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Observational Study
. 2021 Apr;47(4):444-454.
doi: 10.1007/s00134-021-06373-7. Epub 2021 Mar 20.

Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study

Giovanni Volpicelli #  1 , Luna Gargani #  2 , Stefano Perlini  3 , Stefano Spinelli  4 , Greta Barbieri  4 , Antonella Lanotte  5 , Gonzalo García Casasola  6 , Ramon Nogué-Bou  7 , Alessandro Lamorte  8 , Eustachio Agricola  9   10 , Tomas Villén  11 , Paramjeet Singh Deol  12 , Peiman Nazerian  13 , Francesco Corradi  14   15 , Valerio Stefanone  16 , Denise Nicole Fraga  17 , Paolo Navalesi  18 , Robinson Ferre  19 , Enrico Boero  20 , Giampaolo Martinelli  21 , Lorenzo Cristoni  22 , Cristiano Perani  23 , Luigi Vetrugno  24 , Cian McDermott  25 , Francisco Miralles-Aguiar  26 , Gianmarco Secco  3 , Caterina Zattera  3 , Francesco Salinaro  3 , Alice Grignaschi  5 , Andrea Boccatonda  5 , Fabrizio Giostra  5 , Marta Nogué Infante  7 , Michele Covella  8 , Giacomo Ingallina  10 , Julia Burkert  12 , Paolo Frumento  27 , Francesco Forfori  14 , Lorenzo Ghiadoni  4 ; on behalf of the International Multicenter Study Group on LUS in COVID-19
Collaborators, Affiliations
Observational Study

Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study

Giovanni Volpicelli et al. Intensive Care Med. 2021 Apr.

Abstract

Purpose: To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient's symptoms and clinical history.

Methods: This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed.

Results: We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23-91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients with objective respiratory failure (99.3%). The HighLUS showed a specificity of 88.8% (CI 85.55-91.65%) that was higher in the mild phenotype (94.4%; CI 90.0-97.0%). At multivariate analysis, the HighLUS was a strong independent predictor of RT-PCR positivity (odds ratio 4.2, confidence interval 2.6-6.7, p < 0.0001).

Conclusion: Combining LUS patterns of probability with clinical phenotypes at presentation can rapidly identify those patients with or without COVID-19 pneumonia at bedside. This approach could support and expedite patients' management during a pandemic surge.

Keywords: COVID-19; Interstitial pneumonia; Lung ultrasound; SARS-CoV-2.

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Conflict of interest statement

All the authors have had access to all the data of the study and accept responsibility for its validity. None of the authors and collaborators has conflicts of interest related to the present paper to diclose.

Figures

Fig. 1
Fig. 1
Representative images of the four probability patterns in symptomatic patients, showing the distribution of the LUS signs of COVID-19 pneumonia. First row: bilateral distribution of typical LUS interstitial signs (high probability) in a case RT-PCR positive. Second row: monolateral distribution of interstitial LUS signs (intermediate probability) in a case RT-PCR positive. Third row: presence of atypical signs (alternative probability) in a case showing an isolated large consolidation with air bronchograms, due to bacterial pneumonia, and RT-PCR negative. Fourth row: absence of interstitial LUS signs (low probability) in a case RT-PCR negative. LUS lung ultrasound, COVID-19 Corona Virus Disease 2019, RT-PCR reverse transcriptase-polymerase chain reaction
Fig. 2
Fig. 2
Proposed operative algorithm on the interpretation of LUS signs in the first approach to patients suspected of COVID-19 pneumonia. The algorithm must be considered as a schematic guidance to be always clinically integrated with the overall picture, and never in isolation. Notes: *highly suggestive of bacterial pneumonia with isolated consolidation of large size and with dynamic air bronchogram; **suggestive of cardiogenic edema when visualized bilaterally with homogeneous and gravity-related distribution; ***when multiple clusters with light beam, coalescent B-lines and pleural irregularities are observed monolaterally (multifocal), it may be still classified HighLUS. HighLUS high-probability lung ultrasound pattern, LowLUS low-probability lung ultrasound pattern, IntLUS intermediate-probability lung ultrasound pattern, AltLUS alternative probability lung ultrasound pattern, COVID-19 Corona Virus Disease 2019.
Fig. 3
Fig. 3
Proposed operative flowchart on early management of patients suspected of COVID-19 during a pandemic surge, according to the clinical evaluation at presentation and the assignment of the LUS probability pattern. Final decision should consider that the protocol allows to rule-in or rule-out COVID-19 as the main cause of the presenting symptoms. HighLUS high-probability lung ultrasound pattern, LowLUS low-probability lung ultrasound pattern, IntLUS intermediate-probability lung ultrasound pattern, AltLUS alternative probability lung ultrasound pattern, COVID-19 Corona Virus Disease 2019
Fig. 4
Fig. 4
The case of a 65-year-old patient complaining of fever, cough, and fatigue for 4 days, without signs of respiratory failure and showing normal saturation in room air. The CT scan shows bilateral early smooth GGO affecting main part of the lung periphery. The correspondent LUS exam shows the typical interstitial signs with patchy distribution well characterized by the “light beam” in abrupt alternance with “spared areas”. CT computed tomography, LUS lung ultrasound, GGO ground-glass opacity
See this image and copyright information in PMC

Comment in

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