Background: Information on the cardiac manifestations of coronavirus disease 2019 (COVID-19) is scarce. We performed a systematic and comprehensive echocardiographic evaluation of consecutive patie...

Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study.

Point-of-care ultrasound is increasingly used at the bedside to integrate the clinical assessment of the critically ill; in particular, lung ultrasound has greatly developed in the last decade. This review describes basic lung ultrasound signs and focuses on their applications in critical care. Lung semiotics are composed of artifacts (derived by air/tissue interface) and real images (i.e., effusions and consolidations), both providing significant information to identify the main acute respiratory disorders. Lung ultrasound signs, either alone or combined with other point-of-care ultrasound techniques, are helpful in the diagnostic approach to patients with acute respiratory failure, circulatory shock, or cardiac arrest. Moreover, a semiquantification of lung aeration can be performed at the bedside and used in mechanically ventilated patients to guide positive end-expiratory pressure setting, assess the efficacy of treatments, monitor the evolution of the respiratory disorder, and help the weaning process. Finally, lung ultrasound can be used for early detection and management of respiratory complications under mechanical ventilation, such as pneumothorax, ventilator-associated pneumonia, atelectasis, and pleural effusions. Lung ultrasound is a useful diagnostic and monitoring tool that might in the near future become part of the basic knowledge of physicians caring for the critically ill patient.

https://www.atsjournals.org/doi/pdf/10.1164/rccm.201802-0236CI

Lung Ultrasound for Critically Ill Patients.

The SARS-CoV-2 pandemic is undermining the ability of many advanced healthcare systems worldwide to provide quality care [1, 2]. COVID-19 is the disease caused by infection with SARS-CoV-2, a virus with specific tropism for the lower respiratory tract in the early disease stage [3]. Computed tomography scans of patients with COVID-19 typically show a diffuse bilateral interstitial pneumonia, with asymmetric, patchy lesions distributed mainly in the periphery of the lung [4–6]. In the context of a pandemic, rapid case identification, classification of disease severity and correct treatment allocation are crucial for increasing surge capacity. Overtriage to admission and to intensive care by clinicians working in the department of emergency medicine (ED) will overwhelm system capacity. Undertriage can lead to loss of life and cross infections. Similarly, selection of those patients most likely to respond to specific treatments and determining the response to treatment in the intensive care unit (ICU) can conserve scarce resources. Lung ultrasound (LUS) is well known for its feasibility and high accuracy when used at the bedside for diagnosing pulmonary diseases [7, 8]. As the most striking manifestation of COVID-19 disease is in the pulmonary system, LUS performed by a trained and knowledgeable clinician may aid precisely in triage, classification of disease severity and treatment allocation in both the ED and the ICU. In this paper, we describe the use of LUS in treating patients with COVID-19. Case identification and classification of disease severity Pending RT-PCR test results, other patients (or staff) may be unnecessarily exposed to those carrying the disease. Verifying that patients have COVID-19 therefore remains the rate-limiting step in patient triage. Alternatively, redundant implementation of precautions may lead to unnecessary resource consumption. The use of LUS in this context could revolutionize patient triage. The LUS technique described in this paper is detailed in the supplementary material (Online Resources Supplementary file 12 LUS_TECHNIQUE.docx and Figure_1-6 and Video_1-2). The pretest probability of gaining useful information from LUS is likely to be highest when the clinician seeks to correlate clinical findings with those seen in LUS and knows what information to seek in order to do so. COVID-19 presents with not only specific LUS signs but also with typical patterns of LUS findings.

/pdf/what-s-new-in-lung-ultrasound-during-the-covid-19-pandemic-22lm0lfwrr.pdf

What's new in lung ultrasound during the COVID-19 pandemic.

This narrative review focuses on thoracic ultrasonography (lung and pleural) with the aim of outlining its utility for the critical care clinician. The article summarizes the applications of thoracic ultrasonography for the evaluation and management of pneumothorax, pleural effusion, acute dyspnea, pulmonary edema, pulmonary embolism, pneumonia, interstitial processes, and the patient on mechanical ventilatory support. Mastery of lung and pleural ultrasonography allows the intensivist to rapidly diagnose and guide the management of a wide variety of disease processes that are common features of critical illness. Its ease of use, rapidity, repeatability, and reliability make thoracic ultrasonography the "go to" modality for imaging the lung and pleura in an efficient, cost effective, and safe manner, such that it can largely replace chest imaging in critical care practice. It is best used in conjunction with other components of critical care ultrasonography to yield a comprehensive evaluation of the critically ill patient at point of care.

