Echocardiography in Pandemic: Front-Line Perspective, Expanding Role of Ultrasound, and Ethics of Resource Allocation

Abstract

The grave clinical context of the coronavirus disease 2019 (COVID-19) pandemic must be understood. Italy is immersed in the COVID-19 pandemic. Most of the world will soon follow. The United States currently has the most documented cases of COVID-19 of any nation. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated acute cardiomyopathy is common in critical care patients and is associated with a high mortality rate. Patients with COVID-19 frequently require mechanical support for adequate oxygenation. A severe shortfall of ventilators is predicted. Of equal concern is the projected shortage of trained professionals required to care for patients on mechanical ventilation. Ultrasonography is proving to be a valuable tool for identifying the pulmonary manifestations and progression of COVID-19. Lung ultrasound also facilitates successful weaning from mechanical ventilation. Ultrasonography of the lung, pleura, and diaphragm are easily mastered by experienced echocardiographers. Echocardiography has an established role for optimal fluid management and recognition of cardiac disease, including SARS-CoV-2-associated acute cardiomyopathy. Cardiologists, anesthesiologists, sonographers, and all providers should be prepared to commit their full spectrum of skills to mitigate the consequences of the pandemic. We should also be prepared to collaborate and cross-train to expand professional services as necessary. During a declared health care crisis, providers must be familiar with the ethical principles, organizational structure, practical application, and gravity of limited resource allocation.

Keywords: Echocardiography; Mechanical; Pandemics; Resource allocation; Ultrasonography; Ventilators.

Figure 1

Lung POCUS in patients with COVID-19. Pulmonary involvement generally begins in the terminal alveoli, which are close to the pleura and easily visible on ultrasound. The basal lateral and posterior lung fields are most frequently involved. Images are acquired through intercostal windows on the anterior, lateral, and posterior chest. Typically, 12 to 14 brief video clips are obtained. (A) The upper bright horizontal line is normal pleura. Below is a normal lung demonstrating four horizontal A lines that are the result of reverberation artifact from normal tissue. (B) A single vertical B line is present. A few scattered nonconfluent B lines indicate a mild interstitial syndrome. (C) Multiple coalescing B lines indicate moderate to severe interstitial syndrome. (D) Skip lesions (arrows) are an early diagnostic feature of COVID-19. (E) More advanced skip lesions and subpulmonic consolidation are demonstrated. (F) Hyperechoic densities indicate complete consolidation in a patient with COVID-19 pneumonia.