key: cord-0740347-e1mb7uuh
authors: Nouvenne, Antonio; Ticinesi, Andrea; Parise, Alberto; Prati, Beatrice; Esposito, Marcello; Cocchi, Valentina; Crisafulli, Emanuele; Volpi, Annalisa; Rossi, Sandra; Bignami, Elena Giovanna; Baciarello, Marco; Brianti, Ettore; Fabi, Massimo; Meschi, Tiziana
title: Point-of-care chest ultrasonography as a diagnostic resource for COVID-19 outbreak in nursing homes
date: 2020-05-25
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.05.050
sha: 40004b1ec45efd83444db8fe2fec870986c34d46
doc_id: 740347
cord_uid: e1mb7uuh

ABSTRACT Objective Bedside chest ultrasound, when integrated with clinical data, is an accurate tool improving the diagnostic process of many respiratory diseases. This study aims to evaluate the feasibility of a chest ultrasound screening program in nursing homes for detecting coronavirus disease-19 (COVID-19)-related pneumonia and improving the appropriateness of hospital referral of residents. Design Pragmatic, descriptive, feasibility study from April 2nd to April 9th, 2020. Setting and participants: A total of 83 older residents (age 85±8) presenting mild to moderate respiratory symptoms and not previously tested for COVID-19, residing in five nursing homes in Northern Italy. Methods Chest ultrasound was performed at the bedside by a team of hospital specialists with certified expertise in thoracic ultrasonography, following a systematic approach exploring four different areas for each hemithorax, from the anterior and posterior side. Presence of ultrasonographic signs of interstitial pneumonia, including comet-tail artifacts (B-lines) with focal or diffuse distribution, subpleural consolidations and pleural line indentation was detected. The specialist team integrated ultrasound data with clinical and anamnestic information, and gave personalized therapeutic advice for each patient, including hospital referral when needed. Results The most frequent reasons for ultrasound evaluation were fever (63% of participants) and mild dyspnea (40%). Fifty-six patients (67%) had abnormal ultrasound findings. The most common patterns were presence of multiple subpleural consolidations (32 patients) and diffuse B-lines (24 patients), with bilateral involvement. A diagnosis of suspect COVID-19 pneumonia was made in 44 patients, and six of them required hospitalization. Twelve patients had ultrasound patterns suggesting other respiratory diseases, and two patients with normal ultrasound findings were diagnosed with COPD exacerbation. Conclusions and implications In nursing home residents, screening of COVID-19 pneumonia with bedside chest ultrasonography is feasible and may represent a valid diagnostic aid for an early detection of COVID-19 outbreaks and adequate patient management.

Coronavirus disease 2019 (COVID-19) represents a big challenge for geriatric medicine. 1, 2 Frail 33 older people are particularly at risk of developing severe acute respiratory syndrome coronavirus 2 34 (SARS-CoV-2) infection, 3, 4 and their clinical course is often characterized by severe respiratory 35 failure and adverse outcomes. 5 In Italy, the COVID-19 pandemic has been associated with high 36 mortality rates, particularly in subjects older than 65 with multimorbidity. 6

Nursing home residents represent a category of subjects particularly vulnerable to the spread of 38 respiratory viruses, including coronaviruses. 7-9 COVID-19 outbreaks are being increasingly 39 described in nursing homes and long-term care facilities, 10 and health systems need to put up rapid 40 and effective responses to prevent or detect such outbreaks at an early stage. 11,12

Reverse-transcriptase polymerase-chain reaction (RT-PCR) for SARS-CoV-2 and high-resolution 42 chest CT are the reference standard tests for diagnosing SARS-CoV-2 infection and COVID-19-43 related pneumonia, respectively. 13 However, the limited accessibility to these diagnostic resources 44 in nursing homes could lead to delayed diagnosis or increased rates of hospital admission. 45 Alternative diagnostic tests are thus needed in these healthcare settings, to effectively screen 46 residents that should primarily undergo RT-PCR and chest CT testing.

Point-of-care chest ultrasound is a rapid, inexpensive and reliable diagnostic tool, available directly 48 at the patient's bedside, assisting the diagnostic process of several respiratory diseases. 14,15 This 49 technique is particularly useful in older patients with mobility-limitations and multimorbidity, when consolidations and, in most severe cases, white lung pattern. 17, 18 Although not fully specific of 54 COVID-19 pneumonia, in the epidemiological context of a pandemic the detection of one or more 55 of these signs is highly suggestive for the disease. 19 Thus, in older multimorbid nursing home 56 residents with mild/moderate respiratory symptoms or fever, chest ultrasound could help clinicians 57 to gain important diagnostic information, prioritize the access to SARS-CoV-2 testing, and avoid 58 many hospital admissions.

The objective of this study was to evaluate the feasibility of a chest ultrasound program for the 60 screening of COVID-19 in a group of Italian nursing homes located in the same district in Northern 61 Italy, and to describe its impact on patient management. was included in this pragmatic descriptive feasibility study conducted from April 2 nd to April 9 th , 66 2020. The nursing homes were chosen among those of the district where some cases of COVID-19, 67 requiring hospital admission, were detected among residents in March 2020. All participants were 68 isolated in compliance with recommendations of local health authorities. Included in the study were 69 residents with respiratory symptoms, including cough and mild dyspnea with oxygen saturation in 70 room air between 90% and 95% and respiratory rate >18, or fever, for which the nursing home Each hemithorax was split into anterior-lateral sectors and posterior sectors, and each sector was then divided into upper and lower halves using the third intercostal space as reference, as to obtain 89 four areas for each hemithorax, according to our previously published research. 16 The patient was 90 kept in sitting position during examination whenever possible, with the aid of a second operator in 91 case of severe mobility-limitation. Images were saved on the ultrasound software for review. Data were expressed as mean ± standard deviation or percentages, as appropriate. Comparisons 113 between subjects with normal ultrasound and subjects with ultrasound abnormalities were made 114 using t test and chi-square test. Data were analyzed with SPSS software (IBM, United States).

The study protocol was approved by the Ethics Committee of Area Vasta Emilia Nord, Emilia- prescribed. An overview of the study findings is depicted in Figure 2 . 

Overview of demographic, clinical and ultrasound data of the 83 nursing home residents that were screened for COVID-19 by chest ultrasonography. 

Geriatric medicine in Italy in the time of COVID-19

Lung ultrasound for the emergency 278 diagnosis of pneumonia, acute heart failure, and exacerbations of chronic obstructive 279 pulmonary disease/asthma in adults: a systematic review and meta-analysis

Chest ultrasound in Italian geriatric wards: use, 282 applications and clinicians' attitudes

The authors wish to thank the management, the doctors and personnel of the five nursing homes of Parma province that participated to this study, and the management of Azienda Unità Sanitaria Locale di Parma for the support in the UMM project. The authors also wish to thank Dr. Angela Guerra for assistance in data collection and analysis and Dr. Nicoletta Cerundolo for advice in manuscript revision.Financial disclosure: No specific funding must be reported for this research. The study has been entirely supported by institutional funds.