key: cord-0991457-uhdlbkl9
authors: Ma, Irene W. Y.; Noble, Vicki E.; Mints, Gregory; Wong, Tanping; Tonelli, Ana Claudia; Hussain, Arif; Liu, Rachel B.; Hergott, Christopher A.; Dumoulin, Elaine; Chee, Alex; Miller, Daniel J.; Walker, Brandie; Buchanan, Brian; Wagner, Michael; Arishenkoff, Shane; Liteplo, Andrew S.
title: On Recommending Specific Lung Ultrasound Protocols in the Assessment of Medical Inpatients with Known or Suspected Coronavirus Disease‐19 Reply
date: 2021-02-08
journal: J Ultrasound Med
DOI: 10.1002/jum.15650
sha: 963caf80c579a89bcaffabda752916ddd1d5ed17
doc_id: 991457
cord_uid: uhdlbkl9

nan

To the Editor: We thank Drs Soldati, Smargiassi, Perrone, Torri, Mento, Demi, and Inchingolo for their comments on our article. 1 Their group pointed to their excellent prior studies, including their work on correlating lung ultrasound (LUS) score with prognosis in 52 patients, 2 as well as their work on elucidating the number of zones necessary to be scanned in order to achieve comparable diagnostic accuracy to their proposed 14-zone protocol in 88 patients. 3, 4 Work such as these contribute to furthering our understanding of LUS use in COVID-19.

In our consensus-based recommendations on how LUS should be performed, our group favored a flexible rather than a prescriptive approach, 5 recommending the inclusion of posterior lung zones wherever possible, in addition to the usual lung regions. Our recommendation was based on three primary reasons. First and foremost, we anticipate that the clinical indications for performing LUS will vary. Scans done to rule out specific causes of acute deterioration in a patient may differ from those done as an initial evaluation of a clinically stable patient, which will also differ from a follow-up scan done to assess newly developed symptoms such as focal chest pain. Thus, while existing data have validity evidence to support its use in diagnosis and prognosis, the extension of this evidence may not apply broadly in the clinical setting, especially if the diagnosis or prognosis of COVID-19 is not the clinical question at hand. Second, we anticipate that a multitude of factors must be considered by the clinician when deciding which and how many areas of the lungs to scan. For example, is there time to perform a more extensive evaluation or is the time available or the status of the patient limiting the scanning task to answering only focused questions? While a more extensive scan will typically increase the sensitivity of LUS, this sensitivity may come at a cost of increased time spent and thus increased time exposed to the patient as well.

Other factors must also be considered: What additional information influences the focused questions being asked? For example, does the patient have preexisting conditions that must be considered, such as congestive heart failure or interstitial lung disease and so on? Is the patient able to sit up or be placed in a lateral decubitus position, or would posterior findings need to be confined for the time being to the lateral posterior windows? What additional imaging and other diagnostic results are available to the clinician at the time of the LUS? The use of a single protocol across all settings is unlikely prudent, as the task of clinical integration is often complex. Third, it remains unclear at this time how clinical management decisions are to be specifically altered based on LUS findings alone. Our group does not currently endorse patient disposition decisions be made based solely on LUS findings. 5 And while prognostic information may be an additional benefit to performing LUS, how to modify management based on this prognostic information is unknown.

We further acknowledge that many clinicians and experts worldwide have extensive experience with standardized LUS protocols. [6] [7] [8] [9] [10] [11] A number of these also have accompanying supportive validity evidence. 6, 9, 11 Thus, existing evidence is not sufficiently compelling to justify the need to endorse a single protocol over another in the clinical setting. Our group continues to endorse a flexible approach, rather than a specific protocol. The majority of members from our group are based in North America; our recommendations are primarily intended for a Canadian internal medicine practice setting and may not apply broadly to other sites. Nonetheless, our recommendation is concordant with a recently published international expert consensus, 12 which comprises of an independent voting expert panel, whose members were different from ours, except for one individual who voted in both panels. Finally, it is important to note that data will continue to evolve and our recommendations will need to be revisited in the future. We greatly appreciate the rigorous research from clinician investigators around the world that contributes to this valuable ongoing dialog.

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Canadian Internal Medicine Ultrasound (CIMUS) expert consensus statement on the use of lung ultrasound for the assessment of medical inpatients with known or suspected coronavirus disease 2019

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Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus