Can Alveolar-Arterial Difference and Lung Ultrasound Help the Clinical Decision Making in Patients with COVID-19?

Abstract

Background: COVID-19 is an emerging infectious disease, that is heavily challenging health systems worldwide. Admission Arterial Blood Gas (ABG) and Lung Ultrasound (LUS) can be of great help in clinical decision making, especially during the current pandemic and the consequent overcrowding of the Emergency Department (ED). The aim of the study was to demonstrate the capability of alveolar-to-arterial oxygen difference (AaDO₂) in predicting the need for subsequent oxygen support and survival in patients with COVID-19 infection, especially in the presence of baseline normal PaO₂/FiO₂ ratio (P/F) values.

Methods: A cohort of 223 swab-confirmed COVID-19 patients underwent clinical evaluation, blood tests, ABG and LUS in the ED. LUS score was derived from 12 ultrasound lung windows. AaDO₂ was derived as AaDO₂ = ((FiO₂) (Atmospheric pressure - H₂O pressure) - (PaCO₂/R)) - PaO₂. Endpoints were subsequent oxygen support need and survival.

Results: A close relationship between AaDO₂ and P/F and between AaDO₂ and LUS score was observed (R² = 0.88 and R² = 0.67, respectively; p < 0.001 for both). In the subgroup of patients with P/F between 300 and 400, 94.7% (n = 107) had high AaDO₂ values, and 51.4% (n = 55) received oxygen support, with 2 ICU admissions and 10 deaths. According to ROC analysis, AaDO₂ > 39.4 had 83.6% sensitivity and 90.5% specificity (AUC 0.936; p < 0.001) in predicting subsequent oxygen support, whereas a LUS score > 6 showed 89.7% sensitivity and 75.0% specificity (AUC 0.896; p < 0.001). Kaplan-Meier curves showed different mortality in the AaDO₂ subgroups (p = 0.0025).

Conclusions: LUS and AaDO₂ are easy and effective tools, which allow bedside risk stratification in patients with COVID-19, especially when P/F values, signs, and symptoms are not indicative of severe lung dysfunction.

Keywords: COVID-19; P/F; arterial-alveolar difference; emergency department; lung injury; lung ultrasound; pneumonia.

Figure 1

(a) relationship between AaDO2 and P/F and (b) between AaDO2 and LUS.

Figure 2

AaDO2 mean values and P/F groups.

Figure 3

Distribution of AaDO2 values in the P/F 300–400 group. (a) Oxygen therapy (b) LUS score distribution: blue (0–6), red (7–11), orange (12–17) and green (18–20).

Figure 4

ROC curves in whole cohort. (a) AaDO₂ and Oxygen Therapy. (b) LUS score and Oxygen Therapy.

Figure 5

AaDO₂ Kaplan–Meier curves in whole cohort. AaDO₂ groups of values: blue line (0.5–29), yellow line (30–45) and orange line (46–81).