key: cord-0682256-8w3bewlw
authors: Levy Adatto, Nimrod; Preisler, Yoav; Shetrit, Aviel; Shepshelovich, Daniel; Hershkoviz, Rami; Isakov, Ofer
title: Rapid 8‐Zone Lung Ultrasound Protocol is Comparable to a Full 12‐Zone Protocol for Outcome Prediction in Hospitalized COVID‐19 Patients
date: 2021-10-26
journal: J Ultrasound Med
DOI: 10.1002/jum.15849
sha: fe7add25e7ed630730473160095e8986f00ebc52
doc_id: 682256
cord_uid: 8w3bewlw

OBJECTIVES: Safety precautions limit the clinical assessment of hospitalized Coronavirus disease 2019 (COVID‐19) patients. The minimal exposure required to perform lung ultrasound (LUS) paired with its high accuracy, reproducibility, and availability make it an attractive solution for initial assessment of COVID‐19 patients. We aim to evaluate whether the association between sonographic findings and clinical outcomes among COVID 19 patients is comparable between the validated 12‐zone protocol and a shorter, 8‐zone protocol, in which the posterior lung regions are omitted. METHODS: One hundred and one COVID‐19 patients hospitalized in a dedicated COVID‐19 ward in a tertiary referral hospital were examined upon admission and scored by 2 LUS protocols. The association between the scores and a composite outcome consisting of death, transfer to the intensive care unit (ICU) or initiation of invasive or noninvasive mechanical ventilation was estimated and compared. RESULTS: LUS scores in both the 8‐ and the 12‐zone protocols were associated with the composite outcome during hospitalization (hazard ratio [HR] 1.21 [1.03–1.42, P = .022] and HR 1.13 [1.01–1.27, P = .037], respectively). The observed difference in the discriminatory ROC‐AUC values for the 8‐ and 12‐zone scores was not significant (0.767 and 0.754 [P = .647], respectively). CONCLUSION: A short 8‐zone LUS protocol is as accurate as the previously validated, 12‐zone protocol for prognostication of clinical deterioration in nonventilated COVID‐19 patients.

accurate radiographic results, and minimization of computer tomography (CT) scans and other procedures that expose the hospital population to these patients. 4 In the last decade, lung ultrasound (LUS) has become an essential tool in diagnosis and followup of hospitalized patients with various respiratory disorders, ranging from critical care patients with respiratory failure and expanding into various other medical disorders, including pneumonia, pneumothorax, and pulmonary congestion. [5] [6] [7] The minimal staff and equipment exposure required to perform LUS paired with its high accuracy, reproducibility, and availability as a bedside tool make it an attractive tool for initial assessment, risk-stratification and monitoring of COVID-19 patients. [8] [9] [10] [11] Various LUS protocols requiring between eight and 18 zone of assessment have been used for the assessment of COVID-19 patients. [12] [13] [14] [15] [16] [17] [18] [19] The commonly used bedside lung ultrasound in emergency (BLUE) protocol, consisting of 12-zone assessment comprising the anterior, lateral, and posterior lung regions, has shown strong association between LUS findings and patient outcomes in myriad clinical conditions. 20, 21 However, whether more time and effort consuming protocols provide more robust assessments of patient outcome is unknown.

In this study, we aimed to evaluate whether the association between sonographic findings and clinical outcomes among COVID 19 patients is comparable between the validated BLUE protocol and a shorter, 8-zone protocol, in which the posterior lung regions are omitted.

Ethics Committee Approval Ethical approval for this study was obtained from Tel Aviv Sourasky Medical Center Helsinki Committee (approval number 0712-20-TLV), no need for written informed consent was required.

The study cohort included consecutive COVID-19 patients hospitalized in a dedicated COVID-19 ward in a tertiary university affiliated referral hospital between July, 2020 and October, 2020. All patients had a positive molecular test for COVID-19 infection upon admission. Patients who required mechanical ventilatory support prior to admission were excluded. COVID-19 disease severity of the included patients according to the National Institute of Health classification (mild, moderate, serve, critical) (https://www. covid19treatmentguidelines.nih.gov/overview/clinicalspectrum/).

The composite outcome was defined as either death, transfer to the intensive care unit (ICU) or initiation of invasive or noninvasive mechanical ventilation during the index hospitalization.

LUS was performed on all admitted patients. A dedicated General Electric Venue Go ultrasonic device was used. The frequency was 1 to 5 MHz for the convex array probe and 5 to 20 MHz for the linear probe. Film and 70% alcohol were used to protect and disinfect the probe and scanner after each examination. All evaluations were performed by an experienced physician certified in general point-of-care ultrasound (POCUS training program, Soroka Medical Center, Israel), with more than 5 years experience in both practicing and teaching POCUS at the Tel Aviv Sourasky Medical Center. Protective equipment was used for all scans.

Sonographic assessments were performed with the patient being in the semirecumbent position. We performed a 12-zone LUS examination, assessing each hemithorax systematically at the anterior, lateral, and posterior lung zone ( Figure 1 ). We used the R1-6 and L1-6 labeling method. The right (R) zones were divided to: R1-right upper anterior; R2-right lower anterior; R3-right upper lateral; R4-right lower lateral; R5-right upper posterior; R6-right lower posterior. The left (L) zones were divided similarly. When assessing the R5/6 and L5/6 zone, the patient was sitting in an erect position, and the physician assessed these lung zone from behind, avoiding leaning across the patient, in order to minimize exposure to the patient and by that reduce the risk of transmission.

The eight-zone LUS protocol was defined as assessment of the anterior and lateral zone, omitting the posterior zones. On each examination, assessment included the presence of A-lines, pleural line morphology including pleural irregularities, thickening, or sub pleural consolidations. Presence of B-lines and their maximum number

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