POINT OF CARE CHEST ULTRASOUND IN COVID-19

Dr Leena R V1, Dr Aparna Irodi1 and Dr Smita Manchanda2Department of Radiology

1Christian Medical College, Vellore, 2AIIMS, Delhi

Indications of Chest USG

• Evolving• Risk stratification- Few studies, not established• Monitoring and Decision making in ICU- Useful and advocated

Chest USG is not a screening tool for diagnosis or exclusion.

POCUS in COVID 19

USG

COVID 19 patient may require USG for abdomen/ antenatal evaluation

Preparation and Cleaning of USG Room

Poon LC et al. ISUOG Safety Committee Position Statemen: safe performance of obstetric and gynecological scans and equipment cleaning in the context of COVID-19. March 2020

• The USG room should be cleaned thoroughly each morning.

• All contents should be wiped with a compatible low-level disinfectant (LLD), including USG monitor, computer keyboard and mouse, stretcher rails, transducer holder, gel container, door handles, cabinet knobs, light switches, chairs and counter tops.

Preparation and Cleaning of USG Room

• Number of transducers connected to USG machine should be reduced to a minimum

• All unnecessary accessories in the room should be removed

• Fabric-covered chairs should be replaced with hard-surface chairs that can be wiped

• If possible, replace all washable linen, such as towels, pillow covers and sheets, with disposable covers

• Transducers and cables should be cleaned every morning and this should also be performed after each scan.

• Use of single-use USG gel packs • Patient bed or couch should be

wiped with a LLD prior to replacing the disposable paper cover.

• Disposable paper cover should be removed with gloved hands and folded and disposed of immediately at the end of each examination.

Preparation and Cleaning of USG Room

• Highly touched surfaces (e.g. keyboard, cord and screen) of USG machine are thoroughly cleaned after each examination.

• At the end of the day:o Soiled linen should be handled

using two pairs of gloves and disposed of in the appropriate container without shaking the linen.

o The room and equipment should undergo terminal cleaning using a LLD.

o Hands should be washed for 20 sec afterwards.

• The transducer and ultrasound equipment must be cleaned with a compatible LLD after each patient, in accordance with local guidelines and vendor specifics.

• All vendors have put up compatible disinfectants and methods of use on their website.

• Low level Disinfection (LLD) required for general purpose probes• High Level Disinfection (HLD) required for TEE, TVS, TRUS probes

Preparation and Cleaning of USG Equipment

CLEANING• Should be performed wearing disposable gloves• Disconnect the transducer. • Remove the transducer cover (if applicable) and dispose of in clinical

waste. • Rinse the operative end of the transducer with running tap water

(NOT the electronic contact end). • Clean the transducer with a soft brush and nonabrasive detergent. • Rinse the transducer with tap water. • Clean the transducer cable with a LLD wipe. • Dry with a cloth or towel (residual water can dilute chemical

disinfectants, if this is the preferred method).

Preparation of the ultrasound transducer consists of two steps: cleaning and disinfection.

DISINFECTION

• Specific product instructions must be consulted (at vendor site).

Chemical ‘wet’ disinfection: • 2.4–3.2% glutaraldehyde products (such as Cidex, Metricide, Procide). • Non-glutaraldehyde agents (such as Cidex OPA (o-phthalaldehyde)

and Cidex PA (hydrogen peroxide and peroxyacetic acid). • Approved multistep disinfectant wipes containing chlorine dioxide• 7.5% hydrogen peroxide solution• Sodium hypochlorite 0.21% (Antisapril Blu 2%)• Ethanol 80-95%• 2-propanol 75-100%• 2-propanol and 1-propanol 45% and 30%

IN ISOLATION WARD

• Ideally one portable ultrasound machine can be stationed in the Isolation ward

• Sonologist to wear all personal protective equipment during scan. • In absence of PPE, sonologist can guide the medical officer/ nurse

with single page pictorial guide for chest USG• Single use plastic covers to be used to cover the probe and wires

and the plastic covers can be disposed after the scan• Machine (monitor, keyboard and accessories to be covered in plastic

covers)

POCUS in COVID 19

Technique of Chest USG in ICU

• Sonologist should save 10 seconds video clips in the anterior, lateral and posterior (wherever feasible) landmarks as described later.

• These video clips can be interpreted later outside the isolation room.

• Intensive care nurse can also be trained to keep the probe at defined landmarks and save video clips of 10 seconds duration each.

• The same can be shared with the radiologist in DICOM format for interpretation.

Technique

• Use Convex or Linear probes, according to the patient’s body size

• Single focal point, kept on the pleural line (not multifocussing)

• Low MI (mechanical index): start from 0.7

• Avoid use of cosmetic filters and specific imaging modalities (Harmonic Imaging, Contrast, Doppler, Compounding)

• Achieve the highest frame rate possible

• Save in DICOM format, wherever possible as videos

• Scans need to be intercostal, as to cover the widest surface possible with one scan.

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

Technique POCUS in COVID 19

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

For patients on invasive ventilation and those not able to maintain sitting position

POCUS in COVID 19

Minimum of 8 areas to be scanned

• 2 anterior – At mid clavicular line, below and above the internipple line • 2 lateral – At mid-axillary line, below and above the internipple line• Posterior areas might be difficult to evaluate: Hence, try and have a partial view of

the posterior basal areas(The total scan duration would be approximately 2-3 minutes).

