Point-of-care ultrasound COVID-19 · Point-of-care Ultrasound in COVID-19 Nilam J. Soni, MD, MS...
Transcript of Point-of-care ultrasound COVID-19 · Point-of-care Ultrasound in COVID-19 Nilam J. Soni, MD, MS...
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COVID-19Point-of-care ultrasound
March 24, 20203:00 pm
https://zoom.us/j/4899792292
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Point-of-care Ultrasound in COVID-19
Nilam J. Soni, MD, MSProfessor of Medicine
South Texas Veterans Health Care SystemUniversity of Texas Health San Antonio
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Welcome!Diverse Group of Participants…• Specialties• Geographically• Settings
• POCUS skills
WE are all in this together
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GOAL
Become familiar with the use of point-of-care ultrasound in COVID-19.
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Objectives1. Recognize unique lung US findings in the diagnosis
and management of COVID-19.
2. Describe other high-yield POCUS applications in a closed COVID-19 unit.
3. Propose protocols for integration of POCUS use in COVID-19.
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Reminders• Enter question in “chat” box at bottom
• Mute your microphone while not speaking
• All slides and recording will be posted – open access for all
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Lung Ultrasound & COVID-19
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Lung Ultrasound in COVID-19
I. What are the lung ultrasound patterns in COVID-19?
II. How can lung ultrasound be used in the diagnosis and management of patients with COVID-19?
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Lauer et al. Annals Int Med 2020; Ai et al, Radiology 2020
PCR Positive
Incubation Period: 2 – 14 days
• 98% symptomatic by 11 days• Case Severity (Wu et al. 2020)• Mild – 81%• Severe – 14%• Critical – 5%
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Limitation of PCR for COVID-19n Limited availability of testing
n 97% of U.S. land area; 60 million people live in rural settings1
n 200 of 254 counties of TX don’t have access to testing on 3/23/20
n Diminishing supply of viral swabsn Errors in sample collectionn Delays up to 7 days for resultsn False negatives of PCR (20-30%? initially - low viral loads)n Local Testing & New Tests – accuracy?
1. https://www.census.gov/library/stories/2017/08/rural-america.html
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Fang Y, et al. Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiology 2020 Feb 19:200432.
Conclusions:1. Sensitivity of chest CT vs. PCR (98% vs 71%, p<.001)2. Use chest CT for screening for COVD-19, especially if PCR negative
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Ai, et al. Radiology, February 26, 2020https://pubs.rsna.org/doi/full/10.1148/radiol.2020200642
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Correlation of CT & PCR Testing• Retrospective study of 1014 suspected patients• All pts had CT chest and serial PCR testing
Conclusions1. CT chest positive in 93% while initial PCR was negative2. Mean delay in initial negative to positive PCR 5.1 days3. CT chest had 97% sensitivity and 25% specificity
Ai, et al. Radiology, February 26, 2020https://pubs.rsna.org/doi/full/10.1148/radiol.2020200642
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Lauer et al. Annals Int Med 2020; Ai et al, Radiology 2020
PCR Positive
CTPositive
93%(subgroup with
negative initial PCR)
CT Sensitivity:Days 0-5 = 84%Days 6-11= 99%
(Wang et al, Radiology 2020)
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CT Chest Findings in COVID-19nBilateral findings (88-90%)nPeripheral distribution (72%)nGround glass opacities alone (34-46%)nGround glass opacities + Consolidation (50-60%)
Ai et al. Radiology February 26, 2020; Bernheim et al, Radiology Feb 20, 2020
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CT Chest Findings Based on Time Course
Bernheim et al. Radiology February 20, 2020
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Temporal Changes in CT Findings in COVID-19
Wang et al. Radiology, March 2020
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ACR Recommendations
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Hmmm……
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ACR Recommendations
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Current Dilemma• CT chest is not feasible in every suspected COVID-19 case
• Rationale for not CT scanning every patient– Disinfection of CT scanner – Risk to other patients, staff, and radiologists– Radiology overload
• Radiology suites (and echo labs) want to minimize exposure to these pts
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https://www.vox.com/2020/3/2/21161067/coronavirus-covid19-china
Everyone in China got a CT Chest!
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https://www.thesun.co.uk/news/10875354/chinas-first-coronavirus-hospital/
China built two 1,000-bed hospitals in 10 days!
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Lung Ultrasound
Diagnostic accuracy of lung ultrasound is superior to chest x-ray and similar to CT scans for common lung pathologies when
performed by a trained provider.
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Disposable Stethoscopes
vs.
