key: cord-1043307-pgfqkwqg
authors: Rali, Aniket S; Trevino, Sergio; Yang, Edward; Herlihy, James P; Diaz-Gomez, Jose
title: Cardiopulmonary Ultrasonography for Severe Coronavirus Disease 2019 Patients in Prone Position
date: 2020-05-14
journal: Card Fail Rev
DOI: 10.15420/cfr.2020.12
sha: cc725224f1ba5bc74e85afa5f464a0de0330daaa
doc_id: 1043307
cord_uid: pgfqkwqg

nan

anyone who had been recently unwell or had been travelling. Upon arrival to the emergency room, the patient was noted to be severely hypoxaemic by pulse oximetry (66%) and in impeding respiratory failure, so she was emergently intubated for mechanical ventilatory support. Immediately post-intubation, arterial blood gas was as follows: pH 7.34, pCO 2 31 mmHg, pO 2 60 mmHg, O 2 saturation 90%, calculated HCO 3 16 mmol/l on FiO 2 of 100% and PaO 2 /FIO 2 ratio of 60. Her ventilatory mode was set at controlled minute ventilation, with a respiratory rate of 24, tidal volume of 300 cc (6 cc/ ideal body weight), positive end-expiratory pressure (PEEP) of 20 cmH 2 O and FiO 2 of 100%. The patient's chest X-ray at the time of admission showed diffuse bilateral pulmonary opacities consistent with multifocal pneumonia or pulmonary oedema ( Figure 1 ).

Polymerase chain reaction (PCR) testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was sent and came back positive after 48 hours.

The patient was diagnosed with severe acute respiratory distress syndrome (ARDS), so was treated with inhaled pulmonary vasodilators, neuromuscular blockade and prone-position ventilation.

In addition, she was evaluated for extracorporeal membrane oxygenation (ECMO) support. Her respiratory ECMO survival prediction score was 5, which classified her as risk class II, with an expected in-hospital survival of 76%. Cardiac biomarkers of brain natriuretic peptide (BNP) and troponin were 150 pg/ml and w0.26 ng/ ml, respectively, on admission. Therefore, the critical care team deemed that the patient would benefit from ECMO. However, her underlying cardiovascular comorbidities raised concerns, such as the evaluation of volume status, cardiac function, lung and pleura evaluation, reassessment of lung recruitment with high PEEP and decision-making with regard to ECMO support. Furthermore, the results of the SARS-CoV2 test were still pending, thus the exact aetiology of her ARDS remained unclear.

Her medical history was significant for morbid obesity (BMI of 54), type 2 diabetes, hypertension, non-alcoholic steatohepatitis, bipolar disorder and anxiety.

Our current diagnostic options for COVID-19 suspected/confirmed patients include supine transthoracic echocardiography, supine transthoracic echocardiography, prone transthoracic echocardiography and prone transoesophageal echocardiography. Forty-eight hours after initial presentation, the patient's PCR testing for SARS-CoV-2 returned positive, confirming the diagnosis of COVID-19.

The key to the correct diagnosis, monitoring and management in (Figures 3 and 4) . The lung ultrasonography findings included bilateral normal lung sliding, thickening of pleural lines, absence of pleural effusions and presence of 1-2 B-lines (Figures 5 and 6) . 

Findings of lung ultrasonography of novel corona virus pneumonia during the 2019-2020 epidemic

The pathogenesis of acute pulmonary edema associated with hypertension

Critical care ultrasonography in acute respiratory failure

Acute respiratory distress syndrome (ARDS)-associated acute cor pulmonale and patent foramen ovale: a multicenter noninvasive hemodynamic study

Transthoracic cardiac ultrasound in prone position: a technique variation description