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

POCUS in COVID 19Proposed standardized sequence of image acquisition

For patient able to maintain sitting position, 14 areas to be scanned

2 anterior - Mid clavicular line,internipple line

2 lateral - mid-axillary , internipple line

3 posterior - paravertebral line, diaphragm, Inf angle & spine of scapula

Summary of 14 areas to be scanned for stable patient in sitting position

5. Right basal on mid-axillary line below the internipple line (RBL)6. Right upper on mid axillary line above the internipple line (RUL)7. Left basal on mid-axillary line below the internipple line (LBL)8. Left upper on mid axillary line above the internipple line (LUL)

POSTERIORLATERALANTERIOR

9. Right basal on paravertebral line at costophrenic recess (RBP)10. Right middle on paravertebral line at the inferior angle of shoulder blade (RMP)11. Right upper on paravertebral line at spine of shoulder blade (RUP)12. Left basal on paravertebral line at costophrenic recess (LBP)13. Left middle on paravertebral line at the inferior angle of shoulder blade (LMP)14. Left upper on paravertebral line at spine of shoulder blade (LUP)

1. Right basal on mid-clavicular line below the internipple line (RBA)2. Right upper on mid-clavicular line above the internipple line (RUA)3. Left basal on mid-clavicular line below the internipple line (LBA)4. Left upper on mid-clavicular line above the internipple line (LUA)

POCUS in COVID 19

Chest USG Findings

Normal lung USG – sliding movement and ‘A’ lines – horizontal reverberation artifacts.

COVID-19 /ARDS – B lines (vertical laser like artifacts from pleura) / posterior subpleural consolidations.

Chest USG in COVID-19 POCUS in COVID 19

Chest USG findings described in COVID – 19• Posterior lower lung fields more involved• B lines and waterfall sign• Interrupted pleural line• Subpleural consolidation• Air bronchogram• Localised pleural effusion• Reduced blood supply on Doppler

Huang, Yi and Wang, Sihan and Liu, et al. A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19) (Feb 26, 2020). Available at SRN: https://ssrn.com/abstract=3544750

POCUS in COVID 19

https://link.springer.com/content/pdf/10.1007/s00134-020-05996-6.pdf

POCUS in COVID 19

https://www.youtube.com/watch?v=EQtzCVMC_Dk

Link for YouTube video on chest USG in COVID 19 patients

POCUS in COVID 19

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

POCUS in COVID 19

Score 0

Pleura line is continuous, regular.

Horizontal artifacts (A-line) are present.

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

POCUS in COVID 19

Score 1

The pleura line is indented.

B lines are present.

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

POCUS in COVID 19

Score 2

The pleura line is broken. Small to large consolidated areas (darker areas) with associated areas of white below them.

Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

POCUS in COVID 19

Score 3

Dense and largely extended white lung (coalescent B lines) with or without larger consolidations

PROPOSED REPORTING TEMPLATE POCUS in COVID 19

• Rapid assessment of the severity of SARS-CoV-2 pneumonia/ARDS at presentation

• Track the evolution of disease• To monitor lung recruitment maneuvers, to guide response to prone

position, the management of extracorporeal membrane therapy• Making decisions related to weaning the patient from ventilatory

support• Assess complications

Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6Available at https://link.springer.com/content/pdf/10.1007/s00134-020-05996-6.pdf

POCUS in COVID 19

Potential utility of chest USG in COVID 19

References:

1. Huang, Yi and Wang, Sihan and Liu, Yue and Zhang, Yaohui and Zheng, Chuyun and Zheng, Yu and Zhang, Chaoyangand Min, Weili and Zhou, Huihui and Yu, Ming and Hu, Mingjun, A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19) (February 26, 2020). Available at SSRN: https://ssrn.com/abstract=3544750 or http://dx.doi.org/10.2139/ssrn.3544750

2. Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6 Available at https://link.springer.com/content/pdf/10.1007/s00134-020-05996-6.pdf

3. Mongodi, Silvia MSc, MD, PhD; Bonaiti, Silvia MD; Stella, Andrea MD; Colombo, Andrea MD; Santangelo, Erminio MD‡; Vaschetto, Rosanna MSc, MD, PhD; Orlando, Anita MD, PhD; Bouhemad, Bélaïd MD, PhD; Mojoli, Francesco MD Clinical Pulmonary Medicine: May 2019 –Volume 26 – Issue 3 – p 92–97 doi: 10.1097/CPM.0000000000000311

4. Soldati, G., Smargiassi, A., et al. (2020), Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method. J Ultrasound Med. Accepted Author Manuscript. doi:10.1002/jum.15285 Available at - https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

POCUS in COVID 19

References:

5. AIUM Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as well as Safe Handling and Use of Ultrasound Coupling Gel https://www.aium.org/officialStatements/57

6. CDC / EPA list of disinfectants https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

7. Can Lung US Help Critical Care Clinicians in the Early Diagnosis of Novel Coronavirus (COVID-19) Pneumonia? Erika Poggiali, Alessandro Dacrema, Davide Bastoni, Valentina Tinelli, Elena Demichele, Pau Mateo Ramos, Teodoro Marcianò, Matteo Silva, Andrea Vercelli, and Andrea Magnacavallo Radiology 0 0:0 https://pubs.rsna.org/doi/pdf/10.1148/radiol.2020200847

8. Poon LC et al. ISUOG Safety Committee Position Statemen: safe performance of obstetric and gynecological scans and equipment cleaning in the context of COVID-19. March 2020. https://doi.org/10.1002/uog.22027

POCUS in COVID 19

Acknowledgement:

Dr. Ashu Seith Bhalla,AIIMS, New Delhi