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Huang et al. Radiology February 28, 2020
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Intensive Care Med, March 12, 2020
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Lung US Findings in COVID-19
n Thickened, irregular pleural linen B-lines (focal, multifocal, confluent)n Small, multifocal subpleural consolidationsn Posterior lung fields (75% of pts)n Absence of pleural effusion
Qian-Yi Peng, et al. ICM 2020; Huang et al. Radiology 2020
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NORMAL Lung Ultrasound1. Lung Sliding 2. A-linesAND
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Pleural EvaluationPhased-array Linear
Chest wall
Pleural lineRib Rib
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Thick, Irregular Pleural Line
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B-linesConfluentMultiple (≥3)Few (<3)
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Confluent B-lines in COVID-19
Courtesy of Gigi Liu, MD
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Subpleural Consolidation
Courtesy of Gigi Liu, MD
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Absence of Pleural Effusion
Mirror Image Curtain Sign
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Classic Sonographic SignsPleural Effusion PRESENT
Pleural Effusion ABSENT
Curtain Sign +Mirror Image +Spine Sign +
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Pleural Effusion PRESENT
Spine Sign
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COVID + ???
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Day 2
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Different Lung Ultrasound Protocols…
Mid-clavicle
Posterior Axillary
Anterior Axillary
Anterior
Lateral
Posterior
Label your images!
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4-Point Lung Ultrasound Exam1
3 4
2
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Lung Ultrasound ProtocolAnterior Posterior
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Lung Ultrasound Protocol
RUL
RML
RLL-ANT
RLL-POST
LUL
Lingula
LLL-ANT
LLL-POST
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Proposed Lung Ultrasound Scoring
0 = Normal1 = ≥3 discrete, well spaced B-lines2 = ≥3 confluent, fused B-lines 3 = Subpleural consolidations4 = Lobar consolidation
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VA POCUS Template
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Proposed Triage of PUI’sRISK
(Age>60; CVD; D-dimer, CRP, LDH, Lymph)
LUNG ULTRASOUND
DISPOSITION
Low Normal Home Observation
Low Abnormal Home vs. Hospital Observation
Intermediate / High
Normal Hospital Wards
Intermediate / High Abnormal Intensive Care
Unit
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POCUS Applications in COVID-19
1. Goal-directed Echocardiography
2. Confirmation of endotracheal tube placement
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Cardiomyopathy in COVID-19
§ Seattle experience: 33% of elderly pts in ICU (Arentz et al. JAMA 2020)
§ Goal-directed Echocardiography§ Standard 5 views§Minimum 2 views
§Parasternal long-axis§Subcostal or apical 4-chamber view
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Cardiac Dysfunction in COVID-19
Recommendation:For adults with COVID-19 and shock with evidence of cardiac dysfunction and persistent hypoperfusion despite fluid resuscitation and norepinephrine, we suggest adding dobutamine, over increasing norepinephrine dose (weak recommendation, very low quality evidence).
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) by Society of Critical Care Medicine
https://www.sccm.org/disaster
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Cardiomyopathy in COVID-19
Courtesy of Gigi Liu, MD
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Confirmation of ETT Placement
Courtesy of Jeremy Boyd, MD
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Confirmation of ETT Placement
Courtesy of Jeremy Boyd, MD
Trachea
Esophagus
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www.twitter.com
From foot of bed
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Absent Lung SlidingNormal
Confirm Bilateral Lung Sliding Post-ETT Placement
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Disinfection of Ultrasound Machine
https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
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Disinfection of Ultrasound Machine
• Active Ingredients–Sodium hypochlorite–Hydrogen peroxide–Quaternary ammonium
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Disinfection of Ultrasound Machine
Clorox Disinfecting Wipes, Clorox Healthcare Bleach Germicidal Wipes
4 minutes
Cavicide, CaviWipes 1, Caviwipes Bleach
3 minutes
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Sani-Cloth Germicidal Wipes
EPA Registration Number 9480
3 minutes2 min (Super)1 min (Bleach)
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https://www.acep.org/globalassets/images/acep-us-machine-cleaning-covid-19.pdf
Cleaning the US MachinenRemove supplies from basketn Wipe down entire machine
nBefore entering pt roomnBefore leaving pt roomnAfter leaving pt room
nRequired wet time: >2-3 min
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How long does COVID-19 live on surfaces?
Van Doremalen, et al. NEJM. Mar 17, 2020.
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Buonsenso,et al. Eur Review Med Parm Sci 2020
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Resources
https://lsom.uthscsa.edu/pulmonary-diseases/covid-19-resources/
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"Alone we can do so little, together we can do so much." --Helen Keller
Discussion
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Guest SpeakerMangala Narasimhan, DODirector, Critical Care Unit Northwell HealthcareLong Island Jewish / NorthshoreNew York
https://www.youtube.com/watch?v=9CegCk3FwvQ&=&feature=youtu.be
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"Coming together is a beginning. Keeping together is progress. Working together is success." --Henry
Ford
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https://www.sccm.org/disaster
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https://www.sccm.org/disaster
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Godspeed…Be Safe