YL, Sahagun J, Taculod J. Chest radiography versus lung ultrasound for identification of acute respiratory distress syndrome: a retrospective observational study. Crit Care 2018;22:203.
Posted on: (31 March 2020)

RE: Lung ultrasound findings in a 64-year-old woman with Covid-19: This examination could be remote!
Andrew W Kirkpatrick [MD MHSc FRCSC], Acute Care, Trauma, and General Surgery and Critical Care Medicine, TeleMedical Ultrasound Enhanced Medical Interventions (TMUSMI) Group of the University of Calgary
Other Contributors:
Jessica L Mckee, Project Manager
We applaud the efforts of Thomas and colleagues, in recognizing the utility of lung ultrasound as a valuable tool in the workup of patients with suspected COVID-19. They report multi-focal B-lines, pleural thickening, and subpleural consolidation, similar to findings of Peng(1), who noted that lung ultrasound gives similar results to Chest CT, but with markedly simplified logistics. Both examinations may show findings even before PCR results. Beyond this we wish to also stress the logistical attributes of lung ultrasound that include ease of performance and interpretation, and the fact that it can be interpreted far physically removed from the site of examination using telemedicine. Front-line health care providers are increasingly succumbing to COVID-19, and there are world-wide concerns regarding inadequate personal protective equipment. Remote telementored ultrasound (RTMUS) is just one format of telemedical communication, but provides a wealth of anatomic and physiologic information that can be remotely interpreted from anywhere in the world with Internet Connectivity. We have previously demonstrated that lung ultrasound can be performed accurately with economical mobile equipment in the hands of non-physicians when remotely guided(2, 3), a paradigm largely initiated to support Space Medicine(4). In addition to augmenting diagnosis, we also suggest that RTMUS might aid ongoing screening in their own homes of self-isolating adults at risk of, or with self-limited...
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We applaud the efforts of Thomas and colleagues, in recognizing the utility of lung ultrasound as a valuable tool in the workup of patients with suspected COVID-19. They report multi-focal B-lines, pleural thickening, and subpleural consolidation, similar to findings of Peng(1), who noted that lung ultrasound gives similar results to Chest CT, but with markedly simplified logistics. Both examinations may show findings even before PCR results. Beyond this we wish to also stress the logistical attributes of lung ultrasound that include ease of performance and interpretation, and the fact that it can be interpreted far physically removed from the site of examination using telemedicine. Front-line health care providers are increasingly succumbing to COVID-19, and there are world-wide concerns regarding inadequate personal protective equipment. Remote telementored ultrasound (RTMUS) is just one format of telemedical communication, but provides a wealth of anatomic and physiologic information that can be remotely interpreted from anywhere in the world with Internet Connectivity. We have previously demonstrated that lung ultrasound can be performed accurately with economical mobile equipment in the hands of non-physicians when remotely guided(2, 3), a paradigm largely initiated to support Space Medicine(4). In addition to augmenting diagnosis, we also suggest that RTMUS might aid ongoing screening in their own homes of self-isolating adults at risk of, or with self-limited COVID-19. We propose that a family member and/or the patient themselves could be guided to examine their lung fields as an early warning of COVID-19 progression, allowing earlier rescue to a higher level of assessment for the minority who will deteriorate during home isolation.

Andrew W Kirkpatrick MD Andrew.kirkpatrick@ahs.ca
Jessica L McKee jlb9@ualberta.ca
TeleMedical Ultrasound Enhanced Medical Interventions (TMUSMI) Group of the University of Calgary

1. Peng, INtensive Care Med 2020
2. McBeth, J Trauma 2011
3. McBeth Telemed J e-heath 2013
4. Sargsyan, J Trauma 2005
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Competing Interests: The authors have no direct conflicts of interest regarding this article. Unrelated potential conflicts of interest are that AW Kirkpatrick is the PI of the COOL trial ( https://clinicaltrials.gov/ct2/show/NCT03163095).) with partial unrestricted funding from the Acelity Corporation. AW Kirkpatrick has also consulted for the Innovative Trauma Care and SAM Medical Corporations. JL McKee is the Research Director of Innovative Trauma Care and has consulted for the Aceso, SAM, and Acelity Corporations. AW Kirkpatrick and JL McKee also disclose a personal relationship.
References
Adam Thomas, Greg Haljan, Anish Mitra. Lung ultrasound findings in a 64-year-old woman with COVID-19. CMAJ 2020;10.1503/cmaj.200414.
Qian-Yi Peng, Xiao-Ting Wang, Li-Na Zhang and the Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epIntensive Care Med 2020 Mar 12. doi: 10.1007/s00134-020-05996-6
Paul McBeth, Innes Crawford, Michael Blaivas, Trevor Hamilton, Kim Musselwhite, Nova Pannebianco, et al.,Simple, almost anywhere, with almost anyone: remote low-cost telementored resuscitative lung ultrasound. J Trauma. 2011;71(6):1528-35.
Paul McBeth, Innes Crawford, Corina Tiruta, James Xiao, George Qiaohao Zhu, Michael Shuster, et al.,Help is in your pocket: the potential accuracy of smartphone- and laptop-based remotely guided resuscitative teleson Telemed J e-health 2013;19(12):924-30.
Ashot Sargsyan, Douglas Hamilton, Jeff Jones, Shannon Melton, Peggy Whitson, Andrew Kirkpatrick. FAST at MACH 20: clinical ultrasound aboard the International Space Station. J Trauma. 2005;58(1):35-9.