Health care workers see patients with undifferentiated symptoms day and night in emergency departments, hospitals, and outpatient clinics, so we are hard-pressed to identify symptoms that are NOT part of the constellation of symptoms seen with COVID-19. Practically speaking, any patient we encounter is likely to have one or more of the symptoms, which include incredibly common findings such as fever, chills, cough, shortness of breath, chest pain, headache, myalgias, nausea, vomiting, diarrhea, abdominal pain, and rash!

A Critical Question Exists: How Might Point-of-Care Ultrasound (POCUS) Be Best Utilized in This Pandemic?

While data is still being collected and definite answers may not be attainable, we seek to outline a few scenarios where POCUS may greatly aid every-day patient care.

No Test or Slow Test Scenario

While COVID-19 testing is more available than early in the pandemic, there are still communities in the U.S. and worldwide that lack access to testing or expeditious results. A prior post on AIUM’s The Scan, “My Sonography Experience With COVID-19”, (https://aiumthescan.blog/2020/04/21/my-sonography-experience-with-covid-19/) by Yale Tung Chen, MD, PhD, details common POCUS findings that may aid in diagnosing COVID-19 when tests or test results are not available.¹

POCUS offers greater sensitivity for COVID-19 pneumonia than CXR and is safer (no ionizing radiation) and more cost-effective in comparison to CT imaging of the chest.²

Is This Patient’s Shortness of Breath Due to COVID-19 Pneumonia?

The differential diagnosis of a patient with undifferentiated shortness of breath can be broad. It includes not just COVID-19 pneumonia, but also pulmonary embolism, heart failure, pericarditis, pericardial effusion/tamponade, pneumothorax, and many more.

POCUS can reliably exclude decreased left ventricular ejection fraction, pericardial effusion, and pneumothorax, often rapidly shortening the differential. And POCUS findings of right heart strain may help direct clinicians toward further testing for pulmonary embolism (PE) or the use of thrombolytics in patients in extremis. Detection of a deep venous thrombosis (DVT) may serve as a proxy for diagnosing PE in a patient with shortness of breath or chest pain with a high probability of PE.

As has long been recognized but is reinforced in the COVID-19 pandemic, the ability to detect these pathologies at the bedside makes POCUS an invaluable tool for patients who are too critically ill to be transported for further diagnostic studies.

POCUS Takes One for the Team, Limiting Healthcare Worker Exposure

Limiting the number of people involved in the hands-on care of a patient with COVID-19 is an important principle in reducing healthcare worker (HCW) exposure.

In another previous post on The Scan, “How the COVID-19 Pandemic Has Changed Your Practice”, Margarita V. Revzin, MD, MS, detailed the time-intensive protocols that are in place to protect both the patients receiving and the HCWs performing ultrasound exams in the radiology department (https://aiumthescan.blog/2020/12/15/how-the-covid-19-pandemic-has-changed-your-practice/).

The ability of POCUS to answer binary clinical questions may help limit the exposure of HCWs who are not part of the primary team for the infected patients. In POCUS, the ultrasound exam is performed by a provider responsible for the comprehensive care of the patient—in essence, one of the HCWs who is primarily caring for the patient. When POCUS is able to definitively answer the clinical question at the bedside, additional imaging studies may be unnecessary, thus reducing the number of consulting providers exposed to a patient with COVID-19.

POCUS as the Great Prognosticator

The lung ultrasound findings of COVID-19 pneumonia precede findings on physical exam and x-ray imaging. Therefore, ultrasound could be used as a screening tool and additional data point in triaging patients and determining if they can be treated as an outpatient or admitted to the hospital.

Studies have suggested that infero-posterior lung POCUS findings are most sensitive for the diagnosis of COVID-19 pneumonia but that anterior lung findings best predict the need for non-invasive ventilation support while hospitalized.³

In addition, calculation of a lung ultrasound score (LUS) may help quantify severity of disease, with higher LUS predicting invasive ventilatory support need, ARDS, and death.⁴

The Future

POCUS is unique. It is the imaging modality that most easily incorporates into telehealth via remote guidance. As the role of POCUS in diagnosis, monitoring, and prognostication in pulmonary disease is better defined, it may play a role in determining care plans for patients seeking care via telehealth while minimizing COVID-19 exposure for both HCWs and patients.^5,6

Furthermore, combining handheld ultrasound devices with novel artificial intelligence algorithms may allow for the automation of diagnosis and monitoring as described in a prior blog post by Alper Yilmaz, PhD, “Using AI and Ultrasound to Diagnose COVID-19 Faster” (https://aiumthescan.blog/2020/08/11/using-ai-and-ultrasound-to-diagnose-covid-19-faster/).

References

1. Soldati G, Smargiassi A, Inchingolo R, et al. Proposal for international standardization of the use of lung ultrasound for patients with COVID-19: a simple, quantitative, reproducible method. J Ultrasound Med. 2020 Jul;39(7):1413-1419. doi: 10.1002/jum.15285. Epub 2020 Apr 13. PMID: 32227492; PMCID: PMC7228287.
2. Peng QY, Wang XT, Zhang LN; Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic. Intensive Care Med. 2020 May;46(5):849-850. doi: 10.1007/s00134-020-05996-6. Epub 2020 Mar 12. PMID: 32166346; PMCID: PMC7080149.
3. Castelao J, Graziani D, Soriano JB, Izquierdo JL. Findings and prognostic value of lung ultrasound in COVID-19 pneumonia. J Ultrasound Med. 2020 Sep 16. doi: 10.1002/jum.15508. Epub ahead of print. PMID: 32936491.
4. Ji L, Cao C, Gao Y, et al. Prognostic value of bedside lung ultrasound score in patients with COVID-19. Crit Care. 2020 Dec 22;24(1):700. doi: 10.1186/s13054-020-03416-1. PMID: 33353548; PMCID: PMC7754180.
5. Kirkpatrick AW, McKee JL, Volpicelli G, Ma IWY. The potential for remotely mentored patient-performed home self-monitoring for new onset alveolar-interstitial lung disease. Telemed J E Health. 2020 Oct;26(10):1304-1307. doi: 10.1089/tmj.2020.0078. Epub 2020 Jul 10. PMID: 32654656.
6. Kirkpatrick AW, McKee JL. Re: “Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID-19: A Simple, Quantitative, Reproducible Method”-Could Telementoring of Lung Ultrasound Reduce Health Care Provider Risks, Especially for Paucisymptomatic Home-Isolating Patients? J Ultrasound Med. 2021 Jan;40(1):211-212. doi: 10.1002/jum.15390. Epub 2020 Jul 8. PMID: 32639037; PMCID: PMC7362148.

Jennifer Carnell, Tobias Kummer, and Arun Nagdev are the leaders (2020–2022) of the AIUM Point-of-Care Ultrasound Community. Jennifer Carnell is the Secretary, Tobias Kummer is the Vice-Chair, and Arun Nagdev Arun is the Chair.

Interested in learning more about POCUS? Check out the following posts from the Scan:

• Who Owns POCUS?
• The Place of POCUS in Prevention of Physician Burnout
• The Democratization of Point-of-Care Ultrasound
• Patient Zero: My rock, my reminder, my inspiration, my failure