Best Practice Recommendations for Point-of-Care Lung Ultrasound in Patients with Suspected COVID-19

Abstract

Background: Lung point-of-care ultrasound (POCUS) is a critical tool for evaluating patients with dyspnea in the emergency department (ED), including patients with suspected coronavirus disease (COVID)-19. However, given the threat of nosocomial disease spread, the use of ultrasound is no longer risk free.

Objective: Here, we review the lung POCUS findings in patients with COVID-19. In doing so we present a scanning protocol for lung POCUS in COVID-19 that maximizes clinical utility and provider safety.

Discussion: In COVID-19 lung, POCUS findings are predominantly located in the posterior and lateral lung zones bilaterally. A six-zone scanning protocol that prioritizes obtaining images in these locations optimizes provider positioning, and minimizes time spent scanning, which can reduce risk to health care workers performing POCUS.

Conclusions: Lung POCUS can offer valuable clinical data when evaluating patients with COVID-19. Scanning protocols such as that presented here, which target clinical utility and decreased nosocomial disease spread, must be prioritized.

Keywords: COVID-19; POCUS; coronavirus; lung; safety; ultrasound.

Figure 1

Lung point-of-care ultrasound findings associated with coronavirus disease (COVID)-19 infections. Hyperechoic artifacts originating from the pleural, known as B-lines, are seen ranging from (A, red arrows) isolated to (B, white arrow) confluent. (C) Pleural lines are often irregular (red box), and can be observed alongside (D, white asterisk) peri-pleural edema. (E) Subpleural consolidations (red asterisks) are a hallmark of COVID-19 pneumonia and are often seen in the posterior, lateral, and inferior lung zones.

Figure 2

Lung point-of-care ultrasound positioning and image acquisition for scanning patients with suspected coronavirus disease (COVID)-19. (A) In a patient positioned upright, the operator and machine should be positioned behind the patient to minimize exposure risk. (B) Safe positioning can be similarly achieved in a prone patient.

Figure 3

Anatomy and scanning technique for lung POCUS in patient with COVID-19. (A) Landmarks for scanning include the inferior thorax at the level of the diaphragm (curved line), the spine (solid vertical line), the scapula (triangle), and the posterior axillary line (dotted line). Lung position is outlined in blue. Lung zones to be scanned include the areas under the scapula border known as the right posterior (RP) and left posterior (LP) zones. Laterally, landmarks include the posterior axillary line (dotted line) to the anterior axillary line. Lateral lung zones to be scanned include the right lateral superior (RLs) and (B) right lateral inferior (RLi), and on the left include the left lateral superior (LLs), and (C) left lateral inferior (LLi). (D) To obtain scans, position a linear or curvilinear probe sagittal with probe marker cranially to the patient and slide the probe across the posterior surfaces of the patient as shown by the blue arrows (i.e., lawnmower). Repeat this technique in the (E) right and (F) left lateral zones.