key: cord-0995329-ah05j694
authors: Shokoohi, Hamid; Duggan, Nicole M.; Sánchez, Gonzalo García-de-Casasola; Torres-Arrese, Marta; Tung-Chen, Yale
title: Lung ultrasound monitoring in patients with COVID-19 on home isolation
date: 2020-05-28
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.05.079
sha: 01395bc42ee7a98fed21b2985de2afe4db7d2295
doc_id: 995329
cord_uid: ah05j694

Many patients with COVID-19, the clinical illness caused by SARS-CoV-2 infection, exhibit mild symptoms and do not require hospitalization. Instead, these patients are often referred for 14-days of home isolation as symptoms resolve. Lung ultrasound is well-established as an important means of evaluating lung pathology in patients in the emergency department and in intensive care units. Ultrasound is also being used to assess admitted patients with COVID-19. However, data on the progression of sonographic findings in patients with COVID-19 on home isolation is lacking. Here we present a case series of a group of physician patients with COVID-19 who monitored themselves daily while in home isolation using lung point-of-care ultrasound (POCUS). Lung POCUS findings corresponded with symptom onset and resolution in all 3 patients with confirmed COVID-19 during the 14-day isolation period. Lung POCUS may offer a feasible means of monitoring patients with COVID-19 who are on home isolation. Further studies correlating sonographic findings to disease progression and prognosis will be valuable.

J o u r n a l P r e -p r o o f Lung ultrasound monitoring in patients with COVID-19 on home isolation

The spectrum of clinical illness caused by SARS-CoV-2 infection, called COVID-19, ranges from mild cold-like symptoms to acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) hospitalization [1] . Home isolation is suggested for patients with COVID-19 with stable clinical presentations to avoid hospitalization and minimize spread of the disease.

Typically, in an emergency department (ED) or inpatient setting monitoring the progression of patients' lung findings is achieved with daily chest x-rays (CXR) or intermittent computed tomography (CT) scans [2] [3] [4] . While helpful in inpatient settings, CXR and CT have distinct disadvantages for patients on home isolation, most notably the need to present to a hospital or healthcare setting and risk further exposure of both the patient, healthcare workers, and potentially future patients from scanner contamination. Currently there is limited information characterizing the progression of imaging findings throughout the disease course for patients in home isolation.

Point-of-care lung ultrasound (POCUS) is an important tool in evaluating patients with acute dyspnea in the ED. This tool has also shown promising results in assessing patients with COVID-19 [5] [6] [7] . Typical sonographic findings in patients with viral pneumonia range from minimal change in the normal aerated lung pattern to severe bilateral interstitial disease [8, 9] .

Lung ultrasound monitoring in patients with COVID-19 on home isolation which can coalesce into a confluent pattern, as well as development of sub-pleural consolidations, irregular pleural lines, and air bronchograms [8, 9] .

While lung POCUS is fairly well-documented in initial evaluation of ED patients suspected of COVID-19, and in assessing critically ill patients in the ICU [11, 12] , little is known about the use of lung POCUS in patients with COVID-19 on home isolation. Additionally, there is a paucity of data documenting the progression of sonographic findings over an entire COVID-19 disease course. Here we present a case series of physician-patients with confirmed COVID-19 who used sequential lung POCUS for tracking pulmonary disease while in home isolation. They provided full consent to use their images and stories. We demonstrate the sonographic progression of COVID-19 in three patients with clinically stable presentations. 

This was a 58-year-old physician with no significant past medical history. He began developing symptoms 48-hours after contact with a patient with severe COVID-19 who ultimately required admission to the ICU. Initial presenting symptoms included low-grade fever, general malaise, headache, myalgias, and a dry cough. He did not experience dyspnea. 12-hours after symptom onset, RT-PCR testing for SARS-CoV-2 was performed and resulted positive.

Given his reassuring clinical presentation CXR was not obtained and he was sent home for isolation.

On day 2, symptoms had progressed to include dyspnea on exertion and cough, as well as lowgrade fevers and room air oxygen saturations as low as 92%. Lung POCUS using MyLab™Gamma portable ultrasound device (Esaote Inc. Genoa Italy) demonstrated subpleural consolidations, a thickened pleural line (Fig 2A) and focal B-lines (Fig 2B) on days 2 and 3 (video 2). By day 6 of illness his symptoms began to improve, however by day 7 lung POCUS findings progressed to include confluent B-lines (Fig 2C) . The pathological findings were bilateral and were primarily detected in the posterior inferior lobes. Upon detecting these J o u r n a l P r e -p r o o f Lung ultrasound monitoring in patients with COVID-19 on home isolation serial lung POCUS images on patients who were either clinically less well, or who required repeat medical examinations during their illness course would likely have been informative regarding the variability of POCUS progression and findings. Additionally, none of our patients had repeat RT-PCR tests performed once clinical symptoms or POCUS findings resolved.

Establishing the timing of RT-PCR clearance to correlate with either symptomatic or sonographic progression might have been revealing. Finally, the lung POCUS findings seen in COVID-19 which are described here and in other studies are not specific to SARS-CoV-2 infection. Rather, these findings can be seen in cases of interstitial syndrome triggered by various causes. While our patients all had RT-PCR testing confirming SARS-CoV-2 infection, in situations where testing is not available lung POCUS can only suggest COVID-19 however other sources of interstitial syndrome must be be diagnostically considered.

In this case series we present serial lung POCUS findings from patients with COVID-19 while on home isolation. This study identifies B-lines as one of the earliest sonographic findings in SARS-CoV-2 infection and demonstrates that improvement in lung POCUS changes lag behind resolution of clinical symptoms. Lung POCUS may have an important role in monitoring patients with COVID-19 in the future, however further work correlating POCUS findings with infectivity, viral clearance, disease progression, and prognosis are needed.

Pathological findings of COVID-19 associated with acute respiratory distress syndrome

Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases

Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study

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Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath

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A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19)

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Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT

Could the use of bedside lung ultrasound reduce the number of chest x-rays in the intensive care unit? Cardiovasc Ultrasound

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Complete GUIDE to LUNG ultrasound in COVID-19 (Coronavirus) Patients

Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19

Symptom-Based Strategy to Discontinue Isolation for Patients with COVID-19