key: cord-0709111-voyjcjzw
authors: Soldati, Gino; Smargiassi, Andrea; Inchingolo, Riccardo; Demi, Libertario
title: Reply to colorimetric triage for patients with COVID‐19
date: 2020-08-27
journal: J Ultrasound Med
DOI: 10.1002/jum.15460
sha: 67b6dc3573b38074b8a6d3ffc9d18514c2b909e4
doc_id: 709111
cord_uid: voyjcjzw

nan

To the Editor: We thank Dr Antúnez Montes for his interesting proposal to link the colorimetric triage for patients with COVID-19 based on both POCUS findings and clinical parameters and our LUS scoring system and acquisition protocol together in a joint classification. 1 Indeed, LUS can be very useful to widen the medical examination and intercept peripheral changes in COVID-19 pneumonias. Although LUS has low specificity, by detecting and assessing lung involvement in suspected or confirmed cases, it can support clinical suspicions and potentially play a role in managing decisions. In our scoring system, 1 pathologic LUS findings in patients with COVID-19 patients can be classified as follows:

Score 0: The pleural line is regular. Horizontal reverberant artifacts and mirror effects are present. Score 1: The pleural line has slight alterations with sporadic vertical artifacts. Score 2: The pleural line has relevant alterations. There is a predominance of vertical artifacts. Smallto-large subpleural consolidations are present. Score 3: The pleural line is irregular and cobbled. Dense and extended white lung, with or without large consolidations, is present.

The above-described scoring system is linked to progressive and variegated alterations of peripheral lung tissue. [1] [2] [3] [4] [5] These alterations can be due to, eg, diffuse alveolar damage with alveolar-interstitial exudation, alveolar shrinking and collapse with microatelectasis, subpleural consolidations caused by inflammation phenomena, and, at least in part, ischemic lesions from coagulation disorders. 6 When multiple areas are labeled with a high score, clinical conditions are likely to be worse. Therefore, the idea to link the scoring system to the colorimetric triage is interesting and may add more information during the first medical approach.

In a pandemic context, patients admitted to the ED with nonspecific respiratory symptoms but suspected of COVID-19 should undergo an early LUS examination performed according to a standardized acquisition protocol and scoring system. 1 Patients should be kept isolated and hospitalized while waiting for virologic tests in cases with LUS findings suggestive of pulmonary involvement compatible with COVID-19 pneumonia: ie, the presence of areas with a score of 2 or 3 concurrently with altered intrapulmonary gas exchanges (yellow and red colorimetric triage). Next, a high-resolution computed tomographic scan of the chest should be performed with or without administration of an iodinated contrast agent, depending on each clinical case and according to local protocols. 7 Differently, patients with good clinical conditions (ie, patients for whom most of the examined areas are associated with score of 0, few with a score of 1, and who have conserved intrapulmonary gas exchanges) may be considered at low risk (green colorimetric triage) and can be monitored even at home according to local protocols and kept isolated while waiting for virologic tests. 7 In conclusion, we would like add a consideration on the counting of vertical artifacts. 8 Since the imaging frequency, bandwidth, and focal point position can influence the appearance of vertical artifacts, 3, [9] [10] [11] and the subjective nature of the counting operation itself introduces another strong degree of variability, we advise the authors not to rely on counting vertical artifacts in the generation of the colorimetric triage.

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