key: cord-347631-78h9w2ty
authors: Yun, Debo; Cui, Yan; Geng, Yuan; Yang, Yujiao
title: Use of lung ultrasound for diagnosis and monitoring of coronavirus disease 2019 pneumonia: A case report
date: 2020-10-10
journal: SAGE Open Med Case Rep
DOI: 10.1177/2050313x20958915
sha: 
doc_id: 347631
cord_uid: 78h9w2ty

Knowledge of lung ultrasound characteristics of coronavirus disease 2019 pneumonia might be useful for early diagnosis and clinical monitoring of patients, and lung ultrasound can help to control the spread of infection in healthcare settings. In this case report, a 36-year-old man with severe acute respiratory syndrome coronavirus 2 infection was diagnosed by reverse transcription-polymerase chain reaction testing of a nasopharyngeal swab. The lung ultrasound findings for this patient were the interstitial-alveolar damage showing bilateral, diffuse pleural line abnormalities, subpleural consolidations, white lung areas and thick, irregular vertical artifacts. When the patient recovered from the severe acute respiratory syndrome coronavirus 2 infection, lung ultrasound images showed a normal pleural line with A-lines regularly reverberating. Performing lung ultrasound at the bedside minimizes the need to move the patient, thus reducing the risk of spreading infection among healthcare staff. Lung ultrasound is useful for early diagnosis and evaluation of the severity of coronavirus disease 2019 pneumonia and for monitoring its progress over the course of the disease.

An outbreak of the novel coronavirus disease 2019 (COVID-19) that began in Wuhan, China, in December 2019, has spread in over 200 different countries in the world. Since then (4 June 2020), the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused 6,416,828 people infected with 382,867 deaths (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/).

The SARS-CoV-2 has a coronavirus envelope, is highly infectious and can cause a variety of symptoms such as headache, dry cough, dyspnea, myalgia, fatigue and fever. 1, 2 The imaging of COVID-19 pneumonia mainly involves computed tomography (CT) and chest X-ray. 3 The characteristic feature is a development of pneumonia that is seen as groundglass opacity in the peripheric parts of the lungs as the main finding on chest CT. 4 Several studies have shown that LUS is useful for diagnosing COVID-19 pneumonia. [5] [6] [7] Moreover, advantages of LUS, such as reduced healthcare worker exposure to infected patients, repeatability during follow-up, lowcost and ease of application in limited-resource settings, makes LUS a valuable and accessible clinical tool. 7

A 36-year-old man presented to our fever clinic on 13 February 2020 in Nanchong, Sichuan, China, with a dry cough, headache, asthenia and fever, which had started 10 days previously. He denied any recent travel, but reported a history of contact with a family member from Wuhan, China (who had not been diagnosed with SARS-CoV-2 infection), which was considered a high-risk area for COVID-19 infection by the Chinese health authorities at the time.

The patient did not have any chronic medical problems and was a non-smoker. The physical examination revealed that body temperature of 38.2°C, respiratory rate of 20 breaths per minute, pulse of 105 beats per minute, blood pressure of 109/71 mmHg, and his oxygen saturation was 91% in room air. The thoracic CT image (Figure 1 (a) and (b)) showed bilateral lesions, patchy, also confluent and ground glass with the mixed consolidation. Blood tests showed lymphocytopenia, thrombocytopenia and high levels of lactate dehydrogenase (LDH) and other inflammatory markers. A nasopharyngeal swab sample was collected and tested for SARS-CoV-2. The test result was positive. The patient was isolated and was provided with symptomatic support and antiviral treatment (recombinant human interferon, lopinavir/ritonavir oral solution, diammonium glycyrrhizinate injection and methylprednisolone).

The ethics committee of North Sichuan Medical College approved this study. Informed consent was obtained before the LUS procedure. The LUS examinations were performed using a portable device (Mindray/UMT-500, China) with a 5-MHz convex probe. Settings were set to penetration mode with a low center frequency and a single focus zone at the level of pleura, and compound scan technology was used in the diagnosis of consolidation. In order to reduce the exposure risk, only one emergency department (ED) physician (Y.C.) entered the isolation room, observing all the standard preventive measures for respiratory, droplet and contact isolation provided by the National Health Commission of the People's Republic of China for the COVID-19 outbreak. The ultrasound probe was enclosed in a sterile, plastic probe cover. The patient was scanned in the supine position following the LUS examination method described in a previous study. 3 Each hemithorax was divided into six regions using three longitudinal lines (parasternal, anterior and posterior axillary) and two axial lines (one above the diaphragm and the other 1 cm above the nipples). The ultrasound device was sterilized in a dedicated area and put enclosed in a new sterile plastic bag at the end of the procedure.

