key: cord-0926119-jdddm2rz authors: Neves, Sara E.; Fatima, Huma; Walsh, Daniel P.; Mahmood, Feroze; Chaudhary, Omar; Matyal, Robina title: Role of Ultrasound Guided Evaluation of Dyspnea in Coronavirus Disease 2019 Pandemic date: 2020-07-07 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.07.005 sha: f1e60edb24020aee915c68d864adabd3b35610c7 doc_id: 926119 cord_uid: jdddm2rz nan patients on lung ultrasonography which were consistent with CT findings. 9 Another study further supported the use of ultrasound as a superior modality to chest X-ray and comparable to CT in 20 COVID-19 patients. 10 Answer: Thank you for your advice. The change has been added to the revised manuscript.  We have added a revised version of Figure 5 due to an error in the previous version. Novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-Cov2), has led to a global pandemic termed as coronavirus disease 2019 (COVID-19, COVID) causing an unprecedented pressure on healthcare systems. Clinical care for COVID patients varies widely in different parts of the world with rapid evolution in diagnostic and therapeutic management. New insights in clinical imaging techniques are being acquired rapidly to reduce infection risk and maximize resource utilization. Previously, ultrasonography has been established as an effective and inexpensive alternative imaging modality in the identification and monitoring of pneumonia and acute respiratory distress syndrome (ARDS). 1, 2 Additional benefits of using bedside ultrasound in COVID patients include the ability to evaluate cardiac function in real-time and the reduction in number of health care workers exposed during clinical management (both medical examination and imaging assessment can be performed by a single physician at the bedside). The existing data on integration of ultrasound imaging in COVID-19 care pathways is scarce. Although initial reports showed predilection of this virus for the lungs, emerging reports demonstrate cardiac involvement as well. 3 Thus it is imperative to have a basic understanding of lung and cardiac ultrasonography to differentiate between cardiac and respiratory involvement as both can present clinically as dyspnea. In this article, we present three case scenarios which highlight the clinical feasibility of using ultrasonography along with discussion on a training model implemented by our team to educate the existing workforce on the principles of lung and cardiac point of care ultrasound in patients with COVID-19. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 Serial TTE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 hemodynamics and hypoxia; subsequently a chest tube was placed for definitive management of the pneumothorax. A forty-five year old female with history of hypertension and type 2 diabetes mellitus ventilator support with reduction of PEEP was seen with continued diuresis over the next few days. The patient's condition improved; she was extubated after ten days and subsequently discharged home. 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 Although only three cases are described here, we observed similar lung ultrasound findings in our many COVID-19 patient. More than 300 COVID-19 patients have been admitted and 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 that lung ultrasound has high sensitivity for diagnosing pneumothorax. 5 We suggest that in addition to the utilization of ultrasound for central line placement, standard use of lung ultrasound immediately post-procedure to confirm the absence of pneumothorax. This method has the advantage of limiting additional personnel exposure to COVID-19 patients, as the ultrasound equipment will already be in the room from line placement. Furthermore, we have occasionally observed delay in the ability to obtain chest x-ray due to high demand for radiography and increase in the time it takes for radiology personnel to don PPE and prepare equipment to enter a COVID-19 isolation room. With this method, point-of-care lung ultrasound is immediately available. Lung pulse is a rhythmic motion of the pleura in synchrony with cardiac rhythm. The movement of the heart cannot be detected with the presence of air between visceral and parietal pleura, therefore as with lung sliding the presence of lung pulse rules out pneumothorax. Lung point is defined as the junction between sliding lung and absent sliding and its identification is 100% specific for pneumothorax. 6 (Video 7) 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 deterioration of pre-existing structural cardiovascular pathologies. Parasternal long-axis, parasternal short-axis, apical 4-chamber, subxiphoid 4-chamber and inferior vena cava views (IVC) are recommended. IVC diameter and its collapsibility can be utilised to determine volume status. Evaluation of LV systolic function can rule out presence of cardiomyopathy, myocarditis, and myocardial injury seen in patients with COVID 19. 7 Additionally, evaluation of right ventricular function can identify pulmonary hypertension resulting from severe respiratory failure as well as support suspected pulmonary embolism resulting from prothrombotic state seen in some COVID patients. While TTE cannot diagnose pulmonary embolism, for unstable patients who are unable to be transported to obtain definitive imaging TTE may offer some guidance to empiric management. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 patients on lung ultrasonography which were consistent with CT findings. 9 Another study further supported the use of ultrasound as a superior modality to chest X-ray and comparable to CT in 20 COVID-19 patients. 10 The case scenarios in our study highlight the benefit of surface imaging techniques to 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 hospital protocol and guidance considerations. 11 Particularly, ensure to wipe the probe, cable and connector and allow the surfaces to remain wet for two minutes. Use additional fresh wipes to confirm contact time of two minutes and allow it to air dry. At our institution, we employed Butterfly IQ handheld probe (Butterfly Network, Inc., Connecticut, United States) and VScan Extend handheld ultrasound dual probe (GE Healthcare, Chicago, IL, United States). Portability of these devices allows enhanced vigilance, saves time in equipment sterilization, and offers integrated teleguidance to allow a trained practitioner to collaborate with a novice or a junior colleague at bedside. Although the power of current studies on ultrasound use in COVID 19 is low, these results are promising and advocated by multiple expert groups across different countries. 4, 12, 13 This delineates the need to gather high quality clinical evidence by designing large scale studies implementing ultrasound as a real time diagnostic and navigation tool for management. Here we offer further evidence of the value of point-of-care ultrasound in a challenging clinical environment and propose a pragmatic method for provider training as well as incorporation of ultrasound into clinical management. Future study can further illustrate the effectiveness of these techniques. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 Thoracic ultrasonography: a narrative review Lung ultrasound for diagnosis of pneumonia in emergency department The variety of cardiovascular presentations of COVID-19. 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