key: cord-354376-ghxy727r authors: Duggan, Nicole M.; Shokoohi, Hamid; Liteplo, Andrew S.; Huang, Calvin; Goldsmith, Andrew J. title: Best practice recommendations for point-of-care lung ultrasound in patients with suspected COVID-19 date: 2020-06-12 journal: J Emerg Med DOI: 10.1016/j.jemermed.2020.06.033 sha: doc_id: 354376 cord_uid: ghxy727r Abstract Background Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected COVID-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk-free. Objective of the Review: Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 which maximizes clinical utility and provider safety. Discussion In COVID-19 lung, POCUS findings are predominatly located in the posterior and lateral lung zones bilaterally. A 6-zone scanning protocol which prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning which can reduce risk to health care workers performing POCUS. Conclusions Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here which target clinical utility and decreased nosocomial disease spread must be prioritized. INTRODUCTION 26 27 Lung point-of-care ultrasound (POCUS) is an invaluable tool for assessing emergency 28 department (ED) patients with dyspnea (1-3). Lung POCUS demonstrates a higher sensitivity 29 than chest x-ray (CXR) in detecting pulmonary pathologies such as pleural effusion, alveolar 30 consolidation, pneumothorax and interstitial syndrome (3-7). Ultrasound also offers benefits over 31 computed tomography (CT), or magnetic resonance imaging (MRI) given its low cost, ease of 32 use, ability to offer real-time data, and lack of radiation exposure. Streamlined protocols aimed at 33 differentiating etiologies of dyspnea using POCUS are widely used in the ED, and often are 34 considered standard of care (8). 35 COVID-19, the clinical illness caused by SARS-CoV-2, evolved into a global pandemic 36 over a few short months (9). COVID-19 exhibits a wide range of clinical presentations from 37 asymptomatic to acute respiratory distress syndrome (ARDS) (10). Given its value in assessing 38 pulmonary pathology, lung POCUS has evolved as an important strategy to evaluate patients 39 with suspected COVID-19 (11-13). Among many challenges encountered during this global 40 crisis, maintaining the health and safety of health care workers (HCWs) has been critical (14-16). 41 Properties of COVID-19 which put HCWs at risk of nosocomial spread include human-to-human 42 transmission via respiratory droplets (17, 18) , and viral fomites which can survive on surfaces for 43 up to 72 hours (19). Unfortunately, given these properties, the time spent scanning potentially 44 infectious patients and the multi-use nature of ultrasound machines makes POCUS a possible Recognizing the dissonance between the clinical utility of POCUS and the added risk of nosocomial spread, emergency medicine and ultrasound professional organizations have 48 published guidelines outlining safe use of ultrasound in the setting of COVID-19 (12, 20-22). 49 These guidelines however largely focus on equipment disinfection, sterilization, and data-sharing 50 while providing few suggestions on best practice image acquisition or scanning protocols. Here, 51 we discuss the typical findings of lung POCUS in cases of COVID-19 leading us to propose a 52 pathologic changes tend to be particularly amenable to assessment by lung POCUS given their 61 peripheral and peri-pleural location. As is also true for other viral or bacterial pneumonias, 62 sonographic findings of COVID-19 can precede radiographic findings (23,24,27). 63 64 Based on our concern for prolonged exposure during scanning, we propose the following 67 protocol. We recommend positioning the patient sitting upright with the operator and machine 68 positioned behind the patient at all times ( Figure 2A ). This avoids direct exposure of the machine and provider to respiratory droplets produced by a tachypneic patient. Additionally, upright 70 positioning may be more comfortable for many patients in acute respiratory distress facilitating 71 easier access to the posterior lung fields. Awake prone positioning may prevent alveolar 72 collapse, improve oxygenation, and in some cases avoid intubation (29-31) . A comparable 73 positioning approach to scanning can be taken in a prone patient ( Figure 2B ). This positioning 74 gives access to the regions with most prominent imaging findings in COVID-19, and thus 75 represent the highest yield scans (23-26). 76 In an upright or proned patient, using either a linear or curvilinear probe locate the most 77 BLUE-protocol and FALLS-protocol: two applications of lung 150 ultrasound in the critically ill The role of ultrasound lung 153 artifacts in the diagnosis of respiratory distress Integrating point-of-care ultrasound 155 in the ED evaluation of patients presenting with chest pain and shortness of breath Lung ultrasound is an accurate diagnostic tool 158 for the diagnosis of pneumonia in the emergency department World Health Organization (WHO) Rolling updates on coronavirus disease Pathological findings of COVID-19 associated with acute respiratory distress 175 syndrome Is There a Role for Lung Ultrasound During 177 the COVID-19 Pandemic? COVID 19 Pandemic. Recommendations. WINFOCUS. Website: 179 Complete GUIDE to LUNG ultrasound in COVID-19 (Coronavirus) Patients. Website: 182 Center for Disease Control Interim Infection Prevention and Control 185 Recommendations for Patients with Suspected or Confirmed Coronavirus Disease COVID-19) in Healthcare Settings ncov/hcp/infection-control-recommendations.html. Accessed Staff safety during emergency airway management 189 for COVID-19 in Hong Kong Protecting health-care workers from subclinical 192 coronavirus infection Coronavirus Infections-More Than Just the Common 195 Presumed Asymptomatic Carrier Transmission of COVID-19 Aerosol and Surface Stability of Guidelines for Cleaning and Preparing External-and Internal-Use Ultrasound 202 Transducers and Equipment Between Patients as well as Safe Handling and ACEP COVID-19 FIELD GUIDE: Ultrasound Cleaning WFUMB Position Paper: How to perform a safe ultrasound examination and clean 209 equipment in the context of COVID-19 Findings of lung ultrasonography of novel corona virus 213 pneumonia during the 2019-2020 epidemic. Intensiv Care Med Available at Correlation of Chest CT and RT-PCR Testing in Coronavirus 219 Disease 2019 (COVID-19) in China: A Report of 1014 Cases Radiological findings from 81 patients with COVID-19 222 pneumonia in Wuhan, China: a descriptive study Proposal for international standardization of 225 the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible 226 method Prone positioning in severe acute respiratory 228 distress syndrome Lower mortality of COVID-19 by early recognition 231 and intervention: experience from Jiangsu Province. Ann Intensive Care Patient self-proning with high-flow 234 nasal cannula improved oxygenation in COVID-19 pneumonia Early Self-Proning in Awake, Non-intubated Patients 237 How is patient care impacted? Using a focused scanning protocol will minimize time spent in patients' rooms thus reducing risk 267 of exposure., This scanning protocol focuses on rapidly and accurately identifying most 268 common sonographic findings in COVID-19 and adhering to recommended device 269 decontamination protocols will reduce risk of nosocomial spread to subsequent patients. linear or curvilinear probe sagittal with probe marker cranially to the patient and slide 297 the probe across the posterior surfaces of the patient as shown by the blue arrows (i.e. 298 lawnmower) We would like to acknowledge Dr. Bryant Shannon and Dr. Paul Ginart for their assistance with figure production.