During the hospitalization, the patient conducted a total of four ultrasound examinations, which were first, fifth, tenth, and fifteenth days of admission, respectively. The LUS was performed by the same ED physician using the same ultrasound device. The specific LUS findings for this patient were the interstitial-alveolar damage showing bilateral, diffuse pleural line abnormalities, subpleural consolidations, white lung areas and thick, irregular vertical artifacts (Figure 1(c)-(h) ). When the patient recovered from the SARS-CoV-2 infection, LUS images showed a normal pleural line with A-lines regularly reverberating (Figure 1(i) and (j) ). Detailed report of LUS findings at each examination are shown in Table 1 .

This report describes the use of LUS in a 36-year-old man with COVID-19 pneumonia who was admitted to our hospital in Nanchong in Sichuan Province in China. Our hospital has a policy of performing serial LUS examinations on the patients with COVID-19, so we performed LUS on this patients with COVID-19 and use this as a basis for a broader discussion of the benefits of LUS. We believe that our study makes a significant contribution to the literature because LUS is a potentially very useful clinical tool for the diagnosis and management of COVID-19, but it has not been recommended by the guide- The use of LUS in the evaluation of a suspected COVID-19 patient has several implications. First, LUS images can be obtained instantly at bedside by one clinician, therefore reducing the number of health workers potentially exposed to the patient. Currently, the use of traditional imaging, such as chest X-ray or CT scan, require that the patient to be moved to the radiology unit, potentially exposing several healthcare workers and other patients to the risk of SARS-CoV-2 infection. 9 While using LUS, the same evaluating clinician can do other essential tests such as blood tests, intravenous feeding and injections and respiratory support. This is a primary advantage of LUS as SARS-CoV-2 is very contagious, and reducing exposure is the most effective way to prevent infection. Second, LUS can be used to perform an initial screening of lung pathology in individuals diagnosed as positive for SARS-CoV-2 infection in order to distinguish low-risk patients from high-risk patients. Patients with negative lung images can wait for second-level imaging if clinically stable and, thereby, reduce the risk of nosocomial transmission. Third, routine use of CT scan has certain implications especially a potential high-risk of radiation. 10 While LUS has the advantages of being easy to use, reliable, radiation-free, and it can be performed repeatedly in real time. Finally, the portable devices are easier to sterilize than CT scanners and radiography equipment due to their smaller surface area. In case of a massive spread of this pandemic, traditional imaging is much more difficult to perform than LUS. We therefore recommend that clinicians working in countries affected by the COVID-19 pandemic use and further evaluate the role of LUS in patients with COVID-19 pneumonia.

The LUS images of patients with COVID-19 pneumonia are quite characteristic. Performing LUS at the bedside minimizes the need to move patients within the hospital, thus reducing the risk of transmitting infection. LUS might be useful for early detection and evaluation of severity of COVID-19 pneumonia. Table 1 . LUS images at each examination.

The first day of admission (early stage of the disease) Thickened pleural line with a small amount of B-line The fifth day of admission (progression stage) A large number of discrete B-lines, more visible small consolidations and areas of white lung The tenth day of admission (early recovery) Confluent B-lines, less small consolidations and less areas of white lung The fifteenth day of admission (late recovery) Lung ultrasound shows normal images, the bat sign and the A-lines LUS: lung ultrasound.

COVID-19 assessment with bedside lung ultrasound in a population of intensive care patients treated with mechanical ventilation and ECMO

Relation between chest CT findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: a multicenter study

The role of ultrasound lung artifacts in the diagnosis of respiratory diseases

Coronavirus disease 2019 (COVID-19): role of chest CT in diagnosis and management

CLUE: COVID-19 lung ultrasound in emergency department

Frequency of abnormalities detected by point-of-care lung ultrasound in symptomatic COVID-19 patients: systematic review and meta-analysis

Performance of lung ultrasound in detecting peri-operative atelectasis after general anesthesia

Point-of-care lung ultrasound findings in novel coronavirus disease-19 pneumonia: a case report and potential applications during COVID-19 outbreak

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Correlation between chest computed tomography and lung ultrasonography in patients with coronavirus disease 2019 (COVID-19)

The authors would like to thank Editage (www.editage.com) for English language editing.

Y.Y. and D.Y. were involved in conceptualization; Y.C. and Y.G. were involved in data curation; Y.Y. was involved in formal analysis, funding acquisition, investigation, and writing-review and editing; Y.Y. and Y.C. were involved in project administration; and D.Y. was involved in writing-original draft.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

All procedures performed in this case involving the patient were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the project of North Sichuan Medical College (CBY18-A-YB47).

Informed consent was obtained from the patient included in the study. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Yujiao Yang https://orcid.org/0000-0002-5409-6007