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What did a nine-expert panel hosted by the American College of Emergency Physicians say about using Point-of-Care Ultrasound recently? The group of experts including emergency medicine experts from the U.S., Spain and Italy reported their findings in Academic Emergency Medicine in late April. The goal was to highlight the efficacy of POCUS and outline recommendations for its use with COVID-19 patients.

Lead report author and panel moderator Rachel Liu, M.D. said, “Ultrasound as a diagnostic test presents distinct advantages for imaging in COVID-19. It is a mobile technology that can be used in diverse environments, including in triage tents or makeshift hospitals that are now established for COVID-19 evaluation at many centers,” she said. “POCUS, in particular, where the clinician both performs and interprets the images immediately at the bedside, can minimize involvement of additional personnel in an infectious situation and provide immediate diagnostic information.”

The panel of experts provided five reasons why POCUS should be used more widely with patients suspected of COVID-19 infection than X-ray or CT scans.

It can rule out other pulmonary diseases like pneumothorax or pleural effusion. Being able to remove these conditions from your list of possibilities can be helpful, even if a patient is already sick.

POCUS can serve as a guide with venous access, particularly with critically ill patients who need peripheral or central venous access. Because some patients with respiratory distress can’t lie flat, ultrasound can facilitate central venous access. In addition, it can help diagnose venous thromboembolism.

Cardiac ultrasound can help pinpoint any new heart issues or ones that COVID-19 has made worse. The panel suggests that emergency departments integrate focused cardiac ultrasound into symptomatic COVID-19 patient workups and assessments.

Ultrasound can identify more severe illness prior to the development of severe symptoms. Abnormalities characteristic of COVID-19 can help you direct a patient to the appropriate hospital unit early, even before lab results return.

Performing bedside ultrasound can limit the number of healthcare workers that are put at risk. Of course, the sonographer needs to use all the recommended and appropriate personal protective equipment and disinfect the machine.

A group of Italian experts has published the first protocol for the use of lung ultrasound to quantitively and reproducibly assess the degree of lung involvement in patients suspected of having COVID-19 infection.

Libertario Demi, PhD, head of the ultrasound laboratory, University of Trento, Italy, and colleagues have developed a protocol to standardize practice, which was published online on March 30 in the Journal of Ultrasound Medicine, to standardize practice. Their research offers broad agreement with industry-led algorithms and emphasizes the use of wireless, handheld ultrasound devices, ideally consisting of a separate probe and tablet, to make sterilization easy. Butterfly Network, Phillips, Clarius, GE Healthcare and Siemens are among numerous companies that produce one or more such devices, including some that are completely integrated.

While lung ultrasound is not universally accepted for diagnosing pneumonia in the context of COVID-19 and triaging patients, Giovanni Volpicelli, MD, University Hospital San Luigi Gonzaga, Turin, Italy says many COVID-19 patients that presented with a negative chest x-ray were found to have interstitial pneumonia on lung ultrasound. And when patients don’t have to be transported to the radiology department but can remain in the emergency room and undergo lung ultrasound there, the risk of nosocomial infection is more easily controlled.

The goal of publishing the protocol was “to share our experience and to propose a standardization with respect to the use of lung ultrasound in the management of COVID-19 patients.”

Approximately 60,000 ultrasound images of confirmed COVID-19 cases were reviewed without access to the patients’ clinical backgrounds.

The authors recommend scanning 14 areas in each patient for 10 seconds, making the scans intercoastal to cover the widest possible surface area. They also advise the use of a single focal point on the pleural line which optimizes the beam shape for observing the lung surface. Cosmetic filters and modalities like harmonic imaging, doppler, contrast and compounding should be avoided and the mechanical index should be kept low.

Volpicelli said, “There are situations where lung ultrasound can be considered definitive. For instance, if I see a patient with mild signs of the disease, just fever, and I perform lung ultrasound and see nothing,

lung ultrasound rules out pneumonia." He said, "This patient may have COVID-19 of course, but they do not have pneumonia, and they can be treated at home, awaiting the result of the swab test. And this is useful because you can reduce the burden in the emergency department."

He continued, "On the other hand, there are patients with acute respiratory failure in respiratory distress. If the lung ultrasound is normal, you can rule out COVID-19 and you need to use other diagnostic procedures to understand the problem. This is also very important for us because it's crucial to be able to remove the patient from the isolation area and perform CT scan, chest radiography, and all the other diagnostic tools that we need."

The Italian team said, “in the setting of COVID-19, wireless probes and tablets represent the most appropriate ultrasound equipment," as they can "easily be wrapped in single-use plastic covers, reducing the risk of contamination," and making sterilization easy.

Volpicelli doesn't like what he sees as undue focus on wireless devices for lung ultrasound in the COVID-19 protocols. For him, the issue of cross-contamination with standard lung ultrasound machines is "nonexistent. Cleaning the machine is quite easy and I do it hundreds of times per week." However, if the lung ultrasound is performed  when a patient is using a continuous positive airway pressure (CPAP) machine, the risk of contamination is much higher and a more intensive cleaning procedure is warranted.

"Not all centers have wireless machines, whereas a normal machine is usually in all hospitals,” he said. “The advantages of using lung ultrasound [in COVID-19] are too great to be limited by something that is not important in my opinion.”