Going live with the @bartspom #covid19pocus meeting

Join an excellent international faculty discussing all things #pocus and #COVID19!
First up are lung ultrasound royalty -
@LunaGargani and @giovolpicelli

Discussing their extensive experience of lung ultrasound in #COVID19 #covid19pocus
Reviewing the initial data on lung ultrasound in #covid19

https://www.escardio.org/Education/E-Learning/Webinars/COVID-19-how-to-use-and-interpret-lung-ultrasound

https://theultrasoundjournal.springeropen.com/articles/10.1186/s13089-020-00171-w

#covid19pocus
Sonographic signs and patterns of COVID-19 pneumonia

The pandemic of COVID-19 is seriously challenging the medical organization in many parts of the world. This novel corona virus SARS-CoV-2 has a specific tropism for the low respiratory airways, but...

https://www.escardio.org/Education/E-Learning/Webinars/COVID-19-how-to-use-and-interpret-lung-ultrasound
Latest paper from Luna and Gio here https://link.springer.com/article/10.1007/s00134-020-06048-9

And a lovely review from @cianmcdermott and @EMManchester here https://www.medrxiv.org/content/10.1101/2020.06.15.20130344v1
Utility of Lung Ultrasound in COVID-19: A Systematic Scoping Review

Lung ultrasound (LUS) has an established evidence base and has proven useful in previous viral epidemics. An understanding of the utility of LUS in COVID-19 is crucial to determine its most suitable...

https://link.springer.com/article/10.1007/s00134-020-06048-9
Little reminder on technique for lung ultrasound

I love this video from @kyliebaker888



#covid19pocus
Differential diagnosis of B Lines

From this excellent article featuring @hatemsoliman

#covid19pocus
Check out the excellent resource https://www.openlus.com/en/ 

Which contains tutorials, videos and literature- direct from Gio and Luna

#covid19pocus
share knowledge, experience, videos and perspectives about lung ultrasound

https://www.openlus.com/en/
Now @giovolpicelli discussing his experience

in ED, their LUS use was mainly for triage

LUS is very sensitive (more so than CXR and CT in some studies) but not specific https://www.stemlynsblog.org/combatting-covid19-is-lung-ultrasound-an-option/

However it is “typical”- which means if PTP is high it’s suggestive.

#covid19pocus
Combatting COVID19 - Is Lung Ultrasound an Option? • St Emlyn's

Cian McDermott and Rachel Liu take us through how ultrasound can be used in the diagosis and prognostication of Covid 19 patients #FOAMed

https://www.stemlynsblog.org/combatting-covid19-is-lung-ultrasound-an-option/
The proper terminology for ultrasound (and arguably all imaging) is to speak in terms of probabilities, and not in terms of diagnosis

Gio is giving us a Bayesian lesson here

(Discuss twitter!)
Probabilities of #COVID19 based on imaging findings

From https://link.springer.com/content/pdf/10.1007/s00134-020-06048-9.pdf

#covid19pocus
@giovolpicelli takes this one step further

Combining the imaging with the patient’s presenting “phenotype” as seen below #covid19pocus

This is called “clinical integration” and I think it’s something we sometimes forget to do. It can also be quite hard.
A key point here, which you might here repeated later today...

Lung ultrasound does not predict outcomes in #covid19 patients.

#covid19pocus
Interesting question on subpleural consolidations on lung ultrasound- seeing that they may be small infarcts https://link.springer.com/article/10.1007/s00134-020-06085-4

More data is needed… #covid19pocus
Contrast-enhanced ultrasound (CEUS) of the lung reveals multiple areas

https://link.springer.com/article/10.1007/s00134-020-06085-4
Does lung ultrasound still have a role now the pandemic is slowing?

@giovolpicelli reckons it has a role both in the pandemic and in the quiet phase to improve diagnostic accuracy

#covid19pocus
Further discussion on semiotics

We should stop using the term “subpleural consolidation” as all consolidations are subpleural

Gio prefers “peripheral consolidations"
Now Annia Schreiber from Toronto is discussing lung ultrasound scoring in intensive care

Useful papers:
Bouhemad https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2091559

Soldati (COVID19 specific) https://onlinelibrary.wiley.com/doi/full/10.1002/jum.15285

#covid19pocus
Proposal for International Standardization of the Use of Lung Ultrasound for Patients With COVID‐19

Growing evidence is showing the usefulness of lung ultrasound in patients with the 2019 new coronavirus disease (COVID‐19). Severe acute respiratory syndrome coronavirus 2 has now spread in almost...