/pdf/thoracic-ultrasonography-a-narrative-review-4lw4vza7c8.pdf

Thoracic ultrasonography: a narrative review

Information regarding the use of lung ultrasound (LUS) in patients with Coronavirus disease 2019 (COVID-19) is quickly accumulating, but its use for risk stratification and outcome prediction has yet to be described. We performed the first systematic and comprehensive LUS evaluation of consecutive patients hospitalized with COVID-19 infection, in order to describe LUS findings and their association with clinical course and outcome. Between 21/03/2020 and 04/05/2020, 120 consecutive patients admitted to the Tel Aviv Medical Center due to COVID-19, underwent complete LUS within 24 h of admission. A second exam was performed in case of clinical deterioration. LUS score of 0 (best)—36 (worst) was assigned to each patient. LUS findings were compared with clinical data. The median baseline total LUS score was 15, IQR [7–20]. Baseline LUS score was 0–18 in 80 (67%) patients, and 19–36 in 40 (33%) patients. The majority had patchy pleural thickening (n = 100; 83%), or patchy subpleural consolidations (n = 93; 78%) in at least one zone. The prevalence of pleural thickening, subpleural consolidations and the total LUS score were all correlated with severity of illness on admission. Clinical deterioration was associated with increased follow-up LUS scores (p = 0.0009), mostly due to loss of aeration in anterior lung segments. The optimal cutoff point for LUS score was 18 (sensitivity = 62%, specificity = 74%). Both mortality and need for invasive mechanical ventilation were increased with baseline LUS score > 18 compared to baseline LUS score 0–18. Unadjusted hazard ratio of death for LUS score was 1.08 per point [1.02–1.16], p = 0.008; Unadjusted hazard ratio of the composite endpoint (death or need for invasive mechanical ventilation) for LUS score was 1.12 per point [1.05–1.2], p = 0.0008. Hospitalized patients with COVID-19, at all clinical grades, present with pathological LUS findings. Baseline LUS score strongly correlates with the eventual need for invasive mechanical ventilation and is a strong predictor of mortality. Routine use of LUS may guide patients’ management strategies, as well as resource allocation in case of surge capacity.

/pdf/lung-ultrasound-predicts-clinical-course-and-outcomes-in-2lybn6ulxa.pdf

Lung ultrasound predicts clinical course and outcomes in COVID-19 patients.

LUS is normally performed in supine patients. Operator should firstly locate the diaphragm and the lungs. Lung consolidation or pleural effusion is found predominantly in dependent and dorsal lung regions and can be easily distinguished from liver or spleen once the diaphragm has been identified. By using the anterior and posterior axillary lines as anatomical landmarks, three areas per hemithorax (anterior, lateral, and posterior) can be iden-tified. Each area is divided in two, superior and inferior. In a given region of interest, lung surface of all adjacent inter-costal spaces must be explored by moving the probe trans-versally.

Ultrasound for "lung monitoring" of ventilated patients.

Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia

Weaning failure from mechanical ventilation may be due to lung de-recruitment or weaning-induced pulmonary oedema (WIPO). Both can be diagnosed by lung ultrasound (LUS) and transthoracic echocardiography (TTE), respectively. We conducted a prospective observational study, combining TTE and LUS, to determine if LUS alone may identify elderly patients at high risk of weaning or extubation failure. Before and at the end of spontaneous breathing trials (SBT) in 40 elderly patients, we prospectively performed LUS and TTE. Extubation was decided by an independent operator. LUS included global and anterolateral LUS score. TTE included measurement of E/A and E/Ea ratios to determine LV filling pressures. SBT LUS scores for prediction of weaning outcome and for the diagnosis of WIPO were studied. Weaning or extubation failure was observed in 45% (95% CI 28–61) of patients. ROC analysis for ability of global SBT LUS to predict weaning/extubation failure and extubation failure found AUC of 0.80 and 0.81, respectively. AUC for anterolateral SBT LUS to predict weaning/extubation failure and extubation failure was 0.79 and 0.81, respectively. Increased LV filling pressure during SBT was observed without increase of anterolateral LUS score. Inversely, increase of anterolateral LUS was observed without increased filling pressure and was associated with extubation failure. Global and anterolateral SBT LUS were not correlated to E/Ea. In elderly patients, global and anterolateral LUS scores were associated with weaning and extubation failures while echocardiographic indices of filling pressures were not. ClinicalTrials.gov No. NCT03261440.

Use of combined cardiac and lung ultrasound to predict weaning failure in elderly, high-risk cardiac patients: a pilot study.

http://icaa.ir/Portals/0/cardiothoracic%20and%20vascular%20anesthesia/Late%20Diagnosis%20of%20Congenital%20Methemoglobinemia.pdf

Isabelle Rouquette

Papers

Ultrasound for "lung monitoring" of ventilated patients.

Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia

Use of combined cardiac and lung ultrasound to predict weaning failure in elderly, high-risk cardiac patients: a pilot study.

Late diagnosis of congenital methemoglobinemia in an elderly patient during cardiac surgery.