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2091559
There’s also a lung ultrasound reaeration score https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069489/
Lung ultrasound reaeration score: a useful tool to predict non-invasive ventilation effectiveness

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069489/
Evidence for lung ultrasound scoring:

Septic shock https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0755-9

ECMO:
https://pubmed.ncbi.nlm.nih.gov/28936711/ 

Recruitment:
https://pubmed.ncbi.nlm.nih.gov/20851923/ 

(More on ECMO later) #covid19pocus
Bedside Ultrasound Assessment of Positive End-Expiratory Pressure-Induced Lung Recruitment - PubMed

PEEP-induced lung recruitment can be adequately estimated with bedside LUS. Because LUS cannot assess PEEP-induced lung hyperinflation, it should not be the sole method for PEEP titration.

https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0755-9
How can we integrate this into our ICU patients?

Useful study from @cardiacACCP et al here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228719/

#covid19pocus
Personalizing Invasive Mechanical Ventilation Strategies in Coronavirus Disease 2019 (COVID-19)–A...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228719/
Annia is suggesting LUS has a role in:
1. Initial diagnosis
2. Selection of therapies
3. EVLW
4. Proning/ECMO
5. Weaning

These are empirical suggestions based on experience, with no data to support this

#covid19pocus
A proposed Lung ultrasound score at presentation to the ED- the CLUE score https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13546

#covid19pocus
CLUE: COVID‐19 lung ultrasound in emergency department

Lung ultrasound (LUS) plays a critical role in the SARS‐CoV‐2 pandemic. Evidence is mounting on its utility to diagnose, assess the severity and as a triage tool in the ED. Sonographic features...

https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13546
Using a previous score https://pubmed.ncbi.nlm.nih.gov/32396163/ 

And modifying it by adding lung ultrasound, AUROC improved from 0.73 to 0.78

So lung ultrasound by itself does not predict, but it may be another useful data point
Take home messages:
Lots of potential of Lung ultrasound scoring, but limited data

#covid19pocus
Next up- Enrico Boero on diaphragm monitoring in #COVID19 using ultrasound

Ping @sonophysio

#covid19pocus
Diaphgramatic dysfunction is twice as common as limb weakness following ICU admission

https://www.atsjournals.org/doi/full/10.1164/rccm.201602-0367OC

#covid19pocus
Causes of Ventilator induced diaphragmatic dysfunction (VIDD)

https://link.springer.com/article/10.1186/s40635-019-0259-9

#covid19pocus

(I do wonder about using ultrasound to assess P-SILI…?)
Diaphgragm ultrasound - uses and how to

https://link.springer.com/article/10.1007/s00134-013-2823-1?utm_content=buffercbc97&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

https://pubmed.ncbi.nlm.nih.gov/31938825/ 

#covid19pocus
Respiratory Muscle Ultrasonography: Methodology, Basic and Advanced Principles and Clinical...

Respiratory muscle ultrasound is used to evaluate the anatomy and function of the respiratory muscle pump. It is a safe, repeatable, accurate, and non-invasive bedside technique that can be success...

https://link.springer.com/article/10.1007/s00134-013-2823-1?utm_content=buffercbc97&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer
Does it predict weaning outcomes?

Maybe https://journal.chestnet.org/article/S0012-3692(17)31482-4/pdf

Maybe not:
https://pubmed.ncbi.nlm.nih.gov/30910636/ 

#covid19pocus
Inability of Diaphragm Ultrasound to Predict Extubation Failure: A Multicenter Study - PubMed

Diaphragmatic dysfunction assessed by ultrasound was not associated with an increased risk of extubation failure.

https://journal.chestnet.org/article/S0012-3692(17)31482-4/pdf
Beautiful work from my friend @aron_jonny

Describing the role of advanced echocardiography in managing the #COVID19 patient

Including a huge focus on the right ventricle ping @concernecus
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